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Su1629 Cost Effectiveness of Endoscopic Mucosal Resection Compared to Transanal Resection of Complex Rectal Polyps
Abstracts
Su1628 A Novel Lens Cleaner That Prevent and Remove Water Drop Adhesions During Colonoscopy Naohisa Yoshida*1, Yuji Naito1, Takaaki Murakami1, Kiyoshi Ogiso1, Ryohei Hirose1, Yutaka Inada1, Osamu Dohi1, Kazuhiro Kamada1, Kazuhiko Uchiyama1, Osamu Handa1, Hideyuki Konishi1, Rafiz A. Rani1,2, Yoshito Itoh1 1 Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2Gastroenterology Unit, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia Background: Water drop adhesions disturb the clarity of endoscopic view during gastrointestinal endoscopy. Recently, we developed a novel lens cleaner (Yoshida N, et al. Dig Endosc 2015;27:609-17). In this study, we developed a new unique usage and examined its ability in preventing and removing water drop adhesions during colonoscopic examinations and treatments. Methods: The novel lens cleaner (CleashÒ) was made mainly using two types of harmless non-ionic surfactant. We first analysed the efficacy for preventing water drop adhesions by basic research. The lens cleaner was applied on the tip of the endoscope and submerged in water 100 times for 5 cycles and the number of water drop adhesions were calculated and compared to the endoscope without this cleaner. Secondly, we performed a clinical research and recruited 25 patients undergoing colonoscopy including polypectomy at the Kyoto Prefectural University of Medicine from October 2015 to November 2015. The cleaner was applied on the tip of the endoscope and was added into an air/water device (water 200ml: CleashÒ 1ml: dimethicon 1ml) for 12 cases, compared to 13 cases without any cleaner. The procedures were recorded and subsequently evaluated by a panel of endoscopist. During colonoscopy, the number of water drop adhesions on the lens and the number of non-rapid removal of water drop adhesions were calculated. Results: With respect to the basic research, the mean rate of water drop adhesion with the novel cleaner was lower than that without it at 19.3% and 31.7% respectively. The mean number of water drop adhesions with the novel cleaner was also significantly lower than that without it as follows; 8.43.3 vs. 13.58.9, pZ0.004. Additionally, the mean number of non-rapid removal of water drop adhesions with the novel cleaner was significantly lower than that without it at 4.32.0 vs. 7.05.8, PZ0.002. Conclusion: Water drop adhesions on the endoscopic lens during colonoscopy were significantly improved with this novel cleaner. Our original, unique method of adding the cleaner into an air/water device shows positive impact by improving efficacy for removal of water drop adhesions.
Su1629 Cost Effectiveness of Endoscopic Mucosal Resection Compared to Transanal Resection of Complex Rectal Polyps Jessica X. Yu*1, W. A. Russell3, Nathan G. Kim4, Jack Ching5, Eran Bendavid5, Douglas K. Owens5, Tonya R. Kaltenbach2 1 Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA; 2Department of Veterans Affairs, University of California San Francisco, San Francisco, CA; 3Department of Management Science and Engineering, Stanford University, Stanford, CA; 4School of Medicine, Stanford University, Stanford, CA; 5Department of Health Policy and Research, Stanford University, Stanford, CA Introduction: Endoscopic mucosal resection (EMR) of complex colon polyps has been found to be cost-effective compared to laparoscopic surgery. However, the optimal management of complex rectal polyps is not well defined. The recommended surgical management for rectal polyps involves a transanal approach, including newer techniques such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). We aimed to model the lifetime clinical and economic impact of EMR compared to transanal resection for the management of complex rectal polyps. Methods: We developed a Markov model with a 50-year time horizon to simulate the outcomes and costs of treatment of a large (>2cm) rectal polyp in a 50 year-old patient with EMR, TEM and TAMIS. Based on literature review, we estimated that complication rates were 4.2% for EMR, 8.7% for TEM and 13.4% for TAMIS and mortality rate was 0.08%. We assumed the utility loss of transanal surgery to be 0.4 for 2 days and EMR to be 0.25 for 2 days. Costs were based on Centers for Medicare and Medicaid Services (CMS) 2015 average reimbursement data. Transition probabilities for the Markov states of high frequency surveillance, low frequency surveillance and rectal cancer were determined from SEER rectal cancer statistics, CDC national life expectancy tables and published literature. We calculated cost, quality adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER). We also assumed 100% surveillance protocol compliance and a standard 3% discount rate. One-way sensitivity analyses were also performed. Results: Given the higher complication rates for TEM and TAMIS in our base case, we found EMR to cost less and have similar effectiveness compared to TEM and TAMIS. EMR costs $17,264.25 vs. $22,115.68 - $22,237.96 and had similar QALYs (18.95 vs. 18.94) compared to TAMIS and TEM (Table 1). One-way sensitivity analysis on all variables demonstrated that our model was sensitive to procedural complication rates and costs. For TEM and TAMIS to be favored, the cost of the procedures would need to be less than $62.61 and $207.99, respectively. Alterna-
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tively, the complication rate of EMR would need to be greater than 16.5%. Conclusion: In our base case analysis, EMR offers similar health benefits to TEM and TAMIS at a lower cost. However, our estimates were sensitive to the quality of life decrement related to the procedures, their costs, and the rate of complications.
Su1630 Impact of Training on Scar Assessment After Endoscopic Mucosal Resection of Colorectal Polyp With White Light and Nbi With or Without Near Focus Pujan Kandel*1, Eelco C. Brand2, Wei C. Chen1, Bhaumik Brahmbhatt1, Michael J. Bartel1,3, Russell Bingham1, Ernest P. Bouras1, Massimo Raimondo1, Timothy A. Woodward1, Victoria Gomez1, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; 3 Gastroenterology, Fox Chase Cancer Center, Philadelphia, FL Background: High definition colonoscopy with narrow band imaging (NBI) with nearfocus is a new imaging modality that may thereby help in differentiating residual neoplasia from granular tissue. This could potentially reduce the need for pathologic assessment during EMR follow-up. The main objective of this study is to assess the effect of training on the diagnostic accuracy of the optical detection of residual neoplasia after EMR with high-definition white light and NBI with and without nearfocus. Methods: This is a double-blind review of 121 images from EMR sites assessed with different imaging modalities. Histological confirmed residual neoplasia was used as reference standard. During pre-training 20 different EMR scar site images were scored by five endoscopists after which they received immediate feedback on the presence or absence of residual neoplasia, The training module images of presence and absence of residual neoplasia with all different image modalities, a description of the NICE classification criteria and an ASGE expert video module (Michael Bourke) showing the procedure of scar assessment. During the post-training phase 101 images of 25 patients were assessed by five experts in EMR from a single center. Negative predictive value, positive predictive value, sensitivity, specificity, diagnostic accuracy and interobserver agreement for all imaging modalities including 95% confidence intervals were calculated. Result: Diagnostic values and interobserver agreement for all image modalities before and after training are summarized in table 1 and 2. When white light and NBI with near-focus images were assessed with high confidence the accuracy was significantly increased after training (Table 3). There was a strong increase in agreement between all the EMR endoscopists post training in assessment of EMR scar with different diagnostic modalities Table 2. Conclusion: These results suggest that a brief offline training module improved endoscopists accuracy for the optical diagnosis for residual neoplasia of EMR scar sites in still images.
Table 1. Pre-training diagnostic value of optical detection of residual neoplasia on offline images All EMR-images, n[20 NPV (%) PPV,(%) Sensitivity (%) Specificity, (%) Accuracy,(%) Interobserver agreement, kappa High confidence diagnosis, % NPV, (%) PPV, (%)
NBI
NBI with near-focus
White light
93 [70-100] 74 [49-91] 93 [68-100] 75 [50-91] 82 [66-92] 0.6 [0.4-0.9] 68% 87 [47-100] 87 [62-98]
100 [66-100] 47 [26-70] 100 [70-100] 45 [23-68] 63 [45-78] 0.3 [0.1-0.5] 70% 100 [54-100] 57 [29-82]
71 [47-88] 44 [13-79] 40 [12-73] 75 [51-91] 63 [45-78] 0.1 [-0.2-0.5] 50% 76 [46-94] 100 [16-100]
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB371
Su1628 A Novel Lens Cleaner That Prevent and Remove Water Drop Adhesions During Colonoscopy Naohisa Yoshida*1, Yuji Naito1, Takaaki Murakami1, Kiyoshi Ogiso1, Ryohei Hirose1, Yutaka Inada1, Osamu Dohi1, Kazuhiro Kamada1, Kazuhiko Uchiyama1, Osamu Handa1, Hideyuki Konishi1, Rafiz A. Rani1,2, Yoshito Itoh1 1 Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2Gastroenterology Unit, Faculty of Medicine, Universiti Teknologi MARA, Selangor, Malaysia Background: Water drop adhesions disturb the clarity of endoscopic view during gastrointestinal endoscopy. Recently, we developed a novel lens cleaner (Yoshida N, et al. Dig Endosc 2015;27:609-17). In this study, we developed a new unique usage and examined its ability in preventing and removing water drop adhesions during colonoscopic examinations and treatments. Methods: The novel lens cleaner (CleashÒ) was made mainly using two types of harmless non-ionic surfactant. We first analysed the efficacy for preventing water drop adhesions by basic research. The lens cleaner was applied on the tip of the endoscope and submerged in water 100 times for 5 cycles and the number of water drop adhesions were calculated and compared to the endoscope without this cleaner. Secondly, we performed a clinical research and recruited 25 patients undergoing colonoscopy including polypectomy at the Kyoto Prefectural University of Medicine from October 2015 to November 2015. The cleaner was applied on the tip of the endoscope and was added into an air/water device (water 200ml: CleashÒ 1ml: dimethicon 1ml) for 12 cases, compared to 13 cases without any cleaner. The procedures were recorded and subsequently evaluated by a panel of endoscopist. During colonoscopy, the number of water drop adhesions on the lens and the number of non-rapid removal of water drop adhesions were calculated. Results: With respect to the basic research, the mean rate of water drop adhesion with the novel cleaner was lower than that without it at 19.3% and 31.7% respectively. The mean number of water drop adhesions with the novel cleaner was also significantly lower than that without it as follows; 8.43.3 vs. 13.58.9, pZ0.004. Additionally, the mean number of non-rapid removal of water drop adhesions with the novel cleaner was significantly lower than that without it at 4.32.0 vs. 7.05.8, PZ0.002. Conclusion: Water drop adhesions on the endoscopic lens during colonoscopy were significantly improved with this novel cleaner. Our original, unique method of adding the cleaner into an air/water device shows positive impact by improving efficacy for removal of water drop adhesions.
Su1629 Cost Effectiveness of Endoscopic Mucosal Resection Compared to Transanal Resection of Complex Rectal Polyps Jessica X. Yu*1, W. A. Russell3, Nathan G. Kim4, Jack Ching5, Eran Bendavid5, Douglas K. Owens5, Tonya R. Kaltenbach2 1 Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA; 2Department of Veterans Affairs, University of California San Francisco, San Francisco, CA; 3Department of Management Science and Engineering, Stanford University, Stanford, CA; 4School of Medicine, Stanford University, Stanford, CA; 5Department of Health Policy and Research, Stanford University, Stanford, CA Introduction: Endoscopic mucosal resection (EMR) of complex colon polyps has been found to be cost-effective compared to laparoscopic surgery. However, the optimal management of complex rectal polyps is not well defined. The recommended surgical management for rectal polyps involves a transanal approach, including newer techniques such as transanal endoscopic microsurgery (TEM) and transanal minimally invasive surgery (TAMIS). We aimed to model the lifetime clinical and economic impact of EMR compared to transanal resection for the management of complex rectal polyps. Methods: We developed a Markov model with a 50-year time horizon to simulate the outcomes and costs of treatment of a large (>2cm) rectal polyp in a 50 year-old patient with EMR, TEM and TAMIS. Based on literature review, we estimated that complication rates were 4.2% for EMR, 8.7% for TEM and 13.4% for TAMIS and mortality rate was 0.08%. We assumed the utility loss of transanal surgery to be 0.4 for 2 days and EMR to be 0.25 for 2 days. Costs were based on Centers for Medicare and Medicaid Services (CMS) 2015 average reimbursement data. Transition probabilities for the Markov states of high frequency surveillance, low frequency surveillance and rectal cancer were determined from SEER rectal cancer statistics, CDC national life expectancy tables and published literature. We calculated cost, quality adjusted life years (QALY) and incremental cost-effectiveness ratio (ICER). We also assumed 100% surveillance protocol compliance and a standard 3% discount rate. One-way sensitivity analyses were also performed. Results: Given the higher complication rates for TEM and TAMIS in our base case, we found EMR to cost less and have similar effectiveness compared to TEM and TAMIS. EMR costs $17,264.25 vs. $22,115.68 - $22,237.96 and had similar QALYs (18.95 vs. 18.94) compared to TAMIS and TEM (Table 1). One-way sensitivity analysis on all variables demonstrated that our model was sensitive to procedural complication rates and costs. For TEM and TAMIS to be favored, the cost of the procedures would need to be less than $62.61 and $207.99, respectively. Alterna-
www.giejournal.org
tively, the complication rate of EMR would need to be greater than 16.5%. Conclusion: In our base case analysis, EMR offers similar health benefits to TEM and TAMIS at a lower cost. However, our estimates were sensitive to the quality of life decrement related to the procedures, their costs, and the rate of complications.
Su1630 Impact of Training on Scar Assessment After Endoscopic Mucosal Resection of Colorectal Polyp With White Light and Nbi With or Without Near Focus Pujan Kandel*1, Eelco C. Brand2, Wei C. Chen1, Bhaumik Brahmbhatt1, Michael J. Bartel1,3, Russell Bingham1, Ernest P. Bouras1, Massimo Raimondo1, Timothy A. Woodward1, Victoria Gomez1, Michael B. Wallace1 1 Gastroenterology, Mayo Clinic, Jacksonville, FL; 2Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; 3 Gastroenterology, Fox Chase Cancer Center, Philadelphia, FL Background: High definition colonoscopy with narrow band imaging (NBI) with nearfocus is a new imaging modality that may thereby help in differentiating residual neoplasia from granular tissue. This could potentially reduce the need for pathologic assessment during EMR follow-up. The main objective of this study is to assess the effect of training on the diagnostic accuracy of the optical detection of residual neoplasia after EMR with high-definition white light and NBI with and without nearfocus. Methods: This is a double-blind review of 121 images from EMR sites assessed with different imaging modalities. Histological confirmed residual neoplasia was used as reference standard. During pre-training 20 different EMR scar site images were scored by five endoscopists after which they received immediate feedback on the presence or absence of residual neoplasia, The training module images of presence and absence of residual neoplasia with all different image modalities, a description of the NICE classification criteria and an ASGE expert video module (Michael Bourke) showing the procedure of scar assessment. During the post-training phase 101 images of 25 patients were assessed by five experts in EMR from a single center. Negative predictive value, positive predictive value, sensitivity, specificity, diagnostic accuracy and interobserver agreement for all imaging modalities including 95% confidence intervals were calculated. Result: Diagnostic values and interobserver agreement for all image modalities before and after training are summarized in table 1 and 2. When white light and NBI with near-focus images were assessed with high confidence the accuracy was significantly increased after training (Table 3). There was a strong increase in agreement between all the EMR endoscopists post training in assessment of EMR scar with different diagnostic modalities Table 2. Conclusion: These results suggest that a brief offline training module improved endoscopists accuracy for the optical diagnosis for residual neoplasia of EMR scar sites in still images.
Table 1. Pre-training diagnostic value of optical detection of residual neoplasia on offline images All EMR-images, n[20 NPV (%) PPV,(%) Sensitivity (%) Specificity, (%) Accuracy,(%) Interobserver agreement, kappa High confidence diagnosis, % NPV, (%) PPV, (%)
NBI
NBI with near-focus
White light
93 [70-100] 74 [49-91] 93 [68-100] 75 [50-91] 82 [66-92] 0.6 [0.4-0.9] 68% 87 [47-100] 87 [62-98]
100 [66-100] 47 [26-70] 100 [70-100] 45 [23-68] 63 [45-78] 0.3 [0.1-0.5] 70% 100 [54-100] 57 [29-82]
71 [47-88] 44 [13-79] 40 [12-73] 75 [51-91] 63 [45-78] 0.1 [-0.2-0.5] 50% 76 [46-94] 100 [16-100]
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB371