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Irish Society of Gastroenterology (ISG) Winter Meeting

Variation in hospital performance, ISG hears

Irish data for GI endoscopy reveals a number of areas for improvement, Dr Chris Steele, HSE National Clinical Lead for Endoscopy told the Winter Meeting of the Irish Society of Gastroenterology (ISG).

In a joint lecture on the national plan for GI endoscopy, Dr Steele said that anonymised data from 34 public hospitals had shown a wide variation in meeting national targets. The data is up-to-date as of July 2016.

Despite a national average of 92 per cent, a lot of hospitals have a cecal intubation rate of less than 80 per cent, he said.

“Nationally almost 60 per cent of our endoscopists are meeting the targets which isn’t that great,” he said. “Ten per cent have a cecal intubation rate of less than 80 per cent.”

Seventy per cent of patients are having their endoscopies performed by endoscopists who meet the target and this suggests that endoscopists who are meeting targets are high volume.

“Now we have one year of complete data, which allows us to produce guidelines and set targets. We have now released phase one of our targets.”

The reference to a minimum volume of procedures has been removed as a key performance indicator, but must still be recorded. Clarification has also been brought on back to back sedation, an area that has caused a lot of confusion, Dr Steele acknowledged.

“If a patient is having a gastroscopy and a colonoscopy, the sedation entered for the colonoscopy is the total sedation on board at the time of the procedure.”

Terms have been standardised and targets have been set based on international evidence evaluation.

Other targets include a 90 per cent success rate for upper GI endoscopy intubation.

Duodenal intubation should be 95 per cent, said Dr Steele, and the recall for patients with gastric ulcers should be 80 per cent.

“With regard to colonoscopy phase one data, sedation rates for colonoscopy are equivalent to gastrostomy. Eighty per cent of patients should have a comfort score of one or two.”

 Cecal intubation rates have been set at 90 per cent, while polyp detection rates are set at 20 per cent. In bowel prep, it is expected that 90 per cent should be classified as either adequate or excellent.

In phase two guidelines, which will be published shortly, targets include retroflextion rates of 95 per cent and polyp retrieval of 90 per cent.

“At the moment for complications post endoscopy, we don’t have recommendations,” Dr Steele said.

Approximately the same number of gastroscopies and colonoscopies are being performed and “this is interesting given the very scarce resource that colonoscopy is”.

“We have a national cecal intubation rate of 92 per cent, considerably better than the original BSG data published 10 or 12 years ago. However, if you look at this on a per hospital basis it throws up some concerns.”

Regarding duodenal intubation rates, it was only in the last month of data collection that the hospitals started to meet the target. However, he said this clearly relates to the learning curve needed to master the endoscopy reporting systems (ERS) and proper induction on new systems is required.

There is also variation in sedation rates.

With comfort scores, it was estimated that over 80 per cent of patients have a score of one or two. However, only 55 per cent of endoscopists were achieving this comfort score for their patients.

In polyp detection, the data shows a 27 per cent achievement, with most of the hospitals over the 20 per cent target. Again though, a relatively large number of endoscopists, 45 per cent, are not achieving the 20 per cent detection rate target.

Dr Steele said that it is essential that ERSs are rolled out to the remaining seven hospitals and he urged that the data is uploaded in a timely fashion.

“Most importantly, action is really what is needed. It is critical that there is action locally around meeting targets,” he told the ISG. This may involve additional training in order to raise standards. He also asked that endoscopists review their own performances.

His colleague Prof Stephen Patchett, Consultant Gastroenterologist, Bon Secours Hospital, Dublin and Beaumont Hospital, Dublin, said there has been a decade of change in endoscopy with 130,000 endoscopies annually in public hospitals.  However, the exponential expansion in work has not been met with the same growth in resources.

Around 2012, the activity plateaued as the existing units had reached saturation point, he said.

Waiting lists continue to climb, with the average in the last couple of years being approximately 5,000 patients per annum. Furthermore, while BowelScreen accounts for only around 4 per cent of the workload, it has created a big challenge to roll it out nationally, Prof Patchett said.

