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Antibiotic Prophylaxis with Piperacillin (PIP) does not prevent ERCP-induced cholangitis
CLINICAL ENDOSCOPIC PRACTICE t145
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A NEW SYSTEM FOR DEFINING ENDOSCOPIC COMPLICATIONS EMPHASIZING THE MEASURE OF IMPORTANCE. F Van de Mierop, FH
ENDOSCOPIC EDUCATION: WHAT IS THE COST OF TRAINING ? KK Wang, B Ott, A Geller, J Densmore, Laser Photodynamics Laboratory, Mayo Clinic, Rochester, MN.
AI-Kawas, SB Benjamin, JH Lewis, CC Nguyen, M Avigan, JA Kidwell and DE Fleischer. Georgetown University Medical Center, Washington, DC. There are no good classifications for defining endoscopic complicatisns (EC). Fleischer and Cotton (GIE, igg4) suggested that approaches which incorporate measures of importance (MI) would be helpful. We propose a new system that characterizes specific MI and uses a scoring system to quantify them so they might be weighted and compared. A total complication score (TCS) was calculated based on 6 separate aspects of the complication. I. Did EC affect the completion of the endoscopy? II. Did EC cause the level of care to be altered (e.g., Did outpt require hospitalization?)? Ill. Did EC cause new additional hospital days? IV. Did EC lead to a need for an invasive procedure (e.g., endoscopy, interventioaal radiology, surgery)? V. Was there any residual effect from the EC? VI. Did patient die? Ascoring system was utilized weighted to the importance of the specific MI. For example, i f a p t with a post-polypectomy bleed required management to stop bleeding, i t would be scored differently for endoscopic Rx (15 points) than surgery (50 points). Therefore, a p t with post-polyp bleeding that required admission to hospital for a total of 2 days, during which colonoscopy was necessary to control bleeding, the complication would be scored as follows: I=O; II=20; IIl:lO; IV=Z0; V=O; VI:O. The TCS=50 points. Apt who had bradycardia requiring atropine during a successful calonoscopywould be scored: I=3; II-V=O. The TCS~3 points. RESULTS: 50 consecutive complications occurring over a 6 month period were reviewed and scored. The TCS ranged from I-]00 (]:uncomplicated Mallory Weiss tear; lO0=death caused by perf esoph CA after dilation). 28 pts had TCS of 10 or less; 18 had TCS of 10-49; 2 had TCS of 50-99; 2 pts died and had TCS~]O0. MeanTCS=Z2.6. Median TCS=IO. CONCLUSIONS: The actual number of complications is not the best index of their importance. A system is proposed that allows the measure of importance of each complication to be scored. This is useful for Q/A and outcomes research.
Health care reforms have led to more accountability in endoscopic resources. In order to ascertain the effect of endoscopic training on endoscopist efficiency, we studied the time required to perform diagnostic colonoscopies by experienced endoscopists alone and with trainees. Aim: To determine the effect of trainee participation on procedural length, Methods: We examined the effect of trainee involvement in diagnostic colonoscopies (without polypectomy) at our institution. A total of 3063 consecutive diagnostic cases were prospectively timed. Initiation of the procedure was defined as when the physician actually entered the endoscopi c suite. This time was recorded on a computerized database system by the GI assistant who assisted in the case. At the completion of the procedure, the time was again recorded. Thirty-one gastroenterologists and 18 GI trainees were evaluated. Results: A total of 2090procedures were done without trainees while 973 procedures were done with trainees. There was a significant increase in procedural times if a trainee was involved in the case (p_<0.01), Procedure times were increased a mean of 14+_2 minutes (range 1-31 minutes). The mean procedure time with a trainee was 47+2 minutes. No endoscopist experienced a decrease in procedure time with a trainee. Using the difference of each individual endoscopist's procedure time with and without a trainee, approximately 230 extra hours of endoscopiet time was involved in these 973 cases. Although it was not possible to quantify the level of experience of the trainee at each procedure, it was apparant that senior trainees still increased the procedure
length. Conclusions: Endoscopic education significantly increases procedure length in diagnostic colonoscopy. The increased colonoscopist time required for education needs to be factored into assessments of cost of procedures of educational centers,
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ANTIBIOTIC PROPHYLAXIS WITH PIPERACILLIN (PIPI DOES NOT PREVENT ERCP-INDUCED CHOLANGITIS, S.J. van den _Hazel~, P. Speelman ~, G.N.J. Tytgat 1, J. Dankert 3, D.J. van Leeuwen 4. Departments of Gastroenterology 1, Internal Medicine 2 & Medical Microbiology 3, Academic Medical Center, Amsterdam, The Netherlands. Division of Gastroenterology", University of Alabama, Birmingham, USA. Antibiotic prophylaxis is widely used in the prevention of ERCP-induced cholangitis, but its efficacy remains to be proven. We report a double blind, placebo controlled trial of the efficacy of single dose PIP in reducing the incidence of acute cholangitis (AC) within 1 week after ERCP. Methods: Patients who underwent ERCP for suspected biliary stones or a distal common bile duct obstruction were selected. Major exclusion criteria were a previous ERCP within 7 days, a biliary endoprosthesis in situ, and use of antimicrobial agents or fever within 7 days prior to the procedure. PIP (4g) or placebo was given (i.v.) ~ 30 minutes before ERCP. AC was diagnosed when there was fever of > 38~ a necessity for antibiotic treatment and no symptoms indicating a source of infection outside the biliary tree. Results: Between April '91 and June '94 551 patients were included. During ERCP stones were found in 147 patients, a malignant distal obstruction in 203, other pathology in 88, and a normal biliary tract in 113. Of the 281 patients on placebo 17 developed AC (6,0%), as compared to 12 of 270 patients on PIP (4.4%, RR = 0.73, 95% CI 0.36-1.51, p = 0 . 4 0 ) . Analyzing patients with stones or a malignancy separately, there was still no significant advantage of PiP over placebo. Conclusion: Single dose PIP does not reduce the incidence of acute cholangitis after ERCP in patients with suspected bUiary tract stones or a malignant distal common bile duct obstruction.
IS ENDOSCOPY SAFE IN THE VERY ELDERLY? Donald Wurzburg, MD, Sylvia S. Ham, MPH, KevinW. Otden~MD. Divisionsof Gastroenterology, St. Mary's Medical Center, San Francisco, CA and UC Davis Medical Center, Sacramento, CA As an invasive procedure, (31endoscopymay be associated with increased morbidity and mortality in very eldedy patients. The purpose of this study was to determine the safety of performing endoscopy, including monitored anesthesia care (MAC), in a group of very elderly patients (75+ yrs) compared to sex-matched younger patients (<75 yrs). Method: All patients who underwent endoscopy during a four month period from 811194.11130194were studied. Age, gender, procedure type, sedative/narcotic medication dosage, and complications were all recorded. Results: 440 patients who underwent 451 procedures were studied; 168 aged 75+ yrs (mean 81, range 74-94) and 272 aged <75 yrs (mean 57, range 21-74). As shown below, the very elderiy underwent proportionately more colonoscopies and fewer flexible sigmoidoscopies than their youngercounterparts. " E(3D Colon FlexSi 9 " ERCP Total ) { 75+ 65 (37%) " 79 (45%) 17 (10%) '13 (7%) 174 L<75 107 (39%) 106 (38%) 43 (16%) 21 (8%) 277
This research was funded in part by Cyanarnid/Lederle B.V., The Nether/ands.
332
GASTROINTESTINAL ENDOSCOPY
I
Only 3 patientsoverall had complications: 2 very eldedy patients (1 episode of asymptomatic hypoxia, and 1 esophageal perforation during stenting) and 1 patient < 75 yrs who had asymptomatic hypoxia. Very elderly patients had a significantly higher rate of MAC usage (p <0.04). But no significant differences in complication rate or mean medication dosage was found between very ekfedy and youngerpatients as shown below. 75+ <75 p Complications 2 (1.2%) 1 (0.4%) NS MAC usage 11 (6.5%) 6 (2.2%) <0.04 Mean dosage Versed EGD 2.3 3.7 NS Colonoacopy 2.9 3.3 NS Mean dosage Demerol E(3D 35.9 39.4 NS Colonoecopy 40.7 46.4 NS Conclusions: Very elderly patients requiresimilar dosages of medications as their younger cohorts but may require usage of MAC more frequently. Advancedage per se does not add increased risk to performing endoscopy.
VOLUME 41, NO. 4, 1995
t147
A NEW SYSTEM FOR DEFINING ENDOSCOPIC COMPLICATIONS EMPHASIZING THE MEASURE OF IMPORTANCE. F Van de Mierop, FH
ENDOSCOPIC EDUCATION: WHAT IS THE COST OF TRAINING ? KK Wang, B Ott, A Geller, J Densmore, Laser Photodynamics Laboratory, Mayo Clinic, Rochester, MN.
AI-Kawas, SB Benjamin, JH Lewis, CC Nguyen, M Avigan, JA Kidwell and DE Fleischer. Georgetown University Medical Center, Washington, DC. There are no good classifications for defining endoscopic complicatisns (EC). Fleischer and Cotton (GIE, igg4) suggested that approaches which incorporate measures of importance (MI) would be helpful. We propose a new system that characterizes specific MI and uses a scoring system to quantify them so they might be weighted and compared. A total complication score (TCS) was calculated based on 6 separate aspects of the complication. I. Did EC affect the completion of the endoscopy? II. Did EC cause the level of care to be altered (e.g., Did outpt require hospitalization?)? Ill. Did EC cause new additional hospital days? IV. Did EC lead to a need for an invasive procedure (e.g., endoscopy, interventioaal radiology, surgery)? V. Was there any residual effect from the EC? VI. Did patient die? Ascoring system was utilized weighted to the importance of the specific MI. For example, i f a p t with a post-polypectomy bleed required management to stop bleeding, i t would be scored differently for endoscopic Rx (15 points) than surgery (50 points). Therefore, a p t with post-polyp bleeding that required admission to hospital for a total of 2 days, during which colonoscopy was necessary to control bleeding, the complication would be scored as follows: I=O; II=20; IIl:lO; IV=Z0; V=O; VI:O. The TCS=50 points. Apt who had bradycardia requiring atropine during a successful calonoscopywould be scored: I=3; II-V=O. The TCS~3 points. RESULTS: 50 consecutive complications occurring over a 6 month period were reviewed and scored. The TCS ranged from I-]00 (]:uncomplicated Mallory Weiss tear; lO0=death caused by perf esoph CA after dilation). 28 pts had TCS of 10 or less; 18 had TCS of 10-49; 2 had TCS of 50-99; 2 pts died and had TCS~]O0. MeanTCS=Z2.6. Median TCS=IO. CONCLUSIONS: The actual number of complications is not the best index of their importance. A system is proposed that allows the measure of importance of each complication to be scored. This is useful for Q/A and outcomes research.
Health care reforms have led to more accountability in endoscopic resources. In order to ascertain the effect of endoscopic training on endoscopist efficiency, we studied the time required to perform diagnostic colonoscopies by experienced endoscopists alone and with trainees. Aim: To determine the effect of trainee participation on procedural length, Methods: We examined the effect of trainee involvement in diagnostic colonoscopies (without polypectomy) at our institution. A total of 3063 consecutive diagnostic cases were prospectively timed. Initiation of the procedure was defined as when the physician actually entered the endoscopi c suite. This time was recorded on a computerized database system by the GI assistant who assisted in the case. At the completion of the procedure, the time was again recorded. Thirty-one gastroenterologists and 18 GI trainees were evaluated. Results: A total of 2090procedures were done without trainees while 973 procedures were done with trainees. There was a significant increase in procedural times if a trainee was involved in the case (p_<0.01), Procedure times were increased a mean of 14+_2 minutes (range 1-31 minutes). The mean procedure time with a trainee was 47+2 minutes. No endoscopist experienced a decrease in procedure time with a trainee. Using the difference of each individual endoscopist's procedure time with and without a trainee, approximately 230 extra hours of endoscopiet time was involved in these 973 cases. Although it was not possible to quantify the level of experience of the trainee at each procedure, it was apparant that senior trainees still increased the procedure
length. Conclusions: Endoscopic education significantly increases procedure length in diagnostic colonoscopy. The increased colonoscopist time required for education needs to be factored into assessments of cost of procedures of educational centers,
t146
148
ANTIBIOTIC PROPHYLAXIS WITH PIPERACILLIN (PIPI DOES NOT PREVENT ERCP-INDUCED CHOLANGITIS, S.J. van den _Hazel~, P. Speelman ~, G.N.J. Tytgat 1, J. Dankert 3, D.J. van Leeuwen 4. Departments of Gastroenterology 1, Internal Medicine 2 & Medical Microbiology 3, Academic Medical Center, Amsterdam, The Netherlands. Division of Gastroenterology", University of Alabama, Birmingham, USA. Antibiotic prophylaxis is widely used in the prevention of ERCP-induced cholangitis, but its efficacy remains to be proven. We report a double blind, placebo controlled trial of the efficacy of single dose PIP in reducing the incidence of acute cholangitis (AC) within 1 week after ERCP. Methods: Patients who underwent ERCP for suspected biliary stones or a distal common bile duct obstruction were selected. Major exclusion criteria were a previous ERCP within 7 days, a biliary endoprosthesis in situ, and use of antimicrobial agents or fever within 7 days prior to the procedure. PIP (4g) or placebo was given (i.v.) ~ 30 minutes before ERCP. AC was diagnosed when there was fever of > 38~ a necessity for antibiotic treatment and no symptoms indicating a source of infection outside the biliary tree. Results: Between April '91 and June '94 551 patients were included. During ERCP stones were found in 147 patients, a malignant distal obstruction in 203, other pathology in 88, and a normal biliary tract in 113. Of the 281 patients on placebo 17 developed AC (6,0%), as compared to 12 of 270 patients on PIP (4.4%, RR = 0.73, 95% CI 0.36-1.51, p = 0 . 4 0 ) . Analyzing patients with stones or a malignancy separately, there was still no significant advantage of PiP over placebo. Conclusion: Single dose PIP does not reduce the incidence of acute cholangitis after ERCP in patients with suspected bUiary tract stones or a malignant distal common bile duct obstruction.
IS ENDOSCOPY SAFE IN THE VERY ELDERLY? Donald Wurzburg, MD, Sylvia S. Ham, MPH, KevinW. Otden~MD. Divisionsof Gastroenterology, St. Mary's Medical Center, San Francisco, CA and UC Davis Medical Center, Sacramento, CA As an invasive procedure, (31endoscopymay be associated with increased morbidity and mortality in very eldedy patients. The purpose of this study was to determine the safety of performing endoscopy, including monitored anesthesia care (MAC), in a group of very elderly patients (75+ yrs) compared to sex-matched younger patients (<75 yrs). Method: All patients who underwent endoscopy during a four month period from 811194.11130194were studied. Age, gender, procedure type, sedative/narcotic medication dosage, and complications were all recorded. Results: 440 patients who underwent 451 procedures were studied; 168 aged 75+ yrs (mean 81, range 74-94) and 272 aged <75 yrs (mean 57, range 21-74). As shown below, the very elderiy underwent proportionately more colonoscopies and fewer flexible sigmoidoscopies than their youngercounterparts. " E(3D Colon FlexSi 9 " ERCP Total ) { 75+ 65 (37%) " 79 (45%) 17 (10%) '13 (7%) 174 L<75 107 (39%) 106 (38%) 43 (16%) 21 (8%) 277
This research was funded in part by Cyanarnid/Lederle B.V., The Nether/ands.
332
GASTROINTESTINAL ENDOSCOPY
I
Only 3 patientsoverall had complications: 2 very eldedy patients (1 episode of asymptomatic hypoxia, and 1 esophageal perforation during stenting) and 1 patient < 75 yrs who had asymptomatic hypoxia. Very elderly patients had a significantly higher rate of MAC usage (p <0.04). But no significant differences in complication rate or mean medication dosage was found between very ekfedy and youngerpatients as shown below. 75+ <75 p Complications 2 (1.2%) 1 (0.4%) NS MAC usage 11 (6.5%) 6 (2.2%) <0.04 Mean dosage Versed EGD 2.3 3.7 NS Colonoacopy 2.9 3.3 NS Mean dosage Demerol E(3D 35.9 39.4 NS Colonoecopy 40.7 46.4 NS Conclusions: Very elderly patients requiresimilar dosages of medications as their younger cohorts but may require usage of MAC more frequently. Advancedage per se does not add increased risk to performing endoscopy.
VOLUME 41, NO. 4, 1995