Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time.

BACKGROUND: In 2002, a U.S. Multi-Society Task Force on Colorectal Cancer recommended that the withdrawal phase for colonoscopy should average at least 6-10 min. This was based on 10 consecutive colonoscopies by two endoscopists with different adenoma miss rates. AIMS: To characterize the relationship between endoscopist withdrawal time and polyp detection at colonoscopy, and to determine the withdrawal time that corresponds to the median polyp detection rate. DESIGN: Procedural data from out-patient colonoscopies performed at the Mayo Clinic, Rochester during 2003 were reviewed. Endoscopists were characterized by their mean withdrawal time for a negative procedure and individual polyp detection rate. RESULTS: A total of 10 955 colonoscopies performed by 43 endoscopists were analysed. Median withdrawal time was 6.3 min (range: 4.2-11.9); polyp detection rate was 44.0% (all polyps), 29.8% (< or = 5 mm), 5.9% (6-9 mm), 6.7% (10-19 mm), 2.1% (> or = 20 mm). Longer withdrawal time was associated with higher polyp detection rate (r = 0.76; P < 0.0001); this relationship weakened for larger polyps (r = 0.19 for polyps 6-9 mm, r = 0.28 for polyps 10-19 mm, r = 0.02 for polyps > or = 20 mm). Overall median polyp detection rate corresponded to a withdrawal time of 6.7 min. CONCLUSION: Our findings support a colonoscopy withdrawal time of at least 7 min, which correlates with higher colon polyp detection rates.

Prospective assessment of the impact of feedback on colonoscopy performance.

BACKGROUND: Colonoscopy is an operator-dependent procedure. The medical literature describes disparity in colonoscopy performance with respect to polyp detection, caecal intubation rates and procedural times. AIM: To assess prospectively the impact of feedback among a large cohort of colonoscopists on three performance parameters: caecal intubation rate, insertion time and withdrawal time. METHOD: In a prospective clinical study, procedural data from all out-patient colonoscopies performed by attending gastroenterologists at our institution were recorded routinely in a computerized database. Enhanced serial feedback was provided on a quarterly basis for three procedure parameters: intubation to caecum, insertion time and withdrawal time. Feedback (absolute value, % rank and group distribution) was sent by email every 3 months beginning with January 2005 feedback for all of 2004, and subsequently quarterly in April 2005 (for January-March 2005), July 2005 (for April-June 2005) and October 2005 (for July-September 2005). RESULTS: Feedback was provided to 58 endoscopists with a median experience level of 8 years. There was a relative decline of 19% in incomplete procedures, with median caecal non-intubation rates decreasing from 4.7% to 3.8% following the introduction of feedback while median insertion times declined from 10.6 to 9.5 mins, P = 0.02. Median withdrawal times did not change significantly, 9.1-8.9 mins, P = 0.6. CONCLUSIONS: Feedback by email appears to improve colonoscopy performance, enhancing completion rates and shortening insertion times without compromising withdrawal times.

A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings.

BACKGROUND: The optimum choice of dilator (rigid vs. balloon) for benign esophageal strictures has not been well studied. The aim of this study was to compare the immediate relief of dysphagia and the incidence of repeat dilatation within the first year with the use of either a rigid (Savary) dilator or balloon dilator for benign lower esophageal strictures. METHODS: Patients with dysphagia found to have benign esophageal strictures during endoscopy were randomized to undergo dilation with a rigid (Savary) or a balloon dilator (Microvasive or Bard). The 1-year incidence of repeat dilatation was estimated by the Kaplan-Meier method. RESULTS: A total of 251 subjects were stratified at entry according to the type of stricture (peptic vs. Schatzki ring) and severity of stricture (mild vs. moderate/severe) and then randomized to either a Savary (n = 88), Microvasive (n = 81), or Bard (n = 82) dilator. There were no significant differences between the rigid dilator or the two balloons with regard to immediate relief of dysphagia or the need for repeat dilatation at one year. Patients with moderate/severe strictures required repeat dilatation at one year twice as often as those with mild strictures. There were no significant complications reported in these patients. CONCLUSIONS: Both rigid and balloon dilators are equally effective and safe in the treatment of benign lower esophageal strictures caused by acid reflux and Schatzki rings.

The structure and function of endoscope channels: the inside story.

The GIA who has knowledge of channels in the flexible endoscope can avoid the need for repairs due to channel blockage and will be able to achieve the best possible instrument care. This paper provides a detailed description of the channels of the working endoscope, including location, access and functional interrelation-ships, to help make cleaning, disinfecting and troubleshooting a logical process. Diagrams are included to clarify the descriptions.

Staffing levels in endoscopy units.

Staffing the endoscopy area has become increasingly complex. Growth in procedure volumes, changes in technology, and the application of endoscopy in the diagnosis and treatment of disease contribute to the complexities. The manager must deal with these changes, maintain costs, and still provide adequate staffing to ensure patient safety and quality care. The purpose of this article is to present the results of a laboratory manager survey conducted in 1990. Of 51 laboratory managers who responded, those who rated their laboratories to be adequately staffed averaged 4.2 hr per procedure. The survey results may be useful to laboratory managers seeking to calculate staff needs in a typical endoscopy area.

A 21-year experience with major hemorrhage after percutaneous liver biopsy.

Nine thousand two hundred twelve liver biopsies were performed according to a defined protocol, and data were prospectively recorded to identify risk factors for major bleeding. There were 10 fatal and 22 nonfatal hemorrhages (0.11% and 0.24%, respectively). By comparison with a control group that did not hemorrhage, malignancy, age, sex, and the number of passes were the only predictable risk factors. The risk of fatal hemorrhage in patients with malignancy is estimated to be 0.4%; for nonfatal hemorrhage, 0.57%. In patients undergoing liver biopsy for nonmalignant disease, the risks are 0.04% and 0.16%, respectively.

Diagnostic laparoscopy in gastroenterology. A 14-year experience.

Between 1970 and 1983, we performed 1121 diagnostic laparoscopies in 1119 patients. More than 50% of the examinations were performed for malignant disease. An adequate examination was accomplished in 917 (82%) procedures. The most frequent reason for inadequate evaluation was the presence of dense intraabdominal adhesions from previous surgery. We observed 105 (9.4%) minor complications and 20 (1.8%) major complications including one death following hemorrhage from liver biopsy. Major complications included abdominal wall hematoma, perforated abdominal viscus, hemoperitoneum, bleeding from liver biopsy, and respiratory depression. We observed a trend to decreased use of laparoscopy. Ascites of unknown origin and certain specific situations in patients with chronic liver disease remain as major indications for this diagnostic technique.

The structure and function of the outpatient endoscopy unit.

The authors present an analysis of the requirements for space, equipment, and personnel for an outpatient unit. These studies were derived from personnel and procedure time studies, evaluation of equipment and maintenance costs, and utilization of space studies and should be applicable to any outpatient endoscopy unit performing more than 1000 procedures per year.

The incidence of adenocarcinoma in columnar-lined (Barrett's) esophagus.

We evaluated the risk of adenocarcinoma developing in Barrett's esophagus (esophagus lined with columnar epithelium). Mayo Clinic records were reviewed, and all cases that met predefined histologic criteria for the diagnosis of Barrett's esophagus in 1979 or earlier were included. In 18 of 122 such cases, adenocarcinoma of the esophagus and Barrett's esophagus were diagnosed simultaneously. The status of the remaining 104 cases was determined after a mean interval of 8.5 years. During this time, adenocarcinoma of the esophagus developed in 2 patients, and 24 died from other causes. We conclude that although the incidence of esophageal adenocarcinoma is increased in patients with symptomatic Barrett's esophagus, it does not occur in the majority of such patients.

Balloon dilatation of upper digestive tract strictures.

The results of balloon dilatation of upper digestive tract stricture in 111 patients were evaluated. Eighty-eight patients had esophageal strictures and 23 had gastric or pyloric strictures. Thirty-six patients had strictures associated with previous operations. Twenty-two percent of the patients with esophageal strictures had malignancies. Overall, 92% were successfully dilated, with a complication rate of 3%. Follow-up information was available in 95% of patients. Eighty-seven percent of living patients experienced symptomatic improvement, which lasted for a median period of 12 mo. Forty percent required a further procedure during the period of follow-up. We found no difference between esophageal strictures and gastric or pyloric strictures in success rate, complications, or need for further dilatation, although patients with esophageal strictures were more apt to have symptomatic improvement. Postoperative strictures responded as well as nonoperative strictures. Previously dilated strictures in patients with esophageal reflux were managed as successfully as strictures never before dilated. We found balloon dilatation of upper digestive tract stricture to be a safe, effective technique.

Percutaneous endoscopic gastrostomy. Simplified access for enteral nutrition.

The recently described technique of endoscopic placement of a permanent feeding gastrostomy is reviewed with several modifications. Our experience in 23 adults has led us to conclude that this nonsurgical technique is the procedure of choice in achieving long-term enteral nutrition in patients who have an intact, nonobstructed gut and in whom the stomach can be directly apposed to the anterior abdominal wall.

Differing effects of ursodeoxycholic or chenodeoxycholic acid on biliary cholesterol saturation and bile acid metabolism in man. A dose-response study.

A dose-response study comparing ursodeoxycholic and chenodeoxycholic acid was carried out in six men with asymptomatic radiolucent gallstones present in well-visualizing gallbladders. The study tested the effects of a low (averaging 6 mg/kg/day) or medium dose (averaging 11 mg/kg/day) of each bile acid on the cholesterol saturation of bile as well as on bile acid metabolism, as inferred from biliary and fecal bile acid composition. Ursodeoxycholic acid, at low or medium doses, induced bile desaturation in most patients, whereas chenodeoxycholic acid did not. Despite the greater desaturation efficacy of ursodeoxycholic acid, biliary bile acids became less enriched with the administered bile acid during ursodeoxycholic acid treatment than during chenodeoxycholic acid treatment. Both bile acids were nearly completely 7-dehydroxylated to lithocholic acid by colonic bacteria, but biliary lithocholic increased only slightly (and similarly) with each bile acid. Fecal bile acid composition suggested that administered ursodeoxycholic acid suppressed endogenous bile acid synthesis much less than chenodeoxycholic acid. The results indicate that ursodeoxycholic acid and chenodeoxycholic acid have similar but not identical effects on bile acid metabolism, but that for a given dose, ursodeoxycholic acid is a more potent desaturating agent than chenodeoxycholic acid. The results suggest that cholesterol gallstone dissolution with ursodeoxycholic acid should occur with a dose of 8-10 mg/kg in most nonobese patients.

Chenotherapy for gallstone dissolution. I. Efficacy and safety.

Clinical experience with chenodeoxycholic acid therapy for dissolving gallstones is reported, with particular attention to determinants of response. Of 12 patients receiving 15 mg/kg/day or more, ten responded (83%); only 15 of 40 patients (38%) receiving less than 15 mg/kg/day responded. Large solitary stones and stones in gallbladders that visualized poorly after oral cholecystography had a lower response rate. Radiopaque stones did not respond in 18 patients. Five of ten patients with stones in the common bile duct responded. Small, dose-related elevations in SGOT were the only biochemical abnormality observed. Liver biopsy specimens showed no notable abnormality. Diarrhea was an infrequent problem. Stones recurred in three of 15 patients during six to 48 months of observation without treatment. Chenodeoxycholic acid, when given in adequate dosage, continues to appear promising as medical therapy for asymptomatic radiolucent gallstones in radiologically visualizing gallbladders.

Liver biopsy: complications in 1000 inpatients and outpatients.

We prospectively evaluated risk factors in 1000 consecutive patients who underwent liver biopsy: 829 outpatients and 171 inpatients. The two groups were similar except that the outpatient group had a higher percentage of patients with hepatitis-cirrhosis and a lower percentage with neoplasia when compared with the inpatient group (P less than 0.01). The inpatient group had more relative contraindications (P less than 0.01). Among the 1000 patients, none died and none required laparotomy. If moderate to severe pain or hypotension or both developed (5.9%), they first became manifest during a 3-hr period of observation after biopsy. Forty-four outpatients (5.3%) were hospitalized; 39 were dismissed within 36 hr and 5 within 4 days. Complications were more often experienced by those with relative contraindications (P less than 0.05) and increased number of passes (P less than 0.01). Inpatients with hepatitis-cirrhosis experienced more complications (P less than 0.05) than did patients with other diagnoses (12.8 versus 3.8%). Complications were not related to type of needle, site of entry, or experience of operator. Liver biopsy as an outpatient procedure is safe if facilities are available for 3 hr of observation and hospital support; 5% of patients will require immediate hospitalization.

The value of gastroscopy in clinical diagnosis: a computer-assisted study.

The additional information obtained by gastroscopy in patients already examined by upper gastrointestinal roentgenography was assessed. For this purpose, a data sheet for computer analysis was filled in at the time of gastroscopy and again at patient dismissal. Overall, gastroscopy resulted in an altered diagnosis in 18 percent of 1, 368 examinations, and in another 7 percent of cases there were findings of possible clinical significance. Gastroscopic findings differed significantly from x-ray findings in 7 to 35 percent of cases, depending on the indication for the procedure.