BMJ Open Gastroenterology最新文献

Objective: To compare water-assisted colonoscopy (WAC) using the water immersion technique with conventional carbon dioxide insufflation colonoscopy (CC) in novice endoscopists, focusing on procedure time, safety and learning curves.

Methods: We conducted a prospective, randomised (1:1), single-centre trial at Chiang Mai University Hospital, Thailand. Six gastroenterology fellows with <150 prior colonoscopies received standardised training before performing elective screening colonoscopies using either WAC or CC techniques. Patients were randomly assigned to WAC or CC groups. The primary outcome was caecal intubation time (CIT). Secondary outcomes included technical failure, procedural difficulty, patient discomfort, complications, withdrawal time and adenoma detection rate (ADR).

Results: Of 250 randomised patients, 230 completed the protocol (WAC, n=113; CC, n=117). Mean CIT was comparable between groups (10.6±4.2 min vs 9.8±3.9 min; p=0.35). Technical failure occurred in 6.2% of WAC and 5.1% of CC procedures, with no significant differences in procedural difficulty ratings, analgesic requirements or patient discomfort scores. ADR was similar between arms (40.7% vs 33.3%; p=0.25). Learning curves demonstrated parallel, progressive reductions in CIT among fellows in both groups.

Conclusion: WAC is a safe and effective alternative to CC for novice endoscopists, with similar procedure times, learning curves and safety profiles. These findings support the inclusion of WAC in gastroenterology training programmes.

Trial registration number: TCTR20230324001.

Objective: This study evaluates the experiences, perceptions, and attitudes of people with Lynch syndrome (LS) towards faecal immunochemical testing (FIT) as an adjunct to colonoscopy for colorectal cancer surveillance.

Methods: A mixed-methods design included two cohorts: an emergency clinical service during the COVID-19 pandemic and a longitudinal research initiative. Paper-based surveys assessed user experiences and attitudes using Likert scales and open-ended questions. Quantitative data were analysed for response patterns, while thematic analysis explored qualitative feedback.

Results: Among 85% of participants who rated FIT positively, 90% were confident in using the test correctly. Women reported higher anxiety (7.8%) compared with men (2.0%, p=0.045). Thematic analysis revealed gratitude for FIT's convenience during healthcare disruptions but emphasised concerns about its accuracy.

Conclusions: FIT is widely perceived as an acceptable supplemental tool among surveyed people with LS, who appreciate its potential to reduce intervals between colonoscopies without compromising surveillance quality. Ongoing patient engagement is crucial to addressing concerns about FIT's reliability. Future research should evaluate long-term outcomes and explore diverse population perspectives to guide FIT implementation in LS surveillance.

Objective: To assess the safety and quality of baseline screening colonoscopy in a randomised controlled trial (RCT).

Methods: A population-based RCT with an explanatory design is ongoing to evaluate the efficacy of colonoscopy screening in 9751 men and women aged 40-74 years at average risk of colorectal cancer (CRC) in Japan. Screening colonoscopies for the intervention group were performed from June 2009 to June 2017.

Results: Of the 4861 participants in the intervention group, 4495 (92.5%) underwent screening colonoscopy. The quality of bowel preparation was excellent (34.8%) or good (45.6%) in 80.4% of cases. The caecal intubation rate was 99.7% (4483/4495), and the mean (±SD) withdrawal time was 9.7 (±5.3) min. The adenoma detection rate (ADR) was 39.4% (1770/4495). A total of 27 participants (0.6%) were diagnosed with CRC, and 266 (5.9%) were diagnosed with advanced neoplasia (AN). In women, adenomas were more frequently detected in the proximal colon than in the distal colon (proximal: 18.9% vs distal: 16.4%, p=0.024), and a similar trend was observed for AN (proximal: 2.4% vs distal: 1.5%, p=0.045). No serious adverse events related to screening colonoscopy were reported, and minor adverse events were observed in two participants (0.04%).

Conclusions: Adequate performance in compliance, ADR, and safety was confirmed in the intervention arm of the RCT evaluating the efficacy of screening colonoscopy. The high quality of screening colonoscopy observed in the trial suggests its feasibility as a population-based screening approach.

Trial registration number: UMIN000001980.

Objectives: In many countries, single-use endoscopy accessories such as forceps have almost replaced their reusable counterparts. We reviewed the evidence on the broader economic cost and environmental impacts associated with single-use and multiple-use accessories for gastrointestinal (GI) endoscopes.

Design: Systematic review following the reporting guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data sources: MEDLINE, Embase, Web of Science and Cochrane Database of Systematic Reviews were searched from 1 January 2000 to 25 September 2024.

Eligibility criteria: We included published economic evaluations on single-use and reusable GI endoscope accessories which were written in English.

Data extraction and synthesis: Two independent reviewers extracted data and quality-assessed identified studies according to the Consensus on Health Economic Criteria checklist.

Results: Seven economic analyses were included: all were cost analyses. Three studies were from the USA, three from Europe and one from Korea. Patients in these studies underwent GI endoscopy (n=3), colonoscopy (n=2), gastroscopy (n=1) and endoscopic retrograde cholangiopancreatography (n=1). All studies compared single-use with reusable accessories, of which six were forceps. Reprocessing and purchase costs were included in all studies, repair costs were included in three studies, and environmental impact was only considered in one study. Most studies (n=5) reported a higher cost per procedure associated with single-use accessories.

