Efficacy of high-level disinfectants for reprocessing GI endoscopes in simulated-use testing.

BACKGROUND: There has been recent public concern regarding the adequacy of current practices for flexible endoscope reprocessing. High-level disinfection is defined by the Food and Drug Administration (FDA) as a minimum of 6-log reduction of mycobacteria under a worst-case scenario. Several agents are currently approved by the FDA, but published data on their relative efficacies against mycobacteria are lacking. The objective of this study was to determine the efficacy of these agents for high-level disinfection. METHODS: In simulated-use testing, video endoscopes (5 colonoscopes and 5 duodenoscopes) were each inoculated with 9.0 x 10(7) colony-forming units of Mycobacterium chelonae. Cleaning was performed by using a standardized protocol. Each endoscope was then subjected to chemical disinfection with Cidex (2.0% glutaraldehyde) at 20 degrees C for 20 minutes, Sporox (7.5% hydrogen peroxide) at 20 degrees for 30 minutes, and Steris 20 (0.2% peracetic acid) at 50 degrees C to 56 degrees C for 12 minutes using the Steris System 1 processor. Although not FDA-approved, tests were also conducted by using 70% isopropyl alcohol at 20 degrees C for 20 minutes. These results were compared with disinfection with ethylene oxide gas. All channels were sampled for M chelonae before and after manual cleaning and after disinfection. RESULTS: Cleaning alone resulted in an average log reduction of 3. Cidex, Sporox, Steris 20, ethylene oxide gas, and isopropyl alcohol, in combination with manual cleaning, each achieved a 6-log or greater reduction of the mycobacterial inoculum. No organisms were recovered from any channel after reprocessing with ethylene oxide and Steris 20. CONCLUSIONS: Commercially available high-level disinfectants are equally efficacious for reprocessing flexible GI endoscopes when used in conjunction with cleaning and in accordance with recommended guidelines.

Endoscopic cecal perforation: mechanisms of injury.

OBJECTIVE: Most endoscopic perforations of the colon occur in the rectosigmoid area and are thought to be secondary to direct injury from the endoscopic instrument. The aim of this study was to describe the mechanisms of injury and clinical outcome of endoscopic perforation involving the cecum. METHODS: Retrospective review of 6684 consecutive colonoscopic procedures performed at a university hospital over a 7-yr period. RESULTS: Colonoscopy was complicated by perforation in 0.22%. Five of the 15 perforations occurred in the cecum. The mean age of these five patients was 79.6 +/- 17.7 yr (mean +/- SD). Indications for the procedure were bleeding (n = 4) and suspected obstructing cecal mass (n = 1). Abnormal endoscopic findings included diverticulosis, vascular malformations, cecal ulcer/inflammation, mass, and polyps. Perforation was directly attributable to an ancillary procedure (three routine biopsies, one electrocautery) in the cecal area in four patients, and cecal pathology (inflammation, ulceration) was a contributing risk factor in three patients. Mortality was 80%. In contrast, a noncecal perforation usually occurred at the sigmoid region and was associated with technical difficulties, e.g., inability to traverse a stricture or reach the cecum. CONCLUSIONS: Routine forceps biopsy (without electrocautery) is an under-recognized cause of cecal perforation. Ancillary endoscopic interventions in the cecal region should be minimized in elderly patients with evidence of cecal inflammation. Pneumatic injury may be an additional risk factor for cecal perforation in patients with a colonic stricture or a tortuous colon.

Clinical outcome of post-ERCP pancreatitis: relationship to history of previous pancreatitis.

OBJECTIVE: The aim of this prospective study was to evaluate the relationship between clinical outcome of post-ERCP pancreatitis and history of previous pancreatitis. METHODS: Fifty patients (3.5%) developed procedure-related pancreatitis during the study period. Twenty-one patients had a history of previous pancreatitis (group I), and 29 patients had no history of previous pancreatitis (group II). There were no significant differences between the two groups with regard to age, gender, pancreatic duct injection, acinarization, or type of ERCP procedure. Grading of clinical severity was based on length of hospitalization, presence of pancreatic complications, and need for intervention: mild 28%, moderate 54%, and severe 18%. Four patients (8.0%) had pancreatic complications, but only one patient required surgery. There were no associated mortalities. RESULTS: Patients in group I had a shorter median hospital stay and were less likely to develop severe pancreatitis than patients in group II: 4.0 versus 7.0 days, p = 0.001 and 4.8 versus 27.6%, p = 0.038, respectively. CONCLUSIONS: Intralobular and/or periductal fibrosis secondary to prior pancreatitis may limit the degree of ERCP-induced pancreatic acinar damage.

Colocare self-test versus Hemoccult II Sensa for fecal occult blood testing.

OBJECTIVES: To compare the efficacy of ColoCARE Self-Test pads against Hemooccult II SENSA, a traditional guaiac-based card test, in the screening for colorectal neoplasia. METHODS: Prospective crossover analysis of 102 high-risk patients for screening of colorectal neoplasia with fecal occult blood testing, using ColoCARE Self-Test pads and Hemoccult II SENSA cards. RESULTS: Sixty-eight of the 102 patients (67%) had colorectal lesions diagnosed at colonoscopy. Of this group, 55 patients (81%) had either a polyp or cancer diagnosed at colonoscopy, with 13 of these 55 patients having polyps > or = 1 cm. ColoCARE detected 21% of all lesions, compared with 72% for Hemoccult II SENSA. ColoCARE detected only 16% of cases involving either a cancer or a polyp, and 24% of cases involving either a cancer or polyp > or = 1 cm in size. This compares with 75% and 95%, respectively, for Hemoccult II SENSA. Significantly more patients preferred ColoCARE (84%) to Hemoccult II SENSA (5%) (p < 0.00001), and patients found it easier to use ColoCARE (p < 0.01). However, 33% of patients did not feel comfortable interpreting the ColoCARE results, and 29% found it difficult to interpret the color change. CONCLUSION: These results indicate that patients may prefer the simplicity and convenience of ColoCARE; however, the test is not sensitive for the detection of colorectal neoplasia. Furthermore, patients do not feel comfortable interpreting ColoCARE results and prefer to have fecal occult blood testing interpreted by medical personnel.

Endoscopic sphincterotomy-induced pancreatitis: increased risk associated with nondilated bile ducts and sphincter of Oddi dysfunction.

OBJECTIVE: to evaluate the relationship between common bile duct diameter and the risk of sphincterotomy-induced pancreatitis. METHODS: Two hundred and ten consecutive patients were prospectively investigated. Patients were divided into three groups according to the indication for sphincterotomy: Group I had common bile duct stones (n = 108), group II had sphincter of Oddi dysfunction (n = 48), and group III had sphincterotomy for other indications (n = 54) (i.e., stent, dilation). RESULTS: There were 62 males and 148 females with a mean age of 60 yr (range 15-93 yr). Eleven of the 210 patients (5.2%) developed pancreatitis. Other sphincterotomy-induced complications were bleeding (n = 2), cholangitis (n = 2), retroperitoneal duodenal perforation (n = 1), and bile duct leakage (n = 1). The percentages of pancreatitis in groups I (3.7%), II (12.5%), and III (1.9%) were significantly different (p = 0.03). Patients with nondilated common bile ducts (< or = 10 mm) had more pancreatitis than patients with dilated common bile ducts (8.8% vs. 2.8%), but the difference was not significant (p = 0.07). However, when group III was excluded from the analysis, there was a significant difference in the percentage of pancreatitis between the patients with nondilated bile ducts and those patients with dilated bile ducts (13.1% vs. 2.2%, respectively; p < 0.01). Analysis for trend did not show a significant inverse relationship between bile duct diameter and the rate of sphincterotomy-induced pancreatitis. However, for all complications combined, the inverse relationship between bile duct diameter and rate of sphincterotomy-induced complications was significant: < or = 5 mm (23.1%), > 5-10 mm (13.8%), > 10-15 mm (3.2%), > 15 mm (2.4%) (p = 0.002). CONCLUSIONS: Endoscopic sphincterotomy is more hazardous in patients with nondilated bile ducts and sphincter of Oddi dysfunction. Further studies are needed to determine whether pancreatic stenting reduces the risk of sphincterotomy-induced pancreatitis in those clinical settings.