Nicholas Ewin Burr

Background: Patients with inflammatory bowel disease (IBD) undergo colonoscopy for diagnosis, disease assessment, and colorectal cancer surveillance. We used the UK National Endoscopy Database (NED) to evaluate the quality of IBD surveillance and identify factors associated with procedural quality. Design: All colonoscopies uploaded to NED between January 1 and December 31, 2024 were analyzed. IBD procedures were identified from recorded indications and classified as assessment or surveillance. Key performance indicators (KPIs) were assessed against national guidance. Case-mix-adjusted impacts of endoscopist- and service-level factors were evaluated using multilevel mixed-effects logistic regression. Results: Of 588 841 colonoscopies, 2.7% (n = 15 971) were IBD surveillance. Although 56.8% of endoscopists performed at least one surveillance procedure, 18.9% performed one or more per month and delivered 57.1% of all surveillance. IBD surveillance quality was high (cecal intubation 96.1%; median withdrawal time 13 min), but adequate bowel preparation was below target (80.2%). Endoscopists performing ≥1 surveillance/month had higher adjusted polyp detection (used as a surrogate marker of mucosal inspection quality rather than true dysplasia) (odds ratio [OR] 1.26), and procedures allocated extended time had higher detection (OR 1.40). Conclusion: These findings suggest that regular exposure to IBD surveillance, adequate procedural time, and consistent use/documentation of dye-based chromoendoscopy are associated with higher polyp detection during IBD surveillance colonoscopy. Importantly, these findings relate to polyp detection rather than histologically confirmed dysplasia detection. Further work is required to determine whether service concentration or minimum surveillance volumes improve dysplasia-related outcomes. Service-level pathways analogous to English Bowel Cancer Screening with national standards and performance monitoring may warrant consideration.

Background: Inflammatory bowel disease (IBD) is associated with colorectal cancer (CRC), but contemporary population-based estimates that distinguish relative hazards from age-specific incidence rates and compare IBD phenotypes are limited.Methods: We did a nationwide retrospective cohort study using linked Hospital Episode Statistics and Office for National Statistics mortality data for England from April 1, 2006, to Dec 31, 2024. People with a hospital record of ulcerative colitis (UC), Crohn's disease (CD), or IBD-unclassified (IBD-U) entered at their first IBD-coded hospital contact. The reference cohort comprised individuals admitted for common low-severity conditions or elective procedures. Cox models estimated adjusted hazard ratios (HRs) for recorded CRC and CRC-related death.Findings: Of 696,792 people with hospital-managed IBD, 366,653 had UC, 233,023 had CD, and 97,116 had IBD-U; the reference cohort included 20,273,587 individuals. Adjusted HRs for CRC were 1·55 (95% CI 1·51-1·60) in UC, 1·46 (1·41-1·52) in CD, and 1·99 (1·90-2·09) in IBD-U. HRs for CRC-related death were 1·65 (1·58-1·72), 1·66 (1·56-1·77), and 1·98 (1·83-2·15), respectively. Relative hazards were highest before age 30 years, whereas incidence rates rose with age and reached 5·27 per 1000 person-years in UC and 5·02 in CD among people aged 75 years or older. HRs were 2·64 in extensive UC and 3·83 in UC with primary sclerosing cholangitis.Interpretation: Hospital-managed IBD was associated with increased recorded CRC incidence and mortality, with marked variation by age and phenotype. Relative hazards were highest at younger ages, but age-specific incidence rates were greatest in older people.

Objective: Upadacitinib is the first Janus kinase inhibitor and oral advanced therapy licensed for Crohn’s disease (CD). Following NICE approval in 2023, real-world data on outcomes are limited. The effectiveness and safety of upadacitinib in a cohort of patients with CD was assessed. Methods: A multicentre retrospective cohort analysis across 19 UK hospitals. Adult patients with active CD who started upadacitinib between April 2023 and October 2023 were included. Outcomes were reviewed over 24 weeks. The primary endpoint was clinical remission (Harvey Bradshaw Index (HBI) <4) at 12 and 24 weeks. Biochemical remission (faecal calprotectin <200 μg/g and C-reactive protein ≤5) and endoscopic remission (Simple Endoscopic Score for Crohn’s Disease ≤3) were assessed at the same intervals. Adverse events (AEs) were recorded until 24 weeks or drug withdrawal. Results: 312 patients were included, with a minimum follow-up of 12 weeks. The cohort had difficult-to-treat disease; 64% failing 3 or more biologics, 51% exhibiting penetrating or stricturing disease and 41% requiring prior resection. 50% (113/227) of patients achieved clinical remission at 12 weeks and 45% (77/172) at 24 weeks. Patients with colonic disease had higher remission rates at 24 weeks compared with other disease locations. At 24 weeks, 51 patients (16%) had discontinued upadacitinib. Treatment persistence was 90.3% at 12 weeks and 84.1% at 24 weeks. 28% had AEs, with 18% experiencing serious AEs and 16.6% requiring hospitalisation. Conclusion: This is a large real-world study reporting outcomes in patients with CD treated with upadacitinib. Our data demonstrated good short-term effectiveness and tolerance in a clinically refractory population.

Background and Aims: Janus kinase inhibitors (JAKi) provide effective treatment for ulcerative colitis (UC), but inadequate response (IR) or intolerance occurs frequently. This study aimed to assess the effectiveness of a second JAKi in a real-world UC cohort. Methods: A retrospective multicenter cohort study encompassing 19 UK hospitals was undertaken. Primary outcome was clinical remission (Simple Clinical Colitis Activity Index/partial Mayo Score ≤ 1) at weeks 8 and 24, based on available assessments. Biochemical (CRP ≤ 5mg/L and fecal calprotectin ≤ 200µg/g) and endoscopic (Ulcerative Colitis Endoscopic Index of Severity/Mayo Endoscopic Subscore ≤ 1) remission were also assessed. Results: A total of 131 patients with active UC were included. The majority (60%) had exposure to ≥3 advanced therapies and 50% required corticosteroids at induction. Clinical remission rates were 59% and 51% at weeks 8 and 24. Biochemical and endoscopic remission rates were 61% and 60% at week 8, and 47% and 32% at week 24. All disease activity parameters significantly reduced by week 8 (P < .001). At week 24 no difference was detected in clinical remission rates between those with primary non-response (42%) or secondary loss of response (52%) to their first JAKi (P = .518). Clinical remission did not differ between upadacitinib (54%) and filgotinib (36%), P = .253. Adverse events occurred in 27% of patients, and serious adverse events in 8%. Conclusions: In this highly refractory cohort with active UC a second JAKi effectively achieved remission following IR to first JAKi. Type of first JAKi failure did not appear to influence clinical remission. No new safety signals were found.

Background Determining optimal management of colorectal polyps in patients with limited life expectancy of under 10 years can be difficult, due to challenges balancing an uncertain natural history of polyp progression to symptomatic malignancy versus the increased risk and consequences of polypectomy complications. Aim This British Society of Gastroenterology and Association of Coloproctologists of Great Britain and Ireland guidance aims to help clinicians and patients consider these risks to aid decision-making for polypectomy versus a conservative approach. Methods A guidance development group comprising 28 members was established, including gastroenterologists, colorectal surgeons, elderly care physicians, anaesthetists, epidemiologists, nurse endoscopists, a general practitioner and patient representatives. Estimates on life expectancy stratified by age and comorbidity, polyp dwell time for differing polyp sizes, cancer sojourn time and polypectomy complication rates for comorbid/elderly patients both on and off antithrombotic medication were collated from various literature searches. A model was created to compare the risk of symptomatic malignancy in a patient’s lifetime against the risk of significant complications. Results Following a modified Delphi consensus process and after three rounds of voting, 33 recommendations were made within 10 domains (principles, diagnostic investigation, life expectancy, polyp and cancer natural history, polypectomy risks, management recommendations, follow-up, decision-making practicalities, training and education, future research). A table was created, summarising whether polypectomy or conservative management might be the favoured option for 40 clinical scenarios of patients with differing life expectancy, polyp sizes and use of antithrombotic medication. Conclusions This guidance provides a framework to facilitate more objective and informed decision-making, from which an individualised plan can be developed between the patient and their clinician.

Objective Studies in the USA examining the relationship between ethnicity and colorectal cancer (CRC) identified significant variation. This study sought to examine the relationship between ethnic group, route to diagnosis, early-onset CRC and stage at diagnosis in the English National Health Service. Methods Data from COloRECTal cancer data Repository for all individuals diagnosed with CRC (International Classification of Diseases version 10, C18–C20) between 2012 and 2017. A descriptive analysis of the characteristics of the study population was performed. Multivariable logistic regression models were used to assess the association between ethnicity, route to diagnosis, stage at diagnosis and early-onset CRC. Results Early-onset CRC was least common in those in the white ethnic group (5.5% diagnosed Conclusion This study identified different demographic profiles of those diagnosed with CRC between broad ethnic groups, highlighting the need to consider access to diagnostic CRC services in the context of ethnicity.

The incidence of colonic inflammatory bowel disease (IBD) is increasing globally, with prevalence rates of approximately 1 in 200 adults in the highest-risk populations [1]. One of the consequences of longstanding colonic inflammation is the potential development of premalignant lesions and colorectal cancer (CRC). Although the risk of CRC in IBD is declining, the cumulative risk is estimated to be 1%, 2%, and 5% after 10, 20, and >20 years of disease, respectively [2]. Therefore, patients with IBD are usually invited to undergo screening colonoscopies 8 years after symptom onset, followed by surveillance procedures depending on patient-specific risk factors. The aim of any screening and surveillance program is to reduce morbidity and mortality due to the disease. With improvements in colonoscopy, most IBD dysplasia can be detected and removed, meaning that the prevention of CRC is possible. To improve prevention, complete endoscopic resection of the dysplastic lesions is important. The challenges associated with IBD dysplasia are that these lesions are often flat, without clear and discrete borders, and can be within inflamed areas of the colon. Inflammation can lead to fibrosis and tethering, limiting endoscopic resection. In this issue of Endoscopy, Angajala et al. [3] explore the challenges associated with endoscopic resection of laterally spreading IBD-associated dysplastic lesions. The authors compared outcomes between IBD- and non-IBD-associated lesions at a tertiary referral center between 2015 and 2021. The majority of the procedures were performed by “expert endoscopists” with dedicated training in endoscopic colonic resection. A total of 210 lesions were included (187 non-IBD and 23 IBD). The average size of the lesions was “large” at 25 mm in the IBD group and 20 mm in the non-IBD group. Most lesions were tubular adenomas with low grade dysplasia or sessile serrated lesions (91% in both cohorts). The morphology of the lesions was similar, and they were also distributed similarly throughout the colon. Despite comparable baseline characteristics, the primary outcome of the study reported significantly higher recurrence rates in the IBD cohort (30%) than in the controls (21%). The recurrence rates in this tertiary center were high in both groups, which is a notable finding. While most recurrences can usually be dealt with endoscopically, this can be more challenging with laterally spreading lesions, and current or prior inflammation can hamper the complete removal of recurrent tissue. With techniques such as excision of a 2–3-mm margin of normal tissue and thermal ablation of defect margins following endoscopic mucosal resection, much lower rates of recurrence are possible. In recent non-IBD cohorts, rates as low as 2% have been reported [4]. Whether these results can be achieved in IBD remains uncertain and it would be interesting to observe whether a significant difference in recurrence persists in contemporary cohorts. The rates of en bloc resection were significantly lower in the IBD cohort (9% vs. 57%), but the difference in recurrence was maintained after adjustment, bearing in mind the small sample size. There are several reasons why en bloc endoscopic mucosal resection may be more challenging in patients with IBD. These lesions can be more difficult to inspect in areas of the colon with active or prior inflammation and scarring, and submucosal injection can be complicated by inflammation and fibrosis. Endoscopic submucosal dissection (ESD) is an obvious candidate technique for improving the rate of en bloc resection. Although ESD is technically challenging and time consuming, the efficacy of the technique is supported in the literature, with an en bloc resection rate of 100% and R0 rate of 96% achieved in a recent IBD cohort [5]. The increased risk with ESD is important to consider, with perforation and bleeding rates being 6% and 8%, respectively. Complications from ESD could be higher in a delicate IBD colon, but most can be managed endoscopically [6]. The additional benefit of achieving R0 resection is that there is a reduced need for “site-check” procedures and surveillance, which is important as the IBD cohort can be subjected to numerous endoscopies, particularly those with dysplastic lesions who undergo more intense surveillance. There will be a rise in the overall number of IBD dysplastic lesions due to the increasing incidence of IBD, longer survival, and increased use of colonoscopy. However, it is important to remember that the overall scale of this problem is relatively small. This is reflected in the small number of patients with IBD included in this (n = 14) and other studies. This means that the experience of managing these lesions is difficult to achieve in most practices; therefore, an argument for the centralization of services in tertiary referral hospitals could be made. To improve outcomes, the same principles for safe and complete endoscopic removal should be applied to both IBD and non-IBD lesions. These include accurate assessment of the lesion, borders, and risk of submucosal invasion, which precludes removal. A case-by-case review should be conducted to determine the appropriate resection technique that considers all options and available expertise. Before removal, there should be an open and honest discussion with the patient about the potential for recurrence, complications, risk of incomplete resection, need for surveillance, importance of controlling ongoing inflammation, and early surgical discussion where appropriate. The responsible team also needs to ensure that, as far as possible, there has been a meticulous screening procedure for synchronous lesions. We should be optimistic that with improved assessment and resection techniques, high rates of en bloc, safe, and complete resection will be achieved, resulting in the very low recurrence rates seen in the non-IBD population. As we learn...

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.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.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.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.

In 2016, the British Society of Gastroenterology (BSG) published comprehensive guidelines for obtaining consent for endoscopic procedures. In November 2020, the General Medical Council (GMC) introduced updated guidelines on shared decision making and consent. These guidelines followed the Montgomery ruling in 2015, which changed the legal doctrine determining what information should be given to a patient before a medical intervention. The GMC guidance and Montgomery ruling expand on the role of shared decision making between the clinician and patient, explicitly highlighting the importance of understanding the values of the patient. In November 2021, the BSG President’s Bulletin highlighted the 2020 GMC guidance and the need to incorporate patient -related factors into decision making. Here, we make formal recommendations in support of this communication, and update the 2016 BSG endoscopy consent guidelines. The BSG guideline refers to the Montgomery legislation, but this document expands on the findings and gives proposals for how to incorporate it into the consent process. The document is to accompany, not replace the recent GMC and BSG guidelines. The recommendations are made in the understanding that there is not a single solution to the consent process, but that medical practitioners and services must work together to ensure that the principles and recommendations laid out below are deliverable at a local level. The 2020 GMC and 2016 BSG guidance had patient representatives involved throughout the process. Further patient involvement was not sought here as this update is to give practical advice on how to incorporate these guidelines into clinical practice and the consent process. This document should be read by endoscopists and referrers from primary and secondary care.