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Colorectal Stenting: An Effective and Costsaving Therapy in Acute Leftsided Obstruction
*W1643 Colonoscopic Surveillance of Adenomatous Polyps: A Survey of Primary Care Physicians Knowledge of Current Guidelines Gregory Olds, Pankaj Singh, Amitabh Chak, Gregory Cooper
*W1645 Recommendations Following Screening Colonoscopy Limited by Inadequate Bowel Preparation Christine T. Bang, Christopher S. Lee, Shahzad Iqbal, Albert D. Min
Background-With the increased demand for screening and surveillance colonoscopies the open access method of referral is likely to become more prevalent. With open access referral, greater responsibility may be placed upon primary care physicians to decide at what interval patients should be referred back for surveillance colonoscopy. Even in a non-open access system, primary care physicians may often have to decide when to refer patients back to a gastroenterologist to arrange a surveillance colonoscopy. Methods-A survey comprised of six different clinical vignettes of the endoscopic and pathologic findings of an average risk 55 year old male undergoing a screening or surveillance was mailed to 115 university affiliated community based internal medicine and family medicine physicians. Physicians were asked to choose an interval at which surveillance colonoscopy should be repeated. Results-53 physicians (46%) responded to the survey. 80% of responders reported they refer patients via open access endoscopy. 51% of respondents would survey a patient with a single hyperplastic polyp at 5 years or less, including 30% at 3 years or less, and 19% at one year. 71% of respondents would survey a patient with a single 6 mm tubular adenoma at 3 years or less including 9% at one year. 94% of respondents would survey a single 12 mm adenoma at 3 years or less including 53% at 1 year. 72% of respondents would survey a patient with two 6 mm tubular adenomas at 3 years or less, including 15% at 1 year. Only 11% would survey this patient at the current AGA/ACG recomended interval of 5 years. 58% would survey a patient with a history of adenomatous polyps, but with a most recent normal colonscopy, at 5 years, with 19% surveying at 3 years or lcss. Conclusion-A majority of primary care physicians would survey adenomatous and hyperplastic polyps at internal sooner than the currently recomended guidelines. If this translates in actual practice, the overall availability of colon colon screening is likely to be affected. When performing open access procedures gastroenterologists should provide recomendations at which interval a surveillance colonoscopy should be obtained.
Quality of bowel preparation plays an important role in the efficacy of colonoscopy. Up to 25% of routine screening colonoscopy is limited as a result of poor or inadequate bowel preparation. Rescreening within a short time interval yields greater cost, inconvenience and risks without reducing mortality. Currently, there are no guidelines for clinicians to follow after an incomplete examination from poor bowel preparation. The aim of this study was to examine the recommendations after average-risk screening colonoscopy limited by poor bowel preparation. Methods: A prospectively collected database of colonoscopy reports from October 1999 to October 2003 at Beth Israel Medical Center, NY, was retrospectively analyzed. All colonoscopy reports with the indication of averagerisk screening and documented poor/inadequate bowel preparation were reviewed. Data collected included age, gender, amount of sedation administered, complications, extent of examination, reasons for early termination, endoscopic findings, and follow-up recommendations. Results: Of the 2,808 average-risk screening colonoscopies, 130 (4%), performed by 26 endoscopists, were documented to have poor or inadequate preparation. The mean age of those 130 patients was 59.7 years (range 46-82). There were 71 (55%) women and 59 (45%) men. Eighty-one (62%) of the 130 colonoscopies reached the cecum, while 49 (38%) were aborted prior to cecal intubation. In those 81 patients in which cecal intubation was successful, the most commonly recommended time intervals for repeat colonoscopy were one to three years (32%), three to five years (27%), and more than 5 years (10%). Other recommendations included barium enema (9%) and follow-up pending biopsy results (9%). Thirteen percent of reports had no recommendations. In the group with colonoscopy terminated prior to reaching the cecum, the recommended follow-up included repeat colonoscopy in less than one year (45%), in one to five years (14%), and in more than 5 years (4%). Barium enema was recommended in 27%, while no recommendations were made in 9%. Overall, the time recommended for rescreening in these patients ranged from 2 days to 10 years. Conclusions: There is a wide range of recommendations regarding the rescreening time interval after colonoscopy limited by inadequate bowel preparation. There is a need for practice guidelines on the follow-up after average-risk screening colonoscopy with inadequate bowel preparation.
*W1644 Racial Variation in Colon Pathology Detected After a Positive Screening Flexible Sigmoidoscopy Fritz Francois, James Park, Edmund J. Bini Background: Several studies have reported racial differences in the incidence of adenomas as well as the distribution of colon carcinomas. We hypothesized that the prevalence of proximal adenomas differs by ethnicity in the subset of patients with a distal polyp. The aim of this study was to evaluate ethnic variations in the prevalence of significant proximal lesions on follow-up colonoscopy after a polyp is found on screening flexible sigmoidoscopy (FS). Methods: Consecutive asymptomatic patients at average-risk for colorectal cancer who were referred for screening FS were prospectively enrolled from 1/98 through 10/03. A detailed medical history was obtained from all patients prior to FS, and colonoscopy was recommended for all subjects with a polyp on FS, regardless of size. Advanced colonic neoplasms were defined as adenomas $ 10mm in diameter or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or cancer. Results: A total of 2,084 patients were enrolled, of which 923 (44.3%) were Caucasian, 711 (34.1%) were African American (AA), 373 (17.9%) were Hispanic, and 60 (3.3%) were Asian. The prevalence of one or more polyps on FS (hyperplastic or adenomatous) was 22.5% in Caucasians, 22.8% in AA, 25.7% in Hispanics, and 36.2% in Asians (p = 0.049). One or more adenomas of any size was found in 12.8% of Caucasians, 11.1% of AA, 15.8% of Hispanics, and 24.6% of Asians (p = 0.005). After adjusting for age and gender, only Asians (OR 2.2; 95% CI 1.2 - 4.1; p = 0.007) were significantly more likely to have an adenoma on FS compared to Caucasians. Colonoscopy was performed in 482 of the 491 patients (98.2%) with a polyp (hyperplastic or adenomatous) on FS. There was a trend towards a difference in the prevalence of proximal adenomas on colonoscopy between Caucasians (52.2%), AA (41.5%), Hispanics (48.4%), and Asians (32.0%), although this difference was not statistically significant (p = 0.09). The prevalence of advanced colonic neoplasms did not differ (p = 0.81) between Caucasians (22.7%), AA (20.1%), Hispanics (17.9%), and Asians (20.0%). Conclusions: In this asymptomatic screening population, the overall prevalence of distal adenomas was highest among Asians when compared to other ethnic groups. The prevalence of significant proximal adenomas after a positive FS did not differ significantly according to ethnicity. The reasons for ethnic variations in the overall prevalence of adenomas should be further evaluated in screening colonoscopy studies.
VOLUME 59, NO. 5, 2004
*W1646 Colorectal Stenting: An Effective and Costsaving Therapy in Acute Leftsided Obstruction Res Jost, Rahel Jost, Marco Decurtins, Eric Schoch, Brigitte Brunner, Christoph Zollikofer Background / Purpose: In a previous study (1) we demonstrated that metallic stent placement in acute colonic obstruction is a minimally invasive and cost effective procedure allowing single step surgery in most cases. The purpose of this study is to confirm these results with a current, larger and more detailed study. Material and Methods: 45 consecutive pts (23 f, 22 m) with clinical and radiological signs of acute colonic obstruction distal from the splenic flexure were treated by preoperative stenting and secondary operation (Stent group, SG n= 27) or by direct surgery alone (control group, CG n = 18). Enteric Wallstents were implanted preoperatively under combined fluoroscopic and endoscopic guidance. The costs were calculated according to the rates provided by the hospitals finance department based on the true costs generated in our institution for every individual patient. Cost analysis include the following aspects: Total hospital stay (general unit and intensive care unit, ICU), the costs of colonoscopy (with or without tube placement) and the costs of stent placement and surgery. Results: Both groups were comparable in respect of age, sex and malign (37 pts) or benign (8 pts) stenoses. The SG had significant more primary anastomoses (SG: 89 %; CG 33 %), a lower need for colostomy (SG: 3 %; CG: 39 %), fewer reinterventions (SG: 1,1 ; CG 1,9 per case) and a lower postoperative morbidity, resulting in shorter hospital stays especially in the ICU unit. The overall costs per case were therefore significantly lower in the SG compared to the CG (USD 35‘877 vs. 45‘933 per case; cost reduction 22 %). Conclusions: Metallic stent placement in acute left sided colonic obstruction is an effective procedure, which allows an elective one-stage operation in most cases. Furthermore the need of repeated interventions, prolonged hospitalisation, temporary or permanent colostomy is greatly reduced compared to conventionally treated patients without preoperative stenting thus leading to lower overall costs per patient treated. 1. Binkert CHA et al.: Acute colonic obstruction: clinical aspects and cost effectiveness of preoperative and palliative treatment with self-expanding metallic stents. A preliminary report. Radiology 206:199-204 (1998).
GASTROINTESTINAL ENDOSCOPY
P277
*W1645 Recommendations Following Screening Colonoscopy Limited by Inadequate Bowel Preparation Christine T. Bang, Christopher S. Lee, Shahzad Iqbal, Albert D. Min
Background-With the increased demand for screening and surveillance colonoscopies the open access method of referral is likely to become more prevalent. With open access referral, greater responsibility may be placed upon primary care physicians to decide at what interval patients should be referred back for surveillance colonoscopy. Even in a non-open access system, primary care physicians may often have to decide when to refer patients back to a gastroenterologist to arrange a surveillance colonoscopy. Methods-A survey comprised of six different clinical vignettes of the endoscopic and pathologic findings of an average risk 55 year old male undergoing a screening or surveillance was mailed to 115 university affiliated community based internal medicine and family medicine physicians. Physicians were asked to choose an interval at which surveillance colonoscopy should be repeated. Results-53 physicians (46%) responded to the survey. 80% of responders reported they refer patients via open access endoscopy. 51% of respondents would survey a patient with a single hyperplastic polyp at 5 years or less, including 30% at 3 years or less, and 19% at one year. 71% of respondents would survey a patient with a single 6 mm tubular adenoma at 3 years or less including 9% at one year. 94% of respondents would survey a single 12 mm adenoma at 3 years or less including 53% at 1 year. 72% of respondents would survey a patient with two 6 mm tubular adenomas at 3 years or less, including 15% at 1 year. Only 11% would survey this patient at the current AGA/ACG recomended interval of 5 years. 58% would survey a patient with a history of adenomatous polyps, but with a most recent normal colonscopy, at 5 years, with 19% surveying at 3 years or lcss. Conclusion-A majority of primary care physicians would survey adenomatous and hyperplastic polyps at internal sooner than the currently recomended guidelines. If this translates in actual practice, the overall availability of colon colon screening is likely to be affected. When performing open access procedures gastroenterologists should provide recomendations at which interval a surveillance colonoscopy should be obtained.
Quality of bowel preparation plays an important role in the efficacy of colonoscopy. Up to 25% of routine screening colonoscopy is limited as a result of poor or inadequate bowel preparation. Rescreening within a short time interval yields greater cost, inconvenience and risks without reducing mortality. Currently, there are no guidelines for clinicians to follow after an incomplete examination from poor bowel preparation. The aim of this study was to examine the recommendations after average-risk screening colonoscopy limited by poor bowel preparation. Methods: A prospectively collected database of colonoscopy reports from October 1999 to October 2003 at Beth Israel Medical Center, NY, was retrospectively analyzed. All colonoscopy reports with the indication of averagerisk screening and documented poor/inadequate bowel preparation were reviewed. Data collected included age, gender, amount of sedation administered, complications, extent of examination, reasons for early termination, endoscopic findings, and follow-up recommendations. Results: Of the 2,808 average-risk screening colonoscopies, 130 (4%), performed by 26 endoscopists, were documented to have poor or inadequate preparation. The mean age of those 130 patients was 59.7 years (range 46-82). There were 71 (55%) women and 59 (45%) men. Eighty-one (62%) of the 130 colonoscopies reached the cecum, while 49 (38%) were aborted prior to cecal intubation. In those 81 patients in which cecal intubation was successful, the most commonly recommended time intervals for repeat colonoscopy were one to three years (32%), three to five years (27%), and more than 5 years (10%). Other recommendations included barium enema (9%) and follow-up pending biopsy results (9%). Thirteen percent of reports had no recommendations. In the group with colonoscopy terminated prior to reaching the cecum, the recommended follow-up included repeat colonoscopy in less than one year (45%), in one to five years (14%), and in more than 5 years (4%). Barium enema was recommended in 27%, while no recommendations were made in 9%. Overall, the time recommended for rescreening in these patients ranged from 2 days to 10 years. Conclusions: There is a wide range of recommendations regarding the rescreening time interval after colonoscopy limited by inadequate bowel preparation. There is a need for practice guidelines on the follow-up after average-risk screening colonoscopy with inadequate bowel preparation.
*W1644 Racial Variation in Colon Pathology Detected After a Positive Screening Flexible Sigmoidoscopy Fritz Francois, James Park, Edmund J. Bini Background: Several studies have reported racial differences in the incidence of adenomas as well as the distribution of colon carcinomas. We hypothesized that the prevalence of proximal adenomas differs by ethnicity in the subset of patients with a distal polyp. The aim of this study was to evaluate ethnic variations in the prevalence of significant proximal lesions on follow-up colonoscopy after a polyp is found on screening flexible sigmoidoscopy (FS). Methods: Consecutive asymptomatic patients at average-risk for colorectal cancer who were referred for screening FS were prospectively enrolled from 1/98 through 10/03. A detailed medical history was obtained from all patients prior to FS, and colonoscopy was recommended for all subjects with a polyp on FS, regardless of size. Advanced colonic neoplasms were defined as adenomas $ 10mm in diameter or any adenoma, regardless of size, with villous histology, high-grade dysplasia, or cancer. Results: A total of 2,084 patients were enrolled, of which 923 (44.3%) were Caucasian, 711 (34.1%) were African American (AA), 373 (17.9%) were Hispanic, and 60 (3.3%) were Asian. The prevalence of one or more polyps on FS (hyperplastic or adenomatous) was 22.5% in Caucasians, 22.8% in AA, 25.7% in Hispanics, and 36.2% in Asians (p = 0.049). One or more adenomas of any size was found in 12.8% of Caucasians, 11.1% of AA, 15.8% of Hispanics, and 24.6% of Asians (p = 0.005). After adjusting for age and gender, only Asians (OR 2.2; 95% CI 1.2 - 4.1; p = 0.007) were significantly more likely to have an adenoma on FS compared to Caucasians. Colonoscopy was performed in 482 of the 491 patients (98.2%) with a polyp (hyperplastic or adenomatous) on FS. There was a trend towards a difference in the prevalence of proximal adenomas on colonoscopy between Caucasians (52.2%), AA (41.5%), Hispanics (48.4%), and Asians (32.0%), although this difference was not statistically significant (p = 0.09). The prevalence of advanced colonic neoplasms did not differ (p = 0.81) between Caucasians (22.7%), AA (20.1%), Hispanics (17.9%), and Asians (20.0%). Conclusions: In this asymptomatic screening population, the overall prevalence of distal adenomas was highest among Asians when compared to other ethnic groups. The prevalence of significant proximal adenomas after a positive FS did not differ significantly according to ethnicity. The reasons for ethnic variations in the overall prevalence of adenomas should be further evaluated in screening colonoscopy studies.
VOLUME 59, NO. 5, 2004
*W1646 Colorectal Stenting: An Effective and Costsaving Therapy in Acute Leftsided Obstruction Res Jost, Rahel Jost, Marco Decurtins, Eric Schoch, Brigitte Brunner, Christoph Zollikofer Background / Purpose: In a previous study (1) we demonstrated that metallic stent placement in acute colonic obstruction is a minimally invasive and cost effective procedure allowing single step surgery in most cases. The purpose of this study is to confirm these results with a current, larger and more detailed study. Material and Methods: 45 consecutive pts (23 f, 22 m) with clinical and radiological signs of acute colonic obstruction distal from the splenic flexure were treated by preoperative stenting and secondary operation (Stent group, SG n= 27) or by direct surgery alone (control group, CG n = 18). Enteric Wallstents were implanted preoperatively under combined fluoroscopic and endoscopic guidance. The costs were calculated according to the rates provided by the hospitals finance department based on the true costs generated in our institution for every individual patient. Cost analysis include the following aspects: Total hospital stay (general unit and intensive care unit, ICU), the costs of colonoscopy (with or without tube placement) and the costs of stent placement and surgery. Results: Both groups were comparable in respect of age, sex and malign (37 pts) or benign (8 pts) stenoses. The SG had significant more primary anastomoses (SG: 89 %; CG 33 %), a lower need for colostomy (SG: 3 %; CG: 39 %), fewer reinterventions (SG: 1,1 ; CG 1,9 per case) and a lower postoperative morbidity, resulting in shorter hospital stays especially in the ICU unit. The overall costs per case were therefore significantly lower in the SG compared to the CG (USD 35‘877 vs. 45‘933 per case; cost reduction 22 %). Conclusions: Metallic stent placement in acute left sided colonic obstruction is an effective procedure, which allows an elective one-stage operation in most cases. Furthermore the need of repeated interventions, prolonged hospitalisation, temporary or permanent colostomy is greatly reduced compared to conventionally treated patients without preoperative stenting thus leading to lower overall costs per patient treated. 1. Binkert CHA et al.: Acute colonic obstruction: clinical aspects and cost effectiveness of preoperative and palliative treatment with self-expanding metallic stents. A preliminary report. Radiology 206:199-204 (1998).
GASTROINTESTINAL ENDOSCOPY
P277