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891d: Antiplatelet Medications Increase the Risk of Post-Polypectomy Bleeding
Abstracts 891d Antiplatelet Medications Increase the Risk of Post-Polypectomy Bleeding Evan B. Grossman, Ashley N. Maranino, Diana C. Zamora, Christopher J. Dimaio, Emmy Ludwig, Arnold J. Markowitz, Mithat Gonen, Mark A. Schattner, Moshe Shike, Robert C. Kurtz, Sidney J. Winawer, Hans Gerdes Aim: To determine whether antiplatelet agents affect the incidence of immediate and delayed post-polypectomy bleeding. Methods:Patients who had colonoscopic polypectomy at a cancer center from June 2005 to January 2009 were identified retrospectively from a hospital database as well as a prospectively maintained complication database. Polyp location and size, polypectomy method, use of anticoagulant or antiplatelet agents, and the prevalence of immediate (bleeding at the time of colonoscopy) or delayed postpolypectomy bleeding (within 30 days of polypectomy) and management were recorded. Statistical analysis was performed using Pearson’s chi-square and logistic regression.Results:A total of 3191 colonoscopies with polypectomy were performed, with 6134 polyps removed. There were 41 patients (1.3%) with immediate bleeding (median age 66, range 49-88) and 36 patients (1.1%) with delayed bleeding (median age 64, range 39-92), at a median of 7 days (range 1-14) post-polypectomy. The use of aspirin or other NSAIDs was associated with an increased prevalence of delayed bleeding (p⫽0.0423 and p⬍.0001, respectively), but not immediate bleeding (table). Patients who used both aspirin and other NSAIDs had an increased risk of both immediate (p⬍.0001) and delayed bleeding (p⫽0.0327). Clopidogrel increased the prevalence of both immediate (p⫽0.0242) and delayed bleeding (p⫽0.0114). After adjusting for age, gender, race, medications, and polypectomy number, clopidogrel continued to be significantly associated with an increased risk of delayed bleeding. An increased number of polypectomies during colonoscopy was also associated with an increased risk of immediate bleeding (p⫽0.0046, OR 1.15, 1.044-1.268). Conclusions: This study confirms that the overall risk of immediate and delayed post-polypectomy bleeding is low. However, the use of aspirin or other NSAIDs is associated with an increased risk of delayed bleeding and the combined use of aspirin and other NSAIDs is associated with an increased risk of both immediate and delayed bleeding. Clopidogrel is also associated with an increased risk of both immediate and delayed post-polypectomy bleeding. Since these antiplatelet agents increase the risk of bleeding, clinicians should consider discontinuing them prior to polypectomy. Effect of Antiplatelet Agents on Immediate and Delayed Post-Polypectomy Bleeding (nⴝ3191) No No Immediate Logistic Delayed Delayed Logistic Bleeding Immediate Univariate Regression Bleeding Bleeding Univariate Regression nⴝ3150 Bleeding Analysis p (OR, 95% Nⴝ3155 nⴝ36 Analysis p (OR, 95% (%) nⴝ41 (%) value CI) (%) (%) value CI) ASA Other NSAIDs
627 (19.9) 90 (2.9)
8 (19.5) 2 (4.9)
0.9501 0.4423
-
623 (19.7) 87 (2.8)
12 (33.3) 5 (13.8)
0.0423 <.0001
ASA ⫹ Other NSAIDS
12 (0.4)
2 (4.9)
<.0001
13 (0.4)
1 (2.8)
0.0327
Clopidogrel
67 (2.1)
3 (7.3)
0.0242
0.0009 (13.88, 2.95-65.39) 0.0592 (3.24, 0.9610.97)
67 (2.1)
3 (8.3)
0.0114
0.0004 (5.7, 2.1715.14) -
0.0197 (4.2, 1.2614.32)
891e Learning Curve for Endoscopic Mucosal Resection As Measured by Recurrence Rates Patrick W. Cleveland, Timothy A. Woodward, Silvio W. De Melo, Massimo Raimondo, Michael G. Heckman, Michael B. Wallace Background: Endoscopic Mucosal Resection (EMR) has become an important therapy in the management of flat and depressed gastrointestinal neoplasia. EMR caries higher risk and has a higher failure rate compared to standard polypectomy with highly experienced Japanese endoscopists reporting failure rates of approximately 20%. Benchmarks and learning curve data are needed to guide training and credentialing decisions. The objective of this study was to assess the learning curve for EMR in a Western practice using failure rate as the primary measure of learning.Methods: All EMR’s of flat (Paris type 2) neoplasia performed by two highly skilled endoscopists from a referral center were analyzed independent of each other. Neither of the two endoscopists had received special training in EMR other than completion of advanced endoscopy fellowships, and reviewing the limited amount of available educational materials. Cases with prior polypectomy or EMR or those that did not complete at least one on-site follow up endoscopy with biopsy of the EMR site within 1 year were excluded. A moving average of 50 cases was graphed to observe the presence of an asymptote (flattening of the learning curve). Results: Of cases by endoscopists one (n⫽490) and two (n⫽277), only 186 and 134 cases were included in the recurrence analysis, respectively although the absolute number of cases (not only included cases) performed was used as the horizontal axis. Both Endoscopists
AB138 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
showed improvement with repetition, however, the number of repetitions differed between endoscopists (Fig 1 and 2). Endoscopist 1 showed the beginning of an asymptote (flattening of the learning curve) at n⫽245 cases but a slight downward trend still persisted. Endoscopist 2 also improved steadily over time but did not show the beginning of an asymptote, but was limited by a smaller volume of cases that were able to be evaluated.Conclusions: The learning curve for EMR among these two, high volume self-taught advanced endoscopists is long and similar to other complex procedures (EUS, ERCP). At a benchmark of ⬍ 20% recurrence rate, at least 160-200 cases are needed. Educational opportunities are needed to train endoscopists in EMR to accelerate this learning curve.
891f Complications After Endoscopic Dilation in Eosinophilic Esophagitis and Associated Risk Factors Kee Wook Jung, Nancy Gundersen, Amindra S. Arora, Yvonne Romero, Dawn L. Francis, Julie A. Schreiber, Ross A. Dierkhising, Nick Talley, Jeffrey A. Alexander Background: Several case reports and small series have suggested an increased risk of complication associated with esophageal dilation in patients with eosinophilic esophagitis (EoE). The risk has not been quantified in a large series of patients. We aimed to quantitate the risk and identify risk factors of luminal dilation in EoE patients in a single tertiary care center. Methods: A restrospective analysis of EoE patients who underwent luminal dilation from 1990 to 2009 was performed. Univariate logistic regression models were used to model the risk of a severe complication (deep mucosal tear, major bleeding, or perforation). Generalized estimating equations were used to adjust for the multiple dilations for each subject. Results: A total of 161 patients (mean age⫽44.3⫾15.3 yrs, M: F⫽112:49, Caucasian: 150, unknown: 10, Asian:1 ) were identified. A total of 293 sessions of dilations were performed (mean numbers of dilation per patient ⫽1.8⫾1.4). The location of dilation was lower third (N⫽222, 75.8%), upper third (N⫽37, 12.6%), and middle third (N⫽34, 11.6%). Savary (N⫽77, 26.3%) and Through-The-Scope balloon (N⫽216, 73.7%) dilations were performed. Complications reported were deep mucosal tear (27, 9.2%), major bleeding (1, 0.3%), and immediate perforation (3, 1.0%). Two of 3 perforated patients underwent Savary dilation. One of the perforated patients had extravasation of gastrograffin esophagogram. The other two patients with perforation had no leak on gastrograffin swallow with only pneumomediastinum evident on chest CT scan. All of the immediate perforated patients were successfully treated medically without surgery (mean hospital stay: 5.3⫾3.2 days). Factors associated with increased risk of severe complication (deep mucosal tear, major bleeding, or immediate perforation) were: Luminal narrowing in the upper (OR: 5.62, 95% CI: 2.07-15.26, P⬍0.001) and middle third of the esophagus (OR: 4.93, 95% CI: 1.6414.83, P⬍0.01) vs. lower third, luminal stricture unable to be traversed with a standard upper endoscope (OR: 2.48, 95% CI: 1.06-5.83, P⫽0.04), and use of Savary dilator (OR: 2.63, 95% CI: 1.18-5.83, P⫽0.02). Conclusions: Deep mucosal tears are common after dilation (9%) but the risk of immediate transluminal perforation with EoE is about 1%; the risk of severe complications is increased in patients with more proximal strictures, very narrowed esophagus or who require use of a Savary dilator.
891g Real NOTES®, Hybrid and Laparoscopic Appendectomy in Human, a Prospective Quality of Life Study Comparing Outcome After Flexible NOTES® Appendectomy in Hybrid Technique and Laparoscopic Appendectomy Joern Bernhardt, Sylke Schneider-Koriath, Holger Steffen, Kaja Ludwig Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique. The proposed advantages should be established by its comparison with standard procedures. Peri- and postoperative complications are a major focus of its evaluation.Material and methods: Having performed our first transvaginal flexible appendectomy using a true NOTES technique in 2007, we initiated the prospective comparison between transvaginal appendectomy in hybrid technique versus standard laparoscopic appendectomy. Questionairebased evaluation included issues related to quality of life in addition to objective clinical findings.From 10/2007 to 06/2009, appendectomy was performed in 110 women of whom 42 agreed to participate in the study with follow-up documentation for 35 days and after one year. In five patients (mean age 29 ys), transvaginal appendectomy was performed employing a two-channel gastroscope (Storz, Germany) with the use of a 5 mm trocare at the umbilicus. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient’s consent. Pre- and postoperative gynecological examinations were performed.Laparoscopic appendectomy was used in 37 women (mean age 38 ys) using three trocars. The study is approved by the ethics committee of the University of Rostock.Results: All five women of the NOTES group and 16 of 37 women of the laparoscopy group returned questionnaires for evaluation. All removed appendices demonstrated typical
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627 (19.9) 90 (2.9)
8 (19.5) 2 (4.9)
0.9501 0.4423
-
623 (19.7) 87 (2.8)
12 (33.3) 5 (13.8)
0.0423 <.0001
ASA ⫹ Other NSAIDS
12 (0.4)
2 (4.9)
<.0001
13 (0.4)
1 (2.8)
0.0327
Clopidogrel
67 (2.1)
3 (7.3)
0.0242
0.0009 (13.88, 2.95-65.39) 0.0592 (3.24, 0.9610.97)
67 (2.1)
3 (8.3)
0.0114
0.0004 (5.7, 2.1715.14) -
0.0197 (4.2, 1.2614.32)
891e Learning Curve for Endoscopic Mucosal Resection As Measured by Recurrence Rates Patrick W. Cleveland, Timothy A. Woodward, Silvio W. De Melo, Massimo Raimondo, Michael G. Heckman, Michael B. Wallace Background: Endoscopic Mucosal Resection (EMR) has become an important therapy in the management of flat and depressed gastrointestinal neoplasia. EMR caries higher risk and has a higher failure rate compared to standard polypectomy with highly experienced Japanese endoscopists reporting failure rates of approximately 20%. Benchmarks and learning curve data are needed to guide training and credentialing decisions. The objective of this study was to assess the learning curve for EMR in a Western practice using failure rate as the primary measure of learning.Methods: All EMR’s of flat (Paris type 2) neoplasia performed by two highly skilled endoscopists from a referral center were analyzed independent of each other. Neither of the two endoscopists had received special training in EMR other than completion of advanced endoscopy fellowships, and reviewing the limited amount of available educational materials. Cases with prior polypectomy or EMR or those that did not complete at least one on-site follow up endoscopy with biopsy of the EMR site within 1 year were excluded. A moving average of 50 cases was graphed to observe the presence of an asymptote (flattening of the learning curve). Results: Of cases by endoscopists one (n⫽490) and two (n⫽277), only 186 and 134 cases were included in the recurrence analysis, respectively although the absolute number of cases (not only included cases) performed was used as the horizontal axis. Both Endoscopists
AB138 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
showed improvement with repetition, however, the number of repetitions differed between endoscopists (Fig 1 and 2). Endoscopist 1 showed the beginning of an asymptote (flattening of the learning curve) at n⫽245 cases but a slight downward trend still persisted. Endoscopist 2 also improved steadily over time but did not show the beginning of an asymptote, but was limited by a smaller volume of cases that were able to be evaluated.Conclusions: The learning curve for EMR among these two, high volume self-taught advanced endoscopists is long and similar to other complex procedures (EUS, ERCP). At a benchmark of ⬍ 20% recurrence rate, at least 160-200 cases are needed. Educational opportunities are needed to train endoscopists in EMR to accelerate this learning curve.
891f Complications After Endoscopic Dilation in Eosinophilic Esophagitis and Associated Risk Factors Kee Wook Jung, Nancy Gundersen, Amindra S. Arora, Yvonne Romero, Dawn L. Francis, Julie A. Schreiber, Ross A. Dierkhising, Nick Talley, Jeffrey A. Alexander Background: Several case reports and small series have suggested an increased risk of complication associated with esophageal dilation in patients with eosinophilic esophagitis (EoE). The risk has not been quantified in a large series of patients. We aimed to quantitate the risk and identify risk factors of luminal dilation in EoE patients in a single tertiary care center. Methods: A restrospective analysis of EoE patients who underwent luminal dilation from 1990 to 2009 was performed. Univariate logistic regression models were used to model the risk of a severe complication (deep mucosal tear, major bleeding, or perforation). Generalized estimating equations were used to adjust for the multiple dilations for each subject. Results: A total of 161 patients (mean age⫽44.3⫾15.3 yrs, M: F⫽112:49, Caucasian: 150, unknown: 10, Asian:1 ) were identified. A total of 293 sessions of dilations were performed (mean numbers of dilation per patient ⫽1.8⫾1.4). The location of dilation was lower third (N⫽222, 75.8%), upper third (N⫽37, 12.6%), and middle third (N⫽34, 11.6%). Savary (N⫽77, 26.3%) and Through-The-Scope balloon (N⫽216, 73.7%) dilations were performed. Complications reported were deep mucosal tear (27, 9.2%), major bleeding (1, 0.3%), and immediate perforation (3, 1.0%). Two of 3 perforated patients underwent Savary dilation. One of the perforated patients had extravasation of gastrograffin esophagogram. The other two patients with perforation had no leak on gastrograffin swallow with only pneumomediastinum evident on chest CT scan. All of the immediate perforated patients were successfully treated medically without surgery (mean hospital stay: 5.3⫾3.2 days). Factors associated with increased risk of severe complication (deep mucosal tear, major bleeding, or immediate perforation) were: Luminal narrowing in the upper (OR: 5.62, 95% CI: 2.07-15.26, P⬍0.001) and middle third of the esophagus (OR: 4.93, 95% CI: 1.6414.83, P⬍0.01) vs. lower third, luminal stricture unable to be traversed with a standard upper endoscope (OR: 2.48, 95% CI: 1.06-5.83, P⫽0.04), and use of Savary dilator (OR: 2.63, 95% CI: 1.18-5.83, P⫽0.02). Conclusions: Deep mucosal tears are common after dilation (9%) but the risk of immediate transluminal perforation with EoE is about 1%; the risk of severe complications is increased in patients with more proximal strictures, very narrowed esophagus or who require use of a Savary dilator.
891g Real NOTES®, Hybrid and Laparoscopic Appendectomy in Human, a Prospective Quality of Life Study Comparing Outcome After Flexible NOTES® Appendectomy in Hybrid Technique and Laparoscopic Appendectomy Joern Bernhardt, Sylke Schneider-Koriath, Holger Steffen, Kaja Ludwig Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is an emerging technique. The proposed advantages should be established by its comparison with standard procedures. Peri- and postoperative complications are a major focus of its evaluation.Material and methods: Having performed our first transvaginal flexible appendectomy using a true NOTES technique in 2007, we initiated the prospective comparison between transvaginal appendectomy in hybrid technique versus standard laparoscopic appendectomy. Questionairebased evaluation included issues related to quality of life in addition to objective clinical findings.From 10/2007 to 06/2009, appendectomy was performed in 110 women of whom 42 agreed to participate in the study with follow-up documentation for 35 days and after one year. In five patients (mean age 29 ys), transvaginal appendectomy was performed employing a two-channel gastroscope (Storz, Germany) with the use of a 5 mm trocare at the umbilicus. Transvaginal appendectomy was considered a non-standard medical procedure and required individual patient’s consent. Pre- and postoperative gynecological examinations were performed.Laparoscopic appendectomy was used in 37 women (mean age 38 ys) using three trocars. The study is approved by the ethics committee of the University of Rostock.Results: All five women of the NOTES group and 16 of 37 women of the laparoscopy group returned questionnaires for evaluation. All removed appendices demonstrated typical
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