- Email: [email protected]
Mo1085 Incidence and Characteristics of Interval Colorectal Carcinoma: A Single Center Experience
of the splenic flexure) CRC. The rate of interval carcinoma was 4.6 % (11 patients). Patients with interval carcinoma were elder, compared with non-interval cases (median 82 years vs. 72 years; n.s.) and more often female (55 % vs, 45 %; n.s.). Interval tumors were more frequently located in the right colon (82 % vs. 37 %; p=0.01). Markers for microsatellite instability (MSI) and mismatch repair (MMR) defects were positive in 45 % of the interval tumors, which represents, compared to available data, a 2 to 4.5-times higher prevalence than in a sporadic CRC population. Conclusion: Postcolonoscopy interval CRC occur in a small, but significant rate. There are differences in the patients and tumor characteristics compared to non-interval CRC, which suggests that, besides missed lesions and incompletely removed polyps, a particular tumor biology may play a role in the development of interval CRC. Mo1086 The Predictors and Outcomes of Poor Bowel Preparation During Colonoscopy: an Analysis From Colonoscopy Outcome in Minority Population (COMP) Registry Kinesh Changela, Anju Malieckal, Manhal J. Izzy, Kshitij Bhalani, Devin Lane, Shashideep Singhal, Sushil Duddempudi, Sury Anand Background: Bowel preparation for colonoscopy continues to play an important role in screening and surveillance. Poor bowel preparation can result in incomplete visualization, missed lesions, increased procedure time and impact complication rates. Limited data has been published to investigate the predictors and outcomes of poor bowel preparation during colonoscopy in minority populations. This study was designed to analyze specific patient characteristics in minorities, which is associated with inadequate bowel preparation. In this study, the difference in procedural outcomes among good and poor bowel preparation was investigated. Methods: Colonoscopy Outcome in Minority Population (COMP) registry, a patient based registry in minorities was created at our community teaching hospital. A total of 3,751 patients from the registry were included in study. The subjects were divided into good/fair bowel preparation (Group A) or poor bowel preparation (Group B). Study groups were further divided into three groups depending upon the age; young (age less than 50 years), middle age (age between 50-75 years) and elderly (age more than 75 years). The demographics, indications, completion of procedure and detection rate of different colonic pathologies were collected from procedure reports. Data was analyzed using SPSS statistical software to identify major predictors and variable outcomes of procedure in subjects with inadequate bowel preparation. Results: Of all 3,751 subjects included in study, Group A had 3,255 (86.8%) subjects and Group B had 496 (13.2%) subjects (p 0.001). Poor bowel preparation was more frequently observed in females (54.6%) compared to males (45.4%) (p 0.001). Group B had 17.7 % elderly subjects compared 10.7 % youngor middle age adults (9.8 %) ( p value 0.001). 14.9% African American (AA's) and 9.7% Hispanics (H) subjects were reported to have poor bowel preparation (p value < 0.001). The highest incidence of poor bowel prep was found in subjects who underwent colonoscopy for the indication of weight loss (27.4%) followed by abnormal imaging (24.2%) and anemia (23.9%) ( p value 0.001). 96.8% of subjects from group A compared to 62.3% of subjects from group B had a complete procedure with visualization of the ileocecal valve ( p value 0.001). Adenoma detection rate was 26.8% in Group A compared to 19.4% in Group B (p value 0.001). Advanced adenoma detection rate was 15.4% in Group A and 11.9% in Group B (p 0.04). Conclusions: A good prep continues to be the cornerstone of achieving optimal outcomes for colonoscopy with significant differences between the two bowel prep groups. This study, mainly in a minority population, suggests that the elderly, females and patients undergoing prep for weight loss may be at risk for poor bowel prep. Selection of alternative bowel preparation regimens should be made based upon age and comorbidities.
Mo1084 Standard Surveillance Intervals Appear Appropriate for Patients At Increased Risk of Colorectal Cancer Due to Renal Transplantation Paul Spizzo Background We have previously demonstrated that renal transplant recipients have a 2-3 fold increased prevalence of colorectal cancer compared with the general population1. However, appropriate colonoscopic surveillance intervals for these patients are not known. Objective To investigate whether renal transplant recipients over the age of 50 years with colorectal neoplasia on index colonoscopy should undergo more frequent endoscopic screening and surveillance for colorectal neoplasia than the general population by determining the incidence of recurrent colorectal neoplasia in transplant recipients compared with the general population. Methods Between June 2008 to March 2013,229 renal transplant recipients over the age of fifty who were at least six months post-transplant underwent a screening colonoscopy. Based upon the results of their index colonoscopy, they were recalled for a repeat colonoscopy at a specified duration according to the current NHMRC guidelines. Each patient was matched with 3 controls of similar age, gender and risk on the basis of the histology of polyps removed at their index colonoscopy. Control subjects were identified using a well characterised data base of patients at increased risk of colorectal cancer2. Fisher's exact test was used. Results As previously reported, of 229 renal transplant recipients who underwent screening via colonoscopy, 29 patients had advanced colorectal neoplasia or colorectal cancer (13%)1. Twenty five follow up colonoscopies were performed in accordance to the NHMRC guidelines and the yield of repeat colonoscopy compared with 75 matched controls over a period of 5 years. The rate of advanced adenomas was not statistically different compared with the control group (13 of 75 vs. 2 of 25; P=0.32), nor was the rate of non-advanced adenomas (32 of 75 vs. 8 of 25; P= 0.48). Conclusions Renal transplant recipients over the age of 50 years are at increased risk of colorectal neoplasia. Our preliminary data demonstrated that the prevalence of recurrent colorectal neoplasia in renal transplant recipients at their first surveillance, in accordance to the NHMRC guidelines for nontransplant patients, is similar to that of matched patients from the general population. Further study with a larger cohort of patients over the next 5 years, however, is warranted. References Collins MG et al Screening for colorectal cancer and advanced colorectal neoplasia in kidney transplant recipients: cross sectional prevalence and diagnostic accuracy study of faecal immunochemical testing for haemoglobin and colonoscopy..BMJ. 2012 Jul 25;345 Lane J et al Interval fecal immunochemical testing in a colonoscopic surveillance program speeds detection of colorectal neoplasia.Gastroenterology. 2010 Dec;139(6):1918-26
Mo1087 Malpractice Claims Alleging Failure to Screen for Esophageal Cancer: Commonplace or Boogeyman? Megan A. Adams, Joel H. Rubenstein BACKGROUND: Defensive medicine is cited as a contributor to rising health care costs. Surveys of gastroenterologists indicate that fear of litigation may drive endoscopic screening for esophageal cancer in low risk patients. Roughly 8,000 cases of esophageal adenocarcinoma are diagnosed annually in the U.S., with fewer than 15% of patients having undergone prior screening. However, we were not aware of a single case of a malpractice claim alleging failure to screen. Although complications from EGDs are rare, ~7 million EGDs are performed annually in the U.S. We hypothesized that the incidence of liability claims alleging delay in diagnosis of esophageal cancer in the absence of alarm symptoms is less than the incidence of claims alleging complications from an EGD performed with inadequate indication. METHODS: The Physician Insurers Association of America (PIAA) Database includes malpractice claims reported by insurers of over 2/3 of private practice physicians and 3,000 hospitals in the U.S., including claims settled out of court. We performed 2 database queries using ICD-9 codes. In the first, we identified all claims relating to an EGD (1985-2012), and then restricted to claims alleging inadequate indication for EGD. In the second query, we identified all claims related to esophageal cancer, and then restricted to claims alleging delay in diagnosis. We then restricted this further to claims in which the presenting condition was a non-alarm symptom. Data on presenting symptom is only available for 2002-2012, so the second query focused on that time frame. Descriptive statistics were used for data analysis. RESULTS: The database contains 278,220 claims filed against physicians in 1985-2012, and 103,381 in 2002-2012. Query 1: 761 claims in 1985-2012 were EGD-related (25.4% paid, average indemnity $242,414). 17 claims (2.2%) alleged inadequate indication for EGD (47.1% paid, average indemnity $174,634). Query 2: 268 total claims in 1985-2012 involved esophageal malignancies, including 122 in 2002-2012 (24.6% paid, average indemnity $354,175). Of these 122 claims, 62 (50.8%) alleged delay in diagnosis. 19 claims reported presenting symptoms that were not alarm symptoms, 4 of which (21.1%) were paid [Table 1]. LIMITATIONS: No ability to discriminate between adenocarcinomas and squamous cell carcinomas. Potential for misclassification of alarm symptoms. Due to privacy restrictions (too few claims), we were unable to obtain data on the presenting medical symptom for
Mo1085 Incidence and Characteristics of Interval Colorectal Carcinoma: A Single Center Experience Bernhard Rieder, Peter Koenigsberger, Walter Hofmann, Albrecht Pfeiffer Background: Colonoscopy with removal of adenomatous polyps prevents development and mortality of colorectal cancer (CRC). Nevertheless, there is a small but substantial rate of colorectal carcinoma diagnosed after a complete colonoscopy. Aim: Our objective was to evaluate the incidence rate of postcolonoscopy interval CRC in a six year period and to compare patients and tumor characteristics with the remaining cases of CRC. Methods: We analyzed data of all patients with a new diagnosis of CRC at our institution (Colorectal Cancer Center Memmingen) from January 1, 2007 to December 31, 2012. Patients, who had complete colonoscopy 6 to 60 months before diagnosis were considered as interval CRC. Patients with a known history of CRC were excluded. We examined patients (gender, age) and tumor characteristics (localization, immunohistochemical features). Results: CRC was diagnosed in 238 patients, 151 (63 %) had left sided, 87 (37 %) right sided (proximal
S-553
AGA Abstracts
AGA Abstracts
physicians. Methods: A retrospective cohort study was conducted of all patients referred to an adult specialty hospital for colonoscopy. Abstracted data included patient age, gender, priority according to the CTS and the endoscopy report, bowel preparation adequacy, cecal intubation, significant endoscopic findings (cancer, ileocolitis, polyp > 10mm). Weighted kappa was calculated to assess priority inter-rater agreement between referring physician and endoscopist. Multivariable models were created to identify independent predictors of cancer and of agreement on priority ratings. Results: Data on 1230 patients were collected (mean age 60.3+12.1 yrs, 52.5% female, 86.7% good or excellent preparations 95.9%, cecal intubation and 45.6% polyp detection rate. Significant findings included cancers (1.7%), polyps >10mm (20%), and ileocolitis (7.2%). Priority ratings are listed in Table 1. The weighted kappa value for all colonoscopies was 0.55 (0.51; 0.59). Predictors of cancer were increasing age (in years, OR=1.126 95% CI [1.06; 1.195]), and CRS priority of 1 or 2 (9.54 [1.73; 52.4]). Significant predictors of increased priority rating agreement between referring physician and endoscopist were ratings of P4 and P5. Conclusion: Agreement on triaging priorities between referring physician and endoscopist was moderate-good. Predictors of increased agreement were related to the selection of less urgent priority ratings. Predictors of cancer were age and urgent priority ratings. These findings appear to validate the CTS hierarchal priority rating scheme. Physician education may be required to improve CTS priority rating selection. Table 1: Priority by referring physician and endoscopist for all colonoscopies
Mo1084 Standard Surveillance Intervals Appear Appropriate for Patients At Increased Risk of Colorectal Cancer Due to Renal Transplantation Paul Spizzo Background We have previously demonstrated that renal transplant recipients have a 2-3 fold increased prevalence of colorectal cancer compared with the general population1. However, appropriate colonoscopic surveillance intervals for these patients are not known. Objective To investigate whether renal transplant recipients over the age of 50 years with colorectal neoplasia on index colonoscopy should undergo more frequent endoscopic screening and surveillance for colorectal neoplasia than the general population by determining the incidence of recurrent colorectal neoplasia in transplant recipients compared with the general population. Methods Between June 2008 to March 2013,229 renal transplant recipients over the age of fifty who were at least six months post-transplant underwent a screening colonoscopy. Based upon the results of their index colonoscopy, they were recalled for a repeat colonoscopy at a specified duration according to the current NHMRC guidelines. Each patient was matched with 3 controls of similar age, gender and risk on the basis of the histology of polyps removed at their index colonoscopy. Control subjects were identified using a well characterised data base of patients at increased risk of colorectal cancer2. Fisher's exact test was used. Results As previously reported, of 229 renal transplant recipients who underwent screening via colonoscopy, 29 patients had advanced colorectal neoplasia or colorectal cancer (13%)1. Twenty five follow up colonoscopies were performed in accordance to the NHMRC guidelines and the yield of repeat colonoscopy compared with 75 matched controls over a period of 5 years. The rate of advanced adenomas was not statistically different compared with the control group (13 of 75 vs. 2 of 25; P=0.32), nor was the rate of non-advanced adenomas (32 of 75 vs. 8 of 25; P= 0.48). Conclusions Renal transplant recipients over the age of 50 years are at increased risk of colorectal neoplasia. Our preliminary data demonstrated that the prevalence of recurrent colorectal neoplasia in renal transplant recipients at their first surveillance, in accordance to the NHMRC guidelines for nontransplant patients, is similar to that of matched patients from the general population. Further study with a larger cohort of patients over the next 5 years, however, is warranted. References Collins MG et al Screening for colorectal cancer and advanced colorectal neoplasia in kidney transplant recipients: cross sectional prevalence and diagnostic accuracy study of faecal immunochemical testing for haemoglobin and colonoscopy..BMJ. 2012 Jul 25;345 Lane J et al Interval fecal immunochemical testing in a colonoscopic surveillance program speeds detection of colorectal neoplasia.Gastroenterology. 2010 Dec;139(6):1918-26
Mo1087 Malpractice Claims Alleging Failure to Screen for Esophageal Cancer: Commonplace or Boogeyman? Megan A. Adams, Joel H. Rubenstein BACKGROUND: Defensive medicine is cited as a contributor to rising health care costs. Surveys of gastroenterologists indicate that fear of litigation may drive endoscopic screening for esophageal cancer in low risk patients. Roughly 8,000 cases of esophageal adenocarcinoma are diagnosed annually in the U.S., with fewer than 15% of patients having undergone prior screening. However, we were not aware of a single case of a malpractice claim alleging failure to screen. Although complications from EGDs are rare, ~7 million EGDs are performed annually in the U.S. We hypothesized that the incidence of liability claims alleging delay in diagnosis of esophageal cancer in the absence of alarm symptoms is less than the incidence of claims alleging complications from an EGD performed with inadequate indication. METHODS: The Physician Insurers Association of America (PIAA) Database includes malpractice claims reported by insurers of over 2/3 of private practice physicians and 3,000 hospitals in the U.S., including claims settled out of court. We performed 2 database queries using ICD-9 codes. In the first, we identified all claims relating to an EGD (1985-2012), and then restricted to claims alleging inadequate indication for EGD. In the second query, we identified all claims related to esophageal cancer, and then restricted to claims alleging delay in diagnosis. We then restricted this further to claims in which the presenting condition was a non-alarm symptom. Data on presenting symptom is only available for 2002-2012, so the second query focused on that time frame. Descriptive statistics were used for data analysis. RESULTS: The database contains 278,220 claims filed against physicians in 1985-2012, and 103,381 in 2002-2012. Query 1: 761 claims in 1985-2012 were EGD-related (25.4% paid, average indemnity $242,414). 17 claims (2.2%) alleged inadequate indication for EGD (47.1% paid, average indemnity $174,634). Query 2: 268 total claims in 1985-2012 involved esophageal malignancies, including 122 in 2002-2012 (24.6% paid, average indemnity $354,175). Of these 122 claims, 62 (50.8%) alleged delay in diagnosis. 19 claims reported presenting symptoms that were not alarm symptoms, 4 of which (21.1%) were paid [Table 1]. LIMITATIONS: No ability to discriminate between adenocarcinomas and squamous cell carcinomas. Potential for misclassification of alarm symptoms. Due to privacy restrictions (too few claims), we were unable to obtain data on the presenting medical symptom for
Mo1085 Incidence and Characteristics of Interval Colorectal Carcinoma: A Single Center Experience Bernhard Rieder, Peter Koenigsberger, Walter Hofmann, Albrecht Pfeiffer Background: Colonoscopy with removal of adenomatous polyps prevents development and mortality of colorectal cancer (CRC). Nevertheless, there is a small but substantial rate of colorectal carcinoma diagnosed after a complete colonoscopy. Aim: Our objective was to evaluate the incidence rate of postcolonoscopy interval CRC in a six year period and to compare patients and tumor characteristics with the remaining cases of CRC. Methods: We analyzed data of all patients with a new diagnosis of CRC at our institution (Colorectal Cancer Center Memmingen) from January 1, 2007 to December 31, 2012. Patients, who had complete colonoscopy 6 to 60 months before diagnosis were considered as interval CRC. Patients with a known history of CRC were excluded. We examined patients (gender, age) and tumor characteristics (localization, immunohistochemical features). Results: CRC was diagnosed in 238 patients, 151 (63 %) had left sided, 87 (37 %) right sided (proximal
S-553
AGA Abstracts
AGA Abstracts
physicians. Methods: A retrospective cohort study was conducted of all patients referred to an adult specialty hospital for colonoscopy. Abstracted data included patient age, gender, priority according to the CTS and the endoscopy report, bowel preparation adequacy, cecal intubation, significant endoscopic findings (cancer, ileocolitis, polyp > 10mm). Weighted kappa was calculated to assess priority inter-rater agreement between referring physician and endoscopist. Multivariable models were created to identify independent predictors of cancer and of agreement on priority ratings. Results: Data on 1230 patients were collected (mean age 60.3+12.1 yrs, 52.5% female, 86.7% good or excellent preparations 95.9%, cecal intubation and 45.6% polyp detection rate. Significant findings included cancers (1.7%), polyps >10mm (20%), and ileocolitis (7.2%). Priority ratings are listed in Table 1. The weighted kappa value for all colonoscopies was 0.55 (0.51; 0.59). Predictors of cancer were increasing age (in years, OR=1.126 95% CI [1.06; 1.195]), and CRS priority of 1 or 2 (9.54 [1.73; 52.4]). Significant predictors of increased priority rating agreement between referring physician and endoscopist were ratings of P4 and P5. Conclusion: Agreement on triaging priorities between referring physician and endoscopist was moderate-good. Predictors of increased agreement were related to the selection of less urgent priority ratings. Predictors of cancer were age and urgent priority ratings. These findings appear to validate the CTS hierarchal priority rating scheme. Physician education may be required to improve CTS priority rating selection. Table 1: Priority by referring physician and endoscopist for all colonoscopies