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The Efficacy of Argon Plasma Coagulation for the Salvage Treatment of Gastric Intramucosal Tumor
Abstracts
M1287 Do We Perform a Colonoscopy for Colorectal Cancer Screening Before Surgery for Diverticulitis? Stephane Nahon, Francois Agret, Bruno Lesgourgues, Pierre Lahmek, Thierry Tuszynski, Tony Rahme, Nicolas Delas
M1289 Impact of Two Procedure Rooms Per Physician on Productivity: Computer Simulation Examines the Impact of Process Change in the Hospital Gastroenterology Department Douglas K. Rex, Betsy J. Lahue, Rainer W. Dronzek, Mike J. Lacey
Background and Aim: A colorectal cancer screening is usually performed before surgery for diverticulitis. However, this procedure is not built on evidence-based medicine. The aim of this study was to assess the frequency of premalignant and malignant colonic lesions in a group of patients with diverticulitis before surgery, and to compare this with a control group of asymptomatic patients undergoing screening colonoscopy. Methods: in a case-control study, 184 patients [103 women and 81 men, 61G13 years (30-80)] with a diverticulitis requiring a surgery procedure were identified from 1990 to 2004. They have no history or symptoms suggestive of colorectal cancer, and they underwent perioperative colonoscopy. The patients were stratified in two age groups: patients less than 50 years old (group 1) and patients more than 50 years old (group 2). The colonoscopic findings were compared with findings in 704 asymptomatic control patients who underwent screening colonoscopy. Results: the mean age of patients with diverticulitis (nZ39) and control patients (nZ288) in group 1 was not significantly different (43,1G5 vs 41G6 years; pZ0,66). In group 2, the mean age of patients with diverticulitis (nZ145) and control patients (nZ416) was not also significantly different (64G10 vs 63,2G6,2, pZ0,23). In group 1, no colorectal cancer was observed in patients with diverticulitis and only one in control group (pZ0,9). In group 2, no colorectal cancer was observed in patients with diverticulitis and 7 in control group (pZ0,2). In group 1 and 2, the number of polyps over 10 mm was not significantly different between diverticulitis and control subjects (group 1: 3 vs 15 (pZ0,37); group 2 : 9 vs 30; (pZ0,7)). Conclusion: this study suggests that in asymptomatic patients, diverticulitis is not associated with an increased risk of colorectal cancer. Therefore, a colonoscopy before surgery for diverticulitis might be avoid.
Background: Endoscopy physicians cite long waits, or down time, between procedures as a barrier to productivity. A potential solution is to allocate two staffed procedure rooms to each physician so that when one procedure is completed, the next patient is ready and waiting in the second room. However, hospital administrators may be reluctant to experiment with such process changes without the ability to predict the outcome in advance. Simulation modeling can create a virtual representation of endoscopy lab operations to test the impact of potential changes on efficiency outcomes. Purpose: To quantify the impact of a strategy to reduce physician down time in the endoscopy lab using simulation modeling. Methods: We designed a computer simulation model (AnylogicTM 5.0 software, AccessTM interface) of a hospital endoscopy lab by documenting patient flow; determining process times via observation studies, chart reviews, and staff interviews; and validating model output with collected data metrics. The model simulates 20 working days and generates mean daily statistics. To test the strategy of providing one physician with two staffed rooms, we compared a baseline (2 physicians, 2 staffed procedure rooms) to a new scenario (1 physician, 2 staffed procedure rooms). Outcome measures include: patients per physician, length of stay (LOS), total facility time (first patient arrival to last patient discharge), and staff utilization (percent of time engaged in patient care tasks). Results: Compared to baseline, individual physician productivity is improved with the new strategy resulting in a 23% increase in patients per physician (9.8 to 12.8) and a 25% increase in physician utilization. But when two procedure rooms are allocated to one physician, the overall performance of the simulated endoscopy lab is sub-optimized compared to baseline; mean patient LOS increased 25% (175 to 234 minutes), nonphysician staff utilization decreased 24-41%, and total facility time increased 7% (9.9 to 10.6 hours). Conclusions: While physician productivity improves by dedicating two procedure rooms to one physician, there is an overall reduction in endoscopy lab performance in the simulated environment. Further simulation may illuminate alternative strategies to optimize physician productivity without lowering utilization of non-physician staff or negatively affecting customer satisfaction predictors such as LOS.
