Adverse events requiring hospitalization within 30 days after outpatient screening and nonscreening colonoscopies

Curable giant hematoma due to small bowel mesenteric laceration after screening colonoscopy: a case report

Introduction and importance

Mesenteric laceration after screening colonoscopy is a rare and fatal complication. This case reported a giant hematoma due to a small intestinal mesenteric laceration after a screening colonoscopy.

Case description

A 56-year-old woman complained of persistent dramatic abdominal pain after the screening colonoscopy. This patient has appendectomy, rheumatic heart disease, IgG4-related disease, type 2 diabetes mellitus, and coronary atherosclerotic heart disease. Blood tests showed hemoglobin concentration sharply fell to 87 g/L and computed tomography scans confirmed a 16.4 cm × 6.1 cm × 9.5 cm hematoma abdominal hematoma near the small intestine. Digital subtraction angiography consistently showed rough and disordered the fourth group of the superior mesenteric artery. The main diagnosis was mesenteric laceration of the small intestine following colonoscopy. The patient was treated with fasting, gastrointestinal decompression, rehydration, inhibition of gastric acid, and meropenem to fight infection, 4 U suspended red blood cells and 400 mL fresh frozen plasma. Finally, this patient was discharged after conservative treatment, and the abdominal hematoma was significantly shrunk after 3 months.

Clinical discussion

Anticoagulants, a history of previous abdominal surgery, and IgG-RD leading to abdominal fibrosis were possible risk factors for mesenteric laceration. When the patient's condition is complex and has no absolute indication for surgery, conservative management could be appropriately considered.

Conclusions

We reported a case of abdominal hematoma due to colonoscopy. The successful conservative therapy may provide a novel experience for intra-abdominal hematoma treatment.

Negative predictive value of fecal immunochemical testing in significant bowel disease screening: a systematic review and meta-analysis

OBJECTIVES

General practitioners (GPs) must assess significant bowel disease (SBD) in patients with lower bowel symptoms during primary care. Studies have evaluated the efficacy of fecal immunochemical testing (FIT) for SBD screening. However, the effectiveness of FIT remains controversial. This study aimed to investigate the value of FIT in SBD screening.

METHODS

PubMed, the Cochrane Database, and EMBASE were systematically searched. Studies that estimated FIT values in screening for SBD among patients with lower bowel symptoms were included. Sensitivity, specificity, negative likelihood ratio (NLR), positive likelihood ratio (PLR), diagnostic odds ratio (DOR), and negative predictive value (NPV) were calculated. Additionally, the pooled area under the summary receiver operating characteristic (SROC) curve was analyzed.

RESULTS

A total of 8615 patients with lower bowel symptoms who underwent FIT and colonoscopy to screen for SBD were enrolled and assessed in this meta-analysis; of these, 1226 patients were ultimately diagnosed with SBD. The pooled sensitivity, specificity, PLR, NLR, DOR, and NPV of FIT in SBD screening were 0.65 (95% CI: 0.50-0.78), 0.85 (95% CI: 0.72-0.92), 4.2 (95% CI: 2.60-6.90), 0.41 (95% CI: 0.29-0.58), 10 (95% CI: 6-17), and 0.90 (95% CI: 0.87-0.94), respectively. Besides, the pooled SROC was 0.82 (95% CI: 0.78-0.85).

CONCLUSIONS

This study indicates that the FIT provides a favorable NPV for SBD screening and could be a valuable technique for GPs to rule out SBD in primary care. At the same time, GPs need to remain vigilant and refer patients to gastroenterologists when necessary.

Would initiating colorectal cancer screening from age of 45 be cost-effective in Germany? An individual-level simulation analysis

Background

Colorectal cancer (CRC) screening has been shown to be effective and cost-saving. However, the trend of rising incidence of early-onset CRC challenges the current national screening program solely for people ≥50 years in Germany, where extending the screening to those 45-49 years might be justified. This study aims to evaluate the cost-effectiveness of CRC screening strategies starting at 45 years in Germany.

Method

DECAS, an individual-level simulation model accounting for both adenoma and serrated pathways of CRC development and validated with German CRC epidemiology and screening effects, was used for the cost-effectiveness analysis. Four CRC screening strategies starting at age 45, including 10-yearly colonoscopy (COL), annual/biennial fecal immunochemical test (FIT), or the combination of the two, were compared with the current screening offer starting at age 50 years in Germany. Three adherence scenarios were considered: perfect adherence, current adherence, and high screening adherence. For each strategy, a cohort of 100,000 individuals with average CRC risk was simulated from age 20 until 90 or death. Outcomes included CRC cases averted, prevented death, quality-adjusted life-years gained (QALYG), and total incremental costs considering both CRC treatment and screening costs. A 3% discount rate was applied and costs were in 2023 Euro.

Result

Initiating 10-yearly colonoscopy-only or combined FIT + COL strategies at age 45 resulted in incremental gains of 7-28 QALYs with incremental costs of €28,360-€71,759 per 1,000 individuals, compared to the current strategy. The ICER varied from €1,029 to €9,763 per QALYG, and the additional number needed for colonoscopy ranged from 129 to 885 per 1,000 individuals. Among the alternatives, a three times colonoscopy strategy starting at 45 years of age proves to be the most effective, while the FIT-only strategy was dominated by the currently implemented strategy. The findings remained consistent across probabilistic sensitivity analyses.

Conclusion

The cost-effectiveness findings support initiating CRC screening at age 45 with either colonoscopy alone or combined with FIT, demonstrating substantial gains in quality-adjusted life-years with a modest increase in costs. Our findings emphasize the importance of implementing CRC screening 5 years earlier than the current practice to achieve more significant health and economic benefits.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos)

BACKGROUND AND AIMS

Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes.

METHODS

This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes.

RESULTS

Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization.

CONCLUSIONS

This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience

BACKGROUND

We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record.

METHODS

This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020.

RESULTS

A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%).

CONCLUSIONS

The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.

10-year prevalence of diagnostic and screening colonoscopy use in Germany: a claims data analysis

INTRODUCTION

Studies providing detailed information on colonoscopy use are important for the interpretation of patterns and trends in colorectal cancer incidence and mortality, but there is a lack of such studies from Germany. To fill this gap, we aimed to describe the 10-year prevalence of colonoscopy use based on German health claims data.

METHODS

Using the German Pharmacoepidemiological Research Database (short GePaRD; claims data from ~20% of the German population), we determined the 10-year prevalence of colonoscopy use for the year 2017. We determined this prevalence for any colonoscopy, screening (reimbursable from age 55) and diagnostic colonoscopy, stratified by sex, age, educational level and regional factors (e.g. federal state, physicians density in the district of residence).

RESULTS

In men, the 10-year prevalence of colonoscopy use was as follows (not all age groups reported): 30-34 years: 8%, 40-44 years: 12%, 50-54 years: 21%, 55-59 years: 33% (screening: 10%), 60-64 years: 44% (screening: 23%), 70-74 years: 53% (screening: 23%), 80-84 years: 52% (screening: 15%). In women, the prevalences were similar, with differences mostly less than or equal to 3 percentage points. Also, in analyses stratified by educational level or regional factors, prevalences were mostly similar or varied by less than or equal to 4 percentage points.

