Colorectal cancer (CRC) occurring after a negative colonoscopy is called a post-colonoscopy colorectal cancer (PCCRC). Until recently, it has been difficult to compare global performance due to different methods used to define PCCRC rates. In 2018, the World Endoscopy Organization (WEO) standardised the methodology to calculate unadjusted PCCRC-3yr rates (PCCRC-3yr). The PCCRC-3yr is a "false-negative" rate of CRC diagnosed by colonoscopy. A recent systematic review investigated PCCRC-3yr rates but included studies outside the WEO's methodology. Therefore, the true global prevalence of PCCRC as per the WEO methodology remains unknown.
Methods
We searched six databases for studies calculating the PCCRC-3yr rate using the WEO methodology. We performed a systematic review and meta-analysis to calculate the global PCCRC prevalence, change in prevalence over time and associated characteristics.
Results
Our search identified 4 studies reporting 13,791 cases of PCCRC. The pooled PCCRC prevalence is 7.5% (95% CI=6.6-8.4%) with high heterogeneity observed (I2 = 98%, p<0.001)(Figure 1). Compared to the combined baseline year category of 2011-12, the odds of PCCRC occurrence were significantly higher in 2008 – 2010 (OR 1.12 (95% CI =1.01–1.24), p=0.03) and 2004 – 2007 (OR 1.19, 95% CI =1.06-1.33, p=0.03) for three studies combined with high heterogeneity. Patients with inflammatory bowel diseases (IBD) had a pooled PCCRC-3yr rate of 29.3% (95% CI =21.3 – 38.1%), 6-times the odds than those without (OR 6.17, 95% CI =1.06-1.33) based on three studies combined with high heterogeneity. The pooled PCCRC-3yr rate in the right colon (two studies) was 8.6% (95% CI =8.3 – 8.8%), 50% higher than those with disease in the left colon (OR 1.51, 95% CI =1.41-1.61).
Conclusions
The global pooled PCCRC prevalence was 7.5%. Encouragingly, the results show a reduction in the PCCRC-3yr rate over time. We also identified that IBD patients have over 6 times higher odds than those without for developing a PCCRC.
PCCRC rate is a key quality indicator of colonoscopy. The Word Endoscopy Organisation has reached consensus agreement to use one method for calculating 3 year PCCRC rates (termed PCCRC-3 y) to enable benchmarking of rates.1 This methodology, used previously by Morris et al.2, showed a PCCRC-3 y rate of 8.6% across the English National Health Service (NHS) from 2001–2007.2 with a rate of 7.3% in 2007. This study aimed to determine the rate of PCCRC-3 y in the English NHS Bowel Cancer Screening Programme (BCSP).
Methods
Data from each colonoscopy in the BCSP is entered into a national database, the Bowel Cancer Screening System. All colorectal adenocarcinomas, within and outside the BCSP, are validated and registered by the National Cancer Registration and Analysis Service. This retrospective observational study interrogated these databases to identify those BCSP colonoscopies detecting colorectal cancers within 6 months (true positive colonoscopies) and those BCSP colonoscopies in patients who subsequently developed a colorectal cancer 6 months – 3 years after the colonoscopy (false negatives) between 2006 and 2013.
Conclusions
The overall English NHS BCSP PCCRC–3 y rate from 2006–2010 is 3.1% – less than half the 7.3% PCCRC rate seen in the symptomatic English NHS for 2007, providing further evidence that high quality colonoscopy, such as that performed by screening–accredited colonoscopists in the BCSP, results in a lower rate of PCCRC.3 4 Despite the high quality of colonoscopy in the BCSP, PCCRCs still occur, showing the importance of vigilance during all colonoscopies. Diagnosis of >2000 colorectal cancers (true positive colonoscopies) each year indicates there is an adequate sample size for annual reporting of PCCRC–3 y rate within the BCSP and comparison with PCCRC–3 yr rates in symptomatic services.
References
1. Beintaris I, et al. United European Gastroenterology Journal 5(5_Suppl):PO436. 2. Morris EJA et al. Gut 2014;0:1–9. 3. Corley DA, et al. N Engl. J Med 2014;370:1298–306. 4. Kaminski MF, et al. N Engl. J Med 2010;362:1795–803.
Introduction Successful negotiation of the splenic flexure (SF) during colonoscopy is essential in achieving caecal intubation. Our aim was to assess patient characteristics and colonoscopic manoeuvres (CM) that facilitate insertion through and beyond the SF. Method We conducted a prospective observational study of colonoscopies performed within 2 high volume national training centres in the United Kingdom (UK) where the average caecal intubation rate is 97%. All colonoscopists were certified for colonoscopy within the UK. Data was collected on a pro-forma which was completed by the colonoscopist or an assistant, during or post colonoscopy. Patient sex, age, body mass index (BMI-kg/m²), history of past major abdominal surgery and sedation used were documented. Magnetic endoscope imager (ScopeGuide, Olympus Medical Systems Corporation, Japan) was used for all procedures to determine scope and tip position at the SF. CM employed, patient position, time and success at each SF pass attempt was recorded. The CM that were recorded included, breath in and hold, mid/lower abdominal pressure, left upper quadrant/flank pressure, slowing down, suction and tip deangulation. Results 10 colonoscopists recorded data on 158 colonoscopies. 140 (88.6%) of these were performed by Gastroenterologists. 43 (27.2%) colonoscopies were unsedated. No patients had more than 3 mg Midazolam or 100mcg Fentanyl. 123 (77.8%) initial attempts at splenic flexure (SF) passes were successful. Of these successful SF passes, the scope stiffener was used in 81 (65.8%) patients. 76 (61.8%) patients were supine and 31 (25.2%) were in the right lateral position. Additional CM was not used in 84 (68.2%) of these patients. Specific slowing of the scope insertion was the most common CM used for successful 1 st pass and was used in 21 (17.1%) patients. Patients with a BMI >30 kg/m² (obese) were more likely to require >1 attempt at negotiation of the SF compared to BMI Conclusion Patient satisfaction and comfort are essential, especially where no or minimal sedation is used in colonoscopy. Left upper quadrant pressure can aid passage through the SF in obese patients. Further studies are needed to determine the optimal patient positions and CM to facilitate comfortable, effective and efficient colonoscopy. Disclosure of Interest None Declared
The number of colonoscopies required to reach competency is not well established. Nevertheless, a minimal number forms part of UK certification criteria. The Cusum technique is a statistical analysis of sequential data to determine if a process is ‘in control’. The Joint Advisory Group on GI Endoscopy have developed an e-portfolio for users to record their endoscopic experience. The primary aim of this study was to determine the range of experience required by individuals to attain a caecal intubation rate (CIR) ≥90%, as defined by Cusum. A secondary aim was to assess which training factors are associated with attaining competence.
Methods
Inclusion criteria were all e-portfolio users who had performed ≤50 (‘baseline’) colonoscopies prior to submission of data to the e-portfolio; termed ‘trainees’. All colonoscopy records for the trainees were retrieved from the e-portfolio database and learning curve-Cusum analysis was performed. This analysis of colonoscopy completion reports the number of procedures required for CIR performance to reach ≥90%. A colonoscopy was defined complete if the caecum or ileum was reached and was performed without assistance. Trainees who had attained a CIR≥90% were compared to those with a CIR < 90% for differences in previous endoscopic experience, case volume and other trainee factors by univariate (Mann-Whitney, Chi-squared) and multivariate (binomial logistic regression) analysis.
Results
The e-portfolio contained 169,515 colonoscopy records entered by 1,572 different users. 265 users (‘trainees’) were confirmed to have performed ≤50 baseline colonoscopies and were included in subsequent analyses. By Cusum method, 39 trainees attained a CIR≥90%; 226 achieved a CIR < 90%. For those trainees with over 250 procedures, only 47% attained a CIR≥90%. Factors associated with attaining CIR≥90% were high number of procedures (P < 0.01), high number of colonoscopies per month (P < 0.01), and prior experience of more than 100 sigmoidoscopies (P = 0.017) by univariate and multivariate analysis. Nurse endoscopists attained competency at a higher rate than gastroenterology or surgical trainees by univariate (P = 0.01) but not multivariate analysis.
Conclusion
This is the largest study to date by both procedure and trainee numbers assessing colonoscopy competency by Cusum method. Trainees achieve competency at different rates. A high proportion of trainees will not attain a CIR > 90% even after 250 procedures. High case volume and prior sigmoidoscopy experience are associated with a CIR > 90%. The potential of both these factors to influence the attainment of competency should be exploited within endoscopy training programmes.
This article reviews a number of advances in small intestinal motility that are of particular interest to clinicians. New methods involve studying relationships between contractions and transit and between luminal distension, tone, and sensation. Interactions between brain and gut are helping us understand how hypnosis helps alleviate symptoms, and treatment of transit failure with pacing or transplantation seems much more feasible than ever before. There is now evidence that duodenal ulcer disease is due to a motility disorder after all, and there are reports of prokinetic drugs that may eventually be used to treat it.
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