Frequency and Predictors of Emergency Department Visits Following Colonoscopy: An Assessment of Procedure Safety

Introduction: Colonoscopy is the most commonly performed colorectal cancer screening test in the US, and is associated with known adverse events (AE), including gastrointestinal bleeding (GIB), bowel perforation, abdominal pain, and others. Despite this, post-colonoscopy AEs are rarely monitored by current colonoscopy quality programs. This study investigated the frequency of ED visits in the two weeks following an outpatient colonoscopy at a multi-site academic center. Method(s): We conducted a retrospective cohort study including all adults aged >= 40 who underwent an outpatient colonoscopy at a single academic center between 2016-2019. Data from 2020 were excluded given unpredicTable effects of the COVID-19 pandemic on healthcare utilization. Patients were identified using procedural codes and administrative claims records were used to identify persons who had a subsequent ED visit up to 14 days after their procedure date. For those with ED visits, patient charts were reviewed to data including details of ED presentation. Descriptive statistics were used to characterize the sample. Result(s): There were 187 patients who had an ED visit within two weeks of their colonoscopy, among 34,222 total colonoscopies during the same 4 year time period (0.44%). 46.1% of the ED visits reviewed were either definitely or possibly related to post-colonoscopy AEs. The mean age of the population sample was 61 years. The most common presenting symptoms to the ED post-colonoscopy included abdominal pain (47%), GI bleeding (27.7%), and nausea/vomiting (20.6%). The most common ED diagnosis included GI bleed (26.2%), dehydration (6.4%), and obstruction (3.6%). Nearly half of patients presenting to the ED were admitted (47.2%). In terms of clinical details of the colonoscopies of those who presented to the ED, polypectomy was performed in 67.4% of patients and polypectomy of a large (>=10mm) polyp was performed in 22.7% of patients. Hot snare/biopsy was used in 36.9% of patients and periprocedural use of anti-thrombotics occurred in 36.9% of patients. (Table) Conclusion(s): ED visits occurred in roughly 4 out of 1000 patients within two weeks of a colonoscopy at our center, and nearly half of these patients were admitted. A high proportion of ED visits were for GI symptoms. Furthermore, over 1/3rd of patients with ED visits following a colonoscopy had polyps removed with electrosurgical techniques. These data suggest that regular monitoring of post-colonoscopy ED visits may be valuable for quality improvement purposes.

The hidden dangers of SARS-CoV-2 testing

A foreign body can be intentionally or accidentally ingested. Timing of endoscopy relies on foreign body shape and size, location in gastrointestinal tract, patient's clinical conditions, occurrence of symptoms or onset of complications. In this short case, we present a middle age woman, who accidentally swallowed a portion of a nasopharyngeal swab half-broken during a diagnostic test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Upper gastrointestinal endoscopy was promptly performed to prevent the swab from crossing the pylorus leading to serious complications and, therefore, risk of surgical intervention. The broken nasopharyngeal swab was detected in the gastric body, and immediately removed with a foreign body forceps. Our hospital performs many nasopharyngeal swabs and to our knowledge, this is only the second reported swab ingestion during SARS-CoV-2 test.Copyright © 2021 The Gastroenterological Society of Taiwan, The Digestive Endoscopy Society of Taiwan and Taiwan Association for the Study of the Liver.

Dupilumab as a steroid-sparing treatment option in pediatric severe asthma and chronic rhinosinusitis with nasal polyps

