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Effectiveness of Colonoscopy: Quality Indicators
Abstracts
S1447 Is N-2-Butyl-Cyanoacrilate a Really Good Option for the Treatment of Gastric Varices? Nestor Landoni, Alberto Bernedo, Cesar Calderon, Horacio Martinez, Augusto Villaverde, Nestor Chopita Aim: To evaluate the success of hystoacryl in primary hemostasis, rebleeding and erradication of gastric varices. Patients and Methods: Since january 1999 to october 2005, 46 patients with bleeding for gastric varices were treated in our unit with n-2butyl-cyanoacrylate . A mixture of 0.5 ml of hystoacryl and 0.5 ml of lypiodol was used with a maximum of two ml. per session. Sclerotherapy needles of 21 g, Olympus endoscopes (145 series) and sedation with midazolam were used in all patients. Data was analized by chi-square test. Results: we included 46 patients, 32 males and 14 females with a mean age of 56.13 years, range 18-77 and a median of 55. The patients were clasiffied as Child A 18, Child B 21 and Child C 5; two patients were not classified. According to Sarin classification 15 patients presented GOV 1 varices, 22 GOV 2, 5 GOV 1 y 2 and 4 IGV 1. Forty-five patients (97.8%) had active bleeding or recent bleeding stigmata at the moment of the endoscopy. Primary hemostasis was achieved in 80.4% (37 patients) in agreement with Baveno IV. Nine patients with rebleeding were retreated with hystoscryl. Definitive hemostasis was succesful in 6 of them, 2 were sent to surgical treatment and 1 to endovascular therapy. After the definitive hemostasis the patients were discharged with treatment with propanolol in different dosis. After one year of follow up 7 patients rebleed (15,2%) and they were all successfully treated endoscopically . The gastric varices were erradicated in 15 patients (32.6%) with a recurrence in 6 patients (40 %). Conclusion: In our series primary hemostasis was achieved in 80.4% and definitive hemostasis in 93.47% of the patients. The erradication of gastric varices was obtained in 32.6 %. During the follow up 40% of these patients had a recurrence. We conclude that n-2-butyl-cyanoacrilate is a very good method for the bleeding of gastric varices but it is not recommended for their erradication.
S1448 Effectiveness of Colonoscopy: Quality Indicators Gianmichele Meucci, Franco Radaelli, Gabriella Bartesaghi, Silvia Porta, Giorgio Minoli Aim: To evaluate the effectiveness of colonoscopy in Italian Endoscopy Units. Methods. A large, multicenter prospective study was conducted over a two-week period in 308 endoscopic units to assess the colonoscopy practice in Italy. For each unit, structure indicators on organizational framework in which the endoscopy is provided (i.e. type of structure and setting, volume of endoscopic procedures, information on medical and nursing staff, facilities) were collected using a standardized questionnaire. A second questionnaire was used to prospectively record details of each colonoscopy consecutively performed in the study period. Process measures (patient demographics, procedure indication, sedation practice, experience of endoscopists, endoscopic diagnosis, therapeutic interventions), and outcomes measures (caecal intubation, prevalence of polyps, and immediate complications) were recorded. Results: Data of 13.364 colonoscopies performed at 299 institutions were evaluated; sufficient information was available for 12.835 of them (96%). Some sedation was provided in 55% of examinations (52% before starting the exam and 3% on demand); benzodiazepines alone were administered in 29% of cases, benzodiazepines plus opioids in 15% propofol in 3% and other medications in 8%. Bowel cleansing was considered excellent or good in 84% of examinations, fair or insufficient in the remaining 16%. Poliethilenglicole was used in 79% of examinations, sodium phosphate in 19% and other agents in the remaining 2%. Caecal intubation (defined as visualization of the ileo-caecal valve) was achieved in 82,8% of examinations; the rate of caecal intubation was at least 90% in only 22% of centers. The cause of failure was insufficient bowel cleansing in 6,4% of cases, patients intolerance in 5%, excessive looping in 3% and the presence of a stricture in 3%. Conclusions: Our data show that the rate of caecal intubation in most Italian endoscopic Units is far from optimal and conscious sedation is underutilized.
