Multidisciplinary team meeting before therapeutic ERCP: A prospective study with 1,909 cases

Outcomes of complex colorectal polyps managed by multi-disciplinary team strategies-a multi-centre observational study

PURPOSE

Team management strategies for complex colorectal polyps are recommended by professional guidelines. Multi-disciplinary meetings are used across the UK with limited information regarding their impact. The aim of this multi-centre observational study was to assess procedures and outcomes of patients managed using these approaches.

METHOD

This was a retrospective, observational study of patients managed by six UK sites. Information was collected regarding procedures and outcomes including length of stay, adverse events, readmissions and cancers.

RESULTS

Two thousand one hundred ninety-two complex polyps in 2109 patients were analysed with increasing referrals annually. Most presented symptomatically and the mean polyp size was 32.1 mm. Primary interventions included endoscopic therapy (75.6%), conservative management (8.3%), colonic resection (8.1%), trans-anal surgery (6.8%) or combined procedures (1.1%). The number of primary colonic resections decreased over the study period without a reciprocal increase in secondary procedures or recurrence. Secondary procedures were required in 7.8%. The median length of stay for endoscopic procedures was 0 days with 77.5% completed as day cases. Median length of stay was 5 days for colonic resections. Overall adverse event and 30-day readmission rates were 9.0% and 3.3% respectively. Malignancy was identified in 8.8%. Benign polyp recurrence occurred in 13.1% with a median follow up of 30.4 months. Screening detected lesions were more likely to undergo bowel resection. Colonic resection was associated with longer stays, higher adverse events and more cancers on final histology.

CONCLUSION

Multi-disciplinary team management of complex polyps is safe and effective. Standardisation of organisation and quality monitoring is needed to continue positive effects on outcomes and services.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

Multidisciplinary decision-making strategies may reduce the need for secondary surgery in complex colonic polyps - A systematic review and pooled analysis

AIM

The recognition of complex colonic polyps is increasing. Management varies considerably and the impact of this on clinical outcomes is unclear. The aim of this systematic review was to assess the impact of group decision-making strategies and defined selection criteria on the treatment outcomes of complex colonic polyps.

METHOD

A systematic literature review identified studies reporting complex polyp treatment outcomes and describing their decision-making strategies. Databases searched included PubMed, Web of Science, CINAHL and Scopus. Articles were identified by two blinded reviewers using defined inclusion criteria. The review protocol was registered on PROSPERO and performed in line with PRISMA guidelines.

RESULTS

There were 303 identified articles describing treatment outcomes of complex colonic polyps. Only nine of these fully described the decision-making strategy and met the inclusion criteria. Adverse events ranged from 1.3% to 10% across the studies. Unsuspected malignancy and secondary surgery rates ranged from 2.4% to 15.4% and 3.3% to 43.9%, respectively. Grouping of articles into a hierarchy of decision-making strategies demonstrated a sequential reduction in secondary surgery rates with improving strategies. There were no differences in comparisons of adverse event or unsuspected malignancy rates.

CONCLUSIONS

There is limited description of decision-making strategies and variability in reporting of studies describing complex polyp treatment outcomes. The use of multidisciplinary decision-making and defined selection criteria may reduce the need for secondary surgical intervention in complex colonic polyps, but further evidence is required to draw definite conclusions.

ERCP development in the largest developing country: a national survey from China in 2013

BACKGROUND AND AIMS

The ERCP volume in developed countries has decreased recently, whereas the ERCP trend is unknown in developing countries. This study aimed to evaluate the ERCP development in China between 2006 and 2012.

METHODS

All hospitals performing ERCP in mainland China in 2012 participated in an online survey. Data on ERCP infrastructure, volume, indication, and adverse events were collected and compared with those in a previous national survey and in developed countries.

RESULTS

From 2006 to 2012 the number of hospitals performing ERCP in China increased from 470 to 1156. The total ERCP volume increased from 63,787 to 195,643, of which >95% were therapeutic. The ERCP rate in China (14.4 per 100,000 inhabitants) in 2012 was still much lower than that in developed countries. There was significant imbalance between different regions (1.3-99.1 per 100,000 inhabitants). The median ERCP volume per hospital decreased from 80 (interquartile range [IQR], 31-150) in 2006 to 52 (IQR, 20-146) in 2012. The median volume of the 686 hospitals that started ERCP after 2006 was 31.5 (IQR, 11-82). The post-ERCP adverse event rate in 2012 was comparable between hospitals in terms of volume (≥500 or <500 per year: 5.8% vs 5.6%) and practice durations (starting ERCP before or after 2006: 5.5% vs 5.6%).

CONCLUSIONS

ERCP has developed considerably in China in recent years. Despite low annual volume, the hospitals starting ERCP after 2006 have acceptable adverse event rates and will be promising and important sources of ERCP development in China.

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

ERCP service in China: results from a national survey

BACKGROUND

ERCP had been performed throughout China for decades.

OBJECTIVE

To determine the status of ERCP service in China.

DESIGN

A national survey.

SETTING

All of the hospitals performing ERCP in mainland China in 2006.

PATIENTS

All of the patients undergoing ERCP in mainland China in 2006.

MAIN OUTCOME MEASUREMENTS

The questionnaire included the (1) type of hospitals involved; (2) ownership of the endoscopy unit; (3) ERCP infrastructure; (4) volume, indication, setting, and anesthesia methods; and (5) training and research. The correlation between economic development and ERCP status in different regions was investigated, and the ERCP rates in China and developed countries were compared.

RESULTS

Completed questionnaires were returned by 449 (95.5%) of the 470 hospitals providing ERCP service. Among the 449 hospitals, 186 (41.4%) did not have separate ERCP suites, 379 (84.4%) shared fluoroscopy with their radiology departments, and the average number of duodenoscopes was 1.58. A total of 63,787 ERCP procedures were performed in mainland China in 2006, with an estimated annual ERCP rate of 4.87 per 100,000 inhabitants, much lower than that of developed countries. Ninety-six percent of patients were admitted to undergo ERCP, and 94.4% of hospitals used pharyngeal local anesthesia and conscious sedation, whereas 5.6% used general anesthesia. There was a significant correlation between the ERCP rate and gross domestic product per capita (r = 0.871, P < .001).

LIMITATIONS

The survey was retrospective and descriptive.

CONCLUSIONS

There is an enormous gap in ERCP service between China and developed countries. The imbalance of ERCP status between different regions is significant, which correlates with economic development. Great effort is needed to develop the technique nationwide.