Abstracts
M1268 Pancreas Divisum: Long-Term Follow Up after Endoscopic Therapy Gregory Borak, Mohammad Alsolaimon, Edward Holt, Joseph Romagnuolo, Robert H. Hawes, Peter B. Cotton Background: Pancreas Divisum (PD) occurs in approximately 8% of the population, and may cause pancreatic pain and pancreatitis. Small short-term studies have shown that many patients with PD and recurrent pancreatitis benefit from endoscopic therapy, but results are less impressive in other contexts. We have completed a long term study of the effects of endoscopic therapy; preliminary data (n Z 47) were presented at DDW 2004. (ASGE) Methods: We identified all patients coded in our prospective endoscopy database (GITrac) as having minor papilla endoscopic therapy for PD at MUSC between July 1997 to May 2003, and grouped them into 3 categories:- acute recurrent pancreatitis (ARP), chronic pancreatitis (CP), or chronic pain without evidence for pancreatitis (P). We noted the types of endoscopic therapy performed, and then (with IRB approval) attempted to contact the patients to determine their outcomes. Patients were considered to have ‘‘clinical success’’ if they reported improvement or resolution of symptoms and did not require greater than 2 repeat ERCPs or pancreatic surgery. All others were considered treatment failures. Fisher Exact p-values were calculated for comparisons of proportions, with 95% binomial confidence intervals (CI) Results: Follow up was obtained on 114(65%) of the 176 patients identified, at a median of 44 months (range 14-75 months). Patients, who died, were lost to follow up, had only biliary sphincterotomy or no endoscopic therapies were excluded from the analysis(n Z 37 excluded in total). The majority of the remainder patients (78%) were treated with a minor papilla sphincterotomy and stent. Clinical success (defined above) was achieved in 89% [95% CI: 78-95%](55/62) of patients with ARP, 43% [23-66%](10/23) with CP(p!0.001 vs. ARP), and 69% [49-85%] (20/29) with pain only (p Z 0.04 vs.ARP). There was no significant difference between the pain only and the CP groups. Conclusions: This study confirms and expands prior data which show that minor papilla endotherapy is effective for most patients with PD who have acute recurrent pancreatitis, and this benefit persists long-term. Results are less impressive, but not negligible, in patients CP or pain only (at least 23% and 49% respectively, based on CI). Better predictors of success are needed to facilitate patient selection, and the role of co-existing biliary sphincter hypertension needs clarification.
M1270 Factors Predictive of a Difficult Colonoscopy: Does Experience Make a Difference? Marek Czajkowski, Stephen Gerred, Mahfuzul Haque, Susan Parry Background/Aims: To identify within our public hospital gastroenterology unit factors which prolong or make colonoscopy more uncomfortable, and to determine whether these factors are different for experienced or trainee colonoscopists. Methods: Patient information and outcome data were collected prospectively between 1/1/2002 and 31/12/2003. Trainees in this audit were in their second or third year of training and were under indirect supervision unless assistance was requested. Results: 2031 colonoscopies were performed by 7 consultants, 438 by 5 trainees. The preoperative characteristics in both groups were similar although the proportion of inpatients was higher for trainees (31% vs 18%, p Z 0.001).Trainees requested assistance in 24% of cases, however assistance adjusted completion rates were similar (93% vs 95%, p Z 0.082).The median insertion time for consultants and trainees was 11 and 18 minutes respectively. Long ´20 minutes) occurred more commonly with trainees procedures (insertion time Y ´4/5) was reported by 18% of (46% vs 15%, p Z 0.001). Significant pain (score Y patients in both groups. The amount of sedation used by both groups was similar. Factors associated with a long colonoscopy for consultants on uni- or multivariate analysis were: (OR in brackets) female gender (1.6), age O80 years(1.3), BMI !20 (1.5), constipation (2.0), pelvic surgery (1.7), inpatient status(1.8), poor bowel preparation (1.5), and anaemia (1.8). For trainees: age O80 years(1.2), female gender (1.5), pelvic surgery (2.0) and anaemia (1.7). Factors associated with increased discomfort were: Female gender (2.2) BMIO40 (1.8) hysterectomy (3.2), pelvic surgery (2.5), haematochezia (2.5) (trainees only), diarrhoea (1.6) and colorectal cancer screening procedures (1.6). Trainees were more likely to request assistance with in-patients, females, those aged O80 years or where anaemia was the indication. Conclusion: Experience significantly shortens insertion time to the caecum. Common factors predicting a long or painful colonoscopy were identified for both consultants and trainees. Additional factors predicting a prolonged colonoscopy for consultants were masked by the longer insertion times for trainees. Factors anticipating a request for assistance by trainees were identified. If assistance and time are available, patient discomfort and completion rates are not compromised by a trainee performing colonoscopy.
M1269 Cost-Effectiveness of the STRETTA Procedure and Competing Therapies in the Management of Gastroesophageal Reflux Disease (GERD) Dan Comay, Viviane Adam, Wendy Kennedy, Alan Barkun, Serge Mayrand
M1271 Predictors of Time to Endoscopy in Acute Non-Variceal Upper Gastrointestinal Bleeding Using the RUGBE Data Eduardo da Silveira, Alan Barkun, Eric Lam, Lawrence Joseph, Myriam Martel, Karen Bensoussan
Background: Proton pump inhibitors (PPI) are effective in the acute and long-term treatment of GERD, however costs and burden of daily PPI use have driven interest in surgical and endoscopic options. Aim: To evaluate the cost-effectiveness of the Stretta procedure, daily PPI use and laparoscopic Nissen fundoplication (LNF) in the long-term management of GERD. Methods: A Markov model was built to estimate costs and health outcomes in Canadian patients with documented GERD from the perspective of a provincial Ministry of Health. Strategies included daily PPI, LNF and Stretta. Patients were assumed responsive to PPI at enrollment. Probabilities, such as response, relapse and complication rates, and utility weights were derived from published literature and subjected to sensitivity analyses. Initial Stretta response rates were drawn from a sham-controlled trial, with long-term efficacy extrapolated from published clinical experience. Outcomes were costs (CDN$, 2004), symptom-free months (SFM), quality-adjusted life-years (QALY) and incremental cost-effectiveness ratios (ICER). Length of cycles was 6 months for a time horizon of 5 years (60 months). Results: Stretta was the least costly strategy ($4,143) followed by PPI ($4,703) and LNF ($6,233). PPI had the greatest SFM (60.00), compared to LNF (58.32) and Stretta (56.77). QALYs were 4.965, 4.954 and 4.950 for LNF, Stretta and PPI respectively. PPI dominated LNF (for SFM) and Stretta dominated PPI (for QALY) in the base-case. The ICERs were $173/SFM for PPI and $190,000/QALY for LNF, both relative to Stretta. The cost advantage for Stretta was challenged if initial Stretta success rate was !43% (base-case 61%) or if recurrence of symptoms post Stretta (requiring daily PPI) was O19% (base-case 6.5%). Stretta was the most effective strategy (QALY) when initial success rate was O79%. Disposable Stretta catheter costs of !$1,795 (base-case $1,235) rendered this arm more costly than PPI. If a 20mg-tablet of omeprazole cost !$1.92 (base-case $2.52) or total costs of surgery were !$2,926 (base-case $5,016), then PPI and LNF would be least costly, respectively. Conclusions: In patients with GERD responsive to PPI, the Stretta procedure was an effective, cost-saving alternative to daily PPI use and LNF. Results were sensitive to initial treatment success (symptom-free off PPI over 43%), durability of response (symptom recurrence below 19%) and variation in key cost drivers.
Introduction: Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness when managing patients with non variceal upper gastrointestinal bleeding (NVUGIB). However little information is known about factors which may affect the time from onset of bleeding until performance of the endoscopy. Aim: To determine variables which predict time to endoscopy in patients with new onset NVUGIB. Methods: The Canadian Registry of patients with Upper Gastrointestinal Bleeding undergoing Endoscopy (RUGBE) is a multi-center database collected for the purpose of obtaining descriptive data on patients with NVUGIB in Canada. RUGBE includes 217 variables on 1869 patients collected between 1999 and 2002 and methods have been validated and detailed in full publications previously. Linear regression models were used with time between admission (outpatients) or onset of bleeding (inpatients) and performance of endoscopy as the dependent variable. Selected variables relating to patients’ characteristics prior to endoscopy were assessed as independent predictors. Results: The study population consisted of 1675 patients (89.6%) who underwent gastroscopy within 48 hours. Endoscopy after working hours (6 PM–8 AM) [CI (-5.62; -1.65)], availability of nurse on-call for the procedure [CI (ÿ3.84; ÿ1.16)], worsening in health status (ASA score) [CI (ÿ1.77; ÿ0.33)] and admission to ICU [CI (ÿ5.12; ÿ1.67)] were associated with a shorter interval to endoscopy. Increasing age [CI (0.005; 0.077)], presence of chest pain (CP) [CI (1.63; 5.72)] or dyspnea [CI (1.42; 4.84), absence of gross blood on rectal examination [CI (1.20; 4.23)] and inpatient status [CI (4.31; 7.45)] were independent predictors of delayed endoscopy. A subgroup analysis showed that health status, presence of CP and findings on rectal were independent predictors in hospitalized patients. In contrast, time of the day of the endoscopy, availability of on-call nurse, age, admission to ICU, dyspnea, chest pain and absence of gross blood on rectal exam were independent predictors for outpatients. Conclusions: These predictive models suggest that the timing of endoscopy in patients with NVUGIB is dependent on both clinical and administrative parameters, which differ between in- and out-patient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy as is currently recommended to improve patient outcomes.
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Volume 61, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY AB149