He added that discussions are ongoing with JAG to try and make the accreditation of units “a much more acceptable and common feature”.

“Waiting lists, which are the main target, are beyond the control of most units at the moment.”

Surveillance is also a challenge and he estimated that there are 36,000 patients that need surveillance.

“There have been some units built over the last decade but not very many,” he said, adding that a small investment would help a lot.

“You talk to the quality assurance people in the Department of Health and [HSE] Acute Hospitals and they don’t quite understand why things haven’t improved. It’s really down to funding at the end of the day.”

Training has also been affected by the workload due to time constraints. Currently there are “no real skills development or skills update courses” in Ireland. However, he said the Department of Health has agreed to fund an endoscopy training lead.

For the Department, the NTPF represents the solution to the endoscopy problems, he said. However, this is not the means towards a sustainable future.

“We need clinical input into the national endoscopy working group. This will be achieved working through the Hospital Groups with hopefully a group lead for endoscopy in each Group.”

The working group aims to strengthen clinical governance, develop a national quality assurance framework, increase capacity, and develop a training programme. 

Cancer patients at high risk of malnutrition and cachexia

Cancer patients are a group at high risk of malnutrition and cachexia, while an estimated one-in-three patients coming into hospital are malnourished based on body composition, Consultant Medical Oncologist at Cork University Hospital and Mercy University Hospital, Dr Derek Power, told the Irish Society of Gastroenterology (ISG) Winter Meeting.

However, while malnutrition and sarcopenia are incredibly prevalent, nutrition in cancer patients is an evolving area “with a lot of ignorance”.

Dr Power and Dr Aoife Ryan, Lecturer in Nutritional Sciences at University College Cork, found that at least half of 1,000 patients with cancer who had their nutritional status and body composition assessed by qualified clinical and academic dieticians at the time of diagnosis were overweight or obese.

However, despite such a high prevalence of weight issues, between 25-45 per cent of these patients had noteworthy signs of significant deterioration in their muscles, including muscle wasting.

“We are in the middle of a cancer epidemic,” said Dr Power. “Over the next 15-20 years we are going to have at least 60,000 cases based on actuarial data from the NCCP [National Cancer Control Programme].”

A significant percentage of patients with local and advanced metastatic cancers such as colorectal, pancreatic, hepatobiliary, and upper GI lose weight.

“Over 5 per cent weight loss within six months of diagnosis is a diagnostic criteria for cancer cachexia. Ten per cent weight loss is clinically severe and has adverse consequences for cancer and for surgical outcomes and for lengths of hospital stay.”

The treatment and aetiologies of the disease can all contribute to cachexia. For example, with an upper GI cancer, patients cannot swallow, which will cause them to be malnourished.

“Radiotherapy, chemotherapy are toxic and can cause the patient to lose weight,” said Dr Power.

Unfortunately, both appetite loss and early satiety is very common in newly diagnosed patients. This is especially worrying as a person with a cancer need 35-40 kilocalories per kilogramme a day more than a healthy person.

“Thankfully we don’t usually see a person with a BMI of less than 16 or 18 in our practices.” However, patients may not look malnourished but can still be cachectic.

Almost half of European adults are overweight or obese and Dr Power highlighted the link between obesity and cancer.

“In advanced cancer many, many, many patients are overweight or obese. But these patients are malnourished as they will have cachexia.” Some 40-63 per cent of cancer patients will have a BMI of over 25.

As cancer is a system inflammatory state, malignant cells produce proinflammatory cytokines and this leads to adverse reactions in terms of nutrition.

“Acute phase proteins, such as CRP, fibrinogen, etc, are produced in huge quantities by the liver,” he said “and this is very energy inefficient.”

In parallel with weight loss is the decrease in muscle mass.  Cancer patients are as inactive as those with spinal cord injuries and cerebral palsy.

Dr Power explained that cachexia was very complex, characterised by muscle loss with or without fat loss. However, in today’s obesogenic world, very few patients have a low BMI.

The symptoms of cachexia, he added, include weight loss, systemic inflammation, muscle loss and immunodeficiency.

