Letters to the Editor
endoscopic treatment of a persistent bile leak by ablating the mucosa at the cystic duct orifice using EHL by way of cholangioscopy. EHL generates electrical energy to the target tissue, and the closure of the cystic duct orifice can be attributed to mechanical trauma causing an inflammatory reaction, re-epithelialization, and stimulation of fibrosis. Haroon Shahid, MD Jason Korenblit, MD Thomas Kowalski, MD David E. Loren, MD Ali A. Siddiqui, MD Division of Gastroenterology and Hepatology Department of Internal Medicine Thomas Jefferson University Hospital Philadelphia, Pennsylvania, USA
REFERENCES 1. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007;65:247-52. 2. Sandha GS, Bourke MJ, Haber GB, et al. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004;60:567-74. 3. Kaffes AJ, Hourigan L, De LN, et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005;61:269-75. 4. Fasoulas K, Zavos C, Chatzimavroudis G, et al. Eleven-year experience on the endoscopic treatment of post-cholecystectomy bile leaks. Ann Gastroenterol 2011;24:200-5. http://dx.doi.org/10.1016/j.gie.2014.04.047
Barriers to colonoscopy among New York City homeless To the Editor: Colorectal cancer is the second leading cause of cancerrelated death in the developed world,1 and although screening has become more commonplace among the population as a whole, rates of colorectal cancer screening in poor communities, particularly the homeless, are significantly lower than in the general population, and these groups more often present with advanced cancer.2,3 For the homeless, limited access to health care, lack of follow-up, and an often transitory lifestyle limit the use of screening techniques requiring annual or biannual testing, such as fecal-occult blood testing, but a full colonoscopy every 10 years could provide effective screening in this population. We surveyed 164 adults aged O50 years at homeless shelters in New York City and found that a mere 27% of respondents had undergone screening colonoscopy within the last 10 years, whereas 69% reported never having a www.giejournal.org
Figure 1. Colonoscopy in New York City homeless. A, Percentage of respondents who report having had colonoscopies in the last 10 years (!10 years), more than 10 years ago (O10 years), or never. B, Whether respondents have a primary care physician and barriers to colonoscopy. PCP, primary care physician; MD, medical doctor.
colonoscopy (Fig. 1). The reasons for this low rate were mixed: 37% reported that they were concerned about pain and discomfort involved in the procedure, and 21% were concerned about colon preparation without access to private restrooms. Only 37% reported having ever discussed colonoscopy or colon-cancer screening with their physicians, compared with 75% of the general population.4 This suggests that one of the greatest barriers is the health care practitioners, who should be regularly addressing primary and secondary health care preventative practices, particularly with patients such as these, who often “fall through the cracks” of our health care system. Efforts should be made to better educate this population about colonoscopy, both on the specifics of the procedure (many of those interviewed confused a digital rectal examination with the term colonoscopy) and the use of analgesics to limit discomfort during the procedure. Given the significant challenges this population faces in accessing the health care system, primary care providers should not be a barrier to regular cancer screening. Thomas U. Marron, MD, PhD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital Amy Weiner, MPH State University of New York, Downstate School of Medicine Volume 80, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 745
Letters to the Editor
Mark Rabiner, MD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital New York, New York
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431-8. 3. Gawron AJ, Yadlapati R. Disparities in endoscopy use for colorectal cancer screening in the United States. Dig Dis Sci 2014;59:530-7. 4. Brawarsky P, Brooks DR, Mucci LA, et al. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect Prev 2004;28:260-8. http://dx.doi.org/10.1016/j.gie.2014.05.309
Colonoscopy in the tilt-down position To the Editor: Changing a patient’s body position during colonoscopy from left lateral to supine is often a helpful maneuver to advance the colonoscope.1 We previously reported our clinical experience with placement of the patient in the Trendelenburg position as a maneuver to help negotiate a tortuous sigmoid colon.2 A steep (60 ) Trendelenburg position during surgery has 2 reported risks: increased intraocular pressure and reduced arterial oxygen pressure.3,4 Regurgitation of gastric contents is an additional concern for the sedated colonoscopy patient, especially those with a history of acid reflux. To study this technique further, 3 studies were attempted to address the safety and efficacy of tilting a patient downward during colonoscopy. A pilot study of colonoscopy performed with patients in the 15 Trendelenburg position throughout cecal insertion for nonobese men and women showed that there was less oxygen desaturation in the Trendelenburg position compared with the level position.5 There was a 1-minute decrease in cecal insertion time in the 20 patients in the 15 Trendelenburg position compared with the 20 patients in the left lateral horizontal position. A second study randomized 173 female patients to the left lateral 15 tilt-down position versus the left lateral horizontal position. It allowed enrollment of obese patients (body mass index 30-34.9). All tilt-down position patients were kept in this position until the cecum was reached.6 A 10% reduction in cecal insertion time by using tiltdown positioning was found by 3 of 5 physicians ( 10%, 23% [P Z .04], 32%). When severe diverticulosis was present, a trend toward reducing cecal insertion time by 1.3 minutes less in the tilt-down position group
746 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
was seen. Furthermore, in the left lateral position group, 9% required a change to the tilt-down position to negotiate past a difficult sigmoid. Bradycardia occurred in none of the patients in the tilt-down position compared with 2 (2.3%) of the patients in the left lateral position. Transient oxygen desaturation occurred in 9 of 85 (10.6%) tilt-down position and 2 of 88 (2.3%) left lateral position patients (P Z .02), and this event was associated with obesity (P Z .02). No subject required mask-assisted ventilation or had clinical sequelae including aspiration. Finally, a third study included 92 nonobese women and men placed in the 15 tilt-down position during advancement through the sigmoid colon. After passing the sigmoid, the stretcher was leveled out. Application of abdominal pressure was prohibited while the subject was in this position. In these patients, there were no cardiopulmonary adverse events. A sex difference was noted for cecal insertion time: 3.3 1.4 minutes in men compared with 4.9 1.8 minutes in women (P ! .001).6 From these studies and additional clinical experience, the tilt-down position technique is a helpful method to assist colonoscope passage through a difficult sigmoid colon. Based on these published data, we recommend that the tilt-down position be used only during advancement through the sigmoid colon, be limited to nonobese patients, and be avoided in patients at risk of regurgitation, and abdominal pressure should not be applied with patients in this position. Leonard B. Weinstock, MD, FACG Specialists in Gastroenterology, LLC Washington University School of Medicine St. Louis, Missouri, USA Dayna S. Early, MD, FASGE Washington University School of Medicine St. Louis, Missouri, USA
REFERENCES 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. 2. Weinstock LB. Body positions for colonoscopy: value of Trendelenburg. Gastrointest Endosc 2009;69:1409-10. 3. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg 2004;99:1152-8. 4. Meinninger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006;30:520-6. 5. Saad AM, Winn J, Chennamaneni V, et al. The value of the Trendelenburg position during routine colonoscopy: a pilot study [Abstract]. Gastroenterology 2012;A142S1:S229. 6. Weinstock LB, Early DS, Saad AM. Tilt down method for colonoscopy: novel safe and effective scope insertion technique [Abstract]. Am J Gastroenterol 2013;A1693:108(Sl). http://dx.doi.org/10.1016/j.gie.2014.05.328
www.giejournal.org
endoscopic treatment of a persistent bile leak by ablating the mucosa at the cystic duct orifice using EHL by way of cholangioscopy. EHL generates electrical energy to the target tissue, and the closure of the cystic duct orifice can be attributed to mechanical trauma causing an inflammatory reaction, re-epithelialization, and stimulation of fibrosis. Haroon Shahid, MD Jason Korenblit, MD Thomas Kowalski, MD David E. Loren, MD Ali A. Siddiqui, MD Division of Gastroenterology and Hepatology Department of Internal Medicine Thomas Jefferson University Hospital Philadelphia, Pennsylvania, USA
REFERENCES 1. Khan MH, Howard TJ, Fogel EL, et al. Frequency of biliary complications after laparoscopic cholecystectomy detected by ERCP: experience at a large tertiary referral center. Gastrointest Endosc 2007;65:247-52. 2. Sandha GS, Bourke MJ, Haber GB, et al. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004;60:567-74. 3. Kaffes AJ, Hourigan L, De LN, et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005;61:269-75. 4. Fasoulas K, Zavos C, Chatzimavroudis G, et al. Eleven-year experience on the endoscopic treatment of post-cholecystectomy bile leaks. Ann Gastroenterol 2011;24:200-5. http://dx.doi.org/10.1016/j.gie.2014.04.047
Barriers to colonoscopy among New York City homeless To the Editor: Colorectal cancer is the second leading cause of cancerrelated death in the developed world,1 and although screening has become more commonplace among the population as a whole, rates of colorectal cancer screening in poor communities, particularly the homeless, are significantly lower than in the general population, and these groups more often present with advanced cancer.2,3 For the homeless, limited access to health care, lack of follow-up, and an often transitory lifestyle limit the use of screening techniques requiring annual or biannual testing, such as fecal-occult blood testing, but a full colonoscopy every 10 years could provide effective screening in this population. We surveyed 164 adults aged O50 years at homeless shelters in New York City and found that a mere 27% of respondents had undergone screening colonoscopy within the last 10 years, whereas 69% reported never having a www.giejournal.org
Figure 1. Colonoscopy in New York City homeless. A, Percentage of respondents who report having had colonoscopies in the last 10 years (!10 years), more than 10 years ago (O10 years), or never. B, Whether respondents have a primary care physician and barriers to colonoscopy. PCP, primary care physician; MD, medical doctor.
colonoscopy (Fig. 1). The reasons for this low rate were mixed: 37% reported that they were concerned about pain and discomfort involved in the procedure, and 21% were concerned about colon preparation without access to private restrooms. Only 37% reported having ever discussed colonoscopy or colon-cancer screening with their physicians, compared with 75% of the general population.4 This suggests that one of the greatest barriers is the health care practitioners, who should be regularly addressing primary and secondary health care preventative practices, particularly with patients such as these, who often “fall through the cracks” of our health care system. Efforts should be made to better educate this population about colonoscopy, both on the specifics of the procedure (many of those interviewed confused a digital rectal examination with the term colonoscopy) and the use of analgesics to limit discomfort during the procedure. Given the significant challenges this population faces in accessing the health care system, primary care providers should not be a barrier to regular cancer screening. Thomas U. Marron, MD, PhD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital Amy Weiner, MPH State University of New York, Downstate School of Medicine Volume 80, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 745
Letters to the Editor
Mark Rabiner, MD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital New York, New York
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431-8. 3. Gawron AJ, Yadlapati R. Disparities in endoscopy use for colorectal cancer screening in the United States. Dig Dis Sci 2014;59:530-7. 4. Brawarsky P, Brooks DR, Mucci LA, et al. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect Prev 2004;28:260-8. http://dx.doi.org/10.1016/j.gie.2014.05.309
Colonoscopy in the tilt-down position To the Editor: Changing a patient’s body position during colonoscopy from left lateral to supine is often a helpful maneuver to advance the colonoscope.1 We previously reported our clinical experience with placement of the patient in the Trendelenburg position as a maneuver to help negotiate a tortuous sigmoid colon.2 A steep (60 ) Trendelenburg position during surgery has 2 reported risks: increased intraocular pressure and reduced arterial oxygen pressure.3,4 Regurgitation of gastric contents is an additional concern for the sedated colonoscopy patient, especially those with a history of acid reflux. To study this technique further, 3 studies were attempted to address the safety and efficacy of tilting a patient downward during colonoscopy. A pilot study of colonoscopy performed with patients in the 15 Trendelenburg position throughout cecal insertion for nonobese men and women showed that there was less oxygen desaturation in the Trendelenburg position compared with the level position.5 There was a 1-minute decrease in cecal insertion time in the 20 patients in the 15 Trendelenburg position compared with the 20 patients in the left lateral horizontal position. A second study randomized 173 female patients to the left lateral 15 tilt-down position versus the left lateral horizontal position. It allowed enrollment of obese patients (body mass index 30-34.9). All tilt-down position patients were kept in this position until the cecum was reached.6 A 10% reduction in cecal insertion time by using tiltdown positioning was found by 3 of 5 physicians ( 10%, 23% [P Z .04], 32%). When severe diverticulosis was present, a trend toward reducing cecal insertion time by 1.3 minutes less in the tilt-down position group
746 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
was seen. Furthermore, in the left lateral position group, 9% required a change to the tilt-down position to negotiate past a difficult sigmoid. Bradycardia occurred in none of the patients in the tilt-down position compared with 2 (2.3%) of the patients in the left lateral position. Transient oxygen desaturation occurred in 9 of 85 (10.6%) tilt-down position and 2 of 88 (2.3%) left lateral position patients (P Z .02), and this event was associated with obesity (P Z .02). No subject required mask-assisted ventilation or had clinical sequelae including aspiration. Finally, a third study included 92 nonobese women and men placed in the 15 tilt-down position during advancement through the sigmoid colon. After passing the sigmoid, the stretcher was leveled out. Application of abdominal pressure was prohibited while the subject was in this position. In these patients, there were no cardiopulmonary adverse events. A sex difference was noted for cecal insertion time: 3.3 1.4 minutes in men compared with 4.9 1.8 minutes in women (P ! .001).6 From these studies and additional clinical experience, the tilt-down position technique is a helpful method to assist colonoscope passage through a difficult sigmoid colon. Based on these published data, we recommend that the tilt-down position be used only during advancement through the sigmoid colon, be limited to nonobese patients, and be avoided in patients at risk of regurgitation, and abdominal pressure should not be applied with patients in this position. Leonard B. Weinstock, MD, FACG Specialists in Gastroenterology, LLC Washington University School of Medicine St. Louis, Missouri, USA Dayna S. Early, MD, FASGE Washington University School of Medicine St. Louis, Missouri, USA
REFERENCES 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. 2. Weinstock LB. Body positions for colonoscopy: value of Trendelenburg. Gastrointest Endosc 2009;69:1409-10. 3. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg 2004;99:1152-8. 4. Meinninger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006;30:520-6. 5. Saad AM, Winn J, Chennamaneni V, et al. The value of the Trendelenburg position during routine colonoscopy: a pilot study [Abstract]. Gastroenterology 2012;A142S1:S229. 6. Weinstock LB, Early DS, Saad AM. Tilt down method for colonoscopy: novel safe and effective scope insertion technique [Abstract]. Am J Gastroenterol 2013;A1693:108(Sl). http://dx.doi.org/10.1016/j.gie.2014.05.328
www.giejournal.org
