Iosif Beintaris

World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer

BACKGROUND & AIMS Colonoscopy examination does not always detect colorectal cancer (CRC)- some patients develop CRC after negative findings from an examination. When this occurs before the next recommended examination, it is called interval cancer. From a colonoscopy quality assurance perspective, that term is too restrictive, so the term post-colonoscopy colorectal cancer (PCCRC) was created in 2010. However, PCCRC definitions and methods for calculating rates vary among studies, making it impossible to compare results. We aimed to standardize the terminology, identification, analysis, and reporting of PCCRCs and CRCs detected after other whole-colon imaging evaluations (post-imaging colorectal cancers [PICRCs]). METHODS A 20-member international team of gastroenterologists, pathologists, and epidemiologists; a radiologist; and a non-medical professional met to formulate a series of recommendations, standardize definitions and categories (to align with interval cancer terminology), develop an algorithm to determine most-plausible etiologies, and develop standardized methodology to calculate rates of PCCRC and PICRC. The team followed the Appraisal of Guidelines for Research and Evaluation II tool. A literature review provided 401 articles to support proposed statements; evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The statements were voted on anonymously by team members, using a modified Delphi approach. RESULTS The team produced 21 statements that provide comprehensive guidance on PCCRCs and PICRCs. The statements present standardized definitions and terms, as well as methods for qualitative review, determination of etiology, calculation of PCCRC rates, and non-colonoscopic imaging of the colon. CONCLUSIONS A 20-member international team has provided standardized methods for analysis of etiologies of PCCRCs and PICRCs and defines its use as a quality indicator. The team provides recommendations for clinicians, organizations, researchers, policy makers, and patients.

Advanced imaging in colonoscopy: contemporary approach to dysplasia surveillance in inflammatory bowel disease

Inflammatory bowel disease (IBD) (ulcerative colitis (UC) and Crohn’s disease (CD)) is a chronic relapsing/remitting condition characterised by intestinal inflammation. One of the main concerns in patients with longstanding ulcerative and Crohn’s colitis is development of colonic dysplasia and colorectal cancer (CRC), a risk higher than that of the general population. Colonoscopy surveillance programmes have been developed by major societies worldwide to improve early dysplasia detection and treatment, thus preventing progression to colorectal cancer. Colonoscopy is an imperfect tool as lesions can be missed, an issue even more relevant to colitic patients, where mucosal inspection and lesion recognition may prove challenging. Extensive research has been undertaken on performance improvement in this area while technical advances in optical imaging, such as high-definition, have made their way into modern endoscopy units. Techniques and technologies available to enhance optical diagnosis of dysplasia in inflammatory bowel disease are reviewed in this paper, focusing on those that are realistic, widely available and feasible for everyday practice.

Recent advances in colonoscopy

Colonoscopy is an important and frequently performed procedure. It is effective in the prevention of colorectal cancer and is an important test in the investigation of many gastrointestinal symptoms. This review focuses on developments over the last 5 years that have led to changes in aspects of colonoscopy, including patient preparation, technical factors, therapeutic procedures, safety, and quality.

OC-010 Implementation of a Novel Colonoscopy Performance Index, The Composite Caecal Intubation Rate (CIRC), in a UK Tertiary Centre

Introduction The Composite Caecal Intubation Rate (CIRc) has been proposed as a more pragmatic colonoscopy performance index, encompassing three key components; caecal intubation rate (CIR), patient comfort and sedation dose.1 We calculated CIRcs within a Tertiary Unit (St Mark’s Hospital,UK), aiming to assess performance and look for possible correlation between CIRc and adenoma detection rate (ADR).2 Methods We analysed all colonoscopies performed by 32 Endoscopists in 12 months. CIRc was the proportion of procedures fulfilling the following criteria; procedure completion, comfort score ≤3 (Gloucester scale)3 and midazolam dose 0–2 mg. We examined the association between CIRc and annual colonoscopy volume, completion rate, midazolam dose and polyp detection rate (PDR). Finally, we sought for a correlation between CIRc and ADR for 7 Bowel Cancer Screening Programme (BCSP) Endoscopists. Results Analysis included 5416 colonoscopies. Overall CIRc was 85.6%. There was significant correlation between CIRc and annual colonoscopy volume; all colonoscopists with >250 procedures had CIRcs >85%. The majority of operators with <200 procedures had the lower scores, but still more than 70%. There were Endoscopists with low annual volumes and high CIRc meaning that expert endoscopists with high lifetime (but low annual) volumes can nonetheless deliver high quality colonoscopy. There was also evidence of a negative correlation between midazolam and CIRc, but of no statistical significance. No significant association was observed with CIR or PDR. There was a reasonable positive correlation, albeit non significant, between ADR and CIRc in the BCSP Endoscopists’ subgroup. Conclusion CIRc is a more informative performance index, reflecting key aspects of colonoscopy. Reassuringly, overall CIRc achievement in the Unit was above National Audit data (54.1%).1 Endoscopists with larger procedure volumes performed better. No significant correlation with ADR was seen, although a positive trend was noted. The small amount of patients included in the ADR analysis group is insufficient to draw definite conclusions. Applying CIRc at a local level may aid in identification of under-performers, although case-mix factors may affect results. References 1 Valori R, Damery S, Swarbrick E, et al. PWE-057 A composite measure of colonic intubation is better able to distinguish performance of colonoscopy and is associated with higher polyp detection rates. Gut 2014;63:A148. 2 Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:1298–306. 3 Ekkelenkamp VE, Dowler K, Valori RM, Dunckley P. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013;19:2355–61. Disclosure of Interest None Declared

Implementing quality improvement programs for colonoscopy: the emerging need for an international, standardized, multidisciplinary approach

The importance of quality in everyday endoscopy practice is increasingly recognized. The advent of organized bowel cancer screening programs has brought a focus on high-quality colonoscopy worldwide and has driven the desire to extend quality assurance to all aspects of endoscopic practice. Quality assurance has been shown to improve performance 1, leading to increased patient satisfaction and improved health outcomes2. A significant variation exists in the performance of endoscopists and of endoscopy units 3. In colonoscopy, rates of cecal intubation, adenoma detection, and post-colonoscopy colorectal cancer (an indicator of overlooked or incompletely excised premalignant or malignant lesions) vary considerably between units 4, raising concerns about the quality of some services. These differences only come to light when performance is measured, without which there is no opportunity to support individuals or for endoscopy services to improve. To maximize the potential to improve endoscopy quality, all domains of the service should be measured, including equipment, staffing levels, timeliness, adherence to clinical guidelines, and adherence to minimum recognized clinical quality standards of procedures. However, establishing a quality assurance structure for endoscopists and endoscopy units is not a simple task. Candas and colleagues attempt to address this hot topic in this issue of EIO 5. The authors performed a robust mixed-methods systematic review of current literature aiming to identify barriers and facilitators of colonoscopy quality program implementation in endoscopy units. They examined the issue from four different perspectives: endoscopists, nurses, patients, and healthcare managers. In total, 15 studies from across the globe were included in the analysis, most being questionnaires or surveys. Disappointingly, but perhaps not surprisingly, very few studies examined the issue from the perspective of patients, nurses or managers. Mixed-methods review methodology, although technically challenging due to the methodological diversities between qualitative and quantitative studies 6 , is appealing as it incorporates qualitative and quantitative components of the subject under research and can potentially provide robust answers to complex questions. Candas and colleagues should be credited for selecting this method to determine factors that can facilitate policy changes in endoscopy units toward the goal of quality improvement. They grouped responses into three broad categories: features of continuous quality improvement (CQI) programs, attitudes and perceptions, and organizational characteristics. A couple of themes emerge. First, receptive users understand and are willing to embrace quality improvement, particularly when there is clear evidence of gain and they have some sense of ownership of the process. Nevertheless, they desire such a process to be formative – involving education and training – and supportive rather than punitive. We concur that such a holistic approach is far more likely to succeed. Users express concern about the safeguarding of endoscopists’ confidentiality: this is understandable and should be acknowledged when programmes are being instigated – in our experience using a degree of data anonymity gives individuals greater confidence that the process is supportive. The paper identifies that users want quality improvement programs to be voluntary; surprisingly the authors appear to support this. We would argue to the contrary: while a voluntary program is better than nothing, when possible, quality assurance programs should be mandatory, otherwise those whose performance is suboptimal may simply not participate, to the ongoing detriment of patient care. Second, users correctly identify that for quality improvement to work, it needs to be part of a broader culture of clinical excellence, incorporating strong leadership and multidisciplinary teamwork. For such a program to succeed in the long term, it needs to be organized and embedded in the routine activities of an endoscopy service. Management buy-in and support with adequate resourcing (both financial and time) is seen as important, as is keeping the scope of the project feasible by focusing on a manageable number of key performance measures. Their study also shows that there is a need to increase multidisciplinary involvement (nurse, managers, and patients, as well as clinicians) in the development of quality improvement programs and in their evaluation. This is especially pertinent for performance measures assessing the quality of pre- and post-endoscopy components of a service, including patient satisfaction and procedure timeliness. While the paper does not deliver any surprises, it does nicely encapsulate the perceived challenges of implementing quality assurance programs, which may promote the success and endurance of future quality initiatives. Although the paper in this issue focuses on colonoscopy, the message it delivers is equally applicable to all endoscopy. There are several aspects of quality improvement and performance measures that are not covered by the paper, presumably because they were not identified in the underlying studies. These include using objective performance measures less susceptible to “gaming,” and using standardized, evidence-based performance measures to allow meaningful comparison between endoscopy services. We believe that these aspects are important. The ESGE, supported by UEG, is currently developing such performance measures for endoscopy, incorporating endoscopy service measures along with lower gastrointestinal, upper gastrointestinal, small bowel, and pancreatobiliary endoscopy. This process is truly multidisciplinary, involving clinicians, nurses, managers and, importantly, patients 7. The need for a standardized, global approach to quality improvement processes is now more relevant than ever. Comparison of local quality data with standardized, international performance measures can be a powerful motivation for individual services to aim to higher standards, reducing performance variation between operators and units. That, of course, is not an easy task, as it requires commitment from all involved parties, including management. Nevertheless, the goal of improved patient health outcomes alone justifies coordinated efforts towards this approach.

OC-047 A multi disciplinary team (mdt) approach for complex benign colo rectal polyps: a tertiary referral centre experience

Introduction Multi-disciplinary team (MDT) working is an established part of cancer care. Limited data is available on their impact for benign complex colorectal polyps. Increased numbers of these polyps are referred to our tertiary centre for further management. Method Polyp MDT comprising of gastroenterologists, colorectal surgeons and histopathologists was established in January 2013 to discuss the management of complex polyps (large or recurrent polyps or those where endoscopic access was difficult). Cases that were referred to individual consultants and had a provisional management plan made were then discussed at the MDT and a consensus management plan was agreed. The impact of MDT management plan was then evaluated. Results 96 cases were discussed between January 2013 and October 2014. Of those 75 (78%) were tertiary referrals. The reasons for polyp complexity included large polyps 53 (55%), those with difficult access 52 (54%) and previous failed attempt 35 (36%). Majority of the polyps were in recto sigmoid, 49 (51%) or in caecum, 32 (32%). In 38 cases (40%) provisional management plan was changed after MDT discussion. This plan was then followed in 80/96 (82%) cases. Combined surgical-endoscopic approaches were proposed in 68 cases (65%). 25/96 patients had polypectomy during a single hospital visit. The remaining cases (71/96) needed further assessment before attempted polypectomy. Complete polypectomy was achieved in 85/96 (89%) of patients: endoscopically in 75/96 cases (78%): 38 by endoscopic excision alone and 37 by combined endo-surgical approaches. Ten polyps were resected surgically. Of the remaining 11 patients no polyps were found in 2 of those referred, 2 patients were referred back their local hospital for surgery, 5 were not fit for a polypectomy and are under surveillance, 1 had metastatic colorectal cancer and 1 declined any intervention. Cancer was found in 7/96 polyps and 6/7 had surgical resection (the remaining patient had metastatic disease). Conclusion The polyp MDT consensus management plan led to a change in the proposed management in almost half of the patients. This resulted in complete polypectomy for a large majority of patients referred to our service. Disclosure of interest None Declared.

PTH-040 Laparoscopic-assisted colonoscopic polypectomy is a safe and effective option for difficult polyps: a single tertiary referral centre experience

Introduction Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical resection. We report our experience using laparoscopic assisted colonoscopic polyp resection at a single tertiary referral centre. Method Combined procedures from 2012 to 2014 for patients referred for resection of colonic polypsons deemed not amenable for safe endoscopic resection or where access was difficult, and therefore planned for laparoscopic assistance, were analysed. Clinical data regarding primary lesion, reason for referral for laparoscopic assistance, and outcomes were recorded. Results 15 patients have so far been planned for laparo-endoscopic procedures following multidisciplinary meetings, of whom 1 patient proceeded with surgery alone. 14 patients, with median age 73.0 years (range 35.7–85.1 years) were studied. The main reasons for laparoscopic assistance were: large high risk polyps, unfavourable location and the presence of diverticular disease. The median size of the polyps was 5 cm (range 2.3–15 cm). All procedures were performed under general anaesthetic. Completion of colonoscopic resection was performed with surgical presence without laparoscopic assistance in one. Laparoscopic adhesiolysis was performed in 5 patients to facilitate access. Seven patients required surgical resection (laparoscopic right hemicolectomy in 6 and sigmoid resection in 1). A cancer was confirmed histologically in 3 of these patients, with the other four being adenomas with high-grade dysplasia (HGD, 1) or low grade dysplasia (LGD, 3). In the remaining 7 patients, complete polypectomy was achieved, with histopathology showing adenomas with HGD (2), LGD (1), and lipomas in 3 patients with submucosal lesions, and non-diagnostic material in one patient. Median post-operative length of stay was 2 days (range 1 to 5 days) following colonoscopic resection, and uncomplicated except for post-polypectomy syndrome in one patient. Three of these patients have been followed-up to 6 months, with no recurrence of the lesion seen. Amongst patients requiring surgical resection, length of stay was longer (median 6 days [range 3–21 days], p = 0.002, Mann Whitney), with one patient suffering from anastomotic leak and another from an intra-abdominal fluid collection managed conservatively. Conclusion Attempted laparoscopic-assisted colonoscopic polypectomy is an effective strategy in a selected patients, enabling safe and complete polypectomy for lesions that are difficult to resect at primary colonoscopy. This approach may help to reduce surgical morbidity and reduce length of hospital stay. Disclosure of interest None Declared.