“Patients will die of these things. The indirect manifestations of cancer.

“This is where dieticians can have a massive impact into the outcome of cancer in my view,” explained Dr Power. “Nutrition matters and the outcome is worse if the patient is malnourished.

“How much weight loss is clinically significant? The answer is very little, so it is very important that early intervention happens when the diagnosis is made.”

Sarcopenia is associated with musculoskeletal loss and is very common. It is also defined on DEXA and especially CT scans.

It has a multiplicity of effects throughout the body, such as on the brain, brown and white adipose tissue, the liver, the heart, and the gut.

“Every patient with cancer will get a baseline CT scan. This can be exploited to look at body composition,” he said. “Cancer is a sarcopenic state. Even in young patients, their muscle is the same as a 70-80 year old.”

With sacropenia, chemotherapy toxicity can be very severe and was associated with dose limiting toxicity.

Research showed that patients with sacropenia do worse and have worse toxicity while on medications. Dr Power explained that a clinical trial has been established to examine dosing chemotherapy based on lean muscle mass per CT criteria rather than the BSA.

“And this is the right thing to do.”

Regarding immunotherapy, Dr Power said it does not work so well in upper GI cancer.

When assessing a patient’s response to treatment, quality-of-life (QoL) must not be ignored. Meta analysis had shown that better nutritional status is an indicator for better QoL.

Cachexia and sarcopenia need to be looked for, but they are not an inevitable consequence of cancer. Dr Power called for a change in attitude among healthcare professionals in this regard

The aim of intervention should centre on preserving muscle and functional status. If the patients cannot exercise, their muscles decondition and they die from muscle wasting.

He suggested the need for a parallel pathway in cancer treatment where dieticians with an interest in cancer become involved at an early stage. 

CTC use will increase – leading radiologist 

CT colonography (CTC) is a safe method of increasing bowel screening participation, the recent Winter Meeting of the Irish Society of Gastroenterology (ISG) heard. Consultant Radiologist at the Mater Misericordiae University Hospital, Dublin, Prof Helen Fenlon, said CTC had improved dramatically in recent years and has many advantages.

New developments in software have allowed radiologists to reduce the dose of radiation that patients are exposed to during the scan, she said. CTC also improves patient participation in bowel screening programmes.

“Down side, it is a diagnosis only test,” she said, “we’re never going to be able to do what you do, which is remove the polyps.”

However, the results from single and multi-centre trials would suggest that CTC is very close to colonoscopy in terms of cancer and polyp detection, she added.

While it is a good test to detect polyps in the 6mm to 9mm range, it is not as good as colonoscopy and “drops right off” for tiny polyps.

However, she argued that 6mm was an acceptable bar as universal polypectomy is neither unjustifiable nor feasible. She added that there is a randomised controlled trial being carried out in the Netherlands with a polyp threshold size of 10mm, which she felt may be too generous.

The subject of flat lesions is very topical, she added, but while there is limited data on CTC’s performance for this, some trends are emerging.

“Lesions with flat morphology are, not surprisingly, more difficult to detect with CT colonography. It would

appear that you need a minimum height of 2mm and a footprint of about 6mm,” said Prof Fenlon. Of possible significance, CT colonography works much better in the right colon as there is good distension. 

“As radiologists we are now more aware of them, we’re looking for them. We’re slowing down.”

Flat lesion can be very subtle, she added, as they are only in the field of vision for a very brief time.

 A US CTC screening trial of 5,107 patients showed that 13 per cent of all polyps had a flat morphology.

“And it would appear that we performed at around the 60-70 per cent level in terms of detection.”

The UK bowel screening programme did a retrospective review of patients not fit for colonoscopy. They were a specific group of patients who were either medically unfit or unwilling to undergo colonoscopy and were given CTC. Within this 2,731 patient group there was a reasonable detection rate of anomalies and cancers.

“However, when they compared that with patients who had colonoscopies, who were likely to be a fitter group of patients, there was a definite difference in detection rates,” she said. Colonoscopy was picking up more lesions than CTC.

“It is hard to compare because they are not identical patient groups but there does appear to be a difference.”

However, the programme also found a significantly better performance of CTC polyp detection where radiologists were very experienced and used three-dimensional imaging.

In terms of the safeness of CTC, perforation rates are extremely rare with factors that contributed to early perforation rates, such as the use of rigid tubes, no longer present. Pressure monitors also prevent radiologists from “over stepping” patients with obstructive cancer.

“The risk of perforation is virtually nil.”

Prof Fenlon said radiologists are very aware of the benefit and risk of screening and radiation. However, she added that the cancer-inducing effect of low dose radiation is neither demonstrated nor demonstrable.

The current models of risk are based on high-dose radiation exposures and assume a linear relation between a high exposure and risk of cancer. While this may not necessarily be the case, the models are worst case scenario and keep radiologists on the safe side of practice.

Californian research looked at CTC in screening populations using this worst case model. It found that, depending on the interval screening, between 24 and 37 cancers would be detected for every one cancer which might be induced.

The level of radiation dose has also fallen from around 10 millisieverts in 1996 to around two millisieverts now. Putting these figures in context, Prof Fenlon said the annual background radiation of living on Earth was three millisieverts.

Long haul airline cabin crew are exposed to nine millisieverts annually and have no recorded increased appreciable risk to cancer.

In terms of benefits there is some evidence that informed patients do prefer CTC and that lower bowel prep represents a significant advantage. This could help boost participation rates in bowel screening, which the meeting heard represented a major challenge.

The cost assessment of CTC needs to be reviewed to reflect the increased participation rates, said Prof Fenlon.

The news that CTC was endorsed as a primary screening test by the US Preventative Service Task Force, the FDA, and the American Cancer Society means that it is likely Medicare will approve screening with CT colonography in the next 12 months.

“After a generation of waiting in the wings it has been accepted by the cancer societies and policy-makers in the US,” she said.

In BowelScreen, CTC does feature and is offered to Faecal Immunochemical Test (FIT) positive patients with an incomplete colonoscopy. There are currently five centres – four in Dublin and one in Cork – and it is hoped there will be a greater geographical spread in the future. While only a small number of patients have been scanned, the service has been standardised.

“It has a unique ability to appeal to the population but I think it’s underutilised,” said Prof Fenlon, who believed this would change.

Answering questions from the floor on the global shortage of radiologists, Prof Fenlon said shortages are felt across services.

“There is a huge gap to bridge in order to provide this service at a greater level. But I would say that all of our trainees now are trained in CT colonography.”

Oral prize winners, ISG Winter Meeting 2016

1st Oral Clinical Prize

Ms Lillian Barry, Mercy University Hospital, Cork.

Can symptoms predict findings of High Resolution Ano-rectal Manometry? 

2nd Oral Clinical Prize

Dr Mary Hussey, Tallaght Hospital, Dublin.

Feasibility of same day Colon Capsule Endoscopy (CCE) in patients with incomplete colonoscopy.

1st Oral Scientific Prize

Dr Anne-Marie Byrne, St James’s Hospital, Dublin.

Identification of novel PGE2 Receptor Antagonists that modulate angiogenesis and inflammation in Oesophageal Adenocarcinoma.

2nd Oral Scientific Prize

Dr Zaid Heetun, University College Dublin.

CD4+ and CD8+ T cells in Crohn’s Disease show a dysfunctional and incongruent response to TCR ligation.

Poster prize winners, ISG Winter Meeting 2016

1st Poster Prize

Dr Catherine Rowan, St Vincent’s University Hospital, Dublin.

Degree of Ulcerative Colitis Burden of Luminal Inflammation score, a simple method to quantify inflammatory burden in Ulcerative Colitis.

2nd Poster Prize

Dr Neil O’Morain, Tallaght Hospital, Dublin.

Adherence to European Society of Gastroenterology Endoscopy (ESGE) Polypectomy Guidelines:   Retrospective experience from a tertiary Irish Hospital.

3rd Poster Prize

Dr Niamh Peters, St James’s Hospital, Dublin.

Oesophageal cancer: Commonly familial, possibly heritable.

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