M1288 The Efficacy of Argon Plasma Coagulation for the Salvage Treatment of Gastric Intramucosal Tumor Jong-Jae Park, Yeon Seok Seo, Yun Jung Chang, Ji Yeon Lee, Cheol Hyun Kim, Jin Yong Kim, Jong Eun Yeon, Jae Seon Kim, Kwan Soo Byun, Young Tae Bak, Chang Hong Lee Background: Currently endoscopic mucosal resection (EMR) is used to treat gastric tumors (early cancer and adenoma) and considered safe and effective. However, the number of patients with gastric tumors who have comorbidities that preclude either surgical resection or EMR is increasing. The aim of this study is to determine the efficacy of argon plasma coagulation (APC) for the salvage treatment of gastric tumors. Methods: This study included 14 patients (male:female 10:4, mean age 62.2 years). 7 patients had gastric adenomas (elevated lesion: 5 cases, flat lesion: 2 cases, mean size: 16 mm in diameter) and 7 patients had EGC (depressed lesion: 3 cases, elevated lesion: 4 cases, mean size: 14 mm in diameter). Ex-vivo experiment was performed to determine irradiation condition for APC treatment. Irradiation was performed with the electrode at a distance of 1-2 mm from the surgically resected fresh human gastric tissues after obtaining informed consent. The power of the high frequency currents was 30W, 50W, 70W and 90W, while irradiation times were 2, 4, 6, 8 and 10 seconds. Coagulation depth with various irradiation conditions based on histological analysis was scored from 0 to 4 (0: none or minimal, 1: confined to the mucosa, 2: !1/2 of submucosa, 3: O1/2 of submucosa, 4: extending into muscularis propria). Indication of APC was recurrence after EMR (1), remnant tumor after EMR (2), incomplete EMR due to severe bleeding (3) and untreatable patients due to old age or comorbidities (8). Results: According to the result of the ex vivo experiment, the optimum APC treatment condition for complete cauterization of mucosal and less than half of the submucosal layer was a current of 70W for 6 seconds. Mucosal cauterization after marking around each tumor, was performed in the manner determined by the ex-vivo experiments. The number of sessions for complete cauterization was 1.6 (1.4 for adenoma, 2 for EGC). No serious complications occurred. During the mean follow-up of 9 months (5-19 months), complete cauterization was achieved in 13 patients. One patient with EGC was found to have recurrence 2 months after treatment and managed by repeated APC Conclusions: APC could be considered as a salvage treatment for gastric tumors. Further study with long term follow up is required to evaluate the role of APC in the treatment of early gastric cancer untreatable by surgical resection or endoscopic mucosal resection.
AB154 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
M1290 Correlation of the Serum Levels of Pepsinogen I and II Gastrin 17, H pylori Antibodies with the Endoscopic Biopsies of Dispeptic Patients Carlos A. Robles-Jara, Carlos A. Robles-Medranda, Johnny H. Parrales, Ruth Armijos, Jorge Suppo, Byron Landı´var Background: Gastric Cancer is a major cause of cancer mortality in Ecuador. Atrophic chronic gastritis and intestinal metaplasia are considered premalignant lesions. H. pylori play a role in the carcinogenesis of this entity. Our objective was to evaluate the efectivity of Gastropanel (Biohit-Finland) composed by Pepsinogen I (PGI), Pepsinogen II (PGII), Gastrin-17 (G-17), and H. pylori IgG antibodies (HpIgG) in patients with dyspeptic symptoms correlated with the histologic findings from gastric biopsies. Methods: 75 patients with dyspeptic symptoms (M/F ratio 35/40) over 40 years old were selected randomly. A first blood sample was taken to obtain a basal level of GI7, PGI, PGII, I and HpIgG. A second sample was obtained 20 minutes later, after ingestion of a proteic solution for G 17 stimulation. Endoscopic evaluation and gastric biopsies were done after 24 hours according to the new Sidney System, and also an additional sample for the fast ureasa test analysis (UT). The histologic analysis was considered as ‘‘Gold’’. Results: The gastric lesions were of erosive type in 33.3% and 7 cases of gastric cancer diagnosed (9.3 %). The determination of Hp showed a diagnostic sensibility for the HpIgG 78% with a specificity of 67%, the PPV was 90.4% and the NPV 43%. The diagnostic sensibility for the (UT) was 96.5% and the specificity of 76.4%, the PPV was 93% and the NPV 87%. Histologically 76% were non atrophic chronic gastritis (57/75) and the 24% were atrophic (18/75).In the atrophic cases, the sensibility of G17 was 23.5%, it’s specificity 94%, the PPV 50% and the NPV 79%. The PGI/PGII relation was 18.1% of sensibility and 100% of specificity with a PPV of 100% and NPV of 86%. The global sensibility of the Gastropanel as an identifier of atrophic was 33% with a specificity of 93%, it’s PPV was 60% and it’s NPV was 81%. Conclusions: The result of the endoscopic and histologic study in this group of selected dyspeptic patients for diagnosis of gastric patology, were better than the ones obtained from the Gastropanel. Nevertheless, the Gastropanel could be considered as a useful, non invasive test, at a low cost, in screening programs.
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M1287 Do We Perform a Colonoscopy for Colorectal Cancer Screening Before Surgery for Diverticulitis? Stephane Nahon, Francois Agret, Bruno Lesgourgues, Pierre Lahmek, Thierry Tuszynski, Tony Rahme, Nicolas Delas
M1289 Impact of Two Procedure Rooms Per Physician on Productivity: Computer Simulation Examines the Impact of Process Change in the Hospital Gastroenterology Department Douglas K. Rex, Betsy J. Lahue, Rainer W. Dronzek, Mike J. Lacey
Background and Aim: A colorectal cancer screening is usually performed before surgery for diverticulitis. However, this procedure is not built on evidence-based medicine. The aim of this study was to assess the frequency of premalignant and malignant colonic lesions in a group of patients with diverticulitis before surgery, and to compare this with a control group of asymptomatic patients undergoing screening colonoscopy. Methods: in a case-control study, 184 patients [103 women and 81 men, 61G13 years (30-80)] with a diverticulitis requiring a surgery procedure were identified from 1990 to 2004. They have no history or symptoms suggestive of colorectal cancer, and they underwent perioperative colonoscopy. The patients were stratified in two age groups: patients less than 50 years old (group 1) and patients more than 50 years old (group 2). The colonoscopic findings were compared with findings in 704 asymptomatic control patients who underwent screening colonoscopy. Results: the mean age of patients with diverticulitis (nZ39) and control patients (nZ288) in group 1 was not significantly different (43,1G5 vs 41G6 years; pZ0,66). In group 2, the mean age of patients with diverticulitis (nZ145) and control patients (nZ416) was not also significantly different (64G10 vs 63,2G6,2, pZ0,23). In group 1, no colorectal cancer was observed in patients with diverticulitis and only one in control group (pZ0,9). In group 2, no colorectal cancer was observed in patients with diverticulitis and 7 in control group (pZ0,2). In group 1 and 2, the number of polyps over 10 mm was not significantly different between diverticulitis and control subjects (group 1: 3 vs 15 (pZ0,37); group 2 : 9 vs 30; (pZ0,7)). Conclusion: this study suggests that in asymptomatic patients, diverticulitis is not associated with an increased risk of colorectal cancer. Therefore, a colonoscopy before surgery for diverticulitis might be avoid.
Background: Endoscopy physicians cite long waits, or down time, between procedures as a barrier to productivity. A potential solution is to allocate two staffed procedure rooms to each physician so that when one procedure is completed, the next patient is ready and waiting in the second room. However, hospital administrators may be reluctant to experiment with such process changes without the ability to predict the outcome in advance. Simulation modeling can create a virtual representation of endoscopy lab operations to test the impact of potential changes on efficiency outcomes. Purpose: To quantify the impact of a strategy to reduce physician down time in the endoscopy lab using simulation modeling. Methods: We designed a computer simulation model (AnylogicTM 5.0 software, AccessTM interface) of a hospital endoscopy lab by documenting patient flow; determining process times via observation studies, chart reviews, and staff interviews; and validating model output with collected data metrics. The model simulates 20 working days and generates mean daily statistics. To test the strategy of providing one physician with two staffed rooms, we compared a baseline (2 physicians, 2 staffed procedure rooms) to a new scenario (1 physician, 2 staffed procedure rooms). Outcome measures include: patients per physician, length of stay (LOS), total facility time (first patient arrival to last patient discharge), and staff utilization (percent of time engaged in patient care tasks). Results: Compared to baseline, individual physician productivity is improved with the new strategy resulting in a 23% increase in patients per physician (9.8 to 12.8) and a 25% increase in physician utilization. But when two procedure rooms are allocated to one physician, the overall performance of the simulated endoscopy lab is sub-optimized compared to baseline; mean patient LOS increased 25% (175 to 234 minutes), nonphysician staff utilization decreased 24-41%, and total facility time increased 7% (9.9 to 10.6 hours). Conclusions: While physician productivity improves by dedicating two procedure rooms to one physician, there is an overall reduction in endoscopy lab performance in the simulated environment. Further simulation may illuminate alternative strategies to optimize physician productivity without lowering utilization of non-physician staff or negatively affecting customer satisfaction predictors such as LOS.
M1288 The Efficacy of Argon Plasma Coagulation for the Salvage Treatment of Gastric Intramucosal Tumor Jong-Jae Park, Yeon Seok Seo, Yun Jung Chang, Ji Yeon Lee, Cheol Hyun Kim, Jin Yong Kim, Jong Eun Yeon, Jae Seon Kim, Kwan Soo Byun, Young Tae Bak, Chang Hong Lee Background: Currently endoscopic mucosal resection (EMR) is used to treat gastric tumors (early cancer and adenoma) and considered safe and effective. However, the number of patients with gastric tumors who have comorbidities that preclude either surgical resection or EMR is increasing. The aim of this study is to determine the efficacy of argon plasma coagulation (APC) for the salvage treatment of gastric tumors. Methods: This study included 14 patients (male:female 10:4, mean age 62.2 years). 7 patients had gastric adenomas (elevated lesion: 5 cases, flat lesion: 2 cases, mean size: 16 mm in diameter) and 7 patients had EGC (depressed lesion: 3 cases, elevated lesion: 4 cases, mean size: 14 mm in diameter). Ex-vivo experiment was performed to determine irradiation condition for APC treatment. Irradiation was performed with the electrode at a distance of 1-2 mm from the surgically resected fresh human gastric tissues after obtaining informed consent. The power of the high frequency currents was 30W, 50W, 70W and 90W, while irradiation times were 2, 4, 6, 8 and 10 seconds. Coagulation depth with various irradiation conditions based on histological analysis was scored from 0 to 4 (0: none or minimal, 1: confined to the mucosa, 2: !1/2 of submucosa, 3: O1/2 of submucosa, 4: extending into muscularis propria). Indication of APC was recurrence after EMR (1), remnant tumor after EMR (2), incomplete EMR due to severe bleeding (3) and untreatable patients due to old age or comorbidities (8). Results: According to the result of the ex vivo experiment, the optimum APC treatment condition for complete cauterization of mucosal and less than half of the submucosal layer was a current of 70W for 6 seconds. Mucosal cauterization after marking around each tumor, was performed in the manner determined by the ex-vivo experiments. The number of sessions for complete cauterization was 1.6 (1.4 for adenoma, 2 for EGC). No serious complications occurred. During the mean follow-up of 9 months (5-19 months), complete cauterization was achieved in 13 patients. One patient with EGC was found to have recurrence 2 months after treatment and managed by repeated APC Conclusions: APC could be considered as a salvage treatment for gastric tumors. Further study with long term follow up is required to evaluate the role of APC in the treatment of early gastric cancer untreatable by surgical resection or endoscopic mucosal resection.
AB154 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
M1290 Correlation of the Serum Levels of Pepsinogen I and II Gastrin 17, H pylori Antibodies with the Endoscopic Biopsies of Dispeptic Patients Carlos A. Robles-Jara, Carlos A. Robles-Medranda, Johnny H. Parrales, Ruth Armijos, Jorge Suppo, Byron Landı´var Background: Gastric Cancer is a major cause of cancer mortality in Ecuador. Atrophic chronic gastritis and intestinal metaplasia are considered premalignant lesions. H. pylori play a role in the carcinogenesis of this entity. Our objective was to evaluate the efectivity of Gastropanel (Biohit-Finland) composed by Pepsinogen I (PGI), Pepsinogen II (PGII), Gastrin-17 (G-17), and H. pylori IgG antibodies (HpIgG) in patients with dyspeptic symptoms correlated with the histologic findings from gastric biopsies. Methods: 75 patients with dyspeptic symptoms (M/F ratio 35/40) over 40 years old were selected randomly. A first blood sample was taken to obtain a basal level of GI7, PGI, PGII, I and HpIgG. A second sample was obtained 20 minutes later, after ingestion of a proteic solution for G 17 stimulation. Endoscopic evaluation and gastric biopsies were done after 24 hours according to the new Sidney System, and also an additional sample for the fast ureasa test analysis (UT). The histologic analysis was considered as ‘‘Gold’’. Results: The gastric lesions were of erosive type in 33.3% and 7 cases of gastric cancer diagnosed (9.3 %). The determination of Hp showed a diagnostic sensibility for the HpIgG 78% with a specificity of 67%, the PPV was 90.4% and the NPV 43%. The diagnostic sensibility for the (UT) was 96.5% and the specificity of 76.4%, the PPV was 93% and the NPV 87%. Histologically 76% were non atrophic chronic gastritis (57/75) and the 24% were atrophic (18/75).In the atrophic cases, the sensibility of G17 was 23.5%, it’s specificity 94%, the PPV 50% and the NPV 79%. The PGI/PGII relation was 18.1% of sensibility and 100% of specificity with a PPV of 100% and NPV of 86%. The global sensibility of the Gastropanel as an identifier of atrophic was 33% with a specificity of 93%, it’s PPV was 60% and it’s NPV was 81%. Conclusions: The result of the endoscopic and histologic study in this group of selected dyspeptic patients for diagnosis of gastric patology, were better than the ones obtained from the Gastropanel. Nevertheless, the Gastropanel could be considered as a useful, non invasive test, at a low cost, in screening programs.
www.mosby.com/gie