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An Adequate Level of Training for Technical Competence in Diagnostic Unsedated Transnasal Endoscopy: A Prospective Assessment of the Learning Curve
Abstracts
and Methods: A total of fifty eight consecutive esophageal and gastric cancer patients who treated by ESD under combination sedation method in our hospital were enrolled in this study (BISþTCI group). Other twenty eight patients who treated ESD under propofol sedation without using BIS monitor and TCI system were compared as a control group. We compared two aspects of safety and effectiveness: (1) frequencies of body movement per hour, (2) rate of incidence of under 90% oxygen saturation. All patients were sedated under oxygen inhalation (2 L/min) by nasotrachial airway. Sedation was provided by a doctor with prior experiences in anesthesia. In BISþTCI group, the propofol infusion (1% propofol) was started at an initial target blood concentration of 2.2 mg/mL. When BIS score became under 40, we decreased target blood concentration by 0.2 mg/mL, and when BIS score became over 80 or patient began to move, we increased target blood concentration by 0.2mg/mL. In control group, we administered propofol by conventional pump without using BIS monitor and TCI system. The initial intravenous dose of propofol was 1.0-1.4 mg/kg, and propofol was administered at 1.0-2.0mg/kg/hour continuously during the procedure. If the patient began to move, additional doses of propofol were administered by 0.4-0.6mg/kg. Results: (1) the mean body motion per hour in BISþTCI group was significantly lower than that in control group (0.27 vs. 1.16, P!0.01). (2) rate of incidence of under 90% oxygen saturation in BISþTCI group was lower than that in control group, though it was not significant (15.5% vs. 21.4%, PZ0.50). Conclusion: Administration of propofol by using combination method of BIS monitor and TCI system can sedate more stably and safely than conventional method for ESD procedure.
M1363 The Role of Liquid Simethicone in Enhancing Endoscopic Visibility Prior to Esophagogastroduodenoscopy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial Suriya Keeratichananont, Abhasnee Sobhonslidsuk, Narin Achalanan, Taya Kitiyakara, Supamai Soonthornpun Background: Esophagogastroduodenoscopy (EGD) is the procedure of choice for making the diagnosis of upper digestive diseases. However, intraluminal foam and bubbles can impair endoscopic visibility, resulting in missing tiny lesions. Simethicone, a defoaming agent, was shown to improve endoscopic visibility and diagnostic accuracy during colonoscopy and small bowel capsule endoscopy. Nevertheless, there has been limited data on the usefulness of simethicone in EGD. Objective: To evaluate the effectiveness of liquid simethicone on enhancing endoscopic visibility in patients who underwent elective diagnostic EGD. Methods: Patients scheduled for EGD were prospectively enrolled. After inform consent was obtained, they were randomized to take 60 ml of water with either liquid simethicone (133.3 mg) or placebo at 15-30 minutes before EGD. The examination was recorded on CDs and video images were assessed by a single investigator who was blinded to treatment arm. The severity of foam and bubbles was scored as grade 1 (no foam and bubbles), 2 (minimal; must actively look for them), 3 (moderate) or 4 (abundant; obscuring of mucosal surface) at four areas of esophagus, stomach and duodenum. The cumulative score of the maximum grading of foam and bubbles, and the maximum grading of each area were compared between 2 groups. Furthermore, the number of patients who needed adjunctive simethicone washing, timing required for simethicone washing, endoscopist and patient satisfaction, and adverse effects of medications were also compared. Results: There were 63 and 58 patients with mean ages of 59 13 and 56 14 years in simethicone and placebo group. Simethicone led to better endoscopic visibility by diminishing mean cumulative score of foam and bubbles.(6.83 2.4 vs. 11.05 2.6, pZ0.000). At each area, the grading of foam and bubbles was lower in simethicone group (esophagus, 1.62 0.6 vs. 2.10 0.7; fundus & body, 2.43 1.0 vs. 3.47 0.8; antrum & angulus, 1.44 0.8 vs. 2.53 1.1; duodenum 1.35 0.7 vs. 2.95 0.9, pZ0.000). Adjunctive simethicone washing was less demanded in simethicone group (17.5% vs. 74.1%, pZ0.000). In addition, endoscopist and patient satisfaction increased significantly in this group. No significant difference was found for timing of adjunctive simethicone washing, total EGD time and the adverse effects of medications. Conclusions: Using liquid simethicone before EGD enhances endoscopic visibility and reduces the need for simethicone washing during EGD. Taking liquid simethicone before EGD may be more practical. However, further studies are warrant to answer whether or not improved endoscopic visibility will lead to increase detection of subtle lesions.
