UK key performance indicators and quality assurance standards for colonoscopy

Lynch syndrome: from detection to treatment

Lynch syndrome (LS) is an inherited cancer predisposition syndrome associated with high lifetime risk of developing tumours, most notably colorectal and endometrial. It arises in the context of pathogenic germline variants in one of the mismatch repair genes, that are necessary to maintain genomic stability. LS remains underdiagnosed in the population despite national recommendations for empirical testing in all new colorectal and endometrial cancer cases. There are now well-established colorectal cancer surveillance programmes, but the high rate of interval cancers identified, coupled with a paucity of high-quality evidence for extra-colonic cancer surveillance, means there is still much that can be achieved in diagnosis, risk-stratification and management. The widespread adoption of preventative pharmacological measures is on the horizon and there are exciting advances in the role of immunotherapy and anti-cancer vaccines for treatment of these highly immunogenic LS-associated tumours. In this review, we explore the current landscape and future perspectives for the identification, risk stratification and optimised management of LS with a focus on the gastrointestinal system. We highlight the current guidelines on diagnosis, surveillance, prevention and treatment and link molecular disease mechanisms to clinical practice recommendations.

Post-colonoscopy cancer rate at a tertiary referral hospital in Australia: A data linkage analysis

BACKGROUND AND AIM

Colorectal cancer (CRC) diagnosed following a cancer-negative colonoscopy is termed as post-colonoscopy CRC (PCCRC). The World Endoscopy Organization has recently standardized the definition of PCCRC-3Y (CRC developing within 3 years of a cancer-negative colonoscopy). In the present study, we sought to assess PCCRC-3Y rate, perform root-cause analyses, and identify factors associated with development of PCCRC at a tertiary referral hospital in Australia.

METHODS

All patients undergoing colonoscopy from 2011 to 2018 were matched to a population-based cancer register. PCCRC-3Y rate was assessed for years 2011-2015. All PCCRC cases that developed within 6-48 months after a cancer-negative colonoscopy underwent root-cause analyses. Descriptive statistics were used to summarize data.

RESULTS

Among 17 828 patients undergoing colonoscopy, 367 CRC cases were diagnosed during the study period. This included nine PCCRC cases, which developed at a median of 14 months (range 7-34 months) after cancer-negative colonoscopy. The PCCRC-3Y rate for years 2011-2015 was 2.16% (95% CI 0.91-5.15). All nine PCCRC cases were moderately or poorly differentiated adenocarcinomas; seven of nine were early-stage CRC (stages I and II) and six of nine probably represented missed lesions at index colonoscopy despite an apparently adequate examination. History of inflammatory bowel disease (IBD) (odds ratio [OR] 21.9, 95% confidence interval [CI] 4.6-103.7, P < 0.001) and diverticulosis (OR 5.4, 95% CI 1.4-20.5, P = 0.01) were significantly associated with development of missed CRC.

CONCLUSIONS

In our tertiary referral colonoscopy cohort, PCCRC-3Y rate was 2.16% (95% CI 0.91-5.15). IBD and diverticulosis were significantly associated with risk of PCCRC. The majority of PCCRC lesions were likely missed at index colonoscopy, despite an apparently adequate examination.

Test performance metrics for breast, cervical, colon, and lung cancer screening: a systematic review

BACKGROUND

Multiple quality metrics have been recommended to ensure consistent, high-quality execution of screening tests for breast, cervical, colorectal, and lung cancers. However, minimal data exist evaluating the evidence base supporting these recommendations and the consistency of definitions and concepts included within and between cancer types.

METHODS

We performed a systematic review for each cancer type using MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 2010 to April 2020 to identify guidelines from screening programs or professional organizations containing quality metrics for tests used in breast, cervical, colorectal, and lung cancer screening. We abstracted metrics' definitions, target performance levels, and related supporting evidence for test completeness, adequacy (sufficient visualization or collection), accuracy, and safety.

RESULTS

We identified 11 relevant guidelines with 20 suggested quality metrics for breast cancer, 5 guidelines with 9 metrics for cervical cancer, 13 guidelines with 18 metrics for colorectal cancer (CRC), and 3 guidelines with 7 metrics for lung cancer. These included 54 metrics related to adequacy (n = 6), test completeness (n = 3), accuracy (n = 33), and safety (n = 12). Target performance levels were defined for 30 metrics (56%). Ten (19%) were supported by evidence, all from breast and CRC, with no evidence cited to support metrics from cervical and lung cancer screening.

CONCLUSIONS

Considerably more guideline-recommended test performance metrics exist for breast and CRC screening than cervical or lung cancer. The domains covered are inconsistent among cancers, and few targets are supported by evidence. Clearer evidence-based domains and targets are needed for test performance metrics.

REGISTRATION

PROSPERO 2020 CRD42020179139.

Eye tracking technology in endoscopy: Looking to the future

The visual patterns of an endoscopist, that is, what the endoscopist is looking at during luminal endoscopy, is an interesting area with an evolving evidence base. The tools required for gaze analysis have become cheaper and more easily accessible. A comprehensive literature search was undertaken identifying 19 relevant papers. Gaze analysis has been used to identify certain visual patterns associated with higher polyp detection rates. There have also been increasing applications of gaze analysis as an objective study tool to compare the effectiveness of endoscopic imaging technologies. Gaze analysis also has the potential to be incorporated into endoscopic training. Eye movements have been used to control and steer a robotic endoscope. This review presents the current evidence available in this novel and evolving field of endoscopic research.

Outcomes of patients with non-lower gastrointestinal cancer diagnosed via the lower gastrointestinal two-week-wait service

INTRODUCTION

Patients referred via lower gastrointestinal two-week-wait (LGI-2WW) services deemed at 'low risk' of LGI cancer may have delayed or no investigation. However, 20% of patients diagnosed with cancer via the LGI-2WW have non-LGI cancer. This study investigates the outcomes in this under-reported group.

METHODS

A retrospective analysis of patients referred to a UK LGI-2WW service with a non-LGI cancer diagnosis (International Classification of Diseases 10th revision) between 1 January 2015 and 31 December 2018. The primary outcome was all-cause mortality. Statistical analysis was undertaken using Kaplan-Meier survival curves with generalised log-rank test and binomial logistic regression of pre-investigation information to predict death. A p-value of < 0.05 represented statistical significance.

RESULTS

In total, 140 patients were diagnosed with non-LGI cancer (of 10,155 patients referred via the LGI-2WW pathway). Median follow-up was 13 months (range 0-65 months). Thirty-five patients (35/140; 25%) did not meet LGI-2WW referral criteria. Median survival varied by cancer site (upper gastrointestinal: 43/140 patients, median survival 4 months; gynaecological: 25/140, 25 months; haematological: 22/140, < 50% died; urological: 21/140, 47 months; unknown primary: 12/140, 3 months; lung: 10/140, 17 months; breast: 3/140, 5 months; retroperitoneal: 2/140, 9 months; brain: 1/140, 4 months; adrenal: 1/140, 52 months). Binomial logistic regression was statistically significant (chi-squared goodness-of-fit test = 12.334; p = 0.03); but the presence of comorbidity was the only significant predictive factor of death (p = 0.03).

CONCLUSIONS

Patients with non-LGI cancers cannot be easily predicted and have a poor prognosis. Pathways to streamline investigations for LGI cancer should include computed tomography scans for patients at 'low risk' of LGI cancer to ensure that non-LGI cancers are diagnosed.

A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer

BACKGROUND : Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. METHODS : The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6-36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. RESULTS : Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5-81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett's esophagus. PEUGICs were categorized as: A - lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B - lesion detected, inadequate assessment or decision-making (34.8 %); C - possible missed lesion, endoscopy and decision-making adequate (8.9 %); D - possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E - deviated from management pathway but appropriate (5.6 %); F - deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists' mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient -0.57; P = 0.004). CONCLUSION : Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.

