Accuracy of endoscopic ultrasound-fine needle aspiration of solid lesions over time: Experience from a new endoscopic ultrasound program at a Canadian community hospital.

BACKGROUND AND OBJECTIVES: A Canadian Community Hospital launched a new Endoscopic Ultrasound (EUS) Program in 2011. The aim of this study was to report the accuracy of EUS-fine needle aspiration (EUS-FNA) of solid lesions over time as it pertains to cytotechnologists' involvement and learning curves. METHODS: The electronic medical records of patients that had a EUS from July 2011 to January 2014 were retrospectively reviewed. Only solid lesions with FNA sampling were included in the study. The primary outcome assessed was the accuracy of specimen acquisition for pathological review. The secondary outcome was diagnostic accuracy. Cases were separated by chronological order into thirds for the assessment of learning curves. Cytotechnologists' involvement was correlated to determine its impact on accuracy. RESULTS: Two hundred and seventy-one EUS-FNA procedures were completed for solid lesions. Cytotechnologists' involvement resulted in a specimen acquisition accuracy of 82.6%, compared with 68.8% without a cytotechnologist (P = 0.009; 95% confidence interval [CI] 3.2%-25.0%). Diagnostic accuracy was 74.2% with a cytotechnologist while 62.4% without a cytotechnologist (P = 0.038; 95% CI 0.3%-23.7%). The specimen acquisition accuracy increased from 73.2% from the first third of cases to 92.3% for the last third with a cytotechnologist (P = 0.004; 95% CI 6%-33.0%). Without a cytotechnologist, the specimen accuracy was 67.6% for the first third while 57.7% for the last third of cases (P = 0.434; 95% CI - 33.9-14.4%). In the multivariable regression analysis, after adjusting for other predictors, a present cytotechnologist (P = 0.022) and lesion size 21 mm-30 mm (P = 0.039) and >30 mm (P = 0.001) were significantly associated with increased specimen acquisition accuracy. Only a present cytotechnologist (P = 0.046) was significantly associated with increased diagnostic accuracy. INTERPRETATION: Cytotechnologists' involvement significantly improved the accuracy of specimen acquisition. Although accuracy was impacted by a cytotechnologist learning curve, our results highlight the importance of a cytotechnologist being present for EUS-FNA sampling of solid lesions.

Community experience of colonic stenting in patients with acute large bowel obstructions.

BACKGROUND: Self-expandable metal stents (SEMS) can provide temporary relief of acute large bowel obstructions. Placement of SEMS creates the opportunity for semi-elective 1-stage surgical resections, use of possible adjuvant therapy or palliative relief of malignant obstructions. Our aim was to assess the likelihood of success and possible complication rates of SEMS insertion in a community hospital setting in patients presenting with large bowel obstructions. METHODS: We conducted a retrospective chart review at a single community-based hospital. This review addressed the technical success in deployment of the SEMS, clinical success defined by relief of the obstruction, procedure-related complications, surgical interventions and completion of adjuvant therapy for patients with large bowel obstructions. RESULTS: In a 34-month period, 16 patients underwent 16 SEMS procedures. The average age of patients was 69.4 years and 7 (44%) were women. Thirteen patients had intrinsic colorectal cancers, 1 had an extracolonic lesion (ovarian cancer) and 2 had strictures due to diverticular disease. Technical success occurred in all 16 patients, but only 15 (94%) had clinical success. No procedure-related deaths (defined as death within 7 days) occurred. Palliative stenting occurred in 5 patients (31%). Eleven patients (69%) eventually had surgery. Stenting allowed a window for neoadjuvant therapy in 4 patients. Ten of 11 patients (91%) had a 1-stage procedure. One patient had a cecal perforation presenting 2 days after SEMS. This patient received a defunctioning ileostomy. CONCLUSION: In appropriate patients with large bowel obstructions, SEMS proced ures can be safely and effectively performed in a community-based setting.

The quality of screening colonoscopies in an office-based endoscopy clinic.

BACKGROUND: Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures. OBJECTIVE: To compare the quality of office-based screening colonoscopies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications. METHODS: Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained. RESULTS: A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy. CONCLUSIONS: The Ontario Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.