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Sa1032 Current State of Endoscopic Submucosal Dissection for Gastric Tumor in Patients Treated With Oral Anticoagulants
Abstracts
submucosal dissection (ESD) is an effective treatment for early stage CRC. However, there is a problem that pain often occurs after treatment. Patients received colorectal ESD often complain of pain, even if colorectal ESD was successful perfomed. The mechanisum of pain is still unknown. The aim of this study is to explore the risk factors of Post colorectal ESD Localized Pain Syndrome (PELPS). Methods: From December 2013 to Octorber 2015, a total of 112 patients (66 men and 46 women) with colorectal tumor who underwent ESD were enrolled in this study at Yokohama City University Hospital. The diagnosis of the colon ESD adaptation lesions was established according to colon ESD/EMR guidelines of the Japan Gastroenterological Endoscopy Society. We investigated age, sex, location of the lesions, operator, the time of ESD, morphological type, the size of lesions, histlogical type, use of antibiotics and the frequency of post colon ESD pain. We defined the local abdominal pain that matched ESD underwent site and that have occurred within two days after colorectal ESD and without perforation as PELPS. We excluded patients who were taking non-steroidal anti-inflammatory drugs (NSAIDs) and history of psychiatric diseases. Results: We performed colon ESD (14 cecum, 35 ascending colon, 9 transverse colon, 8 descending colon, 16 sigmoid colon, 30 rectum) for 112 patients and the size of lesions was 35.5 (11-115)mm. PELPS occurred in 30 patients (17.8%) and 14 of the 20 patients were women. Right lower quadrant pain occurred in 12 (7 cecum and 5 ascending colon) of the 20 patients. Resected specimen>35mm pain occurred in 12 of the 20 patients. Conclusions: PELPS occurred in 20 patinets (17.8%) with colorectal ESD, however, all cases had a good outcome with conservative management. There is a possibility that Women and the location of lesions (cecum and ascending colon) and resected specimen>35mm are significant risk factors for PELPS.
Sa1031 Injection Pain of Propofol During Endoscopy Influences Patient’s Preference of Sedative Agents for the Next Examination Tae Hyung Kwon*, Eun Soo Kim, Yoo Jin Lee, Wang Yong Choi, Jeong Min Kim, Ju yup Lee, Yoon Suk Lee, Kwang Bum Cho, Kyung Sik Park Dong-san Medical Center, Dae-gu, Korea (the Republic of) Background/Aims: Many patients have reported injection pain because of the longchain triglyceride (LCT) in propofol. Recently, propofol formulated with long-/medium-chain triglyceride (LCT/MCT) has been introduced and is expected to reduce injection pain compared with LCT propofol. This study aimed to measure the degree of injection pain caused by these two propofol formulations and to evaluate its impact on patient’s preference of the sedatives for the next EGD. Methods: Subjects scheduled to undergo sedative diagnostic EGD were randomized to LCT/MCT and LCT groups. Each solution was administered into the largest dorsal vein of the nondominant hand. Pain intensity was estimated by an examiner blinded to the group assignment using ‘0–10 Numeric Pain Rating Scale’. Then, patients were asked whether they could remember the pain and their willingness to use the same agent for the next examination after fully waking up in the recovery room. The same questions were asked one week later by a phone call. Results: A total of 129 patients were enrolled in this study; 68 and 61 subjects were randomly assigned to LCT/MCT and LCT groups, respectively. There were no significant differences between two groups in baseline characteristics and indication of endoscopy. LCT/MCT group showed significantly less pain than LCT group (median pain score, 1 vs. 2, pZ0.005). After waking up in the recovery room, more patients in LCT could remember the pain (63.9% vs. 38.2%, pZ0.005) although there was no difference in the willingness to use the same agent for the future examination. However, when asked in one week later, significantly more patients in LCT did not want to use the same one for the next examination (pZ0.048). Conclusions: MCT/LCT propofol is effective in reducing the injection pain during EGD. Injection pain of propofol influences the choice of sedative agents for further examination.
