Performance measures of surgeon-performed colonoscopy in a Veterans Affairs medical center

Factors affecting successful colonoscopy procedures: Single-center experience

Objective

Colonoscopy is a gold standard procedure for several colon pathologies. Successful colonoscopy means demonstration of the ileocecal valve and determination of colon polyps. Here we aimed to evaluate our colonoscopy success and results.

Material and Methods

This retrospective descriptive study was performed in İstanbul Eren hospital endoscopy unit between 2012 and 2015. Colonoscopy results and patient demographics were obtained from the hospital database. All colonoscopy procedures were performed under general anesthesia and after full bowel preparation.

Results

In all, 870 patients were included to the study. We reached to the cecum in 850 (97.8%) patients. We were unable to reach the cecum in patients who were old and obese and those with previous lower abdominal operations. Angulation, inability to move forward, and tortuous colon were the reasons for inability to reach the cecum. Total 203 polyp samplings were performed in 139 patients. We performed 1, 2, and 3 polypectomies in 97, 28, and 10 patients, respectively. There were 29 (3.3%) colorectal cancers in our series. There was no mortality or morbidity in our study.

Conclusion

General anesthesia and full bowel preparation may be the reason for increased success of colonoscopy. Increased experience and patient-endoscopist cooperation increased the rate of cecum access and polyp resection and decreased the complication rate.

Findings in young adults at colonoscopy from a hospital service database audit

BACKGROUND

Colorectal cancer (CRC) diagnosed at <50 years is predominantly located in the distal colon and rectum. Little is known about which lesion subtypes may serve as CRC precursors in young adults. The aim of this work was to document the prevalence and histological subtype of lesions seen in patients aged <50 years, and any associated clinical features.

METHODS

An audit of the colonoscopy database at The Queen Elizabeth Hospital in Adelaide, South Australia over a 12-month period was undertaken. Findings were recorded from both colonoscopy reports and corresponding histological examination of excised lesions.

RESULTS

Data were extracted from colonoscopies in 2064 patients. Those aged <50 comprised 485 (24%) of the total. CRC precursor lesions (including sessile serrated adenoma/polyps (SSA/P), traditional serrated adenomas, tubular adenomas ≥10 mm or with high-grade dysplasia, and conventional adenomas with villous histology) were seen in 4.3% of patients aged <50 and 12.9% of patients aged ≥50 (P <0.001). Among colonoscopies yielding CRC precursor lesions in patients under 50 years, SSA/P occurred in 52% of procedures (11/21), compared with 27% (55/204) of procedures in patients aged 50 and older (P = 0.02). SSA/P were proximally located in (10/11) 90% of patients aged under 50, and 80% (43/54) of those aged 50 and older (P = 0.46).

CONCLUSIONS

SSA/P were the most frequently observed CRC precursor lesions in patients aged <50. Most CRCs in this age group are known to arise in the distal colon and rectum suggesting that lesions other than SSA/P may serve as the precursor for the majority of early-onset CRC.

Location, size, and distance: criteria for quality in esophagogastroduodenos copy reporting for pre-operative gastric cancer evaluation

BACKGROUND

There is a lack of existing literature regarding the quality of esophagogastroduodenoscopy (EGD) reporting for gastric cancer evaluation. This study aims to determine criteria for quality endoscopic evaluation of gastric cancer in North America by identifying important features of the EGD report for pre-operative evaluation of gastric cancer and assessing inclusion of these features in existing reports.

METHODS

Semi-structured interviews were conducted with experienced endoscopists from community and academic hospitals affiliated with the University of Toronto to identify essential elements for an EGD report. Then, 225 EGD reports from 2005 to 2008 were evaluated by two trained reviewers for inclusion of recommended EGD report elements and global assessment of report quality and adequacy for surgical planning.

RESULTS

Essential elements recommended by interviewed endoscopists include tumor size, location, and distance from gastroesophageal junction (GEJ). Approximately 95 % of all reports documented the location of lesions, <5 % documented distance from the GEJ, and <15 % documented tumor size. Overall report quality was rated as excellent for 4-5 % of reports; 20-42 % of all reports were deemed to be adequate for surgical planning. All surgeons interviewed as part of the endoscopist panel indicated that they would repeat the EGD before consulting with patients regarding surgical planning.

CONCLUSIONS

For pre-operative evaluation of gastric cancer, tumor size, location, and distance from key anatomical landmarks were proposed as essential elements of a quality EGD report. Most of the reviewed reports did not document these elements. Report quality is perceived to be poor and may lead to repeat endoscopy. Developing a standardized EGD reporting format based on inclusion of individual parameters can improve the quality of gastric cancer management.

Gastrointestinal endoscopy in Nigeria--a prospective two year audit

Introduction

Gastrointestinal (GI) endoscopy is currently performed by different specialties. Information on GI endoscopy resources in Nigeria is limited. Training, cost, availability and maintenance of equipment are some unique challenges. Despite these challenges, the quality and completion rates are important.

Methods

Prospective audit of endoscopic procedures by an endoscopist in a Nigerian hospital over a 24 month period.

Results

One hundred and ninety endoscopic procedures were performed in 187 patients (109 male, 78 female) by a surgeon during this period. Mean age was 47.6 years (range 17 - 90 years). All patients were symptomatic. One hundred and twenty-two procedures (64.2%) were upper GI endoscopy, 52 (27.4%) colonoscopy and 16 (8.4%) sigmoidoscopy. Majority of endoscopies 182 (95.8%) were performed electively and only 7 (3.7%) were therapeutic. Upper GI endoscopy findings included 14 (11.5%) cases of peptic ulcer disease, 5 complicated by gastric outlet obstruction, and 21 (17.3%) cases of upper gastrointestinal cancer. Lower gastrointestinal endoscopy findings included 7 cases of polyps, 3 cases of colorectal cancer and 2 cases of diverticulosis. Commonest lesion on lower GI endoscopy was haemorrhoids (41.7%). Adjusted caecal intubation was 81.4% for colonoscopies performed. Overall adenoma detection rate for male and female patients were 18.2% and 5.3% respectively; in patients over 50 years these were 6.3% and 14.3%. Two complications, rupture of oesophageal varices, and respiratory arrest in bulbar palsy patient occurred.

Conclusion

An endoscopist can perform GI endoscopy effectively in developing countries like Nigeria but attention to equipment need and training is important.

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.

The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria

BACKGROUND

The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care.

OBJECTIVES

To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria.

DESIGN

Cross-sectional study.

SETTING

Endoscopy unit of a teaching hospital in Spain.

PATIENTS

Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing.

MAIN OUTCOME MEASUREMENTS

Appropriateness of colonoscopies according to the EPAGE criteria.

RESULTS

From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels.

LIMITATIONS

The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria.

CONCLUSIONS

Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.

Characterization of forces applied by endoscopists during colonoscopy by using a wireless colonoscopy force monitor

BACKGROUND

To perform a colonoscopy, the endoscopist maneuvers the colonoscope through a series of loops by applying force to the insertion tube. Colonoscopy insertion techniques are operator dependent but have never been comprehensively quantified.

OBJECTIVE

To determine whether the Colonoscopy Force Monitor (CFM), a device that continually measures force applied to the insertion tube, can identify different force application patterns among experienced endoscopists.

DESIGN

Observational study of 6 experienced endoscopists performing routine diagnostic and therapeutic colonoscopy in 30 patients.

SETTING

Outpatient ambulatory endoscopy center.

PATIENTS

Adult male and female patients between 30 and 75 years of age undergoing routine colonoscopy.

INTERVENTIONS

CFM monitoring of force applied to the colonoscope insertion tube during colonoscopy.

MAIN OUTCOME MEASUREMENTS

Maximum and mean linear and torque force, time derivative of force, combined linear and torque vector force, and total manipulation time.

RESULTS

The CFM demonstrates differences among endoscopists for maximum and average push/pull and mean torque forces, time derivatives of force, combined push/torque force vector, and total manipulation time. Endoscopists could be grouped by force application patterns.

LIMITATIONS

Only experienced endoscopists using conscious sedation in the patients were studied. Sample size was 30 patients.

CONCLUSIONS

This study demonstrates that CFM allows continuous force monitoring, characterization, and display of similarities and differences in endoscopic technique. CFM has the potential to facilitate training by enabling trainees to assess, compare, and quantify their techniques and progress.