Effect of an educational intervention on colonoscopy quality outcomes

Ergonomic wellness for the trainee in gastrointestinal endoscopy

PURPOSE OF REVIEW

Endoscopy-related injuries (ERIs) are prevalent in gastrointestinal endoscopy. The aim of this review is to address the growing concern of ERIs by evaluating the ergonomic risk factors and the efficacy of interventions and educational strategies aimed at mitigating these risks, including novel approaches.

RECENT FINDINGS

ERIs are highly prevalent, exacerbated by factors such as repetitive strain, nonneutral postures, suboptimal equipment design, and the procedural learning curve. Female sex and smaller hand sizes have been identified as specific risk factors. Recent guidelines underscore the importance of ergonomic education and the integration of ergonomic principles into the foundational training of gastroenterology fellows. Advances in equipment design focus on adaptability to different hand sizes and ergonomic positions. Furthermore, the incorporation of microbreaks and macrobreaks, along with neutral monitor and bed positioning, has shown promise in reducing the incidence of ERIs. Wearable sensors may be helpful in monitoring and promoting ergonomic practices among trainees.

SUMMARY

Ergonomic wellness is paramount for gastroenterology trainees to prevent ERIs and ensure a sustainable career. Effective strategies include ergonomic education integrated into curricula, equipment design improvements, and procedural adaptations such as scheduled breaks and optimal positioning. Sensor-based and camera-based systems may allow for education and feedback to be provided regarding ergonomics to trainees in the future.

Starting position during colonoscopy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Traditional teaching has been to place patients in the left lateral decubitus starting position for colonoscopies. Recent randomized controlled trials (RCTs) have compared left lateral decubitus starting position to other approaches. The aim of this systematic review and meta-analysis was to compare different starting positions for colonoscopies and their effect on cecal intubation.

METHODS

MEDLINE, Embase, and CENTRAL were searched from inception to July 2023. Articles were eligible for inclusion if they were RCTs comparing at least two different starting positions for adults undergoing colonoscopy. The main outcome was cecal intubation time. Meta-analysis used an inverse variance random effects model. Risk of bias was assessed with the Cochrane Tool for RCTs 2.0.

RESULTS

After screening 1523 citations, 14 RCTs were included. Four studies compared left lateral decubitus to right lateral decubitus, four studies compared left lateral decubitus to left lateral tilt-down, three studies compared left lateral decubitus to prone, and three studies compared left lateral decubitus to supine. There were no statistically significant differences in cecal intubation time in seconds across all comparisons: left lateral decubitus vs. right lateral decubitus (MD 14.9, 95% CI - 111.8 to 141.6, p = 0.82, I2 = 85%); left lateral decubitus vs. left lateral tilt-down (MD - 31.3, 95% CI - 70.8 to 8.3, p = 0.12, I2 = 82%); left lateral decubitus vs. prone (MD 17.2, 95% CI - 174.9 to 209.4, p = 0.86, I2 = 94%); left lateral decubitus vs. supine (MD - 149.9, 95% CI - 443.6 to 143.9, p = 0.32, I2 = 89%).

CONCLUSION

The starting position for colonoscopies likely does not influence cecal intubation time. This study was limited by heterogeneity.

Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.

RESULTS

From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11).

CONCLUSIONS

The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

Impact of a scalable training program on the quality of colonoscopy performance and risk of postcolonoscopy colorectal cancer

BACKGROUND AND AIMS

Endoscopist adenoma detection rates (ADRs) vary widely and are associated with patients' risk of postcolonoscopy colorectal cancers (PCCRCs). However, few scalable physician-directed interventions demonstrably both improve ADR and reduce PCCRC risk.

METHODS

Among patients undergoing colonoscopy, we evaluated the influence of a scalable online training on individual-level ADRs and PCCRC risk. The intervention was a 30-minute, interactive, online training, developed using behavior change theory, to address factors that potentially impede detection of adenomas. Analyses included interrupted time series analyses for pretraining versus posttraining individual-physician ADR changes (adjusted for temporal trends) and Cox regression for associations between ADR changes and patients' PCCRC risk.

RESULTS

Across 21 endoscopy centers and all 86 eligible endoscopists, ADRs increased immediately by an absolute 3.13% (95% confidence interval [CI], 1.31-4.94) in the 3-month quarter after training compared with .58% per quarter (95% CI, .40-.77) and 0.33% per quarter (95% CI, .16-.49) in the 3-year pretraining and posttraining periods, respectively. Posttraining ADR increases were higher among endoscopists with pretraining ADRs below the median. Among 146,786 posttraining colonoscopies (all indications), each 1% absolute increase in screening ADR posttraining was associated with a 4% decrease in their patients' PCCRC risk (hazard ratio, .96; 95% CI, .93-.99). An ADR increase of ≥10% versus <1% was associated with a 55% reduced risk of PCCRC (hazard ratio, .45; 95% CI, .24-.82).

CONCLUSIONS

A scalable, online behavior change training intervention focused on modifiable factors was associated with significant and sustained improvements in ADR, particularly among endoscopists with lower ADRs. These ADR changes were associated with substantial reductions in their patients' risk of PCCRC.

Characteristics of Interval Colorectal Cancer: A Canadian Retrospective Population-Level Analysis from Newfoundland and Labrador

Interval colorectal cancers (I-CRCs) arise during the interval time period between scheduled colonoscopies. Predicting which patients are at risk of I-CRCs remains an elusive undertaking, but evidence would suggest that most I-CRCs arise from lesions missed on index endoscopy. The procedural factors that lead to missed lesions are numerous and lack consensus in the literature. In Canada, the province of Newfoundland and Labrador has the highest incidence of CRCs. In this study our aim was to examine I-CRCs (3-60 months after last colonoscopy) in NL through a population-level analysis covering 67% of the province from 2001-2018. We estimated the I-CRC rate to be up to 9.3%. Median age of I-CRC diagnosis was 67.1 years with an interval time of 2.9 years. About 57% of these tumors occurred proximal to the splenic flexure, with 53% presenting as local disease. No temporal differences were observed in interval time or tumor distribution. On univariate and multivariable logistical regression, risk of right-sided I-CRC did not correlate to the index colonoscopy indication, bowel preparation quality, size of largest polyp removed, colonoscopy completion rate, or stage at presentation. Improvements in synoptic reporting utilization and national registries are needed to identity risk factors and reduce I-CRC frequency.

Pre-colonoscopy special guidance and education on intestinal cleaning and examination in older adult patients with constipation

BACKGROUND

The prevalence of constipation in the Chinese population over 60 years of age is 11.5%, and this prevalence increases with age, which seriously affects the quality of life in older adults. Therefore, reducing the incidence of constipation in older adults is necessary to promote a healthy lifestyle as well as biochemical health.

AIM

To explore the value of preoperative guidance and education to improve the effects of bowel cleaning in older adult patients undergoing colonoscopy.

METHODS

In this study, 160 older adult patients with constipation requiring colonoscopy at Shandong Provincial Hospital between January 2019 and March 2021 were selected and randomly divided into a study group and a control group, with 80 patients in each group. The study group received medication guidance and targeted educational guidance before the operation, while the control group received only medication and dietary guidance. The baseline data, colonoscopy duration, bowel preparation compliance, Boston bowel preparation (BBPS) assessment score, intestinal bubble score, the incidence of adverse reactions during bowel preparation, and nursing appointment satisfaction were compared between the two groups.

RESULTS

The colonoscopy duration times and intestinal bubble scores of the study group were shorter than those of the control group, with statistically significant differences. The BBPS scores for the right, left, and interrupted colon in the study group were also higher than those in the control group, and the difference was statistically significant. Additionally, the study group had a higher rate of liquid diet one day before the examination, higher rate of correct bowel-clearing agent dilution method, higher rate of accurate time of ingesting the bowel-clearing agent, and a higher proportion of patients ingesting bowel-clearing agent at the specified time than the control group, with statistically significant differences. The incidence of nausea and vomiting during bowel clearance in the study group was significantly lower than that in the control group. The incidence of abdominal pain, abdominal distension, dizziness, and fatigue was compared between the two groups, but the difference was not statistically significant. The scores of service attitude, detailed notification of dietary precautions, clear and easy-to-understand health educational content, and receiving care and comfort in the study group were significantly higher than those in the control group.

CONCLUSION

Preoperative special guidance and education were shown to significantly improve bowel clearance and compliance and reduce the incidence of adverse reactions in older adult patients with constipation undergoing colonoscopy. These factors are beneficial for improving patient satisfaction with nursing services.

Colonoscopy skills improvement training improves patient comfort during colonoscopy

INTRODUCTION

We aimed to assess the effect of Colonoscopy Skills Improvement (CSI) training on patient comfort and sedation-related complications during colonoscopy.

METHODS

This retrospective cohort study was performed on 19 endoscopists practicing in a Canadian tertiary care center who completed CSI training between October 2014 and May 2016. Data from 50 procedures immediately prior to, immediately after, and eight months following CSI training were included for each endoscopist. The primary outcome variable was intraprocedural comfort, and secondary outcomes included intraprocedural hypotension and hypoxia. Data were extracted from an electronic medical record and analyzed using SPSS version 20.0. Univariate analysis and stepwise multivariable logistic regression were performed to determine if there was an association between patient comfort and CSI training. Predictors of these outcomes including patient age, gender, sedation use and dosing, procedure completion, quality of bowel preparation, endoscopist experience, and specialty were included in the analysis.

RESULTS

2533 colonoscopies were included in the study. The mean dose of sedatives was reduced immediately following CSI training and at 8 months for both Fentanyl (75.4 mcg v. 67.8 mcg v. 65.9 mcg, p < 0.001) and Midazolam (2.57 mg v. 2.27 mg v. 2.19 mg, p < 0.001). The percentage of patients deemed to have a comfortable exam improved following endoscopist participation in CSI training and remained improved at 8 months (55.1% v. 70.2% v. 69.8%, p < 0.001). No significant change in rates of intraprocedural hypoxia or hypotension were noted following CSI training.

CONCLUSION

CSI training is associated with improved patient comfort and reduced sedation requirements during colonoscopy.

Advances in stent therapy for malignant biliary obstruction

Malignant biliary obstruction (MBO), result of pancreatobiliary diseases is a challenging condition. Most patients with MBO are inoperable at the time of diagnosis, and the disease is poorly controlled using external-beam radiotherapy and chemotherapy. Biliary stent therapy emerged as a promising strategy for alleviating MBO and prolonging life. However, physicians find it difficult to determine the optimal type of biliary stent for the palliation of MBO. Here, we review the safety and efficacy of available biliary stents, used alone or in combination with brachytherapy, photodynamic therapy and advanced chemotherapeutics, in patients with pancreatobiliary malignancies and put forward countermeasures involving stent obstruction. Furthermore, 3D-printing stents and nanoparticle-loaded stents have broad application prospects for fabricating tailor-made biliary stents.

Educational interventions are associated with improvements in colonoscopy quality indicators: a systematic review and meta-analysis

Background and study aims  The quality of screening-related colonoscopy depends on several physician- and patient-related factors. Adenoma detection rate (ADR) varies considerably between endoscopists. Educational interventions aim to improve endoscopists' ADRs, but their overall impact is uncertain. We aimed to assess whether there is an association between educational interventions and colonoscopy quality indicators. Methods  A comprehensive search was performed through August 2019 for studies reporting any associations between educational interventions and any colonoscopy quality indicators. Our primary outcome of interest was ADR. Two authors assessed eligibility criteria and extracted data independently. Risk of bias was also assessed for included studies. Pooled rate ratios (RR) with 95 % confidence intervals (CI) were reported using DerSimonian and Laird random effects models. Results  From 2,253 initial studies, eight were included in the meta-analysis for ADR, representing 86,008 colonoscopies. Educational interventions were associated with improvements in overall ADR (RR 1.29, 95 % CI 1.25 to 1.42, 95 % prediction interval 1.09 to 1.53) and proximal ADR (RR 1.39, 95 % CI 1.29 to 1.48), with borderline increases in withdrawal time, ([WT], mean difference 0.29 minutes, 95 % CI - 0.12 to 0.70 minutes). Educational interventions did not affect cecal intubation rate ([CIR], RR 1.01, 95 % CI 1.00 to 1.01). Heterogeneity was considerable across many of the analyses. Conclusions  Educational interventions are associated with significant improvements in ADR, in particular, proximal ADR, and are not associated with improvements in WT or CIR. Educational interventions should be considered an important option in quality improvement programs aiming to optimize the performance of screening-related colonoscopy.