A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines.

BACKGROUND: The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines. METHODS: A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed. RESULTS: Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001). CONCLUSIONS: This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.

The effects of practice and instruction on speed and accuracy during resident acquisition of simulated laparoscopic skills.

To assess the effects of practice and dynamic instruction on changes in speed and accuracy during acquisition of simulated laparoscopic surgical skills.Fourteen PGY-1 general surgery residents were randomly assigned to 1 of 2 experimental conditions (n = 7 per group), either practice only or practice with instruction, and required to perform 10 trials of each of 2 laparoscopic surgical skills-cannulation and object passing. Practice only subjects were given verbal instructions for each task, and corrective feedback only after trial 1. Practice with instruction subjects were treated the same, but also saw a videotaped demonstration and received dynamic feedback during and between each trial. Performance speed was recorded for each trial and number of errors was recorded for trials 8 to 10 by videotape review.Mean speed for subjects in both groups increased significantly for both tasks (p < 0.01). Practice with instruction subjects committed significantly fewer errors on object passing (p < 0.04) and were less variable in the number of errors committed during the cannulation task (p < 0.01).Practice, with or without dynamic instruction, results in significant improvement in the speed of performance of simulated laparoscopic surgical skills. The addition of dynamic instruction to simulator-based practice improves the quality and consistency of resident acquisition of laparoscopic surgical skills.

Granular cell tumor--a unique neoplasm of the internal anal sphincter: report of a case.

Granular cell tumors are rare, invariably benign, and often solitary tumors, which infrequently involve the gastrointestinal tract. We report the unique presentation of a granular cell tumor of the internal anal sphincter in a 75 year-old female. The tumor was detected during investigation of new rectal bleeding and was excised using a transanal approach and sphincter repair. At five-year follow-up the patient reported normal continence to stool and flatus and demonstrated no evidence of tumor recurrence. Immunohistochemical studies cite the Schwann neural cell as the origin of the granular cell tumor. Cytoplasmic features include acidophilic, p-aminosalicylic acid-positive, diastaseresistant granules. Granular cell tumors may be located anywhere in the body, but anorectal involvement is rare. In our own search of the world literature, no other cases were reported specifically to involve the anal sphincter. Granular cell tumors are usually detected incidentally but may be symptomatic, especially when the anorectal region is involved. Symptoms include perianal discomfort and bleeding. Adequate local excision is effective for both diagnosis and treatment of anorectal granular cell tumors. Careful follow-up should be performed after excision because of the risk of recurrence.

Jejunal diverticulosis: a rare entity with multiple presentations, a series of cases.

BACKGROUND/AIMS: Jejunal diverticulosis (JD) is a rare disease that has a variable presentation. The signs, symptoms, diagnosis, complications and treatment of JD will be discussed through a review of the literature and a series of cases from our own institution. METHODS: A retrospective analysis of the diagnosis, treatment and complications of JD was performed by a literature review. This was accompanied by a series of four cases of JD diagnosed and treated in our own institution. CONCLUSIONS: JD is a rare disease in which most patients are asymptomatic. However, JD's different complications are serious and can be fatal. The treatment is mainly surgical; however, there have been cases where nonsurgical management was successful.