Laura J Neilson

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial

Objective Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC). Design Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured. Results 1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events. Conclusion EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection. Trial registration number NCT02552017, Results; ISRCTN11821044, Results.

Terminal ileal intubation and biopsy in routine colonoscopy practice

This special report focuses on the current literature regarding the utility of terminal ileal (TI) intubation and biopsy. The authors reviewed the literature regarding the clinical benefit of TI intubation at the time of colonoscopy and also the evidence for TI intubation as a colonoscopy quality indicator. TI intubation is useful to identify ileal diseases such as Crohn’s disease and additionally as a means of confirming colonoscopy completion when classical caecal landmarks are not confidently seen. Previous studies have demonstrated that TI intubation has variable yield but may be more useful in patients presenting with diarrhea. Reported rates of TI intubation at colonoscopy vary. The authors demonstrate that terminal ileoscopy is feasible in clinical practice and sometimes yields additional clinical information. Additionally it may be used as an indicator of colonoscopy completion. It may be particularly helpful when investigating patients with diarrhea, abnormalities seen on other imaging modalities and patients with suspected Crohn’s disease. TIs reported as normal at endoscopy have a low yield when biopsied; however, biopsies from abnormal-looking TIs demonstrate a higher yield and have greater diagnostic value.

ESGE Survey: worldwide practice patterns amongst gastroenterologists regarding the endoscopic management of Barrett's esophagus.

Background and study aims: Barrett’s esophagus is a common condition that is widely encountered in clinical practice. This European Society of Gastrointestinal Endoscopy (ESGE) survey aimed to determine practice patterns amongst European clinicians with regard to the diagnosis and management of Barrett’s esophagus. Methods: Clinicians attending the ESGE learning area at the United European Gastroenterology Week in 2014 were invited to complete a 10-question survey. This survey was programed on to two Apple iPads. Information was gathered with regard to demographics, practice settings, and diagnosis and management strategies for Barrett’s esophagus. Results: In total, 163 responses were obtained. Over half of respondents (61 %) were based in university hospitals, the majority (78 %) were aged 30 – 50 and half had more than 10 years’ experience; 66 % had attended courses on Barrett’s esophagus and more than half (60 %) used the Prague C & M classification. Advanced imaging was used by 73 % of clinicians and 72 % of respondents stated that their group practiced ablation therapy. Most (76 %) practiced surveillance for non-dysplastic Barrett’s, 6 % offered ablation therapy in some situations, and 18 % offered no intervention. For low grade dysplasia, 56 % practiced surveillance, 19 % ablated some cases and 15 % ablated all cases. In total, 32 % of clinicians referred high grade dysplasia to expert centers, with 20 % referring directly for surgery and 46 % using ablation therapy in certain cases. Endoscopic mucosal resection was the most commonly used ablation technique (44 %). Conclusions: There has been reasonable uptake of the Prague C & M classification for describing Barrett’s esophagus, and ablation is widely practiced. However, practice patterns for Barrett’s esophagus vary widely between clinicians with clear guidance and quality standards required.

Assessment and management of the malignant colorectal polyp

Colorectal cancer is the second most common cancer affecting men and women in England. The introduction of National Bowel Cancer Screening in 2006 has led to a rise in the proportion of colorectal cancers detected at an early stage. Many screen-detected cancers are malignant colorectal polyps and may potentially be cured with endoscopic resection, without recourse to the risk of major surgery or prolonged adjuvant therapies. Endoscopic decision making is crucial to select those early lesions that may be suitable for local endoscopic excision as well as identifying lesions for surgical resection, thus avoiding unnecessary surgical intervention in some and ensuring potentially curative surgery in others. This paper uses the current evidence base to provide a structured approach to the assessment of potentially malignant polyps and their management. http://group.bmj.com/products/journals/instructions-for-authors/licence-forms

The NHS Bowel Cancer Screening Program: current perspectives on strategies for improvement

Colorectal cancer (CRC) is the third most common cancer in the UK. The English National Health Service (NHS) Bowel Cancer Screening Program (BCSP) was introduced in 2006 to improve CRC mortality by earlier detection of CRC. It is now offered to patients aged 60–74 years and involves a home-based guaiac fecal occult blood test (gFOBt) biennially, and if positive, patients are offered a colonoscopy. This has been associated with a 15% reduction in mortality. In 2013, an additional arm to BCSP was introduced, Bowelscope. This offers patients aged 55 years a one-off flexible sigmoidoscopy, and if several adenomas are found, the patients are offered a completion colonoscopy. BCSP has been associated with a significant stage shift in CRC diagnosis; however, the uptake of bowel cancer screening remains lower than that for other screening programs. Further work is required to understand the reasons for nonparticipation of patients to ensure optimal uptake. A change of gFOBt kit to the fecal immunochemical tests (FIT) in the English BCSP may further increase patient participation. This, in addition to increased yield of neoplasia and cancers with the FIT kit, is likely to further improve CRC outcomes in the screened population.

AODTU-003 Sustained change in colonoscopy practice 3 years after introduction of quality in colonoscopy (qic) bundle

Introduction Adenoma detection rate (ADR) is the most widely used contemporaneous measure of colonoscopy quality. Low ADRs are associated with higher post colonoscopy colorectal cancer rates and poorer patient outcomes.1 A study implementing a “bundle” of evidence-based interventions demonstrated practice change and ADR improvement driven by improvements amongst the poorest performing colonoscopists.2 Interventions were: withdrawal time ≥6 min; hyoscine butylbromide use; position change; rectal retroflexion. We assessed whether practice change and ADR improvements were sustained 3 years following intervention. Method Data were collected from the original study sites, including ADR and hyoscine butylbromide use (marker of bundle uptake). Comparisons were made with baseline data collected for 3 months prior to bundle implementation and for a duration of 9 months following completion. Sustainability data were collected for 6 months, 3 years following implementation. Data were compared globally, by endoscopy unit and by quartile, where colonoscopists were ranked by baseline ADR. Multilevel logistic regression analyses were undertaken. Results 12 endoscopy units housed within 8 UK NHS Trusts participated. Global analyses included data from a total of 184 colonoscopists and 28 615 procedures. Quartile analyses included data from 50 colonoscopists and 14 435 procedures. Hyoscine butylbromide use rose and was sustained above baseline globally in all units and quartiles. A sustained ADR increase (18.2%) was observed globally. Quartile analyses demonstrated that improvement was most marked in the lowest colonoscopist quartile (Table 1). Quartile Buscopan Rate (%) Adenoma Detection Rate (%) Pre-QiC Post- QiC Sustain-ability Overall P-value Pre-QiC Post- QiC Sustain-ability Overall P-value Upper 19.1 71.7 77.2 <0.001 26.9 21.9 21.0 0.04 Upper Middle 25.6 58.9 57.3 <0.001 18.0 20.5 19.0 0.39 Lower Middle 7.6 36.4 34.3 <0.001 14.2 19.7 17.3 0.009 Lower 9.3 45.9 39.9 <0.001 8.0 15.7 15.9 <0.001 All 15.5 52.9 52.2 <0.001 16.3 19.3 18.2 0.006 Conclusion A simple, evidence-based intervention changed colonoscopy practice and improved ADR. These effects were sustained 3 years following implementation, suggesting this approach is a feasible and durable means of improving ADR with minimal resources. References . Corley DA, et al. N Engl J Med2014;370(14):1298–306. . Rajasekhar PT, et al. Endoscopy2015;47(3):217–24. Disclosure of Interest None Declared

PTH-031 Pillcam sb2 and sb3 small bowel capsule endoscopy – comparisons and implications for practice

Introduction South Tyneside Hospital has been a referral centre for capsule endoscopy since 2005, performing over 1000 studies. We have previously shown that the diagnostic yield (DY) of the PillCam SB3 capsule (Given Imaging, Israel) is significantly higher than that of the PillCam SB2.1Here we present additional data on “learning curve” and offer suggestions for practice. Method Previous work compared the DY of the last 100 SB2 capsules with the first 100 SB3s. To assess for a “learning curve” effect we reviewed our first 100 SB2 capsules (Oct 2007–Aug 2008). Indications, completion rates, small bowel recording times and pathology were recorded. Pathology was classed as significant if it related directly to indication. Results 46 of the first 100 SB2 capsules were abnormal, of which 31 had significant pathology; almost identical to the last 100 SB2s (45 abnormal, 30 significant). Most tests (255/300, 85%) were for unexplained anaemia or Crohn’s disease assessment. More capsules are now done for acute GI bleeding; 4 of the first 100 SB2 capsules, 12 of the last 100 SB2s and 15 of the first 100 SB3s. There were 23 incomplete SB2 capsules (11.5%) of which 18 (9%) were in small bowel at the end of recording and 5 were held up by pathology (2.5%). Only 5 SB3 studies (5%) were incomplete, with 4 (4%) not entering the colon and 1 (1%) held up by pathology. On average SB3 capsules had a longer recording time of 9 h and 24 min compared to 8 h and 2 min for the SB2s. Conclusion 219 capsules were reported before the SB2 was introduced. Between the first hundred and last hundred SB2 capsules there were 1003 SB2 studies. This suggests that the increased DY is not due to a “learning curve”, supporting our finding of increased DY with the SB3. Any “learning curve” is likely to be from the first 200 studies. Most studies are for iron deficiency anaemia and Crohn’s disease assessment but there is a trend towards using capsules as a diagnostic tool in overt GI bleeds. Fewer SB3 studies were incomplete compared to SB2s. Our unit is now more proactive in monitoring gastric transit and colonic entry using the real time viewer and this change in practice may have helped with this. Longer recording times due to increased battery life may also play a part. We recommend monitoring capsules in real time and leaving the recorder on for longer if gastric transit is delayed or colonic entry is not clear.Abstract PTH-031 Table 1 Pathology by capsule group Capsule Type First 100 SB2 Last 100 SB2 First 100 SB3 Angioectasia 7 6 18 Blood 4 3 4 Coeliac changes 2 3 1 Polyp/Mass 1 1 4 Stricture 1 3 1 Ulcers/erosions 16 14 20 Other 0 0 1 Total 31 30 49 Disclosure of interest None Declared. Reference Dunn, S. et al. PTU-053 Is It Worth Repeating Previous Unremarkable Sb2 Capsules With The New Sb3? Gut 63 Suppl 1(2014):A61–A62