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Improving the quality of colonoscopy
Letters to the Editor
John Blomberg, MD, PhD Upper Gastrointestinal Research Department of Molecular Medicine and Surgery Karolinska Institute Department of Surgery Karolinska University Hospital Stockholm, Sweden Jesper Lagergren, MD, PhD Upper Gastrointestinal Research Department of Molecular Medicine and Surgery Karolinska Institute Stockholm, Sweden Cancer Division King=s College London, United Kingdom
REFERENCES 1. Blomberg J, Lagergren P, Martin L, et al. Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointest Endosc 2011;73: 29-36. 2. McMillan DC, Crozier JE, Canna K, et al. Evaluation of an inflammationbased prognostic score (GPS) in patients undergoing resection for colon and rectal cancer. Int J Colorectal Dis 2007;22:881-6. 3. Forrest LM, McMillan DC, McArdle CS, et al. Evaluation of cumulative prognostic scores based on the systemic inflammatory response in patients with inoperable non-small-cell lung cancer. Br J Cancer 2003;89: 1028-30. 4. McMillan DC. An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc 2008;67:257-62. 5. Moyes LH, Leitch EF, McKee RF, et al. Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer. Br J Cancer 2009;100:1236-9. 6. Ishizuka M, Nagata H, Takagi K, et al. Influence of inflammation-based prognostic score on mortality of patients undergoing chemotherapy for far advanced or recurrent unresectable colorectal cancer. Ann Surg 2009; 250:268-72. 7. Pfitzner T, Krocker D, Perka C, et al. C-reactive protein. an independent risk factor for the development of infection after primary arthroplasty [German]. Orthopade 2008;37:1116-20. doi:10.1016/j.gie.2011.09.035
Improving the quality of colonoscopy To the Editor: We read with interest the article by Lee et al,1 which investigated the relationship among colonoscopy withdrawal technique, withdrawal times, and adenoma detection rates (ADR). The authors demonstrated that colonoscopists with a lower ADR had significantly lower scores for the components of withdrawal technique but not for withdrawal times, compared with those with moderate and high ADRs. We agree that good colonoscopy withdrawal technique is vital to ensure a thorough colonic examination. The use of dynamic position change has been shown to improve luminal distenwww.giejournal.org
sion and adenoma detection,2 and the use of antispasmodics, such as hyoscine butylbromide, increases the visible mucosal area by reducing spasm, thereby improving lesion detection.3 The use of these measures was not reported in this study. We believe the routine use of position change and antispasmodics together with a minimum withdrawal time of 6 minutes4 and rectal retroflexion5 can improve ADR. We are currently testing this hypothesis in a service development study, entitled the Quality Improvement in Colonoscopy (QIC) study. The implementation of evidence into clinical practice can be challenging. Pronovost et al6 demonstrated that a model combining central training, locally led implementation, and ongoing central support could achieve a state-wide sustained reduction in catheter-related bloodstream infections through implementation of available clinical evidence. We aim to replicate this model for colonoscopy. The QIC study is taking place in 14 district hospitals in England, led by the Northern Region Endoscopy Group, a group developed to allow highquality collaborative research, in conjunction with Durham University, St. Mark’s Hospital, and the Oxford Translational Gastroenterology Unit. The importance of good colonoscopy withdrawal technique cannot be overstated. In addition, the routine use of simple maneuvers to maximize luminal distension and the visible mucosal area as an adjunct may improve ADR and thereby quality in colonoscopy at minimal cost. Praveen T. Rajasekhar, MBCHB, BMedSci, MRCP South Tyneside Foundation Trust The Northern Region Endoscopy Group Colin J. Rees, MBBS, FRCP South Tyneside Foundation Trust Durham University The Northern Region Endoscopy Group Matthew D. Rutter, MBBS, MD, FRCP University Hospital North Tees Durham University The Northern Region Endoscopy Group Brian P. Saunders, MBBS, MD, FRCP St. Marks Hospital Michael G. Bramble, MBBS, MD, FRCP Durham University The Northern Region Group Pali Hungin, MBBS, MD, FRCP, FRCGP Durham University James E. East, MBBS, MD, MRCP John Radcliffe Hospital Presented on behalf of the Quality Improvement in Colonoscopy Study Group
REFERENCES 1. Lee RH, Tang RS, Muthusamy VR, et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest Endosc 2011;74:128-34.
Volume 75, No. 1 : 2012 GASTROINTESTINAL ENDOSCOPY 229
Letters to the Editor
2. East JE, Bassett P, Arebi N, et al. Dynamic patient position changes during colonoscope withdrawal increase adenoma detection: a randomized, crossover trial. Gastrointest Endosc 2011;73:456-63. 3. Lee JM, Cheon JH, Park JJ, et al. Effects of hyoscine N-butyl bromide on the detection of polyps during colonoscopy. Hepatogastroenterology 2010;57:90-4. 4. Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. New Engl J Med 355;24:2533-41. 5. Hanson JM, Atkin WS, Cunliffe WJ, et al. Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum 2001;44:1706-82. 6. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-32. doi:10.1016/j.gie.2011.08.023
Robert H. Lee, MD University of California Irvine Veterans Affairs Long Beach Health Care System Raymond S. Tang, MD University of California San Diego San Diego, California V. Raman Muthusamy, MD University of California Irvine Samuel B. Ho, MD Veterans Affairs Medical Center San Diego Nimeesh K. Shah, MD University of California Irvine Laura Wetzel Veterans Affairs Long Beach Health Care System Andrew S. Bain, MD University of California San Diego Erin E. Mackintosh University of California San Diego Aeri M. Paek University of California Irvine Veterans Affairs Long Beach Health Care System Ana Maria Crissien, MD University of California Irvine Lida Jafari Saraf, MD University of California Irvine Veterans Affairs Long Beach Health Care System Denise M. Kalmaz, MD University of California San Diego Thomas J. Savides, MD, FASGE University of California San Diego San Diego, California, USA
Response: We appreciate Dr Rajasekhar’s comments on behalf of the QIC Study Group regarding our article on colonoscopy withdrawal technique and adenoma detection rates. In particular, we appreciate the author’s thoughts regarding the potential importance of dynamic position change and the use of antispasmodic agents in optimizing luminal distension during mucosal inspection. In our study, none of the endoscopists used these methods during the recorded colonoscopy withdrawals. To the best of our knowledge, none of the endoscopists regularly used these approaches in their everyday practices of colonoscopy. In general, the results of our study and the astute comments of the QIC Study Group highlight the importance of incorporating aspects of good withdrawal technique in quality improvement measures for screening colonoscopy. Given the contrasting results found in studies by Sawhney et al1 and Barclay et al,2 it is apparent that initiatives that focus solely on minimal withdrawal times without paying attention to withdrawal technique do not guarantee acceptable adenoma detection rates. Consequently, we look forward to Dr Rajasekhar’s pending study to determine whether a more holistic approach to quality improvement can enhance adenoma detection during screening colonoscopy.
REFERENCES 1. Sawhney MS, Cury MS, Neeman N, et al. Effect of institution-wide policy of colonoscopy withdrawal time ⬎ or ⫽ 7 minutes on polyp detection. Gastroenterology 2008;135:1892-8. 2. Barclay RL, Vicari JJ, Greenlaw RL. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol 2008;6:1091-8. doi:10.1016/j.gie.2011.09.036
ERRATUM In the Guideline, “The role of endoscopy in the management of choledocholithiasis,” which was published in the October 2011 issue of the Journal (Gastrointest Endosc 2011;74:731-44), some of the references were incorrectly cited in the text. Also, Dr Fanelli’s disclosure should read as follows: royalties, Cook Surgical, Inc; honoraria, Ethicon EndoSurgery, Inc; owner/governor, New Wave Surgical Corp. The complete text of the corrected article can be found with the online version of this Erratum at www.giejournal.org.
230 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 1 : 2012
www.giejournal.org
John Blomberg, MD, PhD Upper Gastrointestinal Research Department of Molecular Medicine and Surgery Karolinska Institute Department of Surgery Karolinska University Hospital Stockholm, Sweden Jesper Lagergren, MD, PhD Upper Gastrointestinal Research Department of Molecular Medicine and Surgery Karolinska Institute Stockholm, Sweden Cancer Division King=s College London, United Kingdom
REFERENCES 1. Blomberg J, Lagergren P, Martin L, et al. Albumin and C-reactive protein levels predict short-term mortality after percutaneous endoscopic gastrostomy in a prospective cohort study. Gastrointest Endosc 2011;73: 29-36. 2. McMillan DC, Crozier JE, Canna K, et al. Evaluation of an inflammationbased prognostic score (GPS) in patients undergoing resection for colon and rectal cancer. Int J Colorectal Dis 2007;22:881-6. 3. Forrest LM, McMillan DC, McArdle CS, et al. Evaluation of cumulative prognostic scores based on the systemic inflammatory response in patients with inoperable non-small-cell lung cancer. Br J Cancer 2003;89: 1028-30. 4. McMillan DC. An inflammation-based prognostic score and its role in the nutrition-based management of patients with cancer. Proc Nutr Soc 2008;67:257-62. 5. Moyes LH, Leitch EF, McKee RF, et al. Preoperative systemic inflammation predicts postoperative infectious complications in patients undergoing curative resection for colorectal cancer. Br J Cancer 2009;100:1236-9. 6. Ishizuka M, Nagata H, Takagi K, et al. Influence of inflammation-based prognostic score on mortality of patients undergoing chemotherapy for far advanced or recurrent unresectable colorectal cancer. Ann Surg 2009; 250:268-72. 7. Pfitzner T, Krocker D, Perka C, et al. C-reactive protein. an independent risk factor for the development of infection after primary arthroplasty [German]. Orthopade 2008;37:1116-20. doi:10.1016/j.gie.2011.09.035
Improving the quality of colonoscopy To the Editor: We read with interest the article by Lee et al,1 which investigated the relationship among colonoscopy withdrawal technique, withdrawal times, and adenoma detection rates (ADR). The authors demonstrated that colonoscopists with a lower ADR had significantly lower scores for the components of withdrawal technique but not for withdrawal times, compared with those with moderate and high ADRs. We agree that good colonoscopy withdrawal technique is vital to ensure a thorough colonic examination. The use of dynamic position change has been shown to improve luminal distenwww.giejournal.org
sion and adenoma detection,2 and the use of antispasmodics, such as hyoscine butylbromide, increases the visible mucosal area by reducing spasm, thereby improving lesion detection.3 The use of these measures was not reported in this study. We believe the routine use of position change and antispasmodics together with a minimum withdrawal time of 6 minutes4 and rectal retroflexion5 can improve ADR. We are currently testing this hypothesis in a service development study, entitled the Quality Improvement in Colonoscopy (QIC) study. The implementation of evidence into clinical practice can be challenging. Pronovost et al6 demonstrated that a model combining central training, locally led implementation, and ongoing central support could achieve a state-wide sustained reduction in catheter-related bloodstream infections through implementation of available clinical evidence. We aim to replicate this model for colonoscopy. The QIC study is taking place in 14 district hospitals in England, led by the Northern Region Endoscopy Group, a group developed to allow highquality collaborative research, in conjunction with Durham University, St. Mark’s Hospital, and the Oxford Translational Gastroenterology Unit. The importance of good colonoscopy withdrawal technique cannot be overstated. In addition, the routine use of simple maneuvers to maximize luminal distension and the visible mucosal area as an adjunct may improve ADR and thereby quality in colonoscopy at minimal cost. Praveen T. Rajasekhar, MBCHB, BMedSci, MRCP South Tyneside Foundation Trust The Northern Region Endoscopy Group Colin J. Rees, MBBS, FRCP South Tyneside Foundation Trust Durham University The Northern Region Endoscopy Group Matthew D. Rutter, MBBS, MD, FRCP University Hospital North Tees Durham University The Northern Region Endoscopy Group Brian P. Saunders, MBBS, MD, FRCP St. Marks Hospital Michael G. Bramble, MBBS, MD, FRCP Durham University The Northern Region Group Pali Hungin, MBBS, MD, FRCP, FRCGP Durham University James E. East, MBBS, MD, MRCP John Radcliffe Hospital Presented on behalf of the Quality Improvement in Colonoscopy Study Group
REFERENCES 1. Lee RH, Tang RS, Muthusamy VR, et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest Endosc 2011;74:128-34.
Volume 75, No. 1 : 2012 GASTROINTESTINAL ENDOSCOPY 229
Letters to the Editor
2. East JE, Bassett P, Arebi N, et al. Dynamic patient position changes during colonoscope withdrawal increase adenoma detection: a randomized, crossover trial. Gastrointest Endosc 2011;73:456-63. 3. Lee JM, Cheon JH, Park JJ, et al. Effects of hyoscine N-butyl bromide on the detection of polyps during colonoscopy. Hepatogastroenterology 2010;57:90-4. 4. Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. New Engl J Med 355;24:2533-41. 5. Hanson JM, Atkin WS, Cunliffe WJ, et al. Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum 2001;44:1706-82. 6. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-32. doi:10.1016/j.gie.2011.08.023
Robert H. Lee, MD University of California Irvine Veterans Affairs Long Beach Health Care System Raymond S. Tang, MD University of California San Diego San Diego, California V. Raman Muthusamy, MD University of California Irvine Samuel B. Ho, MD Veterans Affairs Medical Center San Diego Nimeesh K. Shah, MD University of California Irvine Laura Wetzel Veterans Affairs Long Beach Health Care System Andrew S. Bain, MD University of California San Diego Erin E. Mackintosh University of California San Diego Aeri M. Paek University of California Irvine Veterans Affairs Long Beach Health Care System Ana Maria Crissien, MD University of California Irvine Lida Jafari Saraf, MD University of California Irvine Veterans Affairs Long Beach Health Care System Denise M. Kalmaz, MD University of California San Diego Thomas J. Savides, MD, FASGE University of California San Diego San Diego, California, USA
Response: We appreciate Dr Rajasekhar’s comments on behalf of the QIC Study Group regarding our article on colonoscopy withdrawal technique and adenoma detection rates. In particular, we appreciate the author’s thoughts regarding the potential importance of dynamic position change and the use of antispasmodic agents in optimizing luminal distension during mucosal inspection. In our study, none of the endoscopists used these methods during the recorded colonoscopy withdrawals. To the best of our knowledge, none of the endoscopists regularly used these approaches in their everyday practices of colonoscopy. In general, the results of our study and the astute comments of the QIC Study Group highlight the importance of incorporating aspects of good withdrawal technique in quality improvement measures for screening colonoscopy. Given the contrasting results found in studies by Sawhney et al1 and Barclay et al,2 it is apparent that initiatives that focus solely on minimal withdrawal times without paying attention to withdrawal technique do not guarantee acceptable adenoma detection rates. Consequently, we look forward to Dr Rajasekhar’s pending study to determine whether a more holistic approach to quality improvement can enhance adenoma detection during screening colonoscopy.
REFERENCES 1. Sawhney MS, Cury MS, Neeman N, et al. Effect of institution-wide policy of colonoscopy withdrawal time ⬎ or ⫽ 7 minutes on polyp detection. Gastroenterology 2008;135:1892-8. 2. Barclay RL, Vicari JJ, Greenlaw RL. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol 2008;6:1091-8. doi:10.1016/j.gie.2011.09.036
ERRATUM In the Guideline, “The role of endoscopy in the management of choledocholithiasis,” which was published in the October 2011 issue of the Journal (Gastrointest Endosc 2011;74:731-44), some of the references were incorrectly cited in the text. Also, Dr Fanelli’s disclosure should read as follows: royalties, Cook Surgical, Inc; honoraria, Ethicon EndoSurgery, Inc; owner/governor, New Wave Surgical Corp. The complete text of the corrected article can be found with the online version of this Erratum at www.giejournal.org.
230 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 1 : 2012
www.giejournal.org