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Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Have a Comparable Diagnostic Yield in Patients with Suspected Small Bowel Disease: A Meta-Analysis
Abstracts
W1428 Cost-Effectiveness of String Capsule Endoscopy for Screening for Barrett’s Esophagus Hector Rodriguez-Luna, Ananya Das, Virender K. Sharma, Francisco C. Ramirez
W1430 Effects of Concomitant Polyethylene Glycol Ingestion During Capsule Endoscopy On the Quality of Image and Completion Rate to the Cecum Hiroki Endo, Nobuyuki Matsuhashi
Screening for Barrett’s esophagus (BE) is recommended for patients with chronic gastro-esophageal reflux disease (GERD) symptoms. Although EGD is commonly used for screening of BE, we have recently reported on excellent performance characteristics of string capsule endoscopy (SCE) in screening for BE. String capsule endoscopy (SCE) allows multiple uses after high-grade disinfection but its costeffectiveness has not been tested. Aim: To evaluate the cost-effectiveness of SCE in screening for BE compared to EGD and PillCam Eso(PCE). Methods: A Markov model with a third party payer’s perspective was built to compare different competing strategies of screening for BE and subsequent management in a hypothetical cohort of 50 year old patients with chronic GERD. In strategy I, no screening was performed and natural history of BE was modeled. In strategies II, III, and IV, SCE, PCE, and EGD, respectively were used for screening of BE. With SCE and PCE, positive findings were confirmed subsequently by EGD and biopsy. In the last three strategies, management of BE was based on the ACG guidelines. Incidence, Prevalence, and Natural history of BE was obtained from published information. Cost estimates were obtained from Medicare reimbursement data. Only discounted direct costs were considered. Incremental cost-effectiveness ratio (ICER) in terms of quality adjusted life years (QALYs) gained under each strategy was the main outcome compared. Results: Table shows the results of the baseline analysis. The SCE based strategy was more cost-effective compared to strategy of no screening and dominated the PCE based strategy. Although EGD based screening strategy yielded higher QALY, its ICER over SCE was prohibitively high. The results of the baseline analysis were robust and sensitivity analyses with important clinical variables, performance characteristics of different endoscopic procedures, and cost estimates did not change the conclusions. Conclusion: Screening of BE by string capsule endoscopy is more cost-effective compared to strategies of no screening, PillCam Eso, and importantly by EGD.
Background: The best preparation for capsule endoscopy (CE) remains unclear. Some investigators have used bowel preparation similar to that in colonoscopy. To drink 2-4 liters of polyethylene glycol (PEG) solution, however, is rather uncomfortable to patients. In addition, such preparations reportedly do not always improve CE images or completion rate to the cecum. Here, we examined whether drinking a small amount of PEG after swallowing the capsule could improve CE image and completion rate to the cecum. Methods: A total of 59 consecutive patients were enrolled in the study. CE was performed following a 12-hour fasting period. The initial 32 patients (Group A) received no preparation, and the following 27 patients (Group B) took 500 ml of PEG solution within 2-h starting at 30 minutes after capsule swallowing. The rate of reaching cecum within the 8-hour study period and the quality of images were evaluated for each group. The quality of image was assessed by using a 5-step scoring system taking into account the presence of biliary secretion and residue. Visibility was assessed as the percentage of visualized bowel surface area: 1, less than 25%; 2,25% to 49%; 3,50% to 74%; 4,75% to 89%; 5, greater than 90%. We divided the small intestinal record into 5 segment by time, and evaluated the score for each segment. Results: The capsule reached the cecum in 88.9% of patients in Group B, compared with 65.6% in Group A (p Z 0.04). The use of PEG in the course of CE examination improved the quality of images significantly; this effect was more pronounced in the distal small bowel. None of the patients in group B felt difficulty in completing the PEG ingestion. Conclusions: Our study demonstrated that using 500 ml of PEG after swallowing the capsule significantly improves both the quality of CE images and the capsule reaching rate the cecum.
Screening strategies Strategy
Cost
QALY
ICER
No screening SCE PCE EGD
1,077 1,980 2,380 2,499
18.967 18.991 18.990 18.992
– 36,383 compared to no screening Dominated 592,847 compared to SCE
W1429 Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Have a Comparable Diagnostic Yield in Patients with Suspected Small Bowel Disease: A Meta-Analysis Shabana F. Pasha, Jonathan A. Leighton, Ananya Das, M. Edwyn Harrison, G. Anton Decker, David E. Fleischer, Virender K. Sharma Background: Endoscopic small bowel imaging has been significantly advanced by the introduction of both CE and DBE. It is not known for certain which modality has the best diagnostic yield. Aim: To compare the diagnostic yield of CE with that of DBE in patients with suspected small bowel disease using meta-analysis. Methods: A recursive literature search of studies comparing the yield of CE to other modalities in patients with suspected small bowel disease was performed. Data on the diagnostic yield in CE and DBE were extracted, pooled and analyzed using RevMan 4.2.9 software; heterogeneity was tested by the chi2 method and a p-value of !0.1 was considered significant heterogeneity. Weighted incremental yield (IYW) (yield of CE - yield of DBE) of CE over DBE and 95% confidence intervals (CI) for the pooled data was calculated using a fixed effect model (FEM) for analyses without and a random effect model (REM) for analyses with significant heterogeneity. Results: Eleven studies compared the diagnostic yield of CE with DBE. The pooled overall yield for CE and DBE was 60% (n Z 393) and 57% (n Z 356), respectively (IYW Z 3%; CI -3-10%; P Z 0.34; FEM). Eight studies reported the yield of vascular findings on CE and DBE. The pooled yield for CE and DBE for vascular findings was 24% (n Z 313) and 25% (n Z 306), respectively (IYW Z 3%; CI -14-8%; P Z 0.62; REM). Seven studies reported the yield of inflammatory findings (erosions, ulcers and strictures) on CE and DBE. The pooled yield for CE and DBE was 18% (n Z 285) and 16% (n Z 278), respectively (IYW Z 0%; CI -6-6%; P Z 0.93; FEM). Seven studies reported the yield of polyps/tumors on CE and DBE. The pooled yield for CE and DBE was 7% (n Z 285) and 12% (n Z 278), respectively (IYW Z 3%; CI -8-2%; P Z 0.25; FEM). Conclusions: In patients with suspected small bowel disease, DBE had a comparable yield to CE for the diagnosis of small bowel pathology. Because the capsule is non-invasive, these results would suggest that CE is the initial diagnostic test of choice in most patients with suspected small bowel disease. In those patients with a positive finding on CE or a high suspicion of a small bowel lesion despite a negative CE, DBE would be indicated for further evaluation due to its diagnostic and therapeutic capabilities.
AB364 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1431 Trends in the Diagnostic Yield of Open Access Upper Gastrointestinal Endoscopy Marcel Groenen, E.J. Kuipers, R.J. Ouwendijk Background: Open access upper endoscopy has had an enormously impact on the workload for endoscopy units. It was questioned of the yield of open access upper gastrointestinal endoscopy is still high enough in time of endoscopy scarcity. Methods: We analyzed the 10-year cumulative data of an open access endoscopy unit in a district hospital. The data of all patients referred for their first diagnostic upper endoscopy were exported and statistically analyzed using SPSS. Diagnostic yield of upper endoscopy was compared between different referring groups and trends of diagnoses were analyzed. Results: In total 22,525 endoscopies were performed by 4 endoscopists. So far, the data of 21,441 examinations were eligible for analysis. General practitioners referred 8971 (41.8%) patients (first line), specialists referred 8197 (38.2%) patients (second line), and 4273 (19.9%) of the patients were referred from out of the hospital. Over the years there was a raise in the proportion of patients referred by a general practitioner with a linear regression coefficient of .615 (p Z 0.036) to about 45% in the last years. In the first line the mean age was 51.2 years compared to 54.7 years for the second line and 67.1 years for the clinical patients (p ! 0.001). Pathology was found in 74.9% of the first line referred, 72.5% of the second line referred and 73.9% of the clinical patients. The diagnostic yield of endoscopy, consisting of any pathology increased in the last ten years from 58.7% to 79%. The main diagnoses were hiatal hernia (24.1%), reflux esophagitis (16.2%) and gastritis (21.6%). Reflux esophagitis was graded by SavaryMiller and in the last 6 years by LA classification. More than half of the reflux esophagitis was graded I or A. Reflux esophagitis was seen more in male patients especially for the mildest grades. Malignancies of the esophagus, stomach and duodenum were found in 1.8% of the patients (0.7%, 1.0% and 0.1% resp.). Gastric and duodenal ulcers were found in 2.6% and 3.5% respectively. Conclusions: The yield of diagnostic upper gastrointestinal endoscopies is high. In more than two thirds of the patients in all referring groups, abnormalities were found. The yield increased in all referral groups. Despite the high claim on capacity by the first line, open access upper gastrointestinal endoscopy is rewarding.
www.giejournal.org
W1428 Cost-Effectiveness of String Capsule Endoscopy for Screening for Barrett’s Esophagus Hector Rodriguez-Luna, Ananya Das, Virender K. Sharma, Francisco C. Ramirez
W1430 Effects of Concomitant Polyethylene Glycol Ingestion During Capsule Endoscopy On the Quality of Image and Completion Rate to the Cecum Hiroki Endo, Nobuyuki Matsuhashi
Screening for Barrett’s esophagus (BE) is recommended for patients with chronic gastro-esophageal reflux disease (GERD) symptoms. Although EGD is commonly used for screening of BE, we have recently reported on excellent performance characteristics of string capsule endoscopy (SCE) in screening for BE. String capsule endoscopy (SCE) allows multiple uses after high-grade disinfection but its costeffectiveness has not been tested. Aim: To evaluate the cost-effectiveness of SCE in screening for BE compared to EGD and PillCam Eso(PCE). Methods: A Markov model with a third party payer’s perspective was built to compare different competing strategies of screening for BE and subsequent management in a hypothetical cohort of 50 year old patients with chronic GERD. In strategy I, no screening was performed and natural history of BE was modeled. In strategies II, III, and IV, SCE, PCE, and EGD, respectively were used for screening of BE. With SCE and PCE, positive findings were confirmed subsequently by EGD and biopsy. In the last three strategies, management of BE was based on the ACG guidelines. Incidence, Prevalence, and Natural history of BE was obtained from published information. Cost estimates were obtained from Medicare reimbursement data. Only discounted direct costs were considered. Incremental cost-effectiveness ratio (ICER) in terms of quality adjusted life years (QALYs) gained under each strategy was the main outcome compared. Results: Table shows the results of the baseline analysis. The SCE based strategy was more cost-effective compared to strategy of no screening and dominated the PCE based strategy. Although EGD based screening strategy yielded higher QALY, its ICER over SCE was prohibitively high. The results of the baseline analysis were robust and sensitivity analyses with important clinical variables, performance characteristics of different endoscopic procedures, and cost estimates did not change the conclusions. Conclusion: Screening of BE by string capsule endoscopy is more cost-effective compared to strategies of no screening, PillCam Eso, and importantly by EGD.
Background: The best preparation for capsule endoscopy (CE) remains unclear. Some investigators have used bowel preparation similar to that in colonoscopy. To drink 2-4 liters of polyethylene glycol (PEG) solution, however, is rather uncomfortable to patients. In addition, such preparations reportedly do not always improve CE images or completion rate to the cecum. Here, we examined whether drinking a small amount of PEG after swallowing the capsule could improve CE image and completion rate to the cecum. Methods: A total of 59 consecutive patients were enrolled in the study. CE was performed following a 12-hour fasting period. The initial 32 patients (Group A) received no preparation, and the following 27 patients (Group B) took 500 ml of PEG solution within 2-h starting at 30 minutes after capsule swallowing. The rate of reaching cecum within the 8-hour study period and the quality of images were evaluated for each group. The quality of image was assessed by using a 5-step scoring system taking into account the presence of biliary secretion and residue. Visibility was assessed as the percentage of visualized bowel surface area: 1, less than 25%; 2,25% to 49%; 3,50% to 74%; 4,75% to 89%; 5, greater than 90%. We divided the small intestinal record into 5 segment by time, and evaluated the score for each segment. Results: The capsule reached the cecum in 88.9% of patients in Group B, compared with 65.6% in Group A (p Z 0.04). The use of PEG in the course of CE examination improved the quality of images significantly; this effect was more pronounced in the distal small bowel. None of the patients in group B felt difficulty in completing the PEG ingestion. Conclusions: Our study demonstrated that using 500 ml of PEG after swallowing the capsule significantly improves both the quality of CE images and the capsule reaching rate the cecum.
Screening strategies Strategy
Cost
QALY
ICER
No screening SCE PCE EGD
1,077 1,980 2,380 2,499
18.967 18.991 18.990 18.992
– 36,383 compared to no screening Dominated 592,847 compared to SCE
W1429 Double-Balloon Enteroscopy (DBE) and Capsule Endoscopy (CE) Have a Comparable Diagnostic Yield in Patients with Suspected Small Bowel Disease: A Meta-Analysis Shabana F. Pasha, Jonathan A. Leighton, Ananya Das, M. Edwyn Harrison, G. Anton Decker, David E. Fleischer, Virender K. Sharma Background: Endoscopic small bowel imaging has been significantly advanced by the introduction of both CE and DBE. It is not known for certain which modality has the best diagnostic yield. Aim: To compare the diagnostic yield of CE with that of DBE in patients with suspected small bowel disease using meta-analysis. Methods: A recursive literature search of studies comparing the yield of CE to other modalities in patients with suspected small bowel disease was performed. Data on the diagnostic yield in CE and DBE were extracted, pooled and analyzed using RevMan 4.2.9 software; heterogeneity was tested by the chi2 method and a p-value of !0.1 was considered significant heterogeneity. Weighted incremental yield (IYW) (yield of CE - yield of DBE) of CE over DBE and 95% confidence intervals (CI) for the pooled data was calculated using a fixed effect model (FEM) for analyses without and a random effect model (REM) for analyses with significant heterogeneity. Results: Eleven studies compared the diagnostic yield of CE with DBE. The pooled overall yield for CE and DBE was 60% (n Z 393) and 57% (n Z 356), respectively (IYW Z 3%; CI -3-10%; P Z 0.34; FEM). Eight studies reported the yield of vascular findings on CE and DBE. The pooled yield for CE and DBE for vascular findings was 24% (n Z 313) and 25% (n Z 306), respectively (IYW Z 3%; CI -14-8%; P Z 0.62; REM). Seven studies reported the yield of inflammatory findings (erosions, ulcers and strictures) on CE and DBE. The pooled yield for CE and DBE was 18% (n Z 285) and 16% (n Z 278), respectively (IYW Z 0%; CI -6-6%; P Z 0.93; FEM). Seven studies reported the yield of polyps/tumors on CE and DBE. The pooled yield for CE and DBE was 7% (n Z 285) and 12% (n Z 278), respectively (IYW Z 3%; CI -8-2%; P Z 0.25; FEM). Conclusions: In patients with suspected small bowel disease, DBE had a comparable yield to CE for the diagnosis of small bowel pathology. Because the capsule is non-invasive, these results would suggest that CE is the initial diagnostic test of choice in most patients with suspected small bowel disease. In those patients with a positive finding on CE or a high suspicion of a small bowel lesion despite a negative CE, DBE would be indicated for further evaluation due to its diagnostic and therapeutic capabilities.
AB364 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1431 Trends in the Diagnostic Yield of Open Access Upper Gastrointestinal Endoscopy Marcel Groenen, E.J. Kuipers, R.J. Ouwendijk Background: Open access upper endoscopy has had an enormously impact on the workload for endoscopy units. It was questioned of the yield of open access upper gastrointestinal endoscopy is still high enough in time of endoscopy scarcity. Methods: We analyzed the 10-year cumulative data of an open access endoscopy unit in a district hospital. The data of all patients referred for their first diagnostic upper endoscopy were exported and statistically analyzed using SPSS. Diagnostic yield of upper endoscopy was compared between different referring groups and trends of diagnoses were analyzed. Results: In total 22,525 endoscopies were performed by 4 endoscopists. So far, the data of 21,441 examinations were eligible for analysis. General practitioners referred 8971 (41.8%) patients (first line), specialists referred 8197 (38.2%) patients (second line), and 4273 (19.9%) of the patients were referred from out of the hospital. Over the years there was a raise in the proportion of patients referred by a general practitioner with a linear regression coefficient of .615 (p Z 0.036) to about 45% in the last years. In the first line the mean age was 51.2 years compared to 54.7 years for the second line and 67.1 years for the clinical patients (p ! 0.001). Pathology was found in 74.9% of the first line referred, 72.5% of the second line referred and 73.9% of the clinical patients. The diagnostic yield of endoscopy, consisting of any pathology increased in the last ten years from 58.7% to 79%. The main diagnoses were hiatal hernia (24.1%), reflux esophagitis (16.2%) and gastritis (21.6%). Reflux esophagitis was graded by SavaryMiller and in the last 6 years by LA classification. More than half of the reflux esophagitis was graded I or A. Reflux esophagitis was seen more in male patients especially for the mildest grades. Malignancies of the esophagus, stomach and duodenum were found in 1.8% of the patients (0.7%, 1.0% and 0.1% resp.). Gastric and duodenal ulcers were found in 2.6% and 3.5% respectively. Conclusions: The yield of diagnostic upper gastrointestinal endoscopies is high. In more than two thirds of the patients in all referring groups, abnormalities were found. The yield increased in all referral groups. Despite the high claim on capacity by the first line, open access upper gastrointestinal endoscopy is rewarding.
www.giejournal.org