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Feasible Endoscopic Removal of Covered Self-Expandable Biliary Metallic Stents in Contrast to Uncovered One
Abstracts
S1432 Feasible Endoscopic Removal of Covered Self-Expandable Biliary Metallic Stents in Contrast to Uncovered One Hyun Phil Shin, Myung-Hwan Kim, Seok Won Jung, Jong Cheol Kim, Eun Kwang Choi, Jimin Han, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee Background and Study Aims: The transpapillary endoscopic insertion of selfexpandable metallic stents (SEMS) have been widely used for obstructive jaundice associated with inoperable malignant biliary stricture. The most frequent problem of SEMS is stent occlusion and endoscopic removal of malfunctioning biliary SEMS is known to be difficult. We tried removal of malfunctioning SEMS endoscopically and compared the results between covered and uncovered SEMS group. Patients and Methods: In a prospective study, twenty six patients with malfunctioning SEMS underwent endoscopic removal of biliary SEMS over 2-year period. Removal of malfunctioning SEMS were performed with therapeutic duodenoscope (ED450XT5; Fujinon, TJF-240; Olympus) and only by using rat tooth forceps. All covered SEMS were silicone-covered Wallstent (Boston Scientific corp.). Among the 7 uncovered SEMS, 4 were Wallstent and the other 3 were Zilver stent (Cook corp.). Results: Covered SEMS were easily removed in 16 out of 19 patients (84.2%) compared with uncovered SEMS (0/7, 0%). Median duration of stents placement was 4 months (range 1-10 months) in the covered stent group and 3 months (range 1-5 months) in the uncoverd one. In the covered stent group, stents could be removed endoscopically 100% (13/13) in patients with less than 5 months of stents placement in situ while 50% (3/6) in patients with more than 5 months of stents placement in situ. On the contrary, in the uncovered stent group, stents could be removed endoscopically in none (0/7, 0%) of the patients irrespective of duration of stents placement. There was no complication associated with endoscopic stents removal. Conclusions: Unlike uncovered SEMS, endoscopic removal of malfunctioning covered SEMS can be removed easily and safely by rat tooth forceps in most case and the feasibility of removal may be influenced by duration of stent placement.
Introduction: Sometimes colonoscopy is hindered due to pain during insertion into the cecum. One of the causes of pain during insertion of the colonoscope is stretching of the mesenterium by loop formation of the instrument and the degree of the pain is different from types of looping formation. (N,a, reverse a,g, unclassified looping) On the other hand these are said to be predictive factors of difficult colonoscopy in patient to insertion to the cecum: female, older age, slim patient, history of abdominal or pelvic surgery, severe deverticulosis, constipation and laxative use. And we expected those patient who have these factors might sense a pain during procedure. The aims of this study were 1, to assess the degree of pain according to the type of loop formation during colonoscopy. 2, to assess the degree of pain by each of those factors. Method: Consecutive two hundreds eightythree patients undergoing colonoscopy were enrolled from June 2004 to May 2005. Patients with colonic resections, poor bowel preparation and severe stricture in the colon were excluded. All procedures were performed by two expert endoscopists, blind to imager view. The device was 130cm video colonoscope with an in-built magnetic imaging (Olympus Optical Co, Ltd, Tokyo Japan 240DI). Stiffening function was not used. All patients were sedated with meperidine (17.5 mg to 35 mg). The degree of patient pain was assessed using the visual analogue scale (VAS 0 Z not at all 100 Z very severe). And following patient data which are predictive factor of pain were recorded: age, gender, BMI, history of abdominal surgery, pelvic surgery including gynetic operation, diverticular disease, constipation, laxative use. The degree of pain of each type of loops and the degree of pain in those patients were retrospectively analyzed. Result: The degree of pain were significantly higher in reverse alpha loop (55.9 mm; p ! 0.05), gamma loop (48.6 mm; p ! 0.05), uncommon loop (55 mm; p ! 0.05) than in N loop (34.1 mm), alpha loop (35.7 mm), none (11.6 mm). Women experienced more pain than men significantly. (43.6 mm vs. 28.1 mm; p ! 0.001) Women who have diverticular disease in sigmoid colon (72.1 mm; p ! 0.05) and prior history of pelvic surgery (62.0 mm; p ! 0.05) have pain more severe than those who don’t have. In men there were no differences between the each group. Conclusion: In reverse alpha loop, gamma loop, uncommon loop patient had severe pain even if expert colonoscopists do the procedure, so the beginners had better use MEI before these loops were formed. Pediatric colonoscope or dosages of sedation should be considered in women who have diverticular disease in sigmoid colon and prior history of pelvic surgery.
