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Vajpeyi A, Naidu AS, Hawel JD, Schlachta CM, Patel RV. A multi-modal training environment for colonoscopy with pressure feedback. Surg Endosc 2025; 39:960-969. [PMID: 39658674 DOI: 10.1007/s00464-024-11442-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 11/19/2024] [Indexed: 12/12/2024]
Abstract
BACKGROUND Colonoscopy is a complex procedure with a 3-5% failure rate even for experts. Mastering endoscopy skills and reducing complication rates extend well beyond the initial training phase for most endoscopists, and continues into their clinical experience. Thus, continuing efforts should focus on optimizing training methods to make them individualized with clear objective learning goals for trainees. METHODS A hybrid (physical and computer) colonoscopy training simulator was developed using a novel pressure-sensing sleeve covering the full length of a colonoscope, and a physical colon simulator (Kyoto Kagaku) along with custom-designed training software to visualize the color-mapped 3D pressure profile of the colonoscope during the simulated procedure and provide a visual and quantitative evaluation of the endoscopist's skills post-procedure. A system usability questionnaire and objective evaluation metrics were used to determine the model's effectiveness as a training tool. RESULTS Thirty-three participants were enrolled in the study, among which 8 were experts and 25 trainees. The interactive maximum and average pressures applied by the trainees were generally higher than those applied by experts, however, this difference was only statistically significant in the recto-sigmoid region. The mean average pressure applied in the rectum and the rectosigmoid region was 6.5 kPa for the experts compared to 13.7 kPa for the trainees, with a p-value of 0.011. Both groups agreed that the system is easy to understand and use, and would be helpful as a learning aid in training programs for colonoscopy skills. CONCLUSIONS The proposed system is expected to enhance the quality of colonoscopy procedures by enabling endoscopists to adopt safer and more efficient navigational skills. The evaluation metrics discussed in this research offer useful insights into the performance of endoscopists, and the ability of trainees to compare their performance against expert benchmarks will enable them to establish personalized objective training goals.
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Affiliation(s)
- Anirudh Vajpeyi
- Department of Electrical and Computer Engineering, Thompson Engineering Building - Western University, 1151 Richmond St, London, ON, N6A 5B9, Canada.
- Canadian Surgical Technologies and Advanced Robotics (CSTAR), University Hospital - London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
| | - Anish S Naidu
- Canadian Surgical Technologies and Advanced Robotics (CSTAR), University Hospital - London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Jeffrey D Hawel
- Canadian Surgical Technologies and Advanced Robotics (CSTAR), University Hospital - London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Clinical Skills Building - Western University, 1151 Richmond St, London, ON, N6A 5C1, Canada
| | - Christopher M Schlachta
- Canadian Surgical Technologies and Advanced Robotics (CSTAR), University Hospital - London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Clinical Skills Building - Western University, 1151 Richmond St, London, ON, N6A 5C1, Canada
| | - Rajni V Patel
- Department of Electrical and Computer Engineering, Thompson Engineering Building - Western University, 1151 Richmond St, London, ON, N6A 5B9, Canada
- Canadian Surgical Technologies and Advanced Robotics (CSTAR), University Hospital - London Health Sciences Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Clinical Skills Building - Western University, 1151 Richmond St, London, ON, N6A 5C1, Canada
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Kang SJ, Tae CH, Bang CS, Shin CM, Jeong YH, Choi M, Hwang JH, Saito Y, Chiu PWY, Rerknimitr R, Khor C, Khien VV, Choi KD, Shim KN, Song GA, Lee OY. International Digestive Endoscopy Network Consensus on the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Gut Liver 2024; 18:764-780. [PMID: 39223080 PMCID: PMC11391130 DOI: 10.5009/gnl240176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 09/04/2024] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore
| | - Vu Van Khien
- Department of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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Kang SJ, Tae CH, Bang CS, Shin CM, Jeong YH, Choi M, Hwang JH, Saito Y, Chiu PWY, Rerknimitr R, Khor C, Khien VV, Choi KD, Shim KN, Song GA, Lee OY. [IDEN Consensus on Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 83:217-232. [PMID: 38918035 DOI: 10.4166/kjg.2024.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 06/27/2024]
Abstract
Antithrombotic agents, including antiplatelet agent and anticoagulants are widely used in Korea due to increasing incidence of cardio-cerebrovascular disease and aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. Clinical practice guideline regarding this issue which was developed by the Korean Society of Gastrointestinal Endoscopy was published in 2020. However, since then, new evidence has emerged for the use of dual antiplatelet therapy and direct anticoagulant management, and revised guidelines were issued in the US and Europe. Accordingly, the previous guidelines were revised, cardiologists also participated in the development group, and the recommendations went through a consensus process among international experts. This guideline presents 14 recommendations made according to the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and was reviewed by multidisciplinary experts. This guideline provides useful information that can assist endoscopists in the management of patients on antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - Vu Van Khien
- Departments of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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Kang SJ, Tae CH, Bang CS, Shin CM, Jeong YH, Choi M, Hwang JH, Saito Y, Chiu PWY, Rerknimitr R, Khor C, Khien VV, Choi KD, Shim KN, Song GA, Lee OY. International Digestive Endoscopy Network consensus on the management of antithrombotic agents in patients undergoing gastrointestinal endoscopy. Clin Endosc 2024; 57:141-157. [PMID: 38556472 PMCID: PMC10984749 DOI: 10.5946/ce.2024.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/04/2024] [Accepted: 02/09/2024] [Indexed: 04/02/2024] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are widely used in Korea because of the increasing incidence of cardiocerebrovascular disease and the aging population. The management of patients using antithrombotic agents during endoscopic procedures is an important clinical challenge. The clinical practice guidelines for this issue, developed by the Korean Society of Gastrointestinal Endoscopy, were published in 2020. However, new evidence on the use of dual antiplatelet therapy and direct anticoagulant management has emerged, and revised guidelines have been issued in the United States and Europe. Accordingly, the previous guidelines were revised. Cardiologists were part of the group that developed the guideline, and the recommendations went through a consensus-reaching process among international experts. This guideline presents 14 recommendations made based on the Grading of Recommendations, Assessment, Development, and Evaluation methodology and was reviewed by multidisciplinary experts. These guidelines provide useful information that can assist endoscopists in the management of patients receiving antithrombotic agents who require diagnostic and elective therapeutic endoscopy. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Miyoung Choi
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christopher Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - Vu Van Khien
- Departments of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Nam Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Geun Am Song
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
| | - Oh Young Lee
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
| | - The Korean Society of Gastrointestinal Endoscopy Task Force on Clinical Practice Guidelines
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Division of Upper GI and Metabolic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of Gastroenterology and Hepatology, Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
- Departments of GI Endoscopy, 108 Central Hospital, Hanoi, Vietnam
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University College of Medicine and Biomedical Research Institute, Busan, Korea
- Department of Internal Medicine, Hanyang University School of Medicine, Seoul, Korea
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5
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Neilson LJ, Dew R, Hampton JS, Sharp L, Rees CJ. Quality in colonoscopy: time to ensure national standards are implemented? Frontline Gastroenterol 2023; 14:392-398. [PMID: 37581182 PMCID: PMC10423601 DOI: 10.1136/flgastro-2022-102371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 04/21/2023] [Indexed: 08/16/2023] Open
Abstract
Background High-quality colonoscopy is crucial to ensure complete mucosal visualisation and to maximise detection of pathology. Previous audits showing variable quality have prompted national and international colonoscopy improvement programmes, including the development of quality assurance standards and key performance indicators (KPIs). The most widely used marker of mucosal visualisation is the adenoma detection rate (ADR), however, histological confirmation is required to calculate this. We explored the relationship between core colonoscopy KPIs. Methods Data were collected from colonoscopists in eight hospitals in North East England over a 6-month period, as part of a quality improvement study. Procedural information was collected including number of colonoscopies, caecal intubation rate (CIR), ADR and polyp detection rate (PDR). Associations between KPIs and colonoscopy performance were analysed. Results 9265 colonoscopies performed by 118 endoscopists were included. Mean ADR and PDR per endoscopist were 16.6% (range 0-36.3, SD 7.4) and 27.2% (range 0-57.5, SD 9.3), respectively. Mean number of colonoscopies conducted in 6 months was 78.5 (range 4-334, SD 61). Mean CIR was 91.2% (range 55.5-100, SD 6.6). Total number of colonoscopies and ADR>15% were significantly associated (p=0.04). Undertaking fewer colonoscopies and using hyoscine butylbromide less frequently was significantly associated with ADR<15%. CIR, endoscopist grade, % male patients, mean patient age and CIR were not significantly related to ADR<15%. In adjusted analyses, factors which affected ADR were PDR and mean patient age. Conclusion Colonoscopists who perform fewer than the nationally stipulated minimum of 100 procedures per year had significantly lower ADRs. This study demonstrates that PDR can be used as a marker of ADR; providing age is also considered.
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Affiliation(s)
- Laura J Neilson
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Region Endoscopy Group, North East England, UK
| | - Rosie Dew
- School of Medicine, University of Sunderland, Sunderland, UK
| | - James S Hampton
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | - Colin J Rees
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Region Endoscopy Group, North East England, UK
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol 2023; 14:181-200. [PMID: 37056324 PMCID: PMC10086722 DOI: 10.1136/flgastro-2022-102259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS). METHODS A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway. RESULTS In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort <10% with moderate-severe discomfort); (B) minimum procedure count ≥175; (C) performing 15+ procedures over the preceding 3 months; (D) attendance of the JAG Basic Skills in Lower gastrointestinal Endoscopy course; (E) satisfying requirements for formative direct observation of procedural skill (DOPS) and direct observation of polypectomy skill (SMSA level 1); (F) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool and (G) successful performance in summative DOPS. CONCLUSION The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, UK
| | - Vathsan Ravindran
- Department of Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Ian L P Beales
- University of East Anglia, Norwich, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | | | - Elizabeth Ratcliffe
- Department of Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, UK
- Division of Diabetes, Endocrinology and Gastroenterology Faculty of Biology, Medicine and Health School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Catherine Regan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, UK
| | - Eleanor Wood
- Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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7
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Siau K, Pelitari S, Green S, McKaig B, Rajendran A, Feeney M, Thoufeeq M, Anderson J, Ravindran V, Hagan P, Cripps N, Beales ILP, Church K, Church NI, Ratcliffe E, Din S, Pullan RD, Powell S, Regan C, Ngu WS, Wood E, Mills S, Hawkes N, Dunckley P, Iacucci M, Thomas-Gibson S, Wells C, Murugananthan A. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol 2023; 14:201-221. [PMID: 37056319 PMCID: PMC10086724 DOI: 10.1136/flgastro-2022-102260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/04/2022] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, UK
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
| | - Stavroula Pelitari
- Department of Gastroenterology, Royal Free London NHS Foundation Trust, London, London, UK
| | - Susi Green
- Department of Gastroenterology, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Brian McKaig
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Arun Rajendran
- Department of Gastroenterology, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, Greater London, UK
| | - Mark Feeney
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - John Anderson
- Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, Gloucestershire, UK
| | - Vathsan Ravindran
- Gastroenterology, St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Paul Hagan
- Endoscopy, Royal Derby Hospital, Derby, UK
| | - Neil Cripps
- Colorectal Surgery, University Hospitals Sussex NHS Foundation Trust, Worthing, West Sussex, UK
| | - Ian L P Beales
- Department of Gastroenterology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
- University of East Anglia, Norwich, Norfolk, UK
| | | | - Nicholas I Church
- Department of Gastroenterology, NHS Lothian, Edinburgh, Edinburgh, UK
| | - Elizabeth Ratcliffe
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, Manchester, UK
- Wrightington Wigan and Leigh NHS Foundation Trust, Wigan, Wigan, UK
| | - Said Din
- Department of Gastroenterology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rupert D Pullan
- Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, Torbay, UK
| | - Sharon Powell
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Catherine Regan
- Endoscopy, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
| | - Wee Sing Ngu
- Colorectal Surgery, City Hospitals Sunderland NHS Foundation Trust, South Shields, Tyne and Wear, UK
| | - Eleanor Wood
- Department of Gastroenterology, Homerton University Hospital NHS Foundation Trust, London, London, UK
| | - Sarah Mills
- Colorectal Surgery, Chelsea and Westminster Hospital, London, UK
- Imperial College London, London, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
| | - Paul Dunckley
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, Gloucestershire, UK
| | - Marietta Iacucci
- University of Birmingham College of Medical and Dental Sciences, Birmingham, Birmingham, UK
- Department of Gastroenterology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Siwan Thomas-Gibson
- Imperial College London, London, UK
- St Mark's Hospital and Academic Institute Wolfson Unit for Endoscopy, Harrow, London, UK
| | - Christopher Wells
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, Hartlepool, UK
| | - Aravinth Murugananthan
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, Wolverhampton, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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8
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Endoscopic Balloon Dilation Is Cost-Effective for Crohn's Disease Strictures. Dig Dis Sci 2022; 67:5462-5471. [PMID: 35290570 DOI: 10.1007/s10620-022-07420-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/19/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endoscopic balloon dilation (EBD) has emerged as an alternative intervention to manage Crohn's disease (CD) strictures. We determined the cost-effectiveness of EBD versus resection surgery for patients with short (< 4-5 cm) primary or secondary/anastomotic small or large bowel strictures. METHODS A microsimulation state-transition model analyzed the benefits and risks of EBD and resection surgery for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared using a willingness to pay of $100,000/QALY from a societal perspective. Costs (2021 $US) and incremental cost-effectiveness ratios (ICER) were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. RESULTS The EBD strategy cost $19,822 and resulted in 6.18 QALYs while the surgery strategy cost $41,358 and resulted in 6.37 QALYs. Surgery had an ICER of $113,332 per QALY, making EBD a cost-effective strategy. The median number of EBDs was 5 in the EBD strategy and 0 in the surgery strategy. The median number of surgeries was 2 in the surgery strategy and 1 in the EBD strategy. Of individuals who initially received EBD, 50.4% underwent subsequent surgery. One-way sensitivity analyses showed that the probabilities of requiring repeated interventions, surgery mortality (< 0.7%), and quality of life after interventions were the most influential model parameters. Probabilistic sensitivity analyses favored EBD in 50.9% of iterations. CONCLUSIONS EBD is a cost-effective strategy for managing CD strictures. Differences in patient risk and quality of life after intervention impact cost-effectiveness. Intervention decisions should consider cost-effectiveness, patient risks, and quality of life.
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9
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Adverse Events Associated with Routine Colonoscopy in Patients with End-Stage Renal Disease. Dig Dis Sci 2022; 67:3158-3165. [PMID: 34383200 DOI: 10.1007/s10620-021-07137-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/24/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Although colonoscopy has been widely performed in patients with end-stage renal disease (ESRD), studies on the safety of routine colonoscopy, including bowel preparation and sedation, in these patients are limited. This study aimed to investigate the safety of colonoscopy in patients with ESRD who underwent peritoneal dialysis (PD) or hemodialysis (HD). METHODS We retrospectively reviewed 538 patients with ESRD who underwent colonoscopy between 2010 and 2020. We compared the incidence of adverse events (AEs) between the ESRD group and a propensity score-matched control group of healthy adults. Cardiovascular/pulmonary and procedure-related AEs were analyzed. We also compared the rates of AEs between patients who underwent PD or HD. RESULTS The overall rate of AEs was 5.7% in patients with ESRD, which was significantly higher than that in healthy adults (0.6%, P < 0.001). All AEs were cardiovascular/pulmonary in nature, but no perforation or bleeding occurred. Most AEs were not severe and resolved with medical treatment. The incidence of AEs was higher in the HD group than in the PD group, but the difference was not significant (6.1% vs. 3.5%, respectively, P = 0.451). In the HD group, patients with AEs were significantly older than those without AEs (P = 0.009). CONCLUSIONS The rate of colonoscopy-related AEs in patients with ESRD on dialysis was higher than that in healthy adults, but most AEs were not severe. Routine colonoscopy may be safely performed in patients with ESRD regardless of the method of dialysis, but more carefully in older patients on HD.
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10
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Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data. Surg Endosc 2022; 36:7673-7678. [PMID: 35729404 DOI: 10.1007/s00464-022-09083-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database. METHODS AND PROCEDURES The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people). RESULTS Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001). CONCLUSIONS Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.
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11
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Keraliya A, Yu HS, Uyeda JW. CT imaging findings of complications of optical colonoscopy. Emerg Radiol 2022; 29:915-923. [PMID: 35710648 DOI: 10.1007/s10140-022-02058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/06/2022] [Indexed: 10/18/2022]
Abstract
Colonoscopy is one of the most commonly performed endoscopic procedures and remains the most commonly used screening modality method for colorectal cancer (CRC) screening in the USA. Although serious complications of fiberoptic colonoscopy are uncommon due to technical advances, due to increasing number of colonoscopy procedures, post-procedural complications are not uncommonly encountered in the routine clinical practice. Also, as some of the post-colonoscopy complications are life threatening, it is important to diagnose them early so that timely treatment measures can be taken to decrease mortality and morbidity. In this review, we present a case-based illustration of the utility of CT to detect complications of colonoscopy including bowel perforation, hemorrhage, splenic injury, and postpolypectomy syndrome.
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Affiliation(s)
- Abhishek Keraliya
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Hei Shun Yu
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Jennifer W Uyeda
- Department of Radiology, Emergency Radiology Division, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.
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12
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Zarandi-Nowroozi M, Djinbachian R, von Renteln D. Polypectomy for Diminutive and Small Colorectal Polyps. Gastrointest Endosc Clin N Am 2022; 32:241-257. [PMID: 35361334 DOI: 10.1016/j.giec.2021.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diminutive and small colorectal polyps are common findings during colonoscopies, and rarely contain dysplastic elements and progress to colorectal cancer. With improving technology and the advent of artificial intelligence, detection rates of small or diminutive polyps and adenomas are rising, resulting in increasing costs associated with colonoscopy. Incomplete resection rates are an outcome of interest because it correlates with interval colorectal cancer. More effort is warranted to standardize training programs and sensitize endoscopists to the importance of personal performance as a quality metric of colonoscopy. This article reviews indications, methods, and recent developments in polypectomy for small and diminutive polyps.
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Affiliation(s)
- Melissa Zarandi-Nowroozi
- Department of Medicine, Division of Gastroenterology, Montreal University Hospital (CHUM) and Montreal University Hospital Research Center (CRCHUM), 900 Rue Saint-Denis, Montréal, QC H2X 0A9, Canada
| | - Roupen Djinbachian
- Department of Medicine, Division of Gastroenterology, Montreal University Hospital (CHUM) and Montreal University Hospital Research Center (CRCHUM), 900 Rue Saint-Denis, Montréal, QC H2X 0A9, Canada
| | - Daniel von Renteln
- Department of Medicine, Division of Gastroenterology, Montreal University Hospital (CHUM) and Montreal University Hospital Research Center (CRCHUM), 900 Rue Saint-Denis, Montréal, QC H2X 0A9, Canada.
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13
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Sundaram E, Bhimanakunte K. 10 reasons why surgeons should continue performing flexible endoscopy. J Minim Access Surg 2022; 18:635-637. [DOI: 10.4103/jmas.jmas_317_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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14
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Endoscopy 2021; 53:947-969. [PMID: 34359080 PMCID: PMC8390296 DOI: 10.1055/a-1547-2282] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles, and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M. Veitch
- Department of Gastroenterology, Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | | | - Raza Alikhan
- Department of Haematology Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Jean-Marc Dumonceau
- Department of Gastroenterology, Charleroi University Hospitals, Charleroi, Belgium
| | | | | | - Will Lester
- Department of Haematology University Hospitals Birmingham NHS Foundation Trust, Birmingham,
| | - David Nylander
- Department of Gastroenterology, The Newcastle-upon-Tyne NHS Foundation Trust, Newcastle-upon-Tyne
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | | | - James R. Wilkinson
- Department of Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, Netherlands
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15
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Veitch AM, Radaelli F, Alikhan R, Dumonceau JM, Eaton D, Jerrome J, Lester W, Nylander D, Thoufeeq M, Vanbiervliet G, Wilkinson JR, Van Hooft JE. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70:1611-1628. [PMID: 34362780 PMCID: PMC8355884 DOI: 10.1136/gutjnl-2021-325184] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/20/2021] [Indexed: 12/17/2022]
Abstract
This is a collaboration between the British Society of Gastroenterology (BSG) and the European Society of Gastrointestinal Endoscopy (ESGE), and is a scheduled update of their 2016 guideline on endoscopy in patients on antiplatelet or anticoagulant therapy. The guideline development committee included representatives from the British Society of Haematology, the British Cardiovascular Intervention Society, and two patient representatives from the charities Anticoagulation UK and Thrombosis UK, as well as gastroenterologists. The process conformed to AGREE II principles and the quality of evidence and strength of recommendations were derived using GRADE methodology. Prior to submission for publication, consultation was made with all member societies of ESGE, including BSG. Evidence-based revisions have been made to the risk categories for endoscopic procedures, and to the categories for risks of thrombosis. In particular a more detailed risk analysis for atrial fibrillation has been employed, and the recommendations for direct oral anticoagulants have been strengthened in light of trial data published since the previous version. A section has been added on the management of patients presenting with acute GI haemorrhage. Important patient considerations are highlighted. Recommendations are based on the risk balance between thrombosis and haemorrhage in given situations.
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Affiliation(s)
- Andrew M Veitch
- Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | | | - Raza Alikhan
- Haematology, Cardiff and Vale University Health Board, Cardiff, UK
| | | | | | | | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Nylander
- Gastroenterology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mo Thoufeeq
- Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - James R Wilkinson
- Interventional Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jeanin E Van Hooft
- Gastroenterology and Hepatology, Leiden University Medical Centre, Leiden, The Netherlands
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16
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Serdar Karaca A, Özmen MM, Çınar Yastı A, Demirer S. Endoscopy in surgery. Turk J Surg 2021. [DOI: 10.47717/turkjsurg.2021.000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the last 20 years, there have been important developments in endoscopy. Initially, endoscopy was developed and used as a diagnostic tool. As new technology developed, these devices also became the basis for therapeutic maneuvers. In recent years, flexible endoscopes have been used to per- form procedures replacing traditional surgical approaches. Examples of this field are transanal minimally invasive surgery, natural orifice transluminal endoscopic surgery, endoscopic metabolic surgery and third space endoscopies. Throughout history, surgeons have played a vital role in the design and development of endoscopic techniques, procedures, and equipment. Surgeons continue to lead the advancement of endoscopy, make important contributions, and serve as role models for innovation.
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17
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. [Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2020; 76:282-296. [PMID: 33361705 DOI: 10.4166/kjg.2020.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/03/2022]
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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18
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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19
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Lim H. Management of antithrombotic agents for gastrointestinal endoscopy. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.11.711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. Antithrombotic agents reduce the risk of thromboembolism; however, they increase the risk of bleeding. The management of patients on antithrombotic agents, who are also undergoing endoscopic procedures, has become a common and significant clinical challenge. Decisions regarding the management of antithrombotic agents prior to endoscopic procedures should be made with a comprehensive consideration of the risk of thromboembolism related to the discontinuation of antithrombotic agents, along with the risk of bleeding associated with the endoscopic procedures. Four major endoscopy organizations (American Society of Gastrointestinal Endoscopy, Asian Pacific Association of Gastroenterology/Asian Pacific Society for Digestive Endoscopy, British Society of Gastroenterology/European Society of Gastrointestinal Endoscopy, and Japan Gastroenterological Endoscopy Society) have put-forth clinical practice guidelines to assist gastroenterologists in making decisions regarding the appropriate choice of treatments pertaining to the use of antithrombotic agents before and after endoscopic procedures. This review aimed to analyze the current clinical practice guidelines and provide general recommendations on the management of antithrombotic agents in patients undergoing elective gastrointestinal endoscopy.
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20
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Ritter EM, Dyke C, Marks JM. Fact or Fiction? Practice on a Simulator is Not Required to Pass the Fundamentals of Endoscopic Surgery (FES) TM Skills Exam. JOURNAL OF SURGICAL EDUCATION 2020; 77:e229-e236. [PMID: 32532697 DOI: 10.1016/j.jsurg.2020.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Initial work on the validity evidence used to support the Fundamentals of Endoscopic Surgery (FES) performance exam as a measure of technical competency showed a strong relationship to clinical experience. Despite this evidence, there is a perception among some program directors that the exam cannot be successfully passed without practice on a simulator. We assess the validity of this perception. METHODS Deidentified data from the initial FES skills examination (prior to the 2014 FEC requirement) was reviewed, and 335 unique participants with reported simulation experience demographics were identified. Self reported data analyzed included gender, total clinical endoscopy procedure experience (1-150, 151-300, >300), and endoscopy simulator training hours (0, 1-5, 6-10, 11-20, >20). Final FES skills exam scores, and pass/fail designations for each participant were reported by the FES program staff. Continuous variables were compared between groups using one-way analysis of variance with post-hoc analysis where appropriate. Categorical variables were compared using Pearson Chi-Squared. The effect of variables on pass rate was assessed using univariate and multivariate logistic regression. RESULTS Simulation training experience (SE) was categorically reported in hours(n,%): 0 (98, 29%), 1-5 (135, 40%), 6-10 (52, 16%), 11-20 (24, 7%), and >20 (26, 8%). Clinical endoscopy experience (CE), reported categorically as total cases performed (n,%), was available for 323 of 355 identified participants: 1-150 (126, 39%), 151-300 (99, 31%), >300 (98, 30%). There was no statistically discernible differences in mean FES total or task scores across the SE groups (total score 0:72 ± 15, 1-5:72 ± 13, 6-10:71 ± 14, 11-20:71 ± 16, 20:78 ± 13; p = 0.28), while both total score and task scores were discernibly higher in the more experienced CE groups (>151) compared to the least experienced group (total score; <150:67 ± 15, 151-300:75 ± 1, >300:77 ± 14; p < 0.01). Similarly, there was no statistically discernible difference in FES skills exam pass rates between SE groups (0: 80%, 1-5: 82%, 6-10: 79%, 11-20: 75%, >20: 85%; x2 = 2.5, p = 0.6), but there was a strong relationship between clinical experience and pass rate (<150: 70%, 151-300: 87%, >300: 89%; x2 = 15.8, p < 0.001). Finally, on both univariate and multivariate logistic regression, CE remained a discernible predictor of passing, even when controlling for SE (odds ratio = 2, 95% confidence interval 1.4-2.9, p < 0.001). CONCLUSIONS FES skills examination data collected on participants completing the examination before the FEC requirement shows no demonstrable relationship with self-reported training experience on a simulator but confirms a strong relationship with clinical endoscopy experience. This lends further evidence to the validity of the FES exam as a marker of clinical endoscopic skill.
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Affiliation(s)
- E Matthew Ritter
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Christopher Dyke
- Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Jeffrey M Marks
- University Hospitals, Cleveland Medical Center, Cleveland, Ohio
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21
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Forbes N, Boyne DJ, Mazurek MS, Hilsden RJ, Sutherland RL, Pader J, Ruan Y, Shaheen AA, Wong C, Lamidi M, Lorenzetti DL, Brenner DR, Heitman SJ. Association Between Endoscopist Annual Procedure Volume and Colonoscopy Quality: Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2020; 18:2192-2208.e12. [PMID: 32240836 DOI: 10.1016/j.cgh.2020.03.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS In addition to monitoring adverse events (AEs) and post-colonoscopy colorectal cancers (PCCRC), indicators for assessing colonoscopy quality include adenoma detection rate (ADR) and cecal intubation rate (CIR). It is unclear whether there is an association between annual colonoscopy volume and ADR, CIR, AEs, or PCCRC. METHODS We searched publication databases through March 2019 for studies assessing the relationship between annual colonoscopy volume and outcomes, including ADR, CIR, AEs, or PCCRC. Pooled odds ratios (ORs) were calculated using DerSimonian and Laird random effects models. Sensitivity analyses were performed to assess for potential methodological or clinical factors associated with outcomes. RESULTS We performed a systematic review of 9235 initial citations, generating 27 retained studies comprising 11,276,244 colonoscopies. There was no association between procedural volume and ADR (OR, 1.00; 95% CI, 0.98-1.02 per additional 100 annual procedures). CIR improved with each additional 100 annual procedures (OR, 1.17; 95% CI, 1.08-1.28). There was a non-significant trend toward decreased overall AEs per additional 100 annual procedures (OR, 0.95; 95% CI, 0.90-1.00). There was considerable heterogeneity among most analyses. CONCLUSIONS In a systematic review and meta-analysis, we found higher annual colonoscopy volumes to correlate with higher CIR, but not with ADR or PCCRC. Trends toward fewer AEs were associated with higher annual colonoscopy volumes. There are few data available from endoscopists who perform fewer than 100 annual colonoscopies. Studies are needed on extremes in performance volumes to more clearly elucidate associations between colonoscopy volumes and outcomes.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta
| | - Devon J Boyne
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta
| | - Matthew S Mazurek
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta
| | - R Liam Sutherland
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Joy Pader
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta
| | - Yibing Ruan
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Abdel Aziz Shaheen
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Clarence Wong
- Department of Medicine, University of Alberta, Edmonton, Alberta
| | - Mubasiru Lamidi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta
| | - Diane L Lorenzetti
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Health Sciences Library, University of Calgary, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta; Forzani & MacPhail Colon Cancer Screening Centre, Alberta Health Services, Calgary, Alberta.
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22
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Garg R, Singh A, Ahuja KR, Mohan BP, Ravi SJK, Shen B, Kirby DF, Regueiro M. Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients. J Gastroenterol Hepatol 2020; 35:1381-1386. [PMID: 32003069 DOI: 10.1111/jgh.14996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/13/2020] [Accepted: 01/27/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited. METHODS Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses. RESULTS A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period. CONCLUSIONS Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.
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Affiliation(s)
- Rajat Garg
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Keerat R Ahuja
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Babu P Mohan
- Department of Inpatient Medicine, University of Arizona, Banner University Medical Center, Tucson, Arizona, USA
| | - Shri J K Ravi
- Department of Internal Medicine, Guthrie Robert Packer Hospital, Sayre, Pennsylvania, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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23
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Sutton E, Chase SC, Klein R, Zhu Y, Godinez C, Youssef Y, Park A. Development of Simulator Guidelines for Resident Assessment in Flexible Endoscopy. Am Surg 2020. [DOI: 10.1177/000313481307900109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE Endoscopy VR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners’ knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.
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Affiliation(s)
- Erica Sutton
- Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky; the
| | - Sheree Carter Chase
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; the
| | | | - Yue Zhu
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; the
| | - Carlos Godinez
- Department of Surgery, U.S. Naval Hospital, Jacksonville, Florida; the
| | - Yassar Youssef
- Department of Surgery, Sinai Hospital, Baltimore, Maryland
| | - Adrian Park
- Department of Surgery, Anne Arundel Health System, Annapolis, Maryland
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24
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Maida M, Sferrazza S, Maida C, Morreale GC, Vitello A, Longo G, Garofalo V, Sinagra E. Management of antiplatelet or anticoagulant therapy in endoscopy: A review of literature. World J Gastrointest Endosc 2020; 12:172-192. [PMID: 32843928 PMCID: PMC7415229 DOI: 10.4253/wjge.v12.i6.172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/09/2020] [Accepted: 05/19/2020] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures hold a basal risk of bleeding that depends on the type of procedure and patients' comorbidities. Moreover, they are often performed in patients taking antiplatelet and anticoagulants agents, increasing the potential risk of intraprocedural and delayed bleeding. Even if the interruption of antithrombotic therapies is undoubtful effective in reducing the risk of bleeding, the thromboembolic risk that follows their suspension should not be underestimated. Therefore, it is fundamental for each endoscopist to be aware of the bleeding risk for every procedure, in order to measure the risk-benefit ratio for each patient. Moreover, knowledge of the proper management of antithrombotic agents before endoscopy, as well as the adequate timing for their resumption is essential. This review aims to analyze current evidence from literature assessing, for each procedure, the basal risk of bleeding and the risk of bleeding in patients taking antithrombotic therapy, as well as to review the recommendation of American society for gastrointestinal endoscopy, European society of gastrointestinal endoscopy, British society of gastroenterology, Asian pacific association of gastroenterology and Asian pacific society for digestive endoscopy guidelines for the management of antithrombotic agents in urgent and elective endoscopic procedures.
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Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento 38123, Italy
| | - Carlo Maida
- U.O.C di Medicina Interna con Stroke Care, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Palermo 93100, Italy
| | | | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Giovanni Longo
- Cardiology Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Vincenzo Garofalo
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta 93100, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Istituto San Raffaele Giglio, Cefalù 90015, Italy
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25
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Khalid M, Khalid M, Gayam V, Yeddi A, Adam O, Chakraborty S, Abdallah M, Abu-Heija A, Kaloti Z, Mukhtar O, Shereef H, Judd S. The Impact of Hospital Teaching Status on Colonoscopy Perforation Risk: A National Inpatient Sample Study. Gastroenterology Res 2020; 13:19-24. [PMID: 32095169 PMCID: PMC7011915 DOI: 10.14740/gr1234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/06/2019] [Indexed: 12/24/2022] Open
Abstract
Background Colonoscopy has been widely used as a diagnostic tool for many conditions, including inflammatory bowel disease and colorectal cancer. Colonoscopy complications include perforation, hemorrhage, abdominal pain, as well as anesthesia risk. Although rare, perforation is the most dangerous complication that occurs in the immediate post-colonoscopy period with an estimated risk of less than 0.1%. Studies on colonoscopy perforation risk between teaching hospitals and non-teaching hospitals are scarce. Methods The National Inpatient Sample database was queried for patients who underwent inpatient colonoscopy between January 2010 and December 2014 in teaching versus non-teaching facilities in order to study their perforation rates. Our study population included 257,006 patients. Univariate regression was performed, and the positive results were analyzed using a multivariate regression module. Results Teaching hospitals had a higher risk of perforation (odds ratio 1.23, confidence interval 1.07 - 1.42, P = 0.004). Perforation rates were higher in females, patients with inflammatory bowel disease and dilatation of strictures. Polypectomy did not yield any statistical difference between the study groups. Other factors such as African-American ethnicity appeared to have a lower risk. Conclusion Perforation rates are higher in teaching hospitals. More studies are needed to examine the difference and how to mitigate the risks.
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Affiliation(s)
- Mowyad Khalid
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Mazin Khalid
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Vijay Gayam
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Ahmed Yeddi
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Omeralfaroug Adam
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | | | - Mohamed Abdallah
- Department of Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Ahmad Abu-Heija
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Zaid Kaloti
- Department of Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, MI, USA
| | - Osama Mukhtar
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Hammam Shereef
- Department of Internal Medicine, Beaumont Hospital, Dearborn, MI, USA
| | - Stephanie Judd
- Department of Gastroenterology, Wayne State University/John D. Dingell VA Medical Center, Detroit, Michigan, USA
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26
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Koichopolos J, Hawel J, Shlomovitz E, Habaz I, Elnahas A, Alkhamesi NA, Schlachta CM. Correlation of surgical trainee performance on laparoscopic versus endoscopic simulation. Surg Endosc 2019; 34:2007-2011. [PMID: 31321533 DOI: 10.1007/s00464-019-06978-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 07/10/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Both laparoscopy and endoscopy are image-based procedures, which are less intuitive than traditional open surgery and require extensive training to reach adequate proficiency. Currently, there is lack of understanding as to how the skills in one image-based procedure translate to another, such as endoscopy to laparoscopy and vice versa. The aim of our study was to explore the relationship between endoscopic and laparoscopic skills using a Fundamentals of Laparoscopic Surgery (FLS) trainer, a traditional virtual reality endoscopic trainer and a "desk-top" endoscopic physical simulator. METHODS Senior surgical residents from across Canada participating in an advanced laparoscopic foregut training course were enrolled in the study. Participants were assessed performing the FLS laparoscopic suturing task, the Endobubble 2 task (Simbionix, GI Mentor), and a forward viewing peg transfer on the novel Basics in Endoscopic Skills Training Box (BEST Box). RESULTS There was significant correlation between the participant's skill in simulated laparoscopic suturing and simulated endoscopic skill using the BEST box (Pearson coefficient (r) was 0.551 (p = 0.033) and the coefficient of determination (r2) was 0.304). There was a trend towards correlation between laparoscopic suturing time and Endobubble 2 score, but this did not reach statistical significance (r = 0.458, p = 0.086; r2 = 0.210). CONCLUSIONS Performance in the two physical simulators, laparoscopic suturing and simulated flexible endoscopy using the BEST box, showed a correlation. This study adds to the growing body of evidence that laparoscopic and endoscopic skills are complementary and has the potential to impact simulation training involving both skill sets.
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Affiliation(s)
- Jennifer Koichopolos
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Jeffrey Hawel
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, ON, Canada
| | - Eran Shlomovitz
- Division of General Surgery, University Health Network - University of Toronto, Toronto, ON, Canada.,Division of Interventional Radiology, University Health Network, Toronto, ON, Canada
| | - Ilay Habaz
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ahmad Elnahas
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, ON, Canada
| | - Nawar A Alkhamesi
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.,CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, ON, Canada
| | - Christopher M Schlachta
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada. .,CSTAR (Canadian Surgical Technologies & Advanced Robotics), London Health Sciences Centre, London, ON, Canada.
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27
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Jaafar S, Hung Fong SS, Waheed A, Misra S, Chavda K. Pneumoretroperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation. Int J Surg Case Rep 2019; 58:117-120. [PMID: 31035226 PMCID: PMC6487361 DOI: 10.1016/j.ijscr.2019.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/11/2019] [Accepted: 03/24/2019] [Indexed: 02/06/2023] Open
Abstract
Colonic perforation after colonoscopy could be intraperitoneal, extraperitoneal or a combination of both. Majority of the perforations are intraperitoneal. Risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures. Extraperitoneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema. Non operative management in isolated retroperitoneum while surgery required in majority of peritoneal perforation. Introduction Colonoscopy is considered as one of the most common performed procedures for both diagnostic and therapeutic purposes. Serious complication after colonoscopy could occurs like bleeding or perforation. Majority of the perforations are intraperitoneal, while extraperitoneal perforations are very rare and it may cause pneumoretroperitoneum, pneumomediastinum, pneumothorax and subcutaneous emphysema. Presentation of the case A case report was described of 80-year-old female who underwent a diagnostic colonoscopy for recurrent abdominal pain who presented with severe abdominal pain and tenderness with CT findings of pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema. The patient successfully treated surgically with laparoscopic Hartman procedure. Discussion Colonic perforation is rare complication of colonoscopy that can manifest intraperitoneal, extraperitoneal or a combination of both. Patient risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and pre-existing colonic strictures. Technical risk factors includes excessive shearing forces during endoscopic insertion, dilation, biopsy and using electrocautery. Majority of the intraperitoneal perforation warrant a surgical intervention whereas isolated extraperitoneal perforation may be managed conservatively. Conclusion Combined intraperitoneal and extraperitoneal colonic perforation are rare presentations following diagnostic colonoscopy and often difficult to diagnose based on the clinical manifestation only. Understanding the manifestation of extraperitoneal perforation will help to properly identify the condition and preventing morbidity and mortality in these patients.
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Affiliation(s)
| | | | - Abdul Waheed
- Brandon Regional Hospital, Brandon, FL, 33511, USA
| | | | - Keyur Chavda
- Brandon Regional Hospital, Brandon, FL, 33511, USA
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28
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Leslie K, Tay T, Neo E. Intravenous Fluid to Prevent Hypotension in Patients Undergoing Elective Colonoscopy. Anaesth Intensive Care 2019; 34:316-21. [PMID: 16802483 DOI: 10.1177/0310057x0603400314] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Colonoscopy may be associated with hypotension during sedation leading to postoperative morbidity. However, no treatment is proven to ameliorate intraoperative hypotension for this procedure. We therefore conducted a randomized trial to determine the effect of intravenous fluid infusion on the incidence of hypotension during sedation for colonoscopy. With institutional approval, 160 patients presenting for elective colonoscopy were randomized to 1.5 ml/kg or 15 ml/kg Hartmann's solution before colonoscopy. All observers were blind to group allocation. The incidence of hypotension during sedation (29% vs 25%; P=0.59) and postoperative morbidity (nausea, vomiting, headache, drowsiness and dizziness) (41% vs 39%; P=0.75) did not differ between the two groups. Hypotensive patients were older, had a higher baseline systolic blood pressure, and were thirstier after fluid infusion than normotensive patients. This study does not support the use of 15 ml/kg Hartmann's solution to reduce the incidence of hypotension or postoperative morbidity in patients undergoing elective colonoscopy.
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Affiliation(s)
- K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Victoria, Australia
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29
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Placek SB, Franklin BR, Ritter EM. Simulation in Surgical Endoscopy. COMPREHENSIVE HEALTHCARE SIMULATION: SURGERY AND SURGICAL SUBSPECIALTIES 2019. [DOI: 10.1007/978-3-319-98276-2_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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30
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Josey MJ, Eberth JM, Mobley LR, Schootman M, Probst JC, Strayer SM, Sercy E. Should Measures of Health Care Availability Be Based on the Providers or the Procedures? A Case Study with Implications for Rural Colorectal Cancer Disparities. J Rural Health 2018; 35:236-243. [PMID: 30430641 DOI: 10.1111/jrh.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE Patients with colorectal cancer (CRC) living in rural areas have lower survival rates than those in urban areas, potentially because of lack of access to quality CRC screening and treatment. The purpose of this study was to compare traditional physician density (ie, colonoscopy provider availability per capita) against a new physician density measure using an example case of colonoscopy volume and quality. The latter is particularly relevant for rural providers, who may have fewer patients and are more frequently nongastroenterologists. METHODS We conducted a secondary data analysis of the 2014 Medicare Provider Utilization and Payment Database and the National Cancer Institute State Cancer Profile Database. Volume-weighted physician density scores at the state and county levels were created, accounting for (1) the physician's annual colonoscopy volume and (2) whether the physician performs ≥100 procedures per year. We compared volume-weighted versus traditional density, overall and by rurality, and examined their correlation with CRC screening, incidence, and mortality rates. FINDINGS The difference between volume-weighted and traditional density scores was particularly large in rural parts of the West and Midwest, and it was most similar in the Northeast. Although weak, correlations with CRC outcomes were stronger for volume-weighted density, and they did not differ by rurality. CONCLUSIONS Our new method is an improvement over traditional methods because it considers the variation of physician procedure volume, and it has a stronger correlation with population health outcomes. Weighted density scores portray a more realistic picture of physician supply, particularly in rural areas.
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Affiliation(s)
- Michele J Josey
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina.,Statewide Cancer Prevention and Control Program, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina.,Statewide Cancer Prevention and Control Program, University of South Carolina Arnold School of Public Health, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
| | - Lee R Mobley
- School of Public Health and Andrew Young School of Policy Studies, Georgia State University, Atlanta, Georgia
| | - Mario Schootman
- Department of Epidemiology, , College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri
| | - Janice C Probst
- Rural and Minority Health Research Center, University of South Carolina Arnold School of Public Health, Columbia, South Carolina.,Department of Health Services Policy and Management, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
| | - Scott M Strayer
- Department of Family and Preventive Medicine, University of South Carolina School of Medicine, Columbia, South Carolina
| | - Erica Sercy
- Department of Epidemiology and Biostatistics, University of South Carolina Arnold School of Public Health, Columbia, South Carolina.,Statewide Cancer Prevention and Control Program, University of South Carolina Arnold School of Public Health, Columbia, South Carolina
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31
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Winder JS, Juza RM. Curriculum for surgical training. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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32
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Coser RB, Dalio MB, Martins LCP, Alvarenga GFD, Cruz CA, Imperiale AR, Padovese CC, Paulo GAD, Teixeira Júnior JC. Colonoscopy complications: experience with 8968 consecutive patients in a single institution. Rev Col Bras Cir 2018; 45:e1858. [PMID: 30231113 DOI: 10.1590/0100-6991e-20181858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/18/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the incidence, epidemiological characteristics, diagnosis and evolution of patients who returned to the emergency care units of the Albert Einstein Hospital in São Paulo/SP with signs and symptoms suggestive of colonoscopy complications up to 30 days after the procedure. METHODS we conducted a retrospective, uni-institutional study of patients submitted to colonoscopy in 2014 who returned to the Emergency department (ED) within 30 days after the procedure. RESULTS 8968 patients underwent colonoscopies, 95 (1.06%) of whom had complaints related to possible complications. Most of the procedures were elective ones. Minor complications (nonspecific abdominal pain/distension) were frequent (0.49%) and most of the patients were discharged after consultation at the ED. Severe complications were less frequent: perforation (0.033%), lower gastrointestinal bleeding (0.044%), and intestinal obstruction (0.044%). ED consultations in less than 24 hours after the procedure was associated with a higher index of normal colonoscopies (p=0.006), more diagnosis of fever (p=0.0003) and dyspeptic syndrome (p=0.043), and less diagnosis of colitis/ileitis (p=0.015). The observation of fever in patients treated at the ED was associated with the diagnosis of polyps at colonoscopy (p=0.030). CONCLUSION the data corroborate the safety of the colonoscopy exam and points to a reduction in major complications rates.
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Kim DW, Kim MH, Kim HA, Lee KY, Jeong SY, Lee WY. Colonoscopy education for surgical residents in Korea: a national survey of Korean Surgical Skill Study Group. Ann Surg Treat Res 2018; 95:121-128. [PMID: 30182017 PMCID: PMC6121164 DOI: 10.4174/astr.2018.95.3.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 11/30/2022] Open
Abstract
Purpose A standardized colonoscopy training program surgical residents is still unestablished. The aim of this study was to assess the current status of colonoscopy training for surgical residents and collect the opinions on the direction for future colonoscopy education. Methods A questionnaire survey containing 24 items was conducted by sending an email to 310 colorectal surgeons in 84 training hospitals across the country. Results One hundred fifteen staff surgeons (115 of 310, 37%) of 84 institutions returned fully completed questionnaires. Most surgeons were working at tertiary hospitals with more than 5 years of clinical experience. About half of the responding surgeons answered that they perform colonoscopy in clinical practice and the main purpose of colonoscopy was follow-up after colorectal resection. Only 9 of 84 hospitals (10.7%) had a regular program on colonoscopy training for surgical residents. Most of colonoscopy education was conducted irregularly in a form of staff lecture, conferences or hands-on workshops. According to the future directions, 72 of 115 surgeons (62.6%) answered judging competency in colonoscopy should be needed for professional qualification of the surgeon. About 50 cases of colonoscopy seem appropriate during the 4-year-training of surgical residency, especially during the third- and fourth-year. Conclusion This survey shows colonoscopy education for surgical residents is still insufficient in Korea and that most surgeons feel that regular colonoscopy training is needed during the surgical residency period. There needs to be efforts to standardize the education program as well as various institutional and academic societal supports to achieve this goal.
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Affiliation(s)
- Duck-Woo Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Hyun Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | - Kil Yeon Lee
- Department of Surgery, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Doumouras AG, Anvari S, Cadeddu M, Anvari M, Hong D. Geographic variation in the provider of screening colonoscopy in Canada: a population-based cohort study. CMAJ Open 2018; 6. [PMID: 29535104 PMCID: PMC5878955 DOI: 10.9778/cmajo.20170131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Screening colonoscopy for the detection of colorectal carcinoma is provided by several specialties. Few studies have assessed geographic variation in the delivery of this care. Our objective was to investigate how geographic and socioeconomic factors affect who provides screening colonoscopy in Canada. METHODS This was a population-based cohort of all screening colonoscopy procedures performed at publicly funded Canadian health care facilities (excluding those in Quebec) between April 2008 and March 2015. The main outcome of interest was the proportion of colonoscopy procedures performed by surgeons versus gastroenterologists at the neighbourhood level. Predictors of interest included socioeconomic and geographic variables. We used spatial analysis to evaluate significant clustering of practitioner services and multinomial logistic regression to model predictors. RESULTS We identified 658 113 screening colonoscopy procedures performed by 1886 providers (1169 surgeons and 717 gastroenterologists) over the study period, of which 353 165 (53.7%) were performed by surgeons. A total of 24.2% of neighbourhoods were located within clusters predominantly served by gastroenterologists, and 19.5% were within surgeon clusters; the remainder were in mixed clusters. Rural neighbourhoods had a significantly increased relative risk of being within a surgeon cluster (relative risk [RR] 5.38, 95% confidence interval [CI] 3.48-8.01) compared to mixed clusters and nearly 100 times higher relative risk of being in a surgeon cluster compared to gastroenterologist clusters (RR 98.95, 95% CI 15.3-427.2). Neighbourhoods with the highest socioeconomic status were 1.74 (95% CI 1.14-2.56) times likelier to be in gastroenterologist clusters than in mixed clusters. INTERPRETATION Surgeons provide a large proportion of colonoscopy procedures in Canada and are essential for access to care, particularly in rural regions. Most Canadians are served relatively equally by surgeons and gastroenterologists. This emphasizes the importance of both specialties to the delivery of colonoscopy care across the country.
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Affiliation(s)
- Aristithes G Doumouras
- Affiliations: Department of Surgery (Doumouras, Cadeddu, M. Anvari, Hong), McMaster University; Division of General Surgery (Doumouras, M. Anvari, Cadeddu, S. Anvari, Hong), St. Joseph's Healthcare, Hamilton, Ont
| | - Sama Anvari
- Affiliations: Department of Surgery (Doumouras, Cadeddu, M. Anvari, Hong), McMaster University; Division of General Surgery (Doumouras, M. Anvari, Cadeddu, S. Anvari, Hong), St. Joseph's Healthcare, Hamilton, Ont
| | - Margherita Cadeddu
- Affiliations: Department of Surgery (Doumouras, Cadeddu, M. Anvari, Hong), McMaster University; Division of General Surgery (Doumouras, M. Anvari, Cadeddu, S. Anvari, Hong), St. Joseph's Healthcare, Hamilton, Ont
| | - Mehran Anvari
- Affiliations: Department of Surgery (Doumouras, Cadeddu, M. Anvari, Hong), McMaster University; Division of General Surgery (Doumouras, M. Anvari, Cadeddu, S. Anvari, Hong), St. Joseph's Healthcare, Hamilton, Ont
| | - Dennis Hong
- Affiliations: Department of Surgery (Doumouras, Cadeddu, M. Anvari, Hong), McMaster University; Division of General Surgery (Doumouras, M. Anvari, Cadeddu, S. Anvari, Hong), St. Joseph's Healthcare, Hamilton, Ont
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Heublein V, Pannach S, Daschkow K, Tittl L, Beyer-Westendorf J. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry. J Gastroenterol 2018; 53:236-246. [PMID: 28493007 DOI: 10.1007/s00535-017-1346-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients receiving direct-acting, non-vitamin K oral anticoagulants (NOAC) frequently undergo gastrointestinal endoscopies (GIE) but little is known on the management and outcome of these interventions. METHODS With use of data from an ongoing, prospective, noninterventional registry of NOAC patients, the management and outcome of GIE were evaluated with use of standard event definitions. Patients undergoing GIE were categorized into two subgroups: (1) scheduled GIE (scheduled appointment, no acute bleeding) and (2) unscheduled GIE (unscheduled including management of acute gastrointestinal bleeding). The rates of major bleeding complications, cardiovascular complications, and all-cause death within 30 days after the procedure were evaluated. RESULTS Between October 1, 2011, and March 31, 2015, 492 patients underwent a total of 713 GIE (44.5% gastroscopies, 53.0% colonoscopies, 2.5% endoscopic retrograde cholangiopancreatography procedures), with 70.0% being scheduled procedures and 30.0% being unscheduled procedures. Endoscopies were performed within 24 h after the last NOAC intake in 45 of 713 cases (6.3%), between 24 and 48 h after the last intake in 336 cases (47.1%), and after NOAC therapy interruption for more than 48 h in 213 cases (29.9%). Heparin bridging therapy was used in 180 of 713 procedures (25.3%) and predominantly (170/180; 94.4%) in cases of NOAC therapy interruption for longer than 72 h. Until day 30 after the procedure, the event rates were 1.4% for cardiovascular events and 0.7% for major bleeding events. CONCLUSION Continuation or short-term interruption of NOAC therapy seems to be a safe strategy for GIE. Heparin bridging therapy is predominantly used in cases of prolonged NOAC therapy interruption.
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Affiliation(s)
- Vera Heublein
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sven Pannach
- Division of Gastroenterology, Department of Medicine I, Carl Gustav Carus University Hospital, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Katharina Daschkow
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Luise Tittl
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany.
- Kings Thrombosis Service, Department of Hematology, Kings College London, London, UK.
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Adenoma detection rate metrics in colorectal cancer surveillance colonoscopy. Surg Endosc 2018; 32:3108-3113. [PMID: 29340817 DOI: 10.1007/s00464-018-6025-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND A target goal for screening adenoma detection rate (S-ADR) of ≥ 25% has been set to define high-quality colonoscopy performance. However, there is no current accepted target goal for ADR in colorectal cancer (CRC) surveillance. This makes quality assessment challenging when physicians perform cancer surveillance colonoscopy but minimal screening procedures. METHODS In this cohort study, consecutive colonoscopies performed at either Rush University Medical Center or Rush Oak Park Hospital by a gastroenterologist or colorectal surgeon in average risk screening population and CRC surveillance population were reviewed retrospectively from 2006 to 2012 and prospectively from 2013 to 2016. ADR in first surveillance colonoscopy following surgical resection of CRC (CRC-ADR) was reported in high-quality detectors (HQD) or low-quality detectors (LQD) based on achievement of 25% ADR in consecutive screening colonoscopy in average risk patients. Pearson's correlation was used to describe the association between individual S-ADR and CRC-ADR for colonoscopists. RESULTS There was a very strong positive correlation (r = 0.88, p = 0.002) between ADR in average risk screening and first time CRC surveillance. For HQD as defined by S-ADR ≥ 25% (n = 10 colonoscopists), the CRC-ADR was 37.7% (78/207, SD 8%) which was very similar to their respective S-ADR of 33.4% (816/2440, p = 0.22). For LQD (n = 5 colonoscopists), the CRC-ADR was 20.2% (40/198) which was similar to their respective S-ADR of 20.1% (119/591, p = 0.99). The CRC-ADR was significantly higher for HQD than for LQD (37.7 vs. 20.2%, p < 0.0001). CONCLUSIONS The major finding of this study is a defined CRC-ADR for HQD based on the ability to achieve S-ADR ≥ 25%. S-ADR strongly correlates with CRC-ADR. CRC-ADR is quite similar to the colonoscopists' respective S-ADR for both HQD and LQD. For colonoscopists who perform limited screening colonoscopies but do perform CRC surveillance colonoscopies, ADR metrics similar to S-ADR to assess quality in colonoscopy could be considered.
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Pigò F, Bertani H, Grande G, Abate F, Vavassori S, Conigliaro RL. Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis. Dig Liver Dis 2018; 50:20-26. [PMID: 29089272 DOI: 10.1016/j.dld.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/12/2017] [Accepted: 10/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM The aim of this systematic review and meta-analysis was to assess the risk of post-polypectomy bleeding (PPB) in patients that underwent colorectal polypectomy and exposed to ASA/NSAIDs. METHODS Relevant publications were identified in MEDLINE/EMBASE for the period 1950-2016. Studies with specified ASA/NSAIDs exposure and bleeding rate were included. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was based on fixed or random effect models in relation to the heterogeneity. RESULTS 11 studies (4 prospective and 7 retrospective) including 9307 patients were included in the analyses. Overall, 344 patients (OR 1.8; 95% CI 1.2-2.7; p-value 0.001, I2 52%) experienced rectal bleeding after procedure. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR 1.1; CI 95% 0.6-2.1; d.f.=1, p=0.64, I2 0%), the risk of delayed PPB was augmented (OR 1.7; 95% CI 1.2-2.2; d.f.=8, p=0.127, I2 36%). CONCLUSIONS ASA/NSAIDs are not a risk factor for immediate PPB but the chance of delayed is increased.
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Affiliation(s)
- Flavia Pigò
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy.
| | - Helga Bertani
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy
| | - Giuseppe Grande
- Endoscopy Unit, New Civil Hospital S. Agostino Estense, Modena, Italy
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Del Prete V, Antonino M, Vincenzo Buccino R, Muscatiello N, Facciorusso A. Management of Complications After Endoscopic Polypectomy. COLON POLYPECTOMY 2018:107-119. [DOI: 10.1007/978-3-319-59457-6_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Al-Mansour MR, Fung EC, Jones EL, Zayan NE, Wetzel TD, Martin Del Campo SE, Jalilvand AD, Suzo AJ, Dettorre RR, Fullerton JK, Meara MP, Mellinger JD, Narula VK, Hazey JW. Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers. Surg Endosc 2017; 32:2871-2876. [PMID: 29273876 DOI: 10.1007/s00464-017-5995-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.
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Affiliation(s)
- Mazen R Al-Mansour
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Eleanor C Fung
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Edward L Jones
- Department of Surgery, Denver Veterans Affairs Medical Center, University of Colorado, Denver, CO, USA
| | - Nichole E Zayan
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Timothy D Wetzel
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Sara E Martin Del Campo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Andrew J Suzo
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Rebecca R Dettorre
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - James K Fullerton
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Michael P Meara
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - John D Mellinger
- Department of General Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Vimal K Narula
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Jeffrey W Hazey
- Department of Surgery, The Ohio State University/Wexner Medical Center, N729 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.
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Eberth JM, Josey MJ, Mobley LR, Nicholas DO, Jeffe DB, Odahowski C, Probst JC, Schootman M. Who Performs Colonoscopy? Workforce Trends Over Space and Time. J Rural Health 2017; 34:138-147. [PMID: 29143383 DOI: 10.1111/jrh.12286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/01/2017] [Accepted: 10/16/2017] [Indexed: 01/18/2023]
Abstract
PURPOSE With the increased availability of colonoscopy to average risk persons due to insurance coverage benefit changes, we sought to identify changes in the colonoscopy workforce. We used outpatient discharge records from South Carolina between 2001 and 2010 to examine shifts over time and in urban versus rural areas in the types of medical providers who perform colonoscopy, and the practice settings in which they occur, and to explore variation in colonoscopy volume across facility and provider types. METHODS Using an all-payer outpatient discharge records database from South Carolina, we conducted a retrospective analysis of all colonoscopy procedures performed between 2001 and 2010. FINDINGS We identified a major shift in the type of facilities performing colonoscopy in South Carolina since 2001, with substantial gains in ambulatory surgery settings (2001: 15, 2010: 34, +127%) versus hospitals (2001: 58, 2010: 59, +2%), particularly in urban areas (2001: 12, 2010: 27, +125%). The number of internists (2001: 46, 2010: 76) and family physicians (2001: 34, 2010: 106) performing colonoscopies also increased (+65% and +212%, respectively), while their annual procedures volumes stayed fairly constant. Significant variation in annual colonoscopy volume was observed across medical specialties (P < .001), with nongastroenterologists having lower volumes versus gastroenterologists and colon and rectal surgeons. CONCLUSIONS There have been substantial changes over time in the number of facilities and physicians performing colonoscopy in South Carolina since 2001, particularly in urban counties. Findings suggest nongastroenterologists are meeting a need for colonoscopies in rural areas.
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Affiliation(s)
- Jan M Eberth
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Michele J Josey
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Lee R Mobley
- Department of Health Management and Policy, School of Public Health, Georgia State University, Atlanta, Georgia
| | - Davidson O Nicholas
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri.,Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Donna B Jeffe
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Cassie Odahowski
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Janice C Probst
- Department of Health Services Policy and Management and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Mario Schootman
- Department of Epidemiology, College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri
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Yung DE, Banfi T, Ciuti G, Arezzo A, Dario P, Koulaouzidis A. Musculoskeletal injuries in gastrointestinal endoscopists: a systematic review. Expert Rev Gastroenterol Hepatol 2017; 11:939-947. [PMID: 28705042 DOI: 10.1080/17474124.2017.1356225] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Gastrointestinal(GI) endoscopy forms a significant proportion of clinicians' workloads. However, little attention is given to the ergonomic aspects of endoscopy. This systematic review of musculoskeletal pain and/or injuries in GI endoscopists aims to better understand the types of occupational injuries resulting from endoscopic procedures and associated risk factors. Areas covered: Systematic literature search conducted for articles evaluating prevalence, risk factors and mechanism of musculoskeletal pain and/or injuries related to GI endoscopy. In 13 included studies, 39-89% of surveyed endoscopists reported pain and/or injuries related to endoscopy. Common areas of pain were the back(15-57%), neck(9-46%), shoulders(9-19%), elbows(8-15%) and hands/fingers(14-82%). Risk factors included procedure volume, time spent doing endoscopy, cumulative time in practice and endoscopist age. Experimental studies showed that forces and loads placed on endoscopists' bodies during procedures place them at risk of occupational injury. Areas of pain differed between novice and experienced endoscopists implying separate mechanisms of injury. Expert commentary: Comprehensive investigation into the prevalence, types, pathophysiology and methods to minimise endoscopy-related musculoskeletal injuries is vital to ensure the continued efficient provision of endoscopy services in the face of rising demands worldwide. A paradigm shift is required in endoscopic devices and techniques to improve safety and comfort.
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Affiliation(s)
- Diana E Yung
- a The Royal Infirmary of Edinburgh , Centre for Liver & Digestive Disorders , Edinburgh , UK
| | - Tommaso Banfi
- b Sant'Anna School of Advanced Studies , The Biorobotics Institute , Pisa , Italy
| | - Gastone Ciuti
- b Sant'Anna School of Advanced Studies , The Biorobotics Institute , Pisa , Italy
| | - Alberto Arezzo
- c Department of Surgical Sciences , University of Torino , Torino , Italy
| | - Paolo Dario
- b Sant'Anna School of Advanced Studies , The Biorobotics Institute , Pisa , Italy
| | - Anastasios Koulaouzidis
- a The Royal Infirmary of Edinburgh , Centre for Liver & Digestive Disorders , Edinburgh , UK
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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Pigò F, Bertani H, Manno M, Mirante VG, Caruso A, Mangiafico S, Manta R, Rebecchi AM, Conigliaro RL. Colonic Postpolypectomy Bleeding Is Related to Polyp Size and Heparin Use. Clin Endosc 2017; 50:287-292. [PMID: 28183158 PMCID: PMC5475522 DOI: 10.5946/ce.2016.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 09/15/2016] [Accepted: 10/04/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND/AIMS We studied factors influencing colon postpolypectomy bleeding (PPB), with a focus on antithrombotic and anticoagulation therapy. METHODS We conducted a retrospective case-control study of all patients who underwent polypectomy at our tertiary referral center in Italy between 2007 and 2014. Polyp characteristics (number of polyps removed per patient, size, morphology, location, resection technique, prophylactic hemostasis methods) and patient characteristics (age, sex, comorbidities, medication) were analyzed. RESULTS The case and control groups included 118 and 539 patients, respectively. The two groups differed in the frequency of comorbidities (69% vs. 40%, p=0.001), polyps removed (27% vs. 18%, p=0.02), and use of heparin therapy (23% vs. 1%, p<0.001). A total of 279 polyps in the case group and 966 in the control group were nonpedunculated (69% vs. 81%, p=0.01) and measured ≥10 mm (78% vs. 32%, p=0.001). Multivariate analysis showed that polyps ≥10 mm (odds ratio [OR], 6.1; 95% confidence interval [CI], 2.3-15.5), administration of heparin (OR, 16.5; 95% CI, 6.2-44), comorbidity (OR, 2.3; 95% CI, 1.4-3.9), and presence of ≥2 risk factors (OR, 3.2; 95% CI, 1.7-6.0) were associated with PPB. CONCLUSIONS The incidence of PPB increases with polyp size ≥10 mm, heparin use, comorbidity, and presence of ≥2 risk factors.
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Affiliation(s)
- Flavia Pigò
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Helga Bertani
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Mauro Manno
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Vincenzo Giorgio Mirante
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Angelo Caruso
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Santi Mangiafico
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | - Raffaele Manta
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
| | | | - Rita Luisa Conigliaro
- Digestive Endoscopic Unit, New Civil Hospital S. Agostino Estense, Baggiovara, Vignola Hospital, Vignola, Modena, Italy
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Han SH, Lee JH, Kim SH. Splenic rupture following colon polypectomy: a case report and review of literature. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2017; 65:123-6. [PMID: 25716716 DOI: 10.4166/kjg.2015.65.2.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Colonoscopy is a safe procedure performed routinely worldwide. Splenic rupture is a rare complication of colonoscopy with several reported cases since 1974. We report the first case of a complication in the Republic of Korea. The literature on this rare complication is also reviewed here, with focus on the analysis of risk, diagnosis, and treatment. A 77-year-old patient receiving oral aspirin underwent colonoscopy with polypectomy. After 24 hours, the patient experienced dizziness and hypotension. Colonoscopy was performed to exclude intestinal bleeding, which could be diagnosed with hemoperitoneum. A computed tomography scan showed copious abdominal free blood and a splenic rupture. An urgent splenectomy was performed, which was the recognized procedure of choice. Physicians should have greater awareness of the possibility of splenic rupture following colonoscopy in order to avoid delay of diagnosis and treatment for this life-threatening complication.
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Affiliation(s)
- Seung Hee Han
- Departments of Internal Medicine and General Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Jong Hoon Lee
- Departments of Internal Medicine and General Surgery, Dong-A University College of Medicine, Busan, Korea
| | - Sung Heun Kim
- Departments of Internal Medicine and General Surgery, Dong-A University College of Medicine, Busan, Korea
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Rees CJ, Thomas Gibson S, Rutter MD, Baragwanath P, Pullan R, Feeney M, Haslam N. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65:1923-1929. [PMID: 27531829 PMCID: PMC5136732 DOI: 10.1136/gutjnl-2016-312044] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/08/2016] [Accepted: 07/17/2016] [Indexed: 12/12/2022]
Abstract
Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.
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Affiliation(s)
- Colin J Rees
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK,Durham University School of Medicine, Pharmacy and Health,Northern Region Endoscopy Group
| | | | - Matt D Rutter
- Durham University School of Medicine, Pharmacy and Health,Northern Region Endoscopy Group,Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - Phil Baragwanath
- University Hospital of Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Rupert Pullan
- South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Mark Feeney
- South Devon Healthcare NHS Foundation Trust, Torquay, UK
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Validation of a Patient Satisfaction Scale in Patients Undergoing Bowel Preparation Prior to Colonoscopy. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2016; 9:27-34. [PMID: 26714490 PMCID: PMC4720697 DOI: 10.1007/s40271-015-0154-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Colonoscopy is the most widely used test to screen for colorectal cancer but its use may be hindered by patients' inability to complete the bowel preparation. Patient-reported satisfaction with bowel-cleansing preparations has received little attention. We assessed the reliability and validity of a patient satisfaction survey used in two large, multicenter, randomized, assessor-blinded colonoscopy trials. METHODS Datasets from two pivotal trials were combined. Patients in both trials included men and women aged 18-80 years who were scheduled for an elective outpatient colonoscopy. Questions relevant to satisfaction with bowel preparation prior to colonoscopy were identified from the literature and incorporated into a 7-item survey administered to patients on the day of colonoscopy. Domain 1 of the satisfaction measure assessed difficulty using bowel-cleansing preparations, ability to consume preparations, acceptability of taste, and overall experience; questions regarding acceptance or refusal of future use of the same bowel preparation were asked in Domain 2. Responses from each item of Domain 1 were transformed on a scale ranging from 0 to 100 and summed as total satisfaction scores. Cronbach's alpha was used to measure reliability; validity was assessed by evaluating relationship between total satisfaction (Domain 1) and willingness to use preparation in the future (Domain 2). RESULTS Mean age of the 1211 trial participants was 56: 61 % female, 89.5 % Caucasian. Domain 1 had a Cronbach's alpha of 0.79, with higher satisfaction predicting higher future acceptability (p < 0.0001). CONCLUSION The patient-reported satisfaction measure of bowel-cleansing preparations possesses good validity and reliability.
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Pace D, Borgaonkar M, Evans B, Marcoux C, Lougheed M, Falk V, Hickey N, O'Leary M, McGrath J, Boone D. Annual colonoscopy volume and maintenance of competency for surgeons. Surg Endosc 2016; 31:2630-2635. [PMID: 27752813 DOI: 10.1007/s00464-016-5275-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 10/04/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION To determine whether the annual case volume of general surgeons (greater or less than 200 colonoscopies) is associated with quality outcomes. METHODS This retrospective cohort study involved all adults who underwent colonoscopy by a surgeon in the city of St. John's, NL, during the first 6 months of 2012. Subjects were identified through records from the health authority, and data were recorded on a standardized data sheet. Univariate analysis followed by stepwise multivariable logistic regression was performed to determine whether there was an association between quality outcomes (colonoscopy completion rate, adenoma detection rate) and predictors of these outcomes including annual colonoscopy volume, patient age, gender, indication for colonoscopy, and ASA score. A Chi-squared test was used to determine whether other outcomes were associated with annual colonoscopy volume. RESULTS Data were collected on 1060 patients. Mean age was 59.5 (sd 12.2) years with 550 females. A total of 13 surgeons were studied, of which 7 performed less than 200 annual colonoscopies over the previous 2 years (low-volume group) and 6 performed more than 200 annual colonoscopies over the previous 2 years (high-volume group). While there was a significant difference in the colonoscopy completion rate favoring the high-volume group (82.2 vs. 91.1 %, p < 0.001), no difference was noted in the adenoma detection rate between groups (16.7 vs. 17.7 %, p = 0.762). The regression model revealed that colonoscopy completion was also associated with an indication of screening or surveillance and an ASA score of 1 or 2. The adenoma detection rate was associated with older age and male gender. There was no statistically significant association between annual colonoscopy volume and other safety outcome measures. CONCLUSION Performing over 200 colonoscopies annually is associated with higher colonoscopy completion rates, but does not appear to be associated with other quality measures.
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Affiliation(s)
- David Pace
- Department of Surgery, Memorial University, St. John's, Canada.
- Department of Surgery, Health Sciences Center, St. John's, NL, A1B 3V6, Canada.
| | - Mark Borgaonkar
- Department of Medicine, Memorial University, St. John's, Canada
| | - Brad Evans
- Department of Surgery, Memorial University, St. John's, Canada
| | - Curtis Marcoux
- Department of Surgery, Memorial University, St. John's, Canada
| | - Muna Lougheed
- Department of Surgery, Memorial University, St. John's, Canada
| | - Vanessa Falk
- Department of Surgery, Memorial University, St. John's, Canada
| | - Nikita Hickey
- Department of Surgery, Memorial University, St. John's, Canada
| | - Meghan O'Leary
- Department of Surgery, Memorial University, St. John's, Canada
| | - Jerry McGrath
- Department of Medicine, Memorial University, St. John's, Canada
| | - Darrel Boone
- Department of Surgery, Memorial University, St. John's, Canada
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Pearl J, Fellinger E, Dunkin B, Pauli E, Trus T, Marks J, Fanelli R, Meara M, Stefanidis D, Richardson W. Guidelines for privileging and credentialing physicians in gastrointestinal endoscopy. Surg Endosc 2016; 30:3184-3190. [DOI: 10.1007/s00464-016-5066-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 12/31/2022]
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Campos S, Amaro P, Portela F, Sofia C. Iatrogenic Perforations During Colonoscopy In a Portuguese Population: A Study Including In and Out-Of-Hospital Procedures. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:183-190. [PMID: 28868458 PMCID: PMC5580015 DOI: 10.1016/j.jpge.2016.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 02/29/2016] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The risk of iatrogenic perforations in colonoscopy is not negligible. Experience with endoscopic closure of perforations is increasing and new devices for this purpose are being released, making endoscopy a therapeutic option. National data regarding iatrogenic perforations is scarce and the burden of iatrogenic perforations in out-hospital procedures is poorly characterized in the literature. OBJECTIVE Evaluation of iatrogenic perforations rate during colonoscopy, their characteristics, management and prognosis. METHODS Retrospective study of all patients with perforations secondary to in-hospital and non-hospital colonoscopies treated in a tertiary hospital between 01-01-2006 and 01-10-2014. Demographic, endoscopic, radiological and therapeutic data were analyzed. RESULTS Fifty-three perforations were identified, 20 occurring in colonoscopies performed in non-hospital environment (45% with therapeutic procedures) and 33 occurring in-hospital procedures (73% in therapeutic colonoscopies; representing 0.12% of all colonoscopies carried out in-hospital). Patients: male in 56%, average age of 71 years, history of previous abdominopelvic surgery in 31% and diverticulosis in 10%. Colonoscopy: elective in 93%, under deep sedation in 21%, with less than excellent/good bowel preparation in 56%. A resident was the first performer in 10 cases. Perforations: average size of 21 mm (4-130 mm), diagnosed during the procedure in 51% of cases and occurred in rectum-sigmoid transition in 58.5%. Regarding therapeutics, all patients with perforation occurring in non-hospital colonoscopies were managed by surgery. Concerning treatment of those in our unit: 2-conservative, 12-endoscopic (10 successfully), 21-surgical (including the 2 cases with failure of the endoscopic approach). Comparing endoscopic treatment (n = 10, G1) versus surgery (n = 21; G2): perforation size - 9 mm (G1) versus 28 mm (G2); perforation location - 7/10 in rectum-sigmoid (G1) versus 8/21 in rectum-sigmoid and 10/21 transverse/ascending colon/hepatic angle (G2). Morbidity: 1 infection in G1 and 13 complications in G2 (infection, hemorrhage, fistula). Mortality: no deaths in G1 and 2 deaths at 30 days due to septic shock in G2. CONCLUSION Perforations in colonoscopy are rare in our clinical practice. Endoscopic closure was effective, though limited to perforations found during the procedure. The mortality was relatively low and endoscopic management did not seem to worsen it. An additional effort is necessary in order to detect perforations during colonoscopy.
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Fonseca AL, Reddy V, Yoo PS, Gusberg RJ, Longo WE. Senior Surgical Resident Confidence in Performing Flexible Endoscopy: What Can We Do Differently? JOURNAL OF SURGICAL EDUCATION 2016; 73:311-316. [PMID: 26531744 DOI: 10.1016/j.jsurg.2015.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/21/2015] [Accepted: 09/25/2015] [Indexed: 06/05/2023]
Abstract
INTRODUCTION The American Board of Surgery endoscopy requirements for general surgery training are evolving. In 2006, the Residency Review Committee in Surgery increased the total number of endoscopy cases required before completion of general surgery residency training. This requirement is set to change further, given the new Flexible Endoscopic Curriculum that would be a requirement for applicants graduating surgical training during or after the 2017 to 2018 academic year. Given these changes, our goal was to evaluate the confidence of senior surgical residents performing flexible endoscopy. METHODS A survey was developed and sent to general surgery residents nationally, querying them regarding demographics and program-specific characteristics; additionally they were asked to rate their confidence level in performing flexible upper endoscopy and colonoscopy on a Likert scale of 1 to 5. We then compared those residents who indicated confidence (Likert scale 4-5) to those who did not (Likert scale 1-3). For the purpose of this study, only senior (postgraduate year 4 and 5) general surgery residents were assessed. RESULTS We received 1176 responses from senior surgical residents: 56% of these were postgraduate year 5 residents, 65% male, 68% from University Programs, and 56% from programs associated with a Veteran's Affairs Hospital; 33% were from programs in the Northeast, 29% in the South, 24% in the Midwest, and 14% in the West; 75% were going on to additional fellowship training after the completion of residency; 42% indicated that they would go into academic practice and 32% into private practice; 66.7% reported confidence performing upper endoscopy and 52.7% reported confidence performing colonoscopy. Male gender, overall operative volume, and graduating from a medium-sized program or program in the South were associated with increased confidence performing flexible endoscopy. CONCLUSIONS A large percentage of senior residents do not report confidence in performing flexible endoscopy. Although increasing the number of cases required for graduation has likely helped improve the training of residents in endoscopy, additional improvements in training are required. The Flexible Endoscopic Curriculum helps standardize the curriculum and demonstrate that the graduating resident has the fundamental knowledge and skills required in the performance of endoscopy. Simulation training and dedicated endoscopic rotations during the course of residency training could help improve endoscopy training and proficiency for future graduating residents.
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Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Vikram Reddy
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Peter S Yoo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard J Gusberg
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Walter E Longo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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