Colonoscopy: why are general surgeons being excluded?

Evaluating the Safety and Quality of Diagnostic Colonoscopies Performed by General Surgeons: A Retrospective Study

Introduction Colonoscopy, which is a challenging procedure and requires adequate time to master the skill, is the procedure of choice to visualize colonic mucosa to rule out many colonic pathologies. There is a dearth of published information from real clinical experiences regarding successful procedures and limitations. The end point of colonoscopy is the visualization of the cecal pole by intubating the cecum. Many Europeans and English health organizations recommend that the procedure should have a completion rate of around or above 90%. Gut preparation is an important determinant for a successful procedure and obviates the need for further invasive and/or expensive procedures such as imaging. The majority of colonoscopies are being performed by gastroenterologists (GI) throughout the world, and the role of a surgeon as an endoscopist is in debate. Before this study, neither a retrospective nor a prospective evaluation of the general surgeon's (GS) endoscopy's quality and safety had been evaluated in our institution. Material and method This retrospective observational study was carried out from 1 January 2022 to 31 August 2022 in the Department of Surgery at Mayo Hospital, Lahore, to evaluate colonoscopy completion rates, reason for failure, and complications in terms of bleeding and perforation. All patients undergoing lower gastrointestinal endoscopy (LGiE), both elective and emergency, were included. Patients under 15 years of age and patients known to be hepatitis B-positive or hepatitis C-positive were excluded from the study. All relevant data were entered into a data sheet. Qualitative variables such as gender, cecal intubation, adjusted cecal intubation, gut preparation, reasons for failed colonoscopy, analgesia use, and complications (bleeding and perforation) were calculated as frequency and percentage. Quantitative data such as age and pain score were reported as mean and standard deviation (SD). Details obtained were tabulated and analyzed via the Statistical Package for Social Sciences (SPSS) version 29.0 (IBM SPSS Statistics, Armonk, NY). Results A total of 57 patient data were collected; 35.1% (n=20) were female, and 64.9% (n=37) were males. The cecal intubation rate (CIR) was 49.1% (n=28), and the adjusted rate was 71.9%, excluding incompleteness due to mass obstructing lumen, 8.8% (n=5); planned left colonoscopy, 7% (n=4); sigmoidoscopy, 3.5% (n=2); distal stoma scope, 1.8% (n=1); and colonic stricture, 1.8% (n=1). The prevalent reason for failed colonoscopy was inadequate gut preparation (15.8% {n=9}). Other reasons include patient discomfort, 3.5% (n=2); looping of scope, 7% (n=4); and acute colonic angulation, 1.8% (n=1). No complications were recorded. Conclusion This study shows that colonoscopy can be done by general surgeons safely and effectively with adequate training. High rates of cecal intubation emerge during colonoscopies performed under deep sedation and by skilled colonoscopists. Adequate bowel preparatory regimen is compulsory for quality procedure.

Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data

INTRODUCTION

Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database.

METHODS AND PROCEDURES

The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people).

RESULTS

Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001).

CONCLUSIONS

Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.

Geographic variation in the provider of screening colonoscopy in Canada: a population-based cohort study

BACKGROUND

Screening colonoscopy for the detection of colorectal carcinoma is provided by several specialties. Few studies have assessed geographic variation in the delivery of this care. Our objective was to investigate how geographic and socioeconomic factors affect who provides screening colonoscopy in Canada.

METHODS

This was a population-based cohort of all screening colonoscopy procedures performed at publicly funded Canadian health care facilities (excluding those in Quebec) between April 2008 and March 2015. The main outcome of interest was the proportion of colonoscopy procedures performed by surgeons versus gastroenterologists at the neighbourhood level. Predictors of interest included socioeconomic and geographic variables. We used spatial analysis to evaluate significant clustering of practitioner services and multinomial logistic regression to model predictors.

RESULTS

We identified 658 113 screening colonoscopy procedures performed by 1886 providers (1169 surgeons and 717 gastroenterologists) over the study period, of which 353 165 (53.7%) were performed by surgeons. A total of 24.2% of neighbourhoods were located within clusters predominantly served by gastroenterologists, and 19.5% were within surgeon clusters; the remainder were in mixed clusters. Rural neighbourhoods had a significantly increased relative risk of being within a surgeon cluster (relative risk [RR] 5.38, 95% confidence interval [CI] 3.48-8.01) compared to mixed clusters and nearly 100 times higher relative risk of being in a surgeon cluster compared to gastroenterologist clusters (RR 98.95, 95% CI 15.3-427.2). Neighbourhoods with the highest socioeconomic status were 1.74 (95% CI 1.14-2.56) times likelier to be in gastroenterologist clusters than in mixed clusters.

INTERPRETATION

Surgeons provide a large proportion of colonoscopy procedures in Canada and are essential for access to care, particularly in rural regions. Most Canadians are served relatively equally by surgeons and gastroenterologists. This emphasizes the importance of both specialties to the delivery of colonoscopy care across the country.

Patient comfort scores do not affect endoscopist behavior during colonoscopy, while trainee involvement has negative effects on patient comfort

INTRODUCTION

Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists.

PATIENTS AND METHODS

The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis.

RESULTS

NAPCOMS consists of 3 domains - pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P  = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P  = 0.01) and fentanyl ( P  = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P  < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P  = 0.037), decreased midazolam use ( P  = 0.001), and more position changes ( P  = 0.002) among gastroenterologists.

CONCLUSIONS

The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.

Who Performs Colonoscopy? Workforce Trends Over Space and Time

PURPOSE

With the increased availability of colonoscopy to average risk persons due to insurance coverage benefit changes, we sought to identify changes in the colonoscopy workforce. We used outpatient discharge records from South Carolina between 2001 and 2010 to examine shifts over time and in urban versus rural areas in the types of medical providers who perform colonoscopy, and the practice settings in which they occur, and to explore variation in colonoscopy volume across facility and provider types.

METHODS

Using an all-payer outpatient discharge records database from South Carolina, we conducted a retrospective analysis of all colonoscopy procedures performed between 2001 and 2010.

FINDINGS

We identified a major shift in the type of facilities performing colonoscopy in South Carolina since 2001, with substantial gains in ambulatory surgery settings (2001: 15, 2010: 34, +127%) versus hospitals (2001: 58, 2010: 59, +2%), particularly in urban areas (2001: 12, 2010: 27, +125%). The number of internists (2001: 46, 2010: 76) and family physicians (2001: 34, 2010: 106) performing colonoscopies also increased (+65% and +212%, respectively), while their annual procedures volumes stayed fairly constant. Significant variation in annual colonoscopy volume was observed across medical specialties (P < .001), with nongastroenterologists having lower volumes versus gastroenterologists and colon and rectal surgeons.

CONCLUSIONS

There have been substantial changes over time in the number of facilities and physicians performing colonoscopy in South Carolina since 2001, particularly in urban counties. Findings suggest nongastroenterologists are meeting a need for colonoscopies in rural areas.

The role of surgeons on the development and performance of endoscopy

Endoscopy is being frequently performed for both diagnostic and therapeutic applications in surgical practice. Surgery, as a scientific area, has an important role in the propagation of therapeutic endoscopic procedures. The contribution of surgeons to the evolution of endoscopic applications and its practice is a triggering factor for the improvement of endoscopic instruments and their widespread use. Training and education on basic diagnostic and therapeutic surgical endoscopy should be implemented as part of general surgery residency core program, according to accepted standardized criteria, in order for general surgeons to perform endoscopic applications in the future. In light of this information, it can be concluded that endoscopy training and skills should be standardized within accepted general principles. Standards to be used during post-graduate endoscopic practice should be precisely stated. In addition to accreditation of both surgeons and endoscopic centers, theoretical and practical education programs should be composed and organized.

Prevalence of and risk factors for gastrointestinal diseases in korean americans and native koreans undergoing screening endoscopy

BACKGROUND/AIMS

In South Korea, health check-ups are readily accessible to the public. We aimed to compare the prevalence of upper gastrointestinal (GI) and lower GI diseases in Korean Americans and native Koreans to determine differences and risk factors.

METHODS

In total, 1,942 subjects who visited Gangnam Severance Hospital from July 2008 to November 2010 for a health check-up were enrolled. Basic characteristics and laboratory data for the subjects were collected. Esophagogastroduodenoscopy and colonoscopy were performed. In total, 940 Korean Americans (group 1) and 1,002 native Koreans (group 2) were enrolled.

RESULTS

The overall prevalence of GI diseases for each group (group 1 vs group 2) were as follows: reflux esophagitis (RE) (9.65% vs 7.9%), gastric ulcer (2.8% vs 3.4%), duodenal ulcer (2.3% vs 3.6%), gastric cancer (0.4% vs 0.3%), colorectal polyp (35.9% vs 35.6%), colorectal cancer (0.5% vs 0.5%), and hemorrhoids (29.4% vs 21.3%). The prevalence of hemorrhoids was significantly higher in group 1 than in group 2 (p=0.001). In the multivariable analysis of group 1, male sex, age over 50 years, hypercholesterolemia and hypertriglyceridemia predicted colorectal polyps. Male sex and high fasting glucose levels were associated with RE.

CONCLUSIONS

Our study showed that the prevalence of GI diseases (except hemorrhoids) in Korean Americans was similar to that observed in native Koreans. Therefore, the Korean guidelines for upper and lower screening endoscopy may be applicable to Korean Americans.

Volume and accreditation, but not specialty, affect quality standards in colonoscopy

BACKGROUND

The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy.

METHODS

Data collected prospectively from a UK hospital endoscopy service between June 2007 and January 2010 were analysed. The main endpoint was the adenoma detection rate (ADR). Secondary endpoints were polyp detection rate (PDR), reported caecal intubation rate (CIR) and reported complications. Multivariable binary regression models were built to adjust for confounding patient-level and endoscopist-level variation.

RESULTS

A total of 10,026 colonoscopies were included, with an overall ADR of 19.2 per cent, a CIR of 90.2 per cent and a perforation rate of 0.06 per cent. In univariable analyses, surgeons had a higher ADR and higher PDR, but lower CIR, compared with physicians. Surgeons had a significantly different case mix in terms of age, sex and indication for colonoscopy. After adjusting for this case mix in multivariable analysis, specialty was no longer a significant predictor of ADR; however, surgeons retained their higher PDR and physicians their higher CIR. Endoscopists accredited for screening and those performing more than 100 colonoscopies per year had a higher ADR.

CONCLUSION

Adjusting for case mix, physicians and surgeons performed equally well in terms of ADR. Accreditation and a higher annual number of colonoscopies were more important factors in achieving quality standards.

Do basic psychomotor skills transfer between different image-based procedures?

Background

Surgical techniques that draw from multiple types of image-based procedures (IBP) are increasing, such as Natural Orifice Transluminal Endoscopic Surgery, fusing laparoscopy and flexible endoscopy. However, little is known about the relation between psychomotor skills for performing different types of IBP. For example, do basic psychomotor colonoscopy and laparoscopy skills interact?

Methods

Following a cross-over study design, 29 naïve endoscopists were trained on the Simbionix GI Mentor and the SimSurgery SEP simulators. Group C (n = 15) commenced with a laparoscopy session, followed by four colonoscopy sessions and a second laparoscopy session. Group L (n = 14) started with a colonoscopy session, followed by four laparoscopy sessions and a second colonoscopy session.

Results

No significant differences were found between the performances of group L and group C in their first training sessions on either technique. With additional colonoscopy training, group C outperformed group L in the second laparoscopy training session on the camera navigation task.

Conclusions

Overall, training in the basic colonoscopy tasks does not affect performance of basic laparoscopy tasks (and vice versa). However, to limited extent, training of basic psychomotor skills for colonoscopy do appear to contribute to the performance of angled laparoscope navigation tasks. Thus, training and assessment of IBP type-specific skills should focus on each type of tasks independently. Future research should further investigate the influence of psychometric abilities on the performance of IBP and the transfer of skills for physicians who are experienced in one IBP type and would like to become proficient in another type of IBP.

Integrated flexible endoscopy training during surgical residency

BACKGROUND

New advances in endoscopic surgery make it imperative that future gastrointestinal surgeons obtain adequate endoscopy skills. An evaluation of the 2001-02 general surgery residency endoscopy experience at the University of Missouri revealed that chief residents were graduating with an average of 43 endoscopic cases. This met American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) requirements but is inadequate preparation for carrying out advanced endoscopic surgery. Our aim was to determine if endoscopy volume could be improved by dedicating specific staff surgeon time to a gastrointestinal diagnostic center at an affiliated Veterans Administration Hospital.

METHODS

During the academic years 2002-05, two general surgeons who routinely perform endoscopy staffed the gastrointestinal endoscopy center at the Harry S. Truman Hospital two days per week. A minimum of one categorical surgical resident participated during these endoscopy training days while on the Veterans Hospital surgical service. A retrospective observational review of ACGME surgery resident case logs from 2001 to 2005 was conducted to document the changes in resident endoscopy experience. The cases were compiled by postgraduate year (PGY).

RESULTS

Resident endoscopy case volume increased 850% from 2001 to 2005. Graduating residents completed an average of 161 endoscopies. Endoscopic experience was attained at all levels of training: 26, 21, 34, 23, and 26 mean endoscopies/year for PGY-1 to PGY-5, respectively.

CONCLUSIONS

Having specific endoscopy training days at a VA Hospital under the guidance of a dedicated staff surgeon is a successful method to improve surgical resident endoscopy case volume. An integrated endoscopy training curriculum results in early skills acquisition, continued proficiency throughout residency, and is an efficient way to obtain endoscopic skills. In addition, the foundation of flexible endoscopic skill and experience has allowed early integration of surgery residents into research efforts in natural orifice transluminal endoscopic surgery.

Racial disparities in colon cancer. Primary care endoscopy as a tool to increase screening rates among minority patients

Colon cancer is a condition whose far-reaching effects have been well documented nationally and within the state of South Carolina. Fortunately, the disease is amenable to both primary and secondary prevention through screening colonoscopy. Despite the conceptual simplicity of recommending colonoscopy, barriers exist to universal (or even widespread) screening. Currently the infrastructure necessary to achieve screening goals set by the American Cancer Society (ACS), the American College of Gastroenterology (ACG), and the South Carolina Department of Health and Environmental Control (DHEC) has not been established. At current rates of training gastroenterologists, the medical community will not be able to come close to achieving widespread screening. Given the discrepancy between the public health benefit of achieving the goals and the deaths that have occurred because of the resource shortfall, we propose alternative measures to screen the at-risk population for consideration. This need is most acute in the black community, in which where screening rates tend to be lower and polyps have been found to progress more quickly than among white populations. In South Carolina, one model has used primary care physicians as the labor force to provide routine screening colonoscopy for their own patients. This model makes screening much more accessible to minority patients, as the wait is shorter and the cost typically lower. In combination with a faith-based partnership with minority religious organizations, this model has begun to make needed inroads toward addressing the disparities associated with colon cancer. Cancer 2007. (c) 2006 American Cancer Society.