Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience.

Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff.  Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.

Impact of ethylene oxide gas sterilization of duodenoscopes after a carbapenem-resistant Enterobacteriaceae outbreak.

BACKGROUND AND AIMS: Carbapenem-resistant Enterobacteriaceae (CRE) outbreaks have been implicated at several medical institutions involving gastroenterology laboratories and, specifically, duodenoscopes. Currently, there are no specific guidelines to eradicate or prevent the outbreak of this bacteria. We describe ethylene oxide (ETO) gas sterilizations of duodenoscopes to address this issue. METHODS: A complete investigation of the gastroenterology laboratory and an evaluation by the Centers for Disease Control and Prevention concluded that no lapses were found in the reprocessing of the equipment. With no deficiencies to address, we began a novel cleaning process using surgical ETO gas sterilizers in addition to standard endoscope reprocessing recommendations and guidelines, all while trying to eradicate the CRE contamination and prevent future recurrences. We also instituted a surveillance system for recurrence of CRE contamination via monthly cultures of the duodenoscopes. RESULTS: Between October 2013 and April 2014, 589 ERCPs were performed with 645 ETO gas sterilizations of 6 duodenoscopes. Given the extra 16 hours needed to sterilize the duodenoscopes, our institution incurred costs resulting from purchasing additional equipment and surveillance cultures. Four duodenoscopes sustained damage during this period; however, this could not be directly attributed to the sterilization process. Furthermore, after an 18-month success period we encountered a positive CRE culture after sterilization, albeit of a different strain than originally detected during the outbreak. The duodenoscope underwent additional ETO gas sterilization, with a negative repeated culture; all potentially exposed individuals screened negative for CRE. CONCLUSIONS: Proper use of high-level disinfection alone may not eliminate multidrug-resistant organisms from duodenoscopes. In this single-center study, the addition of ETO sterilization and frequent monitoring with cultures reduced duodenoscope contamination and eliminated clinical infections. As such, ETO gas sterilization may provide benefit in further decontamination of duodenoscopes, but further investigation is necessary.

Eosinophilic Pancreatitis Diagnosed With Endoscopic Ultrasound.

Eosinophilic pancreatitis (EP) is a rare clinical entity, and few cases have been reported. It usually presents on imaging as a pancreatic mass leading to common bile duct obstruction and jaundice. Since it can mimic a malignancy, eosinophilic pancreatitis is often diagnosed after "false positive" pancreatic resections. To our knowledge, we report the only known case of EP in which the diagnosis was made by fine needle aspiration and core biopsy of the pancreas during EUS, sparing the patient a surgical resection. After a steroid course, there was improvement of clinical symptoms.

Accuracy and reliability of the endoscopic classification of chronic radiation-induced proctopathy using a novel grading method.

GOALS: To assess a novel grading method of radiation proctitis for intraobserver and interobserver agreement among endoscopists. BACKGROUND: There are no established criteria for the endoscopic classification of chronic radiation-induced proctopathy. We introduce a classification system based on telangiectasia density and vascular coalescence. Accuracy and reproducibility of this system were examined. STUDY: A total of 131 endoscopic images of the rectum in 74 consecutive patients undergoing lower endoscopy who had received pelvic radiation therapy were analyzed. Each image was duplicated, reversed, and rotated 90 degrees for a total of 262 images. These were shown in random order to 13 endoscopist evaluators (6 attending physicians, 7 gastroenterology fellows) using an online computer testing program. Each image was scored from grade 0 to 3 using criteria from the rectal telangiectasia density (RTD) classification we developed. Kappa (kappa) statistics and percent agreement were used to quantify the reproducibility and level of agreement. RESULTS: Intraobserver agreement: The mean (SD) for kappa among the 13 raters was 0.58 (0.09); 95% confidence interval [CI] = 0.527-0.636. Interobserver agreement: The estimated kappa across all 13 raters was 0.518 (95% CI = 0.506-0.530). For the 7 trainees, kappa was 0.547 (95% CI = 0.523-0.571). For the 6 attending physicians, the kappa was 0.481 (95% CI = 0.453-0.509). As another indicator of agreement, all 13 evaluators agreed on 30 (22.9%) of images, differed by no more than 1 grade on 60 (45.8%) images, no more than 2 grades on 33 (25.2%) of images, and no more than 3 grades on 8 of the images (6.1%); 73% of patients referred for bleeding control were RTD grade 2 or 3. CONCLUSIONS: The RTD grading scale for radiation proctopathy is reproducible among endoscopists. Hematochezia is associated with high RTD grade.