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Tu1415 Risk of Perforation During Endoscopic Submucosal Dissection for Colorectal Tumors
Abstracts
Nurse who was present in the room. Trainees were credited with successful cecal intubation or detection and removal of adenomatous polyps only in circumstances in which the attending did not have to lay hands on the colonoscope. Each fellow was assessed with 15 evaluations for every 50 procedures performed over the first 2 years of training. Descriptive statistics were utilized to calculate mean ADR, WT, CIR and SRPR among the trainees with 95% confidence intervals with a primary focus on the number of cases at which all the fellows matched ASGE benchmarks for quality colonoscopy. Results: The goal for independent cecal intubation was met with a mean CIR of 95.9% (95% CI: 92.1-99.7%) upon completion of 201-250 supervised colonoscopies (Figure 1). At 51-100 cases, all trainees had an independent ADR of ⬎25% for male patients with a mean ADR of 32.7% (95% CI: 26.7-38.6%). At an early stage in training (0-50 cases), trainees met the goal WT with a mean of 12.7 minutes (95% CI: 10.7-14.59) that remained consistently above the 6 minute threshold throughout the first 2 years of training. SRPR for polyps ⬍ 2 cm in size did not reach the 95% target until 201-250 cases were completed. Conclusions: The current threshold of 140 cases is not sufficient to ensure that trainees are able to perform quality colonoscopy. Fellows do not meet all of the quality goals for colonoscopy until at least 201-250 cases are completed. This conclusion highlights the importance of revising the guideline on competency and training in colonoscopy to incorporate quality benchmarks.
Tu1414 Effects of Orally Disintegrated Metoclopramide (ODM) in Optimizing Late Out Patient Endoscopy: A Randomized DoubleBlinded Placebo Control Clinical Trial P Patrick Basu1,2, Hemanth Hampole3, Niraj James Shah2, Vinod Mohan4, Nithya Krishnaswamy2, Chris Tang2, Tamer Montaser2 1 Department of Gastroenterology, Hepatology and Liver Transplant, Columbia University College of Physicians and Surgeons, New York, NY; 2Medicine, North Shore Forest Hills Hospital LIJ, Forest Hills, NY; 3 Medicine, Cook County Hospital, Chicago, IL; 4Medicine, St Francis Hospital, Boston, MA Objectives: Out patient Endoscopy is a standard procedure. Six hours fasting of solids and two hours of liquid are standard anesthesia guidelines prior to sedation.. This study evaluates the beneficial effects of a pro motility agent, ODM, given half hour prior to the procedure in the late afternoon with five hours post lunch interval. This minimizes procedure time, with optimal visual field, reduces sedation, and recovery time and saves a day’s work loss. Method: One Hundred and twenty-nine (n⫽129) patients of ages (25 to 75years) were randomize in to three arms, each (n⫽43), in a blinded method. Arm A is the placebo; Arm B (n⫽43), ODM 10 mg twenty minutes before Endoscopy in the late afternoon; Arm C (n⫽85) oral Metoclopramide 10mg thirty minutes prior to endoscopy. The last solid meals were given at noon that consists of (one oz of either Chicken, Turkey or Tuna with half an oz of Potato or Fruits, Salads without Mayonnaise or dairy products, with 12oz of Water), five hours prior to endoscopy. The Anesthesiologist administered routine IV Propofol with documented pre and post sedation time. Total time of Pan Endoscopy with six biopsies and suction of fluid with recovery time and comfort score were evaluated. Exclusions: Patients with active GI bleeding, DM, BMI⬎33, neuromuscular diseases, known gastric motility disorders, gastric malignancy, and drugs altering GI motility Results: Use of ODM in late afternoon endoscopy
www.giejournal.org
was well tolerated with a mean total time of, 4 minutes and 40seconds, compared to oral Metoclopramide of 6 minutes 30 seconds and placebo of 10 minutes 40seconds. No Major side effects were observed in any groups. Nausea 11%, abdominal distension 24%, vomiting 7%, urinary retention 2%, were observed in the placebo. Conclusion: This clinical study evaluates the role of ODM in late outpatient endoscopy. It is beneficial over standard endoscopy with lesser amount of IV sedation, faster recovery, and optimal biopsies without having to loose a day’s work with an economic impact and productivity. A multicenter trial is needed to validate.
Tu1415 Risk of Perforation During Endoscopic Submucosal Dissection for Colorectal Tumors Eun-Jung Lee1, Yong Sung Choi2, Jae Bum Lee1, Eui Gon Youk1 1 Surgery, Daehang Hospital, Seoul, Republic of Korea; 2Internal medicine, Daehang hospital, Seoul, Republic of Korea Background: Endoscopic submucosal dissection (ESD) emerged as a curative treatment for early gastrointestinal tumors due to resection of tumor regardless of size. However, for colorectal tumors, there are some barriers to wide application including a remarkable risk of perforation because of thin colonic wall and tortuous structure of the colon. This study was performed to evaluate the risk and the predictive factors for perforation during ESD procedures. Methods: Between October 2006 and November 2010, a total 686 consecutive ESD cases of colorectal tumors were analyzed. First, incidence rate and clinical course of perforation were evaluated. Second, patient-related variables (age, sex, history of aspirin or anti-platelet agents and comorbidity), endoscopic variables (tumor size, location and gross type), procedure-related variables (experience of procedures, procedure time and materials of submucosal injection), and the pathologic diagnosis were analyzed as potential risk factors. Results: The mean age of the patients was 59.9 years. The mean size of the lesions was 25.3 mm. The overall en bloc resection rate was 95.9%. Perforation occurred in 44 out of 686 cases (6.4%). 41 patients recovered through conservative treatment. The other three patients received emergency operations due to large perforation. The gross type (laterally spreading tumor) and the location (right-sided colon) of the tumors, experience of the procedure (⬍100 cases) and submucosal injection without hyaluronic acid were associated with a higher frequency of perforation (p⫽0.006, p⫽0.01, 0.02 and p⫽0.006, respectively). On multivariate analysis, submucosal injection with hyaluronic acid (OR⫽0.31, 95% CI 0.13-0.72) was a significant predictive factor for a successful ESD without perforation. Conclusion: Perforation rate was 6.4% and most of cases could be successfully managed non-surgically. Submucosal injection with hyaluronic acid is very useful for preventing colon perforation during ESD procedures.
Tu1416 Quality Improvement Project to Increase the Rate of Screening Colonoscopy At Internal Medicine Resident Clinics: Results From Two Sites Tarun Rustagi1,2, Angela Stein1,2, Luis F. Diez2,1, Rebecca Andrews1, Steven Angus1 1 Department of Internal Medicine, University of Connecticut, Farmington, CT; 2Department of Internal Medicine, Saint Francis Hospital and Medical Center, Hartford, CT Introduction: The American College of Gastroenterology guideline recommends that all patients above 50 years of age should undergo colorectal cancer (CRC) screening and colonoscopy is the preferred and recommended modality. With the health care reform, disease prevention is crucial. However, the rates of screening colonoscopy are disappointingly low. Innovative interventions are needed to increase adherence and improve awareness among residents to increase screening for CRC. The aim of this study is to evaluate the effectiveness of self-audit tool in increasing the rate of screening colonoscopy at Internal Medicine resident clinics. Methods: Clinic patients at 2 sites (university hospital and teaching community hospital) seen by Internal Medicine residents during their weekly continuity clinic, eligible for screening colonoscopy, were enrolled in the study. Documentation of the screening status was incorporated into a preexisting, standardized, self-audit tool. The audit was completed by residents after each patient encounter. Clinic directors emphasized audit completion. The audits were then submitted to the program director. We compared the number of referrals made by residents for screening colonoscopy and number of screening colonoscopy done at each clinic site 15 months before and after implementation of this audit tool. Collected data was also analyzed for rate of screening colonoscopy, age appropriate screening, documentation, patient refusal. We also compared data among different levels of training. Fischer-exact test or chi-square was used for categorical variables. P ⬍ 0.05 was considered significant. Results: A total of 3171 self-audit forms were collected during the 15month intervention period. Completion of the screening colonoscopy series questionnaire was noted in 63% audit forms. Number of referrals made by
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB401
Nurse who was present in the room. Trainees were credited with successful cecal intubation or detection and removal of adenomatous polyps only in circumstances in which the attending did not have to lay hands on the colonoscope. Each fellow was assessed with 15 evaluations for every 50 procedures performed over the first 2 years of training. Descriptive statistics were utilized to calculate mean ADR, WT, CIR and SRPR among the trainees with 95% confidence intervals with a primary focus on the number of cases at which all the fellows matched ASGE benchmarks for quality colonoscopy. Results: The goal for independent cecal intubation was met with a mean CIR of 95.9% (95% CI: 92.1-99.7%) upon completion of 201-250 supervised colonoscopies (Figure 1). At 51-100 cases, all trainees had an independent ADR of ⬎25% for male patients with a mean ADR of 32.7% (95% CI: 26.7-38.6%). At an early stage in training (0-50 cases), trainees met the goal WT with a mean of 12.7 minutes (95% CI: 10.7-14.59) that remained consistently above the 6 minute threshold throughout the first 2 years of training. SRPR for polyps ⬍ 2 cm in size did not reach the 95% target until 201-250 cases were completed. Conclusions: The current threshold of 140 cases is not sufficient to ensure that trainees are able to perform quality colonoscopy. Fellows do not meet all of the quality goals for colonoscopy until at least 201-250 cases are completed. This conclusion highlights the importance of revising the guideline on competency and training in colonoscopy to incorporate quality benchmarks.
Tu1414 Effects of Orally Disintegrated Metoclopramide (ODM) in Optimizing Late Out Patient Endoscopy: A Randomized DoubleBlinded Placebo Control Clinical Trial P Patrick Basu1,2, Hemanth Hampole3, Niraj James Shah2, Vinod Mohan4, Nithya Krishnaswamy2, Chris Tang2, Tamer Montaser2 1 Department of Gastroenterology, Hepatology and Liver Transplant, Columbia University College of Physicians and Surgeons, New York, NY; 2Medicine, North Shore Forest Hills Hospital LIJ, Forest Hills, NY; 3 Medicine, Cook County Hospital, Chicago, IL; 4Medicine, St Francis Hospital, Boston, MA Objectives: Out patient Endoscopy is a standard procedure. Six hours fasting of solids and two hours of liquid are standard anesthesia guidelines prior to sedation.. This study evaluates the beneficial effects of a pro motility agent, ODM, given half hour prior to the procedure in the late afternoon with five hours post lunch interval. This minimizes procedure time, with optimal visual field, reduces sedation, and recovery time and saves a day’s work loss. Method: One Hundred and twenty-nine (n⫽129) patients of ages (25 to 75years) were randomize in to three arms, each (n⫽43), in a blinded method. Arm A is the placebo; Arm B (n⫽43), ODM 10 mg twenty minutes before Endoscopy in the late afternoon; Arm C (n⫽85) oral Metoclopramide 10mg thirty minutes prior to endoscopy. The last solid meals were given at noon that consists of (one oz of either Chicken, Turkey or Tuna with half an oz of Potato or Fruits, Salads without Mayonnaise or dairy products, with 12oz of Water), five hours prior to endoscopy. The Anesthesiologist administered routine IV Propofol with documented pre and post sedation time. Total time of Pan Endoscopy with six biopsies and suction of fluid with recovery time and comfort score were evaluated. Exclusions: Patients with active GI bleeding, DM, BMI⬎33, neuromuscular diseases, known gastric motility disorders, gastric malignancy, and drugs altering GI motility Results: Use of ODM in late afternoon endoscopy
www.giejournal.org
was well tolerated with a mean total time of, 4 minutes and 40seconds, compared to oral Metoclopramide of 6 minutes 30 seconds and placebo of 10 minutes 40seconds. No Major side effects were observed in any groups. Nausea 11%, abdominal distension 24%, vomiting 7%, urinary retention 2%, were observed in the placebo. Conclusion: This clinical study evaluates the role of ODM in late outpatient endoscopy. It is beneficial over standard endoscopy with lesser amount of IV sedation, faster recovery, and optimal biopsies without having to loose a day’s work with an economic impact and productivity. A multicenter trial is needed to validate.
Tu1415 Risk of Perforation During Endoscopic Submucosal Dissection for Colorectal Tumors Eun-Jung Lee1, Yong Sung Choi2, Jae Bum Lee1, Eui Gon Youk1 1 Surgery, Daehang Hospital, Seoul, Republic of Korea; 2Internal medicine, Daehang hospital, Seoul, Republic of Korea Background: Endoscopic submucosal dissection (ESD) emerged as a curative treatment for early gastrointestinal tumors due to resection of tumor regardless of size. However, for colorectal tumors, there are some barriers to wide application including a remarkable risk of perforation because of thin colonic wall and tortuous structure of the colon. This study was performed to evaluate the risk and the predictive factors for perforation during ESD procedures. Methods: Between October 2006 and November 2010, a total 686 consecutive ESD cases of colorectal tumors were analyzed. First, incidence rate and clinical course of perforation were evaluated. Second, patient-related variables (age, sex, history of aspirin or anti-platelet agents and comorbidity), endoscopic variables (tumor size, location and gross type), procedure-related variables (experience of procedures, procedure time and materials of submucosal injection), and the pathologic diagnosis were analyzed as potential risk factors. Results: The mean age of the patients was 59.9 years. The mean size of the lesions was 25.3 mm. The overall en bloc resection rate was 95.9%. Perforation occurred in 44 out of 686 cases (6.4%). 41 patients recovered through conservative treatment. The other three patients received emergency operations due to large perforation. The gross type (laterally spreading tumor) and the location (right-sided colon) of the tumors, experience of the procedure (⬍100 cases) and submucosal injection without hyaluronic acid were associated with a higher frequency of perforation (p⫽0.006, p⫽0.01, 0.02 and p⫽0.006, respectively). On multivariate analysis, submucosal injection with hyaluronic acid (OR⫽0.31, 95% CI 0.13-0.72) was a significant predictive factor for a successful ESD without perforation. Conclusion: Perforation rate was 6.4% and most of cases could be successfully managed non-surgically. Submucosal injection with hyaluronic acid is very useful for preventing colon perforation during ESD procedures.
Tu1416 Quality Improvement Project to Increase the Rate of Screening Colonoscopy At Internal Medicine Resident Clinics: Results From Two Sites Tarun Rustagi1,2, Angela Stein1,2, Luis F. Diez2,1, Rebecca Andrews1, Steven Angus1 1 Department of Internal Medicine, University of Connecticut, Farmington, CT; 2Department of Internal Medicine, Saint Francis Hospital and Medical Center, Hartford, CT Introduction: The American College of Gastroenterology guideline recommends that all patients above 50 years of age should undergo colorectal cancer (CRC) screening and colonoscopy is the preferred and recommended modality. With the health care reform, disease prevention is crucial. However, the rates of screening colonoscopy are disappointingly low. Innovative interventions are needed to increase adherence and improve awareness among residents to increase screening for CRC. The aim of this study is to evaluate the effectiveness of self-audit tool in increasing the rate of screening colonoscopy at Internal Medicine resident clinics. Methods: Clinic patients at 2 sites (university hospital and teaching community hospital) seen by Internal Medicine residents during their weekly continuity clinic, eligible for screening colonoscopy, were enrolled in the study. Documentation of the screening status was incorporated into a preexisting, standardized, self-audit tool. The audit was completed by residents after each patient encounter. Clinic directors emphasized audit completion. The audits were then submitted to the program director. We compared the number of referrals made by residents for screening colonoscopy and number of screening colonoscopy done at each clinic site 15 months before and after implementation of this audit tool. Collected data was also analyzed for rate of screening colonoscopy, age appropriate screening, documentation, patient refusal. We also compared data among different levels of training. Fischer-exact test or chi-square was used for categorical variables. P ⬍ 0.05 was considered significant. Results: A total of 3171 self-audit forms were collected during the 15month intervention period. Completion of the screening colonoscopy series questionnaire was noted in 63% audit forms. Number of referrals made by
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB401