Unsedated endoscopy.

To the Editor: The editorial remark and article regarding "Unsedated Endoscopy" were interesting and well-written. (1, 2) It should be noted that the authors do not describe the diameter of the endoscope used. I would agree with the premise that unsedated standard endoscopy could be a problem. The recruiting methods may have shown some bias on the part of the researchers, especially in the section dealing with recruiting of health care professionals.

In an attempt to evaluate office endoscopy, the Ultraslim instruments have been used. No sedation was used in 63 patients. No sedation was selected by the patients based on factors including not having a responsible individual to drive them home, fear of analgesia or sedation, or previous endoscopic experience with sedation. All 65 completed the procedure. The average time of the procedure was 10 minutes. Forty-two patients had previously undergone sedation endoscopy. Of these, 39 preferred no sedation, and the remaining three agreed that they would, if necessary, undergo endoscopy without sedation. Twenty-one patients had no experience with sedation and were satisfied with the procedure. Only one patient stated that if they were to have the procedure repeated, they would prefer sedation.

Many factors influence the ability to perform unsedated procedures. In this study, the same nurse and physician completed all procedures. Ample time was given to each patient to ask questions, and it was suggested before the procedure that the patients would experience no pain, no discomfort, and at all times a physician and nurse would be readily available to them to assist in their breathing and to help with cooperation. The rooms were kept lit, and no attempt was made to darken the room for the procedures. The pharynx was sprayed and a bite block was used. No attempt was made to do these through the transnasal approach. The peroral intubation to the stomach was completed in all cases.

Although standard endoscopes and sedation are the norm, consideration should be given to peroral unsedated endoscopy with the Ultraslim endoscopes. The average savings based on cost at outpatient facilities in metropolitan areas amount to $1,200.00 per procedure by eliminating the facility fees. The professional fees remained the same. The immediate return to work is not a calculable economic savings. Although this procedure may not be the procedure for all patients, it is certainly something that should be given consideration, and experienced endoscopists can certainly perform this procedure well.

References

1. Madan A, Minocha A. Who is willing to undergo endoscopy without sedation? Patient, nurses, or the physicians? South Med J 2004;97:800-805.

2. Leo R. Unsedated endoscopy: You don't get a medal for it. South Med J 2004;97:797-798.

John J. O'Connor, MD, FACS 

Surgical Endoscopy

Rockville Ambulatory Surgery Center 

Rockville, MD