Abstracts

T1537

Impact of Endoscopist’s Experience On Success Rate of En-Bloc

and En Bloc-Cure of Large Colorectal Polyps By Endoscopic

Submucosal Dissection: A Meta-Analysis and Systematic ReviewSrinivas R. Puli, Yasuo Kakugawa, Takuji Gotoda, Jyotsna Bk Reddy,Daphne Antillon, Yutaka Saito, Mainor R. AntillonBackground: Endoscopic submucosal dissection (ESD) has emerged as analternative to surgery for the resection of large (O 2 cm) colorectal polyps. ESD isa technically demanding procedure. From published data, it is not clear howendoscopists’ experience affects successful en-block resection of large colonicpolyps. Aim: To evaluate how endoscopists experience in performing ESD affectsthe proportion of successful en-block resection of large colonic polyps. Method:Study Selection Criteria: Studies using ESD technique to resect large colonic polypswere selected. Successful cure en-block resection was defined as margins free polypresection. Data collection & extraction: Articles were searched in Medline, Japaneselanguage literature, and Cochrane control trial registry. Two reviewersindependently searched and extracted data. Statistical Method: Summary estimatesare expressed as pooled proportions. Studies were grouped into !100 ESD’sperformed and O 100 ESD’s performed. First, the individual study proportions ofsuccessful resection are transformed into a quantity using Freeman-Tukey variant ofthe arcsine square root transformed proportion. The pooled proportion iscalculated as the back-transform of the weighted mean of the transformedproportions, using inverse arcsine variance weights for the fixed effects model andDerSimonian-Laird weights for the random effects model. Results: Initial searchidentified 2,120 reference articles, in which, 389 relevant articles were selected andreviewed. Data was extracted from 13 studies (N Z 1,080) which met the inclusioncriteria. 9 Studies had !100 ESD’s (N Z 394) and 4 studies had O100 ESD’s (N Z686). The mean size of the polyps was 30.65 � SE 2.88 mm. The pooledproportions are shown in table 1. The fixed effect model was not used because ofthe heterogeneity among studies. The publication bias calculated by Begg-Mazumdar bias indicator for successful en-bloc resection gave a Kendall’s taub value of -0.22 (p Z 0.32) and the same for successful cure en-block resection was-0.23 (p Z 0.25). Conclusion: ESD is an innovative technique for resection of largecolonic polyps that offers an alternative to surgery. Our meta-analysis shows thatthe success rate for both en-bloc and en-bloc cure improves with O100 ESDs.Endoscopist’s experience significantly improves the success rates of this techniqueto treat large colorectal polyps.

Pooled proportion using random effect model of successful en-block and cureen-block resection based on study size

Study Size No of studies Successful En-bloc Resection Successful Cure En-bloc Resection

AB242 G

ASTROINTE STINAL ENDOSCOPY V

! 100 Patients

9 82.60 % (95% CI Z 66.45 to 94.22) 71.23 % (95% CI Z 57.17 to 83.46) O 100 Patients 4 88.37 % (95% CI Z 82.19 to 93.37) 82.25 % (95% CI Z 71.56 to 90.85)

T1538

Propofol Vs. Traditional Sedation Agents for Colonoscopy:

A Meta-AnalysisHarminder Singh, William Poluha, Mary S. Cheang, Nicole Choptain,Ken I. Baron, Shayne P. TabackPropofol is increasingly being utilized for sedation during colonoscopy, withmany recent reports of large non-randomized case series. Our aim was toidentify, analyze and summarize RCTs comparing the relative effectiveness,patient acceptance and safety of propofol for colonoscopy, to traditionalsedatives. Our secondary goal was to synthesize the studies comparing propofoladministration by anesthetists to that by non-anesthetists. Methods: We searchedMedline, Cancerlit, EMBASE, CINAHL, LILACS, Biological Abstracts, Web ofScience and the Cochrane Controlled Trials Registry database between Jan 1980and June 2007; and conference proceeding abstracts for DDW, EUGW and ACGbetween 1990 and June 2007. There were no language restrictions. Data fromeligible studies were abstracted by two reviewers. The outcomes comparedincluded overall patient satisfaction, recovery time after the procedure, dischargetime and complications (hypoxia, hypotension, arrhythmias, and colonicperforations). RevMan 4.2.8 was used for data analysis. Both fixed and randomeffects models were examined. Results from studies evaluating propofol asa single agent in one of the arms are reported here. Results: Of the 267 citations,20 studies met the inclusion criteria for our primary objective. There was onlyone study, reported in abstract form comparing propofol administration byanesthetists to that by gastroenterologists. Eight studies evaluated propofol asa single agent. Mean sedation level was higher with the use of propofol (SMD1.38; 95% CI: 1.11-1.65). The analysis of recovery time (four trials) demonstratedheterogeneity, but a sensitivity analysis, excluding the one study in which allpatients in the control arm remained responsive through-out the procedures,was shorter for propofol, with no significant heterogeneity in the remainingstudies (WMD -14 min; 95% CI, -17,-10). Discharge time (three trials) was shorterwith the use of propofol (WMD -22 min; 95% CI, -29,-17). Overall patientsatisfaction favored the use of propofol (studies reporting as dichotomous

olume 67, No. 5 : 2008

and continuous outcomes analyzed separately). There was no difference inoccurrence of hypoxia (6 studies; OR 0.76; 95% CI, 0.32-1.81), hypotension(2 studies; OR 1.03; 95% CI, 0.28-3.84) or arrhythmias (3 studies; OR 0.55;95% CI, 0.11-2.61). For colonic perforations, there was one large study(n Z 7,286 patients) reported only in abstract form, which did not finda significant difference (OR 2.87; 95% CI, 0.60-13.83). Conclusions: Propofolused alone for sedation during colonoscopy leads to faster discharge from theendoscopy unit and higher patient satisfaction with no increase in thecomplication rates.

