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Missed Diagnoses in Patients with Gastric Cancer in Endoscopic Screening
Abstracts
phosphate loading in order to enhance renal phosphate excretion and prevent phosphate nephropathy. No significantly different parameters were identified in patients with AKI. Further study is essential to confirm our study. Serum biochemical changes following NaP for bowel preparation
Parameter
Pre-NaP
Sodium (mEq/L) Potassium (mEq/L) Chloride (mEq/L) Bicarbonate (mEq/L) Calcium (mg/dl) Phosphate (mg/dl) Magnesium (mg/dl) Creatinine (mg/dl)
140.53 4.13 103.23 28.39 9.11 3.64 2.12 1.01
24-hour Post-NaP
(136-146) 136.67 (3.4-5.12) 3.45 (99-107) 99.77 (20.5-32.4) 27.17 (8.2-10.0) 8.65 (2.6-4.7) 5.39 (1.6-2.4) 1.87 (0.5-1.5) 0.96
p3-day value Post-NaP
(125-145) 0.00 (2.67-5.44)0.00 (89-112) 0.001 (18.3-31.3)0.07 (7.5-9.7) 0.00 (3.0-11.0) 0.00 (1.5-2.4) 0.00 (0.3-1.6) 0.06
139.73 4.10 103 28.63 9.03 2.86 2.05 0.95
(135-145) (3.25-5.06) (95-110) (22.9-33.2) (8.2-10.5) (1.6-4.1) (1.6-2.5) (0.6-1.6)
Urine biochemical changes following NaP for bowel preparation
Parameter Urine Calcium/ Creatinine Urine Phosphate/ Creatinine Urine pH Urine specific gravity
Pre-NaP
Post-1st dose NaP
Post-2nd dose NaP
pvalue
0.15 (0.02-0.74)
0.11 (0.02-1.08)
0.07 (0.01-0.57)
0.002
0.59 (0.24-1.37)
2.97 (0.46-10.35)
3.64 (3.64-16.45) 0.001
propofol group and 251.4 76.8 mg in combination group. Mean propofol infusion rate in combination group was lower (0.13 0.044 mg/min/kg vs 0.16 0.047 mg/ mim/kg, p Z 0.082). Based on 10-point visual analogue scale, patients in the both groups showed similar degree of overall satisfaction (8.9 vs 0.1, p Z 0.18). Mean recovery time was similar between both groups (6.8 5.3 vs 8.35 5.5 min, p Z 0.37). Eight minor compliations occurred in the propofol group; 2 episodes of hypoxemia, 6 episodes of hypotension and 7 minor complications in the combination group: 3 episodes of hypoxemia, 4 episodes of hypotension. All of these minor complications improved immediately after lowering infusion rate of propofol. Conclusions: Deep sedation induced by continuous propofol infusion is thought to be relatively safe and efficious in ESD procecure. Procecural characteristics and results
Age (yrs) Total dose (mg) Infusion rate (mg/kg/min) Procedure time (min) Recovery time (min) Adverse event
Propofol (nZ50)
Propofol D midazolam (nZ50)
60.1 11.8 419.9 191.5 0.16 0.047 45.4 22.3 6.8 5.3 hypoxemia 2 hypotension 6
59.6 9.1 251.4 76.8 0.13 0.044 27.3 9.8 8.35 5.5 hypoxemia 3 hypotension 4
P-value 0.872 ! 0.05 0.082 !0.05 0.37 0.779
6.18 (5.05-7.83) 5.71 (5.04-6.36) 5.48 (4.66-6.21) 0.03 1.012 (1.005-1.030) 1.015 (1.005-1.030) 1.018 (1.005-1.030) 0.99
M1383 MRI Safety of Two Endoscopic Homeostasis Clips Paul Yeaton, Andrew Y. Wang, Matthew J. Bassignani Endoscopic placement of tissue opposition devices has gained widespread adoption since their introduction, primarily for hemostasis. They generally remain affixed to tissue for a period of days, bit may persist indefinitely. The material of their construction is proprietary, and may contain variable amounts of ferrous material. Being magnetic confers some risk when exposed to a magnetic field, either because of motion or inductive heating. Our goal was to assess the magnetic properties of the Olympus QuickClip2, and the Boston Scientific Resolution Clip. First, each clip was placed in a plastic zip-lock bag and placed on the 3 Tesla MR table which was then advanced toward the magnet to observe motion of the bag containing the clip. Then a 1200 gauss (0.12 Tesla) rare earth neodynium screening magnet was fixed on a tabletop; the clips were attached to a force gauge (Imada DPS-11) with suture material. Each clip was lowered to the magnetic surface, measuring the peak force required to separate the clip from the magnet. The Resolution clip was visibly more magnetic than the QuickClip2, with the zip-lock bag containing the Resolution clip flying through the air on the MR table. There was limited motion of the QuickClip in the same setting. The Resolution clip was removed from the screening magnetic surface with 0.04 Newton. The QuickClip2 was removed from the screening magnetic surface with 0.01 Newton. Conclusion: The Resolution clip contains more ferrous material than the QuickClip2, and has approximately four times the magnetic force of the QuickClip2.
M1384 Safety and Efficacy of Deep Sedation for Endoscopic Submucosal Dissection: Propofol Versus Propofol Plus Midazolam, Randomized Prospective Study Kyoung-Oh Kim, Kyung Rim Huh, Cheol Hee Park, Taeho Hahn, Sang Hoon Park, Kyo-Sang Yoo, Jong Hyeok Kim, Choong Kee Park, KyungHun Lee Background/Aims: The sedation induced by propofol for routine endoscopic procedures is widely used, of which safety and efficacy have been well described. However, there are few studies regarding deep sedation for more complex procedure such as endoscopic submucosal dissection (ESD). The aim of this study was to evaluate safety and efficacy of deep sedation induced by continuous infusion of propofol in ESD procedure. Methods: A total of 100 patients diagnosed as early gastric cancer or adenoma with dysplasia were randomized to sedation with propofol alone (nZ50) or midazolam plus propofol (nZ50) group. Propofol was continuously infused intravenously using infusion pump and midazolam was administered intravenously in 2mg boluses. Blood pressure, oxygen saturation, and heart rate were measured. The level of sedation was assessed by an independent observer based on the American Society of Anesthesiologists criteria. Results: Mean procedure time in propofol group was longer than that of combination group (45.4 22.3 min vs 27.3 9.8 min). Total dose of propofol was 419 191.5 mg in
AB228 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
M1385 Deep Sedation for Prolonged Endoscopic Procedures in Cirrhotic Patients: Results of a Prospective Controlled Study Maria De Cento, Chiara Giordanino, Emanuela Faga`, Claudio Barletti, Mauro Bruno, Patrizia Carucci, Claudio G. De Angelis, Wilma Debernardi Venon, Alessandro Musso, Mario Rizzetto, Giorgio Saracco Background: There are no formal guidelines regarding sedation for endoscopy in cirrhotic patients (CP). The use of propofol has been shown to be effective and safe for gastroscopy but its use for prolonged endoscopic procedure remains to be studied. Aim: To evaluate the efficacy and safety of propofol in CP undergoing prolonged endoscopic procedures compared with non-cirrhotic patients (NCP). Methods: Twenty-nine consecutively collected inpatients (mean age 58 SD7, M/ FZ18/11) with known liver cirrhosis (Child-Pugh class AZ12, BZ9, CZ8) undergoing colonoscopy (21) or ERCP (8) received propofol by an anesthetist; the outcome measures studied (induction and recovery times, efficacy and safety of sedation, return to baseline function) were compared with those recorded among 68 consecutively collected NCP (mean age 61 SD8, M/FZ41/27) undergoing the same endoscopic procedures (colonoscopy: 49, ERCP: 19). Results: the mean dose of propofol administered in CP was 242 mg (SD 38, range 100-350) compared with 260 mg (SD 48, range 120-380) in NCP (pZ0.2). The mean time to achieve sedation was 2.8 min (SD 1.1) in CP and 3.1 (SD 1.2) in NCP (pZ0.9). The mean time to reach a maximal level of alertness on the Observer’S Assessment of Alertness and Sedation Scale (OAASS) in CP was 13.8 min (SD 4.2) compared with 12.7 (SD 4) in NCP (pZ0.7). Time to full recovery was 28.6 min (SD 9.1) in CP compared with 26.2 min (SD 8) in NCP (pZ0.72). Procedures times between the groups were similar: 26 min (SD 12) in CP vs 29 min (SD 14) in NCP (pZ 0.8). No significant complication related to sedation was observed in the 2 groups. Conclusions: propofol sedation is efficacious, safe and well tolerated in CP undergoing prolonged endoscopic procedures.
M1386 Missed Diagnoses in Patients with Gastric Cancer in Endoscopic Screening Hye Kyung Song Background and Aim: In Korea, a high incidence area of gastric cancer, screening of asymptomatic population has been advocated. A large number of patients are examined using endoscopy for screening gastric cancer. A few studies have been published on gastric cancer missed on previous endoscopy. But data is lacking on the analysis of causes for missed diagnoses. The aim of this study was to examine why gastric cancer is missed on endoscopic screening. Patients and Methods: Out of consecutive series of 440 patients diagnosed with early and advanced gastric cancer in endoscopic screening, we retrospectively identified patients who had endoscopic screening within 3 years before the diagnosis. The timing of previous endoscopies, endoscopic findings, endoscopist’s years of experience and observation time of endoscopic procedure were recorded. Missed diagnoses were categorized as either definitely or possibly missed and the reasons for being missed were documented. For patients with definitely missed diagnoses, previous endoscopic procedure was compared with final diagnostic procedure in observation time. Results Out of 440 patients, 114 (25.9%) had endoscopic screening within the previous 3 years and 27 (6.1%) of these within the previous 1 year. Among those patients with definitely missed diagnoses (24: 5.4%), errors by
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Abstracts
endoscopist accounted for majority of the reasons for being missed (95.8%). In those patients with definitely missed diagnoses, previous and final diagnostic endoscopic mean observation time were 3.8 min and 6.3 min respectively (P!0.01). There was no difference in endoscopist’s years of experience. Conclusion: Missed gastric cancer was a frequent finding on endoscopic screening and errors by endoscopist accounted for the majority of missed lesions. Errors by endoscopist were related to observation time. This study emphasizes the importance of sufficient observation time on endoscopic gastric cancer screening.
M1387 Role of Intravenous Hyoscine N-Butyl Bromide At the Time of Colonoscopic Withdrawal for Polyp Detection Rates: A Randomized, Double-Blinded, Placebo-Controlled Trial Tae Jun Byun, Dong Soo Han, Sang Bong Ahn, Hyun Seok Cho, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: Colonoscopy is currently the gold standard for detection and removal of colonic neoplasia. A number of factors may contribute to the accuracy of colonoscopy. Colonic spasm is a relatively common problem, and may impede colonoscopic insertion, inspection of the mucosal surface and polypectomy. Most endoscopists perform detection and removal of colonic polyps at the time of withdrawal, and they may often feel that colonic spasm makes detection and removal of colonic polyps difficult. The aim of this study was to determine whether there was any benefit for polyp detection rates in using hyoscine N-butyl bromide (BuscopanÒ) at the time of colonoscopic withdrawal. Methods: We conducted a randomized double-blinded, placebo controlled trial in a single center from July 2008 to September 2008. A total of 205 patients undergoing colonoscopy were randomized to receive either 20mg of hyoscine N-butyl bromide (Buscopan group (BG), nZ103) or normal saline (placebo group (PG), nZ102) intravenously at the time of colonoscopic withdrawal after cecal intubation. Outcome measures included polyp and adenoma detection rate, characteristics of polyps, insertion and withdrawal time, spasm score, vital signs, and side effects. Results: There was no difference of baseline characteristics between two groups. The polyp and adenoma detection rates in the BG were some higher than the PG, but there were no significant differences between two groups (respectively, 45.6% and 35.0% vs. 39.2% and 29.4%; pZ0.353 and pZ0.396). The size, location, number, shape and histology of polyps and adenomas did not significantly differ between two groups. No significant difference was found in the insertion time, withdrawal time and spasm score. Blood pressure after colonoscopy was significant lower than before colonoscopy in two groups, but pulse rate after colonoscopy was significant higher than before colonoscopy in BG (pZ0.000). In side effects, dry mouth was significant higher in BG than PG (pZ0.013). Conclusion: Intravenously administered hyoscine N-butyl bromide at the time of colonoscopic withdrawal cannot improve polyp and adenoma detection rates.
M1388 Standardized Procedural Evaluation (SPE) for the Assessment of Esophagogastroduodenoscopy Skills Vishal Ghevariya, Sushil Duddempudi, Malvinder Singh, Vani Paleti, Mojdeh Momeni, Mahesh Krishnaiah, Sury Anand Purpose: To develop an assessment tool, to objectively evaluate progression of GI fellows-in-training endoscopic skills. Methods: Trainees were proctored at the endoscopy unit of The Brooklyn Hospital Center, 450- bed community hospital in New York City. The center performs approximately 2500 EGDs every year. Three GI faculty members with extensive endoscopic experience and the chief GI fellow designed the SPE. A standard EGD including perioperative tasks was itemized into a 26-point grading system (Table 1). Nine GI fellows (four 3rd year, one 2nd year, four 1st year) were graded prospectively. Three GI faculty members randomly completed the SPEs during the first three months of each academic year for each fellow. Fellows were graded without their knowledge during each diagnostic endoscopy session. The gold standard in each case was that which the faculty gastroenterologist could do and what they saw. Results: This pilot project demonstrated a difference in endoscopic skill based on level of training (Graph 1). The 1st year fellows attained an average score of 43.9 out of 76. This improved to 65.5 for 2nd and 70.2 for 3rd year fellows. Analysis showed the difference of means between SPE scores of each year of training was statistically significant (p !.05). Among the individual techniques, intubation of Upper Esophageal Sphincter (UES), intubation of duodenum and technique of retroflexion are acquired early in training and are perfected during second year of training (Graph-2,3). Intubation of pylorus is learned slowly and improves significantly during third year of training. However, adequate examination of lesser curvature and slow duodenal withdrawal are among the most difficult endoscopic skills that are learned during the training (Graph-2,3). Conclusion: The SPE that was developed appears to be a good tool for the assessment of endoscopic skills for fellows in training. This evaluation also grades individual endoscopic skills, thus, focused guidance can be given. Further testing with larger number of fellows and evaluators is needed to validate the tool for widespread use. Intubation of UES, duodenum and retroflexion maneuver are acquired early, while examination of lesser curvature and slow duodenal withdrawal requires more training and skills to master.
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M1389 Bowel Preparation for Colonoscopy: A New Physician-Patient Satisfaction Questionnaire Oscar Teramoto-Matsubara, Sergio R. Sobrino-Cossio, Juan C. LopezAlvarenga, Jose-Antonio Vargas, Julio-Cesar Soto-Perez, Ma. Elena Hernandez, Rolando Armienta, Yasmin Crespo, Armando Ramirez, Jorge Gonzalez, Luis Charua-Guindic Background: Bowel preparation for colonoscopy is in most cases an unpleasant experience. Physician & patient’s satisfaction can help to choose which preparation has the best acceptance, cleanliness of colon and presence of potential complications. Objective: To evaluate if a questionnaire that assesses patient & physician satisfaction (PPSQ) after bowel preparation for colonoscopy has enough sensitivity to differentiate two different types of preparations. The PPSQ is a 10-item questionnaire measured by a 5-point Likert scale. Material & Method: We included 220 ITT patients, who underwent to bowel preparation for colonoscopy, in a crosssectional multi-center study. They were randomly assigned to oral solution of sodium phosphate (NaP) or polyethylene glycol (PEG). These preparations have differences that can be used to contrast the PPSQ. Upon arrival at the endoscopy center, patients were asked to fill out the PPSQ. The endoscopist evaluated colon visibility, colonoscopy duration, and any complications in the physician’s section of the PPSQ. Contrast between groups was made using chi-square and Student t test adjusted for variances. Results: Age & gender were comparable between groups (51.2 24 yrs; 57.9% fem.). The NaP volume was completely ingested by 95% (115/ 120) of subjects compared with 49% of the PEG group (p!0.001). The PPSQ showed that the NaP group considered the preparation easier (85.8% vs 57.5%; p!0.001); they would prefer to take the preparation again if they had to repeat the colonoscopy (86.6% vs 50%; pZ0.014). Both groups reported unpleasant taste of the solutions; but complaints about the volume taken were related to PEG (NaP 38.3% vs PEG 60.8%; p!0.009). Common reported side effects (NaP vs PEG, respectively) were: unpleasant flavor (2.3 .06 vs 2.60.09; p!0.026), vomiting (0.13 0.05 vs 0.46 0.08; p!0.001) and abdominal pain (0.43 0.08 vs 1 0.12; p!0.001). No differences were found for nausea, headache and weakness. Thirst was only reported in the NaP group (10.83% vs 0%). No complications were reported during the preparations or colonoscopy procedure. Endoscopists reported better colon visibility in the NaP group (90% vs 62%, pZ0.022) leading to easier polyp finding (66% vs 44% pZ0.027). Conclusion: The PPSQ showed enough sensitivity to detect differences between both bowel preparations for colonoscopy. PPSQ provides an objective tool for satisfaction assessment during bowel preparation for colonoscopy helping both, patients & physicians to choose the best treatment based on patient acceptance and colon cleanliness. In this study, the NaP group had better scores for acceptability and colon cleanliness despite the unpleasant flavor.
M1390 Newer Generation Colonoscopes Do Increase Detection of Polyps and Adenomas in Patients Undergoing Screening Colonoscopy J. Reggie Thomas, Richard D. Gerkin, Veronika Karasek, Benjamin Brichler, Nooman Gilani Background: Technology in endoscopy is continually advancing to new levels. Optical improvements in newer generation colonoscopes like high definition and wider viewing angle undoubtedly provide better visualization. Coupled with good technique, this new technology may improve quality of a colonoscopic examination. There is a paucity of data regarding using technologically advanced colonoscopes to achieve better quality exams. Aim: To compare the polyp and adenoma detection rates among the 140, 160, and 180 series Olympus colonoscopes. Methods: Consecutive screening colonoscopic exams were reviewed starting 12/2007 until 100 exams each with 180, 160 and 140 series Olympus colonoscopes were encountered. Demographic information including age, sex, and presence of diabetes was recorded. Patients with poor prep/incomplete tests were excluded. Number of polyps, number of adenomas, presence of advanced neoplasia, total exam time, time to cecum, quality of preparation and fellow involvement were also recorded. A Kruskall-Wallis test was used to compare continuous variables and Chi square was used to analyze categorical data. Results: The average age in group 1 (140 scope) was 59.3, group 2 (160 scope) was 61.3 and group 3 (180 scope) was 61.4 years (NS). Of the population, 95.5% were men and 23.8% were diabetic. Fellows were involved in 23.3% of cases. There was no difference in sex, DM, prep quality or fellow involvement among groups. Primary results are listed in table 1. Cecal time was predicted by fellow involvement (p!0.001) and presence of AN (pZ0.013). Involvement of a fellow added 4.65 minutes to the cecal time. Six factors were predictive of exam time: cecal time (p!0.001), presence of AN (pZ0.001), number of polyps (p!0.001), fellow involvement (p!0.001), quality of preparation (pZ0.040), and size of largest polyp (p!0.001). Each additional polyp found added 1.63 minutes and fellow involvement added 4.97 minutes to the total exam time. The presence of advanced neoplasia was not associated with DM, prep quality or the type of scope used. Conclusions: Screening colonoscopy performed with 180 series Olympus colonoscopes was associated with a higher number of polyps and adenomas found, and longer exam times. A wider field of view and enhanced image quality associated
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB229
phosphate loading in order to enhance renal phosphate excretion and prevent phosphate nephropathy. No significantly different parameters were identified in patients with AKI. Further study is essential to confirm our study. Serum biochemical changes following NaP for bowel preparation
Parameter
Pre-NaP
Sodium (mEq/L) Potassium (mEq/L) Chloride (mEq/L) Bicarbonate (mEq/L) Calcium (mg/dl) Phosphate (mg/dl) Magnesium (mg/dl) Creatinine (mg/dl)
140.53 4.13 103.23 28.39 9.11 3.64 2.12 1.01
24-hour Post-NaP
(136-146) 136.67 (3.4-5.12) 3.45 (99-107) 99.77 (20.5-32.4) 27.17 (8.2-10.0) 8.65 (2.6-4.7) 5.39 (1.6-2.4) 1.87 (0.5-1.5) 0.96
p3-day value Post-NaP
(125-145) 0.00 (2.67-5.44)0.00 (89-112) 0.001 (18.3-31.3)0.07 (7.5-9.7) 0.00 (3.0-11.0) 0.00 (1.5-2.4) 0.00 (0.3-1.6) 0.06
139.73 4.10 103 28.63 9.03 2.86 2.05 0.95
(135-145) (3.25-5.06) (95-110) (22.9-33.2) (8.2-10.5) (1.6-4.1) (1.6-2.5) (0.6-1.6)
Urine biochemical changes following NaP for bowel preparation
Parameter Urine Calcium/ Creatinine Urine Phosphate/ Creatinine Urine pH Urine specific gravity
Pre-NaP
Post-1st dose NaP
Post-2nd dose NaP
pvalue
0.15 (0.02-0.74)
0.11 (0.02-1.08)
0.07 (0.01-0.57)
0.002
0.59 (0.24-1.37)
2.97 (0.46-10.35)
3.64 (3.64-16.45) 0.001
propofol group and 251.4 76.8 mg in combination group. Mean propofol infusion rate in combination group was lower (0.13 0.044 mg/min/kg vs 0.16 0.047 mg/ mim/kg, p Z 0.082). Based on 10-point visual analogue scale, patients in the both groups showed similar degree of overall satisfaction (8.9 vs 0.1, p Z 0.18). Mean recovery time was similar between both groups (6.8 5.3 vs 8.35 5.5 min, p Z 0.37). Eight minor compliations occurred in the propofol group; 2 episodes of hypoxemia, 6 episodes of hypotension and 7 minor complications in the combination group: 3 episodes of hypoxemia, 4 episodes of hypotension. All of these minor complications improved immediately after lowering infusion rate of propofol. Conclusions: Deep sedation induced by continuous propofol infusion is thought to be relatively safe and efficious in ESD procecure. Procecural characteristics and results
Age (yrs) Total dose (mg) Infusion rate (mg/kg/min) Procedure time (min) Recovery time (min) Adverse event
Propofol (nZ50)
Propofol D midazolam (nZ50)
60.1 11.8 419.9 191.5 0.16 0.047 45.4 22.3 6.8 5.3 hypoxemia 2 hypotension 6
59.6 9.1 251.4 76.8 0.13 0.044 27.3 9.8 8.35 5.5 hypoxemia 3 hypotension 4
P-value 0.872 ! 0.05 0.082 !0.05 0.37 0.779
6.18 (5.05-7.83) 5.71 (5.04-6.36) 5.48 (4.66-6.21) 0.03 1.012 (1.005-1.030) 1.015 (1.005-1.030) 1.018 (1.005-1.030) 0.99
M1383 MRI Safety of Two Endoscopic Homeostasis Clips Paul Yeaton, Andrew Y. Wang, Matthew J. Bassignani Endoscopic placement of tissue opposition devices has gained widespread adoption since their introduction, primarily for hemostasis. They generally remain affixed to tissue for a period of days, bit may persist indefinitely. The material of their construction is proprietary, and may contain variable amounts of ferrous material. Being magnetic confers some risk when exposed to a magnetic field, either because of motion or inductive heating. Our goal was to assess the magnetic properties of the Olympus QuickClip2, and the Boston Scientific Resolution Clip. First, each clip was placed in a plastic zip-lock bag and placed on the 3 Tesla MR table which was then advanced toward the magnet to observe motion of the bag containing the clip. Then a 1200 gauss (0.12 Tesla) rare earth neodynium screening magnet was fixed on a tabletop; the clips were attached to a force gauge (Imada DPS-11) with suture material. Each clip was lowered to the magnetic surface, measuring the peak force required to separate the clip from the magnet. The Resolution clip was visibly more magnetic than the QuickClip2, with the zip-lock bag containing the Resolution clip flying through the air on the MR table. There was limited motion of the QuickClip in the same setting. The Resolution clip was removed from the screening magnetic surface with 0.04 Newton. The QuickClip2 was removed from the screening magnetic surface with 0.01 Newton. Conclusion: The Resolution clip contains more ferrous material than the QuickClip2, and has approximately four times the magnetic force of the QuickClip2.
M1384 Safety and Efficacy of Deep Sedation for Endoscopic Submucosal Dissection: Propofol Versus Propofol Plus Midazolam, Randomized Prospective Study Kyoung-Oh Kim, Kyung Rim Huh, Cheol Hee Park, Taeho Hahn, Sang Hoon Park, Kyo-Sang Yoo, Jong Hyeok Kim, Choong Kee Park, KyungHun Lee Background/Aims: The sedation induced by propofol for routine endoscopic procedures is widely used, of which safety and efficacy have been well described. However, there are few studies regarding deep sedation for more complex procedure such as endoscopic submucosal dissection (ESD). The aim of this study was to evaluate safety and efficacy of deep sedation induced by continuous infusion of propofol in ESD procedure. Methods: A total of 100 patients diagnosed as early gastric cancer or adenoma with dysplasia were randomized to sedation with propofol alone (nZ50) or midazolam plus propofol (nZ50) group. Propofol was continuously infused intravenously using infusion pump and midazolam was administered intravenously in 2mg boluses. Blood pressure, oxygen saturation, and heart rate were measured. The level of sedation was assessed by an independent observer based on the American Society of Anesthesiologists criteria. Results: Mean procedure time in propofol group was longer than that of combination group (45.4 22.3 min vs 27.3 9.8 min). Total dose of propofol was 419 191.5 mg in
AB228 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
M1385 Deep Sedation for Prolonged Endoscopic Procedures in Cirrhotic Patients: Results of a Prospective Controlled Study Maria De Cento, Chiara Giordanino, Emanuela Faga`, Claudio Barletti, Mauro Bruno, Patrizia Carucci, Claudio G. De Angelis, Wilma Debernardi Venon, Alessandro Musso, Mario Rizzetto, Giorgio Saracco Background: There are no formal guidelines regarding sedation for endoscopy in cirrhotic patients (CP). The use of propofol has been shown to be effective and safe for gastroscopy but its use for prolonged endoscopic procedure remains to be studied. Aim: To evaluate the efficacy and safety of propofol in CP undergoing prolonged endoscopic procedures compared with non-cirrhotic patients (NCP). Methods: Twenty-nine consecutively collected inpatients (mean age 58 SD7, M/ FZ18/11) with known liver cirrhosis (Child-Pugh class AZ12, BZ9, CZ8) undergoing colonoscopy (21) or ERCP (8) received propofol by an anesthetist; the outcome measures studied (induction and recovery times, efficacy and safety of sedation, return to baseline function) were compared with those recorded among 68 consecutively collected NCP (mean age 61 SD8, M/FZ41/27) undergoing the same endoscopic procedures (colonoscopy: 49, ERCP: 19). Results: the mean dose of propofol administered in CP was 242 mg (SD 38, range 100-350) compared with 260 mg (SD 48, range 120-380) in NCP (pZ0.2). The mean time to achieve sedation was 2.8 min (SD 1.1) in CP and 3.1 (SD 1.2) in NCP (pZ0.9). The mean time to reach a maximal level of alertness on the Observer’S Assessment of Alertness and Sedation Scale (OAASS) in CP was 13.8 min (SD 4.2) compared with 12.7 (SD 4) in NCP (pZ0.7). Time to full recovery was 28.6 min (SD 9.1) in CP compared with 26.2 min (SD 8) in NCP (pZ0.72). Procedures times between the groups were similar: 26 min (SD 12) in CP vs 29 min (SD 14) in NCP (pZ 0.8). No significant complication related to sedation was observed in the 2 groups. Conclusions: propofol sedation is efficacious, safe and well tolerated in CP undergoing prolonged endoscopic procedures.
M1386 Missed Diagnoses in Patients with Gastric Cancer in Endoscopic Screening Hye Kyung Song Background and Aim: In Korea, a high incidence area of gastric cancer, screening of asymptomatic population has been advocated. A large number of patients are examined using endoscopy for screening gastric cancer. A few studies have been published on gastric cancer missed on previous endoscopy. But data is lacking on the analysis of causes for missed diagnoses. The aim of this study was to examine why gastric cancer is missed on endoscopic screening. Patients and Methods: Out of consecutive series of 440 patients diagnosed with early and advanced gastric cancer in endoscopic screening, we retrospectively identified patients who had endoscopic screening within 3 years before the diagnosis. The timing of previous endoscopies, endoscopic findings, endoscopist’s years of experience and observation time of endoscopic procedure were recorded. Missed diagnoses were categorized as either definitely or possibly missed and the reasons for being missed were documented. For patients with definitely missed diagnoses, previous endoscopic procedure was compared with final diagnostic procedure in observation time. Results Out of 440 patients, 114 (25.9%) had endoscopic screening within the previous 3 years and 27 (6.1%) of these within the previous 1 year. Among those patients with definitely missed diagnoses (24: 5.4%), errors by
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Abstracts
endoscopist accounted for majority of the reasons for being missed (95.8%). In those patients with definitely missed diagnoses, previous and final diagnostic endoscopic mean observation time were 3.8 min and 6.3 min respectively (P!0.01). There was no difference in endoscopist’s years of experience. Conclusion: Missed gastric cancer was a frequent finding on endoscopic screening and errors by endoscopist accounted for the majority of missed lesions. Errors by endoscopist were related to observation time. This study emphasizes the importance of sufficient observation time on endoscopic gastric cancer screening.
M1387 Role of Intravenous Hyoscine N-Butyl Bromide At the Time of Colonoscopic Withdrawal for Polyp Detection Rates: A Randomized, Double-Blinded, Placebo-Controlled Trial Tae Jun Byun, Dong Soo Han, Sang Bong Ahn, Hyun Seok Cho, Tae Yeob Kim, Chang Soo Eun, Yong Cheol Jeon, Joo Hyun Sohn Background/Aims: Colonoscopy is currently the gold standard for detection and removal of colonic neoplasia. A number of factors may contribute to the accuracy of colonoscopy. Colonic spasm is a relatively common problem, and may impede colonoscopic insertion, inspection of the mucosal surface and polypectomy. Most endoscopists perform detection and removal of colonic polyps at the time of withdrawal, and they may often feel that colonic spasm makes detection and removal of colonic polyps difficult. The aim of this study was to determine whether there was any benefit for polyp detection rates in using hyoscine N-butyl bromide (BuscopanÒ) at the time of colonoscopic withdrawal. Methods: We conducted a randomized double-blinded, placebo controlled trial in a single center from July 2008 to September 2008. A total of 205 patients undergoing colonoscopy were randomized to receive either 20mg of hyoscine N-butyl bromide (Buscopan group (BG), nZ103) or normal saline (placebo group (PG), nZ102) intravenously at the time of colonoscopic withdrawal after cecal intubation. Outcome measures included polyp and adenoma detection rate, characteristics of polyps, insertion and withdrawal time, spasm score, vital signs, and side effects. Results: There was no difference of baseline characteristics between two groups. The polyp and adenoma detection rates in the BG were some higher than the PG, but there were no significant differences between two groups (respectively, 45.6% and 35.0% vs. 39.2% and 29.4%; pZ0.353 and pZ0.396). The size, location, number, shape and histology of polyps and adenomas did not significantly differ between two groups. No significant difference was found in the insertion time, withdrawal time and spasm score. Blood pressure after colonoscopy was significant lower than before colonoscopy in two groups, but pulse rate after colonoscopy was significant higher than before colonoscopy in BG (pZ0.000). In side effects, dry mouth was significant higher in BG than PG (pZ0.013). Conclusion: Intravenously administered hyoscine N-butyl bromide at the time of colonoscopic withdrawal cannot improve polyp and adenoma detection rates.
M1388 Standardized Procedural Evaluation (SPE) for the Assessment of Esophagogastroduodenoscopy Skills Vishal Ghevariya, Sushil Duddempudi, Malvinder Singh, Vani Paleti, Mojdeh Momeni, Mahesh Krishnaiah, Sury Anand Purpose: To develop an assessment tool, to objectively evaluate progression of GI fellows-in-training endoscopic skills. Methods: Trainees were proctored at the endoscopy unit of The Brooklyn Hospital Center, 450- bed community hospital in New York City. The center performs approximately 2500 EGDs every year. Three GI faculty members with extensive endoscopic experience and the chief GI fellow designed the SPE. A standard EGD including perioperative tasks was itemized into a 26-point grading system (Table 1). Nine GI fellows (four 3rd year, one 2nd year, four 1st year) were graded prospectively. Three GI faculty members randomly completed the SPEs during the first three months of each academic year for each fellow. Fellows were graded without their knowledge during each diagnostic endoscopy session. The gold standard in each case was that which the faculty gastroenterologist could do and what they saw. Results: This pilot project demonstrated a difference in endoscopic skill based on level of training (Graph 1). The 1st year fellows attained an average score of 43.9 out of 76. This improved to 65.5 for 2nd and 70.2 for 3rd year fellows. Analysis showed the difference of means between SPE scores of each year of training was statistically significant (p !.05). Among the individual techniques, intubation of Upper Esophageal Sphincter (UES), intubation of duodenum and technique of retroflexion are acquired early in training and are perfected during second year of training (Graph-2,3). Intubation of pylorus is learned slowly and improves significantly during third year of training. However, adequate examination of lesser curvature and slow duodenal withdrawal are among the most difficult endoscopic skills that are learned during the training (Graph-2,3). Conclusion: The SPE that was developed appears to be a good tool for the assessment of endoscopic skills for fellows in training. This evaluation also grades individual endoscopic skills, thus, focused guidance can be given. Further testing with larger number of fellows and evaluators is needed to validate the tool for widespread use. Intubation of UES, duodenum and retroflexion maneuver are acquired early, while examination of lesser curvature and slow duodenal withdrawal requires more training and skills to master.
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M1389 Bowel Preparation for Colonoscopy: A New Physician-Patient Satisfaction Questionnaire Oscar Teramoto-Matsubara, Sergio R. Sobrino-Cossio, Juan C. LopezAlvarenga, Jose-Antonio Vargas, Julio-Cesar Soto-Perez, Ma. Elena Hernandez, Rolando Armienta, Yasmin Crespo, Armando Ramirez, Jorge Gonzalez, Luis Charua-Guindic Background: Bowel preparation for colonoscopy is in most cases an unpleasant experience. Physician & patient’s satisfaction can help to choose which preparation has the best acceptance, cleanliness of colon and presence of potential complications. Objective: To evaluate if a questionnaire that assesses patient & physician satisfaction (PPSQ) after bowel preparation for colonoscopy has enough sensitivity to differentiate two different types of preparations. The PPSQ is a 10-item questionnaire measured by a 5-point Likert scale. Material & Method: We included 220 ITT patients, who underwent to bowel preparation for colonoscopy, in a crosssectional multi-center study. They were randomly assigned to oral solution of sodium phosphate (NaP) or polyethylene glycol (PEG). These preparations have differences that can be used to contrast the PPSQ. Upon arrival at the endoscopy center, patients were asked to fill out the PPSQ. The endoscopist evaluated colon visibility, colonoscopy duration, and any complications in the physician’s section of the PPSQ. Contrast between groups was made using chi-square and Student t test adjusted for variances. Results: Age & gender were comparable between groups (51.2 24 yrs; 57.9% fem.). The NaP volume was completely ingested by 95% (115/ 120) of subjects compared with 49% of the PEG group (p!0.001). The PPSQ showed that the NaP group considered the preparation easier (85.8% vs 57.5%; p!0.001); they would prefer to take the preparation again if they had to repeat the colonoscopy (86.6% vs 50%; pZ0.014). Both groups reported unpleasant taste of the solutions; but complaints about the volume taken were related to PEG (NaP 38.3% vs PEG 60.8%; p!0.009). Common reported side effects (NaP vs PEG, respectively) were: unpleasant flavor (2.3 .06 vs 2.60.09; p!0.026), vomiting (0.13 0.05 vs 0.46 0.08; p!0.001) and abdominal pain (0.43 0.08 vs 1 0.12; p!0.001). No differences were found for nausea, headache and weakness. Thirst was only reported in the NaP group (10.83% vs 0%). No complications were reported during the preparations or colonoscopy procedure. Endoscopists reported better colon visibility in the NaP group (90% vs 62%, pZ0.022) leading to easier polyp finding (66% vs 44% pZ0.027). Conclusion: The PPSQ showed enough sensitivity to detect differences between both bowel preparations for colonoscopy. PPSQ provides an objective tool for satisfaction assessment during bowel preparation for colonoscopy helping both, patients & physicians to choose the best treatment based on patient acceptance and colon cleanliness. In this study, the NaP group had better scores for acceptability and colon cleanliness despite the unpleasant flavor.
M1390 Newer Generation Colonoscopes Do Increase Detection of Polyps and Adenomas in Patients Undergoing Screening Colonoscopy J. Reggie Thomas, Richard D. Gerkin, Veronika Karasek, Benjamin Brichler, Nooman Gilani Background: Technology in endoscopy is continually advancing to new levels. Optical improvements in newer generation colonoscopes like high definition and wider viewing angle undoubtedly provide better visualization. Coupled with good technique, this new technology may improve quality of a colonoscopic examination. There is a paucity of data regarding using technologically advanced colonoscopes to achieve better quality exams. Aim: To compare the polyp and adenoma detection rates among the 140, 160, and 180 series Olympus colonoscopes. Methods: Consecutive screening colonoscopic exams were reviewed starting 12/2007 until 100 exams each with 180, 160 and 140 series Olympus colonoscopes were encountered. Demographic information including age, sex, and presence of diabetes was recorded. Patients with poor prep/incomplete tests were excluded. Number of polyps, number of adenomas, presence of advanced neoplasia, total exam time, time to cecum, quality of preparation and fellow involvement were also recorded. A Kruskall-Wallis test was used to compare continuous variables and Chi square was used to analyze categorical data. Results: The average age in group 1 (140 scope) was 59.3, group 2 (160 scope) was 61.3 and group 3 (180 scope) was 61.4 years (NS). Of the population, 95.5% were men and 23.8% were diabetic. Fellows were involved in 23.3% of cases. There was no difference in sex, DM, prep quality or fellow involvement among groups. Primary results are listed in table 1. Cecal time was predicted by fellow involvement (p!0.001) and presence of AN (pZ0.013). Involvement of a fellow added 4.65 minutes to the cecal time. Six factors were predictive of exam time: cecal time (p!0.001), presence of AN (pZ0.001), number of polyps (p!0.001), fellow involvement (p!0.001), quality of preparation (pZ0.040), and size of largest polyp (p!0.001). Each additional polyp found added 1.63 minutes and fellow involvement added 4.97 minutes to the total exam time. The presence of advanced neoplasia was not associated with DM, prep quality or the type of scope used. Conclusions: Screening colonoscopy performed with 180 series Olympus colonoscopes was associated with a higher number of polyps and adenomas found, and longer exam times. A wider field of view and enhanced image quality associated
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB229