Assessment and improvement of access and quality in lower gastrointestinal endoscopy

Quality assurance in lower gastrointestinal endoscopy (LGE) is gaining increasing attention. Simultaneously, there is an increasing demand for LGE. The overall aims of this thesis were to identify methods of improving both the availability and the technical quality of LGE in the National Health Service, United Kingdom.This thesis attempts to bring some of these concepts together in a series of studies as listed below:Study 1: The aim of this study was to assess patient satisfaction with LGE, and to determine factors that affect patient satisfaction. A new patient satisfaction questionnaire was developed and internally validated. The most important factors affecting patient satisfaction in this study were the technical skills of the endoscopist and the degree of discomfort/ pain experienced by the patient. This study has also shown that there are no differences between medical, nurse and non-medical endoscopists in terms of patient satisfaction with lower gastrointestinal endoscopy. Based on this understanding of factors affecting patient satisfaction with LGE, we performed the following studies (2, 3, 4 and 5) to determine methods of assessing technical quality of LGE and the best sedative regimen to ensure higher patient satisfaction.Studies 2 and 3: The aims of these studies were to assess the technique of endoscopic clipping with follow up abdominal x-ray for objective validation of completion in colonoscopy and flexible sigmoidoscopy. Both studies have shown that this technique is useful not only for assessment of completion but also for validation of pathology miss rates in LGE. This is a proof of concept study and further validation against current standards would be required.Studies 4 and 5: These two randomised controlled trials were performed to determine the best sedative/analgesic regimen for colonoscopy. The first study has shown that Entonox is associated with better pain relief, faster recovery of psychomotor function and higher patient satisfaction, as compared to conventional intravenous sedation. The second study has shown that there is no difference between Entonox and Propofol sedation in terms of pain relief, recovery of function, and time to discharge and patient satisfaction. However, propofol sedation is more resource intensive and makes patient manoeuvring more difficult. A further conclusion from the subset analysis of these studies is that there is no difference between doctors, nurses and non-medical colonoscopists in terms of patient satisfaction, pain relief, time for procedure or discharge and recovery of function.Study 6: The aims of this study were to develop, train and validate artificial neural network (ANN) algorithms capable of accurately identifying individual patients attending routine colorectal clinics likely to have a positive diagnosis (cancer, polyp, or colitis) necessitating a lower gastrointestinal endoscopy. This study has shown that artificial neural networks offer the possibility of personal prediction of outcome for individual patients presenting in clinics with colorectal symptoms, making it possible to make more appropriate requests for lower gastrointestinal endoscopy

Anterior anal sphincter repair for fecal incontinence: Good longterm results are possible

Background: Anterior anal sphincter repair (ASR) is standard treatment for fecal incontinence resulting from an obstetrically damaged anal sphincter. Longterm results of repair have generally been shown to be poor. This review of single-unit series aimed to determine longterm outcomes of primary ASR for patients with fecal incontinence from obstetrically damaged anal sphincter. Study design: This study included patients undergoing ASR from 1995 to 1999. We perform standard overlapping ASR, but external and internal sphincters are repaired separately. The internal sphincter is sutured by direct method and only if damaged. Telephone interview was conducted with all patients, after which questionnaires, including SF-36 survey, Fecal Incontinence Quality of Life Scale questions, and Wexner score-type questions, were sent at median followup of 7 years. Demographic data, anorectal physiology, and data on short-term followup (median 12 months) were prospectively collected. Results: Sixty-four of 72 patients returned questionnaires and the operation was considered a success in 80% of patients at median followup of 84 months. Six patients underwent additional procedures for incontinence and 58 patients were analyzed. Fourteen patients reported complete continence to stool and flatus (20%). Continence had improved from median Wexner score of 14 to 7 (p < 0.001). Ninety-five percent of patients were satisfied with their operation. There was substantial improvement in all aspects of Fecal Incontinence Quality of Life Scale questionnaire and SF-36. None of the anorectal physiology variables were of value in predicting outcomes. Conclusions: We have shown that good longterm results can be achieved with anterior anal sphincter repair. The independent muscle repair technique could explain the improved outcomes. © 2007 American College of Surgeons

Non-medical colonoscopy

Aims: There is increasing demand for colonoscopy especially with introduction of screening programmes. Though colonoscopy is performed by doctors and nurses, there is an acute shortage of trained colonoscopist

Quality assurance in flexible sigmoidoscopy: Medical and nonmedical endoscopists

Purpose: The clinical assessment of position in colon and hence completion during flexible sigmoidoscopy (FS) is believed to be inaccurate. The technique of applying endomucosal clips with follow-up X-ray has previously been used for establishing completion in colonoscopy. Furthermore, we have now trained non-healthcare professionals (non-medical endoscopists, NME) to perform FS, but there is no data on assessment of their performance of FS. We performed this study with the aims of determining accuracy of endoscopists' clinical impression regarding actual position of endoscope in colon during FS, comparing medical (ME) and NME in terms of clinical accuracy, and to determine role of endomucosal clips with follow-up X-rays in documenting completion and hence quality assurance. Methods: All patients undergoing elective FS, except those with surgical resection, were included, after ethics approval. During FS, endoscopist applied an endomucosal clip at most proximal bowel reached and endoscopists recorded their independent opinion about position of clip. Post procedure, all patients underwent an abdominal X-ray, reported by consultant radiologist, blinded to outcome of FS. X-ray results were compared with endoscopist findings. Complete FS was defined as one where descending colon was reached. Results: Fifty-one patients, with median age of 55 years, participated in study. The endoscopists were accurate in their assessment of position in colon in 38 patients (75%). The attending nurse was accurate in only 31% of cases. The crude and corrected completion rates were 73% and 84%, respectively. There was no correlation between length of endoscope and its position in colon. There were no differences between NME and ME in terms of clinical accuracy. Conclusion: This study has shown that clinical impression of endoscopist during FS regarding position is not very accurate, implying need for regular quality assurance. The technique of applying endomucosal clips with follow-on abdominal X-ray is an excellent objective measure of quality assurance in FS. NME can perform FS with comparable completion rates and accuracy. © 2009 Springer Science+Business Media, LLC

Randomised controlled trial of sedation for colonoscopy: Entonox versus intravenous sedation

Introduction: Intravenous sedation for colonoscopy is associated with cardio-respiratory complications, delayed recovery and prolonged drowsiness. We aimed to determine whether inhaled Entono

Predictive Factors and Risk Model for Positive Circumferential Resection Margin Rate after Transanal Total Mesorectal Excision in 2653 Patients with Rectal Cancer

The aim of this study was to determine the incidence of, and preoperative risk factors for, positive circumferential resection margin (CRM) after transanal total mesorectal excision (TaTME). Background: TaTME has the potential to further reduce the rate of positive CRM for patients with low rectal cancer, thereby improving oncological outcome. Methods: A prospective registry-based study including all cases recorded on the international TaTME registry between July 2014 and January 2018 was performed. Endpoints were the incidence of, and predictive factors for, positive CRM. Univariate and multivariate logistic regressions were performed, and factors for positive CRM were then assessed by formulating a predictive model. Results: In total, 2653 patients undergoing TaTME for rectal cancer were included. The incidence of positive CRM was 107 (4.0%). In multivariate logistic regression analysis, a positive CRM after TaTME was significantly associated with tumors located up to 1 cm from the anorectal junction, anterior tumors, cT4 tumors, extra-mural venous invasion (EMVI), and threatened or involved CRM on baseline MRI (odds ratios 2.09, 1.66, 1.93, 1.94, and 1.72, respectively). The predictive model showed adequate discrimination (area under the receiver-operating characteristic curve &gt;0.70), and predicted a 28% risk of positive CRM if all risk factors were present. Conclusion: Five preoperative tumor-related characteristics had an adverse effect on CRM involvement after TaTME. The predicted risk of positive CRM after TaTME for a specific patient can be calculated preoperatively with the proposed model and may help guide patient selection for optimal treatment and enhance a tailored treatment approach to further optimize oncological outcomes