Nurse-Administered Propofol Continuous Infusion Sedation for Gastrointestinal Endoscopy in Patients Who Are Difficult to Sedate.

BACKGROUND & AIMS: Patients who chronically use alcohol, marijuana, or opioids, or suffer from post-traumatic stress disorder (PTSD), can be difficult to sedate with midazolam and fentanyl, and often are referred for monitored anesthesia care during endoscopy. Nurse-administered propofol continuous infusion sedation (NAPCIS), which confers the benefit of propofol-based sedation without the added expense of anesthesia, is effective and safe for sedation of healthy patients. We investigated whether NAPCIS also is effective for patients who are difficult to sedate. METHODS: We performed a retrospective study of patients who underwent upper endoscopy or colonoscopy with NAPCIS at a single center from January 2018 through April 2018. We reviewed records from patients who were heavy users of alcohol (n = 105), daily users of marijuana (n = 267) or opioids (n = 178), had a diagnosis of PTSD (n = 91), or were none of these (controls, n = 786). We compared mean fentanyl and propofol doses (adjusted for body weight), procedure and recovery times, procedure success rates, and adverse events. RESULTS: Compared with the controls, the marijuana group required higher mean adjusted sedative doses for colonoscopies (0.6 vs 0.4 mcg/kg fentanyl and 5.0 vs 4.7 mg/kg propofol; P ≤ .025 for both) and upper endoscopies (0.8 vs 0.3 mcg/kg fentanyl and 3.7 vs 3.2 mg/kg propofol; P ≤ .021 for both), the PTSD group required a higher dose of fentanyl for colonoscopies (0.6 vs 0.4 mcg/kg; P = .009), and the alcohol group required a higher dose of fentanyl for upper endoscopies (0.7 vs 0.3 mcg/kg; P < .001). Procedure success rates were high (95.1%-100%) and did not differ significantly between the difficult-to-sedate groups and controls; mean procedure times (7.0-9.0 minutes for upper endoscopies, 21.1-22.9 minutes for colonoscopies) and recovery times (22.5-29.6 minutes) also were similar among groups. Upper endoscopies were associated with lower sedative doses and shorter procedure and recovery times than colonoscopies. Sedation-related adverse events were rare in all groups (only 26 cases total), and there were no serious complications or deaths. CONCLUSIONS: NAPCIS seems to be a safe and effective means of providing sedation for endoscopy to patients who may be difficult to sedate owing to alcohol, marijuana, or opioid use, or PTSD.

Nurse-Administered Propofol Continuous Infusion Sedation: A New Paradigm for Gastrointestinal Procedural Sedation.

INTRODUCTION: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects. METHODS: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation. RESULTS: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases). DISCUSSION: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span.

BACKGROUND: There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade. STUDY: We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients). RESULTS: Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017. CONCLUSIONS: Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.

A Review of the Management of Sporadic Colorectal Adenomas in Young People: Is Surveillance Wasted on the Young?

The national incidence of colorectal cancer is increasing in people younger than 50 years old. Although diagnostic colonoscopy is detecting more sporadic adenomas in young adults, there are no guidelines for post-polypectomy surveillance. The aim of this review was to survey the medical literature on the prevalence of sporadic adenomas in young adults, subsequent risk of metachronous neoplasia, and lastly to provide several concluding recommendations for clinical practice. We found that the prevalence of sporadic adenomas in young adults is greater than initially estimated and dependent upon factors such as colonoscopy indication and age. The incidence of metachronous colorectal neoplasia following polypectomy is unclear but does not appear to be greater than that of older adults. Risk factors for metachronous neoplasia include findings on index colonoscopy, male gender, smoking status, and certain medical comorbidities. Upon finding a colorectal adenoma in a young person, we suggest that a detailed family history be obtained to confirm that it is truly sporadic. Testing adenomas for evidence of Lynch syndrome is low yield. Strategies to inform surveillance intervals may include an assessment of risk factors for metachronous neoplasia, although surveillance intervals shorter than those recommended in current guidelines are not warranted. Future research should focus on obtaining long-term, prospective data on the incidence of metachronous neoplasia in diverse patient populations.

Computer-Assisted Propofol Sedation for Esophagogastroduodenoscopy Is Effective, Efficient, and Safe.

BACKGROUND AND AIMS: Computer-assisted propofol sedation (CAPS) allows non-anesthesiologists to administer propofol for gastrointestinal procedures in relatively healthy patients. As the first US medical center to adopt CAPS technology for routine clinical use, we report our 1-year experience with CAPS for esophagogastroduodenoscopy (EGD). METHODS: Between September 2014 and August 2015, 926 outpatients underwent elective EGDs with CAPS at our center. All EGDs were performed by 1 of 17 gastroenterologists certified in the use of CAPS. Procedural success rates, procedure times, and recovery times were compared against corresponding historical controls done with midazolam and fentanyl sedation from September 2013 to August 2014. Adverse events in CAPS patients were recorded. RESULTS: The mean age of the CAPS cohort was 56.7 years (45% male); 16.2% of the EGDs were for variceal screening or Barrett's surveillance and 83.8% for symptoms. The procedural success rates were similar to that of historical controls (99.0% vs. 99.3%; p = 0.532); procedure times were also similar (6.6 vs. 7.4 min; p = 0.280), but recovery time was markedly shorter (31.7 vs. 52.4 min; p < 0.001). There were 11 (1.2%) cases of mild transient oxygen desaturation (< 90%), 15 (1.6%) cases of marked agitation due to undersedation, and 1 case of asymptomatic hypotension. In addition, there were six (0.6%) patients with more pronounced desaturation episodes that required brief (< 1 min) mask ventilation. There were no other serious adverse events. CONCLUSIONS: CAPS appears to be a safe, effective, and efficient means of providing sedation for EGD in healthy patients. Recovery times were much shorter than historical controls.

Young patients with sporadic colorectal adenomas: current endoscopic surveillance practices and outcomes.

BACKGROUND AND AIMS: For young individuals (age <40 years) without strong family histories that would put them at risk for genetic colorectal cancer syndromes, it is unclear if national Multi-Society Task Force surveillance recommendations apply or if endoscopists follow these guideline recommendations when such patients are incidentally found to have adenoma(s) on colonoscopy. METHODS: We reviewed records on young (age <40 years) patients, with either no family history or only a moderate family history (1 first-degree family member with colorectal cancer at age ≥50), who were found to have neoplastic polyp(s) on their index colonoscopy. We assessed the pattern of endoscopist surveillance recommendations, whether endoscopist recommendations complied with national guidelines, and compliance with surveillance recommendations. RESULTS: One hundred forty-one subjects were included, of whom 19 (13.5%) had a moderate family history of colorectal cancer. For patients with non-high-risk findings, 27.7% were asked to repeat their colonoscopy in ≤3 years and 99.0% within 5 years. Endoscopist surveillance recommendation compliance rates with national guidelines were >65.0% for low-risk neoplasia but lower for high-risk (40.0%), nonpolypoid (44.2%), and serrated neoplasia (54.2%, P < .001 for all). Subjects whose endoscopist recommendations were noncompliant with guidelines were usually recalled too early (96%). Only 24.7% of subjects were actually compliant with endoscopist surveillance recommendations. CONCLUSIONS: For young patients with neoplastic polyp(s) but no strong family history, most endoscopists complied with national guidelines and recommended repeat colonoscopy in 3 to 5 years. However, relatively few patients were compliant with repeat colonoscopy recommendations. For most cases that were noncompliant with guidelines, patients were recalled too early as opposed to too late.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures.

PURPOSE OF REVIEW: To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. RECENT FINDINGS: The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

The First US Clinical Experience With Computer-Assisted Propofol Sedation: A Retrospective Observational Comparative Study on Efficacy, Safety, Efficiency, and Endoscopist and Patient Satisfaction.

BACKGROUND: Computer-assisted propofol sedation (CAPS) is now approved for moderate sedation of American Society of Anesthesiologists (ASA) class I and II patients undergoing routine endoscopy. As the first US medical center to adopt CAPS for routine clinical use, we compared patient and endoscopist satisfaction with CAPS versus midazolam and fentanyl (MF) sedation. METHODS: Patients who underwent elective outpatient upper endoscopy and colonoscopy with CAPS were compared with concurrent patients sedated with MF. The primary end points were patient satisfaction (measured by the validated Patient Sedation Satisfaction Index [PSSI]), and endoscopist satisfaction (Clinician Sedation Satisfaction Index [CSSI]). Secondary end points included procedural success rates, polyp detection rates, adverse events, and procedure/recovery times. Multivariable regression was used for comparative analysis. RESULTS: CAPS was utilized to sedate 244 patients, of whom 55 underwent upper endoscopy, 173 colonoscopy, and 16 double procedures. During the same period, 75 upper endoscopies, 223 colonoscopies, and 30 doubles were performed with MF on similar patients. For upper endoscopy, the procedural success rate was 98.2% for CAPS versus 98.7% for MF (P = .96), whereas for colonoscopy, the success rate was 98.9% vs 98.8% (P = .59). Colonoscopic polyp detection rate was 54.5% for CAPS and 59.3% for MF (P = .67). Procedure times were similar between CAPS and MF. For CAPS, the mean recovery time was 26.4 vs 39.1 minutes for MF (P < .001). One CAPS patient required mask ventilation, 4 experienced asymptomatic hypotension or desaturation, and 5 experienced marked agitation resulting from undersedation. For MF, 5 patients had hypotension or desaturation, and 8 experienced undersedation. For colonoscopy, the CAPS group had higher PSSI scores for sedation adequacy, the recovery process and global satisfaction, and higher CSSI scores for ease of sedation administration, the recovery process and global satisfaction. For upper endoscopy and doubles, the CAPS CSSI score was higher for the recovery process only. All P values were adjusted for confounding by using regression analysis. CONCLUSIONS: In low-risk patients, CAPS appears to be effective and efficient. CAPS is associated with higher satisfaction than MF for colonoscopies and, to a lesser extent, upper endoscopies.

Risks and Benefits of Colonoscopy in Patients 90 Years or Older, Compared With Younger Patients.

BACKGROUND & AIMS: Although the numbers of medical procedures performed on extremely elderly patients (90 years or older, nonagenarians) are increasing, there are no data on the performance, diagnostic yield, or safety of colonoscopy for these patients. We compared the performance and safety of diagnostic colonoscopy, as well as lesions detected, in nonagenarians with patients who were 75 to 79 years old. METHODS: In a retrospective study, we compared data from 76 extremely elderly patients (90 years or older) with data from 140 very elderly patients (75 to 79 years old, controls), all of whom underwent diagnostic colonoscopy from January 2010 through March 2013 at Virginia Mason Medical Center. All colonoscopies were performed by 15 endoscopists. We compared rates of colonoscopy completion, bowel preparation quality, diagnostic yield, and adverse events. RESULTS: In extremely elderly patients, more colonoscopies were performed under general anesthesia, compared with controls (P < .001). When extremely elderly patients underwent colonoscopies with moderate sedation, lower doses of midazolam and fentanyl were given, compared with controls (P < .001). Colonoscopies were completed in a lower proportion of extremely elderly patients (88.2% vs. 99.3% for controls, P < .001), and these patients had a higher incidence of inadequate bowel preparation (29.7% vs. 15.0% for controls, P = .011). Colonoscopies were also associated with cardiopulmonary events in a higher proportion of extremely elderly patients (P = .006) as well as overall adverse events, compared with controls (P = .002). A higher proportion of extremely elderly patients were found to have advanced neoplasia (28.4% vs. 6.4% of controls, P < .001) as well as any neoplasia (P < .001 vs. controls). A greater percentage of extremely elderly patients also had large lesions (P = .002) and malignancies detected by histology (P < .001 vs. controls). Eleven extremely elderly patients (14.9%) were found to have cancer or high-grade dysplasia by colonoscopy. CONCLUSIONS: In patients 90 years or older, diagnostic colonoscopy is associated with increased risk for incomplete procedure, inadequate bowel preparation, and adverse events. However, a large proportion of patients are found to have advanced neoplasia and cancer, compared with patients 75 to 79 years old.

Validation of colonoscopic findings from a structured endoscopic documentation database against manually collected medical records data.

BACKGROUND: Endoscopic documentation software can generate research data on large numbers of subjects automatically. There are increasing numbers of published studies based on endoscopic databases such as the Clinical Outcomes Research Initiative. However, no study has yet validated such data. We compared colonoscopic findings reported by an endoscopic documentation software (Provation) against manually collected medical records data from two similar patient cohorts in the same endoscopy unit. METHODS: In November 2011, our unit switched from dictation-based text documentation to the Provation system. As a quality control initiative, we collected data on 9614 patients who had undergone colonoscopies from January 2010 to November 2011, using manual electronic chart review. We compared these data against those generated by Provation on 7091 similar patients who underwent colonoscopy from November 2011 to March 2013. RESULTS: Age, sex and procedural indication distribution were similar between the Manual and Provation cohorts, as were the large (≥1 cm) polyp (7.6 vs. 8.1%; p = 0.25) and advanced neoplasia (8.3 vs. 8.2%; p = 0.80) prevalences. However, there were significant differences in the polyp (46.9 vs. 49.8%) and adenoma prevalences (31.3 vs. 26.8%; p < 0.001). Furthermore, the Manual cohort had a higher prevalence of diverticulosis and hemorrhoids, and a lower colonoscopy completion rate. Stratification by indication resulted in additional discrepancies between the two cohorts for screening and surveillance patients. There were also differences in the anatomic (right vs. left colon) distribution of large polyps. CONCLUSIONS: There were significant discrepancies between data from Provation and manually collected medical records data. Although the two cohorts were enrolled during slightly different time periods, they came from the same endoscopy unit, had the same endoscopists and indications, and demonstrated similar demographics, making it unlikely for there to be true differences between the cohorts independent of documentation method. Thus, caution is advised when using endoscopic data for research.

Findings of diagnostic colonoscopy in young adults versus findings of screening colonoscopy in patients aged 50 to 54 years: a comparative study stratified by symptom category.

BACKGROUND: The threshold for diagnostic colonoscopy in symptomatic patients aged <50 years remains controversial. Previous studies on the prevalence of neoplasia or other serious pathology in young patients mostly have been uncontrolled, providing only limited data on the risk associated with specific symptoms. OBJECTIVE: To compare colonoscopy findings in patients aged <50 years who have various symptoms (diagnostic cohort) against those of concurrent patients aged 50 to 54 years who are asymptomatic (screening cohort). DESIGN: Retrospective controlled cohort study. SETTING: Teaching hospital. PATIENTS: Symptomatic patients aged between 18 and 49 years and asymptomatic patients aged between 50 and 54 years. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Prevalence of advanced neoplasia. RESULTS: During the study period, 1638 patients underwent colonoscopy in the screening cohort (mean [± standard deviation{SD}] age 51.7 ± 1.4 years) and 1266 underwent colonoscopy in the diagnostic cohort (40.4 ± 8.0 years). Despite the age difference, the prevalence of advanced neoplasia in patients with rectal bleeding was comparable with that in the screening controls: 28 of 472 (5.9%) versus 113 of 1638 patients (6.9%) (P = .459). Furthermore, 10 patients (2.1%) with rectal bleeding were newly diagnosed with inflammatory bowel disease. In contrast, other symptoms that commonly lead to colonoscopy, such as abdominal pain, changes in bowel habits, and weight loss, were associated with much lower risks for neoplasia. As a result, the overall prevalences of neoplasia and advanced neoplasia were significantly higher in the screening cohort than in the diagnostic cohort: 467 of 1638 patients (28.5%) versus 179 of 1266 patients (14.1%), and 113 patients (6.9%) versus 48 patients (3.8%), respectively (both P < .001). LIMITATIONS: No data on duration of symptoms; discrepant sex ratios between cohorts. CONCLUSION: The threshold for diagnostic colonoscopy in symptomatic young adults should be individualized for each symptom category. Rectal bleeding warrants colonoscopy to detect advanced neoplasia or inflammatory bowel disease in most young patients, especially those aged 40 to 49 years, whereas non-bleeding symptoms, including some traditionally regarded as "alarm" symptoms, were associated with a much lower risk for neoplasia compared with the risk in screening patients aged 50 to 54 years.

Disparities in prevalence, location, and shape characteristics of colorectal neoplasia between South Korean and U.S. patients.

BACKGROUND: Colon cancer screening is being introduced in many countries, but standard Western screening approaches may not be appropriate for Asian societies if differences in colon cancer epidemiology exist. Comparative analysis of colorectal neoplasia patterns in South Korean and Western subjects has implications for appropriate screening approaches in non-Western societies. METHODS: The results of concurrent screening colonoscopies performed in average-risk patients 50 to 69 years old in 2 teaching hospitals, Kyung Hee University Hospital (Seoul, South Korea) and Virginia Mason Medical Center (Seattle, Wash), were compared with respect to prevalence, histologic features, anatomic distribution, and shape characteristics of colorectal neoplasia. RESULTS: The U.S. (n = 3460) and South Korean (n = 2193) cohorts were similar with regard to the prevalence of adenomas (28.5% vs 29.8%, respectively, P = .312) and advanced neoplasia (6.4% vs 5.4%, respectively, P = .102), but the proportion of proximal adenomas was greater in the U.S. cohort (62.8% vs 45.9%, P < .001). The prevalence of adenomas and advanced neoplasia was similar in male patients, but there was a greater prevalence of neoplasia (23.5% vs 18.8%, P = .006) and advanced neoplasia (5.1% vs 2.7%, P < .001) in U.S. women than South Korean women. When large (≥10 mm) adenomas were considered, proximal location and nonpolypoid (flat) shape were more common in the U.S. cohort (79.4% vs 37.1%, P = .003 and 43.5% vs 12.3%, P < .001, respectively). The overall prevalence of large flat adenomas in the U.S. cohort was 5 times that of the South Korean cohort (2.6% vs 0.5%, P < .001). Adjustment for sex ratio discrepancies (48.3% men in the U.S. cohort vs 60.8% in the South Korean cohort, P < .001) did not result in any significant changes in the conclusions. CONCLUSION: Compared with Westerners, South Koreans have a more distal distribution of adenomas and advanced neoplasia and lower prevalence of large flat adenomas. South Korean women have a lower prevalence of colorectal neoplasia than Western women. Such disparities suggest that Western screening strategies cannot be directly adopted by other countries, but need to be customized by society.

Endoscopic treatment of benign biliary strictures using covered self-expandable metal stents (CSEMS).

BACKGROUND AND AIMS: Traditional endoscopic management of benign biliary strictures (BBS) consists of placement of one or more plastic stents. Emerging data support the use of covered self-expandable metal stents (CSEMS). We sought to assess outcome of endoscopic temporary placement of CSEMS in patients with BBS. METHODS: This was a retrospective study of CSEMS placement for BBS between May 2005 and July 2012 from two tertiary care centers. A total of 145 patients (81 males, median age 59 years) with BBS were identified; 73 of which were classified as extrinsic and were caused by chronic pancreatitis, and 70 were intrinsic. Main outcome measures were resolution of stricture and adverse events (AEs) due to self-expandable metal stents (SEMS)-related therapy. RESULTS: Fully covered and partially covered 8-10 mm diameter SEMS were placed and subsequently removed in 121/125 (97 %) attempts in BBS (failure to remove four partially covered stents). Stricture resolution occurred in 83/125 (66 %) patients after a median stent duration of 26 weeks (median follow-up 90 weeks). Resolution of extrinsic strictures was significantly lower compared to intrinsic strictures (31/65, 48 % vs. 52/60, 87 %, p = 0.004) despite longer median stent duration (30 vs. 20 weeks). Thirty-seven AEs occurred in 25 patients (17 %), with 12 developing multiple AEs including cholangitis (n = 17), pancreatitis (n = 5), proximal stent migration (n = 3), cholecystitis (n = 2), pain requiring SEMS removal and/or hospitalization (n = 3), inability to remove (n = 4), and new stricture formation (n = 3). CONCLUSIONS: Benign biliary strictures can be effectively treated with CSEMS. Successful resolution of biliary strictures due to extrinsic disease is seen significantly less often than those due to intrinsic disease. Removal is successful in all patients with fully covered SEMS.

Screening patterns in patients with a family history of colorectal cancer often do not adhere to national guidelines.

BACKGROUND: Currently, there are no data on adherence to guidelines for colorectal cancer (CRC) screening in patients with a family history. AIM: We conducted a retrospective study to assess if such patients were being appropriately screened according to American Gastroenterological Association (AGA) guidelines. METHODS: Two independent reviewers performed a comprehensive medical record review of family and CRC screening history on 362 adults with a family history of CRC in a first-degree relative who had recently undergone screening colonoscopy. The endpoint was appropriate initiation of screening and endoscopist-recommended subsequent screening intervals, as compared to AGA guideline recommendations. RESULTS: Of 362 subjects, only 146 (40.3 %) were screened appropriately; 213 (58.9 %) had late initiation of screening (i.e., screening was started ≥5 years later than the age recommended by guidelines) and three (0.8 %) had premature initiation (i.e., screening was started ≥1 year too early). Of cases involving delayed screening initiation, 126 were not under primary care at the time when screening was supposed to have started, while most of the remaining received either no or incorrect screening recommendations from their primary care provider. Of 270 subjects with no neoplasia found on initial screening, 112 (41.5 %) had endoscopist-recommended subsequent screening intervals that were ≥2 years shorter than that recommended by guidelines. Results were similar if American Society of Gastrointestinal Endoscopy or American College of Gastroenterology guidelines were used. CONCLUSIONS: Patients with a family history often suffer from late initiation of screening and overly short endoscopist-recommended subsequent intervals for colonoscopy. Further education of patients and providers on screening recommendations may be helpful.

Explosion from argon cautery during proctoileoscopy of a patient with a colectomy.

We report a unique case of a 70-year-old woman with Gardner's 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.

Preference for colonoscopy versus computerized tomographic colonography: a systematic review and meta-analysis of observational studies.

In recent years, colorectal cancer (CRC) screening using computerized tomographic colonography (CTC) has attracted considerable attention. In order to better understand patient preferences for CTC versus colonoscopy, we performed a systematic review and meta-analysis of the available literature. Data sources included published studies, abstracts and book chapters, in any language, with publication dates from 1995 through February 2012, and with prospective or retrospective enrollment of diagnostic or screening patients who had undergone both procedures and explicit assessment of their preference for colonoscopy versus CTC. A predefined algorithm identified eligible studies using computer and hand searches performed by two independent investigators. We used a mixed effects model to pool preference differences (defined as the proportion of subjects who preferred CTC minus the proportion who preferred colonoscopy for each study). Twenty-three studies met inclusion criteria, totaling 5616 subjects. In 16 of these studies, patients preferred CTC over colonoscopy, while colonoscopy was preferred in three studies. Due to the high degree of heterogeneity, an overall pooled preference difference was not calculated. Stratified analysis revealed that studies published in radiology journals (preference difference 0.590 [95 % CI 0.485, 0.694]) seemed more likely than studies in gastroenterology (0.218 [-0.015-0.451]) or general medicine journals (-0.158 [-0.389-0.072]) to report preference for CTC (p<0.001). Studies by radiology authors showed a trend towards stronger preference for CTC compared with studies by gastroenterology authors. Symptomatic patients expressed no preference, but screening patients preferred CTC. There was no difference in preferences between studies using "masked" and "unmasked" preference ascertainment methods. Three studies featuring limited bowel preparations for CTC reported marked preference for CTC. There was no evidence of publication bias, while cumulative and exclusion analysis did not show any temporal trend or dominant study. Limitations included data heterogeneity and preference ascertainment limitations. In conclusion, most included studies reported preference for CTC. On stratified analysis, screening patients preferred CTC while diagnostic patients showed no preference. Studies published in radiology journals showed significantly stronger preference for CTC compared with studies in gastroenterology or general medicine journals.

Long-term outcomes associated with pancreatic extracorporeal shock wave lithotripsy for chronic calcific pancreatitis.

BACKGROUND: Most outcomes data on pancreatic extracorporeal shock wave lithotripsy (P-ESWL) for chronic calcific pancreatitis (CCP) are based on studies with <4 years' follow-up, and U.S. long-term studies are lacking. OBJECTIVE: To report long-term P-ESWL outcomes for CCP and to assess whether smoking or alcohol use influences P-ESWL outcomes. DESIGN: Cross-sectional study, retrospective chart review. SETTING: Virginia Mason Medical Center, Seattle, Washington. PATIENTS: This study involved 120 patients who underwent P-ESWL and ERCP for CCP and completed an outcomes questionnaire. INTERVENTION: P-ESWL and ERCP, outcomes survey. MAIN OUTCOME MEASUREMENTS: Pain, quality of life, narcotics use, diabetes status, pancreatic enzyme requirement, repeat P-ESWL, repeat ERCP, surgery. RESULTS: A total of 120 patients underwent P-ESWL followed by ERCP (mean ± standard deviation [SD] follow-up 4.3 [± 3.7] years) and completed a survey. The mean (± SD) before-P-ESWL pain score was 7.9 (± 2.6) compared with 2.9 (± 2.6) after P-ESWL (P < .001). Improved pain was reported by 102 patients (85%); 60 (50%) reported complete pain relief and no narcotic use. The mean (± SD) before-P-ESWL quality-of-life score was 3.7 (± 2.4) compared with 7.3 (± 2.7) after P-ESWL (P < .001). In patients with ≥ 4 years' follow-up, repeat procedures included P-ESWL (29%), ERCP (84%), and surgery (16%). Smokers who quit smoking after P-ESWL had improved narcotic requirements compared with those who continued smoking (95% vs 67%; P = .014), and a trend suggested a decreased need for repeat ERCPs (68% vs 84%; P = .071). LIMITATIONS: Single center, retrospective, recall bias, nonvalidated pain and quality-of-life scales. CONCLUSION: P-ESWL as the initial therapy for CCP may lead to more lifetime procedures; however, partial pain relief in 85%, complete pain relief with no narcotic use in 50%, and avoidance of surgery in 84% of patients may be achieved. Quitting smoking after P-ESWL may improve outcomes.

Editorial: risk scoring for colon cancer screening: validated, but still not ready for prime time.

Risk stratification for colorectal cancer screening would allow us to use less expensive screening tests, such as sigmoidoscopy with or without fecal blood testing, on lower risk individuals, and reserve colonoscopy for those at higher risk. In this issue, Levitzky et al. validates a risk score that was previously developed by Imperiale et al., finding similar results among three ethnic groups. Risk scoring would detect 82-87% of proximal advanced neoplasia while decreasing colonoscopy use by 33-46%. However, before risk scoring is ready for widespread use, sigmoidoscopy access and performance issues need to be addressed, and we must be comfortable with missing some proximal neoplasms.