A retrospective analysis of the histology of resected polyps and colonoscopy quality parameters in Belgium.

Background and aims: adenoma detection rate is a well known quality parameter for colonoscopy. However recently other quality parameters have emerged. We wanted to evaluate the histology of the resected polyps, different quality indicators of colonoscopy and post colonoscopy colorectal cancer (PCCRC) in Belgium and analyzed data about colonoscopies performed between 2008-2015. Methods: Reimbursement data on colorectal related medical procedures from the Intermutualistic Agency were linked with data on clinical and pathological staging of colorectal cancer and with histologic data of resected polyps available at the Belgian Cancer Registry over a period covering 8 years (2008-2015). Results: 298,246 polyps were resected in 294,923 colonoscopies, of which 275,182 were adenomas (92 %) and 13,616 were SSLs (4%). There was a significant but small correlation between the different quality parameters and PCCRC. Post colonoscopy colorectal cancer rate after 3 years was 7.29 %. There were marked geographic differences in Belgium concerning adenoma detection rate, sessile adenoma detection rate and post colonoscopy colorectal cancer. Conclusion: Most resected polyps were adenomas, only a small percentage involved sessile serrated lesions. There was a significant correlation between adenoma detection rate and other quality parameters, and a small but significant correlation between PCCRC and the different quality parameters. The lowest post colonoscopy colorectal cancer rate was reached with an ADR of 31.4 % and a SSL-DR of 1.2 %.

Necrotizing soft tissue infection of the upper leg as first presentation of necrotizing pancreatitis: a case report.

Acute pancreatitis can be complicated with necrosis of the pancreatic or peripancreatic tissue. This necrosis can become liquified and form a well-defined wall (walled-off necrosis or WON) and can become infected and form abscesses. Necrotizing soft tissue infections are rare infections of the deep tissue and subcutaneous fat and are mostly caused by trauma or perforated visceral organs. They can, however, rarely be caused by infected retroperitoneal collections. To date only 3 case reports have been published of a necrotizing soft tissue infection complicating a necrotizing pancreatitis. Both acute, complicated pancreatitis and necrotizing soft tissue infections carry a high mortality and morbidity rate with surgery being the mainstay therapy for the latter, often leaving the patient disfigured. We report the case of a 62-year-old man presenting to the emergency department with a painful and erythematous rash of the upper leg as complication of an acute necrotizing pancreatitis.

Parameters influencing the quality of colonoscopy in Belgium : a critical evaluation.

BACKGROUND AND STUDY AIMS: In relation to recent implementation of colorectal cancer screening programs at the regional level, quality assessment of colonoscopy gains more interest in Belgium. In order to evaluate quality indicators of colonoscopies in Belgium, we retrospectively analysed data about colonoscopies performed between 2002-2010. PATIENTS AND METHODS: Coded data concerning number of medical procedures and polypectomy were provided by the Intermutualistic Agency (IMA). This database was used to calculate different quality indicators such as polyp detection rate (PDR), use of sedation, amount of procedures and time interval according to physician and center type. RESULTS: Considerable differences in polyp detection rate (PDR) exist between different physicians and centers. Mean PDR significantly correlated with the number of colonoscopies performed each year. A minimum of 106 colonoscopies per year was identified to maintain competence. Recuperation rate for polyps was low, and time intervals between colonoscopies were generally too short in comparison to European and international guidelines. CONCLUSIONS: In absence of a central colonoscopy registry in Belgium, our results were based on reimbursement data. Other quality parameters, although accuracy is questionable (eg. bowel cleansing and withdrawal time) are not systematically registered. Despite these difficulties, we were able to demonstrate that a minimum amount of 106 colonoscopies per year is necessary to maintain competence. The results from this large database can be used as a foundation to work out a quality colonoscopy bundle.

Dysplasia in inflammatory bowel disease.

Ulcerative colitis and Crohn's diseases are relapsing longstanding inflammatory bowel diseases, associated with an increased risk of developing colorectal cancer. Continuous surveillance is necessary to detect the preneoplastic lesions in an early stage. New endoscopic techniques have improved the diagnostic accuracy and have resulted in a new and more simplified classification system of the dysplastic lesions in the bowel. Histopathologically these lesions are very heterogenous, consisting of adenomatous, villous and the more recently discovered serrated dysplasia. Its diagnosis may be hampered by the inflamed mucosa, resulting in a high interobserver variability in the categories of indefinite for dysplasia and low-grade dysplasia. Therefore the ECCO guidelines recommend to confirm the diagnosis of dysplasia by a pathologist with expertise in gastrointestinal pathology. In this article we give an overview of colitis-associated dysplasia from the point of view of the endoscopist and the pathologist.

Comparison of side-viewing duodenoscope and single-balloon enteroscope to perform ERCP in patients with Billroth II gastrectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II patients is challenging and different endoscopes can be used. We retrospectively analysed 67 ERCP procedures in 38 Billroth II patients focussing on endoscope type and respective technical success and adverse event rate. 33 (49.2 %) ERCPs were performed using a duodenoscope, 87.9 % were successful and 3 were completed with the single-balloon enteroscope. 28 (41.8 %) ERCPs were performed with the single-balloon enteroscope, 82.1 % were successful and 2 were completed with a paediatric colonoscope. For 6 (9.0 %) ERCPs a paediatric colonoscope was used but only 3 (50.0 %) were successful. Overall technical success rate was 82.1 % without difference between the success rate of the duodenoscope and the single-balloon enteroscope. Overall adverse event rate was 10.5 %: 6.1 % duodenoscope,10.7 % single-balloon enteroscope, 33.3 % paediatric colonoscope. The duodenoscope allowed all conventional ERCP procedures, whereas the singleballoon enteroscope required dedicated ERCP catheters and did not allow metallic stent placement. However, the single-balloon enteroscope facilitated access to the papilla and sphincteroplasty allowed direct cholangioscopy. ERCP indications were bile duct stones (53.7 %), cholangitis (20.9 %), chronic pancreatitis (20.9 %), pancreatic cancer (1.5 %) and liver transplantation (3%). Therapeutic ERCP success rate is high in patients with Billroth II gastrectomy using either a conventional duodenoscope or the single-balloon enteroscope, with an acceptable and comparable adverse event rate. The choice of endoscope may depend on local experience, post-operative anatomy and therapeutic indication.

Quality assessment of colonoscopy in Flanders: a voluntary survey among Flemish gastroenterologist.

Colonoscopy is an important endoscopic examination for the diagnosis and treatment of pathological conditions of the colon, like polyps and colorectal cancer. However, several factors determine the quality of colonoscopy and thus the quality of polyp and colorectal cancer detection. The Flemish Society of Gastroenterology (VVGE) performed a voluntary on-line registry among its members to identify quality of colonoscopy in Flanders, Belgium. 64 gastroenterologists voluntarily registered 4276 consecutive colonoscopies performed during a 3 month study period. Colonoscopy quality indicators were prospectively collected and analysed. Results showed a low voluntary participation rate (17%), acceptable overall adenoma detection rate of 20,5% and colorectal cancer interval rate of 5,4%. Complications were low (perforation 0,1% and major bleeding 1,5%). The current study showed that in Flanders, Belgium on-line registration of colonoscopy quality indicators is feasible and that quality of colonoscopy in daily practice meets the expectations of (inter)national guidelines. However, further improvement of the registry and an open debate on the quality control of colonoscopy in Flanders is warranted (Belgian Registry B30020096548).

The ABC of apheresis.

Apheresis is a collective term for several activities in which a desirable specific blood component is separated and collected or a harmful component is removed. During the last decades the application of apheresis has expanded to a broad spectrum of diseases due to various studies on the clinical efficacy of this therapy as well as the innovation of new techniques. However, adverse events quite often occur during apheresis. In this article we will give a brief overview on general principles, indications and complications of apheresis.

Monitoring and documentation of side effects from depot antipsychotic medication: an interdisciplinary audit of practice in a regional mental health service.

