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IntroductionTraining and quality assurance in oesophagogastroduodenoscopy (OGD) is important to ensure competent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for OGD training and certification.MethodsUnder the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted with stakeholder representation from British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on OGD training and certification were formulated following literature review and appraised using Grading of Recommendations Assessment, Development and Evaluation. These were subjected to electronic voting to achieve consensus. Accepted statements were incorporated into the updated certification pathway.ResultsIn total, 32 recommendation statements were generated for the following domains: definition of competence (4 statements), acquisition of competence (12 statements), assessment of competence (10 statements) and post-certification support (6 statements). The consensus process led to following certification criteria: (1) performing ≥250 hands-on procedures; (2) attending a JAG-accredited basic skills course; (3) attainment of relevant minimal performance standards defined by British Society of Gastroenterology/Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, (4) achieving physically unassisted D2 intubation and J-manoeuvre in ≥95% of recent procedures, (5) satisfactory performance in formative and summative direct observation of procedural skills assessments.ConclusionThe JAG standards for diagnostic OGD have been updated following evidence-based consensus. These standards are intended to support training, improve competency assessment to uphold standards of practice and provide support to the newly-independent practitioner.

Background Gastro‐oesophageal reflux disease (GERD) is difficult to diagnose without invasive testing. Peptest (RD Biomed, Hull, UK) is a recently marketed diagnostic tool which aims to quantify salivary pepsin as a marker of reflux, providing a rapid alternative to invasive procedures. Aim To evaluate optimal timing for sampling, and to evaluate the accuracy of Peptest against an independent measure. Methods Thirty diagnosed GERD patients (12 female, mean age 49 [range 20‐72]) and 20 asymptomatic subjects (14 female, mean age 56 [range 21‐56]) were subject to diurnal saliva sampling, with additional samples for 60 minutes following self‐reported reflux symptoms and triggering of a proximal reflux alarm. Saliva samples were split and were analysed by both Peptest and ELISA with operators for each blinded to sample identity. Results Salivary pepsin was detectable in most patients and most volunteers. Peptest scores were significantly lower for patients than controls (P < 0.005). ELISA scores showed no difference between patients and controls. There was no effect of diurnal sampling time (P = 0.75) or time after symptoms (P = 0.76) on Peptest readout. There was no correlation between Peptest and Pepsin ELISA (P = 0.55); Bland‐Altman analysis suggested no agreement between the tests (P = 0.414). Receiver‐operator curve suggests that neither Peptest (P = 0.3328) nor pepsin (P = 0.4476) is useful for predicting GERD. Conclusion Salivary pepsin is not a reliable tool for the diagnosis of GERD.

Introduction The investigation of iron deficiency anaemia (IDA) in the over 80-year-olds presents a unique challenge due to co-morbidity, uncertain prognosis and differing attitudes to acceptability of invasive investigation. We evaluated the investigations accepted and the subsequent outcomes for elderly patients. Methods We prospectively collected consecutive GP referrals of IDA patients aged 80+ between 2015 and 2018 seen by a single gastroenterologist. The options of invasive investigation (bidirectional endoscopy), non-invasive investigation (CTC – CT pneumocolon; CT long oral prep; CT TAP – CT thorax, abdomen, pelvis), or no investigation, were discussed and offered in a standardised manner. Results 173 patients (64.7% female, 80–95 yrs) were seen. 28 (16.2%) declined all investigations, while 39 (22.5%) underwent bidirectional endoscopy. Investigations accepted and performed were: OGD 93 (53.7%), colonoscopy 40 (23.1%), CTC 52 (30%), CT long oral prep 47 (27.2%), and CT TAP 34 (19.7%). Carcinoma was identified in 21 (14.5%) patients who underwent investigations - 19 (13.1%) were gastrointestinal (GI) cancers (16 colorectal, 3 gastric), one metastatic. Two patients with GI malignancy were also diagnosed with myeloma. The 2 non-GI cancers were metastatic renal cell carcinoma and hepatocellular carcinoma. There were significant differences in investigations undertaken between the elderly (80–84 yrs) and very elderly (85+yrs) as shown in the table 1. Of the 17 potentially operable GI cancers, 9 procedures with curative intent were performed (8 hemicolectomy, 1 transanal resection). Two of these were in patients aged 85+. 1 subject, aged 89, was offered curative surgery but declined. Outcomes from surgery were very positive, with 8/9 patients undergoing surgery still alive (median follow up 984 days, range 454–2151). The single death occurred 1247 days post-clinic. This compared with on-going survival of 2/8 patients who did not undergo surgery (421 and 701 days), with a median survival of 495 days (range 93–1562) for those who died. Conclusions The over 80-year-olds with IDA are a heterogeneous group. Overall 16% of patients declined all investigations, though this rose to 26% in those aged over 85. Non-invasive tests were much more likely to be undertaken in the 85+ age group, with only 3% having ‘gold standard’ bidirectional endoscopy. Half of patients with potentially curable GI cancers discovered underwent surgery, with 8/9 alive at a mean follow-up of 2.5 years.

IntroductionAdequate bowel preparation is a prerequisite for effective colonoscopy. Split bowel preparation results in optimal cleansing. This study assessed the bowel preparation regimes advised by endoscopy units across the UK, and correlated the differences with outcomes.MethodsTrusts in the UK were surveyed, with data requested between January 2018 and January 2019, including: the type and timing of preparation, pre-endoscopy diet, adequacy rates and polyp detection. Trusts were grouped according to the timing of bowel preparation. χ2 test was used to assess for differences in bowel preparation adequacy.ResultsMoviprep was the first line bowel preparation in 79% of trusts. Only 7% of trusts advised splitting bowel preparation for all procedures, however, 91% used split bowel preparation for afternoon procedures. Trusts that split preparation for all procedures had an inadequacy rate of 6.7%, compared with 8.5% (pConclusionMost trusts in the UK do not provide instructions optimising the timing of bowel preparation prior to colonoscopy. This correlated with an increased rate of inadequate cleansing. Splitting bowel preparation is likely to reduce the impacts of poor cleansing: missed lesions, repeat colonoscopies and significant costs.

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.

Introduction Split dose preparation has been shown to optimise mucosal cleansing, enhance endoscopic views, and improve pathology detection. Split dosing for morning appointments necessitates waking early to take the second dose at an appropriate time. Many units therefore advise that all the preparation is taken the day before the procedure. Our aim was to assess whether patients would be willing to wake-up early to facilitate split dose preparation. Methods Consecutive patients attending for bowel cancer screening and symptomatic colonoscopy were invited to complete a standardised questionnaire. The results were collated, and logistic regressions were performed in both groups. Results 418 patients were asked to complete the questionnaire (119 screening and 299 symptomatic); 8 questionnaires were incomplete (6 screening and 2 symptomatic) and were excluded. The M:F ratio was 1.64:1 and 1.03:1; and ages ranged from 55–74 (mean 64.5) and 17–81 (mean 51.5), in the screening and symptomatic groups respectively. Overall, 89% of screening and 85% of symptomatic patients reported they would be willing to wake up early to take split-dose preparation for morning appointments. 78% of screening and 61% of symptomatic patients would be willing to wake between 4–6 am, to facilitate split dosing for morning scheduled colonoscopies. In the screening patients, 3 factors were found to affect willingness to wake up early: scheduled appointment time, whether they perceived the bowel preparation had a severely unpleasant taste and whether taking the preparation had made them interrupt their journey to the hospital to defaecate. Conclusions This study indicates that most patients would be willing to wake-up early to take adequately spaced split doses of bowel preparation, irrespective of age, sex, socioeconomic background, indication, or previous colonoscopy. In the screening group, those that felt that the preparation tasted severely unpleasant and those who had to interrupt their journey to hospital to use a toilet, were less likely to be willing to wake early to take bowel preparation. All endoscopy units should be encouraged to invite patients scheduled for morning colonoscopy to wake early to facilitate split dose bowel preparation.

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 Adenocarcinomas can arise in a variety of circumstances in which intestinal segments have been used for urinary diversions. Whereas ureterosigmoidostomy is the oldest and simplest form of continent urinary diversion it also seems to be the most dangerous in this regard. Herein we present a case of colonic neoplasia complicating a non-functioning ureterosigmoidostomy after 55 years; the longest latent period documented to date. Case presentation A 56-year-old lady born with congenital bladder exystrophy and who had a functional ileal conduit presented to us with a 6 month history of change in bowel habit and rectal bleeding. Prior to this she had had multiple abdominal surgeries as a child and had suffered from lifelong recurrent urinary tract infections. Colonoscopy revealed the presence of two large sessile polyps in close proximity to a diverticulum-like structure that after surgical resection turned out to be a non-functioning ureterosigmoidostomy from when she was an infant. Conclusions Our case highlights the importance of enrolling patients with ureterosigmoidostomies into long-term colonoscopic surveillance programmes. This is also true for those patients who undergo revisional surgery but have preserved ureteric stumps. Endoscopists should be aware of the varied endoscopic appearances of the anastamosis in order to be able to recognise these structures when present.

Introduction Eosinophilic oesophagitis (EO) is a recognised cause of dysphagia, with an estimated annual incidence of 6–13 cases/100,000 persons. Endoscopic features may be subtle or absent and as such societal guidelines advocate the acquisition of six non-targeted oesophageal biopsies, where a cause has not been identified. We aim to determine whether these recommendations are adhered to in clinical practice. Methods We performed a database review of all diagnostic OGDs performed to investigate dysphagia or food bolus obstruction, during the 12 month period between 1 st July 2016–30th June 2017 within three large teaching hospitals (Cambridge University Hospital, Sheffield Teaching Hospitals and Nottingham University Hospital). Endoscopy reports were reviewed to determine endoscopic findings. Histology reports were examined to establish the number of biopsy samples received and whether a diagnosis of EO was made. Results During this time period a total of 25,495 OGDs were performed, of which 4056 (16%) were carried out as part of the investigation of dysphagia. Failed and repeat procedures were excluded leaving a total study population of 3712. An endoscopic diagnosis potentially causing dysphagia was observed in 1286 patients (oesophagitis/ulceration 583 (15.7%), benign stricture 311 (8.4%), malignancy 188 (5.1%) or other causes 156 (4.2%). In the remaining 2468 patients (66.5%) an endoscopic cause of dysphagia was not identified. Biopsies to exclude EO were taken during 923 (37.4%) of these non-diagnostic procedures. A reason for not taking biopsies was documented in 19 cases. The recommended 6 biopsies were received by histopathology in 87 patients. A diagnosis of EO was considered in 42 patients based on endoscopic features, of which 68% went on to be confirmed with histology. During the 12 month period a total of 83 histologically confirmed cases of EO were diagnosed. Endoscopy had a sensitivity and specificity for the diagnosis of EO of 33.7% and 96.8% respectively. Physician endoscopists were more likely take biopsies, acquiring these in 46.4% of procedures where this would be appropriate, compared to surgical endoscopists who took these in 13.3%. Physicians consequently diagnosed 77 (93%) of confirmed cases. Conclusions This study demonstrates variable adherence to recommendations for the investigation of EO. The hospitals included serve a combined population of approximately 3.2 million, giving rise to a below expected incidence of 2.6 cases per 1 00 000 per year

Background It has been suggested that changing patient position during colonoscope withdrawal increases adenoma detection. The results of previous studies have been conflicting. Objective To evaluate whether routine position change during colonoscope withdrawal improves polyp detection. Design Randomized, 2-way, crossover study. Setting Teaching hospital. Patients A total of 130 patients attending for diagnostic colonoscopy. Interventions Patients undergoing colonoscopy had each colon segment examined twice: the right side of the colon (cecum to hepatic flexure) in the supine and left lateral position and the left side of the colon (splenic flexure and descending colon) in the supine and right lateral position. The transverse colon was examined twice in the supine position. Main Outcome Measurements The primary outcome measure was the polyp detection rate (≥1 polyp) per colon segment. Secondary outcome measures included the number and proportion of patients with ≥1 adenoma in each segment and adequacy of luminal distension (1 = total collapse and 5 = no collapse). Results Examination of the right side of the colon in the left lateral position significantly improved polyp detection (26.2% vs 17.7%; P = .01) and luminal distension (mean = 4.0 vs 3.5; P P = .99). There was no significant correlation between luminal distension and polyp detection in the right side of the colon ( r = .03). Limitations Single center and open study design. Conclusion Examining the right side of the colon in the left lateral position increased polyp detection compared with examination in the supine position. Polyp detection in the left side of the colon was similar in the right lateral and supine positions. (Clinical trial registration number: NCT01554098.)

Background: Cold snare techniques are widely used for removal of diminutive and small colorectal polyps. The influence of resection technique on the effectiveness of polypectomy is unknown. We therefore compared standard cold snare polypectomy with a newly described suction pseudopolyp technique, for completeness of excision and for complications. Patients and methods: In this single-center study, 112 patients were randomized to cold snare polypectomy or the suction pseudopolyp technique. Primary outcome was endoscopic completeness of excision. Consensus regarding the endoscopic assessment of completeness of excision was standardized and aided by chromoendoscopy. Secondary outcomes included: completeness of histological excision, polyp “fly away” and retrieval rates, early bleeding (48 hours), delayed bleeding (2 weeks), and perforation. Results: 148 polyps were removed, with size range 3 – 7 mm, 60 % in the left colon, and 90 % being sessile. Regarding completeness of excision (with uncertain findings omitted): endoscopically, this was higher with the suction pseudopolyp technique compared with cold snare polypectomy but not statistically significantly so (73/74 [98.6 %] vs. 63/68 [92.6 %]; P = 0.08). A trend towards a higher complete histological excision rate with the suction pseudopolyp technique was also not statistically significant (45/59 [76.3 %] vs. 37/58 [63.8 %]; P = 0.14). Polyp retrieval rate was not significantly different (suction 68/76 [89.5 %] vs. cold snare 64/72 [88.9 %]; P = 0.91). No perforation or bleeding requiring hemostasis occurred in either group. Conclusion: In this study both polypectomy techniques were found to be safe and highly effective, but further large multicenter trials are required. Clinical trial registration at www.clinicaltrials.gov: NCT02208401

AIM Medication may be used to manage discomfort during colonoscopy but practice varies. The relationship between medication use and comfort during colonoscopy was examined in the English Bowel Cancer Screening Programme. METHODS Data related to patient comfort and medication use from all 113,316 examinations performed within the English Bowel Cancer Screening Programme between 1 January 2010 and 31 December 2012 were analysed. Comfort was rated on the five-point Modified Gloucester Comfort Scale: 1, no discomfort; 5, severe discomfort. Scores of 4 and 5 were considered to indicate significant discomfort. Correlations between the proportion of examinations associated with significant discomfort and the amounts of medication used by colonoscopists were assessed using Spearman's ρ. Logistic regression modelling examined the independent predictors of significant discomfort. RESULTS Patients had a mean age of 65.7 years, and 58% were male. Examinations were performed by 290 endoscopists. In 91% of examinations, there was no significant discomfort reported during examination; however, there was considerable variation between individual colonoscopists (range 76.1-99.2%).Intravenous sedation and opiate analgesia were used during most examinations, but there was wide variation between colonoscopists, with a median (range) usage of 95.1% (4.1-100%) and 97.3% (5.6-100%), respectively. There was no association between the amount of sedation and analgesia used and significant discomfort (ρ

Background and Aim Cold snare techniques are widely used for the removal of small and diminutive polyps. The influence of snare type on the effectiveness of cold snare polypectomy is unknown. Methods Cold snare polypectomy of 3–7-mm polyps was undertaken using either a thin wire mini-snare (0.30 mm) or a thick wire mini-snare (0.47 mm). Primary outcome was endoscopic completeness of excision. Consensus regarding endoscopic assessment of completeness of excision was standardized and aided by chromoendoscopy. Secondary outcomes included: completeness of histological excision, polyp ‘fly away’, polyp retrieval rate, early or delayed bleeding and perforation. Results One hundred and fifty-seven polyps were removed ranging from 3 to 7 mm, 62% were situated in the left side of the colon and 89.4% were sessile. Endoscopic completeness of excision was significantly higher with the thin wire snare compared to the thick wire snare (90.2% vs 73.3%, P

Most colonic polyps are small, and several polypectomy techniques are available. We aimed to describe the variation in polypectomy techniques employed for the removal of sub-centimeter polyps in relation to polyp characteristics, completeness of histological excision and safety.Prospectively collected data relating to the removal of sub-centimeter polyps over a 3-year period (between January 2010 and December 2012) were retrieved from the English Bowel Cancer Screening Programme.A total of 147,174 sub-centimeter polyps were removed during 62,679 procedures. For pedunculated polyps, hot snare was most common in the left (median 92 %, IQR 83.3-97.0 %) and right colon (median 75 %, IQR 3-92 %). For non-pedunculated polyps, cold snare was most common in the right colon (median 24 %, IQR 9-47 %); whereas hot snare remained most common in the left colon (median 32 %, IQR 19-49 %). Surgeons were more likely than physicians to use diathermy-assisted techniques (65.6 vs. 56.5 %, p 0.001). Twelve (0.03 %) bleeding episodes required transfusion with no polypectomy technique dominating and 16 (0.04 %) perforations with 81 % of polypectomies performed using diathermy-assisted techniques. There was substantial variation between screening centers for the completeness of histological excision. For non-pedunculated polyps, histologically confirmed complete excision was more after EMR (23.4 %) compared with other techniques (cold biopsy forceps 17.7 %, cold snare 15.1 %, hot biopsy forceps 19.1 %, hot snare 21.5 %). The use of cold techniques and EMR has increased over time, whereas the use of hot biopsy forceps and hot snare has decreased (p 0.001).The removal of sub-centimeter polyps within the BCSP is safe despite wide variations in practice. The use of cold resection techniques and EMR has increased over time. The histological assessment for completeness of excision is limited and should be confirmed endoscopically at the time of polypectomy.

OBJECTIVES: The International Classification of Diseases 10th Revision (ICD-10) system used in the English hospital administrative database (Hospital Episode Statistics (HES)) does not contain a specific code for oesophageal high-grade dysplasia (HGD). The aim of this paper was to examine how patients with HGD were coded in HES and whether it was done consistently.SETTING: National population-based cohort study of patients with newly diagnosed with HGD in England. The study used data collected prospectively as part of the National Oesophago-Gastric Cancer Audit (NOGCA). These records were linked to HES to investigate the pattern of ICD-10 codes recorded for these patients at the time of diagnosis.PARTICIPANTS: All patients with a new diagnosis of HGD between 1 April 2013 and 31 March 2014 in England, who had data submitted to the NOGCA.OUTCOMES MEASURED: The main outcome assessed was the pattern of primary and secondary ICD-10 diagnostic codes recorded in the HES records at endoscopy at the time of diagnosis of HGD.RESULTS: Among 452 patients with a new diagnosis of HGD between 1 April 2013 and 31 March 2014, Barrett's oesophagus was the only condition coded in 200 (44.2%) HES records. Records for 59 patients (13.1%) contained no oesophageal conditions. The remaining 193 patients had various diagnostic codes recorded, 93 included a diagnosis of Barrett's oesophagus and 57 included a diagnosis of oesophageal/gastric cardia cancer.CONCLUSIONS: HES is not suitable to support national studies looking at the management of HGD. This is one reason for the UK to adopt an extended ICD system (akin to ICD-10-CM).

Several studies have suggested that a significant minority of esophageal cancers are missed at endoscopy The aim of this study was to estimate the proportion of esophageal cancers missed at endoscopy on a national level, and to investigate the relationship between miss rates and patient and tumor characteristics.This retrospective, population-based, cohort study identified patients diagnosed with esophageal cancer between April 2011 and March 2012 in England, using two linked databases (National Oesophago-Gastric Cancer Audit and Hospital Episode Statistics). The main outcome was the rate of previous endoscopy within 3 - 36 months of cancer diagnosis. This was calculated for the overall cohort and by patient characteristics, including tumor site and disease stage.A total of 6943 new cases of esophageal cancer were identified, of which 7.8 % (95 % confidence interval 7.1 - 8.4) had undergone endoscopy in the 3 - 36 months preceding diagnosis. Of patients with stage 0/1 cancers, 34.0 % had undergone endoscopy in the 3 - 36 months before diagnosis compared with 10.0 % of stage 2 cancers and 4.5 % of stage 3/4 cancers. Of patients with stage 0/1 cancers, 22.1 % were diagnosed after ≥ 3 endoscopies in the previous 3 years. Patients diagnosed with an upper esophageal lesion were more likely to have had an endoscopy in the previous 3 - 12 months (P = 0.040). The most common diagnosis at previous endoscopy was an esophageal ulcer (48.2 % of investigations).Esophageal cancer may be missed at endoscopy in up to 7.8 % of patients who are subsequently diagnosed with cancer. Endoscopists should make a detailed examination of the whole esophageal mucosa to avoid missing subtle early cancers and lesions in the proximal esophagus. Patients with an esophageal cancer may be misdiagnosed as having a benign esophageal ulcer.

Introduction Nitrous oxide can improve patient experience during colonoscopy, and its rapid elimination minimises after effects and inconvenience. Despite its advantages, nitrous oxide is used infrequently in the UK. We sought to understand the reasons for its low use. Methods Colonoscopists within the English Bowel Cancer Screening Programme (BCSP) were invited to participate in a web-based survey assessing the availability, current practices and perceptions towards nitrous oxide. Respondents were able to select predefined answers or offer written responses. Free text responses were assessed using thematic analysis. Results The survey was completed by 68% of the English BCSP colonoscopists. Nitrous oxide was available to 73% of respondents but with considerable regional variation. Most colonoscopists rated the properties of nitrous oxide favourably and would use it if they had a colonoscopy themselves. Despite this, nearly half used it in less than 20% of examinations. 80% instruct patients to use nitrous oxide as required, and differences in how it was used in combination with intravenous sedation and analgesia were reported. Written responses suggest nitrous oxide is often used in the patients who are expected to have the least discomfort. Conclusions Most colonoscopists perceive that nitrous oxide is effective and reduces inconvenience and would use it themselves if they required a colonoscopy. Studies to improve patient selection and optimise the use of nitrous oxide would be of value.

Aim The centralisation of oesophago-gastric (O-G) cancer services in England was recommended in 2001, partly because of evidence for a volume-outcome effect for patients having surgery. This study investigated the changes in surgical services for O-G cancer and postoperative mortality since centralisation. Methods Patients with O-G cancer who had an oesophageal or gastric resection between April 2003 and March 2014 were identified in the national Hospital Episodes Statistics database. We derived information on the number of NHS trusts performing surgery, their surgical volume, and the number of consultants operating. Postoperative mortality was measured at 30 days, 90 days and 1 year. Logistic regression was used to examine how surgical outcomes were related to patient characteristics and organisational variables. Results During this period, 29 205 patients underwent an oesophagectomy or gastrectomy. The number of NHS trusts performing surgery decreased from 113 in 2003–04 to 43 in 2013–14, and the median annual surgical volume in NHS trusts rose from 21 to 55 patients. The annual 30 day, 90 day and 1 year mortality decreased from 7.4%, 11.3% and 29.7% in 2003–04 to 2.5%, 4.6% and 19.8% in 2013–14, respectively. There was no evidence that high-risk patients were not undergoing surgery. Changes in NHS trust volume explained only a small proportion of the observed fall in mortality. Conclusion Centralisation of surgical services for O-G cancer in England has resulted in lower postoperative mortality. This cannot be explained by increased volume alone.

Background Although conventional colonoscopy is the most accurate test available for the investigation of the colorectum for polyps, data exist that raise concerns about its sensitivity. Chromoscopy (spraying dye onto the surface of the colon to make polyps more visible) may be one way of enhancing the ability of colonoscopy to detect polyps, particularly diminutive flat lesions, which otherwise may be difficult to detect. Objectives To determine whether the use of chromoscopy enhances the detection of polyps and neoplasia during endoscopic examination of the colon and rectum. Search methods We searched the following databases: Cochrane Colorectal Cancer Group Specialised Register (October 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library; Issue 10, 2015), MEDLINE (January 1950 to October 2015), EMBASE (January 1974 to October 2015), and ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (both November 2015). We also handsearched abstracts from relevant meetings from 1980 to 2015. Search terms included 'randomised trials' containing combinations of the following: 'chromoscopy' 'colonoscopy' 'dye-spray' 'chromo-endoscopy' 'indigo-carmine' 'magnifying endoscopy'. Selection criteria We included all prospective randomised trials comparing chromoscopic with conventional endoscopic examination of the whole of the colon and rectum. We excluded studies of people with inflammatory bowel disease or polyposis syndromes and any studies that combined chromoscopy with additional interventions (cap assistance, water-perfused, etc.). Data collection and analysis Two review authors independently assessed the methodological quality of potentially eligible trials, and two review authors independently extracted data from the included trials. Outcome measures included the detection of polyps (neoplastic and non-neoplastic), the detection of diminutive lesions, the number of participants with multiple neoplastic lesions, and the extubation time. Main results We included seven trials (2727 participants) in this update. Five trials were of sufficiently similar design to allow for pooled results. Two trials differed substantially in design and were included in a subgroup analysis. All the trials had some methodological drawbacks. However, combining the results showed a significant difference in favour of chromoscopy for all detection outcomes. In particular, chromoscopy was likely to yield significantly more people with at least one neoplastic lesion (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.31 to 1.79; 7 trials; 2727 participants), and at least one diminutive neoplastic lesion (OR 1.51, 95% CI 1.19 to 1.92; 4 trials; 1757 participants). Significantly more people with three or more neoplastic lesions were also detected, but only when studies that used high-definition colonoscopy in the control group were excluded (OR 4.63, 95% CI 1.99 to 10.80; 2 trials; 519 participants). None of the included studies reported any adverse events related to the use of the contrast dye. Authors' conclusions There is strong evidence that chromoscopy enhances the detection of neoplasia in the colon and rectum. People with neoplastic polyps, particularly those with multiple polyps, are at increased risk of developing colorectal cancer. Such lesions, which presumably would be missed with conventional colonoscopy, could contribute to the interval cancer numbers on any surveillance programme.

Riboflavin (vitamin B2) is an essential dietary component with a known function in oxidative metabolism. Our previous data using a rat model of riboflavin deficiency suggested that riboflavin also functions as a luminal signaling molecule regulating crypt development and cell turnover. Riboflavin deficiency is prevalent in both high- and low-income countries across the globe. This study aims to establish whether riboflavin deficiency has consequences for gastrointestinal (GI) morphology in adults and what the effects and effectors of any such alteration may be. Duodenal biopsies and blood samples were collected from a cross-section of gastroscopy patients. Crypt morphology and cell division were studied by immunohistochemistry, and biochemical riboflavin status was determined. Additionally a cell culture model of riboflavin deficiency was developed and analyzed using a combination of flow cytometry, and microarray and clonogenic assays. Duodenal crypts from subjects in the lowest quartile of riboflavin status were significantly shorter (P = 0.023), less cellular (P = 0.007), and had fewer cell divisions (P = 0.034) than the crypts of subjects in the top quartile of riboflavin status. Following riboflavin depletion of colon cells in culture, cell cycle slowed. Microscopy revealed impaired mitosis and accumulation of aneuploid cells. Alterations in gene expression profiles reflected this alteration, with several mitosis-related genes altered, including AspM, cyclin B1, and Birc5 downregulated and Kif23 upregulated. Riboflavin depletion in vitro caused irreversible loss of proliferative potential of cells. Riboflavin depletion in adult humans impairs proliferation and proliferative potential of intestinal cells, which may have implications for gastrointestinal function.

Colonoscopy can be uncomfortable. To increase safety, there is a trend, in the UK, towards reduced sedative use. We aimed to determine factors predictive of discomfort during colonoscopy.Prospectively recruited patients were asked to grade anticipated discomfort on a Numeric Rating Scale ranging from 0 to 10. Discomfort scores were recorded every 2 min during the procedure and during peaks of discomfort. An overall discomfort score was recorded.One hundred and nine patients [44 male, 65 female; median 61.5 (21-80) years] were recruited. One hundred and three procedures were completed. Forty-five patients received midazolam [median 2 (1.5-5) mg]. Mean overall Numeric Rating Scale score was 4.7 (men 4.0; women 5.2; P0.01) and median peak score 7. Discomfort was usually greatest at the beginning of the procedure, while in the sigmoid colon. Discomfort scores were higher in patients with irritable bowel syndrome (P = 0.03); diverticular disease (P0.01); midazolam (P = 0.02), buscopan (P0.001) or nitrous oxide (P0.001) use; endoscope tracker use (P = 0.01); incomplete procedures (P0.001) or a preceding gastroscopy (P = 0.02), but were not correlated with discomfort during venous cannulation or digital rectal examination. Multivariate analysis showed that female sex, high anxiety, anticipation of high discomfort, longer intubation time and higher endoscopist's grade of procedural difficulty were independent factors significantly related to overall discomfort scores. Recollected discomfort scores 2-3 months later were lower (P0.01). Low-dose midazolam had no appreciable amnesic effect.Factors indicative of difficult colonoscopy, and preceding gastroscopy, are associated with greater discomfort, as are the presence of female sex, irritable bowel, anxiety and anticipated discomfort. Low-dose midazolam neither relieves discomfort nor makes patients forget it. Selected patients may benefit from increased analgesia.

Objectives: Palliative chemotherapy is routinely given to patients diagnosed with locally advanced or metastatic oesophagogastric (O-G) cancer. We examine which patients with O-G cancer in England receive palliative chemotherapy, and identify factors associated with treatment completion. Design: A prospective population-based observational study. Setting: All English National Health Service (NHS) trusts diagnosing patients with O-G cancer. Participants: Data were prospectively collected on patients diagnosed with invasive epithelial cancer of the oesophagus or stomach between 1 October 2007 and 30 June 2009 in English NHS hospitals, and those who had palliative treatment intent. Outcome measure: We calculated the proportion of patients with different characteristics (eg, age, sex, stage at diagnosis, performance status) starting palliative chemotherapy. Multiple logistic regression was used to identify characteristics associated with non-completion of chemotherapy. Results: There were 9768 patients in the study whose treatment intent was palliative. Among these, 2313 (24%) received palliative chemotherapy. It was received by 51% of patients aged under 55 years but only 9% of patients aged 75 years or over. Overall, 917 patients (53%) completed their treatment among the 1741 patients for whom information on treatment completion was recorded. Treatment completion ranged from 50–60% for patients with good performance status but was under 35% for patients aged 55 years or older with poor performance status. Treatment completion was not associated with site of cancer, pretreatment stage, sex, comorbidities or histology. Conclusions: Completion rates of palliative chemotherapy in patients with O-G cancer are low and elderly patients with poor performance status are very unlikely to complete a palliative chemotherapy treatment. Clinicians and patients should consider this information when balancing potential (survival) benefits, toxicity of treatment and its effect on quality of life.

Summary Background: Non-compliance with maintenance mesalazine therapy may be a risk factor for relapse in inflammatory bowel disease, but the prevalence and determinants of non-compliance are unknown. Aim: To study the prevalence and determinants of non-compliance in patients with inflammatory bowel disease. Methods: Out-patients receiving delayed-release mesalazine were studied. Compliance was determined by direct enquiry and by analysis of urine samples for 5-aminosalicylic acid/N-acetyl-5-aminosalicylic acid. Potential determinants of compliance were assessed. Results: Ninety-eight patients were studied. Forty-two patients (43%) reported taking

BACKGROUND AND STUDY AIMS Entonox is a 50 : 50 combination of nitrous oxide and oxygen, which may be used to manage pain during colonoscopy. The optimal mode of Entonox administration is unknown. The aim of this study was therefore to compare continuous and as-required Entonox use. PATIENTS AND METHODS Patients attending for screening colonoscopy at a single centre were randomized to continuous or as-required Entonox use. The primary outcome measure was the patient's overall pain rating at the time of discharge (verbally administered numerical ratings scale, 0=no pain and 10=extreme pain). Secondary outcome measures included the patients' experience of pain during the colonoscopy (rated every 2 min), side effects and the need for rescue intravenous medications. RESULTS A total of 108 patients were randomized, and 100 completed the study (46 continuous, 54 as required). The overall pain scores at discharge did not differ between those who used Entonox continuously and as required (mean=2.4 vs. 3.2, P=0.08). There were also no differences in the experience of pain during colonoscopy (mean=1.8 vs. 2.2, P=0.28; peak=4.2 vs. 4.8, P=0.26; and area under curve=23 vs. 30, P=0.24). Patients with high anxiety had greater overall pain scores (mean=3.7 vs. 2.4, P=0.03). Light headedness occurred more often with continuous Entonox use (48 vs. 21%, P=0.009). CONCLUSION Among patients attending for screening colonoscopy, comfort ratings were similar in those using Entonox continuously and as required, but light headedness was more common with continuous use (NCT identifier: 01865721).

Background and study aims: Capsule endoscopy is well tolerated but control of its movement is needed in order to visualize the whole gastric surface. Technological developments have produced an external magnet to allow manipulation of the capsule within the gastric cavity. The aim of this study was to compare magnetically steerable gastric capsule endoscopy (MSGCE) with flexible endoscopy for the detection of beads in a porcine stomach. Materials and methods: Beads were sewn onto the mucosal surface of 12 ex vivo porcine stomachs. Each model was examined by flexible endoscopy and MSGCE by two blinded investigators. MSGCE was performed according to a protocol using positional changes and magnetic steering. Outcome measures were number and location of beads identified, and duration of procedure. Results: Flexible endoscopy identified 79 /90 beads (88 %), and MSGCE identified 80 /90 (89 %). The difference in sensitivities was 1.11 (95 % confidence interval 0.06 – 28.26). Thus, MSGCE was noninferior to flexible endoscopy. Mean examination times for flexible endoscopy and MSGCE were 3.34 minutes and 9.90 minutes, respectively. Conclusion: MSGCE was equivalent to conventional flexible endoscopy in the detection of beads in a porcine stomach model.

Cold snare techniques are widely used for the removal of small and diminutive polyps. The influence of snare type on the effectiveness of cold snare polypectomy is unknown.Cold snare polypectomy of 3-7-mm polyps was undertaken using either a thin wire mini-snare (0.30 mm) or a thick wire mini-snare (0.47 mm). Primary outcome was endoscopic completeness of excision. Consensus regarding endoscopic assessment of completeness of excision was standardized and aided by chromoendoscopy. Secondary outcomes included: completeness of histological excision, polyp 'fly away', polyp retrieval rate, early or delayed bleeding and perforation.One hundred and fifty-seven polyps were removed ranging from 3 to 7 mm, 62% were situated in the left side of the colon and 89.4% were sessile. Endoscopic completeness of excision was significantly higher with the thin wire snare compared to the thick wire snare (90.2% vs 73.3%, P 0.05). There was a numerical trend towards a higher complete histological excision rate with the thin wire snare, but this did not reach statistical significance (73.3% vs 65.2%, P = 0.4). There was a fair level of agreement (kappa = 0.36) between endoscopic and histological completeness of excision. Polyp 'fly away' occurred less often with the thin wire snare (14.6% vs 35.3%, P = 0.002), but there was no significant difference in polyp retrieval rate (84.3% vs 83.8%, P = 0.94). There were no complications with either snare.Snare type appears to be an important determinant of completeness of excision when removing small polyps by the cold snare technique.

Background: Postprandial acid reflux is thought to be mediated by the increase in transient lower oesophageal sphincter relaxations (TLOSR) frequency and fall in lower oesophageal sphincter (LOS) pressure seen after ingestion of a meal. Studies in animals and healthy volunteers suggest that cholecystokinin (CCK) may play a role. Aim: To study the role of CCK in postprandial LOS function using the CCK antagonist loxiglumide. Subjects: 10 asymptomatic volunteers (7 male, 20–29 years) and 9 patients with symptomatic gastro-oesophageal reflux (4 male, 33–66 years). Methods: Oesophageal, LOS and gastric pressure and oesophageal pH readings were recorded for 1 h before and 2 h after intragastric infusion of a 200 kCal, 300 mL long chain triglyceride meal. Each subject underwent two studies and received intravenous loxiglumide or placebo infusion in randomized order. Results: During placebo infusion, postprandial LOS pressure fell [volunteers: 17 (9–31) to 7 (1–19) mmHg (P

Background: Delayed-release mesalazine is traditionally taken as three divided doses. However, it is well-recognized that dosing frequency has a significant impact on compliance and that once daily dosing is preferable. Methods: We measured serum, urinary, faecal and rectal tissue concentrations of 5-aminosalicylic acid and N-acetyl 5-aminosalicylic acid in 24 healthy volunteers following dosing with delayed-release mesalazine, 1.2 g or 2.4 g daily, given as either a single daily dose at 08:00 hours or in three divided doses at 08:00, 13:00 and 18:00 hours. Results: Urinary and faecal excretion and rectal tissue concentrations of 5-aminosalicylic acid and N-acetyl 5-aminosalicylic acid were similar following single or divided daily dosing, at both doses studied. Peak serum concentrations were found at 06:00–09:00 following divided dosing and at 17:00–20:00 following once daily dosing. However, peak and trough serum levels and serum area under curve values (AUC) were similar with both regimens and at both doses. Conclusions: Urinary, faecal and rectal tissue concentrations are similar following single or divided daily dosing. Minor differences in serum levels were apparent but maximum, minimum and AUC values were similar. Clinical trials should examine the efficacy and toxicity of once daily dosing in patients with ulcerative colitis.

Aims Tissue concentrations of 5-aminosalicylic acid (5ASA) and its metabolites may influence the clinical course of inflammatory bowel disease. Since the factors that determine tissue drug concentrations are unknown we have studied the relationships between the oral dose of delayed-release mesalazine, rectal tissue drug concentrations and standard pharmacokinetic parameters. Methods Twelve healthy volunteers were studied following 7 days treatment with 1.2, 2.4 and 4.8 g of delayed-release mesalazine daily. 5-aminosalicylic acid and N-acetyl 5-aminosalicylic acid concentrations were measured in serum, urine, stool and rectal tissue biopsies. Results Serum concentrations and 24 h urinary excretion of 5ASA and N-acetyl 5ASA increased as the oral dose of mesalazine was increased from 1.2 g through 2.4 g to 4.8 g daily (serum area under curve (AUC):5ASA = 3.9, 15.4 and 46.8 µg ml−1 h, P

Post-mortem studies in patients with achalasia reveal degenerative changes in the vagus and its dorsal motor nuclei suggesting the possibility of widespread autonomic dysfunction.To study a broad range of autonomic function in patients with achalasia and nutcracker oesophagus and in asymptomatic volunteers.Patients with a manometric diagnosis of achalasia and nutcracker oesophagus and age- and sex-matched asymptomatic volunteers.Subjects underwent measurement of: (1) pupil cycle time estimation; (2) heart rate response to the Valsalva manoeuvre, standing and deep breathing; (3) systolic blood pressure response to standing; (4) diastolic response to sustained handgrip; (5) spectral analysis of heart rate variability; and (6) heart rate and blood pressure during the Valsalva manoeuvre.No significant differences were found between patients with achalasia and asymptomatic volunteers. Patients with nutcracker oesophagus, however, had longer pupil cycle times (1.2 (0.9-1.4) s versus 0.9 (0.8-1.2) s, P= 0.02) and had attenuation of both the rise in the low frequency peak of heart rate variability and the fall in the high frequency peak on standing (rise in low frequency peak - patients 26.6 (10.4-52.3)% to 42.2 (15.5-54.0)%, P = 0.46, volunteers 16.9 (8.4-37.2)% to 47.4 (21.1-66.3)%, P = 0.03; fall in high frequency peak - patients 18.1 (0.9-43.3)% to 10.1 (0.5-26.6)%, P= 0.46, volunteers 24.8 (8.5-44.4)% to 9.3 (2.6-35.6)%, P= 0.03). The rise in blood pressure during the Valsalva manoeuvre was also attenuated in patients with nutcracker oesophagus compared with asymptomatic volunteers (6.9 (1.0-9.3) mmHg versus 12.9 (11 -23.0) mmHg, P0.01).Whereas tests of cardiovascular and pupillary autonomic function are normal in patients with achalasia, patients with nutcracker oesophagus show defects in both parasympathetic and sympathetic function.

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.

A patient with anaemia was initially thought to have gastrointestinal cancer and subsequently Crohn’s disease, but pathological examination revealed a much rarer condition.

Objective To investigate the relationship between the route to diagnosis, patient characteristics, treatment intent and 1 -year survival among patients with oesophagogastric (O-G) cancer. Setting Cohort study in 142 English NHS trusts and 30 cancer networks. Participants Patients diagnosed with O-G cancer between October 2007 and June 2009. Design Prospective cohort study. Route to diagnosis defined as general practitioner (GP) referral—urgent (suspected cancer) or non-urgent, hospital consultant referral, or after an emergency admission. Logistic regression was used to estimate associations and adjust for differences in casemix. Main outcome measures Proportion of patients diagnosed by route of diagnosis; proportion of patients selected for curative treatment; 1-year survival. Results Among 14 102 cancer patients, 66.3% were diagnosed after a GP referral, 16.4% after an emergency admission and 17.4% after a hospital consultant referral. Of the 9351 GP referrals, 68.8% were urgent. Compared to urgent GP referrals, a markedly lower proportion of patients diagnosed after emergency admission had a curative treatment plan (36% vs 16%; adjusted OR=0.62, 95% CI 0.52 to 0.74) and a lower proportion survived 1 year (43% vs 27%; OR 0.78; 95% CI 0.68 to 0.89). Urgency of GP referral did not affect treatment intent or survival. Routes to diagnosis varied across cancer networks, with the adjusted proportion of patients diagnosed after emergency admission ranging from 8.7 to 32.3%. Conclusions Outcomes for cancer patients are worse if diagnosed after emergency admission. Primary care and hospital services should work together to reduce rates of diagnosis after emergency admission and the variation across cancer networks.

Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines.From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy.Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P.001), ranging from 19.5% in patients aged65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P.001) or managed at higher-volume trusts (87.8% vs 55.4%; P.001).There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.

A 69-year-old man presented to bowel cancer screening after testing for faecal occult blood. Initial colonoscopy had been limited by a sigmoid stricture and a barium enema had revealed a suspicious mass in the corresponding area. He was referred for repeat colonoscopy, which showed a hard structure crossing the mid sigmoid colon, with both ends impacted into the bowel wall. A CT scan revealed what appeared to be a small bone impacted in a diverticulum with evidence of recent inflammation and a sealed perforation. The patient had recently been managed conservatively for an episode of diverticulitis at his local hospital but was currently asymptomatic. Owing to the possibility of future complications he underwent a laparoscopic sigmoid colectomy to remove the offending foreign body.

Background Butyrate has been implicated in the mechanistic basis of the prevention of colorectal cancer by dietary fibre. Numerous in vitro studies have shown that butyrate regulates cell cycle and cell death. More recently we have shown that butyrate also regulates the integrity of the intermediate filament (IF) cytoskeleton in vitro. These and other data suggest a link between the role of diet and the implication of a central role for the keratin 8 (K8) as guardian of the colorectal epithelium. Methods In this cross-sectional study possible links between butyrate levels, field effects and keratin expression in cancer were addressed directly by analysing how levels of expression of the IF protein K8 in tumours, in adjacent fields and at a distant landmark site may be affected by the level of butyrate in the colon microenvironment. An immunohistochemical scoring protocol for K8 was developed and applied to samples, findings were further tested by immunoblotting. Results Levels of K8 in colorectal tumours are lower in subjects with higher levels of faecal butyrate. Immunoblotting supported this finding.Although there were no significant relationships with butyrate on the non-tumour tissues, there was a consistent trend in all measures of extent or intensity of staining towards a reduction in expression with elevated butyrate, consistent with the inverse association in tumours. Conclusions The data suggest that butyrate may associate with down-regulation of the expression of K8 in the cancerized colon. If further validated these findings may suggest the chemopreventive value of butyrate is limited to early stage carcinogenesis as low K8 expression is associated with a poor prognosis.

Item does not contain fulltext BACKGROUND: Despite its ubiquitous use over the past 4 decades, there is no structured, formal method with which to assess polypectomy. OBJECTIVE: To develop and validate a new method with which to assess competency in polypectomy. DESIGN: Polypectomy underwent task deconstruction, and a structured checklist and global assessment scale were developed (direct observation of polypectomy skills [DOPyS]). Sixty bowel cancer screening polypectomy videos were randomly chosen for analysis and were scored independently by 7 expert assessors by using DOPyS. Each parameter and the global rating were scored from 1 to 4 (scores >/=3 = competency). The scores were analyzed by using generalizability theory (G theory). SETTING: Multicenter. RESULTS: Fifty-nine of the 60 videos were assessable and scored. The majority of the assessors agreed across the pass/fail divide for the global assessment scale in 58 of 59 (98%) polyps. For G-theory analysis, 47 of the 60 videos were analyzed. G-theory analysis suggested that DOPyS is a reliable assessment tool, provided that it is used by 2 assessors to score 5 polypectomy videos all performed by 1 endoscopist. DOPyS scores obtained in this format would reflect the endoscopist's competence. LIMITATIONS: Small sample and polyp size. CONCLUSIONS: This study is the first attempt to develop and validate a tool designed specifically for the assessment of technical skills in performing polypectomy. G-theory analysis suggests that DOPyS could reliably reflect an endoscopist's competence in performing polypectomy provided a requisite number of assessors and cases were used. 01 juni 2011

A new photoactive bis-anthracenyl crown undergoes a reversible photocyclisation to form a cryptand, with the efficiency of the forward reaction and the rate of the thermal reverse reaction strongly affected by the presence of cation substrates.

Background Oesophago-gastric cancer services in England have been extensively reorganised since 2001 to deliver a centralised, specialist-led service. Our aim was to assess how well the National Health Service (NHS) in England met organisational standards for oesophago-gastric cancer care. Methods Questionnaires that asked about the provision of staging investigations, curative and palliative treatments and key personnel were sent in September 2007 to the lead clinician for oesophago-gastric cancer at all 30 cancer networks and 156 NHS acute trusts in England. Results Responses were received from all networks and 81% of NHS trusts. All networks provided essential staging investigations and a range of endoscopic palliative therapies. Only 16 of the 30 cancer networks discussed all patients at the specialist multi-disciplinary team meeting and 11 networks had not fully centralised curative surgery. There was also variation between NHS trusts in the integration of the palliative care team, the availability of nurse specialists and the use of dieticians to provide nutritional support. Conclusion There has been considerable progress in reforming oesophago-gastric cancer services but the process of reorganisation is still incomplete and regional differences in service provision exist that may lead to variation in patient outcomes.

Background A number of studies, notably EPIC, have shown a descrease in colorectal cancer risk associated with increased fibre consumption. Whilst the underlying mechanisms are likely to be multifactorial, production of the short-chain fatty-acid butyrate fro butyratye is frequently cited as a major potential contributor to the effect. Butyrate inhibits histone deacetylases, which work on a wide range of proteins over and above histones. We therefore hypothesized that alterations in the acetylated proteome may be associated with a cancer risk phenotype in the colorectal mucosa, and that such alterations are candidate biomarkers for effectiveness of fibre interventions in cancer prevention. Methods an design There are two principal arms to this study: (i) a cross-sectional study (FACT OBS) of 90 subjects recruited from gastroenterology clinics and; (ii) an intervention trial in 40 subjects with an 8 week high fibre intervention. In both studies the principal goal is to investigate a link between fibre intake, SCFA production and global protein acetylation. The primary measure is level of faecal butyrate, which it is hoped will be elevated by moving subjects to a high fibre diet. Fibre intakes will be estimated in the cross-sectional group using the EPIC Food Frequency Questionnaire. Subsidiary measures of the effect of butyrate on colon mucosal function and pre-cancerous phenotype will include measures of apoptosis, apoptotic regulators cell cycle and cell division. Discussion This study will provide a new level of mechanistic data on alterations in the functional proteome in response to the colon microenvironment which may underwrite the observed cancer preventive effect of fibre. The study may yield novel candidate biomarkers of fibre fermentation and colon mucosal function. Trial Registration Trial Registration Number: ISRCTN90852168