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Clinical Presentation and Non-Surgical Management of Colonic Perforations Complicating Endoscopic Submucosal Dissection
Abstracts
W1590 Does the Colonic Capsule PillCam ColonÒ Efficiently Screen Patients Who Would Deserve a Complete Colonoscopy for Colo-Rectal Cancer Screening? Michel Delvaux, Muriel Frederic, Isaac Fassler, Gerard Gay Colo-rectal cancer (CRC) screening is based on fecal occult blood test in large populations and more recently on a colonoscopy recommended at the age of 50. This attitude has led to perform a number of normal colonoscopies. Preliminary studies have shown the possibility to detect colonic polyps and tumors with the PillCam Colon capsule (CCE) (Given Imaging Yoqneam, Israel). The aim of the present study was to evaluate the positive (PPV) and negative (NPV) predictive value of the colonic capsule to detect colonic diseases and polyps as compared to colonoscopy and test the assumption that it could accurately discriminate patients deserving a complete colonoscopy in the frame of CRC screening. Patients and Method: 77 patients (43 men, 54 14 years) with an indication of colonoscopy (Familial history 24, personal history 13, IBD 3, iron-deficiency anaemia 4, rectal bleeding 18, change in bowel habits 15) were investigated by CCE followed on the next day by colonoscopy under general anaesthesia, as usually performed at our Institution. Bowel cleansing was obtained according to the previously published protocol (Endoscopy 2006;38:971-7). All CCE recordings were read by the same physician (GG) and all colonoscopies performed by the same operator (MD), unaware of the results of the CCE before the end of the colonoscopy. The primary outcome of the study was the decision made by the CCE reader to indicate a colonoscopy, compared with the final result of the colonoscopy Secondary outcomes were the agreement between CCE and colonoscopy for making a diagnosis of colo-rectal disease, detection rate, number and size of the polyps. Results. 2 patients were excluded: 1 did not swallow the capsule and 1 was diagnosed with a jejunal stenosis by the CCE. The mean colonic transit time of the capsule was 157 132 min. (ext. 5-481min.). CCE was normal in 17 (22%) and colonoscopy in 34 patients (31%). Polyps were detected in 36 patients by CCE (48.5%) and in 44 by colonoscopy (58.8%). CCE results indicated a colonoscopy in 48 patients (64.7%) and the colonoscopy results confirmed this indication in 44 (57.4%). The PPV of CCE was 75% and the NPV, 62%. The agreement between CCE and colonoscopy was significant for the detection of any colonic lesion (kappa Z 0.68, P ! 0.0001), detection of polyps (kappa Z 0.47, P ! 0.001), number (kappa Z 0.32, P ! 0.02) and size of the polyps (r Z 0.84, P Z 0.0007). Conclusion: The results of this preliminary study show the clinical usefulness of the CCE to detect colo-rectal diseases in patients referred for CRC screening. However, the PPV and NPV of the CCE for detection of the polyps need to be further improved to propose it in larger CRC screening programs.
W1591 Appropriateness of Colonoscopy for Patients with Isolated Abdominal Pain Nick Powell, Joel Dunn, Thomas A. Treibel, Joel Mawdsley, Julian P. Teare, Rupert Negus, Jonathan M. Hoare, Huw J. Thomas, Timothy Orchard Colonoscopy remains the gold standard investigation in the diagnosis of important colonic lesions, including colorectal cancer (CRC), colonic polyps (CP) and inflammatory bowel disease (IBD). The diagnostic yield of colonoscopy in patients with isolated abdominal pain is uncertain. We conducted a retrospective case control study. Colonoscopic findings and histology results were identified in all patients referred to our unit with abdominal pain as the sole indication for colonoscopy during a 20 year period (1986-2005 inclusive). For comparison colonoscopic findings and histology were identified in patients referred with isolated anemia or isolated change in bowel habit, which are more established indications for colonoscopy. 22,165 colonoscopies were performed during the study period. Abdominal pain was listed as the sole indication in 3.4% cases, anemia in 7.5% and change in bowel habit in 12.8%. There were significantly fewer cases of CRC and CP in patients with abdominal pain compared to patients with anemia (OR 0.26, 95% CI 0.16-0.44 and OR 0.74, 95% CI 0.59-0.93, respectively) (Table 1). Although the prevalence of CRC and CP did not differ significantly between patients with abdominal pain and patients with change in bowel habit, the proportion of patients diagnosed with IBD was significantly higher in patients with change in bowel habit (OR 2.05, 95% CI 1.39-3.03) (Table 1). We also analyzed the prevalence of important lesions in age specific strata. In the 298 young patients (aged ! 50 years) with isolated abdominal pain, the prevalence of significant neoplastic lesions (CRC and CP O 1 cm) was very low (0% and 1.3% respectively). The prevalence of IBD in young patients with abdominal pain (3.4%) was significantly lower than in young patients with change in bowel habit (9.3%, OR 0.34, 95% CI 0.20-0.59, P ! 0.0005). The diagnostic yield of colonoscopy for patients with isolated abdominal pain is very low and is significantly lower than in patients with either change in bowel habit or anemia. The yield is especially low in younger patients (aged ! 50 years) in whom clinically important lesions, including CRC (0%), adenomas O 1 cm (1.3%) and IBD (3%) were rarely identified. Isolated abdominal pain should be considered a contentious indication for colonoscopy and is arguably not appropriate.
AB322 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Table 1. Abdominal pain Anemia Change in bowel habit
nZ
CRC
CP
IBD
841 1673 2834
1.4% 5.1%) 1.8%
13.2% 17.0%)) 15.6%
2.5% 1.9% 5.0%)
)P ! 0.0001 ))P ! 0.02 compared to abdominal pain
W1592 Clinical Presentation and Non-Surgical Management of Colonic Perforations Complicating Endoscopic Submucosal Dissection Kyoung Hoon Rhee, Jeong-Sik Byeon, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim Background and Aims: Endoscopic submucosal dissection (ESD) in treating early stage colorectal neoplasia is getting its popularity. During therapeutic colonoscopy, However, the risk of perforation is increasing and frequently requires surgical management. The aim of this study was to analyze the clinical presentation and endoscopic management of colonic perforation that occurred during therapeutic endoscopy. Patients and Methods: Endoscopic database of 18 consecutive patients [age (median, range; years): 58, 41-75; gender (M:F): 12:6] who had undergone ESD for colonic adenoma or superficial, early stage colorectal cancer and have developed iatrogenic perforation between August 2005 and October 2007 were retrospectively reviewed. Results: The common presenting symtoms related to perforation were abdominal pain (7), chest discomfort (3), and shoulder pain (2). But eight patients (45%) were asymptomatic. Perforations were noticed during procedure in 12 patients (67%), and immediate closure using hemoclips were successfully performed in all. The rest 6 cases of perforation were noticed after 1 hour (3), 6 hours (1), 12 hours (1), and 18 hours (1) after procedures, and all but one patients were also medically treated well (clipping in 2, antibiotics only in 3). The mean size of perforation was 3.5 6.2 mm, and the maximal size of perforating hole experienced was 25 mm in diameter. The median number of hemoclips requiring primary closure was 6.5 (3-15). Air accumulation was detected radiographically in 13 (72%) including 4 asymptomatic patients. The mean white blood cell count was 7,022/mm3, and the mean C-reactive protein level was 2.5 mg/ dl. The mean duration of antibiotics treatment was 6.4 days, and the mean period of fasting time was 3.2 days. All the patients were discharged from hospital after a mean time of 9.6 days after perforation occured. Conclusion: Not all the perforation accompanies clinical symptoms, and routine check-up of radiograph after ESD could enhance the early detection rate of perforation. Non-surgical management comprising endoluminal application of hemoclips after ESD complicated by perforation was successful in most of the cases.
W1593 Use of Electromagnetic (EM) Colonoscope to Assess Maneuvers Associated with Cecal Intubation Russell I. Heigh, James A. Prechel, Billie J. Horn, Sara San Miguel, Evelyn G. Heigh, John K. Dibaise, Jonathan A. Leighton, Cynthia J. Edgelow, David E. Fleischer Background: Safe and effective colonoscopy is aided by endoscopic techniques and maneuvers (ETM) during the exam. Among these are patient repositioning, stiffening of the endoscope and abdominal pressure. To better understand how these maneuvers affect cecal intubation, we used a device that allows real time imaging of the colonoscope insertion shaft. Methods: An EM transmitter and a special adult variable stiffness instrument (outer diameter 13.2 mm, length 1680 mm, 140 degree view angle, and 3.7 mm working channel) with 12 embedded sensors (ScopeGuide (SG) system, CF-Q160DL, Olympus) was used. Between 9/1411/8/2007, 46 pts were examined. SG was used when the endoscopist determined a patient was suitable for examination with an adult variable stiffness colonoscope. Three highly experienced colonoscopists and endoscopy technicians performed the examinations. 5/46 pts were examined with an EM probe passed through the instrument channel of a pediatric variable stiffness colonoscope (our most common scope choice). Excellent images were obtained, but this practice was halted due to difficulties in performing colonoscopy without suction. Results: Pts: M 39: F 7; Age 33-90 (mean 63.6) yrs; Weight 52-110 (83.1) kg Cecum (C) reached 43/46 (93.5%); Time to C 3-25 (10.6) minutes Pts need ETM to reach C: 41/46 Z 89.1% Total pauses for ETM to reach C: 121; mean ETM/pt: 121/46 Z 2.63ETM/pt; mean ETM/pt when ETM required 121/41 Z 2.95 ETM/pt Reason For ETM: Rectosigmoid Angulation (Ang) 3.3%, Sigmoid Loop 47.1%, Sigmoid Ang 1.6%, Descending Loop 2.4%, Splenic Flex Loop 11.6%, Splenic Flex Ang 6.6%, Transverse (Trans) Loop 9.0%, Hepatic Flex Ang 9.9%, Unspecified 13.2% Scope Tip Position Needing ETM (Success of ETM At That Position): Rectum 5% (83.3%); Sig 20.7% (84%); Descending 5% (100%); Splenic Flex 11.6% (85.7%); Trans 14.8% (61.1%); Hepatic Flex 20.7% (52%); Ascending 19.8% (41.7%) Success of ETM Component Interventions n Z 174: Patient Repositioning 28/38 (73.7%); Stiffening of Endoscope 18/26 (69.2%); Abdominal Pressure {varied types & sites} 100/72 (72.0%); Other 2/3 (66.7%); Unspecified 4/7 (57.1%) Conclusions: 1. SG EM colonoscope allows imaging of the insertion shaft of colonoscope without
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W1590 Does the Colonic Capsule PillCam ColonÒ Efficiently Screen Patients Who Would Deserve a Complete Colonoscopy for Colo-Rectal Cancer Screening? Michel Delvaux, Muriel Frederic, Isaac Fassler, Gerard Gay Colo-rectal cancer (CRC) screening is based on fecal occult blood test in large populations and more recently on a colonoscopy recommended at the age of 50. This attitude has led to perform a number of normal colonoscopies. Preliminary studies have shown the possibility to detect colonic polyps and tumors with the PillCam Colon capsule (CCE) (Given Imaging Yoqneam, Israel). The aim of the present study was to evaluate the positive (PPV) and negative (NPV) predictive value of the colonic capsule to detect colonic diseases and polyps as compared to colonoscopy and test the assumption that it could accurately discriminate patients deserving a complete colonoscopy in the frame of CRC screening. Patients and Method: 77 patients (43 men, 54 14 years) with an indication of colonoscopy (Familial history 24, personal history 13, IBD 3, iron-deficiency anaemia 4, rectal bleeding 18, change in bowel habits 15) were investigated by CCE followed on the next day by colonoscopy under general anaesthesia, as usually performed at our Institution. Bowel cleansing was obtained according to the previously published protocol (Endoscopy 2006;38:971-7). All CCE recordings were read by the same physician (GG) and all colonoscopies performed by the same operator (MD), unaware of the results of the CCE before the end of the colonoscopy. The primary outcome of the study was the decision made by the CCE reader to indicate a colonoscopy, compared with the final result of the colonoscopy Secondary outcomes were the agreement between CCE and colonoscopy for making a diagnosis of colo-rectal disease, detection rate, number and size of the polyps. Results. 2 patients were excluded: 1 did not swallow the capsule and 1 was diagnosed with a jejunal stenosis by the CCE. The mean colonic transit time of the capsule was 157 132 min. (ext. 5-481min.). CCE was normal in 17 (22%) and colonoscopy in 34 patients (31%). Polyps were detected in 36 patients by CCE (48.5%) and in 44 by colonoscopy (58.8%). CCE results indicated a colonoscopy in 48 patients (64.7%) and the colonoscopy results confirmed this indication in 44 (57.4%). The PPV of CCE was 75% and the NPV, 62%. The agreement between CCE and colonoscopy was significant for the detection of any colonic lesion (kappa Z 0.68, P ! 0.0001), detection of polyps (kappa Z 0.47, P ! 0.001), number (kappa Z 0.32, P ! 0.02) and size of the polyps (r Z 0.84, P Z 0.0007). Conclusion: The results of this preliminary study show the clinical usefulness of the CCE to detect colo-rectal diseases in patients referred for CRC screening. However, the PPV and NPV of the CCE for detection of the polyps need to be further improved to propose it in larger CRC screening programs.
W1591 Appropriateness of Colonoscopy for Patients with Isolated Abdominal Pain Nick Powell, Joel Dunn, Thomas A. Treibel, Joel Mawdsley, Julian P. Teare, Rupert Negus, Jonathan M. Hoare, Huw J. Thomas, Timothy Orchard Colonoscopy remains the gold standard investigation in the diagnosis of important colonic lesions, including colorectal cancer (CRC), colonic polyps (CP) and inflammatory bowel disease (IBD). The diagnostic yield of colonoscopy in patients with isolated abdominal pain is uncertain. We conducted a retrospective case control study. Colonoscopic findings and histology results were identified in all patients referred to our unit with abdominal pain as the sole indication for colonoscopy during a 20 year period (1986-2005 inclusive). For comparison colonoscopic findings and histology were identified in patients referred with isolated anemia or isolated change in bowel habit, which are more established indications for colonoscopy. 22,165 colonoscopies were performed during the study period. Abdominal pain was listed as the sole indication in 3.4% cases, anemia in 7.5% and change in bowel habit in 12.8%. There were significantly fewer cases of CRC and CP in patients with abdominal pain compared to patients with anemia (OR 0.26, 95% CI 0.16-0.44 and OR 0.74, 95% CI 0.59-0.93, respectively) (Table 1). Although the prevalence of CRC and CP did not differ significantly between patients with abdominal pain and patients with change in bowel habit, the proportion of patients diagnosed with IBD was significantly higher in patients with change in bowel habit (OR 2.05, 95% CI 1.39-3.03) (Table 1). We also analyzed the prevalence of important lesions in age specific strata. In the 298 young patients (aged ! 50 years) with isolated abdominal pain, the prevalence of significant neoplastic lesions (CRC and CP O 1 cm) was very low (0% and 1.3% respectively). The prevalence of IBD in young patients with abdominal pain (3.4%) was significantly lower than in young patients with change in bowel habit (9.3%, OR 0.34, 95% CI 0.20-0.59, P ! 0.0005). The diagnostic yield of colonoscopy for patients with isolated abdominal pain is very low and is significantly lower than in patients with either change in bowel habit or anemia. The yield is especially low in younger patients (aged ! 50 years) in whom clinically important lesions, including CRC (0%), adenomas O 1 cm (1.3%) and IBD (3%) were rarely identified. Isolated abdominal pain should be considered a contentious indication for colonoscopy and is arguably not appropriate.
AB322 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Table 1. Abdominal pain Anemia Change in bowel habit
nZ
CRC
CP
IBD
841 1673 2834
1.4% 5.1%) 1.8%
13.2% 17.0%)) 15.6%
2.5% 1.9% 5.0%)
)P ! 0.0001 ))P ! 0.02 compared to abdominal pain
W1592 Clinical Presentation and Non-Surgical Management of Colonic Perforations Complicating Endoscopic Submucosal Dissection Kyoung Hoon Rhee, Jeong-Sik Byeon, Byong Duk Ye, Seung-Jae Myung, Suk-Kyun Yang, Jin-Ho Kim Background and Aims: Endoscopic submucosal dissection (ESD) in treating early stage colorectal neoplasia is getting its popularity. During therapeutic colonoscopy, However, the risk of perforation is increasing and frequently requires surgical management. The aim of this study was to analyze the clinical presentation and endoscopic management of colonic perforation that occurred during therapeutic endoscopy. Patients and Methods: Endoscopic database of 18 consecutive patients [age (median, range; years): 58, 41-75; gender (M:F): 12:6] who had undergone ESD for colonic adenoma or superficial, early stage colorectal cancer and have developed iatrogenic perforation between August 2005 and October 2007 were retrospectively reviewed. Results: The common presenting symtoms related to perforation were abdominal pain (7), chest discomfort (3), and shoulder pain (2). But eight patients (45%) were asymptomatic. Perforations were noticed during procedure in 12 patients (67%), and immediate closure using hemoclips were successfully performed in all. The rest 6 cases of perforation were noticed after 1 hour (3), 6 hours (1), 12 hours (1), and 18 hours (1) after procedures, and all but one patients were also medically treated well (clipping in 2, antibiotics only in 3). The mean size of perforation was 3.5 6.2 mm, and the maximal size of perforating hole experienced was 25 mm in diameter. The median number of hemoclips requiring primary closure was 6.5 (3-15). Air accumulation was detected radiographically in 13 (72%) including 4 asymptomatic patients. The mean white blood cell count was 7,022/mm3, and the mean C-reactive protein level was 2.5 mg/ dl. The mean duration of antibiotics treatment was 6.4 days, and the mean period of fasting time was 3.2 days. All the patients were discharged from hospital after a mean time of 9.6 days after perforation occured. Conclusion: Not all the perforation accompanies clinical symptoms, and routine check-up of radiograph after ESD could enhance the early detection rate of perforation. Non-surgical management comprising endoluminal application of hemoclips after ESD complicated by perforation was successful in most of the cases.
W1593 Use of Electromagnetic (EM) Colonoscope to Assess Maneuvers Associated with Cecal Intubation Russell I. Heigh, James A. Prechel, Billie J. Horn, Sara San Miguel, Evelyn G. Heigh, John K. Dibaise, Jonathan A. Leighton, Cynthia J. Edgelow, David E. Fleischer Background: Safe and effective colonoscopy is aided by endoscopic techniques and maneuvers (ETM) during the exam. Among these are patient repositioning, stiffening of the endoscope and abdominal pressure. To better understand how these maneuvers affect cecal intubation, we used a device that allows real time imaging of the colonoscope insertion shaft. Methods: An EM transmitter and a special adult variable stiffness instrument (outer diameter 13.2 mm, length 1680 mm, 140 degree view angle, and 3.7 mm working channel) with 12 embedded sensors (ScopeGuide (SG) system, CF-Q160DL, Olympus) was used. Between 9/1411/8/2007, 46 pts were examined. SG was used when the endoscopist determined a patient was suitable for examination with an adult variable stiffness colonoscope. Three highly experienced colonoscopists and endoscopy technicians performed the examinations. 5/46 pts were examined with an EM probe passed through the instrument channel of a pediatric variable stiffness colonoscope (our most common scope choice). Excellent images were obtained, but this practice was halted due to difficulties in performing colonoscopy without suction. Results: Pts: M 39: F 7; Age 33-90 (mean 63.6) yrs; Weight 52-110 (83.1) kg Cecum (C) reached 43/46 (93.5%); Time to C 3-25 (10.6) minutes Pts need ETM to reach C: 41/46 Z 89.1% Total pauses for ETM to reach C: 121; mean ETM/pt: 121/46 Z 2.63ETM/pt; mean ETM/pt when ETM required 121/41 Z 2.95 ETM/pt Reason For ETM: Rectosigmoid Angulation (Ang) 3.3%, Sigmoid Loop 47.1%, Sigmoid Ang 1.6%, Descending Loop 2.4%, Splenic Flex Loop 11.6%, Splenic Flex Ang 6.6%, Transverse (Trans) Loop 9.0%, Hepatic Flex Ang 9.9%, Unspecified 13.2% Scope Tip Position Needing ETM (Success of ETM At That Position): Rectum 5% (83.3%); Sig 20.7% (84%); Descending 5% (100%); Splenic Flex 11.6% (85.7%); Trans 14.8% (61.1%); Hepatic Flex 20.7% (52%); Ascending 19.8% (41.7%) Success of ETM Component Interventions n Z 174: Patient Repositioning 28/38 (73.7%); Stiffening of Endoscope 18/26 (69.2%); Abdominal Pressure {varied types & sites} 100/72 (72.0%); Other 2/3 (66.7%); Unspecified 4/7 (57.1%) Conclusions: 1. SG EM colonoscope allows imaging of the insertion shaft of colonoscope without
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