Background Structural disorders of the hypopharynx can lead to dysphagia‐related morbidity. Endoscopic therapy in this area, for example, myotomy for Zenker's diverticulum (ZD), has traditionally been performed under general anesthesia (GA). We have developed a two‐stage sedation process, which is used along with high‐flow nasal oxygen therapy (HFNOT) to facilitate endoscopic hypopharyngeal procedures. Methods In this prospective, single‐center study, patients undergoing endoscopic procedures between June 2016 and March 2018 were included. All endoscopies were performed with propofol and/or remifentanil and supported with HFNOT. In patients with ZD, the diverticulum and stomach were cleared of debris under conscious sedation to reduce the risk of aspiration, before sedation was deepened to facilitate myotomy. Sedation‐related adverse events were recorded. Results A total of 50 patients were included for analysis (mean age of 71.1, range 31–93; 58% male); 48% were categorized as American Society of Anesthesiologists (ASA) Grade III and 6% as Grade IV. The median procedure time was 20 min. Of patients, 83% were sedated with both propofol and remifentanil using a target‐controlled infusion under specialist anesthetic supervision. Sedation‐related adverse events included transient hypotension (38%), bradycardia (8%), and hypoxia (8%). No procedures were abandoned due to complications, and no patients required conversion to GA. Patients achieved full postprocedure recovery from sedation after a median duration of 5 min. Conclusions HFNOT is a useful adjunct to two‐stage sedation, which can enable high‐risk patients to safely undergo deep sedation during hypopharyngeal endoscopic procedures.

Background Constrictive pericarditis is a challenging diagnosis that is easily overlooked. Worldwide, tuberculosis (TB) is the leading cause; however, in the developed countries pericarditis and cardiac surgery are common aetiologies. Medical therapy can be sufficient in specific aetiologies preventing progression of constriction and thus surgery. Case summary A young student from Nigeria, with established sickle cell disease, presented with hepatomegaly and features of right heart failure. Following multiple investigations for hepatomegaly and pyrexia of unknown origin he was initially treated for hepatic sequestration crisis. After readmission with ongoing pyrexia, he was noted to have features of constrictive physiology on cardiac imaging. Constrictive pericarditis, secondary to TB, was suspected based on the patient’s background and clinical features. He was empirically commenced on anti-TB therapy after a positive interferon-gamma release assay test; Mycobacterium tuberculosis was later isolated in sputum cultures. He made a successful recovery with full radiological resolution of constrictive features on follow-up cardiac imaging. Discussion Constrictive pericarditis remains an elusive diagnosis in the context of coexisting medical problems. Revisiting the presentation and imaging helped in establishing the diagnosis. It is a potentially curable cause of diastolic heart failure with good outcomes if diagnosed and managed early. We were able to successfully manage the patient for TB constrictive pericarditis on medical therapy alone without surgical intervention.

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Background Pharyngeal conditions such as Zenker's Diverticulum (ZD) increase with age and may be amenable to endoscopic therapy. However, therapy is traditionally performed under general anaesthesia (GA) which requires ventilatory support and may preclude therapy in frailer patients. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a non-invasive nasal method of ventilation which obviates the need for tracheal intubation. However, evidence supporting the feasibility of THRIVE for in endoscopic procedures is lacking. This study aimed to assess the feasibility, efficacy and safety of THRIVE as an adjunct to deep sedation in endoscopic pharyngeal and upper oesophageal procedures. Methods In this prospective study, consecutive patients undergoing therapeutic endoscopy of the pharynx and upper oesophagus between June 2016 and March 2018 were included. All procedures were performed under deep sedation with propofol and/or remifentanil in endoscopy unit as a day case. For ZD, the pharyngeal pouch and the stomach were cleared of debris to reduce the risk of aspiration before sedation was up titrated to facilitate therapy. Sedation related adverse events and the total dose of sedative drugs used were recorded. Results A total of 50 patients were included for analysis, with a mean age of 71.1 (range 31-93) and male patients comprising 58%. 46% were categorized as ASA grades I-II, 48% Grade III and 6% as Grade IV. The median procedure time was 20 minutes. 83% of patients were sedated with both propofol (median dose 103 mg) and remifentanil (median dose 167 mcg) using a target controlled infusion under specialist anaesthetic supervision. THRIVE was commenced in all patients, with none requiring conversion to invasive ventilation. The commonest sedation related adverse event was transient hypotension (38%) followed by bradycardia (8%) and hypoxia (8%). No procedures were abandoned due to complications. Patients achieved full post-procedure recovery from sedation after a median of 5 minutes. Conclusions Deep sedation with THRIVE proved to be a useful and safe technique for advanced therapeutic upper GI endoscopy. The role of THRIVE may be generalisable to other invasive therapeutic modalities involving high-risk patients such as ERCP.