- Email: [email protected]
Propofol Vs. Traditional Sedation Agents for Colonoscopy: A Meta-Analysis
Abstracts
T1537 Impact of Endoscopist’s Experience On Success Rate of En-Bloc and En Bloc-Cure of Large Colorectal Polyps By Endoscopic Submucosal Dissection: A Meta-Analysis and Systematic Review Srinivas R. Puli, Yasuo Kakugawa, Takuji Gotoda, Jyotsna Bk Reddy, Daphne Antillon, Yutaka Saito, Mainor R. Antillon Background: Endoscopic submucosal dissection (ESD) has emerged as an alternative to surgery for the resection of large (O 2 cm) colorectal polyps. ESD is a technically demanding procedure. From published data, it is not clear how endoscopists’ experience affects successful en-block resection of large colonic polyps. Aim: To evaluate how endoscopists experience in performing ESD affects the proportion of successful en-block resection of large colonic polyps. Method: Study Selection Criteria: Studies using ESD technique to resect large colonic polyps were selected. Successful cure en-block resection was defined as margins free polyp resection. Data collection & extraction: Articles were searched in Medline, Japanese language literature, and Cochrane control trial registry. Two reviewers independently searched and extracted data. Statistical Method: Summary estimates are expressed as pooled proportions. Studies were grouped into !100 ESD’s performed and O 100 ESD’s performed. First, the individual study proportions of successful resection are transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion is calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed effects model and DerSimonian-Laird weights for the random effects model. Results: Initial search identified 2,120 reference articles, in which, 389 relevant articles were selected and reviewed. Data was extracted from 13 studies (N Z 1,080) which met the inclusion criteria. 9 Studies had !100 ESD’s (N Z 394) and 4 studies had O100 ESD’s (N Z 686). The mean size of the polyps was 30.65 SE 2.88 mm. The pooled proportions are shown in table 1. The fixed effect model was not used because of the heterogeneity among studies. The publication bias calculated by BeggMazumdar bias indicator for successful en-bloc resection gave a Kendall’s tau b value of -0.22 (p Z 0.32) and the same for successful cure en-block resection was -0.23 (p Z 0.25). Conclusion: ESD is an innovative technique for resection of large colonic polyps that offers an alternative to surgery. Our meta-analysis shows that the success rate for both en-bloc and en-bloc cure improves with O100 ESDs. Endoscopist’s experience significantly improves the success rates of this technique to treat large colorectal polyps.
Pooled proportion using random effect model of successful en-block and cure en-block resection based on study size Study Size
No of studies Successful En-bloc Resection
! 100 Patients 9 O 100 Patients 4
82.60 % (95% CI Z 66.45 to 94.22) 88.37 % (95% CI Z 82.19 to 93.37)
Successful Cure En-bloc Resection 71.23 % (95% CI Z 57.17 to 83.46) 82.25 % (95% CI Z 71.56 to 90.85)
T1538 Propofol Vs. Traditional Sedation Agents for Colonoscopy: A Meta-Analysis Harminder Singh, William Poluha, Mary S. Cheang, Nicole Choptain, Ken I. Baron, Shayne P. Taback Propofol is increasingly being utilized for sedation during colonoscopy, with many recent reports of large non-randomized case series. Our aim was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives. Our secondary goal was to synthesize the studies comparing propofol administration by anesthetists to that by non-anesthetists. Methods: We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between Jan 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions. Data from eligible studies were abstracted by two reviewers. The outcomes compared included overall patient satisfaction, recovery time after the procedure, discharge time and complications (hypoxia, hypotension, arrhythmias, and colonic perforations). RevMan 4.2.8 was used for data analysis. Both fixed and random effects models were examined. Results from studies evaluating propofol as a single agent in one of the arms are reported here. Results: Of the 267 citations, 20 studies met the inclusion criteria for our primary objective. There was only one study, reported in abstract form comparing propofol administration by anesthetists to that by gastroenterologists. Eight studies evaluated propofol as a single agent. Mean sedation level was higher with the use of propofol (SMD 1.38; 95% CI: 1.11-1.65). The analysis of recovery time (four trials) demonstrated heterogeneity, but a sensitivity analysis, excluding the one study in which all patients in the control arm remained responsive through-out the procedures, was shorter for propofol, with no significant heterogeneity in the remaining studies (WMD -14 min; 95% CI, -17,-10). Discharge time (three trials) was shorter with the use of propofol (WMD -22 min; 95% CI, -29,-17). Overall patient satisfaction favored the use of propofol (studies reporting as dichotomous
AB242 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
and continuous outcomes analyzed separately). There was no difference in occurrence of hypoxia (6 studies; OR 0.76; 95% CI, 0.32-1.81), hypotension (2 studies; OR 1.03; 95% CI, 0.28-3.84) or arrhythmias (3 studies; OR 0.55; 95% CI, 0.11-2.61). For colonic perforations, there was one large study (n Z 7,286 patients) reported only in abstract form, which did not find a significant difference (OR 2.87; 95% CI, 0.60-13.83). Conclusions: Propofol used alone for sedation during colonoscopy leads to faster discharge from the endoscopy unit and higher patient satisfaction with no increase in the complication rates.
T1539 Non-Aggressive Cystoscopy-Guided Debridement and Vigorous Irrigation for the Treatment of Organized Pancreatic Necroses I. Cabral Patricia Anne, M. Sison Ma. Cecilia, A. De Mark Anthony Lusong, Tonya R. Kaltenbach, Roy M. Soetikno, Kenneth F. Binmoeller Background and Objective: Surgical debridement is the current standard of treatment for symptomatic patients with organized pancreatic necrosis, but is associated with high morbidity and mortality rates. Endoscopic transmural debridement under cystoscopic guidance using extraction devices such as baskets and snares has been reported as an alternative approach, though is tedious, labor intensive, and may require multiple sessions. We report a novel approach of performing minimal and non-aggressive mechanical debridement followed by vigorous irrigation and multiple stent placement for the treatment of organized pancreatic necroses. Patients and Methods: We studied symptomatic patients who were diagnosed with organized pancreatic necroses on contrast-enhanced CT and confirmed on EUS from March 2004 to August 2007. EUS-guided cyst puncture was performed using a 19 G needle followed by balloon dilation of the cystenterostomy to 8 mm. The echoendoscope was exchanged over-the-wire for a 3.7 mm therapeutic gastroscope. The cystenterostomy was dilated to 15-18 mm followed by advancement of the endoscope into the cyst. Cystoscopy-guided debridement of loosely adherent material with a basket was followed by vigorous irrigation and suction. Adherent necrotic tissue was left in place. Three 10 Fr stents were inserted under endoscopic guidance. A nasocystic catheter was placed in select patients with infected fluid contents. Results: Endoscopic debridement and drainage of organized necroses was performed in 25 patients. The average size of the organizing fluid collections on initial CT was 12 4 cm. Fluid contents were infected in 15 patients. A total of 20 patients (80%) had symptom and cyst resolution after a mean of 1.9 1.2 procedures. The mean interval between procedures was 10.3 6.7 days. Three patients required subsequent surgical intervention for complications including procedure-related bleeding (n Z 1) and abscess formation (n Z 2). Conclusion: Endoscopic cystoscopy-guided debridement with non-aggressive removal of necrotic material and vigorous irrigation is an effective method for the treatment of organized pancreatic necroses. Resolution may be achieved in one or two sessions. Nasocystic catheter placement is not required in non-infected fluid collections. The indications for active debridement and complete removal of necrotic material using extraction devices require further study.
T1540 The Efficacy of Argon Plasma Coagulation for Gastric Adenoma Eun Ran Kim, Hoi Jin Kim, Young-Ho Kim, Dong Kyung Chang, Hee Jung Son, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee Background: Endoscopic mucosal resection (EMR) is now widely accepted as a useful treatment method for gastric adenoma which was premalignant lesion. But no adequate treatment is available for cases of gastric adenoma which are untreatable by EMR because of their high risk. The aim of the study was to evaluate the clinical efficacy of Argon Plasma Coagulation (APC) in patients with gastric adenoma. Methods: We reviewed medical records of 52 lesions in 52 patients who initially underwent APC for gastric adenoma at the Samsung Medical Center from 2003 through 2006. We analyzed the clinicopathological characteristics of that cases. Result: The patients consisted of 43 men and 9 women. The median age was 65 years old (range: 36-84 years old). The reason for undergoing APC was as follows:in 31 cases (56.4%), ill-defined lesion due to metaplastic changes on background:in 10 cases (18.2%), contraindicated EMR because of concomitant disease:in 9 cases (16.4%), anatomically difficult lesions for EMR:in 5 cases(9.1%), non-lifting after saline injection because of benign scar. The median size was 10 mm (range:2-25 mm). Out of 52 lesions, 10 lesions were high grade adenoma and 48 leisons were macroscopically elevated. No complications were found in any of the 52 patients. The median follow up period was 13 months (range: 5-32 months). Recurrence was seen in 6 cases. The median recurrence period was 10 months(range: 6-15 months). Out of recurred 6 patients, 4 patients were treated with re APC and that lesions were locally controlled until recent follow up (median peroid:4 months). Conclusions: APC for gastric adenoma is a safe and effective modality for elderly patients with concomitant disease, ill-defined lesions due to metaplastic changes and anatomically difficult lesions for EMR. But, the regular follow up is necessary to early detect and treat for recurred adenoma.
www.giejournal.org
T1537 Impact of Endoscopist’s Experience On Success Rate of En-Bloc and En Bloc-Cure of Large Colorectal Polyps By Endoscopic Submucosal Dissection: A Meta-Analysis and Systematic Review Srinivas R. Puli, Yasuo Kakugawa, Takuji Gotoda, Jyotsna Bk Reddy, Daphne Antillon, Yutaka Saito, Mainor R. Antillon Background: Endoscopic submucosal dissection (ESD) has emerged as an alternative to surgery for the resection of large (O 2 cm) colorectal polyps. ESD is a technically demanding procedure. From published data, it is not clear how endoscopists’ experience affects successful en-block resection of large colonic polyps. Aim: To evaluate how endoscopists experience in performing ESD affects the proportion of successful en-block resection of large colonic polyps. Method: Study Selection Criteria: Studies using ESD technique to resect large colonic polyps were selected. Successful cure en-block resection was defined as margins free polyp resection. Data collection & extraction: Articles were searched in Medline, Japanese language literature, and Cochrane control trial registry. Two reviewers independently searched and extracted data. Statistical Method: Summary estimates are expressed as pooled proportions. Studies were grouped into !100 ESD’s performed and O 100 ESD’s performed. First, the individual study proportions of successful resection are transformed into a quantity using Freeman-Tukey variant of the arcsine square root transformed proportion. The pooled proportion is calculated as the back-transform of the weighted mean of the transformed proportions, using inverse arcsine variance weights for the fixed effects model and DerSimonian-Laird weights for the random effects model. Results: Initial search identified 2,120 reference articles, in which, 389 relevant articles were selected and reviewed. Data was extracted from 13 studies (N Z 1,080) which met the inclusion criteria. 9 Studies had !100 ESD’s (N Z 394) and 4 studies had O100 ESD’s (N Z 686). The mean size of the polyps was 30.65 SE 2.88 mm. The pooled proportions are shown in table 1. The fixed effect model was not used because of the heterogeneity among studies. The publication bias calculated by BeggMazumdar bias indicator for successful en-bloc resection gave a Kendall’s tau b value of -0.22 (p Z 0.32) and the same for successful cure en-block resection was -0.23 (p Z 0.25). Conclusion: ESD is an innovative technique for resection of large colonic polyps that offers an alternative to surgery. Our meta-analysis shows that the success rate for both en-bloc and en-bloc cure improves with O100 ESDs. Endoscopist’s experience significantly improves the success rates of this technique to treat large colorectal polyps.
Pooled proportion using random effect model of successful en-block and cure en-block resection based on study size Study Size
No of studies Successful En-bloc Resection
! 100 Patients 9 O 100 Patients 4
82.60 % (95% CI Z 66.45 to 94.22) 88.37 % (95% CI Z 82.19 to 93.37)
Successful Cure En-bloc Resection 71.23 % (95% CI Z 57.17 to 83.46) 82.25 % (95% CI Z 71.56 to 90.85)
T1538 Propofol Vs. Traditional Sedation Agents for Colonoscopy: A Meta-Analysis Harminder Singh, William Poluha, Mary S. Cheang, Nicole Choptain, Ken I. Baron, Shayne P. Taback Propofol is increasingly being utilized for sedation during colonoscopy, with many recent reports of large non-randomized case series. Our aim was to identify, analyze and summarize RCTs comparing the relative effectiveness, patient acceptance and safety of propofol for colonoscopy, to traditional sedatives. Our secondary goal was to synthesize the studies comparing propofol administration by anesthetists to that by non-anesthetists. Methods: We searched Medline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web of Science and the Cochrane Controlled Trials Registry database between Jan 1980 and June 2007; and conference proceeding abstracts for DDW, EUGW and ACG between 1990 and June 2007. There were no language restrictions. Data from eligible studies were abstracted by two reviewers. The outcomes compared included overall patient satisfaction, recovery time after the procedure, discharge time and complications (hypoxia, hypotension, arrhythmias, and colonic perforations). RevMan 4.2.8 was used for data analysis. Both fixed and random effects models were examined. Results from studies evaluating propofol as a single agent in one of the arms are reported here. Results: Of the 267 citations, 20 studies met the inclusion criteria for our primary objective. There was only one study, reported in abstract form comparing propofol administration by anesthetists to that by gastroenterologists. Eight studies evaluated propofol as a single agent. Mean sedation level was higher with the use of propofol (SMD 1.38; 95% CI: 1.11-1.65). The analysis of recovery time (four trials) demonstrated heterogeneity, but a sensitivity analysis, excluding the one study in which all patients in the control arm remained responsive through-out the procedures, was shorter for propofol, with no significant heterogeneity in the remaining studies (WMD -14 min; 95% CI, -17,-10). Discharge time (three trials) was shorter with the use of propofol (WMD -22 min; 95% CI, -29,-17). Overall patient satisfaction favored the use of propofol (studies reporting as dichotomous
AB242 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
and continuous outcomes analyzed separately). There was no difference in occurrence of hypoxia (6 studies; OR 0.76; 95% CI, 0.32-1.81), hypotension (2 studies; OR 1.03; 95% CI, 0.28-3.84) or arrhythmias (3 studies; OR 0.55; 95% CI, 0.11-2.61). For colonic perforations, there was one large study (n Z 7,286 patients) reported only in abstract form, which did not find a significant difference (OR 2.87; 95% CI, 0.60-13.83). Conclusions: Propofol used alone for sedation during colonoscopy leads to faster discharge from the endoscopy unit and higher patient satisfaction with no increase in the complication rates.
T1539 Non-Aggressive Cystoscopy-Guided Debridement and Vigorous Irrigation for the Treatment of Organized Pancreatic Necroses I. Cabral Patricia Anne, M. Sison Ma. Cecilia, A. De Mark Anthony Lusong, Tonya R. Kaltenbach, Roy M. Soetikno, Kenneth F. Binmoeller Background and Objective: Surgical debridement is the current standard of treatment for symptomatic patients with organized pancreatic necrosis, but is associated with high morbidity and mortality rates. Endoscopic transmural debridement under cystoscopic guidance using extraction devices such as baskets and snares has been reported as an alternative approach, though is tedious, labor intensive, and may require multiple sessions. We report a novel approach of performing minimal and non-aggressive mechanical debridement followed by vigorous irrigation and multiple stent placement for the treatment of organized pancreatic necroses. Patients and Methods: We studied symptomatic patients who were diagnosed with organized pancreatic necroses on contrast-enhanced CT and confirmed on EUS from March 2004 to August 2007. EUS-guided cyst puncture was performed using a 19 G needle followed by balloon dilation of the cystenterostomy to 8 mm. The echoendoscope was exchanged over-the-wire for a 3.7 mm therapeutic gastroscope. The cystenterostomy was dilated to 15-18 mm followed by advancement of the endoscope into the cyst. Cystoscopy-guided debridement of loosely adherent material with a basket was followed by vigorous irrigation and suction. Adherent necrotic tissue was left in place. Three 10 Fr stents were inserted under endoscopic guidance. A nasocystic catheter was placed in select patients with infected fluid contents. Results: Endoscopic debridement and drainage of organized necroses was performed in 25 patients. The average size of the organizing fluid collections on initial CT was 12 4 cm. Fluid contents were infected in 15 patients. A total of 20 patients (80%) had symptom and cyst resolution after a mean of 1.9 1.2 procedures. The mean interval between procedures was 10.3 6.7 days. Three patients required subsequent surgical intervention for complications including procedure-related bleeding (n Z 1) and abscess formation (n Z 2). Conclusion: Endoscopic cystoscopy-guided debridement with non-aggressive removal of necrotic material and vigorous irrigation is an effective method for the treatment of organized pancreatic necroses. Resolution may be achieved in one or two sessions. Nasocystic catheter placement is not required in non-infected fluid collections. The indications for active debridement and complete removal of necrotic material using extraction devices require further study.
T1540 The Efficacy of Argon Plasma Coagulation for Gastric Adenoma Eun Ran Kim, Hoi Jin Kim, Young-Ho Kim, Dong Kyung Chang, Hee Jung Son, Poong-Lyul Rhee, Jae J. Kim, Jong Chul Rhee Background: Endoscopic mucosal resection (EMR) is now widely accepted as a useful treatment method for gastric adenoma which was premalignant lesion. But no adequate treatment is available for cases of gastric adenoma which are untreatable by EMR because of their high risk. The aim of the study was to evaluate the clinical efficacy of Argon Plasma Coagulation (APC) in patients with gastric adenoma. Methods: We reviewed medical records of 52 lesions in 52 patients who initially underwent APC for gastric adenoma at the Samsung Medical Center from 2003 through 2006. We analyzed the clinicopathological characteristics of that cases. Result: The patients consisted of 43 men and 9 women. The median age was 65 years old (range: 36-84 years old). The reason for undergoing APC was as follows:in 31 cases (56.4%), ill-defined lesion due to metaplastic changes on background:in 10 cases (18.2%), contraindicated EMR because of concomitant disease:in 9 cases (16.4%), anatomically difficult lesions for EMR:in 5 cases(9.1%), non-lifting after saline injection because of benign scar. The median size was 10 mm (range:2-25 mm). Out of 52 lesions, 10 lesions were high grade adenoma and 48 leisons were macroscopically elevated. No complications were found in any of the 52 patients. The median follow up period was 13 months (range: 5-32 months). Recurrence was seen in 6 cases. The median recurrence period was 10 months(range: 6-15 months). Out of recurred 6 patients, 4 patients were treated with re APC and that lesions were locally controlled until recent follow up (median peroid:4 months). Conclusions: APC for gastric adenoma is a safe and effective modality for elderly patients with concomitant disease, ill-defined lesions due to metaplastic changes and anatomically difficult lesions for EMR. But, the regular follow up is necessary to early detect and treat for recurred adenoma.
www.giejournal.org