Su1281 ERCP Quality Assessment and Outcomes in a Tertiary Referral Center

Abstracts

BPS group

Propofol group

Difficulty of maintenance by 2.57 (2.15) 2.90 (2.32) endoscopist§ Patient cooperation by nurse‡, 8.15 (2.20) 7.84 (2.23) mean (SD), VAS Overall satisfaction with 8.25 (1.82) 7.87 (2.06) sedation by nurse‡ Difficulty of maintenance by 3.25 (2.61) 3.57 (2.69) nurse§ Patient satisfaction with 9.13 (1.16) 8.90 (1.69) sedation‡, mean (SD), VAS Remembered endoscopic 12 (11.8) 18 (17.3) insertion, n (%) Remembered endoscopic 12 (11.8) 13 (12.5) withdrawal, n (%) Felt pain during procedure, n 8 (7.8) 17 (16.3) (%) *Time from sedation start to procedure start. †Time from completion of ERCP or EUS to reaching Aldrete score of 10. ‡0 ⫽ poor; 10 ⫽ excellent. §0 ⫽ easy; 10 ⫽ very difficult.

P value .284 .316 .164 .385 .270 .259 .878 .062

Su1278 Efficacy of Endoluminal Gastroplication in Japanese Patients With Proton Pump Inhibitor-Resistant, Non-Erosive Esophagitis Kunio Kasugai*, Kentaro Tokudome, Yasushi Funaki, Yasuhiro Tamura, Shinya Izawa, Akihito Iida, Mari Mizuno, Naotaka Ogasawara, Makoto Sasaki Gastroenterology, Aichi Medical University, Nagakute, Japan Background and Aims: Non-erosive reflux disease (NERD) accounts for more than half of cases of gastro-esophageal reflux disease. Its pathology is complex, and the disease is often not amenable to treatment with proton pump inhibitor (PPI), which are used as front-line drugs. Though surgical therapy has been reported to be effective as an alternative to drug therapy in NERD, the efficacy of endoscopic treatment in PPI-refractory NERD has not yet been studied. The aim of this study was to evaluate efficacy, safety, and long-term outcomes of endoluminal gastroplication (ELGP) in patients with PPI-resistant NERD. Methods: We evaluated GERD symptoms, QOL, esophageal pH, symptom index (SI), symptom sensitivity index (SSI), number of plications and PPI medication before and after ELGP in patients with PPI-resistant NERD. Results: The mean frequency scale for symptoms of the GERD (FSSG) score decreased significantly from 19.1⫾10.5 before ELGP to 10.3⫾7.4 after 3 months and to 9.3⫾9.9 after 12 months. There were no changes in the number of reflux episodes or SI for reflux events, but the number of symptom events and SSI decreased significantly from before ELGP to 3 months after. After 12 months, 3 patients (16.7%) were able to reduce the amount of PPI medication by 50% or more, and 12 patients (66.7%) were able to discontinue PPI medication altogether. One or more plications remained in 80% and 43% after 3 and 12 months, respectively. There were no serious complications. Conclusions: ELGP was safe, resulted in significant improvement in subjective symptoms, and allowed less medication to be used over the long term, thus demonstrating that it could become an option for the treatment of PPI-refractory NERD.

Su1279 Pre and Post Endoscopic Retrograde Cholangiopancreatography Anesthesia Time in Patients Receiving Monitored Anesthesia Care Versus General Anesthesia Vernon J. Carriere*1, Jason Conway1, Girish Mishra1, Raymond Roy2, John A. Evans1 1 Gastroenterology, Wake Forest University Medical Center, Winston Salem, NC; 2Anesthesia, Wake Forest University Medical Center, Winston Salem, NC Purpose: Many factors determine whether patients will receive monitored anesthesia care (MAC) versus general anesthesia (GA) for an Endoscopic Retrograde Cholangiopancreatography (ERCP). Minimizing delays both pre and post ERCP will maximize throughput, thus allowing for increased procedure volumes.Aim: To determine the contribution of anesthesia to total length of procedure time. Methods: All patients undergoing an ERCP from 1/1/11 to 3/31/ 11 were included. Patients were stratified by indications, type of anesthesia (GA versus MAC) and American Society of Anesthesiologist (ASA) classification. The following times were collected: room in, endoscope insertion, endoscope removal and room out. The time difference between room in and the endoscope insertion was considered the “pre-procedure time”. The time difference between

the endoscope removal and room out was considered the “post-procedure time”. Results: A total of 90 patients were included in the study with 39 MAC cases and 51 GA cases. The mean age was 54.3 years and 58/90 (64.4%) were female. There was no significant difference between the GA and MAC groups in regards to ASA classification (p⫽0.3) with a majority of patients being class II 34/90 (37.8%) or class III 51/90 (56.7%). No statistical significance was found between the groups with regard to indication (p⫽0.8), sex (p⫽0.62) or age (p⫽0.2). The mean pre procedure time for the GA group was 20.8 minutes and 11.1 minutes for the MAC group (p ⬍0.001). The mean post procedure time was 12.9 minutes for the GA group and 6.3 minutes for the MAC group (p ⬍0.001.) The time of the procedure was 33.8 minutes for the GA group and 23.2 minutes for the MAC group (p ⫽ 0.03). The total time was 67.6 minutes for GA and 40.6 minutes for MAC (p ⬍0.001). There were no major complications reported in any of the procedures. Conclusion: The pre and post procedure time, as well as the total procedure time, was significantly shorter for the MAC anesthesia group. In the GA group, the actual procedure time accounted for only 50% of the total time of the procedure. Procedure length and complexity should precipitate discussion between the gastroenterologist and anesthesiologist regarding MAC versus GA. The merits of MAC anesthesia appear implicit for maximizing efficiency while maintaining patient safety when performing ERCP.

Su1280 A Novel Procedure for Gastrocutaneous Fistula Closure Omer J. Deen*1, Keely R. Parisian1, Campbell Harris2, Donald F. Kirby1,2 1 Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 2Gastroenterology, Medical College of Virginia, Richmond, VA Background: PEG tubes have allowed for a safe and efficient way to feed patients who cannot tolerate oral feeding, yet have a functioning gastrointestinal tract. Gastrocutaneous fistulas after PEG removal are an unusual and rare complication in adults and may be in part due to poor tissue healing, delayed gastric emptying or increased gastric acid production. Various approaches have been reported to treat PEG-related gastric fistulashowever, their success rate is variable and patients frequently require repeat procedures or more than one technique in combination, including acid suppression therapy, silver nitrate ablation of the PEG tract lining, argon plasma coagulation, fibrin glue, and/or endoclipping. Upon our review, there have been no published case series reporting the use of endoscopic banding to close persistent gastrocutaneous fistulas after PEG removal. Study Design: Four patients with persistent gastrocutaneous fistulas after PEG removal were taken for EGD with banding of the fistula site. This procedure was chosen due to its relative ease of application, low likelihood of needing repeat procedures, and the ability to seal off the gastric opening immediately upon application. Patient follow-up was by telephone within 3 days of having the procedure and then again 1-2 weeks afterwards, to ensure that there was no persistent leakage through the fistula tract. Results: Of the four patients who had persistent gastrocutaneous fistulas after PEG removal, endoscopic banding resulted in complete closure of the fistula in 3 of our 4 patients. In one case, banding was unsuccessful secondary to scarring from prior radiation treatment as well as having a previous PEG tube placed 1 inch from the current fistula site. In this case, a second PEG tube was placed through the original PEG stoma, leading to cessation of the gastric leak. The first case resulted in no recurrence after 3 years. The second and third cases have shown no recurrence after 3 months. The fourth case resulted in a second PEG tube to manage persistent drainage through the tract after unsuccessful banding of the site due to complex endoscopic and anatomical issues. Conclusion: Endoscopic closure of a gastrocutaneous fistula, regardless of technique used, can help avoid surgical intervention. Anatomical changes from any previous treatment modalities may decrease the success rate of fistula banding. However, in most patients, endoscopic banding is a safe and relatively simple alternative in closing persistent gastrocutaneous fistulas due to prior PEG tubes.

Su1281 ERCP Quality Assessment and Outcomes in a Tertiary Referral Center Vivian E. Ekkelenkamp*1, Arjun D. Koch1, Jelle Haringsma2, Robert A. De Man1, Ernst J. Kuipers1 1 Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands; 2Department of Gastroenterology and Hepatology, Maasstad Ziekenhuis, Rotterdam, Netherlands Introduction: The ASGE Committee on Outcomes Research recommended monitoring 9 ERCP-specific quality indicators for optimal quality assurance in ERCP. There are however little data available on these indicators and measures for quality are sparse. With the development of a self-assessment tool for ERCP (Rotterdam Assessment Form for ERCP - RAF-E), important key parameters (i.e. appropriateness of indication, assessment of procedural difficulty, cannulation rate, and success rates of sphincterotomy, common bile duct stone extraction

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Abstracts

Cannulation rates and outcome data in level 1 ERCPs obtained with this RAF-E provide insight in the quality of individual as well as group performance and can be used to assess and set standards for quality in ERCP.

Typical internal PEG site fistula.

Table 1 Degrees of difficulty in ERCP [Schutz SM, Abbott RM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc 2000 May; 51(5):535-9.].

PEG site fistula with successful band in place.

and stent placement for biliary obstruction) can easily be assessed. This method provides objective data on performance of individual endoscopists as well as group performance. The aim of this study was to determine ERCP quality outcomes in a tertiary referral hospital. Methods: In January 2008 we started a quality self-assessment program in our center. Five qualified endoscopists performing ERCPs in our department participated in this study. All procedures were appraised using RAF-E. The primary parameter was common bile duct (CBD) cannulation rate. The indication for each ERCP was classified and procedural difficulty was graded on a 3-point scale adapted from Schutz’s classification (Table 1); success rates of sphincterotomy, stone removal and stent placement were measured in difficulty level 1 ERCPs. All ERCP-performing endoscopists should be competent in these types of procedures. Results: From January 2008 to September 2011 a total of 1649 ERCPs were evaluated. Of these procedures, 1385 ERCPs (84%) were assessed by RAF-E. Average number of procedures per year per endoscopist was 108 (range 53-184). Overall CBD cannulation success rate averaged 92.4% (range 83.4%-97.0%). Procedures with difficulty level 1 (n⫽814) were further analyzed for therapeutic success. In 444 patients stent placement was performed; this was successful in 97% of the cases. 233 level 1 ERCPs (28.6%) were performed for bile stones. Stone clearance was successful in 88.3% of these cases. In 140 level 1 ERCPs sphincterotomy was performed. All were successful. 149 patients (64%) with indication ‘stones’ and difficulty 1 had a virgin papilla; CBD cannulation success rate was in this group 91.3%. This percentage was not significantly different from cases with previous sphincterotomy (␹2 ⫽1.792; p⫽0.408). All non-assessed ERCPs were checked manually by deriving reports from our endoscopy reporting system; CBD cannulation success rate of these procedures was not significantly different from self-assessed ERCPs (␹2⫽0.338; p⫽0.561). Conclusions: Quality indicators for ERCP can be measured using the Rotterdam self-assessment program for ERCP.

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Su1282 Comparing Warm vs Cool Temperature Water During Colonoscopy Brent Y. Lee*, Ronald Katon, Daniel O. Herzig, M. Brian Fennerty Oregon Health and Science University, Portland, OR Context: Water infusion during colonoscopy has been shown to reduce patient discomfort and decrease sedation medication requirements. Warm water has been suggested to further improve colonoscopy perhaps by decreasing colonic spasm. The purpose of this study is to determine if the temperature of water used in the water infusion method makes a difference in sedation requirements and patient discomfort. Objective: To compare the utility of warm (35-38°C) vs cool (20-23°C) water during colonoscopy by measuring patient sedation medication use and discomfort scores between the warm and cool water groups. Methods: Adults undergoing elective outpatient screening colonoscopies were randomized to receive colonoscopy with warm (n⫽57) or cool (n⫽51) water. Both the endoscopist and patient were blinded to the temperature of water. Patients were premedicated with fentanyl 50 ␮g and midazolam 2 mg. Additional sedating medications were given in increments of fentanyl 25 ␮g and midazolam 1 mg at the endoscopist’s discretion during the procedure for patient comfort. The primary endpoint was amount of sedation medication. Secondary endpoints include pain scores, cecal intubation rate, cecal intubation time, satisfaction scores, and patient willingness to repeat procedure. Results: There was no significant difference in sedation medication requirement during colonoscopies using warm or cool water (fentanyl 85.5⫾ 31.3 ␮g vs 94.6 ⫾ 41.6 ␮g, p⫽0.20; midazolam 3.4 ⫾ 1.3 mg vs 3.6 ⫾ 1.3 mg, p⫽0.66). There was no significant difference in patient pain scores or satisfaction scores (see Chart). Cecal intubation rates (100%) were similar. There was no significant difference in cecal intubation times (411.7 ⫾ 275.6 sec vs 490.9 ⫾ 235.5 sec, p⫽0.11) between the warm and cool water groups. All patients were willing to repeat the colonoscopy using the same method in both groups. Conclusion: In patients undergoing screening colonoscopy, the temperature of the infused water does not affect sedation medication requirements, cecal intubation rates, cecal intubation times,

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