Introduction Endoscopic ultrasound (EUS) is a prolonged procedure using endoscopes nearly twice the diameter of a standard gastroscope and relies on a compliant still patient to obtain images and fine needle aspiration (FNA) samples. Propofol or anaesthetic delivered sedation is used to ensure procedure success and tolerability in many international centres with in-room cytology expertise to optimise the yield of FNA. This practice is potentially costly and labour intensive. We retrospectively and prospectively examined tolerability, completion and FNA accuracy in a recently expanded EUS centre in the UK using midazolam and fentanyl sedation only and no in room cytologist.
Methods Electronic array radial and linear ultrasound scopes with FNA procedures were available to our centre from July 2010. A cytology processing methodology was used with complete expulsion of FNA material into a “cytorich red” medium with no in room slide processing or viewing. A standard three FNA passes was used for pancreatic masses (20 ml suction) and lymph nodes (0–10 ml suction). Accuracy was calculated with follow-up of patients for >3 months for specimens. Also from this time analysis of sedation used, procedure success and any reversal agent/respiratory support required was documented. From 1 September 2011 patients undergoing EUS and gastroscopy examinations were invited to complete questionnaires to score pain during the procedure.
Results From 1 July 2010 until 31 December 2011 450 EUS procedures were performed. 11 were incomplete and all due to luminal stricture formation only. FNA was performed in 126 patients. Accuracy for all lesions was 84.9%, and for solid pancreatic tumours 82.4% (n=68). Midazolam use ranged from 0 to 10 mg (mean 3.44 median 4) and fentanyl use ranged from 0 to 200 μg (mean 67.9; median 50). No reversal agent was used and no patients required any assisted ventilation. Prospective recruitment from 1 September 2011 included 49 patients which participated for EUS. The mean procedure time was 19.5 min (range 8–35), mean pain score during the procedure was 2.26/10 (range 0–9 median 2), and the average dose of sedation was 3.45 mg midazolam and 72.8 μg fentanyl. During the same time period 75 consecutive patients undergoing gastroscopy participated. There was no difference in the average pain score during the procedure compared to EUS: mean=2.6/10 (t test p=0.36) (mean procedure time=6.7 min; sedation given in 14/75; mean=3.3 mg midazolam).
Conclusion Despite prolonged procedure duration and large scope diameter, EUS procedures are safely and well tolerated with midazolam and fentanyl sedation. A high FNA accuracy can be achieved without a cytologist present in the room.
Competing interests None declared.