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Sa1037 Music Therapy for Elderly Patients Undergoing Colonoscopy: A Prospective Randomized Controlled Trial
Abstracts
Sa1037 Music Therapy for Elderly Patients Undergoing Colonoscopy: A Prospective Randomized Controlled Trial Sureeporn Jangsirikul*1, Wiriyaporn Ridtitid1, Tanisa Patcharatrakul1, Rapat Pittayanon1, Chonlada Phathong1, Wachinee Phromchampa1, Yuwadee Y. Ponauthai1, Sookjaroen Tangwongchai2, Rungsun Rerknimitr1, Bussakorn Binson3, Sutep Gonlachanvit1 1 Division of Gastroenterology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand; 2Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 3Faculty of Fine and Applied Arts, Chulalongkorn University, Bangkok, Thailand Although previous studies reported music therapy help reduce anxiety and pain during endoscopy, the outcomes of these data have been inconsistent. Aim: To determine the effects of music therapy on psychological and physiological status in elderly patients undergoing colonoscopy. Methods: We did a 2-month survey in 45 patients undergoing colonoscopy in our institute before study enrollment to find the patients’ most favorable music type. Then, consecutive elderly patients who required colonoscopy were recruited. Patients with hearing problem, dementia, severe comorbidities and history of colorectal surgery were excluded. Patients were randomized into 1) group A: control group (no music); 2) group B: Lug Krung music, a traditional Thai music incorporated Thai melodies with western classical music which was the most favorable music from the survey.; and 3) group C: instrumental music. Music was broadcasted from the central system of the endoscopy unit. Psychological status (fear, nervous and anxiety) was assessed by using a visual analog scale during pre-endoscopy and post-endoscopy periods. During colonoscopy, behavioral pain assessment (BPA) scale was used for evaluating pain. All patients used the same starting dose of 2.5 mg midazolam and 25 mg pethidine and were titrated up 2.5 mg and 25 mg respectively when the pain assessment scale increased at least 2 points. Physiological changes were measured, including blood pressure and heart rate. Results: 37, 40 and 36 patients (age 64.00.7 years) were included in group A, B, and C, respectively. Baseline characteristics were similar between the three groups (Table1). At 10 minutes after registration, the nervous and fear scores in group B were significantly lower than the control group (p<0.05) whereas the psychological status scores in group C were not different from the control group. At the time before starting sedation, the nervous score in group B was still significantly lower than the control group (pZ0.02). During the colonoscopy, total scores of BPA were lower in group B compared to the control group, but did not reach statistical significance except the “restlessness” subscores which were significantly lower than group A and group C (p<0.05). Physiological status was not different among groups. Although the dose of midazolam was similar among groups, the dose of pethidine in group B was significantly lower than group C (pZ0.04) (Table 2). Conclusions: Among elderly patients undergoing colonoscopy, music intervention reduced psychological stress, including nervous and fear, at preendoscopy period. During the procedure, pain relief and lower dosage of analgesics were also documented in patients who listened to their favorable music compared to other music types. This suggests music intervention using patients’ favorable music provides benefit for elderly patients undergoing colonoscopy.
Table 1. Baseline characteristics of the enrolled patients Characteristics Mean age (SEM), years Underlying disease; n (%) Diabetes Coronary heart disease Indications for colonoscopy; n(%) Colorectal cancer screening (no symptoms) Anemia Bowel habit change Abdominal pain Bloating Baseline physiological status; mean (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Subgroup in patients who had baseline SBP > 140 mmHg Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute)
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Group A (n[37)
Group B (n[40)
Group C (n[36)
pvalue
63.0(1.3)
65.3(1.1)
63.7(1.0)
NS
3(8.1) 1(2.7)
6(15) 2(5%)
6(16.7) 0(0)
NS NS
30(81.1)
31(79.5)
31(86.1)
NS
2(5.4) 3(8.1) 2(5.4) 0
2(5.1) 1(2.6) 1(2.6) 3(7.7)
1(2.8) 3(8.3) 0 0
NS NS NS NS
141.3(3.9) 77.0(2.1)* 67.3(1.9) nZ17
142.5(3.6) 81.2(2.0) 72.5(2.1) nZ25
146.9(1.6) 82.6(2.6)* 68.1(1.9) nZ23
NS 0.003* NS
164.1(4.6) 83.8(2.5) 74.0(3.2)
157.5(3.1)* 175.3(5.4)* 0.018* 88.7(2.2) 93.6(2.8) NS 73.6(2.7) 68.7(2.1) NS
Characteristics Subgroup in patients who had baseline SBP 140 mmHg Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute)
Group A (n[37)
Group B (n[40)
Group C (n[36)
nZ20
nZ15
nZ13
125.5(1.6) 71.9(2.7) 65.6(2.0)
122.1(3.9) 75.7(3.0) 70.7(3.6)
125.8(2.6) 78.2(2.1) 66.0(2.6)
pvalue
NS NS NS
Group A Z no music, Group B Z Thai music, Group C Z Instrumental music, NS Z no statistical significance (p>0.05 between 3 groups)
Table 2. Effects of music therapy in patients undergoing colonoscopy Outcomes
Group A (n[37)
Group B (n[40)
Group C (n[36)
p-value
1(0.3)* 1.4(0.3)* 2.2(0.4)
2(0.4) 2.1(0.5) 2.6(0.5)
0.02* 0.04* NS
1.0(0.4)* 1.2(0.4) 2.0(0.4)
1.6(0.4) 1.9(0.5) 2.3(0.5)
0.02* NS NS
-3.8(2.8) -0.1(2.3)
-16.1(6.6) 1.9(3.6)
NS NS
-3.1(1.6)
-7.9(1.8)
NS
12.8(3.5) 2.7(5.2)
7.4(4.3) -0.4(3.5)
NS NS
0.9(2.2)
2.6(1.6)
NS
27(67.5) 13(32.5) 0*
16(44.4) 16(44.4) 4(11.1)*
NS NS 0.046*
7(18.9) 1(2.7)
38(95.0) *,** 2(5.0)* 0
24(66.7) 0.042*,0.002** ** 10(27.8)* 0.01* 2(5.6) NS
32(86.5) 4(10.8) 1(2.7)
39(97.5)* 1(2.5)* 0
26(72.2)* 10(27.8)* 0
0.002* 0.002* NS
32(86.5) 5(13.5) 0
36(90.0) 4(10.0) 0
28(77.8) 7(19.4) 1(2.8)
NS NS NS
31(83.8) 5(13.5) 1(2.7)
38(95.0)* 2(5.0)* 0
26(72.2)* 8(22.2)* 2(5.6)
0.01* 0.04* NS
2.1 Pre-endoscopy (10 minutes after registration) Psychological status (VAS 0-10)(SEM) Nervous 2.3(0.4)* Fear 2.6(0.5)* Anxiety 3.2(0.5) 2.2 At the time before starting procedure Psychological status (VAS 0-10)(SEM) Nervous 2.3(0.5)* Fear 2.5(0.5) Anxiety 2.9(0.5) Physiologic changes vs. pre-endoscopy; (At the time before starting procedure – at 10 minutes after registration) Patients who had baseline SBP > 140 mmHg (SEM) Systolic Blood pressure (mmHg) -8.2(4.7) Diastolic Blood pressure -5.4(2.1) (mmHg) Heart rate (per minute) 0.8(2.2) Patients who had baseline SBP 140 mmHg (SEM) Systolic Blood pressure (mmHg) 12.4(3.7) Diastolic Blood pressure 8.2(3.3) (mmHg) Heart rate (per minute) 4.7(2.2) 2.3 During the procedure (under sedation) Behavioral pain assessment score Face expression (score 0-2), n(%) 0 23(62.2) 1 13(35.1) 2 1(2.7) Restlessness (score 0-2), n(%) 0 29(78.4)* 1 2 Muscle tones (score 0-2), n(%) 0 1 2 Vocalization (score 0-2), n(%) 0 1 2 Consolability (%) 0 1 2
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB163
Abstracts
Outcomes Physiologic changes vs. preendoscopy; (during procedure – at 10 minute after registration) Patients who had baseline SBP > 140 mmHg (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Patients who had baseline SBP 140 mmHg (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Total dose of midazolam required (mg) (SEM) Total dose of pethidine required (mg) (SEM)
Group A (n[37)
Group B (n[40)
Group C (n[36)
p-value
22.9(4.5) -0.5(2.1)
16.2(2.9) -4.6(2.2)
30.0(6.5) -9.3(3.6)
NS NS
-6.0(2.2)
-1.5(2.1)
1.3(1.8)
NS
-3.8(3.5) 7.5(3.2)
-4.8(3.5) 1.3(5.1)
2.9(4.4) -1.5(3.6)
NS NS
4.2(2.0) 3.7(0.6)
0.3(2.2) 3.1(0.2)
1.0(1.5) 3.6(0.2)
NS NS
30.4(1.7)
27.5(1.5)* 32.6(2.0)*
0.04*
Group A Z no music (control), Group B Z Thai music, Group C Z Instrumental music, NS Z no statistical significance Data expressed as standard error of the mean (SEM)
Sa1038 Low Serum Trypsin Levels Predict Deep Pancreatic Cannulation Failure During ERCP in Patients With Chronic Pancreatitis Tina Boortalary*2,3, Niloofar Yahyapourjalaly1,2, Robert Moran2, Yen-I Chen2, Farshid Fargahi2, Mahya Faghih2, Ayesha Kamal2, Venkata S. Akshintala2, Nasim Parsa2, Saowonee Ngamruengphong2, Vivek Kumbhari2, Anthony N. Kalloo2, Mouen A. Khashab2, Vikesh Singh2 1 Medstar Health, Baltimore, MD; 2Department of Gastroenterology, Johns Hopkins University School of medicine, Baltimore, MD; 3George Washington University, Washington Background: Deep pancreatic cannulation failure (DPCF) during ERCP in patients with chronic pancreatitis (CP) can occur in the presence of duct obstruction due to strictures and/or stones. There are currently no simple preprocedure clinical or laboratory tests that can predict DPCF during ERCP. Since low serum trypsin levels have been correlated with advanced chronic pancreatitis and exocrine insufficiency, we hypothesized that it might be a useful preprocedure test for predicting DPCF. Aim: To assess whether low serum trypsin levels predict DPCF during ERCP in patients with chronic pancreatitis. Method: All adult (>18 year of age) patients with definite CP who were referred to a multidisciplinary pancreatitis clinic between 2010-2015 and underwent a serum trypsin level measurement prior to ERCP for the management of abdominal pain were evaluated. Serum trypsin levels are obtained in all CP patients as part of their evaluation for exocrine insufficiency. Exclusion criteria included chronic kidney disease, prior pancreatic resection, and/or type 1 diabetes mellitus as these conditions can affect serum trypsin levels independent of CP. Definite CP was defined as abdominal pain and/or acute recurrent pancreatitis in the presence of calcification(s) on CT scan and endoscopic ultrasound and/or moderate to severe ductal changes based on the MANNHEIM criteria. Low serum trypsin was defined as values < 19 ng/mL or <10 ng/mL based on laboratory assay. Failure of deep cannulation during ERCP was defined as the inability to advance any accessory (sphincterotome, cannula, and/or guidewire) upstream of an obstructing stricture and/or stone which would be necessary for the completion of therapeutic maneuvers (stricture dilation, stone extraction and stent placement). Heavy smoking and alcohol use was defined per NAPS2 study. Factors associated with DPCF during ERCP were evaluated using univariable and multivariable logistic regression analysis. Results: Among 213 patients diagnosed with definite CP, 104 patients underwent trypsin measurements and ERCP, of whom 42 (40.4%) had low/undetectable serum trypsin levels and 37 (35.6%) had DPCF during ERCP. There were no significant differences between patients with and without DPCF with regards to age, gender, etiology, smoking, and pancreas divisum. Patients with DPCF were more likely to have low trypsin levels (68% vs. 25%, p<0.0001), obstructing stones (86% vs. 57%, pZ0.02), and strictures (69%% vs. 30.9%, pZ0.001) compared to those without DPCF. A low serum trypsin level was significantly associated with DPCF in the multivariable (OR: 5.99; 95%CI: 2.13-16.83; PZ0.001) analysis after adjusting for obstructing stones and stricture. Conclusion: Preprocedural low serum trypsin levels independently predict DPCF during ERCP in patients with chronic pancreatitis.
