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Chen JH, Wang HP. Endoscopic retrograde cholangiopancreatography training and education. Dig Endosc 2024; 36:74-85. [PMID: 37792821 DOI: 10.1111/den.14702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/02/2023] [Indexed: 10/06/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic technique used to diagnose and treat biliary and pancreatic diseases. It is one of the most technically demanding endoscopic procedures. ERCP training programs must ensure trainees have adequate knowledge of the anatomy and physiology associated with biliopancreatic diseases. The variety of ERCP procedures included in training programs should provide sufficient basic training for novice trainees and advanced training for experienced endoscopists. The main endoscopic procedures should be trained in ascending order of difficulty. Incorporating models capable of simulating various clinical and anatomical conditions could provide an effective means of fulfilling training requirements, although they are not easily available due to expensive facilities and void of standard assessment. Competency assessment is crucial in ERCP training to ensure trainees can independently and safely perform ERCP. Because of the rapid advancement of diagnostic and therapeutic methods, postgraduate training is critical for ERCP practitioners. Once certificates are attained, practitioners are solely responsible for maintaining their competency, credentialing, and quality.
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Affiliation(s)
- Jiann-Hwa Chen
- Department of Internal Medicine, Tzu Chi University College of Medicine, Hualien, Taiwan
- Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
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Soliman LA, Zayed RA, Omran D, Said F, Darweesh SK, Ghaith DM, Eletreby R, Barakat MS, Bendary MM, Zaky DZ, Amer E, Elmahgoub IR. Apelin Association with Hepatic Fibrosis and Esophageal Varices in Patients with Chronic Hepatitis C Virus. Am J Trop Med Hyg 2022; 107:190-197. [DOI: 10.4269/ajtmh.21-0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/24/2022] [Indexed: 11/07/2022] Open
Abstract
Portal hypertension and esophageal varices complicating hepatitis C virus (HCV)-related chronic liver diseases are some of the most devastating sequelae. Angiogenesis is the hallmark of their pathogenesis. Apelin is one of the recently identified angiogenic and fibrogenic peptides. We studied apelin gene expression, apelin (rs3761581) single-nucleotide polymorphism (SNP), and serum apelin level in patients with chronic HCV, and their association with liver fibrosis and esophageal varices in 112 patients with HCV-related chronic liver disease (40 with liver cirrhosis [LC]/low-grade varices, 33 with LC/high-grade varices, and 39 with fibrotic non-cirrhotic liver/no varices) and 80 healthy control subjects. Real-time polymerase chain reaction was used for apelin gene expression assay and apelin rs3761581 SNP analysis in peripheral blood samples. The serum apelin level was measured by ELISA. Apelin gene expression was undetectable in the studied samples. The SNP analysis revealed a greater frequency of the C (mutant) allele among patients compared with control subjects (P = 0.012; odds ratio, 3.67). The serum apelin level was significantly greater in patients with LC/varices (median, 31.6 ng/L) compared with patients without LC/varices (median, 2.9 ng/L; P < 0.001). A serum apelin level cutoff value of 16.55 ng/L predicted the presence of varices, with an area under the receiver operating characteristic curve value of 0.786. A positive correlation was found between serum apelin level and grade of liver fibrosis (r = 0.346, P < 0.001) and portal hypertension (r = 0.438, P < 0.001). In conclusion, the apelin rs3761581-C allele may be associated with the progression of HCV-related chronic liver disease and varices formation, and can be considered a potential therapeutic target to control fibrosis progression. The serum apelin level provided an accurate prediction of the presence of esophageal varices.
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Affiliation(s)
| | - Rania A. Zayed
- Clinical and Chemical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dalia Omran
- Department of Endemic Medicine and Hepatogastroenterology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Fadwa Said
- Clinical and Chemical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Samar Kamal Darweesh
- Department of Endemic Medicine and Hepatogastroenterology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa Mohamed Ghaith
- Clinical and Chemical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha Eletreby
- Department of Endemic Medicine and Hepatogastroenterology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud Salama Barakat
- Department of Endemic Medicine and Hepatogastroenterology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mahmoud M. Bendary
- Department of Microbiology and Immunology, Faculty of Pharmacy, Port Said University, Port Said, Egypt
| | | | - Eman Amer
- Department of Biochemistry, Faculty of Pharmacy, Ahram Canadian University, Cairo, Egypt
| | - Iman Rifaat Elmahgoub
- Clinical and Chemical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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Boškoski I, Costamagna G. How to Prevent Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis. Gastroenterology 2020; 158:2037-2040. [PMID: 32197979 DOI: 10.1053/j.gastro.2020.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy.
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS; and Centre for Endoscopic Research, Therapeutics and Training (CERTT), Catholic University of Rome, Rome, Italy
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Salerno R, Mezzina N, Ardizzone S. Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care. World J Gastrointest Endosc 2019; 11:219-230. [PMID: 30918587 PMCID: PMC6425281 DOI: 10.4253/wjge.v11.i3.219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/21/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.
