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⁎3358 Warfarin and endoscopy, what does happen?
*3356 AN ENDOSCOPIC RESCUE FROM PERFORATION AFTER ENDOSCOPIC MUCOSAL RESECTION FOR EARLY GASTRIC CANCER. Hiroyuki Ono, Takuji Gotoda, Hitoshi Gene Kondo, Mitsuhiro Fujishiro, Takahiro Kozu, Takahiro Fujii, Hajime Yamaguchi, Daizo Saito, National Cancer Ctr Hosp, Tokyo, Japan. Background. Endoscopic mucosal resection (EMR) has been employed for treatment of early gastric cancer (EGC) in the world, and especially in Japan from the beginning of the 1980s. It has an advantage over surgical gastrectomy in patient’s quality of life. However, there is some possibility of complications, such as perforation of the gastric wall and active bleeding. Especially, up to now, a surgical operation has been required to treat perforation and it causes the deterioration of the patient’s QOL. In this study, we introduce how to manage and rescue the patients from perforation after EMR without surgical treatment from our experience. Methods. We had 618 patients with 780 cancers or severe dysplasias. They received EMR from October 1987 to August 1999 at the National Cancer Center Hospital, Tokyo, Japan. From 1994, we tried to suture the holes of the stomach using clips endoscopically, with insertion of a nasogastric tube for one day. Results. Perforation occurred in 44 patients (7%). In the early period from 1987 to 1993, all 4 patients with perforation underwent surgical treatment. Of the 40 patients with endoscopic sutures, 39 patients (97.5%) except for one patient, who had a perforation hole of more than 40 mm in size, succeeded in recovering without surgical treatment. Conclusions. Our data suggest that endoscopic suture using clips is a good procedure to rescue from perforation after EMR.
*3357 COMPLICATIONS OF DIAGNOSTIC AND THERAPEUTIC ERCP. Madhukar Kaw, Praveena Kaw, Med Coll of Ohio, Toledo, OH; Brooks & Kushman, Southfield, MI. Background: Studies suggest that therapeutic intervention during ERCP increases the procedure related complication rate. Aim: To report our experience with complication rate secondary to diagnostic and therapeutic ERCP at a tertiary care referral center. Methods: 1182 ERCP s were done between July 1995 and September 1999. Patients were divided into five groups: ERCP alone: n=387, ERCP and endoscopic sphincterotomy (ES): n=436, ERCP and sphincter of Oddi manometry (SOM): n=105, ERCP+ SOM+ ES: n=102, and needle knife sphincterotomy (NKS) ± ES: n=152. Complications were assessed using Cotton et al. criteria by review of hospital records and direct follow-up phone calls. Results: See table below. The total morbidity was 9.8%. Three of the 8 with retroperitoneal perforation required surgical management. No mortality was observed. Multifactor analysis revealed risk groups for pancreatitis to be obesity (16.8%) vs. nonobese (3.6%), pancreatic SOM (35.2%) vs. biliary SOM (12.5%), and common bile duct diameter: ≤ 5mm (18.7%), 6-9mm (5.3%), ≥ 10mm (1.7%). All except one perforation occurred in cases with duct diameter of ≤ 5mm. Conclusions: SOM especially pancreatic is associated with a significant risk of pancreatitis. NKS, although an effective biliary access technique in experienced hands, should be reserved only when therapeutic intervention is suspected. Procedure ERCP Only ERCP + ES ERCP + SOM ERCP+ SOM+ES NKS ± ES
Pancreatitis
Bleeding
Perforation
14 (3.6%) 19 (4.3%) 25 (23.8%) 27 (26.5%) 7 (4.6%)
0 9 (2.1%) 0 3 (2.9%) 4 (2.6%)
0 1 (0.2%) 0 2 (1.9%) 5 (3.3%)
*3358 WARFARIN AND ENDOSCOPY, WHAT DOES HAPPEN? Sarah L. Jowett, Irving Cobden, North Tyneside Gen Hosp, North Shields, United Kingdom. Background: It is rare (0.05-0.5%) for clinically significant gastrointestinal haemorrhage to occur as a result of a mucosal biopsy at endoscopy. There
AB70
GASTROINTESTINAL ENDOSCOPY
