Mandatory vs. optional split-dose bowel preparation for morning colonoscopies: a pragmatic noninferiority randomized controlled trial

BACKGROUND : We compared the effectiveness of optional split-dose bowel preparation (SDBP) with mandatory SDBP for morning colonoscopies in usual clinical practice. METHODS : Adult patients undergoing outpatient early morning (8:00 AM-10:30 PM) and late morning (10:30 AM-12:00 PM) colonoscopies were included. Written bowel preparation instructions were provided based on randomization: one group were instructed to take their bowel preparation (4 L polyethylene glycol solution) as a split dose (mandatory), while the comparator group was allowed the choice of SDBP or single-dose bowel preparation administered entirely on the day before (optional). The primary end point, using noninferiority hypothesis testing with a 5 % margin, was adequate bowel cleanliness measured by the Boston Bowel Preparation Scale (BBPS) and defined by a BBPS score ≥ 6. RESULTS : Among 770 randomized patients with complete data, there were 267 mandatory SDBP and 265 optional SDBP patients for early morning colonoscopies, and 120 mandatory SDBP and 118 optional SDBP patients for late morning colonoscopies. Optional SDBP was inferior to mandatory SDBP, with a lower proportion of adequate BBPS cleanliness for early morning colonoscopies (78.9 % vs. 89.9 %; absolute risk difference [aRD] 11.0 %, 95 %CI 5.9 % to 16.1 %), but was not statistically different for late morning colonoscopies (76.3 % vs. 83.3 %; aRD 7.1 %, 95 %CI -1.5 % to 15.5 %). CONCLUSIONS : Optional SDBP is inferior to mandatory SDBP in providing adequate bowel preparation quality for early morning colonoscopies (8:00 AM-10:30 AM), and probably inferior for late morning colonoscopies (10:30 AM-12:00 PM).

Colorectal polyp classification and management of complex polyps for surgeon endoscopists

Increasing familiarity with advanced endoscopic excision techniques allows for more colorectal lesions to be removed without major surgery. Endoscopic excision with negative margins is adequate for most polyps and low-risk T1 cancers. The use of modern polyp classification techniques based on size, morphology and pit pattern by an experienced endoscopist allow for an optical diagnosis of these lesions and can predict, with high accuracy, which lesions contain malignant disease and the level of invasion. A surgeon endoscopist must be able to recognize which complex polyps can be resected with advanced polypectomy techniques and which require upfront surgery. We aimed to provide an overview of polyp classification techniques to help surgeons select the correct treatment algorithm for advanced colorectal lesions based on their visual characteristics at index endoscopy.

Existing Bowel Preparation Quality Scales Are Reliable in the Setting of Centralized Endoscopy Reading

BACKGROUND

Development of bowel preparation products has been based upon colon cleansing rating by a local endoscopist. It is unclear how bowel preparation scales perform when centrally evaluated.

AIMS

To evaluate the reliability of bowel preparation quality scales when assessed by central readers.

METHODS

Four central readers evaluated 52 videos in triplicate, 2 weeks apart, during the entire endoscopic procedure (insertion/withdrawal of the colonoscope) and exclusively on colonoscope withdrawal using the Boston Bowel Preparation Scale (BBPS), Chicago Bowel Preparation scale, Harefield Cleansing Scale, Ottawa Bowel Preparation Quality Scale (OBPQS), Aronchick score, a visual analogue scale, and additional items proposed in a modified Research and Development/University of California Los Angeles appropriateness process. Reliability was assessed with intraclass correlation coefficients.

RESULTS

Intraclass correlation coefficients (95% confidence interval) for inter-rater reliability of the quality scales ranged from 0.51 to 0.65 (consistent with moderate to substantial inter-rater reliability) during the entire procedure. Corresponding intraclass correlation coefficients for intra-rater reliability ranged from 0.69 to 0.77 (consistent with substantial intra-rater reliability). Reliability was highest in the right colon and lowest in the left colon. No differences were observed in reliability when assessed for the procedure overall (insertion/withdrawal) relative to assessment on withdrawal alone.

CONCLUSION

All five bowel preparation quality scales had moderate to substantial inter-rater reliability. Panelists considered the Aronchick score too simplistic for clinical trials and recognized that assessment of residual fluid in the Ottawa Bowel Preparation Quality Scale was not amenable to central assessment.

