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Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database
Abstracts
insertion include using an antegrade approach and the absence of previous small bowel resection. When the location of a small intestinal lesion is uncertain, an antegrade approach is preferred to achieve maximal depth of insertion. Use of fluoroscopy is unlikely to increase depth of insertion and should be avoided to decrease resource utilization.
T1491 Case Series of Endoscopic Submucosal Dissection (ESD) for Early Remnant Gastric Cancer After Subtotal Gastrectomy Satoshi Mochizuki, Tomonori Yano, Shinya Tsuruta, Keiko Minashi, Hiroaki Ikematsu, Kazuhiro Kaneko, Toshihiko Doi, Atsushi Ohtsu Background: ESD for early gastric cancer (GC) is technically well established, and accepted as a less invasive treatment than gastrectomy. ESD for remnant GC is technically difficult because of the narrow working space, severe fibrosis and stapling instrument around the suture line. However, there are few reports on ESD for remnant GC. Aim: This case series was to evaluate the feasibility and efficacy of ESD for early remnant GC. Method: The indication of ESD for early GC in our institution is an intramucosal differentiated adenocarcinoma without ulceration, or with ulceration only if the tumor size is 3 cm or less in diameter. The inclusion criteria of this study were as follows. 1) Patients had previous subtotal gastrectomy. 2) One or more follow-up examinations were performed after ESD to evaluate recurrence. The procedures were as follows. 1) Marking spots were made with argon plasma coagulation (APC; APC300, Erbe, Italy) on circumference of the lesion. 2) Saline solution was injected into the submucosal (SM) layer. 3) A circumferential incision was made with an insulation-tipped knife (IT knife; Olympus, Tokyo, Japan) just outside the marking spots. 4) Direct dissection of the SM layer was made using the IT knife, and occasionally in combination with a conventional needle knife in cases of massive fibrosis in the SM layer. Experienced pathologists evaluated the specimens. If the lateral and deep margins of En Bloc resected specimen was definitely cancer free and no tumor invasion into vessel nor deep SM layer they defined that the ESD had achieved a curative resection. Results: Between Jan 2002 and Dec 2007, 865 patients with early GC underwent ESD in our institution. Seventeen patients with remnant early GC were included: 15 men and 2 women, with a median age of 68 years (range 54-80). The previous gastric resection included distal (nZ12), proximal (nZ4) and partial (nZ1) gastrectomy. The median tumor size was 11 mm (range 6-28 mm). The median duration of the ESD procedure was 60 min (range 25-165 min). En bloc resection was performed in 16 (94%) patients. Fourteen (82%) patients achieved curative resection, and the other three did not achieved because of pathological finding. ESD was interrupted and changed to strip biopsy in a patient because of technical difficulty and bleeding, however there was no case of perforation or severe bleeding requiring blood transfusion. Local recurrence was detected in a patient with noncurative resection, who was cured with a second ESD. No patient required additional total remnant gastrectomy. Conclusion: ESD for early remnant GC is technically feasible, and provides a high curative resection rate.
have normal exams (65.5% vs 30.7%) and a lower prevalence of stricture (9.4% vs 42.3%) and SR (3.7% vs 13.8%) compared to whites. 4202 (13.8%) pts had multiple endoscopies for dysphagia during the time period. Males were more likely to undergo multiple EGD’s than females (15.3% vs 12.8%, pZ0.001). Normal and EU were more frequent in single EGD. Stricture, EFI, suspected malignancy and SR were more frequent in pts undergoing multiple EGD’s (p!0.0001 for all comparisons). Conclusion: The prevalence of endoscopic findings among pts with dysphagia differs significantly by gender, age, and repeat procedure. For all pts, the most common findings in descending order were: stricture, normal, EU, SR, EFI, and suspected malignancy. For pts undergoing repeat procedure, normal and esophagitis were significantly less and all abnormal findings were significantly more common.
T1493 Endoscopy Is Safe in Patients with Upper Gastrointestinal Hemorrhage and Low Hematocrit Valeska Balderas, Luis F. Lara, Jayaprakash Sreenarasimhaiah, Shou Jiang Tang, William C. Santangelo, Samir Gupta, Don C. Rockey Background: In patients with acute upper gastrointestinal bleeding (UGIB), the standard practice is to transfuse packed red blood cells (PRBC) to a minimal hemoglobin (Hgb) of 10 g/dL or hematocrit (HCT) of 30g/dL, endpoints that are largely arbitrary (except perhaps for patients with cardiovascular comorbidities). We have observed low morbidity in patients undergoing endoscopy regardless of HCT at the time of endoscopy suggesting it is safe. Aim: To evaluate the morbidity and mortality according to the hematocrit in patients with UGIB undergoing EGD. Methods: We evaluated patients seen at Parkland Memorial Hospital from July to October 2008 with UGIB who were included in the UT Southwestern GI Bleeding Team registry. Clinical data was abstracted, including demographics, clinical history, laboratory data, blood transfusions and outcomes including death. Patients with lower GI bleeding, age under 18, or who were pregnant were excluded. Results: 108 patients (age 47.7 1.1;72 males) were identified (77 hematemesis, 30 melena, 1 hematochezia). 43 patients were transfused PRBCs. At time of endoscopy, the mean HCT was 29.4% (0.7). The HCT was O30% (mean 35.6 0/7) in 46 (43%), 25.1 to 30% in 34 (31%), 20.1 to 25 in 25 (22%), and ! 20% in 5 (4%). There were 11 (10%) deaths (8 males). Three patients died in 48 hours, 7 during the hospitalization and one in 30 days. There was no difference in the mean HCT between the patients that died and those that survived (25.5% 1.7 vs. 28.2% 0.9, pZNS). No significant difference in any outcome was noted in those with HCT less than 30% compared to those with HCT over 30% including age, gender, platelet count, units of blood transfused, Blatchford or Rockall score, history of smoking or alcohol abuse, length of hospitalization, ICU admission or duration of stay, or cardiovascular events (stroke or myocardial infarction). Conclusion: The outcome of patients presenting with an UGIB did not appear to be affected by the HCT at time of endoscopy. Moreover, the HCT at time of endoscopy was !30% in the majority (57%) of the patients in this cohort, and was ! 25% in 30/108 (28%) of patients. Mortality and morbidity were independent of the HCT at time of endoscopy. A ‘‘restrictive’’ transfusion approach may be indicated in patients with UGIH considering published data that suggests an increased mortality associated with blood transfusions.
T1492 Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database Chaya Krishnamurthy, Kathryn Peterson, Kristen Hilden, Nora Mattek, John C. Fang
T1494 Time Trends in Colonoscopy Volume in the United States from 2002 to 2007 Sameer D. Saini, David A. Lieberman, Jennifer L. Holub, Dawn Peters, Philip Schoenfeld
Background: Dysphagia is a common indication for upper endoscopy. The different endoscopic findings are well known but the prevalence of these findings is not. There is also no data on the prevalence according to demographics or by single vs repeat EGD. Purpose: To determine the prevalence of endoscopic findings in patients (pts) presenting with dysphagia and if these findings differ with regards to age, gender, ethnicity and repeat procedure. Methods: The Clinical Outcomes Research Initiative (CORI) data base was queried from 1/2000 - 9/2006 for upper endoscopies performed for dysphagia. The overall frequency of endoscopic findings was determined and by gender, age, ethnicity and single vs. multiple procedures. Findings were grouped into normal esophagus, esophagitis/ esophageal ulcer (EU), esophageal food impaction (EFI), suspected malignancy, stricture and Schatzki ring (SR). Chi-square analysis was used to analyze categorical variables. Results: 30,377 total pts were identified. For race/ethnicity analyses, a total of 29,337 was used. Esophageal stricture was the most common finding followed by normal, EU, SR, EFI and suspected malignancy. Males were more likely to undergo multiple endoscopies than females (15.3% vs 12.8%, pZ0.001). Women were more likely to have a normal exam (37.2% vs 25.4%, p!0.0001). Men were more likely to have EU, EFI, stricture & suspected malignancy (p! 0.001 for all comparisons). The prevalence of SR among males and females was not different (p Z 0.90). Pts over 60 (vs!60) had a higher prevalence of suspected malignancy (1.3% vs 0.4%), stricture (45.9% vs 35.6%) & SR (14.7% vs 11.9%) (p!0.0001 for all comparisons). (Esophageal stricture was most common in white non-Hispanic pts compared to other ethnic groups. Asian/pacific islander pts were most likely to
Background: In 2001, Medicare instituted reimbursement for average-risk screening colonoscopy. Several studies have reported an increase in colonoscopy volume in the period immediately following this change in Medicare policy. However, it is unknown if colonoscopy volume has continued to increase in the ensuing years. The purpose of this study was to quantify changes in colonoscopy volume between 2002 and 2007. Methods: We performed a longitudinal retrospective cohort study using endoscopist- and procedure-level data from the Clinical Outcomes Research Initiative (CORI) database. All colonoscopies performed between 2002 and 2007 were eligible for inclusion in the analysis. Endoscopists performing fewer than 100 colonoscopies in any year of analysis were excluded. Data were extracted on annual colonoscopy volume for each endoscopist as well as the indication for each colonoscopy (average-risk screening or surveillance). To fully account for the multiple data points (colonoscopies) within each endoscopist (panel data), we used generalized estimating equations (GEE) rather than simple linear regression (aggregate data) to compare annual changes in colonoscopy volume. Results: 142 endoscopists performed 481,883 procedures during the time period and were included in the analysis. 85% of procedures were performed in a community/HMO setting, and 9% and 5% were performed in a VA/Military and non-VA academic setting, respectively. Common indications for colonoscopy were average-risk screening (24% of procedures) and surveillance (21%). Mean colonoscopy volume per endoscopist gradually increased between 2002 (476 colonoscopies per year (CPY)) and 2006 (616 CPY), but then decreased slightly to 574 CPY in 2007 (p!0.0001 for each year compared to 2002). In subgroup analyses by indication
AB310 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
www.giejournal.org
insertion include using an antegrade approach and the absence of previous small bowel resection. When the location of a small intestinal lesion is uncertain, an antegrade approach is preferred to achieve maximal depth of insertion. Use of fluoroscopy is unlikely to increase depth of insertion and should be avoided to decrease resource utilization.
T1491 Case Series of Endoscopic Submucosal Dissection (ESD) for Early Remnant Gastric Cancer After Subtotal Gastrectomy Satoshi Mochizuki, Tomonori Yano, Shinya Tsuruta, Keiko Minashi, Hiroaki Ikematsu, Kazuhiro Kaneko, Toshihiko Doi, Atsushi Ohtsu Background: ESD for early gastric cancer (GC) is technically well established, and accepted as a less invasive treatment than gastrectomy. ESD for remnant GC is technically difficult because of the narrow working space, severe fibrosis and stapling instrument around the suture line. However, there are few reports on ESD for remnant GC. Aim: This case series was to evaluate the feasibility and efficacy of ESD for early remnant GC. Method: The indication of ESD for early GC in our institution is an intramucosal differentiated adenocarcinoma without ulceration, or with ulceration only if the tumor size is 3 cm or less in diameter. The inclusion criteria of this study were as follows. 1) Patients had previous subtotal gastrectomy. 2) One or more follow-up examinations were performed after ESD to evaluate recurrence. The procedures were as follows. 1) Marking spots were made with argon plasma coagulation (APC; APC300, Erbe, Italy) on circumference of the lesion. 2) Saline solution was injected into the submucosal (SM) layer. 3) A circumferential incision was made with an insulation-tipped knife (IT knife; Olympus, Tokyo, Japan) just outside the marking spots. 4) Direct dissection of the SM layer was made using the IT knife, and occasionally in combination with a conventional needle knife in cases of massive fibrosis in the SM layer. Experienced pathologists evaluated the specimens. If the lateral and deep margins of En Bloc resected specimen was definitely cancer free and no tumor invasion into vessel nor deep SM layer they defined that the ESD had achieved a curative resection. Results: Between Jan 2002 and Dec 2007, 865 patients with early GC underwent ESD in our institution. Seventeen patients with remnant early GC were included: 15 men and 2 women, with a median age of 68 years (range 54-80). The previous gastric resection included distal (nZ12), proximal (nZ4) and partial (nZ1) gastrectomy. The median tumor size was 11 mm (range 6-28 mm). The median duration of the ESD procedure was 60 min (range 25-165 min). En bloc resection was performed in 16 (94%) patients. Fourteen (82%) patients achieved curative resection, and the other three did not achieved because of pathological finding. ESD was interrupted and changed to strip biopsy in a patient because of technical difficulty and bleeding, however there was no case of perforation or severe bleeding requiring blood transfusion. Local recurrence was detected in a patient with noncurative resection, who was cured with a second ESD. No patient required additional total remnant gastrectomy. Conclusion: ESD for early remnant GC is technically feasible, and provides a high curative resection rate.
have normal exams (65.5% vs 30.7%) and a lower prevalence of stricture (9.4% vs 42.3%) and SR (3.7% vs 13.8%) compared to whites. 4202 (13.8%) pts had multiple endoscopies for dysphagia during the time period. Males were more likely to undergo multiple EGD’s than females (15.3% vs 12.8%, pZ0.001). Normal and EU were more frequent in single EGD. Stricture, EFI, suspected malignancy and SR were more frequent in pts undergoing multiple EGD’s (p!0.0001 for all comparisons). Conclusion: The prevalence of endoscopic findings among pts with dysphagia differs significantly by gender, age, and repeat procedure. For all pts, the most common findings in descending order were: stricture, normal, EU, SR, EFI, and suspected malignancy. For pts undergoing repeat procedure, normal and esophagitis were significantly less and all abnormal findings were significantly more common.
T1493 Endoscopy Is Safe in Patients with Upper Gastrointestinal Hemorrhage and Low Hematocrit Valeska Balderas, Luis F. Lara, Jayaprakash Sreenarasimhaiah, Shou Jiang Tang, William C. Santangelo, Samir Gupta, Don C. Rockey Background: In patients with acute upper gastrointestinal bleeding (UGIB), the standard practice is to transfuse packed red blood cells (PRBC) to a minimal hemoglobin (Hgb) of 10 g/dL or hematocrit (HCT) of 30g/dL, endpoints that are largely arbitrary (except perhaps for patients with cardiovascular comorbidities). We have observed low morbidity in patients undergoing endoscopy regardless of HCT at the time of endoscopy suggesting it is safe. Aim: To evaluate the morbidity and mortality according to the hematocrit in patients with UGIB undergoing EGD. Methods: We evaluated patients seen at Parkland Memorial Hospital from July to October 2008 with UGIB who were included in the UT Southwestern GI Bleeding Team registry. Clinical data was abstracted, including demographics, clinical history, laboratory data, blood transfusions and outcomes including death. Patients with lower GI bleeding, age under 18, or who were pregnant were excluded. Results: 108 patients (age 47.7 1.1;72 males) were identified (77 hematemesis, 30 melena, 1 hematochezia). 43 patients were transfused PRBCs. At time of endoscopy, the mean HCT was 29.4% (0.7). The HCT was O30% (mean 35.6 0/7) in 46 (43%), 25.1 to 30% in 34 (31%), 20.1 to 25 in 25 (22%), and ! 20% in 5 (4%). There were 11 (10%) deaths (8 males). Three patients died in 48 hours, 7 during the hospitalization and one in 30 days. There was no difference in the mean HCT between the patients that died and those that survived (25.5% 1.7 vs. 28.2% 0.9, pZNS). No significant difference in any outcome was noted in those with HCT less than 30% compared to those with HCT over 30% including age, gender, platelet count, units of blood transfused, Blatchford or Rockall score, history of smoking or alcohol abuse, length of hospitalization, ICU admission or duration of stay, or cardiovascular events (stroke or myocardial infarction). Conclusion: The outcome of patients presenting with an UGIB did not appear to be affected by the HCT at time of endoscopy. Moreover, the HCT at time of endoscopy was !30% in the majority (57%) of the patients in this cohort, and was ! 25% in 30/108 (28%) of patients. Mortality and morbidity were independent of the HCT at time of endoscopy. A ‘‘restrictive’’ transfusion approach may be indicated in patients with UGIH considering published data that suggests an increased mortality associated with blood transfusions.
T1492 Endoscopic Findings in Patients Presenting with Dysphagia: Analysis of a National Endoscopy Database Chaya Krishnamurthy, Kathryn Peterson, Kristen Hilden, Nora Mattek, John C. Fang
T1494 Time Trends in Colonoscopy Volume in the United States from 2002 to 2007 Sameer D. Saini, David A. Lieberman, Jennifer L. Holub, Dawn Peters, Philip Schoenfeld
Background: Dysphagia is a common indication for upper endoscopy. The different endoscopic findings are well known but the prevalence of these findings is not. There is also no data on the prevalence according to demographics or by single vs repeat EGD. Purpose: To determine the prevalence of endoscopic findings in patients (pts) presenting with dysphagia and if these findings differ with regards to age, gender, ethnicity and repeat procedure. Methods: The Clinical Outcomes Research Initiative (CORI) data base was queried from 1/2000 - 9/2006 for upper endoscopies performed for dysphagia. The overall frequency of endoscopic findings was determined and by gender, age, ethnicity and single vs. multiple procedures. Findings were grouped into normal esophagus, esophagitis/ esophageal ulcer (EU), esophageal food impaction (EFI), suspected malignancy, stricture and Schatzki ring (SR). Chi-square analysis was used to analyze categorical variables. Results: 30,377 total pts were identified. For race/ethnicity analyses, a total of 29,337 was used. Esophageal stricture was the most common finding followed by normal, EU, SR, EFI and suspected malignancy. Males were more likely to undergo multiple endoscopies than females (15.3% vs 12.8%, pZ0.001). Women were more likely to have a normal exam (37.2% vs 25.4%, p!0.0001). Men were more likely to have EU, EFI, stricture & suspected malignancy (p! 0.001 for all comparisons). The prevalence of SR among males and females was not different (p Z 0.90). Pts over 60 (vs!60) had a higher prevalence of suspected malignancy (1.3% vs 0.4%), stricture (45.9% vs 35.6%) & SR (14.7% vs 11.9%) (p!0.0001 for all comparisons). (Esophageal stricture was most common in white non-Hispanic pts compared to other ethnic groups. Asian/pacific islander pts were most likely to
Background: In 2001, Medicare instituted reimbursement for average-risk screening colonoscopy. Several studies have reported an increase in colonoscopy volume in the period immediately following this change in Medicare policy. However, it is unknown if colonoscopy volume has continued to increase in the ensuing years. The purpose of this study was to quantify changes in colonoscopy volume between 2002 and 2007. Methods: We performed a longitudinal retrospective cohort study using endoscopist- and procedure-level data from the Clinical Outcomes Research Initiative (CORI) database. All colonoscopies performed between 2002 and 2007 were eligible for inclusion in the analysis. Endoscopists performing fewer than 100 colonoscopies in any year of analysis were excluded. Data were extracted on annual colonoscopy volume for each endoscopist as well as the indication for each colonoscopy (average-risk screening or surveillance). To fully account for the multiple data points (colonoscopies) within each endoscopist (panel data), we used generalized estimating equations (GEE) rather than simple linear regression (aggregate data) to compare annual changes in colonoscopy volume. Results: 142 endoscopists performed 481,883 procedures during the time period and were included in the analysis. 85% of procedures were performed in a community/HMO setting, and 9% and 5% were performed in a VA/Military and non-VA academic setting, respectively. Common indications for colonoscopy were average-risk screening (24% of procedures) and surveillance (21%). Mean colonoscopy volume per endoscopist gradually increased between 2002 (476 colonoscopies per year (CPY)) and 2006 (616 CPY), but then decreased slightly to 574 CPY in 2007 (p!0.0001 for each year compared to 2002). In subgroup analyses by indication
AB310 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
www.giejournal.org