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Background: Fatigue is an underestimated cause of underperformance among physicians. There is evidence that fatigue or other byproducts of production pressure may negatively influence the quality of colonoscopy., Objective: To investigate the practices and perceptions of U.S. endoscopists regarding the effect of production pressure on the performance of colonoscopy., Design: We conducted a 40-question online survey to assess endoscopists' practices and perceptions concerning production pressure., Setting: A total of 5030 U.S. American Society for Gastrointestinal Endoscopy members., Main Outcome Measurements: The proportion of endoscopists responding positively to questions pertaining to the impact of production pressure on colonoscopy practice., Results: Ninety-two percent of respondents indicated that production pressure influenced one or more aspects of their endoscopic practices. Examples of production pressure included (1) postponing polypectomy for a subsequent session (2.8%), (2) reducing the length of time spent inspecting the colon (7.2%), and (3) proceeding with colonoscopy in a patient with an unfavorable risk/benefit ratio (69.2%). Forty-eight percent of respondents reported witnessing the effects of production pressure on a colleague. Respondents working fee-for-service and those with >10 years since completion of fellowship were more likely to describe their weekly workloads as excessive compared with those who were salaried (81.3% vs 71.3%; P = .01) and <10 years out of training (81% vs 72.7%; P = .01)., Limitations: Nonresponse bias due to low response rate (22.3%)., Conclusion: Production pressure influences the conduct of colonoscopy for many endoscopists and could have an adverse effect on the outcome of colorectal cancer screening. (, Clinical Trial Registration Number: RE:GIE D 11-01288R1.) The study was an Internet study and did not involve human subjects., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Proximal colorectal cancer may arise from sessile serrated polyps (SSPs), which are often inconspicuous during colonoscopy. The gross morphologic characteristics of SSPs have not been systematically described, and this omission may contribute to colonoscopists overlooking them., Objectives: To analyze the gross morphologic characteristics of SSPs detected during routine colonoscopy., Design: Retrospective analysis of high-resolution endoscopic video clips depicting SSPs in situ., Setting: Outpatient gastroenterology practice., Patients: A total of 124 subjects undergoing surveillance or screening colonoscopy after split-dose bowel preparation., Interventions: Analysis of 158 SSPs performed by using validated descriptors., Main Outcome Measurements: The prevalence of morphologic characteristics related to polyp shape, color, and texture., Results: A total of 158 SSPs were studied. For 7 visual descriptors, a κ coefficient of ≥ 0.7 was achieved, indicating good to excellent intraobserver agreement. The most prevalent visual descriptors were the presence of a mucous cap (63.9%), rim of debris or bubbles (51.9%), alteration of the contour of a fold (37.3%), and interruption of the underlying mucosal vascular pattern (32.3%). The most common "sentinel signs" were the presence of a mucous cap and alteration of the contour of a mucosal fold (each 24.6%), rim of debris or bubbles (21.7%), and a dome-shaped protuberance (20.3%). When comparing SSPs with adenomatous polyps, the frequencies of 5 of 7 morphologic characteristics and the distribution of sentinel signs differed (P < .01)., Limitations: Single-site, retrospective analysis., Conclusions: SSPs exhibit distinct, variable morphologic characteristics. Many do not display classic features such as a mucous cap. Enhanced appreciation of these morphologic characteristics may improve SSP detection and thereby colorectal cancer prevention., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Recent studies have shown that colonoscopic polyp detection decreases as the workday progresses. This may reflect time-dependent factors such as colonoscopist fatigue and decreased colon cleanliness, which can be addressed through adaptations in colonoscopy practice., Objective: To test for time-of-day differences in adenomatous polyp (AP) and sessile serrated polyp (SSP) detection in a practice that uses split-dose bowel preparation and moderated daily colonoscopist procedure loads., Design: Retrospective chart review., Setting: Community-based, group gastroenterology practice., Patients: This study involved 2439 patients undergoing surveillance or screening colonoscopy., Intervention: Colonoscopy., Main Outcome Measurements: Detection rate of all premalignant polyps (PMPs), and of APs and SSPs, individually., Results: A total of 1183 PMPs were identified in 1486 eligible patients (mean PMP/colonoscopy = 0.80; PMP detection rate = 47%). In univariate and multivariate analyses, PMP detection as well as detection of APs or SSPs individually did not vary significantly in relation to the hour of the day. In a binary comparison of morning (am) versus afternoon (pm) procedures, the total polyp detection rate was 67% and 66%, respectively. For PMPs, APs, SSPs, and hyperplastic polyps (HPs), the am and pm detection rates were 46% and 47%, 41% and 44%, 8% and 8%, and 27% and 24%, respectively. Bowel preparation quality was independent of time of day and was rated excellent or good in 86% to 87% of cases., Limitations: Retrospective, nonrandomized study., Conclusion: Stable PMP, AP, SSP, and HP detection rates throughout the workday occur under certain practice conditions, including the use of split-dose bowel preparation and/or moderated daily colonoscopist procedure loads., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: The Sightline ColonoSight (CS) colonoscopy system presents 3 technologic advances: (1) disposable components protect the reusable parts from contact with colonic contents, eliminating the need for disinfection between procedures, (2) an air-pressure-powered engine assists in colonoscope advancement, (3) light emitting diode (LED) illumination eliminates the need for fiber optics and an external light source., Objectives: To study the operation, performance, and safety of the Sightline CS colonoscopy system., Design: The system was tested during colonoscopy in animals and in human pilot studies. An in vitro dye diffusion test, and bacterial cultures (obtained after using the colonoscope in animals and humans) were performed to ascertain the protective integrity of the disposable components., Setting: Animal centers, hospitals in Israel and Italy, and office endoscopy centers in the United States., Patients: Thirty-three volunteers and 145 patients who required a colonoscopy for various indications., Interventions: Colonoscopy, polypectomy, biopsy, and coagulation., Main Outcome Measures: Complications, system function, cecal intubation, and colonoscopy time., Results: The Sightline CS system performed well during a colonoscopy in 19 animals and 178 patients, without complications. Dye studies and bacterial cultures showed no transfer of dye molecules or bacterial organisms across the protective, disposable components., Limitations: This is an observational pilot study, with no comparative group., Conclusions: The new Sightline CS colonoscopy system performed well. The disposable components eliminated the need for disinfection of the colonoscope between procedures. Advancement of the colonoscope in the colon was helped by self propulsion of the instrument affected by an air-pressure-powered engine. LED illumination eliminated the need for fiber optics and an external light source.

Background: Increased demand for screening colonoscopy necessitates improved efficiency in endoscopy units, especially more efficient use of existing resources. The purpose of this study was to assess the efficiency of the endoscopy unit of a large tertiary care teaching hospital., Objective: To assess the efficiency of the endoscopy unit in a large tertiary care teaching hospital., Design: Prospective study from May 16 to September 5, 2003., Setting: Endoscopy unit of a 650-bed acute care teaching hospital., Patients: Inpatient and outpatient procedures., Main Outcome Measurements: Time elapsed between endoscopic procedures; the duration of the procedures; procedure delays (>15 minutes between procedures) and the reasons for them., Results: The research assistant observed 675 endoscopic procedures done for 625 patients (207 inpatients [33%]). The most common procedure was colonoscopy (42.1%), followed by EGD (36.0%). Overall, procedures for 193 (30.9%) of the 625 patients were delayed (>15 minutes between procedures), 70.5% (136/193) because the physician was not available to start the procedure. The time elapsed between procedures was longer than 30 minutes for 47 of the 193 delayed procedures (24.4%). The duration of procedures was prolonged for about 22% (130/593) of procedures., Conclusions: Physician unavailability contributed to considerable delays in endoscopic procedures. Strategies to reduce procedure delays could have a favorable impact on the volume of procedures performed in the unit, thereby improving the use of existing resources. We encourage other groups to assess the efficiency of their hospital-based endoscopy units.

Background: Enteryx implantation in the esophagus is an alternative therapy for patients with proton pump inhibitor (PPI) dependent GERD. Although this treatment resulted in highly significant improvement at 6 and 12 months, longer follow-up is needed to more fully assess the durability of these positive effects., Methods: An open-label, international clinical trial was conducted in 144 PPI-dependent patients with GERD with follow-up at 6 and 12 months. In addition, the durability and the safety of the treatment were assessed for 24 months in 64 patients enrolled in a postapproval study. The primary study outcome measure was usage of PPI. Secondary outcomes in the multicenter trial were GERD health-related quality of life (GERD-HRQL) symptom score and esophageal acid exposure., Results: At 12 months, PPI use was reduced > or =50% in 84%: 95% confidence interval (CI) [76%, 90%] and was eliminated in 73%: 95% CI[64%, 81%] of evaluable patients (intent-to-treat analysis 78%: 95% CI[70%, 84%] and 68%: 95% CI[60%, 76%], respectively). A GERD-HRQL < or =11 was attained in 78%: 95% CI[69%, 85%] of evaluable patients. Esophageal acid exposure (total time pH <4) was reduced by 31%: 95% CI[17%, 43%]. At 24 months, a > or =50% or greater reduction in PPI use was achieved in 72%: 95% CI[59%, 82%] and PPI use was eliminated in 67%: 95% CI[54%, 78%] of patients., Conclusions: This investigation provides evidence for sustained effectiveness and safety of implantation of Enteryx in the esophagus in PPI-dependent patients with GERD.

Background: Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation., Methods: One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered., Results: For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event., Conclusions: Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.

Background: There is increasing interest in the use of propofol, an ultrashort-acting hypnotic agent, for sedation during endoscopic examinations. A protocol was developed for administration of propofol, combined with small doses of midazolam and meperidine, for endoscopic sedation under the direction of a gastroenterologist. Initial experience with using this protocol is described., Methods: A total of 819 consecutive endoscopic examinations under sedation with propofol, midazolam, and meperidine (or fentanyl), in adherence with the sedation protocol, were reviewed retrospectively., Results: There were 638 colonoscopies and 181 EGDs; 89% of patients were classified as American Society of Anesthesiologists (ASA) class I or II. Mean dosages of medications were: propofol 63 (33.5) mg, meperidine 48 (7.2) mg, and midazolam 1 (0.12) mg. The dose of propofol was inversely correlated with age and ASA class, and positively correlated with patient weight and duration of examination. Hypotension (>20 mm Hg decline in either systolic or diastolic blood pressure) developed in 218 (27%) patients, and hypoxemia (oxygen saturation <90%) developed in 75 (9%). All episodes of hypotension and hypoxemia were transient, and no patient required administration of a pharmacologic antagonist or assisted ventilation. The average time for recovery after colonoscopy and after EGD was, respectively, 25 minutes and 28 minutes. All EGDs and 98% of colonoscopies were completed successfully., Conclusions: On the basis of this initial experience, it is believed that propofol, potentiated by small doses of midazolam and meperidine, can be safely and effectively administered under the direction of a gastroenterologist. Additional research will be necessary to determine whether propofol is superior to the current methods of sedation.

Pancreatic ductal stones may be responsible for attacks of acute pancreatitis (chronic relapsing pancreatitis) or exacerbations of chronic pain in patients with chronic pancreatitis. This study was undertaken to identify those patients with predominantly main pancreatic duct stones most amenable to endoscopic removal and to determine the effects on the patients' clinical course with such removal. Thirty-two patients with ductographic evidence of chronic pancreatitis and pancreatic duct stones underwent attempted endoscopic removal. Of the patients, 71.9% had complete or partial stone removal and 67.7% improved after endoscopic therapy. Symptomatic improvement was most evident in the group of patients with chronic relapsing pancreatitis. Factors favoring stone removal included (1) three or less stones, (2) stones confined to the head and/or body of the pancreas, (3) absence of a downstream stricture, (4) stone diameter less than or equal to 10 mm, and (5) absence of impacted stones. After successful stone removal, 25% of patients had regression of the ductographic changes of chronic pancreatitis and 41.7% had a decrease in the main pancreatic duct diameter. The only complication from therapy was mild pancreatitis in 8.2%. These data suggest that removal of pancreatic duct stones may result in symptomatic improvement. A longer follow-up will be necessary to determine whether endoscopic success results in long-standing clinical improvement and/or permanent regression of the morphologic changes of chronic pancreatitis.

Endoscopic injection sclerosis is a therapeutic alternative in the management of esophageal varices. Complications of sclerotherapy have been minor, including fever, bacteremia, and abnormal chest x-ray. We performed a prospective study to evaluate the frequency of postsclerosis bacteremia. Bacteremia was detected in 14 procedures (50%). There were no cases of bacteremia in a group of control patients with esophageal varices undergoing upper gastrointestinal endoscopy without sclerosis (p less than 0.05). Bacteremia was transient and unrelated to the presence of fever or other clinical complications. The organism most commonly cultured from blood, alpha-hemolytic streptococcus, probably represents a contaminant from the oropharynx, introduced into the bloodstream during sclerosis. We conclude that injection sclerotherapy of esophageal varices is associated with a higher incidence of bacteremia than routine upper endoscopy and that selected patients may require antibiotic prophylaxis when undergoing this procedure.