Clinical Endoscopy

Review

Remimazolam, a novel drug, for safe and effective endoscopic sedation: Jae Min Lee, Yehyun Park, Dong Won Ahn, Jun Kyu Lee, Kwang Hyuck Lee; Received February 7, 2024 Accepted May 8, 2024 Published online January 14, 2025; DOI: https://doi.org/10.5946/ce.2024.026 [Epub ahead of print]

Abstract PDF PubReader ePub: Remimazolam is a novel benzodiazepine with unique pharmacokinetic and pharmacodynamic properties, making it an ideal candidate for sedation during endoscopic procedures. Distinguished by its rapid onset and short duration of action, remimazolam offers a safer and more efficient alternative to traditional sedatives, such as midazolam and propofol, with fewer side effects, such as hypotension, bradycardia, and respiratory depression. This article reviews the characteristics of remimazolam and its practical advantages, including ease of use, quick recovery time, and minimal residual sedation, emphasizing its potential to improve patient safety and procedural efficiency in clinical endoscopy settings.

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Original Article

Medical disputes related to advanced endoscopic procedures with endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography for the management of pancreas and biliary tract diseases: Yoon Suk Lee, Jae-Young Jang, Jun Yong Bae, Eun Hye Oh, Yehyun Park, Yong Hwan Kwon, Jeong Eun Shin, Jun Kyu Lee, Tae Hee Lee, Chang Nyol Paik; Clin Endosc 2023;56(4):499-509. Published online March 28, 2023; DOI: https://doi.org/10.5946/ce.2022.208

Graphical Abstract Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: This study aimed to evaluate the characteristics of endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography (EUS)-related adverse events (AEs) that eventually lead to medical disputes or claims on medical professional liability.
Methods
Medical disputes for ERCP/EUS-related AEs filed in the Korea Medical Dispute Mediation and Arbitration Agency between April 2012 and August 2020 were evaluated using corresponding medical records. AEs were categorized into three sections: procedure-related, sedation-related, and safety-related AEs.
Results
Among a total of 34 cases, procedure-related AEs were 26 (76.5%; 12 duodenal perforations, 7 post-ERCP pancreatitis, 5 bleedings, 2 perforations combined with post-ERCP pancreatitis); sedation-related AEs were 5 (14.7%; 4 cardiac arrests, 1 desaturation), and safety-related AEs were 5 (8.8%; 1 follow-up loss for stent removal, 1 asphyxia, 1 fall). Regarding clinical outcomes, 20 (58.8%) were fatal and eventually succumbed to AEs. For the types of medical institutions, 21 cases (61.8%) occurred at tertiary or academic hospitals, and 13 (38.2%) occurred at community hospitals.
Conclusions
The ERCP/EUS-related AEs filed in Korea Medical Dispute Mediation and Arbitration Agency showed distinct features: duodenal perforation was the most frequent AE, and clinical outcomes were fatal, resulting in at least more than permanent physical impairment.

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Diagnostic Assessment of Endoscopic Ultrasonography–Fine Needle Aspiration Cytology in the Pancreas: A Comparison between Liquid-Based Preparation and Conventional Smear
Jung-Soo Pyo, Dae Hyun Lim, Kyueng-Whan Min, Nae Yu Kim, Il Hwan Oh, Byoung Kwan Son
Medicina.2024; 60(6): 930. CrossRef

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Reviews

New sedatives and analgesic drugs for gastrointestinal endoscopic procedures: Jae Min Lee, Yehyun Park, Jin Myung Park, Hong Jun Park, Jun Yong Bae, Seung Young Seo, Jee Hyun Lee, Hyung Ku Chon, Jun-Won Chung, Hyun Ho Choi, Jun Kyu Lee, Byung-Wook Kim, Endoscopic Sedation Committee of the Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(5):581-587. Published online August 29, 2022; DOI: https://doi.org/10.5946/ce.2021.283

Abstract PDF PubReader ePub

Procedural sedation has become increasingly common in endoscopy. Sedatives and analgesics induce anxiolysis and amnesia. In addition, an appropriate level of sedation is necessary for safe procedures including therapeutic endoscopy. Midazolam and propofol are the most commonly used drugs in sedative endoscopy. In recent years, the need to ascertain the safety and effectiveness of sedation has increased in practice. Therefore, new sedatives and analgesic drugs for optimal sedative endoscopy, have recently emerged. This article reviews the characteristics of sedatives and analgesics, and describes their clinical use in gastrointestinal endoscopy.

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2021 Korean Society of Gastrointestinal Endoscopy Clinical Practice Guidelines for Endoscopic Sedation: Hong Jun Park, Byung-Wook Kim, Jun Kyu Lee, Yehyun Park, Jin Myung Park, Jun Yong Bae, Seung Young Seo, Jae Min Lee, Jee Hyun Lee, Hyung Ku Chon, Jun-Won Chung, Hyun Ho Choi, Myung Ha Kim, Dong Ah Park, Jae Hung Jung, Joo Young Cho, Endoscopic Sedation Committee of Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(2):167-182. Published online February 22, 2022; DOI: https://doi.org/10.5946/ce.2021.282

Abstract PDF Supplementary Material PubReader ePub

Sedation can resolve anxiety and fear in patients undergoing endoscopy. The use of sedatives has increased in Korea. Appropriate sedation is a state in which the patient feels subjectively comfortable while maintaining the airway reflex for stable spontaneous breathing. The patient should maintain a state of consciousness to the extent that he or she can cooperate with the needs of the medical staff. Despite its benefits, endoscopic sedation has been associated with cardiopulmonary complications. Cardiopulmonary complications are usually temporary. Most patients recover without sequelae. However, they may progress to serious complications, such as cardiovascular collapse. Therefore, it is essential to screen high-risk patients before sedation and reduce complications by meticulous monitoring. Additionally, physicians should be familiar with the management of emergencies. The first Korean clinical practice guideline for endoscopic sedation was developed based on previous worldwide guidelines for endoscopic sedation using an adaptation process. The guideline consists of nine recommendations based on a critical review of currently available data and expert consensus when the guideline was drafted. These guidelines should provide clinicians, nurses, medical school students, and policy makers with information on how to perform endoscopic sedation with minimal risk.

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Original Article

Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam: Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang, the Committees of Quality Management and Conscious Sedation of Korean Society of Gastrointestinal Endoscopy; Clin Endosc 2022;55(2):234-239. Published online October 12, 2021; DOI: https://doi.org/10.5946/ce.2021.126

Abstract PDF PubReader ePub

Background
/Aims: The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions.
Methods
This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction.
Results
A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups.
Conclusions
Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.

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Review

Clinical Practice Guidelines for the Endoscopic Management of Peripancreatic Fluid Collections: Chi Hyuk Oh, Jun Kyu Lee, Tae Jun Song, Jin-Seok Park, Jae Min Lee, Jun Hyuk Son, Dong Kee Jang, Miyoung Choi, Jeong-Sik Byeon, In Seok Lee, Soo Teik Lee, Ho Soon Choi, Ho Gak Kim, Hoon Jai Chun, Chan Guk Park, Joo Young Cho; Clin Endosc 2021;54(4):505-521. Published online July 27, 2021; DOI: https://doi.org/10.5946/ce.2021.185

Abstract PDF PubReader ePub

Endoscopic ultrasonography-guided intervention has gradually become a standard treatment for peripancreatic fluid collections (PFCs). However, it is difficult to popularize the procedure in Korea because of restrictions on insurance claims regarding the use of endoscopic accessories, as well as the lack of standardized Korean clinical practice guidelines. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to develope medical guidelines by referring to the manual for clinical practice guidelines development prepared by the National Evidence-Based Healthcare Collaborating Agency. Previous studies on PFCs were searched, and certain studies were selected with the help of experts. Then, a set of key questions was selected, and treatment guidelines were systematically reviewed. Answers to these questions and recommendations were selected via peer review. This guideline discusses endoscopic management of PFCs and makes recommendations on Indications for the procedure, pre-procedural preparations, optimal approach for drainage, procedural considerations (e.g., types of stent, advantages and disadvantages of plastic and metal stents, and accessories), adverse events of endoscopic intervention, and procedural quality issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This will be revised as necessary to address advances and changes in technology and evidence obtained in clinical practice and future studies.

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Original Article

A Nationwide Survey on the Facilities and Personnel for Endoscopic Sedation: Results from 50 Qualified Endoscopy Units of Teaching Hospitals Accredited by the Korean Society of Gastrointestinal Endoscopy (KSGE): Seon-Young Park, Jun Kyu Lee, Jung-Wook Kim, Tae Hee Lee, Chang-Hwan Park, Jae-Yong Jang, Byung-Wook Kim, Byung Ik Jang, the Quality management and Endoscopic sedation committee of Korean Society of Gastrointestinal Endoscopy (KSGE); Clin Endosc 2021;54(6):843-850. Published online July 14, 2021; DOI: https://doi.org/10.5946/ce.2021.014

Abstract PDF Supplementary Material PubReader ePub

Background
/Aims: This study aimed to determine the current status of facilities, equipment, and personnel for endoscopic sedation from endoscopy units of representative hospitals in South Korea.
Methods
A questionnaire survey was conducted on 50 qualified endoscopy units accredited by the Korean Society of Gastrointestinal Endoscopy.
Results
All included endoscopy units had regulations and educational programs regarding sedation training for endoscopists and nursing personnel. There present one assisting nurse during endoscopy in 35 units (70%) and at least two nurses in 12 units (24.0%). All endoscopy units had examination rooms equipped with oxygen supply and suction systems. Endoscopist-directed sedation was performed in 48 units (96.0%). Propofol-based sedation was the most used sedation method. All units had a separate recovery bay. The daily number of patients per bed was greater than 10 in 17 units (34.0%). In 26 (52.0%) units, a single nurse cared for ≥10 patients per day. All the units fulfilled the discharge criteria.
Conclusions
This study presents data regarding endoscopic sedation clinical practice in 50 endoscopy units in South Korea. This study presents the current status of endoscopic sedation clinical practice in 50 qualified endoscopy units accredited by the KSGE, which provide excellent quality management.

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Feyza SEVER, Şamil HIZLI
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Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
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Review

Clinical and Technical Guideline for Endoscopic Ultrasound (EUS)-Guided Tissue Acquisition of Pancreatic Solid Tumor: Korean Society of Gastrointestinal Endoscopy (KSGE): Moon Jae Chung, Se Woo Park, Seong-Hun Kim, Chang Min Cho, Jun-Ho Choi, Eun Kwang Choi, Tae Hoon Lee, Eunae Cho, Jun Kyu Lee, Tae Jun Song, Jae Min Lee, Jun Hyuk Son, Jin Suk Park, Chi Hyuk Oh, Dong-Ah Park, Jeong-Sik Byeon, Soo Teik Lee, Ho Gak Kim, Hoon Jai Chun, Ho Soon Choi, Chan Guk Park, Joo Young Cho; Clin Endosc 2021;54(2):161-181. Published online March 24, 2021; DOI: https://doi.org/10.5946/ce.2021.069

Abstract PDF PubReader ePub

Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a Task Force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in 8 categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice.

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Kentaro SUDO, Emiri KITA, Akiko TSUJIMOTO, Kazuyoshi NAKAMURA, Akiko ODAKA, Makiko ITAMI, Sana YOKOI, Hiroshi ISHII
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Original Article

Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea: Gwan Woo Hong, Jun Kyu Lee, Jung Hyeon Lee, Ji Hun Bong, Sung Hun Choi, Hyeki Cho, Ji Hyung Nam, Dong Kee Jang, Hyoun Woo Kang, Jae Hak Kim, Yun Jeong Lim, Moon Soo Koh, Jin Ho Lee; Clin Endosc 2020;53(5):562-567. Published online July 3, 2020; DOI: https://doi.org/10.5946/ce.2020.022

Abstract PDF PubReader ePub

Background
/Aims: Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy.
Methods
A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes.
Results
A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups.
Conclusions
The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.

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Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam
Ji Hyung Nam, Dong Kee Jang, Jun Kyu Lee, Hyoun Woo Kang, Byung-Wook Kim, Byung Ik Jang
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Naixing Xin, Wei Yan, Shuangfen Jin, Min Tang
BioMed Research International.2022;[Epub] CrossRef
Endoscopist-Driven Sedation Practices in South Korea: Re-evaluation Considering the Nationwide Survey in 2019
Seon-Young Park, Jun Kyu Lee, Chang-Hwan Park, Byung-Wook Kim, Chang Kyun Lee, Hong Jun Park, Byung Ik Jang, Dong Uk Kim, Jin Myung Park, Jae Min Lee, Young Sin Cho, Hyung Ku Chon, Seung Young Seo, Woo Hyun Paik
Gut and Liver.2022; 16(6): 899. CrossRef
Drugs used for sedation in gastrointestinal endoscopy
Jun Kyu Lee
Journal of the Korean Medical Association.2022; 65(11): 735. CrossRef
Risk Factors for Prolonged Hospital Stay after Endoscopy
Toshihiro Nishizawa, Shuntaro Yoshida, Osamu Toyoshima, Tatsuya Matsuno, Masataka Irokawa, Toru Arano, Hirotoshi Ebinuma, Hidekazu Suzuki, Takanori Kanai, Kazuhiko Koike
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Special Review: Korean Society of Gastrointestinal Endoscopy “Accreditation of Qualified Endoscopy Unit” Guideline: Update 2019

Updates on the Sedation for Gastrointestinal Endoscopy: Jun Kyu Lee, Yoo Jin Lee, Jun Hyung Cho, Jong Pil Im, Chang-Hwan Park, Jae-Young Jang, Byung Ik Jang, the Quality Management Committee and the Disinfection Management/Conscious Sedation Committee of Korean Society of Gastrointestinal Endoscopy (KSGE); Clin Endosc 2019;52(5):451-457. Published online September 30, 2019; DOI: https://doi.org/10.5946/ce.2019.172

Abstract PDF Supplementary Material PubReader ePub

Sedation, defined as the depressed level of consciousness, induced by drug administration, is widely used for gastrointestinal endoscopy to relieve a patient’s anxiety and discomfort. In addition, successful procedure is anticipated with control of unintended movements. Endoscopic sedation, however, cannot be free from the risk of serious adverse events, e.g., cardiopulmonary compromise. Therefore, principles on personnel, facility and equipment, as well as performance itself, should be followed to prevent unfavorable incidents. In this article, sedation guidelines for the Accreditation of Qualified Endoscopy Units, issued by the Korean Society of Gastrointestinal Endoscopy, are presented.

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Drugs used for sedation in gastrointestinal endoscopy
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6,739 View
242 Download
9 Web of Science
8 Crossref

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