are no data on the risk of bleeding specifically in anticoagulated patients. However in a prospective audit1 the one death from haemorrhage (in 13,036 diagnostic procedures) occurred in a patient with abnormal clotting. Aims: This survey was undertaken to determine regional practice with regard to management of patients on warfarin who required endoscopy. Methods: 122 questionnaires were sent to endoscopists (physicians and surgeons) in 16 hospitals across the Northern Region of England. Results: We received 100 replies (83%): 66 from consultants, 26 from training grades. The average experience as an endoscopist was 13.5years. 77% of endoscopists routinely stopped warfarin before a procedure. Usually the warfarin was stopped 3 days prior to the procedure (range 2-7 days). When asked, “If a patient is on warfarin at the time of gastroscopy /colonoscopy and a mucosal biopsy is indicated… “, 49% stated they would never take a biopsy, 38% stated that they would, and for the remainder there were various provisos. In the experience of the endoscopists (totalling 1255 years!) 30% had never taken a biopsy from a patient on warfarin. Of those 70 endoscopists who had taken at least one biopsy from a warfarinised patient; 19% admitted it was non-intentional, and 34% stated it was not always intentional. 8 endoscopists were personally aware of complications occurring as a result of taking those biopsies. Rectal bleeding was the most common but unfortunately one patient had severe bleeding, admission to ITU and died, and another had a fatal upper GI bleed. It is not clear if these instances refer to the same patient. Conclusions: The risk anticoagulation poses to bleeding after endoscopic biopsy is not quantified. It is perhaps unsurprising therefore that practice is so diverse in the Northern Region of England. Most endoscopists aim to stop warfarin before a procedure, but the time off warfarin shows considerable variation. An almost equal division of opinion exists as to whether or not a biopsy should be taken if indicated when the patient is warfarinised. As at least one biopsy resulted in fatal bleeding, this survey emphasises the need for a review of practice and complications. Then a more informed risk-benefit assessment may be made as to whether or not biopsy is indicated. Reference: 1.Quine MA, Bell GD et al. Prospective audit of upper GI endoscopy in 2 regions of England: safety, staffing and sedation methods. Gut 1995; 36:462-467.
*3359 MORBIDITY RATE OF DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY AT A SINGLE ENDOSCOPY UNIT AND PATIENT’S PREFERENCE FOR SEDATION. Syed Z. Abbas, Campbell Di, D. K. George, John R. Lowes, Robin H. Teague, Gastrointestinal Unit, Torbay Hosp,, Torquay, United Kingdom. AIM: To prospectively study the immediate and 30 day morbidity for diagnostic esophago-gastro-duodenoscopy (EGD) performed in a single unit, and to assess the patient’s preference for sedation or pharyngeal anesthesia. PATIENTS AND METHODS: To date 409 patients (187 men, 222 women) have been studied in 2 months who had EGD performed by 10 endoscopists as a day-case for various diagnostic indications at Torbay Hospital, Torquay, UK. Clinical and endoscopic data were collected from the endoscopy and nursing records. 30 days after the EGD, 383 patients (93.6%) were contactable (telephone - 359; post - 24). RESULTS: Median age of patients was 61.5 years (range 13 - 94). 157/409 (52/187 men, 103/222 women) chose to have EGD under Midazolam sedation (mean dose 4.8 mgs ± 1.6). All had oxygen saturation monitored and 131 were given supplemental oxygen during EGD. One patient had EGD performed under general anesthesia. 252/409 chose xylocaine throat spray. All 409 patients went home the same day. 30 days later, 50/383 patients contacted (19 men, 31 women - χ2 = 1.3, p = NS) had noted a minor complication including sore throat (n = 28), abdominal pain / discomfort (n = 12), and nausea / vomiting (n = 4). 24/50 of them had EGD performed under sedation. 15 patients (3.9%) required a consultation with their primary care physician. No hospital visit / admission was required and no death occurred within 30 days. Significantly less number of patients contacted who had EGD performed unsedated (180/239), compared to those who had sedation (135/143), would prefer the same again if EGD was required in the future (χ2 = 26.5, p <0.001). 13/239 and 6/143 were uncertain. Significantly more women than men who had no sedation would prefer sedation if required EGD again (31/103 Vs 15/123; χ2 = 11.1, p = < 0.005). CONCLUSION: When performed in appropriate environment, diagnostic EGD is a safe procedure though carries a minor complication rate. Patient’s preference for sedation and sex difference did not effect morbidity rate. Although majority chose to have EGD performed unsedated, a significant number of patients, particularly women, would prefer sedation if EGD was required again.
VOLUME 51, NO. 4, PART 2, 2000
*3357 COMPLICATIONS OF DIAGNOSTIC AND THERAPEUTIC ERCP. Madhukar Kaw, Praveena Kaw, Med Coll of Ohio, Toledo, OH; Brooks & Kushman, Southfield, MI. Background: Studies suggest that therapeutic intervention during ERCP increases the procedure related complication rate. Aim: To report our experience with complication rate secondary to diagnostic and therapeutic ERCP at a tertiary care referral center. Methods: 1182 ERCP s were done between July 1995 and September 1999. Patients were divided into five groups: ERCP alone: n=387, ERCP and endoscopic sphincterotomy (ES): n=436, ERCP and sphincter of Oddi manometry (SOM): n=105, ERCP+ SOM+ ES: n=102, and needle knife sphincterotomy (NKS) ± ES: n=152. Complications were assessed using Cotton et al. criteria by review of hospital records and direct follow-up phone calls. Results: See table below. The total morbidity was 9.8%. Three of the 8 with retroperitoneal perforation required surgical management. No mortality was observed. Multifactor analysis revealed risk groups for pancreatitis to be obesity (16.8%) vs. nonobese (3.6%), pancreatic SOM (35.2%) vs. biliary SOM (12.5%), and common bile duct diameter: ≤ 5mm (18.7%), 6-9mm (5.3%), ≥ 10mm (1.7%). All except one perforation occurred in cases with duct diameter of ≤ 5mm. Conclusions: SOM especially pancreatic is associated with a significant risk of pancreatitis. NKS, although an effective biliary access technique in experienced hands, should be reserved only when therapeutic intervention is suspected. Procedure ERCP Only ERCP + ES ERCP + SOM ERCP+ SOM+ES NKS ± ES
Pancreatitis
Bleeding
Perforation
14 (3.6%) 19 (4.3%) 25 (23.8%) 27 (26.5%) 7 (4.6%)
0 9 (2.1%) 0 3 (2.9%) 4 (2.6%)
0 1 (0.2%) 0 2 (1.9%) 5 (3.3%)
*3358 WARFARIN AND ENDOSCOPY, WHAT DOES HAPPEN? Sarah L. Jowett, Irving Cobden, North Tyneside Gen Hosp, North Shields, United Kingdom. Background: It is rare (0.05-0.5%) for clinically significant gastrointestinal haemorrhage to occur as a result of a mucosal biopsy at endoscopy. There
AB70
GASTROINTESTINAL ENDOSCOPY
are no data on the risk of bleeding specifically in anticoagulated patients. However in a prospective audit1 the one death from haemorrhage (in 13,036 diagnostic procedures) occurred in a patient with abnormal clotting. Aims: This survey was undertaken to determine regional practice with regard to management of patients on warfarin who required endoscopy. Methods: 122 questionnaires were sent to endoscopists (physicians and surgeons) in 16 hospitals across the Northern Region of England. Results: We received 100 replies (83%): 66 from consultants, 26 from training grades. The average experience as an endoscopist was 13.5years. 77% of endoscopists routinely stopped warfarin before a procedure. Usually the warfarin was stopped 3 days prior to the procedure (range 2-7 days). When asked, “If a patient is on warfarin at the time of gastroscopy /colonoscopy and a mucosal biopsy is indicated… “, 49% stated they would never take a biopsy, 38% stated that they would, and for the remainder there were various provisos. In the experience of the endoscopists (totalling 1255 years!) 30% had never taken a biopsy from a patient on warfarin. Of those 70 endoscopists who had taken at least one biopsy from a warfarinised patient; 19% admitted it was non-intentional, and 34% stated it was not always intentional. 8 endoscopists were personally aware of complications occurring as a result of taking those biopsies. Rectal bleeding was the most common but unfortunately one patient had severe bleeding, admission to ITU and died, and another had a fatal upper GI bleed. It is not clear if these instances refer to the same patient. Conclusions: The risk anticoagulation poses to bleeding after endoscopic biopsy is not quantified. It is perhaps unsurprising therefore that practice is so diverse in the Northern Region of England. Most endoscopists aim to stop warfarin before a procedure, but the time off warfarin shows considerable variation. An almost equal division of opinion exists as to whether or not a biopsy should be taken if indicated when the patient is warfarinised. As at least one biopsy resulted in fatal bleeding, this survey emphasises the need for a review of practice and complications. Then a more informed risk-benefit assessment may be made as to whether or not biopsy is indicated. Reference: 1.Quine MA, Bell GD et al. Prospective audit of upper GI endoscopy in 2 regions of England: safety, staffing and sedation methods. Gut 1995; 36:462-467.
*3359 MORBIDITY RATE OF DIAGNOSTIC UPPER GASTROINTESTINAL ENDOSCOPY AT A SINGLE ENDOSCOPY UNIT AND PATIENT’S PREFERENCE FOR SEDATION. Syed Z. Abbas, Campbell Di, D. K. George, John R. Lowes, Robin H. Teague, Gastrointestinal Unit, Torbay Hosp,, Torquay, United Kingdom. AIM: To prospectively study the immediate and 30 day morbidity for diagnostic esophago-gastro-duodenoscopy (EGD) performed in a single unit, and to assess the patient’s preference for sedation or pharyngeal anesthesia. PATIENTS AND METHODS: To date 409 patients (187 men, 222 women) have been studied in 2 months who had EGD performed by 10 endoscopists as a day-case for various diagnostic indications at Torbay Hospital, Torquay, UK. Clinical and endoscopic data were collected from the endoscopy and nursing records. 30 days after the EGD, 383 patients (93.6%) were contactable (telephone - 359; post - 24). RESULTS: Median age of patients was 61.5 years (range 13 - 94). 157/409 (52/187 men, 103/222 women) chose to have EGD under Midazolam sedation (mean dose 4.8 mgs ± 1.6). All had oxygen saturation monitored and 131 were given supplemental oxygen during EGD. One patient had EGD performed under general anesthesia. 252/409 chose xylocaine throat spray. All 409 patients went home the same day. 30 days later, 50/383 patients contacted (19 men, 31 women - χ2 = 1.3, p = NS) had noted a minor complication including sore throat (n = 28), abdominal pain / discomfort (n = 12), and nausea / vomiting (n = 4). 24/50 of them had EGD performed under sedation. 15 patients (3.9%) required a consultation with their primary care physician. No hospital visit / admission was required and no death occurred within 30 days. Significantly less number of patients contacted who had EGD performed unsedated (180/239), compared to those who had sedation (135/143), would prefer the same again if EGD was required in the future (χ2 = 26.5, p <0.001). 13/239 and 6/143 were uncertain. Significantly more women than men who had no sedation would prefer sedation if required EGD again (31/103 Vs 15/123; χ2 = 11.1, p = < 0.005). CONCLUSION: When performed in appropriate environment, diagnostic EGD is a safe procedure though carries a minor complication rate. Patient’s preference for sedation and sex difference did not effect morbidity rate. Although majority chose to have EGD performed unsedated, a significant number of patients, particularly women, would prefer sedation if EGD was required again.
VOLUME 51, NO. 4, PART 2, 2000