- Email: [email protected]
Comparison of Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer According to the Timing of Endoscopy
Abstracts
T1557 Oval Cup Forceps Versus Serrated Jaw Forceps in Gastric Biopsy Daniel A. Sussman, Amar R. Deshpande, Ana Maria Medina, Robert Poppiti, Luigi X. Cubeddu, Jamie S. Barkin Background/Aims: Obtaining quality endoscopic biopsy specimens is vital in making successful diagnoses. The influence of forceps cup shape on biopsy specimens is unclear. The aim of this single-center, prospective, pathologist-blinded, randomized, controlled trial was to identify whether oval cup or serrated jaw biopsy forceps obtain specimens of superior size. Secondary endpoints were adequacy and depth of specimen, crush artifact, and diagnostic yield. Methods: 68 consecutive patients undergoing endoscopic gastric biopsy for diagnostic purposes were enrolled. Patients were randomized to undergo initial biopsy from either a largecapacity, oval cup forceps with needle (Captura, Cook Endoscopy, Winston-Salem, NC) or a large-capacity, serrated jaw forceps with needle (Radial Jaw 3, Boston Scientific, Natick, MA). Biopsy with forceps from the alternate arm was performed sequentially in the same patient. Biopsies were performed on random gastric mucosa; discrete masses were excluded. Biopsy specimens from each forceps were interpreted blindly by a trained pathologist for size (maximal dimension in mm), adequacy (enough tissue for pathological interpretation), depth of penetration (deepest layer of tissue visualized), presence of crush artifact, and diagnostic yield. Results: The difference between means for size of tissue biopsied was 0.046 mm (mean for oval forceps: 2.92 mm, mean for serrated forceps: 2.97, p-value 0.156, CI 0.228 to 0.319). Tissue samples were deemed adequate with ability to make diagnosis in all subjects with both forceps (n Z 68, 100%). With respect to the depth of mucosa reached, no difference was observed between forceps (p Z 0.224). For oval forceps, the deepest layer reached was mucosa in 22 patients, muscularis mucosa in 25, and submucosa in 21. For serrated forceps, the deepest layer reached was mucosa in 14 patients, muscularis mucosa in 33, and submucosa in 21. A trend was demonstrated for the serrated forceps to provide deeper biopsies than the serrated, but it was not statistically significant. For crush artifact, no difference was observed between forceps (p Z 0.53). Conclusions: The shape of the head of the biopsy forceps does not affect the size of gastric biopsy specimens when comparing oval cup to serrated jaw. Both forceps are able to provide adequate tissue for diagnosis. No difference was observed between forceps with respect to depth of mucosa reached or crush artifact. A trend toward deeper specimens was observed with the serrated cup forceps, but this trial was not powered to detect this difference. Overall, no significant differences were observed between the serrated and the oval forceps in all parameters measured.
T1558 Intravenous Metoclopramide to Increase Mucosal Visualization During Endoscopy in Patients with Acute Upper Gastrointestinal Bleeding: A Randomized, Controlled Study Daniel A. Sussman, Amar R. Deshpande, Javier L. Parra, Afonso C. Ribeiro Background/Aims: The presence of residual blood in patients with UGI bleeding often limits visualization during EGD. Erythromycin has been shown to increase mucosal visualization, but may interfere with hemostatic procedures from strong GI contractions. The efficacy of metoclopramide in aiding visualization has not been evaluated. We investigated the effects of an IV metoclopramide bolus on mucosal visualization during EGD for acute UGI bleed. Secondary endpoints included the duration of EGD, rebleeding rate, number of inpatient hospital days, and need for second-look EGD. Methods: This single-center, randomized, prospective, controlled study at the University of Miami enrolled consecutive patients with UGI bleeding who had not received gastric lavage. Only patients with overt hematemesis or melena were included. Patients on medications affecting motility were excluded. Prior to EGD, each patient was randomized to receive either metoclopramide or no premedication. An EGD was performed 30-120 minutes after initiation of the infusion. A visual analog scale created by Avgerinos was used to grade the degree of visualization of the stomach and duodenal bulb (total score range 0-8). Results: A total of 26 patients were enrolled. Patient characteristics were similar in both groups. Mean visual analog scores for the control patients in the fundus, body, antrum, bulb, and total were 1.31, 1.38, 1.92, 1.69, and 6.31, respectively; scores for the metoclopramide patients were 1.54, 1.54, 1.92, 1.69, and 6.69 (t-test, p Z 0.47,0.62,1,1,0.64, respectively). The mean duration of EGD was 21.4 minutes in the control group; 22.2 minutes in the metoclopramide group (p Z 0.86). The mean number of RBC units transfused was 1.54 in the control group; 1.38 in the metoclopramide group (t-test, p Z 0.81). The mean number of hospital days was 9.92 in the control group; 7.46 in the metoclopramide group (t-test, p Z 0.60). Repeat EGD was necessary in 3 patients in the control group and 4 patients in the metoclopramide group (t-test, p Z 0.67). Six deaths occurred within 1 month of enrollment; two patients in the control arm and 4 in the metoclopramide arm (ttest, p Z 0.37). All deaths were related to progressive liver failure or complications of underlying medical problems. Conclusions: Intravenous metoclopramide may increase visualization of the proximal stomach during EGD, but this was not statistically significant and does not translate into better clinical outcome with respect to duration of EGD, transfusion requirement, need for repeat EGD, or length of hospital stay. The data may have been able to reach statistical significance if the powered number of patients was enrolled.
www.giejournal.org
T1559 Efficacy of Endoscopic Variceal Ligation for Esophageal Varices in Patients with Hepatocellular Carcinoma, Comparison with Patients Without Hepatocellular Carcinoma Hiroshi Araki, Yuko Kimura, Yoichi Yasuda, Fumito Onogi, Takashi Ibuka, Masahito Nagaki, Tomohiro Kato, Hisataka Moriwaki Introduction: Patients with hepatocellular carcinoma (HCC) and acute esophageal variceal bleeding have extremely high rates of recurrent bleeding and mortality. This study evaluates the feasibility and potential benefit of maintenance endoscopic variceal ligation in these patients. Aims & Methods: In this study, we estimated the clinical significance of endoscopic variceal ligation (EVL) for esopageal varices in patients with hepatocellular carcinoma (HCC) in comparison with in patients without HCC retrospectively. A total of 247 consecutive patients with esophageal varices, who underwent EVL from June 1, 1999 to December 31, 2006 in our institution. All subjects continued to receive therapy until the varices disappeared. The underlying diseases of these patients were 118 patients of liver cirrhosis without HCC (LC group), 83 patients of liver cirrhosis with HCC without tumor thrombus of the portal vein trunk (LC þ HCC group), 25 patients of liver cirrhosis with HCC with tumor thrombus of the portal vein trunk, and 16 patients of noncirrhotic portal hypertension. Setting: A historical control study was performed between LC group and LC þ HCC group. Results: The two groups of patients had comparable baseline characteristics; mean age (LC group: 59.4 years old, LCþHCC group 66.4 years old (p ! 0.01) and frequency of Child-Pugh’s A (38 vs 34), B (46 vs 39), and C (33 vs 10) (ns). Form of varices of these patients were F1 26, F2 77, F3 14 in LC group, F1 16, F2 56, F3 11 in LCþHCC group (ns). 21 patients underwent emergent EVL for bleeding varices and the remaining 96 patients underwent prophylactic EVL in LC group, 3 patients underwent emargency EVL, 80 patients enderwent prophylactic EVL in LC þ HCC group(p ! 0.01). The 1-, 3- and 5-year cumulative non-recurrence rates were 79.4%, 66.3%, 48.2% in LC group, 91.3%, 65.2%, 38.9% LC þ HCC group. Non-recurrence rate was similar in both groups. The 1-, 3- and 5-year cumulative mortality rates were 11.3%, 34.3%, 50.7% in LC group, 26.9%, 55.4%, 75.8% in LC þ HCC group. Mortality rates were significantly higher in LC þ HCC group than in LC group (p ! 0.05). Bleed-related mortality rates were 2% in LC group, 0% in LCþHCC group. These are lower than hepatic failure and hepatocellular carcinoma -related mortality (73.5%, 10.2% in LC group, 37.5%, 54.2% in LC þ HCC group) in both groups. Conclusion: There was no significant difference in long-term non-recurrense retes between cirrhotic patients with and without HCC. EVL is feasible in patients with HCC and variceal hemorrhage if they have a good hepatic reserve. EVL might lower the rate of bleedrelated mortality in patients with HCC.
T1560 Comparison of Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer According to the Timing of Endoscopy Hyun Seok Cho, Dong Soo Han, Tae Jun Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: The optimal timing of interventional endoscopy for bleeding peptic ulcer disease is controversial. Various complications may result from early endoscopic treatment. It is especially difficult to manage incidental problems that might arise at nighttime or during weekends due to lack of sufficient assistant, facility and surgical back-up. The aim of this study was to compare the outcomes between early endoscopy and delayed endoscopy for patients with bleeding peptic ulcer disease. Patients and methods: We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer admitted to the emergency room from May 2006 to September 2007 (age range 18-80 years). Patients were divided into two groups: early endoscopy group (who were admitted during the daytime and promptly underwent endoscopy) and delayed endoscopy group (who were admitted in the night or weekends and endoscopy was delayed until the next daytime). We compared the rate of re-bleeding, duration of hospital stay, and the total amount of transfusion between two groups. Results: There were 49 patients (male : 37, female : 12, mean age : 58.7 15.9 years) in the early endoscopy group and 41 patients (male : 34, female : 7, mean age: 55.9 14.8 years) in the delayed endoscopy group. Stages of ulcer bleeding were classified according to the Forrest classification, and showed no significant differences. Patient demographics and clinical characteristics, bleeding control modality, Rockall score (5.1 1.9 vs. 4.9 1.5, p Z 0.08) did not differ between two groups. Re-bleeding rate (3/49 vs. 5/41, p Z 0.313), duration of hospital stay (10.7 days vs. 9.3 days, p Z 0.437), and the total amount of transfusion (3.4 units vs. 2.7 units, p Z 0.240) also showed no significant differences. Conclusion : The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease was not significantly affected by the timing of endoscopy. Further prospective studies about predictive factors on optimal endoscopic timing will be needed.
T1561 Documentation of COMPLETE Colonoscopy; Can We Do It Better? Sebastian N. Abadie, Mahfuzul Haque Background: Colonoscopy is accepted as the most effective screening and surveillance modality for the prevention of colorectal cancer. Photography of cecal landmarks to document ‘‘complete’’ colonoscopy has been suggested as a quality
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB247
T1557 Oval Cup Forceps Versus Serrated Jaw Forceps in Gastric Biopsy Daniel A. Sussman, Amar R. Deshpande, Ana Maria Medina, Robert Poppiti, Luigi X. Cubeddu, Jamie S. Barkin Background/Aims: Obtaining quality endoscopic biopsy specimens is vital in making successful diagnoses. The influence of forceps cup shape on biopsy specimens is unclear. The aim of this single-center, prospective, pathologist-blinded, randomized, controlled trial was to identify whether oval cup or serrated jaw biopsy forceps obtain specimens of superior size. Secondary endpoints were adequacy and depth of specimen, crush artifact, and diagnostic yield. Methods: 68 consecutive patients undergoing endoscopic gastric biopsy for diagnostic purposes were enrolled. Patients were randomized to undergo initial biopsy from either a largecapacity, oval cup forceps with needle (Captura, Cook Endoscopy, Winston-Salem, NC) or a large-capacity, serrated jaw forceps with needle (Radial Jaw 3, Boston Scientific, Natick, MA). Biopsy with forceps from the alternate arm was performed sequentially in the same patient. Biopsies were performed on random gastric mucosa; discrete masses were excluded. Biopsy specimens from each forceps were interpreted blindly by a trained pathologist for size (maximal dimension in mm), adequacy (enough tissue for pathological interpretation), depth of penetration (deepest layer of tissue visualized), presence of crush artifact, and diagnostic yield. Results: The difference between means for size of tissue biopsied was 0.046 mm (mean for oval forceps: 2.92 mm, mean for serrated forceps: 2.97, p-value 0.156, CI 0.228 to 0.319). Tissue samples were deemed adequate with ability to make diagnosis in all subjects with both forceps (n Z 68, 100%). With respect to the depth of mucosa reached, no difference was observed between forceps (p Z 0.224). For oval forceps, the deepest layer reached was mucosa in 22 patients, muscularis mucosa in 25, and submucosa in 21. For serrated forceps, the deepest layer reached was mucosa in 14 patients, muscularis mucosa in 33, and submucosa in 21. A trend was demonstrated for the serrated forceps to provide deeper biopsies than the serrated, but it was not statistically significant. For crush artifact, no difference was observed between forceps (p Z 0.53). Conclusions: The shape of the head of the biopsy forceps does not affect the size of gastric biopsy specimens when comparing oval cup to serrated jaw. Both forceps are able to provide adequate tissue for diagnosis. No difference was observed between forceps with respect to depth of mucosa reached or crush artifact. A trend toward deeper specimens was observed with the serrated cup forceps, but this trial was not powered to detect this difference. Overall, no significant differences were observed between the serrated and the oval forceps in all parameters measured.
T1558 Intravenous Metoclopramide to Increase Mucosal Visualization During Endoscopy in Patients with Acute Upper Gastrointestinal Bleeding: A Randomized, Controlled Study Daniel A. Sussman, Amar R. Deshpande, Javier L. Parra, Afonso C. Ribeiro Background/Aims: The presence of residual blood in patients with UGI bleeding often limits visualization during EGD. Erythromycin has been shown to increase mucosal visualization, but may interfere with hemostatic procedures from strong GI contractions. The efficacy of metoclopramide in aiding visualization has not been evaluated. We investigated the effects of an IV metoclopramide bolus on mucosal visualization during EGD for acute UGI bleed. Secondary endpoints included the duration of EGD, rebleeding rate, number of inpatient hospital days, and need for second-look EGD. Methods: This single-center, randomized, prospective, controlled study at the University of Miami enrolled consecutive patients with UGI bleeding who had not received gastric lavage. Only patients with overt hematemesis or melena were included. Patients on medications affecting motility were excluded. Prior to EGD, each patient was randomized to receive either metoclopramide or no premedication. An EGD was performed 30-120 minutes after initiation of the infusion. A visual analog scale created by Avgerinos was used to grade the degree of visualization of the stomach and duodenal bulb (total score range 0-8). Results: A total of 26 patients were enrolled. Patient characteristics were similar in both groups. Mean visual analog scores for the control patients in the fundus, body, antrum, bulb, and total were 1.31, 1.38, 1.92, 1.69, and 6.31, respectively; scores for the metoclopramide patients were 1.54, 1.54, 1.92, 1.69, and 6.69 (t-test, p Z 0.47,0.62,1,1,0.64, respectively). The mean duration of EGD was 21.4 minutes in the control group; 22.2 minutes in the metoclopramide group (p Z 0.86). The mean number of RBC units transfused was 1.54 in the control group; 1.38 in the metoclopramide group (t-test, p Z 0.81). The mean number of hospital days was 9.92 in the control group; 7.46 in the metoclopramide group (t-test, p Z 0.60). Repeat EGD was necessary in 3 patients in the control group and 4 patients in the metoclopramide group (t-test, p Z 0.67). Six deaths occurred within 1 month of enrollment; two patients in the control arm and 4 in the metoclopramide arm (ttest, p Z 0.37). All deaths were related to progressive liver failure or complications of underlying medical problems. Conclusions: Intravenous metoclopramide may increase visualization of the proximal stomach during EGD, but this was not statistically significant and does not translate into better clinical outcome with respect to duration of EGD, transfusion requirement, need for repeat EGD, or length of hospital stay. The data may have been able to reach statistical significance if the powered number of patients was enrolled.
www.giejournal.org
T1559 Efficacy of Endoscopic Variceal Ligation for Esophageal Varices in Patients with Hepatocellular Carcinoma, Comparison with Patients Without Hepatocellular Carcinoma Hiroshi Araki, Yuko Kimura, Yoichi Yasuda, Fumito Onogi, Takashi Ibuka, Masahito Nagaki, Tomohiro Kato, Hisataka Moriwaki Introduction: Patients with hepatocellular carcinoma (HCC) and acute esophageal variceal bleeding have extremely high rates of recurrent bleeding and mortality. This study evaluates the feasibility and potential benefit of maintenance endoscopic variceal ligation in these patients. Aims & Methods: In this study, we estimated the clinical significance of endoscopic variceal ligation (EVL) for esopageal varices in patients with hepatocellular carcinoma (HCC) in comparison with in patients without HCC retrospectively. A total of 247 consecutive patients with esophageal varices, who underwent EVL from June 1, 1999 to December 31, 2006 in our institution. All subjects continued to receive therapy until the varices disappeared. The underlying diseases of these patients were 118 patients of liver cirrhosis without HCC (LC group), 83 patients of liver cirrhosis with HCC without tumor thrombus of the portal vein trunk (LC þ HCC group), 25 patients of liver cirrhosis with HCC with tumor thrombus of the portal vein trunk, and 16 patients of noncirrhotic portal hypertension. Setting: A historical control study was performed between LC group and LC þ HCC group. Results: The two groups of patients had comparable baseline characteristics; mean age (LC group: 59.4 years old, LCþHCC group 66.4 years old (p ! 0.01) and frequency of Child-Pugh’s A (38 vs 34), B (46 vs 39), and C (33 vs 10) (ns). Form of varices of these patients were F1 26, F2 77, F3 14 in LC group, F1 16, F2 56, F3 11 in LCþHCC group (ns). 21 patients underwent emergent EVL for bleeding varices and the remaining 96 patients underwent prophylactic EVL in LC group, 3 patients underwent emargency EVL, 80 patients enderwent prophylactic EVL in LC þ HCC group(p ! 0.01). The 1-, 3- and 5-year cumulative non-recurrence rates were 79.4%, 66.3%, 48.2% in LC group, 91.3%, 65.2%, 38.9% LC þ HCC group. Non-recurrence rate was similar in both groups. The 1-, 3- and 5-year cumulative mortality rates were 11.3%, 34.3%, 50.7% in LC group, 26.9%, 55.4%, 75.8% in LC þ HCC group. Mortality rates were significantly higher in LC þ HCC group than in LC group (p ! 0.05). Bleed-related mortality rates were 2% in LC group, 0% in LCþHCC group. These are lower than hepatic failure and hepatocellular carcinoma -related mortality (73.5%, 10.2% in LC group, 37.5%, 54.2% in LC þ HCC group) in both groups. Conclusion: There was no significant difference in long-term non-recurrense retes between cirrhotic patients with and without HCC. EVL is feasible in patients with HCC and variceal hemorrhage if they have a good hepatic reserve. EVL might lower the rate of bleedrelated mortality in patients with HCC.
T1560 Comparison of Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer According to the Timing of Endoscopy Hyun Seok Cho, Dong Soo Han, Tae Jun Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: The optimal timing of interventional endoscopy for bleeding peptic ulcer disease is controversial. Various complications may result from early endoscopic treatment. It is especially difficult to manage incidental problems that might arise at nighttime or during weekends due to lack of sufficient assistant, facility and surgical back-up. The aim of this study was to compare the outcomes between early endoscopy and delayed endoscopy for patients with bleeding peptic ulcer disease. Patients and methods: We conducted a prospective analysis of data from 90 patients with bleeding peptic ulcer admitted to the emergency room from May 2006 to September 2007 (age range 18-80 years). Patients were divided into two groups: early endoscopy group (who were admitted during the daytime and promptly underwent endoscopy) and delayed endoscopy group (who were admitted in the night or weekends and endoscopy was delayed until the next daytime). We compared the rate of re-bleeding, duration of hospital stay, and the total amount of transfusion between two groups. Results: There were 49 patients (male : 37, female : 12, mean age : 58.7 15.9 years) in the early endoscopy group and 41 patients (male : 34, female : 7, mean age: 55.9 14.8 years) in the delayed endoscopy group. Stages of ulcer bleeding were classified according to the Forrest classification, and showed no significant differences. Patient demographics and clinical characteristics, bleeding control modality, Rockall score (5.1 1.9 vs. 4.9 1.5, p Z 0.08) did not differ between two groups. Re-bleeding rate (3/49 vs. 5/41, p Z 0.313), duration of hospital stay (10.7 days vs. 9.3 days, p Z 0.437), and the total amount of transfusion (3.4 units vs. 2.7 units, p Z 0.240) also showed no significant differences. Conclusion : The effectiveness of interventional endoscopy for patients with bleeding peptic ulcer disease was not significantly affected by the timing of endoscopy. Further prospective studies about predictive factors on optimal endoscopic timing will be needed.
T1561 Documentation of COMPLETE Colonoscopy; Can We Do It Better? Sebastian N. Abadie, Mahfuzul Haque Background: Colonoscopy is accepted as the most effective screening and surveillance modality for the prevention of colorectal cancer. Photography of cecal landmarks to document ‘‘complete’’ colonoscopy has been suggested as a quality
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB247