Kinesh P. Patel

Factors associated with failed polyp retrieval at screening colonoscopy.

BACKGROUND Colonoscopy reduces colorectal cancer mortality and morbidity principally by the detection and removal of colon polyps. It is important to retrieve resected polyps to be able to ascertain their histologic characteristics. OBJECTIVE The aim of the study was to evaluate the cause of polyp retrieval failure. DESIGN Bowel cancer screening colonoscopy data were collected prospectively. SETTING The Bowel Cancer Screening Program in the National Health Service. PATIENTS Screening participants were referred to our screening center after a positive fecal occult blood test result. INTERVENTION A total of 4383 polyps were endoscopically removed from 1495 patients from October 2006 to February 2011. MAIN OUTCOME MEASUREMENTS The number, size, shape, and location of polyps; polyp removal method; quality of bowel preparation; total examination time; and insertion and withdrawal times in collected data were examined retrospectively. RESULTS The polyp retrieval rate was 93.9%, and the failure rate was 6.1%, thus 267 polyps were not retrieved. In univariate analysis, factors affecting polyp retrieval failure were small polyp size, sessile polyps, and cold snare polypectomy (P < .001). Polyp retrieval was less successful in the proximal colon (P = .002). In multivariate analysis, polyp size and method of removal were independent risk factors for polyp retrieval failure (P < .001). LIMITATIONS Retrospective study. CONCLUSION Small polyp size and cold snare removal were found to be significantly associated with polyp retrieval failure. It was difficult to retrieve small, sessile, and proximal colon polyps. Optical diagnosis could be an efficacious option as a surrogate for histologic diagnosis for these lesions in the near future.

The impact of the introduction of formalised polypectomy assessment on training in the UK

Objective The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process. Design Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. Setting UK National Health Service. Patients None. Interventions None. Main outcome measures The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied. Results Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0–16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3–27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9–199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed. Conclusions Structured polypectomy assessment improves trainees’ documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.

An international survey of polypectomy training and assessment

Background and study aims Colonic polypectomy is acknowledged to be a technically challenging part of colonoscopy. Training in polypectomy is recognized to be often inconsistent. This study aimed to ascertain worldwide practice in polypectomy training. Patients and methods An electronic survey was distributed to endoscopic trainees and trainers in 19 countries asking about their experiences of receiving and delivering training. Participants were also asked about whether formal polypectomy training guidance existed in their country. Results Data were obtained from 610 colonoscopists. Of these responses, 348 (57.0 %) were from trainers and 262 (43.0 %) from trainees; 6.6 % of trainers assessed competency once per year or less often. Just over half (53.1 %) of trainees had ever had their polypectomy technique formally assessed by any trainer. Approximately half the trainees surveyed (51.1 %) stated that the principles of polypectomy had only ever been taught to them intermittently. Of those trainees with the most colonoscopy experience, who had performed over 500 procedures, 48.2 % had had training on removing large polyps of over 10 mm; 46.2 % (121 respondents) of trainees surveyed held no record of the polypectomies they had performed. Only four of the 19 countries surveyed had specific guidelines on polypectomy training. Conclusions A significant number of competent colonoscopists have never been taught how to perform polypectomy. Training guidelines worldwide generally give little direction as to how trainees should acquire polypectomy skills. The learning curve for polypectomy needs to be defined to provide reliable guidance on how to train colonoscopists in this skill.

Crohn's disease presenting as acute hypokalemic paralysis.

