6th Annual SIES Course Syllabus

Page 1

www.sies.org.au

CONFERENCE PROGRAM AND SYLLABUS

6th

SYDNEY INTERNATIONAL ENDOSCOPY SYMPOSIUM

2013

Thursday 7th & Friday 8th March 2013 Hilton Sydney, Australia Ballroom Level 3 Incorporating the Westmead Endoscopy Symposium Nurses’ Workshop – Wednesday 6th March, 2013 INTERNATIONAL FACULTY John Anderson – Gloucestershire

SPECIAL GUEST Peter Cotton - Charleston

Paul Kortan – Toronto James Lau – Hong Kong

AUSTRALIAN FACULTY

Horst Neuhaus – Du ¨sseldorf

Luke Hourigan

Pinghong Zhou – Shanghai

Raj Singh

TOPICS INCLUDE • Colonoscopy

- Optimising insertion

- Best practice withdrawal and adenoma detection

- Enhanced imaging modalities/Optical diagnosis

- New techniques and technology

• Barrett’s Oesophagus

- Detection of inconspicuous neoplasia and dysplasia

- Approach to endoscopic therapy

• Endoscopic stenting for benign and malignant disease • Endoscopic treatment of perforations and fistulas • Endoscopic ultrasound • ERCP: complex and basic therapeutics • Direct cholangioscopy • Balloon and capsule enteroscopy • Novel endoscopic haemostatic therapies

Health Western Sydney Local Health District

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This course is endorsed by the American Society for Gastrointestinal Endoscopy


ADVANCING THE ART OF ENDOSCOPY Come and visit the Olympus booth!

OLYMPUS AUSTRALIA PTY LTD 31 Gilby Road, Mt Waverley, Victoria 3149

Customer Service : 1300 132 992 www.olympusaustralia.com.au


Welcome! Dear Colleagues and friends It is my great pleasure to welcome you to the Sydney International Endoscopy Symposium, our 6th Annual Westmead Endoscopy meeting. I would also like to welcome those who are joining us online from Europe, North America and Asia. Once again we have set ourselves the goal of a comprehensive demonstration of diagnostic and therapeutic endoscopy. I believe that this year will be our most successful event yet. We are delighted to welcome six truly outstanding clinicians from abroad; John Anderson, Peter Cotton, Paul Kortan, James Lau, Horst Neuhaus and Pinghong Zhou, as our expert faculty. All of them are leaders on the international stage having made numerous outstanding contributions to the practice of Endoscopy over the last ten to twenty years. Their insights are eagerly awaited. This year we will especially focus on the fundamentals of core technique. The Symposium’s content has been carefully designed to facilitate discussion. Please relay your questions through the chairs to our proceduralists. A strong emphasis on the cognitive processes behind the delivery of high quality endoscopy will feature. Several novel technologies will also be demonstrated. On behalf of our Department, Nurses and Doctors alike, I thank you for your support and for interrupting your busy schedules to join us here for these two special days. I believe the international guests, in combination with our Australian faculty and the team from Westmead, will provide an enlightening and informative educational experience for you, and hopefully a very enjoyable one. Yours sincerely Michael Bourke Chairman Sydney International Endoscopy Symposium 2013 Director of Gastrointestinal Endoscopy, Westmead Hospital, Sydney

Nurses’ Workshop 2013 I would like to personally welcome each of you to the 6th Sydney International Endoscopy Symposium Nurses’ Workshop. It is an exciting time for the Westmead Hospital Endoscopy Unit staff to be able to offer another stimulating and educational meeting at the Hilton Sydney in our vibrant city of Sydney. Building on the success of previous meetings, the Symposium will feature a variety of fantastic presentations and demonstrations related to important aspects in Endoscopy nursing that will excite and increase your understanding in this specialty! There is always something for everyone to take home after attending our workshop! The Symposium will also provide the ideal forum to stimulate ideas, establish collaborations, allow Nurses to interact and network as well as offering new updates and learn fresh tricks of the trade to promote gastrointestinal / endoscopy nursing. Nurses are also welcome and encouraged to attend the two full days live high quality transmission from the Westmead Endoscopy Suite, which promises to be a fabulous experience showcasing the skills and wisdom of the internationally renowned guest faculty. RCNA points will be available for nurses attending the Symposium. Yours sincerely Mary Bong Nurse Unit Manager Endoscopy Unit, Westmead Hospital Organising Committee Westmead Endoscopy Symposium 2013

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International Faculty DR JOHN ANDERSON

Dr John Anderson graduated from Liverpool University in 1989 and was based in Ninewells Hospital, Dundee, Scotland for the majority of his gastroenterology training. He is a consultant gastroenterologist at Gloucestershire Hospitals NHS Trust, working predominantly as a specialist therapeutic endoscopist. Appointed National Endoscopy Training Lead 2007-2011, he was part of the National Endoscopy Team, formed to enhance UK endoscopy service provision and the develop of training and educational programmes for nurses, doctors and trainees. His main interest is in applied adult education theory in skills acquisition. He is currently the Director of the Gloucestershire Endoscopy Training Centre and has been actively involved in the working groups of the Joint Advisory Groups for Gastrointestinal Endoscopy (JAG) and the BSG Endoscopy committee. As joint clinical lead for NHS e-Endoscopy a project, he was involved in the development of a web based learning tool to provided knowledge and applied knowledge underpinning all forms of endoscopic practice.

A/PROF PAUL KORTAN

Dr Paul Kortan graduated from McMaster Medical School in Hamilton and completed his GI training at the University of Toronto. He completed his post-graduate training at the University of Leuven, Belgium and at University of Hamburg, Germany. He joined the Division of Gastroenterology at The Wellesley Hospital, University of Toronto in 1982. Together with his colleagues they established a successful training programme in therapeutic endoscopy which has moved to St Michael’s Hospital in 2000. He is also on staff at The Hospital for Sick Children where he performs interventional paediatric procedures. Dr Kortan’s expertise is in endoscopic management of pancreaticobiliary diseases. Dr Kortan is a Fellow of the American Association of Gastrointestinal Endoscopy (FASGE) and American Gastroenterologic Association Fellow (AGAF). Dr Kortan is the Director of the GI Fellowship Programme at U of T. He was the recipient of Dr Lou Cole Award for educational excellence for 2010. Dr Kortan is the first holder of the Slaight Family Term Chair in Advanced Therapeutic Endoscopy awarded in 2010.

DR JAMES LAU

Dr James Lau graduated with honors from the Medical School of University of New South Wales in 1987. He joined the Department of Surgery at the Prince of Wales Hospital, Chinese University of Hong Kong in 1993 as a resident. He was trained there in upper gastrointestinal surgery as well as therapeutic endoscopy. Dr Lau was appointed as a Consultant in Surgery in 1999. He became Director to the Endoscopy Center at the same hospital in 2003 and Professor of Surgery in 2007.

Dr Lau is widely known as a surgical endoscopist with research interests in the clinical management of peptic ulcer bleeding. He wrote his MD thesis on the same topic. He has published more than 10 book chapters and 150 peer reviewed clinical papers. Many of his papers appear in the New England Journal of Medicine, Annals of Internal Medicine and Gastroenterology. His current research projects include the supplementary role of angiographic embolization to endoscopic therapy in management of severely bleeding peptic ulcers and others. His part time hobbies include endovascular surgery and en-bloc resection of tumors with major vessels.

PROF HORST NEUHAUS

Professor Horst Neuhaus is the Chief of the Department of Internal Medicine of the Evangelisches Krankenhaus Düsseldorf, teaching hospital of the University of Düsseldorf. Horst Neuhaus graduated from the University of Bonn, Germany, in 1979. In the same year he received his medical degree. After his training in gastroenterology, he became faculty member of the Medical Department II, Klinikum rechts der Isar of the Technical University Munich under the leadership of Professor Meinhard Classen. In 1987, he became head of the endoscopy unit. In 1992, Horst Neuhaus obtained his “Habilitation“ at the Medical Faculty of the Technical University Munich. The thesis was on “In vitro and in vivo studies on electromagnetic shock-wave lithotripsy of gallbladder stones“. In 1995, Professor Neuhaus was appointed as the Chief of the Department of Internal Medicine of the Evangelisches Krankenhaus Düsseldorf, teaching hospital of the University of Düsseldorf. In 2003, he has been President of the German Society of Endoscopy and Imaging Procedures (DGEBV). He has been founder and director on the annual Düsseldorf International Endoscopy Symposium since 1999.

PROF PINGHONG ZHOU

Dr Pinghong Zhou is currently a specialist in therapeutic endoscopy, as well as a general surgeon of Zhongshan Hospital, Fudan University, Shanghai, China. Dr Zhou graduated from Shanghai Medical University in 1992, and obtained his doctorate degree from Fudan University in 2003. Having completed his basic surgical training in the department of general surgery of Zhongshan Hospital from 1992 to 1998, he started his training in digestive endoscopy as a senior resident in 1999. He also received the most comprehensive training in various areas of advanced endoscopy, such as EUS under the mentorship of Kenjiro Yasuda in Kyoto Second Red Cross Hospital of Japan in 2000, ESD under Hiroyuki Ono in Shizuoka Cancer Center of Japan in 2006, ERCP under Peter B Cotton in the Medical University of South Carolina, USA in 2008. His main research focuses on endoscopic diagnosis and treatment of gastrointestinal tumor. He is one of ESD pioneers in China and has gained much experience in EMR, EPMR and ESD. Recently he is very interested in endoscopic resection of submucosal tumor (SMT) and tunnel endoscopic surgery, such as peroral endoscopic myotomy (POEM) of esophageal achalasia.

The attendance of the international faculty has been graciously supported by our Platinum Sponsors

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Advancing science for life

TM


Peter Cotton’s Memoirs

Signed and personalized copies at www.peterbcotton.com Forward by Dr Ian Taylor 1. Introduction 2. Life before endoscopy 3. Gastroscopy in the 1960s 4. Around the world in 1971; my first ERCP 5. British endoscopy in the 1970s 6. My first sphincterotomy 7. International travels in the 1970s 8. London endoscopy phase two (1980-86) 9. Cricket was confusing (especially to Americans) 10. The importance of golf 11. VIPs (Very Important Patients) 12. The travails of travel 13. Digestive adventures 14. Perils of the podium 15. To USA and Duke University 16. On to Charleston and MUSC 17. A seriously royal stone 18. Four days in September (9/11) 19. Partnership with industry 20. A tribute to surgeons, and a plea for restructuring 21. Endoscopy societies 22. British endoscopy revisited 23. Recent meanderings 24. Acknowledgements, afterthoughts and apologies 25. British or American?

26. Concluding

Professor Meinhard Classen, father of European endoscopy and inventor of sphincterotomy, wrote: “This book is just wonderful, historical and entertaining. Endoscopists all over the world should read it” Dr Jerry Waye, President of the World Organization of Endoscopy (and Colonoscopy magician) wrote: “A completely enjoyable chronicle of one famous gastroenterologist’s life journey with interesting and entertaining travels along the way. A tale that every endoscopist must read. From chapter 6. I presented endoscopic removal of stones at the Royal College of Surgeons in London in 1976. The President, a wine connoisseur, stated that they should perhaps license a few medical gastroenterologists to perform the technique, but should charge “corkage” for each stone. From chapter 17. The king arrived eventually at 10pm with a retinue of princes. He cut short my usual discussion of informed consent with a gesture of trust that I found rather menacing, backed up as it was by a rippling of Korans around the procedure room..... From chapter 18. On September 11, we were dozing at 30,000 feet over the Atlantic…… All proceeds from sale of the book go to the “Peter Cotton Endoscopy Training Fund” (in the MUSC Foundation) to support postgraduates seeking advanced endoscopic training.

All funds raised by the Symposium are returned to the Westmead Medical Research Foundation ABN 89 050 329 925 CFN 16180

The world class health care and research at Westmead reaches out locally, regionally and globally. This Hospital provides specialist care to people from Parramatta to Penrith, Castle Hill to Croydon, Rooty Hill to Ryde, Baulkham Hills to Broken Hill. Meanwhile, research undertaken here touches the lives of people all over the world. My Westmead is proud to support the Westmead Endoscopy research program and its innovative approach to education, research and the care of patients. EQUIPMENT • RESEARCH • CARE Donate today www.wmrf.org.au or call 1800 639 037 A fundraising initiative of

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© COOK 2013

ESC-WAPACADV-50404-EN-201302


Sydney International Endoscopy Symposium 2013 Nurses’ Workshop

Nurses’ Workshop Program Nurses’ Workshop - Wednesday 6th March 2013 0730

Registration opens

0830 - 0835

Welcome Note – Mary Bong SECTION 1

This workshop is endorsed by APEC number 014011002 as authorised by Royal College of Nursing, Australia (RCNA) according to approved criteria. Attendance attracts 6 RCNA CNE points as part of RCNA’s Life Long Learning Program (3LP). “Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favouring by RCNA”

0835 - 0905

Advanced resection and innovation in the endoscopy unit: ‘A team sport’ – Prof Michael Bourke

0905 - 0935

Anticoagulants, antiplatelet agents and iatrogenic bleeding in Endoscopy – Dr Nick Burgess

0935 - 1005

Carbon dioxide in Endoscopy – advantages and anaesthetic considerations – Susan Lane, Endoscopy Anaesthetic Nurse

1005 - 1035

Current quality initiatives in Endoscopy in the UK – Vicki Hedley, Lead Nurse for Endoscopy Services, St Georges Hospital, United Kingdom

1035 - 1105

Morning Tea and Trade Displays

The attendance of Vicki Hedley has been graciously supported by

SECTION 2 – Workshop Presentations 1105 - 1120

Unravelling guidelines standards and quality improvements – Di Jones, President SIGNEA

1120 - 1135

Electrosurgery in Endoscopy – Dr Vu Kwan

1135 - 1155

The ABC of GI Research – Dr Nick Burgess

1155 - 1210

Patient’s journey to PEG and beyond – Cathy Zaccaria, CNC Nutritional Support Service SECTION 3 – Workshop demonstrations - Co-ordinators : Judy Tighe-Foster / Jenevieh Junio / Nicky Stojanovic / Kerry Flew 3 Demonstration stations

1215 - 1330 20 minute Workshops

1330 - 1430

Station 1 Di Jones / Helena Lindhout / Robyn Brown Table 1 • Standards and Guidelines Table 2 • Quality improvements initiatives

Station 2 Vu Kwan / Betty Lo / Adenike Adeyemi / Nick Burgess / Rebecca Sonson / Mary Bong Table 1 • ERBE and APC probe Table 2 • Endoclot Table 3 • Thermal probes

Station 3 Cathy Zaccaria / Sally Piggot Table 1 • PEG policies and guidelines Table 2 • Trouble shooting PEGs Table 3 • Dummy demonstration

Lunch and Trade Displays SECTION 4

1430 - 1445

Quiz - Zion Siu

1445 - 1515

Detection and management of small polyps – Vicki Hedley, Lead Nurse for Endoscopy Services, St Georges Hospital, United Kingdom

1515 - 1545

Unlocking the liver – everything you wanted to know but were afraid to ask – Dr Vu Kwan

1545 - 1615

Quiz prizes presentation

1615 - 1620

Closing remarks and thank you

1630

Afternoon Tea and Trade Displays

Each delegate will receive a stylish satchel bag, courtesy of Cook Medical – available for collection when registering.

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Symposium Program Day One – Thursday 7th March 2013 0730

Registration opens

0830 - 0833

Welcome – Michael Bourke

0833 - 0835

Official Conference Open - Danny O’Connor, Chief Executive, Western Sydney Local Health District

0835 - 0900

GI bleeding 2013: Current status and new therapeutic approaches – James Lau

0900 - 0910

Discussion

0915 - 1030

Live Endoscopy Session 1 - Chairs: Vu Kwan, Michael Swan, Paul Edwards

1030 - 1100

Morning Tea

1100 - 1120

New innovations in endoscopic treatments of tumours: Tunnelling and full thickness resection – Pinghong Zhou

1120 - 1300

Live Endoscopy Session 2 - Chairs: Dev Samarasinghe, Mark Appleyard, Pinghong Zhou

1300 - 1400

Lunch

1305 - 1325

Endoscopic Ultrasound Special Interest Session – : The technique and indications for EUS-guided drainage of pancreatic cysts Yury Starkov, Professor of Surgery, Chief, Division of Endoscopic Surgery, A.V. Vishnevsky Institute of Surgery, Moscow, Russia

1325 - 1330

Discussion

1400 - 1530

Live Endoscopy Session 3 - Chairs: Nghi Phung, Philip Craig, Rick Hope

1530 - 1600

Afternoon Tea

1600 - 1625

Teaching and learning colonoscopy: “the do’s and don’ts” – John Anderson

1625 - 1635

Discussion

1635 - 1700

General Endoscopy Quiz – Bronte Holt

1700

Close

1700 - 1800

Experts on the spot – Mini-Symposium: Humility and the humble polyp Chaired by Luke Hourigan, John Anderson, Horst Neuhaus and Michael Bourke

1830

Coaches depart promptly for Symposium Reception Coaches depart from the Pitt Street entrance of the Hilton Sydney Hotel

1845 - 2045

Official Symposium Reception – Sydney Opera House ‘Opera Point Marquee’; Delegates to make their own return travel arrangements

*Coaches will depart the Hilton Sydney Hotel from 6.30pm sharp (one-way transfer), alternatively, you can make your own way to the venue, allow approximately 20 minutes from the Hilton Sydney Hotel.

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Tickets still available – see registration desk

SYMPOSIUM RECEPTION at Sydney Opera House ‘Opera Point Marquee’

Enjoy drinks and canapés on the picturesque Sydney Harbour foreshore! The Opera Point Marquee offers a magnificent vantage point to enjoy one of the world’s most famous views. The venue makes the most of this setting with a private outdoor reception area and clear walls which will ensure you enjoy the vista from every angle. Thursday 7th March 6.45pm – 8.45pm


Symposium Program Day Two – Friday 8th March 2013 0730

Registration opens

0830 - 0900

Endoscopic complications: Mea culpa – Paul Kortan and Peter Cotton

0900 - 1030

Live Endoscopy Session 4 - Chairs: Stephen Williams, Rita Lin, Peter Cotton

1030 - 1100

Morning Tea

1100 - 1230

Live Endoscopy Session 5 - Chairs: David van der Poorten, Mark Appleyard, David Ruppin

1235 - 1300

Biliary pancreatitis: How to recognise and how to treat – James Lau

1300 - 1400

Lunch

1400 - 1530

Live Endoscopy Session 6 - Chairs: Eric Lee, Alan Moss, Thao Lam

1530 - 1600

Afternoon Tea

1600 - 1630

The Peter Gillespie Lecture New Endoscopic Therapies. Where are we and where to? – Horst Neuhaus

1630 - 1645

Awards for the Quiz Winners – Bronte Holt

1645 - 1700

Closing Remarks

Mark your diary NOW, next year’s Symposium dates!

Wednesday 5th - Friday 7th March, 2014

March 2014 S 23 2 9 16 23 30

M 24 3 10 17 24

T 25 4 11 17 25

W 26 5 12 19 26

T 27 6 13 20 27

F 28 7 14 21 28

S 1 8 15 22 29

Each delegate will receive a stylish satchel bag, courtesy of Cook Medical – available for collection when registering.

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3 Feb 2013


Abstracts

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Abstracts

GI bleeding 2013: current status and new therapeutic approaches James Lau The two treatment modalities that have been shown to reduce mortality in patients who present with acute non-variceal upper gastrointestinal bleeding are endoscopic therapy and the use of proton pump inhibitors (PPI). Endoscopic therapy should consist of either hemo-clipping or thermo-coagulation with or without pre-injection with adrenaline. PPI therapy before endoscopy downstages stigmata of bleeding in peptic ulcers, reduces need for therapy but without impact on clinical outcomes. PPI therapy after endoscopic hemostasis to high risk ulcers (actively bleeding and with vessels) significantly improves patients’ outcomes. Newer endoscopic hemostatic methods include a hemostatic powder, clips that are more secure and capture more tissue such as the Instinct ® and OVESCO® clips and Over-stitch®. Future clinical research should direct at a subgroup of patients predicted to fail endo-therapy – these are often elderly patients with major bleeding from larger ulcers (> 2cm) located at posterior duodenal bulb and lesser curve of stomach manifested in shock. Angiographic embolization to the bleeding artery is being evaluated as an alternative surgery in patients with massive bleeding failing endoscopic control. In addition, an ongoing trial evaluates the role of pre-emptive angiographic embolization to high risk ulcers after initial endoscopic hemostasis.

New innovations in endoscopic treatments of tumours: Tunnelling and full thickness resection Pinghong Zhou Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University The attempt to resect gastrointestinal (GI) submucosal tumors originating from muscularis propria by endoscopy was not recommended due to the risk of incomplete resection or high risk of perforation during procedure. New innovations such as tunnelling and full thickness resection are now available at our center for those patients. Tunnelling technique is a novel approach which was initially developed for the purpose of establishing an access for natural orifice transluminal endoscopic surgery (NOTES). Meanwhile, it brought a great idea for endoscopic procedures by using the submucosal tunnel as an operating space. Full thickness resection is a thorough resection of the submucosal tumor, creating a GI wall defect which needs the high expertise of closure. The current status of these two procedures and also the closure technique by metallic clips will be discussed.

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Teaching and learning colonoscopy: “the do’s and don’ts” John Anderson Colonoscopy is a complex psychomotor skill posing significant challenges for both trainers and trainees. Training effectively requires active input from the trainer as against a ‘supervising’ role. Uniform language and technique ensure a consistent and reproducible approach to training, which needs to develop and progress with trainee experience. The main concepts and themes behind effective training will be covered, in addition to some misconceptions and poor training practice which can perpetuate poor technique and ultimately sub-optimal performance of individuals. For the trainee, it is important to recognize what represents a good training environment and experience. The need to develop both technical and non-technical skills will be covered.

Biliary pancreatitis: how to recognize and how to treat James Lau Passage of small gallstones or sludges through the ampulla of Vater causes biliopancreatic reflux and acute pancreatitis. It is important to establish a biliary etiology in patients presenting with acute pancreatitis as this has therapeutic implications. An increased serum level of alanine aminotransferase is associated with a high probably of gallstone pancreatitis (positive predictive value = 80-90%). Choledocholithiasis can be accurately confirmed using endoscopic ultrasonography (EUS), magnetic resonance cholangio-pancreatography or ERCP. EUS in addition can readily diagnose the presence of biliary sludge in the gallbladder. Early endoscopic sphincterotomy reduces rate of local pancreatic complications and mortality in the subgroup of patients with persistent biliary obstructions and cholangitis. In the treatment of local complications of pseudocyst and walled off pancreatic necrosis (WOPN), endoscopy is now preferred over surgery. Drainage of pseudocyst should be guided by endosonography. Compared to a ‘blind’ endoscopic puncture, EUS guided puncture is more likely to be successful and can avoid interposed vessels and bleeding. The reported technical success rate of EUS guided pseudocyst drainage is between 82-94% of cases. When compared to surgical necrosectomy, endoscopic debridement of pancreatic necrosis is associated with reduced incidence of pancreatic exocrine and endocrine insufficiencies, pancreatic fistulas and organ failures.


RISK REDUCTION IN ENDOSCOPY RISK REDUCTION IN ENDOSCOPY

PRIMUM NON NOCERE PRIMUM NON NOCERE

ENDOSCOPIC COMPLICATIONS: ENDOSCOPIC COMPLICATIONS: Mea Culpa Mea Culpa

GALEN

GALEN

HIPPOCRATES HIPPOCRATES

ENDOSCOPIC COMPLICATIONS:

131‐201 AD

Abstracts

131‐201 AD

460 ‐370 BC

Mea Culpa

PAUL KORTAN PAUL KORTAN UNIVERSITY OF TORONTO UNIVERSITY OF TORONTO ST. MICHAEL’S HOSPITAL ST. MICHAEL’S HOSPITAL

460 ‐370 BC

“AN OUNCE OF “AN OUNCE OF PREVENTION IS WORTH A PREVENTION IS WORTH A OF CURE” POUNDPOUND OF CURE” PAUL KORTAN UNIVERSITY OF TORONTO ST. MICHAEL’S HOSPITAL BENJAMIN FRANKLIN BENJAMIN FRANKLIN

Endoscopic complications: Mea culpa RISK REDUCTION IN ENDOSCOPY

SETTING THE STAGE SETTING THE STAGE

Paul Kortan

460 ‐370 BC

Mea Culpa Mea Culpa

“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE” PAUL KORTAN PAUL KORTAN UNIVERSITY OF TORONTO UNIVERSITY OF TORONTO ST. MICHAEL’S HOSPITAL ST. MICHAEL’S HOSPITAL

Is the endoscopist trained to perform the required Is the endoscopist trained to perform the required procedure?

NON NOCERE PRIMUMPRIMUM NON NOCERE

HIPPOCRATES

131‐201 AD

procedure? 1.Before the procedure

2.During the procedure 2.During the procedure GALEN

GALEN

131‐201 AD

131‐201 AD

HIPPOCRATES HIPPOCRATES

3.After the procedure 3.After the procedure

BENJAMIN FRANKLIN

460 ‐370 BC

460 ‐370 BC

“AN OUNCE OF “AN OUNCE OF PREVENTION IS WORTH A PREVENTION IS WORTH A POUND POUND OF CURE” OF CURE” ASA/ANTI‐PLATELET AGENTS/ ASA/ANTI‐PLATELET AGENTS/ ANTI‐COAGULANTS for high risk procedures ANTI‐COAGULANTS for high risk procedures

Is the procedure really indicated? SETTING THE STAGE

SETTING THE STAGE

9 Although the procedure suggested by various MDs, the final responsibility lies with the endoscopist

ASA

ANTI‐PLATELET AGENTS (CLOPIDOGREL, TICLOPIDINE)

ANTI‐PLATELET AGENTS (CLOPIDOGREL, TICLOPIDINE) ESSENTIAL ELEMENTS FOR INFORMED CONSENT (patient 9 Discontinue 7 – 10 d before procedure ESSENTIAL ELEMENTS FOR INFORMED CONSENT (patient 9 Discontinue 7 – 10 d before procedure

and family member) and family member) WARFARIN WARFARIN

1

9 Discontinue 5 d before procedure 9 Discontinue 5 d before procedure The patient’s pertinent medical diagnosis and test results 1 The patient’s pertinent medical diagnosis and test results

2

The nature of the proposed procedure 9 Discontinue 2 d before procedure 2 The nature of the proposed procedure 9 Discontinue 2 d before procedure

BEFORE THE PROCEDURE BEFORE THE PROCEDURE

DABIGATRAN DABIGATRAN

Is the procedure really indicated? HEPARIN Is the procedure really indicated? HEPARIN The reason the procedure is being suggested 3 The reason the procedure is being suggested 9 9 LMWH‐Discontinue at least 12‐24 hrs before procedure 9 LMWH‐Discontinue at least 12‐24 hrs before procedure Although the procedure suggested by various MDs, the final 9 Although the procedure suggested by various MDs, the final 9 Unfractionated heparin 4‐6 hrs responsibility lies with the endoscopist 9 Unfractionated heparin 4‐6 hrs responsibility lies with the endoscopist

3 Is the endoscopist trained to perform the required procedure? 4

1.Before the procedure 1.Before the procedure

Are the patients and family members fully prepared?

3.After the procedure 3.After the procedure

The benefits of the procedure 4 The benefits of the procedure

6

Reasonable alternatives to the proposed procedure 6 Reasonable alternatives to the proposed procedure

7

The patient’s prognosis if the treatment or test is declined 7 The patient’s prognosis if the treatment or test is declined

Are the patients and family members fully Are the patients and family members fully prepared? prepared? Informed consent is a process, not a paper Informed consent is a process, not a paper

INTRAPROCEDURE

“TIME OUT IN SURGERY” “TIME OUT IN SURGERY”

ASA/ANTI‐PLATELET AGENTS/ Time out ? ASA/ANTI‐PLATELET AGENTS/

INTRAPROCEDURE INTRAPROCEDURE

ANTI‐COAGULANTS for high risk procedures ANTI‐COAGULANTS for high risk procedures

Monitoring

ON THE DAY OF THE PROCEDURE

Time out ? Time out ?

9 Need not be discontinued 9 Need not be discontinued 9 We still D/C for large polyps 9 We still D/C for large polyps Administration of sedation

Monitoring Monitoring ANTI‐PLATELET AGENTS (CLOPIDOGREL, TICLOPIDINE) ANTI‐PLATELET AGENTS (CLOPIDOGREL, TICLOPIDINE) ESSENTIAL ELEMENTS FOR INFORMED CONSENT (patient (patient 9 Discontinue 7 – 10 d before procedure ESSENTIAL ELEMENTS FOR INFORMED CONSENT 9 Discontinue 7 – 10 d before procedure ON THE DAY OF THE PROCEDURE ON THE DAY OF THE PROCEDURE Directed history Insertion of endoscope, performance of Death rate at baseline ‐ 1.5% 0.8% p= 0.003 and family member) Administration of sedation Death rate at baseline ‐ 1.5% 0.8% p= 0.003 and family member) WARFARIN Administration of sedation WARFARIN diagnostic and therapeutic elements until 9 Discontinue 5 d before procedure 9 Discontinue 5 d before procedure Inpatient complications ‐ 11% 7.0% p < 0.001 Inpatient complications ‐ 11% 7.0% p < 0.001 The patient’s pertinent medical diagnosis and test results 1 The patient’s pertinent medical diagnosis and test results 1 complete removal DABIGATRAN Mini physical DABIGATRAN Insertion of endoscope, performance of Directed history Directed history Insertion of endoscope, performance of 2 9 Discontinue 2 d before procedure 9 Discontinue 2 d before procedure The nature of the proposed procedure 2The nature of the proposed procedure diagnostic and therapeutic elements until diagnostic and therapeutic elements until HEPARIN HEPARIN complete removal The reason the procedure is being suggested 3 complete removal The reason the procedure is being suggested 3 Medications 9 LMWH‐Discontinue at least 12‐24 hrs before procedure Mini physical 9 LMWH‐Discontinue at least 12‐24 hrs before procedure 4

Informed consent is a process, not a paper Informed consent is a process, not a paper

3.After the procedure

INTRAPROCEDURE INTRAPROCEDURE ANTI‐COAGULANTS for high risk procedures

Monitoring Monitoring

ASA

ON THE DAY OF THE PROCEDURE ON THE DAY OF THE PROCEDURE

9 Need not be discontinued

9 We still D/C for large polyps Administration of sedation Administration of sedation

ANTI‐PLATELET AGENTS (CLOPIDOGREL, TICLOPIDINE)

ESSENTIAL ELEMENTS FOR INFORMED CONSENT (patient 9 Discontinue 7 – 10 d before procedure Directed history Insertion of endoscope, performance of Directed history Insertion of endoscope, performance of and family member) WARFARIN diagnostic and therapeutic elements until diagnostic and therapeutic elements until 9 Discontinue 5 d before procedure The patient’s pertinent medical diagnosis and test results 1 complete removal complete removal

Mini physical DABIGATRAN Mini physical 2

9 Discontinue 2 d before procedure The nature of the proposed procedure

HEPARIN The reason the procedure is being suggested

Medications Medications 9 LMWH‐Discontinue at least 12‐24 hrs before procedure Is the endoscopist trained to perform the required Is the endoscopist trained to perform the required incidence and severity, that is important to the patient’s decision‐ 9 Unfractionated heparin 4‐6 hrs incidence and severity, that is important to the patient’s decision‐ procedure? procedure? making process The benefits of the procedure 4 making process

5

The risks and complications of the procedure including the relative ASGE GuidelinesASGE Guidelines 5 The risks and complications of the procedure including the relative

2.During the procedure 2.During the procedure

Informed consent is a process, not a paper

2.During the procedure

ASA/ANTI‐PLATELET AGENTS/ Time out ? Time out ?

9 Need not be discontinued 9 Need not be discontinued 9 We still D/C for large polyps 9 We still D/C for large polyps

BEFORE THE PROCEDURE

Are the patients and family members fully Are the patients and family members fully prepared? prepared?

BENJAMIN FRANKLINBENJAMIN FRANKLIN

ASA

ASA

9 Although the procedure suggested by various MDs, the final 9 Although the procedure suggested by various MDs, the final responsibility lies with the endoscopist responsibility lies with the endoscopist

1.Before the procedure 1.Before the procedure

ENDOSCOPIC COMPLICATIONS: ENDOSCOPIC COMPLICATIONS:

ASA

Is the procedure really indicated? Is the procedure really indicated? SETTING THE STAGE

RISK REDUCTION IN ENDOSCOPY RISK REDUCTION IN ENDOSCOPY

PRIMUM NON NOCERE GALEN

BEFORE THE PROCEDURE BEFORE THE PROCEDURE

3

Allergies Allergies The risks and complications of the procedure including the relative 5

ASGE Guidelines

incidence and severity, that is important to the patient’s decision‐ making process

6 7

Reasonable alternatives to the proposed procedure

“TIME OUT IN ENDOSCOPY ?” “TIME OUT IN ENDOSCOPY ?” The patient’s prognosis if the treatment or test is declined

To minimize To minimize 9 Wrong person 9 Wrong person 9 Wrong procedure 9 Wrong procedure 9 Wrong site 9 Wrong site

“TIME OUT IN SURGERY”

To have all necessary To have all necessary accessories accessories

Death rate at baseline ‐ 1.5% 0.8% p= 0.003 Inpatient complications ‐ 11% 7.0% p < 0.001

Mini physical

9 Unfractionated heparin 4‐6 hrs 9 Unfractionated heparin 4‐6 hrs The benefits of the procedure 4The benefits of the procedure

5

Allergies The risks and complications of the procedure including the relative 5The risks and complications of the procedure including the relative

6

Reasonable alternatives to the proposed procedure 6Reasonable alternatives to the proposed procedure

7

The patient’s prognosis if the treatment or test is declined 7The patient’s prognosis if the treatment or test is declined

ASGE Guidelines ASGE Guidelines

incidence and severity, that is important to the patient’s decision‐ incidence and severity, that is important to the patient’s decision‐ making process making process

“TIME OUT IN ENDOSCOPY ?”

To minimize 9 Wrong person 9 Wrong procedure 9 Wrong site

“TIME OUT IN SURGERY” “TIME OUT IN SURGERY”

To have all necessary accessories

Medications Medications Allergies Allergies

MONITORING MONITORING Pulse oximetry and Pulse oximetry and supplemental O supplemental O 2 2

“TIME OUT IN ENDOSCOPY ?” “TIME OUT IN ENDOSCOPY ?”

Hemodynamics Hemodynamics

To minimize To minimize 9 Wrong person 9 Wrong person Capnography Capnography 9 Wrong procedure 9 Wrong procedure 9 Wrong site Bispectral (bis) Bispectral (bis) 9 Wrong site

COMPLICATIONS OF SEDATION COMPLICATIONS OF SEDATION Hypoventilation Hypoventilation

MONITORING

Respiratory arrest Respiratory arrest Pulse oximetry and supplemental O2 Bradycardia Bradycardia Hemodynamics Cardiac events – ischemia, MI Cardiac events – ischemia, MI (remember epinephrine injections) (remember epinephrine injections) Capnography Use small amounts incrementally Use small amounts incrementally “Sedate and wait” “Sedate and wait”

Death rate at baseline ‐ 1.5% 0.8% p= 0.003 Death rate at baseline ‐ 1.5% 0.8% p= 0.003 Inpatient complications ‐ 11% 7.0% p < 0.001 Inpatient complications ‐ 11% 7.0% p < 0.001

To have all necessary To have all necessary accessories accessories

Keep naloxone and flumazenil handy Bispectral (bis) Keep naloxone and flumazenil handy

13


COMPLICATIONS OF “SIMPLE PROCEDURES” COMPLICATIONS OF “SIMPLE PROCEDURES” (be vigilant) (be vigilant)

COMPLICATIONS OF “SIMPLE PROCEDURES” Diagnostic colonoscopy Diagnostic colonoscopy

The rarity of serious The rarity of serious endoscopic complications may endoscopic complications may result in reduced vigilance result in reduced vigilance

(be vigilant) 0.2% ‐ 0.35% 0.2% ‐ 0.35%

• Sedation‐related, perforation • Sedation‐related, perforation

The rarity of serious endoscopic complications may Therapeutic colonoscopy (highly variable) Therapeutic colonoscopy (highly variable) result in reduced vigilance 2.3% 2.3%

After 5000 uneventful After 5000 uneventful gastroscopies it may be gastroscopies it may be tempting to short‐cut the tempting to short‐cut the consent process consent process

Abstracts

COMPLICATIONS OF COLONOSCOPY COMPLICATIONS OF COLONOSCOPY

• Bleeding, perforation and post‐polypectomy coagulation syndrome • Bleeding, perforation and post‐polypectomy coagulation syndrome

After 5000 uneventful gastroscopies it may be Mortality Mortality tempting to short‐cut the 0.005% 0.005% consent process

Pay attention to detail, one Pay attention to detail, one procedure at a time procedure at a time

Pay attention to detail, one procedure at a time

Endoscopic complications: Mea culpa (continued) Paul COMPLICATIONS OF COLONOSCOPY Kortan COMPLICATIONS OF “SIMPLE PROCEDURES” COMPLICATIONS OF “SIMPLE PROCEDURES” Diagnostic colonoscopy 0.2% ‐ 0.35% (be vigilant) (be vigilant)

CLINICALLY SIGNIFICANT BLEEDING CLINICALLY SIGNIFICANT BLEEDING

Cold polypectomy for small polyps CLINICALLY SIGNIFICANT BLEEDING Cold polypectomy for small polyps

COMPLICATIONS OF COLONOSCOPY COMPLICATIONS OF COLONOSCOPY

Insufficient application of Insufficient application of coagulationcoagulation

• Sedation‐related, perforation

The rarity of serious The rarity of serious endoscopic complications may endoscopic complications may Therapeutic colonoscopy (highly variable) result in reduced vigilance result in reduced vigilance 2.3%

BLEEDING RISK REDUCTION BLEEDING RISK REDUCTION

Acute bleeding that requires Acute bleeding that requires intervention (1.5%) intervention (1.5%)

Injection of epinephrine Injection of epinephrine Acute bleeding that requires intervention (1.5%) Detachable snares Detachable snares

Diagnostic colonoscopy Diagnostic colonoscopy 0.2% ‐ 0.35% 0.2% ‐ 0.35% Delayed bleeding that prompts Delayed bleeding that prompts re‐evaluation of the patient • Sedation‐related, perforation • Sedation‐related, perforation re‐evaluation of the patient (2%) (2%)

Insufficient application of coagulation Pedunculated polyps with thick Pedunculated polyps with thick

stalks

• Bleeding, perforation and post‐polypectomy coagulation syndrome

1‐21 days post procedure

Mortality Mortality

Pay attention to detail, one Pay attention to detail, one procedure at a time procedure at a time

0.005% 0.005%

RECOGNITION OF PERFORATION AT THE TIME RECOGNITION OF PERFORATION AT THE TIME OF COLONOSCOPY OF COLONOSCOPY

Endoscopic therapy usually curative NON‐LIFTING SIGN NON‐LIFTING SIGN

RECOGNITION OF PERFORATION AT THE TIME

Examination of the resection site is essential Examination of the resection site is essential

BLEEDING RISK REDUCTION

Injection of dilute indigo carmine methylene blue Injection of dilute indigo carmine methylene blue helpful in determining the plane of resection helpful in determining the plane of resection COLONOSCOPIC PERFORATION COLONOSCOPIC PERFORATION Blue ‐ intact submucosa Blue ‐ intact submucosa into muscularis propria White ‐ into muscularis propria Incidence 0.07 ‐ 0.1% 0.1% White ‐ Incidence 0.07 ‐ Bourke’s Target sign ‐ Bourke’s Target sign ‐ white white center surrounded by blue center surrounded by blue Blunt trauma from endoscope

Cold polypectomy for small polyps CLINICALLY SIGNIFICANT BLEEDING CLINICALLY SIGNIFICANT BLEEDING Injection of epinephrine Acute bleeding that requires Acute bleeding that requires intervention (1.5%) intervention (1.5%) Detachable snares

BLEEDING RISK REDUCTION BLEEDING RISK REDUCTION

Positive: cancer in the polyp Positive: cancer in the polyp OF COLONOSCOPY

Negative: does not rule out Negative: does not rule out Examination of the resection site is essential RECOGNITION OF PERFORATION RECOGNITION OF PERFORATION cancer cancer Injection of dilute indigo carmine methylene blue 1/3 diagnosed at the time of procedure 1/3 diagnosed at the time of procedure False positive – previous snare False positive – previous snare helpful in determining the plane of resection COLONOSCOPIC PERFORATION resection resection Blue ‐ intact submucosa 48 hrs Incidence 0.07 ‐ 0.1% 2/3 diagnosed within 24 ‐ White ‐ 2/3 diagnosed within 24 ‐ into muscularis propria Indicates invasion or Indicates invasion or Bourke’s Target sign ‐ white submucosal fixation submucosal fixation center surrounded by blue Blunt trauma from endoscope

Blunt trauma from endoscope

Cold polypectomy for small polyps Cold polypectomy for small polyps

Tension pneumoperitoneum Tension pneumoperitoneum Barotrauma

Barotrauma Injection of epinephrine Injection of epinephrine

Insufficient application of Insufficient application of Pedunculated polyps with thick coagulationcoagulation

stalks

Pedunculated polyps with thick Pedunculated polyps with thick

Tension pneumoperitoneum Barotrauma

stalks stalks Coagulation necrosis of muscularis propria Coagulation necrosis of muscularis propria

Coagulating current‐ulcer Coagulating current‐ulcer

Clips

1‐21 days post procedure 1‐21 days post procedure

Management of antiplatelet agents Management of antiplatelet agents and anticoagulants and anticoagulants

Endoscopic therapy usually Endoscopic therapy usually curative curative NON‐LIFTING SIGN

RECOGNITION OF PERFORATION AT THE TIME RECOGNITION OF PERFORATION AT THE TIME OF COLONOSCOPY Positive: cancer in the polyp OF COLONOSCOPY

Clips

COMPLICATIONS OF ENDOSCOPIC BILIARY COMPLICATIONS OF ENDOSCOPIC BILIARY SPHINCTEROTOMY SPHINCTEROTOMY

NON‐LIFTING SIGN NON‐LIFTING SIGN

Examination of the resection site is essential Examination of the resection site is essential Negative: does not rule out RECOGNITION OF PERFORATION cancer

Positive: cancer in the polyp Positive: cancer in the polyp

Injection of dilute indigo carmine methylene blue Injection of dilute indigo carmine methylene blue 1/3 diagnosed at the time of procedure False positive – previous snare helpful in determining the plane of resection helpful in determining the plane of resection COLONOSCOPIC PERFORATION COLONOSCOPIC PERFORATION resection Blue ‐ intact submucosa Blue ‐ intact submucosa

Negative: does not rule out Negative: does not rule out cancer cancer RECOGNITION OF PERFORATION RECOGNITION OF PERFORATION

2/3 diagnosed within 24 ‐ 48 hrs

White ‐ into muscularis propria White ‐ into muscularis propria Incidence 0.07 ‐ 0.1% 0.1% Incidence 0.07 ‐ Indicates invasion or Bourke’s Target sign ‐ white white Bourke’s Target sign ‐ submucosal fixation center surrounded by blue center surrounded by blue

48 hrs

Rarely as late as 14 days Rarely as late as 14 days

Swan et al; GIE,Jan 2011 Swan et al; GIE,Jan 2011

Detachable snares Detachable snares Unintended resection of muscularis propria Unintended resection of muscularis propria

Clips Delayed bleeding that prompts Delayed bleeding that prompts re‐evaluation of the patient re‐evaluation of the patient Management of antiplatelet agents (2%) (2%) and anticoagulants

14‐day reporting period to capture all 14‐day reporting period to capture all Swan et al; GIE,Jan 2011 perforation perforation Unintended resection of muscularis propria Raju et al; GIE Dec. 2011 Coagulation necrosis of muscularis propria Raju et al; GIE Dec. 2011

PATIENTS AT HIGHER RISK FOR POST ERCP PATIENTS AT HIGHER RISK FOR POST ERCP PANCREATITIS PANCREATITIS COMPLICATIONS OF ENDOSCOPIC BILIARY SPHINCTEROTOMY PRE‐ERCP INTRA‐PROCEDURE PRE‐ERCP INTRA‐PROCEDURE SUSPECTED SOD SUSPECTED SOD PANCREAS DIVISUM PANCREAS DIVISUM PRIOR ACUTE/RECURRENT PRIOR ACUTE/RECURRENT PANCREATITIS PANCREATITIS NO CHRONIC PANCREATITIS NO CHRONIC PANCREATITIS YOUNG AND FEMALE YOUNG AND FEMALE

PRECUT SPHINCTEROTOMY PRECUT SPHINCTEROTOMY DIFFICULT CANNULATION DIFFICULT CANNULATION ENDOSCOPIC AMPULLECTOMY ENDOSCOPIC AMPULLECTOMY BALLOON DILATION OF INTACT BALLOON DILATION OF INTACT SPHINCTER SPHINCTER PANCREATIC DUCT INJECTION PANCREATIC DUCT INJECTION (ANY, MULTIPLE, TO TAIL) (ANY, MULTIPLE, TO TAIL)

False positive – previous snare False positive – previous snare 1/3 diagnosed at the time of procedure 1/3 diagnosed at the time of procedure resection resection

Rarely as late as 14 days Blunt trauma from endoscope Blunt trauma from endoscope

2/3 diagnosed within 24 ‐ 48 hrs FREEMAN et al; NEJM 1996 2/3 diagnosed within 24 ‐ 48 hrs FREEMAN et al; NEJM 1996 Indicates invasion or Indicates invasion or

Tension pneumoperitoneum Tension pneumoperitoneum

Barotrauma Barotrauma 14‐day reporting period to capture all

perforation

stalks

Clips Clips Delayed bleeding that prompts re‐evaluation of the patient 2.3% 2.3% (2%) 1‐21 days post procedure Management of antiplatelet agents 1‐21 days post procedure Management of antiplatelet agents • Bleeding, perforation and post‐polypectomy coagulation syndrome • Bleeding, perforation and post‐polypectomy coagulation syndrome and anticoagulants and anticoagulants Coagulating current‐ulcer Endoscopic therapy usually Endoscopic therapy usually curative curative Coagulating current‐ulcer Therapeutic colonoscopy (highly variable) Coagulating current‐ulcer Therapeutic colonoscopy (highly variable)

After 5000 uneventful After 5000 uneventful gastroscopies it may be gastroscopies it may be Mortality tempting to short‐cut the tempting to short‐cut the 0.005% consent process consent process

Swan et al; GIE,Jan 2011 Swan et al; GIE,Jan 2011

FREEMAN ML et al, NEJM 1996 FREEMAN ML et al, NEJM 1996

submucosal fixation submucosal fixation

Rarely as late as 14 days Rarely as late as 14 days

FREEMAN et al; NEJM 1996

Unintended resection of muscularis propria Unintended resection of muscularis propria Raju et al; GIE Dec. 2011

Coagulation necrosis of muscularis propria Coagulation necrosis of muscularis propria

PATIENTS AT HIGHER RISK FOR POST ERCP PANCREATITIS COMPLICATIONS OF ENDOSCOPIC BILIARY COMPLICATIONS OF ENDOSCOPIC BILIARY SPHINCTEROTOMY SPHINCTEROTOMY PRE‐ERCP INTRA‐PROCEDURE SUSPECTED SOD PANCREAS DIVISUM PRIOR ACUTE/RECURRENT PANCREATITIS NO CHRONIC PANCREATITIS YOUNG AND FEMALE

PRECUT SPHINCTEROTOMY DIFFICULT CANNULATION ENDOSCOPIC AMPULLECTOMY BALLOON DILATION OF INTACT SPHINCTER PANCREATIC DUCT INJECTION (ANY, MULTIPLE, TO TAIL)

14‐day reporting period to capture all 14‐day reporting period to capture all perforation perforation

ERCP ERCP

Raju et al; GIERaju Dec.et 2011 al; GIE Dec. 2011

PANCREATITIS RISK REDUCTION PATIENTS AT HIGHER RISK FOR POST ERCP PANCREATITIS RISK REDUCTION PATIENTS AT HIGHER RISK FOR POST ERCP

PANCREATITIS PANCREATITIS Careful patient selection/indication Careful patient selection/indication

9 MRCP or EUS for purely diagnostic exams/low pretest probability 9 MRCP or EUS for purely diagnostic exams/low pretest probability

Wire guided cannulation Wire guided cannulation PRE‐ERCP PRE‐ERCP

INTRA‐PROCEDURE INTRA‐PROCEDURE

SUSPECTED SOD SUSPECTED SOD Pancreatic stents Pancreatic stents

PRECUT SPHINCTEROTOMY PRECUT SPHINCTEROTOMY PANCREAS DIVISUM DIFFICULT CANNULATION PANCREAS DIVISUM DIFFICULT CANNULATION 9 High risk patients 9 High risk patients PRIOR ACUTE/RECURRENT ENDOSCOPIC AMPULLECTOMY ENDOSCOPIC AMPULLECTOMY PRIOR ACUTE/RECURRENT 9 Overcomes ERCP‐related papillary edema 9 Overcomes ERCP‐related papillary edema PANCREATITIS PANCREATITIS BALLOON DILATION OF INTACT 9 Threefold risk reduction BALLOON DILATION OF INTACT 9 Threefold risk reduction NO CHRONIC PANCREATITIS NO CHRONIC PANCREATITIS SPHINCTER SPHINCTER 9 Small diameter/short stents 9 Small diameter/short stents YOUNG AND FEMALE PANCREATIC DUCT INJECTION YOUNG AND FEMALE PANCREATIC DUCT INJECTION (ANY, MULTIPLE, TO TAIL) (ANY, MULTIPLE, TO TAIL)

FREEMAN ML et al, NEJM 1996

14

FREEMAN et al; NEJM 1996 FREEMAN et al; NEJM 1996

FREEMAN ML et al, NEJM 1996 FREEMAN ML et al, NEJM 1996

ASSISTANTS AND TEAM APPROACH ASSISTANTS AND TEAM APPROACH Assistants Assistants

ERCP

9Complication rates tied to endoscopy assistant 9Complication rates tied to endoscopy assistant

experience experience PANCREATITIS RISK REDUCTION

9Improved polyp detection with experienced

9Improved polyp detection with experienced Careful patient selection/indication assistants assistants

9 MRCP or EUS for purely diagnostic exams/low pretest probability

9Communication 9Communication

Wire guided cannulation 9Check settings

9Check settings Pancreatic stents 9 High risk patients 9Familiarity 9Familiarity 9 Overcomes ERCP‐related papillary edema 9 Threefold risk reduction 9 Small diameter/short stents


AFTER THE PROCEDURE AFTER THE PROCEDURE

FACING YOUR PATIENT/ RELATIVES FACING YOUR PATIENT/ RELATIVES Patient and relatives expect and deserve Patient and relatives expect and deserve to know what has happened during the AFTER THE PROCEDURE to know what has happened during the procedure, whatever the outcome procedure, whatever the outcome

Patient complaints in the recovery room should always Patient complaints in the recovery room should always be taken seriously and investigated be taken seriously and investigated Not all abdominal pain is just “gas pain” Not all abdominal pain is just “gas pain”

When complications occur, it is critical Patient complaints in the recovery room should always When complications occur, it is critical that the physicians are honest with be taken seriously and investigated that the physicians are honest with themselves and with their patients themselves and with their patients Not all abdominal pain is just “gas pain” If not doing well (spiking fevers, ICU, If not doing well (spiking fevers, ICU, intubated), there is never enough time intubated), there is never enough time Recognizing quickly that a complication has occurred is you can spend with the patient you can spend with the patient the 1st step in successful management

Recognizing quickly that a complication has occurred is Recognizing quickly that a complication has occurred is the 1st step in successful management the 1st step in successful management

Abstracts

Admit if any concern, the local ER 100 km away may be Admit if any concern, the local ER 100 km away may be unfamiliar with the modern Rx of post‐ endoscopy unfamiliar with the modern Rx of post‐ endoscopy complications complications

Admit if any concern, the local ER 100 km away may be unfamiliar with the modern Rx of post‐ endoscopy complications

FACING YOUR PATIENT/ RELATIVES Patient and relatives expect and deserve to know what has happened during the AFTER THE PROCEDURE AFTER THE PROCEDURE procedure, whatever the outcome

IMPORTANCE of CLINICAL CONTEXT IMPORTANCE of CLINICAL CONTEXT Express regret for what has Express regret for what has FACING YOUR PATIENT/ RELATIVES FACING YOUR PATIENT/ RELATIVES occurred occurred

Patient and relatives expect and deserve Patient and relatives expect and deserve When complications occur, it is critical Patient complaints in the recovery room should always Patient complaints in the recovery room should always to know what has happened during the to know what has happened during the Profuse apologies may be that the physicians are honest with be taken seriously and investigated Profuse apologies may be be taken seriously and investigated procedure, whatever the outcome procedure, whatever the outcome themselves and with their patients misinterpreted to mean that a misinterpreted to mean that a

mistake has been made mistake has been made Not all abdominal pain is just “gas pain” Not all abdominal pain is just “gas pain” When complications occur, it is critical When complications occur, it is critical If not doing well (spiking fevers, ICU, that the physicians are honest with that the physicians are honest with intubated), there is never enough time themselves and with their patients Recognizing quickly that a complication has occurred is themselves and with their patients Recognizing quickly that a complication has occurred is One can express remorse for the One can express remorse for the you can spend with the patient the 1st step in successful management the 1st step in successful management adverse event occurring and adverse event occurring and If not doing well (spiking fevers, ICU, apologize without implying blame or apologize without implying blame or If not doing well (spiking fevers, ICU, intubated), there is never enough time malpractice intubated), there is never enough time Admit if any concern, the local ER 100 km away may be malpractice Admit if any concern, the local ER 100 km away may be JAMA, September 2006 JAMA, September 2006 you can spend with the patient unfamiliar with the modern Rx of post‐ endoscopy you can spend with the patient unfamiliar with the modern Rx of post‐ endoscopy complications complications

Complication may seem less problematic Complication may seem less problematic when the patient is ill and the indication for when the patient is ill and the indication for Express regret for what has the procedure is strong (GI bleed, cholangitis) the procedure is strong (GI bleed, cholangitis) occurred Patient and relatives realize the risky situation Patient and relatives realize the risky situation Profuse apologies may be Complication in a healthy ambulatory person Complication in a healthy ambulatory person misinterpreted to mean that a mistake has been made (colon perforation during screening) (colon perforation during screening) One can express remorse for the adverse event occurring and apologize without implying blame or malpractice

SUMMARY SUMMARY

IMPORTANCE of CLINICAL CONTEXT

Patient and relatives realize the risky situation

Know your limitations, don’t Know your limitations, don’t SUMMARY allow ego to contribute to allow ego to contribute to adverse events (fellows vs adverse events (fellows vs Make sure the indication is appropriate consultants etc.) consultants etc.)

Know your technical limits and don’t be afraid Know your technical limits and don’t be afraid Complication may seem less problematic Complication may seem less problematic of referring of referring

Ensure the patient + family are aware of the potential for complications

potential for complications potential for complications

when the patient is ill and the indication for when the patient is ill and the indication for Profuse apologies may be Profuse apologies may be Anticipate problems and modify techniques the procedure is strong (GI bleed, cholangitis) Anticipate problems and modify techniques the procedure is strong (GI bleed, cholangitis) Complication in a healthy ambulatory person accordingly misinterpreted to mean that a misinterpreted to mean that a accordingly Patient and relatives realize the risky situation Patient and relatives realize the risky situation mistake has been made (colon perforation during screening) mistake has been made One can express remorse for the One can express remorse for the adverse event occurring and adverse event occurring and apologize without implying blame or apologize without implying blame or malpractice malpractice

When complications occur don’t delay When complications occur don’t delay investigations or treatment, include other Complication in a healthy ambulatory person investigations or treatment, include other Complication in a healthy ambulatory person consultants as necessary consultants as necessary (colon perforation during screening)

(colon perforation during screening)

JAMA, September 2006 JAMA, September 2006

Endoscopic complications: Mea culpa (continued) Peter Cotton

SUMMARY SUMMARY

IMPORTANCE of CLINICAL CONTEXT IMPORTANCE of CLINICAL CONTEXT Ensure the patient + family are aware of the Ensure the patient + family are aware of the

Make sure the indication is appropriate Make sure the indication is appropriate

Complication may seem less problematic when the patient is ill and the indication for Express regret for what has Express regret for what has the procedure is strong (GI bleed, cholangitis) occurred occurred

JAMA, September 2006

SUMMARY

Continuously consider Continuously consider

Know your technical limits and don’t be afraid fluctuations of the risk to fluctuations of the risk to of referring

benefit ratio benefit ratio

Anticipate problems and modify techniques THE ULTIMATE TIP: TO KNOW WHEN accordingly THE ULTIMATE TIP: TO KNOW WHEN

TO STOPTO STOP

When complications occur don’t delay investigations or treatment, include other consultants as necessary

stringent credentialing processes, with accountability, using report cards and benchmarking. I favor a certification process for more complex and risky procedures, such as ERCP, which are often done in USA by endoscopists with inadequate volumes.

Digestive endoscopy has come to dominate the lives of most Know your limitations, don’t practicing gastroenterologists. Not all procedures go well. Reasons for SUMMARY SUMMARY SUMMARY SUMMARY allow ego to contribute to disappointment include technical and clinical failure, adverse events Some procedures may fail because of poor patient toleration, which is adverse events (fellows vs Make sure the indication is appropriate Make sure the indication is appropriate and process issues. Know your limitations, don’t Know your limitations, don’t one reason for the trend towards using anesthesia for more complex consultants etc.) allow ego to contribute to allow ego to contribute to procedures. Others are completed according to plan, but fail to help Ensure the patient + family are aware of the Ensure the patient + family are aware of the adverse events (fellows vs adverse events (fellows vs potential for complications potential for complications the patient. This may involve missing a diagnosis (perhaps a technical Continuously consider consultants etc.) consultants etc.) Technical and clinical failure error), but more often because a treatment provides little or no benefit Know your technical limits and don’t be afraid Know your technical limits and don’t be afraid fluctuations of the risk to of referring of referring benefit ratio (stenting for chronic pancreatitis or sphincterotomy for “sphincter Continuously consider Sometimes it is just not possible to get where you need to Continuously consider go (to the Anticipate problems and modify techniques Anticipate problems and modify techniques of Oddi dysfunction”). Reducing the likelihood of a poor outcome, fluctuations of the risk to fluctuations of the risk to THE ULTIMATE TIP: TO KNOW WHEN cecum or the bile duct), or to do what you had planned to do (dilate accordingly accordingly benefit ratio TO STOP benefit ratio despite technical success, thus depends on clinicians understanding a stricture or place a stent). In some cases the “fault” may lie with When complications occur don’t delay When complications occur don’t delay the chances of success through their knowledge of the literature and THE ULTIMATE TIP: TO KNOW WHEN THE ULTIMATE TIP: TO KNOW WHEN investigations or treatment, include other investigations or treatment, include other the patient. There may be anatomical issues (prior pelvic surgery, or TO STOP consultants as necessary TO STOP of their own results. This is essential if they are to advise patients consultants as necessary a biliary bypass), or awkward pathology (tortuous stricture or large effectively, including the possibility of referral to someone with more polyp). Many of these factors cannot be over come, even by experts, but expertise in that area. many are known beforehand, which led to the development of scales of difficulty or complexity (1). These can be used to advise patients about the likelihood of success in their particular case. Technical failure is more often due to lack of training and expertise by the endoscopist. Variations in the ability to reach the cecum or to access the bile duct are well documented, as are variations in detecting lesions. Clearly these problems can be addressed and overcome (at least partially) only by better training, and, more controversially, by ensuring that procedures are done only by those with proven competence. This should involve

Adverse events Patients are most unhappy when something “goes wrong” and they suffer an adverse event. These can happen before the endoscope is introduced (reaction to prophylactic antibiotics or bowel preparation), during the procedure (hypoxia), immediately afterwards (pain due to perforation), a few hours later (pancreatitis after ERCP), or can be

15


Abstracts

delayed for several days or weeks (delayed bleeding). Some events (viral transmission) may be so far delayed that the connection is difficult to make, or is missed completely. Documentation of these events requires a precise lexicon (2) Factors increasing risk include the patient’s chronic health status (age, cardiac, pulmonary and other co-morbidities, nutrition, coagulopathy, immunosuppression and obesity), any effect of the presenting illness (sepsis, anemia), and the setting (urgency and environment). The nature of the planned procedure also affects the risk (bleeding after treating varices, or pancreatitis after ERCP). Managing adverse events Obviously, when things “go wrong”, the specific issues have to be addressed promptly and efficiently, and explained carefully to the patient and family, who hopefully will remember that they were informed about the possibilities beforehand. No matter how bad you feel, it is a mistake to grovel in distress. However, it is important to show that you care, and that you share their disappointment. Keep in touch, even when the patient has to be transferred elsewhere. Behave professionally, just as you would if things had gone well. Failure to do so will raise questions, generate resentment and may foment legal action (3). Process issues Delays, discourtesies and lack of rapport may leave patients and families unhappy even when the technical and clinical outcomes are good, and when there have been no adverse events. These can be avoided only by assiduous attention to such quality issues in the endoscopy unit. It is self-evident that all of these risks are less likely to occur when the endoscopist, team, patient and family are all well prepared for the specific procedure. Let’s continue to strive to do better. 1. Cotton PB, Eisen G, Romagnuolo J, Vargo J, Baron T, Tarnasky P, Schutz S, Jacobson B, Bott C, Petersen B. Grading the complexity of endoscopic procedures; report of an ASGE working party. Gastrointest Endosc. 2011; 868-74 2. Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. GIE 2010; 72(3):446-54. 3. Cotton PB, Saxton JW, Finkelstein MM. Avoiding medicolegal complications. Gastrointest Endosc Clin N Am. 2007 Jan;17(1):197-207.

16

New endoscopic therapies. Where are we and where to? Horst Neuhaus, MD Professor of Medicine, Head, Dpt. of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Teaching Hospital of the University of Düsseldorf, Kirchfeldstrasse, Düsseldorf, Germany Modern changes in flexible endoscopy have been mainly driven by an increasing variety of indications, new technologies and economics. The selection of diagnostic endoscopic methods depends on the clinical setting which includes screening, surveillance of risk conditions for neoplasia or evaluation of symptomatic patients. In therapeutic endoscopy progress has been made with regard to treatment of early GI neoplasia, benign and malignant gastrointestinal strictures, bleeding and management of even complex of pancreatobiliary diseases. Selected areas of research are endoscopic treatment of obesity, reflux disease, motility disorders (fig. 1) and full-thickness resection, e.g. of submucosal tumors. Enormous improvement in endoscopic and endosonographic imaging has increased the accuracy of detection, discrimination and confirmation of mucosal lesions as well as local tumor staging. Targeted and minimally invasive techniques of tissue sampling facilitate the histological diagnosis. Referral centers of endoscopy should provide advanced imaging and indication-based options of endoscopic access to sites of interest. These include e.g. video-capsules, ultraslim endoscopes, instruments for evaluation of the small bowel or specially designed therapeutic endoscopes. Endoscopes which allow triangulation for independent maneuvering of accessories are currently under evaluation. Their development as well as the introduction of new accessories like knives, clips, suturing machines, thermal devices and various implantable stents, sleeves or valves have been accelerated as spin-off technologies of NOTES (Natural Orifice Translumenal Endoscopic Surgery). These advanced techniques increase options of tissue resection and ablation, tissue apposition, bridging or closure of lumena or fistulae and creation of anastomoses. This progress could be only made by modern options of endoscopic management of procedure related complications. The best centers will provide a wide array of advanced interventions depending on specialization of the individual institution. Advanced endoscopy has to be considered as a part of a multidisciplinary approach which should include particularly radiology, surgery, oncology and histopathology. Centers should offer appropriate training programs with the use of simulators, animal models and access to animal laboratories. New technologies have to be carefully evaluated preferably in controlled trials and registries are warranted for a variety of recently introduced methods. It is mandatory to improve the level of evidence in several areas of endoscopy. International cooperation is particularly important for evaluation of procedures with different experiences in centers of various countries. The future of innovations in endoscopy will furthermore largely depend on their effect on the quality and the cost of care.


Notes

17


Trade Floor Plan



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 THE HILTON SYDNEY HOTEL GRAND BALLROOM 







 Platinum Sponsors 

Gold Sponsors



 1. Boston Scientific 

 2. ERBE Rymed



8. Cook Medical

7. Covidien

4. Norgine

10 &12. Olympus

9. Device Technologies

5. Shire

11. Pentax

6. AbbVie

13. Endomed

14. AtraZeneca

16. Given Imaging

15. Endotherapeutics

23. CR Kennedy

18. Ferring Pharmaceuticals

26. Vitramed

20. Fresenius Kabi

27. Pyramed

21. Flolite

Nurses’ Workshop Sponsor 19. Whitely Medical 28. GENCA

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

 

Silver Sponsors 3. Aspen



22. FujiFilm 24. Janssen 25. Takeda




Thank You

A SINCERE THANK YOU IS EXTENDED TO THE FOLLOWING COLLEAGUES: Westmead Nursing Staff Adeyemi Adenike, RN Alison Bannister, RN Mary Bong, NUM Robyn Brown, CNE Ashley Cosmo, RN Octavio Ferrer, RN Kerry Flew, CNS Stephanie Henshaw, EEN Jenevieh Junio, RN Marriam Khilwati, RN Sandra Ko, RN Susan Lane, RN Polly Leong, RN Helna Lindhout, RN Betty Lo, RN Vanessa McArdle-Gorman, RN Kwok Siu, RN Rebecca Sonson, RN Nicky Stojanovic, RN Amelia Tam, RN Judy Tighe Foster, CNS Helena Tsang, RN Su Wang, RN Janice Waru, RN

Westmead Consultant Endoscopists

Westmead Endoscopy Clerical and Technical Support Team

Prof Michael Bourke

Shamim Ara

Dr Rick Hope

Shashi Bala

Dr Vu Kwan

Nelson Calubad, ST

Dr Thao Lam

Ramona Galea

Dr Eric Lee

Pan Tian Heng

Dr Rita Lin

Amy Kenane

Dr Nghi Phung

Alvi Mackole

Dr David Ruppin

Tiffany Moyle

Dr Dev Samarasinghe

Lila Wati Singh, ST

Dr David van der Poorten Dr Stephen Williams Westmead Medical Production and Co-ordination

Special thanks to: Westmead Department of Anaesthetics – Prof Peter Klineberg and Dr Susan Voss

Dr Golo Ahlenstiel Dr Nick Burgess Dr Farzan Fahtash Dr Bronte Holt Dr Kavin Nanda Dr Adrian Sartoretto Dr Nicholas Tutticci Sydney West Area Health Service Audio Visual Production Team Garry Burns Simon Davies Phillip Edwards Chris Henwood Terry Lawrie Glenn Munro Lesa Posa

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Thank you to our sponsors:

PLATINUM SPONSORS

Advancing science for life

TM

GOLD SPONSORS

PTY LTD

SILVER SPONSORS

MEDICAL SYSTEMS

NURSES’ WORKSHOP est.1978

Conference Organiser and Secretariat For further information please contact e-Kiddna Event Management Ph +61 7 3893 1988 Fax +61 7 3337 9855 email: info@e-Kiddna.com.au Attendance Verification: A Certificate of Attendance will be available from the Registration Desk upon request. Disclaimer: Information contained in this brochure was correct at the time of publication. However, it may be necessary, due to unforeseen circumstances for sections to be changed. The organisers will endeavour to keep changes to a minimum.