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Affiliation(s)
- Raffaele Salerno
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan 20121, Italy
| | - Nicolò Mezzina
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco-Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
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BERTGES LC, DIBAI FN, BEZERRA G, OLIVEIRA ES, AARESTRUP FM, BERTGES KR. COMPARISON BETWEEN THE ENDOSCOPIC FINDINGS AND THE HISTOLOGICAL DIAGNOSIS OF ANTRAL GASTRITES. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:212-215. [DOI: 10.1590/s0004-2803.201800000-56] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 06/05/2018] [Indexed: 12/27/2022]
Abstract
ABSTRACT BACKGROUND: Gastritis is a very common disorder that is widely distributed worldwide, representing one of the most prevalent pathological entities in Gastroenterology and Digestive Endoscopy. OBJECTIVE: This study aims to analyze the correlation between the endoscopic findings and the histological diagnosis of antral gastritis. METHODS: In this study, 92 reports of upper digestive endoscopy were performed between November 2014 and January 2015, including biopsy of the antral gastric mucosa, comparing the endoscopic and histological findings, which were classified according to the Sidney System. The 92 exams included 35 men and 57 women, ranging in age from 15 to 84 years. The most frequent indication was epigastric pain. RESULTS: Of the 92 examinations analyzed, the histological diagnosis of antral gastritis appeared in 75 exams, 59 endoscopic reports contained the diagnosis of antral gastritis, and 33 endoscopic findings were normal. The kappa coefficient was 0.212 (P<0.05), indicating that there was no significant agreement between the endoscopic findings and the histological diagnosis of antral gastritis. CONCLUSION: We conclude that histology represents the gold standard method for the diagnosis of antral gastritis and that in daily clinical practice, biopsies should always be performed, regardless of the endoscopic findings.
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Affiliation(s)
| | | | - Geterson BEZERRA
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Brazil
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Colli A, Gana JC, Yap J, Adams‐Webber T, Rashkovan N, Ling SC, Casazza G, Cochrane Hepato‐Biliary Group. Platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2017; 4:CD008759. [PMID: 28444987 PMCID: PMC6478276 DOI: 10.1002/14651858.cd008759.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current guidelines recommend screening of people with oesophageal varices via oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis. This requires that people repeatedly undergo unpleasant invasive procedures with their attendant risks, although half of these people have no identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Platelet count, spleen length, and platelet count-to-spleen length ratio are non-invasive tests proposed as triage tests for the diagnosis of oesophageal varices. OBJECTIVES Primary objectives To determine the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices of any size in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology. To investigate the accuracy of these non-invasive tests as triage or replacement of oesophago-gastro-duodenoscopy. Secondary objectives To compare the diagnostic accuracy of these same tests for the diagnosis of high-risk oesophageal varices in paediatric or adult patients with chronic liver disease or portal vein thrombosis, irrespective of aetiology.We aimed to perform pair-wise comparisons between the three index tests, while considering predefined cut-off values.We investigated sources of heterogeneity. SEARCH METHODS The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register, the Cochrane Library, MEDLINE (OvidSP), Embase (OvidSP), and Science Citation Index - Expanded (Web of Science) (14 June 2016). We applied no language or document-type restrictions. SELECTION CRITERIA Studies evaluating the diagnostic accuracy of platelet count, spleen length, and platelet count-to-spleen length ratio for the diagnosis of oesophageal varices via oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age with chronic liver disease or portal vein thrombosis, who did not have variceal bleeding. DATA COLLECTION AND ANALYSIS Standard Cochrane methods as outlined in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. MAIN RESULTS We included 71 studies, 67 of which enrolled only adults and four only children. All included studies were cross-sectional and were undertaken at a tertiary care centre. Eight studies reported study results in abstracts or letters. We considered all but one of the included studies to be at high risk of bias. We had major concerns about defining the cut-off value for the three index tests; most included studies derived the best cut-off values a posteriori, thus overestimating accuracy; 16 studies were designed to validate the 909 (n/mm3)/mm cut-off value for platelet count-to-spleen length ratio. Enrolment of participants was not consecutive in six studies and was unclear in 31 studies. Thirty-four studies assessed enrolment consecutively. Eleven studies excluded some included participants from the analyses, and in only one study, the time interval between index tests and the reference standard was longer than three months. Diagnosis of varices of any size. Platelet count showed sensitivity of 0.71 (95% confidence interval (CI) 0.63 to 0.77) and specificity of 0.80 (95% CI 0.69 to 0.88) (cut-off value of around 150,000/mm3 from 140,000 to 150,000/mm3; 10 studies, 2054 participants). When examining potential sources of heterogeneity, we found that of all predefined factors, only aetiology had a role: studies including participants with chronic hepatitis C reported different results when compared with studies including participants with mixed aetiologies (P = 0.036). Spleen length showed sensitivity of 0.85 (95% CI 0.75 to 0.91) and specificity of 0.54 (95% CI 0.46 to 0.62) (cut-off values of around 110 mm, from 110 to 112.5 mm; 13 studies, 1489 participants). Summary estimates for detection of varices of any size showed sensitivity of 0.93 (95% CI 0.83 to 0.97) and specificity of 0.84 (95% CI 0.75 to 0.91) in 17 studies, and 2637 participants had a cut-off value for platelet count-to-spleen length ratio of 909 (n/mm3)/mm. We found no effect of predefined sources of heterogeneity. An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P < 0.001) and spleen length (P < 0.001). Diagnosis of varices at high risk of bleeding. Platelet count showed sensitivity of 0.80 (95% CI 0.73 to 0.85) and specificity of 0.68 (95% CI 0.57 to 0.77) (cut-off value of around 150,000/mm3 from 140,000 to 160,000/mm3; seven studies, 1671 participants). For spleen length, we obtained only a summary ROC curve as we found no common cut-off between studies (six studies, 883 participants). Platelet count-to-spleen length ratio showed sensitivity of 0.85 (95% CI 0.72 to 0.93) and specificity of 0.66 (95% CI 0.52 to 0.77) (cut-off value of around 909 (n/mm3)/mm; from 897 to 921 (n/mm3)/mm; seven studies, 642 participants). An overall indirect comparison of the HSROCs of the three index tests showed that platelet count-to-spleen length ratio was the most accurate index test when compared with platelet count (P = 0.003) and spleen length (P < 0.001). DIagnosis of varices of any size in children. We found four studies including 277 children with different liver diseases and or portal vein thrombosis. Platelet count showed sensitivity of 0.71 (95% CI 0.60 to 0.80) and specificity of 0.83 (95% CI 0.70 to 0.91) (cut-off value of around 115,000/mm3; four studies, 277 participants). Platelet count-to-spleen length z-score ratio showed sensitivity of 0.74 (95% CI 0.65 to 0.81) and specificity of 0.64 (95% CI 0.36 to 0.84) (cut-off value of 25; two studies, 197 participants). AUTHORS' CONCLUSIONS Platelet count-to-spleen length ratio could be used to stratify the risk of oesophageal varices. This test can be used as a triage test before endoscopy, thus ruling out adults without varices. In the case of a ratio > 909 (n/mm3)/mm, the presence of oesophageal varices of any size can be excluded and only 7% of adults with varices of any size would be missed, allowing investigators to spare the number of oesophago-gastro-duodenoscopy examinations. This test is not accurate enough for identification of oesophageal varices at high risk of bleeding that require primary prophylaxis. Future studies should assess the diagnostic accuracy of this test in specific subgroups of patients, as well as its ability to predict variceal bleeding. New non-invasive tests should be examined.
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Affiliation(s)
- Agostino Colli
- A Manzoni Hospital ASST LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de ChileGastroenterology and Nutrition Department85 LiraSantiagoRegion MetropolitanaChile8330074
| | - Jason Yap
- University of AlbertaDivision of Pediatric Gastroenterology, Hepatology and Nutrition, Dept. of Pediatrics, Stollery Children's Hospital, Faculty of MedicineAberhart Centre 111402 University AveEdmontonABCanadaT6G 2J3
| | | | - Natalie Rashkovan
- Sunnybrook Health Sciences CentreDepartment of Neurology2075 Bayview ave., room A448TorontoONCanadaM4N 3M5
| | - Simon C Ling
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology and Nutrition555 University AvenueTorontoONCanadaM5G 1X8
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, Eloubeidi MA, Gurudu SR, Kelsey L, Khashab MA, Kothari S, Muthusamy VR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85:273-281. [PMID: 28089029 DOI: 10.1016/j.gie.2016.10.036] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/08/2023]
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Pearl J, Fellinger E, Dunkin B, Pauli E, Trus T, Marks J, Fanelli R, Meara M, Stefanidis D, Richardson W. Guidelines for privileging and credentialing physicians in gastrointestinal endoscopy. Surg Endosc 2016; 30:3184-3190. [DOI: 10.1007/s00464-016-5066-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 12/31/2022]
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Abstract
Measuring quality in endoscopy includes the assessment of appropriateness of a procedure and the skill with which it is performed. High-quality pediatric endoscopy is safe and efficient, used effectively to make proper diagnoses, is useful for excluding other diagnoses, minimizes adverse events, and is accompanied by appropriate documentation from beginning through end of the procedure. There are no standard quality metrics for pediatric endoscopy, but proposed candidates are both process and outcomes oriented. Both are likely to be used in the near future to increase transparency about patient outcomes, as well as to influence payments for the procedure.
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Affiliation(s)
- Jenifer R Lightdale
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, UMass Memorial Children's Medical Center, University of Massachusetts Medical School, University Campus, 55 Lake Avenue North, Worcester, MA 01655, USA.
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Stagg J, Farukhi I, Lazaga F, Thompson C, Bradshaw L, Kaif M, Gould-Simon A, Schmidt R. Significance of 18F-Fluorodeoxyglucose Uptake at the Gastroesophageal Junction: Comparison of PET to Esophagogastroduodenoscopy. Dig Dis Sci 2015; 60:1335-42. [PMID: 25502332 DOI: 10.1007/s10620-014-3456-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 11/18/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Positron emission tomography-computed tomography (PET/CT) occasionally reveals unexpected uptake of (18)F-fluorodeoxyglucose ((18)F-FDG) at the gastroesophageal junction (GEJ). The aim of this study was to determine the importance of unexpected (18)F-FDG uptake at the GEJ on PET/CT by correlating this finding with endoscopy results. METHODS We reviewed medical records from June 2009 to October 2012 to identify patients in our Veterans Affairs Medical Center who had an esophagogastroduodenoscopy (EGD) performed within 6 months of a PET/CT. Metabolic activity at the GEJ was quantified with standardized uptake values (SUV) and correlated with EGD and histopathology results. RESULTS A total of 219 patients were identified and assigned to one of five groups based upon EGD findings: esophageal malignancy (n = 34), esophagitis (n = 21), Barrett's esophagus (n = 8), other non-malignant disorders (n = 5), and normal (n = 151). The mean SUV Max for the groups was 6.72, 2.47, 2.40, 3.48, and 2.06, respectively. SUV Max and SUV Mean were significantly higher in the esophageal malignancy group than in all other groups (p < 0.001). SUV for patients with high-grade esophagitis was greater than in patients with low-grade esophagitis. A SUV Max ≥ 3.5 was found to predict necessity for EGD with a positive predictive value of 79 %. A SUV Max ≤ 2.2 yielded a negative predictive value of 86 %. CONCLUSION Differentiation between benign and potentially significant disease at the GEJ may be possible with quantification of incidental (18)F-FDG uptake at PET/CT. Our results suggest thresholds that may help determine need for further endoscopic evaluation in patients with abnormal metabolic activity at the GEJ.
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Affiliation(s)
- Joshua Stagg
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390-9030, USA,
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Colli A, Gana JC, Turner D, Yap J, Adams‐Webber T, Ling SC, Casazza G, Cochrane Hepato‐Biliary Group. Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2014; 2014:CD008760. [PMID: 25271409 PMCID: PMC7173747 DOI: 10.1002/14651858.cd008760.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines recommend performance of oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis to screen for oesophageal varices. These guidelines require people to undergo an unpleasant invasive procedure repeatedly with its attendant risks, despite the fact that half of the people do not have identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Video capsule endoscopy is a non-invasive test proposed as an alternative method for the diagnosis of oesophageal varices. OBJECTIVES To determine the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices in children or adults with chronic liver disease or portal vein thrombosis, irrespective of the aetiology. To investigate the accuracy of capsule endoscopy as triage or replacement of oesophago-gastro-duodenoscopy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register (October 2013), MEDLINE (Ovid SP) (1950 to October 2013), EMBASE (Ovid SP) (1980 to October 2013), ACP Journal Club (Ovid SP) (1991 to October 2013), Database of Abstracts of Reviews of Effects (DARE) (Ovid SP) (third quarter), Health Technology Assessment (HTA) (Ovid SP) (third quarter), NHS Economic Evaluation Database (NHSEED) (Ovid SP) (third quarter), and Science Citation Index Expanded (SCI-EXPANDED) (ISI Web of Knowledge) (1955 to October 2013). We applied no language or document type restrictions. SELECTION CRITERIA Studies that evaluated the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices using oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age, with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS We followed the available guidelines provided in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. We calculated the pooled estimates of sensitivity and specificity using the bivariate model due to the absence of a negative correlation in the receiver operating characteristic (ROC) space and of a threshold effect. MAIN RESULTS The search identified 16 eligible studies, in which only adults with cirrhosis were included. In one study, people with portal thrombosis were also included. We classified most of the studies at high risk of bias for the 'Participants selection' and the 'Flow and timing' domains. One study assessed the accuracy of capsule endoscopy for the diagnosis of large (high-risk) oesophageal varices. In the remaining15 studies that assessed the accuracy of capsule endoscopy for the diagnosis of oesophageal varices of any size in people with cirrhosis, 936 participants were included; the pooled estimate of sensitivity was 84.8% (95% confidence interval (CI) 77.3% to 90.2%) and of specificity 84.3% (95% CI 73.1% to 91.4%). Eight of these studies included people with suspected varices or people with already diagnosed or even treated varices, or both, introducing a selection bias. Seven studies including only people with suspected but unknown varices were at low risk of bias; the pooled estimate of sensitivity was 79.7% (95% CI 73.1% to 85.0%) and of specificity 86.1% (95% CI 64.5% to 95.5%). Six studies assessed the diagnostic accuracy of capsule endoscopy for the diagnosis of large oesophageal varices, associated with a higher risk of bleeding; the pooled sensitivity was 73.7% (95% CI 52.4% to 87.7%) and of specificity 90.5% (95% CI 84.1% to 94.4%). Two studies also evaluated the presence of red marks, which are another marker of high risk of bleeding; the estimates of sensitivity and specificity varied widely. Two studies obtained similar results with the use of a modified device as index test (string capsule). Due to the absence of data, we could not perform all planned subgroup analyses. Interobserver agreement in the interpretation of capsule endoscopy results and any adverse event attributable to capsule endoscopy were poorly assessed and reported. Only four studies evaluated the interobserver agreement in the interpretation of capsule endoscopy results: the concordance was moderate. The participants' preferences for capsule endoscopy or oesophago-gastro-duodenoscopy were reported differently but seemed in favour of capsule endoscopy in nine of 10 studies. In 10 studies, participants reported some minor discomfort on swallowing the capsule. Only one study identified other significant adverse events, including impaction of the capsule due to previously unidentified oesophageal strictures in two participants. No adverse events were reported as a consequence of the reference standard. AUTHORS' CONCLUSIONS We cannot support the use of capsule endoscopy as a triage test in adults with cirrhosis, administered before oesophago-gastro-duodenoscopy, despite the low incidence of adverse events and participant reports of being better tolerated. Thus, we cannot conclude that oesophago-gastro-duodenoscopy can be replaced by capsule endoscopy for the detection of oesophageal varices in adults with cirrhosis. We found no data assessing capsule endoscopy in children and in people with portal thrombosis.
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Affiliation(s)
- Agostino Colli
- Ospedale "A Manzoni" LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Juan Cristóbal Gana
- Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de ChileGastroenterology, Hepatology, and Nutrition Unit85 LiraSantiagoRegion MetropolitanaChile8330074
| | - Dan Turner
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitP.O.B 3235JerusalemIsrael91031
| | - Jason Yap
- University of AlbertaDivision of Pediatric Gastroenterology, Hepatology and Nutrition, Dept. of Pediatrics, Stollery Children's Hospital, Faculty of MedicineAberhart Centre 111402 University AveEdmontonABCanadaT6G 2J3
| | | | - Simon C Ling
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University AvenueTorontoONCanadaM5G 1X8
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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Ekkelenkamp VE, Koch AD, Haringsma J, Poley JW, van Buuren HR, Kuipers EJ, de Man RA. Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance. Frontline Gastroenterol 2014; 5:10-16. [PMID: 24416502 PMCID: PMC3880906 DOI: 10.1136/flgastro-2013-100334] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 06/21/2013] [Accepted: 07/02/2013] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The American Society for Gastrointestinal Endoscopy Committee on Outcomes Research has recommended monitoring nine endoscopic retrograde cholangiopancreatography (ERCP)-specific quality indicators for quality assurance in ERCP. With the development of a self-assessment tool for ERCP (Rotterdam Assessment Form for ERCP-RAF-E), key indicators can easily be assessed. OBJECTIVE The aim of this study was to test in daily practice an easy-to-use form for assessment of procedural quality in ERCP and to determine ERCP quality outcomes in a tertiary referral hospital. DESIGN This was a prospective study carried out in a tertiary referral hospital. In January 2008, a quality self-assessment programme was started. Five qualified endoscopists participated in this study. All ERCPs were appraised using RAF-E. Primary parameters were common bile duct (CBD) cannulation rate and procedural success. The indication was classified and procedural difficulty was graded; success rates of therapeutic interventions were measured for all different difficulty degrees. RESULTS A total number of 1691 ERCPs were performed. 1515 (89.6%) of these were appraised using RAF-E. Median CBD cannulation success rate was 94.1%. Successful sphincterotomy was accomplished in almost all patients (median 100%; range 98.2-100%). Stent placement was successful in 97.8% and complete stone extraction, if indicated, was achieved in 86.8%. CONCLUSIONS Quality indicators for ERCP can be measured using the Rotterdam self-assessment programme for ERCP. Outcome data in ERCPs obtained with this RAF-E provide insight into the quality of individual as well as group performance and can be used to assess and set standards for quality control in ERCP.
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Affiliation(s)
- Vivian E Ekkelenkamp
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Jelle Haringsma
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Henk R van Buuren
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Robert A de Man
- Department of Gastroenterology and Hepatology , Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands
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Alharbi A, AlAmeel T, Aljebreen A, Almadi M. Saudi gastroenterology association position statement on privilege and credentialing for performing endoscopic retrograde cholangiopancreatography in Saudi Arabia. Saudi J Gastroenterol 2014; 20:329-30. [PMID: 25434311 PMCID: PMC4271005 DOI: 10.4103/1319-3767.145312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ahmad Alharbi
- Consultant Gastroenterologist, Department of Internal Medicine, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Turki AlAmeel
- Consultant Gastroenterology, King Fahad Specialist Hospital-Dammam, Saudi Arabia
| | - Abdulrahman Aljebreen
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid Almadi
- Department of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada E-mail:
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Cotton PB. Endoscopic retrograde cholangiopancreatography: maximizing benefits and minimizing risks. Gastrointest Endosc Clin N Am 2012; 22:587-99. [PMID: 22748250 DOI: 10.1016/j.giec.2012.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has become enormously popular throughout the world because of its proven value in the management of patients with known and suspected biliary and pancreatic disease. The results of ERCP are operator dependent, and there are significant risks. Adverse events are more likely when procedures are performed by endoscopists with inadequate training and experience. The best outcomes should occur when procedures are done for the best reasons, using optimal techniques in an ideal environment and a well-trained team, conscious of the risks and the ways to minimize them. This article discusses these intertwining elements of ERCP.
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Affiliation(s)
- Peter B Cotton
- Department of Digestive Disease Center, Medical University of South Carolina, Charleston, SC 29425-2900, USA.
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Thompson JS, Lebwohl B, Syngal S, Kastrinos F. Knowledge of quality performance measures associated with endoscopy among gastroenterology trainees and the impact of a web-based intervention. Gastrointest Endosc 2012; 76:100-6.e1-4. [PMID: 22421498 PMCID: PMC3739290 DOI: 10.1016/j.gie.2012.01.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 01/11/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Knowledge of quality measures in endoscopy among trainees is unknown. OBJECTIVE To assess knowledge of endoscopy-related quality indicators among U.S. trainees and determine whether it improves with a Web-based intervention. DESIGN Randomized, controlled study. SETTING Multicenter. PARTICIPANTS This study involved trainees identified from the American Society for Gastrointestinal Endoscopy membership database. INTERVENTION Participants were invited to complete an 18-question online test. Respondents were randomized to receive a Web-based tutorial (intervention) or not. The test was readministered 6 weeks after randomization to determine the intervention's impact. MAIN OUTCOME MEASUREMENTS Baseline knowledge of endoscopy-related quality indicators and impact of the tutorial. RESULTS A total of 347 of 1220 trainees (28%) completed the test; the mean percentage of correct responses was 55%. For screening colonoscopy, 44% knew the adenoma detection rate benchmark, 42% identified the cecal intubation rate goal, and 74% knew the recommended minimum withdrawal time. A total of 208 of 347 trainees (59%) completed the second test; baseline scores were similar for the tutorial (n = 106) and no tutorial (n = 102) groups (56.4% vs 56.9%, respectively). Scores improved after intervention for the tutorial group (65%, P = .003) but remained unchanged in the no tutorial group. On multivariate analysis, each additional year in training (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.5-3.4), training at an academic institution (OR 2.6; 95% CI, 1.1-6.3), and receiving the tutorial (OR 3.2; 95% CI, 1.7-5.9) were associated with scores in the upper tertile. LIMITATIONS Low response rate. CONCLUSION Knowledge of endoscopy-related quality performance measures is low among trainees but can improve with a Web-based tutorial. Gastroenterology training programs may need to incorporate a formal didactic curriculum to supplement practice-based learning of quality standards in endoscopy.
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Affiliation(s)
- Jennifer S Thompson
- Division of Liver and Digestive Diseases at Columbia University Medical Center, New York, New York 10032, USA
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Park WG, Cohen J. Quality measurement and improvement in upper endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2011.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Aslinia FM, Bagi P, Sorkin JD, Williams RB, Knodell RG, Sorkin LF, Greenwald BD, Steele A, Raufman JP. Anatomic classification of the endoscopic appearance of the normal appendiceal orifice: a novel tool for recognition and documentation of cecal intubation. Clin Anat 2011; 25:496-502. [PMID: 21913231 DOI: 10.1002/ca.21276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 06/22/2011] [Accepted: 08/13/2011] [Indexed: 12/16/2022]
Abstract
Complete colonoscopy for cancer screening requires cecal intubation. Failure to reach and examine the cecum may result in missed right colon pathology. We developed and validated a novel classification scheme for the endoscopic appearance of the normal appendiceal orifice (AO). We analyzed 1,456 AO images and grouped them into four categories based on distinguishing features: "diverticuloid," "umbilicoid," "crescent," and "linear." An expert panel classified the images and modified these categories, combining crescent and linear categories into "curvilinear." A 100-image subset was classified twice by a validation cohort consisting of gastroenterology faculty and fellows. Inter-observer agreement among the expert panel, and intra- and inter-observer agreement among the validation cohort were analyzed using Fleiss' kappa statistic. The distribution of AO images was 67% curvilinear, 19% umbilicoid, and 10% diverticuloid; 85 images (4%) were not classifiable. There was substantial inter-observer agreement among the expert panel (κ, 0.72). Inter-observer agreement among the validation cohort was moderate (κ, 0.53 and 0.55 for the first and second viewing, respectively). Intra-observer κ values among the validation cohort were 0.69 for the overall classification, 0.65 for diverticuloid, 0.70 for umbilicoid, and 0.70 for curvilinear, indicating substantial agreement. This simple, validated classification scheme for the endoscopic appearance of the normal AO can be used both as a research and clinical tool to measure endoscopic quality, improve cecal examination, and document successful cecal intubation.
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Affiliation(s)
- Florence M Aslinia
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Cotton PB. Are low-volume ERCPists a problem in the United States? A plea to examine and improve ERCP practice-NOW. Gastrointest Endosc 2011; 74:161-6. [PMID: 21704815 DOI: 10.1016/j.gie.2011.03.1233] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 03/20/2011] [Indexed: 02/08/2023]
Affiliation(s)
- Peter B Cotton
- Medical University of South Carolina, Charleston, SC, USA
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Petersen BT. Quality assurance for endoscopists. Best Pract Res Clin Gastroenterol 2011; 25:349-60. [PMID: 21764003 DOI: 10.1016/j.bpg.2011.05.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 05/04/2011] [Indexed: 01/31/2023]
Abstract
Quality assurance for gastrointestinal endoscopy addresses numerous aspects of unit management and patient care. Quality measures pertinent to patient care delivered by the individual endoscopist include optimal practices in the pre-procedure, intra-procedure, and post-procedure timeframes. Measures commonly employed to monitor colonoscopy care are discussed in detail. Several quality assurance techniques are well defined and useful for application to identified gaps in care. Quality improvement projects and ongoing quality assurance benchmarking against local and national norms are greatly facilitated by use of electronic report generators and computerized databases.
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Affiliation(s)
- Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
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Cotton PB. Quality endoscopists and quality endoscopy units. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:83-87. [PMID: 21776431 DOI: 10.4161/jig.1.2.15048] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 12/24/2010] [Accepted: 01/03/2011] [Indexed: 01/22/2023]
Abstract
Endoscopy plays an important role in the diagnosis and treatment of digestive diseases. The benefits are maximized when procedures are performed at an optimal level of quality. Technical failures and adverse events are more likely to occur when procedures are performed by inexperienced endoscopists. Professional organizations and manufacturing industry which support and represent endoscopy, and their leaders, have increasingly embraced the quality improvement paradigm that is advancing through medicine. We all need to agree on the metrics of endoscopic performance, to develop the infrastructure to collect and analyze the data, and to use the resulting knowledge to stimulate improvements in practice and benefit the patients.
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Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, 25 Courtenay, ART 7100A, MSC 290, Charleston, SC, 29425-2900, USA
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Cohen J. Objective longitudinal performance measurement using the Mayo Colonoscopy Skills Assessment Tool: a step in the right direction. Gastrointest Endosc 2010; 72:1134-7. [PMID: 21111867 DOI: 10.1016/j.gie.2010.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 10/19/2010] [Indexed: 12/10/2022]
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Barkun A, Ginsberg GG, Hawes R, Cotton P. The future of academic endoscopy units: challenges and opportunities. Gastrointest Endosc 2010; 71:1033-7. [PMID: 20438889 DOI: 10.1016/j.gie.2010.01.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 01/20/2010] [Indexed: 01/08/2023]
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Seip B, Bretthauer M, Dahler S, Friestad J, Huppertz-Hauss G, Høie O, Kittang E, Nyhus S, Pallenschat J, Sandvei P, Stallemo A, Svendsen MV, Hoff G. Sustaining the vitality of colonoscopy quality improvement programmes over time. Experience from the Norwegian Gastronet programme. Scand J Gastroenterol 2010; 45:362-9. [PMID: 20095874 DOI: 10.3109/00365520903497106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE An important challenge of any quality assurance (QA) programme is to maintain interest among participants to ensure high data quality over time. The primary aim of this study was to identify factors associated with endoscopist compliance with the Norwegian QA programme for colonoscopies (Gastronet). MATERIAL AND METHODS The Gastronet registration tools are an endoscopy report form to be filled in directly after the procedure by the endoscopist, and a satisfaction questionnaire to be filled in by the patient on the day after the examination. During the study period from 1 January 2004 to 31 December 2006, endoscopist compliance was measured by assessing patient report coverage, defined as the percentage of patient satisfaction questionnaires received by the Gastronet secretariat divided by the total number of colonoscopy reports registered by the individual endoscopists during the study period. Multivariate logistic regression models were applied to identify individual factors related to patient report coverage. RESULTS Eighty-eight endoscopists from 10 hospitals contributed a total of 16,149 colonoscopies. Overall patient report coverage decreased from 87% in 2004 to 80% in 2006. A low patient report coverage was associated with time since the registrations started [odds ratio (OR) 0.98, 95% confidence interval (CI) 0.97-0.98; P < 0.001], use of sedation (OR 0.7, 95% CI 0.61-0.76; P < 0.001), and incomplete colonoscopy (OR 0.6, 95% CI 0.54-0.76; P < 0.001). CONCLUSIONS Decreasing compliance with registration over time may compromise data quality and the validity of the results. Lower coverage of patient's reports (presumably for the most difficult examinations) may lead to erroneous conclusions regarding colonoscopy performance.
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Affiliation(s)
- Birgitte Seip
- Department of Medicine, Telemark Hospital, Skien, Norway.
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Sánchez Del Río A, Baudet JS, Naranjo Rodríguez A, Campo Fernández de Los Ríos R, Salces Franco I, Aparicio Tormo JR, Sánchez Muñoz D, Llach J, Hervás Molina A, Parra-Blanco A, Díaz Acosta JA. [Development and validation of quality standards for colonoscopy]. Med Clin (Barc) 2009; 134:49-56. [PMID: 19913837 DOI: 10.1016/j.medcli.2009.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 07/15/2009] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES Before starting programs for colorectal cancer screening it is necessary to evaluate the quality of colonoscopy. Our objectives were to develop a group of quality indicators of colonoscopy easily applicable and to determine the variability of their achievement. PATIENTS AND METHODS After reviewing the bibliography we prepared 21 potential indicators of quality that were submitted to a process of selection in which we measured their facial validity, content validity, reliability and viability of their measurement. We estimated the variability of their achievement by means of the coefficient of variability (CV) and the variability of the achievement of the standards by means of chi(2). RESULTS Six indicators overcome the selection process: informed consent, medication administered, completed colonoscopy, complications, every polyp removed and recovered, and adenoma detection rate in patients older than 50 years. 1928 colonoscopies were included from eight endoscopy units. Every unit included the same number of colonoscopies selected by means of simple random sampling with substitution. There was an important variability in the achievement of some indicators and standards: medication administered (CV 43%, p<0.01), complications registered (CV 37%, p<0.01), every polyp removed and recovered (CV 12%, p<0.01) and adenoma detection rate in older than fifty years (CV 2%, p<0.01). CONCLUSIONS We have validated six quality indicators for colonoscopy which are easily measurable. An important variability exists in the achievement of some indicators and standards. Our data highlight the importance of the development of continuous quality improvement programmes for colonoscopy before starting colorectal cancer screening.
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Changing trends in acute upper-GI bleeding: a population-based study. Gastrointest Endosc 2009; 70:212-24. [PMID: 19409558 DOI: 10.1016/j.gie.2008.10.051] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Accepted: 10/27/2008] [Indexed: 01/05/2023]
Abstract
BACKGROUND Advances in medical practice in recent decades have influenced the etiology and management of acute upper-GI bleeding (UGIB), but their impact on the incidence and mortality is unclear. OBJECTIVE To analyze the time trends of UGIB in 2 different management eras. DESIGN Prospective observational study. SETTING General university-affiliated hospital. PATIENTS AND INTERVENTIONS A total of 587 patients who presented with UGIB during the 1983-to-1985 period were compared with 539 patient in the 2002-to-2004 period. RESULTS The overall incidence of UGIB decreased from 112.5 to 89.8 per 100,000/y, which corresponds to a 35.5% decrease after adjustment for age (95% CI, 24.2%-46.8%). The age standardized incidence of ulcer bleeding decreased by 41.6% (95% CI, 27.2%-56%); the decrease occurred only in people younger than 70 years of age. The rate of history of peptic ulcer disease decreased from 32.7% in the 1983-to-1985 period versus 19.5% in the 2002-to-2004 period (P < .001). The mean age increased from 61.0 to 68.7 years (P < .001), and the male:female ratio decreased from 2.7 to 1.8 (P = .002). The comorbidities increased from 69% to 75% (P = .01), the use of nonsteroidal anti-inflammatory drugs from 40.0% to 46.4% (P = .03), and the cases of bleeding occurring during hospitalization from 10.4% to 17.1% (P < .001). In the 1983-to-1985 cohort, the endoscopy was solely diagnostic, and antisecretory therapy consisted of H2-antagonists drugs. In the second period, 39.3% of patients underwent endoscopic therapy, whereas proton pump inhibitors were administered in 47%. Rebleeding rates decreased from 32.5% to 7.4% (P < .001) and surgery from 10.2% to 2.0% (P < .001). Overall mortality decreased from 17.1 to 8.2 per 100,000/y, which corresponded to a 60.8% decrease after adjustment for age (95% CI, 46.5%-75.1%). The age standardized mortality rate for ulcer bleeding decreased by 56.5% (95% CI, 41.9%-71.1%). LIMITATIONS A single-center study and a potential lack of generalizability. CONCLUSIONS From the 1983-to-1985 period to the 2002-to-2004 period, major changes occurred in the incidence of UGIB, features of patients, management, and outcomes. The incidence and mortality of UGIB overall and ulcer bleeding decreased significantly, and the decline of incidence occurred only in patients younger than 70 years old.
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Canadian credentialing guidelines for endoscopic retrograde cholangiopancreatography. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:547-51. [PMID: 18560632 DOI: 10.1155/2008/582787] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Dominitz JA, Ikenberry SO, Anderson MA, Banerjee S, Baron TH, Cash BD, Fanelli RD, Gan SI, Harrison ME, Lichtenstein D, Shen B, Van Guilder T, Lee KK. Renewal of and proctoring for endoscopic privileges. Gastrointest Endosc 2008; 67:10-6. [PMID: 18045594 DOI: 10.1016/j.gie.2007.06.020] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 06/13/2007] [Indexed: 02/05/2023]
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Endoscopists attitudes on the publication of "quality" data for endoscopic procedures: a cross-sectional survey. BMC Gastroenterol 2007; 7:30. [PMID: 17650317 PMCID: PMC1950092 DOI: 10.1186/1471-230x-7-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Accepted: 07/24/2007] [Indexed: 11/26/2022] Open
Abstract
Background Whilst the public now have access to mortality & morbidity data for cardiothoracic surgeons, such "quality" data for endoscopy are not generally available. We studied endoscopists' attitudes to and the practicality of this data being published. Methods We sent a questionnaire to all consultant gastrointestinal (GI) surgeons, physicians and medical GI specialist registrars in the Northern region who currently perform GI endoscopic procedures (n = 132). We recorded endoscopist demographics, experience and current data collection practice. We also assessed the acceptability and utility of nine items describing endoscopic "quality" (e.g. mortality, complication & completion rates). Results 103 (78%) doctors responded of whom 79 were consultants (77%). 61 (59%) respondents were physicians. 77 (75%) collect any "quality" data. The most frequently collected item was colonoscopic completion rate. Data were most commonly collected for appraisal, audit or clinical governance. The majority of doctors (54%) kept these data only available to themselves, and just one allowed the public to access this. The most acceptable data item was annual number of endoscopies and the least was crude upper GI bleeding mortality. Surgeons rated information less acceptable and less useful than physicians. Acceptability and utility scores were not related to gender, length of experience or current activity levels. Only two respondents thought all items totally unacceptable and useless. Conclusion The majority of endoscopists currently collect "quality" data for their practice although these are not widely available. The endoscopists in this study consider the publication of their outcome data to be "fairly unacceptable/not very useful" to "neutral" (score 2–3). If these data were made available to patients, consideration must be given to both its value and its acceptability.
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Cotton PB. Simulators in competence assessment and credentialing: prospects and problems. Gastrointest Endosc Clin N Am 2006; 16:577-81, ix. [PMID: 16876727 DOI: 10.1016/j.giec.2006.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Systems that simulate endoscopic procedures have considerable potential in assessing endoscopic competence and assisting credentialing, but there are significant problems. If it can be shown that simulation tests correlate with real performance, the questions will be how to pay for the infrastructure and staff and how to motivate endoscopists to use them.
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Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, 69 Jonathan Lucas Street, #210 CSB, Charleston, SC 39425, USA.
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Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006; 63:378-82; quiz 464. [PMID: 16500382 DOI: 10.1016/j.gie.2005.06.046] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2005] [Accepted: 06/09/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND This study reports the analysis of a personal series of 59 cases in which ERCP malpractice was alleged. METHODS Half of the cases involved pancreatitis; 16 suffered perforation after sphincterotomy (8 of which involved pre-cutting), and 10 had severe biliary infection. There were 2 esophageal perforations. Fifteen of the patients died. The most common allegation (54% of cases) was that the ERCP, or the therapeutic procedure, was not indicated. Most of these patients had pain only, usually after cholecystectomy. Negligent performance was alleged in 19 cases, with corroborating evidence in 8. Inadequate postprocedure care was alleged in 5 cases, including 3 with a delayed diagnosis of perforation. Disputes about the extent of the education and consent process were common. RESULTS The final outcome was available in 40 cases. Sixteen were withdrawn, and 14 were settled. Of the 10 that came to trial, half were defense verdicts. CONCLUSIONS The lessons are clear. ERCP should be done for good indications, by trained endoscopists with standard techniques, with good documented patient informed consent and communication before and after the procedure. Speculative ERCP, sphincterotomy, and pre-cuts are high-risk for patients and for practitioners.
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Affiliation(s)
- Peter B Cotton
- Digestive Disease Center, Medical University of South Carolina, Charleston, 29425, USA
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