The 'ins and outs' of colonoscopy at Wits Donald Gordon Medical Centre, South Africa: A practice audit of the outpatient endoscopy unit.

BACKGROUND: In South Africa, there are no national guidelines for the conduct or quality assessment of colonoscopy, the gold standard for investigation and diagnosis of bowel pathology. OBJECTIVES: To describe the clinical profile of patients and evaluate the practice of colonoscopy using procedural quality indicators at the Wits Donald Gordon Medical Centre (WDGMC) outpatient endoscopy unit (OEU). METHODS: We conducted a prospective, clinical practice audit of colonoscopies performed on adults (≥18 years of age). A total of 1 643 patients were included in the study and variables that were collected enabled the assessment of adequacy of bowel preparation, length of withdrawal time and calculation of caecal intubation rate (CIR), polyp detection rate (PDR) and adenoma detection rate (ADR). We stratified PDR and ADR by sex, age, population group, withdrawal time and bowel preparation. CIR, PDR and ADR estimates were compared between patient groups by the χ2 test; Fisher's exact test was used for 2 × 2 tables. A p-value <0.05 was used. Benchmark recommendations by the American Society for Gastrointestinal Endoscopy (ASGE)/American College of Gastroenterology (ACG) Task Force on Colorectal Cancer (CRC) were used in this audit to assess individual endoscopist performance and that of the endoscopy unit as a whole. RESULTS: The mean age of patients was 55.7 (standard deviation (SD) 14.4; range 18 - 91) years, ~60% were female, and the majority (75.5%) were white. Of the outpatients, 77.6% had adequate bowel preparation (ASGE/ACG benchmark ≥85%). The CIR was 97.0% overall, and screening colonoscopy was 96.3% (ASGE/ACG benchmark ≥90% overall and ≥95% for screening colonoscopies). The median withdrawal time for negative-result screening colonoscopies was 5.7 minutes (interquartile range (IQR) 4.2 - 9.3; range 1.1 - 20.6) (ASGE/ACG benchmark ≥ 6minutes), and PDR and ADR were 27.6% and 15.6%, respectively (ASGE/ACG benchmark ADR ≥25%). We demonstrated a 23.7% increase in PDR and 14.1% increase in ADR between scopes that had mean withdrawal times of ≥6 minutes and <6 minutes, respectively. Although the number of black Africans in the study was relatively small, our results showed that they have similar ADRs and PDRs to the white population group, contradicting popular belief. CONCLUSIONS: The WDGMC OEU performed reasonably well against the international guidelines, despite some inadequacy in bowel preparation and lower than recommended median withdrawal times on negative-result colonoscopy. Annual auditing of clinical practice and availability of these data in the public domain will become standard of care, making this audit a baseline for longitudinal observation, assessing the impact of interventions, and contributing to the development of local guidelines.

Postoperative intensive care and the South African Society of Anaesthetists' patient category.

A group of 412 postoperative patients admitted to an intensive care unit of an academic hospital were evaluated in terms of their need for intensive care. The Acute Physiology and Chronic Health Evaluation score, the Therapeutic Intervention Scoring System (TISS) and the South African Society of Anaesthetists' (SASA) patient category were utilised to determine the level of care required by each patient. A further objective of the study was to determine if the SASA patient category, on its own, adequately described the need for intensive care in postoperative patients. Evaluation of the data indicated that, in terms of TISS, 66% of the patients required intensive care. These patients were distributed throughout all three SASA categories. Of the 137 patients who, according to TISS, did not require intensive care, 122 were SASA category 3 patients. However, of the total number of category 3 patients, just less than half required intensive care. In order to identify better those patients within a specific SASA category who require intensive care we suggest further subdivision of each category into groups A, B and C, according to the number of TISS points scored at 24 hours postoperation. In this way a retrospective audit using SASA categories would clearly identify those postoperative patients who required intensive care.

The syndromes of pancreatic pseudocysts and fluid collections.

The clinical and radiologic spectrum of pseudocysts associated with alcohol-induced pancreatitis is wide and variable. Several illustrative cases which delineate the diversity of syndromes that occur with pseudocysts are presented. A classification is proposed to facilitate a more coherent approach to the concept of pseudocysts and is based on the clinical presentation. Thus, in acute pancreatitis duct disruption and enzyme activation may result in intrapancreatic or extrapancreatic fluid collections. In calcifying chronic pancreatitis duct obstruction may result in pseudocysts of the head, body, or tail of the pancreas, which can enlarge and penetrate into extrapancreatic sites. This subdivision will assist in elucidating the natural history of pseudocysts and pancreatic fluid collections. Furthermore, it may establish new guidelines for diagnosis and therapy.