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The German Sphincterotomy Registry. A Voluntary Quality Assurance Project
*S1611 Endoscopic Evaluation and Treatment of Ampullary Tumors Michel Kahaleh, Vanessa M. Shami, Cynthia Yoshida, Christopher A. Moskaluk, Reid B. Adams, Paul Yeaton OBJECTIVE: Endoscopic treatment of ampullary tumors has been well described but limited data is available regarding features predictive of malignancy and factors associated with successful resection of benign lesions. METHODS: 40 consecutive patients undergoing interventional endoscopy for ampullary tumors between March 2000 and November 2003 at the University of Virginia were included in the study. Clinical presentation, endoscopic treatment (biliary and/or pancreatic sphincterotomy, stenting, APC application, snare resection), EUS staging, pathology and final results were documented. Multivariate analysis was performed to determine whether the presence of Familial adenomatous polyposis (FAP), ability to lift the tumor after submucosal injection (cleavage plane), and EUS staging are predictive of malignancy. Additionally, age, gender, endoscopic treatment and ability to obtain a cleavage plane were statistically analyzed to determine which parameters serve as predictive factors of successful endoscopic resection of benign lesions. RESULTS: The mean age of the patients was 60.5 years. There were 21 males and 19 females. Clinical presentation at the time of diagnosis included: jaundice (21), incidental (9), pancreatitis (4) and other (6). Final diagnosis included: 23 adenomas with one HGD, 11 adenocarcinomas, 3 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Of the 13 patients with malignancy 9 underwent curative surgery and 4 were found to have metastatic disease. 20/28 patients who underwent endoscopic resection were cured. A mean number of 2 endoscopic procedures were needed. 8/20 are still undergoing endoscopic therapy. Complications of endoscopic resection included bleeding requiring hemoclip placement(2) and pancreatitis (3) (two mild and one resulting in death). The factors significantly associated with predicting malignancy was EUS stage and inability to obtain a cleavage plane (see table). In benign lesions no predictive factor of successful endoscopic resection was identified. CONCLUSION: In ampullary lesions, the strongest predictor of malignancy is EUS stage followed by the inability to achieve a cleavage plane. Endoscopic treatment of benign ampullary tumors is effective, but no factors associated with successful resection were identified.
*S1612 A Prospective Study of Colonoscopy Completion Rates for a Single Endoscopy Service Within a University Teaching Hospital Diarmuid S. Manning, Gayle Bennett, Suzi Clarke, Richard Walsh, Hugh E. Mulcahy Introduction: Accreditation guidelines suggest that gastroenterologists should achieve caecal intubation rates of at least 90%. However, studies on variations in colonoscopy practice have tended to concentrate on variations between endoscopists and institutions rather than on case-mix. Aim: We studied multiple variables associated with caecal and terminal ileal intubation for a single attending physician’s service in a university teaching hospital to determine factors associated with completion. Methods: 399 consecutive patients (mean age 55 years; range 1790; 225 female). attending for colonoscopy were prospectively studied. Patients completed a highly structured questionnaire before the procedure and a comprehensive series of demographic, clinical and endoscopic data were collected. Bowel preparation was assessed using conventional guidelines. Results: The caecum was intubated in 298 cases (75%). Reasons for failure included unprepared bowel (n=28), patient discomfort (n=60), stricturing disease (n=7), hypotension or bradycardia (n=4) and equipment failure (n=2). Factors independently associated with caecal intubation included the absence of diverticular disease (p=0.009) and the presence of polyps (p=0.04). The terminal ileum was intubated in 99 cases (25%). Factors associated with ileal intubation included diarrhoea as a presenting symptom (p<0.001), known IBD (p=0.007) and abnormal radiological studies (p=0.003). Conclusion: Caecal and ileal intubation is clearly associated with clinical and endoscopic variables and ileal intubation appears to be performed as a result of perceived clinical need rather than as a matter of routine. Thus, simple numerical criteria for endoscopic competence appears crude and does not reflect the complexity of colonoscopy in clinical practice.
P140
GASTROINTESTINAL ENDOSCOPY
*S1613 The German Sphincterotomy Registry. A Voluntary Quality Assurance Project Matthias Maier, Christian Ell, Franz Hartmann, Ralf Jakobs, Franziska Plath, Thomas Roesch, Alexander Bachor For a project of quality assurance sphincterotomy would be suitable: the complication rate is significant, the procedure is not too frequently done, it is a technically demanding maneuver. We initiated a pilot project to set up a national anonymous sphincterotomy registry.Feasibility in daily practice, quality of the gained data and cost calculation had to be analyzed. 19 services (lowest = 19 procedures, highest = 133procedures) documented their sphincterotomies for 6 months in 2001/2002: 1059 sphincterotomies with a pre-cut rate of 17%, failure rate of 6.14% and 3.97% repeated procedures were registered. More female patients (67%) were investigated with choledocholithiasis being the main indication, pancreatic duct sphincterotomy being rare (4,2%) mostly done in high volume centers. 26.5% of the patients were classified ASA III and IV. Severe complications were found in 2.64% of the cases. Together with mild complications the complication rate was 11.05% and mortality 0.09% (1 patient). The complication rate is slightly elevated in SOD patients(all results were monitored by the biomedical information center to obtain the most accurate data). Though the endocut technique (median 94,7%) and the guide wire sphincterotome (median 80%) are widely used, there are some services who use neither one of them and there are no differences in success and complication rate. Sedation is mainly induced by a benzodiacepine together with morphine derivate in 518 cases and /or propofol in 240 cases. Other drugs (ketamine, neuroleptics) play a minor role as well as gerneral anesthetic (11cases). Though there are no statistically significant differences between the different centers every service can analyze the individual results compared to the anonymous data from the other participants with regard to the sphincterotome used, current or sedation for example. Cost calculation for a one-year participation in a voluntary registry is between 900 and 1400 Euro depending on data accumulation (written or digital) and frequency of sphincterotomy. Conclusion: A registry on the 2-questionnaire basis is feasible and it leads to relevant data to compare results of different services with detailed insight into technical aspects that can lead to new considerations (for example power and coagulation presetting in endocut). Whether participation will change attitudes in some centers will be shown by further documentation. The registry is now open for participation for every center in Germany performing sphincterotomy.
*S1614 Influence of Hypochlorhydria on Bacterial Overgrowth in the Proximal Small Intestine Yoshihisa Urita, Yoshinori Kikuchi, Kazuo Hike, Naotaka Torii, Eiko Kanda, Hidenori Kurakata, Masahiko Sasajima, Motonobu Ozaki, Kazumasa Miki Background: Gastric acid plays an important part in the prevention of bacterial colonization of the gastrointestinal tract. If these bacteria have an ability of hydrogen fermentation, intraluminal hydrogen gas might be detected. We attempted to measure the intraluminal hydrogen concentrations to determine the bacterial overgrowth in the gastrointestinal tract. Patients and Methods: Studies were performed in 647 consecutive patients undergoing esophagogastroscopy, 211 men and 436 women, 19 to 85 years old. At the time of endoscopic examination, we intubated the stomach without inflation by air, and 20 ml of intragastric gas was collected through the biopsy channel using a 30ml syringe. The first 5 ml was discarded for reduction of dead-space error. Once the pylorus is located, the tip of the endoscope is advanced into the descending portion of the duodenum. After that, 20 ml of intraduodenal gas was collected again by the same way. Intragastric and intraduodenal hydrogen concentrations were immediately measured by gaschromatography using Breath Analyzer TGA-2000 (TERAMECS Co.Ltd. Kyoto) and expressed in parts per million (ppm). Results: Over all, intragastric and intraduodenal hydrogen was detected in 566 (87.5%) and 524 (81.0%), respectively. The mean values of intragastric and intraduodenal hydrogen gas were 8.5 +/ÿ 15.9 and 13.2 +/ÿ 58.0 ppm, respectively. The intraduodenal hydrogen level was increased with the progression of atrophic gastritis, whereas the intragastric hydrogen level was the highest in patients without atrophic gastritis. Conclusions: The intraduodenal hydrogen levels were increased with the progression of atrophic gastritis. It is likely that the influence of hypochlorhydria on bacterial overgrowth in the proximal small intestine is more pronounced, compared to that in the stomach.
VOLUME 59, NO. 5, 2004
*S1612 A Prospective Study of Colonoscopy Completion Rates for a Single Endoscopy Service Within a University Teaching Hospital Diarmuid S. Manning, Gayle Bennett, Suzi Clarke, Richard Walsh, Hugh E. Mulcahy Introduction: Accreditation guidelines suggest that gastroenterologists should achieve caecal intubation rates of at least 90%. However, studies on variations in colonoscopy practice have tended to concentrate on variations between endoscopists and institutions rather than on case-mix. Aim: We studied multiple variables associated with caecal and terminal ileal intubation for a single attending physician’s service in a university teaching hospital to determine factors associated with completion. Methods: 399 consecutive patients (mean age 55 years; range 1790; 225 female). attending for colonoscopy were prospectively studied. Patients completed a highly structured questionnaire before the procedure and a comprehensive series of demographic, clinical and endoscopic data were collected. Bowel preparation was assessed using conventional guidelines. Results: The caecum was intubated in 298 cases (75%). Reasons for failure included unprepared bowel (n=28), patient discomfort (n=60), stricturing disease (n=7), hypotension or bradycardia (n=4) and equipment failure (n=2). Factors independently associated with caecal intubation included the absence of diverticular disease (p=0.009) and the presence of polyps (p=0.04). The terminal ileum was intubated in 99 cases (25%). Factors associated with ileal intubation included diarrhoea as a presenting symptom (p<0.001), known IBD (p=0.007) and abnormal radiological studies (p=0.003). Conclusion: Caecal and ileal intubation is clearly associated with clinical and endoscopic variables and ileal intubation appears to be performed as a result of perceived clinical need rather than as a matter of routine. Thus, simple numerical criteria for endoscopic competence appears crude and does not reflect the complexity of colonoscopy in clinical practice.
P140
GASTROINTESTINAL ENDOSCOPY
*S1613 The German Sphincterotomy Registry. A Voluntary Quality Assurance Project Matthias Maier, Christian Ell, Franz Hartmann, Ralf Jakobs, Franziska Plath, Thomas Roesch, Alexander Bachor For a project of quality assurance sphincterotomy would be suitable: the complication rate is significant, the procedure is not too frequently done, it is a technically demanding maneuver. We initiated a pilot project to set up a national anonymous sphincterotomy registry.Feasibility in daily practice, quality of the gained data and cost calculation had to be analyzed. 19 services (lowest = 19 procedures, highest = 133procedures) documented their sphincterotomies for 6 months in 2001/2002: 1059 sphincterotomies with a pre-cut rate of 17%, failure rate of 6.14% and 3.97% repeated procedures were registered. More female patients (67%) were investigated with choledocholithiasis being the main indication, pancreatic duct sphincterotomy being rare (4,2%) mostly done in high volume centers. 26.5% of the patients were classified ASA III and IV. Severe complications were found in 2.64% of the cases. Together with mild complications the complication rate was 11.05% and mortality 0.09% (1 patient). The complication rate is slightly elevated in SOD patients(all results were monitored by the biomedical information center to obtain the most accurate data). Though the endocut technique (median 94,7%) and the guide wire sphincterotome (median 80%) are widely used, there are some services who use neither one of them and there are no differences in success and complication rate. Sedation is mainly induced by a benzodiacepine together with morphine derivate in 518 cases and /or propofol in 240 cases. Other drugs (ketamine, neuroleptics) play a minor role as well as gerneral anesthetic (11cases). Though there are no statistically significant differences between the different centers every service can analyze the individual results compared to the anonymous data from the other participants with regard to the sphincterotome used, current or sedation for example. Cost calculation for a one-year participation in a voluntary registry is between 900 and 1400 Euro depending on data accumulation (written or digital) and frequency of sphincterotomy. Conclusion: A registry on the 2-questionnaire basis is feasible and it leads to relevant data to compare results of different services with detailed insight into technical aspects that can lead to new considerations (for example power and coagulation presetting in endocut). Whether participation will change attitudes in some centers will be shown by further documentation. The registry is now open for participation for every center in Germany performing sphincterotomy.
*S1614 Influence of Hypochlorhydria on Bacterial Overgrowth in the Proximal Small Intestine Yoshihisa Urita, Yoshinori Kikuchi, Kazuo Hike, Naotaka Torii, Eiko Kanda, Hidenori Kurakata, Masahiko Sasajima, Motonobu Ozaki, Kazumasa Miki Background: Gastric acid plays an important part in the prevention of bacterial colonization of the gastrointestinal tract. If these bacteria have an ability of hydrogen fermentation, intraluminal hydrogen gas might be detected. We attempted to measure the intraluminal hydrogen concentrations to determine the bacterial overgrowth in the gastrointestinal tract. Patients and Methods: Studies were performed in 647 consecutive patients undergoing esophagogastroscopy, 211 men and 436 women, 19 to 85 years old. At the time of endoscopic examination, we intubated the stomach without inflation by air, and 20 ml of intragastric gas was collected through the biopsy channel using a 30ml syringe. The first 5 ml was discarded for reduction of dead-space error. Once the pylorus is located, the tip of the endoscope is advanced into the descending portion of the duodenum. After that, 20 ml of intraduodenal gas was collected again by the same way. Intragastric and intraduodenal hydrogen concentrations were immediately measured by gaschromatography using Breath Analyzer TGA-2000 (TERAMECS Co.Ltd. Kyoto) and expressed in parts per million (ppm). Results: Over all, intragastric and intraduodenal hydrogen was detected in 566 (87.5%) and 524 (81.0%), respectively. The mean values of intragastric and intraduodenal hydrogen gas were 8.5 +/ÿ 15.9 and 13.2 +/ÿ 58.0 ppm, respectively. The intraduodenal hydrogen level was increased with the progression of atrophic gastritis, whereas the intragastric hydrogen level was the highest in patients without atrophic gastritis. Conclusions: The intraduodenal hydrogen levels were increased with the progression of atrophic gastritis. It is likely that the influence of hypochlorhydria on bacterial overgrowth in the proximal small intestine is more pronounced, compared to that in the stomach.
VOLUME 59, NO. 5, 2004