Appropriate use of colonoscopy in an open access system

CLINICAL ENDOSCOPIC PRACTICE ill7

119

OPEN-ACCESS ENDOSCOPY: ARE THE REFERRALS APPROPRIATE? Ravish J. Mahaj_~_, James S. Barthel, and John B. Marshall. Division of Gastroenterology, University of Missouri Hospitals and Clinics, Columbia, Missouri. Our Endoscopy Center has operated an open-access endoscopy service since 1990. This service allows a non-gastroenterologist physician to refer an outpatient directly to our Endoscopy Center for an endoscopic procedure without having the patient first seen in clinic. Patients are phoned beforehand by a nurse or GI fellow to complete a short medical history and to give instructions. We prospectively examined all open-access endoscopy referrals performed over the period September 1994 through November 1994 to determine whether the procedures were indicated (ASGE published guidelines used). There were 112 patients referred over this period, including 32 for EGD, 51 for colonoscopy, and 29 for flexible sigmoidoscopy (13S). 104/112 (93%) of the endoscopic procedures were indicated: 31/32 (97%) for EGD, 44/51 (86%) for colonoscopy, and 29/29 (100%) for FS. When we looked just at procedures requiring conscious sedation (EGD and colonoscopy), family practitioners and general internists were noted to refer patients for appropriate indications with a greater frequency than did internal medicine subspecialists and surgeons: 43/45 (96%) and 18/18 (100%) versus 3/7 (43%) and 11/13 (85%), respectively. All the FS procedures (conscious sedation not required) were appropriately referred by the various physician groups. We conclude: (l) 7% of open-access endoscopic referrals in our practice did not meet ASGE indications, the percentage being higher for colonoscopy (14%), than for EGD (3%) and FS (0%). (2) Procedures requiring conscious sedation referred by family practitioners and general internists were more likely to meet approved indications than those referred by internal medicine subspecialists and surgeons. (3) Open-access services need to carefully screen patients being referred to decrease the number of non-indicated procedures and to conserve resources.

A P P R O P R I A T E U S E OF COLONOSCOPY IN R N O P E N ACCESS S Y S T E M ~ M i n o l i (Como), A P r a d a (Rho), F R o c c a ( B u s t o A), A B o r t o l i (Rho), R G u l l o t t a ( V a r e s e ) , A Garripoli (Torino), P Leo (Bologna) A Pera (Torino) a n d A Z a m b e l l i (Crema). Ospedale Valduce, 22100 COMO Italy A I M : T o v e r i f y t h e a p p r o p r i a t e u s e of C o l o n o s c o p y (Col) i n a n " o p e n a c c e s s s y s t e m . " METHODS: T h i s p r o s p e c t i v e a n d m u l t i c e n t e r s t u d y is b e i n g performed in seven different Hospitals. Indications are recorded before the exam and compared w i t h t h e A S G E g u i d e l i n e s f o r a p p r o p r i a t e u s e of Col. ~ b T ~ : 2 3 2 9 C o l ( m e a n a g e 59, r a n g e 1-92, 1 2 2 1 M a l e s ) h a v e b e e n s t u d i e d s o far. T h e e x a m s " n o t g e n e r a l l y i n d i c a t e d " w e r e ~58 (20%) a n d w e r e d i s t r i b u t e d as f o l l o w s : 1) F o l l o w u p n o t in 1 year, then at 3-to 5 years intervals following resection of a colorectal cancer or neoplastic p o l y p : 2 1 5 (57%) 2) B r i g h t r e d r e c t a l b l e e d i n g with a convincing anal source and no symptoms s u g g e s t i v e of a m o r e p r o x i m a l b l e e d i n E s o u r c e : 80 (17%) 3) M e t a s t a t i c a d e n o c a r c i n o m a o f u n k n o w n p r i m a r y s i t e i n a b s e n c e of c o l o n i c s y m p t o m s w h e n i t w i l l n o t i n f l u e n c e m a n a g e m e n t : 39 (9%) ~ ) I B S if a n o r g a n i c d i s e a s e h a s a l r e a d y e x c l u d e d : ~7 (10%) 5) R o u t i n e f o l l o w u p of I B D ( e x c e p t f o r c a n c e r s u r v e i l l a n c e ) : ~i 19%) 6) R o u t i n e e x a m of t h e c o l o n i n p t s a b o u t to u n d e r g o e l e c t i v e abdominal surgery for non colonic disease:23 (5%) 7) A c u t e l i m i t e d d i a r r h o e a 1 0 ( 2 % ) 8) GI B l e e d i n g w i t h d e m o n s t r a t e d u p p e r GI s o u r c e : 3(1%). 2 0 1 0 (86%) p a t i e n t s d i d n o t h a v e a n y b a r i u m e n e m a in t h e p r e v i o u s 6 m o n t h s . I n d i c a tions not provided by the guidelines were 358 (15%). ~ : 1) In o u r s e t t i n g t h e r a t e of c o l o n o s c o p i e s w i t h questionable indication is high, p a r t i c u l a r l y in c a s e of f o l l o w u p of n e o p l a s t i c l e s i o n s ; 2) s o m e indications are not l i s t e d in t h e A S G E g u i d e l i n e s .

118

120

PERFECTING THE COLONIC PREP: A RANDOMIZED DOUBLEBLIND PLACEBO CONTROLLED TRIAL. H.E.Mattox, R.Y.Warren SE Georgia Regional Medical Center, Brunswick, GA

TOTAL COLONOSCOPY~ FACTORS THAT DETERMINE ITS PERFORMANCE IN A TRAINING HOSPITAL. M. Mufioz-Navas. M.T. Betes, C. Corella, P. Perez-Rojo, J.C. Subtil, R. Angos, E. Macias. Endoscopy Unit. University Clinic of Navarra. Pamplona. Spain.

Background: Colonic preparation with oral Fleet Phospbosoda (FP) has been shown to provide superior colonic cleansing and is better tolerated by patients (pts) compared to other prep techniques. One drawback is excessive bubbling of the prep with insufflation which can obscure the muc0sa

Purpose: Assess the efficacy of eliminating bubbles by adding oral simethecone (S), a nonabsorbable surface active agent which disperses bubbles, to the prep regimen. Methods: Patients undergoing colonoscopy received either FP 1 1/2 oz. plus S 125mg. at 5pm and 5am prior to the procedure or FP 1 1/2 oz. plus placebo (P) at 5pro and 5am. Pts, physicians and staffwere blinded in a double-blind fashion. Pt compliance, quality of prep, and amount of bubbles (none, minimal, moderate or heavy) were assessed. Results: Twenty consecutive pts, 10 in each arm, were randomized. All pts complied with prep instructions in both arms of the study. Prep quality was good to excellent in all pts. Severity of Bubbles Bubble Free

Minimal

Moderate

Heavy

FP + S

9/10"

0/10

1/10

0/10"

FP + P

4/10

2/10

1/10

3/10

* p<0.05

1) FP is an effective and well tolerated oral colonic lavage solution. 2) Addition of oral S to the FP prep eliminates bubbles in 90% of pts. Conclusions:

VOLUME 41, NO. 4, 1995

We have carried out a prospective study between February 22th and May 5th 1994, in order to assess the factors that influence the performance of a total colonoscopy. 399 colonoscopies have been included, 248 men and 151 women, with mean age of 56 (ranging from 15 to 88). 10 patients with obstructing lesions that blocked the scope passage and 25 with previous colonic r~section were excluded. The procedures were carried out by residents and members of the staff of our Endoscopy Unit. Colonoscopy was performed under complete sedation controlled by an anesthetist in 171 cases. The remaining patients were medicated with midazolam and pethidine. It was possible to reach cecum in 391 patients (97,9%), in an average time of 8,33 minutes. This time has been significantly less in the following cases: complete sedation, males, good preparation, larger experience of medical and nursing staff (p< 0,001), and the absence of abdomino-pelvic surgery (p< 0,05). No significant differences have been found in patients with colorectal neoplasms, IBD, diverticular disease, previous abdo~inopelvic radiotherapy or obesity. Tolerance was significantly better in patients under complete sedation (p<0,001), without finding significant differences when we took into account the remaining parameters. Manual pressure maneuvering was used in 53,6% of cases, pressure with the help of a compressive ball in 6,6% and patient mobilization in 18,5%. NO maneuvering was necessary in 43,8% of the cases. The endoscope was withdrawn during the insertion in 346 cases (88,5%). Help from more experienced staff was required in 37 cases (9,2%) (endoscopists) and in 35 cases (8,7%) (nursing staff). In the cases in which total colonoscopy could not be done, 3 of them were attributed to bad tolerance, 2 to a possible dolichocolon and 3 to bad preparation. We consider this study interesting because it analyzes the factors which can determine the endoscope to reach the cecum in a training hospital.

GASTROINTESTINAL ENDOSCOPY 3 2 5