David Swain

Endoscopic mucosal resection of 161 cases of large sessile or flat colorectal polyps

Objective. Large sessile or flat colorectal polyps, which are traditionally treated surgically, may be amenable to endoscopic mucosal resection (EMR), often using a piecemeal method. Appropriate selection of lesions and a careful technique may enhance the efficacy of EMR for polyps ≥20 mm in diameter without compromising safety. The aim of this study was to identify the factors that may be predictive of the risk of polyp recurrence. Material and methods. A retrospective analysis was conducted on the outcome of 161 polyps ≥20 mm in diameter, treated by piecemeal EMR at a single centre using the “lift and cut” technique. All records were reviewed for polyp size, site, morphology and histology. Polypectomy technique, patient follow-up, polyp recurrence and surgical interventions were also recorded. Results. Over an 8-year period, 161 colonic polyps measuring ≥20 mm were removed by EMR. Follow-up data were available for 149 cases (93%) with a mean polyp diameter of 32.5 mm; the total success rate of endoscopic polyp removal was 95.4%. The number of cases requiring 1, 2, 3, 4 and 6 attempts at EMR was 89 (60%), 36 (24%), 14 (9%), 2 (1.3%) and 1 (0.7%), respectively. Recurrence was significantly related to polyp size (p<0.001). There was no statistically significant relationship between site and recurrence. Seven patients (4.6%) underwent surgical intervention after EMR because of failed clearance. There were no post-EMR perforations and significant bleeding was reported in only two patients (1.7%). Conclusions. With careful attention to technique, piecemeal EMR is a safe option for the resection of most sessile and flat colorectal polyps ≥20 mm in size. A stricter follow-up may be required for larger lesions because of a higher risk of recurrence.

Prevalence and Morphology of Pouch and Ileal Adenomas in Familial Adenomatous Polyposis

PURPOSEIn familial adenomatous polyposis, the long-term risk of pouch polyposis and potential for pouch cancer are unknown. Our aim was to evaluate prospectively the prevalence, nature, and etiology of pouch ileal adenomas with that of nonpouch ileal adenomas in familial adenomatous polyposis.METHODSSixty patients with familial adenomatous polyposis pouch, 47 familial adenomatous polyposis patients with ileorectal anastomosis, and 20 younger patients with familial adenomatous polyposis who had prophylactic colectomy were examined with videoendoscopy.RESULTSAdenomatous polyps were found in the pouches of 34 patients (57 percent). A total of 362 polyps were identified (range, 0–50 per patient). A logistic regression model confirmed that there was a significant association between the increasing age of the patient and the presence of pouch adenomas (P < 0.02) and the length of follow-up since pouch surgery (P < 0.05). There was no apparent relationship between the development of pouch adenomas and the severity of either colonic or duodenal polyposis and there were no clear genotype or phenotype correlations. Most polyps were tubular adenomas with mild dysplasia, but 11 patients had more advanced histology, including two patients with large villous adenomas. Nonpouch ileal mucosa was spared from visually observed adenomas, with only 1 of 48 (2 percent) patients with ileorectal anastomosis adenomas and 0 of 20 (0 percent) younger, precolectomy patients having terminal ileal adenomas. However, microadenomas were present on random biopsy in 4 percent to 5 percent of nonpouch ileum.CONCLUSIONThe risk of pouch cancer in familial adenomatous polyposis is unclear, but follow-up periods since surgery remain relatively short. Long-term endoscopic surveillance of familial adenomatous polyposis pouches is thus recommended along with evaluation of potential therapeutic options for pouch adenomas.

Development of a Novel Esophageal Stricture Simulation

Background and Study Aims Esophageal stricture dilatation has a significant morbidity and mortality and training can be difficult to obtain. The aim of the study was to investigate the face validity of a novel stricture simulation and evaluate its utility for training in balloon-dilatation technique. Methods Single-use stricture simulations were used to adapt a mechanical model for use in esophageal stricture dilatation. Face validity was evaluated using a questionnaire survey following a 40-min hands-on training session. Performance improvement was evaluated as part of a randomized blinded controlled trial. Results Face validity was established, with all trainees and instructors rating it as good or excellent overall and as adequately realistic or better in appearance. About 74% found it fairly or very realistic to dilate and 91% found it fairly or very useful for learning balloon-dilatation technique. Significant improvements in performance compared with controls were found following use of the simulation in a training episode. Conclusions The novel esophageal stricture simulation had good face validity and has been shown to improve performance when used for training in balloon-dilatation technique. Its use allows practice without risk to patients or the need for animal cadavers.

EFFICACY OF AN ACCELERATED COLONOSCOPY TRAINING WEEK: AUDIT FROM ONE NATIONAL COLONOSCOPY TRAINING CENTER IN THE UK

Background:  Poor performance and inadequate training in colonoscopy in the UK has been reported. Several centers across the UK run intensive hands‐on training courses but their efficacy has not been established.

Performance in Colonoscopy Can Be Reliably Scored in the First 8 Minutes of Insertion: Further Evidence for a Tri-split Video Assessment Tool

Performance in Colonoscopy Can Be Reliably Scored in the First 8 Minutes of Insertion: Further Evidence for a Tri-split Video Assessment Tool Siwan Thomas-Gibson, Syed Shah, David Swain, Catherine Thapar, Gillian Schofield, Brian Saunders Background: We have previously described use of a tri-split video assessment tool to score colonoscopy performance and highlight specific flaws in technique. The aims were 1) to investigate if scoring just the first 8 minutes of insertion was adequate and 2) to test inter-rater agreement (reliability) of the revised performance score. Methods: Ten doctors training in colonoscopy were videoed. The trainer rated all cases as ‘moderately easy’ at the time of the procedure. ’Trisplit’ views (simultaneous views of the endoscopists’ hands, mucosal view and endoscopic imager view) from each case were recorded. Two cases from each endoscopist (total 20)were edited to include only the first 8mins of insertion. These were then edited together in random order. A second tape of the entire insertions from the same cases (different randomisation) was also made. Two experienced endoscopists blinded to the doctors’ identity, independently scored the procedures using amodified version of a score sheet previously described. A Cumulative score (range 5-15) for 5 parameters and an overall Global score (range 1-3: Not competent, Reasonably competent, Fully competent) were given for each case based on the tri-split views. The 5 parameters were: Correct grip of instrument head; Tip steering/maintenance of mucosal view; Appropriate use of suction/ insufflation; Correct grip/manipulation of instrument shaft; Anatomic depth of insertion. Results: There was good correlation (*Pearson’s correlation coefficient) between scores for the 8min and entire insertions suggesting 8mins is long enough to score insertion technique. Scorer 1: Cumulative scores r* = 0.644 p=0.002; Global scores r* = 0.7369 p= 0.0002. Scorer 2: there was a strong correlation between the Global scores for the 8 min and entire insertion tapes: r*=0.6577 p=0.0056 (Cumulative scores not significant). There was moderate inter-rater agreement for Global scores in the 8 min insertions k= 0.46. Conclusions: This provides further evidence for a feasible method of remote objective performance assessment in colonoscopy using tri-split video to highlight specific flaws in technique. It is valid to score performance using only the first 8 minutes of insertion. An overall Global assessment of competence derived from the parameters scored using a tri-split view is most reliable.