RESUMO
BACKGROUND : Cold snare polypectomy (CSP) is the standard of care for the resection of small (<â10âmm) colonic polyps. Limited data exist for its efficacy for medium-sized (10-19âmm) nonpedunculated polyps, especially conventional adenomas. This study evaluated the effectiveness and safety of CSP/cold endoscopic mucosal resection (C-EMR) for medium-sized nonpedunculated colonic polyps. METHODS : A prospective multicenter observational study was conducted of all morphologically suitable nonpedunculated colonic polyps of 10-19âmm removed by CSP/C-EMR between May 2018 and June 2021. Once resection was complete, multiple biopsies were taken of the margins circumferentially and centrally. The primary outcome was the incomplete resection rate (IRR), based on residual polyp in these biopsy specimens. Secondary outcomes were recurrence rate at first surveillance colonoscopy and rates of adverse events (AEs). RESULTS : CSP/C-EMR was performed for 350 polyps (median size 15 mm; 266 [76.0â%] Paris 0-IIa classification) in 295 patients. Submucosal injection was used for 87.1â% (nâ=â305) of polyps. Histology showed 68.6â% adenomas, 26.0â% sessile serrated lesions (SSLs) without dysplasia, 4.0â% SSL with dysplasia, and 1.4â% hyperplastic polyps. The IRRs based on margin or central biopsies being positive were 1.7â% (nâ=â6) and 0.3â% (nâ=â1), respectively. The polyp recurrence rate was 1.7â% (nâ=â4) at first surveillance colonoscopy - completed for 65.4â% (nâ=â229) of polyps at a median interval of 9.7 months. AEs occurred in 3.4â% (nâ=â10) of patients: four with post-polypectomy pain; three self-limiting post-polypectomy bleeds; two post-polypectomy-syndrome-like presentations; and one intraprocedural bleed treated with clips. There were no perforations. CONCLUSION : CSP/C-EMR for morphologically suitable nonpedunculated colonic polyps of 10-19âmm is effective and safe, including for conventional adenomas. Rates of incomplete resection and recurrence were low, with few AEs. Studies directly comparing this method with hot snare resection are required.
Assuntos
Adenoma , Pólipos do Colo , Neoplasias Colorretais , Ressecção Endoscópica de Mucosa , Polipose Intestinal , Humanos , Pólipos do Colo/cirurgia , Pólipos do Colo/patologia , Colonoscopia/efeitos adversos , Colonoscopia/métodos , Estudos Prospectivos , Ressecção Endoscópica de Mucosa/efeitos adversos , Ressecção Endoscópica de Mucosa/métodos , Adenoma/cirurgia , Adenoma/patologia , Polipose Intestinal/etiologia , Neoplasias Colorretais/patologiaRESUMO
BACKGROUND AND AIM: Colorectal cancer (CRC) diagnosed following a cancer-negative colonoscopy is termed as post-colonoscopy CRC (PCCRC). The World Endoscopy Organization has recently standardized the definition of PCCRC-3Y (CRC developing within 3 years of a cancer-negative colonoscopy). In the present study, we sought to assess PCCRC-3Y rate, perform root-cause analyses, and identify factors associated with development of PCCRC at a tertiary referral hospital in Australia. METHODS: All patients undergoing colonoscopy from 2011 to 2018 were matched to a population-based cancer register. PCCRC-3Y rate was assessed for years 2011-2015. All PCCRC cases that developed within 6-48 months after a cancer-negative colonoscopy underwent root-cause analyses. Descriptive statistics were used to summarize data. RESULTS: Among 17 828 patients undergoing colonoscopy, 367 CRC cases were diagnosed during the study period. This included nine PCCRC cases, which developed at a median of 14 months (range 7-34 months) after cancer-negative colonoscopy. The PCCRC-3Y rate for years 2011-2015 was 2.16% (95% CI 0.91-5.15). All nine PCCRC cases were moderately or poorly differentiated adenocarcinomas; seven of nine were early-stage CRC (stages I and II) and six of nine probably represented missed lesions at index colonoscopy despite an apparently adequate examination. History of inflammatory bowel disease (IBD) (odds ratio [OR] 21.9, 95% confidence interval [CI] 4.6-103.7, P < 0.001) and diverticulosis (OR 5.4, 95% CI 1.4-20.5, P = 0.01) were significantly associated with development of missed CRC. CONCLUSIONS: In our tertiary referral colonoscopy cohort, PCCRC-3Y rate was 2.16% (95% CI 0.91-5.15). IBD and diverticulosis were significantly associated with risk of PCCRC. The majority of PCCRC lesions were likely missed at index colonoscopy, despite an apparently adequate examination.
Assuntos
Neoplasias Colorretais , Doenças Inflamatórias Intestinais , Humanos , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/etiologia , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Risco , Colonoscopia , Austrália/epidemiologia , Armazenamento e Recuperação da Informação , Detecção Precoce de CâncerRESUMO
BACKGROUND: Incidental gastrointestinal tract (GIT) uptake is found in up to 6.3% of patients undergoing positron emission tomography (PET). This may be physiologic or pathologic and requires endoscopic assessment. AIM: To determine the diagnostic yield of endoscopy in this setting and characterise PET avidity as a predictor of clinically significant findings. METHODS: We retrospectively reviewed all consecutive patients undergoing upper endoscopy or colonoscopy for incidental 18 FDG PET positivity in the GIT. RESULTS: A total of 255 patients (62% male, median age 67 years) underwent colonoscopy or sigmoidoscopy for 276 separate areas of PET avidity in the colon. Malignancy was found in 44 cases (16%), and a significant polyp was found in an additional 103 cases (37%). Neoplastic change was found more often in the case of intense compared with non-intense PET avidity (odds ratio (OR) 3.40, 95% confidence interval (CI) 1.95-5.93, P < 0.001), and in focal compared with diffuse uptake (OR 5.97, 95% CI 2.9-12.2, P < 0.001). Upper GIT endoscopy was performed in 75 patients (46 male, median age 63 years) for 77 isolated areas with PET avidity. Malignancy was found in 16 cases (21%), and all were new primary lesions. Numerically, malignant findings were more common in intense (29.7%) than non-intense (12.5%) PET avidity (OR 2.96, 95%, CI 0.92-9.57, P = 0.069). CONCLUSIONS: Both focal and intense colonic 18 FDG uptake correlate strongly with a high-risk polyp or malignant lesion. Up to 21% of all gastroscopies performed for evaluation of incidental PET uptake diagnosed a new primary malignancy. These referrals need appropriate triaging and timely endoscopic assessment.
Assuntos
Fluordesoxiglucose F18 , Neoplasias , Humanos , Masculino , Idoso , Pessoa de Meia-Idade , Feminino , Estudos Retrospectivos , Compostos Radiofarmacêuticos , Relevância Clínica , Tomografia Computadorizada por Raios X , Tomografia por Emissão de Pósitrons , Trato Gastrointestinal/diagnóstico por imagem , Achados IncidentaisRESUMO
BACKGROUND AND AIMS: Optimal bowel preparation before capsule endoscopy (CE) is currently unknown. In this multicenter, blinded, randomized controlled trial, we assessed clinical effectiveness of 2 types of purgative regimen and a control arm of clear fluid only. METHODS: Patients with suspected small intestinal bleeding were randomized into 3 arms: arm A, clear fluids only for 18 hours before CE and simethicone 200 mg in 150 mL water immediately before CE; arm B, same as A + 2 L of polyethylene glycol (PEG) 12 hours before CE; and arm C, same as A + 1 L PEG + sodium ascorbate 3 hours before CE. To assess diagnostic yield, lesions were classified either as highly relevant (P2) or less relevant (P0 or P1) lesions. Small-bowel visualization quality (SBVQ) was assessed using the Brotz score. Patient tolerability was assessed using the visual analog scale (0-10, with lower scores indicating better tolerability). RESULTS: Two hundred twenty-nine patients completed the study. The mean age was 58.7 years (95% confidence interval, 29.3-87.9), and 47.2% were men. There was no significant difference in diagnosis of P2 lesions in arms A, B, and C (48.7%, 48.0%, and 45.9%, respectively; P = .94). Overall SBVQ and distal SBVQ were similar across the 3 arms (P = .94 and P = .68, respectively). Patients reported better tolerability in arm A (mean score, 1.5) compared with arms B and C (mean score, 3.5 and 2.6, respectively; P < .001). CONCLUSIONS: The use of a purgative bowel preparation before CE does not improve diagnostic yield or small-bowel visualization and is associated with lower patient tolerance. (Clinical trial registration number: ACTRN 12614000883617.).
Assuntos
Endoscopia por Cápsula , Masculino , Humanos , Pessoa de Meia-Idade , Feminino , Catárticos , Simeticone , Polietilenoglicóis , Ácido Ascórbico , ÁguaRESUMO
INTRODUCTION: "Push" or "pull" techniques with the use of snares, forceps, baskets, and grasping devices are conventionally used to manage esophageal food bolus impaction (FBI). A novel cap-assisted technique has recently been advocated to reduce time taken for food bolus (FB) removal. This study aimed to compare the effectiveness of the cap-assisted technique against conventional methods of esophageal FB removal in a randomized controlled trial. METHODS: Consecutive patients with esophageal FBI requiring endoscopic removal, from 3 Australian tertiary hospitals between 2017 and 2019, were randomized to either the cap-assisted technique or the conventional technique. Primary outcomes were technical success and FB retrieval time. Secondary outcomes were technical success rate, en bloc removal rate, procedure-related complication, length of hospital stay, and cost of consumables. RESULTS: Over 24 months, 342 patients with esophageal FBI were randomized to a cap-assisted (n = 171) or conventional (n = 171) technique. Compared with the conventional approach, the cap-assisted technique was associated with (i) shorter FB retrieval time (4.5 ± 0.5 minutes vs 21.7 ± 0.9 minutes, P < 0.001), (ii) shorter total procedure time (23.0 ± 0.6 minutes vs 47.0 ± 1.3 minutes, P < 0.0001), (iii) higher technical success rate (170/171 vs 160/171, P < 0.001), (iv) higher rate of en bloc removal (159/171 vs 48/171, P < 0.001), and (v) lower rate of procedure-related mucosal tear and bleeding (0/171 vs 13/171, P < 0.001). There were no major adverse events or deaths within 30 days in either group. The total cost of consumables was higher in the conventional group (A$19,644.90 vs A$6,239.90). DISCUSSION: This multicenter randomized controlled trial confirmed that the cap-assisted technique is more effective and less costly than the conventional approach and should be first-line treatment for esophageal FBI.
Assuntos
Esofagoscopia/métodos , Esôfago/cirurgia , Alimentos/efeitos adversos , Corpos Estranhos/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Análise Custo-Benefício/estatística & dados numéricos , Esofagoscopia/efeitos adversos , Esofagoscopia/economia , Esofagoscopia/instrumentação , Esôfago/diagnóstico por imagem , Esôfago/patologia , Feminino , Corpos Estranhos/diagnóstico , Corpos Estranhos/etiologia , Corpos Estranhos/patologia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Demand for gastrointestinal endoscopy in Australia is increasing as a result of the expanding national bowel cancer screening program and a growing, ageing population. More services are required to meet demand and ensure patients are seen within clinically recommended timeframes. METHODS: A discrete event simulation model was developed to project endoscopy waiting list outcomes for two large metropolitan health services encompassing 8 public hospitals in Australia. The model applied routinely collected health service data to forecast the impacts of future endoscopic demand over 5 years and to identify the level of service activity required to address patient waiting times and meet key policy targets. The approach incorporated evidence from the literature to produce estimates of cost-effectiveness by showing longer term costs and Quality Adjusted Life Years (QALYs) associated with service expansion. RESULTS: The modelling revealed that doing nothing would lead to the number of patients waiting longer than clinically recommended doubling across each health service within 5 years. A 38% overall increase in the number of monthly procedures available was required to meet and maintain a target of 95-98% of patients being seen within clinically recommended timeframes to the year 2021. This was projected to cost the funder approximately $140 million in additional activity over a 5 year period. Due to improved patient outcomes associated with timely intervention, it was estimated that the increased activity would generate over 22,000 additional QALYs across the two health services. This translated to an incremental cost-effectiveness ratio of $6467 and $5974 per QALY for each health service respectively. CONCLUSIONS: Discrete event simulation modelling provided a rational, data based approach that allowed decision makers to quantify the future demand for endoscopy services and identify cost-effective strategies to meet community needs.
Assuntos
Endoscopia Gastrointestinal/estatística & dados numéricos , Planejamento em Saúde/métodos , Austrália , Análise Custo-Benefício , Tomada de Decisões , Detecção Precoce de Câncer/economia , Detecção Precoce de Câncer/estatística & dados numéricos , Endoscopia Gastrointestinal/economia , Hospitais Públicos/economia , Hospitais Públicos/estatística & dados numéricos , Humanos , Neoplasias Intestinais/diagnóstico , Modelos Estatísticos , Anos de Vida Ajustados por Qualidade de Vida , Listas de EsperaRESUMO
BACKGROUND: Gastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month. Many of these requests are for colonoscopy. This study aims to evaluate the performance of the current symptoms-based triage system compared to a novel risk score using objective markers. METHODS: Patients with lower abdominal symptoms referred by their GPs and triaged by a Gastroenterology consultant to a colonoscopy consent clinic were recruited into the study. A risk assessment tool (RAT) was developed using objective data (clinical, demographic, pathology (stool test, FIT), standard blood tests and colonoscopy outcome). Colonoscopy and histology results were scored and then stratified as either significant bowel disease (SBD) or non-significant bowel disease (non-SBD). RESULTS: Of the 467 patients in our study, 45.1% were male, the mean age was 54.3 ± 13.8 years and mean BMI was 27.8 ± 6.2. Overall, 26% had SBD compared to 74% with non-SBD (42% of the cohort had a normal colonoscopy). Increasing severity of referral symptoms was related to a higher triage category, (rectal bleeding, P = 2.86*10-9; diarrhoea, P = 0.026; abdominal pain, P = 5.67*10-4). However, there was no significant difference in the prevalence of rectal bleeding (P = 0.991) or diarrhoea (P = 0.843) for SBD. Abdominal pain significantly reduced the risk of SBD (P = 0.0344, OR = 0.52, CI = 0.27-0.95). Conversely, the RAT had a very high specificity of 98% with PPV and NPV of SBD prediction, 74% and 77%, respectively. The RAT provided an odds ratio (OR) of 9.0, 95%CI 4.29-18.75, p = 2.32*10-11), higher than the FIT test (OR = 5.3, 95%CI 2.44-11.69, p = 4.88*10-6), blood score (OR = 2.8, 95%CI 1.72- 4.38, p = 1.47*10-5) or age (OR = 2.5, 95%CI 1.61-4.00, 5.12*10-5) independently. Notably, the ORs of these individual objective measures were higher than the current practice of symptoms-based triaging (OR = 1.4, 95%CI 0.88-2.11, p = 0.153). CONCLUSIONS: It is critical that individuals with high risk of having SBD are triaged to the appropriate category with the shortest wait time. Here we provide evidence that a combination of blood markers, demographic markers and the FIT test have a higher diagnostic accuracy for SBD than FIT alone.
Assuntos
Colonoscopia , Triagem/métodos , Adulto , Idoso , Austrália , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Sensibilidade e EspecificidadeRESUMO
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
Assuntos
Adenocarcinoma/diagnóstico , Esôfago de Barrett/diagnóstico , Neoplasias Esofágicas/diagnóstico , Guias de Prática Clínica como Assunto , Adenocarcinoma/patologia , Adenocarcinoma/terapia , Austrália , Esôfago de Barrett/patologia , Esôfago de Barrett/terapia , Biomarcadores Tumorais/análise , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/terapia , Esofagoscopia , Previsões , Humanos , Fatores de RiscoRESUMO
Repeated intentional foreign body ingestion (RIFBI) in patients with Emotionally Unstable Personality Disorder (EUPD) is a common clinical presentation to the emergency department. The relationship between repeated foreign body ingestion and a co-existent personality disorder diagnosis is complex, making it challenging to manage. Our institution implemented a novel interdisciplinary model of care for RIFBI as a way of improving health outcomes in this cohort of patients. Our observations following the model of care are presented herein. We encourage other health networks to adopt this model of care for managing RIBFI in EUPD.
Assuntos
Corpos Estranhos , Adulto , Feminino , Humanos , Masculino , Ingestão de Alimentos , Serviço Hospitalar de Emergência , Corpos Estranhos/complicações , Transtornos da Personalidade/complicaçõesRESUMO
Increased colonic butyrate from microbial fermentation of fibre may protect from colorectal cancer (CRC). Dietary butyrylated high amylose maize starch (HAMSB) delivers butyrate to the large bowel. The objective of this clinical trial (AusFAP) is to evaluate potential chemoprotective effects of HAMSB on polyposis in individuals with a genetic form of colon cancer, Familial Adenomatous Polyposis (FAP). The study is a multi-site, double blind, randomised, placebo-controlled crossover trial undertaken at major hospitals in Australia. After a baseline endoscopy participants consume either 40g/day of HAMSB or placebo (low amylose maize) starch for 26 weeks. After another endoscopic examination participants consume the alternate starch for 26 weeks. A third endoscopy at 52 weeks is followed by 26 weeks' washout and a final endoscopy at 78 weeks. Primary outcome measure is the global large bowel polyp number. Secondary measures include global polyp size counts, and number and size of polyps at two tattoo sites: one cleared of polyps at baseline, and another safely chosen with polyps left in situ during the study. Other secondary outcome measures include the effects of intervention on cellular proliferation in colonic biopsies, faecal measures including short chain fatty acid concentrations, and participants' dietary intakes. Generalized linear mixed models analysis will be used to estimate differences in primary outcomes between intervention and placebo periods. This study represents the first clinical evaluation of the effects of increased colonic butyrate on polyp burden in FAP which, if effective, may translate to lower risk of sporadic CRC in the community. Australian New Zealand Clinical Trials Registry Number: 12612000804886.
RESUMO
Background and Aims: Sessile serrated lesions (SSLs) develop colorectal cancer (CRC), through a critical intermediary stage of SSL with dysplasia (SSLd). In this prospective observational study, we aimed to assess clinicopathological correlates of SSLd in the setting of a high lesion-detection rate. Methods: Patients diagnosed with SSL and SSLd from February 2018 until January 2020 were prospectively recruited, and SSLd specimens were re-evaluated by 2 expert pathologists in a blinded manner. Associations were analyzed using multivariate logistic regression models. Results: A total of 6425 patients underwent 7423 colonoscopies, and 2671 SSLs were resected from 1047 patients. The overall SSL detection rate per colonoscopy was 15.9%. The median age of patients with SSL was 54 years (interquartile range, 39-66), and 43.3% were male. After pathologist review, 24 SSLds were confirmed in 20 patients. The median size of SSLd was 8 mm (interquartile range, 5.75-15.25), and 13 of 24 SSLds were <10 mm in size. After multivariate analysis, older age (odds ratio = 1.07, 95% confidence interval = 1.03-1.1) and higher number of synchronous SSLs (odds ratio = 1.12, 95% confidence interval = 1.02-1.23) were associated with the presence of dysplasia. Patient sex and number and size of synchronous adenomas were not associated with the presence of SSLd. Seven of 20 patients with SSLd had synchronous or metachronous SSLd. Six of 20 patients with SSLd met the diagnostic criteria for serrated polyposis syndrome. Conclusion: The overall SSL detection rate was 15.9%, and 0.9% of SSLs were dysplastic. Older age and higher number of synchronous SSL were risk factors for the presence of dysplasia in SSLs. Thirty percent of patients with SSLd had serrated polyposis syndrome, and 35% had multiple SSLd.
RESUMO
OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a common presentation to EDs. Limited Australian data are available. Study aims were to assess mortality and re-bleeding rates in patients presenting with UGIB as risk-stratified by the Glasgow Blatchford Score (GBS). METHODS: We conducted a retrospective medical chart review of all patients presenting with UGIB to a Brisbane tertiary hospital ED over a 12-month period. This descriptive study summarised the medical characteristics related to UGIB as risk-stratified by the GBS. Non-variceal bleeding was categorised as low-risk (GBS 0-2) or high-risk (GBS 3+). Variceal bleeding was not risk stratified. RESULTS: A total of 211 patients presented with UGIB to the ED. The median age was 57 years, 67% were male. Mortality rates at 30 days were: 0% for GBS 0-2, 3% (95% confidence interval [CI] 0-6) for GBS 3+ and 10% (95% CI 0-21) for variceal groups. The overall 30-day re-bleeding rate was 4.3% (95% CI 2-7). High-risk patients accessed endoscopy according to international best practice of less than 24 h (GBS 3+, 23.7 h; variceal bleeding, 7.3 h). CONCLUSIONS: Mortality and re-bleeding outcomes are similar to other international UGIB cohorts. Patients with a low-risk bleed were appropriately identified and discharged home. Those at higher risk were correctly identified and accessed timely endoscopy. The GBS demonstrated clinical utility in an Australian ED cohort of UGIB bleeding patients.
Assuntos
Varizes Esofágicas e Gástricas , Austrália/epidemiologia , Estudos de Coortes , Serviço Hospitalar de Emergência , Hemorragia Gastrointestinal/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de RiscoRESUMO
Gallbladder agenesis is a rare condition. Patients with gallbladder agenesis can present with biliary type symptoms and rarely pancreatitis. We present the case of a 35-year-old gentleman who was admitted and treated for recurrent pancreatitis on a background of gallbladder agenesis, ansa pancreatica and Santorinicoele. He has had several admissions with pancreatitis and has had multiple imaging modalities during these admissions which we delineate. We discuss this rare anatomical variant and describe the course and management of his illness leading up to his eventual diagnosis of intraductal papillary neoplasia (IPMN).
RESUMO
PURPOSE: It remains controversial whether chromocolonoscopy using indigocarmine increases the detection of colorectal polyps. We aimed to assess the impact of indigocarmine dye spray on the detection rate of adenomas and the feasibility of learning the technique in a Western practice. METHODS: 400 patients were prospectively allocated into 2 groups; A (n = 200): indigocarmine chromocolonoscopy was performed by a Japanese colonoscopist with expertise in chromoscopy; B (n = 200): initial 100 patients (B-1), a Western colonoscopist with no previous experience of chromoscopy performed conventional colonoscopy, but with at least 10 min observation during colonoscopy withdrawal. In the next 100 patients (B-2), he performed chromocolonoscopy. All polyps found were resected. Regression analysis was used to compare the numbers of polyps detected in groups A, B-1 and B-2, whilst controlling for gender, age, indication and history of colorectal cancer. RESULTS: There were significant differences in the numbers of neoplastic polyps and flat adenomas between groups A and B-1 as well as between B-1 and B-2, but not between A and B-2. There was no significant difference in numbers of advanced lesions. Chromocolonoscopy (A and B-2) detected more neoplastic polyps of Assuntos
Adenoma/diagnóstico
, Colonoscopia/métodos
, Corantes
, Índigo Carmim
, Adenoma/patologia
, Adulto
, Idoso
, Idoso de 80 Anos ou mais
, Colo/patologia
, Neoplasias do Colo/diagnóstico
, Neoplasias do Colo/patologia
, Pólipos do Colo/diagnóstico
, Pólipos do Colo/patologia
, Feminino
, Humanos
, Modelos Logísticos
, Masculino
, Pessoa de Meia-Idade
, Estudos Prospectivos
RESUMO
INTRODUCTION: Gastrostomy insertion either via radiological (radiologically inserted gastrostomy, RIG) or endoscopic (percutaneous endoscopic gastrostomy, PEG) approaches are widely practiced throughout Australia. The purpose of this study was to compare outcomes of inserted tubes and cost evaluation by both methods. METHODS: A retrospective cohort study conducted on all-cause gastrostomy insertions at a quaternary Australian Hospital, Royal Brisbane and Womens' Hospital (RBWH) between January 2012 and August 2015. Current referral pattern is first-line gastrostomy and second-line radiological insertion. RESULTS: A total of 402 gastrostomy tubes were inserted with a total of 307 PEG tubes and 95 RIG tubes, with follow-up to one calendar year. Mean patient age was 61 years ± 14.2 years with 76% male patients. A total of 84% of patients were head and neck cancer patients; major indications for insertion include prophylaxis (58%), dysphagia (32%) and NBM (2.5%). Patient groups were heterogeneous with varied indications for insertion including prophylaxis, dysphagia, decompression, NBM and treatment side effects. Outcomes measured included the following: complications, premature tube failure prior to expected removal and, overall tube outcome/ disposition. A lower incidence of minor complications was observed with the RIG group than the PEG group without differences in major complications over time. Tube failure due to either blockage or dislodgement was assessed. Multivariate analysis of all-cause dislodgement found 'method of insertion' a predictor of dislodgement with RIG 5.4(OR) times more likely to be dislodged than PEG. Competing risk analysis demonstrates equipment as a significant cause of dislodgement occurring more commonly with RIG than PEG tubes. Tubes were removed more often in the PEG group because a large volume were prophylactic. Tubes were replaced more often in the RIG group, with tube blockage and equipment as causes for tube replacement in this group. Replacements occur either in suite or bedside. Costing data were limited with only 94 patients' costing data qualifying for a limited unit cost evaluation, with radiologically inserted tubes marginally more expensive than tubes inserted endoscopically. CONCLUSIONS: Both are safe procedures, with improved techniques; radiologically inserted gastrostomies have an improved profile with respect to dislodgement rates than previously reported in the literature. Radiological tubes remain limited by equipment factors with balloon failure an ongoing issue. Cost analysis was hindered by poor documentation; however, the opportunity cost remains an important advantage of radiological insertion at peripheral sites, increasingly relevant for health service delivery in our geographically vast state.
Assuntos
Gastroscopia , Gastrostomia/métodos , Radiografia Intervencionista , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Queensland , Estudos RetrospectivosRESUMO
BACKGROUND AND AIMS: This study aimed to characterize the mucosa-associated microbiota in ileal Crohn's disease [CD] patients and in healthy controls in terms of host genotype and inflammation status. METHODS: The mucosa-associated microbiotas of intestinal pinch biopsies from 15 ileal CD patients with mild and moderate disease and from 58 healthy controls were analysed based on 16S ribosomal sequencing to determine microbial profile differences between [1] IL23R, NOD2 and ATG16L1 genotypes in healthy subjects, [2] ileal CD patients and control subjects, and [3] inflamed and non-inflamed mucosal tissue in CD patients. RESULTS: The protective variant of the IL23R gene [rs11209026] significantly impacted the microbial composition in the ileum of healthy subjects and was associated with an increased abundance of phylotypes within the family Christensenellaceae as well as increases in diversity and richness. Comparative analysis of healthy and non-inflamed CD microbiome samples indicated a notable decrease in the abundance of Faecalibacterium prausnitzii as well as Shannon diversity and richness. Inflamed and non-inflamed ileal samples of CD subjects had high intra-individual stability and inter-individual variability, but no significant alterations in diversity, richness or taxa were identified. Calprotectin correlated positively with the abundance of Proteobacteria and negatively with diversity in the samples from healthy subjects. CONCLUSIONS: The observation of low diversity and low abundance of beneficial bacteria in healthy control subjects carrying the IL23R [rs11209026] wild-type GG genotype indicates that the gut microbiome is influenced by host genetics and is altered prior to disease diagnosis. Faecal calprotectin may be a potential non-invasive screening tool for dysbiosis in subjects without disorders of intestinal inflammation.
Assuntos
Doença de Crohn/microbiologia , Microbioma Gastrointestinal/genética , Ileíte/microbiologia , Receptores de Interleucina/genética , Adulto , Proteínas Relacionadas à Autofagia/genética , Estudos de Casos e Controles , Doença de Crohn/genética , Doença de Crohn/patologia , Fezes/química , Feminino , Variação Genética , Genótipo , Voluntários Saudáveis , Humanos , Ileíte/genética , Ileíte/patologia , Íleo/microbiologia , Íleo/patologia , Mucosa Intestinal/microbiologia , Mucosa Intestinal/patologia , Complexo Antígeno L1 Leucocitário/análise , Masculino , Pessoa de Meia-Idade , Proteína Adaptadora de Sinalização NOD2/genética , Índice de Gravidade de DoençaRESUMO
We have developed a multi-threaded framework for colonoscopy simulation utilising OpenGL with an interface to a real-time prototype colonoscopy haptic device. A modular framework has enabled us to support multiple haptic devices and efficiently integrate new research into physically based modelling of the colonoscope, colon and surrounding organs. The framework supports GPU accelerated algorithms as runtime modules, allowing the real-time calculations required for haptic feedback.
Assuntos
Colonoscopia , Simulação por Computador , Tato , Interface Usuário-Computador , HumanosRESUMO
AIM: To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. METHODS: The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms. Studies were screened against eligibility criteria and for relevance. Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of non-physician endoscopists. These publications included a total of 28883 procedures performed by non-physician endoscopists. RESULTS: The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter. 17/26 studies related to flexible sigmoidoscopies, 5 to upper GI endoscopy and 6 to colonoscopy. All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists. Geographic distribution of publications showed the majority of research was conducted in the United States (43%), the United Kingdom (39%) and the Netherlands (7%). Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. However, in relation to endoscopic competency, safety or patient satisfaction, all studies had major methodological limitations. Patients were often not randomized (21/26 studies) and not appropriately controlled. In relation to cost-efficiency, nurse endoscopists were less cost-effective per procedure at year 1 when compared to services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. CONCLUSION: Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite. Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.
Assuntos
Competência Clínica , Endoscopia Gastrointestinal/enfermagem , Profissionais de Enfermagem , Recursos Humanos de Enfermagem , Redução de Custos , Análise Custo-Benefício , Educação em Enfermagem , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/economia , Endoscopia Gastrointestinal/educação , Custos de Cuidados de Saúde , Humanos , Profissionais de Enfermagem/economia , Profissionais de Enfermagem/educação , Recursos Humanos de Enfermagem/economiaAssuntos
Endoscópios Gastrointestinais , Endoscopia Gastrointestinal/métodos , Hemorragia Gastrointestinal/patologia , Doenças do Íleo/patologia , Intestino Delgado/patologia , Doenças do Jejuno/patologia , Endoscopia por Cápsula , Desenho de Equipamento , Hemorragia Gastrointestinal/etiologia , Humanos , Doenças do Íleo/etiologia , Doenças do Jejuno/etiologia , Valor Preditivo dos Testes , RecidivaRESUMO
BACKGROUND: Evidence-based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes. METHODS: This retrospective cohort study was carried out for the years before (2005) and after (2007) implementation of these guidelines. RESULTS: In all, 165 patients were treated with radical chemoradiation for head and neck cancer at our institution in the years 2005 and 2007. Gastrostomy tube complications were low. Patients in 2007 had significantly fewer hospital admissions, unexpected admissions, and a shorter mean duration of hospital stay in comparison with those in 2005. CONCLUSIONS: Prophylactic gastrostomy tubes in patients with high-risk head and neck cancer resulted in a significant decrease in hospital admissions and length of stay, and led to increased bed availability.