S1433 Does Aspirin Increase the Risk of Bleeding for Percutaneous Endoscopic Gastrostomy Procedure? Prasun K. Jalal, Mark Hall, Sam Davidoff, Kostas Sideridis, Simmy Bank Background: Bleeding is a potential complication following the placement of a percutaneous endoscopic gastrostomy (PEG) tube. Aspirin is commonly used for associated co morbid condition in patients requiring PEG placement. Although aspirin is commonly withdrawn before the procedure, the risk of bleeding on continuing aspirin is not known. Aim: The aim of the study was to determine the risk of bleeding for PEG tube placement in patients with aspirin. Methods: The records of 312 consecutive patients who had PEG procedure as inpatient were reviewed. The incidence of bleeding was noted in patients who remained on aspirin or received aspirin within 5 days before the procedure (group A) and compared with patients who did not receive aspirin or in whom aspirin was stopped more than 7 days before the procedure (group B). The presence of coagulopathy, thrombocytopenia and other antiplatelet agent, including clopidogrel, was recorded in all patients. The primary outcome was overt bleeding within 48 hrs, and secondary outcomes were drop of hemoglobin by 2 gm, any requirement of blood transfusion, or intervention including endoscoscpy, during the hospital stay. Fisher’s exact test was used to calculate the difference between two groups. Results: 106 (34.4%) patients were included in group A (Age 27-98 yrs, median 79 yrs), and 202 (65.6%) were in group B (Age 22-100 yrs, median 78 yrs); 4 patients were excluded due to discharge within 48 hrs of the procedure. Bleeding was seen in 10 (3.2%) patients; 7 (6.6%) in group A (all received aspirin within 48 hrs before the procedure), and 3 (1.5%) in group B. The difference was not statistically significant (p Z 0.1). Among patients with bleeding, 2 patients in group A and one patient in group B were on coumadin (INR 1.8-2.2) at the time of procedure. In addition, 2 patients in group A were on clopidogrel that was not stopped. One patient in group A had hematoma at the PEG tube site. All patients were managed with stopping the respective drug/s, blood transfusion (required in 7 patients, 1-3 units of PRBC), and one patient in group B required left gastric artery embolization. None of patients in either group died due to bleeding related complications. Conclusions: Use of aspirin does not increase the risk of bleeding in patients undergoing PEG procedure. The post-procedure bleeding does not lead to increase in mortality. Concomitant use of coumadin or anti-platelet agents may increase the risk of bleeding, but it needs confirmation with studies with a larger sample size.
S1434 Evaluation of Patient Pain During Colonoscopy for Types of Looping and Predictive Difficult Factors in Patients: An Analysis Using Magnetic Endoscope Imaging Koichiro Sato, Sayo Itoh, Yoshinori Saegusa, Koichi Hirahata, Kenji Tominaga, Hiroaki Suda, Tadayoshi Kakemura, Sumio Fujinuma, Yoshihiro Sakai
www.giejournal.org
S1435 Diagnostic Yield of Routine Chromoendoscopy for Esophageal Dysplasia in Asymptomatic Older Population Jae Woo Kim, Hyun Soo Kim, Kyu Hong Kim, Hye Jung Kim, Myeong Gwan Jee, Soon Koo Baik, Sang Ok Kwon Background and Aims: Esophageal cancer is one of the neoplasm with the worst prognosis among digestive tract tumors, probably due to late detection. The aim of this study was to evaluate the diagnostic yield of routine chromoendoscopy using Lugol’s solution for the detection of esophageal dysplasia in patients with old age (R65 years). Patients and Method: From March 2005 to October 2005, a prospective observational study involving 143 patients was carried out. All patients underwent conventional esophagoscopy during insertion of scope, and followed by chromoendoscopy using 2% Lugol’s solution on the entire esophagus during scope withdrawal. The endoscopic appearances before and after staining were compared, and biopsies were obtained from all unstained areas after spraying Lugol’s solution. A total of 143 patients were enrolled in the study and were divided into 2 groups according to endoscopic findings or biopsy results; no dysplasia vs. dysplasia group. Factors that can be related to the presence of esophageal dysplasia in asymptomatic older patients were analyzed. Results: The study population was made up of 143 patients between the ages of 65 and 84 (mean 71.5 G 4.9 years; M: F Z 82:61). Chromoendoscopy was well tolerated in all patients without significant adverse effects. Of these, a total of 67 unstained areas in 36 (25.2%) patients (17 patients; one unstained area, 19 patients; more than two unstained areas) were detected by chromoendoscoy in the esophagus and biopsy was performed at each unstained area. However, all of these unstained areas were not detected by conventional endoscopy. Of these 67 areas, 47 areas had diameters between 1 and 5 mm, 19 areas between 6 and 10 mm, and 1 area over 11 mm. About half (n Z 34 areas; 50.7%) of unstained areas were located in the lower esophagus, and the rest of them were in the middle (n Z 27; 40.3%) and upper (n Z 6; 9%) esophagus. As a result of histology, 12 lesions in 7 patients and 2 lesions in 2 patients were diagnosed as low-grade dysplasia and high-grade dysplasia, respectively. However, there were no significant associations between esophageal dysplasia and gender, past history of smoking or alcohol, Barrett’s esophagus, reflux esophagitis, location and diameter of lesion. Conclusions: In asymptomatic older population, routine chromoendoscopy significantly improves the detection rate of esophageal dysplasia, which can be overlooked by conventional endoscopy, and therefore, should be considered for routine clinical practice for this older population.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB107
S1432 Feasible Endoscopic Removal of Covered Self-Expandable Biliary Metallic Stents in Contrast to Uncovered One Hyun Phil Shin, Myung-Hwan Kim, Seok Won Jung, Jong Cheol Kim, Eun Kwang Choi, Jimin Han, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee Background and Study Aims: The transpapillary endoscopic insertion of selfexpandable metallic stents (SEMS) have been widely used for obstructive jaundice associated with inoperable malignant biliary stricture. The most frequent problem of SEMS is stent occlusion and endoscopic removal of malfunctioning biliary SEMS is known to be difficult. We tried removal of malfunctioning SEMS endoscopically and compared the results between covered and uncovered SEMS group. Patients and Methods: In a prospective study, twenty six patients with malfunctioning SEMS underwent endoscopic removal of biliary SEMS over 2-year period. Removal of malfunctioning SEMS were performed with therapeutic duodenoscope (ED450XT5; Fujinon, TJF-240; Olympus) and only by using rat tooth forceps. All covered SEMS were silicone-covered Wallstent (Boston Scientific corp.). Among the 7 uncovered SEMS, 4 were Wallstent and the other 3 were Zilver stent (Cook corp.). Results: Covered SEMS were easily removed in 16 out of 19 patients (84.2%) compared with uncovered SEMS (0/7, 0%). Median duration of stents placement was 4 months (range 1-10 months) in the covered stent group and 3 months (range 1-5 months) in the uncoverd one. In the covered stent group, stents could be removed endoscopically 100% (13/13) in patients with less than 5 months of stents placement in situ while 50% (3/6) in patients with more than 5 months of stents placement in situ. On the contrary, in the uncovered stent group, stents could be removed endoscopically in none (0/7, 0%) of the patients irrespective of duration of stents placement. There was no complication associated with endoscopic stents removal. Conclusions: Unlike uncovered SEMS, endoscopic removal of malfunctioning covered SEMS can be removed easily and safely by rat tooth forceps in most case and the feasibility of removal may be influenced by duration of stent placement.
Introduction: Sometimes colonoscopy is hindered due to pain during insertion into the cecum. One of the causes of pain during insertion of the colonoscope is stretching of the mesenterium by loop formation of the instrument and the degree of the pain is different from types of looping formation. (N,a, reverse a,g, unclassified looping) On the other hand these are said to be predictive factors of difficult colonoscopy in patient to insertion to the cecum: female, older age, slim patient, history of abdominal or pelvic surgery, severe deverticulosis, constipation and laxative use. And we expected those patient who have these factors might sense a pain during procedure. The aims of this study were 1, to assess the degree of pain according to the type of loop formation during colonoscopy. 2, to assess the degree of pain by each of those factors. Method: Consecutive two hundreds eightythree patients undergoing colonoscopy were enrolled from June 2004 to May 2005. Patients with colonic resections, poor bowel preparation and severe stricture in the colon were excluded. All procedures were performed by two expert endoscopists, blind to imager view. The device was 130cm video colonoscope with an in-built magnetic imaging (Olympus Optical Co, Ltd, Tokyo Japan 240DI). Stiffening function was not used. All patients were sedated with meperidine (17.5 mg to 35 mg). The degree of patient pain was assessed using the visual analogue scale (VAS 0 Z not at all 100 Z very severe). And following patient data which are predictive factor of pain were recorded: age, gender, BMI, history of abdominal surgery, pelvic surgery including gynetic operation, diverticular disease, constipation, laxative use. The degree of pain of each type of loops and the degree of pain in those patients were retrospectively analyzed. Result: The degree of pain were significantly higher in reverse alpha loop (55.9 mm; p ! 0.05), gamma loop (48.6 mm; p ! 0.05), uncommon loop (55 mm; p ! 0.05) than in N loop (34.1 mm), alpha loop (35.7 mm), none (11.6 mm). Women experienced more pain than men significantly. (43.6 mm vs. 28.1 mm; p ! 0.001) Women who have diverticular disease in sigmoid colon (72.1 mm; p ! 0.05) and prior history of pelvic surgery (62.0 mm; p ! 0.05) have pain more severe than those who don’t have. In men there were no differences between the each group. Conclusion: In reverse alpha loop, gamma loop, uncommon loop patient had severe pain even if expert colonoscopists do the procedure, so the beginners had better use MEI before these loops were formed. Pediatric colonoscope or dosages of sedation should be considered in women who have diverticular disease in sigmoid colon and prior history of pelvic surgery.
S1433 Does Aspirin Increase the Risk of Bleeding for Percutaneous Endoscopic Gastrostomy Procedure? Prasun K. Jalal, Mark Hall, Sam Davidoff, Kostas Sideridis, Simmy Bank Background: Bleeding is a potential complication following the placement of a percutaneous endoscopic gastrostomy (PEG) tube. Aspirin is commonly used for associated co morbid condition in patients requiring PEG placement. Although aspirin is commonly withdrawn before the procedure, the risk of bleeding on continuing aspirin is not known. Aim: The aim of the study was to determine the risk of bleeding for PEG tube placement in patients with aspirin. Methods: The records of 312 consecutive patients who had PEG procedure as inpatient were reviewed. The incidence of bleeding was noted in patients who remained on aspirin or received aspirin within 5 days before the procedure (group A) and compared with patients who did not receive aspirin or in whom aspirin was stopped more than 7 days before the procedure (group B). The presence of coagulopathy, thrombocytopenia and other antiplatelet agent, including clopidogrel, was recorded in all patients. The primary outcome was overt bleeding within 48 hrs, and secondary outcomes were drop of hemoglobin by 2 gm, any requirement of blood transfusion, or intervention including endoscoscpy, during the hospital stay. Fisher’s exact test was used to calculate the difference between two groups. Results: 106 (34.4%) patients were included in group A (Age 27-98 yrs, median 79 yrs), and 202 (65.6%) were in group B (Age 22-100 yrs, median 78 yrs); 4 patients were excluded due to discharge within 48 hrs of the procedure. Bleeding was seen in 10 (3.2%) patients; 7 (6.6%) in group A (all received aspirin within 48 hrs before the procedure), and 3 (1.5%) in group B. The difference was not statistically significant (p Z 0.1). Among patients with bleeding, 2 patients in group A and one patient in group B were on coumadin (INR 1.8-2.2) at the time of procedure. In addition, 2 patients in group A were on clopidogrel that was not stopped. One patient in group A had hematoma at the PEG tube site. All patients were managed with stopping the respective drug/s, blood transfusion (required in 7 patients, 1-3 units of PRBC), and one patient in group B required left gastric artery embolization. None of patients in either group died due to bleeding related complications. Conclusions: Use of aspirin does not increase the risk of bleeding in patients undergoing PEG procedure. The post-procedure bleeding does not lead to increase in mortality. Concomitant use of coumadin or anti-platelet agents may increase the risk of bleeding, but it needs confirmation with studies with a larger sample size.
S1434 Evaluation of Patient Pain During Colonoscopy for Types of Looping and Predictive Difficult Factors in Patients: An Analysis Using Magnetic Endoscope Imaging Koichiro Sato, Sayo Itoh, Yoshinori Saegusa, Koichi Hirahata, Kenji Tominaga, Hiroaki Suda, Tadayoshi Kakemura, Sumio Fujinuma, Yoshihiro Sakai
www.giejournal.org
S1435 Diagnostic Yield of Routine Chromoendoscopy for Esophageal Dysplasia in Asymptomatic Older Population Jae Woo Kim, Hyun Soo Kim, Kyu Hong Kim, Hye Jung Kim, Myeong Gwan Jee, Soon Koo Baik, Sang Ok Kwon Background and Aims: Esophageal cancer is one of the neoplasm with the worst prognosis among digestive tract tumors, probably due to late detection. The aim of this study was to evaluate the diagnostic yield of routine chromoendoscopy using Lugol’s solution for the detection of esophageal dysplasia in patients with old age (R65 years). Patients and Method: From March 2005 to October 2005, a prospective observational study involving 143 patients was carried out. All patients underwent conventional esophagoscopy during insertion of scope, and followed by chromoendoscopy using 2% Lugol’s solution on the entire esophagus during scope withdrawal. The endoscopic appearances before and after staining were compared, and biopsies were obtained from all unstained areas after spraying Lugol’s solution. A total of 143 patients were enrolled in the study and were divided into 2 groups according to endoscopic findings or biopsy results; no dysplasia vs. dysplasia group. Factors that can be related to the presence of esophageal dysplasia in asymptomatic older patients were analyzed. Results: The study population was made up of 143 patients between the ages of 65 and 84 (mean 71.5 G 4.9 years; M: F Z 82:61). Chromoendoscopy was well tolerated in all patients without significant adverse effects. Of these, a total of 67 unstained areas in 36 (25.2%) patients (17 patients; one unstained area, 19 patients; more than two unstained areas) were detected by chromoendoscoy in the esophagus and biopsy was performed at each unstained area. However, all of these unstained areas were not detected by conventional endoscopy. Of these 67 areas, 47 areas had diameters between 1 and 5 mm, 19 areas between 6 and 10 mm, and 1 area over 11 mm. About half (n Z 34 areas; 50.7%) of unstained areas were located in the lower esophagus, and the rest of them were in the middle (n Z 27; 40.3%) and upper (n Z 6; 9%) esophagus. As a result of histology, 12 lesions in 7 patients and 2 lesions in 2 patients were diagnosed as low-grade dysplasia and high-grade dysplasia, respectively. However, there were no significant associations between esophageal dysplasia and gender, past history of smoking or alcohol, Barrett’s esophagus, reflux esophagitis, location and diameter of lesion. Conclusions: In asymptomatic older population, routine chromoendoscopy significantly improves the detection rate of esophageal dysplasia, which can be overlooked by conventional endoscopy, and therefore, should be considered for routine clinical practice for this older population.
Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB107