Resource utilization for acute lower gastrointestinal bleeding (LGIB): The ontario GI bleed study

*4243 RESOURCE UTILIZATION FOR A C U TE LOWER GASTROINTESTINAL B L E E D I N G (LGIB): TH E ONTARIO GI BLEED STUDY Dan Comay, Amiram Gafni, Stephen M. Collins, John K. Marshall, McMaster Univ, Hamilton Canada BACKGROUND: Acute LGIB is a common indication for hospitalization. However, few published studies have profiled related resource utilization, length of stay (LOS) and direct medical costs. A cohort of consecutive admissions for LGIB to selected centers in Canada was reviewed to identify demographic variables predicting LOS and case cost. METHODS: Consecutive admissions for LGIB were identified at four Ontario hospitals ~1994 to 1996). Profiles of resource utilization and estimates of direct medical costs were compiled through detailed chart review and adaptation of administrative case cost databases. All centers were participants in the Ontario Case Cost Project. Linear regression models were constructed to identify demographic variables (age, gender, comorbidity and NSAID use) which predicted LOS and/or case cost. Log transformation of dependent variables was used to reduce skew. RESULTS: Of 124 patients identified, the average age was 59 (range 20 to 86) and 64 (51.6%) were female. Twenty-eight per cent of patients had at least one comorbid illness and 36 ¢29%) had used NSAID's prior to admission. On average, patients had 6.7 complete blood counts and were transfused 1.6 units of blood. Eighty-four •.olonoscopies and 38 flexible or rigid sigmoidoscopies were performed. Bleeding was attributed to diverticulosis in 43 (34.6%), hemorrhoids in 17 13.7%), ischemic colitis in 12 (9.7%), Crohn's disease 11 (8.9%), polyps in 10 (8.1%), ulcerative colitis in 8 (6.5%), angiodysplasia 7 (5.6%) or another ~ource in 16 (12.9%). Twelve patients (9.7%) underwent surgery and one ~0.8%) died. The mean LOS was 7.5 days (SD 12 days} and the mean case cost was C$4,673 (SD C$6,950). Older age and comorbid illness were associated with both increased LOS and higher case cost in univariate regression analyses, Only age persisted as an independent predictor of LOS and case cost in a stepwise multiple linear regression. Neither gender nor NSAID use predicted LOS or case cost. Among the 27 patients at least 65 years of age with comorbid illness, the average case cost was C$6,038 for 7.96 days in hospital. CONCLUSIONS: Acute LGIB is associated with sig~lificant resource utilization, particularly among the elderly. Supported by lm

unrestricted researchgrant from Searle Canada

':4244 PROSPECTIVE BLINDED EVALUATION OF THE IMPACT OF TRANSRECTAL ULTRASOUND (TRUS) WITH G U ID ED F I N E NEEDLE ASPIRATION BIOPSY (FNA) ON MANAGEMENT OF RECTAL CANCER I ~avin C. Harewood, Maurits J. Wiersema, David A. Ahlquist, Heidi Nelson, l~obert L. Maccarty, Mary Lou Jondal, Mayo Clin, Rochester, MN Introduction: Preoperative staging of rectal cancer may influence therapy. To date, a prospective, blinded evaluation assessing how TRUS + FNA impacts treatment decisions in rectal cancer has not been undertaken. .\ims: To analyze the effect of the addition ofTRUS + FNA on management decisions in patients with rectal cancer. Methods: We prospectively compared tumor (T) and nodal (N) staging accuracy ofTRUS + FNA and CT in :;6 consecutive patients with rectal cancer. The endoscopist committed to a N stage prior to proceeding with FNA. The gold standard for T stage was ~urgical pathology in patients who did not receive preoperative neoadjurant therapy (n = 21); for N stage, documented nodal metastases by surgery or FNA (n = 29). All CT films were read by a single radiologist; both 1he radiologist and endoscopist were blinded to TRUS and CT findings, ~'¢~spectively.The surgeon, who was blinded to all imaging results, was then ~L,quentially informed of the CT and then TRUS + FNA results. After each t,,st result was revealed, the surgeon described their management plan. I~hange in management pre and post provision ofTRUS + FNA results was ~easured. Results: 36 patients with rectal cancer underwent TRUS + FNA ,~l'whom 21 (58%) went directly to surgery. Agreement between TRUS and I'T for T staging was poor, kappa = 0.13. In the 21 patients who went for ~urgery, TRUS was significantly more accurate than CT for T staging, ~1)0% vs 61%, p = 0.002 (table). Of the 29 patients with a gold standard dctermination of N stage, accuracy was 83% for TRUS FNA, 79% for TRUS, ~2% for CT, p = n.s. The addition ofTRUS + FNA to the standard staging work-up ofCT effected a change in management in 11 (31%; 95% C.I. 16 -IS%) patients: addition of preoperative adjuvant therapy in 10 patients ~md change in surgical procedure in 1. Change in therapy was due to T upstaging in 6 patients, N upstaging in 7 patients. Conclusions: TRUS and '['t~US FNA have equivalent N staging accuracy. The routine employment ,,f TRUS along with CT is supported by its significant impact on preoperafive treatment decisions.

V O L U M E 53, NO. 5, 2001

Accuracy

c'r'

TRUS

TRUS + FNA

T Stage N Stage

61%'" 62%

100% 79%

83%

' T1 and T2 collapsed intosingleT1/2 stage for CT staging "" p = 0.002 vs. TRUS

*4245 GREATER THAN 3 DILATIONS IS AN ADVERSE PROGNOSTIC FACTOR IN COLONIC ANASTOMOTIC STRICTURE DILATION Umar Beejay, Afonso Ribeiro, Luke Hourigan, Guillermo De La Mora, Gregory B. Haber, Gabor P. Kandel, Paul Kortan, Norman E. Marcon, St Michael's Hesp, Univ of Toronto, Toronto Canada BACKGROUND: Colonic anastomotic strictures(CAS)occur in up to 5% of patients following cole-rectal surgery. Despite its prevalence, little is known about prognostic factors that may determine long term clinical outcome. AIM: To identify possible prognostic markers associated with successful long term clinical outcome following dilation of CAS. PATIENTS: 42 pts with CAS were identified;follow up data was available for 39 patients(22M, mean age 56(range=19-76). METHODS: Single institution, retrospective case review of consecutive CAS undergoing dilation in a 3 year period. All pts were followed up for 24 months from last dilation. Univariate analysis using the z2/Fisher Exact Test was performed with the following variables: etiology behind CAS,maximum dilation size, no. of dilations and dilation method. Outcome was defined as symptomatic relief at 24 months. RESULTS: Presenting symptoms included change in bowel habits(70%),cramps(61%) and bleatingS31%). Underlying diseases were malignancy in 54%,diverticular disease(DD)in 28% and inflammatory bowel disease(IBD) in 18%. 80% dilations were with balloon dilators, 18% with SavaryTM dilators and 2% with a combination of techniques. Mean maximum dilation achieved was 20mm(range15-25mm). Mean technical success achieved in CAS dilation was 91% and the 24 months symptom relief rate was 57%,76% and 82% for IBD,malignancy and DD respectively. Univariate analysis demonstrated that performing greater than 3 dilations was statistically significant(p<0.05). No correlation was seen between any other variables and symptomatic clinical outcome.CONCLUSION: Performing greater than 3 dilations is an adverse prognostic factor in colonic anastomotic stricture dilation. Neither the etiology behind CAS nor type/size dilation influence outcome.

Outcome and Dilation characteristics for CAS by Etiology Stricture Etiology Malignancy IBD Dlverttcular Total

Number(%) 21 (54) 7(18) 11 (28) 39

Symptom free 3mo (%) 24 mo (%) 17 (81) 6 (86) 10 (91}

16 (76) 4(57) 9 (82)

>3 dilaUons(%)

Max dilation >20mm (%)

4 (19) 3(43) 3 (27) 10 (25)

3 (14) 1(14) 3 (27) 7 (18)

*4246 EMER G EN C Y ANGIO-HELICAL COMPUTED TOMOGRAPHY I N LO WER GI-BLEEDING Ramuntcho Arotcarena, Alexandre Pariente, Philippe Berthelmy, Daniel Bersani, Alain Lippa, Yves Laborde, Ctr Hospitalier, Pau France Exploration of active lower GI bleeding remains difficult, when upper and lower emergency endoscopies are negative. Emergency angiography is invasive, needs special skill, and keeps diagnostic limitations. A recent case report* prompted us to test the diagnostic efficacy of angio-helical CT-scan in this situation. Methods From June 1999 to September 2000, 6 consecutive patients, 46 to 87-years old, whose lower GI bleeding remained unexplained after emergency upper GI endoscopy and colonoscopy, had emergency anglo-helical CT scan. CT-scan examination (Picker CT Twin RTS)included a complete abdominal and pelvic acquisition (5.5 mm-thick slices every 5 ram), before and 30 and 120 sec after 3 mL/sec intravenous injection of 120 mL of Xenetrix 300 TM. Results The bleeding site (ileum, descending colon and sigmoid colon in one patient each) was demonstrated in three patients (extravasation and accumulation of contrast in the intestinal lumen).In one patient, who had a first negative exam, CT-scan was repeated 8 hours later because of recurrent hemorrhage, and showed an ileal bleeding. Emergency surgery was performed in these 3 patients: one signloidectomy and one left colectomy for bleeding diverticula, and one segmental ileectomy for NSAID-induced ileal ulceration. The CT-scan was negative in the three other patients who did not re-bled: final diagnosis were colonic diverticular disease in two cases and severe esophagitis in the third. Conclusion Emergency helical CT-scan, a largely available, non-invasire technique, can help to precisely localize the source of active lower gastrointestinal bleeding. *Combes R et al. H~pato-Gastro 1999; 6: 471.

GASTROINTESTINAL

ENDOSCOPY

AB181