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Improving the Quality of Colonoscopy in Term of Visibility By Adding Simethicone to Sodium Phosphate for Bowel Preparation
Abstracts
the 19 pt (5%), tumour-freedom had not been achieved after a total of 2 ER. This patient died of a heart-attack before surgery could be performed. The calculated 5year survival rate of all 21 pt was 66%. Metastatic disease in Barrett’s cancer or tumour-related death were not observed. Conclusions: As in mucosal Barrett’s cancer, ER is associated with favourable outcomes even in case of ‘‘low risk’’ submucosal Barrett’s cancer. Further and larger clinical trials are required, before a general recommendation for ER as the treatment of choice in ‘‘low risk’’ submucosal Barrett’s cancer can be given.
235 Endoscopic Cryotherapy Ablation Is Safe and Well-Tolerated in Barrett’s Esophagus, Esophageal Dysplasia, and Esophageal Cancer Bruce D. Greenwald, J. David Horwhat, Julian a. Abrams, Charles J. Lightdale, John a. Dumot Background: Endoscopic cryotherapy using low pressure liquid nitrogen spray is a new ablation technique for eliminating malignant and premalignant conditions of the esophagus. Aim: To evaluate the safety and tolerability of endoscopic cryotherapy ablation for malignant and premalignant conditions in the esophagus. Methods: Data from all patients treated under IRB-approved research protocol at 4 sites was analyzed. Conditions treated included Barrett’s esophagus without dysplasia (BE), Barrett’s esophagus with high-grade dysplasia (HGD) or intramucosal cancer (IMCA), esophageal carcinoma (T1 or T2 N0 M0), and severe squamous dysplasia (SSD). All patients were treated with cryotherapy every 4 - 6 weeks to eliminate the target lesion. Adverse events and side effects were reviewed by personal contact or telephone call to the patient 1 to 10 days after every procedure. Symptom severity was described by patients as mild, moderate, or severe. Results: 77 patients (57 male, 20 female) received 323 cryotherapy treatments between 9/28/05 and 11/27/07. Median age was 69 years (range 36-93). Median length of esophagus treated was 4 cm (range 0.5 - 15). Median number of treatments was 4 (range 1 - 10). Diagnoses were BE - 7 (9.1%), HGD - 45 (58.4%), IMCA - 13 (16.9%), cancer - 10 (13.0%), and SSD - 2 (2.6%). Serious adverse events related to treatment included 1 gastric perforation in a patient with Marfan’s syndrome and 1 lip ulcer due to cold injury from scope contact. Minor adverse events included 3 patients with stricture which responded to a single dilation. Patients reported no side effects in 155 procedures (48%). Frequency of side effects for procedures is shown in the table. Conclusion: Endoscopic cryotherapy ablation using low pressure liquid nitrogen spray is safe and very well-tolerated. Table. Side Effects in 323 cryotherapy procedures Side Effect n (%)
Chest Pain
Abdominal Sore Irregular Dysphagia Odynophagia Nausea Pain Throat Heartbeat Fever
45 (13.9%) 24 (7.4%) 10 Moderate (3.1%) 19 (5.9%) Mild
Severe
2 (0.6%) 0
27 (8.4%)
16 (5.0%)
10 (3.1%)
11 (3.4%)
0
1 (0.3%)
1 (0.3%)
0
3 (0.9%)
29 (9.0%) 1 (0.3%) 1 (0.3%)
8 (2.5%)
3 (0.9%)
0
0
0
0
236 Low Rate of Invasive Cancer in Patients Undergoing Mucosectomy for Barrett’s Esophagus (BE) and High Grade Dysplasia (HGD) Or Intramucosal Carcinoma (IMC) Vani J. Konda, Jennifer S. Chennat, Andrew S. Ross, Shang P. Lin, Barbara M. Cislo, Lynne Stearns, Amy E. Noffsinger, John Hart, Mitchell C. Posner, Mark K. Ferguson, Irving Waxman Background: The literature reports vastly different rates of invasive esophageal adenocarcinoma (IEAC) discovered at esophagectomy in patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) and often approximates a rate of around 40%. Our analysis of the literature using strict pathological definitions revealed a prevalence of occult IEAC at 12%. [1] The risk of occult IEAC in patients with BE with HGD and intramucosal carcinoma (IMC) is critical to properly evaluate options as endoscopic treatments emerge for BE. Aim: To determine the prevalence of IEAC in patients who underwent complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for BE with HGD or IMC in order to assess the rate of occult IEAC with current endoscopic technology. Methods: A retrospective analysis of a prospective database of all patients undergoing CBE-EMR at a single tertiary center was performed. We define IEAC as tumor with submucosal invasion or beyond. Non-visible lesions are those not detected with white light endoscopy. Results: 44 patients (34 male) with BE with HGD or IMC underwent CBE-EMR from August 1, 2003 to November 15, 2007. 25 patients had short segment BE, and 20 had no visible lesion. 13 patients had IMC, and the rest had HGD. IEAC was found in EMR specimens in 6.8% (3) of the patients. 2 patients had evidence of submucosal invasion and 1 had evidence of IMC with mucosal lymphatic invasion; these patients were referred for esophagectomy. All IEAC patients had visible lesions seen on endoscopy. None of the patients with non-visible lesions had IEAC.
AB76 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
21 patients have completed the CBE-EMR treatment and are in surveillance; no cases of IEAC have been identified during intensive endoscopic surveillance (median remission time 18 months, up to 51 months). One patient died of unrelated causes. 18 patients are still undergoing CBE-EMR treatment; however, no additional cases of invasive adenocarcinoma have been identified. Conclusions: In BE patients presenting with HGD or IMC, our series demonstrates a rate of occult IEAC at 6.8% in the resection specimens. Furthermore, in the absence of visible lesions, the prevalence was 0%. Further work should clarify what factors, such as visible lesions, improve the diagnosis of IEAC. EMR appears to be a promising treatment modality for BE with HGD or IMC since EMR is less invasive than esophagectomy, and still provides pathologic specimens to gauge success or need for further treatment. [1] Konda, Ross, Ferguson, et al. Is the Risk of Concomitant Invasive Esophageal Cancer in High Grade Dysplasia in Barrett’s Esophagus Overestimated? Clin Gastroenterol Hepatol. In press.
237 Duration of the Interval Between Completion of the Bowel Preparation and Start of the Colonoscopy As a Better Predictor of Bowel Preparation Quality Than Colonoscopy Start Time Alone Kenneth Yang, Ali Siddiqui, Stuart J. Spechler, Byron L. Cryer, Raquel E. Davila, William Harford Objective: Effective bowel preparation (BP) improves colonoscopy by reducing the rate of missed lesions and incomplete examinations. Previous studies have suggested that the time of day when colonoscopy is started has a significant influence on the quality of the BP, with morning procedures having superior quality compared to those performed in the afternoon. The aim of our study was to determine whether the duration of the interval between the end of the BP and the start of the colonoscopy affects the quality of the BP. Methods: We gathered data prospectively over a three month period on consecutive outpatients who had colonoscopies performed at a VA Medical Center. Medical histories, demographics, compliance with the BP and dietary restrictions, and the time since the last dose of BP agent were recorded immediately prior to the colonoscopy. Patients who had a right hemicolectomy were excluded. Senior staff endoscopists and endoscopy nurses independently graded the quality of the BP for the right colon on a five point scale (0 Z excellent to 4 Z inadequate) using a standardized ‘‘preparation quality’’ scale with photographic examples of the 5 BP grades. Endoscopists also were asked to document the presence or absence of succus (thin, adherent, bilestained film) in the right colon. Results: We studied 378 patients (95.7% men, mean age 62.2 years); 97.3% received polyethylene glycol electrolyte-based (PEG) solution, and 2.7% received oral sodium phosphate for BP. In patients whose preparations were scored as excellent/good, the interval between the time of the last BP agent dose and the start time of the colonoscopy was significantly shorter than in those whose preparations were scored fair/poor/inadequate (p Z 0.013). In contrast, we found no significant difference in BP quality between morning and afternoon colonoscopies. We also found no significant relationship between the presence of succus and the time interval from the last dose of BP agent, or between BP quality and the interval from the time of the last solid meal to the start of the colonoscopy. There was good agreement between physician endoscopists and nurses in grading BP quality using our preparation quality scale (Pearson correlation coefficient of 0.74). Conclusions: For bowel preparation quality, the duration of the interval between the completion of the bowel preparation and the start of the colonoscopy appears to be more important than the time of day when colonoscopy is performed. Bowel preparation quality varies inversely with the duration of the interval between the last dose of the bowel preparation agent and the start of the colonoscopy.
238 Improving the Quality of Colonoscopy in Term of Visibility By Adding Simethicone to Sodium Phosphate for Bowel Preparation Sasinee Tongprasert, Abhasnee Sobhonslidsuk, Panida Thong-Uthaisri, Narin Achalanan, Chutima Pramoolsinsap, Chomsri Kositchaiwat, Sasivimol Rattanasiri Background: Sodium phosphate is one of the bowel preparation regimens for colonoscopy. However, intraluminal gas can impair visibility during the examination. Simethicone is medication that works by reducing the surface tension of air bubbles. We aimed to evaluate the effect of simethicone in enhancing visibility and efficacy during colonoscopy. Methods: A prospective, randomized, double-blinded, placebo-controlled study was conducted. One hundred and twenty-four patients were allocated to receive 2 dosages of either 45 ml of sodium phosphate plus 240 mg of simethicone tablets or 45 ml of sodium phosphate plus placebo in the evening before and in the morning of the procedure day. The colonoscopic examination was recorded. Visibility was blindly assessed for the amount of air bubbles and the degree of haziness by a single investigator. Five areas of the colon were graded for the amount of air bubbles, from 0 to 3; grade 0 and 1 were defined as the diminishing of air bubbles. The haziness was graded into 5 levels from excellent to unacceptable. Excellent, good
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Abstracts
and adequate were defined as the diminishing of haziness. The total duration of colonoscopy, the side effect of medication and the endoscopist and patient satisfaction were compared between 2 groups. Endoscopist satisfaction was evaluated by questionnaires. Visual analog scale (0-10) was used for rating patient satisfaction and the side effect of medication. Data analysis was performed by Student’s t test or Chi-square test as appropriate. Results: The demographic data of the 2 groups were comparable. 58% and 41.8% underwent colonoscopy due to the presence of symptoms and screening purpose, respectively. Colonoscopic findings revealed polyps in 48.4%, cancer 3.3% and normal 27.1%. Colonoscopy was not completed in 2 patients (1 from each group). Sodium phosphate plus simethicone, comparing to sodium phosphate plus placebo, improved visibility by diminishing the air bubbles (1.6% vs. 57.6%, P ! 0.0001) but simethicone failed to demonstrate the diminishing of haziness (9.8% vs. 18.6%, P Z 0.15). Endoscopist and patient satisfaction was increased in the simethicone group (95.1% vs. 42.4% (P ! 0.0001) and 8.7 þ 1.8 vs. 7.5þ1.9 (P Z 0.0004), respectively). However, there was no difference in the total duration of colonoscopy (25.0 þ 13.1 vs. 27.5 þ 13.0 minutes) and the side effect of medication (1.37 þ 2.3 vs. 1.79 þ 2.2). Conclusions: The addition of simethicone to sodium phosphate is showed to be benefit for colonoscopic bowel preparation. Simethicone diminishes air bubbles resulting in enhancing visibility and improving the quality of colonoscopy. Endoscopist and patient satisfaction is also heightened by simethicone.
239 Accrediting Competence in Colonoscopy: Validity and Reliability of the UK Joint Advisory Group/NHS Bowel Cancer Screening Programme Accreditation Assessment Roger Barton After national UK audit demonstrated very variable quality of colonoscopy, the introduction of the NHS Bowel Cancer Screening Programme prompted the introduction of a searching assessment to select the screening programme’s future colonoscopists. Leading endoscopists, trainers and the JAG collaborated to develop an appropriate assessment tool after consultation with clinical educationalists in the UK, USA, and Holland. This comprised performance data, a knowledge test (MCQ), and a DOPS (Direct Observation of Procedural Skills) assessment. The aims were to determine the validity and reliability of the assessment. A true/false 30 item x 5 answer MCQ was devised covering key issues. To ensure both professional and educational input, DOPS forms from two national training centres were reviewed by the Trainers Group appointed under the NHS National Endoscopy Training Programme, and important colonoscopy skills were identified and amalgamated into domains. Detailed descriptors for all skill levels were written for each domain. An outline curriculum was published, and assessors underwent both the assessment and detailed assessor training. Performance and demographic data, as well as assessment data both from the MCQ and DOPS over two cases by two assessors were collected prospectively from candidates. Semi-structured questionnaires were collected from candidates and assessors on the validity of the assessment. Colonoscopists submitted performance data and attempted the assessment. In more than 3000 paired judgments on over 100 candidates during more than 200 cases, there was 96% congruence of agreement across the pass/ fail divide (98% for major domains), and between 60-83% absolute congruence across individual domains between assessors, e.g. demonstrates awareness of patient’s consciousness and pain 73%; adequate mucosal visualisation 81%. An expert global opinion agreed with the grading system in 97% of cases. The grading correlated weakly with self-reported caecal intubation rates and MCQ scores (r Z 0.24 & 0.27, p ! 0.01) respectively. No correlation was seen between the grading and colonoscopy numbers in previous year. Of the candidates 93% felt the DOPS assessment was fair or very fair overall, whilst 86% felt the MCQ was fair or very fair. Of the assessors, 75% felt the DOPS was valid or very valid, others felt it was not testing enough nor reliably assessing therapy, whilst 100% of them overall felt the process was fair or very fair. The DOPS accreditation has good face and content validity, and high reliability across the crucial pass/fail divide. Work is in place improving the MCQ.
Patients with colonic resections, poor bowel preparation and severe stricture in the colon were excluded. All procedures were performed by two experienced endoscopists who had performed more than 3000 cases and were blind to the imager view and real-time views were recorded by MEI. The instrument was video colonoscope with an in-built magnetic imaging (CF260DI, Olympus Optical Co., Ltd., Tokyo, Japan). The stiffening function was not used. No sedative medication was given. The time taken to insert the colonoscope into the cecum was measured. The degree of pain in insertion of the colonoscope into the cecum was assessed using the visual analog scale (VAS 0 Z not at all or very easy 100 Z very severe or difficult). Between the OTC-attached group and non-OTC attached group, cecal intubation time and pain in insertion of the colonoscope into the cecum were recorded and with MEI the degree of pain in each type of loop and frequency of loop formation in the sigmoid colon were retrospectively analyzed. Result: Endoscopists performed 483 patients, and 242 patients were randomly allocated to OTC-attached colonoscope and 241 patients to non OTC-attached colonoscope. The median cecal intubation time was 5.6 minutes with the OTC group and 5.9 minutes without OTC group (P Z 0.241). The examination was significantly less painful with the OTC than without OTC (22.8 mm vs. 27.1 mm; p Z 0.014). Loop formation did not occur in 34.8% of cases (168/483). N loop occurred in 47.2% (228/ 483), alpha loop in 11.6% (56/483) and reverse alpha loop in 6.1% (31/483). The degree of pain was significantly higher in reverse alpha loop (53.9mm; p ! 0.001), N loop (33.1 mm; p ! 0.001), alpha loop (38.3 mm; p ! 0.001) than in non loop (9.8mm) and the loops in the sigmoid colon (N, alpha, reverse alpha loop) significantly occurred less in OTC-attached group than in non-OTC attached group. (132/242 vs. 183/241, respectively; p Z 0.0246, by Fisher’s exact test)Conclusions: By attaching the OTC to the tip of the colonoscope, looping (N, a, reverse a) occurred less frequently and resulted in less painful examination compared with conventional colonoscope.
241 Colonoscopy in the Elderly: Worse Preparation, Better Tolerability Kinesh P. Patel, Jocelyn L. Aldridge, Kuldeep Cheent, Gautam Mehta, Neil P. Patel, Nisha Patel, Devinder S. Bansi, Andrew V. Thillainayagam Background: As demographics shift towards an aging population, the use of endoscopy in the elderly is increasing every year. Colonoscopy is safe in this population, but is technically more challenging due to difficulties with adequate bowel preparation and the safe administration of sedation. Aim/Methods: To assess the effectiveness of colonoscopy for complete colonic examination in patients over 75 years of age, all colonoscopies performed in a teaching centre over eight years were analysed for rates of complete examination, as defined by cecal intubation. Any reasons for failure were categorized and recorded. The majority of patients received 4L of polyethylene glycol (PEG) bowel preparation unless contraindicated. Results: In total, 17926 colonoscopies were performed. Under the age of 75, 14.1 per cent of patients had an incomplete examination, rising to 24.6 per cent (p ! 0.001) in those over 75. The reason for the increased failure rate in the elderly was predominantly poor bowel preparation, accounting for 35.0 per cent of unsuccessful examinations. In total, 8.6 per cent of procedures in the elderly were abandoned due to poor preparation against 4.5 per cent in those under 75 (p ! 0.0001). In contrast, only 1.9 per cent of colonoscopies in the elderly were stopped due to discomfort, compared to 3.0 per cent in the younger cohort (p Z 0.001). Conclusion: Colonoscopy in a population over 75 years of age is less successful in imaging the colon, mainly due to problems with bowel preparation. Contrary to popular belief, aborted examinations due to poor patient tolerance in the elderly are unusual; indeed these data clearly show that the elderly tolerate colonoscopy better than younger patients.Strategies to improve bowel preparation will increase the yield of colonoscopy in this population, in whom colonic pathology is common and endoscopy established as safe. Similar tolerability of PEG and sodium phosphate laxatives has been shown in the elderly: hence, further studies on bowel preparation are urgently required to optimise the safety and efficacy of colonoscopy in a vulnerable patient group in which organic pathology is common.
Under 75
240 Evaluation of Patient Pain During Colonoscopy for Types of Looping Between Hood Attached Group and Non-Hood Attached Group: An Analysis Using Magnetic Endoscope Imaging (MEI) Koichiro Sato, Koichi Hirahata, Sumio Fujinuma, Tadayoshi Kakemura, Iruru Maetani Background: Total colonoscopy is usually possible. However it remains at times a technically difficult procedure. The oblique transparent cap (OTC, Top, Tokyo, Japan) attached the tip of the colonoscope allows good visualization and makes the procedure easier by maintaing the distance between the lens and the lumen. The aim of this study was to assess the OTC during the insertion of the colonoscope into the cecum with magnetic endoscope imaging (MEI). Methods: Consecutive 483 patients were randomized to undergo colonoscopy with or without the OTC.
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Successful
Unsuccessful
TOTAL
12488
2047
14535
836 2883
3391 17926
Over 75 2555 TOTAL 15043 Colonoscopic success categorised by age
Organic Poor preparationy Discomforty diseasey Under 75 Over 75 TOTAL Causes
647(4.5%)
434(3.0%)
Technical problemsy
399(2.7%) 374(2.6%) 228 293 (8.6%) 66 (1.9%) (6.7%) 177 (5.2%) 940 500 627 551 of colonoscopic failure (% of all colonoscopies) yp
Not specifiedy TOTAL 193(1.3%) 2047(14.1%) 72 (2.1%) 836 (24.6%) 265 2883 ! 0.001
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB77
the 19 pt (5%), tumour-freedom had not been achieved after a total of 2 ER. This patient died of a heart-attack before surgery could be performed. The calculated 5year survival rate of all 21 pt was 66%. Metastatic disease in Barrett’s cancer or tumour-related death were not observed. Conclusions: As in mucosal Barrett’s cancer, ER is associated with favourable outcomes even in case of ‘‘low risk’’ submucosal Barrett’s cancer. Further and larger clinical trials are required, before a general recommendation for ER as the treatment of choice in ‘‘low risk’’ submucosal Barrett’s cancer can be given.
235 Endoscopic Cryotherapy Ablation Is Safe and Well-Tolerated in Barrett’s Esophagus, Esophageal Dysplasia, and Esophageal Cancer Bruce D. Greenwald, J. David Horwhat, Julian a. Abrams, Charles J. Lightdale, John a. Dumot Background: Endoscopic cryotherapy using low pressure liquid nitrogen spray is a new ablation technique for eliminating malignant and premalignant conditions of the esophagus. Aim: To evaluate the safety and tolerability of endoscopic cryotherapy ablation for malignant and premalignant conditions in the esophagus. Methods: Data from all patients treated under IRB-approved research protocol at 4 sites was analyzed. Conditions treated included Barrett’s esophagus without dysplasia (BE), Barrett’s esophagus with high-grade dysplasia (HGD) or intramucosal cancer (IMCA), esophageal carcinoma (T1 or T2 N0 M0), and severe squamous dysplasia (SSD). All patients were treated with cryotherapy every 4 - 6 weeks to eliminate the target lesion. Adverse events and side effects were reviewed by personal contact or telephone call to the patient 1 to 10 days after every procedure. Symptom severity was described by patients as mild, moderate, or severe. Results: 77 patients (57 male, 20 female) received 323 cryotherapy treatments between 9/28/05 and 11/27/07. Median age was 69 years (range 36-93). Median length of esophagus treated was 4 cm (range 0.5 - 15). Median number of treatments was 4 (range 1 - 10). Diagnoses were BE - 7 (9.1%), HGD - 45 (58.4%), IMCA - 13 (16.9%), cancer - 10 (13.0%), and SSD - 2 (2.6%). Serious adverse events related to treatment included 1 gastric perforation in a patient with Marfan’s syndrome and 1 lip ulcer due to cold injury from scope contact. Minor adverse events included 3 patients with stricture which responded to a single dilation. Patients reported no side effects in 155 procedures (48%). Frequency of side effects for procedures is shown in the table. Conclusion: Endoscopic cryotherapy ablation using low pressure liquid nitrogen spray is safe and very well-tolerated. Table. Side Effects in 323 cryotherapy procedures Side Effect n (%)
Chest Pain
Abdominal Sore Irregular Dysphagia Odynophagia Nausea Pain Throat Heartbeat Fever
45 (13.9%) 24 (7.4%) 10 Moderate (3.1%) 19 (5.9%) Mild
Severe
2 (0.6%) 0
27 (8.4%)
16 (5.0%)
10 (3.1%)
11 (3.4%)
0
1 (0.3%)
1 (0.3%)
0
3 (0.9%)
29 (9.0%) 1 (0.3%) 1 (0.3%)
8 (2.5%)
3 (0.9%)
0
0
0
0
236 Low Rate of Invasive Cancer in Patients Undergoing Mucosectomy for Barrett’s Esophagus (BE) and High Grade Dysplasia (HGD) Or Intramucosal Carcinoma (IMC) Vani J. Konda, Jennifer S. Chennat, Andrew S. Ross, Shang P. Lin, Barbara M. Cislo, Lynne Stearns, Amy E. Noffsinger, John Hart, Mitchell C. Posner, Mark K. Ferguson, Irving Waxman Background: The literature reports vastly different rates of invasive esophageal adenocarcinoma (IEAC) discovered at esophagectomy in patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) and often approximates a rate of around 40%. Our analysis of the literature using strict pathological definitions revealed a prevalence of occult IEAC at 12%. [1] The risk of occult IEAC in patients with BE with HGD and intramucosal carcinoma (IMC) is critical to properly evaluate options as endoscopic treatments emerge for BE. Aim: To determine the prevalence of IEAC in patients who underwent complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for BE with HGD or IMC in order to assess the rate of occult IEAC with current endoscopic technology. Methods: A retrospective analysis of a prospective database of all patients undergoing CBE-EMR at a single tertiary center was performed. We define IEAC as tumor with submucosal invasion or beyond. Non-visible lesions are those not detected with white light endoscopy. Results: 44 patients (34 male) with BE with HGD or IMC underwent CBE-EMR from August 1, 2003 to November 15, 2007. 25 patients had short segment BE, and 20 had no visible lesion. 13 patients had IMC, and the rest had HGD. IEAC was found in EMR specimens in 6.8% (3) of the patients. 2 patients had evidence of submucosal invasion and 1 had evidence of IMC with mucosal lymphatic invasion; these patients were referred for esophagectomy. All IEAC patients had visible lesions seen on endoscopy. None of the patients with non-visible lesions had IEAC.
AB76 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
21 patients have completed the CBE-EMR treatment and are in surveillance; no cases of IEAC have been identified during intensive endoscopic surveillance (median remission time 18 months, up to 51 months). One patient died of unrelated causes. 18 patients are still undergoing CBE-EMR treatment; however, no additional cases of invasive adenocarcinoma have been identified. Conclusions: In BE patients presenting with HGD or IMC, our series demonstrates a rate of occult IEAC at 6.8% in the resection specimens. Furthermore, in the absence of visible lesions, the prevalence was 0%. Further work should clarify what factors, such as visible lesions, improve the diagnosis of IEAC. EMR appears to be a promising treatment modality for BE with HGD or IMC since EMR is less invasive than esophagectomy, and still provides pathologic specimens to gauge success or need for further treatment. [1] Konda, Ross, Ferguson, et al. Is the Risk of Concomitant Invasive Esophageal Cancer in High Grade Dysplasia in Barrett’s Esophagus Overestimated? Clin Gastroenterol Hepatol. In press.
237 Duration of the Interval Between Completion of the Bowel Preparation and Start of the Colonoscopy As a Better Predictor of Bowel Preparation Quality Than Colonoscopy Start Time Alone Kenneth Yang, Ali Siddiqui, Stuart J. Spechler, Byron L. Cryer, Raquel E. Davila, William Harford Objective: Effective bowel preparation (BP) improves colonoscopy by reducing the rate of missed lesions and incomplete examinations. Previous studies have suggested that the time of day when colonoscopy is started has a significant influence on the quality of the BP, with morning procedures having superior quality compared to those performed in the afternoon. The aim of our study was to determine whether the duration of the interval between the end of the BP and the start of the colonoscopy affects the quality of the BP. Methods: We gathered data prospectively over a three month period on consecutive outpatients who had colonoscopies performed at a VA Medical Center. Medical histories, demographics, compliance with the BP and dietary restrictions, and the time since the last dose of BP agent were recorded immediately prior to the colonoscopy. Patients who had a right hemicolectomy were excluded. Senior staff endoscopists and endoscopy nurses independently graded the quality of the BP for the right colon on a five point scale (0 Z excellent to 4 Z inadequate) using a standardized ‘‘preparation quality’’ scale with photographic examples of the 5 BP grades. Endoscopists also were asked to document the presence or absence of succus (thin, adherent, bilestained film) in the right colon. Results: We studied 378 patients (95.7% men, mean age 62.2 years); 97.3% received polyethylene glycol electrolyte-based (PEG) solution, and 2.7% received oral sodium phosphate for BP. In patients whose preparations were scored as excellent/good, the interval between the time of the last BP agent dose and the start time of the colonoscopy was significantly shorter than in those whose preparations were scored fair/poor/inadequate (p Z 0.013). In contrast, we found no significant difference in BP quality between morning and afternoon colonoscopies. We also found no significant relationship between the presence of succus and the time interval from the last dose of BP agent, or between BP quality and the interval from the time of the last solid meal to the start of the colonoscopy. There was good agreement between physician endoscopists and nurses in grading BP quality using our preparation quality scale (Pearson correlation coefficient of 0.74). Conclusions: For bowel preparation quality, the duration of the interval between the completion of the bowel preparation and the start of the colonoscopy appears to be more important than the time of day when colonoscopy is performed. Bowel preparation quality varies inversely with the duration of the interval between the last dose of the bowel preparation agent and the start of the colonoscopy.
238 Improving the Quality of Colonoscopy in Term of Visibility By Adding Simethicone to Sodium Phosphate for Bowel Preparation Sasinee Tongprasert, Abhasnee Sobhonslidsuk, Panida Thong-Uthaisri, Narin Achalanan, Chutima Pramoolsinsap, Chomsri Kositchaiwat, Sasivimol Rattanasiri Background: Sodium phosphate is one of the bowel preparation regimens for colonoscopy. However, intraluminal gas can impair visibility during the examination. Simethicone is medication that works by reducing the surface tension of air bubbles. We aimed to evaluate the effect of simethicone in enhancing visibility and efficacy during colonoscopy. Methods: A prospective, randomized, double-blinded, placebo-controlled study was conducted. One hundred and twenty-four patients were allocated to receive 2 dosages of either 45 ml of sodium phosphate plus 240 mg of simethicone tablets or 45 ml of sodium phosphate plus placebo in the evening before and in the morning of the procedure day. The colonoscopic examination was recorded. Visibility was blindly assessed for the amount of air bubbles and the degree of haziness by a single investigator. Five areas of the colon were graded for the amount of air bubbles, from 0 to 3; grade 0 and 1 were defined as the diminishing of air bubbles. The haziness was graded into 5 levels from excellent to unacceptable. Excellent, good
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Abstracts
and adequate were defined as the diminishing of haziness. The total duration of colonoscopy, the side effect of medication and the endoscopist and patient satisfaction were compared between 2 groups. Endoscopist satisfaction was evaluated by questionnaires. Visual analog scale (0-10) was used for rating patient satisfaction and the side effect of medication. Data analysis was performed by Student’s t test or Chi-square test as appropriate. Results: The demographic data of the 2 groups were comparable. 58% and 41.8% underwent colonoscopy due to the presence of symptoms and screening purpose, respectively. Colonoscopic findings revealed polyps in 48.4%, cancer 3.3% and normal 27.1%. Colonoscopy was not completed in 2 patients (1 from each group). Sodium phosphate plus simethicone, comparing to sodium phosphate plus placebo, improved visibility by diminishing the air bubbles (1.6% vs. 57.6%, P ! 0.0001) but simethicone failed to demonstrate the diminishing of haziness (9.8% vs. 18.6%, P Z 0.15). Endoscopist and patient satisfaction was increased in the simethicone group (95.1% vs. 42.4% (P ! 0.0001) and 8.7 þ 1.8 vs. 7.5þ1.9 (P Z 0.0004), respectively). However, there was no difference in the total duration of colonoscopy (25.0 þ 13.1 vs. 27.5 þ 13.0 minutes) and the side effect of medication (1.37 þ 2.3 vs. 1.79 þ 2.2). Conclusions: The addition of simethicone to sodium phosphate is showed to be benefit for colonoscopic bowel preparation. Simethicone diminishes air bubbles resulting in enhancing visibility and improving the quality of colonoscopy. Endoscopist and patient satisfaction is also heightened by simethicone.
239 Accrediting Competence in Colonoscopy: Validity and Reliability of the UK Joint Advisory Group/NHS Bowel Cancer Screening Programme Accreditation Assessment Roger Barton After national UK audit demonstrated very variable quality of colonoscopy, the introduction of the NHS Bowel Cancer Screening Programme prompted the introduction of a searching assessment to select the screening programme’s future colonoscopists. Leading endoscopists, trainers and the JAG collaborated to develop an appropriate assessment tool after consultation with clinical educationalists in the UK, USA, and Holland. This comprised performance data, a knowledge test (MCQ), and a DOPS (Direct Observation of Procedural Skills) assessment. The aims were to determine the validity and reliability of the assessment. A true/false 30 item x 5 answer MCQ was devised covering key issues. To ensure both professional and educational input, DOPS forms from two national training centres were reviewed by the Trainers Group appointed under the NHS National Endoscopy Training Programme, and important colonoscopy skills were identified and amalgamated into domains. Detailed descriptors for all skill levels were written for each domain. An outline curriculum was published, and assessors underwent both the assessment and detailed assessor training. Performance and demographic data, as well as assessment data both from the MCQ and DOPS over two cases by two assessors were collected prospectively from candidates. Semi-structured questionnaires were collected from candidates and assessors on the validity of the assessment. Colonoscopists submitted performance data and attempted the assessment. In more than 3000 paired judgments on over 100 candidates during more than 200 cases, there was 96% congruence of agreement across the pass/ fail divide (98% for major domains), and between 60-83% absolute congruence across individual domains between assessors, e.g. demonstrates awareness of patient’s consciousness and pain 73%; adequate mucosal visualisation 81%. An expert global opinion agreed with the grading system in 97% of cases. The grading correlated weakly with self-reported caecal intubation rates and MCQ scores (r Z 0.24 & 0.27, p ! 0.01) respectively. No correlation was seen between the grading and colonoscopy numbers in previous year. Of the candidates 93% felt the DOPS assessment was fair or very fair overall, whilst 86% felt the MCQ was fair or very fair. Of the assessors, 75% felt the DOPS was valid or very valid, others felt it was not testing enough nor reliably assessing therapy, whilst 100% of them overall felt the process was fair or very fair. The DOPS accreditation has good face and content validity, and high reliability across the crucial pass/fail divide. Work is in place improving the MCQ.
Patients with colonic resections, poor bowel preparation and severe stricture in the colon were excluded. All procedures were performed by two experienced endoscopists who had performed more than 3000 cases and were blind to the imager view and real-time views were recorded by MEI. The instrument was video colonoscope with an in-built magnetic imaging (CF260DI, Olympus Optical Co., Ltd., Tokyo, Japan). The stiffening function was not used. No sedative medication was given. The time taken to insert the colonoscope into the cecum was measured. The degree of pain in insertion of the colonoscope into the cecum was assessed using the visual analog scale (VAS 0 Z not at all or very easy 100 Z very severe or difficult). Between the OTC-attached group and non-OTC attached group, cecal intubation time and pain in insertion of the colonoscope into the cecum were recorded and with MEI the degree of pain in each type of loop and frequency of loop formation in the sigmoid colon were retrospectively analyzed. Result: Endoscopists performed 483 patients, and 242 patients were randomly allocated to OTC-attached colonoscope and 241 patients to non OTC-attached colonoscope. The median cecal intubation time was 5.6 minutes with the OTC group and 5.9 minutes without OTC group (P Z 0.241). The examination was significantly less painful with the OTC than without OTC (22.8 mm vs. 27.1 mm; p Z 0.014). Loop formation did not occur in 34.8% of cases (168/483). N loop occurred in 47.2% (228/ 483), alpha loop in 11.6% (56/483) and reverse alpha loop in 6.1% (31/483). The degree of pain was significantly higher in reverse alpha loop (53.9mm; p ! 0.001), N loop (33.1 mm; p ! 0.001), alpha loop (38.3 mm; p ! 0.001) than in non loop (9.8mm) and the loops in the sigmoid colon (N, alpha, reverse alpha loop) significantly occurred less in OTC-attached group than in non-OTC attached group. (132/242 vs. 183/241, respectively; p Z 0.0246, by Fisher’s exact test)Conclusions: By attaching the OTC to the tip of the colonoscope, looping (N, a, reverse a) occurred less frequently and resulted in less painful examination compared with conventional colonoscope.
241 Colonoscopy in the Elderly: Worse Preparation, Better Tolerability Kinesh P. Patel, Jocelyn L. Aldridge, Kuldeep Cheent, Gautam Mehta, Neil P. Patel, Nisha Patel, Devinder S. Bansi, Andrew V. Thillainayagam Background: As demographics shift towards an aging population, the use of endoscopy in the elderly is increasing every year. Colonoscopy is safe in this population, but is technically more challenging due to difficulties with adequate bowel preparation and the safe administration of sedation. Aim/Methods: To assess the effectiveness of colonoscopy for complete colonic examination in patients over 75 years of age, all colonoscopies performed in a teaching centre over eight years were analysed for rates of complete examination, as defined by cecal intubation. Any reasons for failure were categorized and recorded. The majority of patients received 4L of polyethylene glycol (PEG) bowel preparation unless contraindicated. Results: In total, 17926 colonoscopies were performed. Under the age of 75, 14.1 per cent of patients had an incomplete examination, rising to 24.6 per cent (p ! 0.001) in those over 75. The reason for the increased failure rate in the elderly was predominantly poor bowel preparation, accounting for 35.0 per cent of unsuccessful examinations. In total, 8.6 per cent of procedures in the elderly were abandoned due to poor preparation against 4.5 per cent in those under 75 (p ! 0.0001). In contrast, only 1.9 per cent of colonoscopies in the elderly were stopped due to discomfort, compared to 3.0 per cent in the younger cohort (p Z 0.001). Conclusion: Colonoscopy in a population over 75 years of age is less successful in imaging the colon, mainly due to problems with bowel preparation. Contrary to popular belief, aborted examinations due to poor patient tolerance in the elderly are unusual; indeed these data clearly show that the elderly tolerate colonoscopy better than younger patients.Strategies to improve bowel preparation will increase the yield of colonoscopy in this population, in whom colonic pathology is common and endoscopy established as safe. Similar tolerability of PEG and sodium phosphate laxatives has been shown in the elderly: hence, further studies on bowel preparation are urgently required to optimise the safety and efficacy of colonoscopy in a vulnerable patient group in which organic pathology is common.
Under 75
240 Evaluation of Patient Pain During Colonoscopy for Types of Looping Between Hood Attached Group and Non-Hood Attached Group: An Analysis Using Magnetic Endoscope Imaging (MEI) Koichiro Sato, Koichi Hirahata, Sumio Fujinuma, Tadayoshi Kakemura, Iruru Maetani Background: Total colonoscopy is usually possible. However it remains at times a technically difficult procedure. The oblique transparent cap (OTC, Top, Tokyo, Japan) attached the tip of the colonoscope allows good visualization and makes the procedure easier by maintaing the distance between the lens and the lumen. The aim of this study was to assess the OTC during the insertion of the colonoscope into the cecum with magnetic endoscope imaging (MEI). Methods: Consecutive 483 patients were randomized to undergo colonoscopy with or without the OTC.
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Successful
Unsuccessful
TOTAL
12488
2047
14535
836 2883
3391 17926
Over 75 2555 TOTAL 15043 Colonoscopic success categorised by age
Organic Poor preparationy Discomforty diseasey Under 75 Over 75 TOTAL Causes
647(4.5%)
434(3.0%)
Technical problemsy
399(2.7%) 374(2.6%) 228 293 (8.6%) 66 (1.9%) (6.7%) 177 (5.2%) 940 500 627 551 of colonoscopic failure (% of all colonoscopies) yp
Not specifiedy TOTAL 193(1.3%) 2047(14.1%) 72 (2.1%) 836 (24.6%) 265 2883 ! 0.001
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB77