Surveillance Colonoscopy in VA Octogenarians. A Most Unnecessary Procedure
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W1452 The Value of Esophagogastroduodenoscopy (EGD) in Patients Referred for Open Access Screening Colonoscopy and Found to Have Anemia Terry L. Jue, Joseph W. Leung, Surinder K. Mann Background: Gastroenterologists receive referrals for open access colonoscopy to evaluate anemia. When colonoscopy does not explain anemia, EGD is usually scheduled. Studies have evaluated upper gastrointestinal findings from same-day EGD and colonoscopy for occult blood positive stool. Yet, many patients have asymptomatic anemia. Aim: Determine if same-day EGD benefits asymptomatic, anemic patients sent for open access screening colonoscopy. Methods: From 2002 to 2005, asymptomatic patients presenting to the Sacramento VA for open access screening colonoscopy who were found to have a hgb of 13.5 g/dl or less were offered same-day EGD. Patients who had an EGD within 5 years were excluded. Age, gender, hgb, and EGD findings were noted. Significant EGD findings were those requiring pharmacologic or surgical intervention, or further diagnostic evaluation. Results: See Tables. Conclusions: We recommend same-day EGD for patients sent for colonoscopy to evaluate asymptomatic anemia. A large proportion (41.8%) of our patients had significant EGD findings, including three early cancers. If EGD was performed later, patients would have risked repeat sedation and lost time from another visit. Without EGD, significant diagnoses may have been delayed. Hgb (g/dl) and Ages All patients Normal EGD Significant EGD Number 110 64(58.2%) 46(41.8%) Range Hgb 9.0-13.7 ) 9.1-13.4 9.0-13.7 ) Average Hgb 12.2 12.1 12.3 Median Hgb 12.4 12.3 12.5 Male:female 97 M 13 F 56 M 8 F 41 M 5 F Range age 45-85 48-85 45-80 Average age 64.2 64.4 64.0 Median age 63 64 63 ) One patient with hgb 13.7 after iron Significant findings and number of patients Findings Number Erosive gastritis 12 Gastritis, Duodenitis 6 Erosive esophagitis 5 Erosive duodenitis 4 Esophagitis, Gastritis 4 Stomach cancer, T1 2 Barrett’s, No dysplasia 4 Barrett’s, Cancer T1 1 Barrett’s, low grade dysplasia 1 Gastric ulcer 1 Duodenal ulcer 2 Esophageal ulcer 1 Mild portal gastropathy 1 Vascular malformation 1 Antral polyp, 1 cm 1 Helicobacter pylori ) 10 ) Determined by biopsies W1453 Quality Assurance in Flexible Sigmoidoscopy Sushil Maslekar, Philip Waudby, Graeme Duthie Introduction: Flexible sigmoidoscopy (FS) is already part of colon cancer screening programmes in the USA. Quality assurance in FS is important and completion to descending colon is a significant indicator. However, it is generally believed that clinical assessment of of position in colon and hence completion during flexible sigmoidoscopy is highly inaccurate. We therefore performed this study with the aims of determining completion rates with flexible sigmoidoscopy and the correlation between clinical and visual impression with actual position of the scope and to determine role of endomucosal clips with follow-up x-rays in objectively documenting completion and hence quality assurance. Methods: The study was approved by local ethics committee, and undertaken to good clinical practice standards. All patients undergoing elective flexible sigmoidoscopy except those with surgical resection were included. During FS, the endoscopist applied an endomucosal clip at the most proximal bowel reached and both endoscopist and attending nurse voiced their independent opinion about the position of the clip. Post procedure, all patients underwent an abdominal x-ray, which was reported by a consultant radiologist, blinded to the outcome of FS. The radiology results were then compared with the endoscopist and nurse assessment. A complete examination was defined as one where descending colon was reached. All data was analysed using SPSS V14.0. Results: 42 patients underwent FS, with a median age of 56 years. The endoscopist was accurate in his assessment of position in colon in 33 patients (79%). The attending nurse was accurate in only 25% of cases. The differences between endoscopist assessment and radiological opinion were not significant (p Z 0.3, paired sample t-test). The descending colon was reached in 22 patients and the splenic flexure in 10 patients, giving a crude completion rate of 78%. and a corrected completion rate of 89%. There was no correlation between the length of the scope and its position in the colon. Conclusion: We believe that the clinical impression of endoscopist during flexible sigmoidoscopy regarding position is very accurate and the length of scope inserted should not be regarded as important. Use of endomucosal clips with follow-on abdominal x-ray is safe and effective method of determining completion, and is an excellent objective measure of quality assurance in flexible sigmoidoscopy. We recommend that this technique should be used to determine completion whenever the endoscopist is in doubt, and repeat flexible sigmoidoscopies performed if proven incomplete. W1454 Surveillance Colonoscopy in VA Octogenarians. A Most Unnecessary Procedure Rozina Mithani, Stephen J. Sontag, Thomas G. Schnell, Jack Leya, Hines-Loyola GI Fellows Introduction: Requests for surveillance (Surv) C-Scope in elderly Pts are becoming more frequent. On 9/01/2001 the Hines VA GI Section began a strict program to deny unnecessary C-Scopes. Presented here are the results of the policy for Surv Colonoscopy. GOALS: To determine whether our new strict policy resulted in (1) missed cancers (CRC), (2) true benefit when CRC was found, or (3) F/U C-Scopes if polyps were found. Methods: All requests for C-scope were reviewed electronically by the GI fellow and approved by a senior GI attending using pre-determined criteria and template response. For Pts R80 yrs requests were approved ONLY IF THE REQUESTOR WAS WILLING TO EXPLICITLY DOCUMENT IN A SEPARATE PROGRESS NOTE THAT THE PT WAS (1) HEALTHY ENOUGH TO UNDERGO THE PROCEDURE AND (2) EXPECTED TO LIVE O5 YRS. C-Scope-Not Done (ND) resulted from 2 factors: (1) Request rejected or (2) Request approved, Pt No-Showed. Results: During the first 5 yrs, there were 82 requests for Surv in Pts R80 yrs (38% for cancer, 62% for polyps). 52% (43/82) were approved, 74% (32/43) completed the C-Scope. Overall, only 39% of requests resulted in C-Scope. K-M Survival showed that C-Scope-ND Pts had 9-fold greater mortality than C-Scope-Done (Hazard Ratio: 9.0; CI:1.4-15.4; P Z 0.01). All Cause Mortality in C-Scope-ND Vs C-Scope-Done Pts was 20% Vs 3.1% (Diff: 16.9; CI: 4-30). Indeed, 40% of C-Scope-ND Pts were dead by 2 yrs. One HGD polyp was removed in an 85y/o. Benign polyps in 4 Pts resulted in 4 (normal) F/U C-Scopes. Conclusion: (1) We found no benefit to Surv C-Scope in the group of VA octogenarians. (2) Octogenarian Pts having a benign C-Scope in their 70’s do not require Surv, as no Pt developed invasive CRC. (3) Our VA ‘‘Controlled Access’’ Program, which requires PCP commitment to safety and benefit, safely avoided unnecessary Surv C-Scopes in 61% of octogenarian Pts, 40% of whom had died within 2 yrs of request. Abstracts AB370 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007 www.giejournal.org
Transcript of Surveillance Colonoscopy in VA Octogenarians. A Most Unnecessary Procedure
W1452
The Value of Esophagogastroduodenoscopy (EGD) in Patients
Referred for Open Access Screening Colonoscopy and Found
to Have AnemiaTerry L. Jue, Joseph W. Leung, Surinder K. MannBackground: Gastroenterologists receive referrals for open access colonoscopy toevaluate anemia. When colonoscopy does not explain anemia, EGD is usuallyscheduled. Studies have evaluated upper gastrointestinal findings from same-dayEGD and colonoscopy for occult blood positive stool. Yet, many patients haveasymptomatic anemia. Aim: Determine if same-day EGD benefits asymptomatic,anemic patients sent for open access screening colonoscopy. Methods: From 2002to 2005, asymptomatic patients presenting to the Sacramento VA for open accessscreening colonoscopy who were found to have a hgb of 13.5 g/dl or less wereoffered same-day EGD. Patients who had an EGD within 5 years were excluded.Age, gender, hgb, and EGD findings were noted. Significant EGD findings werethose requiring pharmacologic or surgical intervention, or further diagnosticevaluation. Results: See Tables. Conclusions: We recommend same-day EGD forpatients sent for colonoscopy to evaluate asymptomatic anemia. A large proportion(41.8%) of our patients had significant EGD findings, including three early cancers.If EGD was performed later, patients would have risked repeat sedation and losttime from another visit. Without EGD, significant diagnoses may have beendelayed.
Hgb (g/dl) and Ages
All patients Normal EGD Significant EGD
Number 110 64(58.2%) 46(41.8%)Range Hgb 9.0-13.7) 9.1-13.4 9.0-13.7)
Average Hgb 12.2 12.1 12.3Median Hgb 12.4 12.3 12.5Male:female 97 M 13 F 56 M 8 F 41 M 5 FRange age 45-85 48-85 45-80Average age 64.2 64.4 64.0Median age 63 64 63
)One patient with hgb 13.7 after iron
Significant findings and number of patients
Findings Number
Erosive gastritis 12Gastritis, Duodenitis 6Erosive esophagitis 5Erosive duodenitis 4Esophagitis, Gastritis 4Stomach cancer, T1 2Barrett’s, No dysplasia 4Barrett’s, Cancer T1 1Barrett’s, low grade dysplasia 1Gastric ulcer 1Duodenal ulcer 2Esophageal ulcer 1Mild portal gastropathy 1Vascular malformation 1Antral polyp, 1 cm 1Helicobacter pylori) 10
)Determined by biopsies
W1453
Quality Assurance in Flexible SigmoidoscopySushil Maslekar, Philip Waudby, Graeme DuthieIntroduction: Flexible sigmoidoscopy (FS) is already part of colon cancer screeningprogrammes in the USA. Quality assurance in FS is important and completion todescending colon is a significant indicator. However, it is generally believed thatclinical assessment of of position in colon and hence completion during flexiblesigmoidoscopy is highly inaccurate. We therefore performed this study with theaims of determining completion rates with flexible sigmoidoscopy and thecorrelation between clinical and visual impression with actual position of the scopeand to determine role of endomucosal clips with follow-up x-rays in objectivelydocumenting completion and hence quality assurance. Methods: The study wasapproved by local ethics committee, and undertaken to good clinical practicestandards. All patients undergoing elective flexible sigmoidoscopy except thosewith surgical resection were included. During FS, the endoscopist applied anendomucosal clip at the most proximal bowel reached and both endoscopist andattending nurse voiced their independent opinion about the position of the clip.Post procedure, all patients underwent an abdominal x-ray, which was reported bya consultant radiologist, blinded to the outcome of FS. The radiology results were
then compared with the endoscopist and nurse assessment. A completeexamination was defined as one where descending colon was reached. All data wasanalysed using SPSS V14.0. Results: 42 patients underwent FS, with a median age of56 years. The endoscopist was accurate in his assessment of position in colon in 33patients (79%). The attending nurse was accurate in only 25% of cases. Thedifferences between endoscopist assessment and radiological opinion were notsignificant (p Z 0.3, paired sample t-test). The descending colon was reached in 22patients and the splenic flexure in 10 patients, giving a crude completion rate of78%. and a corrected completion rate of 89%. There was no correlation betweenthe length of the scope and its position in the colon. Conclusion: We believe thatthe clinical impression of endoscopist during flexible sigmoidoscopy regardingposition is very accurate and the length of scope inserted should not be regarded asimportant. Use of endomucosal clips with follow-on abdominal x-ray is safe andeffective method of determining completion, and is an excellent objective measureof quality assurance in flexible sigmoidoscopy. We recommend that this techniqueshould be used to determine completion whenever the endoscopist is in doubt,and repeat flexible sigmoidoscopies performed if proven incomplete.
Abstracts
AB370 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
W1454
Surveillance Colonoscopy in VA Octogenarians. A Most
Unnecessary ProcedureRozina Mithani, Stephen J. Sontag, Thomas G. Schnell, Jack Leya,Hines-Loyola GI FellowsIntroduction: Requests for surveillance (Surv) C-Scope in elderly Pts are becomingmore frequent. On 9/01/2001 the Hines VA GI Section began a strict program todeny unnecessary C-Scopes. Presented here are the results of the policy for SurvColonoscopy. GOALS: To determine whether our new strict policy resulted in (1)missed cancers (CRC), (2) true benefit when CRC was found, or (3) F/U C-Scopes ifpolyps were found. Methods: All requests for C-scope were reviewed electronicallyby the GI fellow and approved by a senior GI attending using pre-determinedcriteria and template response. For Pts R80 yrs requests were approved ONLY IFTHE REQUESTOR WAS WILLING TO EXPLICITLY DOCUMENT IN A SEPARATEPROGRESS NOTE THAT THE PT WAS (1) HEALTHY ENOUGH TO UNDERGO THEPROCEDURE AND (2) EXPECTED TO LIVE O5 YRS. C-Scope-Not Done (ND)resulted from 2 factors: (1) Request rejected or (2) Request approved,Pt No-Showed. Results: During the first 5 yrs, there were 82 requests for Surv inPts R80 yrs (38% for cancer, 62% for polyps). 52% (43/82) were approved, 74%(32/43) completed the C-Scope. Overall, only 39% of requests resulted in C-Scope.K-M Survival showed that C-Scope-ND Pts had 9-fold greater mortality thanC-Scope-Done (Hazard Ratio: 9.0; CI:1.4-15.4; P Z 0.01). All Cause Mortality inC-Scope-ND Vs C-Scope-Done Pts was 20% Vs 3.1% (Diff: 16.9; CI: 4-30). Indeed,40% of C-Scope-ND Pts were dead by 2 yrs. One HGD polyp was removed in an85y/o. Benign polyps in 4 Pts resulted in 4 (normal) F/U C-Scopes. Conclusion:(1) We found no benefit to Surv C-Scope in the group of VA octogenarians. (2)Octogenarian Pts having a benign C-Scope in their 70’s do not require Surv, as no Ptdeveloped invasive CRC. (3) Our VA ‘‘Controlled Access’’ Program, which requiresPCP commitment to safety and benefit, safely avoided unnecessary Surv C-Scopes in61% of octogenarian Pts, 40% of whom had died within 2 yrs of request.
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