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Introduction\ud The COLO-COHORT study aims to produce a multi-factorial risk prediction model for colorectal neoplasia that will be able to be used to target colonoscopy to those at greatest risk of colorectal neoplasia, ensuring that people are not investigated unnecessarily and maximising the use of limited endoscopy resources. The study will also explore the link between neoplasia and the human gut microbiome. Additionally, the study aims to generate a cohort of colonoscopy patients who are ‘research ready’ through the development of a consent-for-contact platform (C4C), to facilitate a range of CRC prevention studies to be conducted at scale and speed.\ud \ud Methods and Analysis\ud This is a multi-centre observational study involving sites across the UK. Recruitment is over a 6-year period (2019 – 2025). Patients recruited to the study are those attending for colonoscopy. Patients are recruited into two groups, namely; observational Group A (10,000 patients) and C4C Group B (10,000 patients), known as COLO-SPEED (Colorectal Cancer Screening Prevention Endoscopy and Early Diagnosis; https://colospeed.uk).\ud \ud Patients complete a health questionnaire, provide anthropometric measurements and submit biosamples (blood and stool - depending on the part of the study they are recruited into). Patients’ colonoscopy and histology findings are also recorded. Models of factors associated with presence of neoplasia at colonoscopy will be developed using logistic or multinomial regression. For internal validation, model discrimination and calibration will be assessed and bootstrapping and cross-validation approaches used. To enable long-term follow up for outcomes related to CRC and polyps, patients are asked to consent to follow up through data linkage with national databases.\ud \ud Dissemination\ud In keeping with good research practice, following analysis by the study team the study investigators will make the anonymised dataset available to other researchers. The C4C platform will also be accessible to other researchers. The study findings will be submitted for publication in peer reviewed journals and lay summaries will be disseminated to participants and the wider public.

Objectives People who are referred for colonoscopy, following an abnormal colorectal cancer (CRC) screening result, are at increased risk of CRC. Despite this, many individuals decline the procedure. The aim of this study was to investigate why. Methods As little is currently known about non-attendance at follow-up colonoscopy, and follow-up of abnormal screening results is a nurse-led process, we decided to conduct key informant interviews with Specialist Screening Practitioners ([SSPs] nurses working in the English Bowel Cancer Screening Program). Interviews were conducted online. Transcripts were assessed using inductive and deductive coding techniques. Results 21 SSPs participated in an interview. Five main types of barriers and facilitators to colonoscopy were described, namely: Sociocultural, Practical, Psychological, Health-related and COVID-related. Key psychological and sociocultural factors included: ‘Fear of pain and discomfort associated with the procedure’ and ‘Lack of support from family and friends’. Key practical, health-related and COVID-related factors included: ‘Family and work commitments’, ‘Existing health conditions as competing priorities’ and ‘Fear of getting COVID-19 at the hospital'. Conclusions A range of barriers and facilitators to follow-up colonoscopy exist. Future studies conducted with patients are needed to further explore barriers to colonoscopy. Practice implications Strategies to reduce non-attendance should adopt a multifaceted approach.

Underperformance can be defined as performance which persistently falls below a desired minimum standard considered acceptable for patient care. Within gastrointestinal endoscopy, underperformance may be multifactorial, related to an individual’s knowledge, skills, attitudes, health or external factors. If left unchecked, underperformance has the potential to impact on care and ultimately patient safety. Managing underperformance should be a key attribute of high-quality endoscopy service, as recognised in the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation process. However, it is recognised that not all services have robust mechanisms to do this.This article provides the JAG position on managing underperformance in endoscopy, defined through a practical framework. This follows a stepwise process of detecting underperformance, verification, identification of additional causative factors, providing support and reassessment. Detection and verification of issues may require use of multiple evidence sources, including performance data, feedback and appraisal reports. Where technical underperformance is identified, this should be risk stratified by potential risk to patient safety. Support should be tailored to each individual case based on the type of underperformance detected, any causative factors with an action plan developed. Support may include coaching, mentoring, training and upskilling. Wider support from the medical director’s office or external services may also be required. Monitoring and reassessment is a crucial part of the overall process.

BackgroundHigh-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.MethodsData 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.Results9265 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 ADRConclusionColonoscopists 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.

Purpose of review Colorectal cancer (CRC) is the second most common cause of cancer death worldwide, killing approximately 900,000 people each year. An individual’s risk of developing CRC is multi-factorial with known risk factors including increasing age, male sex, family history of CRC and raised body mass index. Population-based screening programmes for CRC exist in many countries, and in the United Kingdom (UK), screening is performed through the NHS Bowel Cancer Screening Programme (BCSP). Screening programmes offer a population-based approach for those at “average risk”, and do not typically offer enhanced screening for groups at increased risk. In the UK, such patients are managed via non-screening symptomatic services but in a non-systematic way. Recent findings There is growing evidence that conditions such as cystic fibrosis and a history of childhood cancer are associated with higher risk of CRC, and surveillance of these groups is advocated by some organizations; however, national recommendations do not exist in most countries. Summary We review the evidence for screening “high risk” groups not covered within most guidelines and discuss health economic issues requiring consideration acknowledging that the demand on colonoscopy services is already overwhelming.

Colorectal cancer is the second commonest cause of cancer death worldwide. Colonoscopy plays a key role in the control of colorectal cancer and, in that regard, maximizing detection (and removal) of pre-cancerous adenomas at colonoscopy is imperative. GI Genius™ (Medtronic Ltd) is a computer-aided detection system that integrates with existing endoscopy systems and improves adenoma detection during colonoscopy. COLO-DETECT aims to assess the clinical and cost effectiveness of GI Genius™ in UK routine colonoscopy practice.Participants will be recruited from patients attending for colonoscopy at National Health Service sites in England, for clinical symptoms, surveillance or within the national Bowel Cancer Screening Programme. Randomization will involve a 1:1 allocation ratio (GI Genius™-assisted colonoscopy:standard colonoscopy) and will be stratified by age category (60 years, 60-74 years, ≥74 years), sex, hospital site and indication for colonoscopy. Demographic data, procedural data, histology and post-procedure patient experience and quality of life will be recorded. COLO-DETECT is designed and powered to detect clinically meaningful differences in mean adenomas per procedure and adenoma detection rate between GI Genius™-assisted colonoscopy and standard colonoscopy groups. The study will close when 1828 participants have had a complete colonoscopy. An economic evaluation will be conducted from the perspective of the National Health Service. A patient and public representative is contributing to all stages of the trial. Registered at ClinicalTrials.gov (NCT04723758) and ISRCTN (10451355). WHAT WILL THIS TRIAL ADD TO THE LITERATURE?: COLO-DETECT will be the first multi-centre randomized controlled trial evaluating GI Genius™ in real world colonoscopy practice and will, uniquely, evaluate both clinical and cost effectiveness.

Population screening and endoscopic surveillance are used widely to prevent the development of and death from colorectal cancer (CRC). However, CRC remains a major cause of cancer mortality and the increasing burden of endoscopic investigations threatens to overwhelm some health services. This Perspective describes the rationale for and approach to improved risk stratification and decision-making for CRC prevention and diagnosis. Limitations of current approaches will be discussed using the UK as an example of the challenges faced by a particular health-care system, followed by discussion of novel risk biomarker utilization. We explore how risk stratification will be advantageous to current health-care providers and users, enabling more efficient use of limited colonoscopy resources. We discuss risk stratification in the setting of population screening as well as the surveillance of high-risk groups and investigation of symptomatic patients. We also address challenges in the development and validation of risk stratification tools and identify key research priorities., Population screening and endoscopic surveillance are widely used for colorectal cancer (CRC) prevention and early diagnosis. This Perspective explores the rationale for and approach to risk stratification for CRC prevention and diagnosis, including the limitations, advantages and future challenges for this approach.

Background Unacceptable variation in colonoscopy quality exists. The Quality Improvement in Colonoscopy (QIC) study in 2011 improved quality by introducing an evidence-based “bundle” of measures into routine colonoscopy practice. The QIC bundle included: minimal cecal withdrawal time of ≥ 6 minutes; hyoscine butylbromide use; supine patient position for transverse colon examination; rectal retroflexion. Colonoscopy quality was measured by adenoma detection rate (ADR). The current study measured whether these effects led to a sustained change in practice 3 years following implementation. Methods This observational study collected data from eight hospital trusts (sites) in the United Kingdom for a 6-month period, 3 years following QIC bundle implementation. Use of the antispasmodic, hyoscine butylbromide, was measured as a marker of bundle uptake. Bundle effectiveness was measured by ADR change. Comparisons were made between data before and immediately after implementation of the bundle. Results 28 615 colonoscopies by 188 colonoscopists were studied. Hyoscine butylbromide use increased from 15.8 % pre-implementation to 47.4 % in the sustainability phase (P Conclusions The introduction of a simple, inexpensive, pragmatic intervention significantly changed practice over a sustained period, improving colonoscopy quality as measured by ADR, particularly in poorer performers. QIC demonstrates that an easy-to-implement quality improvement approach can deliver a sustained change in practice for many years post intervention.

Aim: The adenoma detection rate (ADR) is an important quality measure, with a high ADR reflecting high-quality colonoscopy. This systematic review and meta-analysis aimed to assess the effects of Endocuff™/Endocuff Vision™-assisted colonoscopy (EAC) versus standard colonoscopy (SC) on ADR and other clinical, patient and resource-use outcomes. Method: MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials were searched for full papers reporting randomized studies comparing EAC with SC. The primary outcome was ADR. Secondary outcomes comprised key polyp/adenoma detection, procedure-related, patient-related and health economic measures. Random effects meta-analyses provided pooled estimates of outcomes [risk ratio (RR) or mean difference (MD), with 95% confidence intervals (CI)]. Results: Twelve parallel-group randomized controlled trials (RCTs) and three crossover RCTs with data on 9140 patients were included. EAC significantly increased the ADR (RR 1.18, 95% CI 1.09–1.29), mean adenomas per procedure (MAP) (MD 0.19, 95% CI 0.06–0.33), polyp detection rate (PDR) (RR 1.20, 95% CI 1.10–1.30) and mean polyps per procedure (MPP) (MD 0.39, 95% CI 0.14–0.63) versus SC. EAC significantly increased segmental PDR versus SC in the sigmoid (RR 2.02, 95% CI 1.64–2.49), transverse (RR 1.63, 95% CI 1.09–2.42), ascending (RR 1.74, 95% CI 1.26–2.41) and caecal segments (RR 1.91, 95% CI 1.29–2.82). Procedure-related variables did not differ between arms. There were insufficient data for meta-analysis of health economic or patient-centred outcomes. Conclusions: EAC increased ADR, MAP, PDR and MPP versus SC without detrimental effects on procedure measures. Cost-effectiveness and patient experience data are lacking and would be valuable to inform practice recommendations.

Background High quality colonoscopy is fundamental to good patient outcomes. “Textbook outcome” has proven to be a feasible multidimensional measure for quality assurance between surgical centers. In this study, we sought to establish the “textbook process” (TP) as a new composite measure for the optimal colonoscopy process and assessed how frequently TP was attained in clinical practice and the variation in TP between endoscopists. Methods To reach consensus on the definition of TP, international expert endoscopists completed a modified Delphi consensus process. The achievement of TP was then applied to clinical practice. Prospectively collected data in two endoscopy services were retrospectively evaluated. Data on colonoscopies performed for symptoms or surveillance between 1 January 2018 and 1 August 2021 were analyzed. Results The Delphi consensus process was completed by 20 of 27 invited experts (74.1 %). TP was defined as a colonoscopy fulfilling the following items: explicit colonoscopy indication; successful cecal intubation; adequate bowel preparation; adequate withdrawal time; acceptable patient comfort score; provision of post-polypectomy surveillance recommendations in line with guidelines; and the absence of the use of reversal agents, early adverse events, readmission, and mortality. In the two endoscopy services studied, TP was achieved in 5962/8227 colonoscopies (72.5 %). Of 48 endoscopists performing colonoscopy, attainment of TP varied significantly, ranging per endoscopist from 41.0 % to 89.1 %. Conclusion This study proposes a new composite measure for colonoscopy, namely “textbook process.” TP gives a comprehensive summary of performance and demonstrates significant variation between endoscopists, illustrating the potential benefit of TP as a measure in future quality assessment programs.

Metabolic syndrome (MetS) is a cluster of factors including obesity, hypertension, diabetes, hypercholesterolemia and hyperlipidaemia. It has been associated with an increased risk of colorectal neoplasia. This systematic review and meta-analysis assessed the association between MetS and (i) recurrence of adenomas or occurrence of CRC in patients with prior adenomas, and (ii) survival in patients with CRC.MEDLINE, Embase, Scopus and Web of Science were searched up to 22 November 2019. Two authors independently conducted title and abstract screening; full text of eligible studies was evaluated. Where ≥3 studies reported effect measures for a specific outcome, meta-analysis using random effects model was conducted. IThe search identified 1,764 articles, 55 underwent full text screening, resulting in a total of 15 eligible studies. Five studies reported on metachronous neoplasia, with differing outcomes precluded a meta-analysis. No consistent relationship between MetS and metachronous neoplasia was found. Ten studies reported on survival outcomes. MetS was associated with poorer CRC-specific survival (HR = 1.8, 95% CI: 1.04-3.12, IMetS is associated with poorer CRC-specific survival, but evidence is inconsistent on metachronous neoplasia. Further research is warranted to better understand the impact of MetS on the adenoma-carcinoma pathway.

Infection prevention and control (IPC) measures put in place during the first phases of the COVID-19 pandemic were effective in reducing endoscopy-related transmission while allowing recovery of activity. In late 2020 a novel, more infectious, SARS-CoV-2 variant (VOC 202012/01) was associated with a second ’surge' or acceleration phase in the UK. We sought to measure whether pre-existing IPC guidance would be sufficient to prevent transmission in this scenario. Prospective data were collected from eight UK centres for n=2440 procedures. Pre-endoscopy, nine (0.37%) asymptomatic patients were positive for SARS-CoV-2 by nasopharyngeal swab (NPS) testing and their procedures deferred. Post endoscopy, 30 (1.27%) developed symptoms suspicious for COVID-19, with 15 (0.65%) testing positive on NPS. Three (0.12%) cases were attributed to potential transmission from endoscopy attendance. All 15 patients recovered fully requiring only community treatment. Although we report cases potentially transmitted by endoscopy attendance in this latest study, the risk of COVID-19 transmission following outpatient endoscopy remains very low. Thus, IPC measures developed in earlier pandemic phases appear robust, but our data emphasise the need for vigilance and strict adherence to these measures in order to optimally protect both patients and staff. The effects of the COVID-19 pandemic continue to extend beyond direct care of affected patients,1 particularly impacting outpatient diagnostics including GI endoscopy. Considerable concerns remain around the potential impact on detection of, and survival from, significant disease such as cancer.2 3 In mid-2020, a pandemic deceleration phase4 in the UK led to a period of intense ‘restart and recovery’ activity in endoscopy to mitigate the effects of delayed or cancelled procedures. This was supported by professional society guidance on the development of ‘COVID-minimised’ or ‘green’ pathways with NPS testing of patients before their attendance for the procedure.5–7 Activity was limited by the impact on endoscopy staff …

Background and study aims The English National Bowel Scope Screening Programme (BSSP) invites 55-year-olds for a one-off, unsedated flexible sigmoidoscopy (FSIG). Data from BSSP participant-reported experience studies shows 1 in 3 participants report moderate or severe discomfort. Water-assisted colonoscopy (WAS) may improve participants’ comfort. The primary objective of this study is to ascertain if post-procedural participant-assessed pain is reduced in WAS compared with carbon dioxide (CO2) insufflation, in invitees undergoing FSIG in BSSP. Patients and methods This is a multicenter, prospective, randomized, two-arm, single-blinded trial designed to evaluate the performance of WAS versus CO2 insufflation in BSSP. Participants will be randomized to either CO2 or WAS and will be asked to rate pain post-procedure. Key procedure-related data will be analyzed, including adenoma detection rates (ADR) and degree of sigmoid looping. A cost-effectiveness analysis of WAS versus CO2 and a discrete choice experiment exploring preferences of participants for attributes of sigmoidoscopy will also be performed. Discussion This is the first trial in the United Kingdom (UK) to investigate the effects of WAS in a screening setting. If the trial shows WAS either reduces pain or increases ADR, this may result in a practice change to implement WAS in screening and non-screening endoscopic practice directly impacting on 256,000 people a year who will undergo BSSP FSIG by 2020.Trial funding came from National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) supported by the NIHR Clinical Research Network. The trial is actively recruiting. ID: 35866 ISRCTN: 81466870

Patients with inflammatory bowel disease (IBD), including both ulcerative colitis and Crohn's disease, are at an increased risk of developing colorectal cancer. It is well accepted that this risk increases after 8–10 years of disease duration. Patients should be offered a surveillance colonoscopy after this time. Previously, white-light endoscopy with random biopsies every 10 cm was undertaken for surveillance, but recent evidence suggests that chromoendoscopy along with targeted biopsy is superior to this and the other available methods. This article reviews the available evidence for IBD surveillance, surveillance guidelines and the evidence for chromoendoscopy. Additionally, an overview of the assessment, reporting of any visible abnormal lesions and management of subsequently proven dysplastic lesions is given.

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed. ispartof: UNITED EUROPEAN GASTROENTEROLOGY JOURNAL vol:7 issue:5 pages:614-641 ispartof: location:England status: published

Background A national colorectal cancer screening programme started in England in 2013, offering one-off flexible sigmoidoscopy to all men and women aged 55 years in addition to the biennial faecal occult blood testing programme offered to all individuals aged 60–74 years. We analysed data from six pilot flexible sigmoidoscopy screening centres to examine factors affecting the adenoma detection rate (ADR). Methods We did a retrospective analysis of flexible sigmoidoscopy screening procedures performed in individuals aged 55 years at six pilot sites in England as part of the National Health Service Bowel Scope Screening programme. ADR (number of procedures in which at least one adenoma was removed or biopsied, divided by total number of procedures) was calculated for each site and each endoscopist. Multiple regression models were used to examine the variation in ADR with withdrawal time and extent of examination, and the effect of other factors including comfort and bowel preparation on extent of examination. Findings The analysis included 8256 procedures done between May 7, 2013, and May 6, 2014. The overall ADR was 9·1% (95% CI 8·5–9·8; 755 of 8256 procedures), varying from 7·4% (6·2–8·9) to 11·0% (9·1–13·4) by screening centre. The ADR was 11·5% (95% CI 10·6–12·5; 493 of 4299 procedures) in men and 6·6% (5·9–7·4; 262 of 3957 procedures) in women (p Interpretation Key performance indicators for flexible sigmoidoscopy screening should be defined, including standards for insertion and withdrawal times, optimal depth, and bowel preparation. ADR could be improved by recommending a withdrawal time from the splenic flexure of at least 3·25 min (ideally 3·5–4·0 min).

Flexible sigmoidoscopy (FS) screening has been shown to reduce colorectal cancer (CRC) incidence and mortality among screened adults. The aim of this review was to identify patient-related factors associated with the screening test's use. We searched PubMed for studies that examined the association between FS screening use and one or more factors. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively (by adding ‘OR’ terms) until the number of new publications eligible after abstract review was

Published by BMJ. High quality gastrointestinal (GI) endoscopy improves patient care. Raising standards in endoscopy improves diagnostic accuracy, management of pathology and ultimately improves outcomes. Historical identification of significant variation in colonoscopy quality led to the development of the Joint Advisory Group (JAG) on GI Endoscopy, the Global Rating Scale (GRS), JAG Endoscopy Training System (JETS) training and certification. These measures led to major improvements in UK endoscopy but significant variation in practice still exists. To improve quality further the British Society of Gastroenterology Endoscopy Quality Improvement (EQIP) has been established with the aim of raising quality and reducing variation in the quality of UK endoscopy. A multifaceted approach to quality improvement (QI) will be undertaken and is described in this manuscript. Upper GI EQIP will support adoption of standards alongside regional upskilling courses. Lower GI EQIP will focus on supporting endoscopists to achieve current standards alongside approaches to reducing postcolonoscopy colorectal cancer rates. Endoscopic retrograde cholangiopancreatography EQIP will adopt a regional approach of using local data to support network-based QI. Newer areas of endoscopy practice such as small bowel endoscopy and endoscopic ultrasound will focus on identifying key performance indicators as well as standardising training and accreditation pathways. EQIP will also support QI in management of GI bleeding as well as standardising the approach to new techniques and technologies. Where evidence is lacking, approaches to gather new evidence and support the translation into clinical practice will be supported.

Highlights • Long-term self-referral reminders increased uptake by 4.1%. • 13% of those who self-referred had pre-cancerous lesions detected. • The biggest effects were seen in the most deprived areas., The clinical effectiveness of screening is highly dependent on uptake. Previous randomised controlled trials suggest that non-participant reminders, which highlight the opportunity to re-book an appointment, can improve participation. The present analysis examines the impact of implementing these reminders within the English Flexible Sigmoidoscopy (FS) Screening Programme, which offers once-only FS screening to adults aged 55–59 years. We assessed the screening status of 26,339 individuals invited for once-only FS screening in England. A total of 10,952 (41.6%) had attended screening, and were subsequently ineligible. The remaining 15,387 had not attended screening, and were selected to receive a reminder, 1–2 years after their invitation. Descriptive statistics were used to assess the increase in uptake and the adenoma detection rate (ADR) of those who self-referred, six months after the delivery of the final reminder. Pearson’s Chi-Square was used to compare the ADR between those who attended when invited and those who self-referred. Of the 15,387 adults eligible to receive a reminder, 13,626 (88.6%) were sent a reminder as intended (1,761 were not sent a reminder, due to endoscopy capacity). Of these, 8.0% (n = 1,086) booked and attended an appointment, which equated to a 4.1% increase in uptake from 41.6% at baseline, to 45.7% at follow-up. The ADR was significantly higher for those who self-referred, compared with those who attended when invited (13.3% and 9.5%, respectively; X2 = 16.138, p = 0.000059). The implementation of non-participant reminders led to a moderate increase in uptake. Implementing non-participant reminders could help mitigate the negative effects of COVID-19 on uptake.

Introduction Obesity and non-alcoholic fatty liver disease (NAFLD) is associated with colorectal neoplasia.1 2 In the UK, colonoscopy is performed for patient symptoms, Bowel Cancer Screening Programme (BCSP), family history or surveillance. We aimed to further explore obesity and NAFLD as risk factors with a view to developing a risk model. Methods OSCAR was a cross sectional study recruiting patients attending for colonoscopy. Patients’ medical history, smoking habits, alcohol intake, medication, family history of CRC, waist circumference/height/weight and bloods results were recorded. Multivariate logistic regression was undertaken to test associations between obesity, NAFLD, other risk factors and colorectal adenomas. Preliminary results are reported. Results 1430 patients were recruited (BCSP 410 [28.6%]; symptomatic 1020 [71.3%]). 698 were male (48.8%) with median age: 59 years. The burden of obesity and liver disease was high (reported in a further abstract). 457 patients (31.9%) had colorectal adenomas, 170 (11.9%) had advanced adenomas, and 59 (4.1%) had CRC. Statin use, smoking, metabolic syndrome, abnormal fatty liver index and ALT level were significantly associated with adenoma in univariate analysis, but not in the multivariable model. Variables in the final multivariate model are displayed below. Neither obesity nor NAFLD (established diagnosis; patient reported or in medical notes) were independently associated with adenoma risk in univariate or multivariate analysis (Obesity: multivariable (mv) OR 1.14 [95%CI 0.9–1.4]; NAFLD: mvOR 0.7 [95%CI 0.3–1.5]). Conclusions Older age, referral route, alcohol excess and hypertension were significantly associated with colorectal adenoma. After accounting for these factors, obesity and NAFLD were not independently associated with adenoma. Further work is exploring adenoma burden and more detailed modelling. References Okabayashi K, et al. Body mass index category as a risk factor for colorectal adenomas: a systematic review and meta-analysis. Am J Gastroenterol. 2012;107(8):1175–85. Ding W, et al. Association between nonalcoholic fatty liver disease and colorectal adenoma: A systematic review and meta-analysis. Int J Clin Exp Med. 2015;8(1):322–333.

Introduction Thorough mucosal examination at colonoscopy is essential to detect pathology and ensure high quality procedures. Adenoma detection rate (ADR), defined as the number of colonoscopies where at least one adenoma is detected, is the most important marker of colonic mucosal visualisation and therefore of colonoscopy quality. Histology results are required, making the use of ADR challenging. Polyp detection rate (PDR) is more readily available as it can be collected directly on endoscopy reporting systems. The use of PDR as a substitute for ADR has been deemed acceptable providing it accurately reflects ADR.1 We aim to investigate whether PDR can be reliably used as an alternative to ADR and therefore as a marker of colonoscopy quality. Methods Data were collected from independent endoscopists in eight hospitals in England over a six-month period, including; ADR, PDR, PDR excluding rectal hyperplastic polyps (RHP), mean patient age. The ADR:PDR ratio (APDRQ) per endoscopist and Pearson correlation between ADR and PDR were computed, including and excluding rectal hyperplastic polyps. Multiple linear regression analysis was used to develop a model to predict an endoscopist’s ADR from their PDR. Results 9265 colonoscopies performed by 118 endoscopists were included. Mean ADR and PDR per endoscopist were 17% (range 0–36.3, sd 7.37) and 27.2% (range 0–57.5, sd 9.3), respectively. The mean APDRQ was 0.60 (range 0–1.00, sd 0.21); this was 0.64 (range 0–1.17, sd 0.21) when RHPs were excluded. ADR and PDR were strongly correlated (rho=0.75, p Conclusions This study demonstrates that PDR can accurately be used as a marker of ADR as long as age is also considered. Reference Rees CJ, et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016;65:1923–9

Introduction Bowel cancer is the UK’s 2nd most common cause of cancer death. To reduce this risk, the NHS Bowel Cancer Screening Programme invites 55-year olds for sigmoidoscopy (Bowel Scope Screening-BSS). A national patient survey showed much higher procedural pain than anticipated, potentially impacting on compliance and screening effectiveness. Studies indicate that a new technique using water-assisted scope insertion (WAS) may minimise bowel distension, hence reduce pain and also increase polyp detection. We aimed to assess the effect of WAS on procedural pain and adenomatous polyp detection, compared to CO2 assisted scope insertion. We aimed to perform a cost-effectiveness analysis of WAS, a discrete choice experiment (DCE) to ascertain patient preferences, and to survey trial endoscopists’ technique preference after the trial. Methods We performed an RCT of 1123 people undergoing BSS, randomised 1:1 to WAS (for which the endoscopists received training) or CO2. The primary outcome was patient-reported moderate/severe pain. The key secondary outcome was adenoma detection rate (ADR). Results We found no difference in patient-reported moderate/severe pain between WAS and CO2 (p=0.47;logistic regression; predictive marginal estimates 14% in WAS and 15% in CO2). Moderate/severe pain was significantly lower in both arms than in the previous national survey (p ADR was significantly higher in the CO2 arm (p=0.03, logistic regression; odds ratio 1.45 (95% CI; 1.03, 2.04); predictive marginal estimates 11% in WAS and 15% in CO2). However, it remained above the minimum national performance standard in both arms and there was no statistical difference in mean number of adenomas nor overall polyp detection rate. Cost-consequence analysis revealed a negligible difference between the two techniques. The DCE revealed that patients care more about the risk of missing an abnormality and risk of a serious complication than the level of pain experienced. Exit survey of trial endoscopists revealed 10 preferred WAS, one preferred CO2 and 4 were neutral. Conclusions In the context of enema-prepared unsedated screening sigmoidoscopies performed by screening-accredited endoscopists, no difference in patient-reported pain was seen when using either a CO2 or WAS intubation technique. There is no need for screening sigmoidoscopists to switch to a WAS technique. Caution should be given to monitoring ADR if WAS is used in enema-prepared sigmoidoscopies. Research funded by NIHR RfPB. ISRCTN: 81466870

Colonoscopy is the gold standard test in the diagnosis of colorectal cancer. Despite this, many people across the world decline the procedure when invited for screening, surveillance or diagnostic evaluation. The aim of this review was to characterise the barriers and facilitators of colonoscopy use described in the qualitative literature. We searched PubMed and PsychInfo for studies that explored barriers and facilitators of colonoscopy use. To determine the eligibility of studies, we first reviewed titles, then abstracts, and finally the full paper. We started with a narrow search, which we expanded successively, until the number of new publications eligible after abstract review was

The COVID-19 pandemic has severely curtailed the practice of endoscopy (as an exemplar for outpatient diagnostic procedures) worldwide. Restart and recovery processes will be influenced by the need to protect patients and staff from disease transmission, but data on the risk of COVID-19 transmission after an endoscopy are sparse. This is of particular importance in later pandemic phases when the risk of harm from delayed or missed significant diagnoses is likely to far outweigh the risk of infection. The British Society of Gastroenterology guidance for restarting endoscopy included the stratification of diagnostic procedures according to aerosol generation or assessment of infectious risk as well as pragmatic guidance on the use of personal protective equipment (PPE). We sought to document the risk of COVID-19 transmission after endoscopy in this ‘COVID-minimised’ environment. Prospective data were collected from 18 UK centres for n=6208 procedures. Pre-endoscopy, 3 of 2611 (0.11%; 95% CI 0.00%–0.33%) asymptomatic patients tested positive for SARS-CoV-2 on nasopharyngeal swab. Based on follow-up telephone symptom screening of patients at 7 and 14 days, no cases of COVID-19 were detected by any centre after endoscopy in either patients or staff. Although these data cannot determine the relative contribution of each component of a COVID-minimised pathway, they provide clear support for such an approach. The rational use of PPE and infection control policies should be continued and will aid in planning for outpatient diagnostics in the COVID-19 recovery phase. The COVID-19 pandemic has had an extraordinary impact on the delivery of GI endoscopy, with an initial reduction to 12% of prepandemic levels in the UK.1 In the deceleration and early recovery phases (up to end July 2020), this had risen to 42% of repandemic levels.2 Recovery has been influenced by multiple factors including availability of staff, restrictions caused by longer room cleansing, physical …

Many non-emergency clinical services were suspended during COVID-19 pandemic peak. It is essential to develop a plan for restarting services following the peak. It is equally important to protect patients and staff and to use resources and personal protective equipment (PPE) efficiently. The British Society of Gastroenterology Endoscopy Committee and Quality Improvement Programme has produced guidance on how a restart can be safely delivered. Key recommendations include the following: all patients should have need for endoscopy assessed by senior clinicians and prioritised according to criteria we have outlined; once the need for endoscopy is confirmed, patients should undergo telephone screening for symptoms using systematic questionnaires; all outpatients should undergo RT-PCR testing for COVID-19 virus 1–3 days prior to endoscopy; and PPE should be determined by patient risk stratification, the nature of the procedure and the results of testing. While this guidance is tailored to endoscopy services, it could be adapted for any interventional medical discipline.

The COVID-19 pandemic has placed extraordinary demands on healthcare services worldwide. Strategic planning for acute COVID-19 care has, during the peak phase of the pandemic, rightly overshadowed the provision of diagnostic services, which have been further restricted by the need to minimise viral transmission to reduce the attendant risks to patients and staff. The risk is compounded by the asymptomatic phase of COVID-19 infection1 and is particularly important in relation to GI endoscopy, given the aerosol-generating nature of many endoscopic procedures.2–4 The British Society of Gastroenterology released early guidance to assist local teams in prioritising certain indications for GI endoscopy, even during the tight restrictions demanded by the peak phase of the pandemic.2 Other endoscopy societies or expert groups have also published guidance on the management of GI endoscopy during the pandemic, and these are summarised elsewhere.5 In the deceleration phase of the pandemic, as defined by a sustained fall in new infectious cases over 14 consecutive days,6 7 healthcare systems will rightly look to implement measures to safely restart activity. Endoscopy capacity should be restored as far as possible while ensuring mechanisms are in place to reassure and protect patients and staff from avoidable risk. There is significant risk in continued delay of diagnostic services. For GI endoscopy, this relates to cancers as well as other time-critical conditions such as IBD. While COVID-19 has tragically accounted for over 200 000 reported deaths by the end of April 2020,8 there were around 18 million cases of cancer worldwide in 2018 and 10 million cancer deaths, with colorectal and gastric cancer accounting for 17% of deaths.9 It has been conservatively estimated that delays to cancer diagnoses and treatment could be responsible for nearly 7000 additional deaths in England and over 30 000 deaths in the USA.10 It …

ObjectivesThe English Bowel Cancer Screening Programme invites 55 year olds for a sigmoidoscopy (Bowel Scope Screening (BSS)), aiming to resect premalignant polyps, thus reducing cancer incidence. A national patient survey indicated higher procedural pain than anticipated, potentially impacting on screening compliance and effectiveness. We aimed to assess whether water-assisted sigmoidoscopy (WAS), as opposed to standard CO2 technique, improved procedural pain and detection of adenomatous polyps.DesignThe WASh (Water-Assisted Sigmoidoscopy) trial was a multicentre, single-blind, randomised control trial for people undergoing BSS. Participants were randomised to either receive WAS or CO2 from five sites across England. The primary outcome measure was patient-reported moderate/severe pain, as assessed by patients on a standard Likert scale post procedure prior to discharge. The key secondary outcome was adenoma detection rate (ADR). The costs of each technique were also measured.Results1123 participants (50% women, mean age 55) were randomised (561 WAS, 562 CO2). We found no difference in patient-reported moderate/severe pain between WAS and CO2 (14% in WAS, 15% in CO2; p=0.47). ADR was 15% in the CO2 arm and 11% in the WAS arm (p=0.03); however, it remained above the minimum national performance standard in both arms. There was no statistical difference in mean number of adenomas nor overall polyp detection rate. There was negligible cost difference between the two techniques.ConclusionIn the context of enema-prepared unsedated screening sigmoidoscopies performed by screening-accredited endoscopists, no difference in patient-reported pain was seen when using either a CO2 or WAS intubation technique.Trial registration numberISRCTN81466870.

BackgroundMeasuring patient experience is important for evaluating the quality of patient care, identifying aspects requiring improvement and optimising patient outcomes. Patient Reported Experience Measures (PREMs) should, ideally, be patient derived, however no such PREMs for gastrointestinal (GI) endoscopy exist. This study explored the experiences of patients undergoing GI endoscopy and CT colonography (CTC) in order to: identify aspects of care important to them; determine whether the same themes are relevant across investigative modalities; develop the framework for a GI endoscopy PREM.MethodsPatients aged ≥18 years who had undergone oesophagogastroduodenoscopy (OGD), colonoscopy or CTC for symptoms or surveillance (but not within the national bowel cancer screening programme) in one hospital were invited to participate in semi-structured interviews. Recruitment continued until data saturation. Inductive thematic analysis was undertaken.Results35 patients were interviewed (15 OGD, 10 colonoscopy, 10 CTC). Most patients described their experience chronologically, and five ‘procedural stages’ were evident: before attending for the test; preparing for the test; at the hospital, before the test; during the test; after the test. Six themes were identified: anxiety; expectations; choice & control; communication & information; comfort; embarrassment & dignity. These were present for all three procedures but not all procedure stages. Some themes were inter-related (eg, expectations & anxiety; communication & anxiety).ConclusionWe identified six key themes encapsulating patient experience of GI procedures and these themes were evident for all procedures and across multiple procedure stages. These findings will be used to inform the development of the Newcastle ENDOPREM™.

Rapid reviews enable researchers to obtain a snapshot of what is known about a topic in a quick and systematic way, and are increasingly becoming an important aspect of the research literature. Despite this, there are currently no formal guidelines as to how best to conduct a rapid review. One method is to begin with a narrow search, and to expand the search successively, until the number of new/additional publications considered potentially eligible, based on title and abstract alone, is less than 1% of the total number of publications found overall (at this point, one can be reasonably confident that expanding the search is unlikely to yield any considerable new information). One of the main advantages of this method is that it provides a rationale for terminating the search at a given point, thereby making it less time-consuming than many other methods, which require the reviewer(s) to screen all articles found in response to a comprehensive list of search terms. In this case study, we describe our experience using the aforementioned method to review the literature investigating factors associated with flexible sigmoidoscopy (“bowel scope”) screening use, and the lessons learned from it. We also describe the problems encountered in performing our review, and the steps implemented to overcome them. Finally, we provide suggestions for methodological improvements for the benefit of those considering conducting a rapid review in the future.

Aim The delivery of the Scottish Bowel Screening Programme (SBoSP) is rooted in the provision of a high quality, effective and participant-centred service. Safe and effective colonoscopy forms an integral part of the process. Additional accreditation as part of a multi-faceted programme for participating colonoscopists, as in England, does not exist in Scotland. This study aimed to describe the quality of colonoscopy in the SBoSP and compare this to the English national screening standards. Methods Data were collected from the SBoSP between 2007 and 2014. End-points for analysis were caecal intubation, cancer, polyp and adenoma detection, and complications. Overall results were compared with 2012 published English national standards for screening and outcomes from 2006 to 2009. Results During the study period 53 332 participants attended for colonoscopy. The colonoscopy completion rate was 95.6% overall. The mean cancer detection rate was 7.1%, the polyp detection rate was 45.7% and the adenoma detection rate was 35.5%. The overall complication rate was 0.47%. Conclusion Colonoscopy quality in the SBoSP has exceeded the standard set for screening colonoscopy in England, despite not adopting a multi-faceted programme for screening colonoscopy. However, the overall adenoma detection rate in Scotland was 9.1% lower than that in England which has implications for colonoscopy quality and may have an impact on cancer prevention rates, a key aim of the SBoSP.

ObjectiveLow adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC).DesignPatients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured.Results1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, PConclusionEV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection.Trial registration numberNCT02552017, Results; ISRCTN11821044, Results.

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2 Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3 Bile duct cannulation rate (key performance measure, at least 90 %); 4 Tissue sampling during EUS (key performance measure, at least 85 %); 5 Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6 Bile duct stone extraction (key performance measure, at least 90 %); 7 Post-ERCP pancreatitis (key performance measure, less than 10 %). 8 Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues. ispartof: UNITED EUROPEAN GASTROENTEROLOGY JOURNAL vol:6 issue:10 pages:1448-1460 ispartof: location:England status: published

Background and Aims Distal attachments placed on the colonoscope tip may positively affect performance by assisting insertion and polyp detection. The original Endocuff (ARC Medical Design, Leeds, United Kingdom) appears to improve adenoma detection rate (ADR), but no data assess the performance of the second-generation Endocuff Vision. Methods A pilot service evaluation study (April 2013 to September 2014) was conducted on patients with positive fecal occult blood tests within the National Bowel Cancer Programme during 3 consecutive periods: precuff/no device used, during-cuff/device used, and postcuff/no device used. During the middle period the use of the Endocuff Vision by the 4 screening-accredited colonoscopists was discretional (nonrandomized design). Data were analyzed using pairwise comparisons during the 3 designated periods to examine key performance indicators: adenoma detection, procedural time, sedation requirements, and patient comfort. Results Four hundred ten complete colonoscopies were performed (137 precuff, 136 cuff, and 137 postcuff period). Overall, there was a notable increase in the mean ADR of 16% (P Conclusions In this pilot service evaluation study, the use of the Endocuff Vision appears to be associated with an improvement in overall colonoscopy operator performance. We found increased ADR and MAP as well as decreased time for colonoscope insertion and withdrawal time with no increase in sedation requirements or patient discomfort.

ObjectivesMeasuring patient experience of gastrointestinal (GI) procedures is a key component of evaluation of quality of care. Current measures of patient experience within GI endoscopy are largely clinician derived and measured; however, these do not fully represent the experiences of patients themselves. It is important to measure the entirety of experience and not just experience directly during the procedure. We aimed to develop a patient-reported experience measure (PREM) for GI procedures.DesignPhase 1: semi-structured interviews were conducted in patients who had recently undergone GI endoscopy or CT colonography (CTC) (included as a comparator). Thematic analysis identified the aspects of experience important to patients. Phase 2: a question bank was developed from phase 1 findings, and iteratively refined through rounds of cognitive interviews with patients who had undergone GI procedures, resulting in a pilot PREM. Phase 3: patients who had attended for GI endoscopy or CTC were invited to complete the PREM. Psychometric properties were investigated. Phase 4 involved item reduction and refinement.ResultsPhase 1: interviews with 35 patients identified six overarching themes: anxiety, expectations, information & communication, embarrassment & dignity, choice & control and comfort. Phase 2: cognitive interviews refined questionnaire items and response options. Phase 3: the PREM was distributed to 1650 patients with 799 completing (48%). Psychometric properties were found to be robust. Phase 4: final questionnaire refined including 54 questions assessing patient experience across five temporal procedural stages.ConclusionThis manuscript gives an overview of the development and validation of the Newcastle ENDOPREM™, which assesses all aspects of the GI procedure experience from the patient perspective. It may be used to measure patient experience in clinical care and, in research, to compare patients’ experiences of different endoscopic interventions.

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 Rate of adequate bowel preparation (minimum standard 90 %); 2 Cecal intubation rate (minimum standard 90%); 3 Adenoma de-tection rate (minimum standard 25%); 4 Appropriate polypectomy technique (minimum standard 80%); 5 Complication rate (minimum standard not set); 6 Patient experience (minimum standard not set); 7 Appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.

These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped?two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); orfive or more premalignant polypsThe Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG’s guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); orfive or more premalignant polypsThe key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise either:two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); orfive or more premalignant polypsThis cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.