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Predictive Risk Factors for Rebleeding and Thirty-Day Mortality After Endoscopic Hemostasis in Elderly Bleeding Peptic Ulcer Patients
Abstracts (7 M; 79.4 1.0 yr). All except 3 patients were successfully followed-up with a median (IQR) duration of 25.0 (15.0 42.5) months. Results: There was no difference in tumor size (2.3 0.2 vs. 2.5 0.2 cm, P O 0.05), pre-ampullectomy staging by endoscopic ultrasound (T1/T2 stage: 21/1 vs. 12/2, P O 0.05), and length of follow up (26.4 2.8 vs. 27.5þ2.8 yr, P O 0.05) between the groups. All endoscopic ampullectomy was successfully performed without any immediate complication. Haemostasis was achieved in all patients at the end of the procedure. In the younger group, 2 (10%) patients developed local recurrent adenoma and were treated successfully with repeated endoscopic resection. Two (10%) patients !70 yrs had evidence of adenocarcinoma beyond resected margin on histology and subsequently, underwent Whipple’s resection. In contrast, although no patients R 70 yrs of age developed recurrent adenoma, 4 (30%) patients had adenocarcinoma beyond resected margin on histology. These patients, however, did not have surgery and were palliated successfully by further endoscopic resection and stenting. Compared to the 100% survival rate in younger age group, 3 (23%) patients R 70 yrs died, but 2 were not related to cancer. Overall, the median survival after ampullectomy was similar between the groups (!70 yrs Z 25.5 (15-42.5) months vs. R70 yrs Z 24 (6-40) months; P Z 0.79). Conclusion: Endoscopic ampullectomy was feasible and satisfactory for a large majority of patients with ampullary tumors. Advanced age did not adversely influence either short-term or long-term outcomes of the procedure. Thus, endoscopic ampullectomy appears to be the treatment of choice for elderly patients with localized ampullary tumors, especially for patients who are unfit for surgery.
T1530 Predictive Risk Factors for Rebleeding and Thirty-Day Mortality After Endoscopic Hemostasis in Elderly Bleeding Peptic Ulcer Patients Masao Toki, Yasuharu Yamaguchi, Kenji Nakamura, Kei Aoki, Shin-Ichi Takahashi Background and Aims: The rebleeding and 30-day mortality after initial endoscopic hemostasis are the critical concerns when treating bleeding peptic ulcer patients aged 70 years or older. Early identification of patients with risk factors for rebleeding and 30 day mortality can improve the outcome of endoscopic hemostasis. The purpose of this study was to evaluate the risk factors for rebleeding or 30-days mortality in the view of clinical and endoscopic characteristics. Materials and Methods: Between January 1995 and December 2006, therapeutic endoscopies were carried out in 676 patients with peptic ulcers. Among these patients, a total of 200 elderly patients aged 70 years or older were included in this study. A total of 200 patients aged 70 years or older underwent endoscopic hemostasis for peptic ulcer bleeding between January 1995 and August 2006. Hemoclipping was used as first choice for hemostasis. If hemostasis could not be achieved by a single method, other methods were immediately added. The clinical variables (age, gender, smoking, alcohol, NSAID intake, anticoagulant intake, concomitant disease, ulcer history, presence of shock, transfusion over 6 units, inpatient or outpatient status, hemoglobin and serum albumin concentration at endoscopic hemostasis), and endoscopic characteristics of ulcers (size, number and site of ulcers, the severity of initial bleeding) were compared between the patients who did, and patients who did not have rebleeding or 30-day mortality. Multivariate analysis was performed using a logistic regression model expressed as odds ratio in 95% confidential interval. Results: Among the 200 elderly patients in the study, the rebleeding rate was 15.5% (31case), and the 30-day mortality rate was 7.5% (15 case; the cause of death was peptic ulcer in only one case). The results showed that presence of shock (2.4; 1.0-5.9, p ! 0.05), volume of transfusion over 6 units (11.4; 3.6-36.6, p ! 0.05), and ulcer size over 3 cm (3.2; 1.2-8.7, p ! 0.05) and single ulcer (2.2; 1.6-3.0, p ! 0.05) were significant risk factors for rebleeding. For 30-day mortality, concomitant disease (7.8; 1.0-60.4, p ! 0.05) and inpatient status (31.5; 8.2-121.4, p ! 0.01) were significant risk factors. Conclusions: Serious risk of rebleeding or 30-day mortality after endoscopic hemostasis for bleeding peptic ulcers can be predicted by checking clinical variables, patients background and endoscopic findings. Especially we need more careful attention to bleeding peptic ulcer patients hospitalized for concomitant disease.
T1531 Bolus Dosing for Moderate Sedation Reduces Procedure Time During Esophagogastroduodenoscopy (EGD) Anthony Aghenta, Ayodele T. Osowo, Vinodh Jeevanantham, Deerajnath Lingutla, Tarun Kothari Background: Narcotics and benzodiazepines are the most commonly used combination regimen for routine sedation during EGD. There are several techniques but the consensus on moderate sedation is that these medications must be titrated to effect. Aims: To compare 2 methods of fentanyl and midazolam administration during EGD: bolus dosing (Method I) and titration dosing (Method II). The endpoints were procedure and recovery times. Methods: We retrospectively reviewed all charts of patients at our community hospital that underwent EGD between January and March, 2003. Patients were excluded if the same patient had use of different methods of dosing for fentanyl and midazolam, or
AB240 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
was non- sedated. Apart from demographic variables, data was collected on biopsy, endoscopic treatment, dosing method, total dose of fentanyl, and total dose of midazolam. Procedure time is defined as the time between the endoscope entering and exiting the mouth, while recovery time is defined as the time between the endoscope exiting the mouth and patient discharge from the endoscopy unit. Bolus dose was predetermined based on patient’s age, comorbidities, preprocedure SA02 levels, general condition of patient, and previous procedure experience. Titration dose was attained using incremental small doses titrated to sedative effect during the procedure. Results: After a review of 407 patients, 120 were included in the study. The mean age of the sample was 60 (19) years and there were 59.2% women. 7.5% were ASA class I and 92.5% were ASA class II. 64.2% had biopsy during EGD while 16.7% had some form of endoscopic treatment during EGD. Mean procedure time was significantly lower for Method I compared to Method II (8.4 5.8 vs 10.9 6 min, p Z 0.03). Recovery duration did not differ significantly between Method I and Method II (48.8 14.7 vs 53.7 12.9 min, p Z 0.07). Logistic regression analysis demonstrated that the most significant predictor of procedure time after controlling for biopsy, endoscopic treatment, age, gender, versed and fentanyl dose was Method I (OR 3.37: 95% CI 1.55 7.33). Regression analysis showed that age was the most significant factor for recovery duration (OR 0.97: 95% CI 0.95 0.99). No patient in either methods experienced oxygen desaturation or required reversal agents. Conclusion: Our study showed that bolus dosing of fentanyl and midazolam for moderate sedation during EGD leads to reduced procedure time compared to titration dosing. Reducing procedure time during EGD would lead to less patient discomfort, and improved turnover for endoscopy centers. Both methods are safe. Large prospective studies are needed to further confirm our findings.
T1532 Bolus Dosing for Moderate Sedation Reduces Procedure Time During Colonoscopy Anthony Aghenta, Ayodele T. Osowo, Vinodh Jeevanantham, Deerajnath Lingutla, Tarun Kothari Background: There are several methods but the consensus on moderate sedation is that narcotics and benzodiazepines must be titrated to effect. They both remain the most commonly used drugs for achieving moderate sedation during colonoscopy. Aims: To compare 2 methods of fentanyl and midazolam administration during colonoscopy: bolus dosing (Method I) and titration dosing (Method II). The endpoints were procedure and recovery times. Methods: We retrospectively reviewed all charts of patients at our community hospital that underwent colonoscopy between January and March, 2003. Patients were excluded if the same patient had use of different methods of dosing for fentanyl and midazolam or was non-sedated. Apart from demographic variables, data was collected on biopsy, endoscopic treatment, dosing method, total dose of fentanyl, and total dose of midazolam. Procedure time is defined as the time between the endoscope entering and exiting the anus, while recovery time is defined as the time between the endoscope exiting the anus and patient discharge from the endoscopy unit. Bolus dose was predetermined based on patient’s age, comorbidities, preprocedure SA02 levels, general condition of patient, and previous procedure experience. Titration dosing was attained using incremental small doses titrated to sedative effect during the procedure. Results: After a review of 826 patients, 323 were included in the study. The mean age of the sample was 61 (13) years and there were 51.4% women. 10.8% were ASA class I and 89.2% were ASA class II. 41.8% had biopsy during colonoscopy while 26.9% had some form of endoscopic treatment during colonoscopy. Mean procedure time was significantly lower for Method I compared to Method II (18.4 10.2 vs 23.8 10.9 min, p ! 0.01). Recovery duration did not differ significantly between Method I and Method II (53.1 17.9 vs 52.9 17.3 min, p Z 0.90). Logistic regression analysis demonstrated that the most significant predictors of procedure time after controlling for biopsy, endoscopic treatment, age, gender, total versed dose and total fentanyl dose were Method I (OR 2.47: 95% CI 1.494.07), biopsy (OR 2.02: 95% CI 1.203.40), and endoscopic treatment (OR 2.18: 95% CI 1.213.93). No patient in either methods experienced oxygen desaturation or required reversal agents. Conclusion: Our study showed that bolus dosing of fentanyl and midazolam for moderate sedation during colonoscopy leads to reduced procedure time compared to titration dosing. Reducing colonoscopy procedure time would lead to better efficiency and turnover at endoscopy centers. Both methods are safe. Large prospective studies are needed to confirm these findings.
T1533 Incomplete Colonoscopy: Rate and Associated Factors At a VA Medical Center Endoscopy Unit Brindusa Truta, Nooman Gilani, Francisco C. Ramirez The target of cecal intubation according to the US Multi Society Task Force on colorectal cancer is set at least 95% in screening colonoscopies and 90% of all colonoscopies. Aim: To determine the rate for incomplete colonoscopy in a GI Unit at a VA Medical Center and the factors associated with such incompletion. Setting: Endoscopy Unit VA Medical Center. Study period July 1, 2002 to June 30, 2007. Methods: Colonoscopy reports from an electronic data base were analyzed. Results:
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T1530 Predictive Risk Factors for Rebleeding and Thirty-Day Mortality After Endoscopic Hemostasis in Elderly Bleeding Peptic Ulcer Patients Masao Toki, Yasuharu Yamaguchi, Kenji Nakamura, Kei Aoki, Shin-Ichi Takahashi Background and Aims: The rebleeding and 30-day mortality after initial endoscopic hemostasis are the critical concerns when treating bleeding peptic ulcer patients aged 70 years or older. Early identification of patients with risk factors for rebleeding and 30 day mortality can improve the outcome of endoscopic hemostasis. The purpose of this study was to evaluate the risk factors for rebleeding or 30-days mortality in the view of clinical and endoscopic characteristics. Materials and Methods: Between January 1995 and December 2006, therapeutic endoscopies were carried out in 676 patients with peptic ulcers. Among these patients, a total of 200 elderly patients aged 70 years or older were included in this study. A total of 200 patients aged 70 years or older underwent endoscopic hemostasis for peptic ulcer bleeding between January 1995 and August 2006. Hemoclipping was used as first choice for hemostasis. If hemostasis could not be achieved by a single method, other methods were immediately added. The clinical variables (age, gender, smoking, alcohol, NSAID intake, anticoagulant intake, concomitant disease, ulcer history, presence of shock, transfusion over 6 units, inpatient or outpatient status, hemoglobin and serum albumin concentration at endoscopic hemostasis), and endoscopic characteristics of ulcers (size, number and site of ulcers, the severity of initial bleeding) were compared between the patients who did, and patients who did not have rebleeding or 30-day mortality. Multivariate analysis was performed using a logistic regression model expressed as odds ratio in 95% confidential interval. Results: Among the 200 elderly patients in the study, the rebleeding rate was 15.5% (31case), and the 30-day mortality rate was 7.5% (15 case; the cause of death was peptic ulcer in only one case). The results showed that presence of shock (2.4; 1.0-5.9, p ! 0.05), volume of transfusion over 6 units (11.4; 3.6-36.6, p ! 0.05), and ulcer size over 3 cm (3.2; 1.2-8.7, p ! 0.05) and single ulcer (2.2; 1.6-3.0, p ! 0.05) were significant risk factors for rebleeding. For 30-day mortality, concomitant disease (7.8; 1.0-60.4, p ! 0.05) and inpatient status (31.5; 8.2-121.4, p ! 0.01) were significant risk factors. Conclusions: Serious risk of rebleeding or 30-day mortality after endoscopic hemostasis for bleeding peptic ulcers can be predicted by checking clinical variables, patients background and endoscopic findings. Especially we need more careful attention to bleeding peptic ulcer patients hospitalized for concomitant disease.
T1531 Bolus Dosing for Moderate Sedation Reduces Procedure Time During Esophagogastroduodenoscopy (EGD) Anthony Aghenta, Ayodele T. Osowo, Vinodh Jeevanantham, Deerajnath Lingutla, Tarun Kothari Background: Narcotics and benzodiazepines are the most commonly used combination regimen for routine sedation during EGD. There are several techniques but the consensus on moderate sedation is that these medications must be titrated to effect. Aims: To compare 2 methods of fentanyl and midazolam administration during EGD: bolus dosing (Method I) and titration dosing (Method II). The endpoints were procedure and recovery times. Methods: We retrospectively reviewed all charts of patients at our community hospital that underwent EGD between January and March, 2003. Patients were excluded if the same patient had use of different methods of dosing for fentanyl and midazolam, or
AB240 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
was non- sedated. Apart from demographic variables, data was collected on biopsy, endoscopic treatment, dosing method, total dose of fentanyl, and total dose of midazolam. Procedure time is defined as the time between the endoscope entering and exiting the mouth, while recovery time is defined as the time between the endoscope exiting the mouth and patient discharge from the endoscopy unit. Bolus dose was predetermined based on patient’s age, comorbidities, preprocedure SA02 levels, general condition of patient, and previous procedure experience. Titration dose was attained using incremental small doses titrated to sedative effect during the procedure. Results: After a review of 407 patients, 120 were included in the study. The mean age of the sample was 60 (19) years and there were 59.2% women. 7.5% were ASA class I and 92.5% were ASA class II. 64.2% had biopsy during EGD while 16.7% had some form of endoscopic treatment during EGD. Mean procedure time was significantly lower for Method I compared to Method II (8.4 5.8 vs 10.9 6 min, p Z 0.03). Recovery duration did not differ significantly between Method I and Method II (48.8 14.7 vs 53.7 12.9 min, p Z 0.07). Logistic regression analysis demonstrated that the most significant predictor of procedure time after controlling for biopsy, endoscopic treatment, age, gender, versed and fentanyl dose was Method I (OR 3.37: 95% CI 1.55 7.33). Regression analysis showed that age was the most significant factor for recovery duration (OR 0.97: 95% CI 0.95 0.99). No patient in either methods experienced oxygen desaturation or required reversal agents. Conclusion: Our study showed that bolus dosing of fentanyl and midazolam for moderate sedation during EGD leads to reduced procedure time compared to titration dosing. Reducing procedure time during EGD would lead to less patient discomfort, and improved turnover for endoscopy centers. Both methods are safe. Large prospective studies are needed to further confirm our findings.
T1532 Bolus Dosing for Moderate Sedation Reduces Procedure Time During Colonoscopy Anthony Aghenta, Ayodele T. Osowo, Vinodh Jeevanantham, Deerajnath Lingutla, Tarun Kothari Background: There are several methods but the consensus on moderate sedation is that narcotics and benzodiazepines must be titrated to effect. They both remain the most commonly used drugs for achieving moderate sedation during colonoscopy. Aims: To compare 2 methods of fentanyl and midazolam administration during colonoscopy: bolus dosing (Method I) and titration dosing (Method II). The endpoints were procedure and recovery times. Methods: We retrospectively reviewed all charts of patients at our community hospital that underwent colonoscopy between January and March, 2003. Patients were excluded if the same patient had use of different methods of dosing for fentanyl and midazolam or was non-sedated. Apart from demographic variables, data was collected on biopsy, endoscopic treatment, dosing method, total dose of fentanyl, and total dose of midazolam. Procedure time is defined as the time between the endoscope entering and exiting the anus, while recovery time is defined as the time between the endoscope exiting the anus and patient discharge from the endoscopy unit. Bolus dose was predetermined based on patient’s age, comorbidities, preprocedure SA02 levels, general condition of patient, and previous procedure experience. Titration dosing was attained using incremental small doses titrated to sedative effect during the procedure. Results: After a review of 826 patients, 323 were included in the study. The mean age of the sample was 61 (13) years and there were 51.4% women. 10.8% were ASA class I and 89.2% were ASA class II. 41.8% had biopsy during colonoscopy while 26.9% had some form of endoscopic treatment during colonoscopy. Mean procedure time was significantly lower for Method I compared to Method II (18.4 10.2 vs 23.8 10.9 min, p ! 0.01). Recovery duration did not differ significantly between Method I and Method II (53.1 17.9 vs 52.9 17.3 min, p Z 0.90). Logistic regression analysis demonstrated that the most significant predictors of procedure time after controlling for biopsy, endoscopic treatment, age, gender, total versed dose and total fentanyl dose were Method I (OR 2.47: 95% CI 1.494.07), biopsy (OR 2.02: 95% CI 1.203.40), and endoscopic treatment (OR 2.18: 95% CI 1.213.93). No patient in either methods experienced oxygen desaturation or required reversal agents. Conclusion: Our study showed that bolus dosing of fentanyl and midazolam for moderate sedation during colonoscopy leads to reduced procedure time compared to titration dosing. Reducing colonoscopy procedure time would lead to better efficiency and turnover at endoscopy centers. Both methods are safe. Large prospective studies are needed to confirm these findings.
T1533 Incomplete Colonoscopy: Rate and Associated Factors At a VA Medical Center Endoscopy Unit Brindusa Truta, Nooman Gilani, Francisco C. Ramirez The target of cecal intubation according to the US Multi Society Task Force on colorectal cancer is set at least 95% in screening colonoscopies and 90% of all colonoscopies. Aim: To determine the rate for incomplete colonoscopy in a GI Unit at a VA Medical Center and the factors associated with such incompletion. Setting: Endoscopy Unit VA Medical Center. Study period July 1, 2002 to June 30, 2007. Methods: Colonoscopy reports from an electronic data base were analyzed. Results:
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