A. Musso

Adrenaline plus cyanoacrylate injection for treatment of bleeding peptic ulcers after failure of conventional endoscopic haemostasis

BACKGROUND Endoscopic therapy is a safe and effective method for treating non-variceal upper gastrointestinal bleeding. However failure of therapy, in terms of continuing bleeding or rebleeding, is seen in up to 20%. Cyanoacrylate is a tissue glue used for variceal bleeding that has occasionally been reported as an alternative haemostatic technique in non-variceal haemorrhage. AIM To retrospectively describe personal experience using cyanoacrylate injection in the management of bleeding ulcers after failure of first-line endoscopic modalities. PATIENTS AND METHODS Between January 1995 and March 1998, 18 [12 M/6 F, mean age 68.1 years) out of 176 patients, referred to our Unit for non-variceal upper gastrointestinal bleeding, were treated with intralesional injection of adrenaline plus undiluted cyanoacrylate. Persistent bleeding after endoscopic haemostasis or early rebleeding were the indications for cyanoacrylate treatment. RESULTS Definitive haemostasis was achieved in 17 out of 18 patients treated with cyanoacrylate. One patient needed surgery. No early or late rebleeding occurred during the follow-up. No complications or instrument lesions related to cyanoacrylate were recorded. CONCLUSIONS In our retrospective series, cyanoacrylate plus adrenaline injection was found to be a potentially safe and effective alternative to endoscopic haemostasis when conventional treatment modalities fail in controlling bleeding from gastroduodenal ulcers.

Narrow band imaging vs. high definition colonoscopy for detection of colorectal adenomas in patients with positive faecal occult blood test: A randomised trial

BACKGROUND The impact of narrow band imaging in improving the adenoma detection rate in a screening scenario is still unclear. AIM To evaluate whether narrow band imaging compared with high definition white light colonoscopy can enhance the adenoma detection rate during screening colonoscopy. METHODS Consecutive patients presenting for screening colonoscopy were included into this study and were randomly assigned to the narrow band imaging group (Group 1) or standard colonoscopy group (Group 2). Primary end point was the adenoma detection rate and secondary aim was the detection rate of advanced adenomas. RESULTS Overall, 117 patients were allocated to Group 1 and 120 to Group 2. Both the adenoma detection rate and the detection rate of advanced adenomas were not significantly different between the two groups (respectively, 52.1% vs. 55%, RR=0.95, 95% CI 0.75-1.20; 32.5% vs. 44.2%, RR=0.74, 95% CI 0.53-1.02). No significant difference between the proportions of polypoid and flat adenomas was found. Male gender, no prior history of screening, and endoscopists adenoma detection rate were independent predictive factors of higher advanced adenoma detection rate. CONCLUSIONS In a screening scenario, narrow band imaging did not improve the adenoma nor advanced adenoma detection rates compared to high definition white light colonoscopy.

Pre- and post-procedural quality indicators for colonoscopy: A nationwide survey

BACKGROUND The provision of high-quality colonoscopy can be assessed by evaluating technical aspects of the procedure and, at individual center level, by comparing structural indicators and institutional policies for managing peri-procedural issues with guideline recommendations. AIM To assess the colonoscopy quality (CQ) in Italy at center level. METHODS Gastroenterologists participating in a nationwide colonoscopy education initiative provided information on structural indicators of their centers and on institutional policies by answering 10 multiple-choice clinical scenarios. Practice variation across centers and compliance with guidelines were analyzed. RESULTS Data from 282 Italian centers were evaluated. Overall, a significant proportion of centers did not meet CQ standards as concerns endoscopy facilities and equipments (e.g., dedicated recovery room, dirty-to-clean path, reporting software). CQ assurance programs were implemented in only 25% of centers. Concerning peri-procedural issues, main discrepancies with guidelines were recorded in the underuse of split-dose preparation (routinely adopted by 18% of centers), the routine request of coagulation tests prior to colonoscopy (30%), the routine interruption of aspirin for polypectomy (18%), and the adoption of 3-year surveillance for low-risk adenoma (49%). CONCLUSIONS Present survey shows a significant variation in the CQ of endoscopy centers in Italy on many items of colonoscopy practice that should be targeted for future interventions.

223 SEDATION FOR ENDOSCOPY IN PATIENTS WITH END- STAGE LIVER DISEASE: RESULTS OF A PROSPECTIVE CONTROLLED STUDY

Background: There are no formal guidelines regarding sedation for endoscopy in cirrhotic patients (CP). The use of propofol has been shown to be effective and safe for gastroscopy but its use for prolonged endoscopic procedure remains to be studied. Aim: To evaluate the efficacy and safety of propofol in CP undergoing prolonged endoscopic procedures compared with non-cirrhotic patients (NCP). Methods: Twenty-nine consecutively collected inpatients (mean age 58±SD7, M/F=18/11) with known liver cirrhosis (Child–Pugh class A=12, B=9, C=8) undergoing colonoscopy (21) or ERCP (8) received propofol by an anesthetist; the outcome measures studied (induction and recovery times, efficacy and safety of sedation, return to baseline function) were compared with those recorded among 68 consecutively collected NCP (mean age 61±SD8, M/F=41/27) undergoing the same endoscopic procedures (colonoscopy: 49, ERCP: 19). Results: The mean dose of propofol administered in CP was 242mg (SD±38, range 100–350) compared with 260mg (SD±8, range 120–380) in NCP (p = 0.2). The mean time to achieve sedation was 2.8min (SD±1.1) in CP and 3.1 (SD±1.2) in NCP (p = 0.9). The mean time to reach a maximal level of alertness on the Observer’S Assessment of Alertness and Sedation Scale (OAASS) in CP was 13.8min (SD±4.2) compared with 12.7 (SD±4) in NCP (p = 0.7). Time to full recovery was 28.6min (SD±9.1) in CP compared with 26.2min (SD±8) in NCP (p = 0.72). Procedures times between the groups were similar: 26min (SD±12) in CP vs 29min (SD±14) in NCP (p = 0.8). No significant complication related to sedation was observed in the 2 groups. Conclusions: Propofol sedation is efficacious, safe and well tolerated in CP undergoing prolonged endoscopic procedures.