Jennifer J. Telford

A randomized trial comparing uncovered and partially covered self- expandable metal stents in the palliation of distal malignant biliary obstruction

BACKGROUND The most common complication of uncovered biliary self-expandable metal stents (SEMSs) is tumor ingrowth. The addition of an impenetrable covering may prolong stent patency. OBJECTIVE To compare stent patency between uncovered and partially covered SEMSs in malignant biliary obstruction. DESIGN Multicenter randomized trial. SETTING Four teaching hospitals. PATIENTS Adults with inoperable distal malignant biliary obstruction. INTERVENTIONS Uncovered or partially covered SEMS insertion. MAIN OUTCOME MEASURES Time to recurrent biliary obstruction, patient survival, serious adverse events, and mechanism of recurrent biliary obstruction. RESULTS From October 2002 to May 2008, 129 patients were randomized. Recurrent biliary obstruction was observed in 11 of 61 uncovered SEMSs (18%) and 20 of 68 partially covered SEMSs (29%). The median times to recurrent biliary obstruction were 711 days and 357 days for the uncovered and partially covered SEMS groups, respectively (P = .530). Median patient survival was 239 days for the uncovered SEMS and 227 days for the partially covered SEMS groups (P = .997). Serious adverse events occurred in 27 (44%) and 42 (62%) patients in the uncovered and partially covered SEMS groups, respectively (P = .046). None of the uncovered and 8 (12%) of the partially covered SEMSs migrated (P = .0061). LIMITATIONS Intended sample size was not reached. Allocation to treatment groups was unequal. CONCLUSIONS There was no significant difference in time to recurrent biliary obstruction or patient survival between the partially covered and uncovered SEMS groups. Partially covered SEMSs were associated with more serious adverse events, particularly migration.

The cost-effectiveness of screening for colorectal cancer

Background: Published decision analyses show that screening for colorectal cancer is cost-effective. However, because of the number of tests available, the optimal screening strategy in Canada is unknown. We estimated the incremental cost-effectiveness of 10 strategies for colorectal cancer screening, as well as no screening, incorporating quality of life, noncompliance and data on the costs and benefits of chemotherapy. Methods: We used a probabilistic Markov model to estimate the costs and quality-adjusted life expectancy of 50-year-old average-risk Canadians without screening and with screening by each test. We populated the model with data from the published literature. We calculated costs from the perspective of a third-party payer, with inflation to 2007 Canadian dollars. Results: Of the 10 strategies considered, we focused on three tests currently being used for population screening in some Canadian provinces: low-sensitivity guaiac fecal occult blood test, performed annually; fecal immunochemical test, performed annually; and colonoscopy, performed every 10 years. These strategies reduced the incidence of colorectal cancer by 44%, 65% and 81%, and mortality by 55%, 74% and 83%, respectively, compared with no screening. These strategies generated incremental cost-effectiveness ratios of

Factors influencing patient satisfaction when undergoing endoscopic procedures

9159,

Prospective analysis of fluoroscopy duration during ERCP: critical determinants

611 and

Management of Ingested Foreign Bodies

6133 per quality-adjusted life year, respectively. The findings were robust to probabilistic sensitivity analysis. Colonoscopy every 10 years yielded the greatest net health benefit. Interpretation: Screening for colorectal cancer is cost-effective over conventional levels of willingness to pay. Annual high-sensitivity fecal occult blood testing, such as a fecal immunochemical test, or colonoscopy every 10 years offer the best value for the money in Canada.

A randomized controlled trial assessing the effect of prescribed patient position changes during colonoscope withdrawal on adenoma detection

BACKGROUND Limited data are available regarding the best mechanism and timing for assessing patient satisfaction with endoscopy. OBJECTIVE To identify factors related to patient satisfaction with endoscopy and to determine if satisfaction after the procedure correlates with measurements at a later date. DESIGN A prospective cohort study. SETTING Tertiary academic hospital. PATIENTS Patients undergoing EGD, colonoscopy, or both. INTERVENTIONS Patients received preprocedure and postprocedure questionnaires on the procedure day. A third questionnaire (telephone or mail) was administered at least 1 week later. MAIN OUTCOME MEASUREMENTS Satisfaction scores. RESULTS A total of 261 patients were studied (53% men). The mean age was 55 +/- 14 years. A total of 226 patients (86.6%) were very satisfied with their endoscopy. Factors positively associated with satisfaction were as follow: doctors personal manner (odds ratio [OR] 3.00 [95% CI, 1.80-5.03]), doctors technical skills (OR 2.65 [95% CI, 1.55-4.51]), nurses personal manner (OR 2.84 [95% CI, 1.74-4.63]), physical environment (OR 1.75 [95% CI, 1.16-2.64]), and more time with doctor discussing the procedure (OR 1.66 [95% CI, 1.02-2.69]). Higher levels of pain or discomfort were associated with less satisfaction (OR 0.57 [95% CI, 0.36-0.90]). A total of 141 of 261 patients (54%) were reached for follow-up (mean [SD] 39 +/- 26 days). These patients were less satisfied (rating dropped mean 0.35 points, P = .03) than those questioned sooner after the procedure and recalled experiencing more pain (rating increased mean 0.44 points, P = 0.01). LIMITATION Single center. CONCLUSIONS This study identified several factors that impacted patient satisfaction. Most patients initially appeared very satisfied, perhaps because of residual sedation and the distinct setting of the surveys. However, patient satisfaction tended to decrease over time, possibly because of recall bias. Future studies with patient satisfaction may require assessment at a date further removed from their endoscopy.

Establishing the learning curve for achieving competency in performing colonoscopy: a systematic review.

BACKGROUND Fluoroscopy during ERCP has a linear relationship with radiation, carrying risk of exposure. OBJECTIVE To determine patient, physician, and procedural factors affecting fluoroscopy duration. DESIGN Prospective analysis of ERCPs with evaluation of patient, physician, and procedural variables. SETTING Two tertiary-care hospitals. PATIENTS Consecutive patients undergoing ERCP. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Variables associated with prolonged fluoroscopy duration. RESULTS Mean fluoroscopy time (388 ERCPs) was 6.77 minutes (95% CI, 6.15-7.39). No patient factors were found to significantly affect fluoroscopy duration. Fluoroscopy duration was significantly lower for 2 endoscopists compared with the reference endoscopist (average of 4.16 minutes less; 95% CI, -5.48 to -2.48). Multivariable analysis identified variables associated with longer fluoroscopy duration; stent insertion (+3.11 minutes; 95% CI, 1.91-4.30), lithotripsy (+5.74 minutes; 95% CI, 0.931-10.5), needle-knife sphincterotomy (+4.44 minutes; 95% CI, 2.20-6.67), biopsies (+2.11 minutes; 95% CI, 0.025-4.18), use of a guidewire (+1.55 minutes; 95% CI, 0.025-3.07), additional guidewires (+5.61 minutes; 95% CI, 2.69-8.51), and balloon catheter (+4.27 minutes; 95% CI, 3.00-5.53). Mean fluoroscopy duration when a gastroenterology fellow was involved (n = 318) was 7.05 minutes (95% CI, 6.35-7.76) compared with 5.44 minutes (95% CI, 4.26-6.63) when no fellow present (n = 70) (P < .0451). LIMITATIONS Only 2 centers; others may have different results. Not blinded; investigators may change their practice because fluoroscopy was duration studied. Irrelevance of measuring fluoroscopy duration because endoscopists using protection may not have increased radiation exposure. CONCLUSIONS In this prospective analysis, factors associated with fluoroscopy duration included endoscopists; stent insertion; lithotripsy; biopsies; use of a needle-knife, guidewire, and balloon catheter; and involvement of a gastroenterology fellow. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration and may lead to appropriate precautions.

Endoscopic Management of Benign Biliary Strictures

The majority of foreign bodies are ingested. Up to 90% of these will pass through the gastrointestinal tract spontaneously, 10% to 20% require endoscopic management and approximately 1% require surgical management (1). The pediatric population is most at risk, accounting for 80% of ingested foreign bodies. Adults, especially the mentally impaired, alcoholic and edentulous, may also accidentally ingest a foreign body. Prisoners and psychiatric patients may ingest foreign bodies intentionally for secondary gain, for instance, to instigate transfer to hospital from a prison or psychiatric institution. Purposeful ingestion of foreign bodies for the purpose of drug trafficking also occurs. Ingestion of multiple foreign bodies should always be considered in both children and adults. Among children and mentally impaired adults, commonly ingested objects include coins, small toys, crayons and batteries. In adults, the most common foreign body ingested is a poorly chewed bolus of meat, a bone or dentures. Intentional ingestion of a foreign body by a prisoner or psychiatric patient is often a razor blade or other sharp metallic object. The diagnosis is apparent from the patient’s history. The patient will often report a sudden onset of dysphagia during a meal, which may be accompanied by chest pain or odynophagia and an inability to tolerate secretions. In children or adults unable to provide a history, a sudden refusal to eat, drooling or respiratory symptoms such as coughing or wheezing due to aspiration are reasons to suspect foreign body ingestion. A careful physical examination should be performed to

The 2012 Sage Wait Times Program: Survey of Access to Gastroenterology in Canada

BACKGROUND High-quality colonoscope withdrawal technique is associated with a higher adenoma detection rate. Position change is routinely used in barium enema and CT colonography to facilitate adequate distension of the colon and promote movement of fluid from the segment of the colon being assessed. OBJECTIVE To determine whether prescribed position changes during colonoscope withdrawal affect the adenoma detection rate compared with the usual care per endoscopist. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary-care, university-affiliated hospital. PATIENTS Patients referred for outpatient colonoscopy between July 2011 and July 2012 were evaluated for eligibility. Inclusion criteria were outpatient status and age ≥40 years. Exclusion criteria were (1) complete colonoscopy within 1 year before the procedure, (2) inability to provide informed consent, (3) incomplete colonoscopy to the cecum, (4) previous bowel resection, (5) inflammatory bowel disease, (6) colonic polyposis syndrome, (7) inadequate bowel preparation, and (8) musculoskeletal disorder or other mobility issues limiting effective patient position changes during colonoscopy. INTERVENTIONS Prescribed position changes during colonoscope withdrawal. MAIN OUTCOME MEASUREMENTS Polyp detection rate (PDR) and adenoma detection rate (ADR). RESULTS A total of 776 patients were enrolled, with 388 in the dynamic group. There was no difference in PDR (odds ratio [OR] 0.99; P = .93) or ADR (OR 1.17; P = .28). Colonoscope withdrawal time was longer in the dynamic group (median time 466.5 vs 422.5 seconds; P < .0001). LIMITATIONS Single-center study. Indication for procedure not controlled. Lack of standardized bowel preparation and blinding. CONCLUSION Prescribed position changes during colonoscope withdrawal do not affect polyp/adenoma detection compared with the usual practice when the baseline ADR is above the recommended standard. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01395173.).

> Editorial: Endoscopic Missed Rates of Upper Gastrointestinal Cancers: Parallels With Colonoscopy

Colonoscopy (CSPY) allows competent endoscopists to safely, tolerably, and accurately examine the entire colon, thus facilitating the diagnosis of colonic diseases as well as the performance of therapeutic interventions. It can be technically demanding and requires significant time and practice to master the psychomotor and cognitive aspects of the procedure. Therefore, with a significant number of graduating gastroenterology and surgical trainees expected to perform this procedure as a core component of their future practice, the need for appropriate training to allow for the acquisition of competence is critical. With this in mind, 2 questions arise: (1) what is procedural competence in this setting and (2) at what point do trainees become competent? Unfortunately, even though CSPY allows for objective assessment, the definition of competence remains difficult to delineate. Arguably the most frequently referenced CSPY performance marker is the cecal intubation rate (CIR). Because cecal intubation is a critical component to defining a complete CSPY, it is often reported as a prerequisite for determining competence. The American Society for Gastrointestinal Endoscopy (ASGE) in conjunction with the American College of Gastroenterology (ACG) published quality indicators to help define competence. These, alongside other recommendations, suggest at least a 90% CIR in all cases. However, cecal intubation is only 1 component of a complete CSPY and alone does not sufficiently define competency. Regarding the number of procedures required to become competent, the first guidelines were based on expert opinion. Subsequently, with the emergence of a pivotal study by Cass et al, the ASGE recommended that trainees complete a minimum of 140 CSPYs before competence can be assessed. However, both references above are now relatively outdated, and as additional studies