Neil Haslam

Audit of cyclosporin use in inflammatory bowel disease: limited benefits, numerous side-effects.

Background The failure of standard treatments for inflammatory bowel disease (IBD) has led to the use of immuno-modulatory therapy. Most reports of the use of cyclosporin are from single specialist centres. Aim To survey the use of cyclosporin in IBD in Bristols three teaching hospitals. Patients and methods Over a 4-year period, all patients receiving cyclosporin for IBD were identified and the following data recorded: diagnosis, duration of disease, initial treatment, date initiated, dose of cyclosporin, side-effects, initial clinical response, and current patient status. Results Thirty-three patients were identified, of whom 26 had ulcerative colitis (UC), six had Crohns disease and one had indeterminant colitis. The most frequent indication was as ‘rescue’ therapy in acute severe UC. The overall initial response rate was 63%, but this was only maintained in 30% long-term patients, with over half of them reporting side-effects. Four patients had life threatening side-effects. Conclusion Although the initial response rates are encouraging, the long-term results are poor and at the expense of a high incidence of side-effects. We feel that the use of cyclosporin in IBD should be reconsidered until more information from randomized controlled studies becomes available.Eur J Gastroenterol Hepatol12:657-660

UK key performance indicators and quality assurance standards for colonoscopy

Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.

An investigation of the association of the factor V Leiden mutation and inflammatory bowel disease

BACKGROUND A thrombotic aetiology for inflammatory bowel disease (IBD) has been proposed as a result of its association with thrombo-embolic complications, smoking, the oral contraceptive pill and the response of ulcerative colitis (UC) patients to heparin. The factor V Leiden (FVL) mutation is the commonest inherited risk factor for thrombo-embolism. AIM The aim of the study was to investigate the hypothesis that the pro-thrombotic state associated with the FVL mutation is involved in the aetiology of IBD. PATIENTS AND METHODS A prospective cohort study of patients attending the Bristol Royal Infirmary IBD outpatient clinic was performed. Fifty-four patients with IBD (30 with Crohns disease (CD) and 24 with UC) and 55 historical controls were screened for the presence of FVL using the activated protein C (APC) ratio. Abnormal APC ratios were confirmed to be due to FVL using a heteroduplex-based polymerase chain reaction (PCR) technique. RESULTS Five patients had the FVL mutation, compared to two controls. One of the patients was homozygous. Two of the patients had CD and three UC. The differences between controls and IBD patients was significant when the allelic frequency of the FVL mutation in patients with UC was compared with controls, with a risk ratio of 2.27, but with limited data. CONCLUSION There appears to be a weak association between FVL and UC. This association is not strong enough to imply a causal relationship, but may be responsible for some of the thrombo-embolic complications.

Patients over 45 years with iron deficiency require investigation.

Background Iron deficiency anaemia (IDA) that occurs in patients above the age of 45 years is often caused by gastrointestinal blood loss, and guidelines on the appropriate investigation of these patients have been published. There are few data regarding patients with iron deficiency who are not anaemic and it is not clear how these patients should be managed. Objectives We set out to investigate the hypothesis that similar pathologies are likely to underlie iron deficiency and IDA, and to assess whether IDA was being investigated according to the guidelines published by the British Society of Gastroenterology (BSG). Methods The pathology computer identified 153 consecutive patients over the age of 45 years who had serum ferritin levels below 20 μg/dl (normal range 20‐200 μg/dl) in a 2 month period (i.e., October and November 2000). Medical records were examined and we recorded all investigations, the diagnoses reached, and the investigating specialty. The results were compared using odds ratios (ORs) and 95% confidence intervals (CIs). Results The study shows that the causes of iron deficiency and IDA are similar, but IDA is investigated more thoroughly than iron deficiency, OR 2.07 (CI 1.08‐3.97). Ten patients with iron deficiency without anaemia were found to have coeliac disease, a significant result, OR 6.71 (CI 1.38‐32.6). The majority of patients with IDA are not under the care of a gastroenterologist and this group are significantly less likely to be investigated according to the BSG guidelines, OR 0.15 (0.04‐0.6). Conclusions The study shows that the yield of investigation of iron deficiency is high and, hence, it should be investigated in all patients over the age of 45 years. Despite guidelines published by the BSG, IDA is investigated sub‐optimally and measures other than the issuing of guidelines are needed to change practice.

New-Generation High-Definition Colonoscopes Increase Adenoma Detection when Screening a Moderate-Risk Population for Colorectal Cancer

Background and Aim Adenoma detection rate (ADR) is the most important quality indicator for screening colonoscopy, due to its association with colorectal cancer outcomes. As a result, a number of techniques and technologies have been proposed that have the potential to improve ADR. The aim of this study was to assess the potential impact of new‐generation high‐definition (HD) colonoscopy on ADR within the Bowel Cancer Screening Programme (BCSP). Method This was a retrospective single‐center observational study in patients undergoing an index screening colonoscopy. The examination was performed with either standard‐definition colonoscopes (Olympus Q240/Q260 series) or HD colonoscopes (Olympus HQ290 EVIS LUCERA ELITE system) with the primary outcome measures of ADR and mean adenoma per procedure (MAP) between the 2 groups. Results A total of 395 patients (60.5% male, mean age 66.8 years) underwent screening colonoscopy with 45% performed with HD colonoscopes. The cecal intubation rate was 97.5% on an intention‐to‐treat basis and ADR was 68.6%. ADR with standard‐definition was 63.13%, compared with 75.71% with HD (P = .007). The MAP in the HD group was 2.1 (± 2.0), whereas in the standard‐definition group it was 1.6 (± 1.8) (P = .01). There was no significant difference in withdrawal time between the 2 groups. In the multivariate regression model, only HD scopes (P = .03) and male sex (P = .04) independently influenced ADR. Conclusion Olympus H290 LUCERA ELITE HD colonoscopes improved adenoma detection within the moderate‐risk population. A 12% improvement in ADR might be expected to increase significantly the protection afforded by colonoscopy against subsequent colorectal cancer mortality. Micro‐Abstract This retrospect observational study of 395 patients undergoing colonoscopy as part of the UK Bowel Cancer Screening Programme, demonstrated that the Olympus H290 LUCERA ELITE high‐definition colonoscopes improved adenoma detection within the moderate‐risk population. Moreover, it did so when used by operators with a higher‐than‐average baseline adenoma detection rate.

Colonoscopy performance is stable during the course of an extended three-session working day.

Background: Three-session days were introduced in our endoscopy unit to accommodate the increased demand resulting from the introduction of the National Health Service Bowel Cancer Screening Programme (BCSP). Cecal intubation rate (CIR) and adenoma detection rate (ADR) may decline with time during a standard working day, but data are lacking for an extended three-session day. We assessed colonoscopy performance in an extended three-session day. Methods: Colonoscopies performed during the year 2011 were retrospectively analyzed. The CIR and ADR were analyzed according to the time of day when procedures were done: morning (AM), afternoon (PM), or evening (EVE). Because of an expected higher incidence of adenomas in the BCSP patients, ADR was analyzed according to indication (BCSP or non-BCSP). Results: Of the 2574 colonoscopies, 1328 (51.7 %) were in male patients and 1239 (48.3 %) in female patients with a median age of 63 years (interquartile range [IQR], 51 – 70). Of the 2574 colonoscopies, 1091 (42.4 %) were performed in AM lists, 994 (38.6 %) in PM lists, and 489 (19 %) in EVE lists. Time of day did not affect the CIRs for the AM, PM, and EVE lists (90.5 %, 90.1 %, and 89.9 %, respectively; χ 2 [2, N = 2540] = 0.15, P = 0.927). The CIR was reduced in female patients and those with poor bowel preparation (P < 0.05). After exclusion of the BCSP patients, the ADR was lower in the EVE lists than in the AM and PM lists on univariate analysis, but on multivariate analysis, this difference was not significant (P > 0.05). The ADR was significantly higher in patients older than 60 years and in men (P < 0.001). Queue position did not independently influence the CIR or ADR. Conclusions: Colonoscopy quality does not appear to depend on time of day or queue position in an extended three-session day.

Evaluation of a new anaesthetist-led propofol sedation service for endoscopy within a UK day-case setting

Introduction The use of propofol in endoscopy is becoming more prevalent both in Europe and North America. Potential advantages over conscious sedation include controlled deep sedation for therapeutic endoscopy and improved patient satisfaction. A new anaesthetist-led propofol-based day-case sedation service was introduced within the endoscopy unit at the Royal Liverpool University Hospital in April 2011. Aims To evaluate this new service of anaesthetist-led propofol-based sedation for safety, compliance with current guidelines and satisfaction (patient, anaesthetist and endoscopist). Design A prospective, service evaluation audit of a new, weekly, anaesthetist-led propofol-based sedation service. Administrative records, anaesthetic notes and satisfaction scores (1=very dissatisfied; 5=very satisfied; patients, anaesthetists, endoscopists) and the ‘patient journey’ were evaluated for 40 consecutive patients treated over 18 weeks. Outcomes were measured against current British Society of Gastroenterology/Royal College of Anaesthetists guidelines. Results All procedures were completed (100% intention-to-treat rate), all patients were discharged on the day of the procedure and none were readmitted within 7 days. Adverse events were minor (10%) and there were no deaths within 30 days. The median satisfaction score was 5 for patients, anaesthetists and endoscopists. The additional cost for provision of such a service included the services of the anaesthetist (one programmed activity) and operating department personnel and for drugs (propofol). The demand for the service rapidly increased. Conclusions Anaesthetist-led propofol-assisted endoscopy is safe in a day-case endoscopy unit and is associated with high satisfaction scores for patients, anaesthetists and endoscopists. There is a high demand for this service in this UK endoscopy day-case unit.

Improved clinical outcomes and efficacy with a nurse-led colonoscopy surveillance service

Background A nurse practitioner-led colonoscopy surveillance service was introduced to improve appropriateness, validation and compliance with the National Patient Safety Agency safety alert and British Society of Gastroenterology consensus guidance for bowel cleansing agents. Objective To determine the clinical outcomes and efficacy of this new service. Design and patients A 4-month prospective audit of patients due to attend for surveillance colonoscopy. Setting Royal Liverpool University Hospital. Intervention A new nurse practitioner-led surveillance service reviewed all patients before listing. Outcomes Clinical outcomes, service efficiency and cost effectiveness. Results 224 Patients (median age 68 years, 52% male, and median American Society of Anesthesiologists (ASA) 2) were assessed and 34% had medical factors influencing their colonoscopy. 37% patients were discharged without a colonoscopy, 17% deferred (median >2 years), 6% had died while on the register and the remaining (40%) had their procedure at the agreed interval. The 30-day and 6-month all-cause mortality was 0% for those fit for colonoscopy, compared with 5% and 14%, respectively, for those deemed unfit. The did-not-attend (DNA) rate was reduced from 7.6% to <1%. With 95 patients not requiring a colonoscopy a potential £40 000 saving to the primary care trust was made. Conclusions The nurse practitioner-led surveillance service has been invaluable for guideline adherence and medical management of patients before colonoscopy. In addition, it potentially avoided procedural all-cause mortality in these patients. It has proved to be efficacious with reduced DNA rates and over one-third of patients assessed did not require a colonoscopy.

PTH-171 Colonoscopy Performance in Extended Three Session Working Days

Introduction Three session working days were introduced in our endoscopy unit to accommodate the increasing demand for endoscopic procedures. There is evidence to suggest that caecal intubation rate (CIR) and polyp detection rate (PDR) declines as the day progresses in a standard two session working day. There is currently no literature on CIR and PDR for an extended 3-session working day. The aim of this study was to characterise the impact of endoscopist fatigue on quality of colonoscopy performance by comparing outcomes based on time of day and chronological procedure order for an extended working day. Methods We conducted a retrospective audit of all colonoscopies undertaken in our unit between January and December 2011. In order to assess the effect of repetitive fatigue, endoscopy lists with < 3 colonoscopies were excluded. Time of colonoscopy was stratified into three categories by the starting time of the scheduled list – morning (AM), afternoon (PM), and evening (PM). Queue position was defined as the order that the colonoscopy was performed on the same list i.e. 1st, 2nd and so on. Data on potential confounders including age, sex, quality of bowel preparation (recorded on a three point rating scale of good, satisfactory and poor) were recorded. To evaluate the effect of endoscopist fatigue on colonoscopy performance, we analysed CIR and PDR according to time of day and queue position. Results A total of 2520 colonoscopies were included, of which 1299 (51.5%) were male and 1221 (48.5%) female. The median age was 63 (interquartile range, IQR, 51–70). 1062 (42.2%) were performed in AM lists, 984 PM (39.1%) and 470 EVE (18.7%). CIR did not vary according to time of day (89.8, 90 and 89.5% for AM, PM and EVE lists respectively, p = NS). In multivariate analysis, CIR was adversely affected by age > 70, female gender, poor bowel preparation (all p < 0.01) but not queue position. PDR was not influenced by time of day or queue position. PDR was higher in men in multivariate analyses (p < 0.01). Conclusion Colonoscopy quality is not dependent on time of day or queue position in an extended 3 session day. Our findings support the provision of 3 session days to meet the increasing demand for colonoscopy. Disclosure of Interest S. Subramanian Speaker bureau with: Shire, Dr Falk, Abbott, Conflict with: Advisory board for Abbott, Vifor Pharma, N. Haslam: None Declared, P. Collins: None Declared, S. Sarkar: None Declared

PTH-008 “real-world”, single-centre experience with over-the-scope clip placement

Introduction Over-the-scope clip (OTSC) application is indicated for the management of perforations, leaks, fistulas and gastrointestinal bleeding. We present our “real world” experience of the outcome of this technique in a variety of indications. Method Procedures were performed under moderate sedation or propofol using either a diagnostic (Olympus H260 or HQ290) or therapeutic (Olympus 1 T240 or 2 T240) gastroscope. The OTSC clip (Ovesco Endoscopy) or the Padlock clip (Diagmed Healthcare) was employed. Depending upon indication, tissue was acquired by either suction alone or the use of various accessories (OTSC Tissue Anchor or OTSC Twin Grasper, Ovesco Endoscopy) to enable OTSC deployment. Results All patients undergoing an OTSC procedure were recorded prospectively in an Excel spreadsheet and their outcomes analysed retrospectively after interrogation the hospital clinical, laboratory and endoscopy systems. A total of 16 patients (11 female) mean age 63.2 (range 24–78) years underwent 19 OTSC applications from June 2013 until September 2016. The median follow up was 192 (range 12–1294) days. The site, indication and outcomes are shown in the table. There were 6 deaths; median survival 47.5 (range 12–99) days. Deaths were in patients with aero-digestive (4) or post PEG (1) fistulae and spontaneous oesophageal perforation (1) despite adequate treatment. Site Number of patients (OTSC) Indication Outcome Oesophagus 7 (8) Perforation – 2 iatrogenic, 1 spontaneousAero-digestive fistula – 2 primary closure, 2 stent anchoring Failure – 1Resolution – 6Death – 4 Stomach 5 (5) Post PEG entero-cutaneous fistula?– 3Post-operative oesophagectomy aero-digestive fistula – 1Anastomotic stent anchoring – 1 Resolution – 3Recurrence of fistula – 2Death – 2 Duodenum 3 (4) Perforation – 2 iatrogenicPancreatico-duodenal fistula – 1 Resolution – 2Recurrence of fistula – 1 Jejunum 1 (2) Post DPEJ entero-cutaneous fistula Recurrence after initial and repeat OTSC Conclusion In our centre the commonest indication for OTSC was fistula management. Although initial success in closure was high, recurrence was common (40%). All patients with an aero-digestive fistula had successful closure; however, all but 1 succumbed to their underlying disease, stressing the difficult management challenge of such cases. Disclosure of Interest None Declared