Prediction of Poor Response to Modified Neuroleptanalgesia with Midazolam for Endoscopic Submucosal Dissection for Esophageal Squamous Cell Carcinoma

Abstract

Background/Aims: Modified neuroleptanalgesia (m-NLA) with midazolam is often used for sedation and analgesia during endoscopic submucosal dissection (ESD) for gastrointestinal neoplasia. However, interruption due to poor response to midazolam is often experienced during ESD for esophageal squamous cell carcinoma (ESCC) because most patients with ESCC have a history of heavy alcohol intake. We examined the incidence and risk factors for poor response to m-NLA with midazolam and pethidine hydrochloride. Methods: This retrospective cross-sectional study was conducted at a single institution. Between April 2007 and July 2013, 151 patients with superficial ESCC who underwent ESD under sedation using m-NLA with midazolam and pethidine hydrochloride were enrolled. Poor response to sedation was defined as the use of a second drug when Ramsay Sedation Score 1-2. Results: Poor response to sedation occurred in 66.2% patients. Most cases of poor response were controlled by using additional flunitrazepam. Multivariate logistic regression analysis showed that cumulative alcohol intake and major specimen size were independent risk factors for poor response to sedation (OR 3.63, 95% CI 1.20-10.99, and OR 3.23, 95% CI 1.26-8.25). Conclusion: Our study indicated that cumulative alcohol intake and major specimen size were associated with poor response to m-NLA with midazolam and pethidine hydrochloride.

Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection

“…Complete description of the ESD procedure has been reported . A bipolar needle knife (B knife; Xemex Co., Tokyo, Japan) and a monopolar needle knife (Flush knife, DK2618JN; Fujifilm Medical, Tokyo, Japan) were the main electrosurgical knives used.…”

Single Locoregional Triamcinolone Injection Immediately After Esophageal Endoscopic Submucosal Dissection Prevents Stricture Formation

“…Intravenous midazolam or propofol with pethidine hydrochloride was used to place patients under deep sedation during endoscopic procedures. 16 A single-channel upper gastrointestinal endoscope (GIF-Q260J; Olympus, Tokyo, Japan) and a standard electrosurgical generator (ICC 200 or VIO300D; ERBE Elektromedizin GmbH, Tübingen, Germany) were used. The main electrosurgical knives utilized were a bipolar needle knife (B knife; XEMEX, Tokyo, Japan) in the earlier study period and a monopolar needle knife (Flush knife, DK2618JN; Fujifilm Medical, Tokyo, Japan) in the later period.…”

Feasibility of the lidocaine injection method during esophageal endoscopic submucosal dissection

“…This suggests that the stimulation by ESD affects the mechanical receptors in the muscular layer and extends beyond the muscular layer because of a lack of esophageal serosa. Esophageal pain may not be completely controlled by intravenous analgesics alone considering that body movements occur even when using intravenous analgesics, such as pethidine and pentazocine, under sedation during esophageal ESD . Although there have been no studies evaluating pain during esophageal ESD, esophageal post‐ESD pain was reported in 38.5–58.9% of cases .…”

“…Endoscopic therapy for early esophageal cancer is becoming widely used as a minimally invasive treatment. In particular, endoscopic submucosal dissection (ESD) results in a high en bloc resection rate and accurate pathological diagnosis even for large esophageal cancer . However, a high degree of technical skill is required to perform esophageal ESD because the esophagus has a narrow lumen and a thin wall.…”