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Is It Safe to Place Percutaneous Gastric Feeding Tubes in Cirrhotic Patients?
Abstracts
systematic feedback and educational programs. Age, male gender, adequate prep quality were significantly associated with detection of adenoma and polyps.
M1358 Colonoscopic Withdrawal Times and Detection Rates of Colonic Diverticula Haruka Kajiwara, Yutaka Yamaji, Yoshihiro Isomura, Shuntaro Yoshida, Noriyuki Takano, Takafumi Sugimoto, Atsuo Yamada, Keiji Ogura, Haruhiko Yoshida, Takao Kawabe, Masao Omata Background: The polyp detection rates are regarded as a quality indicator of colonoscopy. The colonoscopic withdrawal time has been elucidated to be highly associated with polyp detectability. However, the variation in detectability of other lesions has not been sufficiently investigated. Colonic diverticula are depressed lesions entirely contrary to polyps. They are more likely to be missed by colonoscopy, while have sometimes more clinical importance than polyps. Objectives: To investigate the association between colorectal diverticula detection rates and colonoscopic withdrawal times in the examinations by trainee colonoscopists for Japanese patients. Methods: Procedural data performed at The University of Tokyo Hospital were reviewed. Thirteen trainee colonoscopists were characterized by their mean withdrawal time for normal colon. The diverticula detection rates were investigated in association with withdrawal times of colonoscopists. Results: Overall, 2,314 colonoscopies were reviewed. Mean withdrawal time ranged from 6.5min to 10.4min among colonoscopists. Colonic diverticula were detected in 29% and diverticulum detection rates varied from 21% to 43%. Withdrawal time and diverticulum detection rate showed a marginal association (p Z 0.058). When stratified by the use of transparent hood, a strong association was shown in the examinations without hood (p Z 0.009), while no association was found with hood attachment. Conclusion: Without hood attachment, the diverticula detection rates were associated with colonoscopic withdrawal times. The association became obscure by hood attachment.
M1359 Colonoscopic Withdrawal Times and Detection Rates of Colorectal Polyps Haruka Kajiwara, Yutaka Yamaji, Yoshihiro Isomura, Shuntaro Yoshida, Noriyuki Takano, Takafumi Sugimoto, Atsuo Yamada, Keiji Ogura, Haruhiko Yoshida, Takao Kawabe, Masao Omata Background: The polyp detection rates have recently been emphasized as a quality indicator of colonoscopy. The colonoscopic withdrawal time has been elucidated to be highly associated with polyp detectability. Objectives: To investigate the association between colorectal polyp detection rates and colonoscopic withdrawal times in the examinations by trainee colonoscopists for Japanese patients. Methods: Procedural data performed at The University of Tokyo Hospital were reviewed. Thirteen trainee colonoscopists were characterized by their mean withdrawal time for normal colon. The polyp detection rates were investigated in association with withdrawal times of colonoscopists. Results: Overall, 2,314 colonoscopies were reviewed. Mean withdrawal time ranged from 6.5min to 10.4 min among colonoscopists. Colorectal polyps were detected in 47% of the patients, and polyp detection rates in individual endoscopists ranged between 36% and 60%. There was no association between mean withdrawal times and polyp detection rates in an overall analysis (p Z 0.21). However, when stratified by the use of transparent hood, an association was shown in the examinations without hood (p Z 0.03), whereas no association was found with hood attachment. In the examinations without hood attachment, the polyp detection rate of the colonoscopists with withdrawal times over 8 minutes were significantly larger than that of the colonoscopists with withdrawal times below 8 minutes (38% vs 49%, p!0.0001). With hood attachment, the polyp detection rates generally increased (49% in total) and the variation according to withdrawal time was lowered (range 38%-60%). Conclusion: Without hood attachment, the polyp detection rates were associated with colonoscopic withdrawal times in our practice, and the withdrawal time over 8 minutes could be recommended. However, the detection rates generally improved and the variation seemed to be relieved by hood attachment.
M1360 Efficacy of Endoscopic Multi-Site Band Ligation in Eradicating Esophageal Varices Kiem C. Nguyen, Tieng H. Nguyen Background/Obiectives: Endoscopic elastic band ligation in eradicating esophageal varices has been shown to be an effective, safe, easy-to-do procedure with few untoward effects. This clinical trial compared the mean number of treatment sessions needed to eradicate esophageal varices and the safety of the Multi-site band ligation (banding 2 sites on the same varix) to those of the Conventional band ligation (banding 1 site on the same varix). Methods: This was a prospective randomized controlled clinical trial. Cirrhotics older than 18 years of age with grade 3 or 4 esophageal varices associated with red color signs were included. The patients had gastric varices, upper gastrointestinal hemorrhage, hepatic
AB222 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
encephalopathy, or hepatorenal syndrome, those had been administering with beta blockers or isosorbid mononitrates, those had been treated esophageal varices via endoscopy all were excluded. The patients in the Multi-site band ligation group were ligated two sites on the same varix in the range of 5 cm proximal to Z line, whereas those in the Conventional band ligation group(controlled group) were only ligated one site at the most distal end of each varix. Repeat ligation treatment sessions aimed at eradication of varices were conducted at 14- to 21- day intervals until varices in the distal esophagus were obliterated. Results: 12 patients were enrolled in the Multi-site band ligation group and 9 patients in the controlled group. There were no significant differences between the two groups with regard to age, gender, Child classification, the number and the grade of varices(pO0.05). Varices were eradicated in 11 out of 12 patients in the Multi-site band ligation group and in 7 out of 9 patients in the controlled group (pO0.05). The mean number of treatment sessions needed to eradicate esophageal varices in the Multi-site band ligation group were significantly fewer than those in the controlled group (2 versus 3.85 sessions, respectively) (pZ0.01). There were no significant differences between the two groups with regard to complications and adverse effects due to the procedure (pO0.05). Conclusions: Multi-site band ligation was as effective and safe in eradicating esophageal varices as Conventional band ligation was. But, Multisite band ligation-treated patients achieved eradication of varices with fewer sessions of treatment than those treated with Conventional band ligation.
M1361 Is It Safe to Place Percutaneous Gastric Feeding Tubes in Cirrhotic Patients? Joel Judah, Gurjit S. Dhatt, Wei Hou, John F. Valentine Background: A dilemma arises in deciding whether to perform percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) in cirrhotic patients, because they may have varices or ascites and are more prone to complications. The literature on this topic is limited to case reports. Design: Case control study was conducted of all cirrhotics (age O 18) who underwent PEG or PRG between 1996 and 2007 at 2 tertiary care hospitals. The control group, selected from the same patient population, was matched for age, sex and type of procedure (PEG or PRG) and had multiple co-morbidities, as expected in those requiring feeding tubes. Baseline, post-procedure and 3 month follow-up labs were collected. Model for end-stage liver disease (MELD) scores were calculated. Charts were reviewed for complications. Mixed effect model of regression analysis assessed differences, both within the cirrhotic group and between the cirrhotic and control groups. Results: 40 cirrhotic patients had PEG (nZ10) or PRG (nZ30) [University hospital (nZ29) or VA hospital (nZ11)]. Mean age was 59.4, with 6 females and 34 males. Pre-procedure evaluation showed esophageal varices in 9, gastric varices in 2, and ascites in 4. The mean follow-up was 11.8 months. No complications were noted during the follow-up period in cirrhotics who underwent PEG. Two cirrhotics experienced significant pain in the immediate post-PRG period (6.7% complication rate), for a 5% overall complication rate in the cirrhotic group. No acute hepatic decompensations were recorded during follow-up. The complication rate in the control group was 18% (7/40), most minor. In cirrhotics with PEG, MELD decreased from 8.7 to 7.8 (p Z 0.28) in the immediate follow-up period and was 6 (p Z 0.77) at 3 month follow-up. Cirrhotics with PRG had a MELD drop from 11.9 to 11.5 (p Z 0.53) during immediate follow-up, and it was 11.9 (p Z 0.77) at 3 months. At baseline, MELD was 11.3 for the combined PEG/PRG cirrhotic group and 11.5 in the control group (p Z 0.47). In the immediate post-procedure period, cirrhotic group MELD was 10.8 vs 13.6 for the control group (p Z 0.04). At 3 months, cirrhotic group MELD was 11.4 vs 11.8 for the control group (p Z 0.14). Conclusions: This is the largest evaluation to date of cirrhotic patients who have undergone PEG and PRG placement. Complication rate in the cirrhotic group was not greater than the control group or that quoted in the literature. This study is limited as selection bias invariably occurred in the cirrhotic group; however, this study found no evidence to support a poorer outcome in the selected cirrhotic patients after PEG or PRG tube placement.
M1362 The New Endoscopic Sedation Method: Administration of Popofol Using BIS Monitor and TCI System Daisuke Tanioka, Yoshiro Kawahara, Hiroyuki Okada, Ryuta Takenaka, Masafumi Inoue, Seiji Kawano, Takao Tsuzuki, Masahide Kita, Keisuke Hori, Masayuki Uemura, Kazuhide Yamamoto Background/Aims: Endoscopic submucosal dissection (ESD) has recently been developed for endoscopic treatment of GI tumors. ESD is one of the most complex and lengthy endoscopic procedure. Thus, an appropriate sedation is indispensable to perform a steady procedure. As for propofol, stable sedation is provided. However, in case of over sedation, there is possibility of respiratory depression. The bispectral index (BIS), a parameter derived from the electroencephalograph (EEG), has been shown to correlate with increasing sedation and loss of consciousness. Target-controlled infusion (TCI) of propofol uses a pharmacokinetic model to maintain a selected target blood propofol concentration. For prevention of respiratory depression, we applied a combination of BIS monitoring and TCI system. We investigated the safety and efficacy of this combination method. Patients
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systematic feedback and educational programs. Age, male gender, adequate prep quality were significantly associated with detection of adenoma and polyps.
M1358 Colonoscopic Withdrawal Times and Detection Rates of Colonic Diverticula Haruka Kajiwara, Yutaka Yamaji, Yoshihiro Isomura, Shuntaro Yoshida, Noriyuki Takano, Takafumi Sugimoto, Atsuo Yamada, Keiji Ogura, Haruhiko Yoshida, Takao Kawabe, Masao Omata Background: The polyp detection rates are regarded as a quality indicator of colonoscopy. The colonoscopic withdrawal time has been elucidated to be highly associated with polyp detectability. However, the variation in detectability of other lesions has not been sufficiently investigated. Colonic diverticula are depressed lesions entirely contrary to polyps. They are more likely to be missed by colonoscopy, while have sometimes more clinical importance than polyps. Objectives: To investigate the association between colorectal diverticula detection rates and colonoscopic withdrawal times in the examinations by trainee colonoscopists for Japanese patients. Methods: Procedural data performed at The University of Tokyo Hospital were reviewed. Thirteen trainee colonoscopists were characterized by their mean withdrawal time for normal colon. The diverticula detection rates were investigated in association with withdrawal times of colonoscopists. Results: Overall, 2,314 colonoscopies were reviewed. Mean withdrawal time ranged from 6.5min to 10.4min among colonoscopists. Colonic diverticula were detected in 29% and diverticulum detection rates varied from 21% to 43%. Withdrawal time and diverticulum detection rate showed a marginal association (p Z 0.058). When stratified by the use of transparent hood, a strong association was shown in the examinations without hood (p Z 0.009), while no association was found with hood attachment. Conclusion: Without hood attachment, the diverticula detection rates were associated with colonoscopic withdrawal times. The association became obscure by hood attachment.
M1359 Colonoscopic Withdrawal Times and Detection Rates of Colorectal Polyps Haruka Kajiwara, Yutaka Yamaji, Yoshihiro Isomura, Shuntaro Yoshida, Noriyuki Takano, Takafumi Sugimoto, Atsuo Yamada, Keiji Ogura, Haruhiko Yoshida, Takao Kawabe, Masao Omata Background: The polyp detection rates have recently been emphasized as a quality indicator of colonoscopy. The colonoscopic withdrawal time has been elucidated to be highly associated with polyp detectability. Objectives: To investigate the association between colorectal polyp detection rates and colonoscopic withdrawal times in the examinations by trainee colonoscopists for Japanese patients. Methods: Procedural data performed at The University of Tokyo Hospital were reviewed. Thirteen trainee colonoscopists were characterized by their mean withdrawal time for normal colon. The polyp detection rates were investigated in association with withdrawal times of colonoscopists. Results: Overall, 2,314 colonoscopies were reviewed. Mean withdrawal time ranged from 6.5min to 10.4 min among colonoscopists. Colorectal polyps were detected in 47% of the patients, and polyp detection rates in individual endoscopists ranged between 36% and 60%. There was no association between mean withdrawal times and polyp detection rates in an overall analysis (p Z 0.21). However, when stratified by the use of transparent hood, an association was shown in the examinations without hood (p Z 0.03), whereas no association was found with hood attachment. In the examinations without hood attachment, the polyp detection rate of the colonoscopists with withdrawal times over 8 minutes were significantly larger than that of the colonoscopists with withdrawal times below 8 minutes (38% vs 49%, p!0.0001). With hood attachment, the polyp detection rates generally increased (49% in total) and the variation according to withdrawal time was lowered (range 38%-60%). Conclusion: Without hood attachment, the polyp detection rates were associated with colonoscopic withdrawal times in our practice, and the withdrawal time over 8 minutes could be recommended. However, the detection rates generally improved and the variation seemed to be relieved by hood attachment.
M1360 Efficacy of Endoscopic Multi-Site Band Ligation in Eradicating Esophageal Varices Kiem C. Nguyen, Tieng H. Nguyen Background/Obiectives: Endoscopic elastic band ligation in eradicating esophageal varices has been shown to be an effective, safe, easy-to-do procedure with few untoward effects. This clinical trial compared the mean number of treatment sessions needed to eradicate esophageal varices and the safety of the Multi-site band ligation (banding 2 sites on the same varix) to those of the Conventional band ligation (banding 1 site on the same varix). Methods: This was a prospective randomized controlled clinical trial. Cirrhotics older than 18 years of age with grade 3 or 4 esophageal varices associated with red color signs were included. The patients had gastric varices, upper gastrointestinal hemorrhage, hepatic
AB222 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
encephalopathy, or hepatorenal syndrome, those had been administering with beta blockers or isosorbid mononitrates, those had been treated esophageal varices via endoscopy all were excluded. The patients in the Multi-site band ligation group were ligated two sites on the same varix in the range of 5 cm proximal to Z line, whereas those in the Conventional band ligation group(controlled group) were only ligated one site at the most distal end of each varix. Repeat ligation treatment sessions aimed at eradication of varices were conducted at 14- to 21- day intervals until varices in the distal esophagus were obliterated. Results: 12 patients were enrolled in the Multi-site band ligation group and 9 patients in the controlled group. There were no significant differences between the two groups with regard to age, gender, Child classification, the number and the grade of varices(pO0.05). Varices were eradicated in 11 out of 12 patients in the Multi-site band ligation group and in 7 out of 9 patients in the controlled group (pO0.05). The mean number of treatment sessions needed to eradicate esophageal varices in the Multi-site band ligation group were significantly fewer than those in the controlled group (2 versus 3.85 sessions, respectively) (pZ0.01). There were no significant differences between the two groups with regard to complications and adverse effects due to the procedure (pO0.05). Conclusions: Multi-site band ligation was as effective and safe in eradicating esophageal varices as Conventional band ligation was. But, Multisite band ligation-treated patients achieved eradication of varices with fewer sessions of treatment than those treated with Conventional band ligation.
M1361 Is It Safe to Place Percutaneous Gastric Feeding Tubes in Cirrhotic Patients? Joel Judah, Gurjit S. Dhatt, Wei Hou, John F. Valentine Background: A dilemma arises in deciding whether to perform percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) in cirrhotic patients, because they may have varices or ascites and are more prone to complications. The literature on this topic is limited to case reports. Design: Case control study was conducted of all cirrhotics (age O 18) who underwent PEG or PRG between 1996 and 2007 at 2 tertiary care hospitals. The control group, selected from the same patient population, was matched for age, sex and type of procedure (PEG or PRG) and had multiple co-morbidities, as expected in those requiring feeding tubes. Baseline, post-procedure and 3 month follow-up labs were collected. Model for end-stage liver disease (MELD) scores were calculated. Charts were reviewed for complications. Mixed effect model of regression analysis assessed differences, both within the cirrhotic group and between the cirrhotic and control groups. Results: 40 cirrhotic patients had PEG (nZ10) or PRG (nZ30) [University hospital (nZ29) or VA hospital (nZ11)]. Mean age was 59.4, with 6 females and 34 males. Pre-procedure evaluation showed esophageal varices in 9, gastric varices in 2, and ascites in 4. The mean follow-up was 11.8 months. No complications were noted during the follow-up period in cirrhotics who underwent PEG. Two cirrhotics experienced significant pain in the immediate post-PRG period (6.7% complication rate), for a 5% overall complication rate in the cirrhotic group. No acute hepatic decompensations were recorded during follow-up. The complication rate in the control group was 18% (7/40), most minor. In cirrhotics with PEG, MELD decreased from 8.7 to 7.8 (p Z 0.28) in the immediate follow-up period and was 6 (p Z 0.77) at 3 month follow-up. Cirrhotics with PRG had a MELD drop from 11.9 to 11.5 (p Z 0.53) during immediate follow-up, and it was 11.9 (p Z 0.77) at 3 months. At baseline, MELD was 11.3 for the combined PEG/PRG cirrhotic group and 11.5 in the control group (p Z 0.47). In the immediate post-procedure period, cirrhotic group MELD was 10.8 vs 13.6 for the control group (p Z 0.04). At 3 months, cirrhotic group MELD was 11.4 vs 11.8 for the control group (p Z 0.14). Conclusions: This is the largest evaluation to date of cirrhotic patients who have undergone PEG and PRG placement. Complication rate in the cirrhotic group was not greater than the control group or that quoted in the literature. This study is limited as selection bias invariably occurred in the cirrhotic group; however, this study found no evidence to support a poorer outcome in the selected cirrhotic patients after PEG or PRG tube placement.
M1362 The New Endoscopic Sedation Method: Administration of Popofol Using BIS Monitor and TCI System Daisuke Tanioka, Yoshiro Kawahara, Hiroyuki Okada, Ryuta Takenaka, Masafumi Inoue, Seiji Kawano, Takao Tsuzuki, Masahide Kita, Keisuke Hori, Masayuki Uemura, Kazuhide Yamamoto Background/Aims: Endoscopic submucosal dissection (ESD) has recently been developed for endoscopic treatment of GI tumors. ESD is one of the most complex and lengthy endoscopic procedure. Thus, an appropriate sedation is indispensable to perform a steady procedure. As for propofol, stable sedation is provided. However, in case of over sedation, there is possibility of respiratory depression. The bispectral index (BIS), a parameter derived from the electroencephalograph (EEG), has been shown to correlate with increasing sedation and loss of consciousness. Target-controlled infusion (TCI) of propofol uses a pharmacokinetic model to maintain a selected target blood propofol concentration. For prevention of respiratory depression, we applied a combination of BIS monitoring and TCI system. We investigated the safety and efficacy of this combination method. Patients
www.giejournal.org