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Effect of Music On Patients Undergoing Colonoscopy: A Meta-Analysis of Randomized Controlled Trials
Abstracts
W1436 Diagnostic Yield and Therapeutic Utility of Double-Balloon Enteroscopy (DBE) in Patients with Obscure Gastrointestinal Bleeding (OGIB): A Systematic Review Shabana F. Pasha, Jonathan A. Leighton, Ananya Das, M Edwyn Harrison, G Anton Decker, David E. Fleischer, Virender K. Sharma Background: DBE is a relatively new endoscopic modality that allows for a more extensive evaluation of the small bowel and treatment of lesions previously inaccessible by conventional enteroscopy. Complete enteroscopy is possible, usually with a combination of an antegrade and retrograde approach. Aim: A systematic review of the literature on DBE was undertaken to determine its diagnostic and therapeutic yield in patients with OGIB. Methods: A recursive literature search of studies evaluating the role of DBE in the diagnosis and treatment of patients with OGIB was performed. Data on DBE findings, treatment and patient outcomes were extracted, pooled and analyzed. Results: Thirteen studies evaluated the role of DBE in patients with OGIB (8 manuscripts and 5 abstracts). The studies included 906 patients with 28.5% males (140/490); mean age 56.5 years (range 8-94 years). The number of DBEs performed per patient was 1.3 (range 1-2). DBE detected a potential bleeding source in 66% of patients (596/906; 95% CI 63-69). The findings included arteriovenous malformations in 25.6% patients (206/804; 95% CI 22.6-28.7); inflammatory lesions (ulcers, erosions or strictures) in 16.1% (130/804; 95% CI 13.6-18.9) and small bowel neoplasms (polyps/tumors) in 13.9% (112/804; 95% CI 11.6-16.5). Subsequent management (medical, surgical or endoscopic) was influenced by DBE findings in 44% patients (355/818; 95% CI 40-47). Endoscopic treatment was performed in 26.6% patients (189/709; 95% CI 23.4-30), and included argon plasma coagulation (62%; 117/189), electrocoagulation (21.6%; 41/189) and polypectomy (3%; 6/189). Eight-four percent of patients (169/200; 95% CI 78.7-89.2) remained transfusion free over a mean follow-up period of 229 days (range 30-480). Conclusion: DBE is an exciting new technology that plays an important role in the diagnosis and treatment of patients with OGIB. Its diagnostic yield is comparable to capsule endoscopy, as reported from prior studies, and superior to other small bowel imaging modalities. DBE results may lead to a new diagnosis, change in management or improve outcomes in a majority of patients with OGIB.
W1437 Effect of Music On Patients Undergoing Colonoscopy: A Meta-Analysis of Randomized Controlled Trials Matthew L. Bechtold, Srinivas R. Puli, Mohamed O. Othman, Christopher R. Bartalos, John B. Marshall, Praveen K. Roy Purpose: Music has been utilized as a therapeutic tool in an effort to reduce patients’ anxiety, pain, and medication requirements during colonoscopy. However, results from various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, DARE, OVID Healthstar & Journals, and CINAHL (from 1966-2006, search date November 2006) were searched. Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Studies were assigned a quality score. Standard forms were used to extract data by two independent reviewers. Meta-analysis for the effect of music on patients undergoing colonoscopy was analyzed by calculating pooled estimates of total procedure time, dose of sedative medications (midazolam & mepiridine), and patients’ pain scores, experience, and willingness to repeat same procedure in the future. Separate analyses were performed for each main outcome by using Odds Ratio (OR), Weighted Mean Difference (WMD), or Standardized Mean Difference (SMD). Heterogeneity was assessed by calculating the I2 measure of inconsistency. Results: 8 studies (N Z 761) met the inclusion criteria. The studies were of good quality. Patients’ overall experience scores were improved with music (SMD -0.47, 95% CI: -0.65-0.28, p ! 0.001, I2 Z 17%). No significant differences were noted between music and no music groups for mean doses of midazolam (WMD 0.03 mg, 95% CI: -0.12-0.18, p Z 0.73, 5 studies). Music was associated with a trend, though not significant, towards shorter procedure times (WMD -1.46 minutes, 95% CI: -2.92 - 0.01, p Z 0.05), lower narcotics dose (mepiridine) (SMD -0.18 mg, 95% CI: -0.360.01, p Z 0.06), and patients’ pain scores (SMD -0.17, 95% CI: -0.36-0.01, p Z 0.06). Music groups demonstrated an increased willingness to have a repeat procedure in the future (OR 3.59, 95% CI: 2.09-6.19, p ! 0.001). Conclusions: Music improves patients’overall experience and their willingness for repeat colonoscopy. However, no statistically significant differences with regards to patients’ pain, doses of sedative medications, or total procedure time were observed for music during colonoscopy.
AB366 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1438 Endoscopic Resection of Upper GI Superficial Tumors: Complications, Management and Outcome Pierre H. Deprez, Tarik Aouattah, Chun-Ping R. Yeung, Yves Horsmans, Hubert Piessevaux Introduction: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are now accepted effective alternatives to radical surgery for the treatment of UGI superficial neoplasms. Most Japanese series report complication rates below 5%, including 1% upper GI tract perforations, maybe related to the high expertise obtained in Japan. Aims-Methods: To prospectively report all complications observed during EMR and ESD for superficial UGI lesions staged as T1 is or T1m N0 by radial or mini-rpobe EUS (20 MHz) and their respective management. Resection involved peripheral marking with needle knife or APC, submucosal injection of saline with methylene blue and adrenaline 1/20000 (plus hydroxylmethylpropylcellulose 1:10 for gastric neoplasms) and either cap aspiration, band ligation technique (Duette, Cook), or ESD with Flex-knife, Hookknife and IT-knife. Complete remission was defined as the absence of adenocarcinoma or HGD at last follow-up. Results: 172 patients were treated between January 2000 and October 2006. Histology on the resected specimens revealed esophageal squamous cell carcinoma in 31 pts, high grade dysplasia (HGD) and adenocarcinoma in Barrett’s esophagus in 42 and 35 pts respectively, gastric tubulo(villous) adenoma with LGD in 6 cases, gastric HGD and adenocarcinoma in 12 and 8 pts respectively gastric carcinoid tumor in 1 pt, duodenal adenovillous lesions with HGD in 37 patients. Complete remission was obtained in 94/108 (87%) esophageal cases and in 22/27 (88%) pts with gastric lesions, with a median follow-up of 26 mths. Metachronous lesions were observed in 10 pts (7.8%). Major complications were seen in 9 pts (3,9%): 2 perforations (EMR at the rugae in hiatal hernia and ESD in an atrophic aged stomach) both closed by endoscopic clipping, 3 severe mid-esophageal stenoses after circumferential SCC resection needing repetitive dilation sessions or transient stenting (n Z 2), and 1 symptomatic bleeding on the first day post-op, endoscopically managed with hemoclips. One patient with a severe stricture died of pneumonia 14 months after mucosectomy, dilatation and stenting. Minor complications occurred in 17 pts (13.3%) consisting in one case of transient dyspnea and dysphagia due to pharyngeal edema and 16 esophageal strictures needing a median of 2 dilation sessions (range 1-6). These were significantly related to circumferential EMR and full Barrett’s resection (P!0.005). Conclusion: The minor and major complication rates compare favorably with Japanese series with less than 1% perforation rate. Esophageal strictures are associated with circumferential esophageal mucosal resections or full Barrett’s mucosa resection.
W1439 Clinical Impact of Partial Submucosal Dissection Compared with Complete Submucosal Dissection During Endoscopic Submucosal Dissection for the Treatment of Early Gastric Cancer Or Adenoma Jong-Jae Park, Woo Sik Han, Do Won Choi, Seong Nam Oh, Yeoun Ho Kim, Jong Eun Yeon, Jae Seon Kim, Kwan Soo Byun, Young-Tae Bak Background/Aims: For complete resection of large gastric mucosal tumors over 2 cm in diameter, endoscopic submucosal dissection (ESD) is reported to be more useful compared with conventional methods such as strip biopsy. However, complete submucosal dissection for removal of tumor in a single fragment necessitate the long procedure time and high complications rate of bleeding or perforation. This long procedure time can be decreased if the tumor is dissected partially until the partially dissected tumor is expected to be easily snared without aid of grasping forcep and removed with electrosurgical snare. The aim of this study was to compare the clinical impact of partial submucosal dissection method with complete submucosal dissection method during ESD for early gastric cancer or gastric adenoma. Methods: During the past 2 years, a total of 186 gastric tumor (EGC, 89; adenoma 97) was resected endoscopically by using ESD techniques. Of these, 56 patient underwent partial submucosal dissection and snare removal (partial ESD group) and 130 patient complete submucosal dissection (complete ESD group). The size of tumor, en bloc and complete resection rate, and complication was assessed and compared. Results: The two groups were similar with respect to age, gender, macroscopic appearance, and the site. The proportion of larger tumor (over 20 mm in longest dimension) was significantly higher in partial ESD group than in complete ESD group (25% vs. 55%) (p ! 0.01). The rate of en bloc resection was significantly higher with complete ESD group (93%) than with partial ESD group (81%) (p ! 0.05). The rate of complete resection (defined as free lateral and vertical margin, negative lymphatic emboli) was higher with complete ESD group than with partial ESD group, but not statistically significant (91% vs. 88%, pO 0.05). As for complications, the rate of bleeding and perforation in partial and complete ESD was not significantly different (23% vs. 19%, 1.8 vs. 2.2%, respectively). Conclusions: ESD is a useful procedure for en bloc resection of large gastric tumor. For the tumor especially less than 20 mm in size, partial submucosal dissection and snare removal can be a time saving and easier ESD method than through-the procedure complete dissection.
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W1436 Diagnostic Yield and Therapeutic Utility of Double-Balloon Enteroscopy (DBE) in Patients with Obscure Gastrointestinal Bleeding (OGIB): A Systematic Review Shabana F. Pasha, Jonathan A. Leighton, Ananya Das, M Edwyn Harrison, G Anton Decker, David E. Fleischer, Virender K. Sharma Background: DBE is a relatively new endoscopic modality that allows for a more extensive evaluation of the small bowel and treatment of lesions previously inaccessible by conventional enteroscopy. Complete enteroscopy is possible, usually with a combination of an antegrade and retrograde approach. Aim: A systematic review of the literature on DBE was undertaken to determine its diagnostic and therapeutic yield in patients with OGIB. Methods: A recursive literature search of studies evaluating the role of DBE in the diagnosis and treatment of patients with OGIB was performed. Data on DBE findings, treatment and patient outcomes were extracted, pooled and analyzed. Results: Thirteen studies evaluated the role of DBE in patients with OGIB (8 manuscripts and 5 abstracts). The studies included 906 patients with 28.5% males (140/490); mean age 56.5 years (range 8-94 years). The number of DBEs performed per patient was 1.3 (range 1-2). DBE detected a potential bleeding source in 66% of patients (596/906; 95% CI 63-69). The findings included arteriovenous malformations in 25.6% patients (206/804; 95% CI 22.6-28.7); inflammatory lesions (ulcers, erosions or strictures) in 16.1% (130/804; 95% CI 13.6-18.9) and small bowel neoplasms (polyps/tumors) in 13.9% (112/804; 95% CI 11.6-16.5). Subsequent management (medical, surgical or endoscopic) was influenced by DBE findings in 44% patients (355/818; 95% CI 40-47). Endoscopic treatment was performed in 26.6% patients (189/709; 95% CI 23.4-30), and included argon plasma coagulation (62%; 117/189), electrocoagulation (21.6%; 41/189) and polypectomy (3%; 6/189). Eight-four percent of patients (169/200; 95% CI 78.7-89.2) remained transfusion free over a mean follow-up period of 229 days (range 30-480). Conclusion: DBE is an exciting new technology that plays an important role in the diagnosis and treatment of patients with OGIB. Its diagnostic yield is comparable to capsule endoscopy, as reported from prior studies, and superior to other small bowel imaging modalities. DBE results may lead to a new diagnosis, change in management or improve outcomes in a majority of patients with OGIB.
W1437 Effect of Music On Patients Undergoing Colonoscopy: A Meta-Analysis of Randomized Controlled Trials Matthew L. Bechtold, Srinivas R. Puli, Mohamed O. Othman, Christopher R. Bartalos, John B. Marshall, Praveen K. Roy Purpose: Music has been utilized as a therapeutic tool in an effort to reduce patients’ anxiety, pain, and medication requirements during colonoscopy. However, results from various randomized controlled trials (RCTs) have been inconsistent. We conducted a meta-analysis to analyze the effect of music on patients undergoing colonoscopy. Methods: MEDLINE, Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, DARE, OVID Healthstar & Journals, and CINAHL (from 1966-2006, search date November 2006) were searched. Only RCTs on adult subjects that compared music versus no music during colonoscopy were included. Studies were assigned a quality score. Standard forms were used to extract data by two independent reviewers. Meta-analysis for the effect of music on patients undergoing colonoscopy was analyzed by calculating pooled estimates of total procedure time, dose of sedative medications (midazolam & mepiridine), and patients’ pain scores, experience, and willingness to repeat same procedure in the future. Separate analyses were performed for each main outcome by using Odds Ratio (OR), Weighted Mean Difference (WMD), or Standardized Mean Difference (SMD). Heterogeneity was assessed by calculating the I2 measure of inconsistency. Results: 8 studies (N Z 761) met the inclusion criteria. The studies were of good quality. Patients’ overall experience scores were improved with music (SMD -0.47, 95% CI: -0.65-0.28, p ! 0.001, I2 Z 17%). No significant differences were noted between music and no music groups for mean doses of midazolam (WMD 0.03 mg, 95% CI: -0.12-0.18, p Z 0.73, 5 studies). Music was associated with a trend, though not significant, towards shorter procedure times (WMD -1.46 minutes, 95% CI: -2.92 - 0.01, p Z 0.05), lower narcotics dose (mepiridine) (SMD -0.18 mg, 95% CI: -0.360.01, p Z 0.06), and patients’ pain scores (SMD -0.17, 95% CI: -0.36-0.01, p Z 0.06). Music groups demonstrated an increased willingness to have a repeat procedure in the future (OR 3.59, 95% CI: 2.09-6.19, p ! 0.001). Conclusions: Music improves patients’overall experience and their willingness for repeat colonoscopy. However, no statistically significant differences with regards to patients’ pain, doses of sedative medications, or total procedure time were observed for music during colonoscopy.
AB366 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1438 Endoscopic Resection of Upper GI Superficial Tumors: Complications, Management and Outcome Pierre H. Deprez, Tarik Aouattah, Chun-Ping R. Yeung, Yves Horsmans, Hubert Piessevaux Introduction: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are now accepted effective alternatives to radical surgery for the treatment of UGI superficial neoplasms. Most Japanese series report complication rates below 5%, including 1% upper GI tract perforations, maybe related to the high expertise obtained in Japan. Aims-Methods: To prospectively report all complications observed during EMR and ESD for superficial UGI lesions staged as T1 is or T1m N0 by radial or mini-rpobe EUS (20 MHz) and their respective management. Resection involved peripheral marking with needle knife or APC, submucosal injection of saline with methylene blue and adrenaline 1/20000 (plus hydroxylmethylpropylcellulose 1:10 for gastric neoplasms) and either cap aspiration, band ligation technique (Duette, Cook), or ESD with Flex-knife, Hookknife and IT-knife. Complete remission was defined as the absence of adenocarcinoma or HGD at last follow-up. Results: 172 patients were treated between January 2000 and October 2006. Histology on the resected specimens revealed esophageal squamous cell carcinoma in 31 pts, high grade dysplasia (HGD) and adenocarcinoma in Barrett’s esophagus in 42 and 35 pts respectively, gastric tubulo(villous) adenoma with LGD in 6 cases, gastric HGD and adenocarcinoma in 12 and 8 pts respectively gastric carcinoid tumor in 1 pt, duodenal adenovillous lesions with HGD in 37 patients. Complete remission was obtained in 94/108 (87%) esophageal cases and in 22/27 (88%) pts with gastric lesions, with a median follow-up of 26 mths. Metachronous lesions were observed in 10 pts (7.8%). Major complications were seen in 9 pts (3,9%): 2 perforations (EMR at the rugae in hiatal hernia and ESD in an atrophic aged stomach) both closed by endoscopic clipping, 3 severe mid-esophageal stenoses after circumferential SCC resection needing repetitive dilation sessions or transient stenting (n Z 2), and 1 symptomatic bleeding on the first day post-op, endoscopically managed with hemoclips. One patient with a severe stricture died of pneumonia 14 months after mucosectomy, dilatation and stenting. Minor complications occurred in 17 pts (13.3%) consisting in one case of transient dyspnea and dysphagia due to pharyngeal edema and 16 esophageal strictures needing a median of 2 dilation sessions (range 1-6). These were significantly related to circumferential EMR and full Barrett’s resection (P!0.005). Conclusion: The minor and major complication rates compare favorably with Japanese series with less than 1% perforation rate. Esophageal strictures are associated with circumferential esophageal mucosal resections or full Barrett’s mucosa resection.
W1439 Clinical Impact of Partial Submucosal Dissection Compared with Complete Submucosal Dissection During Endoscopic Submucosal Dissection for the Treatment of Early Gastric Cancer Or Adenoma Jong-Jae Park, Woo Sik Han, Do Won Choi, Seong Nam Oh, Yeoun Ho Kim, Jong Eun Yeon, Jae Seon Kim, Kwan Soo Byun, Young-Tae Bak Background/Aims: For complete resection of large gastric mucosal tumors over 2 cm in diameter, endoscopic submucosal dissection (ESD) is reported to be more useful compared with conventional methods such as strip biopsy. However, complete submucosal dissection for removal of tumor in a single fragment necessitate the long procedure time and high complications rate of bleeding or perforation. This long procedure time can be decreased if the tumor is dissected partially until the partially dissected tumor is expected to be easily snared without aid of grasping forcep and removed with electrosurgical snare. The aim of this study was to compare the clinical impact of partial submucosal dissection method with complete submucosal dissection method during ESD for early gastric cancer or gastric adenoma. Methods: During the past 2 years, a total of 186 gastric tumor (EGC, 89; adenoma 97) was resected endoscopically by using ESD techniques. Of these, 56 patient underwent partial submucosal dissection and snare removal (partial ESD group) and 130 patient complete submucosal dissection (complete ESD group). The size of tumor, en bloc and complete resection rate, and complication was assessed and compared. Results: The two groups were similar with respect to age, gender, macroscopic appearance, and the site. The proportion of larger tumor (over 20 mm in longest dimension) was significantly higher in partial ESD group than in complete ESD group (25% vs. 55%) (p ! 0.01). The rate of en bloc resection was significantly higher with complete ESD group (93%) than with partial ESD group (81%) (p ! 0.05). The rate of complete resection (defined as free lateral and vertical margin, negative lymphatic emboli) was higher with complete ESD group than with partial ESD group, but not statistically significant (91% vs. 88%, pO 0.05). As for complications, the rate of bleeding and perforation in partial and complete ESD was not significantly different (23% vs. 19%, 1.8 vs. 2.2%, respectively). Conclusions: ESD is a useful procedure for en bloc resection of large gastric tumor. For the tumor especially less than 20 mm in size, partial submucosal dissection and snare removal can be a time saving and easier ESD method than through-the procedure complete dissection.
www.giejournal.org