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M1406: Double-Balloon Colonoscope Can Enhance Cecal Intubation Rate - Evaluation of the Learning Curve in a Colon Model
Abstracts cancer screening programs, and simultaneously as comparator for individualcenter data. Table 1. Perforation and mortality rates of colonoscopy (‰, 95%CI), overall and in a screen and patient population.
PR (‰) Screen population Patient population Total
PR with polypectomy (‰)
0.96 (0.49 2.66 (0.27 - 25.63) 1.85) (n⫽20) (n⫽4) 0.61 (0.43 1.19 (0.56 - 2.52) 0.87) (n⫽45) (n⫽17) 0.66 (0.48 1.26 (0.62 - 2.57) 0.91) (n⫽67) (n⫽22) n ⫽ number of studies included.
PR without polypectomy (‰)
MR (‰)
0.46 (0.05 - 4.07) (n⫽5) 0.21 (0.08 - 0.59) (n⫽9) 0.23 (0.09 - 0.59) (n⫽15)
0.04 (0.01 0.19) (n⫽17) 0.07 (0.04 0.12) (n⫽37) 0.06 (0.04 0.11) (n⫽57)
M1404 Esophageal Perforations: Long Term Results of Endoscopic Stent Therapy Judith Junginger, Markus A. Ku¨per, Alfred Ko¨nigsrainer, Thomas Kratt Introduction:The perforation of the esophagus is an urgent, life-threatening disease accompanied by a high mortality and complication rate. It requires a sophisticated diagnostic and therapeutic procedure. The significance of solely endoscopic stent therapy is discussed controversially. Methods:Single center analysis of 58 patients with esophageal perforation, among them 24 patients with only endoscopic stent treatment of complete perforations of the esophagus caused by iatrogenic lesions (e.g. endoscopic dilation, bougienage, after mucosal resection), by foreign bodies or after excessive vomiting (Boerhaave’s disease). We used coated esophageal Ultraflex stents (Boston Scientific) in all cases. Patients with mediastinal emphysema and infection were included (even with need for intensive care therapy). Patients with mediastinal abscess and necessary initial surgical intervention were excluded.Results:24 patients: mean age 61.3 years; mean time from manifestation of initial symptoms to diagnosis: 23.6 hrs; mean time from diagnosis to endoscopic treatment: 4.1 hrs. Mean inpatient stay 25 days, duration of ICU therapy 8 days. Mean follow up time after endoscopic stent treatment 722 days. Short and long term results after stent placement (29 stents in 24 patients): 12.5% early stent dislocation within 24 hours, stents in situ median 26 days (range 1-730 days), 17% stent coating failure in long-time course. Stent removal in 22 patients (93%) without stenosis or other complications during follow up time, among them 21 patients with complete healing of ruptured area. In 2 patients the stent remained permanently in situ with stent inlet stenosis in one case due to tissue ingrowth treated with repeated endoscopic APC therapy. None of our patients needed a surgical intervention after stent placement. Conclusion:Minimal invasive endoscopic stenting therapy is a sufficient treatment of esophageal perforation in selected cases.
M1405 The Management of Warfarin-Associated Coagulopathy in the Acutely GI Bleeding Patients: A Survey of Current Practice Silvia Paggi, Franco Radaelli, Gianpiero Manes, Gianmichele Meucci, Simone Saibeni Background: The management of VKAs-induced coagulopathy in patients with acute GI bleeding is a more often frequent event and a cornerstone of triage and pre-endoscopic evaluation. The American College of Chest Physicians (ACCP) issued practice guidelines on the management of supra-therapeutic anticoagulation, which has been recently endorsed by ASGE. Aim of the study was to evaluate attitudes and compliance with the ACCP guidelines of gastroenterologists and endoscopists in the management of VKAs-associated coagulopathy in patients presenting with acute GI bleeding. Methods: A webbased survey describing hypothetical three case-scenarios representing various combinations of INR values and severity of GI bleeding with a standardized list of management options was mailed to regional members of three Italian gastroenterological societies (AIGO, SIED, SIGE. Results: 238 surveys were mailed, 105 (48%) returned and were included in the analysis. Among the respondents (median age 49.5 yr, range26-68yr, 68% male), 63% performed “on call” emergency endoscopy in their clinical practice. Treatment preferences by scenario are shown in the Table. For each scenario, compliance to the ACCP guidelines was 32%, 28% and 23% respectively.Conclusions: Our survey has shown a considerable variability among gastroenterologists in the management of patients with VKAs-associated coagulopathy and GI bleeding and a poor compliance to published guidelines. In detail, one of the main findings is an under-use of reversal agents (FFP or PCC) in serious-life threatening bleeding. These data call for the implementation of these guidelines among gastroenterologists.
AB212 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
case scenarios and management options Case scenarios patient age indication to VKAs therapy clinical scenario Hb-value (g/dL) INR-value Management options Conservative approach (VKAs suspension) Vitamin K (oral) Vitamin K (i.v.) Fresh Frozen Plasma (FFP) Prothrombin Complex Concentrate (PCC) FFP ⫹ vit K i.v. PCC ⫹ vit K i.v. Other options
#1
#2
#3
60 yr mitralic prosthesis
75yr atrial fibrillation
80 yr atrial fibrillation
melena, active bleeding, hemorrhagic shock 10.2 4.8
melena, acute anemia, stable patient 9.6 7
scanty hematochezia 13.9 9
23%
18%
35%
2% 13% 22%
8% 28% 12%
23% 32% 2%
6%
7%
0%
26% 6% 2%
18% 6% 3%
6% 2% 0%
M1406 Double-Balloon Colonoscope Can Enhance Cecal Intubation Rate - Evaluation of the Learning Curve in a Colon Model Keijiro Sunada, Hironori Yamamoto, Tomonori Yano, Tomohiko Miyata, Nishimura Naoyuki, Hiroyuki Sato, Yoshimasa Miura, Hakuei Shinhata, Yoshikazu Hayashi, Kentaro Sugano Background: Colonoscopy is now the “gold standard” to detect neoplasm in the colon. However, it requires a substantial training to obtain the proficiency in reaching the cecum constantly. Double-balloon endoscopy (DBE) was originally developed for the purpose of observation/treatment of the small intestine. However, its principle (preventing the extension and shortening the intestinal tract) can be also applied to the colon and make it easier to reach the cecum.Aim: To evaluate the completion rate and learning curve of DBE applied to the colon, compared to conventional colonoscopy (CS).Objects: Eighteen medical students in Jichi Medical University.Materials: All examinations were done with conventional colonoscope (EC-590MP, Fujifilm, Japan), DBE (EC-450BI5, Fujifilm, Japan), and colon model (Kyoto Kagaku, Japan) .Methods: They were divided into 2 groups by the sealed envelope method. In the group A, CS was performed 10 times and subsequently DBE was performed 10 times. In the group B, they were performed in reverse order., Success rate of cecal intubation, cecal intubation time, and extent of colon intubated were recorded. Learning curves were evaluated in 3 consecutive periods, 1 to 4 (first period), 5 to 7 (second period), and 8 to 10 (third period). Time of every procedure was limited up to 20 minutes. Results: The overall success rate was 6.7 % (12/180) with CS and 73.3 % (132/180) with DBE. In both A and B group, success rate was significantly better with DBE than with CS. Learning curves were defined with both CS and DBE. Average success rates of DBE were 63 % in the first period, 80 % in the second period, and 82 % in the third period. In particular, success rate with DBE was over 80% from the first period in group A. In addition, median cecal intubation time decreased from 17.8 to 12.4 minutes with DBE. Conclusion: Using DBE, high completion rate of colonoscopy was achieved even by examiners who had no experience of endoscopy. It was suggested that DBE could be a useful tool to improve performance in colonoscopy with less practice.
www.giejournal.org
PR (‰) Screen population Patient population Total
PR with polypectomy (‰)
0.96 (0.49 2.66 (0.27 - 25.63) 1.85) (n⫽20) (n⫽4) 0.61 (0.43 1.19 (0.56 - 2.52) 0.87) (n⫽45) (n⫽17) 0.66 (0.48 1.26 (0.62 - 2.57) 0.91) (n⫽67) (n⫽22) n ⫽ number of studies included.
PR without polypectomy (‰)
MR (‰)
0.46 (0.05 - 4.07) (n⫽5) 0.21 (0.08 - 0.59) (n⫽9) 0.23 (0.09 - 0.59) (n⫽15)
0.04 (0.01 0.19) (n⫽17) 0.07 (0.04 0.12) (n⫽37) 0.06 (0.04 0.11) (n⫽57)
M1404 Esophageal Perforations: Long Term Results of Endoscopic Stent Therapy Judith Junginger, Markus A. Ku¨per, Alfred Ko¨nigsrainer, Thomas Kratt Introduction:The perforation of the esophagus is an urgent, life-threatening disease accompanied by a high mortality and complication rate. It requires a sophisticated diagnostic and therapeutic procedure. The significance of solely endoscopic stent therapy is discussed controversially. Methods:Single center analysis of 58 patients with esophageal perforation, among them 24 patients with only endoscopic stent treatment of complete perforations of the esophagus caused by iatrogenic lesions (e.g. endoscopic dilation, bougienage, after mucosal resection), by foreign bodies or after excessive vomiting (Boerhaave’s disease). We used coated esophageal Ultraflex stents (Boston Scientific) in all cases. Patients with mediastinal emphysema and infection were included (even with need for intensive care therapy). Patients with mediastinal abscess and necessary initial surgical intervention were excluded.Results:24 patients: mean age 61.3 years; mean time from manifestation of initial symptoms to diagnosis: 23.6 hrs; mean time from diagnosis to endoscopic treatment: 4.1 hrs. Mean inpatient stay 25 days, duration of ICU therapy 8 days. Mean follow up time after endoscopic stent treatment 722 days. Short and long term results after stent placement (29 stents in 24 patients): 12.5% early stent dislocation within 24 hours, stents in situ median 26 days (range 1-730 days), 17% stent coating failure in long-time course. Stent removal in 22 patients (93%) without stenosis or other complications during follow up time, among them 21 patients with complete healing of ruptured area. In 2 patients the stent remained permanently in situ with stent inlet stenosis in one case due to tissue ingrowth treated with repeated endoscopic APC therapy. None of our patients needed a surgical intervention after stent placement. Conclusion:Minimal invasive endoscopic stenting therapy is a sufficient treatment of esophageal perforation in selected cases.
M1405 The Management of Warfarin-Associated Coagulopathy in the Acutely GI Bleeding Patients: A Survey of Current Practice Silvia Paggi, Franco Radaelli, Gianpiero Manes, Gianmichele Meucci, Simone Saibeni Background: The management of VKAs-induced coagulopathy in patients with acute GI bleeding is a more often frequent event and a cornerstone of triage and pre-endoscopic evaluation. The American College of Chest Physicians (ACCP) issued practice guidelines on the management of supra-therapeutic anticoagulation, which has been recently endorsed by ASGE. Aim of the study was to evaluate attitudes and compliance with the ACCP guidelines of gastroenterologists and endoscopists in the management of VKAs-associated coagulopathy in patients presenting with acute GI bleeding. Methods: A webbased survey describing hypothetical three case-scenarios representing various combinations of INR values and severity of GI bleeding with a standardized list of management options was mailed to regional members of three Italian gastroenterological societies (AIGO, SIED, SIGE. Results: 238 surveys were mailed, 105 (48%) returned and were included in the analysis. Among the respondents (median age 49.5 yr, range26-68yr, 68% male), 63% performed “on call” emergency endoscopy in their clinical practice. Treatment preferences by scenario are shown in the Table. For each scenario, compliance to the ACCP guidelines was 32%, 28% and 23% respectively.Conclusions: Our survey has shown a considerable variability among gastroenterologists in the management of patients with VKAs-associated coagulopathy and GI bleeding and a poor compliance to published guidelines. In detail, one of the main findings is an under-use of reversal agents (FFP or PCC) in serious-life threatening bleeding. These data call for the implementation of these guidelines among gastroenterologists.
AB212 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
case scenarios and management options Case scenarios patient age indication to VKAs therapy clinical scenario Hb-value (g/dL) INR-value Management options Conservative approach (VKAs suspension) Vitamin K (oral) Vitamin K (i.v.) Fresh Frozen Plasma (FFP) Prothrombin Complex Concentrate (PCC) FFP ⫹ vit K i.v. PCC ⫹ vit K i.v. Other options
#1
#2
#3
60 yr mitralic prosthesis
75yr atrial fibrillation
80 yr atrial fibrillation
melena, active bleeding, hemorrhagic shock 10.2 4.8
melena, acute anemia, stable patient 9.6 7
scanty hematochezia 13.9 9
23%
18%
35%
2% 13% 22%
8% 28% 12%
23% 32% 2%
6%
7%
0%
26% 6% 2%
18% 6% 3%
6% 2% 0%
M1406 Double-Balloon Colonoscope Can Enhance Cecal Intubation Rate - Evaluation of the Learning Curve in a Colon Model Keijiro Sunada, Hironori Yamamoto, Tomonori Yano, Tomohiko Miyata, Nishimura Naoyuki, Hiroyuki Sato, Yoshimasa Miura, Hakuei Shinhata, Yoshikazu Hayashi, Kentaro Sugano Background: Colonoscopy is now the “gold standard” to detect neoplasm in the colon. However, it requires a substantial training to obtain the proficiency in reaching the cecum constantly. Double-balloon endoscopy (DBE) was originally developed for the purpose of observation/treatment of the small intestine. However, its principle (preventing the extension and shortening the intestinal tract) can be also applied to the colon and make it easier to reach the cecum.Aim: To evaluate the completion rate and learning curve of DBE applied to the colon, compared to conventional colonoscopy (CS).Objects: Eighteen medical students in Jichi Medical University.Materials: All examinations were done with conventional colonoscope (EC-590MP, Fujifilm, Japan), DBE (EC-450BI5, Fujifilm, Japan), and colon model (Kyoto Kagaku, Japan) .Methods: They were divided into 2 groups by the sealed envelope method. In the group A, CS was performed 10 times and subsequently DBE was performed 10 times. In the group B, they were performed in reverse order., Success rate of cecal intubation, cecal intubation time, and extent of colon intubated were recorded. Learning curves were evaluated in 3 consecutive periods, 1 to 4 (first period), 5 to 7 (second period), and 8 to 10 (third period). Time of every procedure was limited up to 20 minutes. Results: The overall success rate was 6.7 % (12/180) with CS and 73.3 % (132/180) with DBE. In both A and B group, success rate was significantly better with DBE than with CS. Learning curves were defined with both CS and DBE. Average success rates of DBE were 63 % in the first period, 80 % in the second period, and 82 % in the third period. In particular, success rate with DBE was over 80% from the first period in group A. In addition, median cecal intubation time decreased from 17.8 to 12.4 minutes with DBE. Conclusion: Using DBE, high completion rate of colonoscopy was achieved even by examiners who had no experience of endoscopy. It was suggested that DBE could be a useful tool to improve performance in colonoscopy with less practice.
www.giejournal.org