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Safe and successful Endoscopic Retrograde Cholangiography (ERC) and stone removal in the nonagenarian with choledocholithiasis
CLINICAL ENDOSCOPIC PRACTICE I"137
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OUTCOME OF ENDOSCOPY IN THE MANAGEMENT OF PAT1ENTS ADMITTED WITH NONGASTROENTEROLOGICAL DIAGNOSES AND FOUND TO HAVE OCCULT GASTROINTESTINAL BLEEDING AND/OR ANEMIA. T.K.Sh~rm~, A.F.Cutler. Section of Gastroenterology, Sinai Hospital, Detroit, MI. Background: At admission, patients routinely undergo digital rectal examination and FOB testing. Occult gastrointestinal bleeding (OGIB) presents as positive fecal occult blood test (FOBT*), anemia with "drop in hemoglobin" or iron deficiency. ~ To determine site of blood loss, significant diagnoses (ulcer disease, adenomatous polyp, colitis, and neoplasm), utilization and yield of endoscopy among inpatients with no GI symptoms referred for OGIB. Methods: Demographic, clinical, hematological, endoscopic (EP) and histologic data were retrospectively collected on inpatients. PatientS were divided into two groups: Groupl (FOBT+or anemia); Groupll (FOBT~& anemia). Utilization rate (total EP/total patients ~.100), yield (diagnoses/total EP x 100) for significant (Y,) and all (Y2) diagnoses were evaluated. Significant result~ were defined as focalization of the site of blood loss or diagnoses that resulted in new treatment or intervemiou. ~ Data on 81 consecutive patients since January 1994 were evaluated. The mean age (years), gender (%male), total EP, utilization rate (UR) and yields (Y, and Y2) were: N Age Male(%) EP UR(%) Y~(%) Y7(%) Groopl 31 71.8 32 35 112 20 77 Groupll 50 68.9 46 55 110 40 67 Localizations of blood loss were: Ulcer Polyp Colitis Neoplasm* Crroupl 6 1 0 0 Groupll 11 2 2 7 *5 colonic and 2 gastric neoplasia were diagnosed. Concl~ Despite equivalent utilization of endoscopy, different yields for significant diagnoses were observed between the two groups. Our data supports the practice of bidirectional endoscopy in patients with OG1B manifesting as FOBT* and anemia (groupll).
COMPUTER ASSISTED MULTIMEDIA EDUCATION OF PATIENTS FOR COLONOSCOPY. MJ Shaw OW Cass, GL Sales, PATomshine, IF Reynolds. Park Nicollet Medical Foundation, and Hennepin County Medical Center, Minneapolis, MN /NTRODUCTION: patient education for endoscopy is a professional and legal responsibility of endoscopic practice. Education should reduce anxiety, increase satisfaction, improve outcomes, and facilitate informed consent. 60% of malpractice claims for eolonoscopy allege inadequate informe d consent; this process needs improvement. Cost constraints prohibit increased health professional time for patient education. Multimedia education possess the benefits of videotapas, the ability for interaction, as well as documentation of use and comprehension. The study's purpose was to develop and test a multimedia education CDKOM for colonoscopy. METHODS: The program was written in Visual Basic for use on a 486DX2-33Mttz IBM-compatible PC with a double speed CDROM and VGA graphics. In this pilot study 10 patients (5F:5M, mean age 59), used the program before preparation for a colonoscopy. Five had colonoscopy before. Anxiety was tested before and after use with a questionnaire specific to eolonoscopy. Comprehension was tested via the program. Patients were interviewed about program quality/ease of use, and for general comments. RESULTS: Five had some computer experience; 4 used a computer weekly; 3 had a home computer. Subjects spent a mean of 47 minutes on the program. The mean comprehension score was 93%. Nine showed a reduction in colonoscopy-specific anxiety. All patients recommended that the program be made available to others. The interview gathered suggestions to ease use of the computer for the inexperienced patient. CONCLUSION: This program is usefu[ as part ofpatiant education prior to colonoscopy. After revision, it will be studied in a rendomized trial. This research was supported, in part, by a grant from Astra/Merck Pharmaceuticals.
138
140
COMPARISON OF ~DEOAND NON-~DEO FLEXIBLE SIGMOIDOSCOPES FOR TRAINING OF MEDICAL RESIDENTS: ~ Shauk~, Sanowski, Carl T. ~ayden VA Medical Center, Phoenix, Arizona. Screening flexible sig~oidoscopy (F/S) for population over 50 years of age is recommended, thus necessitating a large number of procedures. It may be advisable to offer this training to all medical residents. Traditionally this procedure has been performed with a non-video flexible 60cm sigmoidoscope, video F/S is more expensive in cost and maintenance and may not be easily available for office practice. We conducted a randomized comparison of these scopes for training of ~edical residents. METHOD8: 24 residents from Internal Medicine and Family Practice Residency programs were randomly assigned to receive F/S training with one of the instruments. The first 5 procedures were completed with active participation of the instructor. Spbsequently residents were observed for initial i0 minutes without assistance and level of insertion was noted. The procedure was then completed with active assistance" from the instructor. A resident was considered proficient if he/she was able to pass the F/S beyond 45cm without assistance on 3 occasions and was able to identify anatomical landmarks and eormmon lesions with maximum of 20 cases. RESULTS: 9/12 residents in each ~roup completed the training. 2 residents in nonvideo F/S group and 3 residents in video group did not complete maximum number of procedures. Only one resident failed to achieve proficiency after 20 procedures. The average number of procedures needed to complete training was 12.5 and 11.5 in the nonvideo and video group respectively. This difference was not statistically significant (p=0.5 Student TTest). CONCLDSIONS: i. Both video and non-video F/S are adequate for training purposes. 2. The average number of procedures needed to complete training is 12 (range 9-17). 3. It is feasible to offer F/S training to all medical residents.
~30
GASTROINTESTINAL
ENDOSCOPY
SAFE AND SUCCESSFUL ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) AND STONE REMOVAL IN THE NONAGENARIAN WITH CHOLEDOCHOLITHtASIS, Sperlin~. AL Filly and JW Oslxoff, Departmem of Medicine, University of California. San Francisco, San Francisco, CA. Choledocholithiasis appears to have an increasing prevalence in the elderly population. The stones often are large within massively dilated ducts and patients frequently have significant eardiopulmonary compromise. With an aging population this group will present special challenges for the biliary endr3scopist. Issues often arise concerning sedation, esp. surrounding airway management in a group of patients frequendy exhibiting dementia. Often these overriding concerns influence our willingness to perform long endoscopic procedures. Results: We performed 15 ERC's in 12 p~fients over an t8 month period who were in their tenth decade of life; the mean age was 93 y (range 89-100) and thea'e were 3 males and 9 females. The crmical presentations were: eholangitis (7), biliary pain (3), pancreatitis (2). Mean LFT's on presentation were: total bilirubin 4.4 mg/dl, alkaline phosphatase 296 U/I, and AST]ALT 227/448 U/1. Major comorbid illnesses (cardiopulmonary) were present in 8 of 12 (75%) patients. The procedures were performed safely in all patients; 6 of 12 (50%) had general anesthesia, while conscious sedation waS used in the other 6 patients (delivered by an anesthesiologist in three). All patients received prophylactic antibiotics. Endoscopic sphincterotomy was safely performed and all stones extracted in 10 patients; 1 patient required stenting initially, with extraction on a subsequent ERC. One patient who had undergone a previous Billroth II gastrectomy had two 4 cm stones, which were partially fractured using a mechanical lithotripter and currently has two plastic endoprostheses draining her biliary system. There was one failed cannulation due to a distal obsmaction. There were no complications from either the procedures themselves or from the anesthesia. Patients were discharged a mean of 3.3 days after stone extraction. Conclusions: ERC is a safe and effective mode of therapy for choledocholithiasis in the elderly despite comorbid conditions. The utilization of a multidisciplinary approach, incorporating cardiology and anesthesia expertise for cardiopulmonary stabilization and the administration of sedation, which allows this group of very elderly, high-risk patients to benefit from the shorter procedure times and decreased morbidity of ERC as compared with open surgical treatmem of con:~'non bile duct stones.
V O L U M E 41, N O . 4, 1995
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OUTCOME OF ENDOSCOPY IN THE MANAGEMENT OF PAT1ENTS ADMITTED WITH NONGASTROENTEROLOGICAL DIAGNOSES AND FOUND TO HAVE OCCULT GASTROINTESTINAL BLEEDING AND/OR ANEMIA. T.K.Sh~rm~, A.F.Cutler. Section of Gastroenterology, Sinai Hospital, Detroit, MI. Background: At admission, patients routinely undergo digital rectal examination and FOB testing. Occult gastrointestinal bleeding (OGIB) presents as positive fecal occult blood test (FOBT*), anemia with "drop in hemoglobin" or iron deficiency. ~ To determine site of blood loss, significant diagnoses (ulcer disease, adenomatous polyp, colitis, and neoplasm), utilization and yield of endoscopy among inpatients with no GI symptoms referred for OGIB. Methods: Demographic, clinical, hematological, endoscopic (EP) and histologic data were retrospectively collected on inpatients. PatientS were divided into two groups: Groupl (FOBT+or anemia); Groupll (FOBT~& anemia). Utilization rate (total EP/total patients ~.100), yield (diagnoses/total EP x 100) for significant (Y,) and all (Y2) diagnoses were evaluated. Significant result~ were defined as focalization of the site of blood loss or diagnoses that resulted in new treatment or intervemiou. ~ Data on 81 consecutive patients since January 1994 were evaluated. The mean age (years), gender (%male), total EP, utilization rate (UR) and yields (Y, and Y2) were: N Age Male(%) EP UR(%) Y~(%) Y7(%) Groopl 31 71.8 32 35 112 20 77 Groupll 50 68.9 46 55 110 40 67 Localizations of blood loss were: Ulcer Polyp Colitis Neoplasm* Crroupl 6 1 0 0 Groupll 11 2 2 7 *5 colonic and 2 gastric neoplasia were diagnosed. Concl~ Despite equivalent utilization of endoscopy, different yields for significant diagnoses were observed between the two groups. Our data supports the practice of bidirectional endoscopy in patients with OG1B manifesting as FOBT* and anemia (groupll).
COMPUTER ASSISTED MULTIMEDIA EDUCATION OF PATIENTS FOR COLONOSCOPY. MJ Shaw OW Cass, GL Sales, PATomshine, IF Reynolds. Park Nicollet Medical Foundation, and Hennepin County Medical Center, Minneapolis, MN /NTRODUCTION: patient education for endoscopy is a professional and legal responsibility of endoscopic practice. Education should reduce anxiety, increase satisfaction, improve outcomes, and facilitate informed consent. 60% of malpractice claims for eolonoscopy allege inadequate informe d consent; this process needs improvement. Cost constraints prohibit increased health professional time for patient education. Multimedia education possess the benefits of videotapas, the ability for interaction, as well as documentation of use and comprehension. The study's purpose was to develop and test a multimedia education CDKOM for colonoscopy. METHODS: The program was written in Visual Basic for use on a 486DX2-33Mttz IBM-compatible PC with a double speed CDROM and VGA graphics. In this pilot study 10 patients (5F:5M, mean age 59), used the program before preparation for a colonoscopy. Five had colonoscopy before. Anxiety was tested before and after use with a questionnaire specific to eolonoscopy. Comprehension was tested via the program. Patients were interviewed about program quality/ease of use, and for general comments. RESULTS: Five had some computer experience; 4 used a computer weekly; 3 had a home computer. Subjects spent a mean of 47 minutes on the program. The mean comprehension score was 93%. Nine showed a reduction in colonoscopy-specific anxiety. All patients recommended that the program be made available to others. The interview gathered suggestions to ease use of the computer for the inexperienced patient. CONCLUSION: This program is usefu[ as part ofpatiant education prior to colonoscopy. After revision, it will be studied in a rendomized trial. This research was supported, in part, by a grant from Astra/Merck Pharmaceuticals.
138
140
COMPARISON OF ~DEOAND NON-~DEO FLEXIBLE SIGMOIDOSCOPES FOR TRAINING OF MEDICAL RESIDENTS: ~ Shauk~, Sanowski, Carl T. ~ayden VA Medical Center, Phoenix, Arizona. Screening flexible sig~oidoscopy (F/S) for population over 50 years of age is recommended, thus necessitating a large number of procedures. It may be advisable to offer this training to all medical residents. Traditionally this procedure has been performed with a non-video flexible 60cm sigmoidoscope, video F/S is more expensive in cost and maintenance and may not be easily available for office practice. We conducted a randomized comparison of these scopes for training of ~edical residents. METHOD8: 24 residents from Internal Medicine and Family Practice Residency programs were randomly assigned to receive F/S training with one of the instruments. The first 5 procedures were completed with active participation of the instructor. Spbsequently residents were observed for initial i0 minutes without assistance and level of insertion was noted. The procedure was then completed with active assistance" from the instructor. A resident was considered proficient if he/she was able to pass the F/S beyond 45cm without assistance on 3 occasions and was able to identify anatomical landmarks and eormmon lesions with maximum of 20 cases. RESULTS: 9/12 residents in each ~roup completed the training. 2 residents in nonvideo F/S group and 3 residents in video group did not complete maximum number of procedures. Only one resident failed to achieve proficiency after 20 procedures. The average number of procedures needed to complete training was 12.5 and 11.5 in the nonvideo and video group respectively. This difference was not statistically significant (p=0.5 Student TTest). CONCLDSIONS: i. Both video and non-video F/S are adequate for training purposes. 2. The average number of procedures needed to complete training is 12 (range 9-17). 3. It is feasible to offer F/S training to all medical residents.
~30
GASTROINTESTINAL
ENDOSCOPY
SAFE AND SUCCESSFUL ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY (ERC) AND STONE REMOVAL IN THE NONAGENARIAN WITH CHOLEDOCHOLITHtASIS, Sperlin~. AL Filly and JW Oslxoff, Departmem of Medicine, University of California. San Francisco, San Francisco, CA. Choledocholithiasis appears to have an increasing prevalence in the elderly population. The stones often are large within massively dilated ducts and patients frequently have significant eardiopulmonary compromise. With an aging population this group will present special challenges for the biliary endr3scopist. Issues often arise concerning sedation, esp. surrounding airway management in a group of patients frequendy exhibiting dementia. Often these overriding concerns influence our willingness to perform long endoscopic procedures. Results: We performed 15 ERC's in 12 p~fients over an t8 month period who were in their tenth decade of life; the mean age was 93 y (range 89-100) and thea'e were 3 males and 9 females. The crmical presentations were: eholangitis (7), biliary pain (3), pancreatitis (2). Mean LFT's on presentation were: total bilirubin 4.4 mg/dl, alkaline phosphatase 296 U/I, and AST]ALT 227/448 U/1. Major comorbid illnesses (cardiopulmonary) were present in 8 of 12 (75%) patients. The procedures were performed safely in all patients; 6 of 12 (50%) had general anesthesia, while conscious sedation waS used in the other 6 patients (delivered by an anesthesiologist in three). All patients received prophylactic antibiotics. Endoscopic sphincterotomy was safely performed and all stones extracted in 10 patients; 1 patient required stenting initially, with extraction on a subsequent ERC. One patient who had undergone a previous Billroth II gastrectomy had two 4 cm stones, which were partially fractured using a mechanical lithotripter and currently has two plastic endoprostheses draining her biliary system. There was one failed cannulation due to a distal obsmaction. There were no complications from either the procedures themselves or from the anesthesia. Patients were discharged a mean of 3.3 days after stone extraction. Conclusions: ERC is a safe and effective mode of therapy for choledocholithiasis in the elderly despite comorbid conditions. The utilization of a multidisciplinary approach, incorporating cardiology and anesthesia expertise for cardiopulmonary stabilization and the administration of sedation, which allows this group of very elderly, high-risk patients to benefit from the shorter procedure times and decreased morbidity of ERC as compared with open surgical treatmem of con:~'non bile duct stones.
V O L U M E 41, N O . 4, 1995