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Attitudes and Expectations of the 2006 Incoming GI Fellowship Class Towards Advanced Endoscopic Training (AET)
Abstracts
W1245 Attitudes and Expectations of the 2006 Incoming GI Fellowship Class Towards Advanced Endoscopic Training (AET) Michael J. Pollack, Linda C. Cummings, Tina Koral, John J. Vargo, Richard C. Wong, Gerard A. Isenberg, Ashley L. Faulx, Michael V. Sivak, Amitabh Chak Background: Rapid technological advancements in endoscopic procedures such as ERCP and EUS have transformed GI practice and training. However, training in these procedures is demanding, and fellowship opportunities are limited. This study aimed to assess attitudes and expectations of the 2006 incoming GI fellowship class towards AET. Methods: A 23 question survey assessing interest in AET was developed and tested on 20 GI fellows and internal medicine residents interested in GI at our institution. Ambiguous questions were modified and the survey was then administered at the ASGE-sponsored First Year Fellows’ Endoscopy Course, which was attended by 298 of 415 (72%) 1 st year fellows from accredited GI fellowship programs throughout the United States. Results: Responses were obtained from 252 (85%) of attendees. 183 (73%) expressed interest in AET, 50 (20%) were unsure, and 19 (8%) were not interested. Reasons for interest included ‘‘to be a complete gastroenterologist’’ (72%), marketability (51%), interest in pancreaticobiliary disease (54%), interest in technology (54%), and interest in endoscopic research (21%). Among those interested in AET, 138 (77%) desired both EUS and ERCP training, and 132 (73%) rated access to AET during a 3 year fellowship as important to their fellowship program choice; 114 (64%) and 124 (71%) were not sure of or underestimated the number of ERCPs and EUSs, respectively, required to meet competency guidelines; 62 (34%) and 75 (43%) were not sure how many ERCPs and EUSs, respectively, are performed at their institution annually. 119 (65%) of those interested do obtain some AET during their three year fellowship, yet 130 (72%) do not expect to be fully trained or are not sure. If not fully trained, 115 (64%) said they would then seek alternative ways to learn (e.g. weekend hands-on courses, videotapes, web-based learning) and eventually practice advanced endoscopic procedures. Conclusions: While interest in AET is high among 1 st year fellows, interest in endoscopic research is low. A majority of these fellows are unsure of the recommended guidelines or how many advanced procedures are performed at their institution. Fellowship training directors should consider educating incoming fellows about AET. Moreover, formally structured AET programs should be created to fully train those committed to AET in order to promote more endoscopic research and limit AET in a non-fellowship format.
Background: Cimetropium bromide has been widely used as a premedication before endoscopy. However, there has not yet been a well-designed study that proves the effectiveness of cimetropium bromide as a premedication. In order to determine if cimetropium bromide actually has a premedicational effect, and if it does, how effective it is, we undertook a study which compares the effects of cimetropium bromide to that of a placebo as premedications before esophagogastroduodenoscopy (EGD). We measured the comfort level of both the endoscopists and the patients during EGD. Methods: A total of 389 consecutive outpatients (211 men, 178 women, mean age: 49.3 years) were enrolled in this study. Thirty minutes before EGD, randomly selected patients were given intramuscular injection of cimetropium bromide(5 mg) or saline as a placebo, using double-blind technique. The following are the categories for data evaluation: (1) degree of comfort felt by patients while being examined: very good, good, fair, poor, or very poor (2) degree of peristaltic activity felt by endoscopists: very low, low, intermediate, high, or very high (3) degree of secretion: very clean, clean, intermediate, dirty, or very dirty Results: 197 and 192 patients were injected with cimetropium bromide and placebo, respectively. There were no differences in baseline characteristics and adverse effects between the two groups. Table 1 summarizes the results obtained. Conclusion: In this study, cimetropium bromide as a premedication before EGD is found not to be significantly superior to the placebo in terms of the subjective parameters during EGD, although it is widely used. Therefore, we conclude that the routine use of cimetropium bromide may be of little or no value at all as a premedication before EGD considering the cost of drug and labors. Table 1
Degree of comfort felt by patients (very good or good) Degree of peristaltic activity felt by endoscopists (very low or low) Degree of secretion felt by endoscopist (very clean or clean)
Cimetropium bromide
Placebo
pvalue
32/197 (16.2%)
36/156 (18.7%)
0.51
90/197 (45.7%)
73/192 (38.0%)
0.13
134/197 (68.0%)
126/192 (65.6%)
0.62
W1246 Video Capsule Endoscopy: Accuracy of Quick-View Vasu Appalaneni, Tammy Glenn, Brenda J. Hoffman Background: Review and interpretation of wireless video capsule endoscopy (VCE) of the small bowel can be time consuming. The average time for standard viewing is 40 minutes with a range of 20-60 minutes. Newer technologies such as Quad-view have shortened the time to some extent. Quickview v4 allows fast preview of RAPIDÒ video while highlighting images which may be of interest in the video stream of images. Aim: To determine the accuracy of Quickview versus standard review of video capsule endoscopy images. Methods: Small bowel VCE was performed for random indications using capsule endoscopy (GivenÒ Imaging Ltd., PillcamÔ small bowel). 50 prospective studies were reviewed by two reviewers. Preprocedure preparation was done in a standard local protocol. The two reviewers have previously documented their concurrence on standard review of capsule studies. One reviewer (TG) read the studies using standard protocol, the other reviewer (BH) used Quick-view in combination with suspected blood indicator (SBI). Quick-view was interpreted in single view at 25 frames/sec. Both reviewers marked landmarks and captured thumbnail images during their review and saved the findings. Both reviewers were blinded to the other’s findings. The results were then compared. Results: A total of 50 prospective patients were studied after a maximum recording time of 8 hours. The average time for Quick-view was 3 minutes (range 2-6 min). The average small bowel transit time was 208 minutes (range 79-451 minutes). The Quick-view did not record two red spots of unknown significance that were noted on standard review. The Quick-view reported one mosaic pattern in the stomach not recorded on standard review. There was one single frame abnormality of vascular nature which was detected by both measures. The use of SBI added no additional information to the interpretation of the images. Conclusions: There was no significant difference in the findings compared from standard view to Quick-view while interpreting small bowel capsule endoscopy images. Quick-view alone may be used to review VCE studies. More studies with single frame abnormalities are needed prior to acceptance of this as standard. Use of SBI added no value to the study.
W1247 Does the Premedication of Cimetropium Bromide Before Esophagogastroduodenoscopy Really Make Endoscopy Easier and More Comfortable?: A Prospective, Randomized, Double Blind Controlled Trial Jung Eun Lee, Sungjung Kim, Hyun Ju Jeong, Min Jeong Park, Hee Suk Jung, MI Kyeong Heo, Kwang Hee Youn, Sung Wook Song, Gwang Ho Baik, Jin Bong Kim, Dong Joon Kim
www.giejournal.org
W1248 Sedation with Propofol for Interventional Endoscopic Procedures: A Risk Factor Analysis Till Wehrmann, Markus Benno Frenz, Andrea Riphaus Introduction: The safety of propofol sedation, mainly for diagnostic endoscopic procedures was documented in numerous studies. In the context of nurse administered propofol sedation (NAPS) more than 80.000 patients received NAPS without the need for endotracheal intubation. However cardio-respiratory side effects under propofol-sedation are well known and were described in the literature particularly for interventional endoscopic procedures. Aims/Methods: To assess the complication rate of propofol sedation when used for interventional endoscopic procedures in a large cohort of patients. During a six-year period a total of 9.547 examinations under propofol sedation were performed (UGI, n Z 5.374, ERCP, n Z 3.937, EUS, n Z 236). Adverse events were defined as pre-maturely termination of the endoscopic procedure, need for mask-ventilation or endotracheal intubation, or admission to ICU. Sedation was performed by nonanaesthesist-physicians (all board certified for CPR)and not involved in the endoscopic procedure. Heart rate, oxygen saturation, respiratory activity, ECG, and blood pressure were automatically monitored throughout the examination. Results: During the audit period a total of 135 above defined adverse events were documented (frequency of adverse events, 1.4%). There were 133 cases of early termination of the endoscopic procedure, of which 117 cases were due to possibly sedation-related complications. In 40 cases (0.4%) assisted mask ventilation was necessary and lead to successful spontaneous breathing in 29 cases, without any clinical sequel. In 9 patients endotracheal intubation had to be performed (0.09%) because of unsuccessful (n Z 7) or prolonged mask ventilation O15 minutes (n Z 2). Twenty-eight cases required intensive care (ICU-frequency, 0.3%), of which 15 patients needed prolonged mechanical ventilation (for a period of 12.4 10.5 hours, range, 3 - 36 hours). Four patients died (mortality rate per procedure, 0.04%, mortality per patient, 0.05%, sedation-related mortality, 0.03%). During multivariate analysis of different special characteristics, which may promote propofol-induced side effects, only the fact of an emergency endoscopic examination (OR 15.3, CI 9.529.4) and a propofol dose O100 mg (OR 2.1, CI 1.5-6.1) remained as independent risk factors. Both conditions were also significantly associated with the frequency of admission to intensive care. Conclusion: Interventional endoscopy under propofol sedation is, despite of the advantageous efficiency of sedation not risk-free. Therefore increased attention particularly during long lasting interventions and emergency procedures is mandatory.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB313
W1245 Attitudes and Expectations of the 2006 Incoming GI Fellowship Class Towards Advanced Endoscopic Training (AET) Michael J. Pollack, Linda C. Cummings, Tina Koral, John J. Vargo, Richard C. Wong, Gerard A. Isenberg, Ashley L. Faulx, Michael V. Sivak, Amitabh Chak Background: Rapid technological advancements in endoscopic procedures such as ERCP and EUS have transformed GI practice and training. However, training in these procedures is demanding, and fellowship opportunities are limited. This study aimed to assess attitudes and expectations of the 2006 incoming GI fellowship class towards AET. Methods: A 23 question survey assessing interest in AET was developed and tested on 20 GI fellows and internal medicine residents interested in GI at our institution. Ambiguous questions were modified and the survey was then administered at the ASGE-sponsored First Year Fellows’ Endoscopy Course, which was attended by 298 of 415 (72%) 1 st year fellows from accredited GI fellowship programs throughout the United States. Results: Responses were obtained from 252 (85%) of attendees. 183 (73%) expressed interest in AET, 50 (20%) were unsure, and 19 (8%) were not interested. Reasons for interest included ‘‘to be a complete gastroenterologist’’ (72%), marketability (51%), interest in pancreaticobiliary disease (54%), interest in technology (54%), and interest in endoscopic research (21%). Among those interested in AET, 138 (77%) desired both EUS and ERCP training, and 132 (73%) rated access to AET during a 3 year fellowship as important to their fellowship program choice; 114 (64%) and 124 (71%) were not sure of or underestimated the number of ERCPs and EUSs, respectively, required to meet competency guidelines; 62 (34%) and 75 (43%) were not sure how many ERCPs and EUSs, respectively, are performed at their institution annually. 119 (65%) of those interested do obtain some AET during their three year fellowship, yet 130 (72%) do not expect to be fully trained or are not sure. If not fully trained, 115 (64%) said they would then seek alternative ways to learn (e.g. weekend hands-on courses, videotapes, web-based learning) and eventually practice advanced endoscopic procedures. Conclusions: While interest in AET is high among 1 st year fellows, interest in endoscopic research is low. A majority of these fellows are unsure of the recommended guidelines or how many advanced procedures are performed at their institution. Fellowship training directors should consider educating incoming fellows about AET. Moreover, formally structured AET programs should be created to fully train those committed to AET in order to promote more endoscopic research and limit AET in a non-fellowship format.
Background: Cimetropium bromide has been widely used as a premedication before endoscopy. However, there has not yet been a well-designed study that proves the effectiveness of cimetropium bromide as a premedication. In order to determine if cimetropium bromide actually has a premedicational effect, and if it does, how effective it is, we undertook a study which compares the effects of cimetropium bromide to that of a placebo as premedications before esophagogastroduodenoscopy (EGD). We measured the comfort level of both the endoscopists and the patients during EGD. Methods: A total of 389 consecutive outpatients (211 men, 178 women, mean age: 49.3 years) were enrolled in this study. Thirty minutes before EGD, randomly selected patients were given intramuscular injection of cimetropium bromide(5 mg) or saline as a placebo, using double-blind technique. The following are the categories for data evaluation: (1) degree of comfort felt by patients while being examined: very good, good, fair, poor, or very poor (2) degree of peristaltic activity felt by endoscopists: very low, low, intermediate, high, or very high (3) degree of secretion: very clean, clean, intermediate, dirty, or very dirty Results: 197 and 192 patients were injected with cimetropium bromide and placebo, respectively. There were no differences in baseline characteristics and adverse effects between the two groups. Table 1 summarizes the results obtained. Conclusion: In this study, cimetropium bromide as a premedication before EGD is found not to be significantly superior to the placebo in terms of the subjective parameters during EGD, although it is widely used. Therefore, we conclude that the routine use of cimetropium bromide may be of little or no value at all as a premedication before EGD considering the cost of drug and labors. Table 1
Degree of comfort felt by patients (very good or good) Degree of peristaltic activity felt by endoscopists (very low or low) Degree of secretion felt by endoscopist (very clean or clean)
Cimetropium bromide
Placebo
pvalue
32/197 (16.2%)
36/156 (18.7%)
0.51
90/197 (45.7%)
73/192 (38.0%)
0.13
134/197 (68.0%)
126/192 (65.6%)
0.62
W1246 Video Capsule Endoscopy: Accuracy of Quick-View Vasu Appalaneni, Tammy Glenn, Brenda J. Hoffman Background: Review and interpretation of wireless video capsule endoscopy (VCE) of the small bowel can be time consuming. The average time for standard viewing is 40 minutes with a range of 20-60 minutes. Newer technologies such as Quad-view have shortened the time to some extent. Quickview v4 allows fast preview of RAPIDÒ video while highlighting images which may be of interest in the video stream of images. Aim: To determine the accuracy of Quickview versus standard review of video capsule endoscopy images. Methods: Small bowel VCE was performed for random indications using capsule endoscopy (GivenÒ Imaging Ltd., PillcamÔ small bowel). 50 prospective studies were reviewed by two reviewers. Preprocedure preparation was done in a standard local protocol. The two reviewers have previously documented their concurrence on standard review of capsule studies. One reviewer (TG) read the studies using standard protocol, the other reviewer (BH) used Quick-view in combination with suspected blood indicator (SBI). Quick-view was interpreted in single view at 25 frames/sec. Both reviewers marked landmarks and captured thumbnail images during their review and saved the findings. Both reviewers were blinded to the other’s findings. The results were then compared. Results: A total of 50 prospective patients were studied after a maximum recording time of 8 hours. The average time for Quick-view was 3 minutes (range 2-6 min). The average small bowel transit time was 208 minutes (range 79-451 minutes). The Quick-view did not record two red spots of unknown significance that were noted on standard review. The Quick-view reported one mosaic pattern in the stomach not recorded on standard review. There was one single frame abnormality of vascular nature which was detected by both measures. The use of SBI added no additional information to the interpretation of the images. Conclusions: There was no significant difference in the findings compared from standard view to Quick-view while interpreting small bowel capsule endoscopy images. Quick-view alone may be used to review VCE studies. More studies with single frame abnormalities are needed prior to acceptance of this as standard. Use of SBI added no value to the study.
W1247 Does the Premedication of Cimetropium Bromide Before Esophagogastroduodenoscopy Really Make Endoscopy Easier and More Comfortable?: A Prospective, Randomized, Double Blind Controlled Trial Jung Eun Lee, Sungjung Kim, Hyun Ju Jeong, Min Jeong Park, Hee Suk Jung, MI Kyeong Heo, Kwang Hee Youn, Sung Wook Song, Gwang Ho Baik, Jin Bong Kim, Dong Joon Kim
www.giejournal.org
W1248 Sedation with Propofol for Interventional Endoscopic Procedures: A Risk Factor Analysis Till Wehrmann, Markus Benno Frenz, Andrea Riphaus Introduction: The safety of propofol sedation, mainly for diagnostic endoscopic procedures was documented in numerous studies. In the context of nurse administered propofol sedation (NAPS) more than 80.000 patients received NAPS without the need for endotracheal intubation. However cardio-respiratory side effects under propofol-sedation are well known and were described in the literature particularly for interventional endoscopic procedures. Aims/Methods: To assess the complication rate of propofol sedation when used for interventional endoscopic procedures in a large cohort of patients. During a six-year period a total of 9.547 examinations under propofol sedation were performed (UGI, n Z 5.374, ERCP, n Z 3.937, EUS, n Z 236). Adverse events were defined as pre-maturely termination of the endoscopic procedure, need for mask-ventilation or endotracheal intubation, or admission to ICU. Sedation was performed by nonanaesthesist-physicians (all board certified for CPR)and not involved in the endoscopic procedure. Heart rate, oxygen saturation, respiratory activity, ECG, and blood pressure were automatically monitored throughout the examination. Results: During the audit period a total of 135 above defined adverse events were documented (frequency of adverse events, 1.4%). There were 133 cases of early termination of the endoscopic procedure, of which 117 cases were due to possibly sedation-related complications. In 40 cases (0.4%) assisted mask ventilation was necessary and lead to successful spontaneous breathing in 29 cases, without any clinical sequel. In 9 patients endotracheal intubation had to be performed (0.09%) because of unsuccessful (n Z 7) or prolonged mask ventilation O15 minutes (n Z 2). Twenty-eight cases required intensive care (ICU-frequency, 0.3%), of which 15 patients needed prolonged mechanical ventilation (for a period of 12.4 10.5 hours, range, 3 - 36 hours). Four patients died (mortality rate per procedure, 0.04%, mortality per patient, 0.05%, sedation-related mortality, 0.03%). During multivariate analysis of different special characteristics, which may promote propofol-induced side effects, only the fact of an emergency endoscopic examination (OR 15.3, CI 9.529.4) and a propofol dose O100 mg (OR 2.1, CI 1.5-6.1) remained as independent risk factors. Both conditions were also significantly associated with the frequency of admission to intensive care. Conclusion: Interventional endoscopy under propofol sedation is, despite of the advantageous efficiency of sedation not risk-free. Therefore increased attention particularly during long lasting interventions and emergency procedures is mandatory.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB313