Background and study aims Endoscopic retrograde cholangiopancreatgraphy (ERCP) carries a radiation risk to patients undergoing the procedure and the team performing it. Fluoroscopy time (FT) has been shown to have a linear relationship with radiation exposure during ERCP. Recent modifications to our ERCP suite design were felt to impact fluoroscopy time and ergonomics. This multivariate analysis was therefore undertaken to investigate these effects, and to identify and validate various clinical, procedural and ergonomic factors influencing the total fluoroscopy time during ERCP. This would better assist clinicians with predicting prolonged fluoroscopic durations and to undertake relevant precautions accordingly. Patients and methods A retrospective analysis of 299 ERCPs performed by 4 endoscopists over an 18-month period, at a single tertiary care center was conducted. All inpatients/outpatients (121 males, 178 females) undergoing ERCP for any clinical indication from January 2012 to June 2013 in the chosen ERCP suite were included in the study. Various predetermined clinical, procedural and ergonomic factors were obtained via chart review. Univariate analyses identified factors to be included in the multivariate regression model with FT as the dependent variable. Results Bringing the endoscopy and fluoroscopy screens next to each other was associated with a significantly lesser FT than when the screens were separated further (–1.4 min, P = 0.026). Other significant factors associated with a prolonged FT included having a prior ERCP (+ 1.4 min, P = 0.031), and more difficult procedures (+ 4.2 min for each level of difficulty, P < 0.001). ERCPs performed by high-volume endoscopists used lesser FT vs. low-volume endoscopists (–1.82, P = 0.015). Conclusions Our study has identified and validated various factors that affect the total fluoroscopy time during ERCP. This is the first study to show that decreasing the distance between the endoscopy and fluoroscopy screens in the ERCP suite significantly reduces the total fluoroscopy time, and therefore radiation exposure to patients and staff involved in the procedure.
Background and Aims Same day bidirectional endoscopies (esophagogastroduodenoscopies [EGD]s and colonoscopies) are routinely performed. However, the best sequence of procedures is unknown, as is whether the use of carbon dioxide (CO2) affects the preferred sequence of procedures. This study aims to determine the preferred sequence of procedures and choice of insufflation gas (air or CO2) in patients undergoing same day bidirectional endoscopies. Methods Two hundred adults with a clinical indication for same day bidirectional endoscopies were randomized equally into four groups: A1 (EGD first, CO2 as insufflator); A2 (EGD first, air as insufflator); B1 (colonoscopy first, CO2 as insufflator); and B2 (colonoscopy first, air as insufflator). All procedures were performed with conscious sedation (Midazolam/Fentanyl). The primary outcome was patients’ overall comfort/satisfaction with the procedures and sedation received, as assessed by questionnaires and validated scoring scales (Nurse-Assessed Patient Comfort Score [NAPCOMS], La Crosse [WI]) collected during the procedures, before discharge, and on day 7 postprocedure. Results Two hundred patients were randomized, with data available for 186. Mean Midazolam dose between groups was significantly less in the EGD first groups (P=0.01). During the procedures, no differences were found in patients’ comfort as per the nurse reported NAPCOMS scores (P=0.19) or the Lacrosse (WI) endoscopy scores (P=0.05). On postprocedure days 0 and 7, no differences were found in the patients’ reported Lacrosse (WI) scores, nausea, sore throat, dizziness, satisfaction with sedation or overall level of procedural satisfaction (P>0.05 for each). However, bloating and discomfort were significantly lower in the CO2 arms (P<0.001). Conclusions This randomized controlled trial using validated patient comfort scoring assessments for same day bidirectional endoscopies demonstrated that the sequence of procedures affects the sedation used but does not affect overall patient comfort or satisfaction. Lesser sedation is needed in the EGD first group, and less postprocedural abdominal pain/discomfort and bloating is seen with CO2 insufflation.
Background and study aims Methods to improve polyp detection during colonoscopy have been investigated, with conflicting results for warm water irrigation. Carbon Dioxide (CO 2) warmed to 37 °C may have similar or more pronounced effects on bowel motility. This study aimed to assess whether warmed CO 2 would improve polyp detection compared to room temperature air insufflation. Patients and methods This was a double-blind, randomized controlled trial that enrolled 204 patients undergoing screening or surveillance outpatient colonoscopy. The primary outcome was polyp per patient detection rate. Secondary outcomes included adenoma per patient detection rates, bowel spasm, and patient comfort. Results The trial was terminated after an interim analysis determined futility. Between the warmed CO 2 and room air groups, no significant differences were found in the per-colonoscopy polyp detection rate ( P = 0.57); overall polyp detection rate ( P = 0.69); or adenoma detection rates ( P = 0.74). More patients in the room temperature group had lower spasm scores (p = 0.02); however, there was a trend towards greater patient comfort in the warmed CO 2 group ( P = 0.054). An ex-vivo study showed a significant difference between exiting CO 2 temperature at the insufflator end vs. delivered CO 2 temperature at the colonoscope tip end. The temperature of insufflation at the tip of the colonoscope was not different when using warmed vs. unwarmed insufflation ( P = 0.62). Conclusion When compared with room air insufflation, warmed CO 2 insufflation did not affect polyp detection rates.
Endometriosis is typically marked by the implantation and proliferation of foci of endometrial stroma and glands outside the endometrial cavity and uterine musculature. Extra-gonadal seeding has been observed in sites like the small and large bowel, peritoneum, appendix, pleura, umbilicus, old wound scars, subarachnoid space, inguinal canal, heart and lungs.14,7 The gastrointestinal tract is the third most common localization of endometriosis after the ovaries and the peritoneum, with intestinal involvement being reported in about 12 to 37% of individuals.1,2,5-7 Establishing a diagnosis of intestinal endometriosis can often be a diagnostic challenge. We present an interesting case of sigmoidal endometriosis in a 46-year-old female, whose initial presentation was irregular bowel movements with rectal bleeding.
Introduction: The management of Type III sphincter of oddi dysfunction (SOD), or functional biliary pain syndrome, remains challenging. Evidence from the EPISOD study suggests that there is no role for biliary or pancreatic endoscopic
Background Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure used to address pathologies of the pancreatic and biliary systems. ERCP performed under conscious sedation (CS) is the current standard of care but is limited by patient movement and agitation, especially in the context of lengthy or technically complex cases. Recent literature suggests that general anesthesia (GA) may optimize patient comfort and safety while reducing complications such as pancreatitis, perforation, and mortality. In October 2017, Kelowna General Hospital (KGH) transitioned the standard anesthesia modality for ERCP from CS to GA. Aims To investigate differences in complications and patient outcomes for ERCP performed under CS (n=1334) before the practice change compared to GA (n=899) after the practice change. Methods Our study is a pre-post retrospective chart review of 2,233 patients who underwent ERCP between 2015 and 2020 at KGH. Demographic, clinical, procedural and outcome data were extracted from patient charts, and the data in CS and GA groups were compared using univariate statistical analysis. Results Preliminary results show rates of post-ERCP pancreatitis (6% vs. 4%; p=0.018) and rates of procedure failure (8% vs. 3%; p<0.001) were statistically significant and higher under CS before the practice change compared to under GA afterwards, respectively. The 30-day mortality rates, ICU transfer rates, return rates post-discharge, and rates of cholangitis were similar. Our study showed improvements in several patient safety outcomes, including lower procedure failure rates and lower post-ERCP pancreatitis rates with ERCP performed under GA compared to CS. Conclusions Performing ERCP under GA rather than under CS is a valuable practice change that should be considered by ERCP-related programs across all health authorities due to its potential to optimize both patient comfort and safety significantly. The reduction in complication rates may have implications for net cost savings in the long term. Funding Agencies Kelowna General Hospital Foundation, Interior Health
Background Pancreatic and biliary cancer can be difficult to definitively diagnose, and tissue diagnosis defines clinical management in both early and late disease. The majority of patients with pancreaticobiliary malignancy present with late disease and only 30% have resectable tumours, contributing to poor prognosis and outcome. Endoscopic retrograde cholangiopancreatography (ERCP) is a mainstay for diagnosing and treating conditions of the bile and pancreatic duct. Aims This study aimed to provide data on the diagnostic performance of ERCP utilizing conventional methods for tissue acquisition particularly in the setting of an indeterminate stricture. In particular, this was a quality assurance review to determine our centre’s baseline performance as a reference so new methods of tissue acquisition such as SpyglassTM can be benchmarked against. Methods In a tertiary care hospital, 3723 ERCP procedures were performed between 2013 and 2017. Demographic and clinical information was retrospectively collected. Demographic and clinical information was collected. Three ERCP techniques of tissue sampling were analyzed: brushing alone (BiA), biopsy alone (BrA), and brushing and biopsy dual-modality approach (BrBi). The diagnostic performances (sensitivity, specificity, and accuracy) were calculated with data from post-sampling clinical reports, surgical pathological reports, and diagnostic imaging reports. Results 222 patients (285 ERCP procedure) met the study criteria and received fluoroscopy-guided ERCP sampling with cytology brushing and/or tissue biopsies. 36 (13%) patients had BiA, 85 (29%) patients had BrA, and 164 (58%) patients had BrBi. The sensitivities, specificities, and accuracies of the three sampling techniques respectively were: 56%, 93%, and 85% for BiA; 73%, 96%, and 83% for BrA; and 79%, 94%, and 86% for BrBi. Conclusions Our retrospective analysis of fluoroscopic-guided tissue acquisition shows accuracy as high as current published data on direct visualization cholangiosopy guided techniques. A prospective study looking not only at clinical yield but a cost analysis should be put in place prior to a commitment to purchase new equipment such as the SpyglassTM. Funding Agencies None
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