Foreword

Sedation has been essential for endoscopy. In 1955, when gastrointestinal endoscopy was in its infancy, Frank Sinatra introduced a song called “Love and Marriage.” The opening lyrics stated, “Love and marriage go together like a horse and carriage,” perhaps alluding to the classic nature of the relationship. Further along, the song adds, “Dad was told by mother, you can't have one without the other.” Now, without going further down this slippery slope, I think it is fair to say that love and marriage have endured during the half century since the song was introduced, but it is also clear that the concept of the association has evolved considerably.

Endoscopic sedation is in a similar period of flux. Several forces have combined to roil what seemed a serene atmosphere. These forces may not represent a “perfect storm,” but conflicting forces and agendas have created an unsettled feeling in the relationship. The number of upper and lower gastrointestinal endoscopies being performed continues to increase. Although there is good evidence that some endoscopic procedures can be done without sedation, most cases are best done utilizing it. The key to sedation is safety, and this consideration trumps all others. Added to the consideration of safety, however, are patient demand for comfort, the need for detailed monitoring and for documentation during sedation, and the issues of quality, cost, and efficiency. A recent huge change has been the introduction of the anesthetic agent propofol and the increasing utilization of anesthesiologists to administer the drug for endoscopic sedation. This approach can work, but costs are substantial, and insurers are beginning to resist.

In this situation, gastrointestinal endoscopists can feel as if they are in a small boat on the open ocean with storm clouds on the horizon. The best defense probably is to be fully informed and to understand the state of the art of endoscopic sedation as it exists today. Different gastroenterology practices—office-, hospital-, ambulatory center-, and pediatric-based—have differing priorities and concerns when it comes to sedation. When I saw the program for the course “Endoscopic Sedation: Preparing for the Future” held in New York last November, I thought the program could be the basis for an issue of the Gastrointestinal Endoscopy Clinics of North America that could present all the aspects in depth. The Course Directors, Drs. Lawrence B. Cohen and James Aisenberg, have done ground-breaking clinical research in endoscopic sedation and were the perfect choice to be the Guest Editors for this issue. If you agree that in most cases endoscopy and sedation go together, you and your staff must read this issue of the Clinics. For endoscopic sedation, it will help you to navigate through the crashing waves of changing times.