Quality Indicators for Capsule Endoscopy and Deep Enteroscopy.

INTRODUCTION: Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS: An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS: The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. DISCUSSION: Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Quality indicators for capsule endoscopy and deep enteroscopy.

BACKGROUND AND AIMS: Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method. METHODS: An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method. RESULTS: The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE. CONCLUSIONS: Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Review of Duodenoscope Infection Prevention Practices at the Medical University of South Carolina.

A rise in duodenoscope-associated infections, especially in regard to multidrug-resistant organisms, has led to an increase in scrutiny regarding duodenoscope reprocessing. Endoscopic retrograde cholangiopancreatography scopes have a specialized elevator wire channel, allowing more flexible duct cannulation; however, this channel can be difficult to reprocess with standard techniques. Although strict adherence to manufacturer reprocessing protocols remains the primary means of infection prevention, periodic microbiological surveillance is a Food and Drug Administration-recommended practice that the Medical University of South Carolina has implemented to further prevent duodenoscope-associated infections. The Medical University of South Carolina obtains 2 separate cultures from 2 duodenoscopes every 2 months, which undergo standard speciation and sensitivity and are returned to use once negative at 48 hours. The initial results of the Medical University of South Carolina's surveillance cultures are negative for any multidrug-resistant organisms; however, other centers should consider implementing surveillance cultures into their reprocessing practices and closely monitoring for future endoscope infection prevention modalities.

Success of single-balloon enteroscopy in patients with surgically altered anatomy.

BACKGROUND: Single-balloon enteroscopy (SBE) was introduced in 2007 to diagnose and treat small-bowel disorders. No study to date has evaluated SBE in patients with surgically altered anatomy outside of ERCP. OBJECTIVE: To evaluate the efficacy, yield, and safety of SBE in patients with surgically altered anatomy. DESIGN: Retrospective study. SETTING: Tertiary-care academic medical center. PATIENTS: All patients with altered surgical anatomy who underwent SBE at the Medical University of South Carolina from July 2007 to September 2013. INTERVENTIONS: SBE. MAIN OUTCOME MEASUREMENTS: Diagnostic yield, therapeutic yield, technical success, and adverse events. RESULTS: A total of 48 patients met inclusion criteria. Mean age was 56 years (77% female). Eleven patients underwent single-balloon PEG placement, 8 single-balloon ERCP, 22 non-PEG/non-ERCP anterograde SBE, and 7 retrograde SBE. Previous surgeries included Roux-en-Y gastric bypass (n=26), small-intestine resection (n=6), colon resection (n=5), Whipple procedure (n=4), choledochojejunostomy (n=3), hepaticojejunostomy (n=1), Billroth I (n=1), Billroth II (n=1), and Puestow procedure (n=1). Procedural indications were PEG tube placement (n=11), choledocholithiasis (n=2), biliary stricture (n=2), obstructive jaundice (n=1), cholangitis (n=1), ampullary mass (n=1), sphincter of Oddi dysfunction (n=1), anemia and/or bleeding (n=15), abdominal pain (n=9), radiologic evidence of obstruction (n=3), and Peutz-Jeghers syndrome (n=2). The technical success rate was 73% in single-balloon PEG placement, 88% in single-balloon ERCP, 82% in other anterograde SBEs, and 86% in retrograde SBEs. No intraprocedural or postprocedural adverse events were observed. LIMITATIONS: Single center, retrospective study. CONCLUSION: SBE is safe and effective in patients with surgically altered anatomy.

Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessing.

BACKGROUND: Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as long as 21 days without risk of clinically significant contamination. OBJECTIVE: To demonstrate whether flexible endoscopes may be stored for as long as 21 days after reprocessing without colonization by pathogenic microbes. DESIGN: Prospective, observational study. SETTING: Tertiary care center. ENDOSCOPES: Four duodenoscopes, 4 colonoscopes, and 2 gastroscopes. INTERVENTION: Microbial testing of endoscope channels. MAIN OUTCOME MEASUREMENTS: Culture results at days 0, 7, 14, and 21. RESULTS: There were 33 positive cultures from 28 of the 96 sites tested (29.2% overall contamination rate). Twenty-nine of 33 isolates were typical skin or environmental contaminants, thus clinically insignificant. Four potential pathogens were cultured, including Enterococcus, Candida parapsilosis, α-hemolytic Streptococcus, and Aureobasidium pullulans; all were likely clinically insignificant as each was only recovered at 1 time point at 1 site, and all grew in low concentrations. There were no definite pathogenic isolates. LIMITATIONS: Single center. CONCLUSION: Endoscopes can be stored for as long as 21 days after standard reprocessing with a low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.

Is Endoscopic Therapy Effective for Angioectasia in Obscure Gastrointestinal Bleeding?: A Systematic Review of the Literature.

GOAL: We aimed to summarize pooled rebleeding rates of angioectasia after therapeutic endoscopy, and compare these to historical control (no intervention) rates. BACKGROUND: Obscure gastrointestinal bleeding continues to be challenging to diagnose and treat; in America, small bowel angioectasias are the most common cause. Technology advances led to higher diagnostic yield for these lesions; however, therapeutic impact of endoscopy remains unclear. STUDY: A PubMed search (June 1, 2006 to September 19, 2013) with 2 independent reviews sought articles reporting rebleeding rates of symptomatic angioectasia without therapy (natural history) and after endoscopic treatment. This study list was added to studies in the 2007 American Gastroenterological Association systematic review. Data on number of patients who underwent endoscopic therapy, type of therapy used, number of patients who experienced rebleeding, and follow-up time were extracted. Rebleeding data were pooled and weighted averages were reported with 95% confidence intervals (CI). RESULTS: Twenty-four articles (n=490 patients) with data on endoscopic therapy for angioectasia and 6 natural history cohorts (n=130) receiving no therapy for angioectasia were eligible. Of the endoscopic therapy patients, 121 at push enteroscopy and 427 at balloon-assisted enteroscopy; 209/490 (42.7%; 95% CI, 38%-47%) rebled. Of the control (no therapy) patients, 64/130 (49.2%; 95% CI, 40%-58%) rebled. Number needed to treat is estimated at 15 to 16. CONCLUSIONS: Rebleeding rate after endoscopic therapy for symptomatic small bowel angioectasia may be comparable to that expected without therapy. Endoscopic therapy may be ineffective; if effective, the needed to treat is estimated to be high. Controlled studies, with intervention-stratified and etiology-stratified outcomes are needed.

Open-Access Single Balloon Enteroscopy: A Tertiary Care Experience.

OBJECTIVES: To compare single balloon enteroscopy (SBE) between patients seen in consultation by a member of our gastroenterology team with those performed as open-access cases. METHODS: Retrospective study of all patients who underwent SBE at a single tertiary care center from April 2008 to January 2012. Open- and closed-access procedures were compared in terms of diagnostic and therapeutic yield, adverse events, and procedural success. RESULTS: A total of 125 SBEs were performed on 125 patients. The mean age was 63.1 (53% men) years. In all, 43 procedures were performed open access and 82 after face-to-face consultation. Indications included anemia/gastrointestinal bleeding (110), abdominal pain (8), and other (7). Diagnostic yield for open- and closed-access procedures was 53% and 60%, respectively (P = 0.501) and therapeutic yield was 37% and 52%, respectively (P = 0.11). Overall technical success was 91% with no difference between the groups (P = 0.27). There were no major adverse events in either group. CONCLUSIONS: SBE can be performed as an open-access procedure without compromise to safety or diagnostic yield.

Patients' short-term knowledge of personal polyp history inadequate despite systematic notification of results after polypectomy.

OBJECTIVES: Patients' memories of personal polyp characteristics have been shown to be inadequate when compared with the medical record. An accurate polyp history is necessary to adhere to guidelines. We sought to determine whether systematically informing patients of the results of their colonoscopy and pathology in a multifaceted manner could increase their knowledge of their personal polyp history. METHODS: We conducted a prospective pilot study of 240 consecutive patients undergoing screening colonoscopy with polypectomy by a single endoscopist (B.J.H.) at a tertiary care center. All of the patients were provided with a verbal report of findings immediately after the procedure, an endoscopy report specifying polyp size and number, and a mailed letter specifying the pathology results of their polyps. Telephone contact was attempted for all of the patients. Patients were asked to recall the size, number, and histology of their polyps. RESULTS: One hundred (42%) of the patients completed the telephone survey. Forty patients remembered the polyp number; five remembered their polyp histology, and one recalled the polyp size. None of the patients recalled all three factors, although patients who recalled telling a family member the results of the colonoscopy were more likely to recall at least one polyp descriptor (relative risk 2.62 [95% confidence interval 1.01-6.83]). No other variables were associated with polyp recall. CONCLUSIONS: Patients' knowledge of personal polyp characteristics, even after systematic notification, does not seem adequate for determining the best guideline-based colonoscopy surveillance interval. Discussing results with family members may help.

A resource-efficient tool for training novices in wireless capsule endoscopy.

Nurses often function as capsule endoscopy "pre-readers" to save physicians' time and potentially increase diagnostic yield. Training pre-readers is time consuming, not standardized, and may not be feasible during regular business hours. A way to evaluate the progress and accuracy of pre-readers is needed to ensure competency. The aim of this study was to introduce a feedback and progress assessment tool for training novice capsule endoscopy pre-readers. We created a 1-page form with listings of potential findings for each segment of the examination. Findings could be circled or written in. The trainee reviewed capsule studies and filled out the form on each of 220 patients. The physician reviewers subsequently critiqued the data forms, providing feedback regarding missed lesions, overcalls, and overall agreement. Our trainee achieved consistent agreement with the physician reviewers, after reading 80 studies. In conclusion, a simple, 1-page standardized data sheet can be used to facilitate training of novice capsule pre-readers without significant time commitment from the supervising physician. Future studies may validate this resource-efficient instrument as a training and assessment tool for nurses, physicians, and other practitioners learning capsule endoscopy.

Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy.

Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration. Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence. Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction ( P  = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk. Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.

Success of Percutaneous Endoscopic Gastrostomy by Single Balloon Enteroscopy in Patients Who Have Undergone Roux-en-Y Gastric Bypass.

Data is limited regarding the success and safety of percutaneous endoscopic gastrostomy (PEG) placements by single balloon enteroscopy (SBE) in patients with Roux-en-Y gastric bypass (RNY-GB) anatomy. We report on 23 cases of PEG placements by SBE with overall technical success of reaching the excluded stomach 70% and with PEG placement success rate of 69%. No intra-procedural adverse events occurred. This technique seems safe when feasible for PEG placement in patients with RNY-GB anatomy.

Sporadic Fundic Gland Polyps and Gastric Acid Suppression Level.

BACKGROUND: Fundic gland polyps (FGPs) are a common endoscopic finding and are known to be associated with proton pump inhibitors (PPIs) use. It is not known if their prevalence is affected by gastric acidity levels. This study aimed to assess whether there is a correlation between FGPs and gastric acidity levels as identified on 24-hour ambulatory impedance-pH studies in patients on PPI therapy. METHODS: We performed a review of 402 consecutive patients who take at least once daily PPI and underwent esophagogastroduodenoscopy with combined impedance-pH studies in the same setting (time and place) between January 2010 and December 2014. Patients were classified into 2 groups based on the presence or absence of biopsy-confirmed FGPs during endoscopy. RESULTS: Of the 402 patients, 30 (7%) had FGPs. One of these polyps was found with low-grade dysplasia. There was no significant difference of the distributions of the [H+] in the FGPs versus the nonpolyp groups (P = 0.741). There was no significant difference between the 2 groups regarding PPI dose frequency regimens (once and twice) (P = 0.074). However, we found weak ordinal association with PPI duration (P = 0.01) (Spearman = 0.1). CONCLUSIONS: FGPs are common endoscopic lesions. Incidence of dysplasia in FGPs is not only rare, but also of unknown clinical significance. Although they seem to be associated with PPIs, the mechanism remains unclear, as we found no correlation between the presence of FGPs and gastric acid control or PPI dose. Future studies would be useful to elucidate an alternate mechanism.

Cap-assisted retrograde single-balloon enteroscopy results in high terminal ileal intubation rate.

BACKGROUND AND STUDY AIMS: Retrograde single-balloon enteroscopy (RSBE) facilitates evaluation of the distal small bowel and provision of appropriate therapy when necessary. Intubation of the terminal ileum (TI) is a major rate-limiting step, with failure rates as high as 30 %. Cap-assisted endoscopy has proven beneficial in other aspects of endoscopy. We have noticed that it similarly aids in TI intubation during RSBE by facilitating opening of the ileocecal valve (ICV). The primary aim of this study was to measure the TI intubation rate using cap-assisted RSBE. Other procedural details and outcomes were also measured. PATIENTS AND METHODS: A total of 36 consecutive RSBEs performed between July 2011 and May 2014 at the Medical University of South Carolina were retrospectively reviewed. All procedures were performed or supervised by our center's small bowel endoscopist (ASB). Outcomes measured included TI intubation rate, procedure time, depth of maximal insertion (DMI), diagnostic yield (DY), therapeutic yield (TY), and complications. RESULTS: The TI intubation rate was 97 % (35 /36). The one failure was due to stool completely obscuring the cecum. Median procedure time was 54 minutes, with a mean DMI of 68 cm beyond the ICV. The technical success rate was 86 %, whereas DY and TY were 61 % and 25 %, respectively. There were no complications. The study was limited in that it involved a single endoscopist at a single center. CONCLUSIONS: Cap-assisted RSBE results in a high TI intubation rate, without compromise to safety or procedural yield.

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding.

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

Comparison between endoscopic ultrasound and magnetic resonance imaging for the staging of pancreatic cancer.

OBJECTIVE: Preoperative staging of pancreatic cancer is crucial for proper therapy. Through this study, we aimed to compare the ability of endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI) to effectively detect and stage pancreatic cancer. METHODS: One hundred twenty-seven patients undergoing EUS-fine-needle aspiration and MRI for the workup of pancreatic cancer were captured in a prospective database for comparison. The final surgical stage was recorded in patients who went to surgery. RESULTS: Of 127 patients, 48 were surgically explored, and of these, 22 (46%) underwent pancreaticoduodenectomy. Agreement in the patients' staging between EUS and MRI was 94 (74%) of 127. Magnetic resonance imaging was more likely to report metastatic disease or arterial involvement. The overall correlation between EUS and MRI was marginal (κ = 0.42; 95% CI, 0.26-0.58). Of the 48 surgically explored patients, 12 (25%) were understaged by MRI, 13 (27%) were understaged by EUS, and 1 (2%) were overstaged. Endoscopic US and MRI had a sensitivity of 34 (97.2%) of 35 for stage II tumors and 35 (100%) of 35 for lower-stage tumors, respectively. CONCLUSION: Endoscopic US and MRI had marginal correlation for staging, especially the more advanced tumors. Although EUS has the added advantage of tissue acquisition for confirmation, the tumors understaged by both the modalities were different. Therefore, both tests should be performed for accurate staging.