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This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

We present the British Society of Gastroenterology (BSG) position statement on patient experience of GI endoscopy, recently published on the BSG website—www.bsg.org.uk/resource/patient-experience-of-gi-endoscopy-2019.html. The three dimensions of healthcare quality are patient safety, clinical effectiveness and patient experience, with much of healthcare practice focusing on the first two dimensions. Greater emphasis is now being given to the patient experience dimension in light of reports from Francis1 and Darzi2 highlighting the interaction between patient experience and quality of care. Clinical standards and safety in endoscopy are well reported and reviewed via the Joint Advisory Group on GI Endoscopy (JAG) accreditation programme. The Global Rating Scale3 used in JAG assessments includes a patient experience domain, but gives limited guidance available on how that should be measured or what standards should be …

Background—The incidence of adenocarcinoma of the oesophagus and gastric cardia is increasing rapidly. Barrett’s oesophagus is the major risk factor. Intestinal metaplasia at the squamocolumnar junction in the absence of Barrett’s oesophagus is common but its relation to adenocarcinoma and gastro-oesophageal reflux disease is unclear.Aims—To study the prevalence and clinical, endoscopic, and histological associations of intestinal metaplasia at the squamocolumnar junction.Methods—Biopsy specimens were taken from 120 randomly selected patients undergoing routine diagnostic endoscopy. Eight biopsy specimens, taken from above and below the squamocolumnar junction, gastric fundus, and gastric antrum, were stained with haematoxylin/eosin, alcian blue/periodic acid-Schiff, and Gimenez, and graded independently by one pathologist.Results—Intestinal metaplasia at the squamocolumnar junction was found in 21 patients (18%). Metaplasia was associated with increasing age (pConclusions—Intestinal metaplasia at the squamocolumnar junction is a common finding. It is associated with increasing age but not gastro-oesophageal reflux disease.

Introduction The commonest symptom associated with oesophageal cancer is dysphagia, this is frequently managed with an oesophageal stent. A randomised trial 1 suggested that for patients with a life expectancy of >3 months, brachytherapy may provide better symptom relief with fewer complications. But uptake appears to be low in the UK. In 2010, only 54% of Cancer Networks reported having access to brachytherapy. 2 This study investigated the use of these therapeutic options in England and Wales. Method The study used data from the National Oesophago-Gastric Cancer Audit, limited to patients diagnosed with oesophageal cancer between 1 st April 2011 and 31 st March 2013 in England and Wales, where treatment intent was palliative and patients received either brachytherapy or endoscopic stenting. We compared patient characteristics, complication rates and survival across the two groups. Results Overall 9,252 patients were included in the study. Of these 2,333 had an oesophageal stent placed, 49 had brachytherapy and 4 had both. Patient characteristics varied significantly between the two groups (Table 1). The most frequent choice of stent was covered metal (83.2%), with the majority of stents were placed under combined fluoroscopic and endoscopic control (38.2%) or endoscopic control alone (31.9%). 98.3% of stents were successfully inserted. Complication rates associated with both brachytherapy and stenting were under 2%, with no statistically significant difference. Post-intervention 90-day mortality after brachytherapy was 8.2% (95% CI 0.02–16.1%) suggesting appropriate use. But after stent insertion median survival 95 days (IQR: 42–189). This suggests some patients may have been suitable for brachytherapy. Conclusion Half of patients who had a stent inserted survived more than 3 months, these patients may have achieved better symptom control with fewer complications with brachytherapy instead. 1 Only 9 NHS trusts reported using brachytherapy, suggesting it is currently underutilised. Disclosure of interest None Declared. References Homs MYV, Steyerberg EW, Eijkenboom WMH, et al . Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364:1497–504 Groene O, Chadwick G, Riley S, et al . Re-organisation of oesophago-gastric cancer services in England and Wales: a follow-up assessment of progress and remaining challenges. BMC Research Notes 2014;7:24

Oesophageal dilators or bougies have been used since the Middle Ages. Early bougies were made of natural materials and were used to disimpact food boluses by pushing them “blindly” into the stomach. The technique of oesophageal dilatation has evolved considerably in recent years. A range of purpose built dilators is now available, and with present day diagnostic techniques it is possible to select a dilator and dilatation technique appropriate to the clinical setting. The relatively low morbidity and mortality of oesophageal dilatation has encouraged its widespread use. Despite this wealth of clinical experience however, the practice of oesophageal dilatation has been subject to surprisingly few controlled studies. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardised protocols within and between centres. These guidelines have been produced to conform to the North of England evidence based guidelines development project.12 They are based on a Medline literature search using the search term “oesophageal dilatation” and on expert opinion and review. Although oesophageal dilatation may be performed during rigid oesophagoscopy and under radiological screening, this guidance relates primarily to oesophageal dilatation performed during flexible upper gastrointestinal endoscopy. Oesophageal dilatation in the paediatric population is considered outside the scope of these guidelines. ### 2.1 Categories of evidence The strength of evidence used to formulate these guidelines was graded according to the following system: The …

Introduction Most polyps are Methods Data relating to removal of polyps x 2 . Results 147174 polyps were removed during 62679 colonoscopies. A range of techniques was used (cold biopsy forceps (CBF) 19.7%, cold snare (CS) 22.1%, hot biopsy forceps (HBF) 12.2%, hot snare (HS) 35.1%, EMR 10.9%). EMR was used more frequently in the right colon compared to the left (14.3 vs. 8.3%, OR = 1.84, 95% CI: 1.78–1.90). Most pedunculated polyps were removed using HS; this was lower in the right vs. left colon (69.6 vs. 88.3%, OR = 0.30, CI: 0.28–0.33). CS was most common for non-pedunculated polyps in the right colon (29.8 vs. 19.0% in left, OR = 1.81 CI: 1.76–1.85); whereas most common in the left colon was HS (34.8 vs. 22.5% in right, OR = 1.84 CI: 1.79–1.88). Surgeons were more likely than physicians to use diathermy irrespective of site or morphology (65.6 vs. 56.5%, OR = 1.46 CI: 1.43–1.5). In 60% of polyps removed completeness of excision was not histologically assessable. 21.2% were completely excised, 5.8% incomplete and 13% not stated. For non-pedunculated polyps, histologically-confirmed complete excision was more common after EMR (23.4 vs. 6.2%, OR = 1.16, CI: 1.08–1.25) compared to other techniques (CBF 17.7%, CS 15.1%, HBF 19.1%, HS 21.5%); for pedunculated polyps it was more common after EMR (42.3%) and HS (42.0%). Complications were rare for colonoscopies (45227) where only polyps Between 2010 and 2012, use of CBF, CS and EMR increased, whereas HBF and HS decreased (p Conclusion The removal of polyps Disclosure of Interest None Declared.

Introduction Studies suggest that modifying a patient’s position during colonoscope withdrawal may improve luminal distension and polyp detection. It is unclear whether this practice is widely adopted by endoscopists. Methods Colonoscopists within the English Bowel Cancer Screening Programme (BCSP) were invited to participate in a web-based survey assessing the use of position change during colonoscope withdrawal. Free text responses were assessed using thematic analysis. Results The survey was completed by 204/298 (68%) of English BCSP colonoscopists. 64.7% of respondents indicated that they almost always change a patient’s position, 16.7% usually, 13.7% sometimes, 3.4% occasionally and 1.5% rarely do so. 77% of those who almost always or usually changed a patient’s position did so as part of their routine, but 75.3% were less likely to change position in those with poor mobility and 75.3% would not change position if luminal distension was adequate. 93% of these respondents most often positioned patients supine while examining the transverse colon and nearly half examined the right and descending colon in a sub-optimal position (Table 1). Of those respondents who sometimes, occasionally or rarely changed a patient’s position, 42% were unconvinced that routine position change was beneficial. A further 21.1% felt it took too long, 7.8% felt it was inconvenient for the patient and 7.8% felt it was inconvenient for the endoscopist. These respondents were most likely to examine segments without changing patient position. Free text responses revealed that some endoscopists position patients differently during insertion and withdrawal and also use position change to optimise access during therapy. Conclusion Most BCSP colonoscopists change patients’ position during most colonoscope withdrawals, but the patient position is often sub-optimal. Increased awareness of the existing literature and further research assessing positioning strategy is warranted. Reference East JE et al. Gastrointest Endosc . 2011 Mar;73(3):456–63 Disclosure of Interest None Declared.

Introduction Gastroscopy is uncomfortable for patients and incurs the risks of intubation and sedation. Capsule endoscopy is well tolerated and recently a handheld magnet has been developed to enable steering of the capsule to visualise all areas of the capacious stomach. Our preliminary data suggests that a novice can identify all beads sewn into a porcine stomach within 4 min after 40 consecutive examinations. 1 We performed a double blind randomised controlled trial comparing MSGCE with conventional gastroscopy in the detection of beads in the same model. Methods Ex-vivo porcine stomach models were used in a standard housing unit. MSGCE was performed according to a standard protocol using 1000mls of water to distend each stomach and a combination of positional change (head down, 30° left lateral, 30° right lateral) and magnetic control to steer the capsule. Each model was examined in a standard fashion by gastroscopy and subsequently MSGCE using MiroCam Navi (Intromedic Ltd). Two blinded investigators (MFH and IR) competent to perform both procedures were allocated randomly to perform either gastroscopy or MSGCE on each model. This was performed as a non-inferiority study with an expected sensitivity of 90% for both (0 estimated difference), a specificity of 100% and a difference of interest 10 percentage points (i.e., 80% is significantly worse). A sample size of 85 beads was needed to achieve this statistical power. Twelve porcine stomachs were prepared with beads as follows: 2 × 0 beads, 2 × 1 bead, 2 × 2 beads, 2 × 3 beads, 2 × 4 beads, 2 × 5 beads, giving a total of 30 beads. The study was conducted in three rounds, giving a total of 90 beads to be identified. Number of beads identified and procedure duration was recorded. Results Gastroscopy correctly identified 88% (79/90) beads, MSGCE correctly identified 89% (80/90) beads and thus is non-inferior to gastroscopy in this setting (95% CI 82.54–95.46%). Mean examination times for gastroscopy and MSGCE were 3.34 min and 9.90 min respectively. MSGCE overestimated the number of beads present on a single occasion. Conclusion MSGCE is equivalent to conventional gastroscopy in the detection of beads placed in a porcine stomach model. Procedure duration was longer for MSGCE compared to gastroscopy. Further studies in humans are necessary to define the scope and utility of this exciting new technique. Reference Hale MF, Drew K, Baldacchino T, Anderson S, Sanders DS, Riley SA, Sidhu R, McAlindon ME. Gastroscopy without a gastroscope! Feasibility in a porcine stomach model using a magnetic capsule. Abstract. British Society of Gastroenterology Annual Meeting , Jun 2013 Disclosure of Interest None Declared.

Introduction There is little evidence that gastroscopy affects patient outcomes 1 , but it is uncomfortable and incurs the risk of intubation and sedation. Capsule endoscopy is a non-invasive tool used primarily to image the small and large bowel. Although a large volume organ, examination of the stomach might be enabled by magnetic control allowing manoeuvrability and positional change. Methods A standard porcine stomach model, commonly used for endoscopy training purposes was used in a feasibility study of magnetically steerable capsule endoscopy. Different coloured/shaped beads were sewn into each major location of the stomach (cardia, fundus, greater and lesser curve, anterior and posterior wall, antrum and D1). The stomach was distended with 1000mls of water. Endoscopy was performed according to a set protocol using a handheld magnet, Mirocam Navi (Intromedic Ltd), positional changes (supine, 30° right lateral, head down, 30° left lateral) and a “real time” viewer. The order and time each tag was identified was recorded alongside the total procedure time. Results All stomach tags were identified in 87.2% (41/47) of examinations. Missed tags (marked in figure as red dots, representing an incomplete examination) included antrum (3/6), cardia (2/6) and posterior wall (1/6): none were missed in the latter 25 procedures. Mean examination times for the first 23, second 23 and all procedures were 10.28, 6.26 (p Conclusion Examination of the upper gastrointestinal tract is feasible using a magnet and positional change as demonstrated in this porcine model. A learning curve was evident and this model might be used for training in the future. Further investigation using porcine models and in humans is necessary to fully realise the scope of this exciting novel technology. Disclosure of Interest None Declared. Reference Offman JJ, Rabeneck L The effectiveness of endoscopy in the management of dyspepsia: a qualitative systematic review. Am J Med. 1999 Mar; 106(3):335–46.

Introduction Many endoscopists withdraw the colonoscope with the patient in a single position (left lateral or supine), while others advocate position change. A previous study in a small group of patients suggested position change is beneficial in the transverse and left colon. We have compared colonoscope withdrawal in the supine position with position change. Methods A randomised cross-over study compared colonoscope withdrawal in the supine position with position change (caecum to hepatic flexure in the left lateral position, transverse colon in the supine position and the hepatic flexure and descending colon in the right lateral position). Colonic segments were precisely defined using biopsy sites as markers, aided by a Scopeguide imager. Segments were cleansed and examined for at least 2 minutes during which air was insufflated to distend the colon. After each segment was examined the colonoscope was reinserted and the same segment was re-examined in the alternative position. Luminal distension was rated on a validated 5 point scale, ranging from 1 = completely collapsed to 5 = maximal distension. Ordinal and categorical data were compared with the Mann Whitney U test and Fisher’s exact test respectively. Results This is an interim analysis of 65 patients (mean age 62, 38 male). 30 patients were initially examined in the supine position and 35 patients with position change. Distension scores were higher in the right colon when examined in the left lateral position (mean = 3.9 vs. 3.5 p = Conclusion Position change improves suboptimal distension of the right and left colon. Further analysis of this study will clarify whether position change also improves polyp detection. Disclosure of Interest None Declared References East JE et al. Position changes improve visibility during colonoscope withdrawal: a randomised, blinded, crossover trial. Gastrointest Endosc. Feb 2007; 65(2):263–269. East JE et al. Dynamic patient position changes during colonoscope withdrawal increase adenoma detection: a randomised, crossover trial. Gastrointest Endosc. Mar 2011; 73(3):456–463.

Introduction Palliative chemotherapy is routinely offered to patients diagnosed with locally advanced or metastatic oesophago-gastric cancer. Based on data from the National Oesophago-Gastric Cancer Audit (NOGCA), we describe the characteristics of patients being offered palliative chemotherapy, determine the proportion of patients completing treatment, and identify factors associated with treatment completion. Methods The NOGCA prospectively collected data on patients diagnosed with invasive epithelial cancer of the oesophagus or stomach between 1 October 2007 and 30 June 2009. For patients receiving palliative oncology, we compared characteristics of completers and non-completers of chemotherapy using χ 2 tests and multiple logistic regression models with correction for cluster sampling. For variables with missing data we imputed values using multiple imputation by chained equations. Results Of 16 264 patients participating in the NOGCA in England, 2313 received palliative chemotherapy treatment. Female patients or patients of older age were less likely to receive treatment. Overall, only 39.7% completed their treatment. Factors associated with treatment completion were low performance status, high age and high level of deprivation. In our study, treatment completion was not related with site of cancer, pre-treatment stage, sex, co-morbidities or histology. Conclusion Completion rates of palliative chemotherapy in patients with oesophago-gastric cancer are low. The low completion rates may reflect the complex medical decision making for this group of patients and the need to balance survival benefits, toxicity of treatment, patients9 preferences and patients9 quality of life. Patients unlikely to complete chemotherapy may be more appropriately managed on a palliative supportive care pathway with symptom control. Competing interests None declared. References 1. Cromwell DA , Palser T, Van der Meulen J, et al . The National Oesophageal-Gastric Cancer Audit: Third Annual Report. London: The Information Centre, 2010. 2. Lord SR , Hall PS, McShane P, et al. Factors predicting outcome for advanced gastroesophageal cancer in elderly patients receiving palliative chemotherapy. Clin Oncol (R Coll Radiol) 2010; 22 :107–13. 3. Koedoot CG , de Haan RJ, Stiggelbout AM, et al. Palliative chemotherapy or best supportive care? A prospective study explaining patients9 treatment preference and choice. Br J Cancer 2003; 89 :2219–26. 4. Braga S . Why do our patients get chemotherapy until the end of life? Ann Oncol 2011; 22 :2345–8.

Introduction It may be possible to identify several ‘levels’ of polypectomy service within the UK, each requiring a different range of polypectomy skills: flexible sigmoidoscopy screening, non-screening colonoscopy, screening colonoscopy and the specialist endoscopy service. This requires a definition of ‘complexity levels’ of polyps, to reflect the four levels of service, each with clearly defined parameters that represent the bare minimum that an endoscopist operating at a particular level should be able to deal with competently. Methods The aim of this study was to define polyp levels to reflect the four levels of competency required to deliver a particular service, based on polyp characteristics. Consensus by nine experienced endoscopists regarding the parameters that determine the complexity of a polyp, was achieved using group meetings and the Delphi method. The same group of experts then assigned a polyp complexity level to each possible combination of factors. Results The group identified four factors to be most relevant for determining the complexity of a polypectomy: size (S), morphology (M), site (S) and access (A). In two Delphi rounds the benchmarks for each factor were evaluated (see table). After analysing the expected complexity for each polyp type as proposed by the experts, a scoring system was established, based on size (1–9 points), morphology (1–3 points), site (1–2 points) and access (1–3 points). Four polyp levels (with increasing level of complexity) were identified based on the range of expert scores obtained: Level 1 (4–5), Level 2 (6–9), Level 3 (10–12) and Level 4 (>12). Conclusion Defining polyp complexity levels may be useful for planning training, competency assessment and certification in colonoscopic polypectomy. In turn this may allow for more efficient service delivery and referral onto specialist centres where appropriate. Competing interests None.

Introduction The association between gastro-oesophageal reflux (GOR) and various respiratory disorders including cystic fibrosis (CF) is widely acknowledged. Although the exact nature of this relationship is uncertain, it is thought that reflux aspiration is a contributing factor in lung dysfunction in these patients. Patients with GOR typically report symptoms such as heartburn, regurgitation, and occasionally atypical symptoms such as cough. It has been hinted that GOR in CF patients may be “silent” making detection and treatment often difficult. We piloted a cross-sectional survey to gain a better understanding of the perception of GOR and its impact on lung function. Methods Consenting patients completed two validated questionnaires regarding GOR symptoms which were scored and ranked (Gastro-oesophageal Reflux Symptom Questionnaire and Reflux Symptom Index). Patients were stratified by score and divided into two pilot groups; SGOR (symptomatic-highest scores) and AGOR (asymptomatic-lowest scores). Both groups underwent 24-h multiple intraluminal impedance/pH metry (MII) and high-resolution manometry (HRM) for positioning of MII probe. MII studies were assessed for the number of GOR events, proximal reflux events (PREs), and total proximal bolus exposure (TPBE). Patients remained on all current medication including PPIs. Clinical data were collected and compared retrospectively including most recent lung function results (FEV1). Result 53/110 patients completed questionnaires and 10 from each group were invited to undergo investigation—11 were completed successfully (age 18–55 years; four male, seven female; seven SGOR, four AGOR). There was little difference in the mean number of events between the groups (range 16–75, mean—SGOR 38, AGOR 42; (normal on PPI=48, off PPI=73)). There was no correlation between symptom scores (SS) and number of GOR events but there was a moderate negative correlation between the number of GOR events/FEV1. There was no significant difference in the mean number of PREs between the groups (range 1–31; mean SGOR=11, AGOR=22). TPBE ranged from 0.2–342 s. No correlation was shown between; number of PREs/SS, number of PREs/FEV1 and TPBE/FEV1. Conclusion This small pilot study indicated that CF patients demonstrate impaired awareness of GOR and supports the theory that GOR is associated with poorer lung function. While there was no significant difference in the number of PREs between the groups, levels were higher in the AGOR group. This suggests that CF patients have poor perception of proximal reflux, which could increase the likelihood of aspiration. Based on these findings we aim to continue the survey to gain a more comprehensive assessment of the perception of GOR in adults with CF.

The Romans believed that illnesses stemmed from the “heart” but the Greeks from the gut. Were the Greeks right after all? Dietary influence on colorectal cancer (CRC) has been extensively studied but with very little agreed consensus. Pederson et al ( Gut 2003; 52 :861–7) reawaken this idea by showing a causal relationship between alcohol and rectal cancer while Dray et al ( Gut 2003; 52 :868–73) conclude that prolonged survival post curative surgery for CRC was associated with high energy intake. What about fibre? Burkitt was the first to attribute CRC to fibre deficiency1 which was later challenged by Cleave as excess sugar or “the saccharine disease”.2 A wealth of epidemiological and interventional studies have presented conflicting views. Particularly damning were …