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PubMedDate not supplied

Initial experience using an endoscopic simulator to train surgical residents in flexible endoscopy in a community medical center residency program.

INTRODUCTION: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins. METHODS: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed. RESULTS: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%. CONCLUSIONS: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

Colonoscopy↗
PubMed2006

Pharyngeal anesthesia during sedated EGDs: is "the spray" beneficial? A meta-analysis and systematic review.

BACKGROUND: Pharyngeal anesthesia is widely used as an adjunct to sedation during upper endoscopy. Methemoglobinemia and anaphylactic reactions are rare but serious complications of topical anesthetic agents. Individual studies produce variable results about the effectiveness of pharyngeal anesthesia in improving patient tolerance. OBJECTIVE: A systematic review was performed to evaluate the effectiveness of pharyngeal anesthesia in improving patient tolerance and ease of endoscopy during sedated upper endoscopy. DESIGN: A MEDLINE search, an EMBASE search, and manual searches were performed to identify pertinent English language articles. Randomized controlled trials (RCT) comparing the efficacy of pharyngeal anesthesia to placebo or no treatment were identified. Duplicate data extraction about patient tolerance of the procedure and endoscopist assessment regarding the ease of endoscopy was performed. RESULTS: From a pool of 53 studies, 5 RCTs evaluated a total of 491 patients and provided interpretable data. Patients who rated their discomfort during the sedated procedure as none/minimal were more likely to have received pharyngeal anesthesia (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.13-3.12). Endoscopists were more likely to rate the procedure as "not difficult" for patients who received pharyngeal anesthesia (OR 2.60, 95% CI 1.63-4.17). LIMITATIONS: Lack of standardized outcome measurements and standardized sedation strategies led to heterogeneity in the patient-tolerance portion of the meta-analysis. CONCLUSIONS: Pharyngeal anesthesia before upper endoscopy improves ease of endoscopy and also improves patient tolerance.

Anesthesia, Local↗
PubMed2006

Diagnostic yield, safety, and efficacy of push enteroscopy in pediatrics.

BACKGROUND: Push enteroscopy has not been compared to standard endoscopy in children. OBJECTIVE: The aim of this study was to determine the feasibility of push enteroscopy in children with suspected proximal small bowel disease, and to compare its diagnostic yield and safety with standard endoscopy. DESIGN/SETTING: Database review. PATIENTS: A database analysis was performed on all children who underwent push enteroscopy at The Johns Hopkins Children's Center from 2001 to 2005. Patient demographics, clinical history, and indication for push enteroscopy were all recorded. Clinical utility was qualified based on the influence of PE on therapy. MAIN OUTCOME MEASUREMENTS: Diagnostic yield and safety of push enteroscopy in children. RESULTS: Push enteroscopy was performed on 44 children (27 M; 17 F) with a median age (range) of 10 (2-18) years. The most common indications for push enteroscopy were suspected proximal small bowel disease based on radiological criteria (21), and bleeding (9). Push enteroscopy confirmed the diagnosis of proximal small bowel Crohn's disease (CD) in 23, polyps in 5, eosinophilic gastroenteritis in 4, celiac disease in 1, microvillous inclusion disease in 1, and lymphoproliferative disease in 1 patient. An isolated non-Crohn's related gastric (1) and jejunal ulcer (1) was also identified. Just 9 of these identifiable lesions were within reach by esophagogastroduodenoscopy (EGD). Seven patients had a normal push enteroscopy. The clinical management was modified in 34 patients. Push enteroscopy was not shown to significantly alter the time of procedure when compared to EGD. CONCLUSIONS: Push enteroscopy is a safe diagnostic tool with proven clinical utility in children with suspected proximal small bowel disease. Larger studies are needed to establish the widespread application of push enteroscopy in pediatrics.

Adolescent↗
PubMed2004

Electronic endoscopic information systems: what is out there?

This review summarizes some of the endoscopy electronic medical records (EEMRs) that are presently available. The objective is simply to familiarize the reader with some of the important systems and key features. It is not meant to be exhaustive, as a complete review of EEMRs would involve much more than a simple article; this document simply provides an introduction from which the groundwork can be laid.

Database Management Systems↗
PubMed2006

Efficacy and safety of upper endoscopy procedures during pregnancy.

The risks of performing endoscopy become more complex when the patient is pregnant. The endoscopist has to consider all the factors that affect the health of both the patient and the fetus. Although pregnant patients are generally healthy, they may have changes in blood pressure and volume status as well as alterations in tolerance of anesthesia and luminal distention. Maternal complications will impact the health of the fetus. In addition, the fetus can be directly affected by procedural medications, mechanical factors, and therapeutic interventions. The endoscopist must be able to minimize the risks to the fetus and provide the pregnant patient with a safe and comfortable procedure. This review focuses on the risks of upper endoscopy as they relate to the health of a pregnant woman and the fetus.

Electrocoagulation↗
PubMed2004

Prediction of appropriateness of local endoscopic treatment for high-grade dysplasia and early adenocarcinoma by EUS and histopathologic features.

BACKGROUND: Endoscopic techniques are being developed for the local treatment of early stage esophageal cancer. However, such therapy is not appropriate for patients with lymph node metastasis. The aim of this study was to analyze the histopathologic features of high-grade dysplasia and early stage adenocarcinoma and to relate these to lymph node involvement. METHODS: Pathology reports were reviewed for all 367 patients who underwent subtotal esophagectomy for high-grade dysplasia or adenocarcinoma of the esophagus or the gastroesophageal junction between January 1993 and December 2001. Patients with histopathologically confirmed high-grade dysplasia or T1 carcinoma were included (n = 77). Pre-operative EUS results were assessed. All lesions were histopathologically subdivided in 6 different stages (mucosal 1-3 and submucosal 1-3). RESULTS: EUS staged 61 patients as N0. EUS correctly predicted the absence of positive lymph nodes in 57 (93%) of these patients. Histopathologically, m1, m2, m3, and sm1 cancers never had lymph node metastases, whereas 3 of 13 sm2 tumors (23%) and 9 of 13 sm3 tumors (69%) had lymph node involvement. Lymphangio invasion was present exclusively in sm2 and sm3 cancers. Factors that predicted the presence of lymph node metastasis were the following: tumor diameter greater than 3 cm, infiltration of malignancy beyond sm1, poor differentiation grade, and lymphangio invasion, although only infiltration beyond sm1 remained significant in the definitive multivariate analysis. CONCLUSIONS: EUS and the histopathologic features of high-grade dysplasia and early stage adenocarcinoma of the esophagus or the gastroesophageal junction can predict the presence of lymph node involvement. These data can be used to identify patients for whom local endoscopic treatment may be appropriate.

Adenocarcinoma↗
PubMed1996

Gastrointestinal endoscopy in patients taking antiplatelet agents and anticoagulants: survey of ASGE members. American Society for Gastrointestinal Endoscopy.

BACKGROUND: Gastrointestinal endoscopy is often required in patients taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or anticoagulants. Because proper guidelines are lacking, we believe that most endoscopists use their own criteria and judgment for stopping and restarting these agents during the periendoscopic period, and the practice varies widely. The aim of our study was to identify these practices among ASGE members. METHODS: Questionnaires, each containing 22 questions with 157 responses, were sent to 3300 ASGE members, including all Gastroenterology Fellowship Program Directors. One thousand two hundred sixty-nine questionnaires were received and analyzed. RESULTS: Physicians stopped aspirin and NSAIDs more frequently before colonoscopy (81%) and ERCP (79%) than before upper endoscopy (51%) (p < 0.001). Ninety percent of physicians stopped aspirin and NSAIDs for 10 or fewer days. Only 20% of physicians performed sphincterotomy when aspirin and NSAIDs were not stopped compared with 88% and 85% (p < 0.001 for both) of physicians performing cold biopsies at esophagogastroduodenoscopy and colonoscopy, respectively, and 77% and 69% performing hot biopsies for the same procedures (p < 0.001 for all compared with sphincterotomy). Depending on the indication for anticoagulation, 51% to 60% of physicians stopped warfarin before upper endoscopy; 71% to 82% before colonoscopy; and 26% to 51% of physicians used a "heparin window." All physicians restarted warfarin immediately after diagnostic endoscopy, whereas 80% restarted it 7 or fewer days after therapeutic endoscopy. CONCLUSIONS: We conclude that a wide variation exists regarding the management of aspirin, NSAIDs, and anticoagulants in the periendoscopic period. There is a definite need for a consensus statement or guidelines for managing patients taking these agents.

Anti-Inflammatory Agents, Non-Steroidal↗