650

Use of Hemostatic Clips in Patients Undergoing Colonoscopy

in the Setting of Coumadin Anticoagulation TherapyDouglas A. Howell, Sheila L. Eswaran, Burr J. Loew, Michael K. Sanders,John F. Erkkinen, Kirk P. Bernadino, Bejamin B. Potter,Gordon A. Millspaugh, James H. Morse, Michael A. Roy,Andreas M. Stefan, Karl C. Sze, Janice M. CampanaBackground: Coumadin anticoagulation (CAC) presents a significant dilemma in theperformance of colonoscopy. ASGE guidelines have suggested managementoptions, but no consensus exists regarding resumption of CAC which increases therisk of post-polypectomy hemorrhage by 5 fold (GIE 2004;59:44). Definitivehemostasis at the time of polypectomy might permit minimal or no interruption ofCAC. An IRB approved, multi-departmental, prospective study is presented. Patientsand Methods: Patients (pts) on CAC referred for colonoscopy were identified as low-risk or high-risk for interruption of CAC by ASGE criteria. Low-risk pts held CAC 4days; high-risk held CAC for only 48 hours, with no heparin initiated. Duringcolonoscopy, all polypectomy sites larger than forceps biopsies were treated witheither hemostatic clips (Tri Clip (Cook Medical), QuickClip (Olympus), ResolutionClip (Microvasive)) or Endoloops (Olympus). Definitive hemostasis was judged asideal, satisfactory, or unsatisfactory. Resumption of CAC depended on the success ofhemostasis. The option of post-polypectomy heparin therapy was considered on anindividual basis. Follow-up was by telephone at 1, 7 and 30 days. Results: 71 (M Z 44,F Z 27) pts (low-risk n Z 53, high-risk n Z 18) enrolled from 02/05-11/05. 45/71 ptshad polyps (29/45 (64%) had at least 1 adenoma). Total number of polyps removed:n Z 105 (mean Z 2.3, median Z 2, range 1 to 10). Total number of clips used: n Z111 (QuickClip n Z 54, Resolution Clip n Z 30, Tri Clip n Z 27), Endoloop n Z 2.Mean number of hemostatic device per polyp was 1.1 and per patient was 2.5.Definitive hemostasis was judged to be ideal or satisfactory in 44/45 (98%) andunsatisfactory 1/45 (2%). Mean INR values at the time of procedure: low-risk pts 1.4(range 1.1 - 2.8), high-risk pts 1.6 (range 1.1 - 2.6). CAC was immediately resumed in65 of 71 pts (92%). 6 pts had a delay in resuming coumadin for 2 to 4 days due to theremoval of large sessile polyps or physician preference. In follow-up, there was 1case of a moderate LGIB reported at post-procedure day 21. No pts werehospitalized for heparin or experienced a thromboembolism. Conclusions: Patientsreceiving coumadin can safely undergo colonoscopy with or without polypectomy,by brief interruption of Rx and employing definitive mechanical hemostasis ifpolypectomy is needed. Immediate re-anticoagulation can generally be advisedwithout a significant risk of delayed post-polypectomy bleeding. Favorable resultswere noted in both the low-risk (4 day hold) and high-risk (2 day hold) groups.Reimbursement to cover the costs of clips should be provided by third-party payers.

714

Is Variable Stiffness Colonoscope Better Than Regular Adult

Colonoscope for Colonoscopy? Meta-Analysis of Randomized

Controlled Trials.Mohamed O. Othman, Angela G. Bradley, Praveen K. RoyIntroduction: Variable Stiffness Colonoscope (VSC) is believed to have theoreticaladvantages over the standard adult colonoscope (C). There are conflicting dataregarding the usefulness of VSC. We conducted a meta-analysis to compare theefficacy of VSC with C. Methods: MEDLINE (from 1966-2005) and abstracts ofgastroenterology scientific meetings in the last 5 years were searched (search dateNovember 2005). Only randomized clinical trials (RCTs) conducted in adult subjectswere included. We performed a meta-analysis with fixed effects model to comparececal intubation rate, cecal intubation time abdominal pain scores and use ofancillary maneuvers. Separate analyses were performed for each main outcome byusing weight mean difference (WMD) or odds ratio (OR) depending on the natureof the outcome. Results: Six RCTs satisfied the inclusion criteria with a total of 1092patients. Three RCTs compared adult VSC to C, while the other three trialsevaluated pediatric VSC. There was no significant heterogeneity among the studies.All studies evaluated VSC among experienced colonoscopists, while, one studyevaluated VSC among inexperienced colonoscopists. Cecal intubation time wassimilar between the VSC and C groups (WMD Z 0.00, CI Z -0.68 to 0.69).Furthermore, subgroup analysis of RCTs with pediatric VSC also did not show anydifference in cecal intubation time between pediatric VSC and C (WMD Z 0.13,CI Z -0.62 to 0.88). However, cecal intubation rate was higher with the use of VSC(OR Z 1.88, CI Z 1.10- 3.24). Compared to C, VSC was associated with lessabdominal pain (SMD Z -0.23, CI Z -0.41 to 0.06) and decreased need for ancilliarymaneuvers during colonoscopy. Conclusion: VSC does not appear to offer anydistinct advantage over standard adult colonoscopes for routine colonoscopy.Further studies are needed to identify subgroups of patients that may benefit fromthe variable stiffness technology.

Cecal intubation rate

Cecal intubation time

Abstracts

www.giejournal.org

715

The Cost Effectiveness of Colonic Stenting As a Bridge

to Curative Surgery in Patients with Acute Left-Sided Malignant

Colonic Obstruction: A Canadian PerspectiveHarminder Singh, Laura E. Targownik, Steven Latosinsky,Brennan M. SpiegelAcute colonic obstruction will develop in up to one-third of patients with colon cancer.Traditionally, patients with acute colonic obstruction require emergency surgery forcreation of a diverting colostomy, followed by surgical resection of the tumour if thereis no evidence of metastatic disease. Over the last several years, colonic stents has alsobeen proven to be efficacious for relieving malignant obstruction in both the palliativesetting and as a bridge to surgical resection. The aim of this study was to determine themost cost-effective strategy for patients with acute malignant left-sided colonicobstruction in a Canadian setting. Methods: We developed a decision analytical modelto calculate the cost-effectiveness of three competing strategies: 1) emergent colonicstenting (CS) followed by elective surgical resection and reanastomosis, 2) emergentresective surgery (RS) followed by creation of either a diverting colostomy or primaryreanastomosis, 3) emergent diverting colostomy (DC) followed by elective surgicalresection and reanastomosis. The costs were estimated from the perspective ofManitoba’s provincial health plan. Clinical outcomes evaluated included theproportion of patients requiring a permanent or temporary stoma, the total number ofoperations required by a patient, and overall mortality. Results: The use of CS results infewer total operative procedures per patient (mean operations 1.03 vs. 1.32 with RSand 1.9 with DC), a lower mortality rate (5% vs. 11% with RS and 13% with DC) anda lower likelihood of requiring a permanent stoma (7% vs. 14% with RS as well as DC).CS is slightly more expensive than DC, but less costly than RS (11,851 with DC vs.$13,164 for CS vs. $13,820 with RS). The incremental cost effectiveness ratio (ICER)associated with the use of CS vs. DC is $1,415 to prevent a temporary stoma, $1,516 toprevent an additional operation, and $15,734 to prevent an additional death.Conclusions: Colonic stenting for patients with acute colonic obstruction secondaryto a resectable colonic tumor is comparable in cost to surgical options and reduces thelikelihood of requiring both temporary and permanent stomas, and may also beassocited with lower procedure related mortality. Colonic stenting should be offeredas the initial therapeutic modality for Canadian colorectal cancer patients presentingwith acute obstruction as a bridge to definitive surgical resection.

Cost perpatient(\$CDN)

MeanOperationsper patient

%requiringtemp.stoma

% requiringpermanentstoma

%mortality

EmergencyColonic Stenting(CS)

13,164 1.03 7 2 5

EmergencyResectiveSurgery (RS)

13,820 1.32 44 14 11

EmergencyDivertingColostomy (DC)

11,851 1.90 100 14 13

Volume 63, No. 5 : 2006 GASTROINTESTINAL ENDOSCOPY AB99