S1449 Outcome of Bleeding Ulcer Related to Nonsteroidal Anti-Inflammatory Drug Use, Helicobacter Pylori Infection and Idiopathic Cause: A Preliminary Report Chi-Liang Cheng, Nai-Jen Liu, Hao-Tsai Cheng, Jui-Hsiang Tang, Ching-Song Lee, Yui-Yi Chu, Cheng-Hui Lin, Yung-Kuan Tsou Background: NSAIDs and Helicobacter pylori (H pylori) are common risk factors for the development of bleeding peptic ulcer. Helicobacter pylori-negative idiopathic ulcers are also increasingly recognized. The prevalence and short-term outcome of bleeding ulcers related to these conditions are not well known. Methods: We prospectively studied consecutive patients with bleeding gastroduodenal ulcers
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from June to September 2005. H pylori infection is considered to be present if either the biopsy urease test or histology is positive for the bacterium. H pylori ulcer is defined by a positive test for H pylori and no exposure to NSAIDs or aspirin within one week before the bleeding episodes; patients who use one of these drugs are classified to have NSAID ulcers regardless of their H pylori status. H pylorinegative idiopathic ulcers are defined as ulcers without prior exposure to aspirin or NSAIDs, and negative biopsy urease test and histology for H pylori. Grading of overall health and comorbidity was performed according to the American Society of Anesthesiology (ASA) classification. The outcome of ulcer bleeding was scored by Rockall classification. Results: Seventy-seven patients had bleeding ulcers: 47 (61%) were NSAID ulcers, 20 (26%) were H pylori ulcers, and 10 (13%) were H pylorinegative idiopathic ulcers. Patients with H pylori-negative idiopathic ulcers or NSAID ulcers had a higher ASA grade (grade 3 and 4) and Rockall score (score 5 and above) than patients with H pylori ulcers (60% vs. 51% vs. 10% for ASA grade and 70% vs. 48% vs. 10% for Rockall score, respectively, P ! 0.05). H pylori ulcer had smaller ulcer size than H pylori-negative idiopathic ulcer (0.92 cm vs. 1.24 cm, P Z 0.04) and NSAID ulcer (0.92 cm vs. 1.29 cm, P Z 0.14). The probability of recurrent ulcer bleeding within 3 days was 12.8% in patients with NSAID ulcer and 40 % in patients with H pylori-negative idiopathic ulcers (P Z 0.04). In total, rebleeding at one month occurred in 8% of patients; surgical intervention was needed in 3%; and mortality rate during admission was 3%. Conclusions: More than half of all ulcer bleeding is associated with NSAID use. Bleeding related to H pylori-negative idiopathic ulcers is not uncommon. H pylori ulcers have a smaller ulcer size and patients with such ulcers are less comorbid. The probability of recurrent bleeding within 3 days in patients with H pylori-negative idiopathic ulcers is substantial. Further data is necessary and is currently being accumulated at our institution.
S1450 Occupational Injuries to Endoscopists: Report from the ASGE Web Survey Ray F. Keate, Gerald W. Dryden, Kenneth Wang, Yang K. Chen,. ASGE Web Editorial Board Background: Musculoskeletal injuries are common among GI endoscopists. Previous studies (Buschbacher 1994; O’Sullivan 2002) reported an incidence of musculoskeletal injuries as low as 13% (neck injuries) and as high as 57% (back injuries). Associated factors include the volume of endoscopy and the ergonomics of the ERCP suite. Methods: The ASGE Web Editorial Board was charged by Governing Board to develop a survey on occupational injures. Members were encouraged to complete the web-based survey at meetings, membership booths and on the Homepage of the ASGE website. Data from May 2004 through November 5, 2005 is reported. Endoscopy volume data, ergonomic issues, and personal fitness were also assessed. Results: 237 endoscopists completed the survey. 184 (78%) reported one or more injury. Specific injuries were: back (N Z 68, 29%), neck (N Z 66, 28%), hand and or carpal tunnel injuries (N Z 102, 43%) and other (N Z 37, 16%). 203 respondents (86%) described pain when performing endoscopy. (See table). 19% of endoscopists have modified their practice or shortened their endoscopy case load due to occupational injury. 12% reported missing work due to injury and/or having a related surgical procedure. Over 2/3 of those surveyed reported !1 hr of aerobic fitness exercise, !1 hr of stretching and nbsp; !1 hr of resistance training per week. In contrast, the reported level of abdominal fitness exercise was higher; over 60% of respondents reported more than 1 hr of abdominal fitness exercise per week. 79% reported making ergonomic improvements in their workplace including adjusting video monitor heights, wearing soft soled shoes and using rubberized mats Conclusions: Data from this uncontrolled survey of ASGE members provides confirmatory evidence that endoscopy is a hazardous profession. Pain, injury, loss of work and surgery for these conditions are common. Although the respondents to this survey may not be representative of the profession, the results suggest that occupational injuries directly or indirectly affect a significant proportion of practicing endoscopists. Endoscopists should give more attention to ergonomic issues in the endoscopy suite and to maintaining physical fitness. Endoscopy activities associated with pain Activity ERCP elevator use Radiology gown and room Left thumb pain Moving patients Standing for long periods Applying torque to the scope Other
No. reporting
Percentage of respondents
27 27 40 65 27 70 26
11 11 17 27 11 29 10
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB111
S1447 Is N-2-Butyl-Cyanoacrilate a Really Good Option for the Treatment of Gastric Varices? Nestor Landoni, Alberto Bernedo, Cesar Calderon, Horacio Martinez, Augusto Villaverde, Nestor Chopita Aim: To evaluate the success of hystoacryl in primary hemostasis, rebleeding and erradication of gastric varices. Patients and Methods: Since january 1999 to october 2005, 46 patients with bleeding for gastric varices were treated in our unit with n-2butyl-cyanoacrylate . A mixture of 0.5 ml of hystoacryl and 0.5 ml of lypiodol was used with a maximum of two ml. per session. Sclerotherapy needles of 21 g, Olympus endoscopes (145 series) and sedation with midazolam were used in all patients. Data was analized by chi-square test. Results: we included 46 patients, 32 males and 14 females with a mean age of 56.13 years, range 18-77 and a median of 55. The patients were clasiffied as Child A 18, Child B 21 and Child C 5; two patients were not classified. According to Sarin classification 15 patients presented GOV 1 varices, 22 GOV 2, 5 GOV 1 y 2 and 4 IGV 1. Forty-five patients (97.8%) had active bleeding or recent bleeding stigmata at the moment of the endoscopy. Primary hemostasis was achieved in 80.4% (37 patients) in agreement with Baveno IV. Nine patients with rebleeding were retreated with hystoscryl. Definitive hemostasis was succesful in 6 of them, 2 were sent to surgical treatment and 1 to endovascular therapy. After the definitive hemostasis the patients were discharged with treatment with propanolol in different dosis. After one year of follow up 7 patients rebleed (15,2%) and they were all successfully treated endoscopically . The gastric varices were erradicated in 15 patients (32.6%) with a recurrence in 6 patients (40 %). Conclusion: In our series primary hemostasis was achieved in 80.4% and definitive hemostasis in 93.47% of the patients. The erradication of gastric varices was obtained in 32.6 %. During the follow up 40% of these patients had a recurrence. We conclude that n-2-butyl-cyanoacrilate is a very good method for the bleeding of gastric varices but it is not recommended for their erradication.
S1448 Effectiveness of Colonoscopy: Quality Indicators Gianmichele Meucci, Franco Radaelli, Gabriella Bartesaghi, Silvia Porta, Giorgio Minoli Aim: To evaluate the effectiveness of colonoscopy in Italian Endoscopy Units. Methods. A large, multicenter prospective study was conducted over a two-week period in 308 endoscopic units to assess the colonoscopy practice in Italy. For each unit, structure indicators on organizational framework in which the endoscopy is provided (i.e. type of structure and setting, volume of endoscopic procedures, information on medical and nursing staff, facilities) were collected using a standardized questionnaire. A second questionnaire was used to prospectively record details of each colonoscopy consecutively performed in the study period. Process measures (patient demographics, procedure indication, sedation practice, experience of endoscopists, endoscopic diagnosis, therapeutic interventions), and outcomes measures (caecal intubation, prevalence of polyps, and immediate complications) were recorded. Results: Data of 13.364 colonoscopies performed at 299 institutions were evaluated; sufficient information was available for 12.835 of them (96%). Some sedation was provided in 55% of examinations (52% before starting the exam and 3% on demand); benzodiazepines alone were administered in 29% of cases, benzodiazepines plus opioids in 15% propofol in 3% and other medications in 8%. Bowel cleansing was considered excellent or good in 84% of examinations, fair or insufficient in the remaining 16%. Poliethilenglicole was used in 79% of examinations, sodium phosphate in 19% and other agents in the remaining 2%. Caecal intubation (defined as visualization of the ileo-caecal valve) was achieved in 82,8% of examinations; the rate of caecal intubation was at least 90% in only 22% of centers. The cause of failure was insufficient bowel cleansing in 6,4% of cases, patients intolerance in 5%, excessive looping in 3% and the presence of a stricture in 3%. Conclusions: Our data show that the rate of caecal intubation in most Italian endoscopic Units is far from optimal and conscious sedation is underutilized.
