Newer Generation Colonoscopes Do Increase Detection of Polyps and Adenomas in Patients Undergoing Screening Colonoscopy

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

Abstracts

with these endoscopes seems to lead to a higher quality examination resulting in detection of more pathology. Table 1. Variable

140 scope

160 scope

180 scope

Number of polyps (pZ0.013) Number of adenomas (pZ0.005) Exam time, minutes (p!0.001) Cecal time, minutes (pZ0.001)

1.70 0.96 23.74 10.30

1.73 0.92 21.08 5.82

2.87 1.52 25.44 7.38

M1391 Novel Use of Simultaneous Dual Endoscopy to Reconstitute Completely Obstructed Esophagi and Colon John Dever, Drew Schembre, John J. Brandabur, Richard A. Kozarek Background: Complete GI luminal obstruction often requires surgery, however we report four cases of complete visceral obstruction managed with endoscopy. Methods: Case 1. A 50-year-old man who underwent laryngectomy and radiation for laryngeal cancer developed complete proximal esophageal obstruction after radiation therapy. Antegrade and retrograde endoscopy via a gastrostomy site were performed. A 22 gauge EUS aspiration needle was guided fluoroscopically to puncture esophageal scar tissue and to allow wire passage. After balloon dilation, a 1 cm diameter biliary WallstentÒ was placed for 2 weeks followed by an 18 mm  6 cm PolyflexÒ removable stent. Case 2. A 71-year-old man who had radiation for hypopharyngeal cancer 6 months prior presented with aphagia and complete esophageal occlusion. Antegrade passage of a 22 gauge EUS needle and guide wire with fluoroscopy was performed in tandem with retrograde endoscopy via a PEG tract. Dilation and deployment of an 8 mm  8 cm self-expandable metal stent was accomplished followed by a 12 mm  4 cm partially covered bronchial stent. Case 3. A 74-year-old man who had cervical esophageal squamous cell carcinoma treated by chemoradiation developed esophageal occlusion. Retrograde insertion of an endoscope through a gastrostomy site allowed puncture of a blind esophageal lumen and passage of a guidwire. This was followed by antegrade balloon dilation and passage of a NG tube into the stomach. Case 4. A 36-year-old man had a colonic perforation and required a temporary colostomy. Take-down was complicated by a leak, and complete stenosis ensued. One year later, combined antegrade perostomy colonoscopy and proctoscopy was performed with puncture of the stenosed anastomosis by a 22 gauge EUS needle. Balloon dilation was undertaken and a 16 mm PolyflexÒ stent was deployed backwards to reduce migration risk. Results: All patients underwent successful initial recanalization. All patients required additional balloon dilation. Three of 4 patients were able to resume regular diets. Patient 2 developed self-limited pneumomediastinum and C5-C6 osteomyelitis requiring stent removal which led to restenosis. Conclusion: Gastrointestinal reconstitution in cases of complete luminal stenosis is risky yet can be successfully managed with rendezvous endoscopy and temporary stenting.

M1392 Polyp Miss Rates By Colonoscopy Compared with Colon Resection Specimens Kangnyeong Lee, Hang Lak Lee, Jai Hoon Yoon, Seung Chul Cho, Oh Young Lee, Byung Chul Yoon, Ho Soon Choi, Joon Soo Hahm, Sunggon Shim, Narae Ha Background and Aims: Colonoscopy is useful for the detection and removal of colonic polyps but the problems in quality control of colonoscopy is rising as the number of colonoscopic examinations increases as a result of increased health promotion programs. Although many studies determined by tandem colonoscopy reported that the polyp miss rates by colonoscopy were approximately 25%, the miss rates are not clear since there is no gold standard to diagnose colonic polyps comparable to colonoscopy. we compared the number of polyps found by colonoscopy directly with that of polyps present in surgically resected colon to investigate how frequently colonoscopy might miss polyps and which factors could affect the polyp miss rate by colonoscopy. Methods: We retrospectively analysed 38 patients who underwent colon resection for colorectal cancer and had synchronous lesions in the resected portion. The miss rate was determined by comparing the number of polyps detected at colonoscopy with that of the polyps present in the resected colonic segment. A statistical analysis was made about the influences of the location, the pathologic type, or the size of missed polyps on the colonoscopic miss rates. Results: The number of polyps found in resected colon specimen were 93, 68 of which were detected at colonoscopy, so the overall miss rate by colonoscopy was 26.9%. Of 25 polyps missed at colonoscopy, 1 were R 10 mm in size and 24 were ! 10 mm. 9 of 69 adenomatous polyps were missed by colonoscopy, while colonoscopy missed 15 of 18 hyperplastic polyps. In the descending, transverse, ascending and sigmoid colon the miss rates were 0%, 29%, 17%, 22% respectively. Conclusively, !10 mm polyps, hyperplastic polyps, those in rectum and cecum were more frequently missed in our study. Conclusions: Colonoscopy is an effective method to diagnose and treat polyps but we should not miss the significant miss rates of polyps by colonoscopy. Endoscopists should pay

AB230 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009

more attention to find synchronous lesions in patients with known colorectal cancers, and not only technical advances but also quality control of colonoscopy is highly warranted not to miss these synchronous lesions.

M1393 Randomized Trial of Oval Cup Versus Alligator Jaw Biopsy Forceps for Ultrathin Upper Gastrointestinal Endoscopy Justin Cheung, Karen J. Goodman, Robert J. Bailey, Safwat Girgis, Richard N. Fedorak, John Morse, Tomasz Z. Guzowski, Mario S. Millan, Sander Veldhuyzen Van Zanten Background: Ultrathin transnasal endoscopy is an emerging tool for endoscopic evaluation of the upper gastrointestinal tract. The biopsy channel diameter (2 mm) is smaller with the ultrathin endoscope and therefore small caliber forceps must be used. It is unknown if small biopsy forceps type influences histologic interpretation. Methods: As part of a community health project focused on Helicobacter pylori risks, residents (R 9 yrs) of Aklavik, a remote town in Canada’s Northwest Territories, were invited to undergo endoscopy in February 2008. An on-site unit was assembled in the local health centre to perform upper gastrointestinal endoscopy with an ultrathin endoscope (4.9 mm diameter) with gastric biopsies (2 antral, 1 incisura, 2 body) for histology. Participants were randomized to either standard oval cup (OC) or alligator jaw (AJ) 5 mm cup biopsy forceps. A single pathologist blinded to forceps type interpreted the specimens. Outcomes included biopsy size, biopsy quality (scale 1-3, 1 Z suboptimal, 3 Z excellent), and gastric pathology. Results: 191 participants were randomized (OC 105, AJ 86). The mean ( SD) age was 40 (17) years. The mean biopsy sizes were similar between for OC (2.9  0.6 mm) and AJ (2.9  0.5 mm), (diff 0.03, 95% CI -0.12, 0.20). There was no difference in the mean biopsy quality for OC (2.0  0.0) and AJ (2.0  0.0). There were small differences between OC and AJ in diagnoses of H. pylori (70% vs 64%, p Z 0.35), acute gastritis (67% vs 60%, p Z 0.45), chronic gastritis (72% vs 63%, p Z 0.16), atrophy (14% vs 15%, p Z 1.0), and intestinal metaplasia (8% vs 9%, p Z 0.80). Conclusions: For ultrathin upper gastrointestinal endoscopy, there appear to be minimal differences in gastric mucosal biopsy size, quality, and diagnostic yield comparing oval cup and alligator jaw forceps.

M1394 The New Endoscopic Preparation and Risk Factors of Residual Food in Patients Who Have Undergone Disital Gastrectmy: Water Cleaning Method Sung-Bum Cho, Sun Young Park, Kyoung-Won Yoon, Wan-Sik Lee, Young-Eun Joo, Hyeun-Soo Kim, Sung Kyu Choi, Jong-Sun Rew Background: Food residue is frequently observed in the gastric remnant after partial gastrectomy, making it difficult to disgnose metachronous lesion in the residual stomach. The aims of study were to clarify the risk factors of food residue and to study about effectiveness of new methods of endoscopic preparation in the patients with disital gastrectomy. Methods: The endoscopic and clinicopathologic findings of 708 patients with distal gastrectomy for gastric cancer were prospectively reviewed from January to September of 2008. The two groups (Water group: 40 cases, 24 hour NPO (nothing per oral) group: 20 cases) were randomly devided to sixty patients with large amount of food residue. The degrees of food residue were estimated to undergone endoscopic examination after 1-2 week later. The routine endoscopic preparation (20 hour NPO) was used in 708 patents with distal gastrectomy. The water group was used to new endoscopic preparation (water cleaning method) that was ingested to total 1 L of water (150-200 mL/10 minutes) from 19.00 to 20.00 the day before examination concomitant with 20 hour NPO. The NPO group was used to prolong fasting for 24 hours. Results: The incidence of large food residue was 15.7%, 5.8%, 7.5%, 2.8% at 3, 12, 24 and 36 months after distal gastrectomy. The independent risk factors of food residue were 3 month endoscopy (ORZ42.2, 95% C.I.Z17.2-103.3), diabetes mellitus (ORZ3.5, 95% C.I.Z 1.6-7.8), body mass index below 19.5 (ORZ2.3, 95% C.I.Z1.3-.4.0), Laparoscopic surgery (ORZ1.9, 95% C.I.Z1.1-3.3) and Billoth I (ORZ2.2, 95% C.I.Z0.8-5.6). Successful preparations of two groups at follow up endoscopy were higher the water group (70%) more than the 24 hour NPO group (40%) (PZ 0.025). The compliance of water cleaning method was good except two patients that complained to epigastric discomfort. Conclusions: The water cleaning method can be recommended as a preparation for endoscopy in patients who have undergone distial gastrectomy, especially in patients with additional risk factors.

M1395 Improving Patient Process and Cycle Time During Colonoscopy with the Lean and Six Sigma Methodology Elisabeth Raymakers, Hubert Piessevaux, Benoıˆt Debande, Dominique Vandenbosch, Ines Perez Y Mira, Pierre H. Deprez Background and Aims: Improving patient flow process and cycle times in endoscopy is challenging but essential to improve patient’s satisfaction, to reduce

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