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Comparison of Anesthesia Associated (AA) Sedation with Conscious Sedation (CS) in Successful Completion of Endoscopic Retrograde Cholangiopancreatography (ERCP)
Abstracts
S1106 Mortality From EUS Jesse Lachter Introduction: EUS is widely perceived to be, as reported, a very safe procedure. Early statistics, from pooled data, found a one in 37,915 risk of mortality. New instruments, linear EUS, and FNA and other invasive techniques, justify reevaluation of data on complications. Accumulating data on complications suggests major revision of the mortality statistics. Patients and Methods: Following initiation of a national survey of EUS utilization, a repository of information on complications developed. Creation and utilization of this data base led to continuous describing of complications. The higher than expected frequency of such complications, especially of mortalities, led to investigations of each case. Results: Seven local cases, and five cases from outside of Israel, of EUS-caused deaths were found. This series represents more cases than that cumulatively described as case reports in all of the relevant literature of the past 24 years, since the introduction of EUS. In the cases analyzed, FNA was not involved in any procedure. The Pentax instruments with their longer hard tip than the Olympus linear instruments, were involved in six of the seven mortalities; no cases involved Fuji scopes. Notably, only one of the 20 EUS centers in Israel uses a Fuji system. Duodenal tears, leading to retroperitoneal perforations, were the cause of 10 of the 12 deaths. The other two deaths were (one each) from esophageal perforation, and from aspiration. One case occurred from a procedure performed as part of a live demonstration of EUS. At least five cases involved patients with duodenal diverticuli. These diverticuli may have had a role in the cause of doing the EUS, in procedures which were initiated to search for suspected CBD stones. Delay in diagnosis of perforation was common. five of the seven Israeli deaths from EUS occurred during the first year and/or 150 first procedures of the endosonographer. Conclusions: EUS has significantly higher risks than previously thought. The Israeli mortality rate from EUS, averaging about one death from each 2500 procedures, was found to be over 15 times that in the published (somewhat dated) literature. To minimize the risks of death from EUS, this study suggests 1- appropriately long traineeships, 2- attention to duodenal diverticuli, 3- a high index of suspicion of retroperitoneal tears with knowledge of their management, 4- and appreciation of the EUS instrument designs.
S1108 Should Routine Endoscope Cultures Be Done to Monitor Scope Reprocessing? Joseph Leung, Robert Wilson Background: There are strict guidelines for reprocessing of flexible endoscopes. Because of low reported incidence of scope transmitted infections, routine monitoring of scope reprocessing is currently not recommended. However, recent news reports of possible patients’ exposure to hepatitis due to a breach in scope reprocessing prompted hospitals to reassess their scope reprocessing. Aim: Retrospective review of an on-going scope culture protocol. Method: Reprocessed scopes were selected randomly from storage (EGD[e], colonoscope [c], sigmoidoscope [s] and ERCP [E]) and cultured quarterly. We then focused on complex ERCP and EUS (EU) scopes because of more serious consequences of cross infections. With a clean/aseptic approach, sterile saline was flushed through air/water channel and suctioned through biopsy channel, with brushing of the elevator and all suction and biopsy valve ports. All samples from one scope were collected together and sent for routine culture. Positive culture with isolation of bacteria was used as a surrogate for contamination, no viral screening was done. If a scope was tested positive, cultures were repeated till 4 consecutive tests were negative or a cause found to explain the results. Results: Lower GI scopes were more likely to be contaminated (e16%, c44%, s50%, E20%). % positive cultures (table) for past 4 years were E 6,3,14,16,13% and EU24,45,10% respectively. We did not observe any clinically significant infections despite positive cultures. Identified causes included poor technique due to untrained part time technicians; defective automated scope reprocessor; improper scope storage and damaged scopes. Correction of deficiencies led to significant reduction in positive cultures. Conclusions: Routine scope cultures provide assurance that scopes are properly reprocessed. It serves to identify presence or confirm absence of contamination. It detects damaged scopes and justifies repair, and provides quality control for scope reprocessing.
S1107 Comparison of Anesthesia Associated (AA) Sedation with Conscious Sedation (CS) in Successful Completion of Endoscopic Retrograde Cholangiopancreatography (ERCP) Timothy Laurie, Gene L. Chang, Scott Hammerman, Mani Mahdavian Aim: To assess the success rate in ERCP completion using anesthesia associated sedation versus conscious sedation. Methods: A retrospective patient chart review was performed of all ERCPs at a large community teaching hospital from January 2000 to May 2004. Indications included suspected stone(s), abnormal imaging, abnormal labs, suspected neoplasm, obstructive jaundice, bile leak, evaluation of pancreatitis and pseudocyst. Patients were divided into two groups. Group 1 received AA sedation, either general anesthesia or monitored anesthesia care (MAC), at the discretion of the anesthesiologist. Group 2 received CS by the gastroenterologist. Success of ERCP was defined as successful cannulation of the intended duct system, insertion or removal of stents, stone removal, and therapy of strictures. Failure of ERCP was defined as inadequate sedation or failure to achieve the intended ERCP goal. Results: A total of 732 procedures were performed. 19 subjects were excluded secondary to incomplete medical record. 713 subjects were evaluated (284 males, 429 females). 280 patients received AA (109 males, 171 females) and 433 patients received CS (175 males, 258 females). The mean age group was similar in both groups (64 years). 141/280 AA cases received general anesthesia and 139/280 received MAC anesthesia. There was a failure rate of 8.2% with group 1 and a 19.1% failure rate with group 2 (see table 1). Chi squared analysis performed resulted in a p-value less than 0.0001 with an odds ratio of 2.7 {95%CI (1.625 – 4.321)}. There was an 89.5% success rate in patients with AA who initially failed ERCP with CS. Conclusion: The use of anesthesia assisted sedation is associated with improved success in the performance of ERCPs when compared with the use of conscious sedation.
Table 1.
AB118 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
S1109 A Prospective Study of Endoscopic Complications Using the ODD Score LiLin Lim, Adrian Leong, FongYee Kwok, KhekYu Ho Introduction: Currently there is no universally accepted definition, classification or grading for endoscopic complications. Fleischer et al proposed an ODD score (Outcome, Disability and Death) that looks at both immediate and long-term negative outcomes associated with endoscopic procedures. This scoring system was developed based on retrospective analysis of mortality and morbidity data in their centre. Aims: (1) To prospectively determine the frequency of endoscopic complications in a large endoscopy center (2) To prospectively grade these complications using the ODD scoring system. Methods: We prospectively enrolled consecutive patients O18 years of age undergoing endoscopy at our institution into the study and documented any immediate or delayed complications associated with the endoscopy using a standardized form. Trained nurses also phoned all the patients at days 14 and 30 post-procedure and interviewed them regarding possible procedure-related complications. All complications were graded using the ODD score. Results: Over the study period of 9 months, 4063 procedures (2218 OGDs, 1393 colonoscopies, 193 ERCPs) were performed. A total of 3748 patients completed the phone interviews giving a response rate of 92.2%. Overall there were 12 procedure-related complications (0.29%), including 7 post-ERCP pancreatitis (3.63%), 1 post-ERCP cholangitis (0.52%), 1 post-polypectomy bleeding (0.07%), 1 esophageal perforation post-stricture dilation (4.35%), and 2 PEG-related cellulitis (18.2%) with ODD score ranges of O10-70D20-50D0. Twenty diagnostic and 5 therapeutic procedures were unsuccessfully performed (0.62%). Of these failed procedures, there were 5 OGDs (0.23%), 4 colonoscopies (0.29%), 16 ERCPs (8.29%) with ODD score ranges of O2-65D0-20D5-80. One patient died during hospitalization and this was possibly related to the failed procedure. Conclusions: This prospective study with 30-day follow-up data showed that the overall rate of endoscopic complications in a tertiary endoscopy center is low and comparable to those of other international centers. The ODD scoring system can be used as a means of defining, classifying and grading endoscopic complications and failed procedures.
