Roger J. Leicester

A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

Aim: To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions. Method: A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia. Patients: Subjects undergoing colonoscopy in 68 endoscopy units. Results: A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of “at risk” patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course. Conclusion: There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.

Eicosapentaenoic acid reduces rectal polyp number and size in familial adenomatous polyposis

Objective The omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA) has anticolorectal cancer activity in vitro and in preclinical models. The present study tested whether a novel, enteric-coated formulation of EPA, as the free fatty acid (EPA-FFA), has chemopreventative efficacy in patients with familial adenomatous polyposis (FAP), in a randomised, double-blind, placebo-controlled trial. Methods Patients undergoing endoscopic surveillance of their retained rectum postcolectomy were randomised to EPA-FFA (SLA Pharma) 2 g daily or placebo for 6 months. The number and size of polyps in an area of mucosa defined by a tattoo were determined before and after intervention. Global rectal polyp burden was scored (−1, 0, +1) by examination of video endoscopy records. Mucosal fatty acid content was measured by gas chromatography–mass spectrometry. Results 55 patients with FAP were evaluated by an intention-to-treat analysis (EPA-FFA 28, placebo 27). Treatment with EPA-FFA for 6 months was associated with a mean 22.4% (95% CI 5.1% to 39.6%) reduction in polyp number (p=0.012) and a 29.8% (3.6% to 56.1%) decrease in the sum of polyp diameters (p=0.027). Global polyp burden worsened over 6 months in the placebo group (−0.34) unlike the EPA-FFA group (+0.09, difference 0.42 (0.10–0.75), p=0.011). EPA-FFA treatment led to a mean 2.6-fold increase in mucosal EPA levels (p=0.018 compared with placebo). EPA-FFA was well tolerated with an incidence of adverse events similar to placebo. Conclusions EPA-FFA has chemopreventative efficacy in FAP, to a degree similar to that previously observed with selective cyclo-oxygenase-2 inhibitors. EPA holds promise as a colorectal cancer chemoprevention agent with a favourable safety profile. Clinical trial number NCT00510692.

RANITIDINE 150 mg TWICE DAILY VS 300 mg NIGHTLY IN TREATMENT OF DUODENAL ULCERS

102 patients with endoscopically proven duodenal ulcers were randomly allocated to treatment with ranitidine either 150 mg twice a day or 300 mg every evening for 4 weeks in a prospective double-blind study. The two groups were similar. 48/57 (84%) healed on ranitidine 150 mg twice daily and 43/45 (96%) healed on 300 mg every evening (p = 0.9)--that is, ranitidine 300 mg as a single night time dose is as effective as 150 mg twice daily. The results also indicate the importance of overnight gastric acidity in the pathogenesis of duodenal ulcers.

Chemoprevention of colorectal cancer

Colorectal cancer is a disease with a high mortality at present, due to the late stage at which many cases present. Attention is therefore focusing on preventative strategies for colorectal cancer given that polyps appear to be identifiable and treatable precursor lesions of this disease. Endoscopic polypectomy has been shown to reduce the incidence of colorectal cancer and there is a good case for endoscopic screening of the general population. However, this will require a large amount of manpower and resources and its success will also depend on the overall compliance of the population.

Apoptosis in the Colonic Crypt, Colorectal Adenomata, and Manipulation by Chemoprevention

This review discusses the biology and the methods of assessment of apoptosis, of which, the monoclonal antibody M30 would seem to be the most useful; the role of apoptosis in the etiology of colorectal cancer; and its use as a marker to monitor the beneficial effects of chemopreventative interventions to reduce the development of colorectal cancer within the context of clinical trials. (Cancer Epidemiol Biomarkers Prev 2009;18(6):1680–7)

Eight Years Experience of High-Powered Endoscopic Diode Laser Therapy for Palliation of Colorectal Carcinoma

PURPOSEEndoscopic laser therapy using neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has been shown to be effective in palliating symptoms of obstruction, bleeding, and discharge in patients with colorectal cancer. These patients usually have advanced inoperable disease at presentation or are unfit for surgery. We have used high-powered diode laser to palliate patients with inoperable colorectal cancer since 1994. This study was designed to determine the success rate of high-powered diode laser in palliating inoperable colorectal carcinoma and compare these figures with those published for Nd:YAG laser.METHODSA retrospective analysis was performed of all patients undergoing high-powered diode laser therapy for colorectal carcinoma between June 1994 and October 2002 (inclusive) at St. George’s Hospital, London, United Kingdom. Patient’s notes and endoscopy records were reviewed to determine the indications for treatment, success of symptom palliation, complications, and survival for each patient.RESULTSFifty-seven patients (28 males), with a median age at first treatment of 82 (range, 51–93) years, were identified who had been palliated with high-powered diode laser therapy for colorectal carcinoma. The median number of treatments received by each patient was three (range, 1–16 treatments), with a median interval between treatments of 9.5 (range, 1–25) weeks. Lifelong palliation of symptoms occurred in 51 patients (89 percent). Major complications were two perforations and one hemorrhage, giving an overall complication rate of 5.3 percent. One of the patients who experienced perforation died, giving an overall mortality rate of 1.8 percent for the procedure. The median survival of the 51 patients palliated completely by laser therapy was 8.5 (range, 0.6–52) months, with a probability of survival at 24 months of 15 percent.CONCLUSIONSHigh-powered diode laser therapy is an effective method of providing palliation for obstruction, bleeding, and discharge in those patients with inoperable colorectal carcinoma. It produces results comparable to therapy with Nd:YAG laser and the equipment is cheaper, more compact, and portable.

Guidelines for designing a digestive disease endoscopy unit: Report of the World Endoscopy Organization

A dedicated digestive disease endoscopy unit is structurally and functionally differentiating rapidly as a result of increasing diagnostic and therapeutic possibilities in the last 10–20 years. Publications with practical details are scarce, imposing a challenge in the construction of such a unit. The lack of authoritative information about endoscopy unit design means that architects produce their own design with or without consulting endoscopists working in such a unit. A working group of the World Endoscopy Organization discussed and outlined a practical approach fordesign and construction of a modern endoscopy unit. Designing the layout is extremely important, necessitating thoughtful planning to provide comfort to the endoscopy staff and patients, and efficient data archiving and transmission during endoscopic services.

Development and validation of the Bowel Cleansing Impact Review (BOCLIR)

Objective Acceptability and tolerability of bowel cleansers influence whether patients are able to complete the prescribed dose and, consequently, the quality of the cleansing achieved. No standardised means of assessing patients’ experience of using bowel cleansing is currently available. The aim of the study was to develop the Bowel Cleansing Impact Review (BOCLIR) to assess patient response to bowel cleansing products. Design Content was derived from qualitative interviews. Face and content validity were assessed via cognitive-debriefing interviews. Finally, patients completed the BOCLIR and a demographic questionnaire. Item response theory (Rasch analysis) was employed for item reduction and assessment of unidimensionality. Internal consistency and construct validity were also assessed. Results Analysis of 40 interviews resulted in the production of three scales; patient satisfaction, symptomatic impact and activity limitations. Scales were designed to be used alone or together. 19 debriefing interviews demonstrated BOCLIR acceptability, relevance and ease of completion. The validation survey involved 166 patients (52% male, mean (SD) age 54.3 (15.2) years). After misfitting and redundant items were removed all scales fit the Rasch model confirming their unidimensionality. Cronbachs α-coefficients were high (0.77–0.94) indicating good internal consistency. Scores on the BOCLIR were related to patients’ willingness to use the product in future and ease of drinking the full preparation (p<0.01 for each scale). Conclusions The BOCLIR is a new measure consisting of three unidimensional scales (satisfaction, symptoms and activity limitations) with good psychometric and scaling properties. The BOCLIR will allow accurate assessment of patients’ response to bowel cleansing preparations.

PTU-004 Incidental findings in the UK Bowel Cancer Screening Programme

Introduction The UK National Bowel Cancer Screening (BCS) Programme aims to identify individuals between the ages of 60 and 70 years at risk for bowel cancer. Those with a positive faecal occult blood test (FOBT) are offered screening colonoscopy. We aimed to quantify and characterise the incidental findings in individuals attending for colonoscopy. Methods We audited the St Georges Hospital BCS database from Nov 2006 to Sep 2009. We determined the various incidental findings and symptoms in this cohort. Case notes of patients under local follow-up were reviewed. Results 1286 patients have been screened (744 male, 542 female). Colorectal cancer was diagnosed in 128 cases (9.95%). 61 patients had findings other than colonic adenoma or colorectal cancer. 31 individuals (50.8%) were found to have inflammatory bowel disease (IBD) (21 Male, 10 Female). Out of them nine had ulcerative colitis (29%), 11 Crohns disease (35.4%) and in 11 cases IBD was of indeterminate subtype (35.4%). Colitis was a pre-existing diagnosis in eight (25.8%) patients, none of who were receiving treatment at the time of colonoscopy. 11 cases of radiation proctitis and one radiation enterocolitis was found (19.6%). All radiation proctitis was due to radiotherapy for prostate cancer and the enterocolitis due to radiotherapy for lymphoma. We identified three cases of neuroendocrine tumours (4.9%) and one granular cell tumour. Three neuroendocrine tumours were found in the rectum and the granular cell tumour in the caecum. We found seven cases of angiodysplasia (11.5%), and their distribution was 2 in rectum, 2 in caecum, 2 in right colon and 1 in transverse colon. Other incidental findings were: 3 solitary rectal ulcer syndrome, 1 Peutz-Jeghers syndrome, 1 threadworm infection, 1 lipoma and 1 case of lymphoid polyp. None of the cases had coexisting colorectal cancer. Conclusion The relative risk of having IBD in the BCS cohort is approximately nine times greater than in the background population. The majority of IBD patients seemingly had not been investigated previously. These findings suggest that a small but significant group of patients with IBD remain undiagnosed into the seventh decade of life. Radiation colitis and angiodysplasia are also significant cause of positive FOBT. The risk of neuroendocrine tumour (0.23%) in the BCS cohort is hundred times more than the background population. Our findings suggest there has been, prior to the BCS programme, a significant proportion of Colonic tumours other than colorectal cancer that were not identified.

3369 Intercollegiate-british society of gastroenterology national colonoscopy (isbn) audit: are colonoscopists supervised during their initial training?

Introduction: Increasing demand for safe and effective colonoscopy requires all gastroenterology trainees to be highly skilled in endoscopic practice. In 1999 the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) recommended that independent colonoscopy should only be undertaken once a trainee had the experience of 50 assisted colonoscopies followed by 50 closely supervised procedures. As part of the IBNC audit, training was assessed in colonoscopists practising in 73 endoscopy units (44 District General, 10 Teaching, 5 Paediatric, 14 Private). Results: At the outset of their colonoscopy training, experienced assistance and supervision was available to 191 of 236 colonoscopists. 170/191 (89%) had been practising colonoscopy for at least 1 year. The table indicates the proportion of the first 100 procedures which were assisted or supervised by a trainer who was present in the endoscopy room at the time of the procedure. 1/170 did not answer this question. Of 236 colonoscopists, 40% had attended a formal colonoscopy teaching program. Conclusion: Learning colonoscopy is a difficult and time-consuming procedure requiring dedicated training. Where training opportunities were available only 16.6% of colonoscopists fulfilled the JAG recommendations for supervised training. Many colonoscopists have never attended a formal colonoscopy training course.