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Popic J, Tipuric S, Balen I, Mrzljak A. Computed tomography colonography and radiation risk: How low can we go? World J Gastrointest Endosc 2021; 13:72-81. [PMID: 33763187 PMCID: PMC7958467 DOI: 10.4253/wjge.v13.i3.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/23/2021] [Accepted: 02/18/2021] [Indexed: 02/06/2023] Open
Abstract
Computed tomography colonography (CTC) has become a key examination in detecting colonic polyps and colorectal carcinoma (CRC). It is particularly useful after incomplete optical colonoscopy (OC) for patients with sedation risks and patients anxious about the risks or potential discomfort associated with OC. CTC's main advantages compared with OC are its non-invasive nature, better patient compliance, and the ability to assess the extracolonic disease. Despite these advantages, ionizing radiation remains the most significant burden of CTC. This opinion review comprehensively addresses the radiation risk of CTC, incorporating imaging technology refinements such as automatic tube current modulation, filtered back projections, lowering the tube voltage, and iterative reconstructions as tools for optimizing low and ultra-low dose protocols of CTC. Future perspectives arise from integrating artificial intelligence in computed tomography machines for the screening of CRC.
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Affiliation(s)
- Jelena Popic
- Department of Radiology, University Hospital Merkur, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
| | - Sandra Tipuric
- Department of Family Medicine, Health Center Zagreb-East, Zagreb 10000, Croatia
| | - Ivan Balen
- Department of Gastroenterology and Endocrinology, General Hospital Slavonski brod “Dr. Josip Bencevic”, Slavonski Brod 35000, Croatia
| | - Anna Mrzljak
- Department of Medicine, Merkur University Hospital, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
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Chen S, Zhou D, Ruan R, Yu J, Li Y, Liu Y, Wang S. A Novel Bipolar Polypectomy Snare Can Be an Alternative Choice for Endoscopic Resection. Front Med (Lausanne) 2021; 7:619844. [PMID: 33553214 PMCID: PMC7855578 DOI: 10.3389/fmed.2020.619844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022] Open
Abstract
Objective: Endoscopic resection (ER) is more difficult and has a higher rate of complications, such as perforation and bleeding. The aim of this study was to evaluate the safety and feasibility of a bipolar polypectomy snare for ER. Methods: Initial ER procedures in live pigs were carried out. Then, a human feasibility study was performed in patients with colorectal polyps. Finally, the finite element method was used to evaluate the safety and effectiveness of the new bipolar snare. Results: In the live animal model, there were no significant differences in wound size and cutting time between monopolar and bipolar groups. The histological results (histological scores) of the two groups in porcine experiments were almost the same except that the incision flatness of bipolar group was better than that of the monopolar group. Incidence of bleeding and perforation was similar between the two groups in pigs' and patients' study. At last, the finite element model showed that the vertical thermal damage depth produced by bipolar snare system was approximately 71–76% of that produced by monopolar snare system at the same power. Conclusions: The novel bipolar snare is feasible in patients with colorectal polyps and can be an alternative choice for ERs.
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Affiliation(s)
- Shengsen Chen
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Danping Zhou
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Rongwei Ruan
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Jiangping Yu
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Yandong Li
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Yuanshun Liu
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
| | - Shi Wang
- Department of Endoscopy, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou, Zhejiang, China
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Brosnan C, Hannan E, Duggan W, Harding T, Maguire D, Stafford AT. Diagnostic Inaccuracies of Barrett's Oesophagus on Gastroscopy: Are We Performing Unnecessary Surveillance? Cureus 2020; 12:e9850. [PMID: 32953357 PMCID: PMC7497227 DOI: 10.7759/cureus.9850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background It is common for patients to enter Barrett's oesophagus (BO) surveillance based on endoscopic appearances before the diagnosis is histologically confirmed. We set out to review this practice by establishing the accuracy of endoscopic diagnoses of BO. Methods All gastroscopy reports in which a diagnosis of BO was recorded were reviewed over one year. These were compared to the histopathological reports to assess diagnostic accuracy. Results BO was diagnosed in 84 procedures. This diagnosis was incorrect according to histology in 42.9% (n=36) of cases. Diagnostic accuracy was higher with gastroenterologists (38.8% incorrect, n=21) compared to surgeons (50% incorrect, n=15). Diagnostic accuracy was higher with consultants (34.9% incorrect, n=22) compared to registrars (66.7% incorrect, n=14). The dose of sedation used had no impact on accuracy. Unnecessary surveillance was booked in 36.1% (n=13) of cases. Conclusion It is insufficient to rely on endoscopic appearances alone to diagnose BO, irrespective of speciality or experience. The diagnosis should only be made after reviewing the histopathology report. This can eliminate unnecessary repeat endoscopy procedures, sparing patients from unjustifiable risk and helping to cut down on long waiting lists in endoscopy departments. The implementation of the Prague classification and Seattle protocol can improve diagnostic accuracy.
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Affiliation(s)
- Conor Brosnan
- General Surgery, St. Michael's Hospital, Dublin, IRL
| | - Enda Hannan
- Colorectal Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | - Tim Harding
- General Surgery, St. Michael's Hospital, Dublin, IRL
| | - Donal Maguire
- General Surgery, St. Michael's Hospital, Dublin, IRL
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Garg R, Singh A, Ahuja KR, Mohan BP, Ravi SJK, Shen B, Kirby DF, Regueiro M. Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients. J Gastroenterol Hepatol 2020; 35:1381-1386. [PMID: 32003069 DOI: 10.1111/jgh.14996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited. METHODS Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses. RESULTS A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period. CONCLUSIONS Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keerat R Ahuja
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Babu P Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Shri J K Ravi
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Surgical Management of Iatrogenic Perforation of the Gastrointestinal Tract: 15 Years of Experience in a Single Center. World J Surg 2018; 41:1961-1965. [PMID: 28324140 DOI: 10.1007/s00268-017-3986-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastrointestinal (GI) tract perforation during endoscopy is a rare but severe complication. The aim of this study was to determine predictors of morbidity and mortality after iatrogenic endoscopic perforation. MATERIALS AND METHODS All cases with iatrogenic endoscopic perforation receiving surgery at a tertiary referral center in a 15-year period (2000-2015) were retrospectively analyzed. Demographics, type of endoscopy, site of perforation, operative procedure, morbidity and mortality were analyzed. Multiple logistic regression was used to identify parameters predicting survival. RESULTS A total of 106.492 endoscopies were performed, and 82 (0.08%) patients were diagnosed with GI perforation. Most perforations (63.4%) occurred in the lower GI tract, compared to 36.6% in the upper GI tract. In 21 cases (25%), perforation was noticed during endoscopy, whereas 61 perforations (75%) were diagnosed during the further clinical course. Operative care was applied within 24 h in 61%. Surgery of perforations was almost completely performed maintaining the intestinal continuity (68%), whereas diversion was performed in 32%. Mortality was associated with age above 70 (OR 4.89, p = 0.027), ASA class > 3 (OR 4.08, p = 0.018), delayed surgery later than 24 h after perforation (OR 5.9, p = 0.015), peritonitis/mediastinitis intraoperatively (OR 4.68, p = 0.031) and severe postoperative complications with a Clavien-Dindo grade ≥III (OR 5.12, p = 0.023). CONCLUSION The prevalence of iatrogenic endoscopic perforation is low, although it is associated with a serious impact on morbidity and mortality. Delayed management worsens prognosis. To achieve successful management of endoscopic perforations, early diagnosis is essential in cases of deviation from the normal post-interventional course, especially in elderly.
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Fung AM, Chan FS, Wong IY, Law S. Synchronous perforations of the oesophagus and stomach by air insufflation: an uncommon complication of endoscopic dilation. BMJ Case Rep 2016; 2016:bcr-2016-216375. [PMID: 27799228 DOI: 10.1136/bcr-2016-216375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 72-year-old woman had a history of carcinoma of the hypopharynx treated by total laryngectomy, circumferential pharyngectomy and free jejunal graft. Endoscopic dilation of the pharyngojejunal anastomotic stricture resulted in synchronous perforations of the oesophagus and stomach. We postulate that the perforations were caused by high intraoesophageal and intragastric pressure resulted from air insufflation during the procedure; in a situation simulating closed-loop obstruction, because of proximal obstruction by the endoscope at the stricture site and distal obstruction by pylorospasm. The sites of perforations were inherent points of weakness at the left side of the distal oesophagus and at the high lesser curve of stomach. Satisfactory outcome of our patient was attributed to prompt diagnosis and surgical repair. Endoscopists should be aware of this possibility during oesophagogastroduodenoscopy and dilation. Rapid and over insufflation of air should be avoided.
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Affiliation(s)
- Arthur M Fung
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Fion S Chan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Ian Y Wong
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Simon Law
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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Sutton ERH, Walling S, Kimbrough C, Borkhetaria N, Jones W, Sutton B. Cost Analysis of Free Colonoscopies in an Uninsured Population at Increased Risk for Colorectal Cancer. J Am Coll Surg 2016; 223:129-32. [PMID: 27238000 DOI: 10.1016/j.jamcollsurg.2016.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/23/2016] [Accepted: 04/13/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uninsured patients have poor access to screening colonoscopy and subsequently present with advanced stages of colorectal cancer (CRC) that beget worse outcomes and higher total costs. Providing pro bono colonoscopies to uninsured patients at high risk for CRC can detect early stage disease and be cost-effective. STUDY DESIGN Patients considered at increased risk for CRC were offered free screening colonoscopies. Patient data from these colonoscopies were collected during a 12-month period, and the incidence of CRC was compared with a control group of uninsured patients from the Surveillance, Epidemiology, and End Results (SEER) registry. Published estimates derived from SEER Medicare data of health expenditures by CRC stage were used to develop a cost model. To compare overall costs between our cohort and the SEER control, the mean initial cost of care (up to 1 year) was weighted by the stage-specific CRC incidence in each group. RESULTS There were 682 uninsured patients screened, with 9 cancers identified (stage 0, n = 1; stage I, n = 3; stage II, n = 2; and stage III, n = 3) for an incidence of 1.3%. A total cost of $388,137 was estimated to be incurred during the initial phase of care. Compared with the SEER control, our cohort included more early stage cancers and subsequently had a marginally lower per-patient initial cost ($43,126 vs $43,736). CONCLUSIONS Our screening criteria successfully identified a high-risk population with an overall 1.3% incidence of CRC. For these patients, the provision of free screening colonoscopies identified earlier-stage tumors and appears to be cost-neutral.
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Affiliation(s)
- Erica R H Sutton
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY.
| | - Samuel Walling
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Charles Kimbrough
- Hiram C Polk Jr, MD Department of Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Nikhil Borkhetaria
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY
| | - Whitney Jones
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY; The Kentucky Colon Cancer Prevention Project, Louisville, KY
| | - Brad Sutton
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY
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Candas B, Jobin G, Dubé C, Tousignant M, Abdeljelil AB, Grenier S, Gagnon MP. Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review. Endosc Int Open 2016; 4:E118-33. [PMID: 26878037 PMCID: PMC4751006 DOI: 10.1055/s-0041-107901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/05/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND AIM Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients. METHODS We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process. RESULTS We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists' perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources. CONCLUSION Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.
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Affiliation(s)
- Bernard Candas
- Institut d’excellence en santé et services sociaux du Québec, Quebec City, Quebec, Canada
- Université Laval – Department of Social and Preventive Medicine, Quebec City, Quebec, Canada
| | - Gilles Jobin
- Université de Montréal – Department of Medicine, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital – Gastroenterology, Montreal, Quebec, Canada
| | - Catherine Dubé
- University of Calgary – Department of Community Health Sciences, Calgary, Alberta, Canada
| | - Mario Tousignant
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Anis Ben Abdeljelil
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Sonya Grenier
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Marie-Pierre Gagnon
- Université Laval – Faculty of Nursing, Quebec City, Quebec, Canada
- CHU de Québec Research Center – Population Health and Optimal Health Practices, Quebec City, Quebec, Canada
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Saengow U, Chongsuwiwatvong V, Geater A, Birch S. Preferences and acceptance of colorectal cancer screening in Thailand. Asian Pac J Cancer Prev 2016; 16:2269-76. [PMID: 25824749 DOI: 10.7314/apjcp.2015.16.6.2269] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Colorectal cancer (CRC) is now common in Thailand with an increase in incidence over time. Health authorities are planning to implement a nationwide CRC screening program using fecal immunochemical test (FIT) as a primary screening tool. This study aimed to estimate preferences and acceptance of FIT and colonoscopy, explore factors influencing the acceptance, and investigate reasons behind choosing and rejecting to screen before the program was implemented. Patients aged 50-69, visiting the primary care unit during the study period, were invited to join this study. Patients with a history of cancer or past CRC screening were excluded. Face-to-face interviews were conducted. Subjects were informed about CRC and the screening tests: FIT and colonoscopy. Then, they were asked for their opinions regarding the screening. The total number of subjects was 437 (86.7% response rate). Fifty-eight percent were females. The median age was 58 years. FIT was accepted by 74.1% of subjects compared to 55.6% for colonoscopy. The acceptance of colonoscopy was associated with perceived susceptibility to CRC and family history of cancer. No symptoms, unwilling to screen, healthy, too busy and anxious about diagnosis were reasons for refusing to screen. FIT was preferred for its simplicity and non-invasiveness compared with colonoscopy. Those rejecting FIT expressed a strong preference for colonoscopy. Subjects chose colonoscopy because of its accuracy; it was refused for the process and complications. If the screening program is implemented for the entire target population in Thailand, we estimate that 106,546 will have a positive FIT, between 8,618 and 12,749 identified with advanced adenoma and between 2,645 and 3,912 identified with CRC in the first round of the program.
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Affiliation(s)
- Udomsak Saengow
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand E-mail :
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Abstract
BACKGROUND Endoscopy-associated perforation (EAP) is a dreaded adverse event with significant morbidity and even mortality. Whether EAP in patients with inflammatory bowel disease (IBD) is associated with worse outcomes is not known. We aimed to assess the frequency of perforations in patients undergoing lower gastrointestinal (GI) endoscopies and compare the risk factors and perforation-associated complications (PAC) in patients with IBD with those without IBD. METHODS In this case-control study, we identified patients with lower GI EAP from January 2002 to June 2011. PAC was defined as EAP-associated death, colectomy with ileostomy, and bowel resection with/without diverting ostomy. Twenty-nine demographic, clinical, endoscopic, and surgical features were evaluated in univariable and multivariable analyses. RESULTS A total of 217,334 lower GI endoscopies were performed (IBD, N = 9518 and non-IBD, N = 207,816). Eighty-four patients with EAP were included. The rate of perforation was 18.91 per 10,000 and 2.50 per 10,000 procedures for IBD and non-IBD endoscopy, respectively. PAC occurred in 59 patients (70.2%) with death in 4 (4.8%) and bowel resection with or without ostomy in 55 (65.5%) (total colectomy with ileostomy, n = 3; resection with diversion and secondary anastomosis, n = 28; and resection with primary anastomosis, n = 24). On multivariable analysis, the use of systemic corticosteroids at the time of endoscopy was associated with 13 times greater risk for PAC (13.5 [95% confidence interval, 1.3-1839.7] P = 0.007), whereas IBD was not found to be associated with an increased risk for PAC (0.69 [95% confidence interval, 0.23-2.1] P = 0.52). CONCLUSIONS Patients with IBD have a higher frequency of EAP than those without IBD. Endoscopists need to be cautious while performing a lower GI endoscopy in patients taking systemic corticosteroids.
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Skandarajah AR, Moritz RL, Tjandra JJ, Simpson RJ. Proteomic analysis of colorectal cancer: discovering novel biomarkers. Expert Rev Proteomics 2014; 2:681-92. [PMID: 16209648 DOI: 10.1586/14789450.2.5.681] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Colorectal cancer is one of the most common cancers in the Western world. When detected at an early stage, the majority of cancers can be cured with current treatment modalities. However, most cancers present at an intermediate stage. The discovery of sensitive and specific biomarkers has the potential to improve preclinical diagnosis of primary and recurrent colorectal cancer, and holds the promise of prognostic and therapeutic application. Current biomarkers such as carcinoembryonic antigen lack sensitivity and specificity for general population screening. This review aims to highlight the role of current proteomic technologies in the discovery and validation of potential biomarkers with a view to translation to the clinic.
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Affiliation(s)
- Anita R Skandarajah
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Grattan Street, Parkville 3050, Victoria, Australia.
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Iafrate F, Iussich G, Correale L, Hassan C, Regge D, Neri E, Baldassari P, Ciolina M, Pichi A, Iannitti M, Diacinti D, Laghi A. Adverse events of computed tomography colonography: an Italian National Survey. Dig Liver Dis 2013; 45:645-50. [PMID: 23643567 DOI: 10.1016/j.dld.2013.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 02/19/2013] [Accepted: 02/27/2013] [Indexed: 02/06/2023]
Abstract
AIM To retrospectively study the frequency and magnitude of complications associated with computed tomography (CT) colonography in clinical practice. METHODS A questionnaire on complications of CT colonography was sent to Italian public radiology departments identified as practicing CT colonography with a reasonable level of training. The frequency of complications and possible risk factors were retrospectively determined. Responses were collated and row frequencies determined. A multivariate analysis of the factors causing adverse events was also performed. RESULTS 40,121 examinations were performed in13 centers during the study period. No deaths were reported. Bowel perforations occurred in 0.02% (7 exams). All perforations were asymptomatic and occurred in patients undergoing manual insufflation. Five perforations (71%) occurred in procedures performed following a recent colonoscopy. There was no significant difference between perforations associated with rectal balloon (0.017%) and those that were not (0.02%). Complications related to vasovagal reaction (either with or without spasmolytic) occurred in 0.16% (63 exams). All vasovagal reactions resolved in less than 3h, without any sequelae. CONCLUSIONS Perforation rate at CT colonography in Italy is comparable with elsewhere in the world, occurring regardless of the experience of radiology centers. Although the risk is very small, it may not be negligible when compared with the risk of diagnostic colonoscopy.
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Affiliation(s)
- Franco Iafrate
- Department of Radiological Sciences, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
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Magdeburg R, Sold M, Post S, Kaehler G. Differences in the endoscopic closure of colonic perforation due to diagnostic or therapeutic colonoscopy. Scand J Gastroenterol 2013; 48:862-7. [PMID: 23697700 DOI: 10.3109/00365521.2013.793737] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To describe the experience of a single center regarding the feasibility of endoscopic closure of iatrogenic colonic perforations and to elucidate differences between the efficacy of endoscopic clip closure due to diagnostic or therapeutic colonoscopy. MATERIAL AND METHODS A retrospective institutional computer-based search of records of colonoscopic perforation occurring between January 2004 and December 2011 was undertaken. Data on patients undergoing colonoscopy were entered into a clinical database. To further improve the detection of all cases of colon perforations, the authors also searched their separate surgical database for every patient with a colon perforation treated or operated on in the surgery department. Statistical significance was tested using either Fortran-Subroutine Fytest, chi-square testing or t-test. RESULTS Over 8 years, 22,924 patients underwent colonoscopy, of which 105 consecutive patients suffered iatrogenic perforation. Clip application was possible in 62 patients (81.58%) after perforation due to a therapeutic colonoscopy, whereas clip application was only possible in 9 patients (31.03%) after perforation due to a diagnostic colonoscopy. 4 out of 9 patients (44.44%) in the diagnostic group compared with 7 out of 62 patients (11.29%) after clipping a perforation during a therapeutic colonoscopy were sent to surgery. CONCLUSIONS The authors' data indicate significant differences in the potential for and success of endoscopic closure of iatrogenic perforations occurring during diagnostic or therapeutic colonoscopy. The frequency of surgery was significantly greater after clipping a perforation during a diagnostic colonoscopy.
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Affiliation(s)
- Richard Magdeburg
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany.
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Kolber MR, Wong CKW, Fedorak RN, Rowe BH, on behalf of the APC-Endo Study Physicians. Prospective Study of the Quality of Colonoscopies Performed by Primary Care Physicians: The Alberta Primary Care Endoscopy (APC-Endo) Study. PLoS One 2013; 8:e67017. [PMID: 23826186 PMCID: PMC3695091 DOI: 10.1371/journal.pone.0067017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 05/14/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The quality of colonoscopies performed by primary care physicians (PCPs) is unknown. OBJECTIVE To determine whether PCP colonoscopists achieve colonoscopy quality benchmarks, and patient satisfaction with having their colonoscopy performed by a primary care physician. DESIGN Prospective multi-center, multi-physician observational study. Colonoscopic quality data collection occurred via completion of case report forms and pathological confirmation of lesions. Patient satisfaction was captured by a telephone survey. SETTING Thirteen rural and suburban hospitals in Alberta, Canada. MEASUREMENTS Proportion of successful cecal intubations, average number of adenomas detected per colonoscopy, proportion of patients with at least one adenoma, and serious adverse event rates; patient satisfaction with their wait time and procedure, as well as willingness to have a repeat colonoscopy performed by their primary care endoscopist. RESULTS In the two-month study period, 10 study physicians performed 577 colonoscopies. The overall adjusted proportion of successful cecal intubations was 96.5% (95% CI 94.6-97.8), and all physicians achieved the adjusted cecal intubation target of ≥90%. The average number of ademonas detected per colonoscopy was 0.62 (95% CI 0.5-0.74). 46.4% (95% CI 38.5-54.3) of males and 30.2% (95% CI 22.3-38.2) of females ≥50 years of age having their first colonoscopy, had at least one adenoma. Four serious adverse events occurred (three post polypectomy bleeds and one perforation) and 99.3% of patients were willing to have a repeat colonoscopy performed by their primary care colonoscopist. LIMITATIONS Two-month study length and non-universal participation by Alberta primary care endoscopists. CONCLUSIONS Primary care physician colonoscopists can achieve quality benchmarks in colonoscopy. Training additional primary care physicians in endoscopy may improve patient access and decrease endoscopic wait times, especially in rural settings.
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Affiliation(s)
- Michael R. Kolber
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| | - Clarence K. W. Wong
- Department of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Richard N. Fedorak
- Department of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada
| | - Brian H. Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada
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Indicators of safety compromise in gastrointestinal endoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:71-8. [PMID: 22312605 DOI: 10.1155/2012/782790] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs. OBJECTIVE To identify key indicators of safety compromise in gastrointestinal endoscopy. METHODS The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance. RESULTS A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related - the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm⁄bronchospasm; procedure-related early - perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed - death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications. CONCLUSIONS The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.
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Senore C, Ederle A, Fantin A, Andreoni B, Bisanti L, Grazzini G, Zappa M, Ferrero F, Marutti A, Giuliani O, Armaroli P, Segnan N. Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting. J Med Screen 2012; 18:128-34. [PMID: 22045821 DOI: 10.1258/jms.2011.010135] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Quantitative information on adverse reactions associated with colorectal cancer (CRC) screening tests is useful to estimate the balance between benefit and risk in different strategies. SETTING Six Italian screening centres. METHODS Thirty-day active follow-up (interview about side-effects and acceptability of the screening procedure and review of hospital admissions) among average-risk people undergoing flexible sigmoidoscopy (FS), total colonoscopy (TC), fecal immunochemical test (FIT) in a multicentre randomized trial of CRC screening. Multivariable logistic models were used to assess determinants of completion rate and self-reported pain. RESULTS The attendance rate following the first invitation and mail reminder was 28.2% (1696/6018) in the FS and 23.0% (1382/6021) in the TC arm. Response rate to the 30-day follow-up questionnaire was 88.6% (1502/1696) among people undergoing FS, and 86.7% (1198/1382) among those undergoing TC. The proportion of people complaining of serious reactions following bowel preparation (odds ratio [OR], 5.17; 95% confidence interval [CI] 3.70-7.24) or reporting severe pain immediately after the exam (OR, 1.86; 95% CI 1.47-2.34) was higher for TC than for FS. The most common post-procedural complaints were abdominal distension and pain. People mentioning pain or bowel distension following preparation were more likely to report severe pain both after FS (OR, 2.13; 95% CI 1.52-2.97) and TC (OR: 2.03; 95% CI 1.41-2.90). The 30-day hospitalization rate was similar after FS, TC and FIT. CONCLUSIONS Screenees reported higher pain levels after TC than FS. The proportion of people complaining of severe side effects after discharge was similar. Bowel preparation was poorly tolerated by people undergoing TC. Subjects' reactions to the bowel preparation was predictive of post-procedural discomfort. A commitment of at least 48 hours was required of people undergoing TC, compared with 3-4 for FS.
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Affiliation(s)
- Carlo Senore
- Centro Prevenzione Oncologica Regione Piemonte and Azienda Ospedaliero-Universitaria S. Giovanni Battista di Torino, V. San Francesco da Paola 31, 10123 Torino, Italy.
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Francone T, Ricciardi R. Measuring Outcomes in Ambulatory Surgery. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Peutz-Jeghers syndrome: intriguing suggestion of gastrointestinal cancer prevention from surveillance. Dis Colon Rectum 2011; 54:1547-51. [PMID: 22067184 DOI: 10.1097/dcr.0b013e318233a11f] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Peutz-Jeghers syndrome is characterized by GI polyps and mucocutaneous pigmentation and carries an increased risk of GI cancer. GI polyps may bleed or cause intussusception. Luminal GI surveillance is recommended, but there are few data detailing outcomes from GI surveillance in Peutz-Jeghers syndrome. OBJECTIVE This study aimed to assess outcomes from GI surveillance in patients with Peutz-Jeghers syndrome. DESIGN This study is a retrospective review, using hospital and registry notes and endoscopy and histology reports. SETTING The investigation was conducted at a tertiary referral center. PATIENTS All patients with Peutz-Jeghers syndrome who were followed up at St Mark's hospital were included. MAIN OUTCOME MEASURES The primary outcomes measured were surveillance procedures performed, complications, and long-term outcomes. RESULTS Sixty-three patients from 48 pedigrees were included; the median age when patients were first seen was 20 years (range, 3-59). Only baseline investigations were performed in 12 patients. The remaining patients were followed up for 683 patient years, a median of 10 years (range, 2-41). Seven hundred seventy-six procedures were performed to assess the GI tract. These led to 5 double-balloon enteroscopies, 1 push enteroscopy, and 71 surgical procedures. Of the surgical procedures, 20 were performed as a result of baseline investigations, 12 arose from investigations of symptoms, and 39 were due to surveillance of asymptomatic patients. No emergency surgical interventions were performed. No luminal GI cancers were diagnosed. Of the 2461 polypectomies performed, 6 polyps contained atypia or dysplasia. Six complications arose from endoscopy or surgical intervention, requiring 5 laparotomies to manage these complications. CONCLUSION GI surveillance in Peutz-Jeghers syndrome is relatively safe and avoids the need for emergency surgery for small-bowel polyps. The lack of GI cancers may reflect that surveillance and polypectomy have prevented cancer from developing, although the detection of neoplasia or dysplasia is uncommon.
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Day LW, Kwon A, Inadomi JM, Walter LC, Somsouk M. Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis. Gastrointest Endosc 2011; 74:885-96. [PMID: 21951478 PMCID: PMC3371336 DOI: 10.1016/j.gie.2011.06.023] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Accepted: 06/20/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes. OBJECTIVE To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups. SETTING AND PATIENTS Elderly patients undergoing colonoscopy. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASUREMENTS Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality. RESULTS Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0-27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9-1.5) for perforation, 6.3 (95% CI, 5.7-7.0) for GI bleeding, 19.1 (95% CI, 18.0-20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7-2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9-38.0), perforation rate of 1.5 (95% CI, 1.1-1.9), GI bleeding rate of 2.4 (95% CI, 1.1-4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2-31.8), and mortality rate of 0.5 (95% CI, 0.06-1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5-1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2-2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant. LIMITATIONS Heterogeneity of studies included and not all complications related to colonoscopy were captured. CONCLUSIONS Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.
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Saraya T, Ikematsu H, Fu KI, Tsunoda C, Yoda Y, Oono Y, Kojima T, Yano T, Horimatsu T, Sano Y, Kaneko K. Evaluation of complications related to therapeutic colonoscopy using the bipolar snare. Surg Endosc 2011; 26:533-40. [DOI: 10.1007/s00464-011-1914-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 08/06/2011] [Indexed: 01/14/2023]
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Jovanovic I, Zimmermann L, Fry LC, Mönkemüller K. Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy. Gastrointest Endosc 2011; 73:550-5. [PMID: 21353851 DOI: 10.1016/j.gie.2010.12.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Accepted: 12/28/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Colon perforation is one of the most dreaded complications of colonoscopy. Traditionally, patients with a colon perforation have been treated surgically. Although there are several case reports documenting the usefulness of endoscopic closure of colon perforations, there are few current data evaluating the feasibility of endoscopic closure for an iatrogenic perforation on consecutive patients undergoing colonoscopy. OBJECTIVE To assess the incidence of colon perforations and the utility of immediate endoscopic closure during colonoscopy. DESIGN Retrospective, observational study. SETTING Tertiary-care academic medical center. PATIENTS All patients who underwent colonoscopy at 1 institution from June 2002 to December 2008 were identified. INTERVENTION An attempt at immediate colon perforation closure by endoscopic means. MAIN OUTCOME MEASUREMENTS Successful endoscopic closure of colon perforation. RESULTS During the study period, a total of 8601 colonoscopies were performed (2472 therapeutic interventions, 28.7%). A total of 12 iatrogenic colon perforations occurred, yielding a rate of 1.4/1000. Five (41.7%) occurred during a diagnostic colonoscopy (0.8/1000), and 7 perforations (58.3%) occurred as the result of a therapeutic intervention (2.8/1000). Endoscopic closure of the perforation site was possible in 5 patients (42%). Seven patients were treated surgically (large defects [n = 3], including 1 failed endoscopic closure, difficult endoscope position [n = 2], stool contamination [n = 1], and endoscopist's inexperience with closure of mucosal defects [n = 1]). LIMITATION Retrospective design. CONCLUSIONS In this study, the incidence of colon perforations was 1.4/1000. Endoscopic closure of iatrogenic colon perforations was attempted in 50% of patients and was successful in 83%. All patients with successful endoscopic closure had lesions smaller than 10 mm.
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Affiliation(s)
- Ivan Jovanovic
- Clinic for Gastroenterology and Hepatology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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Romagnuolo J, Cotton PB, Eisen G, Vargo J, Petersen BT. Identifying and reporting risk factors for adverse events in endoscopy. Part II: noncardiopulmonary events. Gastrointest Endosc 2011; 73:586-97. [PMID: 21353858 DOI: 10.1016/j.gie.2010.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 11/16/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Joseph Romagnuolo
- Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Telkes G, Peter A, Tulassay Z, Asderakis A. High frequency of ulcers, not associated with Helicobacter pylori, in the stomach in the first year after kidney transplantation. Nephrol Dial Transplant 2011; 26:727-732. [PMID: 20603242 DOI: 10.1093/ndt/gfq401] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although gastrointestinal (GI) symptoms are very frequent in organ transplant patients, there is a paucity of data about the endoscopic findings of kidney recipients. METHODS Two thousand one hundred and thirty-five kidney transplants were performed between 1994 and 2007. During that period, 672 gastroscopies were performed in 543 of those patients. Their mean age was 49.5 years and 56.9% were male. Immunosuppressive combinations included cyclosporine-mycophenolate-steroids, cyclosporine-steroids and tacrolimus-mycophenolate mofetil-steroids. Ninety-eight percent of the patients received acid suppression therapy. RESULTS The rate of clinically significant endoscopic findings was 84%. Macroscopic findings included inflammation in 46.7%, oesophagitis in 24.7%, ulcer in 16.9% and erosions in 14.8% of cases. Twenty-nine percent of endoscopies showed ulcer disease more frequently in the first 3 months (P=0.0014) after transplantation than later, and 45.7% of all ulcers developed in the first year. The presence of Helicobacter pylori was verified in 20.9% of cases, less than in the general, and also in the uraemic population (P<0.0001). There was no association between the presence of H. pylori and ulcers (P=0.28). Steroid pulse treatment for rejection was not associated with more ulcers (P=0.11); the use of mycophenolate mofetil increased the risk of erosions by 1.8-fold. CONCLUSION More than 25% of all kidney recipients required upper endoscopy in their 'post-transplant life'; the prevalence of 'positive findings' and ulcer disease was higher than in the general population (P<0.0001). The most vulnerable period is the first 3 months. Mycophenolate mofetil had an impact on GI complications, whilst the presence of H. pylori in the transplant population is not associated with the presence of ulcers.
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Affiliation(s)
- Gabor Telkes
- Transplantation and Surgical Clinic, Research Group of Hungarian Academy of Sciences, Semmelweis University, Budapest, Hungary.
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Heitman SJ, Hilsden RJ, Au F, Dowden S, Manns BJ. Colorectal cancer screening for average-risk North Americans: an economic evaluation. PLoS Med 2010; 7:e1000370. [PMID: 21124887 PMCID: PMC2990704 DOI: 10.1371/journal.pmed.1000370] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 10/14/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs. METHODS AND FINDINGS An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 [corrected] and the number of CRC deaths from 1,782 [corrected] to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive. CONCLUSIONS CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.
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Affiliation(s)
- Steven J. Heitman
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Robert J. Hilsden
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
| | - Flora Au
- The Department of Medicine, University of Calgary, Alberta, Canada
| | - Scot Dowden
- The Department of Medicine, University of Calgary, Alberta, Canada
- Alberta Health Services - Cancer Care, Alberta, Canada
| | - Braden J. Manns
- The Department of Medicine, University of Calgary, Alberta, Canada
- The Department of Community Health Sciences, University of Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Alberta, Canada
- * E-mail:
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Jobin G, Gagnon MP, Candas B, Dubé C, Ben Abdeljelil A, Grenier S. User's perspectives of barriers and facilitators to implementing quality colonoscopy services in Canada: a study protocol. Implement Sci 2010; 5:85. [PMID: 21044332 PMCID: PMC2988067 DOI: 10.1186/1748-5908-5-85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 11/02/2010] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) represents a serious and growing health problem in Canada. Colonoscopy is used for screening and diagnosis of symptomatic or high CRC risk individuals. Although a number of countries are now implementing quality colonoscopy services, knowledge synthesis of barriers and facilitators perceived by healthcare professionals and patients during implementation has not been carried out. In addition, the perspectives of various stakeholders towards the implementation of quality colonoscopy services and the need of an efficient organisation of such services have been reported in the literature but have not been synthesised yet. The present study aims to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators perceived by all stakeholders to the implementation of quality colonoscopy services in Canada. METHODS First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to implementing quality colonoscopy services. Standardised literature searches and data extraction methods will be used. The quality of the studies and their relevance to informing decisions on colonoscopy services implementation will be assessed. For each group of users identified, barriers and facilitators will be categorised and compiled using narrative synthesis and meta-analytical techniques. The principle factors identified for each group of users will then be validated for its applicability to various Canadian contexts using the Delphi study method. Following this study, a set of strategies will be identified to inform decision makers involved in the implementation of quality colonoscopy services across Canadian jurisdictions. DISCUSSION This study will be the first to systematically summarise the barriers and facilitators to implementation of quality colonoscopy services perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. Linkages with strategic partners and decision makers in the realisation of this project will favour the utilisation of its results to support strategies for implementing quality colonoscopy services and CRC screening programs in the Canadian health system.
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Affiliation(s)
- Gilles Jobin
- Department of Medicine, Université de Montréal, Montréal, Canada
- Maisonneuve-Rosemont Hospital, Montréal, Canada
| | - Marie Pierre Gagnon
- Department of Nursing, Université Laval, Québec, Canada
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
| | - Bernard Candas
- Department of Medicine, Université Laval, Québec, Canada
- Canadian Partnership Against Cancer, Québec, Canada
| | | | - Anis Ben Abdeljelil
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
| | - Sonya Grenier
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
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Rodriguez PM, Marin MR, Marin-Blazquez AA. Image of the month. Perforation of the colon through a hip prosthesis. Clin Gastroenterol Hepatol 2010; 8:A26. [PMID: 20541627 DOI: 10.1016/j.cgh.2010.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 05/22/2010] [Indexed: 02/07/2023]
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Lorenzo-Zúñiga V, Moreno de Vega V, Doménech E, Mañosa M, Planas R, Boix J. Endoscopist experience as a risk factor for colonoscopic complications. Colorectal Dis 2010; 12:e273-7. [PMID: 19930145 DOI: 10.1111/j.1463-1318.2009.02146.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIM We aimed to determine the incidence of colonic perforation (CP) following colonoscopy and postpolypectomy bleeding (PPB) in a teaching hospital, assessing the influence of endoscopist experience as a risk factor. METHOD All colonoscopies performed between 1995 and 2008 were reviewed. Demographic data, endoscopic procedure information, incidence of CP and PPB, and endoscopist experience were recorded. RESULTS In the 14-year period, 25,214 endoscopic colonic procedures were performed, and 3991 patients underwent polypectomy. The overall CP risk was 0.51/1000 procedures; and PPB 14.7/1000. The relative risk (RR) ratio of complications was 2.8/1000 procedures. The RR rate was highest for endoscopists performing less than 591 procedures per year (4.0/1000 [95% CI, 3.7-4.3] vs 2.9/1000 [95% CI, 2.6-3.2]), P < 0.001). CONCLUSION The complication rate after colonoscopy was comparable to that previously reported. Colonoscopy carried out by a low-volume endoscopist was independently associated with bleeding and perforation.
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Affiliation(s)
- V Lorenzo-Zúñiga
- Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.
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Endoscopic mucosal resection with full-thickness closure for difficult polyps: a prospective clinical trial. Gastrointest Endosc 2010; 71:1082-8. [PMID: 20438900 DOI: 10.1016/j.gie.2009.12.036] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2009] [Accepted: 12/27/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available. OBJECTIVE Assessment of feasibility of endoluminal full-thickness closure. DESIGN Prospective, open-label, interventional study. SETTING Tertiary referral center. PATIENTS Patients referred to surgery for endoscopically unresectable polyps. INTERVENTIONS Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system. MAIN OUTCOME MEASUREMENTS Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up. RESULTS Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place. LIMITATIONS Small number of patients, single-center feasibility study without control arm. CONCLUSIONS Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00553436.).
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Park SM, Kim SY, Earle CC, Jeong SY, Yun YH. What is the most cost-effective strategy to screen for second primary colorectal cancers in male cancer survivors in Korea? World J Gastroenterol 2009; 15:3153-60. [PMID: 19575496 PMCID: PMC2705739 DOI: 10.3748/wjg.15.3153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 05/23/2009] [Accepted: 05/30/2009] [Indexed: 02/06/2023] Open
Abstract
AIM To identify a cost-effective strategy of second primary colorectal cancer (CRC) screening for cancer survivors in Korea using a decision-analytic model. METHODS A Markov model estimated the clinical and economic consequences of a simulated 50-year-old male cancer survivors' cohort, and we compared the results of eight screening strategies: no screening, fecal occult blood test (FOBT) annually, FOBT every 2 years, sigmoidoscopy every 5 years, double contrast barium enema every 5 years, and colonoscopy every 10 years (COL10), every 5 years (COL5), and every 3 years (COL3). We included only direct medical costs, and our main outcome measures were discounted lifetime costs, life expectancy, and incremental cost-effectiveness ratio (ICER). RESULTS In the base-case analysis, the non-dominated strategies in cancer survivors were COL5, and COL3. The ICER for COL3 in cancer survivors was $5593/life-year saved (LYS), and did not exceed $10,000/LYS in one-way sensitivity analyses. If the risk of CRC in cancer survivors is at least two times higher than that in the general population, COL5 had an ICER of less than $10,500/LYS among both good and poor prognosis of index cancer. If the age of cancer survivors starting CRC screening was decreased to 40 years, the ICER of COL5 was less than $7400/LYS regardless of screening compliance. CONCLUSION Our study suggests that more strict and frequent recommendations for colonoscopy such as COL5 and COL3 could be considered as economically reasonable second primary CRC screening strategies for Korean male cancer survivors.
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The quality of screening colonoscopies in an office-based endoscopy clinic. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:41-7. [PMID: 19172208 DOI: 10.1155/2009/831029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures. OBJECTIVE To compare the quality of office-based screening colonoscopies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications. METHODS Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained. RESULTS A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy. CONCLUSIONS The Ontario Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.
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Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos G. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009; 69:654-64. [PMID: 19251006 DOI: 10.1016/j.gie.2008.09.008] [Citation(s) in RCA: 188] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 09/05/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies that reported the incidence of perforation from a colonoscopy are limited by small sample sizes, restricted age groups, or single-center data. OBJECTIVE To determine the incidence and risk factors of colonic perforation from a colonoscopy in a large population cohort. DESIGN Retrospective, population-based, cohort study, followed by a nested case-control study. SETTING California Medicaid program claims database. PATIENTS A total of 277,434 patients (aged 18 years and older) who underwent a colonoscopy during 1995 to 2005, age, sex, and time matched to 4 unique general-population controls. MAIN OUTCOME MEASUREMENTS Perforation incidence in the 7 days after colonoscopy (or matched index date for controls) with odds ratio (OR); multivariate logistic regression to calculate adjusted ORs for subsequent analysis of risk factors. RESULTS A total of 228 perforations were diagnosed after 277,434 colonoscopies, which corresponded to a cumulative 7-day incidence of 0.082%. The OR of getting a perforation from a colonoscopy compared with matched controls (n = 1,072,723) who did not undergo a colonoscopy was 27.6 (95% CI, 19.04-39.92), P < .001. On multivariate analysis, when comparing the group that had a perforation after a colonoscopy (n = 216) with those who did not (n = 269,496), increasing age, significant comorbidity, obstruction as an indication for the colonoscopy, and performance of invasive interventions during colonoscopy were significant positive predictors. Performance of biopsy or polypectomy did not affect the perforation risk. The rate of perforation did not change significantly over time. LIMITATIONS Validity of coding and capturing of all perforation diagnoses may possibly be deficient. CONCLUSION The risk of perforation from a colonoscopy is low, but, despite increased experience with the procedure, it remains unchanged over time.
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Affiliation(s)
- Gaurav Arora
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305-5187, USA
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Singh H, Penfold RB, DeCoster C, Kaita L, Proulx C, Taylor G, Bernstein CN, Moffatt M. Colonoscopy and its complications across a Canadian regional health authority. Gastrointest Endosc 2009; 69:665-71. [PMID: 19251007 DOI: 10.1016/j.gie.2008.09.046] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 09/18/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Defining the complication rate of endoscopy performed across an entire city will capture usual as opposed to referral center data. OBJECTIVE Our purpose was to evaluate the current practice of colonoscopy and complications associated with lower GI endoscopy in usual clinical practice. DESIGN All admissions within 30 days of an outpatient lower GI endoscopy at any of the 6 adult-care Winnipeg hospitals were identified. This includes endoscopy for both complex and routine patients. A chart audit of all cases with potential complications was performed. RESULTS A total of 24,509 outpatient lower GI endoscopies for adults were performed at the 6 hospitals over the 2 study years (April 1, 2004, to March 31, 2006). There were 303 admissions with potential complications. The colonoscopy completion rate was 65% (72% for gastroenterologists vs 59% for general surgeons, P < .005). Quality of bowel preparation and nature of polyps were often not documented. The overall rate of complications was 2.9/1000 procedures; the perforation rate after polypectomy was 1.8/1000; and the postpolypectomy bleeding rate was 6.4/1000. Most (67%) complications were recognized after discharge for the index procedure. The complication rate was highest for the endoscopists performing fewer than 200 procedures per year (5.4/1000 vs 2.7/1000 for the rest, P = .02, relative risk 2 [95% CI, 1.1-3.7]). LIMITATIONS Chart audit was limited to cases requiring admission within 30 days of the index procedure. CONCLUSIONS The overall complication rate after lower GI endoscopy in usual clinical practice in Winnipeg is comparable to that previously reported. A higher complication rate after endoscopy by low-volume endoscopists needs to be further evaluated. The reporting of endoscopy must be standardized to enhance outcomes interpretation.
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Affiliation(s)
- Harminder Singh
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Endoscopist-administered propofol: a retrospective safety study. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:617-20. [PMID: 18629390 DOI: 10.1155/2008/265465] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Propofol is an anesthetic agent that is commonly used for conscious sedation. Propofol has advantages as a sedative agent for endoscopic procedures including rapid onset, short half-life and rapid recovery time. However, concerns exist regarding the potential for respiratory depression, hypotension, perforation due to deep sedation and the need for monitoring by an anesthetist. Propofol has been used under endoscopist supervision at the Stanton Territorial Hospital in Yellowknife, Northwest Territories since 1996 (approximately 7000 cases). METHODS A retrospective chart review of endoscopic procedures conducted at the Stanton Territorial Hospital between January 1996 and May 2007 was performed. A random sample of 680 procedures was reviewed from a total of 6396 procedures. RESULTS The mean (+/- SD) baseline systolic blood pressure (SBP) was 122.8+/-17.0 mmHg. The mean lowest SBP was 101.7+/-14.5 mmHg. The mean absolute drop in SBP was 21.1+/-16.7 mmHg, with a mean per cent drop of 16.3%+/-11.7%. Eighty-eight patients (12.9%) developed transient hypotension (SBP lower than 90 mmHg). All patients regained normal blood pressure spontaneously on repeated measurement. No patients required intravenous fluid resuscitation. The mean O2 saturation was 96.4%+/-2.1%. One patient (0.1%) transiently desaturated (O2 saturation 89%), but recovered spontaneously on repeat measurement with no intervention. No procedures were aborted for patient safety. There were no major complications, including perforation or death. There was one mucosal tear during nontherapeutic colonoscopy (0.1%). CONCLUSIONS Propofol can be safely administered in a community hospital setting under endoscopist supervision, with no additional support or monitoring.
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Detection of occult colonic perforation before CT colonography after incomplete colonoscopy: perforation rate and use of a low-dose diagnostic scan before CO2 insufflation. AJR Am J Roentgenol 2008; 191:1077-81. [PMID: 18806146 DOI: 10.2214/ajr.07.2746] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to obtain a low-dose CT scan before CT colonography to estimate the prevalence of occult colonic perforation among patients referred for same-day or next-day CT colonography after incomplete colonoscopy. MATERIALS AND METHODS Two hundred sixty-two patients (74 men, 188 women; mean age, 64 years; range, 21-92 years) consecutively referred for same-day or next-day CT colonography after incomplete colonoscopy underwent low-dose diagnostic CT before rectal tube insertion and CO(2) insufflation. RESULTS Perforation was found on the low-dose CT scans of two of the 262 patients (0.8%; 95% CI, 0.1-2.7%). One of these patients had no symptoms; the other had mild abdominal discomfort at the time of CT. CONCLUSION The rate of occult colonic perforation after incomplete colonoscopy may be significant. For patients referred for CT colonography after incomplete endoscopy, use of low-dose diagnostic CT before rectal tube insertion and insufflation is indicated.
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Avgerinos DV, Llaguna OH, Lo AY, Leitman IM. Evolving management of colonoscopic perforations. J Gastrointest Surg 2008; 12:1783-9. [PMID: 18683006 DOI: 10.1007/s11605-008-0631-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 07/16/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Perforations of the large bowel during diagnostic or therapeutic colonoscopy are a rare but significant complication. Their treatment has evolved over the last decade, but there are still no specific guidelines for their optimal management. MATERIALS AND METHODS Retrospective review of 105,786 consecutive colonoscopies performed in a 21-year period allowed assessment of the medical records in all patients treated at our institution for colonoscopic perforation. RESULTS Thirty-five patients suffered perforation (perforation rate 0.033%) during colonoscopy from January 1986 to October 2007 (14 men, 21 women; mean age 69.4 years). Twenty-four of the perforations occurred during diagnostic colonoscopy, whereas 11 during therapeutic colonoscopy. Twenty-three (66%) of the patients underwent operative treatment and 12 (34%) were managed nonoperatively. The average length of stay was 15.2 days, and there was one death (2.9% 30-day mortality rate) among the patients. CONCLUSIONS Perforations from diagnostic colonoscopy usually are large enough to warrant surgical management, whereas perforations from therapeutic colonoscopy usually are small, leading to successful nonoperative treatment. Over the last decade, the surgical treatment of colonoscopic perforations has evolved, as there has been a trend that favors primary repair versus bowel resection with successful outcome. Careful observation and clinical care adherent to strict guidelines for patients treated nonoperatively is appropriate in order to minimize morbidity and mortality and identify early those who may benefit from operation. Each treatment, however, has to be individualized according to the patients' comorbidities and clinical status, as well as the specific conditions during the colonoscopy that lead to the perforation.
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Affiliation(s)
- Dimitrios V Avgerinos
- Department of Surgery, Beth Israel Medical Center, Albert Einstein College of Medicine, New York, NY 10003, USA.
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Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial (with videos). Gastrointest Endosc 2008; 68:324-32. [PMID: 18561931 DOI: 10.1016/j.gie.2008.03.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Accepted: 03/03/2008] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic closure of inadvertent or intentional colon perforations might be valuable if comparable to surgical closure. OBJECTIVE The aim of this study was to compare endoscopic closure of a 4-cm colon perforation in a porcine model with surgical closure in a multicenter study. SETTING University hospitals in the United States and Europe. DESIGN AND INTERVENTIONS After creating a 4-cm linear colon perforation, the animals were randomized to either endoscopic or surgical closure. The total procedure time from the beginning of perforation to the completion of procedure was measured. The animals were euthanized after 2 weeks to evaluate healing, unless there was a complication. RESULTS Fifty-four animals were randomized to either surgical or endoscopic closure of colon perforation. Eight animals developed complications, and 7 of these were euthanized before 2 weeks. Twenty-three animals in each group survived for 2 weeks. Surgical closure of the perforation was successful in all animals in that group, and endoscopic closure was successful in 25 of the 27 animals. The median procedure time was shorter in the surgery group compared to the endoscopy group (35 vs 44 minutes, P = .016). Peritonitis, local adhesions, and leak test results were comparable in both groups. Distant adhesions were less frequent in the endoscopic closure group (26.1% vs 56.5%, P = .03). Five of the 186 T-tags (2.7%) were noted in the adjacent viscera. LIMITATION This porcine study does not mimic clean colon perforation in humans; it mimics dirty colon perforation in humans. CONCLUSIONS Endoscopic closure of a 4-cm colon perforation was comparable to surgery, and this technique can be potentially used for closure of intentional or inadvertent colon perforations.
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Straumann A, Bussmann C, Zuber M, Vannini S, Simon HU, Schoepfer A. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6:598-600. [PMID: 18407800 DOI: 10.1016/j.cgh.2008.02.003] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Eosinophilic esophagitis is a rapidly emerging, chronic inflammatory disorder. Prolonged inflammation evokes structural alterations and a fragile esophageal wall prone to perforation/rupture and food impaction. This report assesses the risk of spontaneously arising and procedure-induced complications and proposes practical recommendations. METHODS The Swiss Esophageal Esophagitis Database documented 251 confirmed cases. A chart review identified which patients had required endoscopic bolus removal and/or experienced transmural esophageal perforation/rupture. In addition, a MEDLINE search for "eosinophilic esophagitis" with "esophageal perforation" or "esophageal rupture" was undertaken. RESULTS During an 18-year period, 87 patients (34.7%) experienced 134 food impactions requiring flexible (124, 92.5%) or rigid (10, 7.5%) endoscopic bolus removal. Transmural perforation occurred in 20% (2/10) of rigid procedures, and 1 esophageal rupture (Boerhaave's syndrome) was observed. CONCLUSIONS Bolus removal by rigid endoscopy is a high-risk procedure and should be avoided in eosinophilic esophagitis patients who require a gentler approach. Whether food impaction and esophageal wall remodeling can be prevented with anti-inflammatory medication is still undetermined. All Boerhaave's syndrome cases should be evaluated for underlying eosinophilic esophagitis.
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Affiliation(s)
- Alex Straumann
- Department of Gastroenterology, Kantonsspital Olten, Olten, Switzerland.
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Timing of repeat colonoscopy: disparity between guidelines and endoscopists' recommendation. Am J Prev Med 2007; 33:471-8. [PMID: 18022063 DOI: 10.1016/j.amepre.2007.07.039] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 06/01/2007] [Accepted: 07/24/2007] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colonoscopy possesses the highest sensitivity of available screening tests for colorectal cancer and polyps, but it also carries risks. Appropriate intervals for repeating colonoscopy are important to ensure that the benefits of screening and surveillance are not offset by harms. The study objective was to examine whether endoscopists' recommendations for repeat colonoscopy, as communicated to primary care clinicians after the procedure, adhered to published guidelines. METHODS Analysts abstracted medical records at ten primary care practices in Virginia and Maryland in 2006. The records of a random sample of men and women (300 per practice) aged 50 to 70 years were reviewed. The sample included patients who had a colonoscopy and a written report from an endoscopist, and who lacked designated risk factors. The main outcome was concordance between endoscopists' recommendations and published guidelines regarding repeat colonoscopy. RESULTS Of 3000 charts reviewed, 1282 (42.7%) included records of a colonoscopy and 1021 (34%) included an endoscopist's report. In 64.9% of communications, the endoscopist specified when retesting should occur. Recommendations were consistent with contemporaneous guidelines in only 39.2% of cases and with current guidelines in 36.7% of cases. The adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy and 5.8 years and 4.4 years, respectively, when hyperplastic polyps or 1-2 small adenomatous polyps were found. CONCLUSIONS Endoscopists often recommended repeat colonoscopy at shorter intervals than are advised either by current guidelines or by guidelines in effect at the time of the procedure. Endoscopists' communications to primary care clinicians often lacked contextual information that might explain these discrepancies. Unless appropriate caveats apply, adhering to endoscopists' recommendations may incur unnecessary harms and costs.
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Tolan DJM, Armstrong EM, Burling D, Taylor SA. Optimization of CT colonography technique: a practical guide. Clin Radiol 2007; 62:819-27. [PMID: 17662728 DOI: 10.1016/j.crad.2007.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 02/27/2007] [Accepted: 03/05/2007] [Indexed: 12/21/2022]
Abstract
In this article we provide practical advice for optimizing computed tomography colonography (CTC) technique to help ensure that reproducible, high-quality examinations are achieved. Relevant literature is reviewed and specific attention is paid to patient information, bowel cleansing, insufflation, anti-spasmodics, patient positioning, CT technique, post-procedure care and complications, as well as practical problem-solving advice. There are many different approaches to performing CTC; our aim is to not to provide a comprehensive review of the literature, but rather to present a practical and robust protocol, providing guidance, particularly to those clinicians with little prior experience of the technique.
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Affiliation(s)
- D J M Tolan
- Department of Clinical Radiology, St James's University Hospital, Leeds, West Yorkshire, UK
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Abstract
Perforation is an uncommon but important complication of colonoscopy. This review looks at the incidence, clinical features, diagnosis and treatment of this condition.
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Affiliation(s)
- Alok Tiwari
- Department of Surgery, North Middlesex University Hospital, London N18 1QX
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Alfonso-Ballester R, Lo Pez-Mozos F, Mart-Obiol R, Garcia-Botello SA, Lledo-Matoses S. Laparoscopic treatment of endoscopic sigmoid colon perforation: a case report and literature review. Surg Laparosc Endosc Percutan Tech 2006; 16:44-6. [PMID: 16552380 DOI: 10.1097/01.sle.0000202186.72784.7a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Perforation of the colon after colonoscopy is a rare but potentially lethal complication. It usually occurs when endoscopy is performed for therapeutic purposes. In these cases the election of the best treatment is difficult and still controversial. Laparoscopy is a new approach for diagnosis and treatment of this condition. We report a case of a patient who was initially treated laparoscopically after a colonoscopic perforation. A postoperative leak was detected and the patient underwent open surgery. Possible therapeutic approaches and a literature review are discussed.
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Heitman SJ, Manns BJ, Hilsden RJ, Fong A, Dean S, Romagnuolo J. Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening. CMAJ 2005; 173:877-81. [PMID: 16217110 PMCID: PMC1247700 DOI: 10.1503/cmaj.050553] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Computerized tomographic (CT) colonography is a potential alternative to colonoscopy for colorectal cancer screening. Its main advantage, a better safety profile, may be offset by its limitations: lower sensitivity, need for colonoscopy in cases where results are positive, and expense. METHODS We performed an economic evaluation, using decision analysis, to compare CT colonography with colonoscopy for colorectal cancer screening in patients over 50 years of age. Three-year outcomes included number of colonoscopies, perforations and adenomas removed; deaths from perforation and from colorectal cancer from missed adenomas; and direct health care costs. The expected prevalence of adenomas, test performance characteristics of CT colonography and colonoscopy, and probability of colonoscopy complications and cancer from missed adenomas were derived from the literature. Costs were determined in detail locally. RESULTS Using the base-case assumptions, a strategy of CT colonography for colorectal cancer screening would cost 2.27 million dollars extra per 100,000 patients screened; 3.78 perforation-related deaths would be avoided, but 4.11 extra deaths would occur from missed adenomas. Because screening with CT colonography would cost more and result in more deaths overall compared with colonoscopy, the latter remained the dominant strategy. Our results were sensitive to CT colonography's test performance characteristics, the malignant risk of missed adenomas, the risk of perforation and related death, the procedural costs and differences in screening adherence. INTERPRETATION At present, CT colonography cannot be recommended as a primary means of population-based colorectal cancer screening in Canada.
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