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Endoscopic Criteria Used to Distinguish Benign From Malignant Polyps
Abstracts
S1067 Formal and Adequate EUS Training Remains Difficult to Obtain in US GI Three-Year Fellowships Despite Strong Demand for Instruction: Results of a Nationwide Survey of GI Fellowship Program Directors Jaspaul S. Azad, Douglas G. Adler Background: Training in EUS is in high demand among US gastroenterology fellows. The overall availability of EUS training in the US has never been formally studied and quantified. Published data suggests high volume is required for proficiency & safety. Methods: A survey was sent to all US GI Fellowship Program Directors. The survey assessed number and type of fellows, the presence/absence of EUS training, and quantified the exact type and extent of EUS training being offered. Results: 70 responses were received (46% of US GI fellowships). 47% of directors perform either ERCP C/ÿ EUS themselves, while 53% perform neither. 20% of directors perform EUS. Clinical practice was chosen as their area of focus by 60% of respondents, 13% of respondents described their area of focus as basic science. 73% of respondents train 3 or fewer core 3 year GI fellows/year and 43% train 2 or less. 28% of programs offer a 4th year therapeutic endoscopy fellowship. EUS is performed at 83% of programs and totally unavailable at 17%. Among programs that offer EUS training, volume is !300 cases/yr in 48% of these programs. 84% of core 3 year GI fellows have exposure to EUS with 56% of these only receiving training during their 3rd year. This exposure consists of dedicated ‘‘hands on’’ training according to 72% of respondents and occurs over less than 6 months for 71%. The volume of cases participated in by core 3 year GI fellows upon completion of training is less than 75 cases in 75% of the programs, and 60% of these programs do not allow fellows to perform any FNA. 33% of programs offer EUS observation only and no hands-on training. Only 27.5% of respondents have a 4th year fellow with 75% receiving both some EUS training. 89% of these therapeutic fellows get hands on EUS training, but 50% do less than 150 total cases during that training period. Despite these low numbers, 40% of program directors feel that EUS training received during the core 3 year GI fellowship is sufficient training to practice EUS ‘‘successfully and safely.’’ No program director felt that EUS could be successfully/ safely practiced by those self-taught via books, videos, courses, or other informal training.60% recommended 4th year training. Conclusion: Many US GI fellowships do not offer trainees sufficient EUS procedures to achieve clinical competence. Most 3-year programs offer limited or suboptimal training and even some 4th year endoscopy fellows may not receive sufficient EUS volume during training.
S1069 Endoscopic Criteria Used to Distinguish Benign From Malignant Polyps Neville D. Bamji, Purnima Balachandran, Sudhakar V. Balachandran, Jerome D. Waye Aims: The goal of our study is to determine the visual characteristics used by endoscopists to decide whether a polyp is benign or malignant. Design: A video disc containing 20 cases of 8 benign and 12 malignant polyps was sent to endoscopists of varying experience. The respondent was asked to view the video of each polyp and then fill out a questionnaire which listed various characteristics (size, color, margins, surface irregularity, depression, ulceration, bleeding, waxy, and nodularity) and make a visual estimation as to whether the polyp was benign, malignant or indeterminate. Results: Our sample consisted of responses from 61 physicians (1220 observations). Overall, 68% of the responses were correct, 65% of the benign polyps were identified correctly, as were 70% of the malignant polyps. There were substantial differences in the rate of correct response by question, ranging from 27% to 98%. Gastroenterology fellows answered correctly 67% of the time, whereas, gastroenterology attendings responded correctly 69% of the time (the difference was not statistically significant). The criteria of size, irregularity, margins, and color were used more often when describing a malignant polyp. Lack of nodularity and size were used more often when describing a benign polyp. These differences were statistically significant. Surprisingly, irregularity showed a negative association with correctly identifying the polyp as benign (p-value !0.01). In a logistic regression of the overall data for both benign and malignant polyps, the use of ulceration was most positively associated with the likelihood of a correct answer. Color and margins were also predictive of a correct answer. Although ‘‘waxiness’’ is a term often cited in the literature as a determining visual characteristic, it was rarely used in these responses. Taken together, these results suggest that ulceration in a polyp, combined with an evaluation of its margins and its size increase the likelihood of correctly differentiating between a benign and a malignant polyp. Conclusion: Size, margins, bleeding and ulceration were the visual characteristics most often used by physicians to differentiate benign from malignant polyps. Malignant polyps are most often correctly diagnosed by their larger size, irregular margins, bleeding and surface ulcerations. Conversely, smaller size and lack of irregular margins are often used as determinants of benign polyps.
S1068 Colonic Mucosal Pseudolipomatosis: Disinfectant Colitis with Hydrogen Peroxide Ilhyun Baek, Heung Young Oh, Chong Woo Yoo, Gwang Ho Baik, Jin Bae Kim, Myung Seok Lee Backgrounds: Pseudolipomatosis is recently described rare colonoscopic finding with whitish foamy mucosal plaques. Pathogenesis is unknown, but mechanical traumatic injury to mucosa during endoscopic procedure, intramucosal air such as pneumatosis coli, or chemical injury by disinfectant seems to contribute to its pathogenesis. We observed eight cases of colonic pseudolipomatosis during three months only after changing endoscopic disinfectants from glutaraldehyde to peracetic acid (SCOTELIN¢c¸; compounds of hydrogen peroxide with radical oxygen bactericidal effect). Therefore we thought that endoscopic disinfectant such as SCOTELIN¢c¸ seemed to be more possible cause of pseudolipomatosis than mechanical traumatic injury or intramucosal air. The aim of our study was to determine the effect of disinfectant as a major cause of pseudolipomatosis. Methods: We experimentally attempted to induce mucosal pseudolipomatosis by alcohol, SCOTELIN¢c¸ or 3% hydrogen peroxide in pig gut. All specimens were stained with periodic acid-Schiff, alcian blue or mucicarmine to exclude mucin droplet and Oil Red O to exclude fatty infiltration. We compared specimens of the eight patient cases diagnosed to pseudolipomatosis with the three cases of experimental pig gut specimen artificially induced by disinfectants such as alcohol, SCOTELIN¢c¸ or 3% hydrogen peroxide. Results: The specimens of eight patient cases showed multiple aggregations of small air spaces resembling fatty infiltration in lamina propria. These findings were also seen at the three specimens of pig gut cases induced by SCOTELIN¢c¸ and hydrogen peroxide, but were not seen at the specimens of pig gut cases induced by alcohol. Staining with periodic acid-Schiff, alcian blue, mucicarmine, or Oil Red O did not show such findings. Conclusions: Although our study has a limitation of small sample size, these results suggest that endoscopic chemical disinfectants with hydrogen peroxide appeare more important to intestinal mucosal injury than air-pressure related mechanical injury during colonoscopy. Forced air drying and an additional preprocedure rinse of channels and the exterior of the scope should ensure a chemical-free examination.
AB108 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
S1070 Propofol Sedation for Gastrointestinal Endoscopy Administered by Nursing Staff Under Gastroenterologist Supervision Alberto Baptista, Ydali Bonilla, Manuel Bronstein, Ramon Ruiz, Vera Jancovik, Fogel Roberto, Alberto Leamus, Yanira Veliz Introduction: Narcotics and Benzodiazepines has been widely used by gastrointestinal endoscopists. Propofol is a short acting hypnotic agent and its use has been described for gastrointestinal endoscopy sedation under anesthesiologist guidance. We report the use of propofol for GI endoscopy administered by nurses under Endoscopist supervision. Materials and Methods: Between October 2002 and October 2004 a total of 7000 endoscopic procedures were performed: 3494 diagnostic upper endoscopies, 2446 diagnostic colonoscopies, 300 therapeutic ERCP, 70 diagnostic EUS and 690 other therapeutic procedures. 71% of patients were ASA I or II. Total propofol dosages and procedure times were variable (median dose: 10-20 mg/minute of procedure). An additional suction system was used to manage saliva and secretions. Results: Procedure tolerance and sedation satisfaction were reported as good or excellent in 98% of cases. Median time to recovery of normal neuropsychomotor status was on average 15 minutes. Most of the patients (96%) could remember details of post-procedure interview. Ventilatory complication rate was 0.12%: Eight cases of P02 desaturation under 85% required mask ventilation over 1 to 4 minutes. In 1 patient ventilatory failure occurred during induction for ERCP using 30 mg of propofol; tracheal intubation and general anesthesia was used to complete procedure. No colonic perforations occurred in this population. 28% of patients complained of mild local pain at the injection site. Conclusions: Propofol Sedation administered by nursing staff under Gastroenterologist supervision for Gastrointestinal Endoscopy is a safe and efficient modality with high levels of patient acceptance and satisfaction.
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S1067 Formal and Adequate EUS Training Remains Difficult to Obtain in US GI Three-Year Fellowships Despite Strong Demand for Instruction: Results of a Nationwide Survey of GI Fellowship Program Directors Jaspaul S. Azad, Douglas G. Adler Background: Training in EUS is in high demand among US gastroenterology fellows. The overall availability of EUS training in the US has never been formally studied and quantified. Published data suggests high volume is required for proficiency & safety. Methods: A survey was sent to all US GI Fellowship Program Directors. The survey assessed number and type of fellows, the presence/absence of EUS training, and quantified the exact type and extent of EUS training being offered. Results: 70 responses were received (46% of US GI fellowships). 47% of directors perform either ERCP C/ÿ EUS themselves, while 53% perform neither. 20% of directors perform EUS. Clinical practice was chosen as their area of focus by 60% of respondents, 13% of respondents described their area of focus as basic science. 73% of respondents train 3 or fewer core 3 year GI fellows/year and 43% train 2 or less. 28% of programs offer a 4th year therapeutic endoscopy fellowship. EUS is performed at 83% of programs and totally unavailable at 17%. Among programs that offer EUS training, volume is !300 cases/yr in 48% of these programs. 84% of core 3 year GI fellows have exposure to EUS with 56% of these only receiving training during their 3rd year. This exposure consists of dedicated ‘‘hands on’’ training according to 72% of respondents and occurs over less than 6 months for 71%. The volume of cases participated in by core 3 year GI fellows upon completion of training is less than 75 cases in 75% of the programs, and 60% of these programs do not allow fellows to perform any FNA. 33% of programs offer EUS observation only and no hands-on training. Only 27.5% of respondents have a 4th year fellow with 75% receiving both some EUS training. 89% of these therapeutic fellows get hands on EUS training, but 50% do less than 150 total cases during that training period. Despite these low numbers, 40% of program directors feel that EUS training received during the core 3 year GI fellowship is sufficient training to practice EUS ‘‘successfully and safely.’’ No program director felt that EUS could be successfully/ safely practiced by those self-taught via books, videos, courses, or other informal training.60% recommended 4th year training. Conclusion: Many US GI fellowships do not offer trainees sufficient EUS procedures to achieve clinical competence. Most 3-year programs offer limited or suboptimal training and even some 4th year endoscopy fellows may not receive sufficient EUS volume during training.
S1069 Endoscopic Criteria Used to Distinguish Benign From Malignant Polyps Neville D. Bamji, Purnima Balachandran, Sudhakar V. Balachandran, Jerome D. Waye Aims: The goal of our study is to determine the visual characteristics used by endoscopists to decide whether a polyp is benign or malignant. Design: A video disc containing 20 cases of 8 benign and 12 malignant polyps was sent to endoscopists of varying experience. The respondent was asked to view the video of each polyp and then fill out a questionnaire which listed various characteristics (size, color, margins, surface irregularity, depression, ulceration, bleeding, waxy, and nodularity) and make a visual estimation as to whether the polyp was benign, malignant or indeterminate. Results: Our sample consisted of responses from 61 physicians (1220 observations). Overall, 68% of the responses were correct, 65% of the benign polyps were identified correctly, as were 70% of the malignant polyps. There were substantial differences in the rate of correct response by question, ranging from 27% to 98%. Gastroenterology fellows answered correctly 67% of the time, whereas, gastroenterology attendings responded correctly 69% of the time (the difference was not statistically significant). The criteria of size, irregularity, margins, and color were used more often when describing a malignant polyp. Lack of nodularity and size were used more often when describing a benign polyp. These differences were statistically significant. Surprisingly, irregularity showed a negative association with correctly identifying the polyp as benign (p-value !0.01). In a logistic regression of the overall data for both benign and malignant polyps, the use of ulceration was most positively associated with the likelihood of a correct answer. Color and margins were also predictive of a correct answer. Although ‘‘waxiness’’ is a term often cited in the literature as a determining visual characteristic, it was rarely used in these responses. Taken together, these results suggest that ulceration in a polyp, combined with an evaluation of its margins and its size increase the likelihood of correctly differentiating between a benign and a malignant polyp. Conclusion: Size, margins, bleeding and ulceration were the visual characteristics most often used by physicians to differentiate benign from malignant polyps. Malignant polyps are most often correctly diagnosed by their larger size, irregular margins, bleeding and surface ulcerations. Conversely, smaller size and lack of irregular margins are often used as determinants of benign polyps.
S1068 Colonic Mucosal Pseudolipomatosis: Disinfectant Colitis with Hydrogen Peroxide Ilhyun Baek, Heung Young Oh, Chong Woo Yoo, Gwang Ho Baik, Jin Bae Kim, Myung Seok Lee Backgrounds: Pseudolipomatosis is recently described rare colonoscopic finding with whitish foamy mucosal plaques. Pathogenesis is unknown, but mechanical traumatic injury to mucosa during endoscopic procedure, intramucosal air such as pneumatosis coli, or chemical injury by disinfectant seems to contribute to its pathogenesis. We observed eight cases of colonic pseudolipomatosis during three months only after changing endoscopic disinfectants from glutaraldehyde to peracetic acid (SCOTELIN¢c¸; compounds of hydrogen peroxide with radical oxygen bactericidal effect). Therefore we thought that endoscopic disinfectant such as SCOTELIN¢c¸ seemed to be more possible cause of pseudolipomatosis than mechanical traumatic injury or intramucosal air. The aim of our study was to determine the effect of disinfectant as a major cause of pseudolipomatosis. Methods: We experimentally attempted to induce mucosal pseudolipomatosis by alcohol, SCOTELIN¢c¸ or 3% hydrogen peroxide in pig gut. All specimens were stained with periodic acid-Schiff, alcian blue or mucicarmine to exclude mucin droplet and Oil Red O to exclude fatty infiltration. We compared specimens of the eight patient cases diagnosed to pseudolipomatosis with the three cases of experimental pig gut specimen artificially induced by disinfectants such as alcohol, SCOTELIN¢c¸ or 3% hydrogen peroxide. Results: The specimens of eight patient cases showed multiple aggregations of small air spaces resembling fatty infiltration in lamina propria. These findings were also seen at the three specimens of pig gut cases induced by SCOTELIN¢c¸ and hydrogen peroxide, but were not seen at the specimens of pig gut cases induced by alcohol. Staining with periodic acid-Schiff, alcian blue, mucicarmine, or Oil Red O did not show such findings. Conclusions: Although our study has a limitation of small sample size, these results suggest that endoscopic chemical disinfectants with hydrogen peroxide appeare more important to intestinal mucosal injury than air-pressure related mechanical injury during colonoscopy. Forced air drying and an additional preprocedure rinse of channels and the exterior of the scope should ensure a chemical-free examination.
AB108 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
S1070 Propofol Sedation for Gastrointestinal Endoscopy Administered by Nursing Staff Under Gastroenterologist Supervision Alberto Baptista, Ydali Bonilla, Manuel Bronstein, Ramon Ruiz, Vera Jancovik, Fogel Roberto, Alberto Leamus, Yanira Veliz Introduction: Narcotics and Benzodiazepines has been widely used by gastrointestinal endoscopists. Propofol is a short acting hypnotic agent and its use has been described for gastrointestinal endoscopy sedation under anesthesiologist guidance. We report the use of propofol for GI endoscopy administered by nurses under Endoscopist supervision. Materials and Methods: Between October 2002 and October 2004 a total of 7000 endoscopic procedures were performed: 3494 diagnostic upper endoscopies, 2446 diagnostic colonoscopies, 300 therapeutic ERCP, 70 diagnostic EUS and 690 other therapeutic procedures. 71% of patients were ASA I or II. Total propofol dosages and procedure times were variable (median dose: 10-20 mg/minute of procedure). An additional suction system was used to manage saliva and secretions. Results: Procedure tolerance and sedation satisfaction were reported as good or excellent in 98% of cases. Median time to recovery of normal neuropsychomotor status was on average 15 minutes. Most of the patients (96%) could remember details of post-procedure interview. Ventilatory complication rate was 0.12%: Eight cases of P02 desaturation under 85% required mask ventilation over 1 to 4 minutes. In 1 patient ventilatory failure occurred during induction for ERCP using 30 mg of propofol; tracheal intubation and general anesthesia was used to complete procedure. No colonic perforations occurred in this population. 28% of patients complained of mild local pain at the injection site. Conclusions: Propofol Sedation administered by nursing staff under Gastroenterologist supervision for Gastrointestinal Endoscopy is a safe and efficient modality with high levels of patient acceptance and satisfaction.
www.mosby.com/gie