This audit reviewed current practice within a rural mental health service area on the monitoring and documentation of side effects of antipsychotic depot medication. A sample of 60 case files, care plans and prescriptions were audited, which is 31% of the total number of service users receiving depot injections in the mental health service region (n= 181). The sample audited had a range of diagnoses, including: schizophrenia, schizoaffective disorder, bipolar affective disorder, depression, alcoholic hallucinosis and autism. The audit results revealed that most service users had an annual documented medical review and a documented prescription. However, only five (8%) case notes examined had documentation recorded describing the condition of the injection site, and alternation of the injection site was recorded in only 28 (47%) case notes. No case notes examined had written consent to commence treatment recorded. In 57 (95%) of case notes, no documentation of recorded information on the depot and on side effects was given. The failure to monitor and record some blood tests was partly attributed to a lack of clarity regarding whose responsibility it was. A standardized checklist has been developed as a result of the audit and this will be introduced by all teams across the service.

Upper gastrointestinal tract bleeding management: Belgian guidelines for adults and children.

UNLABELLED: Upper gastrointestinal bleeding (UGIB) remains a common disease affecting 100 to 170 per 100 000 adults per year and causing thereby a significant burden to healthcare resources. Despite the improvements in the management of this disorder, the associated mortality ranges from 5 to 14%. Since the general management of UGIB is not uniform, the main objective of this work is to provide guidelines for the care of adults and children presenting with bleeding caused by gastro-duodenal ulcer or variceal rupture. METHODS: In the absence of evidence-based recommendations, these guidelines were proposed after expert opinions reconciliation and graded accordingly. They are based on the published literature up to September 2010 and graded according to the class of evidence. RESULTS: The current guidelines for the management of UGIB include recommendations for the diagnostic process, general supportive care, pharmacological therapy aiming at bleeding control, specific and endoscopic treatment of acute bleeding and follow-up for both gastro-duodenal ulcers and portal hypertension-induced bleeding.

Quality assurance in colonoscopy for colorectal cancer diagnosis.

Colonoscopy can prevent colorectal cancer, but its effectiveness is diminished by operator-dependent factors. Therefore, quality assurance programs should be implemented in all colonoscopy practices. Adherence to quality performance measures varies among different countries, and physicians seem reluctant to adopt them. We provide an overview of the existing guidelines for colonoscopy quality assurance, and a summary of the quality control initiatives in Belgium and the surrounding countries.

Quality assurance and recommendations for quality assessment of screening colonoscopy in Belgium.

As population-wide screening for colorectal cancer is adopted by many western countries for all individuals aged 50-75. The success of screening colonoscopy programs is highly dependent on the quality of the procedures. High-quality complete endoscopy with excellent patient preparation and adequate withdrawal time is necessary for effectively reducing colon cancer risk. In Belgium formal quality assurance programs and principles of credentialing do not exist. The current reimbursement system for colonoscopy does not reward a careful performed examination but rapidly performed examinations at unnecessarily short intervals. There is a clear need for evidence-based quality measures to ensure the quality of screening colonoscopy. In this guideline review we present an overview of the literature concerning criteria for best practice and important quality indicators for colonoscopy. A summary of the latest guidelines is given. Our goal of this update is to provide practical guidelines for endoscopists performing screening colonoscopy. We hope to provide a broad consensus and an increasing adherence to these recommendations.

Video capsule endoscopy in small-bowel malignancy: a multicenter Belgian study.

BACKGROUND AND STUDY AIMS: Early diagnosis of small-bowel tumors is crucial for therapy. Video capsule endoscopy has improved the diagnosis of small-bowel diseases, but data concerning the role of this technique in detecting small-bowel malignancy are scarce. The aim of this paper was to review all capsule endoscopy findings at Belgian hospitals, in order to evaluate the diagnostic yield of capsule endoscopy in the field of small-bowel malignancy. PATIENTS AND METHODS: For this retrospective study, the seven Belgian academic hospitals where the device was being used were asked to review the findings obtained by means of video capsule endoscopy, and to collect information about the cases of small-bowel malignancy. RESULTS: In total, 443 capsule endoscopies were performed up to November 2004, and 11 malignant small-bowel processes were detected (2.5%). The most frequent indications for performing capsule endoscopy in those 11 cases were intestinal bleeding of undefined origin or iron-deficiency anemia. The mean number of diagnostic procedures performed before capsule endoscopy was 3.6. The capsule endoscopy results had a diagnostic yield of 1.6% after classical work-up. In 55% of these cases, capsule endoscopy findings had an influence on therapy. CONCLUSIONS: Tumors of the small bowel remain a rare condition. Video capsule endoscopy is able to detect tumors undiagnosed by classical procedures in about 1.6% of cases and has an impact on the therapy in 55% of the tumor cases.

Autoimmune pancreatitis with evolution to cholangitis: a case report.

We report the case of a 47-year-old Caucasian male patient who presented with obstructive jaundice and mild epigastric pain. Autoimmune pancreatitis was diagnosed based on magnetic resonance imaging, biopsy and clinical evolution, and the patient was successfully treated with corticosteroids. However, a few months later ERCP showed an image compatible with sclerosing cholangitis. Again, treatment with corticosteroids was given, after which the bile ducts became normal. A few months later, again there was a relapse and azathioprine was started. After decreasing the dose of immunesuppression, we saw relapses of cholangitis and pancreatitis, with eventually evolution to chronic calcifying pancreatitis. The aim of this report is to describe autoimmune pancreatitis as a cause of obstructive jaundice, and to illustrate that evolution to an immunesuppression-responsive cholangitis, with evolution to chronic calcifying pancreatitis is possible. Also, our patient had a small fluid collection, possibly a pseudocyst, an unusual finding in autoimmune pancreatitis, which disappeared during treatment.

Endoscopic laser therapy for palliation of patients with distal colorectal carcinoma: analysis of factors influencing long-term outcome.

BACKGROUND: Incurable rectal cancer often reduces the quality of life because of obstruction, bleeding, pain and tenesmus. For such symptoms palliative therapy is often carried out. METHODS: From 1986 to 1995, 219 patients, 118 men and 101 women, mean age 67 years, with distal colorectal adenocarcinoma were referred for palliative endoscopic laser therapy. In this retrospective analysis of outcome, patients were allocated to 3 subgroups according to their dominant symptom: obstruction, bleeding and others (soiling, diarrhea, tenesmus). After initial successful treatment, maintenance therapy was carried out in cases of obstruction at intervals of 2 to 4 months; patients with bleeding, tenesmus or diarrhea were retreated if there was recurrence of symptoms. RESULTS: Initial successful palliation was obtained in 198 patients (92%), with similar results in the 3 subgroups. Long-term, effective palliation was achieved in 160 patients (75%) of the total study population. Seventy-six patients (65.0%) with obstruction, 63 (82.9%) with bleeding and 21 (80.8%) with other symptoms remained symptom free until death or this analysis of results. There was a significantly negative relation between long-term successful outcome and local spread of the tumor in the obstruction (p = 0.040) and bleeding groups (p = 0.014). The total number of treatments was significantly higher if obstruction was present at presentation (p< 0.05) and if tumors were circumferential (p = 0.05). Major complications were perforation (4.1%), fistula (3.2%), abscess (1.7%) and bleeding (4.1%). There were 5 (possibly) procedure-related deaths. The survival rate was 44.4% at 1 year and 20.4% at 2 years. CONCLUSIONS: Laser therapy is effective for initial palliation but careful patient selection is necessary. Long-term palliation is less feasible in patients with obstruction.

Brush cytology of ductal strictures during ERCP.

