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Transnasal gastroscopy(T-EGD):the first preliminary experience in operative digestive endoscopy through trans-nasal route
AJG – September, Suppl., 2003
PCF-160AL) or an AC (Olympus CF-Q140L). All procedures were performed by one endoscopist and timed. If there was difficulty in performing colonoscopy with the assigned scope, the endoscopist was given the option of switching to the alternative instrument. After the exam, the endoscopist graded procedure difficulty (on 2 scales) and patients were given a questionnaire (4 scales) to assess their experience. Patients were re-contacted at 24 hours by phone to grade the same questionnaire. Results: The 168 study patients included 50% females, had a mean age of 57 yrs, 55% had diverticulosis, and 19% had a hysterectomy. Colonoscopy was initially unsuccessful in 2 patients in the VSPC group (2%). The endoscopist switched to the AC in 1 patient (excessive looping), and successfully reached the cecum with it. Colonoscopy was initially unsuccessful in 3 patients in the AC group because of a fixed, angulated sigmoid (4%). The endoscopist switched to the VSPC in all 3 cases, and successfully reached the cecum in 2. There was no statistical difference between the two groups (VSPC vs AC) in terms of initial frequency of cecal intubation (98% vs 96%), final frequency of cecal intubation (99% vs 99%), insertion time (7.8 min vs 7.7 min), total procedure time (19.5 min vs 19.1 min), or scales of procedure difficulty as graded by the endoscopist. Patients in the VSPC group required lower doses of meperidine (57 mg vs 63 mg, p⫽0.01) and midazolam (2.1 mg vs 2.5 mg, p⫽0.002). Results on one of 4 patient satisfaction scales favored the VSPC; the other 3 scales yielded similar results. Conclusions: The VSPC is an effective instrument for routine adult colonoscopy. Smaller medication doses were required with its use versus the AC. No other clear differences were identified in terms of patient tolerance. There may be individual patients in whom one or the other of the two instruments may be advantageous. For instance, the VSPC can be helpful in individuals when there is a fixed angulated sigmoid colon.
850 DETERMINATION OF HELICOBACTER PYLORI VACA GENOTYPES AND CAGA GENE IN RELATIONSHIP TO GASTRODUODENAL DISEASE IN SOUTH INDIA Mohammed Aejaz Habeeb, D.M., Tippavazula Rekha, Ph.D., Aleem Ahmed Khan, Ph.D., Chittoor Mohammed Habibullah, D.M.* Deccan College of Medical Sciences, Hyderabad, Andhra Pradesh, India. Purpose: Two major virulence factors encoded by the cytotoxin-associated gene (cagA) and the vacuolating cytotoxin (vacA) gene of Helicobacter pylori are known to be associated with gastroduodenal pathologic condition. Genetic differences have been identified between the vacA alleles, two families of alleles in the mid region, m1 and m2, and three families of alleles in the signal sequence s1a, s1b, and s2. In total, any H. pylori strain could have one to six possibilities and among them s2m2 are non-toxic, s1/m1 are high toxic producers, and s2/m2 have a bimodal distribution. The aim of the study was to investigate the cagA and vacA subtypes in Indian (Hyderabad) H. pylori isolates and to assess the relationship between genotypes of isolates and clinical features. Methods: A total of 102 H. pylori positive patients with peptic ulcer disease or other H. pylori related diseases were studied for vacA genotypes and the presence of cagA gene by PCR. Results: In 50 (91%) of 55 duodenal ulcer patients were of type s1 (s1m1⫽ 45; s1m2⫽5;s2m2⫽5), similarly 25(63%) of 40 non-ulcer dyspepsia patients were type s1 (s1m1⫽25; s1m2⫽11; s2m2⫽4). The presence of the cagA gene was closely associated with the vac s1 genotype, and was found in 85% of patients with s1m1 and s1m2 genotypes. The cagA gene, which is a marker for duodenal ulceration, was found in 87% of duodenal ulcer patients and 55% of non-ulcer patients. Conclusions: Most H. pylori strains among patients with ulcers possess the vacA s1 and cagA gene. Determination of vacA genotypes and cagA gene may contribute to the potential clinical identification of patients at different levels of risk.
Abstracts
S283
851 TRANSNASAL GASTROSCOPY(T-EGD):THE FIRST PRELIMINARY EXPERIENCE IN OPERATIVE DIGESTIVE ENDOSCOPY THROUGH TRANS-NASAL ROUTE Fausto Barberani, M.D., Maurizio Giovannone, M.D., Mauro Tosoni, M.D., Alessandro Gigliozzi, M.D., Sandro Boschetto, M.D.* S.Camillo Hospital, Rieti, Italy. Purpose: To assess operative power of T-EGD in upper GI diseases. T-EGD by Barberani’s technique is a well tolerated procedure in the routine practice cheaper than conventional (C-EGD) and safer with regard to risk patients.There are only few records concerning T-EGD in operative endoscopy (PEG, dilation on guide wire) when oral route is unavailable. Methods: Sixty-six patients previously underwent to diagnostic unsedated T-EGD,were guided to a second T-EGD when endoscopic therapy was required.Consent was obtained.A 6mm Pentax video EG-1840 with 2mm operative channel was utilized. As additionals:injecting needle and snare Olympus and Deltamed, a 1.8mm Deltamed Roth Net, a Boston CRE and Deltamed pneumatic dilator, a 1.8mm Erbe Argon laser probe, Corpak-Peg 12-16 Fr. Results: We performed 66 therapies (age 28 –90): 26 injective therapy (21 gastric-duodenal ulcers, 2 achalasia, 3 varix); 6 esophageal dilation (4 benign stenosis, 2 malignant); 13 polipectomies (11 gastric, 1 esophageal, 1 duodenal); 14 Argon (7 angiodisplasya, 4 gastric fundic polyps, 1 gastric cancer, 2 Barrett esophagus); 7 prosthesis (6 PEG, 1 esophageal prosthesis). Conclusions: The large experience conducted in diagnostic T-EGD has leaded us to explore operative power of this technique thanks to the availability of hi-tech additionals:polyps’net recovery give this procedure sure and avoid accidental inhalation,guide wire inserted during T-EGD makes easy and safe pneumatic dilation of the esophagus,the argon fine probe treatments resulted definitively at the follow-up as well as the type of PEG and the injective therapy by means of a fine needle in Forrest II a-b lesions, show feasibility of T-EGD not only in diagnostic procedure but also as possible tool for endoscopic therapy in selected patients. 852 CLINICAL EVALUATION IN THE REPROCESSING OF ENDOSCOPES James T. Sing, Jr., D.O., Donald E. Rawls, M.D.*, Robert Fader, Ph.D. Scott & White Memorial Hospital and Clinic, Temple, TX. Purpose: With the discovery of highly infectious organisms, attention to the cleaning and reprocessing of flexible endoscopes has increased considerably over the past several years. Using current infection control guidelines, the true risk of endoscopic infectious transmission remains unknown (American Journal of Infection Control, 1994;22:19 –38). We designed a prospective research study to evaluate the effectiveness of high-level disinfection of gastrointestinal endoscopes after therapeutic and/or diagnostic endoscopy and examined if the current infection control guidelines are adequate and effective in the decontamination of bacterial microorganisms. Methods: Endoscopes used for 50 upper endoscopies (EGD), 50 colonoscopies, and 50 flexible sigmoidoscopies were sampled in sequential order for bacterial specimen collection. Bacterial specimens were collected by 15ml phosphate buffered saline flushings of endoscope accessory channels during a three step process: step 1 pre-endoscopic procedure (B1), step 2 post-manual cleaning with enzymatic agent (B2), and step 3 post-high-level disinfection with orthophthaldehyde solution in reprocessor units, but before drying with alcohol (B3). Microbiologic evaluation for aerobic bacterial identification was performed by culturing 1ml of the bacterial phosphate buffered saline flushings onto pour agar plates. Colony growth and counts, followed by species identification by gram-stain and biochemical analysis, was conducted after 48 hours of incubation. Statistical evaluation was performed by using the 95% confidence interval method. Results: Based on the sample size of 150 endoscopies, this provided an upper confidence limit of 2%, given no cases of positive cultures on steps
PCF-160AL) or an AC (Olympus CF-Q140L). All procedures were performed by one endoscopist and timed. If there was difficulty in performing colonoscopy with the assigned scope, the endoscopist was given the option of switching to the alternative instrument. After the exam, the endoscopist graded procedure difficulty (on 2 scales) and patients were given a questionnaire (4 scales) to assess their experience. Patients were re-contacted at 24 hours by phone to grade the same questionnaire. Results: The 168 study patients included 50% females, had a mean age of 57 yrs, 55% had diverticulosis, and 19% had a hysterectomy. Colonoscopy was initially unsuccessful in 2 patients in the VSPC group (2%). The endoscopist switched to the AC in 1 patient (excessive looping), and successfully reached the cecum with it. Colonoscopy was initially unsuccessful in 3 patients in the AC group because of a fixed, angulated sigmoid (4%). The endoscopist switched to the VSPC in all 3 cases, and successfully reached the cecum in 2. There was no statistical difference between the two groups (VSPC vs AC) in terms of initial frequency of cecal intubation (98% vs 96%), final frequency of cecal intubation (99% vs 99%), insertion time (7.8 min vs 7.7 min), total procedure time (19.5 min vs 19.1 min), or scales of procedure difficulty as graded by the endoscopist. Patients in the VSPC group required lower doses of meperidine (57 mg vs 63 mg, p⫽0.01) and midazolam (2.1 mg vs 2.5 mg, p⫽0.002). Results on one of 4 patient satisfaction scales favored the VSPC; the other 3 scales yielded similar results. Conclusions: The VSPC is an effective instrument for routine adult colonoscopy. Smaller medication doses were required with its use versus the AC. No other clear differences were identified in terms of patient tolerance. There may be individual patients in whom one or the other of the two instruments may be advantageous. For instance, the VSPC can be helpful in individuals when there is a fixed angulated sigmoid colon.
850 DETERMINATION OF HELICOBACTER PYLORI VACA GENOTYPES AND CAGA GENE IN RELATIONSHIP TO GASTRODUODENAL DISEASE IN SOUTH INDIA Mohammed Aejaz Habeeb, D.M., Tippavazula Rekha, Ph.D., Aleem Ahmed Khan, Ph.D., Chittoor Mohammed Habibullah, D.M.* Deccan College of Medical Sciences, Hyderabad, Andhra Pradesh, India. Purpose: Two major virulence factors encoded by the cytotoxin-associated gene (cagA) and the vacuolating cytotoxin (vacA) gene of Helicobacter pylori are known to be associated with gastroduodenal pathologic condition. Genetic differences have been identified between the vacA alleles, two families of alleles in the mid region, m1 and m2, and three families of alleles in the signal sequence s1a, s1b, and s2. In total, any H. pylori strain could have one to six possibilities and among them s2m2 are non-toxic, s1/m1 are high toxic producers, and s2/m2 have a bimodal distribution. The aim of the study was to investigate the cagA and vacA subtypes in Indian (Hyderabad) H. pylori isolates and to assess the relationship between genotypes of isolates and clinical features. Methods: A total of 102 H. pylori positive patients with peptic ulcer disease or other H. pylori related diseases were studied for vacA genotypes and the presence of cagA gene by PCR. Results: In 50 (91%) of 55 duodenal ulcer patients were of type s1 (s1m1⫽ 45; s1m2⫽5;s2m2⫽5), similarly 25(63%) of 40 non-ulcer dyspepsia patients were type s1 (s1m1⫽25; s1m2⫽11; s2m2⫽4). The presence of the cagA gene was closely associated with the vac s1 genotype, and was found in 85% of patients with s1m1 and s1m2 genotypes. The cagA gene, which is a marker for duodenal ulceration, was found in 87% of duodenal ulcer patients and 55% of non-ulcer patients. Conclusions: Most H. pylori strains among patients with ulcers possess the vacA s1 and cagA gene. Determination of vacA genotypes and cagA gene may contribute to the potential clinical identification of patients at different levels of risk.
Abstracts
S283
851 TRANSNASAL GASTROSCOPY(T-EGD):THE FIRST PRELIMINARY EXPERIENCE IN OPERATIVE DIGESTIVE ENDOSCOPY THROUGH TRANS-NASAL ROUTE Fausto Barberani, M.D., Maurizio Giovannone, M.D., Mauro Tosoni, M.D., Alessandro Gigliozzi, M.D., Sandro Boschetto, M.D.* S.Camillo Hospital, Rieti, Italy. Purpose: To assess operative power of T-EGD in upper GI diseases. T-EGD by Barberani’s technique is a well tolerated procedure in the routine practice cheaper than conventional (C-EGD) and safer with regard to risk patients.There are only few records concerning T-EGD in operative endoscopy (PEG, dilation on guide wire) when oral route is unavailable. Methods: Sixty-six patients previously underwent to diagnostic unsedated T-EGD,were guided to a second T-EGD when endoscopic therapy was required.Consent was obtained.A 6mm Pentax video EG-1840 with 2mm operative channel was utilized. As additionals:injecting needle and snare Olympus and Deltamed, a 1.8mm Deltamed Roth Net, a Boston CRE and Deltamed pneumatic dilator, a 1.8mm Erbe Argon laser probe, Corpak-Peg 12-16 Fr. Results: We performed 66 therapies (age 28 –90): 26 injective therapy (21 gastric-duodenal ulcers, 2 achalasia, 3 varix); 6 esophageal dilation (4 benign stenosis, 2 malignant); 13 polipectomies (11 gastric, 1 esophageal, 1 duodenal); 14 Argon (7 angiodisplasya, 4 gastric fundic polyps, 1 gastric cancer, 2 Barrett esophagus); 7 prosthesis (6 PEG, 1 esophageal prosthesis). Conclusions: The large experience conducted in diagnostic T-EGD has leaded us to explore operative power of this technique thanks to the availability of hi-tech additionals:polyps’net recovery give this procedure sure and avoid accidental inhalation,guide wire inserted during T-EGD makes easy and safe pneumatic dilation of the esophagus,the argon fine probe treatments resulted definitively at the follow-up as well as the type of PEG and the injective therapy by means of a fine needle in Forrest II a-b lesions, show feasibility of T-EGD not only in diagnostic procedure but also as possible tool for endoscopic therapy in selected patients. 852 CLINICAL EVALUATION IN THE REPROCESSING OF ENDOSCOPES James T. Sing, Jr., D.O., Donald E. Rawls, M.D.*, Robert Fader, Ph.D. Scott & White Memorial Hospital and Clinic, Temple, TX. Purpose: With the discovery of highly infectious organisms, attention to the cleaning and reprocessing of flexible endoscopes has increased considerably over the past several years. Using current infection control guidelines, the true risk of endoscopic infectious transmission remains unknown (American Journal of Infection Control, 1994;22:19 –38). We designed a prospective research study to evaluate the effectiveness of high-level disinfection of gastrointestinal endoscopes after therapeutic and/or diagnostic endoscopy and examined if the current infection control guidelines are adequate and effective in the decontamination of bacterial microorganisms. Methods: Endoscopes used for 50 upper endoscopies (EGD), 50 colonoscopies, and 50 flexible sigmoidoscopies were sampled in sequential order for bacterial specimen collection. Bacterial specimens were collected by 15ml phosphate buffered saline flushings of endoscope accessory channels during a three step process: step 1 pre-endoscopic procedure (B1), step 2 post-manual cleaning with enzymatic agent (B2), and step 3 post-high-level disinfection with orthophthaldehyde solution in reprocessor units, but before drying with alcohol (B3). Microbiologic evaluation for aerobic bacterial identification was performed by culturing 1ml of the bacterial phosphate buffered saline flushings onto pour agar plates. Colony growth and counts, followed by species identification by gram-stain and biochemical analysis, was conducted after 48 hours of incubation. Statistical evaluation was performed by using the 95% confidence interval method. Results: Based on the sample size of 150 endoscopies, this provided an upper confidence limit of 2%, given no cases of positive cultures on steps