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Su1296 The Use of an Ultra-Thin Instrument for Difficult Colonoscopy in Unsedated Patients
Abstracts
endoscope. During the procedures, CO2 was constantly set at 1.0 l/min. Abdominal girth were recorded at pre-examination, 0minutes and 15minutes after examination. Abdominal girth were measured by nurse blinded about insufflation whether CO2 or air. Pain evaluation using written questionnaire of 100mm visual analogue scale (VAS) was measured at 0minutes and 15minutes after examination. Results: 81 and 80 patients were evaluated as the patients of CO2 and air group, respectively. Mean age, body mass index and examination times did not differ in both groups. There was no significant difference about VAS scores at 0 minutes after examination in both groups (31 in CO2 group and 36 in air group). VAS scores 15 minutes after procedures were significantly lower in CO2 group (17) than air group (26, p⬍0.05). Mean abdominal girth at preexamination, 0 and 15minutes after examination between CO2 and air group were 78.9:81.0:79.5 and 80.5:83.1:82.7cm, respectively. Distention ratio of abdominal girth at 15minutes after colonoscopy was significantly better in CO2 group (1.008) than air group (1.028, p⬍0.001). Conclusion: CO2 insufflation improves patient abdominal distention and abdominal pain after colonoscopy without sedation rather than air insufflation colonoscopy.
Su1295 Randomized Prospective Trial of TransNasal Versus Standard Upper Diagnostic Endoscopy Under Local Anaesthetic: Interim Analysis of Endoscopy Quality, Patient Acceptability and Tolerability Efstratios G. Alexandridis*, Ken Trimble, Peter Hayes, John N. Plevris Centre of Liver and Digestive Disorders, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, United Kingdom Introduction: Transnasal upper gastrointestinal endoscopy (TNE) using ultrathin endoscopes is considered less invasive, thus an attractive alternative, if not a first choice option, for diagnostic upper endoscopy. Aim: This is the first prospective, randomised study, in a UK population to assess tolerability, acceptability and quality of TNE, in comparison with standard upper endoscopy (SOGD) under local anaesthetic (throat spray). Material and Methods: We prospectively recruited up to date 125 patients [59 male/ 66 female] mean age 57 years. To avoid bias, a single experienced endoscopist performed all endoscopies. The Fujinon EG530N (5.9mm) and EG530WR (9.4mm) endoscopes were used. The endoscopist and all patients completed detailed questionnaires regarding tolerability, acceptance and quality of each endoscopy using standard visual analogue scales (VAS). Oxygen saturation [SaO2], heart rate [HR] and systolic blood pressure [SBP] were recorded during procedure. SOGD group received O2 2lt/min. Quality of biopsies was evaluated blindly by the reporting pathologists. Results: Trial interim analysis included 129 endoscopies in 125 patients [TNE⫽65, SOGD⫽64]. In all patients intubation of D2 was achieved. VAS scores for patient comfort (higher score⫽greater comfort) were significantly better in the TNE compared to SOGD group (7 vs 5.6, respectively, p⫽0.0013). 40 patients had previous experience of standard endoscopy, and 22(55%) reported gagging as main reason of discomfort. 22/40 were randomised to TNE. 21 of these 22 patients [95.5%] stated preference to transnasal endoscopy in the future. Gagging score (higher score⫽more gagging) was significantly less in the TNE compared with SOGD group (0.05 vs 3.22 respectively, p⬍0.001). Panendoscopy was achieved in all TNE patients with the hypopharynx, epiglottis and vocal cords significantly better visualised compared with SOGD group (VAS: 10 vs 4.1 respectively, p⬍0.001). Double product reverse [a marker of cardiac stress, DPR⫽(HR x SBP at middle of procedure)] was significantly lower in the TNE group (11049 vs 13536, p⬍0.001). DPR increased only in 8% of TNE vs 32.5% of SOGD patients. There was no difference in procedure time (8.5 vs 7.3 min, respectively, p⫽0.54), quality of images (9.93 vs 9.88, respectively, p⫽0.55) or SaO2 (98 % vs 98.3%, respectively, p⫽0.22). Only 2 (5.4%) of TNE biopsies did not permit a definite diagnosis, but when standard biopsies were later taken, also failed to confirm diagnosis. Conclusions: TNE is equal to SOGD in image quality, endoscope handling and length of procedure. It is superior to SOGD in the ability to perform a panendoscopy and in terms of comfort and patient acceptance. Importantly it induced significantly less stress to the heart, thus should be considered as the endoscopic diagnostic method of choice in patients with significant cardio-respiratory problems.