CONCLUSION

In 2017, about 45-50% of men and women in Germany aged 60-84 years had any colonoscopy in the previous 10 years, and about 11-26% had a screening colonoscopy. Our findings suggest no relevant social or regional disparities in the utilization of colonoscopy in Germany.

Risk of colonoscopy-related complications in a fecal immunochemical test-based population colorectal cancer screening program

BACKGROUND

The likelihood of advanced or synchronous neoplasms is significantly higher in fecal immunochemical test (FIT)-positive individuals than in the general population. The magnitude of the colonoscopy-related complication rate in FIT-positive individuals remains unknown. This study aimed to elucidate the colonoscopy-related complication rate after a positive FIT result and compare it with the rate when colonoscopy was performed for other purposes.

METHODS

Information regarding colonoscopy-related severe complications after a positive FIT result (FIT-colonoscopy) and ordinary colonoscopy during 2010-2014 was collected from the Taiwanese Colorectal Cancer Screening Program Database and National Health Insurance Research Database. Severe complications included significant bleeding, perforation, and cardiopulmonary events ≤ 14 days after colonoscopy. The number of events per 1000 procedures was used to quantify complication rates. Multivariate analysis was conducted to assess the association of various factors with severe complications associated with FIT-colonoscopy compared with ordinary colonoscopy.

RESULTS

319 114 FIT-colonoscopies (214 955 patients) were identified, 51 242 (16.1 %) of which included biopsy and 94 172 (29.5 %) included polypectomy. Overall, 2125 significant bleedings (6.7 ‰) and 277 perforations (0.9 ‰) occurred ≤ 14 days after FIT-colonoscopy. Polypectomy, antiplatelet use, and anticoagulant use were associated with higher risk of complications (adjusted odds ratio [aOR] 4.41, 95 % confidence interval [CI] 4.05-4.81); aOR 1.35, 95 %CI 1.12-1.53; aOR 1.88, 95 %CI 0.61-5.84, respectively). Compared with ordinary colonoscopy, FIT-colonoscopy involved significantly higher risk of significant bleeding (aOR 3.10, 95 %CI 2.90-3.32).

CONCLUSIONS

FIT-colonoscopy was associated with a more than two-fold risk of significant bleeding, especially when polypectomy was performed.

Paradigm shift in management of acute iatrogenic colonic perforations: 24-year retrospective comprehensive study

Background and study aims  Through advanced endoscopic clipping techniques, endoscopic treatment of both diagnostic and therapeutic acute iatrogenic colonic perforations has been shown effective. The main purpose of this study was to compare the management of acute iatrogenic perforations (AIPs) of the colon before and after the introduction of advanced clipping techniques. Methods  We conducted a retrospective study from July 1996 to February 2020. The period was divided into two sub periods, Period 1: from July 1996 to December 2012 and Period 2: from January 2013 to March 2020. All AIPs occurring during a colonoscopy and detected during or immediately (< 4 hours) after the procedure, were included in the study. Results  The total number of colonoscopies performed at our hospital was 33055 and 36831 during Periods 1 and 2 respectively. Fifteen perforations were observed in Period 1 and 11 in Period 2. The rate of surgery was 93.3 % % (14/15) in Period 1 and 27.2 % (3 /11) in Period 2 ( P  < 0.01). The mean hospital stay in Period 1 was 6.9 days and 4 in Period 2 ( P  < 0.01). Conclusions  Data from this historical cohort have clearly shown a decrease in the surgery rate and the length of hospitalization of AIPs in Period 2 compared to Period 1.

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the US.

OBJECTIVE

To systematically review the effectiveness, test accuracy, and harms of screening for CRC to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2015, to December 4, 2019; surveillance through March 26, 2021.

STUDY SELECTION

English-language studies conducted in asymptomatic populations at general risk of CRC.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted.

MAIN OUTCOMES AND MEASURES

Colorectal cancer incidence and mortality, test accuracy in detecting cancers or adenomas, and serious adverse events.

RESULTS

The review included 33 studies (n = 10 776 276) on the effectiveness of screening, 59 (n = 3 491 045) on the test performance of screening tests, and 131 (n = 26 987 366) on the harms of screening. In randomized clinical trials (4 trials, n = 458 002), intention to screen with 1- or 2-time flexible sigmoidoscopy vs no screening was associated with a decrease in CRC-specific mortality (incidence rate ratio, 0.74 [95% CI, 0.68-0.80]). Annual or biennial guaiac fecal occult blood test (gFOBT) vs no screening (5 trials, n = 419 966) was associated with a reduction of CRC-specific mortality after 2 to 9 rounds of screening (relative risk at 19.5 years, 0.91 [95% CI, 0.84-0.98]; relative risk at 30 years, 0.78 [95% CI, 0.65-0.93]). In observational studies, receipt of screening colonoscopy (2 studies, n = 436 927) or fecal immunochemical test (FIT) (1 study, n = 5.4 million) vs no screening was associated with lower risk of CRC incidence or mortality. Nine studies (n = 6497) evaluated the test accuracy of screening computed tomography (CT) colonography, 4 of which also reported the test accuracy of colonoscopy; pooled sensitivity to detect adenomas 6 mm or larger was similar between CT colonography with bowel prep (0.86) and colonoscopy (0.89). In pooled values, commonly evaluated FITs (14 studies, n = 45 403) (sensitivity, 0.74; specificity, 0.94) and stool DNA with FIT (4 studies, n = 12 424) (sensitivity, 0.93; specificity, 0.85) performed better than high-sensitivity gFOBT (2 studies, n = 3503) (sensitivity, 0.50-0.75; specificity, 0.96-0.98) to detect cancers. Serious harms of screening colonoscopy included perforations (3.1/10 000 procedures) and major bleeding (14.6/10 000 procedures). CT colonography may have harms resulting from low-dose ionizing radiation. It is unclear if detection of extracolonic findings on CT colonography is a net benefit or harm.

CONCLUSIONS AND RELEVANCE

There are several options to screen for colorectal cancer, each with a different level of evidence demonstrating its ability to reduce cancer mortality, its ability to detect cancer or precursor lesions, and its risk of harms.

Screening colonoscopy: The present and the future

In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Colonoscopy adverse events: are we getting the full picture?

INTRODUCTION

Colonoscopy adverse events (AEs) are commonly underreported and standardised reporting is rarely used. We aimed to investigate AEs associated with colonoscopy in a real world setting, using the American Society of Gastrointestinal Endoscopy (ASGE) lexicon.

METHODS

This retrospective cohort study of AEs related to outpatient colonoscopies performed in the North Denmark Region from 2015 to 2018 identified AEs from readmission within eight days or death within 30 days of colonoscopy. AEs were investigated in electronic health records and categorised, attributed and graded according to the ASGE lexicon.

RESULTS

Of 49,445 colonoscopies performed, 1141 were potentially associated with AEs (23.07‰). Electronic health record review left 489 AEs attributed to colonoscopy (9.9‰); categorised as cardiovascular (0.65‰), pulmonary (0.36‰), thromboembolic (0.10‰), instrumental incl. perforations (0.99‰), bleeding (3.07‰), infection (0.87‰), drug reactions (0.04‰), pain (2.00‰), integument (damage to skin/bones) (0.34‰) and other (1.62‰) AEs. Ten (0.20‰) AEs were fatal, but only one was procedure related (perforation). All shearing force perforations occurred in the sigmoid colon. Most polypectomy perforations occurred in the caecum (60%).

CONCLUSIONS

Colonoscopy carries important procedure and non-procedure related risks. Non-procedure related AEs are likely underreported. Better attention to patients with pre-existing diseases and further colonoscopist training may lower AE rates. A standardised colonoscopy AE reporting system is warranted.

Age-specific sequence of colorectal cancer screening options in Germany: A model-based critical evaluation

BACKGROUND

The current organized screening program for colorectal cancer in Germany offers both sexes 5 annual fecal immunochemical tests (FITs) between ages 50 and 54 years, followed by a first screening colonoscopy at age 55 years if all of these FITs were negative. We sought to assess the implications of this approach for key parameters of diagnostic performance.

METHODS AND FINDINGS

Using a multistate Markov model, we estimated the expected detection rates of advanced neoplasms (advanced adenomas and cancers) and number needed to scope (NNS) to detect 1 advanced neoplasm at a first screening colonoscopy conducted at age 55 after 5 preceding negative FITs and compared them with the corresponding estimates for a first screening colonoscopy at age 55 with no preceding FIT testing. In individuals with 5 consecutive negative FITs undergoing screening colonoscopy at age 55, expected colonoscopy detection rate (NNS) was 3.7% (27) and 0.10% (1,021) for any advanced neoplasm and cancer, respectively, in men, and 2.1% (47) and 0.05% (1,880) for any advanced neoplasm and cancer, respectively, in women. These NNS values for detecting 1 advanced neoplasm are approximately 3-fold higher, and the NNS values for detecting 1 cancer are approximately 8-fold higher, than those for a first screening colonoscopy at age 55 without prior FITs. This study is limited by model simplifying assumptions and uncertainties related to input parameters.

CONCLUSIONS

Screening colonoscopy at age 55 after 5 consecutive negative FITs at ages 50-54, as currently offered in the German cancer early detection program, is expected to have very low positive predictive value. Our results may inform efforts to enhance the design of screening programs.

Mortality and Rate of Hospitalization in a Colonoscopy Screening Program From a Randomized Health Services Study

BACKGROUND & AIMS

It is difficult to quantify adverse events related to screening colonoscopy due to lack of valid and adequately powered comparison groups. We compared mortality and rate of unplanned hospitalizations among subjects who underwent screening colonoscopies within the Polish Colonoscopy Screening Program (PCSP) vs unscreened matched controls in Poland.

METHODS

Persons 55-64 years old living in the area covered by the PCSP from 2012 through 2015 were assigned in a (1:1) to a group invited for screening colonoscopy (n = 338,477) or a matched group that would be invited 5 years later (controls, n = 338,557). All subjects in the screening group were assigned proposed screening colonoscopy dates (actual dates when invitees confirmed or rescheduled colonoscopy) and those in the control group were assigned virtual dates corresponding to the matched individuals from the screening group. In the screening group, 55,390 subjects (16.4%) underwent screening colonoscopy. Mortality and hospitalization data were obtained from National Registries. We compared mortality and rate of hospitalization between the groups for defined intervals before and after colonoscopy date. Hospitalizations were divided into related and unrelated to colonoscopy based on ICD codes by 3 specialists. Our primary aim was to compare mortality and hospitalization 6 weeks before and 30 days following the actual or virtual date of colonoscopy in the screening or control group.

RESULTS

In the intent to treat analysis, overall there were no significant differences in mortality between the colonoscopy group and control group (0.22% vs 0.22%; risk difference less than .01%; 95% CI, decrease of 0.02% to 0.02%; P = .913). The overall rate of unplanned hospitalization was significantly higher for the colonoscopy group (2.39% vs 2.31% for the control group; risk difference, 0.08%; 95% CI, 0.01%-0.15%; P=.026) for the entire observation period. This was due to the higher rate of hospitalizations after screening (1.10% vs 1.01% for the control group; risk difference, 0.09%; 95% CI, 0.04%-0.14%; P < .001) including higher proportion of hospitalizations that were assessed as related to colonoscopy (0.24% vs 0.22% for the control group; risk difference, 0.02%; 95% CI, 0.00%-0.05%; P = .046). In the per-protocol analysis, the overall rate of hospitalizations did not differ significantly between control and screening colonoscopy groups (1.87% vs 1.90%; P=.709). However, screening colonoscopy did increase rates of related hospitalizations after the date of screening (from 0.14% to 0.31%; P < .001).

CONCLUSIONS

In an analysis of data from the PCSP, we found high-quality evidence that colonoscopy as a screening intervention does not increase mortality before or after colonoscopy. However, it may be associated with a small but significant increase in unplanned hospitalizations, especially after the colonoscopy is completed.

Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions

Background

A multicentre cohort study was performed to analyse the motivations for surgical referral of patients with benign colorectal lesions, and to evaluate the endoscopic and pathological characteristics of these lesions as well as short‐term surgical outcomes.

Methods

Patients who underwent surgery for a benign colorectal lesion in 15 Dutch hospitals between January 2014 and December 2017 were selected from the pathology registry. Lesions were defined as complex when at least one of the following features was present: size at least 40 mm, difficult location according to the endoscopist, previous failed attempt at resection, or non‐lifting sign.

Results

A total of 358 patients were included (322 colonic and 36 rectal lesions). The main reasons for surgical referral of lesions in the colon and rectum were large size (33·5 and 47 per cent respectively) and suspicion of invasive growth (31·1 and 58 per cent). Benign lesions could be categorized as complex in 80·6 per cent for colonic and 80 per cent for rectal locations. Surgery consisted of local excision in 5·9 and 64 per cent of colonic and rectal lesions respectively, and complicated postoperative course rates were noted in 11·2 and 3 per cent. In the majority of patients, no attempt was made to resect the lesion endoscopically (77·0 per cent of colonic and 83 per cent of rectal lesions).

Conclusion

The vast majority of the benign lesions referred for surgical resection could be classified as complex. Considering the substantial morbidity of surgery for benign colonic lesions, reassessment for endoscopic resection by another advanced endoscopy centre seems to be underused and should be encouraged.

[Cancer screening in Germany: availability and participation]

In Germany, approximately 227,000 women and 249,000 men developed cancer in 2014, and nearly 223,000 patients died from the disease that year. Many cancers are curable or have a very good prognosis when they are diagnosed at an early stage. This is where the concept of early detection examinations comes into play.This article describes the current conditions of and participation in examinations for the early detection of cervical, breast, skin, prostate, and colon cancer as provided by Germany's statutory health services. Participation was derived from claims data from the statutory health insurance system as well as from Germany's mammography screening program (MSP). The survey "German Health Update" (GEDA 2014/2015-EHIS) served as an additional data source. According to the claims data and considering the intended intervals, participation quotas among insured persons who are entitled to participate lie between 16% (colonoscopy) and 48% (Pap test). In 2015, 51.5% of invited women participated in the MSP. The results according to self-reports of the GEDA survey lie in part substantially higher. The results according to the claims data, the MSP, as well as the self-reports suggest that a large part of the population utilizes the examinations. Colon and cervical cancer examinations will be expanded as organized and quality-assured early detection programs with regular invitations and information on benefits and risks. These efforts should contribute to reaching eligible people who have thus far not participated.

[Online information about early detection of colorectal cancer to support informed decision-making : Evaluation and reception analysis of an information module at the women's health portal and the men's health portal of the Federal Center for Health Education (BZgA)]

Colorectal cancer is one of the most prevalent types of cancer in Germany. The provided governmental program for early detection of colorectal cancer intends to increase the chances of recovery by identifying colorectal cancer at an early, more treatable stage.An information module with quality-assured, balanced, and target-group specific information about colorectal cancer and early detection was designed for the women's health portal and the men's health portal of the Federal Center for Health Education (BZgA) to promote informed decision-making. A multilevel and multimethodological procedure was chosen to examine if the information module achieved this intended goal and to evaluate how users and experts experienced the information module. User experience was evaluated using an eye-tracking, retrospective think aloud (RTA) technique combined with a quantitative questionnaire, and experts' evaluations using a half-standardized questionnaire. Additionally, factors like age, education level, sex, previous experience, and health literacy were analyzed.Altogether, users and experts rated the information module very positive, comprehensible, and informative. Reception of the information module increased the knowledge about colorectal cancer and early detection of colorectal cancer significantly. Therefore, the designed information module provides the crucial basis for an informed decision-making process.

Patient-rated importance of key information on screening colonoscopy in Germany: a survey of statutory health insurance members

BACKGROUND

Primary colonoscopic screening is considered to be of great benefit but also has the potential to cause severe harm. Thus, eligible subjects should be supported in making an informed choice whether to participate.

OBJECTIVES

To identify information on screening colonoscopy that colonoscopy-naïve subjects rate as particularly important for decision making.

DESIGN

Survey of German statutory health insurance members using a written questionnaire in November 2015.

STUDY POPULATION

Colonoscopy-naïve individuals aged 50 to 65 years.

MAIN OUTCOME MEASURES

Importance of key information about screening colonoscopy, including potential risks and benefits, baseline risk of colorectal cancer/polyps and practical aspects of the procedure, as well as associations between participants' characteristics and their judgement of information as to being 'very important'.

RESULTS

Of 1871 respondents (overall response rate: 31%), a subgroup of 370 colonoscopy-naïve subjects was eligible for inclusion (average age: 55 years, 47% male). Information on the risks was rated as very important by most respondents, unimportant by 6%. Information on the benefits was considered unimportant by 26%. Regression analysis showed that less educated persons regarded most items to be more often relevant than highly educated subjects. A greater proportion of women than men rated details regarding pain and practical aspects as very important. Subjects with a low educational level living alone were identified as the group with the least interest in information on risks.

CONCLUSION

Cultivating awareness around the central meaning of the (quantitative) benefits of screening in informed decision making should be focused on more in future information materials. The high requirement of less educated people to become more informed provides a strong motivation for further efforts to develop evidence-based information that adequately informs this group. Tailoring information according to gender-specific needs may be warranted in light of the observed differences in information preferences between women and men.

Does A Medical Consortium Influence Health Outcomes of Hospitalized Cancer Patients? An Integrated Care Model in Shanxi, China

OBJECTIVE

To assess the effect of the medical consortium policy on the outcomes of cancer patients admitted to secondary hospitals in Shanxi, China.

METHOD

Electronic medical records of lung cancer (n = 8,193), stomach cancer (n = 5,693) and esophagus cancer (n = 2,802) patients hospitalized in secondary hospitals were used. Propensity score matching was used to match each patient enrolled in medical consortium hospitals with a counterpart admitted in non-medical consortium hospitals. Cox proportional hazard models were used to estimate the hazard ratio of patients enrolled different categories of hospitals.

RESULTS

The hazards of lung, stomach and esophageal cancer patients admitted in medical consortium hospitals were consistently and significantly lower than those admitted in non-medical consortium hospitals after adjusting for a number of potential confounders. Lower hazard ratios were associated with lung (hazard ratio (HR) = 0.533, p < 0.001), stomach (HR = 0.494, p < 0.001), and esophagus (HR = 0.505, p < 0.001) cancer patients in medical consortium hospitals.

CONCLUSION

The medical consortium provides an effective strategy to improve the outcomes of cancer patients in Shanxi, China. The partnerships between top-tier hospitals and grassroots medical services bridge the gap in resources and plays a critical role in the quality of care in China.

Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data? A retrospective cohort study

OBJECTIVE

To develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation.

STUDY DESIGN

Retrospective analysis of collected data from hospital information systems combined with clinical indicator definitions to define and compare short-term outcomes for three gastrointestinal pathways using the concept of Textbook Outcome.

SETTING

62 Dutch hospitals.

PARTICIPANTS

45 848 unique gastrointestinal patients discharged in 2015.

MAIN OUTCOME MEASURE

A broad range of clinical outcomes including length of stay, reintervention, readmission and doctor-patient counselling.

RESULTS

Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease (n=4369), colonoscopy for inflammatory bowel disease (IBD; n=19 330) and colonoscopy for colorectal cancer screening (n=22 149) were submitted to five suitable clinical indicators per treatment. The percentage of all patients who met all five criteria was 54%±9% (SD) for ERCP treatment. For IBD this was 47%±7% of the patients, and for colon cancer screening this number was 85%±14%.

CONCLUSION

This study shows that reusing data obtained from hospital information systems combined with clinical indicator definitions can be used to express short-term outcomes using the concept of Textbook Outcome without any excess registration. This information can provide meaningful insight into the clinical care trajectory on the level of individual patient care. Furthermore, this concept can be applied to many clinical trajectories within gastroenterology and beyond for monitoring and improving the clinical pathway and outcome for patients.

Low Rates of Gastrointestinal and Non-Gastrointestinal Complications for Screening or Surveillance Colonoscopies in a Population-Based Study

BACKGROUND

The full spectrum of serious non-gastrointestinal post-colonoscopy complications has not been well characterized. We analyzed rates of and factors associated with adverse post-colonoscopy gastrointestinal (GI) and non-gastrointestinal events (cardiovascular, pulmonary, or infectious) attributable to screening or surveillance colonoscopy (S-colo) and non-screening or non-surveillance colonoscopy (NS-colo).

METHODS

We performed a population-based study of colonoscopy complications using databases from California hospital-owned and nonhospital-owned ambulatory facilities, emergency departments, and hospitals from January 1, 2005 through December 31, 2011. We identified patients who underwent S-colo (1.58 million), NS-colo (1.22 million), or low-risk comparator procedures (joint injection, aspiration, lithotripsy; arthroscopy, carpal tunnel; or cataract; 2.02 million) in California's Ambulatory Services Databases. We identified patients who developed adverse events within 30 days, and factors associated with these events, through patient-level linkage to California's Emergency Department and Inpatient Databases.

RESULTS

After S-colo, the numbers of lower GI bleeding, perforation, myocardial infarction, and ischemic stroke per 10,000-persons were 5.3 (95% confidence interval [CI], 4.8-5.9), 2.9 (95% CI, 2.5-3.3), 2.5 (95% CI, 2.1-2.9), and 4.7 (95% CI, 4.1-5.2) without biopsy or intervention; with biopsy or intervention, numbers per 10,000-persons were 36.4 (95% CI, 35.1-37.6), 6.3 (95% CI, 5.8-6.8), 4.2 (95% CI, 3.8-4.7), and 9.1 (95% CI, 8.5-9.7). Rates of dysrhythmia were higher. After NS-colo, event rates were substantially higher. Most serious complications led to hospitalization, and most GI complications occurred within 14 days of colonoscopy. Ranges of adjusted odds ratios for serious GI complications, myocardial infarction, ischemic stroke, and serious pulmonary events after S-colo vs comparator procedures were 2.18 (95% CI, 2.02-2.36) to 5.13 (95% CI, 4.81-5.47), 0.67 (95% CI, 0.56-0.81) to 0.99 (95% CI, 0.83-1.19), 0.66 (95% CI, 0.59-0.75) to 1.13 (95% CI, 0.99-1.29), and 0.64 (95% CI, 0.61-0.68) to 1.05 (95% CI, 0.98-1.11). Biopsy or intervention, comorbidity, black race, low income, public insurance, and NS-colo were associated with post-colonoscopy adverse events.

CONCLUSIONS

In a population-based study in California, we found that following S-colo, rates of serious GI adverse events were low but clinically relevant, and that rates of myocardial infarction, stroke, and serious pulmonary events were no higher than after low-risk comparator procedures. Rates of myocardial infarction are similar to, but rates of stroke are higher than, those reported for the general population.

Screening Indication Associated With Lower Likelihood of Minor Adverse Events in Patients Undergoing Outpatient Colonoscopy

We sought to determine, among outpatients at one university hospital endoscopy center, rates of self-reported minor adverse events (MAEs) at 2, 14, and 30 days postcolonoscopy and to identify predictors of MAEs at Day 2 postcolonoscopy. A single-center longitudinal cohort study with follow-ups at Days 2, 14, and 30 postcolonoscopy was conducted in Montreal, Canada. Baseline self-report data included patient age, gender, gastrointestinal discomforts and other discomforts in the preceding month, and comorbidity. Intracolonoscopy procedures and the method of insufflation were obtained from endoscopy reports. Minor adverse event data were obtained by either phone or Internet survey. Multivariate logistic regression was used to identify predictors of MAEs at Day 2. Of 705 individuals approached, 420 (mean age = 58.7 years; SD = 8.4, 45.7% female) were eligible and consented to study participation, and 378 (90%) participated in at least one follow-up. At Days 2, 14, and 30, 86 (25.1%), 46 (13.7%), and 13 (3.1%) patients, respectively, experienced at least one MAE. At the Day 30 follow-up, 2 (0.53%) patients reported having experienced a serious adverse event. The multivariable analysis results showed that screening compared with nonscreening colonoscopy was protective for MAEs at 2 days (OR = 0.5, 95% CI [0.3, 0.9]). We found that 25% of patients experienced at least one MAE at 2 days postcolonoscopy, and screening compared with nonscreening colonoscopy patients were half as likely to experience these early MAEs. Nurses may use these findings to educate and reassure patients about colonoscopy risks. Large, longitudinal multicenter studies are needed to corroborate our findings.

Increased Post-procedural Non-gastrointestinal Adverse Events After Outpatient Colonoscopy in High-risk Patients

BACKGROUND & AIMS

The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) after colonoscopy are not well-understood. We studied the effects of antithrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy.

METHODS

We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010-March 2012). Data from patients at increased risk (n = 82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring antithrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (on the basis of age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy.

RESULTS

Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking antithrombotic medications (7.3%; odds ratio [OR], 10.75; 95% confidence interval, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% confidence interval, 2.27-2.62) vs average-risk patients (0.7%) and in patients 60-69 years old (OR, 2.21; 95% confidence interval, 2.01-2.42) or 70 years or older (OR, 6.45; 95% confidence interval, 5.89-7.06), compared with patients younger than 50 years. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy in the anticoagulant group (OR, 2.31; 95% confidence interval, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% confidence interval, 1.13-1.56).

CONCLUSIONS

Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating antithrombotic management before colonoscopy.

Complication Rates in Colonoscopy Screening for Cancer

BACKGROUND

Screening colonoscopy has been offered in Germany since 2002. Complications during colonoscopy were reported to be rare, but data on potential complications after colonoscopy are sparse. We aimed to comprehensively assess the frequency of complications arising during or within four weeks of screening colonoscopy.

METHODS

Residents of the German federal state of Saarland without a history of colorectal cancer and without previous polypectomy who underwent a screening colonoscopy between 2010 and 2013 were included. A follow-up was conducted three months after the screening colonoscopy, including participant questionnaires and subsequent validation of self-reported complications arising during or within four weeks of screening colonoscopy, by reviewing colonoscopy records and contacting the treating physicians. A comprehensive mortality follow-up was conducted for non-responders.

RESULTS

We recruited a total of 5527 participants from 26 practices (median age 61 years, 52% women). 5252 (95%) fully completed the questionnaire on complications and met the inclusion criteria for analysis. Among these participants, 16 cases of physician-confirmed bleeding (0.30%) and four cases of physician-confirmed perforation (0.08%) occurred during or within four weeks of colonoscopy. According to consistent reports from patients and physicians, bleeding and perforation led to hospitalization in 5 (0.095%) and 2 (0.04%) cases, respectively. Three participants died within three months of colo - noscopy. In none of these cases was the cause of death related to colonoscopy.

CONCLUSION

We found the risk of complications of screening colonoscopy to be low, even when taking into account a potential delay of up to four weeks.

Distance from hospital impacts adverse event detection after outpatient endoscopy

BACKGROUND AND AIMS

Monitoring adverse events (AEs) after GI endoscopy is an endorsed quality measure but is challenging to implement in practice. Patients with major AEs may seek care elsewhere after endoscopy. We aimed to determine the hospital utilization patterns of patients with AEs after ambulatory endoscopy.

METHODS

We used the HealthLNK Data Repository, which uses a software application for integration of deidentified, patient-level clinical data across institutions. Data for patients undergoing outpatient endoscopy from 2010 to 2011 at 5 Chicago-area hospitals were used. Early mortality was defined as death no more than 2 months after the outpatient procedure. AEs were defined as a hospital admission for perforation, bleeding, or pancreatitis the same or following month after endoscopy.

RESULTS

During the study period, 42,842 outpatient procedures were performed in 22,898 unique individuals. Early mortality occurred in 86 patients (.4%). Per-patient mortality was greatest after outpatient ERCP (2.5%, P < .0001). Of 86 patients with early mortality, 36 (42%) were not hospitalized at the index hospital after endoscopy. Patients who did not return to the index hospital lived farther from the index hospital (P = .02). In total, 8.3% of ambulatory endoscopies were associated with potential endoscopy-related AEs. The observed rate of potential AEs trended downward as patients' home zip codes moved farther from the index hospital (P = .01).

CONCLUSIONS

Nearly half of patients who die soon after outpatient endoscopy are not hospitalized at their index hospital after endoscopy. The observed AE rate was higher for patients living closer to the index hospital, suggesting that patients who live farther away are less likely to return to the index hospital for emergency care. Novel methods to efficiently track outcomes after outpatient endoscopy are needed.

Factors predicting adverse events associated with therapeutic colonoscopy for colorectal neoplasia: a retrospective nationwide study in Japan

BACKGROUND AND AIMS

Few large studies have evaluated the adverse events associated with therapeutic colonoscopy for colorectal neoplasia, including bleeding and bowel perforation. Our aim was to investigate factors associated with these events, using a Japanese national inpatient database.

METHODS

We extracted data from the nationwide Japan Diagnosis Procedure Combination database for patients who underwent therapeutic colonoscopy for colorectal neoplasia between 2013 and 2014. Therapeutic colonoscopy included endoscopic submucosal dissection (ESD), EMR, and polypectomy. Outcomes included bleeding, perforation, cerebro-cardiovascular events, and in-hospital death. A multivariable logistic regression model was used to evaluate factors associated with bleeding and bowel perforation.

RESULTS

We analyzed 345,546 patients, including 16,812 (4.9%) who underwent ESD, 219,848 (63.6%) who underwent EMR, and 108,886 (31.5%) who underwent polypectomy. The rates of bleeding, bowel perforation, cardiovascular events, cerebrovascular events, and death were 32.5, 0.47, 0.05, 0.88, and 1.32 per 1000 patients, respectively. In the multivariate analysis, a higher bleeding rate was associated with being male, comorbid diseases, ESD, tumor size ≥2 cm, and use of drugs including low-dose aspirin, thienopyridines, non-aspirin antiplatelet drugs, novel oral anticoagulants, warfarin, non-steroidal anti-inflammatory drugs (NSAIDs), and steroids. A higher bowel perforation rate was associated with being male, renal disease, ESD, tumor size ≥2 cm, and drugs including warfarin, NSAIDs, and steroids.

CONCLUSIONS

Although the incidence of adverse events after therapeutic colonoscopy was low, several patient-related factors were significantly associated with bleeding and bowel perforation.

Expert opinions and scientific evidence for colonoscopy key performance indicators

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.

Differences in screening vs non-screening colonoscopy: scope for improvement?

AIM

Colonoscopy performed as part of the NHS Bowel Cancer Screening Programme (BCSP) is of high standard as measured using global rating scale (GRS) criteria. Screening practitioners also provide a non-screening colonoscopy service. The current study compares colonoscopy quality indicators between screening and non-screening groups performed by a single practitioner using the GRS.

METHOD

Patient details were obtained for all consecutive colonoscopies between 2007 and 2014 performed by a single screening practitioner. Data were collected retrospectively from electronic patient records; BCSP Exeter database and non-screening colonoscopies were compared. Data included patient demographics (age, gender), sedation, and the GRS data including caecal intubation, adenoma and neoplasia detection rates.

RESULTS

In all, 1961 colonoscopy procedures (1067 screening and 894 non-screening) were identified; 57% were men. Mean (SD) age for all patients was 64 (± 10.4) years. Non-screening patients were younger [62 (± 14) vs 66 (± 4.8) years; P < 0.05] and were less likely to be men (51.5% vs 61.9%; P < 0.05) than their screening counterparts. Caecal intubation was more successful in screening patients [1027/1067 (96.3%)] than non-screening patients [805/894 (90%)]; P < 0.05. Adenoma detection rate was higher in the screening (46.8 ± 4.4) than non-screening (26.3 ± 11.8) group; P < 0.05. There were no differences in neoplasia detection. Polypectomy was more likely (55.5% vs 30.2%) and polyp retrieval more successful (97.5% vs 86.7%) in the screening group.

CONCLUSION

Screening and non-screening colonoscopy differ in the GRS domains of completion and pathology detection. These differences need to be acknowledged when comparing screeners and non-screeners using GRS within units.

Patient experience of CT colonography and colonoscopy after fecal occult blood test in a national screening programme

OBJECTIVE

To investigate patient experience of CT colonography (CTC) and colonoscopy in a national screening programme.

METHODS

Retrospective analysis of patient experience postal questionnaires. We included screenees from a fecal occult blood test (FOBt) based screening programme, where CTC was performed when colonoscopy was incomplete or deemed unsuitable. We analyzed questionnaire responses concerning communication of test risks, test-related discomfort and post-test pain, as well as complications. CTC and colonoscopy responses were compared using multilevel logistic regression.

RESULTS

Of 67,114 subjects identified, 52,805 (79 %) responded. Understanding of test risks was lower for CTC (1712/1970 = 86.9 %) than colonoscopy (48783/50975 = 95.7 %, p < 0.0001). Overall, a slightly greater proportion of screenees found CTC unexpectedly uncomfortable (506/1970 = 25.7 %) than colonoscopy (10,705/50,975 = 21.0 %, p < 0.0001). CTC was tolerated well as a completion procedure for failed colonoscopy (unexpected discomfort; CTC = 26.3 %: colonoscopy = 57.0 %, p < 0.001). Post-procedural pain was equally common (CTC: 288/1970,14.6 %, colonoscopy: 7544/50,975,14.8 %; p = 0.55). Adverse event rates were similar in both groups (CTC: 20/2947 = 1.2 %; colonoscopy: 683/64,312 = 1.1 %), but generally less serious with CTC.

CONCLUSIONS

Even though CTC was reserved for individuals either unsuitable for or unable to complete colonoscopy, we found only small differences in test-related discomfort. CTC was well tolerated as a completion procedure and was extremely safe. CTC can be delivered across a national screening programme with high patient satisfaction.

KEY POINTS

• High patient satisfaction at CTC is deliverable across a national screening programme. • Patients who cannot tolerate screening colonoscopy are likely to find CTC acceptable. • CTC is extremely safe; complications are rare and almost never serious. • Patients may require more detailed information regarding the expected discomfort of CTC.

Screening for Colorectal Cancer: A Systematic Review and Meta-Analysis

To evaluate the effectiveness of colorectal cancer (CRC) screening in asymptomatic adults. A search was conducted of the Medline, Embase, and the Cochrane Library databases. A targeted search of PubMed was conducted for on-topic randomized controlled trials (RCTs). Meta-analysis across 4 RCTs for guaiac fecal occult blood testing (gFOBT) and flexible sigmoidoscopy (FS) screening showed a reduction of 18% (risk ratio [RR], 0.82; 95% CI [CI], 0.73-0.92) and 26% (RR, 0.74; 95% CI, 0.67-0.83) in CRC mortality for the screening group compared to controls, respectively. The number needed to screen (NNS) were 377 (95% CI, 249-887) and 864 (95% CI, 672-1266) for gFOBT and FS screening, respectively. A reduction of 8% and 27% in incidence of late-stage CRC was also observed for gFOBT and FS screening, respectively, but both had no significant effect on all-cause mortality. A single RCT found that screening with immunochemical fecal occult blood test (iFOBT) had no significant impact on CRC mortality (RR, 0.88; 95% CI, 0.72-1.07). Screening with FS has potential harms such as perforation, major and minor bleeding, and death from the procedure or from follow-up colonoscopy. gFOBT and FS screening reduce CRC mortality and incidence of late-stage disease. The absolute effect and NNS were much more favorable for older adults (≥ 60 years), suggesting that a targeted screening approach may avoid exposing younger adults to the harms of CRC screening, from which they are unlikely to derive any significant benefit. Although there is insufficient RCT evidence on the impact of iFOBT on mortality outcomes. compared to gFOBT, this test showed higher sensitivity and comparable specificity, indicating the need to update and reevaluate the evidence in light of future high-quality research. The protocol for this systematic review have been published with PROSPERO 2014: CRD42014009777.

Splenic rupture following colonoscopy: Case report and literature review

INTRODUCTION

Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for colorectal diseases. Although bleeding and perforation are most common complications, extra colonic or visceral injuries have been described. Splenic rupture is rare with few cases reported in current literature.

PRESENTATION OF CASE

We report the case of a 73-year old man who presented to surgical consultation 50h after colonoscopy. Clinical, laboratory and imaging findings were suggestive for haemoperitoneum. At surgery an almost complete splenic disruption was evident and urgent splenectomy was performed.

DISCUSSION

Splenic injury following colonoscopy is exceptional, probably related to instrumental looping with excessive traction on the splenocolic ligament. In patients with an early presentation a sudden onset of symptoms is the rule. By contrast a delayed presentation (>48h) is nonspecific and subtle with arduous diagnosis.

CONCLUSION

Awareness of this potential complication, high level of suspicion and prompt treatment are at the basis of better outcomes in such patients.

Complications after colonoscopy and surgery in a population-based colorectal cancer screening programme

OBJECTIVES

To report complications after colonoscopy and surgery in patients with neoplasia detected through a population based colorectal cancer (CRC) screening programme in the capital region of Sweden.

METHODS

Patients who after a positive FOBT screening result underwent colonoscopy from 1 January 2008 to 30 June 2012 were included. Mortality and complications within 30 days after colonoscopy or subsequent surgery were identified through national registers, and complications were assessed through review of medical charts. Complications were graded using the Clavien-Dindo classification.

RESULTS

After 2984 colonoscopies, the complication rate was 1%. The risk of post-polypectomy bleeding was 14/1000. The risk of perforation was 1/1000 after a diagnostic colonoscopy and 2.5/1000 after a colonoscopy with polypectomy. One patient developed a post-polypectomy syndrome. There was one death which was not related to the colonoscopy. After surgery for 37 adenomas and 155 CRCs, the total complication rates were 27% and 50%, respectively. The rate of anastomotic leakage was 13% and 12% after surgery for adenomas and CRC, respectively. There were no deaths after surgery. The overall complication rate after colonoscopy and surgery for adenomas and cancer was 4%.

CONCLUSIONS

Overall complication rates were acceptable and mortality low; however, the rate of anastomotic leakage after surgery for both adenomas and CRC was higher than expected.

The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation

BACKGROUND

Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper.

RESULTS

Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed.

CONCLUSION

The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.

Declining Bowel Cancer Incidence and Mortality in Germany

BACKGROUND

In October 2002, screening colonoscopy from age 55 onward was introduced as part of the German national statutory cancer screening program. Screening colonoscopy is intended to lower both the mortality and the incidence of bowel cancer by enabling the detection and removal of precursor lesions.

METHODS

The authors studied trends in bowel cancer incidence and mortality in Germany from 2003 to 2012 on the basis of data from the epidemiological cancer registries and from cause-of-death statistics.

RESULTS

Over the period of investigation, the age-standardized incidence of bowel cancer (with the European population as a standard) fell from 66.1 to 57.0 cases per 100 000 persons per year (-13.8%) in men and from 42.6 to 36.5 per 100 000 persons per year (-14.3%) in women. In parallel with these changes, the age-standardized mortality from bowel cancer fell by 20.8% in men and by 26.5% in women. In the age groups 55-64, 65-74, and 75-84 years, the cumulative risk of receiving a diagnosis of bowel cancer fell by 17-26%; in persons under age 55, this risk fell by only 3% in men, but increased by 14% in women. Long-term data from the cancer registry in the German federal state of Saarland revealed that the incidence of bowel cancer, but not its mortality, had risen over the decades preceding the study; it was only during the period of investigation that the trend reversed itself.

CONCLUSION

Within 10 years of the introduction of screening colonoscopy in Germany, the incidence of bowel cancer in persons over age 55 fell by 17-26%, after having risen steadily over the preceding decades.

The role of STK 11 gene testing in individuals with oral pigmentation

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant condition characterised by mucocutaneous pigmented lesions, gastrointestinal polyposis and a significant risk of cancer. Laugier-Hunziker syndrome (LHS) is a benign condition with similar dermatological features, but with no systemic complications. STK 11 gene testing allows clinicians to differentiate between these two disorders. This case report compares the dermatological similarities in four individuals with PJS or LHS and illustrates the potential benefit of genetic testing. There is > 90% likelihood of identifying a mutation in STK 11 if a patient fulfils the diagnostic criteria for PJS. Lifelong risk management is advised for these individuals with confirmed PJS. Diagnostic confirmation is important to provide rational management, in particular, endoscopic cancer surveillance, and psychological support. STK 11 testing can confirm those at risk of PJS, who require lifelong surveillance, and possibly release those with a simple dermatosis, such as LHS, from invasive and thus potentially harmful surveillance.

Quality measures for colonoscopy: where should we be in 2015?

Colonoscopy is an effective colorectal cancer (CRC) screening and prevention modality as evidenced by a 30-year decline in both incident colon cancers and CRC mortality in the USA. The USA is unique among the developed countries in its use of colonoscopy as the most common method to screen for CRC. Individual patients gain maximum value from their colonoscopy experience when they undergo a comfortable exam that is of highest quality, during which all polyps are found and removed safely and completely, where their physicians adhere to all appropriate guidelines and when they (or their insurance) pay a reasonable amount for their care. Colonoscopy "quality" publications to date have been focused on how to improve the individual physician's procedural results and this narrow focus has birthed an entire industry (usually based on entering data into a national registry) that is focused on demonstrating a physician's success in achieving a certain threshold performance metric that is usually (a) marginally related to true health outcomes, (b) can be captured from the myriad electronic medical records (EMR) in existence today, and (c) is attainable by most practicing gastroenterologists. Medical societies have worked diligently to link these registries and recognition programs to commercial or federal payer-based incentive funds. As health care reform drives massive consolidation of delivery systems and reimbursement moves toward population-level two-sided financial risk models, our current measurement infrastructure will become irrelevant. The focus on "value" and the Triple Aim will drive development of a radically different approach. The process by which individual gastroenterologists (or practices) demonstrate the value of colonoscopy as a colorectal cancer (CRC) prevention tool will change dramatically. Essentially, six measures will be reported by a health system: (1) percent of eligible population screened, (2) access to colonoscopy services, (3) complication rates, (4) patient experience scores, (5) episode (bundle) cost, and (6) frequency with which interval cancers occur after a colonoscopy exam (likely using a 3-year interval). Each gastroenterologist within a health system will be evaluated using familiar metrics (cecal intubation, withdrawal time, adenoma detection rate) but these results will likely be used internally to determine whether they are included in a provider network. If they continue to be used in commercial or government incentive programs, then the enterprise electronic medical record will be constructed to populate external programs directly. Population-level metrics (listed above) will determine whether higher cost provider networks (including academic health centers) who might deliver better health outcomes can compete successfully for regional market share with lower cost providers. This article will outline a plan for a health system initiative focused on provision of colonoscopy for CRC prevention; a plan that will help a group of gastroenterologists (whether employed within a health system or independent) demonstrate why they should be a preferred provider and whether they will survive and thrive in the coming world of accountable care.

[Colorectal cancer screening: evidence and implementation]

BACKGROUND

Colorectal cancer (CRC) is the second most common cancer among both men and women in Germany. Owing to its relatively slow growth, perspectives for effective early detection are much better than for other forms of cancer.

AIM

To summarize the evidence on effectiveness and cost-effectiveness of CRC screening, and to provide an overview on the current state and perspectives for effective CRC screening.

MATERIALS AND METHODS

Summary and critical review of evidence from randomized trials and observational epidemiological studies.

RESULTS

A reduction in CRC mortality by offering annual fecal occult blood tests or once-only flexible sigmoidoscopy has been demonstrated in randomized trials. Novel fecal immunochemical tests for hemoglobin in stool have been shown to be more sensitive than traditional fecal occult blood tests and could substantially improve noninvasive CRC screening. Epidemiological studies suggest that the majority of CRC cases and deaths could be prevented by colonoscopy and removal of colorectal adenomas. However, adherence to screening offered outside organized screening programs is low. The National Cancer Plan recommends an organized CRC screening program in Germany. The law on the early detection of cancer from April 2013 has paved the way for its implementation.

DISCUSSION

The great potential for CRC prevention by early detection has so far only been realized to a very limited extent in Germany. Introduction of an organized screening program and the offer of enhanced noninvasive screening tests could strongly enhance the utilization and effectiveness of CRC screening in Germany. The political frame has been set, and timely quality-assured implementation is required.

Prevention, early detection, and overdiagnosis of colorectal cancer within 10 years of screening colonoscopy in Germany

BACKGROUND & AIMS

Screening colonoscopy was introduced in Germany in October 2002. We aimed to quantify its effects on prevention, early detection, and overdiagnosis of colorectal cancer (CRC) in the 10 years since its introduction.

METHODS

We analyzed data from more than 4.4 million screening colonoscopies (conducted on individuals 55-79 years old from 2003 through 2012) available through the national screening colonoscopy registry. CRCs prevented, detected earlier than they would have been without screening, and overdiagnosed (cancers detected at screening colonoscopy that would not have become clinically manifest during the patient's lifetime) were estimated by Markov models. Model parameters included sex-specific and age-specific findings at screening colonoscopy; mortality; rates of transition from nonadvanced to advanced adenoma, advanced adenoma to preclinical cancer, or preclinical cancer to clinically manifest cancer; and protection from screening colonoscopy.

RESULTS

Overall, approximately 180,000 CRCs (1/28 screening colonoscopies) were estimated to have been prevented, and more than 40,000 CRCs (1/121 screening colonoscopies) were detected earlier than they would have been without screening, compared with approximately 4500 overdiagnoses (1/1089 screening colonoscopies). Almost all CRCs prevented or detected earlier than they would have been without screening resulted from screening colonoscopies performed on individuals up to 75 years old (97% and 89%, respectively), whereas 28% of overdiagnoses occurred from screening colonoscopies of individuals older than 75 years old.

CONCLUSIONS

On the basis of a 10-year analysis of data from a national registry in Germany, screening colonoscopies have large potential for prevention and early detection of CRC, with low risk of overdiagnosis.

Hospital-based acute care after outpatient colonoscopy: implications for quality measurement in the ambulatory setting

INTRODUCTION

Ambulatory surgery centers now report immediate hospital transfer rates as a measure of quality. For patients undergoing colonoscopy, this measure may fail to capture adverse events, which occur after discharge yet still require a hospital-based acute care encounter.

OBJECTIVE

We conducted this study to estimate rates of immediate hospital transfer and hospital-based acute care following outpatient colonoscopy performed in ambulatory surgery centers.

RESEARCH DESIGN AND SUBJECTS

Using state ambulatory surgery databases from the 2009-2010 Healthcare Cost and Utilization Project, we identified adult patients who underwent colonoscopy. Immediate hospital transfer and overall acute health care utilization in the 14 days following colonoscopy was determined from corresponding inpatient, ambulatory surgery, and emergency department databases. To compare rates across centers while accounting for differences in patient populations, we calculated risk-standardized rates using hierarchical generalized linear modeling.

RESULTS

The final sample included 1,137,381 colonoscopy discharges from 1019 centers. At the ambulatory surgery center level, the median risk-standardized hospital transfer rate was 0.0% (interquartile range=0.0%), whereas the hospital-based acute care rate was 2.1% (interquartile range=0.6%), with few centers (N=36) having no observed encounters. No correlation was noted between the risk-standardized hospital transfer and hospital-based acute care rates (volume weighted correlation coefficient=0.04, P=0.16).

CONCLUSIONS

Patients more frequently experience hospital-based acute care encounters after colonoscopy than the need for immediate hospital transfer. Broadening existing quality measures to include hospital-based acute care in the postdischarge period may provide a more complete measure of quality.