Endoscopic Program Research Articles

Surgical Management of Gastric Cancer: An Institutional Experience

Introduction: Gastric cancer (GC) is the second most common cause of cancer-related deaths causing about 800,000 deaths worldwide/year. In Nepal gastric cancer is the second common cancer among males after the lung cancer. Gastric cancer shows a wide variation in incidence worldwide, being highest in Korea and Japan. It is detected early due to the low threshold for upper gastrointestinal endoscopy and screening programs. In the rest of the world and particularly in developing countries, GC is advanced in most of the cases. Inspite of controversies in extent of resection and lymphadenectomy, surgery remains the gold standard treatment. The study was conducted to determine the outcome of the patients with gastric cancer.
 Methods: The study was conducted in the department of surgery at Nepalgunj Medical College and Teaching Hospital Kohalpur from November 2015 to Dec 2018. Patients diagnosed with GC were studied. The patients with resectable disease underwent radical resection followed by adjuvant chemo-radiation as indicated. Patient’s demography, clinical presentation, stage of disease, types of surgery performed and survival were analysed.
 Results: 58 patients were diagnosed with gastric cancer. The age ranged from 20-83 years with the mean of 61.26±11.28. Male to female ratio was 2.41: 1. The common clinical presentations were weight loss, anorexia and anemia, 17 (29.31%) had gastric outlet obstruction at initial presentation and 4 (6.89%) presented with perforation peritonitis. Antropyloric region was the commonest site of tumor location seen in 41 (70.68%). 7 (12.06%) patients had distant metastasis and 5 (8.62%) had ascites at presentation. Out of 58 patients, 43 (74.13%) were operated. Only 18 (41.86%) patients underwent R0 resection. 14 (24.13%) underwent palliative gastrojejunostomy. Two (3.44%) patients underwent primary repair for perforation and in 9 (15.51%) the procedure was abandoned due to and presence of metastasis. There was one post-operative mortality. The histology of gastric cancer was found to be adenocarcinoma in all patients. There was no patient in stage I. 3(16.66%) patients were in stage II and 15 (83.33%) in stage III. 17 (29.31%) had stage IV disease. Out of 43 operated patients, 13 lost follow up. All 17 resected patients and those with metastatic disease were followed up. There was no death and no local recurrence in stage II. In stage III, 78.57% were alive and in stage IV 35.29% were alive.
 Conclusion: Gastric cancer is one of the common gastrointestinal malignancies affecting predominantly male gender. Stage of the disease is one of the major prognostic factors related with the survival. Adenocarcinoma is the commonest histology. Radical resection followed by adjuvant chemotherapy is the standard of care. Palliative chemotherapy can prolong the overall survival in patients with metastatic disease.

Virtual reality simulation training in endoscopy: a Cochrane review and meta-analysis.

Endoscopy programs are increasingly integrating simulation training. We conducted a systematic review to determine whether virtual reality (VR) simulation training can supplement and/or replace conventional patient-based endoscopy training for health professional trainees with limited or no prior endoscopic experience. We searched medical, educational, and computer literature databases in July 2017 for trials that compared VR simulation training with no training, conventional training, another form of simulation training, or an alternative method of VR training. We screened, abstracted data, and performed quantitative analysis and quality assessment through Cochrane methodology. We included 18 trials with 3817 endoscopic procedures. VR training provided no advantage over no training or conventional training based on the primary outcome of composite score of competency. VR training was advantageous over no training based on independent procedure completion (relative risk [RR] = 1.62, 95 % confidence interval [CI] 1.15 - 2.26, moderate-quality evidence), overall rating of performance (mean difference [MD] 0.45, 95 %CI 0.15 - 0.75, very low-quality evidence), and mucosal visualization (MD 0.60, 95 %CI 0.20 - 1.00, very low-quality evidence). Compared with conventional training, VR training resulted in fewer independent procedure completions (RR = 0.45, 95 %CI 0.27 - 0.74, low-quality evidence). We found no differences between VR training and no training or conventional training for other outcomes. Based on qualitative analysis, we found no significant differences between VR training and other forms of simulation training. VR curricula based in educational theory provided benefit with respect to composite score of competency, compared with unstructured curricula. CONCLUSIONS : VR simulation training is advantageous over no training and can supplement conventional endoscopy training. There is insufficient evidence that simulation training provides benefit over conventional training.

Collaboration is Key – Bridging the Gap and Building an IR Endoscopy Practice

While the tools and techniques employed by interventional radiologists on a day-to-day basis translate well to learning the skills required to perform basic endoscopic interventions, collaboration with other specialties is crucial to the success of an interventional radiology endoscopy program. As in any field in medicine, the paramount goal is to improve patient care. Adding the ability to directly visualize structures through an endoscope to certain interventional radiologic procedures may greatly augment the efficacy, safety, and success of interventional radiology procedures. Colleagues in urology, gastroenterology, and surgery should be involved in decision-making and treatment planning to ensure that a shared vision for optimal patient care is achieved.

A Deeper Look at the Small Bowel: Training Pathways in Video Capsule Endoscopy and Device-Assisted Enteroscopy.

Although there are guidelines for video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), little is known about fellowship training in these technologies. The aims were to better characterize current small bowel endoscopy training in 3-year GI fellowship programs and 4th-year advanced endoscopy programs in the U.S. We developed an online multiple-choice survey to assess current GI fellowship program training in small bowel endoscopy. The survey was distributed via email to GI fellowship program directors in the U.S. Of the 168 program directors contacted, 59 responded (response rate = 35.1%). There was no statistically significant difference in the availability of VCE or DAE between respondents and non-respondents. VCE training was universally available in 3-year training programs, with 84.8% (50/59) requiring it for fellows. The majority of 3-year GI fellows graduated with independence in VCE: 83.1% (49/59) of programs reported "most" or "all" graduates were able to read independently. DAE techniques were available in 86.4% of training programs (51/59). Training in DAE was more limited and shared between 3-year and 4th-year programs: 12.1% (7/58) of 3-year programs required training in DAE and 22.9% (8/35) of 4th-year programs required training in DAE . Training in VCE is widely available in U.S. GI fellowship programs, although programs have different ways of incorporating this training into the curriculum and of measuring competency. While DAE technology was available in the majority of programs, training was less frequently available, and training is shared between 3-year fellowship programs and 4th-year advanced endoscopy programs .

Too Much of a Good Thing: An Unusual Complication With an Intragastric Balloon

Introduction: Intragastric balloons (IGB) are a safe and effective endoscopic weight loss procedure that has recently been approved for use in the U.S. The Manhattan VA initiated the first bariatric endoscopy program in the country, which works in conjunction with the MOVE! program. We report an interesting case of an obese man with dramatic weight loss and obstructive symptoms after IGB. Case report: Patient is a 45-year-old veteran with BMI of 38 kg/m2, hypertension, and obstructive sleep apnea, who presented for IGB. Physical exam and labs were unremarkable, with initial weight of 233 lbs. An Orbera IGB (Apollo Endosurgery, Austin, TX) was implanted and filled with 650 mL of saline mixed with methylene blue. At 4 months after implantation, the patient had lost an impressive 46 lbs, with active participation in the MOVE! program. At 4 months, he presented with new-onset nausea and vomiting. He denied abdominal pain, or changes in color of stool and urine. Initial abdominal x-ray(AXR) was unremarkable (Fig. 2a). The patient improved temporarily with dietary changes and anti-emetics, but vomiting after solid meals resumed and he was admitted. On admission, his weight was 169 lbs, with K of 3.1 mEq/L, BUN 32, creatinine of 2.0, normal liver tests and lipase. Hyperinflation of balloon, small bowel obstruction, gastric ulceration and gastroparesis were considered. Repeat AXR showed air-fluid levels (Fig. 2b). Upper endoscopy revealed intact freely movable IGB, located in antrum. IGB was removed, and the patient's symptoms resolved. Four months later, the patient has maintained the weight loss, with weight of 174 lbs (BMI 27 kg/m2) and a total excess weight loss of 68%.Figure: Abdominal x-rays 4 months after IGB placement revealed intact balloon (arrows) with no deflation or migration. Fig. 2b. Air-fluid level on hospital admission, 5 months after balloon implantation.Discussion: We present a patient with BMI of 38 kg/m2 status post IGB therapy with 59-lb total weight loss, later complicated by persistent gastric outlet obstructive symptoms with no evidence of mechanical obstruction.This functional dynamic gastric outlet obstruction may be attributed to the patient's sudden weight loss, especially since typical rate of weight loss after IGB is lower. The patient had no diabetes history, underlying infiltrative process, or medications use that could explain the functional gastroparesis. This study highlights an unexpected phenomenon that physicians should be aware of when monitoring effects of acute weight loss and consider in the presentation of late nausea and vomiting (after 3 months of implantation) in patients with IGB.Figure: Image of endoscopic intragastric balloon placed in gastric fundus and inflated with 650 mL of saline.Figure: BMI trend over 9 months, including time of IGB placement, hospitalization with IGB removal, and four-month follow-up after extraction.

Air Insufflation vs Water Exchange Colonoscopy: A Multiple Cross-over, N-of-1 Study in a Trainee

Introduction: Water exchange (WE) colonoscopy is associated with less discomfort when compared to air insufflation (AI); other likely advantages include a lesser occurrence of loop formation and a higher adenoma detection rate. Yet despite these advantages, colonoscopy training in most endoscopy programs starts with AI. Aim: To study outcomes in a trainee who was randomly assigned to AI vs. WE during the first two weeks of colonoscopy training. Methods: For AI the trainee followed the advice of various staff members; there was no protocol. For WE the trainee worked with a single endoscopist who instructed the following method: (1) all air was removed during insertion and water was used to identify proximal colon; (2) stool containing water was exchanged for clean water; (3) water volume was maintained at the lowest amount allowing endoscope advancement; (4) mandatory rotation of the patient from left to back at the splenic flexure; (5) manual pressure with splenic and hepatic flexure passage. Data collected included gender, age, sedation, insertion extent and time, total time, loop formation, number and type of polyps; T-test was used for analysis. Results: The trainee performed 35 procedures in the first 2 weeks of training with multiple cross-overs: 3AI - 3WE - 4AI - 4WE - 3AI - 4WE - 10AI - 4WE. Gender distribution was 4/20 for AI and 4/15 for WE; ages were 65±9 year (M±SD ) for AI and 60±7 for WE (p=0.15). For AI cecal intubation was successful in 12/20 (60%) patients during 21±9min; for WE this was 14/15 (93%) during 9±3min (p < 0.001). The terminal ileum was intubated in 1/20 during AI and 10/15 during WE. Significant loop formation occurred in 7/20 during AI and 1/15 during WE. For AI sedation consisted of fentanyl 96±32mcg and midazolam 4.5±1.8mg; for WE this was 57±20mcg and 2.5±0.6mg (p < 0.001 both). The ADR was 0.5 during AI and 0.66 during WE (p=.33). Total endoscopy time was 47±18min for AI vs. 42±6min for WE (p=.44). Limitations: This is the experience of a single trainee. The WE technique was more structured than the AI technique. During later AI colonoscopies the trainee started using WE techniques given the experience with WE. Conclusion: WE is statistically superior to AI for most features that were measured for this starting trainee: insertion time, cecal and terminal ileum intubation rates, prevention of loop formation and need for sedation. WE had a trend towards a higher ADR and shorter total endoscopy time. WE should be considered as starting technique for colonoscopy training.

Quality of colonoscopy practice: a single-center experience in Egypt

Colonoscopy is a technically demanding procedure with the potential to cause harm if its performance is suboptimal. It is incumbent on endoscopists, therefore, to evaluate their practices and to make improvements wherever possible. Bolak Eldakror Hospital is a secondary-care governmental hospital in Egypt in which we set up an endoscopy quality-assurance program in 2003. The aim of this study was specifically to evaluate the quality of colonoscopy practice in our endoscopy unit and by publishing our experience to encourage others to develop a quality-improvement program. Predetermined international quality indicators for colonoscopy were employed to monitor the standard of endoscopic procedures between 2010 and 2014. Recorded information included all medical and technical details. A total of 286 colonoscopies were assessed. The main indication of colonoscopy was hematochezia (58.7%). Polyps were the main endoscopic findings (34.6%). Conscious sedation was used in 56.6%. Cecal intubation was achieved in 77.6%. The adjusted cecal intubation was 94%. Image documentation of cecal intubation was achieved in 92.3% examinations reaching the cecum. Mean cecal intubation time was 17.4±10 min. Mean withdrawal time was 6.6±4 min. The main reasons for unsuccessful cecal intubation were impassable mass or stricture in 23 (8%) colonoscopies and poor bowel preparation in 23 (8%). Colon preparation was rated adequate in 66.4%. Diagnostic colorectal biopsies for those with persistent diarrhea were obtained in 97%. Polyp detection rate was 36.1% and adenoma detection rate was 5.3%. Polypectomy was carried out in 89 (93.6%) patients with detected polyp/s. Retrieval of all excised polyps was successful in 84.3%. Postpolypectomy perforation occurred in one (0.4%) patient. A high standard of colonoscopy can be achieved by the rigorous application of quality-assurance measures.

Applying Lean Design Principles to a Gastrointestinal Endoscopy Program for Uninsured Patients Improves Health Care Utilization

There is an emerging national consensus to increase colon and rectal cancer (CRC) screening rates to 80% by 2018. For us, as a nation (and GI specialty) to move from our current 60% to 80% we have to enhance screening among patient populations that are challenged to access our medical system. Those who are underinsured or uninsured pose a special challenge. In this month’s Practice Management column, gastroenterologists in Houston, Texas describe the impact of lean management strategies to enhance colon and rectal cancer screening among lowincome patients in the Harris Health System. Readers are encouraged to refer to a previous article, which focused on similar patients in Connecticut (Lagarde SP. No one left behind: the road to 80% by 2018. Clin Gastroenterol Hepatol 2014;12:1212–1215).

Evaluation of the Quality of Reprocessing of Gastrointestinal Endoscopes

To evaluate the quality of gastrointestinal endoscope reprocessing and discuss the advantages of microbiological surveillance testing of these endoscopes. Retrospective analysis of the results of endoscope sampling performed from October 1, 2006, through December 31, 2014, in a gastrointestinal endoscopy unit of a teaching hospital equipped with 89 endoscopes and 3 automated endoscope reprocessors, with an endoscopy quality assurance program in place. The compliance rate was defined as the proportion of the results classified at target or alert levels according to the French guidelines. A multivariate analysis (logistic regression) was used to identify the parameters influencing compliance. A total of 846 samples were taken. The overall compliance rate was 86% and differed significantly depending on the sampling context (scheduled or not scheduled), the type of endoscope, and the season. No other parameter was associated with compliance. A total of 118 samples carried indicator microorganisms such as Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Enterobacteriaceae, and Candida sp. The systematic use of an automated endoscope reprocessor does not provide totally satisfactory compliance. Microbiological surveillance is indispensable to monitor reprocessing, reinforce good practices (endoscopes, reprocessing units), and detect endoscopes requiring early technical maintenance.

Effect of a quality program with adverse events identification on airway management during overtube-assisted enteroscopy.

Adverse events associated with overtube-assisted enteroscopy are similar to those with routine endoscopy. Our endoscopy quality program identified a number of respiratory adverse events resulting in emergency resuscitation efforts. The aim is to report all adverse events identified by quality monitoring and outcomes of adverse events associated with overtube-assisted enteroscopy. A retrospective study used data prospectively obtained from consecutive patients undergoing overtube-assisted enteroscopy between December 2008 and July 2012. Patient characteristics, medical history, procedure indication, and procedure outcomes, including diagnosis, endoscopic therapy, and complications, were obtained. In 432 overtube-assisted enteroscopies, 15 adverse events (most frequently hypoxemia, 9 /15, 60 %) occurred in 14 patients (3.2 % of total cohort; 12 were outpatients) mostly during antegrade enteroscopy. Four patients required endotracheal intubation and 4 /12 outpatients required intensive care. The procedure was aborted in 13 /14 patients, and only 1 of 10 patients scheduled for repeat antegrade enteroscopy returned. There was no mortality. Based on the frequency of adverse events, and in consultation with anesthesia providers, from August 2012 all antegrade overtube-assisted enteroscopies at our institution were done with general anesthesia. From then till September 2013, 145 antegrade and 52 retrograde overtube-assisted enteroscopies have been done, with no adverse events. Monitoring of endoscopy practice identified adverse events associated with overtube-assisted enteroscopy. The peer-review prompted a change in practice: all patients undergoing antegrade overtube-assisted enteroscopy at our institution now have endotracheal intubation which has dramatically decreased the rate of respiratory adverse events. The impact of endoscopic quality measurements on practices, procedures, and outcomes will be of further interest.

PTH-031 An Increasing Demand For Enhanced Sedation Endoscopy: A Single Centre Experience

IntroductionThe demand for enhanced sedation endoscopy (ESE) appears to be increasing due to increasingly challenging diagnostic and therapeutic procedures. BSG Working Party guidance were issued in 2011.1 Our aim is...

ERCP in the elderly: handle with care.

ERCP in the elderly: handle with care.

High Resolution White Endoscopy with Chromoendoscopy and Confocal Laser Endomicroscopy for Atrophic Gastritis Surveillance: One Center Experience

Purpose: Atrophic gastritis (AG) is a well-characterized premalignant condition with a significantly increased risk for developing gastric neoplasia. A rigorous upper endoscopy surveillance program has been shown to undoubtedly reduce this risk. However, white light endoscopy random multiple biopsies in the regular standard of care missed lesions of high grade dysplasia and neoplasia in atrophic gastritis with commonly in patchy distribution. Recently, multiple new endoscopic imaging technologies such as chromoendoscopy with indigo carmine, which, with increased sensitivity, are able to obtain, and confocal laser endomicroscopy (CLE), which is developed to provide a more detailed visualization of the mucosa by enhancing morphology and vascularization with high specificity. Methods: In this prospective clinical trial, 20 patients from the First Hospital of Jilin University undergoing endoscopic screening and surveillance for AG were enrolled. High-definition white light endoscopy followed by indigo carmine sprayed in the antrum was performed to search for highly interested spot of lesions in antrum, followed by the CLE scan performed by two endoscopists experienced more than 30 CLE examinations and biopsy for standard histological pathologic diagnosis as “ gold standard”, and sent to a single GI pathologist to provide diagnosis. The endoscopists CLE diagnosis and standard pathologic diagnosis were compared. Results: The comparison of CLE plus chromoendoscopy to histological pathology diagnosis is sensitivity 89.00%, and specificity 87.50% in atrophic gastritis (Kappa=0.0495, 0.4<k<0.75), sensitivity 97.98%, specificity 94.59% (Kappa=0.557, 0.4<k<0.75). Conclusion: CLE has significant consistency to the pathology diagnosis in the atrophic gastritis and intestinal metaplasia. CLE with chromoendoscopy enhances the diagnostic accuracy, clinical real-time result and decision. CLE with chromoendoscopy has potential advantage for diagnosis and treatment of atrophic gastritis.

Improving safety of personnel exposed to disinfectants by introducing an Endoscopy Quality Assurance Program

BackgroundChemical disinfection is the most commonly used method in gastrointestinal endoscopy reprocessing. The main problem with chemical disinfection is that it is potentially harmful to humans. Risk assessment of employees using toxic substances is recommended and the control of exposure to these substances is required. In 2003, an endoscopy quality-assurance program was instituted in a secondary care governmental hospital in Egypt. AimThe aim of the study was to assess the risk to health of personnel exposed to disinfectants in the course of their work and determine the effect of instituting an endoscopy quality-assurance program on the safety of personnel exposed to disinfectants. Materials and methodsHealth surveillance was provided for personnel exposed to disinfectants in the endoscopy unit over an 8-year period between January 2004 and January 2012. A quality improvement program was implemented (improving ventilation, providing instructions and education) to control exposure to these substances. The effectiveness of the change was assessed. ResultsPrior to a quality assurance program being implemented, allergic reactions related to disinfectants were reported in 33% of working days in 2004. Subsequent allergic reactions decreased to 6–8% in 2010 and 2011 and this was contingent on the solution used for reprocessing. ConclusionThe implementation of a quality assurance and improvement program in endoscopy unit improved the safety of personnel exposed to disinfectants.

The Global Rating Scale in clinical practice: A comprehensive quality assurance programme for endoscopy departments

BackgroundThe Global Rating Scale is an endoscopy quality assurance programme, successfully implemented in England. It remains uncertain whether it is applicable in another health care setting. AimTo assess the applicability of the Global Rating Scale as benchmark tool in an international context. MethodsEleven Dutch endoscopy departments were included for a Global Rating Scale-census, performed as a cross-sectional evaluation, July 2010. Two Global Rating Scale-dimensions – ‘clinical quality’ and ‘patient experience’ – were assessed across six items using a range of levels: from level-D (basic) to level-A (excellent). Construct validity was assessed by comparing department-specific colonoscopy audit data to GRS-levels. ResultsFor ‘clinical quality’, variable scores were achieved in items ‘safety’ (9%=B, 27%=C, 64%=D) and ‘communication’ (46%=A, 18%=C, 36%=D). All departments achieved a basic score in ‘quality’ (100%=D).For ‘patient experience’, variable scores were achieved in ‘timeliness’ (18%=A, 9%=B, 73%=D) and ‘booking-choice’ (36%=B, 46%=C, 18%=D). All departments achieved basic scores in ‘equality’ (100%=D).Departments obtaining level-C or above in ‘information’, ‘comfort’, ‘communication’, ‘timeliness’ and ‘aftercare’, achieved significantly better audit outcomes compared to those obtaining level-D (p<0.05). ConclusionThe Global Rating Scale is appropriate to use outside England. There was significant variance across departments in dimensions. Most Global Rating Scale-levels were in line with departments’ audit outcomes, indicating construct validity.

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

Upper and Lower Gastrointestinal Findings in PTEN Mutation–Positive Cowden Syndrome Patients Participating in an Active Surveillance Program

OBJECTIVES:Cowden syndrome (CS), associated with germline PTEN mutations, is an autosomal-dominant disorder with increased frequencies of thyroid and breast cancers. Recent reports document the occurrence of gastrointestinal (GI) polyps and increased risk of colon cancer in PTEN mutation carriers. Studies to date, however, have not been based on mutation carriers undergoing active, systematic, routine-interval GI surveillance. Our objective is to document the upper and lower GI findings in CS patients undergoing such an active GI surveillance program.METHODS:In a 5-year period, 3,000 consecutive patients were referred to our high-risk GI cancer clinic for various reasons. Of these 3,000, 10 met full-blown clinical criteria for the diagnosis of CS. Individuals with identified PTEN mutations underwent annual upper and lower endoscopy surveillance programs using dual white light and narrow-band imaging. All biopsies including archived materials were reviewed by a single dedicated GI pathologist.RESULTS:Ten PTEN mutation carriers from different ethnic backgrounds were invited and all participated in the active GI surveillance program. Eight patients had colonic polyps, mostly hyperplastic (eight patients) and hamartomatous (five patients), but also adenomatous (three patients), ganglioneuromatous (three patients), and juvenile polyps (two patients). One patient (10%) had an early-onset rectal cancer (aged 44 years), which was null for PTEN expression on immunohistochemistry. All patients had gastric polyps and nine (90%) had duodenal polyps, mostly hyperplastic and hamartomatous. Additional three patients (30%) had adenomatous duodenal polyps.CONCLUSIONS:PTEN mutation–positive CS patients have a higher frequency of upper GI polyps than previously believed. They appear prone to develop adenomatous upper and lower tract dysplastic polyps and cancer. Thus, the polyps encountered during upper or lower endoscopy in these patients should not be automatically considered innocent hamartomas without malignant potential. Active surveillance programs in specialized centers should be considered in these patients.

The cost impact of in vivo diagnosis of diminutive polyps: experience from a screening endoscopy programme

Introduction The histological evaluation of diminutive polyps is time consuming and expensive. Recent developments in endoscopic techniques have enabled the prediction of histology in vivo using vascular enhancement techniques and dye sprays. This study aims to evaluate the cost effectiveness of in vivo histology prediction using white light (WLI) FICE and indigo carmine (IC) dye spray in the bowel cancer screening programme. Methods Patients undergoing screening on the national bowel cancer screening programme (BCSP) were prospectively evaluated. Polyps were examined using WLI, FICE and IC prior to removal and histological examination. The accuracy of the in vivo histology prediction was calculated. Using a histology cost of £58.90 per polyp the cost of histological analysis for the cohort was calculated. Cost savings for sending neoplastic polyps (Portsmouth protocol) or just polyp cancers (modified Portsmouth protocol) was then calculated. Finally the cost per missed adenoma was assessed for WLI, FICE and IC dye spray. Results 141 patients were examined, with 305 diminutive polyps Conclusion (1) In vivo diagnosis of polyps and retrieving and sending only adenomas can lead to a 1.5–2-fold reduction in pathology costs. (2) In vivo diagnosis where only diminutive cancers are sent for histology can lead to an 75–113-fold reduction in pathology costs. (3) A simple change in practice (after appropriate training) with in vivo polyp diagnosis can significantly reduce the work load for extremely stretched and busy endoscopy and pathology departments.

Providing Endoscopy for Underserved Patients Benefits Public Health and Resident Education

To determine the clinical and educational value of a new model for providing endoscopy for medically indigent patients. A model can be developed at minimal cost to provide essential endoscopy services for underserved patients while providing resident education. In our community, there was limited access to endoscopy for indigent patients, and surgical resident endoscopy experience was inadequate. To address these problems, a new endoscopy program was developed. Procedures were performed during underused times in a hospital endoscopy clinic. Endoscopies were performed on patients referred from the public health clinics. All procedures were performed by senior surgical residents supervised by attending endoscopists. The data were collected over 30 months. Colonoscopies were performed for both diagnostic and screening purposes. In all, 205 colonoscopies, 65 upper endoscopies, and 14 combined endoscopies were performed. Positive findings on endoscopy were documented. The cost-effectiveness was calculated. Of 205 colonoscopies, 35% had positive findings. Sixty-six (32%) patients had polyps and 6 (3%) patients had carcinomas. Of 65 upper endoscopies, 34 (55%) patients had positive findings. Thirty (47%) patients had moderate to severe gastritis/esophagitis or ulcers, 2 (3%) patients had esophageal varices, 2 (5%) patients had carcinomas, 10 (15%) patients had positive H. pylori biopsies, and 2 (3%) patients had Barrett's esophagus. The program incurred minimal incremental costs, and large cost savings were realized in prevention and early detection of colon and gastric carcinomas. Our 30-month experience resulted in clinical benefits to patients at minimal incremental cost while reducing future medical costs by preventing and detecting disease. Surgical residents received essential training.

Barrettʼs Surveillance Interval Repeat Ratio: A Novel Utilization Metric

Purpose: Surveillance endoscopy (EGD) programs in patients with Barrett's Esophagus (BE) are recommended to detect development of dysplasia or early esophageal adenocarcinoma (EAC). Current guidelines recommend repeat EGD within one year for patients without dysplasia and interval EGD every 3 years subsequently; and for patients with low grade dysplasia repeat EGD within 6 months and annually subsequently. The number of patients diagnosed with BE has increased in the recent decades and this increase has significant implications for health care resource utilization and costs. Currently there are no objective criteria which can be used as a utilization measure. We proposed to devise a novel metric of BE Interval Repeat Ratio (BEIRR) to optimize utilization of surveillance EGD in BE. Methods: Retrospective review of medical records for a cohort of patients (≥ 18 years) who had EGD which detected mucosal changes suspicious for BE between January 2004 to December 2006 done by 6 well experienced gastroenterologists at the University setting. These patients were followed till May 2010. BEIRR was calculated as Total number of repeat EGD's + Total number of Initial EGD's/Total number of Initial EGD's for 6 providers separately and statistical analysis was performed. Patients diagnosed to have EAC and patients whose pathology reports could not be obtained were excluded from the final analysis. Results: 151 patients were identified with mucosal changes suspicious for BE (111 Male; Mean Age 61.1 years) and 13 were excluded. 82 patients had BE without dysplasia, 4 patients had BE with low grade dysplasia and 52 patients did not have microscopic changes of BE. 136 EGD's were repeated over 6 years for patients with BE without dysplasia with a cumulative BEIRR of 2.8. Individual BEIRR for 6 providers were 3, 2.26, 3.5, 2.1, 2.1 and 2.3, respectively, with a mean of 2.54, SD 0.57; 95% CI 1.4-3.68. For 4 patients with low grade dysplasia 24 EGD's were repeated with cumulative BEIRR of 7. For patients without BE on microscopy 54 EGD's were repeated of which 33 (61%) were repeated for surveillance and none of the subsequent EGD's showed any evidence of metaplasia, dysplasia or cancer. One patient with LGD progressed to have high grade dysplasia and one patient progressed to have adenocarcinoma. Conclusion: BEIRR's can be used as a benchmark metric to optimize utilization of surveillance EGD's for BE. We found a very low incidence of high grade dysplasia and adenocarcinoma in our cohort of patients consistent with prior reported data. Surveillance EGD for patients with no microscopic evidence of BE did not detect even a single case of metaplasia, dysplasia or cancer.