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Tu1408 Risk Factors for Perforation of Endoscopic Submucosal Dissection in Gastric Tumors
Abstracts
requirement; attenuates discomfort and enhances cecal intubation in unsedated patients. The water method entails the use of warm water infusion in lieu of air insufflation combined with suction removal of residual air to minimize angulations throughout the colon and water exchange to remove feces to clear the luminal view to aid insertion of the colonoscope. Up to one to two liters of water are usually infused and removed during a 15 to 20 min interval of insertion. Most of the infused water is suctioned almost as soon as it is infused to minimize over distension of the colon (GIE 2009;70:505-510, GIE 2010;72:693700). The safety of the water method, however, has not been critically evaluated. We report the vital signs and serum electrolyte levels before and after large volume water exchange used with the water method. Unsedated patients are chosen for evaluation to avoiding the confounding effects of sedation medications on vital signs. Aim: To quantify safety of the water method in terms of the vital signs and serum electrolyte levels before and after large volume water exchange in the colonic lumen used with the water method. We test the hypothesis that these parameters remain stable after colonoscopy is performed using the water method as described above. Patient & method: Patients in 2 RCT comparing the use of air vs. water method for unsedated colonoscopy. Study 1: Patients’ vital signs before (immediately before insertion of the colonoscope into the rectum) and after (immediately after removal of the colonoscope from the rectum) colonoscopy were tabulated for analysis. Study 2: Blood samples (2 ml each) were drawn within 5-10 min before and after colonoscopy for measuring the serum Na⫹ and K⫹ levels using the Istat machine (for bedside measurement of serum electrolytes). Results (Tables). Study 1: There were no significant differences in vital signs before and after colonoscopy in either the air or water method group. All patients were in normal sinus rhythm before and after the colonoscopy. Study 2: There were no significant differences between the serum Na⫹ and K⫹ before and after colonoscopy in either the air or the water group. Overall, the mean volumes of water used were 1500 ml in the water method and 75 ml in the air method. There were no significant correlations between the change (after minus before) in individual parameters (vital signs or serum electrolyte levels) measured and the volume of water used. Conclusion: Vital signs, cardiac rhythm and serum electrolyte levels are well preserved after large volume water exchange in the colonic lumen used with the water method. The water method is a safe modality for examination of the colon. (Supported in part by an ACG grant to FWL). Effect of water method on vital signs Study 1
Before Colonoscopy
After Colonoscopy
Method
N
MBP
Pulse
O2 Saturation
MBP
Pulse
O2 Saturation
Water Air
41 35
87 (14) 87 (15)
69 (11) 69 (11)
98 (4) 97 (2)
84 (14) 82 (10)
66 (10) 67 (10)
98 (2) 97 (2)
MBP, mean blood pressure in mm Hg. Pulse in beats per min. O2 (oxygen) saturation in %. Data are mean (SD). Effect of water method on serum electrolyte levels Study 2
Before Colonoscopy ⴙ
ⴙ
After Colonoscopy
Method
N
K meq/l
Na meq/l
Kⴙ meq/l
Naⴙ meq/l
Water Air
18 23
3.7 (0.4) 3.9 (0.4)
140 (2.6) 138 (3.0)
3.8 (0.4) 4.0 (0.4)
140 (3.7) 138 (2.7)
Data are mean (SD).
Tu1408 Risk Factors for Perforation of Endoscopic Submucosal Dissection in Gastric Tumors Sung Jae Shin, Junhwan Yu, Jae Myoung Choi, Jeong Ook Wi, Sun Gyo Lim, Kee Myung Lee, Kwang Jae Lee, Jin Hong Kim Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea Background: Endoscopic submucosal dissection (ESD) is considered as a relatively noninvasive procedure. One of the major advantages of ESD, compared with conventional EMR, is that en bloc resection is possible. However, injury of proper muscle layer during ESD can cause perforation. There have been a few studies about risk factors for perforation during ESD except for a long operation time, a large tumor size and the location of the lesion in an upper region. The purpose of this study was to clarify the risk factors for perforation during ESD. Methods: ESD was performed in 643 patients with a total of 686 gastric tumors (Gastric adenoma or EGC) between February 2005 and July 2010. Perforation occurred in a total of 65 lesions (9.5%) for which conservative or surgical treatment had been effective. We evaluated risk factors for perforation following ESD, such as patient-, tumor- and treatment-related factors. Patientrelated factors were gender and age (years). Tumor-related factors were tumor location, macroscopic type, fibrosis, initial biopsy pathology, specimen pathology
www.giejournal.org
and depth of invasion. Treatment-related factors were experience of endoscopist (no. of cases), operation time (h), type of knife, resected size (mm), enbloc resection and bleeding. Results: Univariate analysis indicated that age (ⱕ60years: 7.5%; 60-80: 9.7%; ⱖ80: 33.3%; p⫽0.001), tumor location (pylorus/antrum/angle: 8.1%; body: 11.8%; cardia/fundus: 31.3%; p⫽0.004), fibrosis (p⬍0.001), specimen pathology (low grade dysplasia: 6.5%; ⱖ high grade dysplasia: 12.9%; p ⫽0.006), operation time ⱖ 2h (p⬍0.001), type of knife (IT: 10.8%; Flex/Hook: 3.9%; p⫽0.017), resected size ⱖ 50mm (p⫽0.034), piecemeal resection (p⬍0.001) and bleeding (no/mild: 7.4%; moderate/severe: 19.2%; p⫽0.001) were significantly associated with perforation. In multivariate logistic regression analysis of factors associated with perforation during ESD, Fibrosis of lesion (odds ratio (OR), 6.481; 95% confidence interval (CI), 2.13-19.63), the tumor location in cardia or fundus (OR, 21.397; 95%CI, 3.37-135.77) and the specimen pathology (ⱖ high grade dysplasia) (OR, 3.471; 95%CI, 1.09-11.02) were significantly associated with the incidence of perforation. Conclusions: A fibrosis of lesion, the location of the lesion in cardia or fundus and a specimen pathology( ⱖ high grade dysplasia) are risk factors for perforation following ESD.
Tu1409 Efficacy of Transdermal Fentanyl for Pain in ESD Patient Hyuk Soon Choi1, Chang Duck Kim1, Bora Keum1, Yong Sik Kim1, Yoon Tae Jeen1, Hong Sik Lee1, Hoon Jai Chun1, Ho Sang Ryu1, Sung Chul Park2 1 Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea; 2Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea Background: With the recent widespread use of endoscopic submucosal dissection (ESD) as a therapeutic technique, the epigastric pain management of ESD patient after the procedure have been considered as important issues. Several synthetic opioids have been used for pain control after ESD, yet currently there are no studies which have compared their efficacy and safety. Sometimes, repetitive administration of synthetic opioid. On the other hand, transdermal fentanyl patch can provides long-term continuous pain-management. This study investigates the usefulness and safety of the fentanyl patch for pain relief in ESD patients. Methods: The patients with gastric epithelial neoplasia scheduled to undergo ESD were randomly assigned to a fentanyl patch-receiving test group (TDF group) and a placebo control group (P group) prospectively. At the evening before the ESD procedure, the TDF group received a 12.5 mcg/h fentanyl patch, whereas the P group received a placebo patch. The patients and examiners were blinded. An additional IV 25 mg of pethidine was administered at the event of pain development, and a numerical rating scale (NSR) was used to evaluate pre- and post-procedural pain on a scale of 0 to 10. Results: A total of 104 patients enrolled in the study. 50 patients received the fentanyl patch and 54 patients received the placebo patch. There were no differences in age, height, body weight and gastric lesion location, size and pathology. The TDF group showed significantly less pain right after the procedure(median, 5.0 vs 3.0, p⫽0.030). The maximal pain score during 24 hours(6.0 vs 3.0, p⫽0.038), and one-day after the procedure(3.0 vs 1.0, p⬍0.001) were also lower than placebo group. In addition, the TDF group required significantly less pethidine dosage for pain relieve. Both test and control groups showed minor side effects such as anorexia and nausea, but there were no serious side effects. Conclusion: The ESD procedure can cause considerable epigastric pain and therefore requires vigilant pain control. The Transdermal fentanyl patch is effective, convenient, safe to control epigastic pain after ESD.
Tu1410 Does Obesity Have an Impact on Bowel Preparation for Screening Colonoscopy? A Prospective Study Using the Boston Bowel Preparation Score Shashideep Singhal1, Manpreet Singh2, Puneet S. Basi1, Siddharth Mathur1, Harleen Bahga1, Mojdeh Momeni1, Mahesh Krishnaiah1, Sury Anand1 1 Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY; 2 Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY Background: Inadequate bowel preparation is associated with missed lesions, repeat procedures, high cost and increased risk of complications during colonoscopy. Previous studies have shown increased body mass index (BMI) as a predictor of poor bowel preparation. Most studies are retrospective and standardized bowel preparation scoring scales to determine quality of preparation in different segments of colon had not been used. Methods: The prospective case control study enrolled consecutive patients reporting for screening colonoscopy. Study subjects were asked to fill up a questionnaire about compliance with bowel preparation instructions and factors known to affect quality of bowel preparation. After colonoscopy the endoscopists were asked to determine quality of bowel preparation as per Boston Bowel Preparation Score (BBPS). Segmental scores from right, transverse and left side of
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB399
requirement; attenuates discomfort and enhances cecal intubation in unsedated patients. The water method entails the use of warm water infusion in lieu of air insufflation combined with suction removal of residual air to minimize angulations throughout the colon and water exchange to remove feces to clear the luminal view to aid insertion of the colonoscope. Up to one to two liters of water are usually infused and removed during a 15 to 20 min interval of insertion. Most of the infused water is suctioned almost as soon as it is infused to minimize over distension of the colon (GIE 2009;70:505-510, GIE 2010;72:693700). The safety of the water method, however, has not been critically evaluated. We report the vital signs and serum electrolyte levels before and after large volume water exchange used with the water method. Unsedated patients are chosen for evaluation to avoiding the confounding effects of sedation medications on vital signs. Aim: To quantify safety of the water method in terms of the vital signs and serum electrolyte levels before and after large volume water exchange in the colonic lumen used with the water method. We test the hypothesis that these parameters remain stable after colonoscopy is performed using the water method as described above. Patient & method: Patients in 2 RCT comparing the use of air vs. water method for unsedated colonoscopy. Study 1: Patients’ vital signs before (immediately before insertion of the colonoscope into the rectum) and after (immediately after removal of the colonoscope from the rectum) colonoscopy were tabulated for analysis. Study 2: Blood samples (2 ml each) were drawn within 5-10 min before and after colonoscopy for measuring the serum Na⫹ and K⫹ levels using the Istat machine (for bedside measurement of serum electrolytes). Results (Tables). Study 1: There were no significant differences in vital signs before and after colonoscopy in either the air or water method group. All patients were in normal sinus rhythm before and after the colonoscopy. Study 2: There were no significant differences between the serum Na⫹ and K⫹ before and after colonoscopy in either the air or the water group. Overall, the mean volumes of water used were 1500 ml in the water method and 75 ml in the air method. There were no significant correlations between the change (after minus before) in individual parameters (vital signs or serum electrolyte levels) measured and the volume of water used. Conclusion: Vital signs, cardiac rhythm and serum electrolyte levels are well preserved after large volume water exchange in the colonic lumen used with the water method. The water method is a safe modality for examination of the colon. (Supported in part by an ACG grant to FWL). Effect of water method on vital signs Study 1
Before Colonoscopy
After Colonoscopy
Method
N
MBP
Pulse
O2 Saturation
MBP
Pulse
O2 Saturation
Water Air
41 35
87 (14) 87 (15)
69 (11) 69 (11)
98 (4) 97 (2)
84 (14) 82 (10)
66 (10) 67 (10)
98 (2) 97 (2)
MBP, mean blood pressure in mm Hg. Pulse in beats per min. O2 (oxygen) saturation in %. Data are mean (SD). Effect of water method on serum electrolyte levels Study 2
Before Colonoscopy ⴙ
ⴙ
After Colonoscopy
Method
N
K meq/l
Na meq/l
Kⴙ meq/l
Naⴙ meq/l
Water Air
18 23
3.7 (0.4) 3.9 (0.4)
140 (2.6) 138 (3.0)
3.8 (0.4) 4.0 (0.4)
140 (3.7) 138 (2.7)
Data are mean (SD).
Tu1408 Risk Factors for Perforation of Endoscopic Submucosal Dissection in Gastric Tumors Sung Jae Shin, Junhwan Yu, Jae Myoung Choi, Jeong Ook Wi, Sun Gyo Lim, Kee Myung Lee, Kwang Jae Lee, Jin Hong Kim Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea Background: Endoscopic submucosal dissection (ESD) is considered as a relatively noninvasive procedure. One of the major advantages of ESD, compared with conventional EMR, is that en bloc resection is possible. However, injury of proper muscle layer during ESD can cause perforation. There have been a few studies about risk factors for perforation during ESD except for a long operation time, a large tumor size and the location of the lesion in an upper region. The purpose of this study was to clarify the risk factors for perforation during ESD. Methods: ESD was performed in 643 patients with a total of 686 gastric tumors (Gastric adenoma or EGC) between February 2005 and July 2010. Perforation occurred in a total of 65 lesions (9.5%) for which conservative or surgical treatment had been effective. We evaluated risk factors for perforation following ESD, such as patient-, tumor- and treatment-related factors. Patientrelated factors were gender and age (years). Tumor-related factors were tumor location, macroscopic type, fibrosis, initial biopsy pathology, specimen pathology
www.giejournal.org
and depth of invasion. Treatment-related factors were experience of endoscopist (no. of cases), operation time (h), type of knife, resected size (mm), enbloc resection and bleeding. Results: Univariate analysis indicated that age (ⱕ60years: 7.5%; 60-80: 9.7%; ⱖ80: 33.3%; p⫽0.001), tumor location (pylorus/antrum/angle: 8.1%; body: 11.8%; cardia/fundus: 31.3%; p⫽0.004), fibrosis (p⬍0.001), specimen pathology (low grade dysplasia: 6.5%; ⱖ high grade dysplasia: 12.9%; p ⫽0.006), operation time ⱖ 2h (p⬍0.001), type of knife (IT: 10.8%; Flex/Hook: 3.9%; p⫽0.017), resected size ⱖ 50mm (p⫽0.034), piecemeal resection (p⬍0.001) and bleeding (no/mild: 7.4%; moderate/severe: 19.2%; p⫽0.001) were significantly associated with perforation. In multivariate logistic regression analysis of factors associated with perforation during ESD, Fibrosis of lesion (odds ratio (OR), 6.481; 95% confidence interval (CI), 2.13-19.63), the tumor location in cardia or fundus (OR, 21.397; 95%CI, 3.37-135.77) and the specimen pathology (ⱖ high grade dysplasia) (OR, 3.471; 95%CI, 1.09-11.02) were significantly associated with the incidence of perforation. Conclusions: A fibrosis of lesion, the location of the lesion in cardia or fundus and a specimen pathology( ⱖ high grade dysplasia) are risk factors for perforation following ESD.
Tu1409 Efficacy of Transdermal Fentanyl for Pain in ESD Patient Hyuk Soon Choi1, Chang Duck Kim1, Bora Keum1, Yong Sik Kim1, Yoon Tae Jeen1, Hong Sik Lee1, Hoon Jai Chun1, Ho Sang Ryu1, Sung Chul Park2 1 Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea; 2Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea Background: With the recent widespread use of endoscopic submucosal dissection (ESD) as a therapeutic technique, the epigastric pain management of ESD patient after the procedure have been considered as important issues. Several synthetic opioids have been used for pain control after ESD, yet currently there are no studies which have compared their efficacy and safety. Sometimes, repetitive administration of synthetic opioid. On the other hand, transdermal fentanyl patch can provides long-term continuous pain-management. This study investigates the usefulness and safety of the fentanyl patch for pain relief in ESD patients. Methods: The patients with gastric epithelial neoplasia scheduled to undergo ESD were randomly assigned to a fentanyl patch-receiving test group (TDF group) and a placebo control group (P group) prospectively. At the evening before the ESD procedure, the TDF group received a 12.5 mcg/h fentanyl patch, whereas the P group received a placebo patch. The patients and examiners were blinded. An additional IV 25 mg of pethidine was administered at the event of pain development, and a numerical rating scale (NSR) was used to evaluate pre- and post-procedural pain on a scale of 0 to 10. Results: A total of 104 patients enrolled in the study. 50 patients received the fentanyl patch and 54 patients received the placebo patch. There were no differences in age, height, body weight and gastric lesion location, size and pathology. The TDF group showed significantly less pain right after the procedure(median, 5.0 vs 3.0, p⫽0.030). The maximal pain score during 24 hours(6.0 vs 3.0, p⫽0.038), and one-day after the procedure(3.0 vs 1.0, p⬍0.001) were also lower than placebo group. In addition, the TDF group required significantly less pethidine dosage for pain relieve. Both test and control groups showed minor side effects such as anorexia and nausea, but there were no serious side effects. Conclusion: The ESD procedure can cause considerable epigastric pain and therefore requires vigilant pain control. The Transdermal fentanyl patch is effective, convenient, safe to control epigastic pain after ESD.
Tu1410 Does Obesity Have an Impact on Bowel Preparation for Screening Colonoscopy? A Prospective Study Using the Boston Bowel Preparation Score Shashideep Singhal1, Manpreet Singh2, Puneet S. Basi1, Siddharth Mathur1, Harleen Bahga1, Mojdeh Momeni1, Mahesh Krishnaiah1, Sury Anand1 1 Gastroenterology, The Brooklyn Hospital Center, Brooklyn, NY; 2 Internal Medicine, The Brooklyn Hospital Center, Brooklyn, NY Background: Inadequate bowel preparation is associated with missed lesions, repeat procedures, high cost and increased risk of complications during colonoscopy. Previous studies have shown increased body mass index (BMI) as a predictor of poor bowel preparation. Most studies are retrospective and standardized bowel preparation scoring scales to determine quality of preparation in different segments of colon had not been used. Methods: The prospective case control study enrolled consecutive patients reporting for screening colonoscopy. Study subjects were asked to fill up a questionnaire about compliance with bowel preparation instructions and factors known to affect quality of bowel preparation. After colonoscopy the endoscopists were asked to determine quality of bowel preparation as per Boston Bowel Preparation Score (BBPS). Segmental scores from right, transverse and left side of
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB399