COLON CANCER

A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

C J A Bowles¹, R Leicester², C Romaya³, E Swarbrick⁴, C B Williams⁵, O Epstein¹

¹ Department of Gastroenterology, Royal Free Hospital, London
² St George’s Hospital, London, UK
³ BSG Administration Office, London, UK
⁴ New Cross Hospital, Wolverhampton, UK
⁵ St Mark’s Hospital, Harrow, Middlesex, UKDepartment of Gastroenterology, Royal Free Hospital, London, UK

Correspondence to:
Correspondence to:
Dr O Epstein
Department of Gastroenterology, Royal Free Hospital, Pond St, London NW3 2QG, UK; o.epstein{at}btinternet.com

Aim: To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions.

Method: A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia.

Patients: Subjects undergoing colonoscopy in 68 endoscopy units.

Results: A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of "at risk" patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course.

Conclusion: There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.

Keywords: colonoscopy; colonoscopy training; screening; colorectal cancer

Abbreviations: NHS, National Health Service; BSG, British Society of Gastroenterology; DGH, District General Hospital; ASA, American Society of Anesthesiology; JAG, Joint Advisory Group

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