In a series of interviews, guest reporter Owen Haskins from Dendrite Clinical Systems, will be previewing this year’s ACPGBI annual meeting in Edinburgh, Scotland, July 4-6. He talked to Dr James Church about his presentation ‘Colonoscopy in the 21st Century’ and discussed how to limit complications, recent advances, the role of the multidisciplinary team and training.
The aim of colonoscopy is two-fold; it is used in the investigation of symptoms to provide a diagnosis, as well as to treat conditions such as polyps, abnormal blood vessels, colonic dilation. In addition, it is also used to examine asymptomatic patients to detect and diagnose, and treat malignant or premalignant lesions.
According to Dr Church, colorectal cancer is totally preventable because it always arises in a premalignant lesion. Therefore, patients with colorectal cancer represent a failure of screening and he believes everyone at risk of the disease should be screened, ideally with colonoscopy.
“Unfortunately this is not practical nor is it affordable or even available at a national level,” he explained. “However for the individual patient seeking to avoid colorectal cancer, colonoscopy is the obvious choice. Colonoscopy is not perfect and sometimes lesions are missed. There needs to be a huge effort in improving quality of colonoscopy and raising the general level of skill.”
Dr Church added that colonoscopy is a specialised procedure that is difficult to learn and tricky to perform. It is expensive, especially if general anaesthesia is used instead of conscious sedation, and in the United States many patients cannot afford colonscopy or their insurance coverage does not include it.
“Many colonoscopists now use propofol as an anesthetic for patients undergoing colonoscopy,” said Church. “This may increase expense in places where an ananesthetist is required to administer the agent. There has been some progress in preps with a move to lower volumes and better timing. One or two preps with better taste have been introduced.”
He emphasised that it is crucial to understand the procedure from the patient’s point of view. They see colonoscopy as scary because of the need for a bowel prep, because it may find something serious, because it is embarrassing and potentially painful.
“It is important to carefully assess potential patients for co-morbidities and tailor the examination to the patient,” he explained. “Know what you are aiming to do in each case and use adequate sedation but don’t overdose. It is also important to make sure the preparation instructions are understandable and understood, and that the preparation is designed for the patient.”
During the procedure itself, he said that the scope should be inserted with minimal trauma and minimal discomfort. He also explained that it is necessary to achieve a straight scope that allows accurate inspection on withdrawal and safe polypectomy.
“While there is a lot of activity in exploring the feasibility of new ways of examining the colon, most practically useful advances have been in improving optics, widening the field of view, manipulating the image (e.g. narrow band Imaging) and improving the ease of documentation,” he explained. “I think we need to beware of new gadgets, gimmicks and toys. We have the technical capacity now to do a comfortable, accurate and effective exam of the colon. Let’s learn to do it with high quality and not seek to follow every new invention by industry.”
In discussing recent advances in procedures such as advanced polypectomies and treating cancer, Dr Church said that the main thrust has been in endoscopic submucosal dissection (ESD). This is where instruments are inserted through the colonoscope to allow en bloc removal of quite large lesions. This technique was originally designed for gastric lesions by Japanese endoscopists, but has been applied throughout the world to the colon.
“It demands a high level of endoscopic skill, takes a long time to perform, and carries a high risk of perforation and/or hemorrhage. It is still seeking its place in western endoscopy units,” said Dr Church.
In his opinion, colorectal surgeons should be performing colonoscopies because they understand the colon, they handle it every day in the operating room and they can care for their own complications, they have access to the full spectrum of care. In addition, colorectal surgeons need the sort of accurate information about the size, site and nature of lesions that can best come from a colonoscopist’s perspective.
“I think there is a role for nurse endoscopists, especially in the context of screening,” he added. “This should be carefully monitored. The exam is not just insertion of the scope, although that is a huge part of it. It is diagnosing what must be diagnosed, accurately, and treated what should be treated, effectively and safely, that is important. This requires training, experience, wisdom and skill. A MDT is important in areas such as IBD (colitis and Crohn’s) and colorectal neoplasia, so that unnecessary surgeries are avoided but patients who need an operation get the appropriate operation for their diagnosis.
Training and quality
Dr Church said that there is currently a shortage of trained colonoscopists in the United States and the average colonoscopist cannot complete the exam in 10% of patients or more. He also said that there is also a shortage of training resources, and it is vital to increase the quality of training and the number of highly skilled endoscopists available to carry out the procedures.
“Colonoscopy is basically self-taught. Sure there are aids such as simulators, scope guides, books and videos. But to learn it properly you need to do the exams. I would like to see innate skill encouraged, and people with talents in other areas encouraged to move to those areas.”
Finally, he discussed how quality and quality control can be improved and stressed that quality indicators must be appropriate, relevant, validated and well defined, then applied and audited.
“As with any medical procedure, practitioners need to know their outcomes and so be able to evaluate themselves and seek help where it is necessary,” he concluded. “I am a huge fan of the concept of individual coaching and am committed to starting this on a programmatic level.”