Gastroenterology

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QI 2025-02 Improving Ergonomic Practice in Endoscopy
(Gloucestershire Hospitals NHS Foundation Trust, 2025) Prisk, Amber; Layhe, Julian; Prisk, Amber; Layhe, Julian; Nursing and Midwifery Registered
A virtual-live hybrid training session is feasible with positive impact on colonoscopy key performance indicators amongst trainees
(Universa Press, 2025-12) Debels, Lynn; Krott, Louise; Lala, Vikash; Schoonjans, Christophe; Desomer, Lobke; Anderson, John; Valori, Roland; Tate, David; Anderson, John; Valori, Roland; Medical and Dental
Background: Colonoscopy is a complex, operator dependent, practical skill. Attainment of key performance indicators (KPIs) by endoscopists depends primarily upon training. Local factors can lead to unstructured training, contingent upon the observed practice of trainers who may not be consciously competent (understand colonoscopy, can identify and deconstruct problems). We sought to demonstrate the feasibility and impact of a virtuallive colonoscopy-training course. Methods: Trainees underwent a one-day training course (intervention) by physically remote, consciously-competent endoscopists, consisting of interactive theoretical and live sessions, where trainees performed colonoscopy in their local endoscopy unit receiving real-time instructions via a teleconference monitor. KPIs (Caecal intubation rate[CIR], adenoma detection rate[ADR], withdrawal time[WT], Gloucester Comfort Score[GCS] and Visual Analog Scale[VAS]) were assessed on trainee-performed colonoscopies for 3 weeks prior and 4 weeks after the intervention. Qualitative trainee and trainer feedback was obtained. Results: 6 trainees (mean 654 prior colonoscopies) participated performing 60 colonoscopies (33 pre-, 27 post-intervention). Favourable trends in CIR (91% vs 96%, p=0.386), ADR (39% vs 63%, p=0.069) were observed as well as endoscopist-reported GCS>3 (18% vs 11%, p=0.495) and nurse-reported GCS>3 (22% vs 8%, p=0.131). There was good agreement between trainee- and nurse reported GCS and patient reported VAS. Trainees and trainers reported favourable qualitative experiences. Conclusions: This is the first demonstration of colonoscopy training remotely via teleconference with a positive impact on KPIs. This approach has the potential to create standardized colonoscopy training experiences removing the barriers of travel and allowing exposure to consciously-competent trainers. Keywords: colonoscopy; key performance indicators; training.
Greener colonoscopy: effect of judicious carbon dioxide use and adoption of a non-leak gas/water valve on gas emissions during colonoscopy
(Thieme, 2025-11-24) Anderson, Rebecca; Materacki, Luke; Mc Gettigan, Neasa; Valori, Roland; Anderson, Rebecca; Materacki, Luke; Mc Gettigan, Neasa; Valori, Roland; Medical and Dental
Background Healthcare is responsible for ~4.4% of global carbon dioxide (CO2) emissions and endoscopy is the third largest contributor. This study aimed to quantify CO2 use in colonoscopy and assess the impact of different valves and practices on emissions and costs. Methods CO2 use was measured using a mass flow meter. The study compared CO2 flow using the standard gas/water valves, which continuously release CO2, with non-leak valves, which only release CO2 when depressed. It also assessed the impact of judicious use of CO2. An unpaired student t test was used to calculate statistical significance. Results Without a colonoscope attached, CO2 flow averaged 3.24 L/min. With the standard valve, flow dropped to 2.55 L/min, and with the non-leak valve, it was negligible. CO2 emissions were measured intraprocedurally during 351 colonoscopies. Using a non-leak valve and/or judicious CO2 application significantly reduced emissions compared with standard practice using a standard valve. This approach could reduce local emissions by >87%. Nationally, it would lead to emissions reductions of 106.5 metric tons of CO2 per annum with cost savings of >£260 000. Conclusion Judicious CO2 application and use of a non-leak valve significantly reduced CO2 emissions and costs in colonoscopy, contributing to the UK National Health Service goal of delivering a “net zero” service. We suggest turning off CO2 when not needed, adopting non-leak valves, implementing this practice in other endoscopic procedures, and encouraging all endoscope manufacturers to develop similar valves.
British Society of Gastroenterology, Association of Upper Gastrointestinal Surgery of Great Britain and Ireland and Royal College of Pathologists Delphi consensus guidance on biopsy sampling during upper gastrointestinal endoscopy in adult patients
(2025-11-12) Srinivasa, Amar; Bendall, Oliver; Babikir, Amira; Ahmed, Shahd; Griffiths, Helen; Haslam, Neil; Catton, James; Cripps, Neil; Oates, Beverly; Morris, Allan; Bhandari, Pradeep; Banks, Matthew; Shepherd, Neil; Osborn, Michael; Bateman, Adrian; Sultana-Miah, Farhana; Husbands, Nikki; Banerjee, Saswata; Trudgill, Nigel; Shepherd, Neil; Medical and Dental
These guidance statements represent a practical approach to tissue sampling in the upper gastrointestinal tract during endoscopy in adult patients, outlining instances when biopsies should and should not be taken. Analysis of data from the UK National Endoscopy Database has shown wide variations in biopsy practice among endoscopists. Endoscopy providers with high rates of post-endoscopy upper gastrointestinal cancer take more inappropriate and less appropriate biopsies during endoscopy. This guidance document was commissioned by the British Society of Gastroenterology (BSG) as part of its Upper Gastrointestinal Endoscopy Quality Improvement programme and developed in line with the BSG guidance methodology. A systematic literature review was performed to review the evidence base. However, due to the low quality of evidence in this area, application of GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was not possible and therefore Good Practice Statements, along with Expert Opinions, were used for recommendations. In total, 32 statements or recommendations were initially created and voted on by members of the Guidance Development Group on a five-point scale (strongly agree to strongly disagree). Statements achieving over 80% agreement were adopted. Following voting, one statement did not achieve consensus and was removed, and one statement was amended. All statements achieved over 80% agreement following a second round of voting. In formulating this guidance document, we hope that it will standardise biopsy practice for upper gastrointestinal endoscopy. Outlining when not to undertake tissue sampling will in turn reduce pressure on histopathology services, reduce costs in the National Health Service, and improve sustainability in endoscopy and pathology.
Impact of a simulation-based induction programme in gastroscopy on trainee outcomes and learning curves
(Baishideng Publishing Group, 2020-03-16) Siau, Keith; Hodson, James; Neville, Peter; Turner, Jeff; Beale, Amanda; Green, Susi; Murugananthan, Aravinth; Dunckley, Paul; Hawkes, Neil; Dunckley, Paul; Medical and Dental
BACKGROUND Pre-clinical simulation-based training (SBT) in endoscopy has been shown to augment trainee performance in the short-term, but longer-term data are lacking. AIM To assess the impact of a two-day gastroscopy induction course combining theory and SBT (Structured PRogramme of INduction and Training – SPRINT) on trainee outcomes over a 16-mo period. METHODS This prospective case-control study compared outcomes between novice SPRINT attendees and controls matched from a United Kingdom training database. Study outcomes comprised: (1) Unassisted D2 intubation rates; (2) Procedural discomfort scores; (3) Sedation practice; (4) Time to 200 procedures; and (5) Time to certification. RESULTS Total 15 cases and 24 controls were included, with mean procedure counts of 10 and 3 (P = 0.739) pre-SPRINT. Post-SPRINT, no significant differences between the groups were detected in long-term D2 intubation rates (P = 0.332) or discomfort scores (P = 0.090). However, the cases had a significantly higher rate of unsedated procedures than controls post-SPRINT (58% vs 44%, P = 0.018), which was maintained over the subsequent 200 procedures. Cases tended to perform procedures at a greater frequency than controls in the post-SPRINT period (median: 16.2 vs 13.8 per mo, P = 0.051), resulting in a significantly greater proportion of cases achieving gastroscopy certification by the end of follow up (75% vs 36%, P = 0.017). CONCLUSION In this pilot study, attendees of the SPRINT cohort tended to perform more procedures and achieved gastroscopy certification earlier than controls. These data support the role for wider evaluation of pre-clinical induction involving SBT. Key Words: Gastroscopy; Esophagogastroduodenoscopy; Endoscopy training; Induction; Competency development; Simulation
JAG consensus statements for training and certification in colonoscopy
(BMJ Publishing Group, 2023-01-27) Siau, Keith; Pelitari, Stavroula; Green, Susi; McKaig, Brian; Rajendran, Arun; Feeney, Mark; Thoufeeq, Mo; Anderson, John; Ravindran, Vathsan; Hagan, Paul; Cripps, Neil; Beales, Ian; Church, Karen; Church, Nicholas; Ratcliffe, Elizabeth; Din, Said; Pullan, Rupert; Powell, Sharon; Regan, Catherine; Ngu, Wee Sing; Wood, Eleanor; Mills, Sarah; Hawkes, Neil; Dunckley, Paul; Iacucci, Marietta; Thomas-Gibson, Siwan; Wells, Christopher; Murugananthan, Aravinth; Anderson, John; Dunckley, Paul; Medical and Dental
Introduction: In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification. Methods: Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway. Results: In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS. Conclusion: The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.
PP0699 Evaluating the underlying aetiology in patients with reported colitis on computed tomography imaging
(Wiley, 2025-10-05) Chan, Sally; Shaw, Ian; Chan, Sally; Shaw, Ian; Medical and Dental
Introduction: Computed tomography (CT) is a common modality usedto assess patients who present acutely with gastrointestinal symptoms.1The term colitis refers to the thickening of the colonic wall 2 and is oftendescribed in CT reports. Causes of colitis are commonly classified into in-fectious, inflammatory and ischaemic colitis.3Although there are some radiological features that are helpful in suggest-ing a specific diagnosis,4 determining the underlying aetiology of colitisoften requires correlation with clinical history, laboratory results includ-ing stool cultures and endoscopic evaluation.1There is currently limited literature on the prevalence of the different aeti-ologies in patients with colitis reported on CT. 3Identification of the underlying aetiology allows for specific managementof patients as treatment options differ depending on the underlying cause. Aims & Methods: The aim of this study is to identify the aetiology of colitisin patients with reported colitis on CT imaging.A retrospective review of CT reports and patient case notes was per-formed. A text search through our radiology system (CRIS) was used toidentify patients with CT reported colitis during their inpatient admission.Patients with known Inflammatory bowel disease (IBD), colorectal canceras well as outpatient CT reports were excluded.Following identification of our patient cohort, we reviewed their clinicalnotes as well as laboratory, stool and endoscopic results to determine theunderlying aetiology of their colitis. Results: A total of 138 patients with colitis reported on CT imaging wereincluded. 98 patients (71.0%) had a stool culture sent during their admis-sion whilst 83 patients (60.1%) underwent endoscopic evaluation with aflexible sigmoidoscopy (n=49, 59.0%) or colonoscopy (n=34, 41.0%). In 35patients (42.2%) there were no significant abnormalities found endoscop -ically.74 patients (53.6%) were thought to have infectious colitis with mainpathogens including Campylobacter spp. in 19 patients (25.7%), Clost-ridiodes difficile in 11 patients (14.9%) and Salmonella spp. in 1 patient(1.4%). 4 patients (5.4%) had endoscopic features of infectious colitis. 39patients (52.7%) patients were suspected to have infective colitis fromclinical history and laboratory results.25 patients (18.1%) had ischaemic colitis either confirmed endoscopically(n=11, 44.0%) or through clinical history and CT features (n=14, 56.0%).Endoscopically, 6 patients (4.3%) had features compatible with IBD, 2 patients (1.4%) with lymphocytic colitis and 1 patient (0.7%) with an adeno -carcinoma. 15 patients (10.9%) had diverticulosis.C-reactive protein (CRP) was higher in patients with infectious colitis(mean of 141.4 mg/L) and lower in patient with ischaemic colitis (mean of108.6 mg/L). Albumin and haemoglobin levels were highest in those withinfectious colitis (mean of 33.4 g/L and 135.5g/L respectively) and lowestin patients with IBD (mean of 26.8 g/L and 108.5g/L respectively). Conclusion: CT reported colitis was of infectious aetiology in 53.6% of pa-tients, ischaemic in 18.1% and inflammatory in 4.3%. Laboratory resultssuch as haemoglobin and albumin levels can be helpful in determiningaetiology.Despite CT features suggestive of colitis, 42.2% of endoscopic evaluationrevealed no significant abnormality. CT findings of colitis should thereforebe correlated with clinical history, stool results and endoscopic evalua-tion when determining the underlying aetiology. (Full abstract freely available on publisher's site. Click DOI below. PDF pages 430-431, printed pages 1232-1233)
Modern ostomy seals: a clinical perspective on skin protection, fit and function
(MA Healthcare, 2025-10-03) Murray, Catherine; Russell Roberts, Paul; Murray, Catherine; Nursing and Midwifery Registered
Aim: To critically examine the evolving clinical role of ostomy seals in supporting peristomal skin health and to define key performance attributes aligned with evidence-based stoma care. Background: Ostomy seals are often perceived as additional accessories. However, advances in material science and clinical understanding have re-defined their role as essential components in maintaining peristomal integrity and improving patient outcomes. Discussion: This article explores the functional and clinical expectations of modern ostomy seals, including moisture management, adhesion, mouldability and compatibility. It critiques the influence of added ingredients and calls for a return to core performance metrics. Skin protection, wear-time, ease of application and consistency are highlighted as critical domains for clinical decision-making. The importance of nurse confidence in product selection and outcomes is also discussed. Conclusion: Modern ostomy seals should be regarded as active clinical tools, not passive barriers. When selected intentionally, based on clinical reasoning, seals can enhance skin protection, reduce complications and reinforce nurse-led, patient-centred care.
OGC P23 Omentopexy reduces the incidence of Symptomatic Post- Esophagectomy Diaphragmatic Herniation Following Laparoscopically Assisted Oesophagectomy: 15 years of experience from a UK Specialist Center.
(Springer, 2023-06-07) Doe, Matthew; Brown, Oliver; Jones, Michael; Dwerryhouse, Simon; Higgs, Simon; Hornby, Steve; Messenger, David; Wadley, Martin; Doe, Matthew; Brown, Oliver; Jones, Michael; Dwerryhouse, Simon; Higgs, Simon; Hornby, Steve; Wadley, Martin; Medical and Dental
Objectives: Post-esophagectomy diaphragmatic herniation (PEDH) is a recognized complication of laparoscopically assisted esophagectomy (LAE) and occurs in up to 26% of cases. Several preventative measures have been reported but no formal efficacy data are available. LAE has been undertaken since 2005 in our tertiary specialist oesophagogastric unit with a PEDH of 13.2% in our initial published experience. Subsequently, a novel technique of laparoscopic omentopexy was introduced to reduce the incidence of PEDH. Therefore, the objective of this study was to determine the effectiveness of omentopexy in reducing symptomatic PEDH requiring operative intervention. Methods and Procedures: Details on consecutive patients undergoing LAE in our unit were extracted from a prospectively maintained, institution-approved, esophageal resection database since 2005. Data were collected on patient demographics, neoadjuvant treatment, operative technique, morbidity, and survival. Patient records were also reviewed from referring centers to maximise data capture on the development and timing of symptomatic PEDH. Laparoscopic Omentopexy involved suturing the left-side of the greater omentum to the abdominal wall of the left upper quadrant, either by splitting the omentum into two pedicles and affixing around the site of feeding jejunostomy (Fig. 1) or by simple fixation alone, with minimal omental redundancy between the colon and fixation site. Result(s): A total of 243 patients underwent LAE (9 underwent thoracoscopic second stage) with a median follow-up of 23.8 months. 7/142 patients undergoing omentopexy (4.9%) developed symptomatic PEDH necessitating repair, compared to 13/101 patients (12.9%) in the non-omentopexy group [Hazard Ratio = 0.32 (95% Confidence Interval(CI): 0.12-0.80), p = 0.011]. This translated to a 1-year PEDH-free survival of 96.2% (95%CI: 91.1%-98.4%) in the omentopexy cohort and 87.8% (95%CI: 78.9%-93.1%) in the nonomentopexy cohort (Fig. 2). Of the 7 PEDHs in the omentopexy cohort, only one PEDH (14.2%) developed within 30 days of surgery, compared to 6/13 PEDHs (46.2%) in the non-omentopexy cohort (p = 0.329). No demographic or treatment factors contributed to the risk of PEDH. No complications could be attributed to omentopexy. Conclusion(s): Omentopexy is safe and effective at reducing the incidence of symptomatic PEDH and may be of greatest benefit in the early post-operative period. This simple and low-risk technique should be considered in all patients undergoing the laparoscopic abdominal phase of esophagectomy and merits further study in the randomized controlled trial setting.
A national audit of 1724 post-colonoscopy colorectal cancers: understanding causes and consequences
(Thieme Gruppe, 2025-10-24) Burr, Nicholas; Beaton, David; Trudgill, Nigel; Lee, Andrew; Rahman, Tameera; McPhail, Sean; Wood, Natasha; Rutter, Matthew; Valori, Roland; Morris, Eva; Valori, Roland; Medical and Dental
Background Post-colonoscopy colorectal cancer (PCCRC) represents a potential missed opportunity to diagnose or prevent colorectal cancer (CRC). This study aimed to create a standardized, nationwide audit system to determine why PCCRCs occur and to generate evidence to aid prevention. Methods PCCRCs occurring 6–48 months after colonoscopy were identified from English national datasets and uploaded to a secure portal. The portal contained case review forms based on World Endoscopy Organization (WEO) recommendations for PCCRC review. National Health Service colonoscopy providers (n = 126) were asked to review ≤ 25 PCCRCs. The data were analyzed to determine the characteristics of and reasons for PCCRC. Results Of 2859 PCCRCs, 1724 (60.3 %) were reviewed. Colonoscopies were mostly performed for symptoms (59.2 %) or surveillance (26.5 %). PCCRCs were more common at the hepatic and splenic flexures and transverse colon compared with detected CRCs. PCCRC WEO categorizations were: possible missed lesion, examination adequate 68 %; possible missed lesion, examination inadequate 18 %; detected lesion, not resected 9 %; and likely incompletely resected lesion 5 %. Overall, 69.0 % of PCCRCs were avoidable and 44.2 % led to harm, including premature death in 8.0 %. Non-procedural reasons contributed to 27.1 % of PCCRCs: patient factors 10.2 %; clinical decision making 9.5 %; and administrative factors 7.4 %. Conclusions This is the largest detailed PCCRC review to date. The majority of PCCRCs were avoidable and caused significant harm. This study clarifies the causes of diagnostic delays and highlights high-risk patients and areas of the colon, and suggests what needs to be done to reduce PCCRC in the future
P117: A call for inclusion in addressing variation in UK hospital liver care; a review of national audits, surveys, guidelines and guidance documents from the last five years
(BMJ Publishing Group, 2025-10-06) Tavabie, Oliver; Thorburn, Douglas; Ferguson, James; Cross, Tim; Hollywood, Coral; McPherson, Stuart; Aspinall, Richard; Allison, Michael; Yeoman, Andrew; Heydtman, Mathis; McDougall, Neil; Hebditch, Vanessa; Mitchell-Thain, Robert; Walmsley, Martine; Brownlee, Anne; Mansour, Dina; Al-Shamma, Safa; Backhouse, Diane; Boothman, Helen; Shah, Sital; Williams, Felicity; Jones, Rebecca; Hollywood, Coral; Medical and Dental
Introduction The morbidity and mortality from liver disease has continued to rise over the past half a century. This contrasts with other common illnesses. Alongside this, regional variations in care and outcomes have repeatedly been highlighted for patients with liver disease across the UK. Numerous strategies have been proposed to address this issue, but this remains a major healthcare inequity. In this study, we analysed data from national audits/surveys and guidelines/guidance documents to understand common themes, contributorship and propose potential solutions to reduce variation in care. Methods We included all audits/surveys and guidelines/guidance documents endorsed by UK societies over the past 5 years. Specialist and non-specialist liver services were compared for contributions, as were regions. Authorship of guideline/guidance documents was also analysed for proportion of female, non-Gastroenterology/Hepatology and Allied Health Professional/Pharmacist/Liver Nurse authorship. Common themes were identified across audits/surveys. Results Six audit/surveys and twelve separate guidelines/guidance workstreams were identified. Non-specialist liver services were less well represented across audits/surveys (98% v 68%, p<0.001*) although trainee-led audits had greater participation from non-specialist liver services. Common themes from audits/surveys included a global lack of compliance with national standards, better performance/outcomes at specialist liver services, regional variation in outcomes, limited number of patients transferring from non-specialist to specialist liver services, and staffing and social deprivation impacting on patient outcomes (figure 1). Across guidelines/guidance documents, there was variation in the proportion of female, Allied Health Professional/Nursing/Pharmacy and patient representative authorship. Most authors were from specialist liver services (155/166). London (46/166) and Birmingham (28/166) were well represented in authorship with Northern Ireland (0/166) and Wales (2/166) being significantly less well represented.
OC.14.3 Flamingo set for the endoscopic treatment of buried bumper syndrome: Multicentre, retrospective, cohort study
(Elsevier, 2020-10) Costa, Deborah; Despott, Edward; Woodward, Jeremy; Kohout, Pavel; Rath, Timo; Scovell, Louise; Gee, Ian; Hindryckx, Pieter; Forrest, Ewan; Hollywood, Coral; Hollywood, Coral; Medical and Dental
No abstract available
Gastric Outlet Obstruction Secondary to Recurrent Giant Inguino-Scrotal Hernia Containing Greater Curvature of Stomach
(Oxford University Press, 2020-06) Kulikova, Vera; Scroggie, Darren; Glancy, Damian; Peacock, Mark; Kulikova, Vera; Scroggie, Darren; Glancy, Damian; Peacock, Mark; Medical and Dental
A 79- year-old male presented to the emergency department with multiple episodes of coffee ground vomiting, anorexia and intermittent upper abdominal pain. The patient proceeded to have an urgent OGD. The test was limited in extent, as the pylorus could not be visualised due to retained gastric contents suggestive of distal gastric outlet obstruction. Subsequent, computer tomography confirmed this with a massively distended stomach extending all the way down to a point of obstruction within a left inguinal hernia. No evidence of small bowel obstruction was present on the CT scan. The patient underwent a midline laparotomy, reduction of the left inguino-scrotal hernia. The stomach was viable once reduced and so a simple pre-peritoneal mesh repair with a “Perfix Plug” was performed. Six weeks post discharge the patient re-presented with new onset of obstructive symptoms secondary to a recurrent incarcerated giant left inguino-scrotal hernia. Further diagnostic examination revealed once again a pre-pyloric obstruction of the stomach within the hernia along with multiple loops of small bowel. The patient underwent an open recurrent left-sided inguinal hernia repair with a standard Lichtenstein technique, using a “Prolene” mesh via a groin crease incision and a left orchidectomy
Greener Colonoscopy: CO2 emissions are reduced by 87% with judicious CO2 use and adoption of a non-leak gas/water valve
(Thieme Gruppe, 2025-10-03) Anderson, Rebecca; Materacki, Luke; McGettigan, Neasa; Valori, Roland; Anderson, Rebecca; Materacki, Luke; McGettigan, Neasa; Valori, Roland; Medical and Dental
ntroduction: Healthcare is responsible for ~4.4% of global CO2 emissions and endoscopy is the third largest contributor. This study aims to quantify CO2 use in colonoscopy and assess the impact of different valves and practices on emissions and costs. Methods: CO2 use was measured using a mass flow meter. The study compared CO2 flow with the standard gas/water valves, which continuously release CO2, with non-leak valves, which only releases CO2 when depressed. It also assessed the impact of judicious use of CO2. An unpaired student T-test was used to calculate statistical significance. Results: Without a colonoscope attached, CO2 flow averaged 3.24L/min. With the standard valve, flow dropped to 2.55L/min, and with the non-leak valve, it was negligible. CO2 emissions were measured intra-procedurally during 351 colonoscopies. Using a non-leak valve and/or judicious CO2 use significantly reduced emissions compared to standard practice with a standard valve. This practice could reduce local emissions by >87%. Nationally, it would lead to emissions reductions of 106.5 tonnes CO2 per annum with cost savings of >£260,000. Conclusion: Judicious CO2 use and adoption of a non-leak valve significantly reduces CO2 emissions and costs in colonoscopy, contributing to the NHS's goal of delivering a "net zero" service. We suggest turning off CO2 when not needed, adopting non-leak valves, implementing this practice in other endoscopic procedures and encouraging all endoscope manufacturers to develop similar valves.
Patient-reported outcomes after oesophagectomy in the multicentre LASER study
(Oxford University Press, 2021-05-11) Markar, Sheraz; Sounderajah, Viknesh; Johar, Asif; Zaniotto, Giovanni; Castoro, Carlo; Lagergren, Pernilla; Elliot, Jessie; Gisbertz, Suzanne; Huddy, Jeremy; Pinto, Elisa; Jaunoo, Shameen; Jaunoo, Shameen; Medical and Dental
Background: Data on the long-term symptom burden in patients surviving oesophageal cancer surgery are scarce. The aim of this study was to identify the most prevalent symptoms and their interactions with health-related quality of life. Methods: This was a cross-sectional cohort study of patients who underwent oesophageal cancer surgery in 20 European centres between 2010 and 2016. Patients had to be disease-free for at least 1 year. They were asked to complete a 28-symptom questionnaire at a single time point, at least 1 year after surgery. Principal component analysis was used to assess for clustering and association of symptoms. Risk factors associated with the development of severe symptoms were identified by multivariable logistic regression models. Results: Of 1081 invited patients, 876 (81.0 per cent) responded. Symptoms in the preceding 6 months associated with previous surgery were experienced by 586 patients (66.9 per cent). The most common severe symptoms included reduced energy or activity tolerance (30.7 per cent), feeling of early fullness after eating (30.0 per cent), tiredness (28.7 per cent), and heartburn/acid or bile regurgitation (19.6 per cent). Clustering analysis showed that symptoms clustered into six domains: lethargy, musculoskeletal pain, dumping, lower gastrointestinal symptoms, regurgitation/reflux, and swallowing/conduit problems; the latter two were the most closely associated. Surgical approach, neoadjuvant therapy, patient age, and sex were factors associated with severe symptoms. Conclusion: A long-term symptom burden is common after oesophageal cancer surgery.
Clinical implications of decision making in colorectal polypectomy: an international survey of Western endoscopists suggests priorities for change
(Thieme Gruppe, 2020-03) Tate, David; Desomer, Lobke; Heitman, Steven; Forbes, Nauzer; Burgess, Nicholas; Awadie, Halim; Gralnek, Ian; Geldof, Jeroen; De Looze, Danny; Rex, Douglas; Anderson, John; Bourke, Michael; Anderson, John; Medical and Dental
Introduction Colonoscopy prevents colorectal cancer via the detection and resection of premalignant polyps. This effect may be attenuated by variations in polypectomy, with multiple techniques available and a wide range of experience amongst endoscopists. We assessed current practice against the best available contemporary evidence. Methods An online survey was distributed to members of the gastroenterological and surgical societies of seven countries during July 2017. Images of colorectal polyps were presented and respondents requested to provide the polypectomy technique they would employ in their daily practice. Responses were compared to the evidence-based techniques in the 2017 ESGE Colorectal Polypectomy Guideline. Results In total, 707 endoscopists (627 physicians, 71 surgeons, 9 nurse endoscopists, median practice duration 18 years) completed the survey. Of these, 3.1 % selected hot biopsy forceps and 5.2 % hot snare polypectomy (without submucosal lifting) to remove a 3 mm ascending colon polyp. Only 43.3 % selected cold snare polypectomy (CSP) to remove an 8 mm ascending colon polyp. Surgical referral was selected by 16.7 % of respondents for a 45 mm transverse colon polyp without endoscopic evidence of submucosal invasive cancer (SMIC). Endoscopic resection was selected by 12.0 % for an 80 mm sigmoid polyp with imaging consistent with deep SMIC, and a further 26.4 % selected tertiary endoscopist referral, suggesting they had not appreciated that it was endoscopically unresectable. Conclusion CSP is underutilized for small polyp resection despite its favorable safety and efficacy. Benign polyps are commonly referred for surgery and overt SMIC is underappreciated using endoscopic imaging. Addressing these issues may reduce diathermy-related adverse events, surgery, and unnecessary colonoscopic procedures for patients and reduce rates of post-colonoscopy colorectal cancer.
Management of IBD: improving standards of care
(Wiley, 2020-07-06) Simson, Rosie; Blane, Christine; Orchard, Megan; Simson, Rosie; Medical and Dental
Aim: In 2018 ACPGBI published comprehensive guidelines about the management of IBD. We identified 5 key areas of the guideline and assessed current practice at two busy DGHs against this gold standard. Our aim was to identify and reduce variation in practice to improve the management of these complicated patients. Method: We chose 5 areas of the guideline relating to VTE prophylaxis, smoking cessation, endoscopic dilatation, post-operative surveillance and multi-disciplinary team working. A questionnaire was completed by Consultants and Senior Registrars from both Colorectal Surgery and Gastroenterology about their current practice. The results and the ACPGBI guidelines were presented locally at surgical and medical meetings. Results: Thirty-eight clinicians completed the survey. Although all use prophylactic LMWH, only 26% use extended VTE prophylaxis post-operatively. 32% arrange follow up colonoscopy at the recommended 6 months post op. Smoking cessation advice is routinely offered by 84% and 66% are satisfied with the degree of multidisciplinary input. 55% stated they had experience with endoscopic dilatation for Crohn's strictures although outcomes were not always positive. After the data were presented, 100% of participants agreed to: start extended VTE post-operative prophylaxis, request a 6 month follow up colonoscopy and give all in-and-outpatients smoking cessation advice. There were productive discussions about formalising the medical/surgical pathway for the IBD patients. Conclusion: Knowledge of best practice is essential in ensuring optimum patient care and this project enhanced dissemination of the ACPGBI guidelines. More importantly, it encouraged reflection on our current practice and identified areas to improve standards of care.
P0670 Use of Hemospray in The Treatment of Lower Gastrointestinal Bleeds: Outcomes From The International Multicentre Hemospray Registry
(Wiley, 2020-10-08) Hussein, Mohamed; Alzoubaidi, Durayd; Weaver, Michael; Makahamadze, Christwishes; de la Serna, Alvaro; Ortiz-Fernandez-Sordo, Jacobo; Rey, Johannes; Heyee, Bu; Despott, Edward; Murino, Alberto; Anderson, John; Anderson, John; Medical and Dental
Introduction Lower Gastrointestinal bleeding (LGIB) accounts for approximately 20% of all GI bleeds, with significant mortality in the elderly and those with comorbidities. Common current endoscopic methods for achieving haemostasis include Adrenaline injection, Mechanical clips and thermal therapy. Hemospray (Cook Medical, North Carolina, USA) is a haemostatic powder for GI bleeding. There is a small amount of data on its use in LGIB's. The primary aim was to look at the safety and efficacy of Hemospray in the treatment of LGIBs. Aims & Methods Data was prospectively collected on the use of Hemospray in LGIB's in 16 Centres in the USA, UK, Germany, France and Spain (January 2016 - November 2019). Hemospray was used as a monotherapy, combination therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of application of Hemospray. Rebleeding was defined as a sustained drop in Hb (>2g/l), haematemesis or melaena with haemodynamic instability following index endoscopy. Results 24 patients with LGIB's were recruited (16 males, 8 females). The causes of bleeding included malignancy (6/24, 25%), post procedure (pol-ypectomy/ESD) (5/24, 21%), inflammation/angiodysplasia (7/24, 29%), rectal ulcer (3/24, 13%) and oozing polyp (2/24, 8%). The median diameter of lesions was 20mm (IQR, 25-50). 9/24 (38%) of patients were on anti-platelets or anticoagulants. Overall immediate haemostasis was achieved in 22/24 (92%) of patients. 2/19 (11%) had a re-bleed within 7 days, 4/19 (21%) had a re-bleed within 30 days. 2/21 (10%) died within 30 days (all cause mortality). The two patients that failed treatment had surgery. There was haemostasis rates of 100% in the monotherapy cohort and 88% in the combination therapy cohort (Table 1). in combination Hemospray was always used as a second or third modality. There was a 78% immediate haemostasis rate in patients on antiocoagulants or antiplatelets. There was no adverse events associated with the use of Hemospray. Conclusion These results show that Hemospray is safe and also effective to use in LGIB's with 92% overall haemostasis rates. There are better outcomes when used as a Monotherapy. Anticoagulants/antiplatelets seem to have an effect on haemostasis rates with Hemospray in LGIBs (78% vs 100%). Lower GI bleeds are particularly difficult to treat. Hemospray is an effective alternative in situations where the bleeding point is difficult to access and where there is a large surface of bleeding. Larger randomised trials are required to validate these results.
Hemospray in the treatment of variceal bleeds: outcomes from the international hemospray registry
(BMJ Publishing Group, 2021-01-21) Hussein, Mohamed; Alzoubaidi, Durayd; Weaver, Michael; Makahamadze, Christwishes; de la Serna, Alvaro; Sordo, Jacobo; Rey, Johannes; Hayee, Bu; Despott, Edward; Murino, Alberto; Moreea, Sulleman; Boger, Phil; Dunn, Jason; Mainie, Inder; Graham, David; Mullady, Dan; Early, Dayna; Ragunath, Krish; Anderson, John; Bhandari, Pradeep; Goetz, Martin; Rodriguez, Enrique; Gonda, Tamas; Kiesslich, Ralf; Coron, Emmanuel; Lovat, Laurence; Haidry, Rehan; Anderson, John; Medical and Dental
Introduction Early treatment for variceal bleeding is recommended within 12 hours to improve outcomes. Endoscopic therapy in acute variceal bleeding can be technically difficult and not always successful and a bridge is sometimes required towards definitive therapy. Aim of this study was to look at outcomes in patients with upper gastrointestinal bleeds (UGIB’s) secondary to varices. Methods Data was collected prospectively (Jan’16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during emergency endoscopy for a variceal UGIB as a monotherapy, dual therapy or rescue therapy once standard methods have failed. Haemostasis was defined as cessation of bleeding within 5 minutes. Results 12 patients had Hemospray treatment following a variceal UGIB (10 male, 2 female). 10 oesophageal varices, 2 gastric varices. The median Rockall was 8 (IQR, 7–8). The median Blatchford was 15 (IQR, 13–17). The immediate haemostasis rate was 75%. There were no re-bleeds. 4 patients were treated with Hemospray monotherapy, 3 with combination therapy and 5 with rescue therapy. Hemospray was always given after oesophageal banding/injection sclerotherapy in the combination/rescue therapy cohorts. 4/9 patients died within 7 days, 3 out of these 4 patients did not achieve initial haemostasis with Hemospray.
Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus
(Cochrane Collection, 2020-05-22) Bennett, Cathy; Green, Susi; DeCaestecker, John; Almond, Max; Barr, Hugh; Bhandri, Pradeep; Ragunath, Krish; Singh, Rajvinder; Jankowski, Janusz; Almond, Max; Barr, Hugh; Medical and Dental
Background: Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). Objectives: We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). Search methods: We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. Selection criteria: Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. Types of participants: patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. Data collection and analysis: Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. Main results: We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. Authors' conclusions: This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.

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