Colonoscopy – Striving for Excellence

Posted 28 June 2013 in

Colonoscopy – Striving for Excellence
Hall 1A 08.30 Tuesday 2nd July

  • Tips to better colonoscopy John Abercrombie, Nottingham
  • Tips to better training Rupert Pullan, Torquay
  • Polypectomy training Brian McKaig, Wolverhampton
  • Advanced polypectomy techniques Pradeep Bhandari, Portsmouth

Colonoscopy is currently in a golden age – national initiatives to improve earlier diagnosis of colorectal cancer and the NHS Bowel Cancer Screening Programme have been significant factors which have exponentially increased demand for high quality colonoscopy.

Historical audit and epidemiological data demonstrate that the quantity and quality of colonoscopy in the UK has been suboptimal and much resource and enthusiasm has been invested to rectify these shortcomings. These improvements started with the formation of the Joint Advisory Group for GI Endoscopy (JAG) responsible for setting standards and training recommendations. The subsequent development of national and regional endoscopy training centres in 2003 was instrumental in building upon the pioneering work of training enthusiasts and has created an environment to develop and deliver a large variety of quality assured reproducible training courses, not only designed to train endoscopic trainees, but also to train endoscopic trainers. Many of these courses have been adopted internationally. This infrastructure has promoted development of a robust certification and accreditation process for all endoscopists in the UK with a bespoke endoscopy e-portfolio. The UK training structure for endoscopy is deservedly envied throughout the international endoscopy community.

Comparison of the national UK audits in colonoscopy from 2004 and 2012 (1,2) demonstrates the contribution of these interventions with all key performance indicators of colonoscopy significantly improving.

Polypectomy has always been a standard part of colonoscopic practice, however the complication rate from this remain high. The detection and complete resection of polyps is one of the main aims of colonoscopy, but until very recently, this aspect of training has not been formally addressed. There are now JAG approved polypectomy training courses and bespoke assessment tools for polypectomy to ensure competency in this modality prior to certification. On line e-learning modules have been developed and will be free to access for all endoscopists registered with JAG.
With improving quality in colonoscopy, the boundaries for what is achievable is now widening. The input of an experienced endoscopist is now standard within colorectal MDTs and many lesions once entirely within the realms of surgery are now accessible to endoscopic resection.

The National Bowel cancer screening programme has led to a massive increase in the diagnosis of very flat colonic polyps. These are challenging to assess and resect. Endoscopic techniques and devices are available to help resect these polyps safely so the boundaries between endoscopic and surgical resection for large benign polyps are fading away. However, this requires a complex set of skills, advanced endoscopic accessories, highly skilled nursing team, changes in working patterns to allow only one or two cases per list and most importantly appropriate tariffs and management support. We have now reached very high levels in basic colonoscopy & polypectomy training and need to develop a training framework for advanced endoscopic resections including Endoscopic Submucosal dissection (ESD). It is important for an endoscopist to work very closely with the surgical team and also to not forget the role of management support and supporting business case. This should be viewed as an important service development and not just skills acquisition for resecting complex polyps. There are a few select centres around the UK performing very complex resections and providing excellent service to the patients and a lot can be learned from these centres.

1. Bowles et al. Gut2004;53:277–83
2. Gavin et al, Gut. 2013 Feb;62(2):242-9. doi: 10.1136/gutjnl-2011-301848.