The isolated caecal patch lesion: a clinical, endoscopic and histopathological study.

OBJECTIVE: To describe and investigate the potential causes of the isolated caecal patch lesion, a previously undescribed endoscopic phenomenon of a lesion fulfilling endoscopic and histopathological criteria for chronic inflammatory bowel disease but without evidence of similar inflammatory pathology elsewhere at colonoscopy. METHODS: Cases were collected prospectively by one specialist gastrointestinal pathologist over a 10-year period. Full endoscopic and histopathological analysis was undertaken and follow-up sought to understand the likely cause(s) of the lesions. RESULTS: Six cases are described. Two had very close links with ulcerative colitis, one predating the onset of classical distal disease and the other occurring after previous demonstration of classical distal ulcerative colitis. Two occurred in younger patients and we postulate that these lesions may predict the subsequent onset of chronic inflammatory bowel disease. Finally two can be reasonably attributed to the effects of non-steroidal inflammatory agent therapy. CONCLUSIONS: Caecal patch lesions can be demonstrated in isolation. Despite the strong association of caecal patch lesions with ulcerative colitis, solitary lesions may well have disparate causes but nevertheless possess a close relationship with chronic inflammatory bowel disease.

ASGE principles of endoscopic training.

This White Paper shares guidance on the important principles of training endoscopy teachers, the focus of an American Society for Gastrointestinal Endoscopy (ASGE)/World Endoscopy Organization Program for Endoscopic Teachers and Leaders of Endoscopic Training held at the ASGE Institute for Training and Technology. Key topics included the need for institutional support and continuous skills development, the importance of consensus and consistency in content and approach to teaching, the role of conscious competence and content breakdown into discreet steps in effective teaching, defining roles of supervisors versus instructors to ensure teaching consistency across instructors, identification of learning environment factors and barriers impacting effective teaching, and individualized training that incorporates effective feedback and adapts with learner proficiency. Incorporating simulators into endoscopy teaching, applying good endoscopy teaching principles outside the endoscopy room, key principles of hands-on training, and effective use of simulators and models in achieving specific learning objectives were demonstrated with rotations through hands-on simulator stations as part of the program. A discussion of competency-based assessment was followed by live sessions in which attendees applied endoscopy teaching principles covered in the program. Conclusions highlighted the need for the following: formal training of endoscopy teachers to a level of conscious competence, incorporation of formal training structures into existing training curricula, intentional teaching preparation, feedback to trainees and instructors alike aimed at improving performance, and competency-based trainee assessment. The article is intended to help motivate individuals who play a role in training other endoscopists to develop their teaching abilities, promote discussions about endoscopy training, and engage both endoscopy trainers and trainees in a highly rewarding learning process that is in the best interest of patients.

Performance indicators in colonoscopy after certification for independent practice: outcomes and predictors of competence.

BACKGROUND: Robust real-world performance data of newly independent colonoscopists are lacking. In the United Kingdom, provisional colonoscopy certification (PCC) marks the transition from training to newly independent practice. We aimed to assess changes in key performance indicators (KPIs) such as cecal intubation rate (CIR) in the periods pre- and post-PCC, particularly regarding rates and predictors of trainees exhibiting a drop in performance (DIP), defined as CIR <90% in the first 50 procedures post-PCC. METHODS: A prospective United Kingdom-wide observational study of Joint Advisory Group on Gastrointestinal Endoscopy Electronic Training System (JETS) e-portfolio colonoscopy entries (257,800) from trainees awarded PCC between July 2011 and 2016 was undertaken. Moving average analyses were used to study KPI trends relative to PCC. Pre-PCC trainee, trainer, and training environment factors were compared between DIP and non-DIP cohorts to identify predictors of DIP. RESULTS: Seven hundred thirty-three trainees from 180 centers were awarded PCC after a median of 265 procedures and 3.1 years. Throughout the early post-PCC period, average CIRs surpassed the national 90% standard. Despite this, not all trainees achieved this standard post-PCC, with DIP observed in 18.4%. DIP was not influenced by trainer presence and diminished after 100 additional procedures. On multivariable analysis, pre-PCC CIRs and trainer specialty were predictive of DIP. Trainees with DIP incurred higher post-PCC rates of moderate to severe discomfort despite requiring higher analgesic dosages and were more likely to require trainer assistance in failed procedures. CONCLUSIONS: The current PCC requirements are appropriate for diagnostic colonoscopy. It is possible to identify predictors of underperformance in trainees, which may be of value to training leads and could improve the patient experience.

High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps.

BACKGROUND AND STUDY AIMS: The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates. PATIENTS AND METHODS: We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure. RESULTS: Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised. CONCLUSIONS: CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.

A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI).

BACKGROUND AND STUDY AIM: Cecal intubation rate (CIR) is an established performance indicator of colonoscopy. In some patients, cecal intubation with acceptable tolerance is only achieved with additional sedation. This study proposes a composite Performance Indicator of Colonic Intubation (PICI), which combines CIR, comfort, and sedation. METHODS : Data from 20 085 colonoscopies reported in the 2011 UK national audit were analyzed. PICI was defined as the percentage of procedures achieving cecal intubation with median dose (2 mg) of midazolam or less, and nurse-assessed comfort score of 1 - 3/5. Multivariate logistic regression analysis evaluated possible associations between PICI and patient, unit, colonoscopist, and diagnostic factors. RESULTS : PICI was achieved in 54.1 % of procedures. PICI identified factors affecting performance more frequently than single measures such as CIR and polyp detection, or CIR + comfort alone. Older age, male sex, adequate bowel preparation, and a positive fecal occult blood test as indication were associated with a higher PICI. Unit accreditation, the presence of magnetic imagers in the unit, greater annual volume, fewer years' experience, and higher training/trainer status were associated with higher PICI rates. Procedures in which PICI was achieved were associated with significantly higher polyp detection rates than when PICI was not achieved. CONCLUSIONS : PICI provides a simpler picture of performance of colonoscopic intubation than separate measures of CIR, comfort, and sedation. It is associated with more factors that are amenable to change that might improve performance and with higher likelihood of polyp detection. It is proposed that PICI becomes the key performance indicator for intubation of the colon in colonoscopy quality improvement initiatives.

Training the gastrointestinal endoscopy trainer.

Endoscopy training has traditionally been accomplished by an informal process in the endoscopy unit that parallels apprenticeship training seen in other areas of professional education. Subsequent to an audit, a series of interventions were implemented in the English National Health Service to support both service delivery and to improve endoscopy training. The resulting training centers deliver a variety of hands-on endoscopy courses, established in parallel with the roll out of a colon cancer screening program that monitors and documents quality outcomes among endoscopists. The program developed a 'training the trainer' module that subsequently became known as the Training the Colonoscopy Trainer course (TCT). Several years after its implementation, colonoscopy quality outcomes in the UK have improved substantially. The core TCT program has spread to other countries with demonstration of a marked impact on endoscopy training and performance. The aim of this chapter is to describe the principles that underlie effective endoscopy training in this program using the TCT as an example. While the review focuses on the specific example of colonoscopy training, the approach is generic to the teaching of any technical skill; it has been successfully transferred to the teaching of laparoscopic surgery as well as other endoscopic techniques.

Leadership and team building in gastrointestinal endoscopy.

A modern endoscopy service delivers high volume procedures that can be daunting, embarrassing and uncomfortable for patients [1]. Endoscopy is hugely beneficial to patients but only if it is performed to high standards [2]. Some consequences of poor quality endoscopy include worse outcomes for cancer and gastrointestinal bleeding, unnecessary repeat procedures, needless damage to patients and even avoidable death [3]. New endoscopy technology and more rigorous decontamination procedures have made endoscopy more effective and safer, but they have placed additional demands on the service. Ever-scarcer resources require more efficient, higher turnover of patients, which can be at odds with a good patient experience, and with quality and safety. It is clear from the demands put upon it, that to deliver a modern endoscopy service requires effective leadership and team working [4]. This chapter explores what constitutes effective leadership and what makes great clinical teams. It makes the point that endoscopy services are not usually isolated, independent units, and as such are dependent for success on the organisations they sit within. It will explain how endoscopy services are affected by the wider policy and governance context. Finally, within the context of the collection of papers in this edition of Best Practice & Research: Clinical Gastroenterology, it explores the potentially conflicting relationship between training of endoscopists and service delivery. The effectiveness of leadership and teams is rarely the subject of classic experimental designs such as randomized controlled trials. Nevertheless there is a substantial literature on this subject within and particularly outside healthcare [5]. The authors draw on this wider, more diffuse literature and on their experience of delivering a Team Leadership Programme (TLP) to the leaders of 70 endoscopy teams during the period 2008-2012. (Team Leadership Programme Link-http://www.qsfh.co.uk/Page.aspx?PageId=Public).

Development and implementation of the Structured Training Trainer Assessment Report (STTAR) in the English National Training Programme for laparoscopic colorectal surgery.

BACKGROUND: There is a lack of educational tools available for surgical teaching critique, particularly for advanced laparoscopic surgery. The aim was to develop and implement a tool that assesses training quality and structures feedback for trainers in the English National Training Programme for laparoscopic colorectal surgery. METHODS: Semi-structured interviews were performed and analysed, and items were extracted. Through the Delphi process, essential items pertaining to desirable trainer characteristics, training structure and feedback were determined. An assessment tool (Structured Training Trainer Assessment Report-STTAR) was developed and tested for feasibility, acceptability and educational impact. RESULTS: Interview transcripts (29 surgical trainers, 10 trainees, four educationalists) were analysed, and item lists created and distributed for consensus opinion (11 trainers and seven trainees). The STTAR consisted of 64 factors, and its web-based version, the mini-STTAR, included 21 factors that were categorised into four groups (training structure, training behaviour, trainer attributes and role modelling) and structured around a training session timeline (beginning, middle and end). The STTAR (six trainers, 48 different assessments) demonstrated good internal consistency (α = 0.88) and inter-rater reliability (ICC = 0.75). The mini-STTAR demonstrated good inter-item reliability (α = 0.79) and intra-observer reliability on comparison of 85 different trainer/trainee combinations (r = 0.701, p = <0.001). Both were found to be feasible and acceptable. The educational report for trainers was found to be useful (4.4 out of 5). CONCLUSIONS: An assessment tool that evaluates training quality was developed and shown to be reliable, acceptable and of educational value. It has been successfully implemented into the English National Training Programme for laparoscopic colorectal surgery.

The effective use of gastrointestinal histopathology: guidance for endoscopic biopsy in the gastrointestinal tract.

This is the first of three articles, published in Frontline Gastroenterology, that provides practical guidance of what to, and what not to, biopsy in the gastrointestinal (GI) tract. This initiative was established by the Endoscopy and Pathology Sections of the British Society of Gastroenterology, and the guidance is published with an initial general review (this manuscript), followed by practical guidance on upper GI and lower GI endoscopic biopsy practice. The three articles are written by experienced operatives, each one by a pathologist and an endoscopist, working in the same hospital/group of hospitals.

Patient comfort and quality in colonoscopy.

AIM: To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy. METHODS: All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson's correlation coefficient was used to identify relationships between performance indicators. RESULTS: A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r = -0.61, P < 0.005), and with poor patient experience (r = -0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r = -0.59, P < 0.01). CIR was positively correlated with PDR (r = 0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r = 0.64, P < 0.01). CONCLUSION: The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.

The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK.

OBJECTIVE: To perform a comprehensive audit of all colonoscopy undertaken in the UK over a 2-week period. DESIGN: Multi-centre survey. All adult (≥16 years of age) colonoscopies that took place in participating National Health Service hospitals between 28 February 2011 and 11 March 2011 were included. RESULTS: Data on 20,085 colonoscopies and 2681 colonoscopists were collected from 302 units. A validation exercise indicated that data were collected on over 94% of all procedures performed nationally. The unadjusted caecal intubation rate (CIR) was 92.3%. When adjusted for impassable strictures and poor bowel preparation the CIR was 95.8%. The polyp detection rate was 32.1%. The polyp detection rate for larger polyps (≥10 mm diameter) was 11.7%. 92.3% of resected polyps were retrieved. 90.2% of procedures achieved acceptable levels of patient comfort. A total of eight perforations and 52 significant haemorrhages were reported. Eight patients underwent surgery as a consequence of a complication. CONCLUSIONS: This is the first national audit of colonoscopy that has successfully captured the majority of adult colonoscopies performed across an entire nation during a defined time period. The data confirm that there has been a significant improvement in the performance of colonoscopy in the UK since the last study reported seven years ago (CIR 76.9%) and that performance is above the required national standards.

The Global Rating Scale in clinical practice: a comprehensive quality assurance programme for endoscopy departments.

BACKGROUND: The Global Rating Scale is an endoscopy quality assurance programme, successfully implemented in England. It remains uncertain whether it is applicable in another health care setting. AIM: To assess the applicability of the Global Rating Scale as benchmark tool in an international context. METHODS: Eleven Dutch endoscopy departments were included for a Global Rating Scale-census, performed as a cross-sectional evaluation, July 2010. Two Global Rating Scale-dimensions - 'clinical quality' and 'patient experience' - were assessed across six items using a range of levels: from level-D (basic) to level-A (excellent). Construct validity was assessed by comparing department-specific colonoscopy audit data to GRS-levels. RESULTS: For 'clinical quality', variable scores were achieved in items 'safety' (9%=B, 27%=C, 64%=D) and 'communication' (46%=A, 18%=C, 36%=D). All departments achieved a basic score in 'quality' (100%=D). For 'patient experience', variable scores were achieved in 'timeliness' (18%=A, 9%=B, 73%=D) and 'booking-choice' (36%=B, 46%=C, 18%=D). All departments achieved basic scores in 'equality' (100%=D). Departments obtaining level-C or above in 'information', 'comfort', 'communication', 'timeliness' and 'aftercare', achieved significantly better audit outcomes compared to those obtaining level-D (p<0.05). CONCLUSION: The Global Rating Scale is appropriate to use outside England. There was significant variance across departments in dimensions. Most Global Rating Scale-levels were in line with departments' audit outcomes, indicating construct validity.

Focal active colitis: a prospective study of clinicopathological correlations in 90 patients.

AIMS: Considerable controversy exists about the clinical implication of a diagnosis of focal active colitis (FAC). The aim of this study was to assess clinicopathological correlations of FAC in 90 adults, representing the largest and only prospective series of FAC. METHODS AND RESULTS: Patients were assessed by comprehensive clinical follow-up and questionnaires. Fifteen histopathological features were scored and correlated with clinical outcome. In 24% of patients drugs, especially NSAIDs, were implicated. Infection was a probable cause in 19%. In 14 patients (15.6%), predominantly women, a diagnosis of chronic inflammatory bowel disease was ultimately made. Most were Crohn's disease, but this is the first study in which FAC has presaged an ultimate diagnosis of ulcerative colitis in adults (in two patients). A specific subtype of FAC, termed basal FAC, was significantly associated with drugs. These excepted, this study has found no histopathological parameters of FAC, such as amount, location and/or distribution, to correlate with clinical outcome or allowed selection of those patients more likely to show subsequent evidence of chronic inflammatory bowel disease. CONCLUSION: This study has provided powerful information on the implication of a diagnosis of FAC. In a small but not inconsiderable case number, the ultimate diagnosis will be chronic inflammatory bowel disease.

Limited impact on endoscopy demand from a primary care based 'test and treat' dyspepsia management strategy: the results of a randomised controlled trial.

BACKGROUND: Helicobacter pylori testing has been suggested as an alternative to endoscopy for young patients with dyspepsia. Secondary care studies have suggested that demand for endoscopy among this group could be reduced by up to 74%. However, the effect of H. pylori testing in the primary care setting, where the majority of dyspepsia is managed, is unclear. AIM: To determine the effects of providing a H. pylori serology service for GPs upon demand for open access endoscopy. DESIGN OF STUDY: A prospective randomised controlled trial. SETTING: Forty-seven general practices in Gloucestershire. METHOD: General practices were stratified by endoscopy referral rate and randomised into two groups. The intervention group was provided with access to H. pylori serology testing and encouraged to use it in place of endoscopy for patients aged under 55 years with dyspepsia. Endpoints were referral for endoscopy and serology use. RESULTS: There was a significant reduction in referrals for endoscopy in the intervention group compared to the control group: 18.8% (95% confidence interval = 5.0 to 30.6%; P = 0.009). CONCLUSIONS: Providing GPs with H. pylori serology testing reduced demand for open access endoscopy, but by less than previous studies had predicted.