Use of topical mineral powder as monotherapy for treatment of active peptic ulcer bleeding

BACKGROUND AND AIMS

The aim of this study was to evaluate the safety and effectiveness of Hemospray (Cook Medical, Winston-Salem, NC, USA), a hemostatic powder, as monotherapy for active peptic ulcer bleeding.

METHODS

In this prospective, multicenter, single-arm study, patients with Forrest Ia or Ib peptic ulcers underwent endoscopic application of Hemospray as treatment of first intent. Effectiveness endpoints were successful hemostasis at the end of the index endoscopy, recurrent bleeding within 72 hours and from 72 hours to 30 days, adverse events requiring reintervention or resulting in morbidity or mortality, and 30-day mortality.

RESULTS

Hemospray was successfully administered in 98.5% of patients (66/67). Hemostasis was achieved at the index endoscopy in 90.9% of patients (60/66) with Hemospray alone and in an additional 4 patients treated with additional modalities, yielding an overall hemostasis rate of 97.0% (64/66). Rebleeding occurred in 13.3% of patients (8/60), 5 within 72 hours and 3 between 72 hours and 30 days. Two cases of perforation and 2 patient deaths occurred during the study, but none of these cases or any other adverse events were attributed to the use of Hemospray. The rate of early rebleeding was significantly higher in patients with Forrest Ia ulcers compared with patients with Forrest Ib ulcers. Higher rates of early bleeding in patients with Forrest Ia ulcers is consistent with results from studies where Hemospray was used as rescue after failure of conventional methods.

CONCLUSIONS

Hemospray is an effective initial treatment for patients with active peptic ulcer bleeding, but care should be taken to monitor for recurrent bleeding. (Clinical trial registration number: NCT01306864.).

A172 EXPERIENCE AND PERCEPTIONS OF SIMETHICONE USE DURING COLONOSCOPY: A SURVEY OF NORTH AMERICAN ENDOSCOPISTS

Background

Simethicone is an anti-foaming agent which can be used to decrease the surface tension of air bubbles and improve visualization of colonic mucosa during colonoscopy. Recent studies have found that residual simethicone persists in endoscopes despite reprocessing and disinfection and promotes persistent moisture in endoscope channels. Simethicone residues can theoretically contribute to biofilm formation by providing nutritional milieu for microbial growth, which could increase the risk of transmission of infections among patients. Endoscopists’ perceptions on simethicone use and potential benefits are unknown, and this study aims to start filling this gap.

Aims

To assess experience and perceptions of simethicone use during colonoscopy in North America.

Methods

A REDCap® survey was distributed via email to members of various national professional associations and personal contacts of the study authors. Once the survey is complete, logistic regression analysis will be performed to assess univariate and multivariate associations of simethicone use. Preliminary data are reported in this abstract.

Results

47 practicing endoscopists have responded so far, of which 31 (64%) are surgeons and 16 are gastroenterologists (34%). The participants had been in practice for a median of eight years (range 1 – 34 years) and performed a median of ten colonoscopies per week. All 47 endoscopists practiced in Canada, with representation from seven provinces. Two endoscopists (4%) ask patients to use simethicone orally as part of their bowel preparation. During outpatient colonoscopy, 22 endoscopists (47%) never use simethicone, 19 endoscopists (40%) use simethicone less than 50% of the time, and six endoscopists (13%) use simethicone more than 50% of the time. Endoscopists were divided as to whether certain bowel preparations influenced their use of simethicone (agree or strongly agree 9, 19%; neutral 29, 62%; disagree or strongly disagree 9, 19%), that simethicone use could contribute to the transmission of pathogens through endoscopes (agree or strongly agree 6, 13%; neutral 34, 72%; disagree or strongly disagree 7, 15%), or that simethicone use increases their adenoma detection rate (agree or strongly agree 18, 38%; neutral 21, 45%; disagree or strongly disagree 8, 17%).

Conclusions

Of the current respondents of this survey, just over half (53%) of endoscopists report using simethicone during outpatient colonoscopies. Most reported simethicone use was via the water pump or instrument channel; oral simethicone use maybe minimal. Current respondents were divided in their perception that type of bowel preparation influences their use of simethicone or that simethicone use could contribute to the transmission of pathogens. Many endoscopists believed simethicone use could increase their adenoma detection rate.

Funding Agencies

None

SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications

OBJECTIVES

In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis.

METHODS

The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months.

RESULTS

The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency.

CONCLUSIONS

The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.

Trends in utilization of diagnostic and therapeutic ERCP and cholecystectomy over the past 25 years: a population-based study

BACKGROUND

Comprehensive, population-based data on ERCP use over the last 30 years in North America are lacking.

OBJECTIVE

To establish crude and age-adjusted population-based rates of ERCP, evaluate for changing indications for ERCP, and evaluate for interactions between cholecystectomy technique and ERCP use from 1984 to 2009.

DESIGN

Retrospective, comprehensive, population-based study.

SETTING

All inpatient and outpatient ERCPs and cholecystectomies in Manitoba, Canada from 1984 to 2009.

PATIENTS

All residents of Manitoba, Canada with a history of ERCP and/or cholecystectomy.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Yearly crude and age-adjusted rates of ERCP (diagnostic and therapeutic) and cholecystectomy (open, laparoscopic, and with open bile duct exploration), and patient and/or procedure demographics.

RESULTS

The rate of ERCP/10,000 people increased from 7.70 (1984) to 13.86/10,000 (2009) (P = .001). Diagnostic ERCP declined from 7.28/10,000 (1984) to 1.11/10,000 (2009), and therapeutic ERCP increased from 0.42/10,000 (1984) to 12.75/10,000 (2009) (P < .001). ERCPs were more common in women (62%) and in older populations (60-79 years, >80 years), with rates of therapeutic ERCP reaching 62.58/10,000 in the elderly. The primary indication for ERCP has changed over time, with biliary indications increasing from 50.3% to 67.3% and pancreatic indications decreasing from 18.3% to 8.1% (P < .05). The rate of therapeutic ERCP increased during the transition from open to laparoscopic cholecystectomy (1991-1994), whereas open bile duct exploration (OBDE) decreased from 2.0 to 0.18/10,000 (P < .001).

LIMITATIONS

Retrospective analysis, administrative data.

CONCLUSION

ERCP use increased steadily from 1984 to 2009, and changed from a diagnostic modality to a therapeutic one. Changes in cholecystectomy technique may have influenced therapeutic ERCP use and likewise, the availability of therapeutic ERCP has decreased the need for OBDE.

Risk factors for ERCP-related complications in patients with pancreas divisum: a retrospective study

BACKGROUND

Limited data are available on complication rates of ERCP in patients with pancreas divisum (PD), and it is unclear whether traditional risk factors for post-ERCP pancreatitis (PEP) apply.

OBJECTIVES

To describe the rates of ERCP complications in patients with PD and assess patient and procedure-related risk factors for PEP.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care referral center.

PATIENTS

A total of 2753 ERCPs performed in 1476 patients with PD from 1997 to 2010.

MAIN OUTCOME MEASUREMENTS

Rates of PEP, hemorrhage, perforation, cholecystitis, and hospitalization directly attributable to ERCP.

RESULTS

Early complications occurred after 7.8% of procedures, with PEP, hemorrhage, perforation, cholecystitis, and cardiorespiratory complications in 6.8%, 0.7%, 0.2%, 0.1%, and 0.1% of procedures, respectively. PEP was uncommon in patients who did not undergo attempted dorsal duct cannulation, occurring in 1.2% of procedures. With dorsal duct cannulation and cannulation with minor papilla sphincterotomy (MiS), the rates of PEP increased significantly to 8.2% and 10.6%, respectively (P<.01 for each comparison). Significant predictors of PEP after multivariate logistic regression included age younger than 40 (odds ratio [OR] 1.8; 95% CI, 1.27-2.59), female sex (OR 1.94; 95% CI, 1.25-3.01), previous PEP (OR 2.02; 95% CI, 1.32-3.1), attempted dorsal duct cannulation (OR 7.45; 95% CI, 3.25-17.07), and MiS (OR 1.62; 95% CI, 1.05-2.48). Presence of severe chronic pancreatitis was a protective factor (OR 0.46; 95% CI, 0.22-0.98).

LIMITATIONS

Retrospective analysis of prospectively collected data.

CONCLUSIONS

Among patients with PD, the rate of PEP is low (1.2%) if dorsal duct cannulation is not attempted. However, patients with PD undergoing dorsal duct cannulation with or without MiS are at high risk of PEP (8.2% without and 10.6% with). Traditional PEP risk factors apply to patients with PD.

Acute pancreatitis after removal of retained prophylactic pancreatic stents

BACKGROUND

Prophylactic pancreatic stents (PPSs) are used to decrease the risk of post-ERCP pancreatitis (PEP) in high-risk patients. The risk associated with PPS removal is unknown.

OBJECTIVE

To describe the rate of PEP in patients undergoing PPS removal without pancreatogram or other manipulation of the major or minor papilla.

DESIGN

Retrospective, cohort study.

SETTING

Tertiary care academic center.

PATIENTS

This study involved 230 patients undergoing removal of PPSs from 1997 to 2010.

INTERVENTION

PPS removal.

MAIN OUTCOME MEASUREMENTS

Rate of acute pancreatitis associated with removal of PPS alone.

RESULTS

Acute pancreatitis occurred after PPS removal in 7 of 230 (3.0%) cases. PEP was graded as mild, moderate, and severe in 2, 5, and 0 cases, respectively. Statistically significant risk factors of PEP after PPS removal include use of a 5F stent (P=.001), use of a stent with an internal flange (P<.01), and occurrence of PEP after the initial ERCP (P<.01). Longer duration of stent within the pancreatic duct before removal was of borderline significance (P=.06). Patient age; sex; indication for initial procedure; the presence of pancreas divisum, ansa loop, or chronic pancreatitis; and history of pancreatic or biliary sphincterotomy or orifice dilation were not significant risk factors for pancreatitis after PPS removal.

LIMITATIONS

Retrospective analysis of prospectively collected data. Small number of events.

CONCLUSION

Removal of retained PPSs may cause mild or moderate acute pancreatitis. This risk of acute pancreatitis may diminish the overall efficacy of PPS use by delaying the occurrence of PEP rather than eliminating it. This implies that PPSs should be used only in patients at high risk for PEP.

A population-based study of breastfeeding in inflammatory bowel disease: initiation, duration, and effect on disease in the postpartum period

OBJECTIVES

We aimed to assess breastfeeding practices and the impact of breastfeeding on disease flare during the postpartum year in inflammatory bowel disease (IBD).

METHODS

Women of childbearing age from 1985 to 2005 were identified from the University of Manitoba IBD Research Registry. Questionnaires were completed regarding pregnancy and the postpartum period. Data for initiation and duration of breastfeeding were compared with population-based regional data.

RESULTS

Of 204 eligible women, 132 (64.7%) responded to the survey, yielding information on 156 births. Breastfeeding was initiated in 83.3% of women with IBD (n=132), 81.9% of Crohn's disease patients (CD, n=90), and 84.2% of ulcerative colitis patients (UC, n=39) vs. 77.1 % in the general population (P>0.05 for all). Of women with IBD, 56.1% breastfed for >24 weeks vs. 44.4% of controls (P=0.02). The rate of disease flare in the postpartum year was 26% for those who breastfed vs. 29.4% in those who did not (P=0.76) in CD and 29.2% vs. 44.4% (P=0.44) in UC. The odds ratio of disease flare postpartum for those who breastfed vs. those who did not was 0.58 (95% CI: 0.24-1.43), 0.84 (0.19-9.87), and 0.51 (0.12-2.2) for IBD total, CD, and UC, respectively. Risk of disease flare was not related to age at pregnancy, duration of disease, or socioeconomic status.

CONCLUSIONS

Women with IBD are as likely as the general population to breastfeed their infants. Breastfeeding is not associated with an increased risk of disease flare and may even provide a protective effect against disease flare in the postpartum year.

Drug therapy for inflammatory bowel disease in pregnancy and the puerperium

Inflammatory bowel disease (IBD) has a peak age of onset in the 3rd decade and a peak prevalent age in the fourth decade in most studies. As a result many patients affected by Crohn's disease and ulcerative colitis are females of reproductive age interested in bearing children. It has been shown that the most important factor in the success of a pregnancy in patients with IBD is the state of disease activity. Therefore, the goal prior to and during pregnancy is to best optimise control of the disease through medical therapy. Unfortunately, many medications utilised to treat IBD are potentially toxic and/or teratogenic, leaving many physicians and patients without a clear answer as to the safest methods of therapy. This review attempts to summarise the medical literature to date, as it pertains to the safety of medical therapy for IBD during pregnancy and the puerperium.