Colorectal endoscopic submucosal dissection: Systematic review of mid-term clinical outcomes.

With a drive towards minimally invasive surgery, endoscopic submucosal dissection (ESD) is now gaining popularity. In a number of East Asian countries, ESD is now the treatment of choice for early non-metastatic gastric cancer, but the outcomes of ESD for colorectal lesions are unclear. The present review summarizes the mid-term outcomes of colorectal ESD including complication and recurrence rates. A systematic literature search was done in May 2014, identifying 20 publications reporting the outcomes of colorectal ESD which were included in this review. En-bloc resection rates, complete (R0) resection rates, endoscopic clearance rates, complication and recurrences rates were analyzed. Statistical pooling was done to calculate weighted means using random effects modeling. Twenty studies reporting the outcomes of 3060 colorectal ESD procedures were reported. Overall weighted en-bloc resection rate was 89% (95% CI: 83-94%), R0 resection rate 76% (95% CI: 69-83%), endoscopic clearance rate 94% (95% CI: 90-97%) and recurrence rate 1% (95% CI: 0.5-2%). Studies that followed up patients for over 1 year were found to have an en-bloc resection rate of 91% (95% CI: 86-96%), R0 resection rate of 81% (95% CI: 75-88%), endoscopic clearance rate 93% (95% CI: 90-97%) and recurrence rate of 0.8% (95% CI: 0.4-1%). Colorectal ESD can be carried out effectively and safely with a 1% recurrence rate. Further studies with longer follow-up periods are required to determine whether colorectal ESD is a viable alternative to conventional surgical therapy.

Factors associated with failed polyp retrieval at screening colonoscopy.

BACKGROUND: Colonoscopy reduces colorectal cancer mortality and morbidity principally by the detection and removal of colon polyps. It is important to retrieve resected polyps to be able to ascertain their histologic characteristics. OBJECTIVE: The aim of the study was to evaluate the cause of polyp retrieval failure. DESIGN: Bowel cancer screening colonoscopy data were collected prospectively. SETTING: The Bowel Cancer Screening Program in the National Health Service. PATIENTS: Screening participants were referred to our screening center after a positive fecal occult blood test result. INTERVENTION: A total of 4383 polyps were endoscopically removed from 1495 patients from October 2006 to February 2011. MAIN OUTCOME MEASUREMENTS: The number, size, shape, and location of polyps; polyp removal method; quality of bowel preparation; total examination time; and insertion and withdrawal times in collected data were examined retrospectively. RESULTS: The polyp retrieval rate was 93.9%, and the failure rate was 6.1%, thus 267 polyps were not retrieved. In univariate analysis, factors affecting polyp retrieval failure were small polyp size, sessile polyps, and cold snare polypectomy (P < .001). Polyp retrieval was less successful in the proximal colon (P = .002). In multivariate analysis, polyp size and method of removal were independent risk factors for polyp retrieval failure (P < .001). LIMITATIONS: Retrospective study. CONCLUSION: Small polyp size and cold snare removal were found to be significantly associated with polyp retrieval failure. It was difficult to retrieve small, sessile, and proximal colon polyps. Optical diagnosis could be an efficacious option as a surrogate for histologic diagnosis for these lesions in the near future.

Orientation in upper gastrointestinal endoscopy-the only way is up.

BACKGROUND: Oesophagogastroduodenoscopy is the gold standard investigation for the upper gastrointestinal (UGI) tract. Orientation during endoscopy is challenging and United Kingdom training focusses on technical competence and procedural safety. The reported location of UGI pathologies is crucial to post-endoscopic planning. AIM: To evaluate endoscopists' ability to spatially orientate themselves within the UGI tract. METHODS: A cross sectional descriptive study elicited, using an anonymised survey, the ability of endoscopists to orientate themselves within the UGI tract. The primary outcome was percentage of correct answers from all surveyed; secondary outcomes were percentage of correct answers from experienced vs novice endoscopists. Pearson's χ 2 test was applied to compare groups. RESULTS: Of 188 respondents, 86 were experienced endoscopists having completed over 1000 endoscopies. 44.4% of respondents correctly identified the anterior stomach and 47.3% correctly identified the posterior of the second part of the duodenum (D2). Experienced endoscopists were significantly more likely than novice to identify the anterior stomach correctly [61.6% vs 31.3%, X 2 (1, n = 188) = 11.10, P = 0.001]. There was no significant difference between the two groups in identifying the posterior of D2. CONCLUSION: The majority of endoscopists surveyed were unable to identify key landmarks within the UGI tract. Endoscopic orientation appears to improve with experience yet there are some areas still not well recognised. This has potential considerable impact on post-endoscopic management of patients with posterior duodenal ulcers being more likely to perforate and associated with a higher rebleeding risk. We suggest the development of a consensus statement on endoscopic description.

Does computer-aided diagnostic endoscopy improve the detection of commonly missed polyps? A meta-analysis.

BACKGROUND/AIMS: Colonoscopy is the gold standard diagnostic method for colorectal neoplasia, allowing detection and resection of adenomatous polyps; however, significant proportions of adenomas are missed. Computer-aided detection (CADe) systems in endoscopy are currently available to help identify lesions. Diminutive (≤5 mm) and nonpedunculated polyps are most commonly missed. This meta-analysis aimed to assess whether CADe systems can improve the real-time detection of these commonly missed lesions. METHODS: A comprehensive literature search was performed. Randomized controlled trials evaluating CADe systems categorized by morphology and lesion size were included. The mean number of polyps and adenomas per patient was derived. Independent proportions and their differences were calculated using DerSimonian and Laird random-effects modeling. RESULTS: Seven studies, including 2,595 CADe-assisted colonoscopies and 2,622 conventional colonoscopies, were analyzed. CADe-assisted colonoscopy demonstrated an 80% increase in the mean number of diminutive adenomas detected per patient compared with conventional colonoscopy (0.31 vs. 0.17; effect size, 0.13; 95% confidence interval [CI], 0.09-0.18); it also demonstrated a 91.7% increase in the mean number of nonpedunculated adenomas detected per patient (0.32 vs. 0.19; effect size, 0.05; 95% CI, 0.02-0.07). CONCLUSION: CADe-assisted endoscopy significantly improved the detection of most commonly missed adenomas. Although this method is a potentially exciting technology, limitations still apply to current data, prompting the need for further real-time studies.

The evolution of lower gastrointestinal endoscopy: where are we now?

Lower gastrointestinal endoscopy has evolved over time, fulfilling a widening diagnostic and therapeutic remit. As our understanding of colorectal cancer and its prevention has improved, endoscopy has progressed with improved diagnostic technologies and advancing endoscopic therapies. Despite this, the fundamental design of the endoscope has remained similar since its inception. This review presents the important role lower gastrointestinal endoscopy serves in the prevention of colorectal cancer and the desirable characteristics of the endoscope that would enhance this. A brief history of the endoscope is presented. Current and future robotic endoscopic platforms, which may fulfil these desirable characteristics, are discussed. The incorporation of new technologies from allied scientific disciplines will help the endoscope fulfil its maximum potential in preventing the increasing global burden of colorectal cancer. There are a number of endoscopic platforms under development, which show significant promise.

Endoscopic submucosal dissection: an update on tools and accessories.

Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.

The impact of the introduction of formalised polypectomy assessment on training in the UK.

OBJECTIVE: The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process. DESIGN: Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. SETTING: UK National Health Service. PATIENTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied. RESULTS: Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0-16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3-27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9-199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed. CONCLUSIONS: Structured polypectomy assessment improves trainees' documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.

Factors defining expertise in screening colonoscopy.

BACKGROUND AND STUDY AIMS: There is very little literature defining characteristics of expert endoscopists. It is hypothesised that previously undetermined human factors may correlate with high performance in screening colonoscopists. The aim of this study was to determine factors contributing towards expertise in screening colonoscopy. MATERIALS AND METHODS: A focus group was used to hypothesise skills considered to be relevant to high performance in colonoscopy. The skills were then ranked in order of importance by an independent group of screening colonoscopists for both diagnostic and therapeutic colonoscopy. Twenty screening colonoscopists subsequently participated in individual semi-structured interviews to explore participants' views of expertise and the factors contributing to it. Data extracted from the interview transcripts were used to identify the thematic framework associated with expertise. RESULTS: The 5 initial highest-ranked themes were low complication rates, high adenoma detection rates, interpersonal skills with staff, communication skills, and manner with patients. Interviewees considered technical skills (20/20), previous experience of colonoscopy (19/20), judgment/decision-making (18/20), communication (18/20), teamwork (15/20), resources (11/20) and leadership (8/20) to be the most important themes related to expertise. CONCLUSIONS: Both technical and non-technical abilities are considered essential components of expertise by experienced colonoscopists. Further research into targeted interventions to improve the rate of acquisition of these skills in training endoscopists may be useful in improving performance.

Digital dictation and voice transcription software enhances outpatient clinic letter production: a crossover study.

BACKGROUND: Digital voice transcription has been introduced widely in the National Health Service (NHS), though primarily in radiology departments. There has been a long-standing problem with recruitment of medical secretaries within the NHS, leading to long delays in the production of correspondence from outpatient clinics. OBJECTIVE: To determine whether use of widely available digital transcription software improves efficiency and the time taken to produce correspondence. METHODS: The project used a prospective, crossover trial design in a 'real-world' environment. Correspondence from clinics was transcribed after dictation by a secretary using conventional analogue audio tape or the dictation software. After a 2-week washout period the same clinics' dictations were transcribed using the other method to produce identical correspondence. The two sets of letters were compared. RESULTS: The mean time for the secretary to produce letters for a complete clinic using digital dictation was 66 min whereas analogue dictation took 121 min (p<0.00002). There was no difference in the number of mistakes per letter (p>0.05). CONCLUSION: Voice transcription software significantly decreased the time taken to transcribe outpatient clinic letters with minimal training of secretarial staff, resulting in improved efficiency.