BACKGROUND

Numerous agents are available for moderate sedation in endoscopy.

OBJECTIVE

Our purpose was to compare efficacy, safety, and efficiency of agents used for moderate sedation in EGD or colonoscopy.

DESIGN

Systematic review of computerized bibliographic databases for randomized trials of moderate sedation that compared 2 active regimens or 1 active regimen with placebo or no sedation.

PATIENTS

Unselected adults undergoing EGD or colonoscopy with a goal of moderate sedation.

MAIN OUTCOME MEASUREMENTS

Sedation-related complications, patient assessments (satisfaction, pain, memory, willingness to repeat examination), physician assessments (satisfaction, level of sedation, patient cooperation, examination quality), and procedure-related efficiency outcomes (sedation, procedure, or recovery time).

RESULTS

Thirty-six studies (N = 3918 patients) were included. Sedation improved patient satisfaction (relative risk [RR] = 2.29, range 1.16-4.53) and willingness to repeat EGD (RR = 1.25, range 1.13-1.38) versus no sedation. Midazolam provided superior patient satisfaction to diazepam (RR = 1.18, range 1.07-1.29) and less frequent memory of EGD (RR = 0.57, range 0.50-0.60) versus diazepam. Adverse events and patient/physician assessments were not significantly different for midazolam (with or without narcotics) versus propofol except for slightly less patient satisfaction (RR = 0.90, range 0.83-0.97) and more frequent memory (RR = 3.00, range 1.25-7.21) with midazolam plus narcotics. Procedure times were similar, but sedation and recovery times were shorter with propofol than midazolam-based regimens.

LIMITATIONS

Marked variability in design, regimens tested, and outcomes assessed; relatively poor methodologic quality (Jadad score

CONCLUSIONS

Moderate sedation provides a high level of physician and patient satisfaction and a low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than does propofol.

PURPOSE

Colonic lipomas are benign, submucosal tumours that are usually asymptomatic. Typically, they are incidentally diagnosed during colonoscopy. Due to a low prevalence, the natural history of lipomas remains largely unknown. While large (>2 cm) lesions can cause symptoms and complications, their endoscopic treatment is not routinely recommended because of prior reports of a high rate of perforation.

METHODS

We used a standardized technique of polypectomy, using endoscopic looping to resect large colonic lipomas in 8 patients and followed their clinical outcomes.

RESULTS

The mean lipoma size was 3.8+/-1.2 cm (range 2.5-6 cm). No patient developed bleeding or perforation. On follow-up (mean=13.5 months, range 2-29), there was one small residual lesion.

CONCLUSION

Colonic lipomas larger than 2 cm can be safely and efficaciously removed using endoloop assisted polypectomy technique.

BACKGROUND

We hypothesized that laparoscopic adjustable gastric banding (LAGB) reduces weight and modulates ghrelin production, but largely spares gastrointestinal endocrine function. To examine this hypothesis, we determined plasma concentrations of appetite-control, insulinotropic, and digestive hormones in relation to LAGB.

METHODS

Twenty-four patients undergoing LAGB were prospectively enrolled. Body mass index (BMI) was measured and blood samples obtained at baseline and 6 and 12 months post-surgery. Plasma concentrations of leptin, acylated and total ghrelin, pancreatic polypeptide (PP), insulin, glucose-dependent insulinotropic peptide (GIP), active glucagon-like peptide-1 (GLP-1), gastrin, and pepsinogens I and II were measured using enzyme-linked immunoassays.

RESULTS

Median percent excess weight loss (%EWL) over 12 months was 45.7% with median BMI decreasing from 43.2 at baseline to 33.8 at 12 months post-surgery (p < 0.001). Median leptin levels decreased from 19.7 ng/ml at baseline to 6.9 ng/ml at 12 months post-surgery (p < 0.001). In contrast, plasma levels of acylated and total ghrelin, PP, insulin, GIP, GLP-1, gastrin, and pepsinogen I did not change in relation to surgery (p > 0.05). Pepsinogen II levels were significantly lower 6 months after LAGB but returned to baseline levels by 12 months.

CONCLUSIONS

LAGB yielded substantial %EWL and a proportional decrease in plasma leptin. Our results support the hypothesis that LAGB works in part by suppressing the rise in ghrelin that normally accompanies weight loss. Unchanged concentrations of insulinotropic and digestive hormones suggest that gastrointestinal endocrine function is largely maintained in the long term.