T1539

Non-Aggressive Cystoscopy-Guided Debridement and Vigorous

Irrigation for the Treatment of Organized Pancreatic NecrosesI. Cabral Patricia Anne, M. Sison Ma. Cecilia, A. De Mark AnthonyLusong, Tonya R. Kaltenbach, Roy M. Soetikno, Kenneth F. BinmoellerBackground and Objective: Surgical debridement is the current standard oftreatment for symptomatic patients with organized pancreatic necrosis, but isassociated with high morbidity and mortality rates. Endoscopic transmuraldebridement under cystoscopic guidance using extraction devices such as basketsand snares has been reported as an alternative approach, though is tedious, laborintensive, and may require multiple sessions. We report a novel approach ofperforming minimal and non-aggressive mechanical debridement followed byvigorous irrigation and multiple stent placement for the treatment of organizedpancreatic necroses. Patients and Methods: We studied symptomatic patients whowere diagnosed with organized pancreatic necroses on contrast-enhanced CT andconfirmed on EUS from March 2004 to August 2007. EUS-guided cyst puncture wasperformed using a 19 G needle followed by balloon dilation of the cystenterostomyto 8 mm. The echoendoscope was exchanged over-the-wire for a 3.7 mmtherapeutic gastroscope. The cystenterostomy was dilated to 15-18 mm followed byadvancement of the endoscope into the cyst. Cystoscopy-guided debridement ofloosely adherent material with a basket was followed by vigorous irrigation andsuction. Adherent necrotic tissue was left in place. Three 10 Fr stents were insertedunder endoscopic guidance. A nasocystic catheter was placed in select patients withinfected fluid contents. Results: Endoscopic debridement and drainage oforganized necroses was performed in 25 patients. The average size of theorganizing fluid collections on initial CT was 12 � 4 cm. Fluid contents wereinfected in 15 patients. A total of 20 patients (80%) had symptom and cystresolution after a mean of 1.9 � 1.2 procedures. The mean interval betweenprocedures was 10.3 � 6.7 days. Three patients required subsequent surgicalintervention for complications including procedure-related bleeding (n Z 1) andabscess formation (n Z 2). Conclusion: Endoscopic cystoscopy-guideddebridement with non-aggressive removal of necrotic material and vigorousirrigation is an effective method for the treatment of organized pancreatic necroses.Resolution may be achieved in one or two sessions. Nasocystic catheter placementis not required in non-infected fluid collections. The indications for activedebridement and complete removal of necrotic material using extraction devicesrequire further study.

T1540

The Efficacy of Argon Plasma Coagulation for Gastric AdenomaEun Ran Kim, Hoi Jin Kim, Young-Ho Kim, Dong Kyung Chang,Hee Jung Son, Poong-Lyul Rhee, Jae J. Kim, Jong Chul RheeBackground: Endoscopic mucosal resection (EMR) is now widely accepted asa useful treatment method for gastric adenoma which was premalignant lesion.But no adequate treatment is available for cases of gastric adenoma which areuntreatable by EMR because of their high risk. The aim of the study was toevaluate the clinical efficacy of Argon Plasma Coagulation (APC) in patients withgastric adenoma. Methods: We reviewed medical records of 52 lesions in 52patients who initially underwent APC for gastric adenoma at the Samsung MedicalCenter from 2003 through 2006. We analyzed the clinicopathologicalcharacteristics of that cases. Result: The patients consisted of 43 men and 9women. The median age was 65 years old (range: 36-84 years old). The reason forundergoing APC was as follows:in 31 cases (56.4%), ill-defined lesion due tometaplastic changes on background:in 10 cases (18.2%), contraindicated EMRbecause of concomitant disease:in 9 cases (16.4%), anatomically difficult lesionsfor EMR:in 5 cases(9.1%), non-lifting after saline injection because of benign scar.The median size was 10 mm (range:2-25 mm). Out of 52 lesions, 10 lesions werehigh grade adenoma and 48 leisons were macroscopically elevated. Nocomplications were found in any of the 52 patients. The median follow up periodwas 13 months (range: 5-32 months). Recurrence was seen in 6 cases. Themedian recurrence period was 10 months(range: 6-15 months). Out of recurred 6patients, 4 patients were treated with re APC and that lesions were locallycontrolled until recent follow up (median peroid:4 months). Conclusions: APC forgastric adenoma is a safe and effective modality for elderly patients withconcomitant disease, ill-defined lesions due to metaplastic changes andanatomically difficult lesions for EMR. But, the regular follow up is necessary toearly detect and treat for recurred adenoma.

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