Implications of the New Monitoring Guidelines in Endoscopy

We can now offer patients procedures which, 20 yrs ago were unthinkable.  Procedures which improves health, reduces morbidity and saves lives. But, these procedures are longer and more uncomfortable and therefore patients require deeper sedation than before.  Unfortunately, at the same time, patients are older and with more comorbidities.  This dual problem of frail patients requiring deeper sedation for longer procedures, has narrowed our ‘sedation window’. The old way of monitoring patients, with a nurse and an oxygen saturation monitor, is no longer enough.  It's for this reason that the Academy of Medical Royal Colleges in February 2021, updated their guidelines on Safe Sedation practises.  Now they recommend that patients requiring 'moderate sedation' should be monitored more closely, not only by a dedicated nurse and oxygen saturation monitor but also with ECG, BP and Capnography. Of course, this is a huge change for endoscopy units.  Our staff are now asked to do three things at the same time; maintain the airway, listen to the pitch of the oxygen saturation monitor and interpret that ECG and Capnography traces.  Dr Martin Lees , Clinical Director of Cardiac Anaesthesia and Perioperative Medicine at St Barts Heart Centre in London and Nurse Specialist Andreia Trigo with SedateUK, discuss the new guidelines and the implications it has for endoscopy units around the World.

COVID never posed an existential threat but nevertheless had a devastating impact, including on our Endoscopy services. Now we do have an existential threat which Endoscopy is actively driving us towards.  Endoscopy is the third greatest hospital contributor to Global Warming !!!  You may be tempted to 'cop out', deciding that you can do nothing, but you would be wrong. There are 3 things which you can do; Reduce Reuse and Recycle.  Listen to the suggestions, read the NHS Net Zero document and join By Hayee at Kings College as a 'Green Endoscopists'.  By the way, we have had statements from all the main Endoscopy organisations on COVID but apart from BSG and the World Gastroenterology Organisation, very little on 'future sustainability'.   Isn't it about time that we all 'Look UP'? 

Topics included artificial intelligence, an overview of bariatric endoscopy, the less than straightforward management of early rectal cancer, how safe is spiral enteroscopy?, should we place a duodenal or a hot Axios stent in gastric outlet obstruction and why would you take papillary biopsies in FAP?  What would you say to a patient, with a germline E-cadherin mutation, who decline a prophylactic gastrectomy?   As usual, the most interesting findings are hidden in the details. For example, did you know that the introduction of colonic cancer screening doesn't appear to have had any impact on mortality rates ... 

Post colonoscopy colorectal cancer is arguable one of the 'hardest' quality measures in colonoscopy. Until now, it has been difficult to identify cases often presenting several years after their colonoscopy and sometimes to a different institution. From September, NHS endoscopy units will have access to a bespoke online resource identifying cases of PCCRC. From September, this online tool will be used to audit the 1400 PCCRC cases which we see in the NHS every year. Roland Valori explains the idea behind the audit. 

This week, Prof Marco Bruno, Department of Gastroenterology and Hepatology at the Erasmus University Medical Centre in Rotterdam is explaining about the problem we have with scope contamination.  Last year his department published a Nationwide Study of bacterial colonization of endoscopes. The study included 74 Dutch Centres and reported that 17% of duodenoscopes and 13% of EUS scopes were contaminated!  What can we do about this? With Marco, I discuss the current situation and possible solutions, like new endoscope designs, continuous monitoring and culturing of scopes and the training for reprocessing colleagues.

Bjorn's trawl of newsworthy Endoscopy papers currently in press includes; Which patients don't heal well after RFA, Chances of successfully removing a 45mm polyp is only 75% in the Netherlands,  What is 'tip-In EMR?, Tumour biology is important in UC-related PCCRC,  We should be doing more TIPS (and presumably therefore, less emergency band ligation)  and finally musculoskeletal injury is rife amongst endoscopists! 

This time our Podcast is full of both important and interesting studies.  We present new evidence on how to treat pancreatic pseudocysts with hydrogen peroxide, the benefit of PPI's on EoE, an large study of endoscopic treatment of appendicitis, and find that our trusty indigo carmine dye spray is still going strong!  Then we have an interesting paper on the appalling effect of mountain sickness on the stomach, transplantation on the risk of polyps and when to stop Barrett's surveillance.  Thanks to our Partners at Pentax medical for your Support ! References reviewed includes;  Laserna MEJ et.al. Efficacy of Therapy for Eosinophilic Esophagitis in Real-World Practice. Clinical Gastroenterology & Hepatology. 18(13):2903-2911.e4, 2020 12. Greuter T et.al. Effectiveness and Safety of High- vs Low-Dose Swallowed Topical Steroids for Maintenance Treatment of Eosinophilic Esophagitis: A Multicenter Observational Study. Clinical Gastroenterology & Hepatology. 2020 Aug 13. Ding W et.al. Endoscopic retrograde appendicitis therapy (ERAT) for management of acute appendicitis. Surgical Endoscopy. 2021 May 13. Becq A et.al. ERCP within 6 or 12 h for acute cholangitis: a propensity score-matched analysis. Surgical Endoscopy. 2021 May 11. Ashkar MH et.al. Increased Risk of Advanced Colonic Adenomas and Timing of Surveillance Colonoscopy Following Solid Organ Transplantation. Digestive Diseases & Sciences. 2021 May 10. Chandrasekhara V et.al. Predicting the need for step-up therapy after EUS-guided drainage of pancreatic fluid collections with lumen-apposing metal stents. Clinical Gastroenterology & Hepatology. 2021 May 06. Messallam AA et.al. Endoscopic Necrosectomy With and Without Hydrogen Peroxide for Walled-off Pancreatic Necrosis: A Multicenter Comparative Study. American Journal of Gastroenterology. 116(4):700-709, 2021 Apr. Shiroma S et.al. Timing of bleeding and thromboembolism associated with endoscopic submucosal dissection for gastric cancer in Japan. Journal of Gastroenterology & Hepatology. 2021 May 07 Yasuda T et.al. Benefits of linked color imaging for recognition of early differentiated-type gastric cancer: in comparison with indigo carmine contrast method and blue laser imaging. Surgical Endoscopy. 35(6):2750-2758, 2021 Jun. Kim JW et.al. Narrowband imaging with near-focus magnification for discriminating the gastric tumor margin before endoscopic resection: A prospective randomized multicenter trial. Journal of Gastroenterology & Hepatology. 35(11):1930-1937, 2020 Nov. Surek A et.al. Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience. International Journal of Colorectal Disease. 36(6):1221-1229, 2021 Jun. Clark G et.al. Transition to quantitative faecal immunochemical testing from guaiac faecal occult blood testing in a fully rolled-out population-based national bowel screening programme. Gut. 70(1):106-113, 2021 Jan. Gachabayov M et.al. Performance evaluation of stool DNA methylation tests in colorectal cancer screening: a systematic review and meta-analysis. Colorectal Disease. 23(5):1030-1042, 2021 05. Forbes N et.al. Association Between Endoscopist Annual Procedure Volume and Colonoscopy Quality: Systematic Review and Meta-analysis. Clinical Gastroenterology & Hepatology. 18(10):2192-2208.e12, 2020 09. Fruehauf H et.al. Evaluation of Acute Mountain Sickness by Unsedated Transnasal Esophagogastroduodenoscopy at High Altitude. Clinical Gastroenterology & Hepatology. 18(10):2218-2225.e2, 2020 09. Goverde A et.al. Yield of Lynch Syndrome Surveillance for Patients With Pathogenic Variants in DNA Mismatch Repair Genes. Clinical Gastroenterology & Hepatology. 18(5):1112-1120.e1, 2020 05. Lamba M et.al. Associations Between Mutations in MSH6 and PMS2 and Risk of Surveillance-detected Colorectal Cancer. Clinical Gastroenterology & Hepatology. 18(12):2768-2774, 2020 11. Omidvar AH et.al. The optimal age to stop endoscopic surveillance of Barrett's esophagus patients based on sex and comorbidity: a comparative cost-effectiveness analysis. Gastroenterology. 2021 May 08.

Bjorn has reviewed the upcoming 'in-press' endoscopy related manuscripts and provides his usual opinionated and patronising feedback to the brave authors of 14 manuscripts. Of course, you may agree or disagree with his comments and could even find yourself fired up to read some of the articles yourself!  But then again you don't need to, as everything is covered in his Podcast !   References are listed on the website: www.friendsofendoscopy.org  Don't forget to say Thank You, next time you see someone from Pentax Medical because this wouldn't be possible without them !!!  

Dr Andreia Albuguerque from Lisbon discusses her paper on the neglected topic of anal cancer recently published in Lancet Gastroenterology and Hepatology 2021;6:327-34. As larger endoscopy units should find 4-5 early anal cancers every year, I have a terrible suspicion that many of these lesions go undetected. 

In this podcast we discuss Serrated Polyps with Professor Neil Shepherd. There is much more to these lesions than Size and Number!  Did you know that there may be two distinct syndromes and it's the Site of the lesions which distinguishes the two?  That is just the start.  It gets weirder!  We cover a huge amount of ground and headings include (in chronological order): Serrated polyps - one or two distinct syndromes? Can you tell histologically? How does the Serrated Polyposis Syndrome fit ? What matters the most when deciding on the significance of a serrated polyp? Dysplasia inside a serrated polyp? - Well it's complicated !  The heterogeneity of serrated lesions is also problematic Could AI help the Pathologist in the future? How can we identify patients with serrated polyposis syndrome ? Can we explain finding both serrated and adenomatous polyps in serrate polyposis syndrome? Why should I refer patient with serrated polyposis syndrome to geneticists? Can we tell which cancer has developed from a serrated precursor? What is the link between serrated polyps and colitis? The weird issue of stromal changes below serrated polyps 'Mixed polyp' or 'collision polyp'? How can we as endoscopist help the pathologist? Do you believe in DISCARD? What remains the remit of the pathologist to diagnose?