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Efficacy and Safety of Endoscopic Balloon Dilatation of Symptomatic Crohn's Disease Strictures
Abstracts
S1443 Efficacy and Safety of Endoscopic Balloon Dilatation of Symptomatic Crohn’s Disease Strictures Tamas Molnar, Ferenc Nagy, Zoltan Szepes, Janos Lonovics Patients with stricturing Crohn’s disease (CD) commonly develop obstructive symptoms secondary to gastrointestinal stenosis. Endoscopic through-the-scope (TTS) balloon dilatation is one of the reasonable alternatives to surgery. Goals: To evaluate the efficacy and safety of endoscopic balloon dilatation of symptomatic short segment gastrointestinal CD strictures. Methods: We carried out a retrospective review of TTS balloon dilatations performed in CD patients during the period 2002-2005. A stricture was declared when the scope could not be passed through the luminal stenosis. Technical success was defined as the ability of the scope to traverse the stricture postdilatation. Long-term success was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilatation for at least one year. Results: Within the period of the study, we performed 28 stricture dilatations on 23 patients. The mean follow-up period was 18.1 months. Stricture locations were as follows: surgical anastomosis 12, ileocoecal valve 5, colon 5, jejunum 1, ileum 1, and pylorus 1. Technical success was achieved in 25 of the 28 stricture dilatations (89%). Long-term success rate was 21 of 25 dilated cases, 84%. No perforation occurred during the procedures. Conclusion: TTS balloon dilatation is an effective and safe alternative to surgical intervention in selected cases. The best technical and long-term success rate can be achieved with strictures of surgical anastomosis or the Bauhin valve.
S1444 Endoscopy By Non-Gastroenterologists - Who, How Much, and Methods of Credentialing Grant F. Hutchins, Elizabeth Lyden, Tim M. Mccashland Background/Aims: Recent growth in the field of endoscopy has resulted in more non-gastroenterology trained physicians performing endoscopic procedures. Credentialing and quality assessment of endoscopic procedures by nongastroenterologists has been a recent controversial topic. The aims of this study were to evaluate how much endoscopy is being performed by nongastroenterologists and by which means they are credentialed and assessed. Methods: A two-part endoscopic questionnaire consisting of institutional and individual arms was mailed to 103 accredited hospitals in the state of Nebraska. Institutional questions centered on the credentialing process, number of procedures performed /year, and quality assessment measures. Individual physician questionnaires included physician specialty, methods of training in endoscopy, number/type of therapeutics performed, and continuing endoscopic education. Results: 49/103 institutions returned surveys and 73 individual physicians (Family Medicine (FM)-27, General Surgery (GS)-22, General Internist (IM)-7, Colorectal Surgery (GS)-4, and Gastroenterology (GI)-13) who perform endoscopy responded. Procedural numbers during residency (32 institutions) and a letter from a residency program director (28 institutions) were most often cited by institutions as necessary for endoscopic privileges. Verification of endoscopic competency was most often accomplished by an individual hospital using number of procedures performed during residency training although numbers were not reported. Low procedural numbers (median) during residency training were observed (FM-112, GS-182, IM-35 vs. GI -1100, p ! .05) and non-gastroenterologists perform fewer procedures per year (FM-191, GS-295, IM-10 vs. GI-1012, p ! .05). Importantly, therapeutic procedures were not performed by non-gastroenterologists frequently (FM dilation 33%, cold biopsy of polyp 50%, snare polypectomy 25%, hemostasis 7% and IM dilation 14%, cold biopsy of polyp 42%, snare polypectomy 14%, and hemostasis 0%). General surgeons, colorectal surgeons, and gastroenterologists all performed therapeutics equally. Conclusion: The practice of endoscopy by nongastroenterologists is common, especially in rural settings. Defined numbers of procedures needed to obtain endoscopic privileges are not standardized and are not required by many institutions, despite using number of procedures for credentialing. The majority of procedures by non-gastroenterologists were diagnostic only. Uniform credentialing policies and quality assessment of physicians performing endoscopy is lacking.
AB110 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1445 Clinical Significance of Magnifying Endoscopy Combined with Narrow Band Imaging System for Neoplastic Lesions At Oropharyngeal and Hypopharyngeal Sites Ken-Ichi Goda, Yukinaga Yoshida, Masayuki Kato, Takashi Nakayoshi, Kazuki Sumiyama, Takuji Yamasaki, Shouichi Saito, Mitsuru Kaise, Hisao Tajiri, Masahiro Ikegami Backgrounds: It has been extremely difficult to detect superficial neoplastic lesions (NLs), including dysplasia and sqamous cell carcinoma in an earlier stage, at oropharyngeal and hypopharyngeal sites during routine endoscopy. Furthermore, even if the superficial NLs can be pointed out, it has not been established to differentiate NLs from non-neoplastic lesions (non-NLs) in the present. Aim: The present study aim was to clarify characteristic endoscopic findings of the superficial NLs at the oropharyngeal and hypopharyngeal sites. Methods: We undertook endoscopy for 71 patients due to screening / surveillance or work-up for squamous cell carcinoma of the head and neck or the esophagus. Biopsy specimens were obtained from 106 lesions at oropharyngeal and hypopharyngeal sites. Findings of conventional endoscopy and magnifying endoscopy with NBI system (MENBI) at those sites were compared with those histological findings. Results: Histological findings of 61 non-NLs showed normal mucosa: 3; inflammatory change: 38; sqamous cell hyperplasia: 13; papilloma: 7. In addition, histological findings of 45 NLs demonstrated superficial sqamous cell carcinoma (SCC & T1): 35; high-grade dysplasia: 4; low-grade dysplasia: 6. Both frequencies of reddish and flat lesions (P Z 0.001 and 0.003) in NLs were significantly higher than those in non-NLs under a conventional endoscopic observation. Univariate analysis for 5 kinds of MENBI findings demonstrated that brownish-epithelium of interspaced capillaries, dilatation, proliferation, irregularity and frog egg like appearance of superficial capillaries in NLs were significantly more frequent than those in non-NLs, respectively. On multivariate analysis, proliferation (P Z 0.009) and irregularity (P Z 0.0016) of capillaries were independent factors for diagnosing NLs by MENBI. Conclusions: MENBI was useful for diagnosing superficial NLs at oropharyngeal and hypopharyngeal sites. It is suggested that important characteristic findings in the NLs under the MENBI were proliferation and irregularity of superficial capillaries.
S1446 Is a Photograph of the Caecum Or Terminal Ileum Reliable Enough for Documenting Completion of Colonoscopy A Prospective Study? Raman Guruswamy, Jane Skinner, Brett Bernard Introduction and Aim: Documenting colonoscopy completion is an important aspect of quality assurance and a suitable tool is not yet available. The aim of this study was to independently assess the reliability of caecal or terminal ileal photographs as a proof of colonoscopy completion. Materials and Methods: Colonoscopists were requested to take a convincing photograph of the caecum or terminal ileum to document completion of their examination during a prospective colonoscopy audit in a District General Hospital. 177 photographs were collected over 8 months. A further 23 controls (taken of other regions of the large bowel) photographs were added randomly. Based on the landmark captured they were further divided into group ‘‘D’’ when only appendicial orifice was captured, ‘‘E’’ when appendiceal and ileocaecal valve were captured, ‘‘F’’ when only ileocaecal valve was captured, ‘‘G’’ when terminal ileum was captured without water flush and ‘‘H’’ when the terminal ileum was photographed after a water flush. Water flush was used to enhance the villi. Eight independent clinicians (4 colorectal surgeons and 4 gastroenterologists) were requested to categorise the photos as ‘‘caecum, terminal ileum or not sure’’. Those identified as caecum and terminal ileum were further graded as 1, 2 or 3 depending on the level of certainty. Results: A total of 200 photographs were used. The true locations were caecal in 91 (45.5%) cases, terminal ileal in 86 (43%) cases and 23 (11.5%) were controls. Appendiceal orifice is the most commonly captured landmark (group D, 69 cases -34.5%). Other landmarks captured were group E -13 (6.5%), F - 9 (4.5%), G - 47 (23.5%), and H 39 (19.5%). Thirty eight percent of the caecal photographs, 71% of the terminal ileal photographs (with and without water flush) and 85.8% of the terminal ileal photographs with water flush technique were identified with a certainty of grade 2 or 3. When all the grades were considered, 93.9% of the terminal ileal photographs with water flush technique were identified. Appendiceal photos obtained the lowest mean grade of 1.2 and terminal ileal photos with water flush obtained the highest grading with a mean score of 2.6. Interestingly 15% of the control photographs were interpreted as caecum and a further 15% as terminal ileum. Conclusion: A photograph of the terminal ileum after flushing with water appears to be a reliable and safe technique for documenting colonoscopy completion. This is less invasive and less costly when compared to terminal ileal biopsy which is currently the gold standard. Caecal photographs do not appear to be a reliable way to document completion due to high inter-observer variability.
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S1443 Efficacy and Safety of Endoscopic Balloon Dilatation of Symptomatic Crohn’s Disease Strictures Tamas Molnar, Ferenc Nagy, Zoltan Szepes, Janos Lonovics Patients with stricturing Crohn’s disease (CD) commonly develop obstructive symptoms secondary to gastrointestinal stenosis. Endoscopic through-the-scope (TTS) balloon dilatation is one of the reasonable alternatives to surgery. Goals: To evaluate the efficacy and safety of endoscopic balloon dilatation of symptomatic short segment gastrointestinal CD strictures. Methods: We carried out a retrospective review of TTS balloon dilatations performed in CD patients during the period 2002-2005. A stricture was declared when the scope could not be passed through the luminal stenosis. Technical success was defined as the ability of the scope to traverse the stricture postdilatation. Long-term success was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilatation for at least one year. Results: Within the period of the study, we performed 28 stricture dilatations on 23 patients. The mean follow-up period was 18.1 months. Stricture locations were as follows: surgical anastomosis 12, ileocoecal valve 5, colon 5, jejunum 1, ileum 1, and pylorus 1. Technical success was achieved in 25 of the 28 stricture dilatations (89%). Long-term success rate was 21 of 25 dilated cases, 84%. No perforation occurred during the procedures. Conclusion: TTS balloon dilatation is an effective and safe alternative to surgical intervention in selected cases. The best technical and long-term success rate can be achieved with strictures of surgical anastomosis or the Bauhin valve.
S1444 Endoscopy By Non-Gastroenterologists - Who, How Much, and Methods of Credentialing Grant F. Hutchins, Elizabeth Lyden, Tim M. Mccashland Background/Aims: Recent growth in the field of endoscopy has resulted in more non-gastroenterology trained physicians performing endoscopic procedures. Credentialing and quality assessment of endoscopic procedures by nongastroenterologists has been a recent controversial topic. The aims of this study were to evaluate how much endoscopy is being performed by nongastroenterologists and by which means they are credentialed and assessed. Methods: A two-part endoscopic questionnaire consisting of institutional and individual arms was mailed to 103 accredited hospitals in the state of Nebraska. Institutional questions centered on the credentialing process, number of procedures performed /year, and quality assessment measures. Individual physician questionnaires included physician specialty, methods of training in endoscopy, number/type of therapeutics performed, and continuing endoscopic education. Results: 49/103 institutions returned surveys and 73 individual physicians (Family Medicine (FM)-27, General Surgery (GS)-22, General Internist (IM)-7, Colorectal Surgery (GS)-4, and Gastroenterology (GI)-13) who perform endoscopy responded. Procedural numbers during residency (32 institutions) and a letter from a residency program director (28 institutions) were most often cited by institutions as necessary for endoscopic privileges. Verification of endoscopic competency was most often accomplished by an individual hospital using number of procedures performed during residency training although numbers were not reported. Low procedural numbers (median) during residency training were observed (FM-112, GS-182, IM-35 vs. GI -1100, p ! .05) and non-gastroenterologists perform fewer procedures per year (FM-191, GS-295, IM-10 vs. GI-1012, p ! .05). Importantly, therapeutic procedures were not performed by non-gastroenterologists frequently (FM dilation 33%, cold biopsy of polyp 50%, snare polypectomy 25%, hemostasis 7% and IM dilation 14%, cold biopsy of polyp 42%, snare polypectomy 14%, and hemostasis 0%). General surgeons, colorectal surgeons, and gastroenterologists all performed therapeutics equally. Conclusion: The practice of endoscopy by nongastroenterologists is common, especially in rural settings. Defined numbers of procedures needed to obtain endoscopic privileges are not standardized and are not required by many institutions, despite using number of procedures for credentialing. The majority of procedures by non-gastroenterologists were diagnostic only. Uniform credentialing policies and quality assessment of physicians performing endoscopy is lacking.
AB110 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1445 Clinical Significance of Magnifying Endoscopy Combined with Narrow Band Imaging System for Neoplastic Lesions At Oropharyngeal and Hypopharyngeal Sites Ken-Ichi Goda, Yukinaga Yoshida, Masayuki Kato, Takashi Nakayoshi, Kazuki Sumiyama, Takuji Yamasaki, Shouichi Saito, Mitsuru Kaise, Hisao Tajiri, Masahiro Ikegami Backgrounds: It has been extremely difficult to detect superficial neoplastic lesions (NLs), including dysplasia and sqamous cell carcinoma in an earlier stage, at oropharyngeal and hypopharyngeal sites during routine endoscopy. Furthermore, even if the superficial NLs can be pointed out, it has not been established to differentiate NLs from non-neoplastic lesions (non-NLs) in the present. Aim: The present study aim was to clarify characteristic endoscopic findings of the superficial NLs at the oropharyngeal and hypopharyngeal sites. Methods: We undertook endoscopy for 71 patients due to screening / surveillance or work-up for squamous cell carcinoma of the head and neck or the esophagus. Biopsy specimens were obtained from 106 lesions at oropharyngeal and hypopharyngeal sites. Findings of conventional endoscopy and magnifying endoscopy with NBI system (MENBI) at those sites were compared with those histological findings. Results: Histological findings of 61 non-NLs showed normal mucosa: 3; inflammatory change: 38; sqamous cell hyperplasia: 13; papilloma: 7. In addition, histological findings of 45 NLs demonstrated superficial sqamous cell carcinoma (SCC & T1): 35; high-grade dysplasia: 4; low-grade dysplasia: 6. Both frequencies of reddish and flat lesions (P Z 0.001 and 0.003) in NLs were significantly higher than those in non-NLs under a conventional endoscopic observation. Univariate analysis for 5 kinds of MENBI findings demonstrated that brownish-epithelium of interspaced capillaries, dilatation, proliferation, irregularity and frog egg like appearance of superficial capillaries in NLs were significantly more frequent than those in non-NLs, respectively. On multivariate analysis, proliferation (P Z 0.009) and irregularity (P Z 0.0016) of capillaries were independent factors for diagnosing NLs by MENBI. Conclusions: MENBI was useful for diagnosing superficial NLs at oropharyngeal and hypopharyngeal sites. It is suggested that important characteristic findings in the NLs under the MENBI were proliferation and irregularity of superficial capillaries.
S1446 Is a Photograph of the Caecum Or Terminal Ileum Reliable Enough for Documenting Completion of Colonoscopy A Prospective Study? Raman Guruswamy, Jane Skinner, Brett Bernard Introduction and Aim: Documenting colonoscopy completion is an important aspect of quality assurance and a suitable tool is not yet available. The aim of this study was to independently assess the reliability of caecal or terminal ileal photographs as a proof of colonoscopy completion. Materials and Methods: Colonoscopists were requested to take a convincing photograph of the caecum or terminal ileum to document completion of their examination during a prospective colonoscopy audit in a District General Hospital. 177 photographs were collected over 8 months. A further 23 controls (taken of other regions of the large bowel) photographs were added randomly. Based on the landmark captured they were further divided into group ‘‘D’’ when only appendicial orifice was captured, ‘‘E’’ when appendiceal and ileocaecal valve were captured, ‘‘F’’ when only ileocaecal valve was captured, ‘‘G’’ when terminal ileum was captured without water flush and ‘‘H’’ when the terminal ileum was photographed after a water flush. Water flush was used to enhance the villi. Eight independent clinicians (4 colorectal surgeons and 4 gastroenterologists) were requested to categorise the photos as ‘‘caecum, terminal ileum or not sure’’. Those identified as caecum and terminal ileum were further graded as 1, 2 or 3 depending on the level of certainty. Results: A total of 200 photographs were used. The true locations were caecal in 91 (45.5%) cases, terminal ileal in 86 (43%) cases and 23 (11.5%) were controls. Appendiceal orifice is the most commonly captured landmark (group D, 69 cases -34.5%). Other landmarks captured were group E -13 (6.5%), F - 9 (4.5%), G - 47 (23.5%), and H 39 (19.5%). Thirty eight percent of the caecal photographs, 71% of the terminal ileal photographs (with and without water flush) and 85.8% of the terminal ileal photographs with water flush technique were identified with a certainty of grade 2 or 3. When all the grades were considered, 93.9% of the terminal ileal photographs with water flush technique were identified. Appendiceal photos obtained the lowest mean grade of 1.2 and terminal ileal photos with water flush obtained the highest grading with a mean score of 2.6. Interestingly 15% of the control photographs were interpreted as caecum and a further 15% as terminal ileum. Conclusion: A photograph of the terminal ileum after flushing with water appears to be a reliable and safe technique for documenting colonoscopy completion. This is less invasive and less costly when compared to terminal ileal biopsy which is currently the gold standard. Caecal photographs do not appear to be a reliable way to document completion due to high inter-observer variability.
www.giejournal.org