The WIMAT colonoscopy suitcase model: a novel porcine polypectomy trainer

AIM

Simulation allows the acquisition of complex skills within a safe environment. Endoscopic polypectomy has a long learning curve. Our novel polypectomy simulator may be a useful adjunct for training. The aim of this study was to assess its content validity.

METHOD

The Welsh Institute for Minimal Access Therapy (WIMAT) endoscopy suitcase was designed to simulate colonic polypectomy. Participants from regional and national courses were recruited into the study. Each undertook a standardized simulated polypectomy and completed a seven-point Likert scale questionnaire examining its realism.

RESULTS

In all, 17 participants completed the questionnaire: 15 (88.2%) gastroenterologists, one (5.9%) colorectal surgeon and one (5.9%) experienced endoscopic nurse specialist. Of the gastroenterologists, seven (46.7%) were consultants and eight (53.3%) were senior trainees or Post CCT (Certificate of Completion of Training) fellows. The mean number of real-life polypectomies performed by the cohort was 156 (95% CI 35-355). The highest scores were for 'mucosal realism' (median score 6.0, P=0.001), 'endoscopic snare control' (median score 6.0, P=0.001), 'handling the polyp' (median score 6.0, P=0.001) and 'raising mucosa' (median score 6.0, P<0.001). Of the 15 parameters examined only three were not statistically significant in favour of the simulator. These were 'anatomical realism of sessile polyps', 'resistance of scope movement' and 'paradoxical motion'. The overall score for the simulation was 6.0 (P < 0.001). There was no significant difference between the level of difficulty of the simulator compared with real life (median score 4.0, P = 0.559).

CONCLUSION

The WIMAT colonoscopy suitcase model has excellent content validity for several parameters. This may have potential applications in medical training and assessment.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

AIM

To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions.

METHOD

A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia.

PATIENTS

Subjects undergoing colonoscopy in 68 endoscopy units.

RESULTS

A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of "at risk" patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course.

CONCLUSION

There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.

Colonoscopy services in the United Kingdom

BACKGROUND AND STUDY AIMS

Provision of a reasonable colonoscopy service requires approximately 160 procedures per 100000 population per year. The aim of the present study was to document current levels of colonoscopy service, the use of guidelines in surveillance practice and the capacity for expansion in endoscopy units throughout the United Kingdom.

MATERIAL AND METHODS

A postal questionnaire was sent to 294 endoscopy units.

RESULTS

Replies were received from 164 units (60 %). Of the units, 49 % have reached the calculated target figure. In units not meeting the target, 22% have only one colonoscopist, and 31% have one colonoscopy session a week. Overall, 50 % of units are working at full capacity. Out of all units, 70 % are unable to expand their service further, because of lack of nursing support in 81%, non-availability of endoscopist in 72 % and lack of physical space in 51%. Guidelines for surveillance colonoscopy were a problem: 51% of units reported that guidelines were available for surveillance of ulcerative colitis, 28 % for Crohn's disease, 59 % for polyp follow-up, and 44 % for follow-up of resected colorectal cancer. The majority of units (>70%) had no protocols for their surveillance practice. Nonetheless, 92% of units performed surveillance colonoscopy for ulcerative colitis, 34% for Crohn's disease, and 76% for resected colorectal cancer.

CONCLUSIONS

The colonoscopy service has expanded, but there are constraints on further growth. There is a pressing need for national guidelines on surveillance colonoscopy.

The management of rectal bleeding

Rectal bleeding is a common symptom in the general population; it may signal the presence of serious gastrointestinal disease but more frequently is caused by minor and self-limiting local ano-rectal conditions. Appropriate and accurate evaluation of rectal bleeding requires an investigative approach which balances an appreciation of the need to provide an adequate explanation for the bleeding against over-investigation, excessive referral and wasted resources. As doctors of first contact, general practitioners (GPs) are frequently faced with difficult questions concerning the optimum management of rectal bleeding. This paper was prepared as a result of a series of interactive meetings with over 1,000 GPs from throughout the UK, which revealed wide variations in the possession and use of investigative equipment in the surgery, access to secondary care facilities, estimates of the prevalence and potential seriousness of rectal bleeding and the management strategies adopted in response to a series of case histories. We highlight a number of unresolved issues about the roles of GPs and hospital specialists in the management of rectal bleeding and the need for research directed at answering outstanding questions. In addition, a management strategy is proposed which might form the basis for a protocol for care, shared between general practice and the hospital.

Administration of human recombinant insulin-like growth factor-I to patients following major gastrointestinal surgery

OBJECTIVE

The aim was to study the pharmacokinetic parameters and biological activity of a single dose of human recombinant IGF-I (rhIGF-I) administered to patients following major gastrointestinal surgery.

DESIGN

A double blind placebo controlled externally randomized study of 30 patients; the study commencing 24 hours after major colonic or gastric surgery.

MEASUREMENTS

After a baseline blood sampling day, IGF-I (40 micrograms/kg by single subcutaneous dose, n = 20) or placebo (n = 10) was administered and serum and urine samples collected over the ensuing 72 hours. Serum IGF-I, IGF-II, IGF binding proteins (IGFBP-1, IGFBP-3), GH and insulin were measured by radioimmunoassay. Serum IGF bioactivity was assessed using a validated porcine cartilage bioassay. Serum and urinary electrolytes were measured by standard methodology.

RESULTS

Serum immunoreactive IGF-I levels peaked at 4 hours following injection of IGF-I (1.09 +/- 0.12 U/ml mean +/- SEM), remained elevated for 15 hours and returned to basal levels by 24 hours after injection. IGF bioactivity was increased by 57% 6 hours after IGF-I injection. Mean levels of IGFBP-1 and IGFBP-3, IGF-II and GH were unaffected by IGF-I administration. Insulin levels were suppressed at 30 minutes following injection of IGF-I compared with the placebo group (16.9 +/- 3.0 mU/I vs 32.3 +/- 7.1, P = 0.02); thereafter, there were no differences in insulin levels. The mean change in serum creatinine following IGF-I (-6.3 +/- 3.0 mmol/l) was significantly different from that in the control group (+7.2 +/- 6.2, P = 0.03). Creatinine clearance rose from a mean of 71.6 +/- 7.5 ml/min to 83.2 +/- 7.6 ml/min after IGF-I treatment (P = 0.02). In the IGF treated patients, cholesterol levels consistently fell (-0.20 +/- 0.05 mmol/l); this was not observed in the placebo group (+0.20 +/- 0.14, P = 0.006). Basal serum potassium levels in the IGF treatment group (4.1 +/- 0.1 mmol/l) fell to 3.8 +/- 0.1 at 4 hours (P = 0.002) and 3.6 +/- 0.1 at 10 hours (P = 0.001) returning to a level of 4.0 +/- 0.1 (P = 0.293) at 24 hours after injection. There were no other observed differences in serum or urinary electrolytes or serum free fatty acids and triglycerides. Pharmacokinetic parameters derived from baseline adjusted IGF-I measurements revealed a slow absorption of the administered dose with a Tmax of 5.0 +/- 0.43 hours and an elimination half-life of 10.8 +/- 1.2 hours. The computed volume of distribution was 0.33 +/- 0.05 I/kg and the clearance on average 25 ml/min.

CONCLUSION

A single subcutaneous dose of IGF-I normalized circulating IGF-I levels in post-operative patients, was well tolerated and without side-effects. IGF bioactivity was increased and associated with a fall in serum cholesterol, potassium and creatinine levels and a rise in creatinine clearance. Further long-term studies are now required to assess the anabolic effects of rhIGF-I in this type of patient group.

Screening for colorectal cancer

In this study, testing the faeces for occult blood with the Haemoccult test was well accepted by patients. Although this helped to identify those patients whose symptoms needed investigation and led to quicker diagnosis of colorectal neoplasia, the pathological staging was not improved.