Cold Biopsy Polypectomy: Jumbo Versus Standard Size Biopsy Forceps

Abstracts

a prospective study to assess safety of OSPS in them. Methods: AB and SCI subjects were randomized to PEG, OSPS, or dual (OSPSþPEG) preparations. Subjects with GFR %60 ml/min were not randomized to OSPS or dual preparation. Blood and early morning spot urine were collected 1 wk prior to (v1), on day of (v2) and 1 wk after C (v3) for serum creatinine (Cr, mg/dL), estimated glomerular filtration rate (eGFR, ml/min), phosphorous (P, mg/dL), calcium (Ca, mg/dL) with urinary P, creatinine, and N-acetyl-Dglucosaminidase (NAG, IU/mg of creatinine), a lysosomal enzyme released in urine after tubular injury. Effect on renal function was assessed by absolute change in Cr, percent change in Cr and eGFR at v2 and v3 compared to v1. Results: A total of 165 subjects (AB Z 139; mean age: 58  1 y and SCI Z 26; mean age: 60  2y; p Z 0.3) were analyzed. Bowel preparation was achieved with PEG in 55 (AB Z 47; SCI Z 8), OSPS in 55 (AB Z 47; SCI Z 8), and dual in 56 (AB Z 46; SCI Z 10) subjects. In AB subjects, Cr at v2 increased with OSPS (0.9  0.2 to 0.94  0.3) and dual (0.9  0.2 to 0.91  0.2) preparation, but decreased in SCI subjects (0.7  0.2 to 0.6  0.2) and returned to baseline by v3. Absolute change in Cr at v2 was higher in AB subjects compared to SCI with OSPS (0.01  0.02 vs -0.09  0.03, p ! 0.04) and dual (0.04  0.03 vs. -0.1  0.05, p ! 0.07). Percent change in Cr was higher with OSPS (2.1  2.2 vs -12  4.6, p ! 0.01) and dual (4  3.4 vs. -12  6.3, p ! 0.03) but not with PEG (2.1  2.2 vs. -12  4.5, p O 0.1). Changes in eGFR paralleled Cr changes. In AB subjects, OSPS increased serum P (3.2  0.5 to 5.7  1.7, p ! 0.0001), urinary P (67  6 to 405  40, p ! 0.0001), urinary NAG (0.4  0.05 to 0.6  0.1, p ! 0.02) and decreased serum Ca (9.2  0.4 to 8.8  8.8  0.4m p ! 0.0005) at v2. Similar trends were seen with dual but not with PEG. With OSPS in SCI subjects, changes in serum P (increase) and Ca (decrease) were similar to AB subjects without significant change in urinary P or NAG. Conclusion: Ingestion of OSPS alone or in combination with PEG resulted in elevation of serum P with decrease in Ca in AB and SCI subjects. Transient, but clinically insignificant, deterioration of renal function occurs in AB subjects. SCI subjects are less predisposed to this toxicity of OSPS and use of OSPS appears to be safe for routine C in them.

W1451 Should We Be Using Bowel Preparation and Prokinetic Agents for Small Bowel Capsule Endoscopy? A Prospective Randomized Controlled Trial Aymer Postgate, Aine Fitzpatrick, Neil Patterson, Chris H. Fraser Introduction: Capsule Endoscopy (CE) is a sensitive small bowel imaging modality. However, the test is often limited by poor views and incomplete transit. The evidence for bowel preparation/prokinetics is inconclusive, with studies limited by small numbers and retrospective design. Methods: We aimed to identify whether CitramagþSenna þ/or metoclopramide was superior to standard preparation (-clear fluids p.m., nil-by-mouth from midnight) for small bowel CE. Patients were randomised to 1 of 4 groups: I.standard preparation (S) II.standard þ10 mg oral metoclopramide pre-procedure (M) III. Senna (1 sachet)þCitramag (2 sachets in 2L) p.m. prior, nil-by-mouth from midnight (CS) IV. Senna þCitramag (above) þ10 mg metoclopramide pre-procedure (CSM) A single investigator reviewed the studies blind (k Z 0.73, 95% CI 0.59-0.87). The gastric (GTT) and small bowel transit times (SBTT), completion rates, and diagnostic yield were documented. View quality was graded 0-4 in 11  5 min video segments (every 10% of SBTT after duodenal entry max score Z 44). Patient preference was recorded using a visual-analogue scale. Results150 patients were recruited (68 men; mean age 50.2yr, range 17.9-87.7). GTT/ SBTT were shorter in the CSM group compared to standard (GTT 1011 vs.1317sec, SBTT 229 vs.276 min), but this did not reach statistical significance. Completion rates (S-89%; M-86%; CS-85%; CSM-89%) and no. lesions identified were similar across groups. There was no significant difference in view quality between groups (Fig.2). Diagnostic yield was variable -CSM 46%, S 35%, M 26%, CS 13%. CS and CSM were significantly less comfortable/convenient than S preparation (p Z ! 0.001, p Z 0.02 respectively), but most would trade this for greater accuracy (median 94-99%). No complications occurred. Conclusions: Bowel preparation þ/or prokinetics does not significantly improve view quality, completion rates or diagnostic yield at small bowel CE although transit times may be reduced. Bowel preparation is less comfortable and therefore its use in routine cases is not currently indicated.

Background: Adequate bowel cleansing is essential for wireless capsule endoscopy (WCE). So far, grading system for small bowel cleansing has not been standardized. Preexisting grading systems are complicated and not easy to apply practically. So we suggest the new grading system to evaluate small bowel cleaning for WCE. Materials and Methods : 4 investigators randomly reviewed 30 WCE’s performed at our institution between January 2007 and July 2007 and assessed the small bowel cleansing by using our new grading system. Our protocol utilized two visual parameters : proportion of area of the visible lumen and degree of obscuration of the view by any one of bubbles, debris, bile pigments etc. We serially chose one frame of every 5-minute interval (1 frame/5min) of entire small bowel images and scored them with the two parameters. We used Intraclass correlation Coefficient (ICC) to assess the inter-observer reliability. Afterwards, we compared our grading system with preexisting grading system scoring each individual frame for 2 minute of every 5-minute period (e.g. 240 frames /5min or 40% of the small bowel). Results : Mean age of subjects was 46.6 years and 83% were male. Common indications of WCE were gastrointestinal bleeding(60%), iron deficiency anemia (20%), abdominal pain (13%) and diarrhea (6%). Inter-observer reliability on our grading system had a good range agreement with ICC value of 0.642(95%CI 0.480-0.803), and reliability on our grading system with preexisting system also had a good range agreement of 0.626 (95% CI 0.421-0.804). Conclusions : To evaluate small bowel cleansing for WCE, our grading system is a novel, simple and time-sparing system because a number of scoring parameters and frames are smaller than those of preexisting system. We believe that our grading system may be useful to clinical researches in respect of a good range agreement compared preexisting system.

W1453 The Clinical Usefulness of Intravenous Cimetropium Bromide As a Premedication for Upper Gastrointestinal Endoscopy Under Conscious Sedation: A Randomized Double-Blind Controlled Trial Young Mook Kim, Sung Jung Kim, Mi Kyeong Heo, in Suk Park, Hui Suk Jung, Hyun Seo Yun, Jung Eun Lee, Young Sook Oh, Byoung Ho Kim, Jue Yong Lee, Chang Soon Choi, Gwang Ho Baik, Jin Bong Kim, Dong Joon Kim Background and Aims: Antispasmodics such as cimetropium bromide (CB) has been widely used as a premedication to facilitate upper gastrointestinal endoscopy (GIE). But the clinical benefit of CB was questioned with the instrumental and technical advancement of GIE. We performed this study to investigate the clinical usefulness of CB as a premedication for GIE. Methods: In this prospective, doubleblind, randomized trial, 320 consecutive patients undergoing GIE (using Olympus GIF Type H260 or Q260, from September to November 2007) under conscious sedation with midazolam were enrolled and randomly allocated to receive either intravenous CB(CB group, n Z 157) or intravenous normal saline (placebo group, n Z 163). We measured the time required for GIE and the outcome parameters of CB by endoscopists during the procedure in each group. The outcome parameters, scored on a five-point scale, included (1) peristaltic activity score, (2) belching score, (3) difficulty to pass through the pyloric ring score, and (4) intragastric secretion score. Results: Baseline characteristics such as age (CB group: 46.0  13.0, placebo group 44.3  13.5; p Z 0.251), sex (p Z 0.951), and comorbidity (p Z 0.125) in each group were well matched. The time required for GIE (2.26  1.29 minutes in CB group, 2.87  1.48 minutes in placebo group; p Z 0.052) was similar. And there were no statistically significant differences between the two groups in all outcome parameters including peristaltic activity score (p Z 0.827), belching score (p Z 0.939), difficulty to pass through the pyloric ring score (p Z 0.563), and intragastric secretion score (p Z 0.475). Conclusion: This study shows that the use of cimetropium bromide as a premedication for GIE has no clinical benefit in terms of all parameters we used. Therefore, besides the cost of drug and labors, the routine use of cimetropium bromide as a premedication for GIE may be of little or no benefit in facilitating GIE.

W1454 Cold Biopsy Polypectomy: Jumbo Versus Standard Size Biopsy Forceps Ricardo Borsatto, Camron Kiafar, Francisco C. Ramirez

W1452 A Study of Grading System to Evaluate Small Bowel Cleansing for Wireless Capsule Endoscopy Yoon-Tae Jeen, Yong Sik Kim, Ju Young Kim, Chul Young Kim, Jin Su Jang, Yong Dae Kwon, Sanghoon Park, Bora Keum, Yeon Seok Seo, Hong Sik Lee, Hoon Jai Chun, Soon Ho Um, Sang Woo Lee, Jae Hyun Choi, Chang Duck Kim, Ho Sang Ryu

AB288 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

Cold polypectomy is frequently performed during routine colonoscopy via snares and forceps. Among the latter, jumbo biopsy forceps have the perceived performance advantage in requiring fewer passes and/or bites to remove polyps when compared to standard size forceps. However, the cost of jumbo biopsy forceps is twice as much as the cost of standard biopsy forceps. Aim: To compare the performance (number of passes and bites required for polypectomy) between jumbo and standard biopsy forceps for diminutive (%5 mm) and small (6-9 mm) polyps. Methods: Polyps from 100 consecutive patients undergoing screening colonoscopy were included. During polypectomy, at the discretion of a single experienced endoscopist and based on the visual estimated size of the polyp, either a jumbo (Radial Jaw 4, Jumbo with needle. Boston Scientific, Natick, MA) or a standard biopsy forceps (Radial Jaw 3, Large capacity with needle. Boston Scientific, Natick, MA) were used. The biopsy forceps chosen for the first polyp was then used for any subsequent polyps found in the same patient. Only those polyps removed via cold biopsy forceps were analyzed. Statistics: Data is presented as mean  SEM and compared using Student’s t-test. Study period: October to

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Abstracts

November 2007. Setting: Endoscopy unit at a VAMCResults: A total of 247 polyps were removed. Of these, 183 were diminutive (%5 mm) and 33 were small (6-9 mm). There were 31 additional polyps removed via snare polypectomy (electrocautery). Ninety five polyps underwent cold polypectomy via jumbo and 121 via standard biopsy forceps. There were no differences between the number of passes or the number of bites required to remove the polyps with either forceps, irrespective of their size (Table 1). Conclusions: The overall performance of standard biopsy forceps were comparable to the jumbo biopsy forceps when used for cold biopsy polypectomy for both diminutive and small polyps. Based on these findings and from an economic perspective, it may not be justifiable to use jumbo biopsy forceps for cold biopsy polypectomies. Table 1. DIMINUTIVE POLYPS

JUMBO (n Z 77)

STANDARD (n Z 106)

p value

Number passes Number bites SMALL POLYPS Number passes Number bites

1.16  0.05 1.70  0.09 JUMBO (n Z 18) 2.00  0.19 3.44  0.35

1.14  0.04 1.66  0.09 STANDARD (n Z 15) 2.13  0.19 3.53  0.36

n.s n.s n.s n.s

W1455 Does the Addition of Bisacodyl to PEG-3350 Improve Bowel Cleanliness for Colonoscopy? Audrey H. Calderwood, Edwin J. Lai, Gheorghe Doros, Brian C. Jacobson Background: Bowel preparation is inadequate in up to 25% of patients undergoing colonoscopy. The ideal bowel preparation regimen would effectively clean the colon while minimizing patient discomfort. Objective: To compare 4L of polyethylene glycol (PEG) alone to PEG þ four 5 mg oral bisacodyl tablets (PEG þ B) as bowel preparation for colonoscopy. Methods: Between 2/2006 and 11/2007 we prospectively collected information about English-speaking patients undergoing screening colonoscopy at a large urban academic medical center. Data was obtained as part of an ongoing, randomized trial to improve bowel preparation using a visual aid included with preparation instructions. In 12/2006, our endoscopy unit’s standard bowel preparation regimen was changed from PEG to PEG þ B. For this analysis, our primary endpoint was the percentage of patients in each preparation group receiving a qualitative bowel cleanliness rating of excellent or good (E/G) vs. fair, poor, or unsatisfactory. We had 80% power to detect a 10% change (assuming a two-sided p value of 0.05). We also compared bowel cleanliness with a 10-point, validated quantitative scale (0 Z unprepared colon, 9 Z perfectly clean), the percentage of cases needing to be rescheduled because of poor preparation, and colonoscopic insertion and withdrawal times (among cases done without a fellow). We asked patients to quantify bloating, nausea/vomiting, and abdominal pain associated with bowel preparation using a 5 point scale (1 Z none, 5 Z very severe). Results: Among 551 patients, 350 received PEG and 201 received PEG þ B. The percentage of patients receiving PEG with an E/G rating was 83% compared to 86% receiving PEG þ B (p Z 0.36 by chi-square). The mean quantitative score was 5.9 (SD 1.5) with PEG compared to 6.3 (SD 1.5) with PEG þ B (p Z 0.004 by t-test). Among PEG patients, 12% were rescheduled because of poor preparation compared to 8% of PEG þ B patients (p Z 0.10 by chi-square). With PEG, median colonoscope insertion time was 6 minutes [IQR 5-9] vs. 7 minutes [IQR 5-12] with PEG þ B (p Z 0.15 by Wilcoxon rank-sum test). Excluding polyp cases, median withdrawal time was 6 minutes [IQR 5-8] with PEG vs. 7 minutes [IQR 6-9] with PEG þ B (p Z 0.03). No difference was observed between PEG and PEG þ B in the frequency of bloating, nausea/vomiting, or abdominal pain experienced during bowel preparation (p O 0.20 for all comparisons). Conclusions: PEG þ B was only marginally better than PEG alone in bowel cleansing with similar patient tolerability. Withdrawal time was longer with PEG þ B but may relate to temporal changes in practice.

W1456 Risk of Sleep Apnea During Sedation for Endoscopy: Are Current Diagnostic Guidelines Useful? Radha V. Menon, Mini A. Mathew, David Anjelly, Suleman Iqbal, Joanne Getsy, Asyia S. Ahmad, James C. Reynolds Safety is a major goal in outpatient open access endoscopy centers for patients undergoing colon cancer screening. Sleep apnea is a concern for patients receiving sedation due to predisposition to upper airway obstruction, particularly when using propofol for sedation. Various risk assessment methods have been promoted in the anesthesia literature to aid risk stratification of patients for probability of apnea resulting from upper airway collapse. However, none of these tools are well validated. Aim: To determine the predictive value of all currently recommended sleep apnea screening methods, in patients undergoing endoscopic procedures. Methods: A prospective study was performed in patients undergoing outpatient colonoscopy. Patients known to have sleep apnea were excluded. Each patient was given a survey including the Berlin Questionnaire, Epworth Sleepiness Scale, and Stanford Sleepiness Scale. A physical examination was performed to determine each subject’s

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‘‘modified neck circumference,’’ (Flemons et al in 2002) ‘‘modified Mallampati grade,’’ and ‘‘tonsil grade.’’ Patients were carefully evaluated by an anesthesiologist and by portable sleep monitoring while undergoing colonoscopy. All studies were read by a board certified sleep medicine physician blinded to the results (JG). Results: Of the 20 patients enrolled in the study, 16 studies were complete enough to be included in data analysis. Seven patients were found to have positive studies (O5 apneas/hypopneas), and 9 had negative studies. In the positive sleep study group, 43% by Berlin questionnaire, 43% by Epworth, and 40% by Stanford score were determined to be at high risk for sleep apnea. In the negative study group, 33% by Berlin questionnaire, and 0% by Epworth and Stanford scores were determined to be at high risk. Modified Mallampati and Tonsil grades had no significant differences between the groups. The average BMI was identical in both groups (28.4 vs 28.4), and average modified neck circumference were similar (46.2 cm vs 45.6 cm). Inter-test comparability showed poor correlation between the six different screening tools. Conclusion: Risk assessment prior to sedation is critical in determining who may safely undergo colonoscopy in an outpatient ambulatory setting. This is the first study to evaluate the predictive value of various risk assessment methods for screening patients prior to colonoscopy. Our data suggests that Epworth and Stanford Scales may have good negative predictive values. However no risk assessment method revealed a high positive predictive value. Although our data is limited, we are currently evaluating these methods in a larger population.

W1457 Colonoscopy with Polypectomy in Patients Taking Clopidogrel Shai Friedland, Cynthia W. Leung, Daniel Sedehi, Roy M. Soetikno Background: According to current practice guidelines, polypectomy is considered a high-risk procedure for which antiplatelet medications such as clopidogrel should be discontinued for 7-10 days prior. However, these guidelines are based on expert opinion, and the bleeding risk following polypectomy in patients taking clopidogrel is not known. Discontinuation of clopidogrel can expose patients to significant cardiovascular risk. Objective: Measure the risk of post-polypectomy bleeding in patients who undergo colonoscopic polypectomy while maintained on clopidogrel. Design: Retrospective review of patients who underwent polypectomy without discontinuation of clopidogrel at the VA Palo Alto. Patients: 31 polypectomies were performed in 16 male patients. The average age was 64. Patients were on clopidogrel for coronary artery disease/cardiac stents (50%), cerebrovascular disease (44%) or severe peripheral vascular disease (6%). 5 patients (31%) were concomitantly taking aspirin. The average diameter of resected polyps was 5.6 mm (range 3-12 mm). All patients were followed-up by telephone or in clinic. Interventions: All patients underwent snare polypectomy followed immediately by prophylactic application of one or two clips to prevent bleeding. Most polyps less than 5 mm in diameter were snared without cautery. Polyps larger than 5 mm were snared with minimal cautery after submucosal saline injection. Results: Two patients (13%, CI 4-36%) had minor immediate bleeding. In these cases there was significant oozing immediately after polypectomy which ceased with clip application. Both patients were discharged home after the procedure and were asymptomatic. One patient (6%, CI 1-28%) had minor bleeding at home 36 hours after the procedure. He reported 3 episodes of hematochezia which resolved spontaneously; he did not seek medical attention. There were no episodes of major delayed postpolypectomy bleeding (0%, CI 0-19%). There were no thromboembolic events. Conclusions: Our limited experience suggests that small polyps can be removed in patients who are maintained on clopidogrel, but endoscopists need to be prepared to address immediate bleeding. The risk of major delayed post-polypectomy bleeding is no higher than 19% and the risk of minor delayed post-polypectomy bleeding is no higher than 28%. In the absence of additional data, we will perform polypectomy only in selected patients who are at high risk of cardiovascular events if clopidogrel is discontinued. We favor routine prophylactic clip application, cold snare without cautery for lesions up to 5 mm and routine submucosal injection prior to snare cautery application in these patients.

W1458 Comparison of Cecal Intubation Rates and Quality of Bowel Preparation Between Morning and Afternoon Colonoscopies Tae Yeob Kim, Dong Soo Han, Hyun Seok Cho, Tae Jun Byun, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: The timing of colonoscopies has been reported predictive factor of incomplete colonoscopy and poor bowel preparation. We aimed to compare the cecal intubation rates and quality of bowel preparation in morning versus afternoon procedure, and to determine the interval time between polyethylene glycol (PEG) solution starting time and colonoscopy procedure for adequate bowel preparation. Methods: A prospective, case-control, and single-center study comparing cecal intubation rates and quality of bowel preparation according to the timing of procedure were performed between May 2007 and October 2007. Outpatients in the morning and afternoon procedure were advised to drink PEG solution at 5 AM and at 8 AM on the day of colonoscopy, respectively. Quality of bowel preparation was assessed using the Ottawa bowel preparation quality scale. Results: A total of 300 outpatients were enrolled, of which 149 in the morning and 151 were in the afternoon. Several known factors of incomplete colonoscopy, such as female gender, prior hysterectomy, constipation, low body mass index, and diverticulosis were similar between two groups. Complete cecal intubation rates were 97.3%

Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB289