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Endoscopic Mucosal Resection of Large Colorectal Polyps: Feasibility and Safety
Abstracts
weekends versus weekdays. Methods: We conducted a prospective multicenter study from March 2005 to February 2006 in 53 French hospitals that included 3287 patients with UGIB. In a post hoc subanalysis, we analyzed the prognostic factors of UGIB using univariate analysis. Patients who did not undergo endoscopy were excluded (nZ204). Results: 3083 patients had an endoscopy, 684 (22.2%) during a weekend (G1) and 2399 (77.8%) during a weekday (G2). There was no statistical difference between the patients of G1 and G2 as regards the mean age and sex ratio. Patients from G1 were more frequently hospitalized in intensive care unit 21% vs. 11.6% (P!0.0001), however, the mean Rockall score was not different between the two groups 5.2 2.3 vs. 5 2.7 (PZ0.1), moreover, no more serious comorbidities were observed between the two groups 1.64 1.34 vs. 1.59 1.84 (PZ0.5). The mean time to endoscopy was significantly shorter in G1 vs. G2: 0.35 vs. 1.03 days (P !10-6). Specialized help for endoscopy was available in 40% of the cases during weekends vs. 85% of the cases during weekdays (P! 10-6). There was active bleeding (Forrest Ia, Ib, IIa, IIb) in 455 (66.5%) cases in G1 vs. 1288 (53.6%) cases in G2 (PZ0.003) resulting in endoscopic treatment in 208 (45.7%) vs. 634 (49.2%) cases (PZ0.2). In-hospital mortality was not different between G1 and G2: 59 (8.6%) vs. 164 (6.8%) (PZ0.13) while the rate of rebleeding was higher 12.6% vs. 9.1% (PZ0.01) in G1 vs. G2. Conclusion: Although the mean time to endoscopy is shorter during weekends vs. weekdays, this cannot be explained by the greater severity of the patients’ conditions but probably by their more frequent hospitalization in intensive care. The rate of rebleeding was higher among the patients who had had an endoscopy during the weekend but in-hospital mortality was the same; the explanatory reasons could be the frequent absence of specialized help.
M1403 A Novel Scoring System to Predict Poor Bowel Preparation for Colonoscopy Neeraj Prasad, Paul D. Mullins Introduction: Poor bowel preparation at colonoscopy leads to lower completion rates, missed lesions, increased patient discomfort, longer procedure time and higher risk of complications. Inadequate or incomplete examinations may result in the need for repeat procedures or alternative investigations. This has an impact on cost and resources. Good bowel preparation is, therefore, essential for high quality colonoscopy. Aims and Methods: The aim of this study was to analyse the characteristics of patients referred for colonoscopy and to devise a risk score to predict inadequate bowel preparation. This score will be used to identify those patients who require additional measures to ensure good bowel preparation. Data was gathered retrospectively using endoscopy reports, medical notes and nursing records. All patients had received the same bowel preparation (Citramag and Senna). The endoscopist’s judgement of the quality of bowel preparation (good, satisfactory and poor) was obtained from the colonoscopy report. Two groups were formed for analysis: adequate (those with good bowel preparation) and inadequate (those with satisfactory or poor bowel preparation). A total of 44 demographic and clinical parameters were analysed to devise the risk score using univariate statistical techniques and multivariate logistic regression. Results: Data from 127 patient procedures was analysed (56.7% female, median age 62 years, range 21-88). 115 (90.6%) procedures were performed on out-patients. 52 (40.9%) had adequate and 75 (59.1%) had inadequate bowel preparation. Of the inadequate preparation group, 40.2% had satisfactory and 18.9% had poor mucosal views on colonoscopy. Univariate analysis identified 7 possible predictive factors which were significantly associated with inadequate bowel preparation: advancing age (pZ0.045), residence in a nursing home (pZ0.006), lack of capacity to consent (pZ0.049), male gender (pZ0.002), restricted mobility (pZ0.007), procedure not on Monday (pZ0.039) and procedure on a morning list (pZ0.001). Following multivariate analysis, only the latter four factors reached statistical significance as independent risk factors for inadequate bowel preparation. Each of these four factors was assigned 1 point on a scoring system. Using this score, 80.3% of patients with a score of R2 and all patients with a score of R3 had inadequate bowel preparation in this cohort. Conclusion: This study has identified risk factors for inadequate bowel preparation, which were used to devise a predictive four point risk score. A score of R2 was highly predictive of inadequate bowel preparation. A further study is planned to validate the scoring system prospectively.
M1404 Endoscopic Mucosal Resection of Large Colorectal Polyps: Feasibility and Safety Moses Duku, Robert Mead, Pradeep Bhandari Introduction: Endoscopic resection of large and flat colonic polyps is associated with a high risk of perforation and bleeding. Historically, a significant number of these polyps were referred for surgical resection. However, with advances in therapeutic endoscopy, experienced endoscopists can now endoscopically resect most of these polyps safely. We established a colonic EMR service at Portsmouth
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towards the end of 2006. We have a dedicated colonic EMR list every week on which only 2 cases are booked. Our patients are all secondary referrals from other consultant colleagues or those referred to surgeons for surgical resection. Aims and Methods: To assess the feasibility and safety of endoscopic resection of large and difficult colorectal polyps. Records of all patients who had resection of polyps measuring more than 2 cm were retrieved from our EMR service database. We analysed the data for polyp location, morphology, completion of resection, complications and histological staging. Results112 polyps with a mean size of 43 mm (range 20 - 150 mm) were assessed for endoscopic resection. 23/112 (20.5%) appeared invasive and were referred for surgical resection. 79% of all resected polyps were left-sided and 75% were flat lesions (LST). In 92% of cases complete endoscopic resection was achieved in one session. EMR related complications were seen in 8/87 of cases. The complications were 1 micro-perforation (exposed muscle layer with no endoscopically visible defect) which was surgically treated, 2 delayed bleeds successfully treated endoscopically and 5 post polypectomy syndromes treated conservatively. There was no EMR related mortality. Post EMR pathological staging revealed 5 (6.0%) cases with a mean polyp size of 31 mm (range 20 - 50 mm), had adenocarcinoma invading the submucosa and underwent surgical resection. 3/5 had no residual tumour in the surgical resection specimen. Conclusions: Our series demonstrate that endoscopic resection of large (20150mm) and flat colonic polyps is feasible and can be done safely, with minimal morbidity and no mortality by experienced advanced endoscopists. The low incidence of invasive cancer in our series highlights the importance of careful endoscopic assessment before resection. We also found that polyps with cancers were not necessarily the largest in size.
M1405 Is Routine Use of Antispasmodic Necessary for Colonoscopy? Won Joong Jeon, Hee Bok Chae, Seon Mee Park, Sei Jin Youn Backgroud: Usefulness of antispasmodic premedication prior to colonoscopy is controversial and small number of patients had been enrolled in the most previous studies. Especially, there was no study to determine whether antispasmodic for colonoscopy is helpful to detect more polyps. Method: The effects on the performance of colonoscopy by premedication with the antispasmodic scopolamine bromide were studied in a prospective, double-blind, placebocontrolled trial. Two hundred fifty-five patients were randomly assigned to receive intravenous scopolamine 20 mg (n Z 135) or placebo (n Z 120) in conjunction with midazolam 0.07 mg/kg. Parameters measured included the time required to reach the cecum, total procedure time, and the pure withdrawal time except the time consumed during biopsy or polypectomy, difficulty of insertion (VAS 1-5), patient’s discomfort (VAS 1-4). Pulse rates and capillary oxygen concentrations were monitored during the procedure. Total number of observed polyps, number of neoplastic polyps and number of non-neoplastic polyps were counted. Results: Cecal intubation was successful in all patients of the both groups. Intubation times in scopolamine group and placebo group were 3.8 2.0 min and 4.1 1.6 min, respectively (pZ0.32). No significant differences in total procedure time, the pure withdrawal time, difficulty of insertion and patient’s discomfort were found. There were also no significant differences in total number of observed polyps, number of neoplastic polyps and number of non-neoplastic polyps in both groups. Conclusions: Premedication with intravenous scopolamine bromide was not beneficial in terms of the time required for cecal intubation, total procedure time, pure withdrawal time, difficulty of insertion and patient’s discomfort. Also, there was no difference in polyp detection rates in both groups. But, large-scale clinical studies involving multiple endoscopists are still required to confirm this conclusion.
M1406 Outcome and Risk Factors for Post-ERCP Pancreatitis Youn Joo Kim, Sang Hyub Lee, Ki Young Yang, Jeong Kyun Seo Introduction: Pancreatitis is one of the most common complications of ERCP. Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease. The purpose of this study was to identify the outcome and most important risk factors for post-ERCP pancreatitis. Patients and Methods: Patients with pancreatitis from ERCPs that were performed between September, 2004 to May, 2008, at Seoul National University Hospital and Bundang Seoul National University Hospital were analyzed retrospectively. All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, need for surgery and mortality. Risk factors were difficult cannulation, pancreatic opacification, underlying disease, etc. Results: 210 cases of pancreatitis were identified among 4579 ERCPs, with incidence rate of 4.6%. 43 cases needed hospitalization more than 10 days and were classified as severe. 2 out of those 43 cases were necrotizing pancretitis and required intervention, but there was no mortality case. Malignancy constitutes 41.9% of severe cases significantly higher than 27.7% of non-severe cases(pZ0.027). Repeated ERCP within 1 week resulted in 14% of severe pancreatitis as opposed to 4.2% of non-repeated ERCP.(pZ0.018) In addition, severe pancreatitis came about more frequently when biliary obstruction was not completely resolved after ERCP. There was no significant
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB233
weekends versus weekdays. Methods: We conducted a prospective multicenter study from March 2005 to February 2006 in 53 French hospitals that included 3287 patients with UGIB. In a post hoc subanalysis, we analyzed the prognostic factors of UGIB using univariate analysis. Patients who did not undergo endoscopy were excluded (nZ204). Results: 3083 patients had an endoscopy, 684 (22.2%) during a weekend (G1) and 2399 (77.8%) during a weekday (G2). There was no statistical difference between the patients of G1 and G2 as regards the mean age and sex ratio. Patients from G1 were more frequently hospitalized in intensive care unit 21% vs. 11.6% (P!0.0001), however, the mean Rockall score was not different between the two groups 5.2 2.3 vs. 5 2.7 (PZ0.1), moreover, no more serious comorbidities were observed between the two groups 1.64 1.34 vs. 1.59 1.84 (PZ0.5). The mean time to endoscopy was significantly shorter in G1 vs. G2: 0.35 vs. 1.03 days (P !10-6). Specialized help for endoscopy was available in 40% of the cases during weekends vs. 85% of the cases during weekdays (P! 10-6). There was active bleeding (Forrest Ia, Ib, IIa, IIb) in 455 (66.5%) cases in G1 vs. 1288 (53.6%) cases in G2 (PZ0.003) resulting in endoscopic treatment in 208 (45.7%) vs. 634 (49.2%) cases (PZ0.2). In-hospital mortality was not different between G1 and G2: 59 (8.6%) vs. 164 (6.8%) (PZ0.13) while the rate of rebleeding was higher 12.6% vs. 9.1% (PZ0.01) in G1 vs. G2. Conclusion: Although the mean time to endoscopy is shorter during weekends vs. weekdays, this cannot be explained by the greater severity of the patients’ conditions but probably by their more frequent hospitalization in intensive care. The rate of rebleeding was higher among the patients who had had an endoscopy during the weekend but in-hospital mortality was the same; the explanatory reasons could be the frequent absence of specialized help.
M1403 A Novel Scoring System to Predict Poor Bowel Preparation for Colonoscopy Neeraj Prasad, Paul D. Mullins Introduction: Poor bowel preparation at colonoscopy leads to lower completion rates, missed lesions, increased patient discomfort, longer procedure time and higher risk of complications. Inadequate or incomplete examinations may result in the need for repeat procedures or alternative investigations. This has an impact on cost and resources. Good bowel preparation is, therefore, essential for high quality colonoscopy. Aims and Methods: The aim of this study was to analyse the characteristics of patients referred for colonoscopy and to devise a risk score to predict inadequate bowel preparation. This score will be used to identify those patients who require additional measures to ensure good bowel preparation. Data was gathered retrospectively using endoscopy reports, medical notes and nursing records. All patients had received the same bowel preparation (Citramag and Senna). The endoscopist’s judgement of the quality of bowel preparation (good, satisfactory and poor) was obtained from the colonoscopy report. Two groups were formed for analysis: adequate (those with good bowel preparation) and inadequate (those with satisfactory or poor bowel preparation). A total of 44 demographic and clinical parameters were analysed to devise the risk score using univariate statistical techniques and multivariate logistic regression. Results: Data from 127 patient procedures was analysed (56.7% female, median age 62 years, range 21-88). 115 (90.6%) procedures were performed on out-patients. 52 (40.9%) had adequate and 75 (59.1%) had inadequate bowel preparation. Of the inadequate preparation group, 40.2% had satisfactory and 18.9% had poor mucosal views on colonoscopy. Univariate analysis identified 7 possible predictive factors which were significantly associated with inadequate bowel preparation: advancing age (pZ0.045), residence in a nursing home (pZ0.006), lack of capacity to consent (pZ0.049), male gender (pZ0.002), restricted mobility (pZ0.007), procedure not on Monday (pZ0.039) and procedure on a morning list (pZ0.001). Following multivariate analysis, only the latter four factors reached statistical significance as independent risk factors for inadequate bowel preparation. Each of these four factors was assigned 1 point on a scoring system. Using this score, 80.3% of patients with a score of R2 and all patients with a score of R3 had inadequate bowel preparation in this cohort. Conclusion: This study has identified risk factors for inadequate bowel preparation, which were used to devise a predictive four point risk score. A score of R2 was highly predictive of inadequate bowel preparation. A further study is planned to validate the scoring system prospectively.
M1404 Endoscopic Mucosal Resection of Large Colorectal Polyps: Feasibility and Safety Moses Duku, Robert Mead, Pradeep Bhandari Introduction: Endoscopic resection of large and flat colonic polyps is associated with a high risk of perforation and bleeding. Historically, a significant number of these polyps were referred for surgical resection. However, with advances in therapeutic endoscopy, experienced endoscopists can now endoscopically resect most of these polyps safely. We established a colonic EMR service at Portsmouth
www.giejournal.org
towards the end of 2006. We have a dedicated colonic EMR list every week on which only 2 cases are booked. Our patients are all secondary referrals from other consultant colleagues or those referred to surgeons for surgical resection. Aims and Methods: To assess the feasibility and safety of endoscopic resection of large and difficult colorectal polyps. Records of all patients who had resection of polyps measuring more than 2 cm were retrieved from our EMR service database. We analysed the data for polyp location, morphology, completion of resection, complications and histological staging. Results112 polyps with a mean size of 43 mm (range 20 - 150 mm) were assessed for endoscopic resection. 23/112 (20.5%) appeared invasive and were referred for surgical resection. 79% of all resected polyps were left-sided and 75% were flat lesions (LST). In 92% of cases complete endoscopic resection was achieved in one session. EMR related complications were seen in 8/87 of cases. The complications were 1 micro-perforation (exposed muscle layer with no endoscopically visible defect) which was surgically treated, 2 delayed bleeds successfully treated endoscopically and 5 post polypectomy syndromes treated conservatively. There was no EMR related mortality. Post EMR pathological staging revealed 5 (6.0%) cases with a mean polyp size of 31 mm (range 20 - 50 mm), had adenocarcinoma invading the submucosa and underwent surgical resection. 3/5 had no residual tumour in the surgical resection specimen. Conclusions: Our series demonstrate that endoscopic resection of large (20150mm) and flat colonic polyps is feasible and can be done safely, with minimal morbidity and no mortality by experienced advanced endoscopists. The low incidence of invasive cancer in our series highlights the importance of careful endoscopic assessment before resection. We also found that polyps with cancers were not necessarily the largest in size.