Conclusions: Apart from two studies, all studies indicated that the cost per procedure was greater using single-use accessories/forceps. Future economic evaluations of single versus reusable accessories/forceps should include costs and also consequences of health and beyond, especially environmental impact.

Objective: This cost-effectiveness analysis compares vonoprazan against lansoprazole, a gold-standard proton pump inhibitor, in managing erosive oesophagitis.

Methods: The economic evaluation was carried out using data from a double-blind, randomised control trial. Costs were measured in pounds sterling. Effectiveness was assessed on a binary scale, resolution versus non-resolution of disease, after 32 weeks.

Results: The primary analysis produced an incremental cost-effectiveness ratio (ICER) of £3421.27 per resolution. After applying quality-adjusted life year (QALY) data from the REFLUX trial (2008), we derived an ICER/QALY of £34 747.32, marginally exceeding the £30 000 threshold set by the National Institute for Health and Care Excellence. However, further subgroup analysis showed cost-effectiveness when healing severe grades of oesophagitis (ICER/QALY of £22 165.56). The first sensitivity analysis considers the typically non-invasive determination of disease resolution; the ICER/QALY of £15 826.98 supports vonoprazan's use in treating severe oesophagitis. The second considers a longer healing phase alongside a stronger 30 mg maintenance dose of lansoprazole, concordant with current guidelines; the ICER/QALY of £43 998.39 suggests the guidelines (regarding dosage, frequency and duration) must be optimised for vonoprazan. The final sensitivity analysis accounts for variations in quality-of-life measures, which grossly inflate the ICER/QALY (£118 216.32); this emphasises that vonoprazan should mainly be considered for patients with persistent symptoms and high severity.

Conclusion: Vonoprazan is potentially cost-effective for the initial healing of severe oesophagitis, after endoscopic diagnosis. Further trials and economic evaluations are necessary for the symptom-based prescription of vonoprazan and to determine the optimal dosage, frequency and duration.

Objective: Colon capsule endoscopy (CCE) has emerged as a promising alternative for investigating lower gastrointestinal symptoms. However, its adoption has been limited due to concerns about cost-effectiveness, significantly influenced by follow-up endoscopy rates (FERs). Understanding CCE's FERs is crucial for its integration into routine clinical practice. We synthesised the evidence to evaluate the overall rate of further investigation in CCE.

Design: A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data sources: Medline, Embase, and PubMed were searched through 15 August 2024.

Eligibility criteria: Studies included reporting FERs after CCE, including subsequent endoscopic procedures and radiological imaging. There were no language restrictions or limitations in CCE referral indications, patient recruitment criteria, or pathologies investigated.

Data extraction and synthesis: All studies were independently screened and extracted two times by four reviewers. A random-effects model was used for meta-analysis and meta-regression to identify key contributing factors.

Results: 2850 participants from 19 studies were included in the analysis. Compared with the key performance indicators for FERs in colonoscopy (0.10-0.15) and CT colonography (0.25), the pooled FER for CCE was found to be 0.42 (95% CI 0.34 to 0.50). The meta-regression analysis identified complete transit rates and adequate bowel cleansing quality as factors inversely associated with FERs. Furthermore, the CCE2 capsule demonstrated a higher reinvestigation risk than CCE1, likely due to its improved diagnostic accuracy. Although CCE indications were associated with lower FERs, subgroup analysis did not reach statistical significance with high heterogeneity.

Conclusion: This study highlights significant FERs for CCE and identifies key contributing factors, emphasising the importance of appropriate patient selection to reduce reinvestigation needs. Future research should focus on improving completion rates, bowel preparation protocols, and refining CCE indications. This will minimise environmental impact and enhance cost-effectiveness and patient satisfaction.

Prospero registration number: CRD42024567959.

Objective: A case-based survey was conducted to identify practice patterns and knowledge gaps in the management of Crohn's perianal fistulas (CPF) and to further understand approaches to CPF management within the USA by healthcare professionals (HCPs) from different specialties.

Methods: The web-based survey, comprising two hypothetical patient case vignettes (case 1: initial CPF presentation and progression to partial response; case 2: recurrent CPF), was distributed September-October 2020 to US gastroenterologists (GEs) and colorectal surgeons (CRSs), and nurse practitioners (NPs) and physician assistants (PAs) from these specialties, who managed ≥1 patient with CPF/month. The survey included questions on clinician evaluation and treatment approach.

Results: Across surveyed HCPs (127 GEs, 63 GE NP/PAs, 78 CRSs and 14 CRS NP/PAs), 39% stated that they did not use any standard system for classifying/scoring CPF. On initial CPF presentation, ≥98% of HCPs reported a requirement for additional diagnostic/imaging evaluation before proceeding with medical management; GEs preferred pelvic MRI (70%) and CRSs preferred examination under anaesthesia (62%). Preferred management after partial response to initial treatment varied by HCP type (23% GEs vs 71% CRSs preferred continuation of current medical therapy; 60% vs 38% preferred seton continuation; 24% vs 41% preferred seton removal, respectively). For recurrent CPF, most HCPs chose to switch from infliximab to another antitumour necrosis factor agent, while most GEs opted to switch to a different monoclonal antibody. In contrast, 44% of GEs and 27% of CRSs opted to proceed with surgery.

Conclusion: Lack of consensus in CPF management requires improved coordination in treatment approaches among specialists.

Objective: Adenoma 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.

Methods: We 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.

Results: 92 892 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).

Conclusions: We 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.