Anticipating implementation of colorectal cancer screening in The Netherlands: a nation wide survey on endoscopic supply and demand

Faecal immunochemical tests can improve colonoscopy triage in patients with iron deficiency: A systematic review and meta-analysis

BACKGROUND

Use of the faecal immunochemical test (FIT) to triage patients with iron deficiency (ID) for colonoscopy due to suspected colorectal cancer (CRC) may improve distribution of colonoscopic resources. We reviewed the diagnostic performance of FIT for detecting advanced colorectal neoplasia, including CRC and advanced pre-cancerous neoplasia (APCN), in patients with ID, with or without anaemia.

METHODS

We performed a systematic review of three databases for studies comprising of patients with ID, with or without anaemia, completing a quantitative FIT within six months prior to colonoscopy, where test performance was compared against the reference standard colonoscopy. Random effects meta-analyses determined the diagnostic performance of FIT for advanced colorectal neoplasia.

RESULTS

Nine studies were included on a total of n=1761 patients with ID, reporting FIT positivity thresholds between 4-150 µg haemoglobin/g faeces. Only one study included a non-anaemic ID (NAID) cohort. FIT detected CRC and APCN in ID patients with 90.7 % and 49.3 % sensitivity, and 81.0 % and 82.4 % specificity, respectively. FIT was 88.0 % sensitive and 83.4 % specific for CRC in patients with ID anaemia at a FIT positivity threshold of 10 µg haemoglobin/g faeces.

CONCLUSIONS

FIT shows high sensitivity for advanced colorectal neoplasia and may be used to triage those with ID anaemia where colonoscopic resources are limited, enabling those at higher risk of CRC to be prioritised for colonoscopy. There is a need for further research investigating the diagnostic performance of FIT in NAID patients.

The optimal use of colon capsule endoscopes in clinical practice

Colon capsule endoscopy (CCE) has been available for nearly two decades but has grappled with being an equal diagnostic alternative to optical colonoscopy (OC). Due to the COVID-19 pandemic, CCE has gained more foothold in clinical practice. In this cutting-edge review, we aim to present the existing knowledge on the pros and cons of CCE and discuss whether the modality is ready for a larger roll-out in clinical settings. We have included clinical trials and reviews with the most significant impact on the current position of CCE in clinical practice and discuss the challenges that persist and how they could be addressed to make CCE a more sustainable imaging modality with an adenoma detection rate equal to OC and a low re-investigation rate by a proper preselection of suitable populations. CCE is embedded with a very low risk of severe complications and can be performed in the patient's home as a pain-free procedure. The diagnostic accuracy is found to be equal to OC. However, a significant drawback is low completion rates eliciting a high re-investigation rate. Furthermore, the bowel preparation before CCE is extensive due to the high demand for clean mucosa. CCE is currently not suitable for large-scale implementation in clinical practice mainly due to high re-investigation rates. By a better preselection before CCE and the implantation of artificial intelligence for picture and video analysis, CCE could be the alternative to OC needed to move away from in-hospital services and relieve long-waiting lists for OC.

Dedicated staff for patient education improves bowel preparation quality and reduces the cecal intubation time of colonoscopy: A single institution retrospective study

Adequate bowel preparation is an essential part of a high-quality colonoscopy. Recent studies showed that the small-volume bowel cleansing agent Bowklean performs better in terms of tolerability and acceptability. However, its split-dose regimen is sometimes confusing to the patient. To promote Bowklean in Fu Jen Catholic University Hospital, dedicated staff for patient education on bowel preparation were provided by Universal Integrated Corporation (Taiwan), but not in every period because of the clinic room availability and manpower capacity. This provided us an opportunity to compare the quality of colonoscopy between those with and without the dedicated patient education. This study aimed to compare various quality indices between the two groups. We set bowel preparation quality as the primary endpoint, assessed by modified Aronchick scale, and other quality indices including procedure time and adenoma detection rate as the secondary endpoints. We performed a single institution retrospective study. All patients who received colonoscopy from an outpatient setting with Bowklean as the bowel cleansing agent from October 2020 to November 2020 were reviewed. Primary and secondary endpoints were then compared between the conventional group and the dedicated staff group, with StataSE 14 by Wilcoxon rank sum test or logistic regression. Four hundred ten patients were recruited, including 217 patients with dedicated patient education and 193 without. The proportion of bowel preparation quality "Excellent + Good + Fair" was significantly higher in dedicated staff group than conventional group (97.7% vs 93.3%, P = .03; logistic regression coefficient = 1.12). The cecal intubation time was significantly shorter in the dedicated staff group (3.68 ± 2.02 minutes vs 4.52 ± 3.25 minutes, P < .01). After excluding those with polypectomy or biopsy, the total procedure time tended to be shorter in the dedicated staff group (10.2 ± 3.35 minutes vs 9.40 ± 2.43 minutes, P = .06). There was no significant difference regarding adenoma detection rate between the two groups. Our study shows that patient education by dedicated staff can improve bowel preparation quality and has the potential to decrease procedure time. Further large-scale prospective trials are still needed to evaluate if it can also achieve a better adenoma detection rate.

Gastrointestinal endoscopy capacity in Eastern Africa

Background and study aims  Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity. Patients and methods  In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020. Results  Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services. Conclusions  Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.

National Data Analysis and Systematic Review for Human Resources for Cervical Cancer Screening in Japan

BACKGROUND

Although cervical cancer screening has been performed as a national program since 1983 in Japan, the participation rate has remained below 20%. Equity of access is a basic requirement for cancer screening. However, taking smears from the cervix has been limited to gynecologists or obstetricians in Japan and it might be a barrier for accessibility. We examined the current access and its available human resources for cervical cancer screening in Japan.

METHODS

We analyzed the number of gynecologists and obstetricians among 47 prefectures based on a national survey. A systematic review was performed to clarify disparity and use of human resources in cervical cancer screening, diagnosis, and treatment for cervical cancers in Japan. Candidate literature was searched using Ovid-MEDLINE and Ichushi-Web until the end of January 2020. Then, a systematic review regarding accessibility to cervical cancer screening was performed. The results of the selected articles were summarized in the tables.

RESULTS

Although the total number of all physicians in Japan increased from 1996 to 2016, the proportion of gynecologists and obstetricians has remained at approximately 5% over the last 2 decades. 43.6% of municipalities have no gynecologists and obstetricians in 2016. Through a systematic review, 4 English articles and 1 Japanese article were selected. From these 5 articles, the association between human resources and participation rates in cervical cancer screening was examined in 2 articles.

CONCLUSIONS

The human resources for taking smears for cervical cancer screening has remained insufficient with a huge disparity among municipalities in Japan. To improve accessibility for cervical cancer screening another option which may be considered could be involving general physicians as potential smear takers.

Impact of the COVID-19 pandemic on faecal immunochemical test-based colorectal cancer screening programmes in Australia, Canada, and the Netherlands: a comparative modelling study

BACKGROUND

Colorectal cancer screening programmes worldwide have been disrupted during the COVID-19 pandemic. We aimed to estimate the impact of hypothetical disruptions to organised faecal immunochemical test-based colorectal cancer screening programmes on short-term and long-term colorectal cancer incidence and mortality in three countries using microsimulation modelling.

METHODS

In this modelling study, we used four country-specific colorectal cancer microsimulation models-Policy1-Bowel (Australia), OncoSim (Canada), and ASCCA and MISCAN-Colon (the Netherlands)-to estimate the potential impact of COVID-19-related disruptions to screening on colorectal cancer incidence and mortality in Australia, Canada, and the Netherlands annually for the period 2020-24 and cumulatively for the period 2020-50. Modelled scenarios varied by duration of disruption (3, 6, and 12 months), decreases in screening participation after the period of disruption (0%, 25%, or 50% reduction), and catch-up screening strategies (within 6 months after the disruption period or all screening delayed by 6 months).

FINDINGS

Without catch-up screening, our analysis predicted that colorectal cancer deaths among individuals aged 50 years and older, a 3-month disruption would result in 414-902 additional new colorectal cancer diagnoses (relative increase 0·1-0·2%) and 324-440 additional deaths (relative increase 0·2-0·3%) in the Netherlands, 1672 additional diagnoses (relative increase 0·3%) and 979 additional deaths (relative increase 0·5%) in Australia, and 1671 additional diagnoses (relative increase 0·2%) and 799 additional deaths (relative increase 0·3%) in Canada between 2020 and 2050, compared with undisrupted screening. A 6-month disruption would result in 803-1803 additional diagnoses (relative increase 0·2-0·4%) and 678-881 additional deaths (relative increase 0·4-0·6%) in the Netherlands, 3552 additional diagnoses (relative increase 0·6%) and 1961 additional deaths (relative increase 1·0%) in Australia, and 2844 additional diagnoses (relative increase 0·3%) and 1319 additional deaths (relative increase 0·4%) in Canada between 2020 and 2050, compared with undisrupted screening. A 12-month disruption would result in 1619-3615 additional diagnoses (relative increase 0·4-0·9%) and 1360-1762 additional deaths (relative increase 0·8-1·2%) in the Netherlands, 7140 additional diagnoses (relative increase 1·2%) and 3968 additional deaths (relative increase 2·0%) in Australia, and 5212 additional diagnoses (relative increase 0·6%) and 2366 additional deaths (relative increase 0·8%) in Canada between 2020 and 2050, compared with undisrupted screening. Providing immediate catch-up screening could minimise the impact of the disruption, restricting the relative increase in colorectal cancer incidence and deaths between 2020 and 2050 to less than 0·1% in all countries. A post-disruption decrease in participation could increase colorectal cancer incidence by 0·2-0·9% and deaths by 0·6-1·6% between 2020 and 2050, compared with undisrupted screening.

INTERPRETATION

Although the projected effect of short-term disruption to colorectal cancer screening is modest, such disruption will have a marked impact on colorectal cancer incidence and deaths between 2020 and 2050 attributable to missed screening. Thus, it is crucial that, if disrupted, screening programmes ensure participation rates return to previously observed rates and provide catch-up screening wherever possible, since this could mitigate the impact on colorectal cancer deaths.

FUNDING

Cancer Council New South Wales, Health Canada, and Dutch National Institute for Public Health and Environment.

High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study

OBJECTIVE

Increasing numbers of outbreaks caused by contaminated duodenoscopes used for Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures have been reported, some with fatal outcomes. We conducted a nationwide cross-sectional study to determine the prevalence of bacterial contamination of reprocessed duodenoscopes in The Netherlands.

DESIGN

All 73 Dutch ERCP centres were invited to sample ≥2 duodenoscopes using centrally distributed kits according to uniform sampling methods, explained by video instructions. Depending on duodenoscope type, four to six sites were sampled and centrally cultured. Contamination was defined as (1) any microorganism with ≥20 colony forming units (CFU)/20 mL (AM20) and (2) presence of microorganisms with gastrointestinal or oral origin, independent of CFU count (MGO).

RESULTS

Sixty-seven out of 73 centres (92%) sampled 745 sites of 155 duodenoscopes. Ten different duodenoscope types from three distinct manufacturers were sampled including 69 (46%) Olympus TJF-Q180V, 43 (29%) Olympus TJF-160VR, 11 (7%) Pentax ED34-i10T, 8 (5%) Pentax ED-3490TK and 5 (3%) Fujifilm ED-530XT8. Thirty-three (22%) duodenoscopes from 26 (39%) centres were contaminated (AM20). On 23 (15%) duodenoscopes MGO were detected, including Enterobacter cloacae, Escherichia coli, Klebsiella pneumonia and yeasts. For both definitions, contamination was not duodenoscope type dependent (p values: 0.20 and higher).

CONCLUSION

In 39% of all Dutch ERCP centres, at least one AM20-contaminated patient-ready duodenoscope was identified. Fifteen per cent of the duodenoscopes harboured MGO, indicating residual organic material of previous patients, that is, failing of disinfection. These results suggest that the present reprocessing and process control procedures are not adequate and safe.

Volume of surgery for benign colorectal polyps in the last 11 years

BACKGROUND AND AIMS

Traditionally large, complex colorectal polyps were managed by surgical resection (SR), and in recent years endoscopic resection (ER) has progressed significantly. However, to what extent ER has replaced SR remains largely unknown. We performed a multicenter retrospective cohort study to assess the volume and volume changes of SR for benign colorectal polyps over the past decade.

METHODS

Patients who underwent SR for a benign colorectal polyp in the Netherlands between 2005 and 2015 were selected from the prospective nationwide Dutch Pathology Registry (PALGA database). Clinical characteristics were obtained from the charts of patients who underwent SR in the province of Noord-Holland.

RESULTS

A total of 5937 patients were treated with SR for a colorectal polyp and the absolute (454-739 per year) and relative volumes (0.20%-0.37% per colonoscopy per year) of SR remained stable. In the province of Noord-Holland, 928 patients (15.6%) underwent SR. In these patients, submucosal lifting and ER were attempted in 19.9% (n = 175) and 15.0% (n = 134). After 2010, patients were more likely to undergo lifting (27.7% vs 11.4%, P < .001) and ER attempts (18.8% vs 10.9%, P = .001) before definitive SR. Twenty-two patients (2.4%) had been referred to another endoscopy clinic.

CONCLUSIONS

SR for large, complex colorectal polyps is still frequently performed and has remained stable. A small percentage of patients underwent ER attempts before SR, and referral for an additional ER attempt only occurred in a minority of cases. To increase ER attempts, implementation of a regional multidisciplinary referral network should be considered.

Extent of unnecessary surgery for benign rectal polyps in the Netherlands

BACKGROUND AND AIMS

Minimally invasive techniques are available to safely and efficaciously remove even the largest rectal polyps. This study aimed to investigate the magnitude of cases still referred for radical rectal surgery and the reasons for these referrals and to perform a re-evaluation of cases potentially suitable for endoscopic therapy.

METHODS

A retrospective analysis of data from the Dutch Pathology Registry (Pathologic Anatomic Nationwide Automated Archive) was performed using the records of patients who underwent major surgical treatment for a histologically proven benign rectal polyp between 2005 and 2014 in the Netherlands. In a representative subset of 7 hospitals, detailed analysis was performed. An expert panel of 3 endoscopists reassessed all patient data to judge whether endoscopic treatment would have been a reasonable alternative.

RESULTS

In the last decade 575 patients, and 56 patients in the subset of hospitals, were referred for major rectal surgery for a benign rectal polyp in the Netherlands. The number of radical resections declined over the years but stabilized in the last years. The main reasons for surgery were polyp size (34%), suspicion of malignancy (34%), and transanal endoscopic microsurgery failures (20%). In community hospitals, referrals for surgery were relatively more prevalent compared with academic hospitals (P < .01). Thirty-nine percent of patients had perioperative adverse events, and 1 patient (1.8%) died. Seventy-three percent of cases were assessed as "probably feasible" for endoscopic therapy.

CONCLUSIONS

Over the last 10 years the rate of radical rectal surgery for a benign polyp declined. However, a significant subgroup of patients was still referred for invasive surgery at the cost of high morbidity and mortality. Referral to an expert endoscopist may avoid unnecessary surgery in most cases.

The Diagnostic Yield of Colonoscopy Stratified by Indications

Introduction

Danish centers reserve longer time for screening colonoscopies and allocate the most experienced endoscopists to these cases. The objective of this study is to determine the diagnostic yield in colonoscopies for different indications to improve planning of colonoscopy activity and allocation of the highly skilled endoscopists.

Methods

Nine hundred and ninety-nine randomly collected patients from a prospectively maintained database were grouped in defined referral indication groups. Five groups were compared in respect of the detection rate of adenomas and cancers.

Results

Two hundred and eighty-nine of 1098 colonoscopies in 999 patients showed significant neoplastic findings, resulting in 591 adenoma resections. Eighty-five percent were treated with a snare resection, and 15% with endoscopic mucosa resection (EMR). Positive findings in the indication groups were (1) symptoms, 25%; (2) positive screening, 17%; (3) previous resection of adenomas, 45%; (4) previous resection of colorectal cancer, 15%; and (5) surveillance of patients with high-risk family history of cancer, 35%.

Conclusion

The majority of adenomas found during colonoscopy can be treated with simple techniques. If individualized time slots are considered, the adenoma follow-up colonoscopies are likely to be the most time-consuming group with more than twice the number of adenomas detected as compared to other indications.

Adding family history to faecal immunochemical testing increases the detection of advanced neoplasia in a colorectal cancer screening programme

BACKGROUND

Faecal immunochemical testing (FIT) for colorectal cancer (CRC) screening has suboptimal sensitivity for detecting advanced neoplasia. To increase its performance, FIT could be combined with other risk factors.

AIM

To evaluate the incremental yield of a screening programme using a positive FIT or a CRC family history, to offer a diagnostic colonoscopy.

METHODS

For this post hoc analysis, data were collected in the colonoscopy arm of a colonoscopy or colonography for screening study. In this study, 6600 randomly selected, asymptomatic men and women (50-75 years) were invited for screening colonoscopy. 1112 Participants completed a FIT and a questionnaire prior to colonoscopy. We compared the yield of FIT-only and FIT combined with CRC family history, defined as having one or more first-degree relatives with CRC.

RESULTS

At a 10 μg Hb/g faeces FIT-positivity threshold the combined strategy would increase the yield from 36 (3.2%; CI: 2.4-4.5%) to 53 (4.8%; CI: 3.7-6.2%) cases of advanced neoplasia, at the expense of 148 additional negative colonoscopies. Sensitivity in detecting advanced neoplasia would increase from 36% (CI: 26-46%) to 52% (CI: 42-63%), whereas specificity would decrease from 93% (CI: 92-95%) to 79% (CI: 76-81%). The strategy will be preferred if one accepts 8.8 false positives for every additional participant in whom advanced neoplasia can be detected.

CONCLUSIONS

Offering colonoscopy to those with a positive FIT or CRC family history increases the yield of a FIT-based screening programme. Depending on the number of negative colonoscopies one accepts, this combined approach can be considered for improving CRC screening.

Use of an Abdominal Compression Device in Colonoscopy: A Randomized, Sham-Controlled Trial

BACKGROUND & AIMS

Looping is a common problem during colonoscopy that prolongs procedure time. We aimed to determine the efficacy and safety of ColoWrap, an external abdominal compression device, with respect to insertion time and other procedural outcomes.

METHODS

We performed a prospective study of outpatients undergoing elective colonoscopy (40-80 years old; mean age, 60.5 years) at endoscopy facilities in the University of North Carolina Hospitals from April 2013 through March 2014. Subjects were randomly assigned to groups that received either ColoWrap (n = 175) or a sham device (control, n = 175) during colonoscopy. Colonoscopists and staff were blinded to the application. The primary outcome was cecal intubation time (CIT). Secondary outcomes included use of manual pressure and position change.

RESULTS

The mean CIT was similar for the control and ColoWrap groups (6.69 vs 6.67 minutes; P = .98). There were no statistical differences in the frequency of manual pressure (45% for controls vs 37% for ColoWrap group, P = .13) or position changes (4% for controls vs 2% for ColoWrap group, P = .36). Among patients with body mass index between 30 and 40 kg/m(2) (n = 78), CIT was significantly lower for patients in the ColoWrap group (4.69 minutes) than controls (6.10 minutes) (P = .03). Adverse events were similar between groups.

CONCLUSIONS

In patients undergoing elective colonoscopy, application of an external abdominal compression device did not improve CIT or affect the frequency of ancillary maneuvers. A possible benefit was observed in patients with body mass index between 30 and 40 kg/m(2), but further studies are needed. ClinicalTrials.gov number: NCT02025504.

Surveillance colonoscopy after endoscopic treatment for colorectal neoplasia: From the standpoint of the Asia-Pacific region

Colonoscopy is considered the gold standard to detect and remove colorectal neoplasia. The efficacy of colonoscopy with polypectomy to reduce colorectal cancer incidence and mortality has been demonstrated. Recently, post-polypectomy surveillance colonoscopy has become a necessary intervention in daily practice not only in Western countries but also in the Asia-Pacific region. Therefore, it is crucial to establish new clinical practice guidelines to reduce the number of unnecessary surveillance colonoscopies in order to create space for screening colonoscopy. The Asia-Pacific Consensus group recommended that surveillance colonoscopy interval should be tailored according to risk level of index colonoscopy. However, precise guidelines on interval of surveillance cannot be given because of a lack of prospective data. According to Korean and Australian guidelines, surveillance intervals after index colonoscopy of 5 years for low-risk subjects and 3 years for high-risk subjects are recommended in Asia-Pacific regions at present. Prospective data including long-term outcomes from the Japan Polyp Study, which is a multicenter randomized control trial, would be useful to establish the Asia-Pacific consensus in the near future.

Long-Term Impact of the Dutch Colorectal Cancer Screening Program on Cancer Incidence and Mortality-Model-Based Exploration of the Serrated Pathway

BACKGROUND

We aimed to predict the long-term colorectal cancer incidence, mortality, and colonoscopy demand of the recently implemented Dutch colorectal cancer screening program.

METHODS

The Adenoma and Serrated pathway to Colorectal Cancer model was set up to simulate the Dutch screening program consisting of biennial fecal immunochemical testing combined with the new Dutch surveillance guidelines, between 2014 and 2044. The impact of screening and surveillance was evaluated under three sets of natural history assumptions differing in the contribution of the serrated pathway to colorectal cancer incidence. In sensitivity analyses, other assumptions concerning the serrated pathway were varied. Model-predicted outcomes were yearly colorectal cancer incidence, mortality, and colonoscopy demand per year.

RESULTS

Assuming an aging population, colorectal cancer incidence under 30 years of screening is predicted to decrease by 35% and 31% for a contribution of 0% and 30% of the serrated pathway to colorectal cancer, respectively. For colorectal cancer mortality, reductions are 47% and 45%. In 2044, 110,000 colonoscopies will be required annually assuming no contribution of the serrated pathway (27 per 1,000 individuals in the screening age range). Including the serrated pathway influences predicted screening effectiveness if serrated lesions are neither detected nor treated at colonoscopy, and/or if colorectal cancers arising from serrated lesions have substantially lower survival rates than those arising from adenomas.

CONCLUSIONS

The Dutch screening program will markedly decrease colorectal cancer incidence and mortality but considerable colonoscopy resources will be required.

IMPACT

Predictions of long-term screening effectiveness are preferably based on both pathways to colorectal cancer to transparently describe the impact of uncertainties regarding the serrated pathway on long-term predictions.

Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study

OBJECTIVE

To determine adherence to recommended surveillance intervals in clinical practice.

DESIGN

2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing.

RESULTS

Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01).

CONCLUSIONS

There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.

Patient-derived measures of GI endoscopy: a meta-narrative review of the literature

BACKGROUND AND AIMS

GI endoscopy (GIE) is widely performed, with 1 in 3 people requiring an endoscopic procedure at some point. Patient experience of medical procedures is important, but, to date, experience measures of GIE are derived from clinician opinion rather than from patients themselves. In this meta-narrative review, the literature on methods of assessing patient experience in GIE is reported.

METHODS

ScienceDirect, MEDLINE, Web of Knowledge, Web of Science, CINAHL, and PsycINFO were searched to November 2013 using meta-narrative standards. Search terms included those related to endoscopic procedures, combined with those related to patient experience.

RESULTS

A total of 3688 abstracts were identified and reviewed for relevance. A total of 3549 were excluded, leaving 139 for full-text review. We subsequently included 48 articles. Three sub-groups of studies were identified--those developing original measures of endoscopy-specific patient experience (27 articles), those modifying existing measures (10 articles), and those testing existing measures for reliability or validity (11 articles). Most measures focused on pain, discomfort, anxiety, and embarrassment. Three studies explored wider aspects of experience, including preparation, unit organization, and endoscopist preference. Likert scales, visual analog scale scores, and questionnaires were used most commonly. The Global Rating Scale was validated for use in 2 studies, confirming that those domains cover all aspects of endoscopy experience. Other measures were modified to assess endoscopic experience, such as the modified Group Health Association of America survey (mGHAA-9) (modified by 5 studies).

CONCLUSIONS

No patient-derived and validated endoscopy-specific experience measures were found. Patient-derived and validated experience measures should be developed and used to model optimal healthcare delivery.

Incidence of microscopic colitis in the Netherlands. A nationwide population-based study from 2000 to 2012

BACKGROUND

Incidence rates of microscopic colitis are mainly based on regional data from a limited number of countries. To evaluate geographical differences and changes over time, more nationwide incidence rates are needed.

AIMS

The aim of this retrospective study was to assess the incidence rate of microscopic colitis in the Netherlands in a nationwide cohort.

METHODS

A search was performed in the Dutch pathology registry, covering records of all approximately 16.5 million inhabitants. Incident cases were defined as a first diagnosis of microscopic colitis (collagenous or lymphocytic colitis) between 2000 and 2012.

RESULTS

In total, 7228 incident cases were identified with a mean annual incidence rate of 3.4 per 100,000 person years. Collagenous colitis was present in 3741 cases and lymphocytic colitis in 2718 cases, with a mean annual incidence rate of 1.8 and 1.3 per 100,000 person years, respectively. Remaining 769 cases were described as undefined microscopic colitis. Collagenous and lymphocytic colitis incidence rates increased significantly over time (p<0.001) with a male:female ratio of 1:3 and 1:2, respectively.

CONCLUSION

The Dutch mean annual incidence rates of collagenous and lymphocytic colitis were considerably lower than previously reported by other countries. However, incidence rates increased gradually over time, with a clear female predominance.

Triage of colonoscopies: open access endoscopy versus outpatient consultation with a gastroenterologist

BACKGROUND AND STUDY AIMS

In many Dutch hospitals, open access referral for colonoscopy is authorized by a gastroenterologist after screening a standard referral letter (SRL) without face-to-face contact with the patient. We investigated the added value of a 7.5 min outpatient consultation with a gastroenterologist (OC), regarding the patient indications, priority for colonoscopy, and the frequency of correct information about patient medications and comorbidities on SRLs.

PATIENTS AND METHODS

In a prospective, blinded, single-center study, gastroenterologists assessed SRLs for the accuracy and priority of the colonoscopy request (SRL). These data were compared to results from the OC, and primary outcomes were the number of patients who were not recommended for colonoscopy and priority scheduling of colonoscopy for suspicion of cancer.

RESULTS

Patients were analyzed using both SRL and OC and, of 255 patients, 224 of them underwent colonoscopy. Colonoscopy was not recommended for 6.3 % and 11.4 % of patients using the SRL and OC, respectively (P = 0.02). Using the SRL, gastroenterologists did not recommend colonoscopy for seven patients, but the same patients were recommended for colonoscopy when OC was available. This was explained because the indications on the SRL did not match the information obtained from OC. Compared to OC , more colonoscopies were prioritized when the SRL was used to make decisions. Cancer was detected in 7/112 (SRL ) versus 7/65 (OC ) of priority-scheduled patients. SRLs did not report the use of coumarins and insulin in 1.6 % of patients or the prevalence of serious comorbid conditions in 52 % of patients.

CONCLUSIONS

A 7.5 min outpatient consultation with a gastroenterologist improved the identification of indications for colonoscopy, decreased priority scheduling of patients, and increased the number of patients diagnosed with cancer in the prioritized group. SRLs frequently omitted patients' medications and comorbidities.

Is "really conscious" sedation with solely an opioid an alternative to every day used sedation regimes for colonoscopies in a teaching hospital? Midazolam/fentanyl, propofol/alfentanil, or alfentanil only for colonoscopy: a randomized trial

BACKGROUND

We investigated the satisfaction of patients and endoscopists and concurrently safety aspects of an "alfentanil only" and two clinically routinely used sedation regimes in patients undergoing colonoscopy in a teaching hospital.

METHODS

One hundred and eighty patients were prospectively randomized in three groups: M (midazolam/fentanyl), A (alfentanil), and P (propofol/alfentanil); M and A were administered by an endoscopy nurse, P by an anesthesia nurse. Interventions, heart rate, saturation, electrocardiogram, noninvasive blood pressure, and expiratory CO₂ were monitored using video assistance. After endoscopy, patients and gastroenterologists completed questionnaires about satisfaction.

RESULTS

A high level of satisfaction was found in all groups, with patients in group P being more satisfied with their sedation experience (median 1.75, p < 0.001). Gastroenterologist satisfaction varied not significantly between the three alternatives. Patients in group A felt less drowsy, could communicate more rapidly than patients in both other groups, and met discharge criteria immediately after the end of the procedure. Respiratory events associated with sedation were observed in 43% patients in group M, 47% in group P, but only 13% in group A (p < 0.001).

CONCLUSIONS

These results suggest that alfentanil could be an alternative for sedation in colonoscopy even in the setting of a teaching hospital. It results in satisfied patients easily taking up information, and recovering rapidly. Although one might expect to observe more respiratory depression with an "opioid only" sedation technique without involvement of anesthesia partners, respiratory events were less frequent than when other methods were used.

Combining risk factors with faecal immunochemical test outcome for selecting CRC screenees for colonoscopy

OBJECTIVE

Faecal immunochemical testing (FIT) is increasingly used in colorectal cancer (CRC) screening but has a less than perfect sensitivity. Combining risk stratification, based on established risk factors for advanced neoplasia, with the FIT result for allocating screenees to colonoscopy could increase the sensitivity and diagnostic yield of FIT-based screening. We explored the use of a risk prediction model in CRC screening.

DESIGN

We collected data in the colonoscopy arm of the Colonoscopy or Colonography for Screening study, a multicentre screening trial. For this study 6600 randomly selected, asymptomatic men and women between 50 years and 75 years of age were invited to undergo colonoscopy. Screening participants were asked for one sample FIT (OC-sensor) and to complete a risk questionnaire prior to colonoscopy. Based on the questionnaire data and the FIT results, we developed a multivariable risk model with the following factors: total calcium intake, family history, age and FIT result. We evaluated goodness-of-fit, calibration and discrimination, and compared it with a model based on primary screening with FIT only.

RESULTS

Of the 1426 screening participants, 1112 (78%) completed the questionnaire and FIT. Of these, 101 (9.1%) had advanced neoplasia. The risk based model significantly increased the goodness-of-fit compared with a model based on FIT only (p<0.001). Discrimination improved significantly with the risk-based model (area under the receiver operating characteristic (ROC) curve: from 0.69 to 0.76, (p=0.02)). Calibration was good (Hosmer-Lemeshow test; p=0.94). By offering colonoscopy to the 102 patients at highest risk, rather than to the 102 cases with a FIT result >50 ng/mL, 5 more cases of advanced neoplasia would be detected (net reclassification improvement 0.054, p=0.073).

CONCLUSIONS

Adding risk based stratification increases the accuracy FIT-based CRC screening and could be used in preselection for colonoscopy in CRC screening programmes.

Analgesia without sedatives during colonoscopies: worth considering?

Colonoscopy is a proven method for bowel cancer screening and is often experienced as a painful procedure. Today, there are two main strategies to facilitate colonoscopy. First, deep sedation results in satisfied patients but increases sedation-associated risks and raises costs for healthcare providers. Second, there is the advocacy for colonoscopies without any form of sedation. This might be an option for a special group of patients, but does not hold true for everybody. Following Moerman’s hypothesis: “If pain is the crucial point, why do we need sedation?” this review shows the analgesic options for a painless procedure, increasing success rates without increasing risk of sedation. There are two agents, with the potential to be a nearly ideal analgesic agent for colonoscopy: alfentanil and nitrous oxide (N₂O). Administration of either substance causes the patient to be comfortable yet alert and facilitates a short turnover. Advantages of these drugs include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level, rapid recovery, and an excellent safety profile.