M1405 Is Routine Use of Antispasmodic Necessary for Colonoscopy? Won Joong Jeon, Hee Bok Chae, Seon Mee Park, Sei Jin Youn Backgroud: Usefulness of antispasmodic premedication prior to colonoscopy is controversial and small number of patients had been enrolled in the most previous studies. Especially, there was no study to determine whether antispasmodic for colonoscopy is helpful to detect more polyps. Method: The effects on the performance of colonoscopy by premedication with the antispasmodic scopolamine bromide were studied in a prospective, double-blind, placebocontrolled trial. Two hundred fifty-five patients were randomly assigned to receive intravenous scopolamine 20 mg (n Z 135) or placebo (n Z 120) in conjunction with midazolam 0.07 mg/kg. Parameters measured included the time required to reach the cecum, total procedure time, and the pure withdrawal time except the time consumed during biopsy or polypectomy, difficulty of insertion (VAS 1-5), patient’s discomfort (VAS 1-4). Pulse rates and capillary oxygen concentrations were monitored during the procedure. Total number of observed polyps, number of neoplastic polyps and number of non-neoplastic polyps were counted. Results: Cecal intubation was successful in all patients of the both groups. Intubation times in scopolamine group and placebo group were 3.8 2.0 min and 4.1 1.6 min, respectively (pZ0.32). No significant differences in total procedure time, the pure withdrawal time, difficulty of insertion and patient’s discomfort were found. There were also no significant differences in total number of observed polyps, number of neoplastic polyps and number of non-neoplastic polyps in both groups. Conclusions: Premedication with intravenous scopolamine bromide was not beneficial in terms of the time required for cecal intubation, total procedure time, pure withdrawal time, difficulty of insertion and patient’s discomfort. Also, there was no difference in polyp detection rates in both groups. But, large-scale clinical studies involving multiple endoscopists are still required to confirm this conclusion.
M1406 Outcome and Risk Factors for Post-ERCP Pancreatitis Youn Joo Kim, Sang Hyub Lee, Ki Young Yang, Jeong Kyun Seo Introduction: Pancreatitis is one of the most common complications of ERCP. Data regarding the clinical course and outcome of post-ERCP pancreatitis are sparse, although the available data suggest it to be a severe disease. The purpose of this study was to identify the outcome and most important risk factors for post-ERCP pancreatitis. Patients and Methods: Patients with pancreatitis from ERCPs that were performed between September, 2004 to May, 2008, at Seoul National University Hospital and Bundang Seoul National University Hospital were analyzed retrospectively. All consecutive patients with post-ERCP-AP were included. They were managed according to a standard protocol. Outcome measures were severity of pancreatitis, need for surgery and mortality. Risk factors were difficult cannulation, pancreatic opacification, underlying disease, etc. Results: 210 cases of pancreatitis were identified among 4579 ERCPs, with incidence rate of 4.6%. 43 cases needed hospitalization more than 10 days and were classified as severe. 2 out of those 43 cases were necrotizing pancretitis and required intervention, but there was no mortality case. Malignancy constitutes 41.9% of severe cases significantly higher than 27.7% of non-severe cases(pZ0.027). Repeated ERCP within 1 week resulted in 14% of severe pancreatitis as opposed to 4.2% of non-repeated ERCP.(pZ0.018) In addition, severe pancreatitis came about more frequently when biliary obstruction was not completely resolved after ERCP. There was no significant
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB233