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Is gender an independent predictor of difficult colonoscopy?
CLINICAL ENDOSCOPIC PRACTICE 129
-}'131
POSSIBILITIES IN IMPROVEMENT OF ACCEPTATION OF GASTROSCOPY, J.-F. Rey, D. Duforest, P. Termate, Institut Arnauh Tzanek, D~partement de GastrcentErologie, Avenue dn Dr Donat, 067130 Saint Laurent du Var, France. Endoscopic examination is the method of choice in the diagnosis of upper gastrointestinal symptoms. However, many general practitioners send their patients for barium meal examination because of the inacceptability of an endoscopy or the request for intravenous sedation. But sedation means an increase of direct and indirect cost. The aim of the study was to establish the tolerance of endoscopy performed with a thin endoscope using different possible insertion methods. tO healthy volunteers (7 females, 3 males) underwent an endoscopic examination. An Olympus GIF XP 200 endoscope with external diameter of 6 mm was used for these procedures. No biopsy specimen was taken. Each examination was recorded. Volunteers were given a local anesthesia. Each volunteer underwent 2 randomized examinations on consecutive days. After removal of the endoscope, patients completed a first qnestionnaire, then, the second - 1 week later). The questionnaire was formed by two separated items concerning the tolerance of the way uf endoscope insertion and the tolerance of endoscopy procedure itself. 20 consecutive procedures (l failure due to deviation of nasal wall) were performed. Mean time of endoscopy was 185 seconds. The control of quality of examination was assured by a second look at the video tape recording. The degree of satisfaction was significantlyhigher in the oral insertion technique than in transnasal insertion (8.2 VS 4.6). It is important to note that in these series, 3 voluntee~ls did not differentiate the type of insertion. 3 volunteers pret'erred nasal intubation, and 3oral.insertions. The last volunteer demanded an intravenous sedation for further examination. Since then, dais technique has been applied for routine gastruscopy in 34 patients. Tolerance of the examination was satisfactory in 29 cases. In 5 cases a LV sedation was performed due to marked discomfort. The evaluation of factors influencing the acceptance of endoscopic procedures without sedation was the aim of this study : 1) the role of patient selection, 2) the influence of endoscope diameter, 3) the influence of video images on the examination tolerance, 4) the control of the results of endoscopy by a second look at the video tape. Th6 final target of the presented report was to improve the acceptance of upper gastrointestinal endoscopy while reducing the costs and maintaining the same quality of information.
HOT BIOPSYPOLYP~-'I'OMY IS VERYSAFE: AN ANALYSIS OF SERIOUS DELAYEDCOMPLICATIONS AFTERCOLONOSCOPIC POLYPECTOMY, ~ , R.U. van Stulk. Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio. BACKGROUNd: Hot biopsy forceps technique (I-IBF) has been reported to increase the risk of delayed complications after colonoscopic polypeetomy (CP) especially in the right colon and in patients on platelet inhibiting agents or anticoagulants. AIMS: To analyze serious delayed complications following CP, to determine the prevalenca of each complication and to determine whether HBF was a significant risk factor. METHODS: The records of patients who underwent CP in 1992 were identified through the Adenoma Polyp Registry and reviewed to determine the prevalence of delayed bleeding (DB), perforation or post-polypectomy syndrome (PPS). l~,~JJ, ff_S: Of 1290 patients who underwent UP, 3296 polyps were removed; 2690 by HBF and 614 by snare polypectomy. 17 polyps were removed using both techniques. 4 polyps were cold biopsied. Eighteen serious complications occurred: TgI~I B]..eeding Perforation PPS No. 18 12 2 4 %/patient 1.4 0.9 0.16 0.31 %/polypeetomy 0.55 0.36 0.06 0.12 The small number of patients with perforation (2) or PPS (4) precluded meaningful evaluation of technique risk. Twelve patients suffered DB (3I-IBF, 6-snare, 3-multiple polyps/I-IBF and snare both used and technique responsible for DB not known). Two patients were on ASA, one from each group. DB occurred in 3 HBF polypeetomies (0.11%) compared with 6 snare polypectomies (0.98%, p=0.002). Even if all 3 cases of DB which could not be attributed to either HBF or snare were attributed to HBF, the risk for DB increased to 0.22%(still statistically different from mare p=0.013). Two out of 3 HBF bleeds were from polyps in the cecum. CONCLUSIONS: 1) Serious delayed complications following CP are rare. 2) The most common delayed complication is bleeding. 3) Cecal location may impart a higher risk for DB after HBF but the overall risk is very small. 4) Delayed bleeding was nine times more common after snare polypectomy than after HBF.
130
~'132
UPPER GASTROINTESTINAL BLEEDING: OUTCOMES AND UTILIZATION OF THERAPEUTIC ENDOSCOPY ACCORDING TO ETIOLOGY. P,G. Rossos, F. Vale, W. Rossos. Division of Gastroenterology. The Toronto Hospital and Oniversiy of Toronto. We reviewed all cases of UGI bleeding at TTH between Jan. 1, 1993 and May 21, 1994. 36% of 236 patients were reported to have chronic liver disease and 29% had cirrhosis. 236 patients were studied; 171M, 65F, mean age 58y. A partial summary of our data is outlined below.
IS GENDER AN INDEPENDENT PREDICTOR OF DIFFICULT COLONOSCOPY? ~ , G Portwood, SM Schutz, JG Lee. Division of Gastroenterology,Duke Univ Medical Center, Durham, NC. INTRODUCTION: The purposes of this study were to examine selected factors which predict difficult colonoscopy, and to validate these predictors. METHODS: Endoscopists rated procedure difficulty in 328 consecutive outpatients undergoing colonoscopy. We examined the associations between patient variables,and procedure difficulty and duration (a surrogate measure for difficulty). Univariable and multivariable logistic regression were used to develop a model for predictive factors from this set of variables. The model was then tested in a prospective fashion on an independent sample of 223 consecutive outpatients undergoing colonoscopy. In the validation study, we also examined the effect of factors such as prior surgery or radiation therapy on procedure difficulty. Endoscopists were blinded to the study question. RESULTS: Procedure difficulty and procedure type (diagnostic (DX) vs therapeutic (TX)) were each associated with procedure duration (p<.01). After adiusting for procedure duration (short (S) vs long (L)), and procedure type, colonoscopy was still more likely to be rated difficult in females (p<.0I).
ETIOLOGY
,=sophagea varices (EV) gastric varices (GV) duodenal ulcer (DU) gastric ulcer (GU) TOTAL (including all causes) ETIOLOGY
n 1%1
mean sex mortality urgent I PRBCS ( %1 surgery I (median age M/F (%1 units)
61 56.5 40/2 15/61 1 (24.6) 25.7
1/4 2/4 (25.01 (50.0)
4
{1,7) 87 54.s 67/2 i 36.7) 0 37 67.C 24/1 (15.6) 3 236 59.s 172/ 65 (t00)
ICU ADMIT
6/61 (9.8)
ICU DAYS
3/87 (3.4) 2/37 (5.4) 23 (9.7)
DAYS TO STABILITY
10/87 (11.5) 6/37 (16.2) 24 (10,2)
THER. ENDO
total hospital stay (median days1
4.0
9.0
13,0
7.0
2.0
5.0
2.0
7.0
2.0
7.0
NEVER STABLE
TOTAL
REBLEED
55 6 1.52+/99 21 22 (23.3) 1.46 (42.5 (9.1) (9.3) Outcom,~ data for all cau ~. ; of UGI bleeding w be presented in addition to details of the therapeutic modalities employed.
328
GASTROINTESTINAL ENDOSCOPY
50
In the validation sample, gender was not an independent predictor of procedure difficulty. Furthermore, neither prior surgery (59%) nor radiation therapy (4%) was associated with procedure difficulty, even when stratified by gender (p=.4). Only procedure duration was associated with procedure difficulty (p<.01). CONCLUSIONS: Despite similarities in procedure duration, stratified by type, endoscopists find colonoscopy difficult in females more often than males. Reasons for this discrepancy need to be clarified.
VOLUME 41, NO. 4, 1995
-}'131
POSSIBILITIES IN IMPROVEMENT OF ACCEPTATION OF GASTROSCOPY, J.-F. Rey, D. Duforest, P. Termate, Institut Arnauh Tzanek, D~partement de GastrcentErologie, Avenue dn Dr Donat, 067130 Saint Laurent du Var, France. Endoscopic examination is the method of choice in the diagnosis of upper gastrointestinal symptoms. However, many general practitioners send their patients for barium meal examination because of the inacceptability of an endoscopy or the request for intravenous sedation. But sedation means an increase of direct and indirect cost. The aim of the study was to establish the tolerance of endoscopy performed with a thin endoscope using different possible insertion methods. tO healthy volunteers (7 females, 3 males) underwent an endoscopic examination. An Olympus GIF XP 200 endoscope with external diameter of 6 mm was used for these procedures. No biopsy specimen was taken. Each examination was recorded. Volunteers were given a local anesthesia. Each volunteer underwent 2 randomized examinations on consecutive days. After removal of the endoscope, patients completed a first qnestionnaire, then, the second - 1 week later). The questionnaire was formed by two separated items concerning the tolerance of the way uf endoscope insertion and the tolerance of endoscopy procedure itself. 20 consecutive procedures (l failure due to deviation of nasal wall) were performed. Mean time of endoscopy was 185 seconds. The control of quality of examination was assured by a second look at the video tape recording. The degree of satisfaction was significantlyhigher in the oral insertion technique than in transnasal insertion (8.2 VS 4.6). It is important to note that in these series, 3 voluntee~ls did not differentiate the type of insertion. 3 volunteers pret'erred nasal intubation, and 3oral.insertions. The last volunteer demanded an intravenous sedation for further examination. Since then, dais technique has been applied for routine gastruscopy in 34 patients. Tolerance of the examination was satisfactory in 29 cases. In 5 cases a LV sedation was performed due to marked discomfort. The evaluation of factors influencing the acceptance of endoscopic procedures without sedation was the aim of this study : 1) the role of patient selection, 2) the influence of endoscope diameter, 3) the influence of video images on the examination tolerance, 4) the control of the results of endoscopy by a second look at the video tape. Th6 final target of the presented report was to improve the acceptance of upper gastrointestinal endoscopy while reducing the costs and maintaining the same quality of information.
HOT BIOPSYPOLYP~-'I'OMY IS VERYSAFE: AN ANALYSIS OF SERIOUS DELAYEDCOMPLICATIONS AFTERCOLONOSCOPIC POLYPECTOMY, ~ , R.U. van Stulk. Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio. BACKGROUNd: Hot biopsy forceps technique (I-IBF) has been reported to increase the risk of delayed complications after colonoscopic polypeetomy (CP) especially in the right colon and in patients on platelet inhibiting agents or anticoagulants. AIMS: To analyze serious delayed complications following CP, to determine the prevalenca of each complication and to determine whether HBF was a significant risk factor. METHODS: The records of patients who underwent CP in 1992 were identified through the Adenoma Polyp Registry and reviewed to determine the prevalence of delayed bleeding (DB), perforation or post-polypectomy syndrome (PPS). l~,~JJ, ff_S: Of 1290 patients who underwent UP, 3296 polyps were removed; 2690 by HBF and 614 by snare polypectomy. 17 polyps were removed using both techniques. 4 polyps were cold biopsied. Eighteen serious complications occurred: TgI~I B]..eeding Perforation PPS No. 18 12 2 4 %/patient 1.4 0.9 0.16 0.31 %/polypeetomy 0.55 0.36 0.06 0.12 The small number of patients with perforation (2) or PPS (4) precluded meaningful evaluation of technique risk. Twelve patients suffered DB (3I-IBF, 6-snare, 3-multiple polyps/I-IBF and snare both used and technique responsible for DB not known). Two patients were on ASA, one from each group. DB occurred in 3 HBF polypeetomies (0.11%) compared with 6 snare polypectomies (0.98%, p=0.002). Even if all 3 cases of DB which could not be attributed to either HBF or snare were attributed to HBF, the risk for DB increased to 0.22%(still statistically different from mare p=0.013). Two out of 3 HBF bleeds were from polyps in the cecum. CONCLUSIONS: 1) Serious delayed complications following CP are rare. 2) The most common delayed complication is bleeding. 3) Cecal location may impart a higher risk for DB after HBF but the overall risk is very small. 4) Delayed bleeding was nine times more common after snare polypectomy than after HBF.
130
~'132
UPPER GASTROINTESTINAL BLEEDING: OUTCOMES AND UTILIZATION OF THERAPEUTIC ENDOSCOPY ACCORDING TO ETIOLOGY. P,G. Rossos, F. Vale, W. Rossos. Division of Gastroenterology. The Toronto Hospital and Oniversiy of Toronto. We reviewed all cases of UGI bleeding at TTH between Jan. 1, 1993 and May 21, 1994. 36% of 236 patients were reported to have chronic liver disease and 29% had cirrhosis. 236 patients were studied; 171M, 65F, mean age 58y. A partial summary of our data is outlined below.
IS GENDER AN INDEPENDENT PREDICTOR OF DIFFICULT COLONOSCOPY? ~ , G Portwood, SM Schutz, JG Lee. Division of Gastroenterology,Duke Univ Medical Center, Durham, NC. INTRODUCTION: The purposes of this study were to examine selected factors which predict difficult colonoscopy, and to validate these predictors. METHODS: Endoscopists rated procedure difficulty in 328 consecutive outpatients undergoing colonoscopy. We examined the associations between patient variables,and procedure difficulty and duration (a surrogate measure for difficulty). Univariable and multivariable logistic regression were used to develop a model for predictive factors from this set of variables. The model was then tested in a prospective fashion on an independent sample of 223 consecutive outpatients undergoing colonoscopy. In the validation study, we also examined the effect of factors such as prior surgery or radiation therapy on procedure difficulty. Endoscopists were blinded to the study question. RESULTS: Procedure difficulty and procedure type (diagnostic (DX) vs therapeutic (TX)) were each associated with procedure duration (p<.01). After adiusting for procedure duration (short (S) vs long (L)), and procedure type, colonoscopy was still more likely to be rated difficult in females (p<.0I).
ETIOLOGY
,=sophagea varices (EV) gastric varices (GV) duodenal ulcer (DU) gastric ulcer (GU) TOTAL (including all causes) ETIOLOGY
n 1%1
mean sex mortality urgent I PRBCS ( %1 surgery I (median age M/F (%1 units)
61 56.5 40/2 15/61 1 (24.6) 25.7
1/4 2/4 (25.01 (50.0)
4
{1,7) 87 54.s 67/2 i 36.7) 0 37 67.C 24/1 (15.6) 3 236 59.s 172/ 65 (t00)
ICU ADMIT
6/61 (9.8)
ICU DAYS
3/87 (3.4) 2/37 (5.4) 23 (9.7)
DAYS TO STABILITY
10/87 (11.5) 6/37 (16.2) 24 (10,2)
THER. ENDO
total hospital stay (median days1
4.0
9.0
13,0
7.0
2.0
5.0
2.0
7.0
2.0
7.0
NEVER STABLE
TOTAL
REBLEED
55 6 1.52+/99 21 22 (23.3) 1.46 (42.5 (9.1) (9.3) Outcom,~ data for all cau ~. ; of UGI bleeding w be presented in addition to details of the therapeutic modalities employed.
328
GASTROINTESTINAL ENDOSCOPY
50
In the validation sample, gender was not an independent predictor of procedure difficulty. Furthermore, neither prior surgery (59%) nor radiation therapy (4%) was associated with procedure difficulty, even when stratified by gender (p=.4). Only procedure duration was associated with procedure difficulty (p<.01). CONCLUSIONS: Despite similarities in procedure duration, stratified by type, endoscopists find colonoscopy difficult in females more often than males. Reasons for this discrepancy need to be clarified.
VOLUME 41, NO. 4, 1995