314l: Improved Adenoma Detection Rates At an Academic Gastroenterology Unit Following Department Colonoscopy Assessment

Abstracts 16.2% (37/228) vs. 6.9% (62/895), OR 2.6 (95%CI, 1.69-4.01). Neoplasms containing advanced neoplasia detected at surveillance were more likely to be nonpolypoid (25/37, 67.6%) and located in the proximal colon (29/37, 78.4%), even though there were more polypoid (n⫽88) than nonpolypoid (n⫽41) neoplasms. There was no metachronous advanced cancer diagnosed. Patient characteristics and their history of tobacco and NSAID use were similar to those of the control group.Conclusion: Patients who are found to have NP-CRN at the index colonoscopy appear to have an increased incidence to have neoplasms containing advanced pathology at surveillance colonoscopy. Follow-up colonoscopy schedule according to the standardized ASGE guidelines did not lead to unexpected findings of interval colorectal carcinoma.

314i Impact of Family History on Prevalence of Adenomas in 40-49 Year Olds With Family History of Colon Cancer: A Prospective Study Philip S. Schoenfeld, Eric E. Elliott, Elizabeth A. Andraska, Hyung-Jin M. Kim, Carol E. Fletcher Aim: Per current colorectal cancer (CRC) guidelines, individuals with a first degree relative (FDR) with CRC should get screening colonoscopy at age 40. Also, repeat scopes are recommended every 5 yrs if the FDR had CRC ⬍ 60 yrs vs 10yrs if the FDR had CRC ⬎ 60 yrs due to possible increased risk among individuals whose FDR was diagnosed (dx)with CRC ⬍ 60 years. However, there is no prospective data to quantify prevalence of adenomas and advanced adenomas (AA) in these 40-49 yr olds vs 40-49 year old average-risk individuals and identify risk factors for adenomas. Methods: For this multi-center, prospective cross-sectional study, inclusion criteria were: (a) 40-49 yr olds with family history (FH) of CRC in a FDR; or, (b) 40-49 yr olds who underwent colonoscopy for abdominal pain, altered bowel habits, or scant hematochezia (trace of blood on toilet paper after wiping). Exclusion criteria: personal history of CRC/adenomas/hereditary CRC syndrome/IBD, family history of polyps, prior colonoscopy for any reason, active GI bleeding, iron deficiency anemia, unexplained weight loss ⬎10 pounds. Study patients completed a risk factor questionnaire about age, gender, ethnicity, age of FDR at dx of CRC, BMI, concurrent medical disorders, concurrent medication use, tobacco use, and alcohol use. Multiple logistic regression using SAS 9.2 assessed factors associated with adenomas and AA (defined as adenoma ⬎ 10 mm). Results: No significant differences were identified between FH of CRC group (n ⫽ 100) and control group (n ⫽ 113) for age (44.6 ⫹/- 3.0 vs 45.5 ⫹/- 3.0), male gender (51% vs 55%), African-American race (11.2% vs 9.3%) or other demographic data. Age of FDR at dx of CRC was known for most (n ⫽ 83) subjects. There was no significant difference between FH of CRC group and control group for prevalence of adenomas (25% vs 23%, respectively, p ⫽ 0.96) or advanced adenomas (3.1% vs 5.6%, respectively, p ⫽ 0.37). Also, there was no significant difference between individuals with FDR diagnosed with CRC ⬍ 60 years old (n ⫽ 36) versus individuals with FDR diagnosed with CRC ⬎ 60 years old (n ⫽ 47) for prevalence of adenomas (25% vs 21.3%, respectively, p ⫽ 0.69) or advanced adenomas (5.6% vs 2.1%, respectively, p ⫽ 0.58). In multiple logistic regression analysis of age, gender, ethnicity, and BMI, FH of CRC was not associated with adenoma [OR ⫽ 1.023; 95% CI: 0.54-1.94], although male gender [OR ⫽ 2.34; 95% CI: 1.12 - 4.89] and older age (age 45-49 versus age 40-44) [OR ⫽ 2.42; 95% CI: 1.14-5.13] were independently associated with adenomas. Conclusion: In 40-49 yr old individuals, a FH of CRC may not impact the prevalence of adenoma.

model assumed program colonoscopy delivery in one year or phased in over 10 years. RESULTS In 1995, fecal occult blood tests (FOBT) and flexible sigmoidoscopy were the most common screening tests, with higher use of colonoscopy by 2005. Total endoscopies beginning in 2008 include screening, re-screening and surveillance colonoscopies performed for past and new tests. With immediate population-based colonoscopy screening, 52 million colonoscopies would be required for initial screening and surveillance, 5 -12 million colonoscopies required each of the next 9 years for surveillance, and 45 million colonoscopies required in year 10. With phasing in over 10 years, 1216 million colonoscopies per year would be required for screening and surveillance. With immediate population-based FIT, 5-9 million surveillance and diagnostic colonoscopies and 48-94 million FITs would be required annually, with colonoscopy peaks every 10 years. With 10 year phasing-in, colonoscopy delivery would be uniform. CONCLUSION Resource utilization varies based on the initial screening test used, and should consider past screening. To provide screening at a steady state, population-based CRC screening in the US should be phased in over time. Two-stage screening test programs such as FIT, with initial positive tests followed by diagnostic colonoscopy, require fewer overall colonoscopies.

314k Chromoendoscopy (Indigo Carmine) Combined With Warm Water Infusion in Lieu of Air Insufflation (Water Method) During Insertion Enhanced Adenoma Detection in Screening and Surveillance Colonoscopy Joseph W. Leung, Lee Toomsen, Surinder K. Mann, Felix W. Leung Background: Warm water infusion in lieu of air insufflation (water method) improves overall success of screening and surveillance colonoscopy compared with usual air insufflation (air method). To improve neoplastic polyp detection, targeted staining or pancolonic chromoendoscopy requiring up to an average of 33 min to complete, has been described. We previously reported the use of methylene blue (MB) combined with water method to enhance detection of colon adenomas (GIE2009;69:AB363). Aim: To determine if chromoendoscopy using Indigo carmine combined with water method improves adenoma detection in a performance improvement project. Methods: Screening or surveillance colonoscopy was performed with the water infusion method. The air pump was turned off on scope insertion. Warm water (37 degree C) was infused using a needle adaptor through the biopsy channel with a peristaltic pump to distend the colon and facilitate scope insertion till the cecum was reached. Chromoendoscopy was used by adding 10 ml of 0.8% Indigo carmine (IC) to a 1 liter bottle of sterile water (IC concentration of 0.008%) and used with the water method. Historical controls of comparable patients examined with air and water method alone were extracted from database. Primary outcome: adenoma detection rate; secondary outcome: total procedure time. Results: (Table). There was no difference in the mean age. Chromoendoscopy with Indigo carmine combined with the water method provided a significantly higher adenoma detection rate than either the air or water method applied alone. The procedure time was also significantly longer. Limitations: Non-randomized, retrospective comparison at a single VA center. Conclusions: Chromoendoscopy with dye (Indigo carmine) added to the water method is technically feasible for colonoscopy. Combining Indigo carmine solution with water method during screening and surveillance colonoscopy yielded a significantly higher adenoma detection rate compared to either the air or water method applied alone. Comparison of adenoma detection rates between three different methods for screening colonoscopy

314j National Estimates of Endoscopic Resource Requirements for Delivering Colorectal Cancer Screening Laura C. Seeff, Florence Tangka, Ann G. Zauber, Diane L. Manninen, Fred Dong, Marjolein Van Ballegooijen INTRODUCTION Colorectal cancer (CRC) is the second leading cause of cancerrelated deaths among US adults, but is preventable with routine screening. Because colonoscopy is used for primary screening and diagnostic follow-up of other abnormal CRC screening tests, assessing endoscopic capacity is critical in planning for widespread CRC screening. This study estimates the number of colonoscopies needed to conduct CRC screening and surveillance for the US population. METHODS The Micro-Simulation Model of the Adenoma-Carcinoma Sequence for colorectal cancer (MISCAN) model was used to simulate the US population for the years 1995 to 2030. Screening interventions overlay the natural history of colorectal cancer, interrupting the adenoma-carcinoma sequence by detecting early stage disease or detecting and removing adenomas. Two hypothetical single-test screening programs were modeled beginning in 2008, including colonoscopy and immunochemical fecal occult blood tests (FIT). Resource needs were assessed for screening, re-screening, and surveillance prior to 2008 and for newly screened individuals. National Health Interview Survey data were used to estimate past screening. Surveillance colonoscopies were based on findings at index colonoscopy for past and new colonoscopies. The

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Air colonoscopy (nⴝ51)

Water colonoscopy (nⴝ51)

Mean Age 58(1) Proportion of patient with 32% at least 1 adenoma Total procedure time (min) 24(1) Data as mean(SEM); *vs. water, **vs. air; p⬍0.05, contrasts

61(1) 39%

Chromoendoscopy with Indigocarmine (nⴝ51 61(1) 61%*,**

28(2) 32(1) *,** Chi square or ANOVA with

314l Improved Adenoma Detection Rates At an Academic Gastroenterology Unit Following Department Colonoscopy Assessment Benjamin S. Hall, Mark E. Benson, Patrick Pfau, Deepak V. Gopal, Mark Reichelderfer Background: There is a clear association between colonoscopic withdrawal time and adenoma detection rates. Furthermore, there is a wide variation in the

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Abstracts withdrawal times, as well as, adenoma detection rates among academic and private practice gastroenterologists. Aim: To assess for an improvement in withdrawal times and adenoma detection rates following departmental education regarding nationally recommended withdrawal times and expected detection rates.Methods: At a single academic institution, 550 screening colonoscopies were analyzed from October 2006 to March 2007 measuring withdrawal times and adenoma detection rates for average risk patients screened for colorectal cancer. Following the previous study, endoscopists were notified of their comparative results and were educated on the national recommendations for withdrawal during screening colonoscopies and expected adenoma detection. Following the education, data from 413 screening colonoscopies were retrospectively reviewed at the same academic endoscopy unit over a 3 month period from July through September 2009. Data was collected on colonoscopy times to allow calculation of withdrawal times, as well as, polyp detection rates. Results: Eleven academic gastroenterologists were studied. The median patient age was 53. 48% of subjects were male and 52% female. The initial study average overall withdrawal time for 550 colonoscopies was 8.9 minutes. Follow-up overall withdrawal time was 12.6 minutes (P⬍0.001). Initial study withdrawal time for colonoscopies where no polyps detected was 7.0 minutes. Follow-up study withdrawal time where no polyps were detected was 9.7 minutes (P⬍.001). The initial study overall adenoma detection rate was .46 and follow-up adenoma detection rate was .57 (P⫽.051). The initial study detected adenomas in 22% of patients screened. The follow-up study detected adenomas in 34% of patients screened (P⬍.001).Conclusion: Department education about the national recommendations noting improved adenoma detection with cautious withdrawal times yielded a statistically significant improvement in overall withdrawal time and adenoma detection in percentage of patients screened. There was also a near statistically significant improvement in overall adenoma detection rate.

314m Choledochoscopy in Pediatric Patients: The Texas Children’s Hospital Experience Sanjiv Harpavat, Isaac Raijman, Jose Alberto Hernandez, Douglas S. Fishman Introduction: Choledochoscopy offers both diagnostic and therapeutic capabilities in patients with biliary disease, including direct visualization of biliary mucosa, ability to biopsy ductal tissue and lithotripsy. Newer intraductal endoscopes have made it easier to perform. We have previously reported our experience in adults, but choledochoscopy use has not been widely reported in children. We evaluated the performance and feasibility of choledochoscopy in a series of pediatric patients. Patients and Methods: Seven cases of choledochoscopy were performed between 2008 and 2009. Six patients (4 female) ranged from age 2 to 21 (mean 13.4 years). Diagnostic indications were primary sclerosing cholangitis (n⫽3), abnormal imaging with extrahepatic obstruction (n⫽3) and choledochal cyst (n⫽1). Of these patients, 4 of 6 were performed as part of pre- or post-liver transplant care. Two different choledochoscopes were used for choledochoscopy: Spyglass Spyscope © (n⫽6) and the Olympus SIF-180 (n⫽1) in a patient with a Roux-en-y hepaticojejunostomy. Five cases were done perorally and two percutaneously. All peroral choledochoscopy patients had a prior biliary sphincterotomy and percutaneous usage was done as adjunct to primary percutaneous catheter (10 or 11F) placement. All patients received prophylactic antibiotics. Results: Choledochoscopy was used to view biliary mucosa in all seven cases; one case demonstrated complete bile duct obstruction, and in one case the endoscope was unable to pass beyond the distal bile duct due to stricture. In two cases ductal tissue was biopsied, and in one case an obstructed hepatic duct not visualized by ERCP was cannulated and allowed for biliary decompression with stent placement. In 6/7 (86%) cases, choledochoscopy confirmed a suspected diagnosis. In 3/7 (42%) cases, choledochoscopy results determined future management including liver transplantation evaluation (n⫽1), surgical referral for bile duct reconstruction (n⫽1), and initiation of steroids for eosinophilic cholangiopathy (n⫽1). Complications included post-procedure abdominal pain with normal serum amylase and lipase (n⫽1), and bacteremia/sepsis (n⫽1). Conclusions: Choledochoscopy is an important diagnostic and therapeutic tool for children with hepatobiliary disease. Usage altered management and provided important clinical data in the majority of patients. Further experience with this technique will better define specific indications in pediatric populations.

314n New Technique of Retrograde Endoscopic Dilatation of Esophageal Stenosis in Children With Epidermolysis Bullosa Dystrophica Thorsten Vowinkel, Klaus Hahnenkamp, Stefan Venherm, Michael Frosch, Norbert J. Senninger, Dirk Tuebergen Introduction. Epidermolysis bullosa (EB) dystrophica is an inherited disorder of squamous epithelium resulting in bullous lesions and subsequent scarring of the skin and the esophagus after minor trauma. Esophageal scarring leads to

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strictures with dysphagia followed by malnutrition and delayed development of the children. We have been able to show that the combination of early balloon dilatation with percutaneous endoscopic gastrostomy (PEG) in a direct puncture technique is a safe procedure that helps to overcome the poor nutritional status of the children. Here we report on our new technique to treat recurrent esophageal strictures by retrograde endoscopy via the established gastrostomy.Methods. 8 children with EB dystrophica between 6 weeks and 11 years of age received a PEG in our department. So far we have treated esophageal stenosis in these children by orthograde balloon dilatation in general anesthesia. Further necessary dilatations we have now performed in 3 children (aged 10-12 years) retrograde via the established gastrostomy with a 2,9 millimeter pediatric bronchoscope. The children were only sedated for the procedure with ketamine s and midazolam. Via the gastrostomy we placed a wire through the bronchoscope into the esophagus and the wire guided the balloon for dilatation up to 12 millimeters. Results. Balloon dilatations, if necessary on a weekly basis, were technically possible in all children without complications. The children did not experience any pain and were able to eat after the procedure. Conclusions. For the first time we have been able to show that retrograde dilatation of esophageal strictures and stenosis via a gastrostomy is technically possible in children with EB dystrophica. The retrograde technique in sedation only is quicker than the procedure in general anesthesia and avoids trauma to the oropharynx because of intubation and by the endoscope. Furthermore the new technique helps to repetitively treat esophageal stenosis up to an acceptable width without the otherwise necessary anesthesiological extraordinary effort.

314o Two-Day Bowel Preparation With Polyethylene Glycol 3350 and Bisacodyl: A New Safe and Effective Regimen for Colonoscopy in Children Uma P. Phatak, Susanne S. Johnson, Sohail Z. Husain, Dinesh Pashankar Background: We reported the efficacy and safety of a four day bowel preparation (prep) with polyethylene glycol 3350 without electrolytes (PEG) for colonoscopy in children(1). To our knowledge, the use of a shorter duration of PEG for bowel prep has not been reported in children. Aim: To assess the efficacy, safety, and acceptance of a two day bowel prep with PEG and bisacodyl for colonoscopy in children. Methods: 94 children (52 boys, 42 girls) were enrolled in this prospective study. PEG was started at a dose of 2gm/kg/ day divided twice a day for two days prior to the colonoscopy with instructions to mix 17 grams in 8 ounces of beverage of choice. A 5 mg tablet of bisacodyl was given on day 1 and 2. Only clear liquids were allowed on day 2. A diary of daily stool frequency and consistency score (1-hard to 5-watery) was maintained. The presence of adverse effects, compliance to prep, and ease of bowel prep were recorded. The quality of the bowel prep was assessed by 2 observers. Results: The mean age of children was 12.1 years (range 2.5 to 19). The patients used different beverages to mix the PEG which included fruit juice (60), water (27), sports drink (26), and other (29). The patients rated the bowel prep as easy (79%), okay (17%), unpleasant (3%), and difficult (1%). The mean daily stool frequency increased from baseline of 1.8 to 4* on day 1 and 6.3* on day 2. The stool consistency changed from baseline of 3 to 4* on day 1 and 4.8* on day 2. (*p ⬍ 0.001 for difference vs baseline). Adverse effects were mild and included nausea (19%), abdominal pain (11%), bloating (9%), vomiting (3%), and other (2%). The compliance, tolerance, and quality of the bowel prep are shown in the table. The endoscopists were able to reach the terminal ileum or the cecum in 98% of the cases.The bowel prep was rated as excellent or good by the operators at the time of endoscopy in 91% and 95% in the right and left colon respectively. These results were comparable to that of the four day prep with PEG alone (91% and 95% in the right and left colon for both bowel preps)(1). Conclusions: This new 2-day bowel prep with PEG and bisacodyl is safe and effective for colonoscopy in children. It is well accepted and tolerated by children without any significant adverse effects. The efficacy of this bowel prep is comparable to the 4-day bowel prep with PEG alone. Reference: (1)Pashankar D et al. J Pediatr 2004;144:358-62

Compliance Tolerance Right Colon Left Colon

Excellent

Good

Fair

Poor

89 (95%) 72 (77%) 47 (50%) 46 (49%)

4 (4%) 18 (19%) 39 (42%) 43 (46%)

1 (1%) 4 (4%) 7 (7%) 5 (5%)

0 0 1 (1%) 0

314p Endoscopic Ultrasound in Children: Applications and Pitfalls. the UC Davis Experience Antonio Quiros, Michael Haight, Richard Quan There is very limited data on the indications, applications and risks of performing endoscopic ultrasound (EUS) in children. Major limiting factor has

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