Su1296 The Use of an Ultra-Thin Instrument for Difficult Colonoscopy in Unsedated Patients Kazutomo Togashi*1, Daiki Nemoto1, David G. Hewett2, Keijiro Sunada3, Hironori Yamamoto3 1 Coloproctology, Fukushima Medical University, Aizu Medical Center, Aizuwakamatsu, Japan; 2University of Queensland School of Medicine, Brisbane, QLD, Australia; 3Endoscopy, Jichi Medical University, Shimotsuke, Japan Background and study aims: Pediatric colonoscopes with 11 mm diameter are used by many colonoscopists to negotiate the female colon and after previously
incomplete colonoscopy. Gastroscopes are occasionally required to negotiate angulated sigmoid colons. However, the use of ultra-thin colonoscopes for such difficult cases has not been studied. In this study, we report our experience of unsedated colonoscopy with an ultra-thin instrument for elderly female patients and for those with previously difficult examinations. Methods: Between September 2011 and November 2011 in a single center, one expert physician (colonoscopy experience ⬎20,000) performed unsedated colonoscopy on 20 patients with an ultra-thin instrument (EC-530XP, 6.8 mm diameter, standard length). Carbon dioxide insufflation was used, without fluoroscopic guidance. Conventional insertion techniques, including clockwise torque shortening technique, were used with position change and abdominal pressure when necessary. Patients did not receive any sedation. The patients comprised 14 female patients older than 70 years (EF group) and 6 patients with previously difficult colonoscopy (DC group). Patient age ranged from 42 to 87 years (median 72 years) in the DC group and from 72 to 84 years (median 77.5 years) in the EF group. Only one patient in the DC group was male. The reported reasons for previously difficult colonoscopy were adhesions in 4, severe pain during the procedure in 1 and severe diverticular disease in 1. Cecal intubation had been unsuccessful in two patients in the DC group during previous colonoscopy. Cecal intubation rate, ileal intubation rate, time to cecum, adenoma detection rate and additional sedation dose were measured; degree of pain experienced was measured using a visual analogue scale (VAS). We used the Mann-Whitney test to compare between groups. Results: Cecal intubation was achieved in 100% of patients, with an ileal intubation rate of 85%. Time to cecum ranged from 13.4 minutes to 25.4 minutes (median 15.6 minutes) in the DC group, and from 7.1 minutes to 52.4 minutes (median 18.0 minutes) in the EF group. There was no significant difference in insertion time between 2 groups. Adenoma detection rate was 50% in both groups. No patients required sedation. Visual analogue pain scores ranged from 0/10 to 1/10 (median score 0.5/10) in the DC group and from 0/10 to 5/10 (median score 2/10) in the EF group. Conclusions: Unsedated ultra-thin colonoscopy is a useful technique for elderly females and patients with previously difficult examinations, and is an effective alternative to conventional colonoscopes or gastroscopes for difficult cases.
Su1297 Quality Assessment of Colonoscopies Performed by Nurse and Physician Endoscopists Reveals High Safety and Good Quality in Nurse Endoscopists Renate Massl1, Paul G. Van Putten*1, Ewout W Steyerberg2, Antonie J.P.Van Tilburg3, Jonathan Lai4, Rogier J. De Ridder5, Johannes T. Brouwer6, Robert Verburg7, Joyce Alderliesten8, Erik J. Schoon9, Ernst J. Kuipers1,10, Monique Van Leerdam1 1 Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands; 2Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands; 3 Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, Netherlands; 4Department of Gastroenterology, Groene Hart Ziekenhuis, Gouda, Netherlands; 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands; 6 Department of Gastroenterology and Hepatology, Reinier de Graaf Medical Center, Delft, Netherlands; 7Department of Gastroenterology, Medisch Centrum Haaglanden, Den Haag, Netherlands; 8Department of Gastroenterology, Albert Schweitzer Hospital, Dordrecht, Netherlands; 9Department of Gastroenterology, Catharina Hospital, Eindhoven, Netherlands; 10Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands Background: The introduction of colorectal cancer screening leads to an increasing demand for endoscopists. A resulting shortage in physicianendoscopists could be compensated by nurse endoscopists (NE), but the quality and safety of NE has been insufficiently investigated. The aim of this study was to compare the quality and safety of colonoscopies performed by either NE or physicians in a large cohort. Methods: NE and GI fellows both without any endoscopic experience at baseline were evaluated in this prospective multicenter cohort study (Sept 2008-today). After having finished a 2-day background and simulator-training (Olympus and Symbionix), and a training period (part I) of 100 supervised colonoscopies, the endoscopists started to perform colonoscopies independently (part II) with supervision immediately available on request. The first 135 colonoscopies of part II of each endoscopist were used to assess endoscopic quality. Colonoscopies in patients ⬍18 and in those referred for therapeutic procedures were excluded. Evaluation was done using a portfolio in which the following procedure characteristics were assessed: extent of procedure, cecal intubation time, withdrawal time, performance of polypectomy, and use of supervision. Information on adenoma detection rate (ADR) and complications was also collected. Results: A total of 6 NE and 8 GI fellows participated in this study. Five out of 6 NE (83%) were female compared to 4 out of 8 (50%) GI fellows (p⫽0.30). Median age was 32 years in both groups. A total of 1229 diagnostic colonoscopies were performed in 1229 patients. Mean patient
AB283 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
endoscope. During the procedures, CO2 was constantly set at 1.0 l/min. Abdominal girth were recorded at pre-examination, 0minutes and 15minutes after examination. Abdominal girth were measured by nurse blinded about insufflation whether CO2 or air. Pain evaluation using written questionnaire of 100mm visual analogue scale (VAS) was measured at 0minutes and 15minutes after examination. Results: 81 and 80 patients were evaluated as the patients of CO2 and air group, respectively. Mean age, body mass index and examination times did not differ in both groups. There was no significant difference about VAS scores at 0 minutes after examination in both groups (31 in CO2 group and 36 in air group). VAS scores 15 minutes after procedures were significantly lower in CO2 group (17) than air group (26, p⬍0.05). Mean abdominal girth at preexamination, 0 and 15minutes after examination between CO2 and air group were 78.9:81.0:79.5 and 80.5:83.1:82.7cm, respectively. Distention ratio of abdominal girth at 15minutes after colonoscopy was significantly better in CO2 group (1.008) than air group (1.028, p⬍0.001). Conclusion: CO2 insufflation improves patient abdominal distention and abdominal pain after colonoscopy without sedation rather than air insufflation colonoscopy.
Su1295 Randomized Prospective Trial of TransNasal Versus Standard Upper Diagnostic Endoscopy Under Local Anaesthetic: Interim Analysis of Endoscopy Quality, Patient Acceptability and Tolerability Efstratios G. Alexandridis*, Ken Trimble, Peter Hayes, John N. Plevris Centre of Liver and Digestive Disorders, Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh, United Kingdom Introduction: Transnasal upper gastrointestinal endoscopy (TNE) using ultrathin endoscopes is considered less invasive, thus an attractive alternative, if not a first choice option, for diagnostic upper endoscopy. Aim: This is the first prospective, randomised study, in a UK population to assess tolerability, acceptability and quality of TNE, in comparison with standard upper endoscopy (SOGD) under local anaesthetic (throat spray). Material and Methods: We prospectively recruited up to date 125 patients [59 male/ 66 female] mean age 57 years. To avoid bias, a single experienced endoscopist performed all endoscopies. The Fujinon EG530N (5.9mm) and EG530WR (9.4mm) endoscopes were used. The endoscopist and all patients completed detailed questionnaires regarding tolerability, acceptance and quality of each endoscopy using standard visual analogue scales (VAS). Oxygen saturation [SaO2], heart rate [HR] and systolic blood pressure [SBP] were recorded during procedure. SOGD group received O2 2lt/min. Quality of biopsies was evaluated blindly by the reporting pathologists. Results: Trial interim analysis included 129 endoscopies in 125 patients [TNE⫽65, SOGD⫽64]. In all patients intubation of D2 was achieved. VAS scores for patient comfort (higher score⫽greater comfort) were significantly better in the TNE compared to SOGD group (7 vs 5.6, respectively, p⫽0.0013). 40 patients had previous experience of standard endoscopy, and 22(55%) reported gagging as main reason of discomfort. 22/40 were randomised to TNE. 21 of these 22 patients [95.5%] stated preference to transnasal endoscopy in the future. Gagging score (higher score⫽more gagging) was significantly less in the TNE compared with SOGD group (0.05 vs 3.22 respectively, p⬍0.001). Panendoscopy was achieved in all TNE patients with the hypopharynx, epiglottis and vocal cords significantly better visualised compared with SOGD group (VAS: 10 vs 4.1 respectively, p⬍0.001). Double product reverse [a marker of cardiac stress, DPR⫽(HR x SBP at middle of procedure)] was significantly lower in the TNE group (11049 vs 13536, p⬍0.001). DPR increased only in 8% of TNE vs 32.5% of SOGD patients. There was no difference in procedure time (8.5 vs 7.3 min, respectively, p⫽0.54), quality of images (9.93 vs 9.88, respectively, p⫽0.55) or SaO2 (98 % vs 98.3%, respectively, p⫽0.22). Only 2 (5.4%) of TNE biopsies did not permit a definite diagnosis, but when standard biopsies were later taken, also failed to confirm diagnosis. Conclusions: TNE is equal to SOGD in image quality, endoscope handling and length of procedure. It is superior to SOGD in the ability to perform a panendoscopy and in terms of comfort and patient acceptance. Importantly it induced significantly less stress to the heart, thus should be considered as the endoscopic diagnostic method of choice in patients with significant cardio-respiratory problems.
Su1296 The Use of an Ultra-Thin Instrument for Difficult Colonoscopy in Unsedated Patients Kazutomo Togashi*1, Daiki Nemoto1, David G. Hewett2, Keijiro Sunada3, Hironori Yamamoto3 1 Coloproctology, Fukushima Medical University, Aizu Medical Center, Aizuwakamatsu, Japan; 2University of Queensland School of Medicine, Brisbane, QLD, Australia; 3Endoscopy, Jichi Medical University, Shimotsuke, Japan Background and study aims: Pediatric colonoscopes with 11 mm diameter are used by many colonoscopists to negotiate the female colon and after previously
incomplete colonoscopy. Gastroscopes are occasionally required to negotiate angulated sigmoid colons. However, the use of ultra-thin colonoscopes for such difficult cases has not been studied. In this study, we report our experience of unsedated colonoscopy with an ultra-thin instrument for elderly female patients and for those with previously difficult examinations. Methods: Between September 2011 and November 2011 in a single center, one expert physician (colonoscopy experience ⬎20,000) performed unsedated colonoscopy on 20 patients with an ultra-thin instrument (EC-530XP, 6.8 mm diameter, standard length). Carbon dioxide insufflation was used, without fluoroscopic guidance. Conventional insertion techniques, including clockwise torque shortening technique, were used with position change and abdominal pressure when necessary. Patients did not receive any sedation. The patients comprised 14 female patients older than 70 years (EF group) and 6 patients with previously difficult colonoscopy (DC group). Patient age ranged from 42 to 87 years (median 72 years) in the DC group and from 72 to 84 years (median 77.5 years) in the EF group. Only one patient in the DC group was male. The reported reasons for previously difficult colonoscopy were adhesions in 4, severe pain during the procedure in 1 and severe diverticular disease in 1. Cecal intubation had been unsuccessful in two patients in the DC group during previous colonoscopy. Cecal intubation rate, ileal intubation rate, time to cecum, adenoma detection rate and additional sedation dose were measured; degree of pain experienced was measured using a visual analogue scale (VAS). We used the Mann-Whitney test to compare between groups. Results: Cecal intubation was achieved in 100% of patients, with an ileal intubation rate of 85%. Time to cecum ranged from 13.4 minutes to 25.4 minutes (median 15.6 minutes) in the DC group, and from 7.1 minutes to 52.4 minutes (median 18.0 minutes) in the EF group. There was no significant difference in insertion time between 2 groups. Adenoma detection rate was 50% in both groups. No patients required sedation. Visual analogue pain scores ranged from 0/10 to 1/10 (median score 0.5/10) in the DC group and from 0/10 to 5/10 (median score 2/10) in the EF group. Conclusions: Unsedated ultra-thin colonoscopy is a useful technique for elderly females and patients with previously difficult examinations, and is an effective alternative to conventional colonoscopes or gastroscopes for difficult cases.
Su1297 Quality Assessment of Colonoscopies Performed by Nurse and Physician Endoscopists Reveals High Safety and Good Quality in Nurse Endoscopists Renate Massl1, Paul G. Van Putten*1, Ewout W Steyerberg2, Antonie J.P.Van Tilburg3, Jonathan Lai4, Rogier J. De Ridder5, Johannes T. Brouwer6, Robert Verburg7, Joyce Alderliesten8, Erik J. Schoon9, Ernst J. Kuipers1,10, Monique Van Leerdam1 1 Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands; 2Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands; 3 Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, Netherlands; 4Department of Gastroenterology, Groene Hart Ziekenhuis, Gouda, Netherlands; 5Division of Gastroenterology-Hepatology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands; 6 Department of Gastroenterology and Hepatology, Reinier de Graaf Medical Center, Delft, Netherlands; 7Department of Gastroenterology, Medisch Centrum Haaglanden, Den Haag, Netherlands; 8Department of Gastroenterology, Albert Schweitzer Hospital, Dordrecht, Netherlands; 9Department of Gastroenterology, Catharina Hospital, Eindhoven, Netherlands; 10Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands Background: The introduction of colorectal cancer screening leads to an increasing demand for endoscopists. A resulting shortage in physicianendoscopists could be compensated by nurse endoscopists (NE), but the quality and safety of NE has been insufficiently investigated. The aim of this study was to compare the quality and safety of colonoscopies performed by either NE or physicians in a large cohort. Methods: NE and GI fellows both without any endoscopic experience at baseline were evaluated in this prospective multicenter cohort study (Sept 2008-today). After having finished a 2-day background and simulator-training (Olympus and Symbionix), and a training period (part I) of 100 supervised colonoscopies, the endoscopists started to perform colonoscopies independently (part II) with supervision immediately available on request. The first 135 colonoscopies of part II of each endoscopist were used to assess endoscopic quality. Colonoscopies in patients ⬍18 and in those referred for therapeutic procedures were excluded. Evaluation was done using a portfolio in which the following procedure characteristics were assessed: extent of procedure, cecal intubation time, withdrawal time, performance of polypectomy, and use of supervision. Information on adenoma detection rate (ADR) and complications was also collected. Results: A total of 6 NE and 8 GI fellows participated in this study. Five out of 6 NE (83%) were female compared to 4 out of 8 (50%) GI fellows (p⫽0.30). Median age was 32 years in both groups. A total of 1229 diagnostic colonoscopies were performed in 1229 patients. Mean patient
AB283 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org