S1449 Outcome of Bleeding Ulcer Related to Nonsteroidal Anti-Inflammatory Drug Use, Helicobacter Pylori Infection and Idiopathic Cause: A Preliminary Report Chi-Liang Cheng, Nai-Jen Liu, Hao-Tsai Cheng, Jui-Hsiang Tang, Ching-Song Lee, Yui-Yi Chu, Cheng-Hui Lin, Yung-Kuan Tsou Background: NSAIDs and Helicobacter pylori (H pylori) are common risk factors for the development of bleeding peptic ulcer. Helicobacter pylori-negative idiopathic ulcers are also increasingly recognized. The prevalence and short-term outcome of bleeding ulcers related to these conditions are not well known. Methods: We prospectively studied consecutive patients with bleeding gastroduodenal ulcers
www.giejournal.org
from June to September 2005. H pylori infection is considered to be present if either the biopsy urease test or histology is positive for the bacterium. H pylori ulcer is defined by a positive test for H pylori and no exposure to NSAIDs or aspirin within one week before the bleeding episodes; patients who use one of these drugs are classified to have NSAID ulcers regardless of their H pylori status. H pylorinegative idiopathic ulcers are defined as ulcers without prior exposure to aspirin or NSAIDs, and negative biopsy urease test and histology for H pylori. Grading of overall health and comorbidity was performed according to the American Society of Anesthesiology (ASA) classification. The outcome of ulcer bleeding was scored by Rockall classification. Results: Seventy-seven patients had bleeding ulcers: 47 (61%) were NSAID ulcers, 20 (26%) were H pylori ulcers, and 10 (13%) were H pylorinegative idiopathic ulcers. Patients with H pylori-negative idiopathic ulcers or NSAID ulcers had a higher ASA grade (grade 3 and 4) and Rockall score (score 5 and above) than patients with H pylori ulcers (60% vs. 51% vs. 10% for ASA grade and 70% vs. 48% vs. 10% for Rockall score, respectively, P ! 0.05). H pylori ulcer had smaller ulcer size than H pylori-negative idiopathic ulcer (0.92 cm vs. 1.24 cm, P Z 0.04) and NSAID ulcer (0.92 cm vs. 1.29 cm, P Z 0.14). The probability of recurrent ulcer bleeding within 3 days was 12.8% in patients with NSAID ulcer and 40 % in patients with H pylori-negative idiopathic ulcers (P Z 0.04). In total, rebleeding at one month occurred in 8% of patients; surgical intervention was needed in 3%; and mortality rate during admission was 3%. Conclusions: More than half of all ulcer bleeding is associated with NSAID use. Bleeding related to H pylori-negative idiopathic ulcers is not uncommon. H pylori ulcers have a smaller ulcer size and patients with such ulcers are less comorbid. The probability of recurrent bleeding within 3 days in patients with H pylori-negative idiopathic ulcers is substantial. Further data is necessary and is currently being accumulated at our institution.
S1450 Occupational Injuries to Endoscopists: Report from the ASGE Web Survey Ray F. Keate, Gerald W. Dryden, Kenneth Wang, Yang K. Chen,. ASGE Web Editorial Board Background: Musculoskeletal injuries are common among GI endoscopists. Previous studies (Buschbacher 1994; O’Sullivan 2002) reported an incidence of musculoskeletal injuries as low as 13% (neck injuries) and as high as 57% (back injuries). Associated factors include the volume of endoscopy and the ergonomics of the ERCP suite. Methods: The ASGE Web Editorial Board was charged by Governing Board to develop a survey on occupational injures. Members were encouraged to complete the web-based survey at meetings, membership booths and on the Homepage of the ASGE website. Data from May 2004 through November 5, 2005 is reported. Endoscopy volume data, ergonomic issues, and personal fitness were also assessed. Results: 237 endoscopists completed the survey. 184 (78%) reported one or more injury. Specific injuries were: back (N Z 68, 29%), neck (N Z 66, 28%), hand and or carpal tunnel injuries (N Z 102, 43%) and other (N Z 37, 16%). 203 respondents (86%) described pain when performing endoscopy. (See table). 19% of endoscopists have modified their practice or shortened their endoscopy case load due to occupational injury. 12% reported missing work due to injury and/or having a related surgical procedure. Over 2/3 of those surveyed reported !1 hr of aerobic fitness exercise, !1 hr of stretching and nbsp; !1 hr of resistance training per week. In contrast, the reported level of abdominal fitness exercise was higher; over 60% of respondents reported more than 1 hr of abdominal fitness exercise per week. 79% reported making ergonomic improvements in their workplace including adjusting video monitor heights, wearing soft soled shoes and using rubberized mats Conclusions: Data from this uncontrolled survey of ASGE members provides confirmatory evidence that endoscopy is a hazardous profession. Pain, injury, loss of work and surgery for these conditions are common. Although the respondents to this survey may not be representative of the profession, the results suggest that occupational injuries directly or indirectly affect a significant proportion of practicing endoscopists. Endoscopists should give more attention to ergonomic issues in the endoscopy suite and to maintaining physical fitness. Endoscopy activities associated with pain Activity ERCP elevator use Radiology gown and room Left thumb pain Moving patients Standing for long periods Applying torque to the scope Other
No. reporting
Percentage of respondents
27 27 40 65 27 70 26
11 11 17 27 11 29 10
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB111