Devices and methods to improve colonoscopy completion (with videos)

Efficacy of ScopeGuide-Assisted Training in Enhancing Colonoscopy Competence and Reducing Patient Discomfort

OBJECTIVE

In this study, we aimed to evaluate the efficacy of the Magnetic Scope Guide Assist (ScopeGuide) in enhancing the procedural competence of endoscopists and reducing patient discomfort during colonoscopy.

METHODS

This was a retrospective study with 88 trainee participants. The study participants were trained on patients who underwent colonoscopy without anesthesia. Both ScopeGuide-assisted training and conventional training (without ScopeGuide) were utilized for colonoscopy instruction. The outcomes of training were compared, with a particular emphasis on the competency of looping resolution.

RESULTS

ScopeGuide-assisted training was superior to conventional training in multiple aspects, including looping resolution ( Z =-3.681, P <0.001), pain scores ( Z =-4.211, P <0.001), time to reach the cecum ( Z =-4.06, P <0.001), willingness to undergo repeat colonoscopy ( Z =-4.748, P <0.001), competence of positional changes ( Z =-4.079, P <0.001), and the effectiveness of assisted compression ( Z =-3.001, P =0.003). Further stratified analysis revealed that the ScopeGuide-assisted training mode was more beneficial for junior endoscopists ( P <0.05 in all parameters) but not for intermediate endoscopists ( P >0.05) and partially beneficial for senior endoscopists ( P <0.05 for all parameters except looping resolution).

CONCLUSION

ScopeGuide-assisted training can significantly facilitate endoscopists in resolving loops and reducing patient pain, thereby enhancing their colonoscopy abilities.

Randomised controlled trials of non-pharmacological interventions to improve patient-reported outcomes of colonoscopy: a scoping review

BACKGROUND AND AIMS

Non-pharmacological interventions to improve patient-reported outcomes of colonoscopy may be effective at mitigating negative experiences and perceptions of the procedure, but research to characterise the extent and features of studies of these interventions is limited.

METHODS

We conducted a scoping review searching multiple databases for peer-reviewed publications of randomised controlled trials conducted in adults investigating a non-pharmacological intervention to improve patient-reported outcomes of colonoscopy. Study characteristics were tabulated and summarised narratively and graphically.

RESULTS

We screened 5939 citations and 962 full texts, and included 245 publications from 39 countries published between 1992 and 2022. Of these, 80.8% were full publications and 19.2% were abstracts. Of the 41.9% of studies reporting funding sources, 11.4% were unfunded. The most common interventions were carbon dioxide and/or water insufflation methods (33.9%), complementary and alternative medicines (eg, acupuncture) (20.0%), and colonoscope technology (eg, magnetic scope guide) (21.6%). Pain was as an outcome across 82.0% of studies. Studies most often used a patient-reported outcome examining patient experience during the procedure (60.0%), but 42.9% of studies included an outcome without specifying the time that the patient experienced the outcome. Most intraprocedural patient-reported outcomes were measured retrospectively rather than contemporaneously, although studies varied in terms of when outcomes were assessed.

CONCLUSION

Research on non-pharmacological interventions to improve patient-reported outcomes of colonoscopy is unevenly distributed across types of intervention and features high variation in study design and reporting, in particular around outcomes. Future research efforts into non-pharmacological interventions to improve patient-reported outcomes of colonoscopy should be directed at underinvestigated interventions and developing consensus-based guidelines for study design, with particular attention to how and when outcomes are experienced and measured.

PROSPERO REGISTRATION NUMBER

42020173906.

Upskilling Pediatric Ileocolonoscopy

Upskilling in ileocolonoscopy is an important aspect of pediatric endoscopic practice as it enables endoscopists to learn additional skills through education and training to improve outcomes. With the advent of technologies, endoscopy is continuously evolving. Many devices can be applied to improve endoscopy quality and ergonomics. In addition, techniques such as dynamic position change can be employed to increase procedural efficiency and completeness. Key to upskilling is enhancing endoscopists' cognitive, technical and nontechnical skills and the concept of "training the trainer" to ensure trainers have the requisite skills to teach endoscopy effectively. This chapter details aspects of upskilling pediatric ileocolonoscopy.

Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening

Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.

Massive Gastrointestinal Bleeding Due to Jejunal Diverticula in a Community Hospital: A Case Report and Review of Diagnostic and Therapeutic Options

Small bowel diverticula are rare and often asymptomatic. Severe lower gastrointestinal bleeding from jejunal diverticula is rarely reported and, therefore, should be considered a differential diagnosis in all cases of lower gastrointestinal bleeding with nonconclusive gastroscopy and colonoscopy. In this case report, we discuss a case of a 75-year-old male with massive lower gastrointestinal bleeding from jejunal diverticula. Initial gastroscopy did not reveal the source of bleeding. Repeat upper endoscopy with a pediatric colonoscope identified jejunal diverticula as the likely source of bleeding. Angiography identified the site of extravasation, and successful angioembolization was done by interventional radiology.

Endoscopic polypectomy devices

Video 1Use of submucosal injection prior to en-bloc endoscopic mucosal resection.Video 2Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

Magnetic endoscopic imaging as a rational investment for specific colonoscopies: a systematic review and meta-analysis

BACKGROUND

Magnetic endoscopic imaging (MEI) was regarded as an adjuvant device to improve procedural efficacy and patients' comfort during colonoscopy.

METHODS

Several electronic databases were searched to identify eligible studies. Based on the heterogeneity of included studies, random-effects or fixed-effects models were used to calculate pooled risk ratios (RR), risk difference (RD) or mean difference (MD) along with 95% confidence intervals (CIs).

RESULTS

Twenty-one randomized controlled trials (RCTs) were selected for meta-analysis, with a total of 7,060 patients. Although there is a slightly lower risk of cecal intubation failure with the adjuvant of MEI (RD 3%; P < 0.00001) compared to the control group, the updated studies show no significant benefits. Similarly, the cecal intubation time, pain scores, and loop formation with the adjuvant of MEI did not show any advantages. However, considerable significant benefits were found in the subgroup of technically difficult colonoscopy and inexperienced colonoscopists. Moreover, MEI was associated with lower loop intubation time, lower abdominal compression times, and better lesion localization.

CONCLUSION

The clinical benefits of MEI could be exaggerated. However, MEI has considerable advantages in technically difficult colonoscopies, the assistance for inexperienced colonoscopists, loop resolving, and lesion localization.

State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them

Colonoscopy is a safe and effective tool, but operator dependent. Room for improvement in the quality of colonoscopy is the impetus for the development and measurement of colonoscopy quality indicators and the focus of many efforts to improve colonoscopy quality indicator prevention and control in provider practices and health systems. We present the preprocedural, intraprocedural, and postprocedural quality indicators and benchmarks for colonoscopy. Every provider and practice must make a commitment to performing high-quality colonoscopy and implement and monitor quality metrics. There are a variety of tools available to assist in improving quality indicators that range from distal attachment devices to education and feedback. Although technology can help, it is not a substitute for proper technique. The commitment also requires provider feedback through audits and report cards. The impact of these efforts on patient outcomes is an important area of further research.

Diagnostic ileocolonoscopy: getting the basics right

Proficient colonoscopy technique that optimises patient comfort while simultaneously enhancing the timely detection of pathology and subsequent therapy is an aspirational and achievable goal for every endoscopist. This article aims to provide strategies to improve colonoscopy quality for both endoscopists and patients.

Meta-analysis of dye-based chromoendoscopy compared with standard- and high-definition white-light endoscopy in patients with inflammatory bowel disease at increased risk of colon cancer

BACKGROUND

Patients with ulcerative colitis have an increased risk of colorectal cancer. We sought to assess the comparative efficacy of standard white-light endoscopy (SDWLE) or high-definition white-light endoscopy (HDWLE) versus dye-based chromoendoscopy through a meta-analysis and rate the quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.

METHODS

A systematic review of the literature in PubMed, EMBASE, and Web of Science was performed in April 2018. The primary outcome was the number of patients in whom dysplasia was identified using a per patient analysis in randomized controlled trials (RCT) and analyzed separately for non-RCTs. Analysis was performed using RevMan 5.3 reporting random-effects risk ratios.

RESULTS

Of the 27,904 studies identified, 10 studies were included 6 of which were RCTs (3 SDWLE and 3 HDWLE). Seventeen percent (84/494) of patients were noted to have dysplasia using chromoendoscopy compared with 11% (55/496) with white-light endoscopy (relative risk [RR] 1.50; 95% confidence interval [CI], 1.08-2.10). When analyzed separately, chromoendoscopy (n = 249) was more effective at identifying dysplasia than SDWLE (n = 248) (RR, 2.12; 95% CI, 1.15-3.91), but chromoendoscopy (n = 245) was not more effective compared with HDWLE (n = 248) (RR, 1.36; 95% CI, 0.84-2.18). The quality of evidence was moderate. In non-RCTs, dysplasia was identified in 16% (114/698) of patients with chromoendoscopy compared with 6% (62/1069) with white-light endoscopy (RR, 3.41; 95% CI, 2.13-5.47). Chromoendoscopy (n = 58) was more effective than SDWLE (n = 141) for identification of dysplasia (RR, 3.52; 95% CI, 1.38-8.99), and chromoendoscopy (n = 113) was also more effective than HDWLE (n = 257) (RR, 3.15; 95% CI, 1.62-6.13). The quality of the evidence was very low.

CONCLUSION

Based on this meta-analysis, non-RCTs demonstrate a benefit of chromoendoscopy over SDWLE and HDWLE, whereas RCTs only show a small benefit of chromoendoscopy over SDWLE, but not over HDWLE.

Outcomes of use of electromagnetic guidance with responsive insertion technology (RIT) during colonoscopy: a prospective randomized controlled trial

Background and study aims  Colonoscopy can be technically challenging and cause discomfort in patients. The integrated Scope Guide assist is built in to show that with its use outcomes are improved during colonoscopy. We aimed to test the usefulness of the Magnetic Scope Guide Assist (ScopeGuide ) with respect to cecal intubation time, and other procedural quality outcomes. Patients and methods  We conducted a prospective study of outpatients undergoing elective colonoscopy at the endoscopic units of the University of Alabama at Birmingham (UAB) from March 2016 to July 2016. Patients were randomly assigned in a 1:1 block design to groups that either had standard colonoscopy or Scope-guided colonoscopy. The primary outcome measure was cecal intubation time (CIT). Secondary outcome measures included use of manual pressure, position changes for cecal intubation and sedation requirements. Results  Three hundred patients were randomized to either group; standard (n = 150) vs. Scope-guided (n = 150). The mean CIT was not statistically different for the standard and the Scope-guided groups (4.6 vs. 4.3 minutes; P  = 0.46). There were also no statistical differences in frequency of manual pressure applied (16.7 % for Scope-guided vs. 19.1 % for standard; P  = 0.65) or position changes (11.4 % for scope guided vs. 8.8 % standard; P  = 0.56). Sedation requirements showed lesser use of midazolam (3.9 mg vs. 4.7 mg, P  = 0.003) in the Scope-guide group, while there was no significant difference in use of fentanyl (fentanyl - 62.1 mg vs. 68.9 mg, P  = 0.09 similar between groups, for Scope-guided vs. standard groups, respectively). Adverse events were similar in both groups. Conclusions  In patients undergoing routine elective colonoscopy, use of ScopeGuide by experienced colonoscopists did not improve CIT or affect the frequency of ancillary maneuvers. The benefit of this device during training of endoscopists could be considered for further studies.

Salvage nitrous oxide cryotherapy of refractory colon neoplasia embedded within an endoclip

Background and study aims  This is a case report on use of the CryoBalloon as a salvage technique for ablation of residual neoplasia at an endoscopic mucosal resection site. The site contained an embedded clip that could not be removed at two different sessions by three experienced endoscopists. On follow-up endoscopy, the clips and residual polyp no longer remained. The subtle scar that was present was biopsied and confirmed complete eradication of neoplasia and no polyp tissue. This case shows the potential of the CryoBalloon to ablate unwanted tissue outside of the esophagus.

Training in Endoscopy

PURPOSE OF THE REVIEW

Progress towards the goal of high-quality endoscopy across health economies has been founded on high-quality structured training programmes linked to credentialing practice and ongoing performance monitoring. This review appraises the recent literature on training interventions, which may benefit performance and competency acquisition in novice endoscopy trainees.

RECENT FINDINGS

Increasing data on the learning curves for different endoscopic procedures has highlighted variations in performance amongst trainees. These differences may be dependent on the trainee, trainer and training programme. Evidence of the benefit of knowledge-based training, simulation training, hands-on courses and clinical training is available to inform the planning of ideal training pathway elements. The validation of performance assessment measures and global competency tools now also provides evidence on the effectiveness of training programmes to influence the learning curve. The impact of technological advances and intelligent metrics from national databases is also predicted to drive improvements and efficiencies in training programme design and monitoring of post-training outcomes. Training in endoscopy may be augmented through a series of pre-training and in-training interventions. In conjunction with performance metrics, these evidence-based interventions could be implemented into training pathways to optimise and quality assure training in endoscopy.