Does General Anesthesia Increase the Diagnostic Yield of Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Masses?

Abstract

F or patients with pancreatic cancer, early diagnosis may improve the outcome and survival. Endoscopic ultrasoundguided fine-needle aspiration (EUS-FNA) is one of various ways to obtain tissue. It has become the preferred method because of its safety, minimal invasiveness, and good yield (71%Y100%). Although diagnostic yield may be affected by endoscopist experience, type of needle, and use of an in-room cytopathologist, the impact of sedation technique on diagnostic yield is unknown. This retrospective cohort study was undertaken to assess the yield of EUS-FNA when patients are under general anesthesia (GA) as compared with receiving conscious sedation (CS), based on the hypothesis that GA would improve diagnostic yield by improving patient cooperation and stillness during the procedure.Patients underwent CS by a registered nurse who provided intermittent administration of 0.5 to 2 mg midazolam and an opioid (either 20Y50 mg meperidine or 25Y50 Kg fentanyl) injection every 5 to 15 minutes as needed. With the GA approach, an anesthesiologist delivered GA with or without intubation. Without intubation, propofol at 1 mg/kg and alfentanil (5.0 Kg/kg) loading dose were administered followed by a propofol infusion mixed with alfentanil. If endotracheal intubation was used, propofol 1.5 to 2.0 mg/kg and fentanyl 100 Kg intravenous induction doses were given for intubation, and then the patient was maintained with sevoflurane inhalation. Clinical variables were obtained from hospital records, endoscopy reports, and anesthesiology records and included the number of needle passes, size of needle, experience level of the endosonographer, location and size of the pancreatic mass, cytologic results, and procedural complications. The cytology diagnosis was classified as either unsatisfactory specimen, negative for malignancy, atypical or indeterminate, suggestive of malignancy, and positive for malignancy. The diagnostic yield was defined as the proportion of patients who had successful EUS-FNA. General anesthesia and CS groups were compared for complications during and after the EUS-FNA procedure by the Fisher exact test.The study included 371 patients; 283 received CS, and 88 received GA (5 with planned intubation and 83 without intubation). A successful diagnosis was obtained in 73 patients (83%) in the GA group and 206 patients (73%) in the CS group. All instances of failure were the result of an inadequate specimen. The

Guidelines for sedation and anesthesia in GI endoscopy

“…Studies have demonstrated that anesthesia provideradministered sedation for EUS-guided FNA of pancreatic masses and overtube-assisted enteroscopy is associated with improved outcomes. 68,69 Anesthesia provider-administered sedation is advantageous during ERCP, which often involves placing a patient in a prone position. The prone position may be associated with altered cardiovascular and pulmonary physiology and may involve limited airway access.…”

Modeling Respiratory Depression Induced by Remifentanil and Propofol during Sedation and Analgesia Using a Continuous Noninvasive Measurement of pCO2

“…Combining sedation and analgesia provides optimal conditions for endoscopic diagnosis and intervention, and better success rates (Ootaki et al, 2012). Anesthesiologists must administer hypnotic and/or analgesic drugs, observe the effect induced, evaluate possible unwanted side effects, take action if required, and adjust dosing to the individual's response.…”

Evaluation of Pancreatic Lesions With Endoscopic Ultrasound and Fine Needle Aspiration

“…From the literature, other factors that may influence the diagnostic yield include the mode of anaesthesia, 27 experience of the endoscopist, 16 and specimen preparation for cytopathologic interpretation. 28…”