Introduction European guidelines have proposed four levels of competency for polypectomy. The highest competence (level 4) is expected of only a small number of regionally based colonoscopists, to whom patients with large or complex polyps might be referred. We wished to explore whether such a model could be applied to current UK practise.
Methods In a UK national survey of advanced polypectomy, a number of questions were designed to reveal attitudes and beliefs underlying clinical decision-making and referral practises. The survey was directed to all BSG members and BCSP colonoscopists.
Results Respondents 268 independent colonoscopists in UK practise with a median lifetime experience of 3000 procedures. 64% were BCSP colonoscopists and 86% undertook endoscopic mucosal resection (EMR) of polyps > 20mm.
Competence Level When asked to describe the most complex polyp they would tackle, 3.4% fell into competence level 1, 31% level 2, 35% level 3 and 30% level 4. Of the 81 self-rated level 4 operators, 17% had never removed a polyp > 5cm and 32% performed ≤20 EMRs in the previous year. Only 56% of level 4 operators agreed that they would attempt any polyp where EMR was technically feasible. Others felt constrained by their own technical ability or by time and resource limitations.
A quarter of all the respondents considered that they operated close to the limit of what was technically possible by EMR but only 15 operators (5.6%) were identified who had a workload of > 50 EMRs per year and had removed a polyp > 6cm at some point in their career.
Referral behaviour 51% had referred at least one benign polyp for surgical excision in the previous year. 12% refer straight to surgery for any polyp they cannot tackle themselves. 47% had referred a polyp to a colleague for EMR (34% refer to an endoscopist within their own unit, 28% to another hospital and 12% to an expert in a different region). 70% of all respondents declared they would be happy to receive EMR referrals from a colleague.
Future directions 59% indicated support for accreditation in advanced polypectomy but only 41% wanted to see nominated EMR experts for each region. Just 18% supported the concept of an integrated national referral network for complex polyps. The proposal for 3 – 4 national referral centres was also unpopular.
Conclusion Many colonoscopists appear willing to refer cases to a colleague for EMR, even if it involves transfer to another hospital. Evidence emerged for a small group of experts capable of handling very large polyps, yet referral for surgery remains common. A national referral network might reduce the rate of surgical intervention but while so many colonoscopists perceive themselves to be performing at the “cutting edge” support for this is likely to remain limited.
Disclosure of Interest P. O’Toole: None Declared, J. Anderson: None Declared, J. Geraghty Grant/Research Support from: COOK MEDICAL, R. Valori: None Declared, S. Sarkar: None Declared
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