JAG consensus statements for training and certification in flexible sigmoidoscopy

INTRODUCTION

Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).

METHODS

A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.

RESULTS

In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS.

CONCLUSION

The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.

JAG consensus statements for training and certification in colonoscopy

INTRODUCTION

In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.

METHODS

Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.

RESULTS

In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.

CONCLUSION

The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.

Colonoscopy quality improvement after initial training: A cross-sectional study of intensive short-term training

Background and study aims High-quality is crucial for the effectiveness of colonoscopy and can be achieved by high-quality training and verified with assessment of key performance indicators (KPIs) for colonoscopy such as cecum intubation rate (CIR), adenoma detection rate (ADR) and adequate polyp resection. Typically, trainees achieve adequate CIR after 275 procedures, but little is known about learning curves for KPIs after initial training. Methods This cross-sectional study includes work-up colonoscopies after a positive screening test with fecal occult blood testing (FIT) or sigmoidoscopy, performed by either trainees after 300 training colonoscopies or by consultants. Outcome measures were KPIs. We assessed inter-endoscopist variation in trainees and learning curves for trainees as a group. We also compared KPIs for trainees and consultants as a group.  Results Data from 6,655 colonoscopies performed by 21 trainees and 921 colonoscopies performed by 17 consultants were included. Most trainees achieved target standards for main KPIs. With time, trainees shortened cecum intubation time and withdrawal time without decreasing their ADR, reduced the proportion of painful colonoscopies, and increased the adequate polyp resection rate (all P  < 0.01). Compared to consultants, trainees had higher CIR (97.7 % vs. 96.3 %, P  = 0.02), ADR after positive FIT (57.6 % vs. 50.3 %, P  < 0.01), and proximal ADR after sigmoidoscopy screening (41.1 % vs. 29.8 %; P  < 0.01), higher adequate polyp resection rate (94.9 % vs. 93.1 %, P  = 0.01) and fewer serious adverse events (0.65 % vs. 1.41 %, P  = 0.02). Conclusions Trainees performed high-quality colonoscopies and achieved international target standards. Several KPIs continuously improved after initial training. Trainees outperformed consultants on several KPIs.

Complications of diagnostic upper Gastrointestinal endoscopy: common and rare - recognition, assessment and management

A clear understanding of the potential complications or adverse events (AEs) of diagnostic endoscopy is an essential component of being an endoscopist. Creating a culture of safety and prevention of AEs should be part of routine endoscopy practice. Appropriate patient selection for procedures, informed consent, periprocedure risk assessments and a team approach, all contribute to reducing AEs. Early recognition, prompt management and transparent communication with patients are essential for the holistic and optimal management of AEs. In this review, we discuss the complications of diagnostic upper gastrointestinal endoscopy, including their recognition, treatment and prevention.

Where do we stand in AI for endoscopic image analysis? Deciphering gaps and future directions

Recent developments in deep learning have enabled data-driven algorithms that can reach human-level performance and beyond. The development and deployment of medical image analysis methods have several challenges, including data heterogeneity due to population diversity and different device manufacturers. In addition, more input from experts is required for a reliable method development process. While the exponential growth in clinical imaging data has enabled deep learning to flourish, data heterogeneity, multi-modality, and rare or inconspicuous disease cases still need to be explored. Endoscopy being highly operator-dependent with grim clinical outcomes in some disease cases, reliable and accurate automated system guidance can improve patient care. Most designed methods must be more generalisable to the unseen target data, patient population variability, and variable disease appearances. The paper reviews recent works on endoscopic image analysis with artificial intelligence (AI) and emphasises the current unmatched needs in this field. Finally, it outlines the future directions for clinically relevant complex AI solutions to improve patient outcomes.

Comparison of adenoma detection rate and proximal serrated polyp detection rate and their effect on post-colonoscopy colorectal cancer mortality in screening patients

BACKGROUND

Patients with serrated polyps are at increased risk for post-colonoscopy colorectal cancer (PCCRC); however, evidence for a dedicated serrated polyp detection rate is lacking. The aim of this study was to investigate the association of the proximal serrated polyp detection rate (PSDR) and adenoma detection rate (ADR) with PCCRC death.

METHODS

This was a retrospective analysis within the Austrian quality assurance program for screening colonoscopy. Spearman's rank coefficient was calculated for the assessment of association between ADR and PSDR. Whether ADR or PSDR were associated with colorectal cancer mortality was assessed by Cox proportional hazards model.

RESULTS

229 /729 screening colonoscopies performed by 308 endoscopists were analyzed. The ADR (hazard ratio [HR] per 1 percentage point increase 0.98, 95 %CI 0.96-0.99) as well as the PSDR (HR per 1 percentage point increase 0.97, 95 %CI 0.94-0.99) were significantly associated with PCCRC death. The correlation coefficient of the ADR and PSDR calculated at every colonoscopy was 0.70 (95 %CI 0.70-0.71), and the corresponding PSDR value for an ADR performance standard of 25 % was 11.1 %. At the end of the study period, 86 endoscopists (27.9 %) reached an ADR of > 25 % and a PSDR of > 11.1 %.

CONCLUSIONS

The ADR as well as the PSDR were associated with PCCRC death. Striving for a high PSDR in addition to a high ADR might reduce the risk for PCCRC mortality in patients undergoing screening colonoscopy.

The effect of the endoscopic device Endocuff™/Endocuff vision™ on quality standards in colonoscopy: A systematic review and meta-analysis of randomized trials

AIM

The adenoma detection rate (ADR) is an important quality measure, with a high ADR reflecting high-quality colonoscopy. This systematic review and meta-analysis aimed to assess the effects of Endocuff™/Endocuff Vision™-assisted colonoscopy (EAC) versus standard colonoscopy (SC) on ADR and other clinical, patient and resource-use outcomes.

METHOD

MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials were searched for full papers reporting randomized studies comparing EAC with SC. The primary outcome was ADR. Secondary outcomes comprised key polyp/adenoma detection, procedure-related, patient-related and health economic measures. Random effects meta-analyses provided pooled estimates of outcomes [risk ratio (RR) or mean difference (MD), with 95% confidence intervals (CI)].

RESULTS

Twelve parallel-group randomized controlled trials (RCTs) and three crossover RCTs with data on 9140 patients were included. EAC significantly increased the ADR (RR 1.18, 95% CI 1.09-1.29), mean adenomas per procedure (MAP) (MD 0.19, 95% CI 0.06-0.33), polyp detection rate (PDR) (RR 1.20, 95% CI 1.10-1.30) and mean polyps per procedure (MPP) (MD 0.39, 95% CI 0.14-0.63) versus SC. EAC significantly increased segmental PDR versus SC in the sigmoid (RR 2.02, 95% CI 1.64-2.49), transverse (RR 1.63, 95% CI 1.09-2.42), ascending (RR 1.74, 95% CI 1.26-2.41) and caecal segments (RR 1.91, 95% CI 1.29-2.82). Procedure-related variables did not differ between arms. There were insufficient data for meta-analysis of health economic or patient-centred outcomes.

CONCLUSIONS

EAC increased ADR, MAP, PDR and MPP versus SC without detrimental effects on procedure measures. Cost-effectiveness and patient experience data are lacking and would be valuable to inform practice recommendations.

Implementation of optical diagnosis with a "resect and discard" strategy in clinical practice: DISCARD3 study

BACKGROUND AND AIMS

Optical diagnosis (OD) of polyps can be performed with advanced endoscopic imaging. For high-confidence diagnoses, a "resect and discard" strategy could offer significant histopathology time and cost savings. The implementation threshold is a ≥90% OD-histology surveillance interval concordance. Here we assessed the OD learning curve and feasibility of a resect and discard strategy for ≤5-mm and <10-mm polyps in a bowel cancer screening setting.

METHODS

In this prospective feasibility study, 8 bowel cancer screening endoscopists completed a validated OD training module and performed procedures. All <10-mm consecutive polyps had white-light and narrow-band images taken and were given high- or low-confidence diagnoses until 120 high-confidence ≤5-mm polyp diagnoses had been performed. All polyps had standard histology. High-confidence OD errors underwent root-cause analysis. Histology and OD-derived surveillance intervals were calculated.

RESULTS

Of 565 invited patients, 525 patients were included. A total of 1560 <10-mm polyps underwent OD and were resected and retrieved (1329 ≤5 mm and 231 6-9 mm). There were no <10-mm polyp cancers. High-confidence OD was accurate in 81.5% of ≤5-mm and 92.8% of 6-9-mm polyps. Sensitivity for OD of a ≤5-mm adenoma was 93.0% with a positive predictive value of 90.8%. OD-histology surveillance interval concordance for ≤5-mm OD was 91.3% (209/229) for U.S. Multi-Society Task Force, 98.3% (225/229) for European Society of Gastrointestinal Endoscopy, and 98.7% (226/229) for British Society of Gastroenterology guidelines, respectively.

CONCLUSIONS

A resect and discard strategy for high-confidence ≤5-mm polyp OD in a group of bowel cancer screening colonoscopists is feasible and safe, with performance exceeding the 90% surveillance interval concordance required for implementation in clinical practice. (Clinical trial registration number: NCT04710693.).

Interventions to improve the quality of screening-related colonoscopy: protocol for a systematic review and network meta-analysis of randomised controlled trials

INTRODUCTION

Colonoscopy quality can vary depending on endoscopist-related factors. Quality indicators, such as adenoma detection rate (ADR), have been adopted to reduce variations in care. Several interventions aim to improve ADR, but these fall into several domains that have traditionally been difficult to compare. We will conduct a systematic review and network meta-analysis of randomised controlled trials evaluating the efficacies of interventions to improve colonoscopy quality and report our findings according to clinically relevant interventional domains.

METHODS AND ANALYSIS

We will search MEDLINE (Ovid), PubMed, EMBASE, CINAHL, Web of Science, Scopus and Evidence-Based Medicine from inception to September 2022. Four reviewers will screen for eligibility and abstract data in parallel, with two accordant entries establishing agreement and with any discrepancies resolved by consensus. The primary outcome will be ADR. Two authors will independently conduct risk of bias assessments. The analyses of the network will be conducted under a Bayesian random-effects model using Markov-chain Monte-Carlo simulation, with 10 000 burn-ins and 100 000 iterations. We will calculate the ORs and corresponding 95% credible intervals of network estimates with a consistency model. We will report the impact of specific interventions within each domain against standard colonoscopy. We will perform a Bayesian random-effects pairwise meta-analysis to assess heterogeneity based on the I2 statistic. We will assess the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework for network meta-analyses.

ETHICS AND DISSEMINATION

Our study does not require research ethics approval given the lack of patient-specific data being collected. The results will be disseminated at national and international gastroenterology conferences and peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021291814.

[Quality Assurance of Screening Colonoscopy in Austria and Europe]

Die Vorsorgekoloskopie als effizientes Tool zur Reduktion von Kolorektalkarzinominzidenz und -mortalität ist nur dann effektiv, wenn sie unter hohen Qualitätsstandards durchgeführt wurde. Die European Society for Gastrointestinal Endoscopy gibt hierbei Key Performance Measures, wie die Adenomentdeckungsrate, die Zökumerreichsrate und die Rate an adäquater Vorbereitungsqualität, vor, auf die beim Screening geachtet werden sollten. Das „Qualitätszertifikat Darmkrebsvorsorge“, das als Qualitätssicherungsprogramm auf freiwilliger Basis von der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie gemeinsam mit dem Dachverband der österreichischen Sozialversicherungsträger und der Österreichischen Krebshilfe für Endoskopiker:innen in ganz Österreich ins Leben gerufen wurde, überprüft diese Qualitätsparameter. Es wird ein Darmkrebsscreening auf höchsten Standards angestrebt, um somit die besten Outcomes für Patient:innen zu erzielen. Auch europaweit ist das Interesse an einer qualitätsgesicherten Vorsorgekoloskopie groß: Viele Länder, wie z. B. die Niederlande, Norwegen und das Vereinigte Königreich haben Programme, um die Qualität des Screenings zu überwachen und zu verbessern.

Pediatric Endoscopy Quality Improvement Network (PEnQuIN) quality standards and indicators for pediatric endoscopy: an ASGE-endorsed guideline

BACKGROUND AND AIMS

Current endoscopy quality guidelines largely focus on cancer screening-related metrics that are not applicable to pediatric populations. Through an international Pediatric Endoscopy Quality Improvement Network (PEnQuIN), quality standards and indicators for pediatric endoscopic procedures were developed and endorsed by the American Society for Gastrointestinal Endoscopy (ASGE).

METHODS

The Appraisal of Guidelines for REsearch and Evaluation II instrument guided PEnQuIN members, from 31 centers representing 11 countries, in generating and refining proposed quality standards and indicators. Quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation approach. Consensus on reporting elements was sought with an iterative online Delphi process.

RESULTS

Forty-nine quality standards and 47 indicators, encompassing pediatric endoscopy facilities, procedures, and endoscopists, as well as 30 reporting elements essential for inclusion within a pediatric endoscopy report reached consensus. Minimal acceptable standards were defined for 3 key indicators related to pediatric lower endoscopy: terminal ileal intubation rate ≥85%, cecal intubation rate ≥90%, and rate of adequate bowel preparation ≥80%. There was strong consensus that terminal ileal intubation, rather than cecal intubation, is integral to ensuring high-quality endoscopic care in children.

CONCLUSIONS

The PEnQuIN guidelines establish international agreement on clinically meaningful metrics tailored to pediatric endoscopy that can be used to promote safe, high-quality, patient- and family-centered endoscopic care. Moving forward, it is recommended that all providers and facilities involved in endoscopy service for children adopt the PEnQuIN standards, indicators, and key reporting elements outlined in these ASGE-endorsed guidelines.

Visual gaze patterns in trainee endoscopists - a novel assessment tool

BACKGROUND

Colonoscopy proficiency is significantly influenced by skills achieved during training. Although assessment scores exist, they do not evaluate the impact of visual search strategies and their use is time and labour intensive. Eye-tracking has shown significant differences in visual gaze patterns (VGPs) between expert endoscopists with varying polyp detection rates, so may provide a means of automated assessment and guidance for trainees. This study aimed to assess the feasibility of eye-tracking as a novel assessment method for trainee endoscopists.

METHODS

Eye-tracking glasses were used to record 26 colonoscopies from 12 endoscopy trainees who were assessed with directly observed procedural scores (DOPS), devised by the Joint Advisory Group (JAG) on GI endoscopy, and a visual analogue score of overall competence. A 'total weighted procedure score' (TWPS) was calculated from 1 to 20. Primary outcomes of fixation duration (FixD) and fixation frequency (FixF) were analysed according to areas of interest (AOIs) with the bowel surface and lumen represented by three concentric rings. Correlation was assessed using Pearson's coefficient. Significance was set at p<.050.

RESULTS

Trainees displayed a significant positive correlation between TWPS and FixD (R = 0.943, p<.0001) and FixF (R = 0.936, p<.0001) in the anatomical bowel mucosa peripheries. Conversely, they had significant negative correlations between TWPS and the anatomical bowel lumen (FixD: R= -0.546, p=.004; FixF: R= -0.568, p=.002).

CONCLUSIONS

Higher objective performance scores were associated with VGPs focussing on bowel mucosa. This is consistent with prior analysis showing peripheral VGPs correspond with higher polyp detection rates. Analysis of VGPs, therefore, has potential for training and assessment in colonoscopy.

Development and validation of a deep learning-based algorithm for colonoscopy quality assessment

BACKGROUND

Quality indicators should be assessed and monitored to improve colonoscopy quality in clinical practice. Endoscopists must enter relevant information in the endoscopy reporting system to facilitate data collection, which may be inaccurate. The current study aimed to develop a full deep learning-based algorithm to identify and analyze intra-procedural colonoscopy quality indicators based on endoscopy images obtained during the procedure.

METHODS

A deep learning system for classifying colonoscopy images for quality assurance purposes was developed and its performance was assessed with an independent dataset. The system was utilized to analyze captured images and results were compared with those of real-world reports.

RESULTS

In total, 10,417 images from the hospital endoscopy database and 3157 from Hyper-Kvasir open dataset were utilized to develop the quality assurance algorithm. The overall accuracy of the algorithm was 96.72% and that of the independent test dataset was 94.71%. Moreover, 761 real-world reports and colonoscopy images were analyzed. The accuracy of electronic reports about cecal intubation rate was 99.34% and that of the algorithm was 98.95%. The agreement rate for the assessment of polypectomy rates using the electronic reports and the algorithm was 0.87 (95% confidence interval 0.83-0.90). A good correlation was found between the withdrawal time calculated using the algorithm and that entered by the physician (correlation coefficient r = 0.959, p < 0.0001).

CONCLUSION

We proposed a novel deep learning-based algorithm that used colonoscopy images for quality assurance purposes. This model can be used to automatically assess intra-procedural colonoscopy quality indicators in clinical practice.

Association Between Endoscopist Specialty and Colonoscopy Quality: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Colonoscopy quality indicators provide measurable assessments of performance, but significant provider-level variations exist. We performed a systematic review and meta-analysis to assess whether endoscopist specialty is associated with adenoma detection rate (ADR) - the primary outcome - or cecal intubation rate, adverse event rates, and post-colonoscopy colorectal cancer rates.

METHODS

We searched EMBASE, Google Scholar, MEDLINE, and the Cochrane Central Registry of Controlled Trials from inception to December 14, 2020. Two reviewers independently screened titles and abstracts. Citations underwent duplicate full-text review, with disagreements resolved by a third reviewer. Data were abstracted in duplicate. The DerSimonian and Laird random effects model was used to calculate pooled odds ratios (ORs) with respective 95% confidence intervals (CIs). Risk of bias was assessed using Risk of Bias in Non-randomised Studies of Interventions.

RESULTS

Of 11,314 citations, 36 studies representing 3,500,832 colonoscopies were included. Compared with colonoscopies performed by gastroenterologists, those by surgeons were associated with lower ADRs (OR, 0.81; 95% CI, 0.74-0.88) and lower cecal intubation rates (OR, 0.76; 95% CI, 0.63-0.92). Compared with colonoscopies performed by gastroenterologists, those by other (non-gastroenterologist, non-surgeon) endoscopists were associated with lower ADRs (OR, 0.91; 95% CI, 0.87-0.96), higher perforation rates (OR, 3.02; 95% CI, 1.65-5.51), and higher post-colonoscopy colorectal cancer rates (OR, 1.23; 95% CI, 1.14-1.33). Substantial to considerable heterogeneity existed for most analyses, and overall certainty in the evidence was low according to the Grading of Recommendations, Assessment, Development, and Evaluations framework.

CONCLUSION

Colonoscopies performed by surgeons or other endoscopists were associated with poorer quality metrics and outcomes compared with those performed by gastroenterologists. Targeted quality improvement efforts may be warranted.

Effect of nurse-performed enhanced patient education on colonoscopy bowel preparation quality

OBJECTIVE

to evaluate the effect of nurse-performed enhanced patient education sessions on adequate bowel preparation and cecal intubation rates.

METHOD

a prospective, quasi-experimental, comparative study with a quantitative approach. The intervention group (n=150) received education enhanced by a visual presentation and reminder calls. The control group (n=156) received the clinic's standard written instructions. Adequate bowel preparation rates and other colonoscopy quality indicators were compared between the groups.

RESULTS

Boston Bowel Preparation scale scores and adequate bowel preparation rates were higher in the intervention group than in the control group (respectively, 6.76±2.1 vs. 5.56±2.4, p=0.000, and 80% vs. 69.2%, p=0.031). The cecal intubation rates were higher in the intervention group (80% vs. 67.3%, p=0.012). Due to inadequate bowel preparation, unsuccessful cecal intubation rates were 0% in the intervention group and 17.6% in the control group. Biopsy rates were higher in the intervention group (28% vs. 13.3%, p=0.002).

CONCLUSION

the nurse-performed enhanced patient education sessions increase adequate bowel preparation rates and, in parallel, cecal intubation rates. To reach the colonoscopy quality standards recommended in the guidelines, it is suggested that patient education be supported by different training tools and given by health professionals.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

UK endoscopy workload and workforce patterns: is there potential to increase capacity? A BSG analysis of the National Endoscopy Database

Background

The lack of comprehensive national data on endoscopy activity and workforce hampers strategic planning. The National Endoscopy Database (NED) provides a unique opportunity to address this in the UK. We evaluated NED to inform service planning, exploring opportunities to expand capacity to meet service demands.

Design

Data on all procedures between 1 March 2019 and 29 February 2020 were extracted from NED. Endoscopy activity and endoscopist workforce were analysed.

Results

1 639 640 procedures were analysed (oesophagogastroduodenoscopy (OGD) 693 663, colonoscopy 586 464, flexible sigmoidoscopy 335 439 and endoscopic retrograde cholangiopancreatography 23 074) from 407 sites by 4990 endoscopists. 89% of procedures were performed in NHS sites. 17% took place each weekday, 10% on Saturdays and 6% on Sundays. Training procedures accounted for 6% of total activity, over 99% of which took place in NHS sites. Median patient age was younger in the independent sector (IS) (51 vs 60 years, p<0.001). 74% of endoscopists were male. Gastroenterologists and surgeons each comprised one-third of the endoscopist workforce; non-medical endoscopists (NMEs) comprised 12% yet undertook 23% of procedures. Approximately half of endoscopists performing OGD (52%) or colonoscopies (48%) did not meet minimum annual procedure numbers.

Conclusion

This comprehensive analysis reveals endoscopy workload and workforce patterns for the first time across both the NHS and the IS in all four UK nations. Half of all endoscopists perform fewer than the recommended minimum annual procedure numbers: a national strategy to address this, along with expansion of the NME workforce, would increase endoscopy capacity, which could be used to exploit latent weekend capacity.

Effectiveness of low-volume split-dose versus same-day morning polyethylene glycol regimen for adequacy of bowel preparation in patients undergoing colonoscopy: A single-blinded randomized controlled trial

BACKGROUND

Successful completion of colonoscopy depends largely on the quality of bowel preparation. Polyethylene glycol (PEG) is a commonly used preparation for colonoscopy. The timing of bowel preparation has evolved from previous day evening to the currently recommended split-dose regimen. It was observed that consumption of entire or a portion of PEG on the previous day can interfere with work and sleep. Hence, we designed this single-blinded randomized controlled trial (RCT) to evaluate the efficacy, tolerability, and acceptability of the same-day PEG as compared with lowvolume split-dose PEG in patients undergoing late morning colonoscopy.

METHODS

A total of 384 patients were randomized to same-day (SD group; n = 192) and split-dose (SPL group; n = 192) bowel preparation. The patients in both the groups received bisacodyl 10 mg at bedtime on the day prior to colonoscopy. The patients in the SD group took 2 L of PEG between 5:00 AM and 7:00 AM on the day of colonoscopy. The SPL group took 1 L of PEG between 6:00 PM and 7:00 PM on the preceding day and another liter between 6:00 AM and 7:00 AM on the day of colonoscopy. The adequacy of bowel preparation was assessed using the Boston Bowel Preparation Scale (BBPS). Tolerability was scored by recording symptoms such as nausea, vomiting, bloating, and abdominal pain. Acceptability was based on the overall satisfaction, willingness to repeat the same preparation, and interference with sleep on the preceding night.

RESULTS

The median (interquartile range, [IQR]) BBPS in the SD group was 8 (6-9) while that in the SPL group was 6 (5-8) and this difference was statistically significant (p < 0.001). Similarly, a significantly higher proportion of patients in the SD group (86%) achieved adequate bowel preparation (BBPS score ≥ 6) when compared to those in the SPL group (73.4%) (p = 0.002). Tolerability as assessed by nausea, vomiting, bloating, and abdominal pain was similar in both the groups. There was also no significant difference with respect to overall satisfaction of taking bowel preparation (p = 0.33) or willingness to repeat the same regimen (p = 0.37) between the two groups. Patients in the SPL group had more interference with sleep on the preceding night (54% vs. 14.5%, p < 0.001).

CONCLUSION

Same-day morning PEG regimen can be considered an effective, well-tolerated, and acceptable bowel preparation for colonoscopy.

Factors affecting colorectal adenoma detection rate

Colorectal cancer is a kind of malignant tumors that seriously threatens the health of Chinese people, and its morbidity and mortality rank third and fifth among malignant tumors in China, respectively. High-quality colonoscopy is an effective means of preventing colorectal cancer. Adenoma detection rate (ADR) is defined as the proportion of those who have adenomas in the total number of patients undergoing colonoscopy. With the increase of ADR, the incidence rate and mortality rate of colorectal cancer gradually decrease. Previous studies have found that ADR is affected by many factors. In this paper, we describe the factors that affect ADR from the aspects of colonoscopy, doctors, and equipment, with a purpose to strengthen the understanding of endoscopists on ADR and to increase ADR during colonoscopy.

Regular feedback to individual endoscopists is associated with improved adenoma detection rate and other key performance indicators for colonoscopy

OBJECTIVE

Monitoring of key performance indicators (KPIs) is a vital element of endoscopy quality improvement. Adenoma detection rate (ADR) is considered the best marker for colonoscopic quality as it inversely correlates with subsequent colonic cancer incidence and mortality, while polyp detection rate (PDR) is an easier-to-calculate surrogate for ADR. This study assessed whether regular feedback to individual endoscopists about their KPIs improved departmental performance.

METHODS

Individual KPIs were calculated for a period of 8 years (January 2012-December 2019) and fed back to all endoscopists at 6 monthly intervals, alongside anonymised indicators for other endoscopists, aggregate departmental performance data and benchmarks. An automated natural language processing software (EndoMineR) was used to identify adenomas in pathology reports and calculate ADR. Linear regressions were calculated for departmental ADR, PDR and other KPIs at 6 monthly intervals.

RESULTS

39 359 colonoscopies (average 2460 in every 6-month period, range 1799-3059) were performed by an average of 42 (range 34-50) endoscopists. A continuous improvement in collective performance including ADR (12.7%-21.0%, R² 0.92, p<0.001) and PDR (19.0%-29.6%, R² 0.77, p<0.001) was observed throughout the study. Other KPIs showed similar improvement. The detection of non-neoplastic polyps did not increase. When analysed separately, ADR and PDR appeared to improve for gastroenterologists and nurse endoscopists but not for surgeons.

CONCLUSION

Regular feedback with individual and departmental KPIs was associated with improved ADR and overall performance throughout the 8-year study period. Concomitant monitoring of ADR and PDR may prevent 'gaming' behaviour and ensure that genuine improvement is achieved.

ScotCap - A large observational cohort study

AIM

The aim of this work was to evaluate the performance of colon capsule endoscopy (CCE) in a lower gastrointestinal diagnostic care pathway.

METHOD

This large multicentre prospective clinical evaluation recruited symptomatic patients (patients requiring investigation of symptoms suggestive of colorectal pathology) and surveillance patients (patients due to undergo surveillance colonoscopy). Patients aged 18 years or over were invited to participate and undergo CCE by a secondary-care clinician if they met the referral criteria for a colonoscopy. The primary outcome was the test completion rate (visualization of the whole colon and rectum). We also measured the need for further tests after CCE.

RESULTS

A total of 733 patients were invited to take part in this evaluation, with 509 patients undergoing CCE. Of these, 316 were symptomatic patients and 193 were surveillance patients. Two hundred and twenty-eight of the 316 symptomatic patients (72%) and 137 of the 193 surveillance patients (71%) had a complete test. It was found that 118/316 (37%) of symptomatic patients required no further test following CCE, while 103/316 (33%) and 81/316 (26%) required a colonoscopy and flexible sigmoidoscopy, respectively. Fifty-three of the 193 surveillance patients (28%) required no further test following CCE, while 104/193 (54%) and 30/193 (16%) required a colonoscopy and flexible sigmoidoscopy, respectively. No patient in this evaluation was diagnosed with colorectal cancer. Two patients experienced serious adverse events - one capsule retention with obstruction and one hospital admission with dehydration due to the bowel preparation.

CONCLUSION

CCE is a safe, well-tolerated diagnostic test which can reduce the proportion of patients requiring colonoscopy, but the test completion rate needs to be improved to match that of lower gastrointestinal endoscopy.

Artificial intelligence and colonoscopy experience: lessons from two randomised trials

BACKGROUND AND AIMS

Artificial intelligence has been shown to increase adenoma detection rate (ADR) as the main surrogate outcome parameter of colonoscopy quality. To which extent this effect may be related to physician experience is not known. We performed a randomised trial with colonoscopists in their qualification period (AID-2) and compared these data with a previously published randomised trial in expert endoscopists (AID-1).

METHODS

In this prospective, randomised controlled non-inferiority trial (AID-2), 10 non-expert endoscopists (<2000 colonoscopies) performed screening/surveillance/diagnostic colonoscopies in consecutive 40-80 year-old subjects using high-definition colonoscopy with or without a real-time deep-learning computer-aided detection (CADe) (GI Genius, Medtronic). The primary outcome was ADR in both groups with histology of resected lesions as reference. In a post-hoc analysis, data from this randomised controlled trial (RCT) were compared with data from the previous AID-1 RCT involving six experienced endoscopists in an otherwise similar setting.

RESULTS

In 660 patients (62.3±10 years; men/women: 330/330) with equal distribution of study parameters, overall ADR was higher in the CADe than in the control group (53.3% vs 44.5%; relative risk (RR): 1.22; 95% CI: 1.04 to 1.40; p<0.01 for non-inferiority and p=0.02 for superiority). Similar increases were seen in adenoma numbers per colonoscopy and in small and distal lesions. No differences were observed with regards to detection of non-neoplastic lesions. When pooling these data with those from the AID-1 study, use of CADe (RR 1.29; 95% CI: 1.16 to 1.42) and colonoscopy indication, but not the level of examiner experience (RR 1.02; 95% CI: 0.89 to 1.16) were associated with ADR differences in a multivariate analysis.

CONCLUSIONS

In less experienced examiners, CADe assistance during colonoscopy increased ADR and a number of related polyp parameters as compared with the control group. Experience appears to play a minor role as determining factor for ADR.

TRIAL REGISTRATION NUMBER

NCT:04260321.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Overview of the Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

Pediatric-specific quality standards for endoscopy are needed to define best practices, while measurement of associated indicators is critical to guide quality improvement. The international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) working group was assembled to develop and define quality standards and indicators for pediatric gastrointestinal endoscopic procedures through a rigorous guideline consensus process.

METHODS

The Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument guided PEnQuIN members, recruited from 31 centers of various practice types representing 11 countries, in generating and refining proposed quality standards and indicators. Consensus was sought via an iterative online Delphi process, and finalized at an in-person conference. Quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

Forty-nine quality standards and 47 indicators reached consensus, encompassing pediatric endoscopy facilities, procedures, endoscopists, and the patient experience. The evidence base for PEnQuIN standards and indicators was largely adult-based and observational, and downgraded for indirectness, imprecision, and study limitations to "very low" quality, resulting in "conditional" recommendations for most standards (45/49).

CONCLUSIONS

The PEnQuIN guideline development process establishes international agreement on clinically meaningful metrics that can be used to promote safety and quality in endoscopic care for children. Through PEnQuIN, pediatric endoscopists and endoscopy services now have a framework for auditing, providing feedback, and ultimately, benchmarking performance. Expansion of evidence and prospective validation of PEnQuIN standards and indicators as predictors of clinically relevant outcomes and high-quality pediatric endoscopic care is now a research priority.

Effect of oral simethicone on the quality of colonoscopy: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

In this systematic review and meta-analysis, we aimed to investigate the effect of oral simethicone (SIM), an antifoaming agent, on the quality of colonoscopy in terms of bowel preparation quality, adenoma or polyp detection rate (ADR/PDR) and cecal intubation rate (CIR).

METHODS

All randomized controlled trials (RCTs) on the use of SIM during bowel preparation for colonoscopy published up to 17 March 2021 were identified from the PubMed, EMBASE and Cochrane Library databases. Bowel preparation quality, ADR/PDR/CIR, cecal intubation time (CIT), withdrawal time (WT), patients' tolerability, acceptability and volume of foam and bubbles were compared between the SIM and non-SIM groups.

RESULTS

Thirty-eight RCTs with 10 505 patients were included. Oral SIM significantly increased the rate of total Boston bowel preparation scale (BBPS) score ≥6 (risk ratio [RR]  1.13, P < 0.0001), acceptability (RR  1.15, P = 0.01) and the rate of no or minimal foam and bubbles (RR  1.28, P < 0.00001) and decreased abdominal distension (RR  0.64, P < 0.0001). However, it had no significant impact on overall ADR, overall PDR, CIR, CIT or WT. The rate of total BBPS score ≥6 remained significantly higher in the SIM group when a single-dose laxative regimen or a SIM dosage of ≥320 mg was employed; and ADR, PDR and CIR were significantly increased in the SIM group among colonoscopy clinicians who achieved an ADR <31%, PDR <45% and CIR <96%, respectively.

CONCLUSIONS

Oral SIM can improve bowel preparation quality, especially in patients receiving a SIM dosage of ≥320 mg or a single-dose laxative regimen. SIM may be preferred by junior colonoscopy physicians/trainees with a lower ADR/PDR or CIR.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

DISCUSSION

It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopy Facilities: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

There is increasing international recognition of the impact of variability in endoscopy facilities on procedural quality and outcomes. There is also growing precedent for assessing the quality of endoscopy facilities at regional and national levels by using standardized rating scales to identify opportunities for improvement.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of facilities where endoscopic care is provided to children. Consensus was reached via an iterative online Delphi process and subsequent in-person meeting. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 27 standards for facilities supporting pediatric endoscopy, as well 10 indicators that can be used to identify high-quality endoscopic care in children. These standards were subcategorized into three subdomains: Quality of Clinical Operations (15 standards, 5 indicators); Patient and Caregiver Experience (9 standards, 5 indicators); and Workforce (3 standards).

DISCUSSION

The rigorous PEnQuIN process successfully yielded standards and indicators that can be used to universally guide and measure high-quality facilities for procedures around the world where endoscopy is performed in children. It also underscores the current paucity of evidence for pediatric endoscopic care processes, and the need for research into this clinical area.

Safety and importance of colonoscopy in nonagenarians

BACKGROUND

With the growth of the aging population, the need for colonoscopies in nonagenarians is rising. However, few data on colonoscopies in extremely elderly individuals are available. To better acknowledge the role of colonoscopies in this specific group of patients, we conducted this study to evaluate the safety and clinical impact of colonoscopy in nonagenarian patients.

METHODS

We performed a retrospective cohort study comparing nonagenarians who received colonoscopy in a tertiary medical center in Taiwan in 2016 with 76- to 80-year-old patients (relatively elderly patients) who were 1:1 propensity score matched by sex as the control subjects. The postcolonoscopy 30-day adverse events, mortality, and long-term survival were recorded.

RESULTS

A total of 137 nonagenarians and 137 relatively elderly patients were included. The nonagenarians receiving colonoscopy were more likely to be hospitalized (40.1% vs 19.7%, p < 0.001), and the adjusted colonoscopy completion rates were comparable in both groups (92.0% vs 97.1%, p = 0.063). The overall adverse event rate and postcolonoscopy 30-day mortality rates were low in both groups (2.9% vs 1.5%, p = 0.409 and 2.2% vs 1.5%, p = 0.652, respectively). A total of 18.2% of the nonagenarians were diagnosed with advanced neoplasia. Among the nonagenarians diagnosed with colorectal cancer, the patients receiving surgery had a significantly lower risk of death than the patients receiving conservative management (hazards ratio 0.1044, 0.01275-0.8529, p = 0.0352).

CONCLUSION

Colonoscopy in patients older than 90 years is generally safe. Colonoscopy findings that led to surgery in nonagenarians diagnosed with colorectal cancer were associated with survival benefits.

Higher Adenoma Detection Rates at Screening Associated With Lower Long-Term Colorectal Cancer Incidence and Mortality

BACKGROUND & AIMS

Detection and removal of adenomas reduces colorectal cancer (CRC) risk. The impact of adenoma detection rates (ADRs) on long-term CRC incidence and mortality is unknown. We investigated this using data from the UK Flexible Sigmoidoscopy Screening Trial.

METHODS

Of 167,882 UK Flexible Sigmoidoscopy Screening Trial participants, 40,085 were in the intervention arm and underwent flexible sigmoidoscopy screening at 13 trial centers. The median follow-up time was 17 years. At each center, 1 endoscopist performed most flexible sigmoidoscopies. Multivariable logistic regression was used to classify centers into high-, intermediate-, and low-detector groups based on their main endoscopist's ADR. We calculated the incidence and mortality of distal and all-site CRC, and estimated hazard ratios (HRs) with 95% CIs using Cox regression.

RESULTS

Five, 4, and 4 centers, respectively, were classified into the high-detector, intermediate-detector, and low-detector groups. The average ADRs in each respective group were 15%, 12%, and 9%. Distal CRC incidence and mortality were reduced among those screened compared with controls in all groups, and effects of screening varied significantly by detector ranking, with larger reductions in incidence and mortality seen in the high-detector group (incidence: HR, 0.34; 95% CI, 0.27-0.42; mortality: HR, 0.22, 95% CI, 0.13-0.37) than in the low-detector group (incidence: HR, 0.55; 95% CI, 0.44-0.68; mortality: HR, 0.54; 95% CI, 0.34-0.86). Similar results were observed for all-site CRC, with larger effects seen in the high-detector (incidence: HR, 0.58; 95% CI, 0.50-0.67; mortality: HR, 0.52; 95% CI, 0.39-0.69) than in the low-detector group (incidence: HR, 0.72; 95% CI, 0.61-0.85; mortality: HR, 0.68; 95% CI, 0.51-0.92), although the heterogeneity was not statistically significant.

CONCLUSIONS

Higher ADRs at screening provide greater long-term protection against CRC incidence and mortality. Isrctn.org, number: ISRCTN28352761.

Delayed Bleeding After Endoscopic Resection of Colorectal Polyps: Identifying High-Risk Patients

Delayed post-polypectomy bleeding (DPPB) is a potentially severe complication of therapeutic colonoscopy which can result in hospital readmission and re-intervention. Over the last decade, rates of DPPB reported in the literature have fallen from over 2% to 0.3–1.2%, largely due to improvements in resection technique, a shift towards cold snare polypectomy, better training, adherence to guidelines on periprocedural antithrombotic management, and the use of antithrombotics with more favourable bleeding profiles. However, as the complexity of polypectomy undertaken worldwide increases, so does the importance of identifying patients at increased risk of DPPB. Risk factors can be categorised according to patient, polyp and personnel related factors, and their integration together to provide an individualised risk score is an evolving field. Strategies to reduce DPPB include safe practices relevant to all patients undergoing colonoscopy, as well as specific considerations for patients identified to be high risk. This narrative review sets out an evidence-based summary of factors that contribute to the risk of DPPB before discussing pragmatic interventions to mitigate their risk and improve patient safety.

Effect of nurse-performed enhanced patient education on colonoscopy bowel preparation quality

Objective:

to evaluate the effect of nurse-performed enhanced patient education sessions on adequate bowel preparation and cecal intubation rates.

Method:

a prospective, quasi-experimental, comparative study with a quantitative approach. The intervention group (n=150) received education enhanced by a visual presentation and reminder calls. The control group (n=156) received the clinic’s standard written instructions. Adequate bowel preparation rates and other colonoscopy quality indicators were compared between the groups.

Results:

Boston Bowel Preparation scale scores and adequate bowel preparation rates were higher in the intervention group than in the control group (respectively, 6.76±2.1 vs. 5.56±2.4, p=0.000, and 80% vs. 69.2%, p=0.031). The cecal intubation rates were higher in the intervention group (80% vs. 67.3%, p=0.012). Due to inadequate bowel preparation, unsuccessful cecal intubation rates were 0% in the intervention group and 17.6% in the control group. Biopsy rates were higher in the intervention group (28% vs. 13.3%, p=0.002).

Conclusion:

the nurse-performed enhanced patient education sessions increase adequate bowel preparation rates and, in parallel, cecal intubation rates. To reach the colonoscopy quality standards recommended in the guidelines, it is suggested that patient education be supported by different training tools and given by health professionals.

The utility and safety of paediatric endoscopy in a district general hospital in Southeast England

This study was done to evaluate the appropriateness, diagnostic yield, and quality of paediatric gastrointestinal endoscopy in a large DGH with tertiary paediatric gastroenterology services. It was a retrospective cohort study of children who had at least one gastrointestinal endoscopy during 31 months (May 2018-Dec 2020) in a district general hospital in Southeast England. The participants were children (2-17 years). Two hundred ninety-three procedures were performed in total, 80% were diagnostic and 20% for surveillance. The median age was 12 years and 52.5% were males. Oesophago-gastro-duodenoscopy (OGD) corresponded to 79.5% of procedures, ileo-colonoscopy (IC) to 7.2% and the remaining had both procedures. The main diagnostic indication was persistent abdominal pain in 33.5% of cases, followed by suspected GORD (14.8%), recurrent vomiting (14.3%), dysphagia (9.1%) and blood loss per rectum (8.6%). A total of 64.7% showed abnormal macroscopic findings, and 69.2% showed histopathological signs of disease. The most common histological diagnosis was gastritis in 23% followed by coeliac disease in 13%, reflux oesophagitis in 12.2% and inflammatory bowel disease in 9.6%. Procedures were performed with utmost safety with two reported cases of complications, which were appropriately managed. The completion rate of diagnostic IC was 87%. A waiting time of 6 weeks was achieved in 50.4% of cases.

CONCLUSION

Paediatric endoscopy can be safely performed in a district general hospital with the right setup and can aid in the management of gastrointestinal disease in the paediatric patient. It is important to monitor and regularly audit such practices to improve the quality of specialist services.

WHAT IS KNOWN

• Paediatric endoscopy is predominantly performed in large tertiary centres and included in the diagnostic algorithm for many paediatric gastrointestinal conditions. • There are recommendations on clinical indication endorsed by ESPGHAN and key quality indicators published jointly by JAG and BSPGHAN.

WHAT IS NEW

• Paediatric endoscopy can be appropriately and safely performed in district general hospital by trained professionals, decreasing the workload in larger tertiary paediatric centres. • Adoption of regular audit practices is essential to ensure and improve quality and appropriateness of this specialist service.

Los efectos de la educación perfeccionada, realizada por enfermeros en la calidad de la preparación intestinal para colonoscopia

Resumen Objetivo: evaluar el efecto de la educación perfeccionada realizada por enfermeros en la preparación intestinal adecuada y en las tasas de intubación cecal. Método: estudio prospectivo, casi experimental y comparativo, con abordaje cuantitativo. El grupo de intervención (n=150) recibió la educación perfeccionada y llamadas telefónicas recordatorias. El grupo de control (n=156) recibió las instrucciones estándar de la clínica por escrito. Las tasas de preparación intestinal adecuadas y otros indicadores de la calidad de la colonoscopia fueron comparadas entre los grupos. Resultados: las puntuaciones obtenidas en la Boston Bowel Preparation Scale y las tasas de preparación intestinal adecuadas fueron en el grupo de intervención mayores que en el grupo de control (6,76±2,1 vs. 5,56±2,4, p=0,000, y 80% vs. 69,2%, p=0,031, respectivamente). Las tasas de intubación cecal fueron mayores en el grupo de intervención (80% vs. 67,3%, p=0,012). La tasa de intubación cecal fracasada debido a la preparación intestinal inadecuada fue de 0% en el GI, en cuanto que el GC obtuvo una tasa de 17,6%. Además de eso, las tasas de biopsia fueron mayores en el grupo de intervención (28% vs. 13,3%, p=0,002). Conclusión: la educación del paciente perfeccionada y realizada por enfermeros aumenta las tasas de preparación intestinal adecuadas y, consecuentemente, las tasas de intubación cecal. Para alcanzar los estándares de calidad de colonoscopia recomendados en las directrices, recomendamos que la educación del paciente sea apoyada por diferentes herramientas de entrenamiento y realizada por profesionales de la salud.

Computed Tomography Colonography (CTC): Is It Really the Non-Invasive Option We Think It Is? A Patient Experience Study

Aims: Computed tomography colonography (CTC) is seen as a more tolerable alternative to colonoscopy, but patients struggle with the steps required for optimal diagnostic imaging. This prospective study aims to understand the experience of patients undergoing CTC. Methods: A survey was completed by a convenience sample of patients before and after CTC over 7 months. The 13-item questionnaire covered pre-test information, overall and specific experience of the test. The responses were tabulated and analyzed using descriptive statistics. Qualitative free-text responses were coded for content and thematic analysis. Results: At a response rate of 51%, surveys were received from 41 patients. Overall, most patients (54%) found the investigation better than expected. However, 18% stated they were not informed of potential side effects. Side effects were experienced by 49% of patients, including diarrhea (34%) and abdominal pain (24%). About 59% experienced discomfort with gas insufflation, and 86% found turning during the investigation difficult. Conclusion: A significant proportion of patients undergoing CTC experience side effects and difficulties completing the investigation. Patient information is important to improve patient experience of CTC.

Application of robotic technologies in lower gastrointestinal tract endoscopy: A systematic review

BACKGROUND

Conventional optical colonoscopy is considered the gold standard investigation for colorectal tract pathology including colorectal malignancy, polyps and inflammatory bowel disease. Inherent limitations exist with current generation endoscopic technologies, including, but not limited to, patient discomfort, endoscopist fatigue, narrow field of view and missed pathology behind colonic folds. Rapid developments in medical robotics have led to the emergence of a variety of next-generation robotically-augmented technologies that could overcome these limitations.

AIM

To provide a comprehensive summary of recent developments in the application of robotics in lower gastrointestinal tract endoscopy.

METHODS

A systematic review of the literature was performed from January 1, 2000 to the January 7, 2021 using EMBASE, MEDLINE and Cochrane databases. Studies reporting data on the use of robotic technology in ex vivo or in vivo animal and human experiments were included. In vitro studies (studies using synthetic colon models), studies evaluating non-robotic technology, robotic technology aimed at the upper gastrointestinal tract or paediatric endoscopy were excluded. System ergonomics, safety, visualisation, and diagnostic/therapeutic capabilities were assessed.

RESULTS

Initial literature searching identified 814 potentially eligible studies, from which 37 were deemed suitable for inclusion. Included studies were classified according to the actuation modality of the robotic device(s) as electromechanical (EM) (n = 13), pneumatic (n = 11), hydraulic (n = 1), magnetic (n = 10) and hybrid (n = 2) mechanisms. Five devices have been approved by the Food and Drug Administration, however most of the technologies reviewed remain in the early phases of testing and development. Level 1 evidence is lacking at present, but early reports suggest that these technologies may be associated with improved pain and safety. The reviewed devices appear to be ergonomically capable and efficient though to date no reports have convincingly shown diagnostic or therapeutic superiority over conventional colonoscopy.

CONCLUSION

Significant progress in robotic colonoscopy has been made over the last couple of decades. Improvements in design together with the integration of semi-autonomous and autonomous systems over the next decade will potentially result in robotic colonoscopy becoming more commonplace.

Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

BACKGROUND

Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.

METHODS

We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.

RESULTS

Data saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years' experience.When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages' motives and consider gaming.Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient.

CONCLUSION

Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.

TRIAL REGISTRATION NUMBER

ISRCTN11126923.

Automated detection of cecal intubation with variable bowel preparation using a deep convolutional neural network

Background and study aims  Colonoscopy completion reduces post-colonoscopy colorectal cancer. As a result, there have been attempts at implementing artificial intelligence to automate the detection of the appendiceal orifice (AO) for quality assurance. However, the utilization of these algorithms has not been demonstrated in suboptimal conditions, including variable bowel preparation. We present an automated computer-assisted method using a deep convolutional neural network to detect the AO irrespective of bowel preparation. Methods  A total of 13,222 images (6,663 AO and 1,322 non-AO) were extracted from 35 colonoscopy videos recorded between 2015 and 2018. The images were labelled with Boston Bowel Preparation Scale scores. A total of 11,900 images were used for training/validation and 1,322 for testing. We developed a convolutional neural network (CNN) with a DenseNet architecture pre-trained on ImageNet as a feature extractor on our data and trained a classifier uniquely tailored for identification of AO and non-AO images using binary cross entropy loss. Results  The deep convolutional neural network was able to correctly classify the AO and non-AO images with an accuracy of 94 %. The area under the receiver operating curve of this neural network was 0.98. The sensitivity, specificity, positive predictive value, and negative predictive value of the algorithm were 0.96, 0.92, 0.92 and 0.96, respectively. AO detection was > 95 % regardless of BBPS scores, while non-AO detection improved from BBPS 1 score (83.95 %) to BBPS 3 score (98.28 %). Conclusions  A deep convolutional neural network was created demonstrating excellent discrimination between AO from non-AO images despite variable bowel preparation. This algorithm will require further testing to ascertain its effectiveness in real-time colonoscopy.

Endocuff Vision improves adenoma detection rate in a large screening-related cohort

Background and study aims  Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods  In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results  In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P  < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P  < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions  ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.

Is it time we split bowel preparation for all colonoscopies? Outcomes from a national survey of bowel preparation practice in the UK

Introduction

Adequate bowel preparation is a prerequisite for effective colonoscopy. Split bowel preparation results in optimal cleansing. This study assessed the bowel preparation regimes advised by endoscopy units across the UK, and correlated the differences with outcomes.

Methods

Trusts in the UK were surveyed, with data requested between January 2018 and January 2019, including: the type and timing of preparation, pre-endoscopy diet, adequacy rates and polyp detection. Trusts were grouped according to the timing of bowel preparation. χ² test was used to assess for differences in bowel preparation adequacy.

Results

Moviprep was the first line bowel preparation in 79% of trusts. Only 7% of trusts advised splitting bowel preparation for all procedures, however, 91% used split bowel preparation for afternoon procedures. Trusts that split preparation for all procedures had an inadequacy rate of 6.7%, compared with 8.5% (p<0.001) for those that split preparation for PM procedures alone and 9.5% (p<0.001) for those that provided day before preparation for all procedures. Morning procedures with day-before preparation had a higher rate of inadequate cleansing than afternoon procedures that received split preparation (7.7% vs 6.5 %, p<0.001). The polyp detection rate for procedures with adequate preparation was 37.1%, compared with 26.4% for those that were inadequate.

Conclusion

Most trusts in the UK do not provide instructions optimising the timing of bowel preparation prior to colonoscopy. This correlated with an increased rate of inadequate cleansing. Splitting bowel preparation is likely to reduce the impacts of poor cleansing: missed lesions, repeat colonoscopies and significant costs.

A Pragmatic Randomized Controlled Trial of an Endoscopist Audit and Feedback Report for Colonoscopy

INTRODUCTION

Variation in endoscopist performance contributes to poor-quality colonoscopy. Audit and feedback (A/F) can be used to improve physician performance, particularly among lower performing physicians. In this large pragmatic randomized controlled trial, we compared A/F to improve endoscopists' colonoscopy performance to usual practice.

METHODS

Endoscopists practicing in Ontario, Canada, in 2014 were randomly assigned in October 2015 (index date) to receive (intervention group, n = 417) or not receive (control group, n = 416) an A/F report generated centrally using health administrative data. Colonoscopy performance was measured in both groups over two 12-month periods: prereport and postreport (relative to the index date). The primary outcome was polypectomy rate (PR). Secondary outcomes were cecal intubation rate, bowel preparation, and premature repeat after normal colonoscopy. A post hoc analysis used adenoma detection rate as the outcome. Outcomes were compared between groups for all endoscopists and for lower performing endoscopists using Poisson regression analyses under a difference-in-difference framework.

RESULTS

Among all endoscopists, PR did not significantly improve from prereport to postreport periods for those receiving the intervention (relative rate [RR], intervention vs control: 1.07 vs 1.05, P = 0.09). Among lower performing endoscopists, PR improved significantly (RR, intervention vs control 1.34 vs 1.11, P = 0.02) in the intervention group compared with controls. In this subgroup, adenoma detection rate also improved but not significantly (RR, intervention vs control 1.12 vs 1.04, P = 0.12). There was no significant improvement in secondary outcomes between the intervention and control groups.

DISCUSSION

A/F reports for colonoscopy improve performance in lower performing endoscopists (ClinicalTrials.gov: NCT02595775).