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The HRM report was annotated for the use of the sedation. Procedural parameter The anethesia time tracking in the electronic medical record was used to document the duration of the procedure.
The duration of the endscopy, recovery and the manometry were noted to calculate the total procedure duration. Significant events like hypoxia, hypotension or arrythmia, if any, were also reviewed and recorded from the anesthesia notes.
These findings are essential to evaluate for the safety of the procedure. All the procedures were performed by a gastroenterologist. All of these 14 patients underwent esophageal HRM catheter insertion under sedation.
In two patients, the catheter could be negotiated with sedation only and 12 required the endoscopic assistance for catheter insertion.
The mean age of study group was Details are presented in Table 1. Table 1. Patients with elevated IRP with aperistalsis were diagnosed with type I achalasia; elevated IRP with isobaric pan-esophageal pressurization were diagnosed with type II achalasia; elevated IRP with simultaneous esophageal contractions were diagnosed with type III achalasia.
Most patients who underwent an esophagogram had an abnormality reported especially in patients who were later diagnosed as having achalasia Table 2.
Table 2. In the absence of studies exploring the sedation effect on key manometry parameters like IRP, it is not known how to interpret the esophageal manometry studies done under sedation. As discussed later, few studies have shown increase in lower esophageal residual pressure after use of midazolam or opiates. Lower esophageal residual pressure essentially means IRP; hence these studies with midazolam and opiates suggest increase in IRP.
However, the effect of propofol on IRP has not been studied. The two studies which came close to study this effect analyzed the effect of propofol sedation on LES pressure but not the LES relaxation which is the key factor determining IRP. Moreover, results from these two studies about effect on LES pressure are conflicting. If the results of these studies are to be extrapolated to interpret the effect of sedation on IRP, it remains undetermined whether IRP will increase or decrease after sedation.
In four patients with ineffective esophageal motility cases and 13 and three patients with normal motility study cases 7, 11 and 14 , adjustment in IRP did not make any change in the final diagnosis. Out of two patients with EGJ obstruction cases 9 and 10 , one retained the diagnosis case 10 despite the IRP adjustment but the other patient case 9 with pre-adjustment IRP 20 had a change in diagnosis, though it did not change the management. Figure 2. Computed tomography CT scan showing a dilatated and tortuous esophagus, presence of food residue, smooth-tapered appearance bird beak sign of the esophagogastric junction EGJ and loss of gastric air bubble characteristic of achalasia.
One of these patients underwent balloon dilation but the other patient refused balloon dilation as well, and hence was managed with calcium channel blockers. These findings are tabulated in Table 3. Table 3. Patient declined the referral for per-oral endoscopic myotomy POEM.
The patient with the EGJ obstruction had observant management. Patients with the pre-fundoplication motility assessment were awaiting the procedures. There was one patient with the distal esophagectomy who underwent dilatation of the esophago-gastric anastomosis 2 weeks after the motility study. On an average, the entire procedure required 70 min with majority of the time 28 min spent in post-sedation recovery. The details are presented in Table 4. These findings are presented for the time estimation and endoscopy slot planning.
Duration of Manometry Catheter Calibration, Endoscopy, Post-Sedation Recovery, Manometry Acquisition and Total Procedure Duration All patients received intravenous sedation with propofol, while 13 of 14 patients received lidocaine as well. At discretion of the anesthesiologist, some patients also received metoprolol, fentanyl and midazolam Table 5. In two patients that received fentanyl, we re-evaluated manometry findings and found no abnormalities.
Table 5. Physicians should have a thorough insight in need for sedation and endoscopy for the HRM. The suggested indications for sedation use, as in our study, are nasopharyngeal intolerance, excessive pharyngeal gagging, lower esophageal coiling and inability to pass through the EGJ or LES.
The catheter placement can be attempted with minimal sedation in the patient with the nasopharyngeal intolerance or gagging. The lower doses of propofol have been shown to minimally affect the LES in young individuals [ 12 ]. This initial attempt with minimal sedation, if successful, may mitigate sedation effect on key motility findings.
Subsequently, endoscopy-assisted catheter placement can be performed if the initial attempts with minimal sedation are unsuccessful. Patients with moderate to large hiatal hernia or prior lower esophageal surgery, where chances of manometry catheter getting coiled in lower esophagus are higher, can proceed with endoscopic assistance as the initial step.
One should have a clear understanding of the hierarchal steps involved in assessing an esophageal motility disorder.
The evaluation of the LES obstructive pathology remains the key initial step in the overall evaluation [ 1 ]. Turan et al reported the effect of the propofol on LES pressure. Their study intended to review the effect of sedation on LES tone and imply the outcomes towards the gastric content aspiration during the anesthesia. The manometry was performed with the four-sensor manometry catheter with the identification of the LES with the pull through technique [ 14 ]. This certainly has limitation in implementing the results from this study to now prevalent technology of the HRM.
Leon et al, while studying clinical implication of sedation on esophageal manometry [ 12 ], reported findings that were different from Turan et al. Their study revealed that the effect of propofol on LES was more pronounced in the young as compared to the old.
The manometry evaluation was performed with the sensor high-resolution solid-state manometry catheter Sierra Scientific Instruments Inc. The presentation of the post-deglutitive relaxation of the LES would have been really interesting.
Hence exploring the impact of propofol on IRP would be the most important step in determining the reliability of HRM conducted with sedation assistance.
To the best of our knowledge, there have been no clear published data or consensus studying the impact of the propofol on IRP. However, some experts do opine about possible inflation in IRP after sedation. Histoplasmosis is most common in the Mississippi River basin , and coccidioidomycosis is most common in the Southwestern United States. They include diffuse alveolar damage , organizing pneumonia , nonspecific interstitial pneumonia , lymphocytic interstitial pneumonia , desquamative interstitial pneumonia , respiratory bronchiolitis interstitial lung disease , and usual interstitial pneumonia.
The alveolus on the left is normal, whereas the one on the right is full of fluid from pneumonia.
Pneumonia frequently starts as an upper respiratory tract infection that moves into the lower respiratory tract. In the lower airways, reflexes of the glottis , actions of complement proteins and immunoglobulins are important for protection.
Micro aspiration of contaminated secretions can infect the lower airways and cause pneumonia. The virulence of the organism, amount of the organisms to start an infection and body immune response against the infection all determines the progress of pneumonia.
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