Outcomes Following Gastrostomy: Radiologically Inserted Vs. Percutaneous Endoscopic Gastrostomy

Abstracts T1521 Outcomes Following Gastrostomy: Radiologically Inserted Vs. Percutaneous Endoscopic Gastrostomy John S. Leeds, Mark E. Mcalindon, Julia Grant, Helen E. Robson, Stephen Morley, Fred K. Lee, David S. Sanders Introduction: Gastrostomy insertion has been demonstrated to be of benefit in selected patients. Percutaneous endoscopic gastrostomy (PEG) using the pull through technique is the most widely used insertion method, but it is recognised to have significant complications particularly in patients with respiratory risk factors. An alternative is a radiologically inserted gastrostomy (RIG). It has been suggested that RIG may be advantageous in patients who are potentially ‘high risk’ from respiratory complications. However there are no large studies comparing PEG against RIG. Methods All patients referred for a gastrostomy are prospectively included in a database along with demographic, biochemical and outcome data. Analysis of gastrostomy insertions over the period February 2004 to February 2007 was performed with reference to method of insertion and outcome at 30 days. Selection for method of insertion is left to the discretion of the referring clinician. Patients were sub grouped into cognitive impairment (n Z 5), dysphagic stroke (n Z 36), nasopharygeal cancer (n Z 175), neurological (n Z 116) and other (n Z 71). Results Over the study period 170 RIG’s and 233 PEG’s were inserted (mean age 62, 268 males). There were no differences in age between the RIG and PEG group and case mix was comparable except in the nasopharyngeal cancer group (proportionally more RIG’s). The RIG 30 day mortality was 26/170 (15.3%) and the PEG 30-day mortality was 25/233 (10.7%) (p Z 0.17). One year mortality was 92/170 (54.1%) for RIG and 131/233 (56.7%) for PEG (p Z 0.60). Within sub groups the only significant difference in 30 day mortality was in those patients with nasopharyngeal cancer; 14/106 (13.2%) for RIG and 1/69 (1.4%) for PEG (p Z 0.005). However, patients referred for RIG were significantly older than those referred for PEG (mean age 59.7 vs. 64, p Z 0.019) and had a higher prevalence of significant comorbidities (21.1% in the PEG group and 37.7% in the RIG group). Conclusions Overall RIG and PEG appear to have similar 30 day mortality rates. In patients with nasopharyngeal cancer there was a higher mortality in those referred for RIG however pre-selection by the referring clinician due to perceived risk of endoscopic insertion may have biased the outcome. A randomized trial comparing both methods in this sub group is needed.

T1522 Predicting Outcomes Following Gastrostomy Insertion Using the Sheffield Gastrostomy Score. A Prospectively Devised Scoring System with a Validation Cohort John S. Leeds, Stephen Morley, Roger Marr, Helen E. Robson, Julia Grant, Fred K. Lee, Mark T. Donnelly, Mark E. Mcalindon, David S. Sanders Introduction: Several scoring systems are used in the field of Gastroenterology. Although, previous studies have demonstrated the substantial risk of death following gastrostomy insertion and some risk factors have been identified - no previous investigators have described a scoring system for gastrostomy insertion. We undertook a prospective, unselected, dual centre study in order to establish the relative importance of risk factors for mortality after gastrostomy insertion. We then formulated a simple numerical scoring system to categorize patients’ risk of death. We then sought to validate our scoring system on an independent second cohort of patients. Methods All patients referred for gastrostomy are prospectively included in a database along with demographic, biochemical and outcome data. We analysed gastrostomy insertions from 2 teaching hospitals from February 2004 to February 2007. There were 887 referrals resulting in 837 gastrostomy insertions. The largest cohort was at site A and was used to construct a risk stratification scoring system. Site B was used to validate the scoring system. Results Site A received 552 referrals and 403 new gastrostomies were inserted (median age 64, 268 males). Overall 30 day mortality rate was 51/403 (12.7%) with the highest risk in those with dementia (40%) followed by stroke (22.2%). Univariate analysis identified that 30 day mortality was associated with age (OR 3.4), albumin (OR 5.6), cardiac comorbidity (OR 2.0) and neurological comorbidity (OR 1.7). On multivariate analysis only age and albumin remained significant (both p ! 0.001) and were then modelled and attributed scores with age scoring 0 or 1 and albumin scoring 0, 1 or 2 giving composite scores from 0 to 3. Scores of 0, 1, 2 and 3 gave 30 day mortalities (95% confidence interval) of 0% (0 - 2.1), 7% (2.9 - 13.9), 21.3% (13.5 - 30.9) and 37.3% (24.1 - 51.9) respectively. Kaplan-Meier curves stratified by total score showed a significantly increased mortality at 7 (p Z 0.0003), 30 (p ! 0.0001) and 90 (p ! 0.0001) days. Site B (validation cohort) received 335 referrals and inserted 153 new gastrostomies (median age 77, 64 males) with a 30 day mortality of 24/153 (15.7%). Application of the scoring system in this validation cohort gave comparable 30 day mortality figures of 0%, 7.7%, 15.6% and 29.3% for scores 0, 1, 2 and 3 respectively. Conclusions: The Sheffield gastrostomy score can be used to categorise patients being considered for gastrostomy insertion and to calculate risk of death at 30 days. Further external validation is required.

T1523 ERCP-Related Perforations: Analysis of Patient-Outcome After ERCP in Over 2700 Patients Sumit Kapoor, Devi Mukkai Krishnamurty, Frederick Eckhauser, Anthony N. Kalloo, Patrick Okolo, Sanjay B. Jagannath

AB238 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008

ERCP-related perforation is a serious complication. Identifying clinical factors that influence hospital course may lead to better targeted clinical intervention and improve patient outcome. AIM: To identify the clinical factors that affect outcome in patients who suffered an ERCP-related perforation. Methods: IRB-approved, retrospective analysis of ERCP-related perforations at our institution from January 2003 to November 2007. Patient demographics, procedural factors, laboratory and radiographic imaging results, and post-ERCP complications were recorded and analyzed using length of stay (LOS), surgical intervention, and readmission rates as primary endpoints. All procedures were performed by ERCP experts. Results: 2759 ERCP procedures were performed during this time period, and 30 (1.1%) patients (21 Females, mean age 47.4 years) suffered an ERCP-related perforation. Indications for ERCP were: SOD (40.0%), pancreatitis (16.7%), stone/stricture (13.3%), ampullary mass (10.0%), pancreas divisum (6.7%), PSC, abdominal pain, biloma, dilated pancreatic duct (3.3% each). The odds of perforation were higher (OR 40, CI 18-87) in SOD patients, as compared to non-SOD patients. 25 patients underwent endoscopic sphincterotomy and 16 patients had an endoprosthesis placed. 96.7% (29/30) of the perforations were detected within 72 hours; 85.7% were detected by CT. A delay in perforation diagnosis significantly increased the mean LOS (7.0 days if detected at ERCP vs. 15.7 days if detected within 24 hours vs. 23.0 days if detected between 24-72 hours; p Z 0.048), as did the presence or development of one or more of the following clinical features: ascites, abscess, fluid collection, pneumothorax, pneumomediastinum, pleural effusion, thrombophlebitis. In 13 patients who had concomitant post-ERCP pancreatitis, the odds of developing a retroperitoneal fluid collection (OR 13.2; p Z 0.006) was higher than in patients with perforation alone; however, there was no increase in LOS or need for surgical intervention. Patients who underwent surgical intervention (9/30) had a significantly longer LOS (37.7 days vs. 11.1 days; p Z 0.006) as compared to patients managed non-operatively, and surgical patients were more likely to be re-admitted (p ! 0.03). There was no mortality in this cohort. Conclusions: Early diagnosis of the perforation and non-operative management was associated with shorter hospitalization. LOS is increased with the development of several clinical features. Surgical patients had higher readmission rates compared to non-operative patients. This is the first study to identify clinical factors associated with patient outcome after suffering an ERCP-related perforation.

T1524 Comprehensive Colonoscopy Quality in a Community Gastroenterology Practice Scott W. Rathgaber, Laura E. Black, Jacob Gundrum, Wendy Berth, Michelle A. Mathiason Background: The efficacy of colonscopy as a diagnostic and therapeutic tool depends upon the quality of the exam. The quality of colonoscopy within community gastroenterology practices is largely unknown. Gastroenterology professional societies advocate the collection and reporting of quality data. Purpose: To document a range of colonoscopy quality measures within a community gastroenterology practice. Methods: All colonoscopies attempted at a single endoscopy center between 11/1/06 and 4/30/07 were reviewed for quality measures. Additional information was obtained from screening exams only. All seven board-certified gastroenterologists within a single community gastroenterology group participated. Results: 2840 consecutive colonoscopy exams were included, (48.9% male). 1374 exams were for screening (48.4%). 509 exams were for surveillance (17.9%). Consent was documented in the endoscopy note in 98.8%. Cecal intubation rate was 98.6%. Photodocumentation of the cecum was completed in 88.3%. The indications for colonoscopy followed ASGE guidelines in 95.6%. The most common indications for colonoscopy not included in ASGE recommendations were abdominal pain (2.1%) and constipation (2.0%). Adenocarcinomas were detected in 40 patients, more commonly in patients referred for symptoms (3.2%) versus screening (0.5%) or surveillance (0.4%) (p ! 0.0001). Three synchronous cancers were identified (7.5%), all in symptomatic patients. Of 1374 screening exams (47.2% male), adenomas were detected in 38.7% of males and 22.9% of females (p ! 0.0001). Polyps 1 cm and larger were detected in 5.9%. 50 adenomas per 100 colonoscopies were detected within this screening group. No screening colonoscopy had a withdrawal time of less than 6 minutes. No differences in cecal intubation rate or large adenoma detection were noted between individual gastroenterologists. Total adenoma detection (range 25 71 adenomas per 100 colonoscopies) and withdrawal times (9.7 15.2 minutes) varied widely. However, higher detection did not correlate with slower withdrawal times (R Z 0.06). Conclusions: Community gastroenterology practices can demonstrate colonoscopy quality data that compare favorably to academic centers. Colorectal cancer is more likely to be found in patients presenting with symptoms rather than for screening or surveillance. Differences in polyp detection rates exist between gastroenterologists. Factors other than withdrawal times contribute to polyp detection rates.

T1525 Endoscopic Balloon Dilatation to Treat Stricture Caused By Circumferential Resection of the Gastric Antrum By Endoscopic Submucosal Dissection Kotaro Mannen, Seiji Tsunada, Shinichi Ogata, Seiichiro Arima, Yasuhisa Sakata, Ryosuke Shiraishi, Ryo Shimoda, Hibiki Ootani,

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