Keith Siau

Technological advances for improving adenoma detection rates: The changing face of colonoscopy

Worldwide, colorectal cancer is the third commonest cancer. Over 90% follow an adenoma-to-cancer sequence over many years. Colonoscopy is the gold standard method for cancer screening and early adenoma detection. However, considerable variation exists between endoscopists detection rates. This review considers the effects of different endoscopic techniques on adenoma detection. Two areas of technological interest were considered: (1) optical technologies and (2) mechanical technologies. Optical solutions, including FICE, NBI, i-SCAN and high definition colonoscopy showed mixed results. In contrast, mechanical advances, such as cap-assisted colonoscopy, FUSE, EndoCuff and G-EYE™, showed promise, with reported detections rates of up to 69%. However, before definitive recommendations can be made for their incorporation into daily practice, further studies and comparison trials are required.

Analysis of learning curves in gastroscopy training: the need for composite measures for defining competence

We read with interest and commend the study by Ward and colleagues which explores the learning curve in gastroscopy.1 The authors apply a D2 intubation rate of >95% as a proxy marker of trainee competency, and conclude that 187–200 procedures are sufficient to achieve this, in line with Joint Advisory Group (JAG) certification criteria.2 We would like to debate the following points with the authors.nnWhile we agree that D2 intubation and J-maneouvre reflect procedural completion and rely on motor skill, we argue that this stand-alone measure is insufficient to define competence. Competence is defined by the American Society for Gastrointestinal Endoscopy as the ’minimal level of skill, knowledge and/or expertise derived through training and experience that is required to safely and proficiently perform …

Changes in Swallowing-Related Quality of Life After Endoscopic Treatment for Zenker’s Diverticulum Using the SWAL-QOL Questionnaire

Dysphagia affects the most cardinal of human functions: the ability to eat and drink. The aim of this prospective study was to evaluate swallowing dysfunction in patients diagnosed with Zenker’s diverticulum using the Swallowing Quality of Life (SWAL-QOL) questionnaire preoperatively. In addition, SWAL-QOL was used to assess changes in the outcome of swallowing function after endoscopic treatment of Zenker’s diverticulum compared to baseline. Pre- and postoperative SWAL-QOL data were analyzed in 25 patients who underwent endoscopic treatment of Zenker’s diverticulum between January 2011 and December 2013. Patients were treated by different endoscopic techniques, depending on the size of the diverticulum: CO2 laser technique or stapler technique, or the combination of both techniques used in larger diverticula. Their mean age was 69 years, and 28% of patients were female. The mean interval between endoscopic surgery and completion of the postoperative SWAL-QOL was 85 days. The median (min–max) preoperative total SWAL-QOL score was 621 (226–925) out of 1100, indicating the perception of oropharyngeal dysphagia and diminished quality of life. Following endoscopic treatment of Zenker’s diverticulum, significant improvement was demonstrated in the postoperative total SWAL-QOL score of 865 (406–1072) out of 1100 (p < 0.001). On the majority of subscales of SWAL-QOL there was significant improvement between pre- and postoperative scores. To the authors’ knowledge, this is the first report in the literature on the changes in pre- and postoperative SWAL-QOL scores for patients with Zenker’s diverticulum before and after treatment. The results of this study indicate that endoscopic treatment of Zenker’s diverticulum leads to significant symptom relief as documented by significant changes in the majority of the SWAL-QOL domains.

PTU-009 Competency of endoscopic non-technical skills (ents) during endoscopy training

Introduction Endoscopic non-technical skills (ENTS), comprising of communication and teamwork, situation awareness, leadership, and judgement and decision-making, are recognised indicators of quality endoscopy and patient safety. Since July 2016, electronic assessment forms (DOPS) for UK trainee endoscopists have been updated to include ENTS as an assessable domain. We aimed to explore the uptake and distribution of ENTS scoring in DOPS and their correlation with other endoscopic skills. Method We identified all DOPS submitted between July 2016 and Feb 2017 from the national trainee database (JETS) and acquired data on trainees, procedures and scores. We collated scores for each of the 4 assessable domains (pre-procedural, procedural, post-procedural and ENTs) into overall outcomes of “not competent” (if any domain items required supervision) or “competent”, and compared this to the overall competence rating. Statistical analysis was performed using chi2 and regression modelling. Results 8601 DOPS were prospectively collected, with ENTS assessed in 99.3%. Overall competency rates in ENTS varied across procedures (p<0.001): ERCP 39.8%, EUS 44.1%, gastroscopy 59.6%, colonoscopy 62.3%, PEG 71.1%, gastrointestinal bleed (71.5%), sigmoidoscopy 72.4% and polypectomy 73.2%. Of DOPS awarded overall competency, 5.9% (240/4077) lacked full competence in ENTS (p=0.10 across modalities). Across trainee specialties and endoscopic modalities, competence was greatest for “communication and teamwork” (77.1% overall), but least with ‘judgement and decision making’ (68.3%). Competency in ENTS increased with lifetime procedural count (OR 1.008 per increase in procedure, p<0.001), and correlated strongly with other assessable domains (Figure 1), including overall score (p<0.001). After adjusting for procedural count, factors predictive of ENTS competence included trainee seniority (odds ratio [OR] for ST5 level: 1.96, p<0.0001), surgical trainees (OR 1.21, p=0.014), trainees performing polypectomy (OR 2.02, p<0.0001), and higher DOPS count (OR 1.03 per increase in DOPS, p<0.001). Conclusion ENTS is an assessable domain within endoscopy training, with scores that correlate with other procedure-related skills, demonstrating construct validity of the ENTS scoring system. Competency of ENTS develop with procedural count, and vary with trainee seniority and specialty. Longer term data are required to assess the impact of ENTS on certification. Disclosure of Interest None Declared

How long do percutaneous endoscopic gastrostomy feeding tubes last? A retrospective analysis

Background Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term enteral feeding. Disk-retained PEG tubes may be suitable for long-term usage without planned replacement, but data on longevity are limited. We aimed to assess the rates and predictors of PEG longevity and post-PEG mortality. Design Single-centred retrospective cohort study of patients with disk-retained (Freka) PEG tubes. Methods All patients undergoing PEG between 2010 and 2013 were identified, and retrospective analysis of outcomes until 2017 (median 1062 days) was performed. Time-to-event data were plotted using Kaplan-Meier curves, with predictors of survival derived from multivariate Cox-regression analyses. Results 277patients were studied, with a median age of 74 years (IQR 59–82). PEG tube failure occurred in 17.4%, due to: buried bumper syndrome (7.0%), split/broken tube (6.3%), peristomal infection (1.8%) and dislodged tube (1.1%). PEG tube longevity was 95.1% (1u2009year) and 68.5% (5u2009year), with age <70 (HR 2.65, 95%u2009CI 1.25 to 5.62, p=0.011) being predictive of PEG failure. Post-PEG mortality was 10.5% (30u2009day), 35.4% (1u2009year) and 59.7% (5u2009year). Age ≥70 was associated with mortality (HR 2.79, 95%u2009CI 1.92 to 4.05, p<0.001), whereas PEG failure (HR 0.46, 95%u2009CI 0.27 to 0.77, p=0.003) and elective PEG removal (HR 0.23, 95%u2009CI 0.08 to 0.64, p=0.005) were associated with reduced mortality. Conclusions 68.5% of PEG tubes remain intact after 5 years. Younger age was associated with earlier PEG failure, whereas younger age, PEG replacement and elective PEG tube removal were associated with improved survival. These data may inform future guidance for elective PEG tube replacements.

PTH-044 Improving safety and reducing error in endoscopy (ISREE) – a jag initiative

Introduction JAG is committed to providing universal high quality and safe endoscopy as embedded in the Global Rating Scale. This requires acknowledgement that error is common, may not result in harm or complications, but that addressing latent risk can prevent patient safety incidents. Many errors relate to failures in human factors, ENTS and teamwork, which require training and assessment. Medical error is more prevalent in situations of complexity. Though generally safe, endoscopy is a complex task, performed in teams. As population demographics evolve, straight-to-test pathways become embedded and complex therapeutic options extended; endoscopists need to develop a proactive culture towards safety and learning from error. Aims JAG aims to develop a work stream to Improve Safety and Reduce Error in Endoscopy (ISREE). A 1u2009day workshop was designed to develop an implementation plan to achieve this goal. Methods 35 multi-disciplinary clinicians and a patient with specific expertise in this area were invited to ISREE workshop. Participants were asked to recall as many endoscopy adverse events or errors as possible. Key presentations highlighted the background to medical error, how to investigate it, development of non-technical skills frameworks (anaesthetics and endoscopy), safe sedation, human factors training and implementation science. A patient recounted her experiences of endoscopy. Facilitated group sessions focused on 5 key areas – improving training in ENTS and human factors, error prevention, reporting error, learning from error and managing underperformance (endoscopists, teams or units). Wider discussion synthesised a list of feasible actions that JAG could prioritise for staged implementation. Results Multiple errors were reported by all delegates and recurrent themes were common. Examples related to wrong patient for procedure (n=4), histology mislabelling (n=5), drug errors (n=3) and failure to follow MDT advice (n=1). 23 key priorities were agreed and formulate an implementation strategy for JAG (table 1): Table. No title available. Summary JAG plans to develop a 5 y ISREE Implementation Strategy reflecting the identified priorities to 1) improve endoscopists training in effective error reporting and learning and 2) implement system level approaches to safety and performance improvement. JAG also aims to improve its communication to disseminate learning and support endoscopy services in the UK.

PTH-146 Validation of direct observation of procedural skills (DOPS) assessments for paediatric colonoscopy

Introduction Direct observation of procedural skills (DOPS) are tools designed by the Joint Advisory Group (JAG) to assess competence in endoscopy. These were expanded in July 2016 (new DOPS) to include those specific to paediatric colonoscopy. However, paediatric colonoscopy DOPS assessments have not been validated. We aimed to correlate overall trainee competence with components of the paediatric colonoscopy DOPS. Subjects and Methods We performed a prospective UK-wide analysis of formative paediatric colonoscopy DOPS submitted to the JETS e-Portfolio over one-year (August 2016–2017). Scores were averaged across procedural domains (pre-procedural, procedural, post-procedural and endoscopic non-technical skills – ENTS). Each DOPS item, except for ENTS, were grouped into cognitive and technical skillsets by two independent investigators, and correlated with the overall performance score. Correlation analyses were performed using Spearman’s test (rho >0.70 indicating high positive correlation). Results 61 DOPS assessments were completed by 13 unique trainers for 14 trainees. Overall performance score comprised: 1: Maximal supervision (1.6%), 2: Significant supervision (13.1%), 3: Minimal supervision (47.5%) and 4: Competent (37.7%). By domain, overall competence correlated most with scores for the ‘Procedural’ domain (rho: 0.849, p<0.001), ENTS (0.666, p<0.001), ‘Post-procedural’ (rho 0.635, p<0.001) and pre-procedural (rho 0.471, p<0.001). By domain, overall score correlated more with performance in predominantly ‘Cognitive’ (rho 0.834, p<0.001) and ‘Technical’ (rho 0.815, p<0.001) domains compared to ENTS. In terms of DOPS items, overall competence score correlated most with ‘Proactive Problem Solving’ (rho 0.836, p<0.001) and ‘Patient Comfort’ (rho 0.826, p<0.001), and weakest with ‘Confirms Consent’ (rho 0.228, p=0.115) and ‘Equipment Check’ (rho 0.302, p=0.020). Conclusion Competencies in paediatric colonoscopy, as assessed within DOPS, vary in their correlation with overall competence. Performance in the ‘Procedural’ domain, Proactive Problem Solving’ items, and ‘Cognitive’ skillsets had greatest correlation with overall procedural competence. As assessors are completing the new DOPS in a consistent manner, this provides novel validity evidence for the new paediatric colonoscopy DOPS.

Too hard to swallow

An 80-year-old woman presented with a 4-month history of intermittent oropharyngeal dysphagia and aspiration, particularly after eating peas. She had no significant medical history and denied additional symptomatology. Gastroscopy revealed a smooth lesion arising in the pharynx abutting the epiglottis (figure 1) but was otherwise unremarkable. Pillow sign was negative. No neck masses were palpable on examination after endoscopy.nnnnFigure 1 nEndoscopic appearance of the pharynx.nnnn1. What is the endoscopic finding and what are the …

Difficult intubation of a Zenker's diverticulum with an acute angle

A 94-year-old woman was referred because of oropharyngeal dysphagia and previously failed intubation. A barium swallow had revealed Zenker’s diverticulum (ZD) and cricopharyngeal hypertrophy (Fig. 1). The patient had been referred for endoscopic assessment and management of ZD. Gastroscopy with an insertion tube 9.8 mm in diameter (Pentax EG2990i, Pentax, Tokyo, Japan) performed with the patient under propofol revealed a 17-mm ZD, but the upperesophageal sphincter (UES) was at an acute angle, limiting intubation (Fig. 2). Conventional intubation was unsuccessful despite multiple attempts. Eventually,

OC-021 Changes in scoring of direct observation of procedural skills (dops) forms in endoscopy training and their impact on competence assessment

Introduction DOPS are validated tools for assessing competence in endoscopy. Previously, DOPS were scored on a 4-point competence-based scale, with scores of 3 and 4 signifying competence. In July 2016, the DOPS rating scale changed to a supervision-based scale that has been shown to be more reliable, [1] with 4 ratings from maximal supervision, up to competent without supervision. We aimed to assess whether changes to the rating scale have affected distribution of scores and hence demonstrate validity. Method Scores were collected from DOPS for gastroscopy (1934), sigmoidoscopy (517), colonoscopy (2296) and polypectomy (370) in the 6u2009months before July 2016 (old DOPS) and after (new DOPS), for trainees at early stages of training (total procedures<100). To allow analysis, the new DOPS rating scales was aligned to a 4-point scale, hence a score of 4 on new DOPS = Scores 3 or 4 on old DOPS, and scores on the new and old DOPS compared using the Mann-Whitney U-test. Results 5117 DOPS (77.7% new and 22.3% old) were included for analysis. Overall, there were variations in distributions of scores (p<0.001) between forms (Graph). Compared to new DOPS, scores of 1 were underutilised on old DOPS (0.6% vs 3.0%, p<0.001). Frequencies of low scores (pooled scores of 1 and 2) were similar for gastroscopy (p=0.53) and sigmoidoscopy (p=0.34), but not for colonoscopy (new 11.9% vs. old 13.9%, p<0.001) and polypectomy (new 6.8% vs.19.9%, p<0.001). Trainees on old DOPS were more likely to be rated as competent (score 3 or 4) compared to new DOPS (86.4% vs. 55.8%, p<0.001). On subgroup analysis, this was evident for gastroscopy (86.3% vs. 49.1%, p<0.001), colonoscopy (86.1% vs. 58.2%, p<0.001), sigmoidoscopy (90.6% vs. 62.0%, p<0.001), but not polypectomy (80.1% vs. 67.9%, p=0.12). Conclusion Endoscopy assessors are applying a greater range of scores using a new DOPS rating scale based on degree of supervision, in two cohorts of trainees matched for experience. This indicates better construct validity with the new rating scale. Further work is underway to determine the reliability of the new DOPS to inform summative assessment and certification for UK endoscopy trainees. Reference . Crossley Jet al. Med Educ2011Jun;45(6):560–9. Disclosure of Interest None Declared