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Tu1300 Endoscopic Submucosal Dissection for Silent Gastric Dieulafoy Lesions Mimicking Gastrointestinal Stromal Tumors
Abstracts
Tu1299 Patient Factors Predicting Poor Tolerance of Endoscopic Procedures With Moderate Sedation Anna Strongin*1, Pallavi Surana1, Christopher Haydek2, Bryan F. Curtin1, Theo Heller1, Sheila Kumar1, Christopher Koh1 1 NIDDK, National Institutes of Health, Bethesda, MD; 2Loyola University Chicago, Maywood, IL Introduction: Appropriate levels of sedation are paramount for optimizing patient comfort, safety, and technical success during endoscopy. Per current guidelines, adequate sedation can be achieved in most patients undergoing routine esophagogastroduodenoscopy (EGD) and colonoscopy with moderate sedation. Aim: To identify patient factors associated with failure of moderate sedation during endoscopic procedures. Methods: Endoscopic procedures performed under moderate sedation from 2000-2016 were reviewed at the National Institutes of Health Clinical Center. Patients were categorized as “poorly tolerated,” based on the assessment of the performing endoscopist, or “easily sedated,” based on low levels of sedation (fentanyl 50 mcg and versed 2 mg). Epidemiologic and anthropometric data, type/ indication of procedure, inpatient/outpatient status, and benzodiazepine/opiate use were analyzed. Univariate and multivariate analyses comparing the two groups were performed. Results: Over a 16-year period, 307 patients met criteria for inclusion – 227 were categorized as “easily sedated” and 80 as “poorly tolerated.” In the total cohort, 53.4% were Caucasian, 14.3% Black, 22.8% Hispanic, and 9.5% Asian; 55% were male; and the mean age was 53.613.9. 64.8% of patients underwent EGDs and 35.2% colonoscopies. In the “poorly tolerated” group, the median sedation was: fentanyl 125 mcg (interquartile range 100-175), midazolam 4 mg (IQR 3-5), and diphenhydramine 25 (IQR 25-50). On univariate analysis, Hispanic or Asian race was associated with easy sedation, whereas age < 50, female sex, body mass index (BMI) < 25, black race, and undergoing colonoscopy (as compared to EGD) was associated with poor tolerance. On multivariate analysis, Hispanic or Asian race remained predictive for easy sedation (odds ratio [OR] 0.32, 95% CI 0.14-0.76; OR 0.15, 0.0370.59, respectively) whereas younger age (OR 6.7, 3.4-13.0), lower BMI (OR 2.6, 1.44.8), female sex (OR 2.1, 1.1-3.9), and colonoscopy (OR 3.4, 1.7-6.8) was predictive of poor tolerance. Looking only at upper endoscopies, younger age was associated with poor tolerance (OR 4.9, 2.2-11.0). With colonoscopies, Hispanic or Asian race was associated with easy sedation (OR 0.12, 0.02-0.67; OR 0.03, 0.002-0.40), whereas age < 50 (OR 5.1, 1.0-25), BMI < 25 (OR 6.7, 1.8-23.8), and female sex (OR 8.8, 2.234.4) were associated with poor tolerance. Conclusions: Various patient factors including gender, race, age, BMI and type of procedure appear to play a role in the success or failure of moderate sedation in endoscopic procedures. Patients who are female, younger, black, not overweight or obese, or undergo colonoscopy, may be at higher risk of poor tolerance of endoscopies with moderate sedation. Clinicians should be aware of these factors when choosing type of sedation, in order to optimize success and minimize failures of endoscopy.
Tu1300 Endoscopic Submucosal Dissection for Silent Gastric Dieulafoy Lesions Mimicking Gastrointestinal Stromal Tumors Xue Chen1, Hailong Cao*1, Bangmao Wang1, Dan Wang2 1 Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, Tianjin, China; 2Department of Pathology, General Hospital of Tianjin Medical University, Tianjin, Tianjin, China Background and Aim: Dieulafoy lesion is a rare but serious cause of gastrointestinal hemorrhage. However, some cases can be occasionally found without bleeding during the endoscopic screening, and the management remains unclear. The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for silent gastric Dieulafoy lesions, which presented as protrusion lesions mimicked gastrointestinal stromal tumors. Methods: Data from the patients with gastric protrusion lesions who underwent ESD from September 2008 to December 2016 in General Hospital, Tianjin Medical University, China were recorded. Cases with pathological diagnosis of Dieulafoy lesion without bleeding were enrolled for further analysis. Results: A total of 7 patients (2 males and 5 females) with mean age of (57.74.15) years old were pathologically diagnosed as Dieulafoy lesion. Four of the lesions located in gastric antrum, 2 in the fundus and 1 in the body of stomach, respectively. The mean size of the Dieulafoy lesions under white light endoscopy and endoscopic ultrasonography (EUS) were (1.060.28) cm and (0.840.29) cm. The origin of these lesions were submucosa (6/7, 85.7%) and muscularis propria (1/7, 14.3%). Three of them appeared with mixed echo under EUS, 3 with hypoechogenicity and 1 with hyperechogenicity. En bloc complete resection was achieved in all the lesions by ESD with average time of (76.0016.86) mins and no intraoperative bleeding happened. In addition, all patients were followed up for 1-53 months and no recurrence or long-term complications was observed. Conclusions: ESD can be an effective and safe treatment for silent gastric Dieulafoy lesions with clinical presentations of protrusion lesions mimicking gastrointestinal stromal tumors.
Demographics and clinical data of the patients with silent gastric Dieulafoy lesion. Patients Clinical symptoms (n,%) Abdominal discomfort Abdominal distension Epigastric pain Acid reflux Upper gastrointestinal bleeding Others Distribution (n,%) Antrum Fundus Body Size <1cm 1-2cm 2-3cm Layer of origin Submucosa Muscularis propria EUS Mixed echo Hyperechogenicity Hypoechogenicity Complete resection Complications Intraoperative bleeding Delayed bleeding Perforation Mortalities Recurrence
n 3 2 1 1 0 0 0
% 42.8 28.6 14.3 14.3 0.0 0.0 0.0
4 2 1
57.1 28.6 14.3
1 6 0
14.3 85.7 0.0
6 1
85.7 14.3
3 1 3
42.9 14.3 42.8
0 0 0 0 0 0
0.0 0.0 0.0 0.0 0.0 0.0
EUS, endoscopic ultrasound
Figure 2. Endoscopic submucosal dissection procedure and pathological characteristics of silent gastric Dieulafoy lesion. (A) The silent Dieulafoy lesion mimicking gastrointestinal stromal tumors was found. (B) The mucosa around the lesion was marked. (C) A circular incision was made into the mucosa around the lesion. (D) The lesion was removed from the gastric wall. (E) The wound was closed by some clips. (F) The lesion was completely removed. (G) Several arteries with large caliber were observed by pathological examination. (H) Endoscopic view of the wound after 1.5 months follow-up. Tu1301 Safety and Efficacy of Gastroenterologist-Directed Propofol Administration for Endoscopic Procedures: 10Year Experience in a Private Clinic in Lima, Peru Jorge Luis Espinoza-Ríos1, Juan Antonio Chirinos*2,3, Martin Tagle2,3 1 Gastroenterology, Hospital Cayetano Heredia, Lima, Lima, Peru; 2 Gastroenterology, Clínica Angloamericana, Lima, Lima, Peru; 3Faculty Member, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Lima, Peru Background: An adequate sedation is key to perform endoscopic procedures without causing discomfort to the patient, allowing rapid recovery and at the
AB608 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Tu1299 Patient Factors Predicting Poor Tolerance of Endoscopic Procedures With Moderate Sedation Anna Strongin*1, Pallavi Surana1, Christopher Haydek2, Bryan F. Curtin1, Theo Heller1, Sheila Kumar1, Christopher Koh1 1 NIDDK, National Institutes of Health, Bethesda, MD; 2Loyola University Chicago, Maywood, IL Introduction: Appropriate levels of sedation are paramount for optimizing patient comfort, safety, and technical success during endoscopy. Per current guidelines, adequate sedation can be achieved in most patients undergoing routine esophagogastroduodenoscopy (EGD) and colonoscopy with moderate sedation. Aim: To identify patient factors associated with failure of moderate sedation during endoscopic procedures. Methods: Endoscopic procedures performed under moderate sedation from 2000-2016 were reviewed at the National Institutes of Health Clinical Center. Patients were categorized as “poorly tolerated,” based on the assessment of the performing endoscopist, or “easily sedated,” based on low levels of sedation (fentanyl 50 mcg and versed 2 mg). Epidemiologic and anthropometric data, type/ indication of procedure, inpatient/outpatient status, and benzodiazepine/opiate use were analyzed. Univariate and multivariate analyses comparing the two groups were performed. Results: Over a 16-year period, 307 patients met criteria for inclusion – 227 were categorized as “easily sedated” and 80 as “poorly tolerated.” In the total cohort, 53.4% were Caucasian, 14.3% Black, 22.8% Hispanic, and 9.5% Asian; 55% were male; and the mean age was 53.613.9. 64.8% of patients underwent EGDs and 35.2% colonoscopies. In the “poorly tolerated” group, the median sedation was: fentanyl 125 mcg (interquartile range 100-175), midazolam 4 mg (IQR 3-5), and diphenhydramine 25 (IQR 25-50). On univariate analysis, Hispanic or Asian race was associated with easy sedation, whereas age < 50, female sex, body mass index (BMI) < 25, black race, and undergoing colonoscopy (as compared to EGD) was associated with poor tolerance. On multivariate analysis, Hispanic or Asian race remained predictive for easy sedation (odds ratio [OR] 0.32, 95% CI 0.14-0.76; OR 0.15, 0.0370.59, respectively) whereas younger age (OR 6.7, 3.4-13.0), lower BMI (OR 2.6, 1.44.8), female sex (OR 2.1, 1.1-3.9), and colonoscopy (OR 3.4, 1.7-6.8) was predictive of poor tolerance. Looking only at upper endoscopies, younger age was associated with poor tolerance (OR 4.9, 2.2-11.0). With colonoscopies, Hispanic or Asian race was associated with easy sedation (OR 0.12, 0.02-0.67; OR 0.03, 0.002-0.40), whereas age < 50 (OR 5.1, 1.0-25), BMI < 25 (OR 6.7, 1.8-23.8), and female sex (OR 8.8, 2.234.4) were associated with poor tolerance. Conclusions: Various patient factors including gender, race, age, BMI and type of procedure appear to play a role in the success or failure of moderate sedation in endoscopic procedures. Patients who are female, younger, black, not overweight or obese, or undergo colonoscopy, may be at higher risk of poor tolerance of endoscopies with moderate sedation. Clinicians should be aware of these factors when choosing type of sedation, in order to optimize success and minimize failures of endoscopy.
Tu1300 Endoscopic Submucosal Dissection for Silent Gastric Dieulafoy Lesions Mimicking Gastrointestinal Stromal Tumors Xue Chen1, Hailong Cao*1, Bangmao Wang1, Dan Wang2 1 Department of Gastroenterology and Hepatology, General Hospital of Tianjin Medical University, Tianjin, Tianjin, China; 2Department of Pathology, General Hospital of Tianjin Medical University, Tianjin, Tianjin, China Background and Aim: Dieulafoy lesion is a rare but serious cause of gastrointestinal hemorrhage. However, some cases can be occasionally found without bleeding during the endoscopic screening, and the management remains unclear. The aim of this study was to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for silent gastric Dieulafoy lesions, which presented as protrusion lesions mimicked gastrointestinal stromal tumors. Methods: Data from the patients with gastric protrusion lesions who underwent ESD from September 2008 to December 2016 in General Hospital, Tianjin Medical University, China were recorded. Cases with pathological diagnosis of Dieulafoy lesion without bleeding were enrolled for further analysis. Results: A total of 7 patients (2 males and 5 females) with mean age of (57.74.15) years old were pathologically diagnosed as Dieulafoy lesion. Four of the lesions located in gastric antrum, 2 in the fundus and 1 in the body of stomach, respectively. The mean size of the Dieulafoy lesions under white light endoscopy and endoscopic ultrasonography (EUS) were (1.060.28) cm and (0.840.29) cm. The origin of these lesions were submucosa (6/7, 85.7%) and muscularis propria (1/7, 14.3%). Three of them appeared with mixed echo under EUS, 3 with hypoechogenicity and 1 with hyperechogenicity. En bloc complete resection was achieved in all the lesions by ESD with average time of (76.0016.86) mins and no intraoperative bleeding happened. In addition, all patients were followed up for 1-53 months and no recurrence or long-term complications was observed. Conclusions: ESD can be an effective and safe treatment for silent gastric Dieulafoy lesions with clinical presentations of protrusion lesions mimicking gastrointestinal stromal tumors.
Demographics and clinical data of the patients with silent gastric Dieulafoy lesion. Patients Clinical symptoms (n,%) Abdominal discomfort Abdominal distension Epigastric pain Acid reflux Upper gastrointestinal bleeding Others Distribution (n,%) Antrum Fundus Body Size <1cm 1-2cm 2-3cm Layer of origin Submucosa Muscularis propria EUS Mixed echo Hyperechogenicity Hypoechogenicity Complete resection Complications Intraoperative bleeding Delayed bleeding Perforation Mortalities Recurrence
n 3 2 1 1 0 0 0
% 42.8 28.6 14.3 14.3 0.0 0.0 0.0
4 2 1
57.1 28.6 14.3
1 6 0
14.3 85.7 0.0
6 1
85.7 14.3
3 1 3
42.9 14.3 42.8
0 0 0 0 0 0
0.0 0.0 0.0 0.0 0.0 0.0
EUS, endoscopic ultrasound
Figure 2. Endoscopic submucosal dissection procedure and pathological characteristics of silent gastric Dieulafoy lesion. (A) The silent Dieulafoy lesion mimicking gastrointestinal stromal tumors was found. (B) The mucosa around the lesion was marked. (C) A circular incision was made into the mucosa around the lesion. (D) The lesion was removed from the gastric wall. (E) The wound was closed by some clips. (F) The lesion was completely removed. (G) Several arteries with large caliber were observed by pathological examination. (H) Endoscopic view of the wound after 1.5 months follow-up. Tu1301 Safety and Efficacy of Gastroenterologist-Directed Propofol Administration for Endoscopic Procedures: 10Year Experience in a Private Clinic in Lima, Peru Jorge Luis Espinoza-Ríos1, Juan Antonio Chirinos*2,3, Martin Tagle2,3 1 Gastroenterology, Hospital Cayetano Heredia, Lima, Lima, Peru; 2 Gastroenterology, Clínica Angloamericana, Lima, Lima, Peru; 3Faculty Member, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Lima, Peru Background: An adequate sedation is key to perform endoscopic procedures without causing discomfort to the patient, allowing rapid recovery and at the
AB608 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org