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S1106 Mortality From EUS Jesse Lachter Introduction: EUS is widely perceived to be, as reported, a very safe procedure. Early statistics, from pooled data, found a one in 37,915 risk of mortality. New instruments, linear EUS, and FNA and other invasive techniques, justify reevaluation of data on complications. Accumulating data on complications suggests major revision of the mortality statistics. Patients and Methods: Following initiation of a national survey of EUS utilization, a repository of information on complications developed. Creation and utilization of this data base led to continuous describing of complications. The higher than expected frequency of such complications, especially of mortalities, led to investigations of each case. Results: Seven local cases, and five cases from outside of Israel, of EUS-caused deaths were found. This series represents more cases than that cumulatively described as case reports in all of the relevant literature of the past 24 years, since the introduction of EUS. In the cases analyzed, FNA was not involved in any procedure. The Pentax instruments with their longer hard tip than the Olympus linear instruments, were involved in six of the seven mortalities; no cases involved Fuji scopes. Notably, only one of the 20 EUS centers in Israel uses a Fuji system. Duodenal tears, leading to retroperitoneal perforations, were the cause of 10 of the 12 deaths. The other two deaths were (one each) from esophageal perforation, and from aspiration. One case occurred from a procedure performed as part of a live demonstration of EUS. At least five cases involved patients with duodenal diverticuli. These diverticuli may have had a role in the cause of doing the EUS, in procedures which were initiated to search for suspected CBD stones. Delay in diagnosis of perforation was common. five of the seven Israeli deaths from EUS occurred during the first year and/or 150 first procedures of the endosonographer. Conclusions: EUS has significantly higher risks than previously thought. The Israeli mortality rate from EUS, averaging about one death from each 2500 procedures, was found to be over 15 times that in the published (somewhat dated) literature. To minimize the risks of death from EUS, this study suggests 1- appropriately long traineeships, 2- attention to duodenal diverticuli, 3- a high index of suspicion of retroperitoneal tears with knowledge of their management, 4- and appreciation of the EUS instrument designs.
S1108 Should Routine Endoscope Cultures Be Done to Monitor Scope Reprocessing? Joseph Leung, Robert Wilson Background: There are strict guidelines for reprocessing of flexible endoscopes. Because of low reported incidence of scope transmitted infections, routine monitoring of scope reprocessing is currently not recommended. However, recent news reports of possible patients’ exposure to hepatitis due to a breach in scope reprocessing prompted hospitals to reassess their scope reprocessing. Aim: Retrospective review of an on-going scope culture protocol. Method: Reprocessed scopes were selected randomly from storage (EGD[e], colonoscope [c], sigmoidoscope [s] and ERCP [E]) and cultured quarterly. We then focused on complex ERCP and EUS (EU) scopes because of more serious consequences of cross infections. With a clean/aseptic approach, sterile saline was flushed through air/water channel and suctioned through biopsy channel, with brushing of the elevator and all suction and biopsy valve ports. All samples from one scope were collected together and sent for routine culture. Positive culture with isolation of bacteria was used as a surrogate for contamination, no viral screening was done. If a scope was tested positive, cultures were repeated till 4 consecutive tests were negative or a cause found to explain the results. Results: Lower GI scopes were more likely to be contaminated (e16%, c44%, s50%, E20%). % positive cultures (table) for past 4 years were E 6,3,14,16,13% and EU24,45,10% respectively. We did not observe any clinically significant infections despite positive cultures. Identified causes included poor technique due to untrained part time technicians; defective automated scope reprocessor; improper scope storage and damaged scopes. Correction of deficiencies led to significant reduction in positive cultures. Conclusions: Routine scope cultures provide assurance that scopes are properly reprocessed. It serves to identify presence or confirm absence of contamination. It detects damaged scopes and justifies repair, and provides quality control for scope reprocessing.
S1107 Comparison of Anesthesia Associated (AA) Sedation with Conscious Sedation (CS) in Successful Completion of Endoscopic Retrograde Cholangiopancreatography (ERCP) Timothy Laurie, Gene L. Chang, Scott Hammerman, Mani Mahdavian Aim: To assess the success rate in ERCP completion using anesthesia associated sedation versus conscious sedation. Methods: A retrospective patient chart review was performed of all ERCPs at a large community teaching hospital from January 2000 to May 2004. Indications included suspected stone(s), abnormal imaging, abnormal labs, suspected neoplasm, obstructive jaundice, bile leak, evaluation of pancreatitis and pseudocyst. Patients were divided into two groups. Group 1 received AA sedation, either general anesthesia or monitored anesthesia care (MAC), at the discretion of the anesthesiologist. Group 2 received CS by the gastroenterologist. Success of ERCP was defined as successful cannulation of the intended duct system, insertion or removal of stents, stone removal, and therapy of strictures. Failure of ERCP was defined as inadequate sedation or failure to achieve the intended ERCP goal. Results: A total of 732 procedures were performed. 19 subjects were excluded secondary to incomplete medical record. 713 subjects were evaluated (284 males, 429 females). 280 patients received AA (109 males, 171 females) and 433 patients received CS (175 males, 258 females). The mean age group was similar in both groups (64 years). 141/280 AA cases received general anesthesia and 139/280 received MAC anesthesia. There was a failure rate of 8.2% with group 1 and a 19.1% failure rate with group 2 (see table 1). Chi squared analysis performed resulted in a p-value less than 0.0001 with an odds ratio of 2.7 {95%CI (1.625 – 4.321)}. There was an 89.5% success rate in patients with AA who initially failed ERCP with CS. Conclusion: The use of anesthesia assisted sedation is associated with improved success in the performance of ERCPs when compared with the use of conscious sedation.
Table 1.
AB118 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
S1109 A Prospective Study of Endoscopic Complications Using the ODD Score LiLin Lim, Adrian Leong, FongYee Kwok, KhekYu Ho Introduction: Currently there is no universally accepted definition, classification or grading for endoscopic complications. Fleischer et al proposed an ODD score (Outcome, Disability and Death) that looks at both immediate and long-term negative outcomes associated with endoscopic procedures. This scoring system was developed based on retrospective analysis of mortality and morbidity data in their centre. Aims: (1) To prospectively determine the frequency of endoscopic complications in a large endoscopy center (2) To prospectively grade these complications using the ODD scoring system. Methods: We prospectively enrolled consecutive patients O18 years of age undergoing endoscopy at our institution into the study and documented any immediate or delayed complications associated with the endoscopy using a standardized form. Trained nurses also phoned all the patients at days 14 and 30 post-procedure and interviewed them regarding possible procedure-related complications. All complications were graded using the ODD score. Results: Over the study period of 9 months, 4063 procedures (2218 OGDs, 1393 colonoscopies, 193 ERCPs) were performed. A total of 3748 patients completed the phone interviews giving a response rate of 92.2%. Overall there were 12 procedure-related complications (0.29%), including 7 post-ERCP pancreatitis (3.63%), 1 post-ERCP cholangitis (0.52%), 1 post-polypectomy bleeding (0.07%), 1 esophageal perforation post-stricture dilation (4.35%), and 2 PEG-related cellulitis (18.2%) with ODD score ranges of O10-70D20-50D0. Twenty diagnostic and 5 therapeutic procedures were unsuccessfully performed (0.62%). Of these failed procedures, there were 5 OGDs (0.23%), 4 colonoscopies (0.29%), 16 ERCPs (8.29%) with ODD score ranges of O2-65D0-20D5-80. One patient died during hospitalization and this was possibly related to the failed procedure. Conclusions: This prospective study with 30-day follow-up data showed that the overall rate of endoscopic complications in a tertiary endoscopy center is low and comparable to those of other international centers. The ODD scoring system can be used as a means of defining, classifying and grading endoscopic complications and failed procedures.
www.mosby.com/gie