M1364 An Adequate Level of Training for Technical Competence in Diagnostic Unsedated Transnasal Endoscopy: A Prospective Assessment of the Learning Curve Hyun Chul Lim, Kee Myung Lee, Sung Jae Shin, Jin Hong Kim, Soon Sun Kim Backgrounds/Aims: There is a limited study about the training program of unsedated transnasal esophagogastroduodenoscopy (UT-EGD) for a trainee who has no previous experience of this technique. The goal of this study was to determine the adequate level of training for technical competence in diagnostic UTEGD for the trainee. Methods: From May 2008 to November 2008, three hundred patients who underwent UT-EGD under local anesthesia at a tertiary care academic medical center were included in this study. Four trainees who had no experience
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performing UT-EGD but very competent in conventional EGD, performed UT-EGD on 50 patients each. In a control group, four experts performed UT-EGD on a total of 100 patients. All trainees and experts used 5.2mm caliber endoscopes (GIF-260N, Olympus Medical Systems Corp., Tokyo, Japan). Technical success, procedure duration (intubation time to esophagus, intubation time to duodenal 2nd portion), complications, frequency of belching, and vital signs were checked. Results: Technical successes were 85%, 90%, 92.5%, 90%, 100% for every 10 patients totalling 50 patients each per trainee and 98% consistency in the control group. Intubation time to esophagus(sec) was 55.1 26.9, 42.0 13.6, 38.3 13.1, 31.1 7.4, 29.8 6.6 in trainees and 31.5 11.6 in the control group. Intubation time to duodenal 2nd portion(sec) was 130 45.8, 121 34.6, 110.5 29.9, 102.5 28.2, 98.5 25.7 in trainees and 100.9 27.4 in the control group, and showed no statistical significant difference after the first 3 lots of 10 patients. Epistaxis showed no statistical differences in both groups (18/200 vs 7/100), but the patients who complained of nasal pain were lower in the control group (44//200 vs 15/100). Frequencies of belching were 2.45 1.36, 2.24 2.06, 1.89 1.72, 1.68 1.99, 1.05 1.27 in trainees and 1.39 1.97 in the control group, and showed no significant difference after the first 3 lots of 10 patients. The willing to retry (164/200 vs 77/100) showed no significant differences in both groups, but patients who had previously experienced sedated EGD did not want to retry UT-EGD (26/186 vs 33/114). There were no significant difference in change of systolic and diastolic pressure, pulse rate, and oxygen saturation during UT-EGD between trainees and the control group, and there were no patients who experienced unstable vital signs and demanded oxygenation. Conclusions: Endoscopists who are competent in conventional EGD are able to obtain acceptable results from their first attempts, but 30 cases of experience is needed to acquire skillful hands for performing UTEGD. Key words: Unsedated transnasal endoscopy, Learning curve
M1365 Does Intensive Training Improve the Diagnostic Accuracy of Narrow Band Imaging (NBI) in Differentiating Neoplastic from Non-Neoplastic Colorectal Diminutive Polyps? Reiji Higashi, Toshio Uraoka, Jun Kato, Shin Ishikawa, Kenji Kuwaki, Yutaka Saito, Takahisa Matsuda, Hiroaki Ikematsu, Yasushi Sano, Kazuhide Yamamoto Background: To differentiate adenomatous from non-adenomatous colorectal polyps is very important because it would obviate the need to remove hyperplastic polyps. Narrow band imaging(NBI) has been reported to accurately differentiate colorectal polyps. However, these reports were based on the analysis of only highly experienced endoscopists and there were few reports concerning its learning effect. Aims: To establish whether any improvement can be obtained in diagnostic skill for the differentiation of diminutive colorectal polyps using NBI with and without magnification following intensive training. Patients and Methods: This study prospectively enrolled consecutive patients who underwent magnification colonoscopy(CF-H260AZI and PCF-240ZI, Olympus Co.) between September and October 2008 at our hospital. A total of 44 colorectal polyps %5 mm from 32 patients were observed with conventional colonoscopy, non-magnification and magnification NBI and then the polyps were submitted for histopathological analysis by polypectomy or biopsy procedure. Total 132 endoscopic images were stored electronically and randomly allocated twice, before and after an intensive lecture of one hour, to three NBI less experienced endoscopists(LEEs), each of whom performed colonoscopy for more than five years and never used NBI. Each picture was assessed using Sano NBI classification. Diagnostic accuracy of each endoscopic modality was assessed by reference to histopathology and the evaluations of LEEs after an intensive lecture were compared to those of three highly experienced endoscopists(HEEs), each of whom routinely used NBI more than five years. Interobserver agreements of each endoscopic modality in LEEs and HEEs were also evaluated. Results: Of the 44 colorectal polyps, 27 polyps were adenomas, 17 polyps were hyperplastic polyps. The intensive lecture significantly improved diagnostic accuracies of, non-magnification and magnification NBI in LEEs(before vs after the lecture,63.6%vs73.5%; pZ0.048 and 74.2%vs88.6%; pZ0.0001, respectively). The diagnostic accuracies in HEEs were 75.8%(non-magnification NBI) and 90.2%(magnification NBI), respectively and there was no significant difference in the accuracy of NBI diagnosis between LEEs after the lecture and HEEs. High consistencies of interobserver agreements were observed in magnification NBI both among LEEs after the lecture(kappaZ0.77;95%CI: 0.73-0.81) and among HEEs(kappaZ0.75;95%CI: 0.71-0.8). Conclusions: NBI with magnification is a promising tool for the differentiation of neoplastic from non-neoplastic colorectal polyps. Intensive training with a lecture can improve the diagnostic skill for diminutive colorectal polyps in LEEs.
M1366 Interobserver Variance of Endoscopic Findings and Objective Diagnosis of Submucosal Invasion of Colorectal Cancer Yutaka Kawamura, Kazutomo Togashi, Shingo Tsujinaka, Tomonori Yano, Koji Koinuma, Yuichi Kuwahara, Junichi Sasaki, Fumio Konishi Purpose: When polyps are detected during colonoscopy, instaneous decision making regarding the treatment of choice is mandatory to avoid treatment delay and the need
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB223
and Methods: A total of fifty eight consecutive esophageal and gastric cancer patients who treated by ESD under combination sedation method in our hospital were enrolled in this study (BISþTCI group). Other twenty eight patients who treated ESD under propofol sedation without using BIS monitor and TCI system were compared as a control group. We compared two aspects of safety and effectiveness: (1) frequencies of body movement per hour, (2) rate of incidence of under 90% oxygen saturation. All patients were sedated under oxygen inhalation (2 L/min) by nasotrachial airway. Sedation was provided by a doctor with prior experiences in anesthesia. In BISþTCI group, the propofol infusion (1% propofol) was started at an initial target blood concentration of 2.2 mg/mL. When BIS score became under 40, we decreased target blood concentration by 0.2 mg/mL, and when BIS score became over 80 or patient began to move, we increased target blood concentration by 0.2mg/mL. In control group, we administered propofol by conventional pump without using BIS monitor and TCI system. The initial intravenous dose of propofol was 1.0-1.4 mg/kg, and propofol was administered at 1.0-2.0mg/kg/hour continuously during the procedure. If the patient began to move, additional doses of propofol were administered by 0.4-0.6mg/kg. Results: (1) the mean body motion per hour in BISþTCI group was significantly lower than that in control group (0.27 vs. 1.16, P!0.01). (2) rate of incidence of under 90% oxygen saturation in BISþTCI group was lower than that in control group, though it was not significant (15.5% vs. 21.4%, PZ0.50). Conclusion: Administration of propofol by using combination method of BIS monitor and TCI system can sedate more stably and safely than conventional method for ESD procedure.
M1363 The Role of Liquid Simethicone in Enhancing Endoscopic Visibility Prior to Esophagogastroduodenoscopy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial Suriya Keeratichananont, Abhasnee Sobhonslidsuk, Narin Achalanan, Taya Kitiyakara, Supamai Soonthornpun Background: Esophagogastroduodenoscopy (EGD) is the procedure of choice for making the diagnosis of upper digestive diseases. However, intraluminal foam and bubbles can impair endoscopic visibility, resulting in missing tiny lesions. Simethicone, a defoaming agent, was shown to improve endoscopic visibility and diagnostic accuracy during colonoscopy and small bowel capsule endoscopy. Nevertheless, there has been limited data on the usefulness of simethicone in EGD. Objective: To evaluate the effectiveness of liquid simethicone on enhancing endoscopic visibility in patients who underwent elective diagnostic EGD. Methods: Patients scheduled for EGD were prospectively enrolled. After inform consent was obtained, they were randomized to take 60 ml of water with either liquid simethicone (133.3 mg) or placebo at 15-30 minutes before EGD. The examination was recorded on CDs and video images were assessed by a single investigator who was blinded to treatment arm. The severity of foam and bubbles was scored as grade 1 (no foam and bubbles), 2 (minimal; must actively look for them), 3 (moderate) or 4 (abundant; obscuring of mucosal surface) at four areas of esophagus, stomach and duodenum. The cumulative score of the maximum grading of foam and bubbles, and the maximum grading of each area were compared between 2 groups. Furthermore, the number of patients who needed adjunctive simethicone washing, timing required for simethicone washing, endoscopist and patient satisfaction, and adverse effects of medications were also compared. Results: There were 63 and 58 patients with mean ages of 59 13 and 56 14 years in simethicone and placebo group. Simethicone led to better endoscopic visibility by diminishing mean cumulative score of foam and bubbles.(6.83 2.4 vs. 11.05 2.6, pZ0.000). At each area, the grading of foam and bubbles was lower in simethicone group (esophagus, 1.62 0.6 vs. 2.10 0.7; fundus & body, 2.43 1.0 vs. 3.47 0.8; antrum & angulus, 1.44 0.8 vs. 2.53 1.1; duodenum 1.35 0.7 vs. 2.95 0.9, pZ0.000). Adjunctive simethicone washing was less demanded in simethicone group (17.5% vs. 74.1%, pZ0.000). In addition, endoscopist and patient satisfaction increased significantly in this group. No significant difference was found for timing of adjunctive simethicone washing, total EGD time and the adverse effects of medications. Conclusions: Using liquid simethicone before EGD enhances endoscopic visibility and reduces the need for simethicone washing during EGD. Taking liquid simethicone before EGD may be more practical. However, further studies are warrant to answer whether or not improved endoscopic visibility will lead to increase detection of subtle lesions.
M1364 An Adequate Level of Training for Technical Competence in Diagnostic Unsedated Transnasal Endoscopy: A Prospective Assessment of the Learning Curve Hyun Chul Lim, Kee Myung Lee, Sung Jae Shin, Jin Hong Kim, Soon Sun Kim Backgrounds/Aims: There is a limited study about the training program of unsedated transnasal esophagogastroduodenoscopy (UT-EGD) for a trainee who has no previous experience of this technique. The goal of this study was to determine the adequate level of training for technical competence in diagnostic UTEGD for the trainee. Methods: From May 2008 to November 2008, three hundred patients who underwent UT-EGD under local anesthesia at a tertiary care academic medical center were included in this study. Four trainees who had no experience
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performing UT-EGD but very competent in conventional EGD, performed UT-EGD on 50 patients each. In a control group, four experts performed UT-EGD on a total of 100 patients. All trainees and experts used 5.2mm caliber endoscopes (GIF-260N, Olympus Medical Systems Corp., Tokyo, Japan). Technical success, procedure duration (intubation time to esophagus, intubation time to duodenal 2nd portion), complications, frequency of belching, and vital signs were checked. Results: Technical successes were 85%, 90%, 92.5%, 90%, 100% for every 10 patients totalling 50 patients each per trainee and 98% consistency in the control group. Intubation time to esophagus(sec) was 55.1 26.9, 42.0 13.6, 38.3 13.1, 31.1 7.4, 29.8 6.6 in trainees and 31.5 11.6 in the control group. Intubation time to duodenal 2nd portion(sec) was 130 45.8, 121 34.6, 110.5 29.9, 102.5 28.2, 98.5 25.7 in trainees and 100.9 27.4 in the control group, and showed no statistical significant difference after the first 3 lots of 10 patients. Epistaxis showed no statistical differences in both groups (18/200 vs 7/100), but the patients who complained of nasal pain were lower in the control group (44//200 vs 15/100). Frequencies of belching were 2.45 1.36, 2.24 2.06, 1.89 1.72, 1.68 1.99, 1.05 1.27 in trainees and 1.39 1.97 in the control group, and showed no significant difference after the first 3 lots of 10 patients. The willing to retry (164/200 vs 77/100) showed no significant differences in both groups, but patients who had previously experienced sedated EGD did not want to retry UT-EGD (26/186 vs 33/114). There were no significant difference in change of systolic and diastolic pressure, pulse rate, and oxygen saturation during UT-EGD between trainees and the control group, and there were no patients who experienced unstable vital signs and demanded oxygenation. Conclusions: Endoscopists who are competent in conventional EGD are able to obtain acceptable results from their first attempts, but 30 cases of experience is needed to acquire skillful hands for performing UTEGD. Key words: Unsedated transnasal endoscopy, Learning curve
M1365 Does Intensive Training Improve the Diagnostic Accuracy of Narrow Band Imaging (NBI) in Differentiating Neoplastic from Non-Neoplastic Colorectal Diminutive Polyps? Reiji Higashi, Toshio Uraoka, Jun Kato, Shin Ishikawa, Kenji Kuwaki, Yutaka Saito, Takahisa Matsuda, Hiroaki Ikematsu, Yasushi Sano, Kazuhide Yamamoto Background: To differentiate adenomatous from non-adenomatous colorectal polyps is very important because it would obviate the need to remove hyperplastic polyps. Narrow band imaging(NBI) has been reported to accurately differentiate colorectal polyps. However, these reports were based on the analysis of only highly experienced endoscopists and there were few reports concerning its learning effect. Aims: To establish whether any improvement can be obtained in diagnostic skill for the differentiation of diminutive colorectal polyps using NBI with and without magnification following intensive training. Patients and Methods: This study prospectively enrolled consecutive patients who underwent magnification colonoscopy(CF-H260AZI and PCF-240ZI, Olympus Co.) between September and October 2008 at our hospital. A total of 44 colorectal polyps %5 mm from 32 patients were observed with conventional colonoscopy, non-magnification and magnification NBI and then the polyps were submitted for histopathological analysis by polypectomy or biopsy procedure. Total 132 endoscopic images were stored electronically and randomly allocated twice, before and after an intensive lecture of one hour, to three NBI less experienced endoscopists(LEEs), each of whom performed colonoscopy for more than five years and never used NBI. Each picture was assessed using Sano NBI classification. Diagnostic accuracy of each endoscopic modality was assessed by reference to histopathology and the evaluations of LEEs after an intensive lecture were compared to those of three highly experienced endoscopists(HEEs), each of whom routinely used NBI more than five years. Interobserver agreements of each endoscopic modality in LEEs and HEEs were also evaluated. Results: Of the 44 colorectal polyps, 27 polyps were adenomas, 17 polyps were hyperplastic polyps. The intensive lecture significantly improved diagnostic accuracies of, non-magnification and magnification NBI in LEEs(before vs after the lecture,63.6%vs73.5%; pZ0.048 and 74.2%vs88.6%; pZ0.0001, respectively). The diagnostic accuracies in HEEs were 75.8%(non-magnification NBI) and 90.2%(magnification NBI), respectively and there was no significant difference in the accuracy of NBI diagnosis between LEEs after the lecture and HEEs. High consistencies of interobserver agreements were observed in magnification NBI both among LEEs after the lecture(kappaZ0.77;95%CI: 0.73-0.81) and among HEEs(kappaZ0.75;95%CI: 0.71-0.8). Conclusions: NBI with magnification is a promising tool for the differentiation of neoplastic from non-neoplastic colorectal polyps. Intensive training with a lecture can improve the diagnostic skill for diminutive colorectal polyps in LEEs.
M1366 Interobserver Variance of Endoscopic Findings and Objective Diagnosis of Submucosal Invasion of Colorectal Cancer Yutaka Kawamura, Kazutomo Togashi, Shingo Tsujinaka, Tomonori Yano, Koji Koinuma, Yuichi Kuwahara, Junichi Sasaki, Fumio Konishi Purpose: When polyps are detected during colonoscopy, instaneous decision making regarding the treatment of choice is mandatory to avoid treatment delay and the need
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB223