Roland Valori’s research while affiliated with Gloucestershire Hospitals NHS Foundation Trust and other places

Objective Operator technical skill is recognised as a critical determinant of surgical outcomes. However, no equivalent recognition for quality of endoscope tip manipulation (tip-control) exists. We aimed to create an ex-vivo snare tip soft coagulation (STSC) model to objectively quantify endoscopist tip-control. Method This prospective interventional study was conducted at Ghent University Hospital. Participants applied STSC to a training model simulating four endoscopic mucosal resection (EMR) defects on a slice of ham. Accuracy (correct/total-hits) and speed (correct-hits/s) were assessed from a video by a single-blinded rater using a web-based scoring system. Results 22 endoscopists participated. Interventional endoscopists demonstrated significantly higher accuracy (87.0%) and speed (0.184 correct-hits/s) compared with trainees (74.5%, 0.106 correct-hits/s; both p<0.001) and non-interventional consultants (77%, 0.141 correct-hits/s; p<0.001). The tip-control of trainees and non-interventional consultants was not significantly different. Endoscopists having performed ≥1000 colonoscopies, performing SMSA-4 polypectomies or ≥50 EMRs/year showed superior tip-control. Endoscopists with >5 years of endoscopic experience did not have better tip-control (accuracy 88.0%(p=0.07), speed 0.132 hits/s (p=0.36)) when compared with those with ≤4 years of experience. Conclusion This inexpensive ex vivo STSC simulation model effectively quantified endoscopic tip-control, correlating with endoscopist expertise and clinical profiles. The model could support the shift towards competency-based education, potentially improving patient outcomes. Trial registration number NCT05660317 .

Background This study investigated the application of Duty of Candour (DoC) legislation in the context of post-colonoscopy colorectal cancers (PCCRCs). DoC mandates transparent disclosure of notifiable safety incidents to patients in the English National Health Service, including incidences leading to severe or moderate harm. This study aimed to analyze the application of DoC in PCCRCs, improve understanding of the legislation, and identify challenges in DoC implementation. Methods A national audit of PCCRCs was conducted between September 2021 and May 2022. PCCRCs were identified using linked administrative datasets, and root-cause analyses were performed using structured templates. “Avoidability” and harm were categorized into specific levels, and guidance was provided on improving consistency in judgments. Results 16% of 1724 PCCRCs resulted in major harm or death, of which 27% (75) were probably or definitely avoidable. Hospitals deemed DoC discharge necessary in only 53% of these cases. When including moderate harm, 11% of all PCCRCs would trigger DoC discharge, yet this was deemed necessary in only 45% of such cases. Conclusions There is inconsistent application of DoC in PCCRC cases. Challenges include determining “avoidability” and harm, particularly when diagnosis is delayed. Clearer guidance and definitions of harm are needed to improve adherence to regulations.

Background and Aims In 2018, the World Endoscopy Organization (WEO) introduced standardised methods for calculating post-colonoscopy colorectal cancer-3yr rates (PCCRC-3yr). This systematic review aimed to calculate the global PCCRC-3yr according to the WEO methodology, its change over time, and to measure the association between risk factors and PCCRC occurrences. Methods We searched five databases from inception until January 2024 for PCCRC-3yr studies that strictly adhered to the WEO methodology. The overall pooled PCCRC-3yr was calculated. For risk factors and time-trend analyses, the pooled PCCRC-3yr and odds ratio (OR) of subgroups were compared. Results Several studies failed to adhere to the WEO methodology. Eight studies from four Western European and two Northern American countries were included, totalling 220,106 detected-colorectal cancers (CRC) and 18,148 PCCRCs between 2002-2017. The pooled Western World PCCRC-3yr was 7.5% (95%CI 6.4%-8.7%). The PCCRC-3yr significantly (p<0.05) decreased from 7.9% (95%CI 6.6%-9.4%) in 2006 to 6.7% (95%CI 6.1%-7.3%) in 2012 (OR 0.79 (95%CI 0.72-0.87)). There were significantly higher rates for people with inflammatory bowel disease (PCCRC-3yr 29.3%, OR 6.17 (95%CI 4.73-8.06)), prior CRC (PCCRC-3yr 29.8%, OR 3.03 (95% CI 1.34-4.72)), proximal CRC (PCCRC-3yr 8.6%, OR 1.51 (95%CI 1.41-1.61), diverticular disease (PCCRC 3-yr 11.6%, OR 1.74 (95%CI 1.37-2.10)) and female sex (PCCRC-3yr 7.9%, OR 1.15 (95%CI 1.11-1.20)). Conclusion According to the WEO methodology, the Western World PCCRC-3yr was 7.5%. Reassuringly, this has decreased over time, but further work is required to identify the reasons for PCCRCs, especially in higher-risk groups. We devised a WEO methodology checklist to increase its adoption and standardise the categorisation of patients in future PCCRC-3yr studies.

Introduction Post endoscopy upper gastrointestinal cancers (PEUGIC) can be missed opportunities to diagnose earlier or even prevent cancer. PEUGIC in patients undergoing endoscopic surveillance for pre-malignant conditions (e.g. Barrett’s oesophagus) are an important quality metric. A process for identifying PEUGIC and performing root cause analysis was piloted and the results are described. Methods PEUGIC occurring 3–36 months after a non-diagnostic (index) endoscopy between 2017 and 2023 were identified from final or provisional registrations in the National Cancer Registration and Hospital Episode Statistics Datasets held by the National Cancer Registration and Analysis Service. Data for root cause analysis were uploaded onto a secure root cause analysis portal following local hospital review. Only PEUGIC following surveillance endoscopy were included in this analysis. Results 305 PEUGIC were examined by local reviewers in 13 hospitals in England. 40 were excluded, due to errors in provisional cancer data. Data were available for 220 PEUGIC (83%). 54 PEUGIC (26%) were undergoing surveillance for either Barrett’s oesophagus (87%) or chronic atrophic gastritis (13%).Figure 1 shows the PEUGIC root cause analysis based on World Endoscopy Organisation categorisation (Kamran Endoscopy 2023). Inadequate assessment or decision making was found in 11% of PEUGIC. Findings in addition to the pre-malignant lesion: oesophageal PEUGIC focal lesion 17%; gastric PEUGIC focal lesion 29%. For oesophageal PEUGIC, 40% were diagnosed 3 months after the recommended surveillance date and 10% were interval cancers. In gastric PEUGIC, 29% were diagnosed 3 months after the recommended surveillance date and 29% were interval cancers. Gastric PEUGIC tended to present more advanced stage 2 cancer or greater (43% vs 22.5% oesophageal). 2% of oesophageal and 14.3% of gastric PEUGIC were considered potentially avoidable by reviewers. Treatment appeared adversely affected with more invasive or palliative not curative treatment in 17% of oesophageal and 43% of gastric PEUGIC. Reviewers considered that 4% of PEUGIC led directly to a premature death. Conclusions Inadequate assessment or decision making was noted in 11% of surveillance PEUGIC. Focal lesions were noted at non-diagnostic endoscopy in 19%. 43% of gastric surveillance patients presented with stage 2 cancer or greater and adverse treatment outcomes occurred in 22% of surveillance PEUGIC. • Download figure • Open in new tab • Download powerpoint Abstract O53 Figure 1 Root causes of surveillance endoscopy PEUGIC.

Introduction Post endoscopy upper gastrointestinal cancers (PEUGIC) can be missed opportunities to diagnose earlier or even prevent cancer. Up to 71% are potentially avoidable but identifying and investigating PEUGIC is challenging. A process for identifying PEUGIC and performing root cause analysis was piloted and the results are described. Methods PEUGIC occurring 3–36 months after a non-diagnostic (index) endoscopy between 2017 and 2023 were identified from the final or provisional registrations in National Cancer Registration and Hospital Episode Statistics Datasets held by the National Cancer Registration and Analysis Service. Data for root cause analysis were uploaded onto a secure root cause analysis portal following local hospital review. PEUGIC following diagnostic, screening or follow up endoscopies were included in this analysis. Results 305 PEUGIC were examined by local reviewers in 13 hospitals in England. 40 were excluded, mainly due to errors in provisional cancer data. Data were available for 220 PEUGIC (83%). 136 (62%) PEUGIC followed diagnostic, follow-up or screening endoscopies. PEUGIC sites were oesophagus 63% and stomach 37%.Figure 1 shows the PEUGIC root cause analysis based on the World Endoscopy Organisation categorisation (Kamran Endoscopy 2023). Lesion detected but inadequate assessment or decision making occurred in 15% and possible missed lesion with inadequate endoscopy or decision making in 17%. Diagnoses on index endoscopy in oesophageal PEUGIC: no abnormal finding 51%, focal lesion 22%, pre-malignant lesion 21% (e.g. Barrett’s) and cancer associated lesion 6% (e.g. ulcer). Findings on index endoscopy in gastric PEUGIC: no abnormal finding 38%, cancer associated lesion 30%, focal lesion 22% and pre-malignant lesion 10% (e.g. gastric atrophy). Gastric PEUGIC tended to present with more advanced cancer (41% stage 4 vs 33% oesophageal PEUGIC). 13% of oesophageal and 12% of gastric PEUGIC were considered potentially avoidable by reviewers. Treatment appeared adversely affected with more invasive or palliative not curative treatment in 45% of oesophageal and 38% of gastric PEUGIC. Reviewers considered that 9% of PEUGIC led to premature death. Conclusions Abnormalities in the area of the later cancer were detected in 49% of oesophageal PEUGIC and 62% of gastric PEUGIC. Inadequate lesion assessment, endoscopy and/or decision making was noted in 32% of PEUGIC. Many patients had incurable disease when later diagnosed and treatment appeared adversely affected in 42%. • Download figure • Open in new tab • Download powerpoint Abstract P181 Figure 1 Root causes of PEUGIC.

Objective To estimate and quantify the cost implications and health impacts of improving the performance of English endoscopy services to the optimum quality as defined by postcolonoscopy colorectal cancer (PCCRC) rates. Design A semi-Markov state-transition model was constructed, following the logical treatment pathway of individuals who could potentially undergo a diagnostic colonoscopy. The model consisted of three identical arms, each representing a high, middle or low-performing trust’s endoscopy service, defined by PCCRC rates. A cohort of 40-year-old individuals was simulated in each arm of the model. The model’s time horizon was when the cohort reached 90 years of age and the total costs and quality-adjusted life-years (QALYs) were calculated for all trusts. Scenario and sensitivity analyses were also conducted. Results A 40-year-old individual gains 0.0006 QALYs and savings of £6.75 over the model lifetime by attending a high-performing trust compared with attending a middle-performing trust and gains 0.0012 QALYs and savings of £14.64 compared with attending a low-performing trust. For the population of England aged between 40 and 86, if all low and middle-performing trusts were improved to the level of a high-performing trust, QALY gains of 14 044 and cost savings of £249 311 295 are possible. Higher quality trusts dominated lower quality trusts; any improvement in the PCCRC rate was cost-effective. Conclusion Improving the quality of endoscopy services would lead to QALY gains among the population, in addition to cost savings to the healthcare provider. If all middle and low-performing trusts were improved to the level of a high-performing trust, our results estimate that the English National Health Service would save approximately £5 million per year.