Colonoscopy Training and Standards

Graeme Duthie, Castle Hill Hospital

Powerpoint File

Background - Colorectal Surgeons, Gastroenterologists and Colonoscopy

Success of the bowel cancer screening programme will depend on the quality of colonoscopy performed. We have to concede that there is evidence for variable quality of colonoscopy across the UK. Some surgeons and physicians, many of whom are self-taught, offer poor quality colonoscopy. Poor colonoscopy would discredit the screening programme, quickly inviting media attention, by virtue of missed cancers, or excessive mortality and morbidity. The QA Group, chaired by Roland Valori was specifically established to ensure high quality colonoscopy in the screening programme. QA is ensured at two levels: a Global Rating Scale (GRS) used in the assessment of endoscopy units (JAG is currently in the process of detailed visits to those endoscopy units which have expressed an interest in screening) and competence of individual colonoscopists, based on log books and outcomes data using specific criteria.

When the GRS was presented to ACPGBI Council in October 2005, the only negative issues we perceived were the minimum number of colonoscopies per annum, which we felt would be difficult for most surgeons to achieve with a single colonoscopy list, and a 15% adenoma rate that depends on case mix. Minimum numbers as a marker of quality are not evidence based and have since been revised downwards, at our request. The evidence for an adenoma detection rate of >15% as a marker of quality is also weak. Otherwise we were very supportive of the QA initiative and the role of JAG in the accreditation process. We recognize that acceptance of JAG recommendations for colonoscopy training assures that whoever undertakes colonoscopy is trained to an approved standard, whether physician or surgeon.

We do perceive a problem that no surgeon was invited from the outset to assist with colonoscopy QA development and it is a fact that only one surgeon spoke at the recent screening conference. This has also been a similar problem with some recent BSG projects which have encroached on surgical territory. Nevertheless, the ACPGBI has now become more actively involved in colorectal screening development, albeit at a later stage. I have had constructive meetings as President with Roland Valori and Julietta Patnick, who are not only very keen to engage surgeons in the screening process, but also wish to see a multi-agency ownership of screening, symptomatic cancer management, involvement in the national endoscopy team, the BSG endoscopy committee, and training, with the aim of presenting a united approach to the development of endoscopy services. Other initiatives aiming at collaboration with gastroenterologists include Graham Williams being co-opted onto the QA group, Graeme Duthie as a member of JAG, and Andrew Radcliffe and Mike Kelly contributing to the BSG Strategy Document. Mike Saunders, who now attends BSG Council, is our main link between the two organisations. I think it is vitally important for the BSG now to recognise the importance of full

collaboration and representation by the ACPGBI on writing committees of future projects which involve both disciplines.

Marginalisation of surgeons in the screening process reflects the fact that surgeons have not been involved in recent national initiatives for colonoscopy services.

Most of the SHA leads in endoscopy are gastroenterologists. This is exemplified by the “Advanced Driving Test”, introduced in October 2005, to qualify for screening colonoscopy, when there was only one surgeon amongst the first eight candidates. There may be insufficient impetus at present for the majority of surgeons performing diagnostic colonoscopy to put themselves forward for the Advanced Driving Test with a view to becoming involved in screening. Criteria for screening are stringent, so with job plans already comprising diagnostic colonoscopy and filled with other commitments, surgeons may be less likely than physicians to offer their services. Potentially, the accreditation process would favour gastroenterologists and specialist nurse endoscopists, leading to priority for this group in screening, and eventually a two tier colonoscopy service, further weakening the position of the surgeons. It could be argued that if the Advanced Driving Test becomes firmly established, it may percolate downwards to all colonoscopy practise, with unpredictable adverse effects on clinical service. On the other hand, the test may never become compulsory for diagnostic work: the gastroenterologists do recognise the absolute necessity of sharing the colonoscopy workload with colorectal surgeons. However, it makes clear sense that an Advanced Driving Test or similar is applied in due course to diagnostic as well as therapeutic colonoscopy both within screening and in symptomatic work for QA and safety reasons. Surgeons should not shy away from this challenge.

Another concern is that not only have the gastroenterologists been very proactive with screening but they have also taken the initiative with "invasive" colonoscopy, such as endoscopic staging and resection of early cancers. The colorectal surgeons need to embrace developments in new endoscopic technology as a matter of urgency, in what should be perceived as a form of minimally invasive surgery, especially in conjunction with laparoscopy. We now need to move forward with the gastroenterologists as equal partners in screening and other colonoscopy developments, perhaps including more equitable representation on JAG, and more involvement by surgeons in Training the Trainers and regional centre colonoscopy training courses.

Recommendations

1. Colonoscopy is an essential component of the training curriculum and workload of colorectal surgeons, carrying these skills into the theatre environment; they need to become more proactive and regain lost initiative. They need to be involved with colonoscopy developments or they risk further marginalisation

2. The ACPGBI membership is being informed of the need

3. Colorectal surgeons properly trained in colonoscopy should be able to meet the criteria for certification on case numbers and quality indicators without too much difficulty.

a. >150 colonoscopies per year

b. 90% completion rate on intention to treat basis

c. Perforation rate <1:1000

d. Evidence that sedation used is within recommended guidelines

e. Detailed submission of 50 consecutive cases with relevant histology to determine the adenoma detection rate (<15% detection may result from case mix)

4. Prospective data should be collected by all colorectal surgeons from now on, and relevant documentation kept up to date using JAG compliant forms, as endoscopists will eventually be signed off locally for access to endoscopy units, with major implications in the longer term for access to colonoscopy in the private sector

5. Colonoscopy workshops should be established regionally for the benefit of colorectal surgeons who do not yet meet certification criteria.

6. Colorectal surgeons urgently need regain lost initiative and to embrace development and application of new colonoscopic technology, eg resection of early colorectal cancers and large polyps, and especially in conjunction with laparoscopy

7. Colorectal surgeons and gastroenterologists need to work together nationally (to produce guidelines) and locally within MDTs to agree the appropriateness of local excision of early cancers and methods of follow up, to minimise the risks and consequences of recurrence

8. Colorectal surgeons who have not completed JAG compliant Training the Trainers Courses should consider doing so.