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Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.

These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped? two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG’s guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps The key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise either:two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); or five or more premalignant polyps This cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.

This study provides an overview of the largest and longest-running colonoscopic surveillance program for colorectal cancer (CRC) in patients with long-standing ulcerative colitis (UC). Data were obtained from medical records, endoscopy, and histology reports. Primary end points were defined as death, colectomy, withdrawal from surveillance, or censor date (1 January 2013). A total of 1,375 UC patients were followed up for 15,234 patient-years (median, 11 years per patient). CRC was detected in 72 patients (incidence rate (IR), 4.7 per 1,000 patient-years). Time-trend analysis revealed that although there was significant decrease in incidence of colectomy performed for dysplasia (linear regression, R=-0.43; P=0.007), IR of advanced CRC and interval CRC have steadily decreased over past four decades (Pearson's correlation, -0.99; P=0.01 for both trends). The IR of early CRC has increased 2.5-fold in the current decade compared with past decade (χ(2), P=0.045); however, its 10-year survival rate was high (79.6%). The IR of dysplasia has similarly increased (χ(2), P=0.01), potentially attributable to the recent use of chromoendoscopy that was twice more effective at detecting dysplasia compared with white-light endoscopy (χ(2), P<0.001). CRCs were frequently accompanied by synchronous CRC or spatially distinct dysplasia (37.5%). Finally, the risk of CRC was not significantly different between \"indefinite\" or low-grade dysplasia (log-rank, P=0.78). Colonoscopic surveillance may have a significant role in reducing the risk of advanced and interval CRC while allowing more patients to retain their colon for longer. Given the ongoing risk of early CRC, patients with any grade of dysplasia who are managed endoscopically should be monitored closely with advanced techniques.

Background Endoscopic examinations can reduce colorectal cancer (CRC) burden through early detection and removal of precancerous lesions; however, after initial endoscopy, some patients do not attend subsequent examinations. Aims To investigate the impact of patient experience of endoscopic screening on attendance at future examinations and distal CRC incidence. Methods In a cohort study including 40,141 participants who received flexible sigmoidoscopy (FS) screening in the UK FS Screening Trial, median follow-up was 16.8 years. We examined family history of CRC, bowel preparation quality, segment of bowel reached, and responses to patient-reported post-examination questionnaires. We estimated multivariable odds ratios (OR) for attendance at future examinations by logistic regression and hazard ratios (HR) for associations between patient experience at FS and distal CRC incidence. Results Of those recommended a future endoscopy, 7.1% did not attend repeat FS, 3.4% did not attend colonoscopy, 18.3% did not attend surveillance, and 0.5% developed distal CRC. Symptoms of faintness/dizziness (OR = 5.10 95%CI 1.49–17.42) were associated with non-attendance at repeat FS. Non-attendance at surveillance was associated with whether participants felt they had made the right decision to take the tests; that taking the tests was tempting fate; that they needed the tests; or that they would rather have let nature take its course. A FS more painful than expected (HR = 0.57 95%CI 0.37–0.88) was inversely associated with distal CRC incidence. Conclusions We identified aspects of patient experience at endoscopy that could be used to improve attendance at future endoscopic examinations, which in turn could reduce CRC incidence. Trial registration number: ISRCTN28352761. Trial registration date: April 2000.

The aim of this study was to identify risk factors associated with development of high-grade dysplasia (HGD) or colorectal cancer (CRC) in ulcerative colitis (UC) patients diagnosed with low-grade dysplasia (LGD). Patients with histologically confirmed extensive UC, who were diagnosed with LGD between 1993 and 2012 at St Mark's Hospital, were identified and followed up to 1 July 2013. Demographic, endoscopic, and histological data were collected and correlated with the development of HGD or CRC. A total of 172 patients were followed for a median of 48 months from the date of initial LGD diagnosis (interquartile range (IQR), 15-87 months). Overall, 33 patients developed HGD or CRC (19.1% of study population; 20 CRCs) during study period. Multivariate Cox proportional hazard analysis revealed that macroscopically non-polypoid (hazard ratio (HR), 8.6; 95% confidence interval (CI), 3.0-24.8; P<0.001) or invisible (HR, 4.1; 95% CI, 1.3-13.4; P=0.02) dysplasia, dysplastic lesions ≥1 cm in size (HR, 3.8; 95% CI, 1.5-13.4; P=0.01), and a previous history of \"indefinite for dysplasia\" (HR, 2.8; 95% CI, 1.2-6.5; P=0.01) were significant contributory factors for HGD or CRC development. Multifocal dysplasia (HR, 3.9; 95% CI, 1.9-7.8; P<0.001), metachronous dysplasia (HR, 3.5; 95% CI, 1.6-7.5; P=0.001), or a colonic stricture (HR, 7.4; 95% CI, 2.5-22.1; P<0.001) showed only univariate correlation to development of HGD or CRC. Lesions that are non-polypoid or endoscopically invisible, large (≥1 cm), or preceded by indefinite dysplasia are independent risk factors for developing HGD or CRC in UC patients diagnosed with LGD.

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.

IntroductionThe Joint Advisory Group on Gastrointestinal Endoscopy (JAG), hosted by the Royal College of Physicians, London, oversees the quality assurance of endoscopy services across the UK. Additional questions focusing on the pressures faced by endoscopy units to meet targets were added to the 2017 annual Global Rating Scale (GRS) return. This provides a unique insight into endoscopy services across all nations of the UK involving the acute and non-acute Nation Health Service sector as well as the independent sector.MethodsAll 508 services who are registered with JAG were asked to complete every field of the survey online in order to submit their completed April 2017 GRS return.ResultsA number of services reported difficulty in meeting national waiting time targets with a national average of only 55% of units meeting urgent cancer wait targets. Many services were insourcing or outsourcing patients to external providers to improve waiting times. Services are striving hard to increase capacity by backfilling lists and working weekends. Data collection was done in most units to reflect productivity but not to look at demand and capacity. Some of the units did not have an agreed capacity plan. The Did Not Attend rates for patients in the bowel cancer screening programme were much lower compared with standard lists.ConclusionThis review highlights the increased pressure endoscopy services are under and the ‘just about coping’ situation. This is the first published overview of different aspects of UK-wide endoscopy services and the future challenges.

IntroductionThe Joint Advisory Group on Gastrointestinal endoscopy (JAG) conduct a biennial census to understand factors related to endoscopy quality, workforce and training across services in the UK. The study reports the results of the 2019 census.MethodsA census of all UK JAG-registered services was conducted in April 2019. Questions were devised by an expert panel covering domains of activity, workforce and waiting times. Question items were informed by results of the previous census. Results were collated and analysed using Chi Square, Fisher’s exact and Kruskal Wallis tests.ResultsThe response rate was 68.4%. A total of 2,133,541 endoscopic procedures were performed in 2018. In March 2019, 31,938 endoscopy lists were delivered (mean 99.2 ± 95.7 per service).The responding services employed 5,578 endoscopists (mean 17.32 ± 10.13, 12% non-medical), 1,366 trainees (mean 4.24 ± 6.43) and 12,680 nurses and allied health professionals (AHP) (mean 39.94 ± 284.81). There was a nursing and AHP vacancy rate of 7.29%. Region (p = 0.02) and service type (p < 0.001) had a significant association with vacancy.Out of the lists performed by trainees, 51.9% were for training only. An average of 7.46 (± 1.45) oesophago-gastroduodenoscopies and 3.86 (± 0.85) colonoscopies were booked for each training list. There was a significant regional influence on number of trainee lists (p < 0.001).In the first 3 months of 2019, waiting time targets were met by 73.7% of services for urgent cancer, 68.7% for routine waits and 63.4% for surveillance waits. There was a significant difference in meeting targets between region (p < 0.01) and service type (p < 0.01). The commonest reasons for this were endoscopist, physical and nursing capacity. JAG accredited services were more likely to meet routine and surveillance wait targets than unaccredited services (p < 0.001). The mean standard DNA (Did Not Attend) rate for March 2019 was 3.48 (± 3.07) as shown in table 1.Abstract P70 Table 1 List Type DNA rate (mean ± SD) UK region Service type (acute, independent or non-acute) Accreditation status Standard (symptomatic, surveillance, therapeutic) 3.48 ± 3.07 p < 0.001 p < 0.001 p = 0.48 Bowel cancer screening 1.33 ± 2.81 p = 0.07 p = 0.51 p = 0.41 ConclusionsThis census reflects the most extensive data regarding current UK endoscopy practice. There is evidence of service pressure, affecting wait times and training opportunities with significant regional and service-specific variability.

Restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis is the surgical procedure of choice for patients with ulcerative colitis (UC). It is also performed in selected patients with familial adenomatous polyposis (FAP). A significant proportion of patients will develop pouch dysfunction. Flexible pouchoscopy is the most important initial investigation in patients with dysfunction. It is also important in UC and FAP surveillance. The aim is to provide gastroenterologists with a clear understanding of the technique, indications, and diagnostic pitfalls when investigating RPC patients with flexible pouchoscopy. Flexible pouchoscopy for the investigation of RPC patients with pouch dysfunction has a high diagnostic yield, with most causes of pouch dysfunction identifiable during this procedure. The risk of developing dysplasia following RPC is low. Surveillance pouchoscopy is only recommended in those with FAP, those with a previous history of dysplasia or carcinoma, primary sclerosing cholangitis, those with a retained rectal cuff, and those with Type C histological changes. Flexible pouchoscopy is a useful first-line investigation in patients with pouch dysfunction. It can be performed without sedation and has a high diagnostic yield; it is also important as part of surveillance in FAP and selected UC patients.

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.