- Email: [email protected]
Tu1393 Efficacy and Safety of Endoscopic Treatment With Cyanoacrylate Metacrilosisolfolano Without Lipiodol® for Gastric Varices
Abstracts
LFTs, and findings on abdominal ultrasound (GIE 2010; 71: 1-9). The guidelines recommend that high risk patients proceed straight to ERCP. Aim: To evaluate the utilization of MRCP prior to ERCP in patients who are classified as high risk for choledocholithiasis at a tertiary referral center. Methods: An institutional administrative database was searched from 2001-2010 using ICD-9-CM diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis as well as ICD9-CM procedure codes for MRCP and ERCP. Patient demographics, clinical, laboratory, radiologic, and endoscopic data, as well as cost of treatment were extracted. Patients with a history of cholecystectomy, malignant biliary obstruction, chronic pancreatitis, sphincter of Oddi dysfunction, primary sclerosing cholangitis, HIV cholangiopathy, liver transplantation, intrinsic liver disease, or sickle cell anemia were excluded. Patients categorized as high risk for choledocholithiasis per the ASGE guidelines were evaluated. Demographics, clinical endpoints, and cost variables were compared between groups with and without MRCP using chi-square test for proportions, Student’s t-test for means, and Wilcoxon rank-sum test for medians. Results: A total of 2422 patients were reviewed, with 309 patients meeting inclusion criteria and being classified as high risk. 248 patients (80%) underwent ERCP only, while 61 patients (20%) underwent MRCP prior to ERCP. There was no difference in these two groups with regards to age (mean ⫾ SD: 56.2 ⫾ 20.2 years vs. 55.6 ⫾ 18.6 years, p⫽0.83) and gender (41% vs. 43% male, p⫽ 0.79). The delay in ERCP was associated with a significantly longer median (Q1-Q3) length of stay (8 days (515) vs. 6 days (3-10) days, p ⫽ 0.01), higher median total hospital charges ($25,492 vs. $17,160, p ⫽ 0.008) and higher median radiology charges ($3,326 vs. $1,770, p ⬍ 0.0001). In addition, the median (Q1-Q3) post-ERCP recovery time was greater in the MRCP group (4 days (2-9) vs. 3 days (1-7), p⫽0.17), although not statistically significant. The need for ICU (21% vs. 14%, p⫽ 0.26), rate of positive blood cultures (14.8% vs. 12.4%, p ⫽ 0.62) and mortality (4.0% vs. 3.3%, p ⫽ 1.0) were similar in both groups. Conclusions: There is substantial overuse of MRCP in patients who are high risk for choledocholithiasis which is associated with greater length of hospital stay and higher health care cost. Adherence to high risk stratification guidelines would result in substantial systemic cost savings without a compromise in patient outcome.
Mo1583 Second Report of the UK Multi-Center DBE Registry: Furthering the International DBE Experience Edward J. Despott1, Alberto Murino1, Stephen Hughes2, Abhishek Deo2, David S. Sanders3, Reena Sidhu3, Robert P. Willert4, John N. Plevris5, Ken Trimble5, Jason S. Jennings6 1 Wolfson Unit for Endoscopy, St Mark’s Hospital & academic Institute, Imperial College, London, United Kingdom; 2Dept. of Gastroenterology, North Bristol Hospitals NHS Trust, Bristol, United Kingdom; 3Dept. of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom; 4Dept. of Gastroenterology, Manchester Royal Infirmary, Manchester, United Kingdom; 5Centre for Liver & Digestive Disorders, Edinburgh Royal Infirmary, Edinburgh, United Kingdom; 6Dept. of Gastroenterology, Centre for Digestive Diseases, Leeds General Infirmary, Leeds, United Kingdom Introduction: Double balloon enteroscopy (DBE) is now considered to be the ‘gold-standard’ of device assistedenteroscopy, transforming the investigation and management of small bowel (SB) disorders by facilitating directendoscopic access of the entire small bowel. Methods: This is the second UK multi-centre registry (6 centres)report since the introduction of DBE in the UK in 2005. Results: 950cases (534 men) were performed. Mean age was 55years (7-94 years). 290 cases were done under generalanaesthesia, 660 cases under conscious sedation. 643 cases were performed via the oral route, 268 were performed viathe rectal route while 29 cases were performed via an ileostomy. Calculated mean depth of insertion was 240⫾70 cm and 174⫾85 cm for oral and rectal routes respectively. Mean time taken to complete procedures was 68⫾15 minutes. Carbondioxide was used as the insufflating gas in 679 cases while air was used in the remaining 271 cases. DBE was precededby capsule endoscopy (CE) in 720 cases. Concordance of diagnoses at CE and DBE was 61% and the overall diagnosticyield for DBE was 64%. The indications and therapies applied at DBE are shown (Table 1). Significant lesions missed byCE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy atDBE was applied in 37% of procedures. There were 8 reported complications (3 perforations, 1 acute coronarysyndrome, 3 cases of minor bleeding and 1 case of pancreatitis); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.8%, with a complication rate for therapeutic procedures of 2.3%. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Conclusion: The second report of the UK experience mirrors other national series published to date, consolidating that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.
Tu1392 Electronic Time Stamps: A Helpful Tool to Evaluate and Improve Efficiency in the Endoscopy Unit: A Follow Up Study Firas H. Al-Kawas1, Srilakshmi Narra1, Kia Lee1, Sarah Lothrop1, Dariele Burchfield2, Kevin Cooper2 1 Gastroenterology, Georgetown University Hospital, Washington, DC; 2 Paragon Analytical Solutions, Raleigh, NC In today’s Healthcare market, it is very important to be as efficient as possible without sacrificing quality or patient satisfaction. The use of electronic time stamps (ETS) in the endoscopy unit(EU) has the potential to provide ongoing seamless collection of data that is easily repeatable on a real time basis with minimal staff time commitment. The data is collected prospectively and on an ongoing basis to identify inefficiency causes allowing prompt identification and resolution. PENTAX’s i-TRAC software package was utilized to electronically capture critical time stamps for individual patients as they flowed throughout the EU. This required the staff to use a mouse click on the workstations with minimal interference with patient care. The information captured was then stored locally on a server and could easily be extracted. An earlier pilot study over a 7 week period of 1,231 outpatients undergoing a variety of diagnostic and therapeutic procedures suggested significant delays in registration and before patients were moved to the endoscopy room. There was also significant delays before the endoscopist was in the room i.e. physician response time(PRT) and before starting the 8am scheduled procedures. Therefore, follow up meetings were conducted with the EU staff to discuss the pilot study findings and solutions. Data was collected again over the next 10 weeks after a 6 months baseline study period. Good data was defined as staff compliance with capturing the ETS at the actual time of the event. Results: 2,105 patients underwent procedures during the follow up study period. Good data collection improved from 51% during baseline period to 65% during the follow up study. The average time for “registration complete” during the baseline study period was 7:38am and 7:16am for the follow up study. This is partly dependent upon the patient arrival time, but a 60% reduction in the amount of time to register a patient was also realized by streamlining the paperwork process. Average time for “patient ready” after complete pre-op evaluation was 8:04am in the baseline study period and 7:55am during the most current week of the follow up study (due to recently implemented improvement strategies). PRT improved by 30% during the follow up study. Start time for 8 o’clock cases has remained flat at this point, but improving several upstream processes is required prior to impacting the actual start times. Conclusions: ETS can provide a realistic and consistent ongoing assessment of patient throughput in the EU with minimal interference in patient care. Data collection is however dependent on staff commitment to the process and appears to improve over time. Continuous staff education and EU leadership commitment to the process is essential. Data can be customized to EU needs and can be used to improve efficiency the EU. Further long term studies are needed.
Tu1393 Efficacy and Safety of Endoscopic Treatment With Cyanoacrylate Metacrilosisolfolano Without Lipiodol® for Gastric Varices Gustavo F. Gomes, Lucianna M. Correia, Danielle Bonilha, Luciano Lenz, Frank S. Nakao, Gustavo A. De Paulo, Ermelindo Della Libera Universidade Federal de São Paulo, São Paulo, Brazil Background: Gastric varices (GV) are present in approximately 20% of patients with portal hypertension (PH) and are usually diagnosed during the screening of esophageal varices (EV) or after episode of gastrointestinal bleeding. The risk of rupture of the GV is smaller than the esophageal varices (5-20%), however this can be extremely severe, with high mortality (25-40%). The use of tissue adhesives is considered a therapeutic option for treatment of GV. The most used is a combination of cyanoacrylate with Lipiodol ® and that is associated with about 10% of embolic complication rates. Aims: To evaluate the efficacy and safety of the endoscopic injection therapy with N-Butyl-2 Cyanoacrylate Metacrilosisolfolano (NBCM - GLUBRAN 2®) without Lipiodol® for prophylactic bleeding gastric varices.Study:Case report series, ProspectiveMethods: A total of 21 patients (15 male/6 female) with PH and GV were treated with NBCM and followed between october 2009 and october 2010 at an average of 8.5 months. The diagnosis of GV and GV eradication after treatment was performed endoscopically and confirmed with endosonography (EUS). After puncturing GV with a regular injection needle 1 ml of NBCM was injected intravasal with the aid of distilled water. Follow-up at 3 and 6 months to evaluate of GV eradication was made. When necessary the injection was repeated with the maximum volume of 3 ml. Results: The eradication of GV was observed in 21 patients (100%) in a maximum of two sessions (13 patients - 1 session and 8 patients - 2 sessions) with a maximum volume of 2 ml of NBCM. GV recurrence, confirmed by EUS, occurred in 1 patient (4.7%) at 6 month follow-up. Mild epigastric pain was reported in 3 patients (14.2%). No major complications or damage to equipment were observed. Conclusions: Our results confirm that N-Butyl-2
AB394 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
Cyanoacrylate Metacrilosisolfolano (Glubran - 2®) administered with only distilled water was safe and effective to GV eradication. The fast rapid local intravasal polymerization when injected with only water could be associated to lower embolic complications.
bleeding per univariate and multivariate logistic regression (p⫽0.043). Presence or absence of endoscopic mucosal abnormalities was not significantly associated with post procedure bleeding (p ⫽0.157). Conclusion: Endoscopic procedures with mucosal biopsies can be done safely in patients with severe thrombocytopenia with significant bleeding occurring in only 1.7%. Pre procedure platelet count was not associated with post procedure bleeding. Concomitant use of platelet inhibitors did not affect bleeding risk. Chronic renal disease was the only variable that was independently associated with bleeding risk after endoscopy.
Tu1394 Efficacy of Endoscopic Treatment of Symptomatic Upper Gastrointestinal Leaks and Fistulas Post-Bariatric Surgery: Report of 25 Cases Alireza Ghotb, Janak N. Shah, Kenneth F. Binmoeller, Frank Weilert, Yasser M. Bhat Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA Background: Anastomotic leaks causing abscesses and upper gastrointestinal fistulae are a serious complication of bariatric surgery. Surgical management is challenging with significant morbidity. The aim of this study was to evaluate the efficacy of endoscopic treatment at a single center. Methods: Retrospective review of our database from March 2007 to September 2009 (42 months) was performed. Multimodality endoscopic therapy including injection (fibrin glue or cyanoacrylate), endoprosthesis (fully covered plastic or metal stents), endoclips and T-tag placement was performed at the discretion of the endoscopist. Followup included outpatient clinic visits, EGD and upper GI series to confirm resolution. Results: 31 cases of post-surgical gastrointestinal leaks and fistulae were identified. Of these, 25 cases were secondary to bariatric surgery and were included in the study. Types of surgeries were vertical sleeve gastrectomy (n⫽13; 52%), Roux-N-Y gastric bypass (5; 20%), duodenal switch (3, 12%), vertical sleeve gastrectomy and duodenal switch (4, 16%). The average time to diagnosis post-surgery was 56 days (range 2-221). Mean fistula size on presentation was 13.1mm (range 3-30mm). Treatment administered was: injection therapy ⫹ endoprosthesis (12; 48%), injection ⫹ endoprosthesis ⫹ endoclips (6; 24%), injection alone (3; 12%), injection ⫹ endoprosthesis ⫹ T-tag (3; 12%) and endoprosthesis alone (1; 4%). Mean number of endoscopic interventions per patient was 4.48 (range: 2 - 13). Average duration of follow-up was 24 months (range 8 - 42 months). 2 patients were lost to follow-up. 5 patients required surgery for definitive treatment and were considered to have failed endotherapy. Fistulas and leaks were considered healed in 18/25 cases (72%) with endoscopic therapy. There was no difference in healing rate when stratified by type of surgery or fistula size at presentation. No complications were reported. Discussion: Endoscopic treatment of post-bariatric surgery leaks and fistulae is safe. Multimodality therapy appears to effective in the treatment of defects smaller than 30mm.
Tu1395 Safety of Endoscopic Procedures in Patients With Severe Thrombocytopenia Shivakumar Vignesh, Deepti Canchi, Jill Weber, Bhupendra Rawal Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL Background: The risk of performing endoscopic procedures in the setting of severe thrombocytopenia (platelet count less than 50,000) has not been well studied. The effect of co-morbidities and pre-procedure platelet transfusions on the risk of post procedure bleeding in this population is unclear. Methods: We conducted a retrospective chart review of patients with severe thrombocytopenia who underwent endoscopic procedures between August 2002 and April 2010 at Moffitt Cancer Center. Demographics, co-morbidities and medications were collected and patients were followed up to 30 days after endoscopy. Post procedure bleeding was defined as a documented bleed within 30 days of procedure. Significant bleeding was defined as a drop in hemoglobin of 2g/dl. Patients with platelet count ⬍ 30,000 received platelet transfusion. Univariate analysis was performed using Fisher’s exact T test and ANOVA when appropriate. Multivariate analysis was performed using logistic regression. Results: A total of 232 patients (124 male, 108 female) fit criteria for the study. Types of endoscopic procedures included EGD (33%), sigmoidoscopy (2%), EGD and sigmoidoscopy (50%) and other (15%). 169 patients (73%) had multiple mucosal biopsies, 2 had endoscopic clip placement and the rest had no intervention. Post procedure bleeding occurred in 19 patients (8 %) and significant bleeding occurred in 4 (1.7%). No other complications occurred. Of the patients with a platelet count ⬍ 30,000 (n⫽93), 2 patients (2%) had significant post procedure bleeding. The difference in the mean platelet count in patients with post procedure bleeding (31,000) and those without post procedure bleeding (47,000) did not reach statistical significance (p⫽0.316). There was no significant association between post procedure bleeding and age, gender, platelet counts (on day of, week prior to, or 7 days after endoscopy), preprocedure platelet transfusion, Charlson comorbidity index, primary malignancy, use of platelet inhibitors, immunosuppressives, history of bone marrow transplant, GVHD or endoscopic interventions. There was a significant association between the presence of chronic renal disease and post procedure
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Tu1396 Measuring the Quality of Screening Colonoscopy: Moving on From Adenoma Detection Rate Tom J. Lee1, Claire Nickerson2, Colin Rees3, Richard J. McNally1, Matthew D. Rutter4 1 Institute of Health and Society, Newcastle University, Newcastle, United Kingdom; 2NHS Cancer Screening Programmes, Sheffield, United Kingdom; 3South of Tyne Bowel Cancer Screening Centre, South Tyneside District Hospital, South Tyneside, United Kingdom; 4 Tees Bowel Cancer Screening Centre, University Hospital of North Tees, Stockton on Tees, United Kingdom Introduction: Adenoma detection rate (ADR) is the most widely used metric to assess quality of colonoscopy. Studies have shown ADR to correlate with other measures of colonoscopic performance such as withdrawal time, caecal intubation rate and longer term outcomes such as interval cancer rate.ADR is calculated by dividing the number of procedures in which one or more adenomas are detected by the total number of procedures. It has an inherent limitation in that it does not measure the total number of adenomas detected. The ethos of screening colonoscopy, in addition to detecting cancer, is to detect and remove all adenomas. This abstract examines other measures of adenoma detection in the context of the NHS Bowel Cancer Screening Programme (BCSP). Methods: Data from all screening colonoscopies in the BCSP performed between August 206 and August 2009 were analysed. The following measures of adenoma detection were calculated for each colonoscopist who had performed ⱖ50 procedures: ADR (adenoma detection rate), MAP (mean adenomas per patient- total number of adenomas detected/number of procedures), MAP⫹ (mean adenomas per positive procedure- total number of adenomas detected/ number of procedures in which one or more adenoma were detected). Correlation was assessed using Pearson‘s correlation coefficient. Results: 31,088 procedures performed by 148 colonoscopists (mean 210 procedures per colonoscopist) were analysed. The mean, range, standard deviation and correlation with ADR of each of the measures of adenoma detection are shown in table 1.46.5% of patients have one or more adenomas, of these 53% have only 1 adenoma. For this reason, MAP and ADR correlate closely. However, MAP displays much greater variation than ADR. MAP⫹ demonstrated less variation and correlates less well with ADR. Conclusions: ADR and MAP correlate closely but MAP demonstrates a greater variation in colonoscopic performance. MAP reflects the aim of screening colonoscopy to detect and remove all adenomas. MAP may be a more sensitive measure of colonoscopic performance but prospective studies are required to confirm this.MAP⫹ is a less useful measure of adenoma detection in isolation. It is largely dependent on the ADR but may still be high despite a low ADR. It may be useful as an adjunct to ADR or MAP in colonoscopists with evidence of high colonoscopic performance (ADR greater than the mean of the population). In this group, MAP⫹ identifies a group of colonoscopists attaining very high adenoma detection. Table 1.
ADR MAP MAP⫹
Mean
Range
Standard deviation
Variation between highest and lowest colonoscopists
46.5% 0.91 1.94
21.9-59.8% 0.31-1.86 1.3-3.1
7% 0.25 0.35
2.7-fold 6-fold 2.3-fold
Correlation with ADR (r) n/a 0.85 (p⬍0.001) 0.54 (p⬍0.001)
Tu1397 Improving the Quality of Colonoscopy: The Role of Prospective Clinical Audit David G. Hewett1,2, Alicia J. Smith2,3, Nicholas J. Tutticci3, Juergen K. Landmann1, Barbara A. Leggett1,3, Mark N. Appleyard3 1 School of Medicine, University of Queensland, Brisbane, QLD, Australia; 2Skills Development Centre, Queensland Health, Brisbane, QLD, Australia; 3Department of Gastroenterology and Hepatology, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia The quality of colonoscopy is known to vary. Few studies have evaluated methods to improve colonoscopy quality and change physician behaviour. Aim: To evaluate the impact of prospective clinical audit on the quality of
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LFTs, and findings on abdominal ultrasound (GIE 2010; 71: 1-9). The guidelines recommend that high risk patients proceed straight to ERCP. Aim: To evaluate the utilization of MRCP prior to ERCP in patients who are classified as high risk for choledocholithiasis at a tertiary referral center. Methods: An institutional administrative database was searched from 2001-2010 using ICD-9-CM diagnosis codes for choledocholithiasis, cholangitis, and acute pancreatitis as well as ICD9-CM procedure codes for MRCP and ERCP. Patient demographics, clinical, laboratory, radiologic, and endoscopic data, as well as cost of treatment were extracted. Patients with a history of cholecystectomy, malignant biliary obstruction, chronic pancreatitis, sphincter of Oddi dysfunction, primary sclerosing cholangitis, HIV cholangiopathy, liver transplantation, intrinsic liver disease, or sickle cell anemia were excluded. Patients categorized as high risk for choledocholithiasis per the ASGE guidelines were evaluated. Demographics, clinical endpoints, and cost variables were compared between groups with and without MRCP using chi-square test for proportions, Student’s t-test for means, and Wilcoxon rank-sum test for medians. Results: A total of 2422 patients were reviewed, with 309 patients meeting inclusion criteria and being classified as high risk. 248 patients (80%) underwent ERCP only, while 61 patients (20%) underwent MRCP prior to ERCP. There was no difference in these two groups with regards to age (mean ⫾ SD: 56.2 ⫾ 20.2 years vs. 55.6 ⫾ 18.6 years, p⫽0.83) and gender (41% vs. 43% male, p⫽ 0.79). The delay in ERCP was associated with a significantly longer median (Q1-Q3) length of stay (8 days (515) vs. 6 days (3-10) days, p ⫽ 0.01), higher median total hospital charges ($25,492 vs. $17,160, p ⫽ 0.008) and higher median radiology charges ($3,326 vs. $1,770, p ⬍ 0.0001). In addition, the median (Q1-Q3) post-ERCP recovery time was greater in the MRCP group (4 days (2-9) vs. 3 days (1-7), p⫽0.17), although not statistically significant. The need for ICU (21% vs. 14%, p⫽ 0.26), rate of positive blood cultures (14.8% vs. 12.4%, p ⫽ 0.62) and mortality (4.0% vs. 3.3%, p ⫽ 1.0) were similar in both groups. Conclusions: There is substantial overuse of MRCP in patients who are high risk for choledocholithiasis which is associated with greater length of hospital stay and higher health care cost. Adherence to high risk stratification guidelines would result in substantial systemic cost savings without a compromise in patient outcome.
Mo1583 Second Report of the UK Multi-Center DBE Registry: Furthering the International DBE Experience Edward J. Despott1, Alberto Murino1, Stephen Hughes2, Abhishek Deo2, David S. Sanders3, Reena Sidhu3, Robert P. Willert4, John N. Plevris5, Ken Trimble5, Jason S. Jennings6 1 Wolfson Unit for Endoscopy, St Mark’s Hospital & academic Institute, Imperial College, London, United Kingdom; 2Dept. of Gastroenterology, North Bristol Hospitals NHS Trust, Bristol, United Kingdom; 3Dept. of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom; 4Dept. of Gastroenterology, Manchester Royal Infirmary, Manchester, United Kingdom; 5Centre for Liver & Digestive Disorders, Edinburgh Royal Infirmary, Edinburgh, United Kingdom; 6Dept. of Gastroenterology, Centre for Digestive Diseases, Leeds General Infirmary, Leeds, United Kingdom Introduction: Double balloon enteroscopy (DBE) is now considered to be the ‘gold-standard’ of device assistedenteroscopy, transforming the investigation and management of small bowel (SB) disorders by facilitating directendoscopic access of the entire small bowel. Methods: This is the second UK multi-centre registry (6 centres)report since the introduction of DBE in the UK in 2005. Results: 950cases (534 men) were performed. Mean age was 55years (7-94 years). 290 cases were done under generalanaesthesia, 660 cases under conscious sedation. 643 cases were performed via the oral route, 268 were performed viathe rectal route while 29 cases were performed via an ileostomy. Calculated mean depth of insertion was 240⫾70 cm and 174⫾85 cm for oral and rectal routes respectively. Mean time taken to complete procedures was 68⫾15 minutes. Carbondioxide was used as the insufflating gas in 679 cases while air was used in the remaining 271 cases. DBE was precededby capsule endoscopy (CE) in 720 cases. Concordance of diagnoses at CE and DBE was 61% and the overall diagnosticyield for DBE was 64%. The indications and therapies applied at DBE are shown (Table 1). Significant lesions missed byCE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy atDBE was applied in 37% of procedures. There were 8 reported complications (3 perforations, 1 acute coronarysyndrome, 3 cases of minor bleeding and 1 case of pancreatitis); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.8%, with a complication rate for therapeutic procedures of 2.3%. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Conclusion: The second report of the UK experience mirrors other national series published to date, consolidating that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.
Tu1392 Electronic Time Stamps: A Helpful Tool to Evaluate and Improve Efficiency in the Endoscopy Unit: A Follow Up Study Firas H. Al-Kawas1, Srilakshmi Narra1, Kia Lee1, Sarah Lothrop1, Dariele Burchfield2, Kevin Cooper2 1 Gastroenterology, Georgetown University Hospital, Washington, DC; 2 Paragon Analytical Solutions, Raleigh, NC In today’s Healthcare market, it is very important to be as efficient as possible without sacrificing quality or patient satisfaction. The use of electronic time stamps (ETS) in the endoscopy unit(EU) has the potential to provide ongoing seamless collection of data that is easily repeatable on a real time basis with minimal staff time commitment. The data is collected prospectively and on an ongoing basis to identify inefficiency causes allowing prompt identification and resolution. PENTAX’s i-TRAC software package was utilized to electronically capture critical time stamps for individual patients as they flowed throughout the EU. This required the staff to use a mouse click on the workstations with minimal interference with patient care. The information captured was then stored locally on a server and could easily be extracted. An earlier pilot study over a 7 week period of 1,231 outpatients undergoing a variety of diagnostic and therapeutic procedures suggested significant delays in registration and before patients were moved to the endoscopy room. There was also significant delays before the endoscopist was in the room i.e. physician response time(PRT) and before starting the 8am scheduled procedures. Therefore, follow up meetings were conducted with the EU staff to discuss the pilot study findings and solutions. Data was collected again over the next 10 weeks after a 6 months baseline study period. Good data was defined as staff compliance with capturing the ETS at the actual time of the event. Results: 2,105 patients underwent procedures during the follow up study period. Good data collection improved from 51% during baseline period to 65% during the follow up study. The average time for “registration complete” during the baseline study period was 7:38am and 7:16am for the follow up study. This is partly dependent upon the patient arrival time, but a 60% reduction in the amount of time to register a patient was also realized by streamlining the paperwork process. Average time for “patient ready” after complete pre-op evaluation was 8:04am in the baseline study period and 7:55am during the most current week of the follow up study (due to recently implemented improvement strategies). PRT improved by 30% during the follow up study. Start time for 8 o’clock cases has remained flat at this point, but improving several upstream processes is required prior to impacting the actual start times. Conclusions: ETS can provide a realistic and consistent ongoing assessment of patient throughput in the EU with minimal interference in patient care. Data collection is however dependent on staff commitment to the process and appears to improve over time. Continuous staff education and EU leadership commitment to the process is essential. Data can be customized to EU needs and can be used to improve efficiency the EU. Further long term studies are needed.
Tu1393 Efficacy and Safety of Endoscopic Treatment With Cyanoacrylate Metacrilosisolfolano Without Lipiodol® for Gastric Varices Gustavo F. Gomes, Lucianna M. Correia, Danielle Bonilha, Luciano Lenz, Frank S. Nakao, Gustavo A. De Paulo, Ermelindo Della Libera Universidade Federal de São Paulo, São Paulo, Brazil Background: Gastric varices (GV) are present in approximately 20% of patients with portal hypertension (PH) and are usually diagnosed during the screening of esophageal varices (EV) or after episode of gastrointestinal bleeding. The risk of rupture of the GV is smaller than the esophageal varices (5-20%), however this can be extremely severe, with high mortality (25-40%). The use of tissue adhesives is considered a therapeutic option for treatment of GV. The most used is a combination of cyanoacrylate with Lipiodol ® and that is associated with about 10% of embolic complication rates. Aims: To evaluate the efficacy and safety of the endoscopic injection therapy with N-Butyl-2 Cyanoacrylate Metacrilosisolfolano (NBCM - GLUBRAN 2®) without Lipiodol® for prophylactic bleeding gastric varices.Study:Case report series, ProspectiveMethods: A total of 21 patients (15 male/6 female) with PH and GV were treated with NBCM and followed between october 2009 and october 2010 at an average of 8.5 months. The diagnosis of GV and GV eradication after treatment was performed endoscopically and confirmed with endosonography (EUS). After puncturing GV with a regular injection needle 1 ml of NBCM was injected intravasal with the aid of distilled water. Follow-up at 3 and 6 months to evaluate of GV eradication was made. When necessary the injection was repeated with the maximum volume of 3 ml. Results: The eradication of GV was observed in 21 patients (100%) in a maximum of two sessions (13 patients - 1 session and 8 patients - 2 sessions) with a maximum volume of 2 ml of NBCM. GV recurrence, confirmed by EUS, occurred in 1 patient (4.7%) at 6 month follow-up. Mild epigastric pain was reported in 3 patients (14.2%). No major complications or damage to equipment were observed. Conclusions: Our results confirm that N-Butyl-2
AB394 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
Cyanoacrylate Metacrilosisolfolano (Glubran - 2®) administered with only distilled water was safe and effective to GV eradication. The fast rapid local intravasal polymerization when injected with only water could be associated to lower embolic complications.
bleeding per univariate and multivariate logistic regression (p⫽0.043). Presence or absence of endoscopic mucosal abnormalities was not significantly associated with post procedure bleeding (p ⫽0.157). Conclusion: Endoscopic procedures with mucosal biopsies can be done safely in patients with severe thrombocytopenia with significant bleeding occurring in only 1.7%. Pre procedure platelet count was not associated with post procedure bleeding. Concomitant use of platelet inhibitors did not affect bleeding risk. Chronic renal disease was the only variable that was independently associated with bleeding risk after endoscopy.
Tu1394 Efficacy of Endoscopic Treatment of Symptomatic Upper Gastrointestinal Leaks and Fistulas Post-Bariatric Surgery: Report of 25 Cases Alireza Ghotb, Janak N. Shah, Kenneth F. Binmoeller, Frank Weilert, Yasser M. Bhat Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, CA Background: Anastomotic leaks causing abscesses and upper gastrointestinal fistulae are a serious complication of bariatric surgery. Surgical management is challenging with significant morbidity. The aim of this study was to evaluate the efficacy of endoscopic treatment at a single center. Methods: Retrospective review of our database from March 2007 to September 2009 (42 months) was performed. Multimodality endoscopic therapy including injection (fibrin glue or cyanoacrylate), endoprosthesis (fully covered plastic or metal stents), endoclips and T-tag placement was performed at the discretion of the endoscopist. Followup included outpatient clinic visits, EGD and upper GI series to confirm resolution. Results: 31 cases of post-surgical gastrointestinal leaks and fistulae were identified. Of these, 25 cases were secondary to bariatric surgery and were included in the study. Types of surgeries were vertical sleeve gastrectomy (n⫽13; 52%), Roux-N-Y gastric bypass (5; 20%), duodenal switch (3, 12%), vertical sleeve gastrectomy and duodenal switch (4, 16%). The average time to diagnosis post-surgery was 56 days (range 2-221). Mean fistula size on presentation was 13.1mm (range 3-30mm). Treatment administered was: injection therapy ⫹ endoprosthesis (12; 48%), injection ⫹ endoprosthesis ⫹ endoclips (6; 24%), injection alone (3; 12%), injection ⫹ endoprosthesis ⫹ T-tag (3; 12%) and endoprosthesis alone (1; 4%). Mean number of endoscopic interventions per patient was 4.48 (range: 2 - 13). Average duration of follow-up was 24 months (range 8 - 42 months). 2 patients were lost to follow-up. 5 patients required surgery for definitive treatment and were considered to have failed endotherapy. Fistulas and leaks were considered healed in 18/25 cases (72%) with endoscopic therapy. There was no difference in healing rate when stratified by type of surgery or fistula size at presentation. No complications were reported. Discussion: Endoscopic treatment of post-bariatric surgery leaks and fistulae is safe. Multimodality therapy appears to effective in the treatment of defects smaller than 30mm.
Tu1395 Safety of Endoscopic Procedures in Patients With Severe Thrombocytopenia Shivakumar Vignesh, Deepti Canchi, Jill Weber, Bhupendra Rawal Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL Background: The risk of performing endoscopic procedures in the setting of severe thrombocytopenia (platelet count less than 50,000) has not been well studied. The effect of co-morbidities and pre-procedure platelet transfusions on the risk of post procedure bleeding in this population is unclear. Methods: We conducted a retrospective chart review of patients with severe thrombocytopenia who underwent endoscopic procedures between August 2002 and April 2010 at Moffitt Cancer Center. Demographics, co-morbidities and medications were collected and patients were followed up to 30 days after endoscopy. Post procedure bleeding was defined as a documented bleed within 30 days of procedure. Significant bleeding was defined as a drop in hemoglobin of 2g/dl. Patients with platelet count ⬍ 30,000 received platelet transfusion. Univariate analysis was performed using Fisher’s exact T test and ANOVA when appropriate. Multivariate analysis was performed using logistic regression. Results: A total of 232 patients (124 male, 108 female) fit criteria for the study. Types of endoscopic procedures included EGD (33%), sigmoidoscopy (2%), EGD and sigmoidoscopy (50%) and other (15%). 169 patients (73%) had multiple mucosal biopsies, 2 had endoscopic clip placement and the rest had no intervention. Post procedure bleeding occurred in 19 patients (8 %) and significant bleeding occurred in 4 (1.7%). No other complications occurred. Of the patients with a platelet count ⬍ 30,000 (n⫽93), 2 patients (2%) had significant post procedure bleeding. The difference in the mean platelet count in patients with post procedure bleeding (31,000) and those without post procedure bleeding (47,000) did not reach statistical significance (p⫽0.316). There was no significant association between post procedure bleeding and age, gender, platelet counts (on day of, week prior to, or 7 days after endoscopy), preprocedure platelet transfusion, Charlson comorbidity index, primary malignancy, use of platelet inhibitors, immunosuppressives, history of bone marrow transplant, GVHD or endoscopic interventions. There was a significant association between the presence of chronic renal disease and post procedure
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Tu1396 Measuring the Quality of Screening Colonoscopy: Moving on From Adenoma Detection Rate Tom J. Lee1, Claire Nickerson2, Colin Rees3, Richard J. McNally1, Matthew D. Rutter4 1 Institute of Health and Society, Newcastle University, Newcastle, United Kingdom; 2NHS Cancer Screening Programmes, Sheffield, United Kingdom; 3South of Tyne Bowel Cancer Screening Centre, South Tyneside District Hospital, South Tyneside, United Kingdom; 4 Tees Bowel Cancer Screening Centre, University Hospital of North Tees, Stockton on Tees, United Kingdom Introduction: Adenoma detection rate (ADR) is the most widely used metric to assess quality of colonoscopy. Studies have shown ADR to correlate with other measures of colonoscopic performance such as withdrawal time, caecal intubation rate and longer term outcomes such as interval cancer rate.ADR is calculated by dividing the number of procedures in which one or more adenomas are detected by the total number of procedures. It has an inherent limitation in that it does not measure the total number of adenomas detected. The ethos of screening colonoscopy, in addition to detecting cancer, is to detect and remove all adenomas. This abstract examines other measures of adenoma detection in the context of the NHS Bowel Cancer Screening Programme (BCSP). Methods: Data from all screening colonoscopies in the BCSP performed between August 206 and August 2009 were analysed. The following measures of adenoma detection were calculated for each colonoscopist who had performed ⱖ50 procedures: ADR (adenoma detection rate), MAP (mean adenomas per patient- total number of adenomas detected/number of procedures), MAP⫹ (mean adenomas per positive procedure- total number of adenomas detected/ number of procedures in which one or more adenoma were detected). Correlation was assessed using Pearson‘s correlation coefficient. Results: 31,088 procedures performed by 148 colonoscopists (mean 210 procedures per colonoscopist) were analysed. The mean, range, standard deviation and correlation with ADR of each of the measures of adenoma detection are shown in table 1.46.5% of patients have one or more adenomas, of these 53% have only 1 adenoma. For this reason, MAP and ADR correlate closely. However, MAP displays much greater variation than ADR. MAP⫹ demonstrated less variation and correlates less well with ADR. Conclusions: ADR and MAP correlate closely but MAP demonstrates a greater variation in colonoscopic performance. MAP reflects the aim of screening colonoscopy to detect and remove all adenomas. MAP may be a more sensitive measure of colonoscopic performance but prospective studies are required to confirm this.MAP⫹ is a less useful measure of adenoma detection in isolation. It is largely dependent on the ADR but may still be high despite a low ADR. It may be useful as an adjunct to ADR or MAP in colonoscopists with evidence of high colonoscopic performance (ADR greater than the mean of the population). In this group, MAP⫹ identifies a group of colonoscopists attaining very high adenoma detection. Table 1.
ADR MAP MAP⫹
Mean
Range
Standard deviation
Variation between highest and lowest colonoscopists
46.5% 0.91 1.94
21.9-59.8% 0.31-1.86 1.3-3.1
7% 0.25 0.35
2.7-fold 6-fold 2.3-fold
Correlation with ADR (r) n/a 0.85 (p⬍0.001) 0.54 (p⬍0.001)
Tu1397 Improving the Quality of Colonoscopy: The Role of Prospective Clinical Audit David G. Hewett1,2, Alicia J. Smith2,3, Nicholas J. Tutticci3, Juergen K. Landmann1, Barbara A. Leggett1,3, Mark N. Appleyard3 1 School of Medicine, University of Queensland, Brisbane, QLD, Australia; 2Skills Development Centre, Queensland Health, Brisbane, QLD, Australia; 3Department of Gastroenterology and Hepatology, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia The quality of colonoscopy is known to vary. Few studies have evaluated methods to improve colonoscopy quality and change physician behaviour. Aim: To evaluate the impact of prospective clinical audit on the quality of
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
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