Anesthesia for complex endoscopy: a new paradigm

Deep enteroscopy using overtube-assisted methods has been a major advance in endoscopy, allowing the inspection and treatment of small-bowel disorders [1] [2] [3]. Overtube-assisted endoscopy has also increased our ability to perform a myriad of other endoscopic interventions such as endoscopic retrograde cholangiopancreatography (ERCP), direct percutaneous jejunostomy, insertion of stents into previously unreachable areas of stenosis, and other extreme endoscopic interventions [4] [5] [6] [7] [8]. Traditionally, gastrointestinal (GI) endoscopy has been performed using conscious sedation. However, endoscopy has evolved into a broad-spectrum specialty, including standard diagnostic, low level therapeutic, and advanced interventional and therapeutic endoscopy. Whereas most cases of diagnostic and low level therapeutic interventions, such as colon polypectomy, esophageal dilation of simple strictures, and endoscopic mucosal resection, may be performed easily and safely using conscious sedation, the majority of advanced interventional and therapeutic interventions may need to be done with the patient under general anesthesia. Until now, the decision to use general anesthesia rested on individual preferences of the endoscopy team. There are scant data on the reasons and circumstances of when and how to use general anesthesia for advanced endoscopy procedures [9] [10].