*3356AN ENDOSCOPIC RESCUE FROM PERFORATION AFTERENDOSCOPIC MUCOSAL RESECTION FOR EARLY GASTRICCANCER.Hiroyuki Ono, Takuji Gotoda, Hitoshi Gene Kondo, Mitsuhiro Fujishiro,Takahiro Kozu, Takahiro Fujii, Hajime Yamaguchi, Daizo Saito, NationalCancer Ctr Hosp, Tokyo, Japan.Background. Endoscopic mucosal resection (EMR) has been employed fortreatment of early gastric cancer (EGC) in the world, and especially inJapan from the beginning of the 1980s. It has an advantage over surgicalgastrectomy in patient’s quality of life. However, there is some possibilityof complications, such as perforation of the gastric wall and active bleed-ing. Especially, up to now, a surgical operation has been required to treatperforation and it causes the deterioration of the patient’s QOL. In thisstudy, we introduce how to manage and rescue the patients from perfora-tion after EMR without surgical treatment from our experience. Methods.We had 618 patients with 780 cancers or severe dysplasias. They receivedEMR from October 1987 to August 1999 at the National Cancer CenterHospital, Tokyo, Japan. From 1994, we tried to suture the holes of thestomach using clips endoscopically, with insertion of a nasogastric tube forone day. Results. Perforation occurred in 44 patients (7%). In the early peri-od from 1987 to 1993, all 4 patients with perforation underwent surgicaltreatment. Of the 40 patients with endoscopic sutures, 39 patients (97.5%)except for one patient, who had a perforation hole of more than 40 mm insize, succeeded in recovering without surgical treatment. Conclusions. Ourdata suggest that endoscopic suture using clips is a good procedure to res-cue from perforation after EMR.

*3357COMPLICATIONS OF DIAGNOSTIC AND THERAPEUTIC ERCP.Madhukar Kaw, Praveena Kaw, Med Coll of Ohio, Toledo, OH; Brooks &Kushman, Southfield, MI.Background: Studies suggest that therapeutic intervention during ERCPincreases the procedure related complication rate. Aim: To report our expe-rience with complication rate secondary to diagnostic and therapeuticERCP at a tertiary care referral center. Methods: 1182 ERCP s were donebetween July 1995 and September 1999. Patients were divided into fivegroups: ERCP alone: n=387, ERCP and endoscopic sphincterotomy (ES):n=436, ERCP and sphincter of Oddi manometry (SOM): n=105, ERCP+SOM+ ES: n=102, and needle knife sphincterotomy (NKS) ± ES: n=152.Complications were assessed using Cotton et al. criteria by review of hos-pital records and direct follow-up phone calls. Results: See table below. Thetotal morbidity was 9.8%. Three of the 8 with retroperitoneal perforationrequired surgical management. No mortality was observed. Multifactoranalysis revealed risk groups for pancreatitis to be obesity (16.8%) vs. non-obese (3.6%), pancreatic SOM (35.2%) vs. biliary SOM (12.5%), and com-mon bile duct diameter: ≤ 5mm (18.7%), 6-9mm (5.3%), ≥ 10mm (1.7%). Allexcept one perforation occurred in cases with duct diameter of ≤ 5mm.Conclusions: SOM especially pancreatic is associated with a significantrisk of pancreatitis. NKS, although an effective biliary access technique inexperienced hands, should be reserved only when therapeutic interventionis suspected.

Procedure Pancreatitis Bleeding Perforation

ERCP Only 14 (3.6%) 0 0ERCP + ES 19 (4.3%) 9 (2.1%) 1 (0.2%)ERCP + SOM 25 (23.8%) 0 0ERCP+ SOM+ES 27 (26.5%) 3 (2.9%) 2 (1.9%)NKS ± ES 7 (4.6%) 4 (2.6%) 5 (3.3%)

*3358WARFARIN AND ENDOSCOPY, WHAT DOES HAPPEN? Sarah L. Jowett, Irving Cobden, North Tyneside Gen Hosp, North Shields,United Kingdom.Background: It is rare (0.05-0.5%) for clinically significant gastrointestinalhaemorrhage to occur as a result of a mucosal biopsy at endoscopy. There

are no data on the risk of bleeding specifically in anticoagulated patients.However in a prospective audit1 the one death from haemorrhage (in13,036 diagnostic procedures) occurred in a patient with abnormal clot-ting. Aims: This survey was undertaken to determine regional practicewith regard to management of patients on warfarin who required endos-copy. Methods: 122 questionnaires were sent to endoscopists (physiciansand surgeons) in 16 hospitals across the Northern Region of England.Results: We received 100 replies (83%): 66 from consultants, 26 from train-ing grades. The average experience as an endoscopist was 13.5years. 77%of endoscopists routinely stopped warfarin before a procedure. Usually thewarfarin was stopped 3 days prior to the procedure (range 2-7 days). Whenasked, “If a patient is on warfarin at the time of gastroscopy /colonoscopyand a mucosal biopsy is indicated… “, 49% stated they would never take abiopsy, 38% stated that they would, and for the remainder there were var-ious provisos. In the experience of the endoscopists (totalling 1255 years!)30% had never taken a biopsy from a patient on warfarin. Of those 70endoscopists who had taken at least one biopsy from a warfarinisedpatient; 19% admitted it was non-intentional, and 34% stated it was notalways intentional. 8 endoscopists were personally aware of complicationsoccurring as a result of taking those biopsies. Rectal bleeding was the mostcommon but unfortunately one patient had severe bleeding, admission toITU and died, and another had a fatal upper GI bleed. It is not clear ifthese instances refer to the same patient. Conclusions: The risk anticoag-ulation poses to bleeding after endoscopic biopsy is not quantified. It is per-haps unsurprising therefore that practice is so diverse in the NorthernRegion of England. Most endoscopists aim to stop warfarin before a proce-dure, but the time off warfarin shows considerable variation. An almostequal division of opinion exists as to whether or not a biopsy should betaken if indicated when the patient is warfarinised. As at least one biopsyresulted in fatal bleeding, this survey emphasises the need for a review ofpractice and complications. Then a more informed risk-benefit assessmentmay be made as to whether or not biopsy is indicated. Reference: 1.QuineMA, Bell GD et al. Prospective audit of upper GI endoscopy in 2 regions ofEngland: safety, staffing and sedation methods. Gut 1995; 36:462-467.

*3359MORBIDITY RATE OF DIAGNOSTIC UPPER GASTRO-INTESTINAL ENDOSCOPY AT A SINGLE ENDOSCOPY UNIT ANDPATIENT’S PREFERENCE FOR SEDATION.Syed Z. Abbas, Campbell Di, D. K. George, John R. Lowes, Robin H. Teague,Gastrointestinal Unit, Torbay Hosp,, Torquay, United Kingdom.AIM: To prospectively study the immediate and 30 day morbidity for diag-nostic esophago-gastro-duodenoscopy (EGD) performed in a single unit,and to assess the patient’s preference for sedation or pharyngeal anesthe-sia. PATIENTS AND METHODS: To date 409 patients (187 men, 222women) have been studied in 2 months who had EGD performed by 10endoscopists as a day-case for various diagnostic indications at TorbayHospital, Torquay, UK. Clinical and endoscopic data were collected fromthe endoscopy and nursing records. 30 days after the EGD, 383 patients(93.6%) were contactable (telephone - 359; post - 24). RESULTS: Medianage of patients was 61.5 years (range 13 - 94). 157/409 (52/187 men,103/222 women) chose to have EGD under Midazolam sedation (mean dose4.8 mgs ± 1.6). All had oxygen saturation monitored and 131 were givensupplemental oxygen during EGD. One patient had EGD performed undergeneral anesthesia. 252/409 chose xylocaine throat spray. All 409 patientswent home the same day. 30 days later, 50/383 patients contacted (19 men,31 women - χ2 = 1.3, p = NS) had noted a minor complication including sorethroat (n = 28), abdominal pain / discomfort (n = 12), and nausea / vomit-ing (n = 4). 24/50 of them had EGD performed under sedation. 15 patients(3.9%) required a consultation with their primary care physician. No hos-pital visit / admission was required and no death occurred within 30 days.Significantly less number of patients contacted who had EGD performedunsedated (180/239), compared to those who had sedation (135/143), wouldprefer the same again if EGD was required in the future (χ2 = 26.5, p<0.001). 13/239 and 6/143 were uncertain. Significantly more women thanmen who had no sedation would prefer sedation if required EGD again(31/103 Vs 15/123; χ2 = 11.1, p = < 0.005). CONCLUSION: When performedin appropriate environment, diagnostic EGD is a safe procedure thoughcarries a minor complication rate. Patient’s preference for sedation and sexdifference did not effect morbidity rate. Although majority chose to haveEGD performed unsedated, a significant number of patients, particularlywomen, would prefer sedation if EGD was required again.

AB70 GASTROINTESTINAL ENDOSCOPY VOLUME 51, NO. 4, PART 2, 2000