R Pullan

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines. A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements. KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

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.

A retrospective study evaluating the use of Permacol surgical implant in incisional and ventral hernia repair

BACKGROUND The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER NCT01214252 (http://www.clinicaltrials.gov).

A novel method for determining the difficulty of colonoscopic polypectomy

Introduction Endoscopists are now expected to perform polypectomy routinely. Colonic polypectomy varies in difficulty, depending on polyp morphology, size, location and access. The measurement of the degree of difficulty of polypectomy, based on polyp characteristics, has not previously been described. Objective To define the level of difficulty of polypectomy. Methods Consensus by nine endoscopists regarding parameters that determine the complexity of a polyp was achieved through the Delphi method. The endoscopists then assigned a polyp complexity level to each possible combination of parameters. A scoring system to measure the difficulty level of a polyp was developed and validated by two different expert endoscopists. Results Through two Delphi rounds, four factors for determining the complexity of a polypectomy were identified: size (S), morphology (M), site (S) and access (A). A scoring system was established, based on size (1–9 points), morphology (1–3 points), site (1–2 points) and access (1–3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of scores obtained: level I (4–5), level II (6–9), level III (10–12) and level IV (>12). There was a high degree of interrater reliability for the polyp scores (interclass correlation coefficient of 0.93) and levels (κ=0.888). Conclusions The scoring system is feasible and reliable. Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. This may allow for more efficient service delivery and referral pathways.

Report of the Association of Coloproctology of Great Britain and Ireland/British Society of Gastroenterology Colorectal Polyp Working Group: the development of a complex colorectal polyp minimum dataset.

The management of large non‐pedunculated colorectal polyps (LNPCPs) is complex, with widespread variation in management and outcome, even amongst experienced clinicians. Variations in the assessment and decision‐making processes are likely to be a major factor in this variability. The creation of a standardized minimum dataset to aid decision‐making may therefore result in improved clinical management.

The Bowel Cancer Screening Programme: an unusual cause of positive faecal occult bloods

The patient, an asymptomatic 63-year-old gentleman, was invited for colonoscopy through the National Health Service Bowel Cancer Screening Programme (NHS BCSP) after testing positive for faecal occult blood in his stool specimens. Rectal examination was unremarkable; however, colonoscopic examination was limited by an apparent obstruction …

CHARACTERISTICS AND DISTRIBUTION OF POLYPS FOUND IN BOWEL CANCER SCREENING COLONOSCOPY

Introduction Bowel Cancer Screening Programme (BCSP) in the UK achieved nationwide coverage in 20101. We collected data from a local endoscopy unit that performs bowel cancer screening colonoscopy between 2010 and 2011. Aims/Background This audit aims to look at the characteristics and distribution of polyps found in screening as well as surveillance colonoscopies performed under the BCSP. Method Patients aged between 60 and 75 who underwent bowel cancer screening colonoscopy (first and surveillance) in Torbay endoscopy unit from January 2010 to December 2011 were identified from the BCSP database (Oracle BI Interactive Dashboards). Endoscopy reports were drawn from Scorpio© reporting system and corresponding histology results using Cyberlab© integrated pathology system. Results 887 procedures were performed in the 2 year period. 794 polyps were found in 354 procedures, giving a polyp detection rate of 39.9% in this series. Of which 6% contained focus/were of high grade dysplasia. Majority of polyps was found in the sigmoid colon (40.8%) and rectum (13.5%). 669 polyps had histology results, of which 51.8% were Tubular adenomas, 34.7% Tubulovillous adenomas and 7.6% Hyperplastic polyps. There was a 9.6% increase (95% CI 18.5%–0.7%) in the proportion of Tubular adenomas in the over 70s compare with the 60–65 age group (57% vs. 47.4%) (Table 1). There was also an apparent shift from Hyperplastic polyps and Tubulovillous adenoma to Tubular adenoma with increasing age (Figure 1). Figure 1 Table 1 Age Group Tubular Adenoma Tubulovillous Adenoma Hyperplastic Polyp Overall (n=699) 362 (51.8%) 243 (34.7%) 53 (7.6%) 60–65 (n=276) 131 (47.4%) 99 (35.9%) 28 (10.1%) 66–70 (n=213) 111 (52.1%) 75 (35.2%) 15 (7%) >70 (n=210) 120 (57%) 69 (32.9%) 10 (4.8%) n=the no. of polyps found in each age group. Conclusion The most common benign polyp found was Tubular adenomas, and more common amongst the elderly (statistically significant), but further study such as a national BCSP evaluation is needed.

Late complications of an ileal pouch

A 39 year old woman with a stapled J pouch following proctocolectomy for ulcerative colitis in 1998 presented with abdominal pain and diarrhoea during her pregnancy in 2003. She continued to be symptomatic with incomplete pouch evacuation …