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Perspectives from the Waitemata
Bowel Screening Pilot team
-The Endoscopic view
Paul Frankish
Lead Endoscopist
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BSP-the endoscopy perspective
• Can colonoscopy be provided safely and efficiently in a screening programme?
• What is the impact of the BSP on an existing endoscopy service?
• What are the particular characteristics of BSP colonoscopies?
• Conclusions and recommendations
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Colonoscopy in BSP-organisational aspects
• Colonoscopists needed audited completion rates of >90% with mean withdrawal times of >6minutes to enter programme with 100 procedures in prior 12 months
• No two- tier system of endoscopists• Dedicated screening unit with separate governance• Programme aims for a minimum 95% colonoscopy completion
rate. • Failed colonoscopies undergo CT colonography• Lead endoscopist provides 3 monthly feedback to endoscopists• Fortnightly quality meeting to review complications (patients
admitted within 30 days of colonoscopy)
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Total procedures to date 6522
Procedures per endoscopist N=28
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Percentage of complete colonoscopies per endoscopist
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Mean withdrawal time for each endoscopist-standard >6 minutes
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 270.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Series1
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% Polyp detection rate for each colonoscopist
Mean=76%
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BSP colonoscopies
• 5 colonoscopies per session
• Aim to complete all therapeutics at the
index procedure
• Mean 3.1 polyps per patient
• High rate of pathology-adenomas 55%
advanced adenomas 30%,cancer 4%
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Colonoscopies at WDHB 2012-15
• Total BSP colonoscopies 6522• Total non-BSP colonoscopies 8353• Total colonoscopies performed 14875
ie 44% of all colonoscopies performed were BSP• 18% of all WDHB colonoscopies were outsourced• 30% of BSP colonoscopies performed by non-
WDHB endoscopists
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Number of non-BSP colonoscopies at WDHB 2012-15
0
500
1000
1500
2000
2500
3000
3500
2234
2004
2963
1152
1
2012 2013 2014 2015
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Other Monitoring Indicators
• Time to colonoscopy <11 weeks=99.3%(95%)
• Percentage undergoing colonoscopy or CTC =95.8 and 94% in round 2 (>90%)
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Endoscopy adverse events
• 85 patients admitted in the first 3.5 years of BSP (1.2% of total colonoscopies)
• The most frequent complications included bleeding, perforation, pain and hypotension
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Bleeding
• 49 patients admitted with bleeding
• 13 were transfused
• 3 required surgery
• 6 were rescoped
• Bleeding rates reduced after 22 cases in year 1
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Perforation
• 7 perforations
• 2 required surgery
• 22 patients admitted with pain and no evidence of free perforation on CT etc
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Miscellaneous complications
• Anaphylaxis-1
• Hypotension /syncope-3
• Vomiting-1
• Falls-2
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Failed colonoscopies and CTC evaluation in first screening round
• 20 had CTC as primary investigation-polyp detection rate PDR was only 30% cf 76% in colonoscopy cohort
• 68 had CTC for failed colonoscopy-PDR was 23.5% increasing to 35% in those with prior colonoscopic polyp removal.
• In 18 subjects with prior failed colonoscopy who had positive findings on CTC colonoscopy was successful in 17 who had propofol assisted colonoscopy
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Conclusions• The pilot has met acceptable standards for
colonoscopy• BSP colonoscopy has a high rate of positive findings
and need for therapeutics• The role of CTC in a screening programme requires
further evaluation• It is possible to organise a programme largely within
the existing resources of an endoscopy unit• Screening colonoscopy in a fully rolled out
programme has major resource implications (but at least we “sort of” know what they are)
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Recommendations• Governance guidelines for a national programme need
to be developed to ensure integrity and quality of the programme eg underperforming endoscopists.
• Registry needs to incorporate individual endoscopist data eg adenoma detection rate plus accurate data on surveillance
• The programme works well when tasks are entrusted to a defined number of key individuals who decide on endoscopy management eg suitability for screening, consistency of surveillance recommendations and maintenance of endoscopy standards and this should be incorporated in a national programme