Sa1032 Current State of Endoscopic Submucosal Dissection for Gastric Tumor in Patients Treated With Oral Anticoagulants Takuto Hikichi*1, Ko Watanabe1, Jun Nakamura2, Yuichi Waragai1, Hitomi Kikuchi2, Mika Takasumi2, Minami Hashimoto2, Tadayuki Takagi2, Rei Suzuki2, Mitsuru Sugimoto2, Naoki Konno2, Hiroyuki Asama2, Hiromasa Ohira2, Katsutoshi Obara3 1 Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan; 2Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan; 3Advanced Gastroenterological Endoscopy, Fukushima Medical University, Fukushima, Japan
Objective: ”The guideline for gastroenterological endoscopy in patients treated with oral anticoagulants” issued in 2012 by the Japan Gastroenterological Endoscopy Society recommends drug withdrawal and heparin replacement for endoscopic submucosal dissection (ESD) in patients treated with oral anticoagulants. However, the guideline describes procedures only for dabigatran among the novel oral anticoagulants (NOAC), with which patients are increasingly treated recently. We investigated the current state of gastric ESD in patients treated with oral anticoag-
AB210 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
ulants at our hospital. [Methods] We examined data of patients treated with oral anticoagulants who received gastric ESD from September 2012 through July 2015, including 16 lesions in 14 cases of the warfarin group and 8 lesions in 7 cases of the NOAC group. For both groups, patient backgrounds, procedures during ESD, and hemorrhage after ESD were examined. Results: Ages (median) were 78.5 (59–88) years and 73.0 (57–80) years, respectively, in the warfarin group and the NOAC group, and were higher in the warfarin group (p<0.05). The reasons for oral treatment with warfarin were atrial fibrillation in 8 cases, valve replacement in 3 cases, and other reasons in 3 cases. NOACs were dabigatran in 5 cases, apixaban in 2 cases, and rivaroxaban in 1 case. The reason for treatment was atrial fibrillation in all cases. Concomitant antiplatelet agents were used in 4 cases (28.5%) of the warfarin group and in 3 cases (42.8%) of the NOAC group. Withdrawal and heparin replacement for 3–5 days were performed in 13 cases except for 1 case of withdrawal only in the warfarin group. The NOAC group included 5 cases of withdrawal and heparin replacement for 1–2 days and 2 cases of only withdrawal for 1–2 days. For heparin replacement, heparin treatment was continued in the warfarin group for a few days after restarting warfarin until PT-INR reached the therapeutic range, although it was discontinued on the next day of ESD in the NOAC group. Therefore, procedures were generally in compliance with the guidelines in both groups. Postoperative hemorrhage was observed in 4 cases (28.5%) in the warfarin group and in 1 case (14.2%) having a concomitant antiplatelet drug in the NOAC group (pZ0.46). The time of postoperative hemorrhage was 4 days after ESD during combined heparin and warfarin in 3 of 4 cases, and on the next day of ESD in the other 1 case. The case in the NOAC group was 5 days after ESD after discontinuing heparin and restarting oral treatment on the next day of ESD. Conclusion: It was possible that hemorrhage after gastric ESD occurred less with NOACs than with warfarin. This possibility was apparently related with the fact that there was no period of combination with heparin and that the heparin treatment period was short.
Sa1033 Procedural Factors and Perforation Risk Following Colonic Stent Placement Badr Al-Bawardy*, Shahrooz Rashtak, David Johnson, Mark V. Larson Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background/Aims: Colonic stent placement is effective in alleviating large bowel obstruction for palliation and as bridge to surgery. Bowel perforation is a potential complication of colonic stent placement with a reported incidence rate of 4%-10%. The aim of this study was to evaluate whether procedure related factors and participation of gastroenterology trainees are associated with risk of perforation following colonic stent placement. Methods: Patients who underwent colonic stent placement from January 2011 to December 2014 were identified from a prospectively maintained endoscopy database. Data was abstracted for demographics, stent indication, procedure details and incidence of complications up to 3 months postprocedurally. Procedure related factors as well as participation of trainees were compared between the group of patients who had perforation and those who did not. Chi-square and student-t test were used to compare continuous and categorical variables, respectively. Results: A total of 142 patients (mean age 63 13 years; 53% female) were included in the study. Postprocedural perforation was reported in 12 cases (8.4%). There was no significant difference between the perforation and the non-perforation groups in terms of sex, mean age, primary disease (malignant vs benign), stent location, and active chemotherapy. There was no significant difference between the perforation and non-perforation groups in terms of receiving general anesthesia as compared to conscious sedation(58% vs 56%; pZ0.92), mean length of stent deployed in cm (8.5 vs 9.6; pZ0.1) and placement of multiple stents (17% vs 20%; pZ0.78). In the perforation group 16.6% of the procedures were performed on weekends as compared to 6.9 % in non-perforation group (pZ0.22). None of the patients in the perforation group had procedures performed after-hours on weekdays compared to 7% in the non-perforation group (pZ0.32). Participation of gastroenterology trainees was noted in 42% in the perforation group vs 52% in the non-perforation group (pZ0.51). Conclusion: Procedure related factors, such as weekend or after-hours endoscopy, or participation of gastroenterology trainees were not associated with a higher risk of perforation secondary to colonic stent placement. The study is limited by single center experience and sample size. Further large multicenter studies are needed to validate these findings.
Sa1034 Management of Upper Gastrointestinal Bleeding From the View Point of Medical Economy Yusaku Takatori*, Motohiko Kato, Emi Sakaguchi, Keiichiro Abe, Tetsu Hirata, Yoshiaki Takada, Shigeo Banno, Michiko Wada, Satoshi Kinoshita, Kaoru Takabayashi, Miho Kikuchi, Masahiro Kikuchi, Youichi Fujiyama, Masayuki Suzuki, Toshio Uraoka Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan Background: Non variceal upper gastrointestinal bleeding (NVUGIB) is still a common and life threatening disease which often needs intensive care. Therefore,
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submucosal dissection (ESD) is an effective treatment for early stage CRC. However, there is a problem that pain often occurs after treatment. Patients received colorectal ESD often complain of pain, even if colorectal ESD was successful perfomed. The mechanisum of pain is still unknown. The aim of this study is to explore the risk factors of Post colorectal ESD Localized Pain Syndrome (PELPS). Methods: From December 2013 to Octorber 2015, a total of 112 patients (66 men and 46 women) with colorectal tumor who underwent ESD were enrolled in this study at Yokohama City University Hospital. The diagnosis of the colon ESD adaptation lesions was established according to colon ESD/EMR guidelines of the Japan Gastroenterological Endoscopy Society. We investigated age, sex, location of the lesions, operator, the time of ESD, morphological type, the size of lesions, histlogical type, use of antibiotics and the frequency of post colon ESD pain. We defined the local abdominal pain that matched ESD underwent site and that have occurred within two days after colorectal ESD and without perforation as PELPS. We excluded patients who were taking non-steroidal anti-inflammatory drugs (NSAIDs) and history of psychiatric diseases. Results: We performed colon ESD (14 cecum, 35 ascending colon, 9 transverse colon, 8 descending colon, 16 sigmoid colon, 30 rectum) for 112 patients and the size of lesions was 35.5 (11-115)mm. PELPS occurred in 30 patients (17.8%) and 14 of the 20 patients were women. Right lower quadrant pain occurred in 12 (7 cecum and 5 ascending colon) of the 20 patients. Resected specimen>35mm pain occurred in 12 of the 20 patients. Conclusions: PELPS occurred in 20 patinets (17.8%) with colorectal ESD, however, all cases had a good outcome with conservative management. There is a possibility that Women and the location of lesions (cecum and ascending colon) and resected specimen>35mm are significant risk factors for PELPS.
Sa1031 Injection Pain of Propofol During Endoscopy Influences Patient’s Preference of Sedative Agents for the Next Examination Tae Hyung Kwon*, Eun Soo Kim, Yoo Jin Lee, Wang Yong Choi, Jeong Min Kim, Ju yup Lee, Yoon Suk Lee, Kwang Bum Cho, Kyung Sik Park Dong-san Medical Center, Dae-gu, Korea (the Republic of) Background/Aims: Many patients have reported injection pain because of the longchain triglyceride (LCT) in propofol. Recently, propofol formulated with long-/medium-chain triglyceride (LCT/MCT) has been introduced and is expected to reduce injection pain compared with LCT propofol. This study aimed to measure the degree of injection pain caused by these two propofol formulations and to evaluate its impact on patient’s preference of the sedatives for the next EGD. Methods: Subjects scheduled to undergo sedative diagnostic EGD were randomized to LCT/MCT and LCT groups. Each solution was administered into the largest dorsal vein of the nondominant hand. Pain intensity was estimated by an examiner blinded to the group assignment using ‘0–10 Numeric Pain Rating Scale’. Then, patients were asked whether they could remember the pain and their willingness to use the same agent for the next examination after fully waking up in the recovery room. The same questions were asked one week later by a phone call. Results: A total of 129 patients were enrolled in this study; 68 and 61 subjects were randomly assigned to LCT/MCT and LCT groups, respectively. There were no significant differences between two groups in baseline characteristics and indication of endoscopy. LCT/MCT group showed significantly less pain than LCT group (median pain score, 1 vs. 2, pZ0.005). After waking up in the recovery room, more patients in LCT could remember the pain (63.9% vs. 38.2%, pZ0.005) although there was no difference in the willingness to use the same agent for the future examination. However, when asked in one week later, significantly more patients in LCT did not want to use the same one for the next examination (pZ0.048). Conclusions: MCT/LCT propofol is effective in reducing the injection pain during EGD. Injection pain of propofol influences the choice of sedative agents for further examination.
Sa1032 Current State of Endoscopic Submucosal Dissection for Gastric Tumor in Patients Treated With Oral Anticoagulants Takuto Hikichi*1, Ko Watanabe1, Jun Nakamura2, Yuichi Waragai1, Hitomi Kikuchi2, Mika Takasumi2, Minami Hashimoto2, Tadayuki Takagi2, Rei Suzuki2, Mitsuru Sugimoto2, Naoki Konno2, Hiroyuki Asama2, Hiromasa Ohira2, Katsutoshi Obara3 1 Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan; 2Gastroenterology and Rheumatology, Fukushima Medical University, Fukushima, Japan; 3Advanced Gastroenterological Endoscopy, Fukushima Medical University, Fukushima, Japan
Objective: ”The guideline for gastroenterological endoscopy in patients treated with oral anticoagulants” issued in 2012 by the Japan Gastroenterological Endoscopy Society recommends drug withdrawal and heparin replacement for endoscopic submucosal dissection (ESD) in patients treated with oral anticoagulants. However, the guideline describes procedures only for dabigatran among the novel oral anticoagulants (NOAC), with which patients are increasingly treated recently. We investigated the current state of gastric ESD in patients treated with oral anticoag-
AB210 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
ulants at our hospital. [Methods] We examined data of patients treated with oral anticoagulants who received gastric ESD from September 2012 through July 2015, including 16 lesions in 14 cases of the warfarin group and 8 lesions in 7 cases of the NOAC group. For both groups, patient backgrounds, procedures during ESD, and hemorrhage after ESD were examined. Results: Ages (median) were 78.5 (59–88) years and 73.0 (57–80) years, respectively, in the warfarin group and the NOAC group, and were higher in the warfarin group (p<0.05). The reasons for oral treatment with warfarin were atrial fibrillation in 8 cases, valve replacement in 3 cases, and other reasons in 3 cases. NOACs were dabigatran in 5 cases, apixaban in 2 cases, and rivaroxaban in 1 case. The reason for treatment was atrial fibrillation in all cases. Concomitant antiplatelet agents were used in 4 cases (28.5%) of the warfarin group and in 3 cases (42.8%) of the NOAC group. Withdrawal and heparin replacement for 3–5 days were performed in 13 cases except for 1 case of withdrawal only in the warfarin group. The NOAC group included 5 cases of withdrawal and heparin replacement for 1–2 days and 2 cases of only withdrawal for 1–2 days. For heparin replacement, heparin treatment was continued in the warfarin group for a few days after restarting warfarin until PT-INR reached the therapeutic range, although it was discontinued on the next day of ESD in the NOAC group. Therefore, procedures were generally in compliance with the guidelines in both groups. Postoperative hemorrhage was observed in 4 cases (28.5%) in the warfarin group and in 1 case (14.2%) having a concomitant antiplatelet drug in the NOAC group (pZ0.46). The time of postoperative hemorrhage was 4 days after ESD during combined heparin and warfarin in 3 of 4 cases, and on the next day of ESD in the other 1 case. The case in the NOAC group was 5 days after ESD after discontinuing heparin and restarting oral treatment on the next day of ESD. Conclusion: It was possible that hemorrhage after gastric ESD occurred less with NOACs than with warfarin. This possibility was apparently related with the fact that there was no period of combination with heparin and that the heparin treatment period was short.
Sa1033 Procedural Factors and Perforation Risk Following Colonic Stent Placement Badr Al-Bawardy*, Shahrooz Rashtak, David Johnson, Mark V. Larson Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN Background/Aims: Colonic stent placement is effective in alleviating large bowel obstruction for palliation and as bridge to surgery. Bowel perforation is a potential complication of colonic stent placement with a reported incidence rate of 4%-10%. The aim of this study was to evaluate whether procedure related factors and participation of gastroenterology trainees are associated with risk of perforation following colonic stent placement. Methods: Patients who underwent colonic stent placement from January 2011 to December 2014 were identified from a prospectively maintained endoscopy database. Data was abstracted for demographics, stent indication, procedure details and incidence of complications up to 3 months postprocedurally. Procedure related factors as well as participation of trainees were compared between the group of patients who had perforation and those who did not. Chi-square and student-t test were used to compare continuous and categorical variables, respectively. Results: A total of 142 patients (mean age 63 13 years; 53% female) were included in the study. Postprocedural perforation was reported in 12 cases (8.4%). There was no significant difference between the perforation and the non-perforation groups in terms of sex, mean age, primary disease (malignant vs benign), stent location, and active chemotherapy. There was no significant difference between the perforation and non-perforation groups in terms of receiving general anesthesia as compared to conscious sedation(58% vs 56%; pZ0.92), mean length of stent deployed in cm (8.5 vs 9.6; pZ0.1) and placement of multiple stents (17% vs 20%; pZ0.78). In the perforation group 16.6% of the procedures were performed on weekends as compared to 6.9 % in non-perforation group (pZ0.22). None of the patients in the perforation group had procedures performed after-hours on weekdays compared to 7% in the non-perforation group (pZ0.32). Participation of gastroenterology trainees was noted in 42% in the perforation group vs 52% in the non-perforation group (pZ0.51). Conclusion: Procedure related factors, such as weekend or after-hours endoscopy, or participation of gastroenterology trainees were not associated with a higher risk of perforation secondary to colonic stent placement. The study is limited by single center experience and sample size. Further large multicenter studies are needed to validate these findings.
Sa1034 Management of Upper Gastrointestinal Bleeding From the View Point of Medical Economy Yusaku Takatori*, Motohiko Kato, Emi Sakaguchi, Keiichiro Abe, Tetsu Hirata, Yoshiaki Takada, Shigeo Banno, Michiko Wada, Satoshi Kinoshita, Kaoru Takabayashi, Miho Kikuchi, Masahiro Kikuchi, Youichi Fujiyama, Masayuki Suzuki, Toshio Uraoka Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan Background: Non variceal upper gastrointestinal bleeding (NVUGIB) is still a common and life threatening disease which often needs intensive care. Therefore,
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