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Mo1233 Effect of IV PPI During NPO Time on Post-ESD Bleeding
Abstracts
performed at single tertiary center from 2003 to 2005. Procedure quality of index colonoscopy such as bowel preparation, withdrawal time and endoscopists were analyzed. Follow-up interval after index colonoscopy and patients with polyps, or advanced neoplasia on follow-up colonoscopy were evaluated. The association with and independent risk factors for advanced lesion were determined. Results: During the index colonoscopy, the poor bowel preparation rate was 9.4% and mean withdrawal time was 5.5 minutes. Overall 1185 colonoscopies (75.5%) were performed by fellow-ship trainee. Until August, 2011, 512 persons (32.6%, male⫽277, mean age⫽52) had follow-up colonoscopy and 495 persons (89.6%) underwent follow-up colonoscopy within 5 years (mean interval 31.8 months) after negative colonoscopy. Colorectal polyps were detected in 171 (33.4%) patients on follow-up. Advanced colorectal lesions were present in 19 patients (3.7%, male 73.7%, p⫽0.022) including 2 (0.4%) cancers. The patients with advanced lesions had a longer follow-up interval compared to the patients with none of advanced lesions (41.9 vs. 31.4 months, p⫽0.021). The association between procedure index and the presence of advanced lesions was not significant. Advanced lesions were prevalent in right-sided colon (66.7% vs. 42.8%, p⫽0.034) and risk factor for advanced lesions was male gender (odds ratio 2.872, 95% CI 1.190-6.933). Conclusions: Follow-up colonoscopy after negative colonoscopy has been performed with short interval in clinical practice. The incidence of advanced neoplasia after a negative colonoscopy was 3.7% including 2 interval cancers. Advanced lesions were more frequently located in the right colon and predominant in the male sex. Qualified index colonoscopy is important for following guided interval after negative colonoscopy.
Mo1231 Effectiveness of a Model of Filter of Open-Access Colonoscopy Requests: Decrease of the Overuse and Delay Time Control Pilar Diez-Redondo*, Sara Lorenzo-Pelayo, Paula Gil-Simon, Mteresa Herranz, Noelia Alcaide, Carlos De La Serna, Manuel Perez-Miranda Endoscopy Unit, Hospital Rio Hortega, Valladolid, Spain Introduction: To adjust the growing demand of colonoscopy (COL) with available resources and aspire to a quality COL, Endoscopy Units should be involved to minimize the overuse. Aims: To assess the viability and efficacy of a filter of requests of COL from Primary Care System (PCS) that refuses those who do not meet the recommendations gives by the Spanish Association of Gastroenterology (AEG) (www.aegastro.es), essentially mirroring EPAGE, and it classifies the remaining ones as step before a differentiated citation. Material and Methods: We analyzed prospectively (February 2010 - September 2011) all of the colonoscopies requests received in our unit from PCS and checked information against clinical history records, if available. COL requests were classified into adequate/inadequate. The inadequate ones were rejected, sending an explanatory letter to referring physicians (detailing unfulfilled protocol, recommendations of patient follow-up and e-mail address of contact). The adequate ones were qualified: “preferential”, “conventional” or “review” (postpolipectomy vigilance (PPV) and antecedents of colorectal cancer (ACCR) Variable assessed: patients age, indication, family and personal history of CCR of COL/polipectomy and date of latest COL. We analyzed the repercussion of the above mentioned measures in diverse aspects. Results: Checked 2.812 COL requests: Rejected: 479 (17%): ACCR: ⫾ PPV 404 (84.3%) due to shortening of the intervals recommended or start too young ages, symptoms appellants and last colonoscopy ⬍5 years before: 43 (9%) or insufficient information: 32 (6.7%). Acepted: 2.333: Preferential: 174 (7.5%), conventional: 818 (35%), review: 1.341 (57.5%). The monthly average of received requests became stable: 146 (year 2009) vs 144 (2011). With diminishing the rejected/month ones: 26 (2010) vs 20 (2011). So the monthly average of rejected COL was 17.8% in 2010 versus 13.9% in 2011. Of an average global wait of 97.73 days in 2009, it passed in 2011 to 14 days for preferential, 43.39 for conventional and 117.95 for reviews. It has received 5 delay written complaints during the first semester of 2009 vs 4 at first of 2011. 3 were collected claims denial of colonoscopy. We had received a monthly average of 4 emails from PCS with answering ⬍72 hours. Conclusions: The systematic review of all COL requests from PCS is a simple measure that had allowed avoids 17 % of inadequate COL, fundamentally due to inappropriate follow-up of ACCR and PPV (84.3%). Allowed more acceptable wait times on depending the type of indication, with longer time for the “reviews” in favour of “conventional” and “preferential” COL, whose waiting time decreased by half and 7 times less. The acceptance on the part of the user and the PCS physicians is good but it needs of a fluid communication.
www.giejournal.org
Mo1232 Clinicopathological Risk Factors for Delayed Postoperative Bleeding After ESD for Gastric Cancer: Comparison With the Factors for Early Bleeding Ryonho Koh*1, Kingo Hirasawa1, Hiroyuki Oka1, Atsushi Kokawa1, Katsuaki Tanaka2, Shin Maeda3 1 Department of Endoscopy, Yokohama City University Medical Center, Yokohama City, Japan; 2Department of Gastroenterology, Yokohama City University Medical Center, Yokohama City, Japan; 3Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama City, Japan Background: Postoperative bleeding is a major complication of endoscopic submucosal dissection (ESD). The patients who showed ESD related-bleeding after discharge and urgently readmitted into the hospital are tend to be poor outcomes. The aim of this study is to determine the incidence of delayed postoperative bleeding and analyze clinical factors after ESD in case of gastric neoplasm. Methods: We retrospectively investigated 1192 lesions from 1032 consecutive patients undergoing ESD for gastric neoplasm between June 2000 and December 2010. Clinicopathological factors for postoperative bleeding were analyzed. Results: Total (early and delayed) postoperative bleedings were evident in 64 lesions from 63 patients (5.37% of all the lesions and 6.10% of all the patients), and all achieved endoscopic hemostasis. Delayed postoperative bleeding (defined as bleeding occurring on or after the 6th postoperative day) occurred in 33 lesions (3.85% of all the lesions) from 32 patients. Univariate analysis showed that gender (male vs. female, P ⫽ 0.027), oral antithrombotic drugs (P ⫽ 0.017), oral corticosteroids (P ⫽ 0.017), tumor size of ⬎20mm (vs. ⱕ20mm, P ⫽ 0.027), and resected specimen size of ⬎40mm (vs. ⱕ40mm, P ⫽ 0.027) were significantly associated with delayed postoperative bleeding. Multivariate analysis showed that oral antithrombotic drugs (OR 2.184; 95% CI 1.005 to 4.746), oral corticosteroids (OR 8.379; 95% CI 2.117 to 32.249), and resected specimen size of ⬎40mm (OR 3.033; 95% CI 1.282 to 7.178) were independent risk factors for delayed postoperative bleeding. In comparison to patients with early postoperative bleeding (31 lesions from 31 patients), patients with delayed postoperative bleeding were more likely to show severe blood loss (Hb decrease of ⬎2 g/dL vs. ⱕ2 g/dL, P ⫽ 0.008), require blood transfusion (P ⬍ 0.001), have diabetes (P ⫽ 0.049) and have wide resected specimen (⬎40mm vs. ⱕ40mm, P ⫽ 0.048). Conclusions: Patients using oral antithrombotic drugs and corticosteroids and those having wide resected specimen (⬎40mm) were at high risk of delayed postoperative bleeding after ESD for gastric neoplasm. These findings suggest the patients with high risk of delayed postoperative bleeding need strict follow-up.
Mo1233 Effect of IV PPI During NPO Time on Post-ESD Bleeding Dong Chan Kim, Hang Lak Lee*, Kang Nyeong Lee, Dae Won Jun, Oh Young Lee, Byung Chul Yoon, Sang Pyo Lee, Ho Soon Choi Gastroenterology, Hanyang University Medical Center, Seoul, Republic of Korea Background: Intravenous form of proton pump inhibitor (IV PPI) is routinely used before and after ESD to prevent bleeding and to heal ulcer. However, there is controversy about effectiveness of IV PPI treatment during NPO time. Objective: We aimed to clarify that IV PPI really can prevent post ESD bleeding. Materials and Methods: Between March 2009 and September 2011, 209 patients who underwent complete ESD for adenoma and early gastric cancer were enrolled. Post⫺ESD coagulation (PEC) using a coagulation forceps and argon plasma coagulation was introduced. Age, gender, medications, tumor feature (gross type, pathology, size, location, depth), procedure time, second look endoscopy, IV PPI, and PEC were investigated. Results: We used IV PPI in 108 patients, and didn’t use IV PPI in 101 patients. Pathological findings show adenoma in 102 patients, and early gastric cancer in 107 patients. Only mucosal invasion was noted in 181 patients, and submucosal invasion was noted in 28 patients. The tumor located in antrum (120 patients), body (81 patients), and cardia (8 patients). Polypoid or protruded type was noted in 109 patients, flat type was noted in 26 patients, depressed type was noted in 74 patients. Delayed bleeding occurred after ESD in 23 patients, controlled in all cases by endoscopic hemostasis. There was no significant difference between delayed bleeding ratios between IV PPI group and No IV PPI group. Conclusions: This retrospective cohort study suggested that IV PPI before and after ESD can’t lower bleeding rate.
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB358
performed at single tertiary center from 2003 to 2005. Procedure quality of index colonoscopy such as bowel preparation, withdrawal time and endoscopists were analyzed. Follow-up interval after index colonoscopy and patients with polyps, or advanced neoplasia on follow-up colonoscopy were evaluated. The association with and independent risk factors for advanced lesion were determined. Results: During the index colonoscopy, the poor bowel preparation rate was 9.4% and mean withdrawal time was 5.5 minutes. Overall 1185 colonoscopies (75.5%) were performed by fellow-ship trainee. Until August, 2011, 512 persons (32.6%, male⫽277, mean age⫽52) had follow-up colonoscopy and 495 persons (89.6%) underwent follow-up colonoscopy within 5 years (mean interval 31.8 months) after negative colonoscopy. Colorectal polyps were detected in 171 (33.4%) patients on follow-up. Advanced colorectal lesions were present in 19 patients (3.7%, male 73.7%, p⫽0.022) including 2 (0.4%) cancers. The patients with advanced lesions had a longer follow-up interval compared to the patients with none of advanced lesions (41.9 vs. 31.4 months, p⫽0.021). The association between procedure index and the presence of advanced lesions was not significant. Advanced lesions were prevalent in right-sided colon (66.7% vs. 42.8%, p⫽0.034) and risk factor for advanced lesions was male gender (odds ratio 2.872, 95% CI 1.190-6.933). Conclusions: Follow-up colonoscopy after negative colonoscopy has been performed with short interval in clinical practice. The incidence of advanced neoplasia after a negative colonoscopy was 3.7% including 2 interval cancers. Advanced lesions were more frequently located in the right colon and predominant in the male sex. Qualified index colonoscopy is important for following guided interval after negative colonoscopy.
Mo1231 Effectiveness of a Model of Filter of Open-Access Colonoscopy Requests: Decrease of the Overuse and Delay Time Control Pilar Diez-Redondo*, Sara Lorenzo-Pelayo, Paula Gil-Simon, Mteresa Herranz, Noelia Alcaide, Carlos De La Serna, Manuel Perez-Miranda Endoscopy Unit, Hospital Rio Hortega, Valladolid, Spain Introduction: To adjust the growing demand of colonoscopy (COL) with available resources and aspire to a quality COL, Endoscopy Units should be involved to minimize the overuse. Aims: To assess the viability and efficacy of a filter of requests of COL from Primary Care System (PCS) that refuses those who do not meet the recommendations gives by the Spanish Association of Gastroenterology (AEG) (www.aegastro.es), essentially mirroring EPAGE, and it classifies the remaining ones as step before a differentiated citation. Material and Methods: We analyzed prospectively (February 2010 - September 2011) all of the colonoscopies requests received in our unit from PCS and checked information against clinical history records, if available. COL requests were classified into adequate/inadequate. The inadequate ones were rejected, sending an explanatory letter to referring physicians (detailing unfulfilled protocol, recommendations of patient follow-up and e-mail address of contact). The adequate ones were qualified: “preferential”, “conventional” or “review” (postpolipectomy vigilance (PPV) and antecedents of colorectal cancer (ACCR) Variable assessed: patients age, indication, family and personal history of CCR of COL/polipectomy and date of latest COL. We analyzed the repercussion of the above mentioned measures in diverse aspects. Results: Checked 2.812 COL requests: Rejected: 479 (17%): ACCR: ⫾ PPV 404 (84.3%) due to shortening of the intervals recommended or start too young ages, symptoms appellants and last colonoscopy ⬍5 years before: 43 (9%) or insufficient information: 32 (6.7%). Acepted: 2.333: Preferential: 174 (7.5%), conventional: 818 (35%), review: 1.341 (57.5%). The monthly average of received requests became stable: 146 (year 2009) vs 144 (2011). With diminishing the rejected/month ones: 26 (2010) vs 20 (2011). So the monthly average of rejected COL was 17.8% in 2010 versus 13.9% in 2011. Of an average global wait of 97.73 days in 2009, it passed in 2011 to 14 days for preferential, 43.39 for conventional and 117.95 for reviews. It has received 5 delay written complaints during the first semester of 2009 vs 4 at first of 2011. 3 were collected claims denial of colonoscopy. We had received a monthly average of 4 emails from PCS with answering ⬍72 hours. Conclusions: The systematic review of all COL requests from PCS is a simple measure that had allowed avoids 17 % of inadequate COL, fundamentally due to inappropriate follow-up of ACCR and PPV (84.3%). Allowed more acceptable wait times on depending the type of indication, with longer time for the “reviews” in favour of “conventional” and “preferential” COL, whose waiting time decreased by half and 7 times less. The acceptance on the part of the user and the PCS physicians is good but it needs of a fluid communication.
www.giejournal.org
Mo1232 Clinicopathological Risk Factors for Delayed Postoperative Bleeding After ESD for Gastric Cancer: Comparison With the Factors for Early Bleeding Ryonho Koh*1, Kingo Hirasawa1, Hiroyuki Oka1, Atsushi Kokawa1, Katsuaki Tanaka2, Shin Maeda3 1 Department of Endoscopy, Yokohama City University Medical Center, Yokohama City, Japan; 2Department of Gastroenterology, Yokohama City University Medical Center, Yokohama City, Japan; 3Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama City, Japan Background: Postoperative bleeding is a major complication of endoscopic submucosal dissection (ESD). The patients who showed ESD related-bleeding after discharge and urgently readmitted into the hospital are tend to be poor outcomes. The aim of this study is to determine the incidence of delayed postoperative bleeding and analyze clinical factors after ESD in case of gastric neoplasm. Methods: We retrospectively investigated 1192 lesions from 1032 consecutive patients undergoing ESD for gastric neoplasm between June 2000 and December 2010. Clinicopathological factors for postoperative bleeding were analyzed. Results: Total (early and delayed) postoperative bleedings were evident in 64 lesions from 63 patients (5.37% of all the lesions and 6.10% of all the patients), and all achieved endoscopic hemostasis. Delayed postoperative bleeding (defined as bleeding occurring on or after the 6th postoperative day) occurred in 33 lesions (3.85% of all the lesions) from 32 patients. Univariate analysis showed that gender (male vs. female, P ⫽ 0.027), oral antithrombotic drugs (P ⫽ 0.017), oral corticosteroids (P ⫽ 0.017), tumor size of ⬎20mm (vs. ⱕ20mm, P ⫽ 0.027), and resected specimen size of ⬎40mm (vs. ⱕ40mm, P ⫽ 0.027) were significantly associated with delayed postoperative bleeding. Multivariate analysis showed that oral antithrombotic drugs (OR 2.184; 95% CI 1.005 to 4.746), oral corticosteroids (OR 8.379; 95% CI 2.117 to 32.249), and resected specimen size of ⬎40mm (OR 3.033; 95% CI 1.282 to 7.178) were independent risk factors for delayed postoperative bleeding. In comparison to patients with early postoperative bleeding (31 lesions from 31 patients), patients with delayed postoperative bleeding were more likely to show severe blood loss (Hb decrease of ⬎2 g/dL vs. ⱕ2 g/dL, P ⫽ 0.008), require blood transfusion (P ⬍ 0.001), have diabetes (P ⫽ 0.049) and have wide resected specimen (⬎40mm vs. ⱕ40mm, P ⫽ 0.048). Conclusions: Patients using oral antithrombotic drugs and corticosteroids and those having wide resected specimen (⬎40mm) were at high risk of delayed postoperative bleeding after ESD for gastric neoplasm. These findings suggest the patients with high risk of delayed postoperative bleeding need strict follow-up.
Mo1233 Effect of IV PPI During NPO Time on Post-ESD Bleeding Dong Chan Kim, Hang Lak Lee*, Kang Nyeong Lee, Dae Won Jun, Oh Young Lee, Byung Chul Yoon, Sang Pyo Lee, Ho Soon Choi Gastroenterology, Hanyang University Medical Center, Seoul, Republic of Korea Background: Intravenous form of proton pump inhibitor (IV PPI) is routinely used before and after ESD to prevent bleeding and to heal ulcer. However, there is controversy about effectiveness of IV PPI treatment during NPO time. Objective: We aimed to clarify that IV PPI really can prevent post ESD bleeding. Materials and Methods: Between March 2009 and September 2011, 209 patients who underwent complete ESD for adenoma and early gastric cancer were enrolled. Post⫺ESD coagulation (PEC) using a coagulation forceps and argon plasma coagulation was introduced. Age, gender, medications, tumor feature (gross type, pathology, size, location, depth), procedure time, second look endoscopy, IV PPI, and PEC were investigated. Results: We used IV PPI in 108 patients, and didn’t use IV PPI in 101 patients. Pathological findings show adenoma in 102 patients, and early gastric cancer in 107 patients. Only mucosal invasion was noted in 181 patients, and submucosal invasion was noted in 28 patients. The tumor located in antrum (120 patients), body (81 patients), and cardia (8 patients). Polypoid or protruded type was noted in 109 patients, flat type was noted in 26 patients, depressed type was noted in 74 patients. Delayed bleeding occurred after ESD in 23 patients, controlled in all cases by endoscopic hemostasis. There was no significant difference between delayed bleeding ratios between IV PPI group and No IV PPI group. Conclusions: This retrospective cohort study suggested that IV PPI before and after ESD can’t lower bleeding rate.
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB358