Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT).

AIM: A treatment strategy for patients with a significant polyp or early colon cancer (SPECC) of the rectum presents a challenge due to the significant rate of covert malignancy and lack of standardized assessment. For this reason, NICE recommends multidisciplinary meetings to improve outcomes. The primary aim of the present study was to report the performance of our specialist early rectal cancer (SERC) multidisciplinary team (MDT) in correctly substratifying the risk of cancer and to discuss the limitations of staging investigations in those patients with "poor outcomes". METHOD: This was a retrospective review of patients referred to our SERC MDT from 2014 to 2019. Lesions were assigned by the MDT to three pre-resection categories (low, intermediate, high) according to the risk of covert malignancy. Resection method and final histology were compared to the pre-resection categories. RESULTS: Of 350 SPECC lesions, 174 were assessed as low-risk, 108 intermediate-risk and 68 high-risk. The cancer incidence was 4.8%, 8.3% and 53%, respectively (15.5% overall). Eight lesions were categorized as low-risk but following piecemeal resection were found to be malignant. Five lesions, three of which were categorized as high-risk, were ultimately benign following conventional surgery. One pT1sm1 cancer, removed by anterior resection, may have been treated by local excision. CONCLUSION: A total of 83% of malignant polyps were triaged to an en bloc resection technique and surgical resection avoided for nearly all benign lesions. However, 12 patients from this cohort were deemed to have a poor outcome because of miscategorization. Further comparative research is needed to establish the optimum strategy for rectal SPECC lesion assessment. ORIGINALITY STATEMENT: There is currently no consensus for staging significant polyps of the rectum. This paper reports the effectiveness of a specialist early rectal cancer MDT to correctly risk-stratify significant rectal polyps. It underscores the importance of accurate categorization for treatment decision-making, while acknowledging the limitations of current staging modalities.

Outcomes and adverse factors for endoscopic mucosal resection (EMR) of colorectal polyps in elderly patients.

INTRODUCTION: Endoscopic mucosal resection (EMR) is an invaluable technique, however it is associated with significant risks. In the elderly in particular, the long-term survival benefits of polyp resection with EMR are unknown. The aim of this study was to determine the long-term outcomes in elderly patients who had undergone EMR and to identify any adverse factors. METHOD: A retrospective observational study on patients of 75 years of age or greater, who underwent EMR of colorectal polyps, in a single tertiary centre, from 2005 to 2014. Demographics of the patients, including Charlson Comorbidity Index (CCI), endoscopic and histological data, were reviewed to identify potential factors predicting outcomes. RESULTS: The patients' median age was 80 years. In total 239 procedures were performed in 206 unique patients. The complication rate was 1.6%. Mean overall survival was 6.7 years with only one patient dying from metastatic colorectal cancer (0.5%) and 49 dying from non-colorectal cancer conditions (24%). Age more than 79 years and CCI more than 2 were independent predictors of significantly shorter survival (p=<0.01). Gender, size of the removed polyps and total number of polyps were not statistically significantly affecting survival. Patients who had more than two colonoscopies were found to have a survival benefit (p=0.02). CONCLUSION: EMR of colonic polyps is safe even for elderly patients. However, the decision to proceed to complex endoscopic therapy should be individualised considering the patients' age and comorbidities. CCI can help to objectively assess the comorbid state of a patient prior to such decisions.

Volatile organic compounds emitted from faeces as a biomarker for colorectal cancer.

BACKGROUND: Colorectal cancer remains a leading cause of mortality and morbidity. The UK Bowel Cancer Screening Programme (BCSP) has demonstrated that detection of colorectal cancer at an earlier stage and identification of advanced pre-malignant adenomas reduces mortality and morbidity. AIM: To assess the utility of volatile organic compounds as a biomarker for colorectal neoplasia. METHODS: Faeces were collected from symptomatic patients and people participating in the UK BCSP, prior to colonoscopy. Headspace extraction followed by gas chromatography mass spectrometry was performed on faeces to identify volatile organic compounds. Logistic regression modelling and 10-fold cross-validation were used to test potential biomarkers. RESULTS: One hundred and thirty-seven participants were included (mean age 64 years [range 22-85], 54% were male): 60 had no neoplasia, 56 had adenomatous polyp(s) and 21 had adenocarcinoma. Propan-2-ol was significantly more abundant in the cancer samples (P < 0.0001, q = 0.004) with an area under ROC (AUROC) curve of 0.76. When combined with 3-methylbutanoic acid the AUROC curve was 0.82, sensitivity 87.9% (95% CI 0.87-0.99) and specificity 84.6% (95% CI 0.65-1.0). Logistic regression analysis using the presence/absence of specific volatile organic compounds, identified a three volatile organic compound panel (propan-2-ol, hexan-2-one and ethyl 3-methyl- butanoate) to have an AUROC of 0.73, with a person six times more likely to have cancer if all three volatile organic compounds were present (P < 0.0001). CONCLUSIONS: Volatile organic compound analysis may have a superior diagnostic ability for the identification of colorectal adenocarcinoma, when compared to other faecal biomarkers, including those currently employed in UK. Clinical trial details: National Research Ethics Service Committee South West - Central Bristol (REC reference 14/SW/1162) with R&D approval from University of Liverpool and Broadgreen University Hospital Trust (UoL 001098).

Dual-focus Magnification, High-Definition Endoscopy Improves Pathology Detection in Direct-to-Test Diagnostic Upper Gastrointestinal Endoscopy.

BACKGROUND: In the UK, the majority of diagnostic upper gastrointestinal (UGI) endoscopies are a result of direct-to-test referral from the primary care physician. The diagnostic yield of these tests is relatively low, and the burden high on endoscopy services. Dual-focus magnification, high-definition endoscopy is expected to improve detection and classification of UGI mucosal lesions and also help minimize biopsies by allowing better targeting. METHODS: This is a retrospective study of patients attending for direct-to-test UGI endoscopy from January 2015 to June 2015. The primary outcome of interest was the identification of significant pathology. Detection of significant pathology was modelled using logistic regression. RESULTS: 500 procedures were included. The mean age of patients was 61.5 (±15.6) years; 60.8% of patients were female. Ninety-four gastroscopies were performed using dual-focus magnification high-definition endoscopy. Increasing age, male gender, type of endoscope, and type of operator were all identified as significant factors influencing the odds of detecting significant mucosal pathology. Use of dual-focus magnification, high-definition endoscopy was associated with an odds ratio of 1.87 (95%CI 1.11-3.12) favouring the detection of significant pathology. Subsequent analysis suggested that the increased detection of pathology during dual-focus magnification, high-definition endoscopy also influenced patient follow-up and led to a 3.0 fold (p=0.04) increase in the proportion of patients entered into an UGI endoscopic surveillance program. CONCLUSION: Dual-focus magnification, high-definition endoscopy improved the diagnostic yield for significant mucosal pathology in patients referred for direct-to-test endoscopy. If this finding is recapitulated elsewhere it will have substantial impact on the provision of UGI endoscopic services.

Evaluation and long-term outcomes of the different modalities used in colonic endoscopic mucosal resection.

Endoscopic mucosal resection (EMR) has been used in western countries to remove colonic polyps for at least the last two decades. Significant experience has been accumulated and the efficacy of the method has recently been evaluated in a large meta-analysis. A number of variations to modify the technique, including knife-assisted, cap-assisted, ligation devices, and underwater EMR, have been developed in an attempt to improve outcomes. However, to date there are only limited data comparing these techniques or demonstrating the superiority of any one of them. This article reviews the current evidence on the efficacy of each of these modified techniques.

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.

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.

New technologies and techniques to improve adenoma detection in colonoscopy.

Adenoma detection rate (ADR) is a key component of colonoscopy quality assessment, with a direct link between itself and future mortality from colorectal cancer. There are a number of potential factors, both modifiable and non-modifiable that can impact upon ADR. As methods, understanding and technologies advance, so should our ability to improve ADRs, and thus, reduce colorectal cancer mortality. This article will review new technologies and techniques that improve ADR, both in terms of the endoscopes themselves and adjuncts to current systems. In particular it focuses on effective techniques and behaviours, developments in image enhancement, advancement in endoscope design and developments in accessories that may improve ADR. It also highlights the key role that continued medical education plays in improving the quality of colonoscopy and thus ADR. The review aims to present a balanced summary of the evidence currently available and does not propose to serve as a guideline.

Incidence of post-ERCP pancreatitis from direct pancreatic juice collection in hereditary pancreatitis and familial pancreatic cancer before and after the introduction of prophylactic pancreatic stents and rectal diclofenac.

OBJECTIVES: Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP). METHODS: A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008. RESULTS: There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035). CONCLUSIONS: Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.

National survey to determine current practices, training and attitudes towards advanced polypectomy in the UK.

OBJECTIVE: Developments in advanced polypectomy technique provide an alternative to surgery in the management of large and complex colorectal polyps. These endoscopic techniques require expertise and can potentially incur high complication rates. This survey evaluates current UK practice, attitudes and training in advanced polypectomy. DESIGN: Anonymous online questionnaire. SETTING: Colonoscopists within the UK were asked about their approach to large polyps (>2 cm). RESULTS: Among the 268 respondents (64% of whom were BCSP accredited), 86% were confident in removing lesions >2 cm by endoscopic mucosal resection (EMR). Of these, 27% were classed as low volume operators (<10 lesions resected/annum) and 14% as high volume operators (>50/annum). By comparison, only 3% currently performed endoscopic submucosal dissection (ESD). Referring one or more benign polyps for surgery a year was common among responders of all levels (11-68%). Training deficiencies were common: only 21% of responders had received a period of training dedicated to advanced polypectomy; 58% of responders would welcome a national training scheme and a majority supported the implementation of advanced polypectomy accreditation with national guidelines. However, while 41% wanted nominated regional EMR experts, only 18% would welcome an integrated national referral network for large/complex polyps. CONCLUSIONS: EMR is practised widely while ESD service provision is very limited. Most experienced colonoscopists are confident to perform piecemeal EMR, even if their training is suboptimal and annual numbers low. Practices and attitudes were variable, even among self-defined level 4 operators. Improving training and implementation of accreditation were welcomed, but there was little appetite for mandated referral to subspecialist 'experts' and national networks.

Endoscopic balloon dilatation of Crohn's disease strictures: results from a large United kingdom series.

INTRODUCTION: Stricturing is a common complication of Crohn's disease. Endoscopic balloon dilatation (EBD) offers a valuable alternative to surgical intervention, but there are limited data on factors influencing its safety and efficacy. METHODS: A multicenter retrospective audit across 4 U.K. teaching hospitals was performed on the use of EBD for Crohn's strictures between 1998 and 2011. Demographics, smoking status, medications, C-reactive protein, endoscopic findings, and subsequent surgery at follow-up were recorded. Success of EBD was defined as symptomatic improvement without the need for surgery at follow-up. RESULTS: Seventy-nine patients (47 women; median age, 48 yr) were identified for this study. Forty-eight (61%) patients had ileocolonic anastomotic strictures, whereas the rest had de novo strictures. In total, 191 EBDs (range, 1-11; median 2) were carried out on 93 strictures (range, 1-5; median 1) over a median duration of 12 months (range, 1-84). There were no serious adverse events. Success at index EBD was 34%, with a further 43% achieving long-term benefit from additional EBDs. Eighteen (23%) patients required surgery. Time to surgery after the first EDB was 2.6 to 71.1 months (median, 12.8 mo). Longer Crohn's disease duration (P = 0.03) and high C-reactive protein (P = 0.008) were associated with an increased need for subsequent surgery. CONCLUSIONS: EBD was safe and effective in achieving long-term symptom improvement and avoidance of surgery in most patients. Prospective controlled trials are needed to evaluate the effect of other factors, including Crohn's disease phenotype, and the role of concomitant medication to identify those best suited to EBD.

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.

Colonic stenting: a practical update.

Colonic stenting is part of the UK service provision guidelines for colorectal cancer. However, there are issues about availability and expertise within the UK, and controversies remain regarding various clinical and technical aspects of the technique. Based on the current evidence, this article will provide a practical update on the indications, the clinical and technical considerations and the remaining unanswered questions regarding colonic stenting.

A multicentre study to determine the incidence, demographics, aetiology and outcomes of 6-day emergency readmission following day-case endoscopy.

BACKGROUND: Emergency readmission after elective procedures is a quality indicator of healthcare delivery, but data for endoscopy are limited. OBJECTIVES: Using hospital episode statistics (HES) registration systems and a multicentre audit to describe outcomes of emergency readmission following elective endoscopy. METHODS: Emergency readmissions (April 2008-2009) within 6 days of an elective day-case upper-GI endoscopy (UE) and lower GI endoscopy (LE) were subjected to a multicentre retrospective audit (north-west of England) following the identification of cases from routinely coded hospital administrative data from HES. RESULTS: Of 29 868 day cases, there were 235 readmissions, of which 147 (63%) were endoscopy related. The overall endoscopy readmission rate was 0.5% and the highest for therapeutic UE (1.74%; P=0.0001). The rates for therapeutic LE, diagnostic UE and LE were 0.6, 0.5 and 0.4%, respectively. The incidence of readmission was 0.2% because of cardiorespiratory event, 0.14% for symptoms and 0.08, 0.03, 0.02 and 0.016%, respectively, for bleeding, perforation, obstruction and nonrespiratory sepsis. Management was simple observation in 84.4%, intravenous antibiotics in 7.5%, surgery in 4.8% and repeat endoscopy in 2.7%. Although 24.5% were short-stay discharges, the mean hospital stay was 8.2 days. All-cause 30-day mortality was low at 0.06%, but was considerably higher in readmitted patients at 6.8% (P=0.0001). CONCLUSION: Novel insights into readmission rates can be gained following endoscopy using a combination of commercial analytical tools to examine HES data to identify eligible readmitted cases; multicentred patient-level audit readmission rates varied predictably across procedure types with cardiorespiratory events, the major cause. The risk of mortality in readmitted patients was significant.

The effect of high quality assurance measures in bowel cancer screening on patient satisfaction of colonoscopy.

BACKGROUND: To ensure patient safety, rigorous quality assurance (QA) measures for colonoscopy were introduced for the Bowel Cancer Screening Programme (BCSP) in England. The impact of these high QA measures on patient experience and satisfaction is unknown. AIMS: To determine the impact of this high-level QA of colonoscopy on patient satisfaction. METHODS: A case controlled study using a retrospective audit & telephone interview patient survey was performed between 1/1/07-01/10/08 on patients that underwent colonoscopy. Data were analyzed by comparing quantitative and qualitative performance colonoscopy indicators in patients within the BCSP with those outside the programme (NON-BCSP). PARTICIPANTS: 720 patients that had undergone day case colonoscopy. SETTING: Accredited BCSP centre: University Hospitals Aintree, UK. INTERVENTION: Comparing patient satisfaction between BCSP to NON-BCSP populations. RESULTS: Uptake was 68% (n=488). Caecal intubation rate (CIR) was higher (99 v 91%; p=0.001), and sedation doses lower in BCSP compared to NON-BCSP (Midazolam dose Median [IQR] (1 [0, 2] v 2 [1, 3] mg; respectively p=0.0001). For patient satisfaction and experience, scores were high and pain scores were low in both groups; with no statistically significant difference between groups. However, willingness to have a repeat procedure was higher in BCSP (p=0.001). CONCLUSIONS: Whilst superior CIR with less sedation within BCSP, overall scores were similar for patient satisfaction, both in and outside the programme. With the higher 'willingness for repeat' within BCSP, a positive impact of higher level of QA is suggested and that good patient experience can be achieved with minimal conscious sedation in expert hands.

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.

All-cause mortality after first ERCP in England: clinically guided analysis of hospital episode statistics with linkage to registry of death.

BACKGROUND: All-cause death within 30 days of ERCP is a candidate indicator of care, but institutional-level statistics require careful interpretation. National-scale, population-based outcome studies of unselected patients undergoing ERCP are needed to define expected levels of real-world mortality risk and the case-mix factors that predict poor outcome. OBJECTIVE: To develop methods for analyzing administrative data for English hospitals with linkage to death registration to study all-cause mortality after first ERCPs and explore predictors of death and institutional variation. DESIGN: Hospital episode statistics for 2006 to 2007 and 2007 to 2008 were linked to the statutory death register. First ERCP episodes were extracted and analyzed for demographic characteristics, admission method, diagnoses, and comorbidities. Additional linkages identified the last-coded diagnosis before death. Factors associated with 30-day death were identified by univariate and multiple logistic analyses. Pilot data and a survey were sent to clinicians at each institution. Crude and case-mix adjusted mortality were analyzed at the institutional level. MAIN OUTCOME MEASUREMENTS: Death within 30 days of the first ERCP procedure. RESULTS: We analyzed 20,246 first ERCPs from 2006 to 2007 and 20,422 from 2007 to 2008. Diagnostic profile: gallstone related 57.3%; cancer 12.6%; gallstone and cancer 2%; others 28.1%. All-cause 30-day death was 5.3% (2.4% in non-cancer cases). Predictors of 30-day death (adjusted odds ratio [OR]) were as follows: age (OR 6.2, for ≥85 years vs <55 years), male sex (OR 1.2 vs female), emergency admission (OR 2.0 vs elective), cancer (OR 8.6 vs no cancer), and non-cancer comorbidity (OR 1.5 vs none). A mortality risk estimator (look-up table) based on pooled data for >40,000 first ERCPs is provided. Specific procedural complication codes were identified in 1.2% of deaths (0.06% of ERCPs). At the institutional level, analysis of mortality rates was within expected statistical funnel limits, and we found no correlation with ERCP volume (Pearson r = -0.05; P > .05). LIMITATIONS: The completeness and accuracy of coding may vary between different hospitals. Routine coding does not capture information about procedural complexity or severity of illness. CONCLUSION: Linkage analysis of hospital episode statistics data for England provides a powerful tool for studying mortality risk after ERCP on an unselected and truly nationwide scale. Institutional-level statistics suggest that the mortality risk for patients requiring ERCP was comparable across English hospitals.

An unusual presentation of fistulating Crohn's disease: Ascites.

Whilst ascites is a common presenting complaint in patients with decompensated chronic liver disease and disseminated malignancy, in Crohn's disease however, it is exceptionally rare. We describe a patient with no prior history of inflammatory bowel or liver disease, presenting with rapid onset gross ascites and scrotal swelling. Further investigations revealed severe hypoalbuminemia and transudative ascitic fluid with normal other liver function tests and a negative liver screen. Computed tomography revealed widespread ascites and pleural effusions with no features of malignancy or portal hypertension, and a small bowel barium series showed features of fistulating small bowel Crohn's disease. An ileo-colonoscopy confirmed the presence of terminal ileal inflammatory stricture. The patient's clinical condition and serum albumin improved with a combination of diuretics, elemental diet, antibiotics and oral 5-aminosalicylic acid therapy.

Safer sedation practice may not translate into improvements in endoscopic outcomes.

INTRODUCTION: Although the literature surrounding sedation practice and endoscopic outcomes remains sparse and controversial, there have been a number of stringent guidelines issued regarding sedation use in endoscopy. AIMS: To assess the impact of changes to enhance safer sedation practice on endoscopic outcomes. METHODS: Sedation practice was audited in 7234 consecutive gastrointestinal endoscopic procedures in 2004 and protocols for enhancing safer sedation practice were introduced. These included; introduction of a unit sedation policy, exchange of midazolam 10 mg vials to 5 mg repacked syringes, adverse events recording of midazolam use of greater than 5 mg and reversal agents, more stringent patient monitoring procedures and endoscopists education and feedback. A reaudit of 7071 procedures was performed in 2006. Outcomes audited the included midazolam doses, patient intolerance, 30-day postprocedure mortality, reversal agent use and total adverse events. RESULTS: Sedation doses were reduced substantially after intervention [mean midazolam dose (SD): 4.9 mg (2.5) in 2004 vs. 2.9 mg (1.2) in 2006; P<0.0001] with no endoscopist using a mean greater than 5 mg in 2006 compared with 19% in 2004 (P=0.005). The use of reversal agents (0.6 vs. 0.7% for 2004 and 2006, respectively; P=0.74), mortality (1.0 vs. 1.3%; P=0.23) and the adverse events (1.7 vs. 2%; P=0.44) were similar. Unsuccessful procedures because of patient intolerance increased from 0.1 to 1.9% (P<0.0001). CONCLUSION: Although protocols to enhance safer sedation practice substantially reduced sedation doses used; this did not, however, translate into improved endoscopic outcomes. Moreover, incomplete procedures because of poor tolerance increased.

Neurophysiologic assessment of esophageal sensory processing in noncardiac chest pain.

BACKGROUND & AIMS: Esophageal hypersensitivity is thought to be important in the generation and maintenance of symptoms in noncardiac chest pain (NCCP). In this study, we explored the neurophysiologic basis of esophageal hypersensitivity in a cohort of NCCP patients. METHODS: We studied 12 healthy controls (9 women; mean age, 37.1 +/- 8.7 y) and 32 NCCP patients (23 women; mean age, 47.2 +/- 10 y). All had esophageal manometry, esophageal evoked potentials to electrical stimulation, and NCCP patients had 24-hour ambulatory pH testing. RESULTS: The NCCP patients had reduced pain thresholds (PT) (72.1 +/- 19.4 vs 54.2 +/- 23.6, P = .02) and increased P1 latencies (P1 = 105.5 +/- 11.1 vs 118.1 +/- 23.4, P = .02). Subanalysis showed that the NCCP group could be divided into 3 distinct phenotypic classifications. Group 1 had reduced pain thresholds in conjunction with normal/reduced latency P1 latencies (n = 9). Group 2 had reduced pain thresholds in conjunction with increased (>2.5 SD) P1 latencies (n = 7), and group 3 had normal pain thresholds in conjunction with either normal (n = 10) or increased (>2.5 SD, n = 3) P1 latencies. CONCLUSIONS: Normal esophageal evoked potential latencies with reduced PT, as seen in group 1 patients, is indicative of enhanced afferent transmission and therefore increased esophageal afferent pathway sensitivity. Increased esophageal evoked potential latencies with reduced PT in group 2 patients implies normal afferent transmission to the cortex but heightened secondary cortical processing of this information, most likely owing to psychologic factors such as hypervigilance. This study shows that NCCP patients with esophageal hypersensitivity may be subclassified into distinct phenotypic subclasses based on sensory responsiveness and objective neurophysiologic profiles.