Cleaning and disinfection practices in digestive endoscopy in spain: results of a national survey

BACKGROUND AND STUDY AIMS

Disinfection and surveillance of it are important for ensuring safety in gastrointestinal endoscopy. The aim of this survey was to assess the current status of disinfection in gastrointestinal endoscopy units in Spain.

MATERIALS AND METHODS

An anonymous questionnaire on cleaning and disinfection methods was sent to gastrointestinal endoscopy units at 244 public hospitals in Spain. A minimum standard of disinfection (MSD) was defined to evaluate the appropriateness of disinfection practices.

RESULTS

A total of 144 centers responded (58 %). All units perform manual washing of endoscopes before disinfection. Automatic washers are available in only 23 % of the centers. Selective cleaning of internal channels is systematically performed in 85 % of the centers. Glutaraldehyde-based disinfectants are the most commonly employed (84 % of units). The time of exposure to the disinfectant is at least 10 min in 97 % of units, but 20 min or more in only 36 % of them. Endoscopic accessories are sterilized in 57 % of centers. The MSD was complied with by 79 % of the units evaluated. Compliance with the MSD was significantly lower in small units (P = 0.0005) performing small numbers of examinations per month. Quality control tests on the efficacy of disinfection methods are conducted at 66 % of the centers. Specialized personnel record disinfection procedures in 85 % of the centers and supervise them in 55 % of the centers. Half of the units have inadequate equipment and facilities.

CONCLUSIONS

This survey suggests that cleaning and disinfection practices in gastrointestinal endoscopy units in Spain have improved in recent years, and that there is a good compliance with standard guidelines. Most units should improve their equipment and facilities in order to provide better comfort and safety for patients and staff.

An appraisal of the role of laparoscopy: past, present, and future

OBJECTIVE

To review the role of laparoscopy in the management of chronic pelvic pain (CPP).

METHOD

A literature search was conducted to obtain a clear perspective on the role of laparoscopy for CPP.

RESULTS

Laparoscopy has been widely used as a diagnostic tool in CPP, but often falls short in defining the type and activity of ectopic endometrial-like tissue. Because pelvic endometriosis includes a wide range of lesions, histological confirmation varies greatly. The evaluation of peritoneal endometriosis at laparoscopy can be misleading. In one study 43% of the patients with minimal or mild endometriosis were found at second-look laparoscopy to be free of lesions. Finally, laparoscopy is not without major complications and the risk of undiagnosed bowel injury is likely to be underestimated.

CONCLUSION

The diagnosis of endometriosis can no longer be limited to the visual inspection of the pelvis but requires a wider range of investigations to assess the reproductive system and the role of endometriotic lesions and adhesions in CPP.

Modified seven-day, quadruple therapy as a first line Helicobacter pylori treatment

BACKGROUND

Cure rates of 7-day triple therapy seem to be decreasing. Quadruple therapies may be an alternative, although their complex administration makes patient acceptance difficult.

OBJECTIVE

To test the usefulness of a thrice a day, quadruple therapy to cure Helicobacter pylori infection.

PATIENTS AND METHODS

A total of 122 consecutive patients with peptic ulcer and Helicobacter pylori infection were treated with omeprazole 20 mg b.d., tetracycline chlorhydrate 500 mg t.d.s., metronidazole 500 mg t.d.s., and bismuth subcitrate 120 mg t.d.s. administered with meals for 7 days. Cure was tested by either endoscopy or breath test after 2 months, and by urea breath test 6 months after therapy.

RESULTS

Seven patients were lost to follow-up. Of the remaining 115, 110 were cured at the first control, giving an intention-to-treat cure rate of 90.2% (95% CI: 83-95%) and a per protocol cure rate of 95.7% (95% CI: 90-98%). One hundred three patients returned for a 6-month breath test; all but one were cured. Side-effects were minimal or minor in 47 patients (40.8%) and moderate in four (3.4%). Compliance was good, 95% of patients taking more than 90% of the pills. Six (5%) patients stopped treatment after 1, 2, 4 (two patients) and 6 (two patients) days.

CONCLUSION

Thrice a day quadruple therapy shows excellent cure rates, far above 90%, is well-tolerated and compliance is easy. Head-to-head comparison with triple therapies as first line Helicobacter pylori treatment seems warranted.

Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriotic adhesions of the ovary

OBJECTIVE

To determine whether transvaginal hydrolaparoscopy is superior to standard laparoscopy for detection of subtle endometriotic adhesions of the ovary.

DESIGN

Videotapes of standard laparoscopy and transvaginal hydrolaparoscopy were viewed by an independent observer in random order and in a blinded manner.

SETTING

Tertiary referral centers for infertility.

PATIENT(S)

Patients with minimal or mild endometriosis (n = 11) and unexplained infertility (n = 10) on standard laparoscopy from a group of 43 patients with infertility who were undergoing both studies.

INTERVENTION(S)

Transvaginal hydrolaparoscopy followed by standard laparoscopy.

MAIN OUTCOME MEASURE(S)

Detection of unexplained ovarian adhesions.

RESULT(S)

Patients with minimal and mild endometriosis and unexplained infertility had significantly more ovarian adhesions on transvaginal hydrolaparoscopy than on standard laparoscopy. The subtle adhesions seen on transvaginal hydrolaparoscopy but not on standard laparoscopy were filmy, microvascularized, and nonconnecting.

CONCLUSION(S)

Unexplained ovarian adhesions are frequently detected on transvaginal hydrolaparoscopy but not on standard laparoscopy in infertile patients with minimal and mild endometriosis and unexplained infertility.

Limited usefulness of a seven-day twice-a-day quadruple therapy

OBJECTIVE

To test the usefulness of a twice-a-day, simplified quadruple therapy to cure Helicobacter pylori infection.

DESIGN

Helicobacter pylori-positive ulcer patients were treated with omeprazole 20 mg twice a day (b.d.), amoxicillin 1 g b.d., tinidazole 500 mg b.d. and bismuth subcitrate 240 mg b.d. for 7 days in an experimental, noncomparative pilot study.

SETTING

The gastroenterology unit of a county hospital.

PARTICIPANTS

Forty-four consecutive patients with peptic ulcer disease and H. pylori infection.

MEASUREMENTS

Cure was tested by either endoscopy or breath test after 2 months, and by urea breath test 6 months after therapy.

RESULTS

One patient was lost to follow-up. Of the remaining 43, 37 were cured at the first control, giving an intention-to-treat cure rate of 84.1% (95% CI 69-93%) and a per protocol cure rate of 86% (95% CI 71-94%). Thirty-three cured patients agreed to return for a six-month breath test. All but one were cured (long-term per protocol cure rate 82.1%; 95% CI 66-92%).

CONCLUSIONS

This particular quadruple therapy is well tolerated and easy to comply with. However, cure rates did not reach 90%.

Massive rectal bleeding following transrectal ultrasound-guided prostate biopsy

BACKGROUND AND STUDY AIMS

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy, but is usually mild and stops spontaneously. We report five cases of life-threatening hemorrhage following this procedure, which were treated successfully by endoscopic injection.

PATIENTS AND METHODS

A total of 550 consecutive patients underwent TRUS-guided prostate biopsy in an outpatient setting. TRUS was performed using a Sonolayer 140 A (Toshiba) unit with a 7-MHz biplane transrectal probe, which was covered with two prophylactic sheaths. Sextant prostatic biopsies were systematically performed with a 16-gauge or 18-gauge needle without antibiotic prophylaxis.

RESULTS

Five patients (1%) presented rectal bleeding with hypovolemic symptoms shortly after the procedure. Emergency colonoscopy revealed active bleeding from biopsy sites in the anterior rectal wall. Endoscopic injection of epinephrine and polidocanol achieved control of bleeding and permanent hemostasis in all cases. The patients required hospitalization and a mean of 4 packed red blood cell units (range 2-7). The patients were discharged, with uneventful recoveries.

CONCLUSIONS

Colonoscopy should be carried out in patients presenting severe rectal bleeding after TRUS-guided prostate biopsy. Endoscopic treatment can be used to deal with this rare complication.

Validation of phone interview for follow-up in clinical trials on dyspepsia: evaluation of the Glasgow Dyspepsia Severity Score and a Likert-scale symptoms test

OBJECTIVE

To validate two widely used dyspepsia scores performed by phone interview.

DESIGN

Spanish translations of the Glasgow Dyspepsia Severity Score and a Likert-scale symptomatic test were evaluated. Responsiveness to the treatment, validity of the tests, and reproducibility of tests performed by phone interview were assessed.

SETTING

Gastroenterology and endoscopy unit of a county hospital.

PARTICIPANTS

Group I consisted of 16 ulcer patients undergoing Helicobacter pylori eradication; Group II consisted of 29 healthy volunteers; and Group III consisted of 95 patients undergoing upper endoscopy.

MEASUREMENTS

Glasgow Severity Dyspepsia Score and Likert test.

RESULTS

Both tests showed adequate improvement (responsiveness) after H. pylori eradication. With regard to validity, the Glasgow and Likert test were significantly higher in 95 patients undergoing endoscopy than in 29 healthy controls. Analysis of reproducibility showed that intraobserver variation was low on both the Glasgow and Likert scores. No differences were found between consecutive tests regardless of whether both were performed by phone (24 patients) or one by phone and the other by clinical interview (40 patients). Interobserver variation analysis showed that the Glasgow test remained highly reproducible even when performed by different observers using different methods (clinical interview 8.83, phone 8.44, P = 0.12). By contrast, Likert-scale tests showed significant differences between observers for all symptoms except abdominal pain.

CONCLUSIONS

(1) The Glasgow score is highly reproducible even when performed by different observers and using different methods. (2) By contrast, Likert tests show greater variability. To be reproducible in different conditions, they need to be performed by the same observer.

Hydrosalpinx and ART: hydrosalpinx--functional surgery or salpingectomy?

The debate on the effect of the hydrosalpinx on medically-assisted reproduction has demonstrated the importance of understanding the complex pathophysiology of the hydrosalpinx in outlining the principles of its clinical management, whether it is by functional surgery or IVF, preceded or not by salpingectomy. New endoscopic techniques are available to accurately assess, both in the operating room and the office, the quality of the tubal mucosa. The direct endoscopic evaluation of the tubal mucosa in hydrosalpinges is at present the most reliable technique to select between functional surgery and preventive salpingectomy. In future, prospective randomized studies on salpingectomy will benefit greatly from accurate clinicopathological data.

IgG antibody response to ES or somatic antigens of Dicrocoelium dendriticum (Trematoda) in experimentally infected sheep

The ELISA technique was used to study the kinetics of IgG antibodies against excretory-secretory (ES) and somatic (So) antigens of Dicrocoelium dendriticum in the sera of 32 lambs: 12 experimentally infected with 1,000 metacercariae, 12 with 3,000 and 8 controls. Both antigen types were used at a 2 microg/ml concentration. Dilutions of sera and the anti-sheep IgG peroxidase conjugate were: 1:200 and 1:6,000, respectively. Optical density values for each type of antigen in the two infected groups were higher than the cut-off point from day 30 post infection (p.i.), showing positive infection. Maximum antibody levels were observed 60 days p.i. and remained high until the experiment ended 180 days p.i. This pattern was similar for both ES and So antigens, although with slightly lower figures in the latter. Antibody kinetics were very similar for each of the two doses, except on day 30 p.i. No correlation between the antibody level and parasite burden could be established.

Four-day, twice daily, quadruple therapy with amoxicillin, clarithromycin, tinidazole and omeprazole to cure Helicobacter pylori infection: a pilot study

BACKGROUND

The best regimen for the treatment of Helicobacter pylori infection has yet to be defined. Four-day quadruple therapy with tetracycline, metronidazole, bismuth, and a proton pump inhibitor has been shown to obtain a very high cure rate. However, the fact that it must be taken four times daily may interfere with compliance. The objective of the study was to test the efficacy and tolerability of a new 4-day therapy with 4 drugs taken every 12 hours to cure H. pylori infection. Patients and Methods. Fifty-six consecutive patients with peptic ulcer disease and H. pylori infection were treated with an oral 4-day course with omeprazole (20 mg/12 hours), clarithromycin (500 mg/12 hours), amoxicillin (1 g/12 hours) and tinidazole (500 mg/12 hours). Efficacy of the treatment was determined at least 2 months after therapy either by biopsy (in the case of gastric ulcer) or by 13C-urea breath test. A second breath test was performed at least 6 months after therapy.

RESULTS

Two patients were lost to follow-up. Forty-nine of the remaining 54 patients were cured at the first control [intention-to-treat cure rate: 87.5% (CI 95% 75-94%); per protocol cure rate: 90.7% (CI 95% 81-98%)]. Forty-three of these 49 cured patients returned for a second 13C urea breath-test at 6-12 months. Two of them were not cured, giving a long-term cure rate of 85.5% per protocol and 73.2% by intention-to-treat. Compliance was good, although 25 patients had mild side effects.

CONCLUSION

This particular four-day therapy is well tolerated, easy to follow, and achieves an acceptably high cure rate.

Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions

STUDY OBJECTIVE. To evaluate the feasibility of a new endoscopic technique, transvaginal hydrolaparoscopy, for early office screening of subfertile women. DESIGN. Retrospective, descriptive feasibility study (Canadian Task Force classification II-2).

SETTING

Office in an infertility center.

PATIENTS

One hundred fifty-seven continuous women with primary or secondary subfertility.

INTERVENTION

Under local anesthesia, a Veress needle-cannula system was inserted into the posterior fornix with peritoneal distention by saline.

MEASUREMENTS AND MAIN RESULTS

Access was achieved in 95% of patients. In 58.5% the findings were normal and in 28% an explorative or operative laparoscopy was indicated. No major complication occurred. Patients' pain scores were similar to those for office hysteroscopy.

CONCLUSION

Transvaginal hydrolaparoscopy was successfully performed in the office. The technique allows early and complete endoscopic screening of subfertile women.

Efficacy of low and standard midazolam doses for gastroscopy. A randomized, double-blind study

AIM

To evaluate the efficacy and safety of two different doses of intravenous midazolam (35 and 70 microg/kg) compared to placebo in patients undergoing gastroscopy.

PATIENTS AND METHODS

Sixty patients scheduled for diagnostic gastroscopy were selected according to factors previously reported to affect tolerance (Eur J Gastroenterol Hepatol 1999; 11:201-204) and were randomly assigned to receive premedication with midazolam 35 microg/kg iv, midazolam 70 microg/kg iv or placebo iv. Oxygen saturation was continuously monitored during the procedure. Patients' tolerance, time to discharge and post-sedative inconvenience were evaluated using visual analogue scales and a questionnaire.

RESULTS

Patients receiving either dose of midazolam showed better tolerance of gastroscopy than those receiving the placebo. Fewer patients receiving 70 or 35 microg/kg of midazolam were reluctant to undergo a further gastroscopy compared to those receiving the placebo (2, 1 and 9 patients respectively, P = 0.01). Compared to patients receiving midazolam 70 microg/kg, those receiving midazolam 35 microg/kg were discharged earlier (29.3+/-14.4 versus 43.1+/-12.4 min respectively, P < 0.001), experienced less post-sedative inconvenience (8 versus 15 patients slept for > 1 h at home respectively, P = 0.02), and suffered fewer clinically relevant desaturation episodes (< 90%) (0 versus 5 patients respectively, P = 0.04).

CONCLUSIONS

Low doses of intravenous midazolam (35 microg/kg) are adequate and safe when sedation is indicated for gastroscopy.

Relationship between egg output and parasitic burden in lambs experimentally infected with different doses of Dicrocoelium dendriticum (Digenea)

The relationship between egg elimination and parasitic burden was studied in two groups of 12 lambs experimentally infected with 1000 and 3000 Dicrocoelium dendriticum metacercariae, respectively. Half the animals in each group were slaughtered 2 months post-infection (p.i.) and the other half 6 months p.i. In order to detect and follow elimination of D. dendriticum eggs by the lambs, faeces samples collection started one and a half months p.i. and continued fortnightly until the end of the experiment. Egg elimination was first detected between days 49 and 79 p.i. (mean = 59 +/- 1.6 SE). Mean eggs per gram (epg) was higher in the lambs infected with 3000 metacercariae (347.2 +/- 42.4 epg) than in those infected with 1000 (194.8 +/- 14.4), although no significant differences were detected between both groups using the Student 't' test. Egg elimination was higher in the faeces samples taken in the afternoon (mean = 357.8 +/- 47.6 epg) than in those from the morning (mean = 215.7 +/- 21.3). The percentage of metacercariae which became established as worms was higher in the animals dosed with 1000 metacercariae (21.6%) than in those infected with 3000 (16.3%). The number of worms recovered on necropsy of each animal varied between 30 and 2063 (mean = 346.6 +/- 80.5) and their length between 2.6 and 7.1 mm (mean = 5.2 +/- 0.1). The mean number of parasites for lambs infected with 3000 metacercariae (489.3 +/- 163.1) was higher than that obtained from those dosed with 1000 (215.7 +/- 41.4), although more worms were collected in some cases from the lambs infected with the latter dose than the former. In general there was an increase in the number of epg eliminated as days p.i. and parasitic burden increased. A positive relationship was observed via the correlation coefficient between the number of epg eliminated by each of the lambs throughout the experiment and that of worms recovered. This relationship was more intense on considering only the number of epg eliminated between days 120 and 180 p.i.

Office hydrolaparoscopy for the diagnosis of endometriosis and tubal infertility

Transvaginal hydrolaparoscopy has been described as an office procedure that is particularly suitable for the diagnosis of endometriosis and adhesions. It is recommended as a first line procedure in patients with infertility. The procedure is performed under local anaesthesia or sedation in an office setting. The abdominal distension is achieved by transvaginal instillation of warm saline using a combined Veress needle-trocar system. The exploration under fluid allows the inspection of the tubo-ovarian structures in their natural position and the easy identification of endometriotic lesions and adhesions in the posterior pelvis. The limitation of the inspection to the posterior pelvis is not a major problem for the diagnosis of endometriosis because exclusively anterior pelvis endometriosis is rare and of doubtful significance in infertility. Transvaginal hydrolaparoscopy can be performed in the office setting in combination with minihysteroscopy, tubal patency test and salpingoscopy, offering major advantages for the diagnosis of pelvic disease in patients with infertility.

Diagnostic accuracy of transvaginal hydrolaparoscopy in infertility

OBJECTIVE

To determine whether the accuracy of transvaginal hydrolaparoscopy is comparable to that of standard laparoscopy for the diagnosis of infertility.

DESIGN

Prospective, comparative study.

SETTING

General hospital in Belgium.

PATIENT(S)

Ten infertile patients without obvious pelvic pathology.

INTERVENTION(S)

Two gynecologists independently performed transvaginal hydrolaparoscopy and standard laparoscopy and reported the observations in a confidential manner to a third person.

MAIN OUTCOME MEASURE(S)

Endometriosis, adhesions, and other pelvic pathology related to infertility.

RESULT(S)

Minimal or mild endometriosis was diagnosed in seven patients and sequelae of pelvic inflammatory disease in one patient at both procedures. The interobserver agreement for tuboovarian adhesions was 95% at transvaginal hydrolaparoscopy and 74% at standard laparoscopy. Ovarian adhesions were detected in 63% at transvaginal hydrolaparoscopy and in 37% at standard laparoscopy.

CONCLUSION(S)

Transvaginal hydrolaparoscopy is comparable in accuracy to standard laparoscopy for the diagnosis of adhesions and endometriosis in infertile patients without obvious pathology.