Richard A. Kozarek

The effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores

BACKGROUND Previous studies showed a correlation between mean withdrawal times during screening colonoscopy and polyp/neoplasia detection rates. OBJECTIVES To assess the effect of a monitoring and feedback program on withdrawal times, polyp/neoplasia detection rates, and patient satisfaction. DESIGN Comparison of retrospective and prospective data. SETTING Teaching hospital. PATIENTS Asymptomatic adults undergoing screening colonoscopy. INTERVENTIONS Monitoring and feedback program. MAIN OUTCOME MEASUREMENTS Withdrawal times, polyp and neoplasia detection rates, and patient satisfaction scores. METHODS We retrospectively reviewed 850 screening colonoscopies, recording withdrawal times, polyp findings, and patient satisfaction scores. All procedures were performed by 10 experienced gastroenterologists who were then informed that periodic confidential monitoring and feedback of withdrawal times, polyp detection rates, and satisfaction scores would be started. We then prospectively collected data on another 541 screening colonoscopies. We compared pre- and postmonitoring outcome measures. RESULTS Overall, after monitoring had begun, there was an increase in mean withdrawal times (from 6.57 to 8.07 minutes; P < .0001), and polyp detection rates (from 33.1% to 38.1%; P = .04, significance removed by Bonferroni correction). Nine of the 10 endoscopists increased their withdrawal times significantly. There was a small, nonsignificant increase in the neoplasia detection rate (from 19.6% to 22.7%; P = .17), but no significant change in mean satisfaction scores. Across endoscopists, there was a moderate correlation (r = 0.63; P = .04, significance removed by Bonferroni correction) between withdrawal times and polyp detection rates, but not between withdrawal times and satisfaction scores. LIMITATIONS No randomization, possible response bias, confounding of intervention effects, and sample size limitations. CONCLUSIONS Monitoring and feedback are associated with increases in mean withdrawal times and polyp detection rates, but not patient satisfaction scores. Neoplasia detection rates showed a statistically nonsignificant trend toward an increase.

Impact of Sigmoidoscopy and Colonoscopy on Colorectal Cancer Incidence and Mortality: An Evidence-Based Review of Published Prospective and Retrospective Studies

Screening for colorectal cancer (CRC) using sigmoidoscopy or colonoscopy is now common in many developed countries. This concise, evidence-based review looks at the impact of sigmoidoscopy or colonoscopy screening on CRC incidence, CRC mortality and overall mortality. Data from controlled retrospective and prospective (observational or randomized) studies have generally shown that sigmoidoscopy and colonoscopy, whether for diagnostic, screening or surveillance purposes, are associated with a significant reduction in CRC incidence and CRC mortality. The data on their impact on overall mortality is much more limited, with most studies unable to report a reduction in overall mortality. The results of three meta-analyses have confirmed these conclusions. As expected, sigmoidoscopy has a predominant effect on left-sided CRC, although some studies have shown modest effects on right-sided colon cancer as well. Most studies on colonoscopy have demonstrated that the protective effect applies to both right and left-sided cancer, although the protection seemed better on the left side. Despite the introduction of other screening and diagnostic modalities for the colon, such as computed tomography colonography and colonic capsule endoscopy, lower endoscopy will continue to be an important mode of screening for CRC and evaluating the colon.

Self-expandable stents in the gastrointestinal tract /

Self-expandable stents in the gastrointestinal tract / , Self-expandable stents in the gastrointestinal tract / , کتابخانه دیجیتال جندی شاپور اهواز

Explosion From Argon Cautery During Proctoileoscopy of a Patient With a Colectomy

We report a unique case of a 70-year-old woman with Gardners syndrome who had a subtotal colectomy with ileoproctostomy. Since then, she has undergone 12 uncomplicated proctoileoscopies, each time with argon plasma coagulation ablation of small polyps without any bowel preparation. However, during the most recent procedure, when we attempted to cauterize some rectal polyps, an immediate explosion occurred, leading to multiple rectal and ileal perforations that required surgical repair with a temporary end ileostomy. This event suggests that bacterial fermentation of colonic content or visible feces is not necessary for combustion because we observed a cautery-related explosion in the absence of a colon. This case shows the need for adequate bowel preparation if cautery is to be used, even in patients who have undergone a colectomy.

Pancreatic stones as a cause of bile duct and ampullary obstruction: endoscopic treatment approaches

The opening of the common bile duct and the main pancreatic duct often share a common channel at the ampulla of Vater. Gallstones residing in the common bile duct frequently become impacted in the ampulla of Vater, inciting pancreatitis in the adjacent organ. The opposite situation, impaction of pancreatic stones in the ampulla of Vater leading to obstructive biliary tract disease, has rarely been reported. The existence of this disorder and its optimal treatment remains largely unexplored. We report two cases of biliary tract obstruction caused by pancreatic duct (PD) calculi, successfully treated with two different endoscopic management approaches.

USE OF METHOTREXATE FOR REFRACTORY INFLAMMATORY BOWEL DISEASE

Methotrexate is an antimetabolite with significant anti-inflammatory properties. As such, it has been used in a heterogeneous group of inflammatory disorders and prompted a study of its use in idiopathic inflammatory bowel disease. Eighty percent of 38 patients with refractory Crohn’s disease or chronic ulcerative colitis patients had a statistically significant clinical improvement to 25 mg of parenteral methotrexate weekly within 12 weeks. This clinical improvement was associated with steroid reductions and endoscopic and histologic improvement or normalization in a subset of patients. Seventy-seven percent of 30 patients switched to a tapered oral methotrexate dose have maintained remission with oral methotrexate at mean follow-up of approximately one year. Toxicity was generally mild and related to minor liver function abnormalities, nausea and abdominal cramping, or leukopenia, although one opportunistic infection and one case of hypersensitivity pneumonitis were noted. Moreover, given methotrexate’s known ability to induce hepatic fibrosis and cirrhosis, long term follow-up of our patients remains necessary. Additional studies will be required to define what place methotrexate will play in the treatment of idiopathic inflammatory bowel disease.

Gastrointestinal Tract Stenting

Self-expandable enteral stent placement for disorders of the gastrointestinal tract has evolved significantly over the past decade. Improved stent flexibility and the availability of partially, fully and uncovered endoprostheses have allowed the placement of small diameter self-expanding stents with high rates of technical and clinical success. While the majority of enteral stent placement is performed to palliate malignant mechanical obstruction, the advancements in technique and device technology have created suitable alternative endoscopic options for benign conditions. At the present time, outcome data for those receiving enteral stents for malignant conditions supports this as a favorable alternative to more invasive therapeutic options. However, the outcome data for enteral stenting in benign conditions is complex and a direct correlate to the clinical challenges providers face when treating these conditions. This chapter focuses on the indications, techniques, up-to-date outcome data, and currently available technologies for stent placement in the esophagus, small intestine, and colon.