BACKGROUND: Previous reports on endoscopic retrograde brush cytology (ERBC) of bile ducts and of the main pancreatic duct have reached widely varying sensitivity levels of 33 up to 85%. AIMS: To report our experience with ERBC in a series of biliary strictures (n = 98) and pancreatic duct strictures (n = 8). For the purpose of our study, that was mainly directed to the value of the cytologic examination as such, only those specimens that were considered satisfactory for cytological interpretation were studied. PATIENTS: From October 1988 until August 1994, 154 cytologic brushings were performed at ERCP in 132 patients. In 132 brushings obtained from 115 patients (86%), cell yield was satisfactory for cytologic interpretation. Nine patients lacked adequate follow-up. Hence, 123 brushings from 106 patients were included in this study. A final diagnosis of malignancy was obtained in 62 patients. METHODS: Cytological changes were described as 'benign', 'columnar cell intraepithelial neoplasia', 'inconclusive' by the presence of atypical cells, or 'malignant'. RESULTS: For a positive diagnosis of the malignant nature of a stenosis, ERBC had an overall sensitivity of 63% with a specificity of 96%. One false positive result was obtained in a patient with a biliary infection by Fasciola Hepatica. Sensitivity was highest in malignant ampullary strictures (91%). Sensitivity was 60% for cholangiocarcinomas, and 65% for pancreatic cancer. The finding of 'columnar cell intra-epithelial neoplasia' in the ampullary region led to a Whipple resection and diagnosis of invasive carcinoma in one patient. Atypical cells were found in 4 brush specimens: in three of these 4 cases, a malignant lesion proved to be present. CONCLUSIONS: Brush cytology is a simple technique with a high specificity and should be performed in biliary and pancreatic duct strictures of unknown etiology. Categorizing the smears according to cytomorphology may improve diagnostic accuracy.

A comparison of laser therapy, plastic stents, and expandable metal stents for palliation of malignant dysphagia in patients without a fistula.

BACKGROUND: Many options are available for palliation of inoperable malignant stenoses of the esophagus. We report our experience with different modalities of endoscopic therapy. METHODS: From 1986 to 1996, we treated 125 patients with dysphagia caused by unresectable malignant tumors with endoscopic therapy. Seventy patients were treated with laser therapy, 34 with a plastic endoprosthesis, and 21 with an expandable prosthesis. Therapeutic outcome and complication rates were analyzed for the three groups. RESULTS: Mean dysphagia score decreased in the same manner in all three groups. Major and minor complications were significantly more common in the plastic endoprosthesis group and in the metallic stent group compared with the laser therapy group. Therapy and patient survival were not significantly different among the three groups. CONCLUSIONS: Plastic and metal stents carry a high complication rate for a short period of palliation. Endoscopic laser therapy, in contrast, has a low complication rate. Laser therapy should be the first choice for palliation in malignant dysphagia in patients with a short life expectancy. Stents might be used when laser therapy fails, in the presence of fistulas, or in patients with a reasonable life expectancy.

Midazolam versus diazepam in lipid emulsion as conscious sedation for colonoscopy with or without reversal of sedation with flumazenil.

BACKGROUND: The efficacy and tolerance of midazolam (Dormicum R) versus diazepam in lipid emulsion (Diazemuls R, Dumex) was evaluated in a randomized, controlled, double-blind trial in 200 patients undergoing total colonoscopy. METHODS: Diazepam in a dosage of 11.2+/-2.3 mg and midazolam in a dosage of 5.3+/-1.1 mg were given over 2 minutes. Flumazenil in a dosage of 0.2 mg within 15 seconds was administered to 50% of patients after procedure. RESULTS: Diazepam and midazolam were equivalent as judged by sedation, recovery time, patient tolerance, and ease of examination. The effect of flumazenil (Anexate R, Roche) on the recovery time was not significant as most patients were fully awake by the end of the procedure. Midazolam induced significantly more amnesia, and the score for recall of the pain score was significantly less after 14 days in the midazolam group. There were only minor complications in both groups. CONCLUSIONS: We conclude that midazolam can be used safely in relatively fit patients between 17 and 65 years old and that it is the drug of choice if amnesia is desirable. As sole premedication this drug was insufficient in 42% of the patients (pain score was greater than 3), especially in young women.