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Nurse Endoscopists May Take Over
Abstracts
39 experienced (O100) operators of variable experience were asked to perform 264 episodes of colonoscopy on the HT Immersion simulator at random. All the procedure recorded the total amounts of air a) insufflated and left behind b) Pain classified by the simulator as absent, mild, moderate, severe and extreme. The pain was weighed into three categories as Grades 1, 11 and III according to increasing severity. A Pearsons Correlation coefficient was calculated for demonstrating any associative relationship between; a) amounts of air insufflated and pain, b) amount of air left behind and pain. Data was also evaluated according to the level of experience of the operator. Results: Two tailed correlation coefficients of - 0.078 and -0.084 were demonstrated between the amounts of air insufflated, / air left behind respectively and Pain. When data was filtered according to experience of the operator, the correlation coefficients were novice (-0.119, -0.113), intermediate (0.004, -0.059) and expert (-0.076, -0.103) respectively. This indicates that pain is not associated with amount of air insufflated or left behind during simulated colonoscopy and that this holds true even when corrected for the experience of the operators. Discussion: During a simulated colonoscopy, if pain is not affected by air in the colon in any major way, then what represents pain? Possible contenders are excessive looping, exertion of surplus force on the colonoscopy shaft, bowel hypersensitivity and even machine error. What exactly is meant by pain in simulation and the nature of the concept needs to be fully elicited. In context of simulated Colonoscopy, we need to clarify what proportions of each of the above listed contenders contribute in marking pain. Further studies must validate this aspect of the colonoscopy simulator because it is now a recognised teaching and assessment tool.
W1508 Nurse Endoscopists May Take Over Paul G. Van Putten, Monique E. Van Leerdam, E.J. Kuipers Background: Colorectal cancer screening and surveillance is still not feasible in the majority of Europe. Nurse endoscopists (NE) may provide a solution for the high endoscopic demand and shortage of endoscopists. The aim of the present study was to determine expectations, opinions and future perspectives of nurse endoscopy in a Western European community. Methods: A postal questionnaire was send to all registered gastroenterologists (GE) (n Z 301) and gastroenterology residents (n Z 79) in the Netherlands in 2007. Topics that were evaluated included: presumed endoscopic quality, patient experiences and costs. In addition the attitude towards and potential endoscopic procedures to be performed by NE were evaluated. Results: 165 of 380 (43%) GE and residents completed the questionnaire. The distribution of academic versus general hospital employees was 30 vs 70% with a 79 to 21% M/F distribution. Overall, 52% had a positive attitude towards introduction of NE, whereas 18% were neutral and 30% negative. No difference in endoscopic quality between physician and NE was expected by 42% of respondents, 35% expected physicians to perform better and 23% expected nurses to perform better. With regard to patient experiences: 66% of respondents expected physicians to perform better than NE, 18% expected nurses and physicians to perform equally and 16% expected NE to perform better. The majority expected a waiting list and cost reduction of NE. Screening sigmoidoscopy and colonoscopy were considered appropriate procedures to be performed by nurses according to respectively 92% and 73% of respondents. In contrast, only half of the respondents judged that diagnostic endoscopies would be appropriate for NE. Only 45% judged polypectomies of polyps smaller than 10 mm appropriate for NE. Respondents agreed that polypectomies of larger polyps and other therapeutic procedures should not be performed by nurses (respectively 75% and O90%). GE and residents who expected better or comparable endoscopic quality of NE in comparison with physicians, were significantly more positive towards the introduction of NE (70 and 55% vs 38%; p Z 0.004). Those who expected NE to perform better than physicians with regard to patient experiences, were also significantly more positive (77% vs 48%; p Z 0.007). Respondents age, gender or type of hospital was not related with the attitude towards NE. Conclusion: The majority of GE is positive towards the introduction of NE. Screening sigmoidoscopy and colonoscopy may well be performed by NE. To determine the exact place of nurse endoscopy, precise assessment of endoscopic quality and patient experiences of well trained NE is highly needed.
W1509 Prospective Results of Endoscopic Ultrasound Drainage of Pancreatic Pseudocysts in a Centre Starting with This Procedure Riadh Sadik, Claes Jonsson Only a few prospective studies exist on the results of endoscopic pseudocyst drainage. The largest prospective study from a large centre showed a complication rate of 19% (Kahaleh et al, Endoscopy. 2006 Apr;38:355-9.). However, reports from centres starting with the procedure are lacking. The aim of this study was to prospectively analyze the results and complication rate of pseudocyst drainage at a centre starting with the procedure. Methods: All patients referred for endoscopic pseudocyst drainage were prospectively included. The procedures were performed by one endoscopist with long endoscopy experience. The results and complication rate were recorded. Results: In a period of 20 months 10 patients were included. One patient had high Carcino Emberionic Anigen level and was found to have pancreatic cancer. The results are shown in the table. Inspection of the cyst with a gastroscope and flushing with saline and/or necrosectomy was performed in four
AB302 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
patients. Conclusion: Complications of pseudocyst drainage are associated with cyst infection. The results in centres starting with endoscopic pseudocyst drainage are comparable to results from larger centres.
Patient (Age) Gender 1 (52) M 2 (66) M 3 (61) M 4 (76) F 5 (76) M 6 (47) M 7 (61) M 8 (57) M 9 (68) F 10 (51) M
Cyst size Ethiology in cm Idiopathic 13 10 Malignancy 6 7 Alcohol 15 13 Gallstone 7 7 Alcohol 55 Alcohol 75 Alcohol 10 10 Alcohol 55 Gallstone 18 13 Alcohol
83
Infection in the cyst No No No Yes No No No Yes Yes Yes
Number of stents 1 (10F) 1 (10F) 3 (7F) 3 (7F) 1 (10F) 3 (7F) 2 (10F) 0 5(7F)þone naso-cystic 2 (7F)
Hospital stay Complications (days) No 1 No 1 No 2 No 1 No 1 No 1 No 1 Bleeding 6 No 4 Perforation
5
Final result Total regress Total regress Total regress Total regress Total regress Total regress Total regress Operation Total regress Initial regress, perforation during a second procedure
W1510 Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for GI Fellow Trainees in Colonoscopy Jenifer R. Lightdale, Meghan E. Fredette, Paul A. Rufo, Victor L. Fox, John R. Saltzman, John M. Poneros The Simbionix GI Mentor II Endoscopy Simulator is designed to provide detailed feedback, including time to anatomic landmarks, intraprocedural patient discomfort, and visualization of the mucosa. While construct validation studies have shown that the GI Mentor II can distinguish beginners from experts, its capacity to discriminate between fellows in a 3-year training program is unknown. Aim: To determine whether feedback measures provided by the GI Mentor II differ between 1st and 3rd year fellows. Methods: Fellows in their 1st and 3rd years of training at Children’s Hospital Boston and the Brigham and Women’s Hospital were invited to record colonoscopies (6/06 - 11/07) on a GI Mentor II. Fellows were instructed to reach the cecum as quickly as possible, while visualizing the entire mucosa and avoiding colonoscopic looping. Patient discomfort was defined as the # of and % procedure time excessive loops were formed causing local pressure. Other simulator parameters included % time spent with clear view of the lumen, and # of times view of the lumen was lost. Results: 16 GI Trainees (10 1st Yrs, 6 3rd Yrs; 9 male; median age 32 yrs (IQR 29, 35)) recorded a total of 63 simulated colonoscopies. No differences were found between groups in # of pediatric fellows (1st Yr: 80%; 3rd Yr: 50%, p Z .225), nor median # of simulations (1st Yr: 3(2, 7); 3rd Yr: 3 (3, 5). p Z 0.865). 1st year fellows did not spend more total time per simulated procedure than 3rd year fellows (13 min (9, 19) vs. 9 (8, 15), p Z 0.084), but did take longer to reach the cecum (7 min (4, 11) vs. 4 (2, 6), p Z 0.002). Few fellows formed excessive loops (1st Yrs: 0 (0, 1); 3rd Yrs: 0 (0, 1), p Z 0.383), and there was no difference in ‘‘virtual’’ patient discomfort (1st Yr: 1% procedural time in pain (0, 5); 3rd Yr: 0% (0, 2), p Z .108). While 1st and 3rd year fellows did not differ in terms of their propensity to lose view of the lumen (1 time (0, 2) vs. 0 (0,1), p Z 0.102), 1st Years spent less time visualizing the entire mucosa (84% (77, 88) vs. 3rd Yr: 89% (81, 91), p Z .011) and were less efficient in screening as calculated by the simulator (64% (39, 81) vs. 84% (64, 89), p Z .006). Conclusions: Test parameters concerning time to anatomic landmarks and visualization of the mucosa generated by the GI Mentor II Endoscopy Simulator can discriminate between 1st and 3rd year GI fellows. Although the simulator did not detect differences in patient comfort, our findings suggest progression in endoscopy skills over a 3 year fellowship training period. Further study is needed to understand how performance enhancement on simulator measures translates into improved endoscopy in live patients.
W1511 Comparative Study of Conventional Colonoscopy and Pan-Colonic Narrow-Band Imaging System in the Detection of Neoplastic Colonic Polyps: A Randomized, Controlled Trial Takuya Inoue, Mitsuyuki Murano, Naoko Murano, Takanori Kuramoto, Ken Kawakami, Yosuke Abe, Eijiro Morita, Ken Toshina, Yutaro Egashira, Eiji Umegaki, Kazuhide Higuchi Background: Detection and removal of adenomas by colonoscopy is an important means for preventing cancer; however, small adenomas may be missed during colonoscopy. The narrow-band imaging (NBI) system clearly enhances the microvasculature in neoplastic lesions, making it appear as a dark complex. Therefore, the NBI system may improve the detection of colonic neoplasias. The aim of this randomized prospective study was to determine whether the NBI system could increase the adenoma detection rate in routine use. Aim: We conducted a randomized, controlled trial to determine the efficacy of the
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39 experienced (O100) operators of variable experience were asked to perform 264 episodes of colonoscopy on the HT Immersion simulator at random. All the procedure recorded the total amounts of air a) insufflated and left behind b) Pain classified by the simulator as absent, mild, moderate, severe and extreme. The pain was weighed into three categories as Grades 1, 11 and III according to increasing severity. A Pearsons Correlation coefficient was calculated for demonstrating any associative relationship between; a) amounts of air insufflated and pain, b) amount of air left behind and pain. Data was also evaluated according to the level of experience of the operator. Results: Two tailed correlation coefficients of - 0.078 and -0.084 were demonstrated between the amounts of air insufflated, / air left behind respectively and Pain. When data was filtered according to experience of the operator, the correlation coefficients were novice (-0.119, -0.113), intermediate (0.004, -0.059) and expert (-0.076, -0.103) respectively. This indicates that pain is not associated with amount of air insufflated or left behind during simulated colonoscopy and that this holds true even when corrected for the experience of the operators. Discussion: During a simulated colonoscopy, if pain is not affected by air in the colon in any major way, then what represents pain? Possible contenders are excessive looping, exertion of surplus force on the colonoscopy shaft, bowel hypersensitivity and even machine error. What exactly is meant by pain in simulation and the nature of the concept needs to be fully elicited. In context of simulated Colonoscopy, we need to clarify what proportions of each of the above listed contenders contribute in marking pain. Further studies must validate this aspect of the colonoscopy simulator because it is now a recognised teaching and assessment tool.
W1508 Nurse Endoscopists May Take Over Paul G. Van Putten, Monique E. Van Leerdam, E.J. Kuipers Background: Colorectal cancer screening and surveillance is still not feasible in the majority of Europe. Nurse endoscopists (NE) may provide a solution for the high endoscopic demand and shortage of endoscopists. The aim of the present study was to determine expectations, opinions and future perspectives of nurse endoscopy in a Western European community. Methods: A postal questionnaire was send to all registered gastroenterologists (GE) (n Z 301) and gastroenterology residents (n Z 79) in the Netherlands in 2007. Topics that were evaluated included: presumed endoscopic quality, patient experiences and costs. In addition the attitude towards and potential endoscopic procedures to be performed by NE were evaluated. Results: 165 of 380 (43%) GE and residents completed the questionnaire. The distribution of academic versus general hospital employees was 30 vs 70% with a 79 to 21% M/F distribution. Overall, 52% had a positive attitude towards introduction of NE, whereas 18% were neutral and 30% negative. No difference in endoscopic quality between physician and NE was expected by 42% of respondents, 35% expected physicians to perform better and 23% expected nurses to perform better. With regard to patient experiences: 66% of respondents expected physicians to perform better than NE, 18% expected nurses and physicians to perform equally and 16% expected NE to perform better. The majority expected a waiting list and cost reduction of NE. Screening sigmoidoscopy and colonoscopy were considered appropriate procedures to be performed by nurses according to respectively 92% and 73% of respondents. In contrast, only half of the respondents judged that diagnostic endoscopies would be appropriate for NE. Only 45% judged polypectomies of polyps smaller than 10 mm appropriate for NE. Respondents agreed that polypectomies of larger polyps and other therapeutic procedures should not be performed by nurses (respectively 75% and O90%). GE and residents who expected better or comparable endoscopic quality of NE in comparison with physicians, were significantly more positive towards the introduction of NE (70 and 55% vs 38%; p Z 0.004). Those who expected NE to perform better than physicians with regard to patient experiences, were also significantly more positive (77% vs 48%; p Z 0.007). Respondents age, gender or type of hospital was not related with the attitude towards NE. Conclusion: The majority of GE is positive towards the introduction of NE. Screening sigmoidoscopy and colonoscopy may well be performed by NE. To determine the exact place of nurse endoscopy, precise assessment of endoscopic quality and patient experiences of well trained NE is highly needed.
W1509 Prospective Results of Endoscopic Ultrasound Drainage of Pancreatic Pseudocysts in a Centre Starting with This Procedure Riadh Sadik, Claes Jonsson Only a few prospective studies exist on the results of endoscopic pseudocyst drainage. The largest prospective study from a large centre showed a complication rate of 19% (Kahaleh et al, Endoscopy. 2006 Apr;38:355-9.). However, reports from centres starting with the procedure are lacking. The aim of this study was to prospectively analyze the results and complication rate of pseudocyst drainage at a centre starting with the procedure. Methods: All patients referred for endoscopic pseudocyst drainage were prospectively included. The procedures were performed by one endoscopist with long endoscopy experience. The results and complication rate were recorded. Results: In a period of 20 months 10 patients were included. One patient had high Carcino Emberionic Anigen level and was found to have pancreatic cancer. The results are shown in the table. Inspection of the cyst with a gastroscope and flushing with saline and/or necrosectomy was performed in four
AB302 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
patients. Conclusion: Complications of pseudocyst drainage are associated with cyst infection. The results in centres starting with endoscopic pseudocyst drainage are comparable to results from larger centres.
Patient (Age) Gender 1 (52) M 2 (66) M 3 (61) M 4 (76) F 5 (76) M 6 (47) M 7 (61) M 8 (57) M 9 (68) F 10 (51) M
Cyst size Ethiology in cm Idiopathic 13 10 Malignancy 6 7 Alcohol 15 13 Gallstone 7 7 Alcohol 55 Alcohol 75 Alcohol 10 10 Alcohol 55 Gallstone 18 13 Alcohol
83
Infection in the cyst No No No Yes No No No Yes Yes Yes
Number of stents 1 (10F) 1 (10F) 3 (7F) 3 (7F) 1 (10F) 3 (7F) 2 (10F) 0 5(7F)þone naso-cystic 2 (7F)
Hospital stay Complications (days) No 1 No 1 No 2 No 1 No 1 No 1 No 1 Bleeding 6 No 4 Perforation
5
Final result Total regress Total regress Total regress Total regress Total regress Total regress Total regress Operation Total regress Initial regress, perforation during a second procedure
W1510 Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for GI Fellow Trainees in Colonoscopy Jenifer R. Lightdale, Meghan E. Fredette, Paul A. Rufo, Victor L. Fox, John R. Saltzman, John M. Poneros The Simbionix GI Mentor II Endoscopy Simulator is designed to provide detailed feedback, including time to anatomic landmarks, intraprocedural patient discomfort, and visualization of the mucosa. While construct validation studies have shown that the GI Mentor II can distinguish beginners from experts, its capacity to discriminate between fellows in a 3-year training program is unknown. Aim: To determine whether feedback measures provided by the GI Mentor II differ between 1st and 3rd year fellows. Methods: Fellows in their 1st and 3rd years of training at Children’s Hospital Boston and the Brigham and Women’s Hospital were invited to record colonoscopies (6/06 - 11/07) on a GI Mentor II. Fellows were instructed to reach the cecum as quickly as possible, while visualizing the entire mucosa and avoiding colonoscopic looping. Patient discomfort was defined as the # of and % procedure time excessive loops were formed causing local pressure. Other simulator parameters included % time spent with clear view of the lumen, and # of times view of the lumen was lost. Results: 16 GI Trainees (10 1st Yrs, 6 3rd Yrs; 9 male; median age 32 yrs (IQR 29, 35)) recorded a total of 63 simulated colonoscopies. No differences were found between groups in # of pediatric fellows (1st Yr: 80%; 3rd Yr: 50%, p Z .225), nor median # of simulations (1st Yr: 3(2, 7); 3rd Yr: 3 (3, 5). p Z 0.865). 1st year fellows did not spend more total time per simulated procedure than 3rd year fellows (13 min (9, 19) vs. 9 (8, 15), p Z 0.084), but did take longer to reach the cecum (7 min (4, 11) vs. 4 (2, 6), p Z 0.002). Few fellows formed excessive loops (1st Yrs: 0 (0, 1); 3rd Yrs: 0 (0, 1), p Z 0.383), and there was no difference in ‘‘virtual’’ patient discomfort (1st Yr: 1% procedural time in pain (0, 5); 3rd Yr: 0% (0, 2), p Z .108). While 1st and 3rd year fellows did not differ in terms of their propensity to lose view of the lumen (1 time (0, 2) vs. 0 (0,1), p Z 0.102), 1st Years spent less time visualizing the entire mucosa (84% (77, 88) vs. 3rd Yr: 89% (81, 91), p Z .011) and were less efficient in screening as calculated by the simulator (64% (39, 81) vs. 84% (64, 89), p Z .006). Conclusions: Test parameters concerning time to anatomic landmarks and visualization of the mucosa generated by the GI Mentor II Endoscopy Simulator can discriminate between 1st and 3rd year GI fellows. Although the simulator did not detect differences in patient comfort, our findings suggest progression in endoscopy skills over a 3 year fellowship training period. Further study is needed to understand how performance enhancement on simulator measures translates into improved endoscopy in live patients.
W1511 Comparative Study of Conventional Colonoscopy and Pan-Colonic Narrow-Band Imaging System in the Detection of Neoplastic Colonic Polyps: A Randomized, Controlled Trial Takuya Inoue, Mitsuyuki Murano, Naoko Murano, Takanori Kuramoto, Ken Kawakami, Yosuke Abe, Eijiro Morita, Ken Toshina, Yutaro Egashira, Eiji Umegaki, Kazuhide Higuchi Background: Detection and removal of adenomas by colonoscopy is an important means for preventing cancer; however, small adenomas may be missed during colonoscopy. The narrow-band imaging (NBI) system clearly enhances the microvasculature in neoplastic lesions, making it appear as a dark complex. Therefore, the NBI system may improve the detection of colonic neoplasias. The aim of this randomized prospective study was to determine whether the NBI system could increase the adenoma detection rate in routine use. Aim: We conducted a randomized, controlled trial to determine the efficacy of the
www.giejournal.org