- Email: [email protected]
Does Colonoscopic Withdrawal Time Affect Polyp Detection Rate?
Abstracts
lead time of patients, to improve endoscopy suites utilization and make best use of available resources. The aim of our work was to use the Lean & Six Sigma methodologies through the framework: ‘‘DMAIC-Define, Measure, Analyse, Improve, Control’’ to decrease patients cycle time without any change of available resources. Methodology: Colonoscopy was chosen as the main objective since it is one of the most frequent endoscopy performed and involves anaesthesia. The patient profile was further defined as internal/external and with/without anaesthesia. Lead time included pre-exam (registration, preparation), exam (including sedation or anaesthesia with IV propofol) and post-exam times (recovery, report and departure). Measures included statistical process control tools on patient lead time per profile and variability at each step of the process. The study took place in a tertiary academic hospital performing more than 12000 endoscopic procedures per year, with 2100 colonoscopies. Measurements were done during 2 weeks and then discussed during workshops with the entire team (physicians, nurse and support staff, administration and finance, process engineer). Results: 112 pts/colonoscopies were evaluated and total lead times for a colonoscopy with (nZ68) and without (nZ44) anaesthesia were 190 min [range 99-403] and 80 min [35-135], respectively. The differences were mainly due to the preparation step 23 min [0-95] with anaesthesia vs. 2 min [0-37] without and the post-exam period that included recovery until discharge with and without anaesthesia [126 min vs. 15], respectively. Occupation time of exam rooms was 46 vs. 40 min (p!0.015) with and without anaesthesia, respectively. The key bottlenecks were further analysed and improvement opportunities are summarized in table. We have implemented them through small tests of change. This resulted in an increase of 7.6 to 9.7 colonoscopies per day, and of the ratio with/without anaesthesia of 55 to 62%. Conclusions: The use of the Lean & Six Sigma methodologies, to process the patient’s mapping and to measure the lead time, in order to identify bottlenecks and improvement opportunities, led to important changes in the unit organisation and efficiency with a significant decrease of colonoscopy cycle time.
Punctuality for registration Start time of first exam Variability for pre-exam time Room occupancy
Baseline
Target
20% regist. after appointment 8h58 Upper specification limit at 95 min
0% 8h40 Upper specification limit at 50 min 2008 vs. 2007: þ 28%
M1396 Short and Long-Term Outcomes of Patients Sustaining Iatrogenic Endoscopic Colorectal Perforations Ranjith Wijeratne, Karolin Ovrahim, Kevin T. Kao, Thomas Teller, Maher A. Abbas Purpose: Although risk factors for iatrogenic endoscopic perforations have been well delineated, little is known about the outcome of such patients once they leave the endoscopy suite. The purpose of this study was to examine the management and results of patients who sustained endoscopic colorectal perforations at a tertiary care teaching center. Methods: A retrospective review was conducted of all patients who were diagnosed with colorectal perforations following endoscopy over a 10 year period at Kaiser Permanente, Los Angeles. Endoscopy reports and patient’s inpatient and outpatient medical records were reviewed. Variables analyzed included demographics, location of perforation, timing of presentation, surgical management, post-operative complications, and mortality. Results: During the study period a total of 72071 flexible endoscopies were performed [colonoscopy 41115 (57%), sigmoidoscopy 30956 (43%)]. Perforation occurred in 26 patients (0.04%). 24 patients had complete records and were the focus of this study. Mean age was 68 years with male predominance (63%). Majority of procedures (71%) were outpatient and 29% were inpatient (5 patients for bleeding, 2 patients for stent decompression). Most common location of perforation was sigmoid or rectosigmoid (50%). Majority of perforations (67%) presented within 24 hours of endoscopy, 17% O 24 hours, and 17% were recognized at time of procedure. 22 patients (92%) underwent surgical intervention and only 2 (8%) were managed conservatively. Median size of perforation was 2 cm [range 1-8 cm]. Operative interventions consisted of primary repair in 18 (75%) and colectomy in 4 (17%). 5 patients (21%) received colostomy. 30-day mortality was 21% and no death was noted at 90-days. Mortality was 0%, 50%, and 100% in patients with ASA class I-II, III, IV, respectively. Post-operative morbidity rate was 58% with septic complications being most common (54%) followed by cardiac (17%), and pulmonary (13%). Conclusion: Iatrogenic endoscopic colorectal perforation is a rare event in a high volume endoscopy suite. Most patients require surgical intervention which carries a significant risk of mortality especially in patients with ASA class III and IV. Post-operative complications are common and are often infection related.
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M1397 Comparing ERCP Practice and Outcomes By Level of Experience Donald A. Garrow, Joseph Romagnuolo, Peter B. Cotton The ERCP Quality Network is a voluntary reporting system which allows endoscopists to submit data on procedures to a central repository. The data are analyzed and available to contributors in the form of individual practice summaries (‘‘report cards’’) and in comparison with others in the system (‘‘benchmarking’’). No doctors or patients may be identified. By November 2008, 59 doctors from 3 countries provided data on 7896 ERCP cases. Contributors were classified as ‘‘Academic’’ or ‘‘Community’’ and by experience. Less experienced practitioners were defined by ! 150 cases in the last year, or ! 1000 total lifetime. Academic and community groups had the same percentage of ‘‘less experienced" (21% vs 22%). Not surprisingly, Academics performed more complex cases (46% grade 3, vs 28% Community-based, p !.0001), but success rates for deep biliary cannulation, bile duct stone extraction (! 10 mm) and minor papilla cannulation were similar and high. Table 1 compares practice patterns and outcomes by experience. Less experienced endoscopists had fewer Grade 3 cases, were more likely to use conscious sedation rather than anesthesia, did more ‘‘diagnostic’’ cases, used longer total case and fluoroscopy time and had significantly lower success rates for deep biliary cannulation, extraction of bile duct stones (! 10 mm) and minor papilla cannulation. Complication rates were reportedly similar. The ERCP Quality Network project demonstrates that practitioners are interested and willing to share their practice data anonymously and also provides some idea of appropriate benchmarks. The project is ready for substantial enlargement and will facilitate the development of a national system covering all aspects of endoscopy. The data should eventually be extractable from electronic reporting systems. This project is supported by Olympus America. ERCP practice patterns and outcomes by experience
Variable
Less Experienced at ERCP
More Experienced at ERCP
Degree of Difficulty 3 Degree of Difficulty 2 Degree of Difficulty 1 General Anesthesia Propofol/MAC Conscious sedation Fluoroscopy time ! 20 minutes Fluoroscopy time 21-40 minutes Fluoroscopy time O 40 minutes Scope time ! 20 minutes Scope time 21-40 minutes Scope time O 40 minutes Biliary cannulation Minor papilla cannulation Biliary stone extraction ! 10 mm
14.6% 22.5% 62.9% 30.1% 15.1% 54.9% 28.4% 31.1% 40.6% 28.6% 35.0% 36.4% 94.0% 82.1% 98.0%
44.8% 20.1% 35.2% 8.3% 57.3% 34.4% 50.3% 27.0% 22.7% 49.6% 34.5% 15.9% 98.0% 95.7% 100%
p-value ! 0.0001
! 0.0001
! 0.0001
! 0.0001
!0.0001 !0.0001 0.001
M1398 Does Colonoscopic Withdrawal Time Affect Polyp Detection Rate? Sang Bong Ahn, Dong Soo Han, Hyun Seok Cho, Tae Jun Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: Colonoscopic withdrawal time has been proposed as a quality indicator for colonoscopy based on evidence that it is associated with adenoma detection rate. Recent investigations to identify factors which affect adenoma detection rates have focused on technical aspect of the procedures such as cecal intubation rate and colonoscopic withdrawal time. In this study, we examined the difference of polyp detection rates between endoscopists, and analysed certain factors that lead to such differences, particularly colonoscopic withdrawal time. Methods: We retrospectively evaluated the procedures of 7 second-year GI fellows in Hanyang University Guri Hospital. A total of 1,515 colonoscopies were assessed with polyp detection rate, insertion time, withdrawal time, bowel preparation, polyp size and polyp location. Subjects who had a history of colorectal neoplasia, special procedure and inflammatory bowel disease were excluded. A total of 1299 patients were enrolled in the study. Results: There were large differences among endoscopists in the polyp detection rates between a wide range of 15% to 35%. There were no significant differences in the age of subjects, sex, bowel preparation and location of polyps. The median insertion time varied from 7.6 to 12.3 minutes. However, there was no relationship between the colonoscopic insertion time and polyp detection rates. The median withdrawal time in which no polyps were removed was 3.6 to 7.1 minutes. There was a strong positive correlation between the colonoscopic withdrawal time and polyp detection rates (p!0.001). Furthermore, longer withdrawal times resulted in discovering a higher percentage
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB231
Abstracts
of small polyps. When we categorized the endoscopists according to a mean withdrawal time of either less than 6 minutes or 6 minutes or more, the longer withdrawal time group had a greater polyp detection rates (30.7% vs 18.4%, p!0.001). We also observed a negative correlation between colonoscopic insertion times and the withdrawal times among the endoscopists (p!0.001). Conclusion: There is wide range of polyp detection rates among colonoscopists and a strong positive correlation between the colonoscopic withdrawal times and polyp detection rates. Long enough withdrawal times would be necessary to raise the polyp detection rates during colonoscopy.
M1399 Lack of Discriminatory Function for Endoscopy Skills On a Computer-Based Simulator Stephen Kim, Geoffrey Spencer, George Makar, Nuzhat A. Ahmad, David L. Jaffe, Gregory G. Ginsberg, Michael L. Kochman Background: Computer-based endoscopy simulators have been developed to enable trainees to learn and gain technical endoscopic skills before performing on patients. This study prospectively evaluated the capability of a computer-based simulator to discriminate between varying levels of skill and experience in esophagogastroduodenoscopies (EGD) and colonoscopies. Methods: Five first-year gastroenterology fellows with no prior endoscopic experience performed sixty mentored endoscopy cases on the Simbionix GI Mentor II (Simbionix Ltd. Israel). Six experts, with more than 1000 previous EGDs and colonoscopies, performed six cases (three EGDs, three colonoscopies) on the simulator that were selected to represent common clinical scenarios. Performance parameters were collected by the simulator. Results: Novices and experts were able to complete the tasks in the simulated cases with no significant overall differences between the two groups. The computer-based simulator was only able to discriminate levels of expertise on parameters related to the time spent on the procedure (total time, time to second duodenum, time to cecum, and efficiency of screening). No statistically significant differences were found for the other nine performance parameters measured by the simulator. Conclusions: 1. The computer-based endoscopy simulator displays a lack of discriminatory function between novices and experts for endoscopic skills based on measured objective performance parameters.2. Our findings suggest that the computer-based simulator lacks fidelity and is not capable of producing a prediction of skill during in vivo endoscopy. Comparison of Novices and Experts on the Endoscopy Simulator - EGD Cases Perforamance Paremeter
Novice (nZ15) Expert (nZ18) mean (median) mean (median) p-value
Total time (seconds) 421.0 (393.0) Percent mucosa examined 84.3 (84.0) Time to second duodenum (seconds) 100.6 (99.5) Percent time with clear view 97.4 (98.0) Percent time patient in pain 0.0 (0.0) Efficiency of screening 70.7 (72.0)
265.3 81.5 55.3 96.4 0.0 81.8
(257.5) (81.0) (36.0) (98.0) (0.0) (84.5)
0.002 0.294 0.006 0.624 1.000 0.024
Comparison of Novices and Experts on the Endoscopy Simulator - Colonoscopy Cases
Performance Parameter
Novice (nZ15) mean (median)
Expert (nZ18) mean (median)
p-value
Total time (seconds) Caused excessive local pressure Lost view of lumen Excessive loop formed Percent mucosa examined Time to cecum (seconds) Percent time iwth clear view Percent time patient in pain Efficiency of screening
880.2 3.1 1.3 0.7 84.6 391.9 88.7 2.0 66.2
610.1 2.5 0.7 1.7 89.9 228.6 88.9 0.1 82.8
0.021 0.327 0.067 0.107 0.093 0.001 0.280 0.459 0.023
(828.0) (3.0) (1.0) (0.0) (91.0) (350.0) (89.0) (0.0) (71.5)
(572.5) (2.0) (0.5) (1.0) (93.0) (219.0) (91.0) (0.0) (89.0)
M1400 Randomized Study On the Efficacy of Polyethylenglicol and Sodium Phosphate Alone or Associated with Bisacodyl for Bowel Cleansing Prior to Videocolonoscopy Lisandro Pereyra, Daniel G. Cimmino, Carlos E. Gonzalez Malla, Mariano Laporte, Sandra Lencinas, Carlos Peczan, Nicolas A. Rotholtz, Pablo Luna, Silvia C. Pedreira, Luis A. Boerr, Hugo N. Catalano Introduction: An optimal colonic cleansing prior to a videocolonoscopy (VCC) reduces the possible failures in the detection of mucosa lesions and the need to repeat the study. Although a number of papers have been published that assess the safety and efficacy of Polyethilenglicol (PEG) and Sodium Phosphate (NaP), they don’t allow us to draw definitive conclusions on which is the best agent. Aim: To
AB232 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
compare the tolerance and efficacy of NaP and PEG alone and associated with Bisacodyl for colonic cleansing. Method. 353 patients, older than 18 years old, were randomized to receive one of the following preparations: 90 ml of NaP (group A); 45 ml of NaP þ 20 mg of Bisacodyl (group B); 4 liters of PEG (group C) or 2 liters of PEG þ 20 mg of Bisacodyl (group D). The allocation of the randomization was councealed. The patients, the doctors who carried out the VCC, the nurses who conducted surveys on tolerance, the secretary who handed out the boxes to the patients and the ones in charge of the statistical analysis were blinded to the allocated preparation. The primary outcome was the necessity to repeat the VCC due to an inadequate preparation. The secondary outcomes were: quality of preparation (measured with a validated scale), tolerance to the preparation and adverse effects. Results. From the 353 patients, 3 were excluded post randomization for not complying with the inclusion criteria, 7 were unable to finish the study due to a sigmoid colon stenosis or fixed angulation, and 19 did not undergo the VCC. Information about the primary outcome was obtained from 323 patients (92%). The primary outcome (necessity to repeat the study due to an inadequate preparation) was similar in all the groups: A 3.5%, B 4.9%, C 7.1%, D 8.1% (pO0.05). There were no significant differences regarding the quality of the preparation either. The compliance was significantly higher in the NaP preparations (A vs CþD p 0.05, B vs CþD p !0.01) being even higher in the association with Bisacodyl (B vs AþCþD p! 0.01). Patients who received preparations with Bisacodyl presented abdominal pain with more frequency, although this was not a significative observation (pO0.05). The combination of NaP and Bisacodyl was associated with insomnia (p 0.039). Conclusion. 90 ml of NaP is more easily completed and equally effective as the rest of the preparations. The combination with Bisacodyl was associated with a higher number of adverse effects.
M1401 The Risk of Bacterial Contamination to the Endoscopist and Endoscopy Unit During Routine Esophagogastroduodenoscopy and Colonoscopy Natasha Chandok, David G. Morgan Introduction: Although personnel in the endoscopy unit are exposed to enteric pathogens, documented instances of infectious complications are rare. There are no controlled studies on the risk of bacterial transmission from the patient to the endoscopist or endoscopy unit during routine esophagogastroduodenoscopy (EGD) and colonoscopy. It is common for individual institutions to develop their own guidelines on preventing infection with little or no supporting evidence. Aim: To determine the risk of bacterial infection to the endoscopist and endoscopy unit during routine EGD and colonoscopy among outpatients at a university teaching hospital. Methods: 50 random outpatient endoscopic procedures done at McMaster University from May to July 2008 were examined. Before each procedure, the endoscopist changed into a sterile surgical shirt and scrubbed their hands with antimicrobial soap. Subsequently, the endoscopist wore clean non-latex gloves and a disposable plastic apron. Swabs were taken of the endoscopist’s face and forearms before and after the procedure. Agar plates were placed within 1 meter of the procedure to assess for airborne contamination. Results: 21 EGD’s and 29 colonoscopies were analyzed. Swabs taken from the forearms before the procedure were sterile, and swabs taken from the face showed innumerable colonies with mixed skin flora. After the procedure, right forearm cultures were positive in 6 of 50 procedures, 5 of these being colonoscopies. The left forearm cultures were positive in 2 colonoscopies. There was no increased growth of bacteria on the face. Cultures of the endoscopy work-place one meter from the endoscopic procedure grew 1 or 2 colonies of bacteria on average. Conclusion: The endoscopist is at minimal risk for bacterial contamination through colonoscopies, and less so with EGD’s. Routine EGD and colonoscopy does not impose a risk of bacterial contamination of the face, so face shields are not required. The most likely place for the endoscopist to become contaminated is the right arm, likely because this is the arm which manipulates the scope and is closest to the patient. There is minimal contamination of the endoscopy work place. Wiping counters with antiseptic cleansers and exercising handwashing between patients should be routine practice.
M1402 Weekend Versus Weekday Management and Prognosis of Upper GI Bleeding: Results of a Post Hoc Subanalysis of a French Prospective Study ´phane Nahon, E. Alexandre Pariente, Bernard Denis, Bernard Nalet, Ste Herve Hagege, Bruno Bour, Roger Faroux, Jean-Pierre Arpurt, Jacques Denis, Jean Henrion Background: Hospital staffing is often lower at weekends than on weekdays. Consequently, it may be difficult to perform endoscopies and if necessary an appropriate endoscopic treatment. The aims of this study were to evaluate the characteristics and prognostic factors of upper GI bleeding (UGIB) during
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lead time of patients, to improve endoscopy suites utilization and make best use of available resources. The aim of our work was to use the Lean & Six Sigma methodologies through the framework: ‘‘DMAIC-Define, Measure, Analyse, Improve, Control’’ to decrease patients cycle time without any change of available resources. Methodology: Colonoscopy was chosen as the main objective since it is one of the most frequent endoscopy performed and involves anaesthesia. The patient profile was further defined as internal/external and with/without anaesthesia. Lead time included pre-exam (registration, preparation), exam (including sedation or anaesthesia with IV propofol) and post-exam times (recovery, report and departure). Measures included statistical process control tools on patient lead time per profile and variability at each step of the process. The study took place in a tertiary academic hospital performing more than 12000 endoscopic procedures per year, with 2100 colonoscopies. Measurements were done during 2 weeks and then discussed during workshops with the entire team (physicians, nurse and support staff, administration and finance, process engineer). Results: 112 pts/colonoscopies were evaluated and total lead times for a colonoscopy with (nZ68) and without (nZ44) anaesthesia were 190 min [range 99-403] and 80 min [35-135], respectively. The differences were mainly due to the preparation step 23 min [0-95] with anaesthesia vs. 2 min [0-37] without and the post-exam period that included recovery until discharge with and without anaesthesia [126 min vs. 15], respectively. Occupation time of exam rooms was 46 vs. 40 min (p!0.015) with and without anaesthesia, respectively. The key bottlenecks were further analysed and improvement opportunities are summarized in table. We have implemented them through small tests of change. This resulted in an increase of 7.6 to 9.7 colonoscopies per day, and of the ratio with/without anaesthesia of 55 to 62%. Conclusions: The use of the Lean & Six Sigma methodologies, to process the patient’s mapping and to measure the lead time, in order to identify bottlenecks and improvement opportunities, led to important changes in the unit organisation and efficiency with a significant decrease of colonoscopy cycle time.
Punctuality for registration Start time of first exam Variability for pre-exam time Room occupancy
Baseline
Target
20% regist. after appointment 8h58 Upper specification limit at 95 min
0% 8h40 Upper specification limit at 50 min 2008 vs. 2007: þ 28%
M1396 Short and Long-Term Outcomes of Patients Sustaining Iatrogenic Endoscopic Colorectal Perforations Ranjith Wijeratne, Karolin Ovrahim, Kevin T. Kao, Thomas Teller, Maher A. Abbas Purpose: Although risk factors for iatrogenic endoscopic perforations have been well delineated, little is known about the outcome of such patients once they leave the endoscopy suite. The purpose of this study was to examine the management and results of patients who sustained endoscopic colorectal perforations at a tertiary care teaching center. Methods: A retrospective review was conducted of all patients who were diagnosed with colorectal perforations following endoscopy over a 10 year period at Kaiser Permanente, Los Angeles. Endoscopy reports and patient’s inpatient and outpatient medical records were reviewed. Variables analyzed included demographics, location of perforation, timing of presentation, surgical management, post-operative complications, and mortality. Results: During the study period a total of 72071 flexible endoscopies were performed [colonoscopy 41115 (57%), sigmoidoscopy 30956 (43%)]. Perforation occurred in 26 patients (0.04%). 24 patients had complete records and were the focus of this study. Mean age was 68 years with male predominance (63%). Majority of procedures (71%) were outpatient and 29% were inpatient (5 patients for bleeding, 2 patients for stent decompression). Most common location of perforation was sigmoid or rectosigmoid (50%). Majority of perforations (67%) presented within 24 hours of endoscopy, 17% O 24 hours, and 17% were recognized at time of procedure. 22 patients (92%) underwent surgical intervention and only 2 (8%) were managed conservatively. Median size of perforation was 2 cm [range 1-8 cm]. Operative interventions consisted of primary repair in 18 (75%) and colectomy in 4 (17%). 5 patients (21%) received colostomy. 30-day mortality was 21% and no death was noted at 90-days. Mortality was 0%, 50%, and 100% in patients with ASA class I-II, III, IV, respectively. Post-operative morbidity rate was 58% with septic complications being most common (54%) followed by cardiac (17%), and pulmonary (13%). Conclusion: Iatrogenic endoscopic colorectal perforation is a rare event in a high volume endoscopy suite. Most patients require surgical intervention which carries a significant risk of mortality especially in patients with ASA class III and IV. Post-operative complications are common and are often infection related.
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M1397 Comparing ERCP Practice and Outcomes By Level of Experience Donald A. Garrow, Joseph Romagnuolo, Peter B. Cotton The ERCP Quality Network is a voluntary reporting system which allows endoscopists to submit data on procedures to a central repository. The data are analyzed and available to contributors in the form of individual practice summaries (‘‘report cards’’) and in comparison with others in the system (‘‘benchmarking’’). No doctors or patients may be identified. By November 2008, 59 doctors from 3 countries provided data on 7896 ERCP cases. Contributors were classified as ‘‘Academic’’ or ‘‘Community’’ and by experience. Less experienced practitioners were defined by ! 150 cases in the last year, or ! 1000 total lifetime. Academic and community groups had the same percentage of ‘‘less experienced" (21% vs 22%). Not surprisingly, Academics performed more complex cases (46% grade 3, vs 28% Community-based, p !.0001), but success rates for deep biliary cannulation, bile duct stone extraction (! 10 mm) and minor papilla cannulation were similar and high. Table 1 compares practice patterns and outcomes by experience. Less experienced endoscopists had fewer Grade 3 cases, were more likely to use conscious sedation rather than anesthesia, did more ‘‘diagnostic’’ cases, used longer total case and fluoroscopy time and had significantly lower success rates for deep biliary cannulation, extraction of bile duct stones (! 10 mm) and minor papilla cannulation. Complication rates were reportedly similar. The ERCP Quality Network project demonstrates that practitioners are interested and willing to share their practice data anonymously and also provides some idea of appropriate benchmarks. The project is ready for substantial enlargement and will facilitate the development of a national system covering all aspects of endoscopy. The data should eventually be extractable from electronic reporting systems. This project is supported by Olympus America. ERCP practice patterns and outcomes by experience
Variable
Less Experienced at ERCP
More Experienced at ERCP
Degree of Difficulty 3 Degree of Difficulty 2 Degree of Difficulty 1 General Anesthesia Propofol/MAC Conscious sedation Fluoroscopy time ! 20 minutes Fluoroscopy time 21-40 minutes Fluoroscopy time O 40 minutes Scope time ! 20 minutes Scope time 21-40 minutes Scope time O 40 minutes Biliary cannulation Minor papilla cannulation Biliary stone extraction ! 10 mm
14.6% 22.5% 62.9% 30.1% 15.1% 54.9% 28.4% 31.1% 40.6% 28.6% 35.0% 36.4% 94.0% 82.1% 98.0%
44.8% 20.1% 35.2% 8.3% 57.3% 34.4% 50.3% 27.0% 22.7% 49.6% 34.5% 15.9% 98.0% 95.7% 100%
p-value ! 0.0001
! 0.0001
! 0.0001
! 0.0001
!0.0001 !0.0001 0.001
M1398 Does Colonoscopic Withdrawal Time Affect Polyp Detection Rate? Sang Bong Ahn, Dong Soo Han, Hyun Seok Cho, Tae Jun Byun, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: Colonoscopic withdrawal time has been proposed as a quality indicator for colonoscopy based on evidence that it is associated with adenoma detection rate. Recent investigations to identify factors which affect adenoma detection rates have focused on technical aspect of the procedures such as cecal intubation rate and colonoscopic withdrawal time. In this study, we examined the difference of polyp detection rates between endoscopists, and analysed certain factors that lead to such differences, particularly colonoscopic withdrawal time. Methods: We retrospectively evaluated the procedures of 7 second-year GI fellows in Hanyang University Guri Hospital. A total of 1,515 colonoscopies were assessed with polyp detection rate, insertion time, withdrawal time, bowel preparation, polyp size and polyp location. Subjects who had a history of colorectal neoplasia, special procedure and inflammatory bowel disease were excluded. A total of 1299 patients were enrolled in the study. Results: There were large differences among endoscopists in the polyp detection rates between a wide range of 15% to 35%. There were no significant differences in the age of subjects, sex, bowel preparation and location of polyps. The median insertion time varied from 7.6 to 12.3 minutes. However, there was no relationship between the colonoscopic insertion time and polyp detection rates. The median withdrawal time in which no polyps were removed was 3.6 to 7.1 minutes. There was a strong positive correlation between the colonoscopic withdrawal time and polyp detection rates (p!0.001). Furthermore, longer withdrawal times resulted in discovering a higher percentage
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB231
Abstracts
of small polyps. When we categorized the endoscopists according to a mean withdrawal time of either less than 6 minutes or 6 minutes or more, the longer withdrawal time group had a greater polyp detection rates (30.7% vs 18.4%, p!0.001). We also observed a negative correlation between colonoscopic insertion times and the withdrawal times among the endoscopists (p!0.001). Conclusion: There is wide range of polyp detection rates among colonoscopists and a strong positive correlation between the colonoscopic withdrawal times and polyp detection rates. Long enough withdrawal times would be necessary to raise the polyp detection rates during colonoscopy.
M1399 Lack of Discriminatory Function for Endoscopy Skills On a Computer-Based Simulator Stephen Kim, Geoffrey Spencer, George Makar, Nuzhat A. Ahmad, David L. Jaffe, Gregory G. Ginsberg, Michael L. Kochman Background: Computer-based endoscopy simulators have been developed to enable trainees to learn and gain technical endoscopic skills before performing on patients. This study prospectively evaluated the capability of a computer-based simulator to discriminate between varying levels of skill and experience in esophagogastroduodenoscopies (EGD) and colonoscopies. Methods: Five first-year gastroenterology fellows with no prior endoscopic experience performed sixty mentored endoscopy cases on the Simbionix GI Mentor II (Simbionix Ltd. Israel). Six experts, with more than 1000 previous EGDs and colonoscopies, performed six cases (three EGDs, three colonoscopies) on the simulator that were selected to represent common clinical scenarios. Performance parameters were collected by the simulator. Results: Novices and experts were able to complete the tasks in the simulated cases with no significant overall differences between the two groups. The computer-based simulator was only able to discriminate levels of expertise on parameters related to the time spent on the procedure (total time, time to second duodenum, time to cecum, and efficiency of screening). No statistically significant differences were found for the other nine performance parameters measured by the simulator. Conclusions: 1. The computer-based endoscopy simulator displays a lack of discriminatory function between novices and experts for endoscopic skills based on measured objective performance parameters.2. Our findings suggest that the computer-based simulator lacks fidelity and is not capable of producing a prediction of skill during in vivo endoscopy. Comparison of Novices and Experts on the Endoscopy Simulator - EGD Cases Perforamance Paremeter
Novice (nZ15) Expert (nZ18) mean (median) mean (median) p-value
Total time (seconds) 421.0 (393.0) Percent mucosa examined 84.3 (84.0) Time to second duodenum (seconds) 100.6 (99.5) Percent time with clear view 97.4 (98.0) Percent time patient in pain 0.0 (0.0) Efficiency of screening 70.7 (72.0)
265.3 81.5 55.3 96.4 0.0 81.8
(257.5) (81.0) (36.0) (98.0) (0.0) (84.5)
0.002 0.294 0.006 0.624 1.000 0.024
Comparison of Novices and Experts on the Endoscopy Simulator - Colonoscopy Cases
Performance Parameter
Novice (nZ15) mean (median)
Expert (nZ18) mean (median)
p-value
Total time (seconds) Caused excessive local pressure Lost view of lumen Excessive loop formed Percent mucosa examined Time to cecum (seconds) Percent time iwth clear view Percent time patient in pain Efficiency of screening
880.2 3.1 1.3 0.7 84.6 391.9 88.7 2.0 66.2
610.1 2.5 0.7 1.7 89.9 228.6 88.9 0.1 82.8
0.021 0.327 0.067 0.107 0.093 0.001 0.280 0.459 0.023
(828.0) (3.0) (1.0) (0.0) (91.0) (350.0) (89.0) (0.0) (71.5)
(572.5) (2.0) (0.5) (1.0) (93.0) (219.0) (91.0) (0.0) (89.0)
M1400 Randomized Study On the Efficacy of Polyethylenglicol and Sodium Phosphate Alone or Associated with Bisacodyl for Bowel Cleansing Prior to Videocolonoscopy Lisandro Pereyra, Daniel G. Cimmino, Carlos E. Gonzalez Malla, Mariano Laporte, Sandra Lencinas, Carlos Peczan, Nicolas A. Rotholtz, Pablo Luna, Silvia C. Pedreira, Luis A. Boerr, Hugo N. Catalano Introduction: An optimal colonic cleansing prior to a videocolonoscopy (VCC) reduces the possible failures in the detection of mucosa lesions and the need to repeat the study. Although a number of papers have been published that assess the safety and efficacy of Polyethilenglicol (PEG) and Sodium Phosphate (NaP), they don’t allow us to draw definitive conclusions on which is the best agent. Aim: To
AB232 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
compare the tolerance and efficacy of NaP and PEG alone and associated with Bisacodyl for colonic cleansing. Method. 353 patients, older than 18 years old, were randomized to receive one of the following preparations: 90 ml of NaP (group A); 45 ml of NaP þ 20 mg of Bisacodyl (group B); 4 liters of PEG (group C) or 2 liters of PEG þ 20 mg of Bisacodyl (group D). The allocation of the randomization was councealed. The patients, the doctors who carried out the VCC, the nurses who conducted surveys on tolerance, the secretary who handed out the boxes to the patients and the ones in charge of the statistical analysis were blinded to the allocated preparation. The primary outcome was the necessity to repeat the VCC due to an inadequate preparation. The secondary outcomes were: quality of preparation (measured with a validated scale), tolerance to the preparation and adverse effects. Results. From the 353 patients, 3 were excluded post randomization for not complying with the inclusion criteria, 7 were unable to finish the study due to a sigmoid colon stenosis or fixed angulation, and 19 did not undergo the VCC. Information about the primary outcome was obtained from 323 patients (92%). The primary outcome (necessity to repeat the study due to an inadequate preparation) was similar in all the groups: A 3.5%, B 4.9%, C 7.1%, D 8.1% (pO0.05). There were no significant differences regarding the quality of the preparation either. The compliance was significantly higher in the NaP preparations (A vs CþD p 0.05, B vs CþD p !0.01) being even higher in the association with Bisacodyl (B vs AþCþD p! 0.01). Patients who received preparations with Bisacodyl presented abdominal pain with more frequency, although this was not a significative observation (pO0.05). The combination of NaP and Bisacodyl was associated with insomnia (p 0.039). Conclusion. 90 ml of NaP is more easily completed and equally effective as the rest of the preparations. The combination with Bisacodyl was associated with a higher number of adverse effects.
M1401 The Risk of Bacterial Contamination to the Endoscopist and Endoscopy Unit During Routine Esophagogastroduodenoscopy and Colonoscopy Natasha Chandok, David G. Morgan Introduction: Although personnel in the endoscopy unit are exposed to enteric pathogens, documented instances of infectious complications are rare. There are no controlled studies on the risk of bacterial transmission from the patient to the endoscopist or endoscopy unit during routine esophagogastroduodenoscopy (EGD) and colonoscopy. It is common for individual institutions to develop their own guidelines on preventing infection with little or no supporting evidence. Aim: To determine the risk of bacterial infection to the endoscopist and endoscopy unit during routine EGD and colonoscopy among outpatients at a university teaching hospital. Methods: 50 random outpatient endoscopic procedures done at McMaster University from May to July 2008 were examined. Before each procedure, the endoscopist changed into a sterile surgical shirt and scrubbed their hands with antimicrobial soap. Subsequently, the endoscopist wore clean non-latex gloves and a disposable plastic apron. Swabs were taken of the endoscopist’s face and forearms before and after the procedure. Agar plates were placed within 1 meter of the procedure to assess for airborne contamination. Results: 21 EGD’s and 29 colonoscopies were analyzed. Swabs taken from the forearms before the procedure were sterile, and swabs taken from the face showed innumerable colonies with mixed skin flora. After the procedure, right forearm cultures were positive in 6 of 50 procedures, 5 of these being colonoscopies. The left forearm cultures were positive in 2 colonoscopies. There was no increased growth of bacteria on the face. Cultures of the endoscopy work-place one meter from the endoscopic procedure grew 1 or 2 colonies of bacteria on average. Conclusion: The endoscopist is at minimal risk for bacterial contamination through colonoscopies, and less so with EGD’s. Routine EGD and colonoscopy does not impose a risk of bacterial contamination of the face, so face shields are not required. The most likely place for the endoscopist to become contaminated is the right arm, likely because this is the arm which manipulates the scope and is closest to the patient. There is minimal contamination of the endoscopy work place. Wiping counters with antiseptic cleansers and exercising handwashing between patients should be routine practice.
M1402 Weekend Versus Weekday Management and Prognosis of Upper GI Bleeding: Results of a Post Hoc Subanalysis of a French Prospective Study ´phane Nahon, E. Alexandre Pariente, Bernard Denis, Bernard Nalet, Ste Herve Hagege, Bruno Bour, Roger Faroux, Jean-Pierre Arpurt, Jacques Denis, Jean Henrion Background: Hospital staffing is often lower at weekends than on weekdays. Consequently, it may be difficult to perform endoscopies and if necessary an appropriate endoscopic treatment. The aims of this study were to evaluate the characteristics and prognostic factors of upper GI bleeding (UGIB) during
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