AB164 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Sa1039 Usefulness of Clip-Snare-Lifting Endoscopic Submucosal Dissection (CSL-ESD), a Convenient and Low-Cost Traction Technique Developed by Mimicking the Surgeon’s Left Hand’s Traction Mitsunori Yasuda*1, Yuji Naito2, Yoshito Itoh2 1 Gastroenterology, Endoscopic Division, Uji-Tokushukai Medical Center, Uji-city, Japan; 2Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan Background and objectives: ESD consists of two elements, dissection around lesions and submucosal dissection. Although dissecting around lesions can be mastered relatively quickly, submucosal dissection requires a relatively high skill level. Assuming that easy and continuous spreading of submucosal layer would simplify ESD and make it more convenient, we developed the clip-snare-lifting ESD (CSLESD) as an easy and low-cost alternative to conventional ESD based on simple principles using commercially-available clips and snares to lift lesions. This technique enables stable, quick, and safe submucosal dissection to be performed by mimicking the surgeon’s left hand which pushes and pulls lesions by freely applying traction during the dissection procedure. We reported this novel and useful technique at DDW 2012. Our subsequent study revealed this method to facilitate ESD for trainees and to expedite ESD for experts. Subjects and methods (1): Of 350 patients with early-stage gastric cancer who underwent ESD between 2008 and 2012, we prospectively studied 25 in group A and 25 in group B who were matched for age, sex, lesion site, pathological type, fibrosis, and the presence of scar. In group A, after normal local injection and the dissection of the surrounding area, a clip was attached to the edge of the lesion at an optimal position to apply traction, as an adjunct to ESD assistance, the snare was guided to the clip by biopsy forceps through the endoscope channel, and the clip was grasped with the snare. The lesion was lifted with application of traction (CSL-ESD). In group B, ESD with lifting was performed with local injection alone (non-CSL-ESD). IT-2 was basically used in groups A and B. Subjects and methods (2): This technique was also studied in trainees after 2015. Subjects and methods (3): Ex vivo models were used for objective comparison. Subjects and methods (4): CSL-ESD was applied to the esophagus and large intestine. Results: (1)Although the en bloc resection rate was 100% in both groups, operative time was significantly shorter (40.525.3min vs. 59.230.7min) and the frequency of using hemostasis forceps was significantly lower (1.31.3 vs. 3.02.1) in CSL-ESD than in non-CSL-ESD group, showing the superiority of CSL-ESD. Results: (2) (3) (4) ESD completion time was significantly reduced in the CSL-ESD group. This operation could be performed by one doctor and a technician with a clothespin grasping snare. The questionnaire answered by operators also revealed stress reduction during ESD performed by both experts and trainees. Conclusions: Our CSL-ESD technique allows both pull and push maneuvers, additional lifting as needed, and consistently maintains a good visual field with appropriate application of traction. It is clinically useful as it enables operators to efficiently perform convenient, safe, low-cost, and quick ESD.
Sa1040 A Comparison of Adequacy of Ventilation With a Non-Invasive Ventilator System vs. Standard O2 With a Nasal Cannula for Colonoscopy With Moderate Sedation Using Propofol and Fentanyl Mike Fogarty1, Kai Kuck1, Joseph A. Orr1, Derek Sakata1, Lara Brewer1, Ken B. Johnson1, John C. Fang*2 1 Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT; 2gastroenterology, University of Utah, Salt Lake City, UT Background: The American Society of Anesthesiology found drug-induced respiratory depression and airway obstruction to be the primary cause of morbidity associated with moderate and deep sedation[KB1] [MF2]. We have developed a prototype non-invasive ventilator (NIV) system. It provides CPAP (continuous positive airway pressure) with accurate monitoring of ventilation, regardless of whether there is a poor mask fit or excessive leak. Because the system monitors respiratory rate and tidal volume during CPAP, the clinician is aware of slowed respiratory rate and/or of upper airway obstruction caused by sedative medication. The objective of this study was to demonstrate in patients undergoing moderate sedation for colonoscopy if obstructive apnea and oxygen desaturation can be prevented by stenting the airway open using CPAP. Methods: The Respironics V60 noninvasive ventilator was used to provide airway support to ventilate and monitor patients during the intervention arm of this study. Supplemental oxygen (100%) was delivered by the V60 ventilator through a modified mask with multiple small leaks[KB3] [MF4] secured to the patient’s face with a standard elastomeric H-strap. The effectiveness of using the NIV system with CPAP during procedural sedation was compared to a similar population of control patients receiving standard care with 6 L/min oxygen by nasal cannula. The clinical procedure and administration of sedation medication (fentanyl and propofol) other than the ventilatory support and monitoring followed the usual standard procedure for colonoscopies. Apnea was standardly defined as greater than 10 seconds without respiration. Results: 29 patients were enrolled in
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Sa1037 Music Therapy for Elderly Patients Undergoing Colonoscopy: A Prospective Randomized Controlled Trial Sureeporn Jangsirikul*1, Wiriyaporn Ridtitid1, Tanisa Patcharatrakul1, Rapat Pittayanon1, Chonlada Phathong1, Wachinee Phromchampa1, Yuwadee Y. Ponauthai1, Sookjaroen Tangwongchai2, Rungsun Rerknimitr1, Bussakorn Binson3, Sutep Gonlachanvit1 1 Division of Gastroenterology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand; 2Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 3Faculty of Fine and Applied Arts, Chulalongkorn University, Bangkok, Thailand Although previous studies reported music therapy help reduce anxiety and pain during endoscopy, the outcomes of these data have been inconsistent. Aim: To determine the effects of music therapy on psychological and physiological status in elderly patients undergoing colonoscopy. Methods: We did a 2-month survey in 45 patients undergoing colonoscopy in our institute before study enrollment to find the patients’ most favorable music type. Then, consecutive elderly patients who required colonoscopy were recruited. Patients with hearing problem, dementia, severe comorbidities and history of colorectal surgery were excluded. Patients were randomized into 1) group A: control group (no music); 2) group B: Lug Krung music, a traditional Thai music incorporated Thai melodies with western classical music which was the most favorable music from the survey.; and 3) group C: instrumental music. Music was broadcasted from the central system of the endoscopy unit. Psychological status (fear, nervous and anxiety) was assessed by using a visual analog scale during pre-endoscopy and post-endoscopy periods. During colonoscopy, behavioral pain assessment (BPA) scale was used for evaluating pain. All patients used the same starting dose of 2.5 mg midazolam and 25 mg pethidine and were titrated up 2.5 mg and 25 mg respectively when the pain assessment scale increased at least 2 points. Physiological changes were measured, including blood pressure and heart rate. Results: 37, 40 and 36 patients (age 64.00.7 years) were included in group A, B, and C, respectively. Baseline characteristics were similar between the three groups (Table1). At 10 minutes after registration, the nervous and fear scores in group B were significantly lower than the control group (p<0.05) whereas the psychological status scores in group C were not different from the control group. At the time before starting sedation, the nervous score in group B was still significantly lower than the control group (pZ0.02). During the colonoscopy, total scores of BPA were lower in group B compared to the control group, but did not reach statistical significance except the “restlessness” subscores which were significantly lower than group A and group C (p<0.05). Physiological status was not different among groups. Although the dose of midazolam was similar among groups, the dose of pethidine in group B was significantly lower than group C (pZ0.04) (Table 2). Conclusions: Among elderly patients undergoing colonoscopy, music intervention reduced psychological stress, including nervous and fear, at preendoscopy period. During the procedure, pain relief and lower dosage of analgesics were also documented in patients who listened to their favorable music compared to other music types. This suggests music intervention using patients’ favorable music provides benefit for elderly patients undergoing colonoscopy.
Table 1. Baseline characteristics of the enrolled patients Characteristics Mean age (SEM), years Underlying disease; n (%) Diabetes Coronary heart disease Indications for colonoscopy; n(%) Colorectal cancer screening (no symptoms) Anemia Bowel habit change Abdominal pain Bloating Baseline physiological status; mean (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Subgroup in patients who had baseline SBP > 140 mmHg Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute)
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Group A (n[37)
Group B (n[40)
Group C (n[36)
pvalue
63.0(1.3)
65.3(1.1)
63.7(1.0)
NS
3(8.1) 1(2.7)
6(15) 2(5%)
6(16.7) 0(0)
NS NS
30(81.1)
31(79.5)
31(86.1)
NS
2(5.4) 3(8.1) 2(5.4) 0
2(5.1) 1(2.6) 1(2.6) 3(7.7)
1(2.8) 3(8.3) 0 0
NS NS NS NS
141.3(3.9) 77.0(2.1)* 67.3(1.9) nZ17
142.5(3.6) 81.2(2.0) 72.5(2.1) nZ25
146.9(1.6) 82.6(2.6)* 68.1(1.9) nZ23
NS 0.003* NS
164.1(4.6) 83.8(2.5) 74.0(3.2)
157.5(3.1)* 175.3(5.4)* 0.018* 88.7(2.2) 93.6(2.8) NS 73.6(2.7) 68.7(2.1) NS
Characteristics Subgroup in patients who had baseline SBP 140 mmHg Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute)
Group A (n[37)
Group B (n[40)
Group C (n[36)
nZ20
nZ15
nZ13
125.5(1.6) 71.9(2.7) 65.6(2.0)
122.1(3.9) 75.7(3.0) 70.7(3.6)
125.8(2.6) 78.2(2.1) 66.0(2.6)
pvalue
NS NS NS
Group A Z no music, Group B Z Thai music, Group C Z Instrumental music, NS Z no statistical significance (p>0.05 between 3 groups)
Table 2. Effects of music therapy in patients undergoing colonoscopy Outcomes
Group A (n[37)
Group B (n[40)
Group C (n[36)
p-value
1(0.3)* 1.4(0.3)* 2.2(0.4)
2(0.4) 2.1(0.5) 2.6(0.5)
0.02* 0.04* NS
1.0(0.4)* 1.2(0.4) 2.0(0.4)
1.6(0.4) 1.9(0.5) 2.3(0.5)
0.02* NS NS
-3.8(2.8) -0.1(2.3)
-16.1(6.6) 1.9(3.6)
NS NS
-3.1(1.6)
-7.9(1.8)
NS
12.8(3.5) 2.7(5.2)
7.4(4.3) -0.4(3.5)
NS NS
0.9(2.2)
2.6(1.6)
NS
27(67.5) 13(32.5) 0*
16(44.4) 16(44.4) 4(11.1)*
NS NS 0.046*
7(18.9) 1(2.7)
38(95.0) *,** 2(5.0)* 0
24(66.7) 0.042*,0.002** ** 10(27.8)* 0.01* 2(5.6) NS
32(86.5) 4(10.8) 1(2.7)
39(97.5)* 1(2.5)* 0
26(72.2)* 10(27.8)* 0
0.002* 0.002* NS
32(86.5) 5(13.5) 0
36(90.0) 4(10.0) 0
28(77.8) 7(19.4) 1(2.8)
NS NS NS
31(83.8) 5(13.5) 1(2.7)
38(95.0)* 2(5.0)* 0
26(72.2)* 8(22.2)* 2(5.6)
0.01* 0.04* NS
2.1 Pre-endoscopy (10 minutes after registration) Psychological status (VAS 0-10)(SEM) Nervous 2.3(0.4)* Fear 2.6(0.5)* Anxiety 3.2(0.5) 2.2 At the time before starting procedure Psychological status (VAS 0-10)(SEM) Nervous 2.3(0.5)* Fear 2.5(0.5) Anxiety 2.9(0.5) Physiologic changes vs. pre-endoscopy; (At the time before starting procedure – at 10 minutes after registration) Patients who had baseline SBP > 140 mmHg (SEM) Systolic Blood pressure (mmHg) -8.2(4.7) Diastolic Blood pressure -5.4(2.1) (mmHg) Heart rate (per minute) 0.8(2.2) Patients who had baseline SBP 140 mmHg (SEM) Systolic Blood pressure (mmHg) 12.4(3.7) Diastolic Blood pressure 8.2(3.3) (mmHg) Heart rate (per minute) 4.7(2.2) 2.3 During the procedure (under sedation) Behavioral pain assessment score Face expression (score 0-2), n(%) 0 23(62.2) 1 13(35.1) 2 1(2.7) Restlessness (score 0-2), n(%) 0 29(78.4)* 1 2 Muscle tones (score 0-2), n(%) 0 1 2 Vocalization (score 0-2), n(%) 0 1 2 Consolability (%) 0 1 2
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB163
Abstracts
Outcomes Physiologic changes vs. preendoscopy; (during procedure – at 10 minute after registration) Patients who had baseline SBP > 140 mmHg (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Patients who had baseline SBP 140 mmHg (SEM) Systolic Blood pressure (mmHg) Diastolic Blood pressure (mmHg) Heart rate (per minute) Total dose of midazolam required (mg) (SEM) Total dose of pethidine required (mg) (SEM)
Group A (n[37)
Group B (n[40)
Group C (n[36)
p-value
22.9(4.5) -0.5(2.1)
16.2(2.9) -4.6(2.2)
30.0(6.5) -9.3(3.6)
NS NS
-6.0(2.2)
-1.5(2.1)
1.3(1.8)
NS
-3.8(3.5) 7.5(3.2)
-4.8(3.5) 1.3(5.1)
2.9(4.4) -1.5(3.6)
NS NS
4.2(2.0) 3.7(0.6)
0.3(2.2) 3.1(0.2)
1.0(1.5) 3.6(0.2)
NS NS
30.4(1.7)
27.5(1.5)* 32.6(2.0)*
0.04*
Group A Z no music (control), Group B Z Thai music, Group C Z Instrumental music, NS Z no statistical significance Data expressed as standard error of the mean (SEM)
Sa1038 Low Serum Trypsin Levels Predict Deep Pancreatic Cannulation Failure During ERCP in Patients With Chronic Pancreatitis Tina Boortalary*2,3, Niloofar Yahyapourjalaly1,2, Robert Moran2, Yen-I Chen2, Farshid Fargahi2, Mahya Faghih2, Ayesha Kamal2, Venkata S. Akshintala2, Nasim Parsa2, Saowonee Ngamruengphong2, Vivek Kumbhari2, Anthony N. Kalloo2, Mouen A. Khashab2, Vikesh Singh2 1 Medstar Health, Baltimore, MD; 2Department of Gastroenterology, Johns Hopkins University School of medicine, Baltimore, MD; 3George Washington University, Washington Background: Deep pancreatic cannulation failure (DPCF) during ERCP in patients with chronic pancreatitis (CP) can occur in the presence of duct obstruction due to strictures and/or stones. There are currently no simple preprocedure clinical or laboratory tests that can predict DPCF during ERCP. Since low serum trypsin levels have been correlated with advanced chronic pancreatitis and exocrine insufficiency, we hypothesized that it might be a useful preprocedure test for predicting DPCF. Aim: To assess whether low serum trypsin levels predict DPCF during ERCP in patients with chronic pancreatitis. Method: All adult (>18 year of age) patients with definite CP who were referred to a multidisciplinary pancreatitis clinic between 2010-2015 and underwent a serum trypsin level measurement prior to ERCP for the management of abdominal pain were evaluated. Serum trypsin levels are obtained in all CP patients as part of their evaluation for exocrine insufficiency. Exclusion criteria included chronic kidney disease, prior pancreatic resection, and/or type 1 diabetes mellitus as these conditions can affect serum trypsin levels independent of CP. Definite CP was defined as abdominal pain and/or acute recurrent pancreatitis in the presence of calcification(s) on CT scan and endoscopic ultrasound and/or moderate to severe ductal changes based on the MANNHEIM criteria. Low serum trypsin was defined as values < 19 ng/mL or <10 ng/mL based on laboratory assay. Failure of deep cannulation during ERCP was defined as the inability to advance any accessory (sphincterotome, cannula, and/or guidewire) upstream of an obstructing stricture and/or stone which would be necessary for the completion of therapeutic maneuvers (stricture dilation, stone extraction and stent placement). Heavy smoking and alcohol use was defined per NAPS2 study. Factors associated with DPCF during ERCP were evaluated using univariable and multivariable logistic regression analysis. Results: Among 213 patients diagnosed with definite CP, 104 patients underwent trypsin measurements and ERCP, of whom 42 (40.4%) had low/undetectable serum trypsin levels and 37 (35.6%) had DPCF during ERCP. There were no significant differences between patients with and without DPCF with regards to age, gender, etiology, smoking, and pancreas divisum. Patients with DPCF were more likely to have low trypsin levels (68% vs. 25%, p<0.0001), obstructing stones (86% vs. 57%, pZ0.02), and strictures (69%% vs. 30.9%, pZ0.001) compared to those without DPCF. A low serum trypsin level was significantly associated with DPCF in the multivariable (OR: 5.99; 95%CI: 2.13-16.83; PZ0.001) analysis after adjusting for obstructing stones and stricture. Conclusion: Preprocedural low serum trypsin levels independently predict DPCF during ERCP in patients with chronic pancreatitis.
AB164 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Sa1039 Usefulness of Clip-Snare-Lifting Endoscopic Submucosal Dissection (CSL-ESD), a Convenient and Low-Cost Traction Technique Developed by Mimicking the Surgeon’s Left Hand’s Traction Mitsunori Yasuda*1, Yuji Naito2, Yoshito Itoh2 1 Gastroenterology, Endoscopic Division, Uji-Tokushukai Medical Center, Uji-city, Japan; 2Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan Background and objectives: ESD consists of two elements, dissection around lesions and submucosal dissection. Although dissecting around lesions can be mastered relatively quickly, submucosal dissection requires a relatively high skill level. Assuming that easy and continuous spreading of submucosal layer would simplify ESD and make it more convenient, we developed the clip-snare-lifting ESD (CSLESD) as an easy and low-cost alternative to conventional ESD based on simple principles using commercially-available clips and snares to lift lesions. This technique enables stable, quick, and safe submucosal dissection to be performed by mimicking the surgeon’s left hand which pushes and pulls lesions by freely applying traction during the dissection procedure. We reported this novel and useful technique at DDW 2012. Our subsequent study revealed this method to facilitate ESD for trainees and to expedite ESD for experts. Subjects and methods (1): Of 350 patients with early-stage gastric cancer who underwent ESD between 2008 and 2012, we prospectively studied 25 in group A and 25 in group B who were matched for age, sex, lesion site, pathological type, fibrosis, and the presence of scar. In group A, after normal local injection and the dissection of the surrounding area, a clip was attached to the edge of the lesion at an optimal position to apply traction, as an adjunct to ESD assistance, the snare was guided to the clip by biopsy forceps through the endoscope channel, and the clip was grasped with the snare. The lesion was lifted with application of traction (CSL-ESD). In group B, ESD with lifting was performed with local injection alone (non-CSL-ESD). IT-2 was basically used in groups A and B. Subjects and methods (2): This technique was also studied in trainees after 2015. Subjects and methods (3): Ex vivo models were used for objective comparison. Subjects and methods (4): CSL-ESD was applied to the esophagus and large intestine. Results: (1)Although the en bloc resection rate was 100% in both groups, operative time was significantly shorter (40.525.3min vs. 59.230.7min) and the frequency of using hemostasis forceps was significantly lower (1.31.3 vs. 3.02.1) in CSL-ESD than in non-CSL-ESD group, showing the superiority of CSL-ESD. Results: (2) (3) (4) ESD completion time was significantly reduced in the CSL-ESD group. This operation could be performed by one doctor and a technician with a clothespin grasping snare. The questionnaire answered by operators also revealed stress reduction during ESD performed by both experts and trainees. Conclusions: Our CSL-ESD technique allows both pull and push maneuvers, additional lifting as needed, and consistently maintains a good visual field with appropriate application of traction. It is clinically useful as it enables operators to efficiently perform convenient, safe, low-cost, and quick ESD.
Sa1040 A Comparison of Adequacy of Ventilation With a Non-Invasive Ventilator System vs. Standard O2 With a Nasal Cannula for Colonoscopy With Moderate Sedation Using Propofol and Fentanyl Mike Fogarty1, Kai Kuck1, Joseph A. Orr1, Derek Sakata1, Lara Brewer1, Ken B. Johnson1, John C. Fang*2 1 Anesthesiology and Bioengineering, University of Utah, Salt Lake City, UT; 2gastroenterology, University of Utah, Salt Lake City, UT Background: The American Society of Anesthesiology found drug-induced respiratory depression and airway obstruction to be the primary cause of morbidity associated with moderate and deep sedation[KB1] [MF2]. We have developed a prototype non-invasive ventilator (NIV) system. It provides CPAP (continuous positive airway pressure) with accurate monitoring of ventilation, regardless of whether there is a poor mask fit or excessive leak. Because the system monitors respiratory rate and tidal volume during CPAP, the clinician is aware of slowed respiratory rate and/or of upper airway obstruction caused by sedative medication. The objective of this study was to demonstrate in patients undergoing moderate sedation for colonoscopy if obstructive apnea and oxygen desaturation can be prevented by stenting the airway open using CPAP. Methods: The Respironics V60 noninvasive ventilator was used to provide airway support to ventilate and monitor patients during the intervention arm of this study. Supplemental oxygen (100%) was delivered by the V60 ventilator through a modified mask with multiple small leaks[KB3] [MF4] secured to the patient’s face with a standard elastomeric H-strap. The effectiveness of using the NIV system with CPAP during procedural sedation was compared to a similar population of control patients receiving standard care with 6 L/min oxygen by nasal cannula. The clinical procedure and administration of sedation medication (fentanyl and propofol) other than the ventilatory support and monitoring followed the usual standard procedure for colonoscopies. Apnea was standardly defined as greater than 10 seconds without respiration. Results: 29 patients were enrolled in
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