Adenoma detection rates decline with increasing procedural hours in an endoscopist’s workload

BACKGROUND:

Operator fatigue may negatively influence adenoma detection (AD) during screening colonoscopy.

OBJECTIVE:

To better characterize factors affecting AD, including the number of hours worked, and the number and type of procedures performed before an index screening colonoscopy.

METHODS:

A retrospective cohort study was conducted involving individuals undergoing a screening colonoscopy at a major tertiary care hospital in Montreal, Quebec. Individuals were identified using an endoscopic reporting database; AD was identified by an electronic chart review. A hierarchical logistic regression analysis was performed to determine the association between patient- and endoscopist-related variables and AD.

RESULTS:

A total of 430 consecutive colonoscopies performed by 10 gastroenterologists and two surgeons were included. Patient mean (± SD) age was 63.4±10.9 years, 56.3% were males, 27.7% had undergone a previous colonoscopy and the cecal intubation rate was 95.7%. The overall AD rate was 25.7%. Age was associated with AD (OR 1.06 [95% CI 1.03 to 1.08]), while female sex (OR 0.44 [95% CI 0.25 to 0.75]), an indication for average-risk screening (OR 0.47 [95% CI 0.27 to 0.80]) and an increase in the number of hours during which endoscopies were performed before the index colonoscopy (OR 0.87 [95% CI 0.76 to 0.99]) were associated with lower AD rates. On exploratory univariable analysis, a threshold of 3 h of endoscopy time performed before the index colonoscopy was associated with decreased AD.

CONCLUSION:

The number of hours devoted to endoscopies before the index colonoscopy was inversely associated with AD rate, with decreased performance possibly as early as within 3 h. This metric should be confirmed in future studies and considered when optimizing scheduling practices.     

Is it possible to predict the procedural time of endoscopic submucosal dissection for early gastric cancer?

Background and Aim:  Endoscopic submucosal dissection (ESD) has been expected to be a possible curative treatment, especially for node-negative early gastric cancer (EGC). We investigated the influential factors on the procedural time of gastric ESD with a Flex knife for the estimation.
Methods:  In 222 intestinal-type EGC resected by ESD experts with established techniques, age, sex, location, circumference, gross type, tumor size, tumor depth, ulcerative findings, the period of ESD, the operator, and the experience of the operator were retrospectively analyzed. Predictors with a significant difference, as determined by multivariate analysis, were used to compose a predictive formula of procedural time.
Results:  Location, gross type, tumor depth, ulcerative findings, and tumor size were considered influential factors on the procedural time by univariate analysis. Location in the upper-third of the stomach, presence of ulcerative findings, and > 20 mm in size were independent factors, as determined by multivariate analysis. Procedural time (min) was nearly equal to the maximal tumor size (mm) multiplied by 2.5, and an additional 40 min was required if the tumor was located in the upper-third of the stomach or had ulcerative findings (in both situations, an additional 80 min was needed).
Conclusion:  The procedural time of ESD with a Flex knife for EGC can be predicted by tumor size, location, and existence of ulcerative findings. The estimation of procedural time may be very useful to determine the operation schedule.     

Magnetically guided irrigated gold-tip catheter ablation of persistent atrial fibrillation—techniques, procedural parameters and outcome

Purpose

Magnetically guided irrigated ablation has been introduced for atrial fibrillation (AF) ablation. However, data on ablation of persistent AF is scarce, and first-generation platinum–iridium catheters were burdened by char formation at the catheter tip. Furthermore, energy transmission of these catheters may be suboptimal. Irrigated gold-tip catheters have been introduced to overcome these problems.

Methods

Antral pulmonary vein (PV) isolation (PVAI) was performed using a 5-mm irrigated gold-tip magnetic catheter (power setting, 48 °C maximum, 50 W, 15 s lesion duration; flow-rate, 30 mL/min). The catheter tip was guided by a uniform magnetic field and a motor drive. Left atrial maps were created using an impedance-based left atrial reconstruction and fused with a preprocedural CT or an intraprocedural rotational angiography-based scan.

Results

Fifty-seven patients (42 male, 61.9?±?8.8 years) underwent PVAI for symptomatic, drug-refractory persistent AF. PVAI was performed successfully in all patients confirmed by entrance block. Procedure time (skin-to-skin) was 214?±?47 min (104–354 min). Fluoroscopy time was 31?±?21 min. Ablation time was 4,153?±?1,350 s. No char or thrombus formation was found at the catheter tip. One pericardial tamponade was observed. Freedom from atrial tachyarrhythmias could be achieved in 57.9 % of the patients included in a follow-up of 11.6?±?4.2 month. There was a trend to a better outcome in patients without previous attempts of AF ablation (n?=?48; 60.4 % vs. 44.4 %, p?=?0.47).

Conclusions

Remote magnetic navigation for PVAI seems to be safe and feasible using an irrigated gold-tip catheter. Effectiveness of this novel technique can be confirmed by mid-term outcome.     

Acute and intermediate‐term procedural results using cypher stenting to treat multi‐vessel coronary artery disease

OBJECTIVE: We examined our experience using the sirolimus eluting stents (Cypher) as an alternative to surgical revascularization in carefully selected cohort of patients undergoing multi‐vessel percutaneous coronary intervention. METHODS: Fifty consecutive patients with multi‐vessel disease who were good candidates for both surgical and percutaneous revascularization were included in the current analysis. All patients underwent a careful clinical evaluation prior to the intervention, and they were followed for procedural and clinical outcomes for nine months. RESULTS: Mean age was 64±11 years (40 males, 30% diabetics) and 10 patients (20%) had three‐vessel disease. Angina class was 2.7±0.6 at baseline. Overall, 116 lesions were treated using 122 stents (mean 2.4 stents per patient). Total mean stent length was 43±12?mm (range: 21–90?mm). Overall, one patient died during follow‐up (2%), no patient had stroke or Q wave MI and one patient experienced non‐Q myocardial infarction. There was no documented stent thrombosis and two patients (4%) underwent target‐vessel revascularization. The hierarchical cumulative major adverse cardiac event rate was 8% and the cardiac event‐free survival rate was thus 92%. CONCLUSION: Multi‐vessel stenting using Cypher stents is a viable treatment strategy in selected group of patients with multi‐vessel coronary artery disease. It is associated with excellent intermediate‐term clinical outcomes and thus it could serve as the primary revascularization strategy of choice in appropriate candidates.     

An evaluation of procedural training in Canadian respirology fellowship programs: Program directors’ and fellows’ perspectives

BACKGROUND:

In recent years, there has been a rapid growth in diagnostic and therapeutic procedures performed by respirologists.

OBJECTIVES:

To assess the number and type of procedures performed in Canadian respirology training programs, for comparison with the American College of Chest Physicians minimum competency guidelines, and to assess fellow satisfaction with procedural training during their fellowships.

METHODS:

Internet-based surveys of Canadian respirology fellows and respirology fellowship program directors were conducted.

RESULTS:

Response rates for program director and respirology fellow surveys were 71% (10 of 14) and 62% (41 of 66), respectively. Thirty-eight per cent of respirology fellows reported the presence of an interventional pulmonologist at their institution. Flexible bronchoscopy was the only procedure reported by a large majority of respirology fellows (79.5%) to meet American College of Chest Physicians recommendations (100 procedures). As reported by respirology fellows, recommended numbers of procedures were met by 59.5% of fellows for tube thoracostomy, 21% for transbronchial needle aspiration and 5.4% for closed pleural biopsy. Respirology fellows in programs with an interventional pulmonologist were more likely to have completed some form of additional interventional bronchoscopy training (80% versus 32%; P=0.003), had increased exposure to and expressed improved satisfaction with training in advanced diagnostic and therapeutic procedures, but did not increase their likelihood of achieving recommended numbers for any procedures.

CONCLUSIONS:

Canadian respirology fellows perform lower numbers of basic respiratory procedures, other than flexible bronchoscopy, than that suggested by the American College of Chest Physicians guidelines. Exposure and training in advanced diagnostic and therapeutic procedures is minimal. A concerted effort to improve procedural training is required to improve these results.     

Partial malposition of PFO closure device: indication for elective surgical removal? Discussion of indications,procedural and anatomical aspects

Partial malposition of a PFO closure device occurred, probably due to a right atrial ligamentous structure. Despite absence of residual shunt and uneventful postprocedural course, elective surgical removal was performed. Indications, procedural and anatomical aspects are discussed.     

How to duplicate the procedural success of coronary interventions by the radial approach:tips and tricks in the selection and manipulations of guides

In this issue of the Journal of Geriatric Cardiology, Jing et al. showed off their near perfect results of percuta- neous coronary interventions     

Performance and acute procedural outcomes of the EnSite Precision™ cardiac mapping system for electrophysiology mapping and ablation procedures: results from the EnSite Precision™ observational study

Journal of Interventional Cardiac Electrophysiology - The EnSite Precision? cardiac mapping system (Abbott) is a catheter navigation and mapping system capable of displaying the...