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Self Expanding Metal Stents for Malignant Colorectal Obstruction Experience At a Private Hospital in Turkey
Abstracts
T1473 Usefulness of NBI to Distinguish Between Non-Neoplastic and Neoplastic Lesions Without the Influence of Performer Whether He Is Expert Or Not Hiroaki Ikematsu, Takahiro Horimatsu, Yasushi Sano, Toyoki Kudo, Atushi Katagiri, Kuang I. Fu, Atushi Ohtsu, Shigeaki Yoshida Background and Aim: We reported that the presence of meshed brown capillary vessels on magnifying endoscopy using narrow-band imaging (NBI) is useful to distinguish between non-neoplastic and neoplastic lesions without the application of any dye solution. We believe that the using NBI as optical chromoendoscopy save the time and cost on screening colonoscopy. But it is not defined whether the accuracy of diagnosis is influenced by the experience of endoscopists. The study aimed to evaluate the efficacy of accuracy using NBI without the influence from performer. Methods: From 2005 October to 2006 October, 50 lesions of less than 10 mm in size (hyperplastic polyp 25 lesions and adenoma 25 lesions), observed sufficiently with conventional colonoscopy, NBI, chromoendoscopy and magnifying chromoendoscopy. All lesions were diagnosed separately under each method in order to avoid the influence from other methods. This study is participated with total of 13 endoscopists in National Cancer Center East, including 5 experts (Group A), 2 experts in upper endoscopy (Group B), 6 beginners (Group C). The Group C was given basic education before diagnosing lesions. We compared the accuracy of endoscopic diagnosis among these endoscopists groups under each observation method respectively. Results: We excluded the lesions which accuracy were less than 50% in all four methods of observation from this study because we concluded the pictures of lesion were poor. So, we studied 47 lesions (hyperplastic polyp 22 lesions and adenoma 25 lesions). Total accuracy of conventional colonoscopy, NBI, chromoendoscopy and magnifying chromoendoscopy were 69.4%, 81.5%, 65.3%, 73.1% respectively. The most agreeable accuracy was diagnosis by NBI, there was significant difference in accuracy between conventional colonoscopy and NBI (P ! 0.001). In Group A, accuracy of each methods were: 77.6%, 88.1%, 70.6% and 80.4%. Group B: 70.2%, 76.6% and 62.3%, 64.9%. Group C: 63.5%, 77.7%, 61.7%, 69.5%. In each Group, the accuracy of diagnosis by NBI was most favorable. In Group C, there was significant difference in accuracy between conventional colonoscopy and NBI (P ! 0.05). In Group A and B, there was not statistically significant. Compared the accuracy according to four observation methods among the Group A, B and C. In conventional colonoscopy, there was significant difference between Group A and C (P ! 0.05). In other observation methods, there were not statistically significant. Conclusion: By giving basic education before diagnosis, the accuracy of endoscopic diagnosis to distinguish between non-neoplastic and neoplastic by using NBI was agreeable independent of performer whether he is expert or non expert.
T1474 Self Expanding Metal Stents for Malignant Colorectal Obstruction Experience At a Private Hospital in Turkey Zekeriya S. Ozden Background: The treatment of malignant obstruction of the colon or rectum usually requires emergency surgery on poor risk patients and the creation of a stoma is usually inevitable. SEMS have made prompt relief of obstruction without surgery possible. Aims: The purpose of our study was to evaluate the feasibility, effectiveness, safety and outcome in using SEMS to relieve acute colorectal obstruction for two different treatment in tentions, group I; preoperative decompression before surgical resection with primary anastomosis, group II; palliation for patients with inoperable malignant colorectal obstruction. Methods; From July 2003 to July 2006 10 SEMS (enteral wallstents) were placed in 10 patients under fluoroscopic and endoscopic control by a single experienced endoscopist. The data on the nature of pathology, success of the procedure, the complications and the outcomes of the patients were collected prospectively. Results: Nine patients had colorectal cancer, one patient had recurrent inoperable ovarian cancer. The procedure was for palliative intend in 5 patients (50%). Successfull insertion of the stent was achieved in 9 patients (90%). The clinical success rate was 90% . In one patient two stents were placed coaxially and overlapping for a long stricture. Location of the stricture were left colon (6 patients), transvers colon (3), cecum (1), colostomy site (1). In the patient with the obstruction at the level of cecum the stent could not be carried over the guidewire to the stricture site due to a long redundant sigmoid colon. The patient with two overlapping stents had a perforation 5 days after the procedure which was managed surgically. In group one all patients underwent subsequent definitive surgery, one had an ileostomy, mean ICU stay was 1.2 days, mean hospital stay was 7.6 days, no major perioperative complications occured. In group II, the mean survival was 8 months, all the patients died from reasons unrelated to stent obstruction. Conclusions: The use of SEMS for malignant colorectal obstruction is safe and effective. It provides good palliation for unresectable advanced tumors. It may also have a role in the temporary relief of obstruction so that subsequent definitive surgery can be performed under elective conditions. Through the scope technique with a large channel colonoscope rather than carrying the stent over a guidewire under floroscopic control might be preferable for right sided colonic strictures.
