Headline : BMJ Specialist Journal Press Release
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GUT
Newswise — [A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal screening tomorrow? 2004: 53: 277-83] (paper) [A snapshot of colonoscopy practice in England: stimulus for improvement 2004; 163-5] (editorial)
Services for diagnosing gut disorders, which are already overstretched, would sink beneath the increased demands posed by a national bowel cancer screening programme, suggests a study in Gut.
"Unless there is a dramatic increase in manpower and resources available for lower gastrointestinal investigations, the introduction of a national screening programme would rapidly overburden already inadequate facilities," state the authors. More than 30 000 new cases of bowel cancer are diagnosed every year.
The authors base their conclusions on a study of over 9000 colonoscopies carried out over four months in English district general and teaching hospitals in North East Thames, West Midlands, and East Anglia.
During colonoscopy, a colonoscope?a long flexible viewing tube?is inserted through the rectum so that the entire bowel can be seen and checked for abnormalities. Colonoscopy is a difficult skill to learn, and can lead to bleeding, a perforated bowel, and even death, if carried out incorrectly.
Of the 9223 procedures carried out during the study period, normal results were found in only four out of 10 patients. Polyps, a frequent precursor to bowel cancer, were found in around one in four cases, although actual cancer was found in less than 4% of patients. The other most common diagnoses included diverticular disease and inflammatory bowel disease.
One in five procedures failed to view the top of the bowel, an area called the caecum. In one in three cases, this was because the patient found it too painful. But in the remainder, inexpert handling of the colonoscope or inadequate bowel preparation were responsible.
Worryingly, only 17% of those carrying out the procedure had received supervised training for their first 100 colonoscopies, as recommended, and only four out of 10 had received formal training.
The bowel was perforated in 12 patients; 13 bled after the procedure, six of whom required admission to hospital, as a result; and 10 patients died within a month, although in only six was the procedure thought to have contributed.
The authors note that demand for colonoscopy has quintupled in 15 years. In 1987, there were an estimated 160 colonoscopies for every 100 000 of the population. In 1990 this had risen to 200. The latest estimates from the British Society of Gastroenterology now put the figure closer to between 800 and 1000.
It has been estimated that the introduction of a national bowel screening programme would require at least six extra colonoscopies a week in district general hospitals, say the authors.
"While there are centres where practice is of the highest quality, considerable effort is required to raise the overall quality of colonoscopy," they conclude.
In an accompanying editorial, Drs Palmer and Morris, from the British Society of Gastroenterology and the Joint Advisory Group on Gastrointestinal Endoscopy, respectively, comment that the snapshot of practice in England, exposed by the audit is "disturbing."
But they point out that these findings have already prompted both their organisations and the government to review training, equipment, and facilities and to implement appropriate measures.
But it will take some time before these measures take full effect, they say. While they anticipate that colonoscopy practice will undoubtedly improve as a result, they point out that regular audits are the only way of confirming this.
However, they write: "The Department of Health seems remarkably unenthusiastic to support large scale audits of gastrointestinal practice."
Click here to view the full text:http://press.psprings.co.uk/gut/february/FebGutpaper.pdf (paper)http://press.psprings.co.uk/gut/february/FebGuteditorial.pdf (editorial)
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