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The impact of Endoscopic Ultrasonography (EUS) on the management of patients with gastric lesions diagnosed by other methods
CLINICAL ENDOSCOPIC PRACTICE 101
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CAN QUALITY ASSURANCE ( Q A ) IN EMERGENCY ENDOSCOPY (EE) IMPROVE MEDICAL CARE? A.Barrlpoll, A. Ferrari, C . D e Angells, A. Mondardlnl, C. P e r o t t o , A. $ambataro, A.Pera, C. B a r l e t t i , L.Todros, F.Rosina and G.Verme. Exp. Dept. o f G a s t r o e n t e r o l o g y , Molinette Hospital, Turin I t a l y .
THE IMPACT OF ENDOSCOPIC ULTRASONOGRAPHY (EUS) ON THE MANAGEMENT OF PATIENTS WITH GASTRIC LESIONS DIAGNOSED BY OTHER METHODS AI Geller, CC Nguyen, AM Axelrad, DE Fleischer, FH AI-Kawas, JH Lewis, SB Benjamin. Georgetown University Medical Center, Washington, DC
In 1992 a study on QA in EE was s t a r t e d in order to evaluate quality of emergency medlcal approach to patients with active upper GI bleeding. The s t u d y was d i v i d e d into three phases: 1)observation (1992): I month c l i n i c a l f o l l o w - u p a f t e r EE o f a l l p a t i e n t s w i t h v a r l c e a l and non v a r t c e a l b l e e d i n g , t r e a t e d on t h e b a s i s of prefixed g u i d e lines~ 2) r e s u l t s evaluation (QA) based on chosen quality indicators (rebleeding, surgery, mortality r a t e ) 3) guide lines modification on t h e b a s i s o f achieved r e s u l t s and a new o b s e r v a t i o n a l period of I year (1994)o Preliminary r e s u l t s : A) In 2B p a t i e n t s endoscopically t r e a t e d f o r bleeding esophageal v a r i c e s (January-September 1994) compared t o 46 s i m i l a r p a t i e n t s t r e a t e d fn 1992 a satfsfacLory decrease was observed concerning rebleedtng -(from 43.49 to 19.29), total mortality (from 32.69 to 11.5X) and bleedlng r e l a t e d m o r t a l i t y (from 259 t o 7.79). B) In non v a r i c e a l hemorrhage (1992:29 p t s , l g 9 4 : 4 0 p t s . ) no s i g n i f i c a n t change was o b s e r v e d i n F o r r e s t IA, IB and I I A u l c e r s , whereas a more a g g r e s s i v e endoscopic approach seemed t o improve the prognosis of Forrest IIB lesions. C o n c l u s i o n s : t h e o b t a i n e d r e s u l t s s u g g e s t t h a t QA can r e a l l y improve m e d i c a l approach fn emergency endoscopy.
EUS provides detailed information about the layers of the GI tract unequalled by other imaging methods. However, how EUS contributes to the care of patients (pts) has not been critically appraised. AIM: This study was conducted to evaluate the clinical impact of EUS in pts with gastric lesions identified previously or pts with a history of gastric pathology referred for EUS follow-up. METHODS: Consecutive pts undergoing EUS for the aforementioned indications from 7/93 to 12/94 were enrolled. RESULTS: 53 pts (21 men, 32 women, ages 22-82) comprised the study population. Because the stomach was found to be normal on EUS, 21 pts were reassured (19 with follow-up available at 1-16 months). Smooth muscle tumors were identified in 7 pts with 2 confirmed surgically. The other 5 pts were believed to have benign smooth muscle tumors, all doing well at 1-14 months follow-up (mean 8 months). Vascular lesions were ruled out in 6 pts, enabling snare biopsy in 5. Varices were diagnosed in 1 patient, averting potential complications from biopsy. Benign submucosal thickening was diagnosed in 4 pls, all well at 1-15 months. EUS staging of gastric cancer in 2 pts led to exploration with staging results confirmed in 1 pt, and surgery pending in the other. Malignancy was suspected by EUS in 3 pts, later histologically confirmed in all. In 9 pts, EUS did not impact because it only confirmed an existing diagnosis, the results were equivocal, or the procedure was technically unfeasible. CONCLUSIONS: In the majority of our patients (83%), the clinical management was changed because of information provided by EUS.
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DOES THE TYPE OF COLONOSCOPEAFFECT THE ABILITY TO PERFORM COMPLETE COLONOSCOPY?AJ Geller, DE Fleischer, FH AI-Kawas, JH Lewis, CC Nguyen, AM Axelrad, SB Benjamin. Division of Gastroenterology, Georgetown University Medical Center, Washington, DC. Whether the type of colonoscope affects the ability to perform complete co]onoscopy or the time required to reach the cecum (time to cecum) has not been c r i t i c a l l y examined. At our institution, the latest colonoscopes manufactured by FuJinon Incorporated (Wayne, NJ), Olympus Corporation (Lake Success, NY) and Pentax Corporation (Orangeburg, NY) are each available. AIR: Weevaluatedtheeffects of using different colonoscopes on the ability to perform complete colonoscopy and on the time to cecum. METHODS: We prospectively measured the time to cecum in consecutive patients undergoing colonoscopy at our institution between 8/94 and 12/94 in whom the procedure was performed by a faculty member alone. Physicians agreed to proceed to cecal intubation before any therapy was performed. RESULTS: During the study period, complete colonoscopy was accomplished in 267 of 272 procedures (98%) performed by 9 faculty members. There were significant differences in average time to cecum among the endoscopists (range 8.4-16.6 minutes) (F=4.19, p<.O05). Average time to cecumwas not a function of the endoscopist's years of experience (Spearman Rank Correlation Coefficient, r=.435, p=NS). A given physician's average time to cecumdid not vary using different colonoscopes (F=.37, p=NS) and average time to cecum for all physicians did not differ significantly using different colonoscopes (F=2.74, p<.07). The proportion of male patients and those with prior radiation therapy did not d i f f e r among the participating endoscopists. However, by Chi-square, the proportion of patients with prior abdominal surgery (p<.025) and patients with diverticulosis (p<.Ol) did d i f f e r as did the endoscopists' frequency of use use of manuevers such as abdominal compression and turning the patient (p<.Ol). CONCLUSIONS: Colonoscopetype does not affect ability to perform complete colonoscopy or time to cecum at our institution.
SIMULATED ENDOSCOPIC SKILLS: HOW "REAL n IS A N ENDOSCOPY SIMULATOR? CE Gesseer', PS Jowell*, DF Gillies", P Burger*', A Haritsis", CB Williams+, J Balllie', Duke University Medical Center, Durham, NC', Imperial College of Science, Technology and Medicine, London, England'*, and St. Mark's Hospital, London, England+ A variety of computer-based endoscopy simulators have beer) developed. However, to date none have undergone formal testing to assess realism and correlation between simulator performance and operator experience. Methods: We tested performance of new GI fellows (no endoscopy experience), experienced fellows ( > 100 real eolonosoopies) and controls (non-endoscopists) using a prototype computer graphics eoloooscopy simulator. Three comparisons were made based on 3 simulated eolonoscope insertions to the cecum by each subject: (1) controls vs. experienced fellows without lool) simulation, (2) new fellows vs. experienced fellows with looo simulation (5 rain limit for each insertion), (3) new fellows at entry vs. their performances after 100 real colonoscopies. A written survey using a 6 point scoring system and yes/no questions to assess realism of the simulator was administered to experienced endoscopists (fellows and attendings). Results: Looo Simulation Off: Controls (n=4) took 172s (mean) to hitubate the "cecum" vs. 36.5s for experienced fellows (n=9) (P < .01). Looo Simulation On: New fellows had a mean cecal intubation rate of 20% vs. 93% for experienced fellows (p< .02). New fellows took 291s vs. 127s for experienced fellows (p<.0l). Two new fellows were retested after completing 100 colonoseopies; their scores increased from 0% to 100%. Survey: Control wheel movements, lens cleaning, torque, patient safety indicators and simulated fluoroscopy were each rated as moderate to completely realistic by at least 70% of those surveyed. 73 % of respondents scored the simulator as either moderately or very realistic, and 93% thought that the simulator would be useful in training endoscopists. Conclusions'- Performance on this colonoseopy simulator correlates well with level of procedural experience. Further research and development are justified.
VOLUME 41, NO. 4, 1995
GASTROINTESTINAL ENDOSCOPY
321
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CAN QUALITY ASSURANCE ( Q A ) IN EMERGENCY ENDOSCOPY (EE) IMPROVE MEDICAL CARE? A.Barrlpoll, A. Ferrari, C . D e Angells, A. Mondardlnl, C. P e r o t t o , A. $ambataro, A.Pera, C. B a r l e t t i , L.Todros, F.Rosina and G.Verme. Exp. Dept. o f G a s t r o e n t e r o l o g y , Molinette Hospital, Turin I t a l y .
THE IMPACT OF ENDOSCOPIC ULTRASONOGRAPHY (EUS) ON THE MANAGEMENT OF PATIENTS WITH GASTRIC LESIONS DIAGNOSED BY OTHER METHODS AI Geller, CC Nguyen, AM Axelrad, DE Fleischer, FH AI-Kawas, JH Lewis, SB Benjamin. Georgetown University Medical Center, Washington, DC
In 1992 a study on QA in EE was s t a r t e d in order to evaluate quality of emergency medlcal approach to patients with active upper GI bleeding. The s t u d y was d i v i d e d into three phases: 1)observation (1992): I month c l i n i c a l f o l l o w - u p a f t e r EE o f a l l p a t i e n t s w i t h v a r l c e a l and non v a r t c e a l b l e e d i n g , t r e a t e d on t h e b a s i s of prefixed g u i d e lines~ 2) r e s u l t s evaluation (QA) based on chosen quality indicators (rebleeding, surgery, mortality r a t e ) 3) guide lines modification on t h e b a s i s o f achieved r e s u l t s and a new o b s e r v a t i o n a l period of I year (1994)o Preliminary r e s u l t s : A) In 2B p a t i e n t s endoscopically t r e a t e d f o r bleeding esophageal v a r i c e s (January-September 1994) compared t o 46 s i m i l a r p a t i e n t s t r e a t e d fn 1992 a satfsfacLory decrease was observed concerning rebleedtng -(from 43.49 to 19.29), total mortality (from 32.69 to 11.5X) and bleedlng r e l a t e d m o r t a l i t y (from 259 t o 7.79). B) In non v a r i c e a l hemorrhage (1992:29 p t s , l g 9 4 : 4 0 p t s . ) no s i g n i f i c a n t change was o b s e r v e d i n F o r r e s t IA, IB and I I A u l c e r s , whereas a more a g g r e s s i v e endoscopic approach seemed t o improve the prognosis of Forrest IIB lesions. C o n c l u s i o n s : t h e o b t a i n e d r e s u l t s s u g g e s t t h a t QA can r e a l l y improve m e d i c a l approach fn emergency endoscopy.
EUS provides detailed information about the layers of the GI tract unequalled by other imaging methods. However, how EUS contributes to the care of patients (pts) has not been critically appraised. AIM: This study was conducted to evaluate the clinical impact of EUS in pts with gastric lesions identified previously or pts with a history of gastric pathology referred for EUS follow-up. METHODS: Consecutive pts undergoing EUS for the aforementioned indications from 7/93 to 12/94 were enrolled. RESULTS: 53 pts (21 men, 32 women, ages 22-82) comprised the study population. Because the stomach was found to be normal on EUS, 21 pts were reassured (19 with follow-up available at 1-16 months). Smooth muscle tumors were identified in 7 pts with 2 confirmed surgically. The other 5 pts were believed to have benign smooth muscle tumors, all doing well at 1-14 months follow-up (mean 8 months). Vascular lesions were ruled out in 6 pts, enabling snare biopsy in 5. Varices were diagnosed in 1 patient, averting potential complications from biopsy. Benign submucosal thickening was diagnosed in 4 pls, all well at 1-15 months. EUS staging of gastric cancer in 2 pts led to exploration with staging results confirmed in 1 pt, and surgery pending in the other. Malignancy was suspected by EUS in 3 pts, later histologically confirmed in all. In 9 pts, EUS did not impact because it only confirmed an existing diagnosis, the results were equivocal, or the procedure was technically unfeasible. CONCLUSIONS: In the majority of our patients (83%), the clinical management was changed because of information provided by EUS.
102
w
DOES THE TYPE OF COLONOSCOPEAFFECT THE ABILITY TO PERFORM COMPLETE COLONOSCOPY?AJ Geller, DE Fleischer, FH AI-Kawas, JH Lewis, CC Nguyen, AM Axelrad, SB Benjamin. Division of Gastroenterology, Georgetown University Medical Center, Washington, DC. Whether the type of colonoscope affects the ability to perform complete co]onoscopy or the time required to reach the cecum (time to cecum) has not been c r i t i c a l l y examined. At our institution, the latest colonoscopes manufactured by FuJinon Incorporated (Wayne, NJ), Olympus Corporation (Lake Success, NY) and Pentax Corporation (Orangeburg, NY) are each available. AIR: Weevaluatedtheeffects of using different colonoscopes on the ability to perform complete colonoscopy and on the time to cecum. METHODS: We prospectively measured the time to cecum in consecutive patients undergoing colonoscopy at our institution between 8/94 and 12/94 in whom the procedure was performed by a faculty member alone. Physicians agreed to proceed to cecal intubation before any therapy was performed. RESULTS: During the study period, complete colonoscopy was accomplished in 267 of 272 procedures (98%) performed by 9 faculty members. There were significant differences in average time to cecum among the endoscopists (range 8.4-16.6 minutes) (F=4.19, p<.O05). Average time to cecumwas not a function of the endoscopist's years of experience (Spearman Rank Correlation Coefficient, r=.435, p=NS). A given physician's average time to cecumdid not vary using different colonoscopes (F=.37, p=NS) and average time to cecum for all physicians did not differ significantly using different colonoscopes (F=2.74, p<.07). The proportion of male patients and those with prior radiation therapy did not d i f f e r among the participating endoscopists. However, by Chi-square, the proportion of patients with prior abdominal surgery (p<.025) and patients with diverticulosis (p<.Ol) did d i f f e r as did the endoscopists' frequency of use use of manuevers such as abdominal compression and turning the patient (p<.Ol). CONCLUSIONS: Colonoscopetype does not affect ability to perform complete colonoscopy or time to cecum at our institution.
SIMULATED ENDOSCOPIC SKILLS: HOW "REAL n IS A N ENDOSCOPY SIMULATOR? CE Gesseer', PS Jowell*, DF Gillies", P Burger*', A Haritsis", CB Williams+, J Balllie', Duke University Medical Center, Durham, NC', Imperial College of Science, Technology and Medicine, London, England'*, and St. Mark's Hospital, London, England+ A variety of computer-based endoscopy simulators have beer) developed. However, to date none have undergone formal testing to assess realism and correlation between simulator performance and operator experience. Methods: We tested performance of new GI fellows (no endoscopy experience), experienced fellows ( > 100 real eolonosoopies) and controls (non-endoscopists) using a prototype computer graphics eoloooscopy simulator. Three comparisons were made based on 3 simulated eolonoscope insertions to the cecum by each subject: (1) controls vs. experienced fellows without lool) simulation, (2) new fellows vs. experienced fellows with looo simulation (5 rain limit for each insertion), (3) new fellows at entry vs. their performances after 100 real colonoscopies. A written survey using a 6 point scoring system and yes/no questions to assess realism of the simulator was administered to experienced endoscopists (fellows and attendings). Results: Looo Simulation Off: Controls (n=4) took 172s (mean) to hitubate the "cecum" vs. 36.5s for experienced fellows (n=9) (P < .01). Looo Simulation On: New fellows had a mean cecal intubation rate of 20% vs. 93% for experienced fellows (p< .02). New fellows took 291s vs. 127s for experienced fellows (p<.0l). Two new fellows were retested after completing 100 colonoseopies; their scores increased from 0% to 100%. Survey: Control wheel movements, lens cleaning, torque, patient safety indicators and simulated fluoroscopy were each rated as moderate to completely realistic by at least 70% of those surveyed. 73 % of respondents scored the simulator as either moderately or very realistic, and 93% thought that the simulator would be useful in training endoscopists. Conclusions'- Performance on this colonoseopy simulator correlates well with level of procedural experience. Further research and development are justified.
VOLUME 41, NO. 4, 1995
GASTROINTESTINAL ENDOSCOPY
321