www.giejournal.org
T1475 The Role of Flexible Sigmoidoscopy and Clostridium Difficile Cytotoxin in Rapid Diagnosis of C. Difficile Associated Diarrhea Sung Hee Jung, Hoon Go, An Na Kim, Hyeon Woong Yang, Sang Woo Cha, Yun Jung Lee, Gi Young Choi Background: Clostridium difficile-associated diarrhea (CDAD), the most important nosocomial diarrhea, may range from mild watery diarrhea to life-threatening colitis and early diagnosis is important for early recovery. Although stool exam and sigmoidoscopy are very valuable during the evaluation, the false negative for C. difficile cytotoxin and absence of pseudomembrane often delay the early diagnosis in each of the modalities. Purpose: To investigate the role of flexible sigmoidoscopy and C. difficile cytotoxin in the diagnosis of CDAD. Materials and Methods: From September 2005 to October 2006, 112 patients with diarrhea were referred to the gastroenterologists of Eulji university hospital. Results of flexible sigmoidoscopy were compared with those of stool assays for C. difficle cytotoxin in them, prospectively. Results: Among them, 39 patients were diagnoised as CDAD (diagnosed by both C. difficile cytotoxin and sigmoidoscopy, 27/39 (69.2%); cytotoxin only, 6/39 (15.4%); sigmoidoscopy only, 6/39 (15.4%)). Most of their CDAD were associated with antibiotic exposure (37/39, 95%) and started during hospitalization period (34/39, 87.2%). Of 27 patients, sigmoidoscopic findings revealed peudomembranes (20/27, 74%), colitis (6/27, 22.2%) and normal (1/27, 3.8%). In 20 patients with pseudomembranous colitis at sigmoidoscopy, the stool C. difficile cytotoxin test was negative in 9 (45%). Conclusions: For the early diagnosis of CDAD, flexible sigmoidoscopy is useful especially in patienits with delayed or negative stool test for C. difficile cytotoxin. However, because the sigmoidoscopic findings can reveal only hyperemia, erosions, and even normal, we recommend early flexible sigmoidoscopy combined with C. difficile cytotoxin assay in patients suggesting CDAD clinically.
T1476 Female Gender: A Risk Factor for Severe Diverticulosis Radha Menon, Maiyen Tran Hawkins, Afkham Merikhi, Alison Schneider, David Anjelly, James Reynolds, Asyia Ahmad Although little is known about the true etiology of diverticulosis, colonic motility is believed to play a role in its development. Potential risk factors for the development of diverticula including gender, race as well as conditions which may alter colonic motility have not been evaluated. Aim: To determine what underlying factors may influence the severity of diverticulosis. Methods: A retrospective chart review was performed of all patients undergoing colonoscopy at our institution from September 12, 2005 to September 8, 2006 who were found to have diverticulosis. Patient data collected included medical history, demographics, hemoglobin A1c (for diabetics), and medications at time of procedure. The amount, size, and location of diverticula, as well as prep quality and indications for procedure were recorded from their colonoscopy reports. Results: Five hundred thirty two patient colonoscopies were reviewed. Fifty seven percent of patients were women, 60% were African-american, and 27% had underlying diabetes. Overall 58% of patients had numerous and 62% had large diverticula. Forty nine percent of patients had diverticula throughout the colon compared to 4% in the right colon and 47% in the left colon. Race, hypothyroidism, narcotic use, diabetes (insulin-dependent and non-insulin-dependent), HgbA1c, and prep quality did not significantly predict the severity of diverticulosis. Surprisingly, women had more numerous diverticula than men (64% vs. 49%, p ! 0.01); however, size and location of the diverticula were not influenced by gender. Female diabetics had more numerous diverticula when compared to male diabetics (p ! 0.025), and female nondiabetics had more numerous diverticula when compared to male nondiabetics (p ! 0.025). A comparison between diabetic and nondiabetic females did not show a significant difference in the amount, severity, or location of diverticula. In women, hormone replacement did not appear to impact severity of diverticulosis, although our data could only be verified in 12 patients. As expected, increasing age was also an independent predictor of more numerous (p ! 0.001) and larger diverticula (p ! 0.001). This held true regardless of gender. Conclusion: Female gender plays a more significant role in the formation of severe diverticulosis than previously thought. Excluding age, other factors which may potentially influence colonic motility did not influence the progression of diverticulosis. Future studies should investigate the role that gender and hormonal factors play in the formation of diverticulosis.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB269
T1473 Usefulness of NBI to Distinguish Between Non-Neoplastic and Neoplastic Lesions Without the Influence of Performer Whether He Is Expert Or Not Hiroaki Ikematsu, Takahiro Horimatsu, Yasushi Sano, Toyoki Kudo, Atushi Katagiri, Kuang I. Fu, Atushi Ohtsu, Shigeaki Yoshida Background and Aim: We reported that the presence of meshed brown capillary vessels on magnifying endoscopy using narrow-band imaging (NBI) is useful to distinguish between non-neoplastic and neoplastic lesions without the application of any dye solution. We believe that the using NBI as optical chromoendoscopy save the time and cost on screening colonoscopy. But it is not defined whether the accuracy of diagnosis is influenced by the experience of endoscopists. The study aimed to evaluate the efficacy of accuracy using NBI without the influence from performer. Methods: From 2005 October to 2006 October, 50 lesions of less than 10 mm in size (hyperplastic polyp 25 lesions and adenoma 25 lesions), observed sufficiently with conventional colonoscopy, NBI, chromoendoscopy and magnifying chromoendoscopy. All lesions were diagnosed separately under each method in order to avoid the influence from other methods. This study is participated with total of 13 endoscopists in National Cancer Center East, including 5 experts (Group A), 2 experts in upper endoscopy (Group B), 6 beginners (Group C). The Group C was given basic education before diagnosing lesions. We compared the accuracy of endoscopic diagnosis among these endoscopists groups under each observation method respectively. Results: We excluded the lesions which accuracy were less than 50% in all four methods of observation from this study because we concluded the pictures of lesion were poor. So, we studied 47 lesions (hyperplastic polyp 22 lesions and adenoma 25 lesions). Total accuracy of conventional colonoscopy, NBI, chromoendoscopy and magnifying chromoendoscopy were 69.4%, 81.5%, 65.3%, 73.1% respectively. The most agreeable accuracy was diagnosis by NBI, there was significant difference in accuracy between conventional colonoscopy and NBI (P ! 0.001). In Group A, accuracy of each methods were: 77.6%, 88.1%, 70.6% and 80.4%. Group B: 70.2%, 76.6% and 62.3%, 64.9%. Group C: 63.5%, 77.7%, 61.7%, 69.5%. In each Group, the accuracy of diagnosis by NBI was most favorable. In Group C, there was significant difference in accuracy between conventional colonoscopy and NBI (P ! 0.05). In Group A and B, there was not statistically significant. Compared the accuracy according to four observation methods among the Group A, B and C. In conventional colonoscopy, there was significant difference between Group A and C (P ! 0.05). In other observation methods, there were not statistically significant. Conclusion: By giving basic education before diagnosis, the accuracy of endoscopic diagnosis to distinguish between non-neoplastic and neoplastic by using NBI was agreeable independent of performer whether he is expert or non expert.
T1474 Self Expanding Metal Stents for Malignant Colorectal Obstruction Experience At a Private Hospital in Turkey Zekeriya S. Ozden Background: The treatment of malignant obstruction of the colon or rectum usually requires emergency surgery on poor risk patients and the creation of a stoma is usually inevitable. SEMS have made prompt relief of obstruction without surgery possible. Aims: The purpose of our study was to evaluate the feasibility, effectiveness, safety and outcome in using SEMS to relieve acute colorectal obstruction for two different treatment in tentions, group I; preoperative decompression before surgical resection with primary anastomosis, group II; palliation for patients with inoperable malignant colorectal obstruction. Methods; From July 2003 to July 2006 10 SEMS (enteral wallstents) were placed in 10 patients under fluoroscopic and endoscopic control by a single experienced endoscopist. The data on the nature of pathology, success of the procedure, the complications and the outcomes of the patients were collected prospectively. Results: Nine patients had colorectal cancer, one patient had recurrent inoperable ovarian cancer. The procedure was for palliative intend in 5 patients (50%). Successfull insertion of the stent was achieved in 9 patients (90%). The clinical success rate was 90% . In one patient two stents were placed coaxially and overlapping for a long stricture. Location of the stricture were left colon (6 patients), transvers colon (3), cecum (1), colostomy site (1). In the patient with the obstruction at the level of cecum the stent could not be carried over the guidewire to the stricture site due to a long redundant sigmoid colon. The patient with two overlapping stents had a perforation 5 days after the procedure which was managed surgically. In group one all patients underwent subsequent definitive surgery, one had an ileostomy, mean ICU stay was 1.2 days, mean hospital stay was 7.6 days, no major perioperative complications occured. In group II, the mean survival was 8 months, all the patients died from reasons unrelated to stent obstruction. Conclusions: The use of SEMS for malignant colorectal obstruction is safe and effective. It provides good palliation for unresectable advanced tumors. It may also have a role in the temporary relief of obstruction so that subsequent definitive surgery can be performed under elective conditions. Through the scope technique with a large channel colonoscope rather than carrying the stent over a guidewire under floroscopic control might be preferable for right sided colonic strictures.
www.giejournal.org
T1475 The Role of Flexible Sigmoidoscopy and Clostridium Difficile Cytotoxin in Rapid Diagnosis of C. Difficile Associated Diarrhea Sung Hee Jung, Hoon Go, An Na Kim, Hyeon Woong Yang, Sang Woo Cha, Yun Jung Lee, Gi Young Choi Background: Clostridium difficile-associated diarrhea (CDAD), the most important nosocomial diarrhea, may range from mild watery diarrhea to life-threatening colitis and early diagnosis is important for early recovery. Although stool exam and sigmoidoscopy are very valuable during the evaluation, the false negative for C. difficile cytotoxin and absence of pseudomembrane often delay the early diagnosis in each of the modalities. Purpose: To investigate the role of flexible sigmoidoscopy and C. difficile cytotoxin in the diagnosis of CDAD. Materials and Methods: From September 2005 to October 2006, 112 patients with diarrhea were referred to the gastroenterologists of Eulji university hospital. Results of flexible sigmoidoscopy were compared with those of stool assays for C. difficle cytotoxin in them, prospectively. Results: Among them, 39 patients were diagnoised as CDAD (diagnosed by both C. difficile cytotoxin and sigmoidoscopy, 27/39 (69.2%); cytotoxin only, 6/39 (15.4%); sigmoidoscopy only, 6/39 (15.4%)). Most of their CDAD were associated with antibiotic exposure (37/39, 95%) and started during hospitalization period (34/39, 87.2%). Of 27 patients, sigmoidoscopic findings revealed peudomembranes (20/27, 74%), colitis (6/27, 22.2%) and normal (1/27, 3.8%). In 20 patients with pseudomembranous colitis at sigmoidoscopy, the stool C. difficile cytotoxin test was negative in 9 (45%). Conclusions: For the early diagnosis of CDAD, flexible sigmoidoscopy is useful especially in patienits with delayed or negative stool test for C. difficile cytotoxin. However, because the sigmoidoscopic findings can reveal only hyperemia, erosions, and even normal, we recommend early flexible sigmoidoscopy combined with C. difficile cytotoxin assay in patients suggesting CDAD clinically.
T1476 Female Gender: A Risk Factor for Severe Diverticulosis Radha Menon, Maiyen Tran Hawkins, Afkham Merikhi, Alison Schneider, David Anjelly, James Reynolds, Asyia Ahmad Although little is known about the true etiology of diverticulosis, colonic motility is believed to play a role in its development. Potential risk factors for the development of diverticula including gender, race as well as conditions which may alter colonic motility have not been evaluated. Aim: To determine what underlying factors may influence the severity of diverticulosis. Methods: A retrospective chart review was performed of all patients undergoing colonoscopy at our institution from September 12, 2005 to September 8, 2006 who were found to have diverticulosis. Patient data collected included medical history, demographics, hemoglobin A1c (for diabetics), and medications at time of procedure. The amount, size, and location of diverticula, as well as prep quality and indications for procedure were recorded from their colonoscopy reports. Results: Five hundred thirty two patient colonoscopies were reviewed. Fifty seven percent of patients were women, 60% were African-american, and 27% had underlying diabetes. Overall 58% of patients had numerous and 62% had large diverticula. Forty nine percent of patients had diverticula throughout the colon compared to 4% in the right colon and 47% in the left colon. Race, hypothyroidism, narcotic use, diabetes (insulin-dependent and non-insulin-dependent), HgbA1c, and prep quality did not significantly predict the severity of diverticulosis. Surprisingly, women had more numerous diverticula than men (64% vs. 49%, p ! 0.01); however, size and location of the diverticula were not influenced by gender. Female diabetics had more numerous diverticula when compared to male diabetics (p ! 0.025), and female nondiabetics had more numerous diverticula when compared to male nondiabetics (p ! 0.025). A comparison between diabetic and nondiabetic females did not show a significant difference in the amount, severity, or location of diverticula. In women, hormone replacement did not appear to impact severity of diverticulosis, although our data could only be verified in 12 patients. As expected, increasing age was also an independent predictor of more numerous (p ! 0.001) and larger diverticula (p ! 0.001). This held true regardless of gender. Conclusion: Female gender plays a more significant role in the formation of severe diverticulosis than previously thought. Excluding age, other factors which may potentially influence colonic motility did not influence the progression of diverticulosis. Future studies should investigate the role that gender and hormonal factors play in the formation of diverticulosis.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB269