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Patients with inflammatory bowel diseases (IBDs) of the colon are at an increased risk of colorectal cancer (CRC). This study investigates the epidemiology of IBD-CRC and its outcomes. Using population data from the English National Health Service held in the CRC data repository, all CRCs with and without prior diagnosis of IBD (Crohn's, ulcerative colitis, IBD unclassified, and IBD with cholangitis) between 2005 and 2018 were identified. Descriptive analyses and logistic regression models were used to compare the characteristics of the 2 groups and their outcomes up to 2 years. Three hundred ninety thousand six hundred fourteen patients diagnosed with CRC were included, of whom 5,141 (1.3%) also had a previous diagnosis of IBD. IBD-CRC cases were younger (median age at CRC diagnosis [interquartile range] 66 [54-76] vs 72 [63-79] years [ P < 0.01]), more likely to be diagnosed with CRC as an emergency (25.1% vs 16.7% [ P < 0.01]), and more likely to have a right-sided colonic tumor (37.4% vs 31.5% [ P < 0.01]). Total colectomy was performed in 36.3% of those with IBD (15.4% of Crohn's, 44.1% of ulcerative colitis, 44.5% of IBD unclassified, and 67.7% of IBD with cholangitis). Synchronous (3.2% vs 1.6% P < 0.01) and metachronous tumors (1.7% vs 0.9% P < 0.01) occurred twice as frequently in patients with IBD compared with those without IBD. Stage-specific survival up to 2 years was worse for IBD-associated cancers. IBD-associated CRCs occur in younger patients and have worse outcomes than sporadic CRCs. There is an urgent need to find reasons for these differences to inform screening, surveillance, and treatment strategies for CRC and its precursors in this high-risk group.

Objective To perform a comprehensive audit of all colonoscopy undertaken in the UK over a 2-week period. Design Multi-centre survey. All adult (≥16 years of age) colonoscopies that took place in participating National Health Service hospitals between 28 February 2011 and 11 March 2011 were included. Results Data on 20 085 colonoscopies and 2681 colonoscopists were collected from 302 units. A validation exercise indicated that data were collected on over 94% of all procedures performed nationally. The unadjusted caecal intubation rate (CIR) was 92.3%. When adjusted for impassable strictures and poor bowel preparation the CIR was 95.8%. The polyp detection rate was 32.1%. The polyp detection rate for larger polyps (≥10mm diameter) was 11.7%. 92.3% of resected polyps were retrieved. 90.2% of procedures achieved acceptable levels of patient comfort. A total of eight perforations and 52 significant haemorrhages were reported. Eight patients underwent surgery as a consequence of a complication. Conclusions This is the first national audit of colonoscopy that has successfully captured the majority of adult colonoscopies performed across an entire nation during a defined time period. The data confirm that there has been a significant improvement in the performance of colonoscopy in the UK since the last study reported seven years ago (CIR 76.9%) and that performance is above the required national standards.

Objective The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion. Design The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects. Results 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion. Conclusions This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

ObjectiveTo describe and investigate the potential causes of the isolated caecal patch lesion, a previously undescribed endoscopic phenomenon of a lesion fulfilling endoscopic and histopathological criteria for chronic inflammatory bowel disease but without evidence of similar inflammatory pathology elsewhere at colonoscopy.MethodsCases were collected prospectively by one specialist gastrointestinal pathologist over a 10-year period. Full endoscopic and histopathological analysis was undertaken and follow-up sought to understand the likely cause(s) of the lesions.ResultsSix cases are described. Two had very close links with ulcerative colitis, one predating the onset of classical distal disease and the other occurring after previous demonstration of classical distal ulcerative colitis. Two occurred in younger patients and we postulate that these lesions may predict the subsequent onset of chronic inflammatory bowel disease. Finally two can be reasonably attributed to the effects of non-steroidal inflammatory agent therapy.ConclusionsCaecal patch lesions can be demonstrated in isolation. Despite the strong association of caecal patch lesions with ulcerative colitis, solitary lesions may well have disparate causes but nevertheless possess a close relationship with chronic inflammatory bowel disease.

Background There is a lack of educational tools available for surgical teaching critique, particularly for advanced laparoscopic surgery. The aim was to develop and implement a tool that assesses training quality and structures feedback for trainers in the English National Training Programme for laparoscopic colorectal surgery. Methods Semi-structured interviews were performed and analysed, and items were extracted. Through the Delphi process, essential items pertaining to desirable trainer characteristics, training structure and feedback were determined. An assessment tool (Structured Training Trainer Assessment Report—STTAR) was developed and tested for feasibility, acceptability and educational impact. Results Interview transcripts (29 surgical trainers, 10 trainees, four educationalists) were analysed, and item lists created and distributed for consensus opinion (11 trainers and seven trainees). The STTAR consisted of 64 factors, and its web-based version, the mini-STTAR, included 21 factors that were categorised into four groups (training structure, training behaviour, trainer attributes and role modelling) and structured around a training session timeline (beginning, middle and end). The STTAR (six trainers, 48 different assessments) demonstrated good internal consistency ( α  = 0.88) and inter-rater reliability (ICC = 0.75). The mini-STTAR demonstrated good inter-item reliability ( α  = 0.79) and intra-observer reliability on comparison of 85 different trainer/trainee combinations ( r  = 0.701, p  = <0.001). Both were found to be feasible and acceptable. The educational report for trainers was found to be useful (4.4 out of 5). Conclusions An assessment tool that evaluates training quality was developed and shown to be reliable, acceptable and of educational value. It has been successfully implemented into the English National Training Programme for laparoscopic colorectal surgery.

IntroductionPCCRC is a key quality indicator for the detection and prevention of colorectal adenocarcinoma (CRC). It is not known whether rates of PCCRC are changing over time. There is limited evidence of factors associated with PCCRC that might be amenable to quality improvement interventions.This study investigated trends in rates of PCCRC in the NHS in England; the extent of variation between NHS trusts; and potential causal associations with PCCRC.MethodsUsing linked national Hospital Episode Statistics and National Cancer Registration and Analysis Service data all individuals who had undergone a colonoscopy procedure between 1/1/2006 and 31/12/2012 and who developed a CRC to 31/12/2015 were identified. NHS trust provider status and potential associations with PCCRC were included in the analysis.International consensus methodology was used to calculate the PCCRC – 3 year rate (PCCRC-3 yr).1 2 Colonoscopies were labelled as true positive (CRC within 0 to 6 months of the procedure), false negative (CRC within 6 to 36 months) and true negative (CRC beyond 36 months). The PCCRC-3 yr rate was calculated as: false negatives/(true positive +false negative) x 100%.The PCCRC-3 yr rate was calculated for each year from 2006 to 2012. In addition, the rate in each colonoscopy provider was calculated, and organisations grouped using quintiles. PCCRC rates were calculated in relation to patient and tumour characteristics.ResultsBetween 2006 and 2012 1 08 908 colonoscopies followed by a diagnosis of CRC were identified. Of these, 93 240 (86%) were labelled true positive, 7781 (7%) were false negatives, and 7887 (7%) were true negative tests. There was a significant reduction in PCCRC-3 yr rates, from 8.6% in 2006 to 7.5% in 2012 (Chi2 for trend p<0.01). There was variation in unadjusted, mean PCCRC-3 yr rate between NHS Trusts from 5% (SD ±2%) in the highest performing quintile to 11% (SD ±2%) in the lowest. PCCRCs were significantly associated with female sex, right-sided colonic lesions, inflammatory bowel disease and diverticular disease diagnosis, mucinous CRC and in individuals with metachronous CRC.ConclusionThere has been a significant reduction in PCCRC-3 yr rates from 2006 to 2012, likely to be related to improvements in colonoscopic quality: particularly improved caecal intubation and bowel preparation resulting in improved lesion recognition and removal. There appears to be unwarranted variation of PCCRC-3 yr rates across NHS trusts. Reasons for this variation need to be explored and subject to quality improvement projects. Evidence from this study can be used to help target those at highest risk of PCCRC.References. Morris EJA, et al. Gut2014;64:1248–56.. Beintaris I, et al. UEG J2017;5:PO436.

ObjectiveOperator technical skill is recognised as a critical determinant of surgical outcomes. However, no equivalent recognition for quality of endoscope tip manipulation (tip-control) exists. We aimed to create an ex-vivo snare tip soft coagulation (STSC) model to objectively quantify endoscopist tip-control.MethodThis prospective interventional study was conducted at Ghent University Hospital. Participants applied STSC to a training model simulating four endoscopic mucosal resection (EMR) defects on a slice of ham. Accuracy (correct/total-hits) and speed (correct-hits/s) were assessed from a video by a single-blinded rater using a web-based scoring system.Results22 endoscopists participated. Interventional endoscopists demonstrated significantly higher accuracy (87.0%) and speed (0.184 correct-hits/s) compared with trainees (74.5%, 0.106 correct-hits/s; both p<0.001) and non-interventional consultants (77%, 0.141 correct-hits/s; p<0.001). The tip-control of trainees and non-interventional consultants was not significantly different. Endoscopists having performed ≥1000 colonoscopies, performing SMSA-4 polypectomies or ≥50 EMRs/year showed superior tip-control. Endoscopists with >5 years of endoscopic experience did not have better tip-control (accuracy 88.0%(p=0.07), speed 0.132 hits/s (p=0.36)) when compared with those with ≤4 years of experience.ConclusionThis inexpensive ex vivo STSC simulation model effectively quantified endoscopic tip-control, correlating with endoscopist expertise and clinical profiles. The model could support the shift towards competency-based education, potentially improving patient outcomes.Trial registration numberNCT05660317.

ObjectiveAdenoma detection rate (ADR) has been criticised as a colonoscopy key performance indicator (KPI), for excluding serrated polyps, requiring histological data and fostering a ‘one-and-done’ attitude. We hypothesised that a case-mix-adjusted mean number of polyps (aMNP) would address these criticisms and provide a better measure of colonoscopy quality. We aimed to develop an aMNP using the National Endoscopy Database (NED) and assess its relationship with quality metrics.MethodsWe extracted colonoscopy data from NED for 1 January 2019–4 April 2019. Multiple negative binomial regression was undertaken to estimate effects of patient variables on MNP and generate aMNP. Associations between aMNP and polyp detection rate (PDR), proximal polypectomy rate (PPR), postcolonoscopy colorectal cancer (PCCRC) rate and Joint Advisory Group for GI endoscopy (JAG) Global Rating Scale (GRS) were explored.Results92 892 colonoscopies were analysed. Patient age, sex and procedure indication were significantly associated with MNP and used to create aMNP. At endoscopist level, aMNP strongly correlated with PDR (Spearman rho=0.834, p<0.001) and PPR (rho=0.709, p<0.001). Median aMNP was significantly lower in Trusts with higher versus lower PCCRC rates (73.9 vs 67.0 polyps per 100 procedures, p=0.047) and higher in units with GRS A/B versus C/D (aMNP 63.5 vs 55.2, p<0.001).ConclusionsWe demonstrate a method to compute a novel case-mix-adjusted KPI, aMNP, which is significantly associated with PDR, PPR, PCCRC and JAG GRS. Histological data were unavailable. aMNP addresses many limitations of ADR, adjusts for warranted variation in detection, and hence may improve audit and feedback engagement. We propose it as a candidate gold standard KPI for reporting endoscopy quality.

IntroductionCCRC is cancer arising 6–36 months after a negative colonoscopy. PCCRCs arise from incompletely or unresected lesions, or are missed or new lesions. PCCRC rates are a key quality marker for colonoscopy. The aim of this study was to test the utility of the World Endoscopy Organisation (WEO) algorithm for categorising avoidable factors leading to PCCRC.1 MethodsAll PCCRCs diagnosed between 01/06/10 and 31/12/16 at one trust were identified by cross-referencing coding and endoscopy data. A root-cause analysis was undertaken for each using the WEO algorithm (figure 1).Abstract PTH-009 Figure 1Results27 PCCRCs were reviewed (age 37–85, median 70). 5 patients had inflammatory bowel disease (IBD), 20 diverticulosis and 1 Lynch syndrome. Chromoendoscopy was used in 1 IBD patient. Adenomas had previously been seen in the cancerous bowel segment in 8 cases (29.6%): 3/8 arose from resected lesions; and 5/8 from unresected lesions. 2/5 unresected lesions were deliberately not investigated further (patient/MDT decision). Bowel preparation was poor in 6 colonoscopies (22.2%). 24 were reported as complete, but only 12 had adequate caecal photographs (44.4%). Overall, follow-up procedures were delayed or not requested in 11 cases (40.7%).Abstract PTH-009 Table 1Distribution of PCCRC originsConclusionsAlthough the WEO algorithm is a useful tool for PCCRC categorisation, a category for conservatively managed cases is missing. Further, a judgement is still required to conclude whether a PCCRC was avoidable or unavoidable. In this cohort, 70% of PCCRCs (19/27) were probably avoidable; 5 possibly avoidable and 3 likely unavoidable. The following are influencing factors and possible means of addressing them:PCCRC rates are high in patients with existing colon pathology. Rates would reduce in certain groups with greater vigilance and use of chromoendoscopy.Surveillance timeframes were often breached. Effective processes should reduce delays.Bowel preparation was often poor. If these colonoscopies are not repeated, the decision should be recorded.Some adenomas were overlooked while endoscopists focussed on large polyps. Early repeat colonoscopy should be considered after complicated procedures.Photodocumentation was adequate in 44.4% of cases. Inadequate photos may be a marker for other shortcomings and repeat colonoscopy considered if caecal documentation is incomplete.These findings indicate that PCCRC rates could be reduced by up to 70% if avoidable factors are addressed. There is a need for quality improvement studies targeting these factors to quantify their impact on PCCRC rates.References1. Beintaris I et al. UEG Journal. 2017;5:PO436

IntroductionHealthcare generates 4.4% of global carbon emissions1 and endoscopy is the 3rd largest contributor.2 CO2 gas insufflation is best practice in colonoscopy, but the volume of CO2 used has not been measured. This study aimed to quantify CO2 use and explored ways to reduce it.MethodsAn Alicat portable mass flow meter was used to measure pre-procedure CO2 flow rate (Litres/min) and volume of CO2 used/colonoscopy (Litres). Case length (min) and type were recorded. Each case used either a standard black Olympus MH-438 valve (continuous CO2 release) or a grey MAJ-2010 valve (only releases CO2 when depressed). Endoscopists used CO2 as standard, or prudently (i.e. only when needed intra-procedurally). Cases were categorised as A (black, standard), B (black, prudent), C (grey, standard) or D (grey, prudent). Average CO2 use was analysed using a student’s t-test with Welch’s correction.ResultsAverage CO2 flow rate using black valves was 2.47L/min, or 0.98L/min with the valve occluded. Grey valves prevented CO2 flow unless depressed. A total of 299 colonoscopies were recorded by 5 endoscopists. Table 1 summarises results:Abstract O59 Table 1Approach Total Cases BCSP Service Training Mean length of case (min) Mean Vol CO2/case (LCO2) Mean Flow rate CO2 (L/min) Mean volume CO2/39.1min colonoscopy A 20 1 3 16 45.4 117.1 2.73 106.7 B 152 43 61 48 39.7 78.5 1.97 77.0 C 36 7 11 18 38.6 17.9 0.46 18.1 D 91 33 39 19 36.7 12.0 0.32 12.6 There were no technical issues with the MAJ-2010 valves during the study.ConclusionsApproach A and C were abandoned early in the study as they were clearly wasteful of CO2. Adjusting for procedure length (mean length = 39.1min), being prudent significantly reduces CO2 use from 106.7 to 77L/case (p=0.01). Careful CO2 use plus grey valve cuts it to 12.6L/case (88.2% saving, p<0.0001).870,000 colonoscopies were performed in the UK in 2023. Assuming 1000L CO2 weighs 1.836Kg at 25°C and normal atmospheric pressure this equates to 170.4 tonnes (T) of CO2. Prudent CO2 use alone could cut this to 123T (average cost 0.377p/LCO2; annual saving £97,413). If 80% of colonoscopies use Olympus scopes, grey valve adoption could reduce annual emissions by 120.2T (annual saving £246,911).Endoscopy units have a duty to minimise their carbon footprints. We recommend that:CO2 is switched off until the procedure starts and as soon as it finishesCO2 is only turned on when required intra–procedurallyOlympus units adopt the MAJ–2010 valveAll manufacturers develop an equivalent valveThese methods are adopted to reduce emissions in flexible sigmoidoscopy and ERCP.Referenceshttps://www.arup.com/perspectives/publications/research/section/healthcares-climate-footprint.Vaccari, et al. Waste Manag Res. 2018;36:39–47.