Kate Donovan

Endoscopic placement of the capsule endoscope in children

BACKGROUND Capsule endoscopy provides a minimally invasive examination of the entire small bowel. However, some children and disabled adults may be unable to independently ingest the capsule. A new method for endoscopic placement of the capsule endoscope is described. METHODS Consecutive children who required capsule endoscopy of the small bowel and who were unable to independently ingest the capsule were selected for endoscopic placement. A net retrieval catheter and a translucent ligation adaptor were used to hold and stabilize alignment of the capsule during endoscopic insertion into the distal duodenum. RESULTS Eleven pediatric patients underwent successful endoscopic placement of a capsule endoscope in the duodenum without complication. One capsule migrated back into the stomach, where it remained for the life of the battery. CONCLUSIONS Endoscopic placement of the capsule endoscope by using the described technique appears to be effective and safe. It facilitates capsule endoscopy in patients who are unable to independently ingest the capsule.

Role of acid and nonacid reflux in children with eosinophilic esophagitis compared with patients with gastroesophageal reflux and control patients.

Objectives: Because of the relationship between food and eosinophilic diseases, we hypothesize that patients with eosinophilic esophagitis (EE) may be repeatedly exposed to nonacid ingested foodstuffs compared with patients without EE. Because inflammation is found throughout the esophagus in patients with EE, we further hypothesize that there would be more full-column reflux in EE patients compared with patients with gastroesophageal reflux disease (GERD) and control patients. Materials and Methods: We retrospectively reviewed pH-multichannel intraluminal impedance tracings of EE patients who were age-matched with control and GERD patients and compared the reflux profiles among the 3 groups. Results: There were no significant differences between the mean numbers of nonacid reflux events in EE patients (4.7 ± 3.3) compared with GERD (7.5 ± 5.3) or control patients (6.8 ± 4.6) (P = 0.36). There were significantly more acid reflux events in patients with GERD (47.4 ± 17.1) compared with patients with EE (24.9 ± 20.0) and control patients (28.4 ± 16.5) (P = 0.02). Patients with EE did not have a higher percentage of full-column reflux (31.9 ± 20.9) compared with control patients (24.4 ± 19.8) or patients with GERD (30.5 ± 14.9) (P = 0.64). Conclusions: Neither full-column reflux nor nonacid reflux is a significant contributor to the pathogenesis of EE.

Preservation of intestinal motility after the serial transverse enteroplasty procedure in a large animal model of short bowel syndrome

INTRODUCTION Serial transverse enteroplasty (STEP) has been shown to improve bowel function in short bowel syndrome. The effect of the STEP procedure on intestinal motility is not known, but some have hypothesized that it could disrupt bowel innervation and thus impair intestinal motility. METHODS Growing Yorkshire pigs (n = 7) underwent 3 operations at 6-week intervals: (1) reversal of 50 cm of jejunum, (2) 90% bowel resection +/- STEP to the proximal dilated bowel (4 STEP, 3 control), and (3) implantation of serosal strain gauges. At each operation, baseline and post-octreotide small intestinal motility was studied with continuously perfused manometry catheters using non-anticholinergic anesthesia. In addition, awake monitoring was performed using strain gauge analysis 1 week after the third operation. Characteristics of phase III of the migrating motor complex (MMC) were compared between and within groups using t test, chi(2), and analysis of variance, with significance set at P < .05. RESULTS Manometry data from the third surgery revealed no differences between groups or compared with baseline within groups for the presence and characteristics of phase III of the MMC. Specifically, the mean amplitude and frequency of phase III after octreotide, and both the mean baseline and mean octreotide-stimulated motility indices were equivalent. The duration of phase III after octreotide stimulation was significantly increased in the STEP animals, suggesting a potential benefit of the STEP procedure. Strain gauge analysis, performed in awake animals, confirmed no differences between the groups for basal and octreotide-stimulated characteristics of phase III of the MMC. CONCLUSIONS These preliminary data suggest that the STEP procedure in a porcine model of short bowel syndrome does not interfere with baseline or hormonally stimulated motility within the small bowel. These findings further support the STEP procedure as a safe option for the surgical management of short bowel syndrome.

A Randomized Double-Blind Controlled Trial of Microstream Capnography to Reduce Oxygen Desaturation During Gastrointestinal Procedures with Conscious Sedation

A Randomized Double-Blind Controlled Trial of Microstream Capnography to Reduce Oxygen Desaturation During Gastrointestinal Procedures with Conscious Sedation Jenifer Lightdale, Henry Feldman, Adrienne Newburg, Victoria Turbini, Lisa Heard, Kate Donovan, James DiNardo, Victor Fox Oxygen desaturation is a relatively late sign of ventilatory compromise. ASGE monitoring guidelines for all GI procedures call for continuous pulse oximetry and visual assessment during conscious sedation (CS), which may not detect apnea until O2 desaturation has occurred. Microstream capnography may provide an ‘‘early warning system’’ by generating real-time waveforms of respiration (capnograms) in non-intubated patients. Aim: To determine whether intervention based on capnography indications of apnea reduces O2 desaturation during CS. Methods: We performed an IRB-approved double-blind randomized controlled trial of ASA Class I/II children undergoing GI procedures with midazolam C fentanyl CS, 2L supplemental O2, standard patient monitoring, and routine care. Endoscopy staff was blinded to additional continuous capnography monitoring (Philips M4 with Microstream CO2). Study arm was determined by opening a pre-numbered sequence of envelopes containing randomly permuted assignments. In the intervention arm, a trained independent monitor (IM) signaled to the endoscopy staff by raised hand if capnograms indicated apnea for O15 sec. In the control arm, an IM signaled if capnograms indicated apnea for O60 sec. Upon IM signals, endoscopy RNs instructed patients to breathe deeply and/or touched their backs. We hypothesized that patients randomized to the intervention arm would have fewer episodes of minor O2 desaturation (O2 sats !95% for 5 sec) than patients in the control arm. Results: 163 participants (89 male; mean age 13 yr, range 6mo19 yr; 86% ASA I) underwent 174 procedures (80% EGD, 13% colonoscopy, 7% both). Intervention and control patients did not differ significantly in sex, age, ASA class, procedures undergone, baseline O2 sats, or doses of midazolam and fentanyl. Endoscopy RNs documented poor ventilation in 2.7% of study patients and no apnea. Capnography indicated disordered ventilation during 56% of all procedures and apnea in 24%. Patients in the intervention arm were significantly less likely to have an intraprocedural episode of O2 desaturation than those in the control arm (11% vs 24%, p ! 0.03). Conclusions: The results of this controlled effectiveness trial support the routine use of microstream capnography to improve detection of apnea and reduce O2 desaturation during CS for GI procedures. Supported by AHRQ (K08 HS1-367502), a Risk Management Foundation Patient Safety Grant and Children’s Hospital Boston GCRC (M01-RR02172).

T1153 Does the Use of Multichannel Intraluminal Impedance with pH (pH-MII) Change the Outcome of Patients with Suspected GERD?

Background: Cornerstones for evaluation of childhood constipation are symptom history and a thorough physical exam. Additional diagnostic tests such as anorectal manometry and colonic transit time measurement are commonly used. However, the childs emotional and behavioral status is not evaluated routinely. Aim: To investigate the possible correlation among anorectal manometry (AM), behavioral scores and colonic transit time in children with combined defecation and voiding disorders. Methods: We prospectively evaluated patients who were referred for combined defecation and voiding symptoms (day and night incontinence or infrequent voiding). All patients underwent AM, behavioral assessment and colonic transit time (CTT) measurement. During AM, we determined threshold for first rectal sensation and lowest volume required to elicit the rectoanal inhibitory reflex (RAIR). Parents were asked to fill out the Parenting Rating Scale about childhood psychopathology and behavior disorders (BASC-2). To measure CTT the patients swallowed a capsule with 10 markers during 6 consecutive days followed by an abdominal radiograph on day 7. A CTT longer than 62 hours was defined as abnormal. Spearmans rank correlation coefficients were calculated for the three different tests. Results: We enrolled 16 patients (10 girls, mean age 7.8 ± 1.8 yrs). Nine children showed a normal CTT (mean 22.7 ± 17, range 2.4-52.8 hours), 7 had a prolonged CTT (mean 80.7 ± 18, range 62.4-103.2 hours). Two children had T scores in the clinical range for externalizing problems and two others had at risk/ clinically significant scores for internalizing problems. Children with delayed CTT and rectal retention of markers required larger volumes to elicit RAIR (correlation coefficient 0.861, p= 0.01). Those with higher thresholds for sensation had lower T scores for externalizing problems (correlation coefficient -0.782, p= 0.04) and behavioral problems (correlation coefficient -0.873, p=0.01). In children with a normal CTT, higher T scores for externalizing problems and behavioral problems were present among those with a lower CTT (correlation coefficient -0.760, p= 0.02 and correlation coefficient -0. 765, p= 0.02 respectively). Conclusions: In children with both defecation and voiding disorders, behavioral problems seem to correlate with objective tests parameters. A significant correlation was found between AM, BASC and CTT. A comprehensive evaluation of the child emotional and behavioral components should be included in the work-up of the child presenting with symptoms of voiding dysfunction.