of this colitis is not known and it is not clear whether any factors predispose to this potentially severe clinical syndrome (1) . We report a case of fulminant colitis aft er docetaxel therapy in a patient with a history of underlying ulcerative colitis. A 72-year-old woman with metastatic breast cancer received her second dose of docetaxel therapy on a Monday before admission. Th e next day, the patient developed diarrhea and abdominal pain, and 48 h later, she presented to the emergency room acutely ill. Her past medical history was signifi cant for a diagnosis of ulcerative colitis. Her last colonoscopy 2 years earlier revealed “ active colitis with pseudopolyps. ” She was initially treated with mercaptopurine and mesalamine and achieved clinical remission. Unfortunately, she discontinued mercaptopurine 4 months before admission but remained symptom free until presentation. On physical examination, she appeared ill with hypotension and tachycardia. Her abdomen examination revealed guarding and rebound tenderness with reduced bowel sounds. A laboratory examination revealed a marked leukocytosis with a left shift . A computed tomography scan of her abdomen (see Figure 1 ) showed diff use thickening of the colon with free fl uid in the peritoneal cavity and a question of free air. Th e patient was started on intravenous antibiotics and underwent emergent laparotomy. At surgery, she was found to have 400 cc of ascitic fl uid that contained infl ammatory cells but no organisms. Signifi cant, diff use colitis was observed, but no sign perforation was found and resection was not performed. She was treated with nil per os (NPO) status and antibiotics and improved over nil per os the following days. Clostridium diffi cile toxin testing was negative and stool cultures for routine pathogens and cytomegalovirus (CMV) were negative. Th e acute onset of symptoms and the temporal relationship with docetaxel therapy suggest that docetaxel was the main factor in the development of colitis and that this was not an exacerbation of ulcerative colitis. Th e cause of taxane-associated colitis is not known. Ischemia may have a role as taxanes are known to be anti-angiogenic agents, and endoscopies in severe cases of taxaneassociated colitis have shown ischemic changes (3) . A direct toxic eff ect of the chemotherapeutic agent on mucosal cells has also been considered as a possible mechanism. Colitis has not recurred in patients who continued to receive taxane chemotherapy aft er dose reductions, suggesting that it is not an idiosyncratic reaction (1) . Factors that predispose patients to this complication of taxane therapy are not known. However, one would imagine that the degree of colonic injury may be dependent on host factors. We surmise that our patient may have had an active underlying colonic mucosal infl ammation related to her ulcerative colitis and was possibly more susceptible to colonic injury. An underlying history of infl ammatory bowel disease was not previously reported in the largest review of cases of taxane-induced colitis (1) . As breast, ovarian, and lung cancers, as well as infl ammatory bowel disease, are not rare diseases, we assume that other patients such as ours may require taxanebased chemotherapy in the future. Th e clinical course in this case suggests that perhaps pretreatment colonoscopy to assess disease activity may be appropriate in patients with a history of infl ammatory bowel disease to make docetaxel dose adjustments or perhaps to fi nd alternative agents for chemotherapy.

Factors defining expertise in screening colonoscopy

Background and study aims  There is very little literature defining characteristics of expert endoscopists. It is hypothesised that previously undetermined human factors may correlate with high performance in screening colonoscopists. The aim of this study was to determine factors contributing towards expertise in screening colonoscopy. Materials and methods  A focus group was used to hypothesise skills considered to be relevant to high performance in colonoscopy. The skills were then ranked in order of importance by an independent group of screening colonoscopists for both diagnostic and therapeutic colonoscopy. Twenty screening colonoscopists subsequently participated in individual semi-structured interviews to explore participants’ views of expertise and the factors contributing to it. Data extracted from the interview transcripts were used to identify the thematic framework associated with expertise. Results  The 5 initial highest-ranked themes were low complication rates, high adenoma detection rates, interpersonal skills with staff, communication skills, and manner with patients. Interviewees considered technical skills (20/20), previous experience of colonoscopy (19/20), judgment/decision-making (18/20), communication (18/20), teamwork (15/20), resources (11/20) and leadership (8/20) to be the most important themes related to expertise. Conclusions  Both technical and non-technical abilities are considered essential components of expertise by experienced colonoscopists. Further research into targeted interventions to improve the rate of acquisition of these skills in training endoscopists may be useful in improving performance.

Gallstones: An Undescribed Cause of Severe Hepatitis

patients needed to use of GCSF or erythropoietin, but all cases could sustain the combination therapy. Three cases had accomplished the combination treatment and showed sustained virological response. Discussion: FLV and other statins (HMG-CoA reductase inhibitors) are reported to have some anti-HCV effects and to enhance the anti-HCV effect of interferon In Vitro. But there are only few clinical studies. This is the first clinical trial of statin, PEGIFN and RBV combination treatment to children and adolescents with CHC. FLV improved the effectiveness of PEG-IFN and RBV dramatically, and disappearance of HCV-RNA was achieved in all 6 patients with treatment resistant CHC. Conclusion: The combination therapy of PEG-IFN, RBV plus FLV was quite effective to CHC in children and adolescents who had not respond to the standard treatment of PEG-IFN and RBV.