Case report Chronic rhinosinusitis with nasal polyps (CRSwNP) is a frequent comorbidity in severe asthma in adults. Both diseases share key pathophysiological mechanisms that can involve type-2 inflammatory pathways. However, this is an uncommon presentation in pediatric patients. Dupilumab, a fully human monoclonal antibody against IL-4Ralpha, inhibits IL-4/ IL-13 signaling, which are key drivers of type-2 inflammation and interfere with both eosinophilic and allergic pathways. It is approved for patients >= 12-year- old with moderate to severe uncontrolled asthma, but its approval in CRSwNP is limited to adults. We report a case of a 12-year- old boy with severe uncontrolled asthma and highly symptomatic CRSwNP referred to our center in May 2021. He was sensitized to house dust mite and pollens, and a specific immunotherapy had been tried previously. He was treated with high dose inhaled corticosteroid, long-acting beta agonist, long-acting muscarinic antagonist, montelukast and daily intra-nasal corticosteroids. Furthermore, a bilateral endoscopic sinus surgery with polypectomy was performed in April 2021. Despite adherence to medication and surgical treatment, both diseases were uncontrolled with frequent exacerbations requiring unscheduled visits and multiple systemic corticosteroid courses. This led to failure to thrive and several missed school days. Oral corticosteroid (OCS) tapering was unachieved due to symptoms rebound and so maintenance therapy with prednisolone 10mg daily was attempted, with only a slight improvement. High levels of eosinophils (1010 cells/muL), FeNO (122 ppb) and IgE (2255 kU/L) were present. Treatment with subcutaneous dupilumab was started in July 2021. A clinical and analytical improvement was evident at the 3-month evaluation (Table 1). He was able to stop prednisolone, and no clinically relevant exacerbations occurred. He also was fully vaccinated and had an asymptomatic COVID-19 infection in December 2021. Patients with CRSwNP and comorbid asthma have a higher disease burden than patients with each disease alone. In this adolescent, dupilumab was effective as an add-on treatment, for both severe asthma and CRSwNP. It led to disease control, OCS withdrawal, reduced eosinophilic inflammation, improved lung function, smell recovery and absence of exacerbations during follow-up. Dupilumab, targeting the type 2 inflammatory process, may allow a better management of pediatric patients >=12 years old with severe CRSwNP and comorbid asthma. (Table Presented).

An audit of compliance with the updated post-polypectomy and post-colorectal cancer resection surveillance guidelines at a District General Hospital (DGH)

Background: It is important we identify cases of premalignant polyps and stratify patients according to future colorectal cancer (CRC) risk to prevent CRC development. In 2020, the British Society of Gastroenterology (BSG) published guidelines to tailor post-polypectomy and post-CRC resection surveillance. The objective of our audit was to determine whether our department was adhering to these guidelines. Method(s): We performed a retrospective audit of patients who had a colonoscopy at a DGH from February to June 2021. We reviewed case notes for indication, findings, and compliance to BSG's guidelines. Result(s): A total of 578 cases were reviewed. The median age was 61 years old. Most of the referrals were via the 2-week-wait pathway. 285 had normal findings on colonoscopy, 28 had CRC, 22 had polyps meeting high risk findings, and 12 had large non-pedunculated colorectal polyps. Our unit was 93.6% (547/578) compliant with the guidelines. 6.4% (31/578) were not compliant. Of those, 18 were scheduled for a surveillance colonoscopy when the polyps did not meet the criteria, 6 colonoscopies were not booked within the appropriate timeframe, 2 did not have their 6-month site check, and 1 had a surveillance colonoscopy despite a normal index colonoscopy. Conclusion(s): Our unit is highly compliant with BSG's guidelines. COVID-19 may have influenced the timing of colonoscopies, which could have impacted our compliance. Furthermore, there is little data on how our DGH compares to national data. We have placed the updated guidelines throughout the department to enhance awareness across the wider team. Copyright © 2022

Malignant polyps in the COVID-19 era: a population-based analysis.

BACKGROUND: Malignant polyps represent the early development of colorectal adenocarcinoma. During 2020, there was widescale rationing of health-care resources in response to the COVID-19 pandemic. In particular there was deferral of some colonoscopy procedures required for timely malignant polyp detection. This study sought to assess how these deferrals affected the diagnosis of malignant polyps. METHODS: A population wide analysis was performed of 2079 malignant polyps, diagnosed in Queensland, Australia from 2011 to 2020. A regression analysis, with 95% prediction intervals, was produced to determine whether there was a significant impact on the number of malignant polyps diagnosed in 2020 compared to previous years. Univariate statistical analysis of patient, procedural, and pathological variables was also performed. RESULTS: In 2020 there were 211 malignant polyps diagnosed, which was significantly lower than was predicted by the univariate regression analysis (r2  = 0.85, 95% prediction interval: 255.07-323.91, P < 0.001). These malignant polyps were less likely to be diagnosed in a private setting (P < 0.001), and exhibited significantly less depth of submucosal invasion (P = 0.017). There was no significant difference in the management strategy (polypectomy, resection or trans-anal resection) between 2011 and 2019 and 2020. CONCLUSION: Because of the significant decrease in the number of malignant polyps, and the natural history of the disease, it is expected that there will be an increase in more advanced colorectal adenocarcinomas presenting in 2021 and beyond. This has implications for healthcare resources, particularly in light of the ongoing strain on health departments as a result of the COVID-19 pandemic.

A RETROSPECTIVE REVIEW OF COMPLEX POLYP MANAGEMENT IN THE CHAMPLAIN REGION, ONTARIO

Background: Advanced endoscopic techniques have enabled the removal of polyps which, due to their size, location, or morphology, would otherwise have been removed surgically. Patients with such complex polyps should be referred promptly to expert centres for adjudication and management. Aims: To review patterns of referral and initial management of complex polyps at The Ottawa Hospital (TOH), to identify gaps in care and to identify strategies to address those gaps. Methods: We performed a retrospective chart review of cases where large (>3cm) colonic polyps were evaluated at TOH, from March 2019-March 2021. Cases were identified using Canadian Institute of Health Information codes. Descriptive statistics were analyzed, and were compared using Mann-Whitney U tests where appropriate. Results: 94 consecutive patients with large polyps (mean age 68;56.4% male) were included. The average polyp size was 4.7(4.4-5.1)cm. 45 patients were referred for a known complex polyp while the rest were referred for FIT/FOBT+ (n=20), symptoms or anemia (n=17), surveillance (n=9), or abnormal imaging (n=3). 32 patients were referred from >50km from Ottawa (travelling), and 62 were referred from <50km from Ottawa (local). Of the 45 referrals for known polyp, 20 (44.4%) included photodocumentation of the lesion;33 (73.3%) had a prior biopsy, and 8 (17.8%) were partially removed. Key statistics are summarized in Table 1. All 8 patients referred with a partially removed polyp eventually had a successful endoscopic polypectomy. 10/94 (10.6%) patients required surgical resection: 7 for malignant pathology, and 3 for endoscopic failure. Overall, 3 patients had post-polypectomy bleeding, and 1 patient sustained a full-thickness perforation. As of October 2021, 26/78 (33.3%) patients eligible for a 4-6 month recheck and 36/48 (75%) patients eligible for a 12-month follow-up colonoscopy were overdue. Conclusions: This retrospective review highlights significant differences in the management of complex polyps based on patient geography and the need to develop strategies to improve access for patients referred from outside of Ottawa. As expected, COVID had a significant impact on the time to complete removal of polyps, and affected the timely endoscopic follow up of these high-risk patients. Strategies to ensure timely endoscopic follow up of patients after complex polyp removal are needed. (Table Presented).

COLONOSCOPY WAITING LIST VALIDATION ACHIEVES TWO-THIRDS REDUCTION OF NUMBERS AWAITING POST-POLYPECTOMY SURVEILLANCE

Introduction Waiting lists in Northern Ireland are the worst in the UK, representing a growing problem and one exacerbated by the Covid-19 pandemic. Those currently awaiting diagnostic services in NI total 147,543 including 31,313 endoscopy investigations (60% of which are waiting >26 weeks). By applying recent BSG/ACPGBI/PHE Guidelines for post-polypectomy surveillance, this study aimed to reduce the numbers of those awaiting planned colonoscopy within our Trust. The Guidelines suggest patients with polyps and high-risk findings should receive a one-off surveillance colonoscopy at 3 years, compared to previous 1-year interval advice. Patients who previously required follow up endoscopy at 5 years may be safely discharged with invitation to screening if no high risk features. Methods Validation of the waiting list was undertaken by consultants and nurse endoscopists with reference made to the current Guidelines. Patient records were reviewed using the Unisoft GI Reporting Tool v14.40.10 and the NI Electronic Care Record. Those relevant to polyp surveillance were identified (n=2001). Each request was categorised to either 'Remove', 'Proceed' or 'Defer'. Outcomes were recorded in an Excel spreadsheet. Patients were informed by letter of any change to their management plan, reasons for removal from the waiting list and given advice on seeking new referral if further symptoms developed. Participation in the Bowel Cancer Screening Programme (BCSP) was encouraged. The NHS England 2021-22 National Tariff for colonoscopy with biopsy (£548) was referenced in calculation of potential cost savings. Results A total of 5403 requests were on the endoscopy waiting list. 84 patients were deceased and were removed from the list. 1964 related to polyp surveillance and 37 to polyp site check. Following validation of 2001 tests, 1286 (64%) were categorised as 'Remove', 588 (29%) 'Proceed' and 127 (6%) 'Defer'. Reasons for removal included no high-risk features, age over 75 or life expectancy less than 10 years. Potential cost savings following removal of 1286 requests totalled £704,728.00. Conclusion Validation of the waiting list, considering updated or incorrect adherence to the current surveillance guidelines, achieved almost two thirds reduction. If applied nationally, this may greatly reduce the burden of outstanding endoscopy procedures and improve access to these services. Current guidelines state that patients >10 years younger than the BCSP who have polyps without high-risk features should be considered for colonoscopy at 5 or 10 years. In Northern Ireland, the BCSP lower age limit is 60 years. If this were reduced in line with England's 50 years, this may further reduce some surveillance burden allowing suitable patients to be invited to the Screening pathway rather than repeat endoscopy.

STUDY METHODS AND INTERIM RESULTS OF RANDOMIZED CONTROLLED TRIAL (RCT) OF BLOOD FLOW MONITORING TO PREVENT DELAYED POST-POLYPECTOMY INDUCED ULCER HEMORRHAGE (DPPIUH)

DDW 2022 Author Disclosures: Dennis Jensen: NO financial relationship with a commercial interest ;Rome Jutabha: NO financial relationship with a commercial interest ;Gareth Dulai: NO financial relationship with a commercial interest ;Noam Jacob: NO financial relationship with a commercial interest ;Jeffrey Gornbein: NO financial relationship with a commercial interest Background and Aims: The best strategy to prevent DPPIUH is controversial. Some colonoscopists recommend hemoclip closure of PPIU’s but this has mixed success rates in different RCT’s and is reported not to be cost effective. In addition to known risks, arterial blood flow detected in PPIU’s is an important predictor of DPPIUH. Our AIMS are to report study methods and interim results of a RCT of blood flow monitoring to prevent DPPIUH. Methods: This is an ongoing blinded RCT at several major Los Angeles Medical Centers by experienced colonoscopists. Outpatients having colonoscopies are screened and consented for enrollment. Sessile and multilobulated polyps are removed by EMR techniques. Thermal coagulation is used for polypectomies in this study. Randomized patients are stratified by whether they take chronic anti-platelet or anti-thrombotic drugs and have PPIU’s of 10-40 mm;or those without bleed drugs and have PPIU’s between 15-40 mm. By opening a sealed envelope after polypectomies, randomization is to either standard management (e.g. following ASGE guidelines of bleed drugs) or DEP interrogation of the PPIU and guided treatment of the artery with hemoclips or multipolar probe coagulation in the PPIU until blood flow is eradicated. Patients and their care givers were blinded to treatments allocated during colonoscopy. Prospective follow-up is by a research coordinator contacting each patient at 7, 14, and 30 days to record whether any complications (e.g. pain, vomiting, or bleeding);or rectal bleeding and its severity (e.g. # and days of bloody BM’s);whether they sought ER, clinic, or telemedicine care for bleeding;or were hospitalized. Major DPPIUH was diagnosed in patients with hospitalization for severe bleeding and/or for 3 or more days of ongoing severe rectal bleeding but refusal of hospitalization because of high rates of COVID here. Demographic, laboratory, colonoscopic, and pathology results are recorded on standard forms along with 30-day outcomes. Patients are assigned a code, data are entered onto HIPAA compliant computer files by a data manager and managed with SAS. With half the projected sample size randomized and followed up (e.g. 133 of 268 total), this is a planned interim analysis of the primary outcome - rates of DPPIUH by treatment. Severe adverse events (SAE’s) were also reviewed. Results: For 133 high risk patients randomized to date, 67 are in the standard group and 66 in the DEP group. The groups were well matched in risk factors – see Table 1. Overall, the Doppler group had lower rates of delayed PPIU bleeding – both major and total- see Table 2. There were no SAE’s. Conclusions: The major DPPIUH rate was higher with standard treatment than DEP treatment (7.46 % vs. 0 %), as was the rate of Total DPPIUH (10.45 % vs. 1.52%). Based upon these promising results, this RCT will continue. [Formula presented] [Formula presented]

Post-polypectomy colonoscopy surveillance: Can we improve the diagnostic yield?

Although adenomas and serrated polyps are the preneoplastic lesions of colorectal cancer, only few of them will eventually progress to cancer. This review provides a comprehensive overview of the present and future of post-polypectomy colonoscopy surveillance. Post-polypectomy surveillance guidelines have recently been updated and all share the aim towards more selective and less frequent surveillance. We have examined these current guidelines and compared the recommendations of each of them. To improve the diagnostic yield of post-polypectomy surveillance it is important to find predictors of metachronous polyps that better identify high-risk individuals of developing advanced neoplasia. For this reason, we have also conducted a literature review of the molecular biomarkers of metachronous advanced colorectal polyps. Finally, we have discussed future directions of post-polypectomy surveillance and identified possible strategies to improve the use of endoscopic resources with the COVID-19 pandemic.

Colon capsule endoscopy versus computed tomographic colonography for identifying colorectal cancer and polyps: A systemic review and meta-analysis

Aim: Early diagnosis and treatment of Colorectal Cancer can improve outcomes. Polypectomy with colonoscopy has failure and incompletion rates with risk of aerosol-generation. Computed Tomographic Colonography, second investigation, is limited by radiation exposure and aerosol generation. Colon Capsule endoscopy is a novel technique without gas insufflation, therefore avoiding the discomfort and aerosol- generation. Our aim is to compare the yield of the CCE with CTC in CRC and polyps in patients with positive stool tests or diagnosed colorectal lesions. Methods: Review followed PRISMA standards. Electronic database (EMBASE, MEDLINE, PubMed, CINAHL) searched for RCTs and Observational studies. MedCalc Statistical Software used for the synthesis of results. Primary (Per-Lesion and Per-Patient sensitivity analysis) and secondary (Other lesion and completion rate sensitivity analysis) outcomes measured using a random-effect model. Results: We found one RCT and three observational studies. Per-Lesion Sensitivity Analysis of CCE versus CTC showed overall effect of 1.903 (0.990- 1.937), p-value-0.057. Per-Patient Sensitivity Analysis of showed overall effect of 1.928 (0.995-1.892), p-value-0.054. Other lesions Sensitivity Analysis showed overall effect of 0.810 (0.121-161.995), pvalue- 0.418. Completion Rate Sensitivity Analysis showed overall effect of -0.419 (0.526-1.516), p-value-0.676. Conclusion: CCE had a better detection rate for colorectal cancer and polyp than the CTC, but this was not statistically significant. Therefore, this study failed to prove CCE's superiority over CTC. A careful decision can be made in current COVID-19 pandemic since its advantage of zero aerosolisation. Researchers should focus on innovation in techniques and simultaneous high-quality studies to evaluate them.

Use of a cost-efficient Colonoscopy simulation model to improve endoscopy skills

Aims: The use of endoscopic simulators as a learning aid in surgical training has been well established, particularly in those with less experience. In the challenging time of COVID-19, when endoscopic procedures are at a minimum, this can become more valuable. However, their utility for training is countered by the high cost of equipment. We demonstrate a cost-efficient alternative to traditional endoscopy simultators, which can be easily made in any centre. Methods: A polypectomy simulator model was created using a drainpipe and surgical gloves. Junior doctors were timed in their ability to remove the 3 polyps from within the simulator. The exercise was repeated over 6 sessions over the course of 3 weeks. Means were compared using ANOVA. Results: There was a mean relative reduction of 75% in overall time taken to complete the task (p<0.0001). This improvement was seen for both surgical trainees with previous endoscopy experience (p=0.005) and FY1 novices (p<0.0001). Conclusions: In our group, we have seen improvement in performance across both surgical trainees and novices. In today's era of COVID-19, when direct training opportunities may become more scarce, simple alternatives may become vital in ensuring progression of basic surgical skills such as endoscopy. This cheap polypectomy simulator can be easily re-created across surgical units and can be used as an adjunct to traditional endoscopic training.