Andrew M. Veitch

Background Recommendations for the first postpolypectomy surveillance colonoscopy (SC1), based on stratifying postpolypectomy colorectal cancer (CRC) risk, are well established. Limited data inform recommendations for surveillance beyond SC1. Objective We investigated which patient groups need surveillance beyond SC1. Design Retrospective analysis of patients who underwent colonoscopy with polypectomy at 17 UK hospitals, mostly from 2000 to 2010, and had ≥1 surveillance colonoscopies. Cancer and death data were collected through 2017. We examined patients in groups defined by risk at baseline and SC1, applying risk definitions from the 2020 UK postpolypectomy surveillance guidelines: ‘low risk, low risk’ (LR-LR), ‘high risk, low risk’ (HR-LR), ‘low risk, high risk’ (LR-HR) and ‘high risk, high risk’ (HR-HR). We examined CRC incidence after SC1, censoring at any second surveillance colonoscopy (SC2), and after SC2 through end of follow-up. We compared incidence with general population incidence using standardised incidence ratios (SIRs). Results Analyses included 10 508 patients: LR-LR=6587 (63%), HR-LR=3272 (31%), LR-HR=248 (2%) and HR-HR=401 (4%). Median follow-up from SC1 was 8.0 years and 151 CRCs were diagnosed. Compared with the general population, CRC incidence after SC1 was lower in the LR-LR group (SIR 0.48, 95% CI 0.34 to 0.67), non-significantly different in the HR-LR (SIR 1.17, 0.85 to 1.58) or LR-HR (SIR 2.51, 0.81 to 5.85) groups, but higher in the HR-HR group (SIR 2.84, 1.30 to 5.39). After SC2, CRC incidence in the HR-HR group was no longer higher than in the general population (SIR 1.86, 0.89 to 3.42). Conclusion Patients with high-risk findings at both baseline and SC1 needed an SC2, while those with low-risk findings at SC1 did not, regardless of their baseline findings.

The nine commentaries published by Gut in this December 2023 issue are coauthored by the webinar speakers and colleagues (figure 1) and provide a synopsis of the webinar topics and related resources and references. They also serve as a compendium of the impact of CC on gastrointestinal health for readers worldwide to use. The nine commentaries begin with an overview of the fundamentals to assist the readership in fully grasping the gravity of the CC crisis,2 and close with an overview of climate action opportunities pertaining to education, empowerment of trainees and research.3 Notably, the Gut commentary series will be freely available to any reader able to connect with the internet.

GI endoscopy is highly resource-intensive with a significant contribution to greenhouse gas (GHG) emissions and waste generation. Sustainable endoscopy in the context of climate change is now the focus of mainstream discussions between endoscopy providers, units and professional societies. In addition to broader global challenges, there are some specific measures relevant to endoscopy units and their practices, which could significantly reduce environmental impact. Awareness of these issues and guidance on practical interventions to mitigate the carbon footprint of GI endoscopy are lacking. In this consensus, we discuss practical measures to reduce the impact of endoscopy on the environment applicable to endoscopy units and practitioners. Adoption of these measures will facilitate and promote new practices and the evolution of a more sustainable specialty.

Introduction Uptake rates and pathology detection has increased significantly with integration of faecal immunochemical testing (FIT) in the English Bowel Cancer Screening Programme (BCSP). However a proportion of patients do not uptake diagnostic tests after positive FIT tests. We compared pre and peri-COVID cohorts to identify current barriers to uptake of diagnostic tests within a single, large BCSP centre. Methods Two patient cohorts were analysed from the Wolverhampton BCSP Centre (September 2019-February 2020 (Group A, pre-Covid) and April-July 2021 (Group B, peri-Covid)). Patients with a positive FIT were assessed by either a face-to-face (F2F) consultation (Group A) or a telephone consultation (TC) (Group B) by a specialist screening practitioner (SSP) and offered information and diagnostic tests. Total overall numbers were recorded and cases not proceeding with diagnostic tests reviewed. Statistical analysis utilised Fisher’s exact test where appropriate. Results In group A, 26293/42545 (61.8%) patients returned a FIT test compared with, 30214/45538 (66.3%) in group B (pConclusion FIT sample return rates have increased in the peri-COVID era but proportions of patients not proceeding with diagnostic investigations following positive FIT testing have risen. Patient choice is a notable barrier to uptake and other barriers which have significantly increased during this current period are patients being assessed as clinically unsuitable due to health reasons, declining initial telephone appointments and DNA tests. Whilst informed patient choice is key in national screening programmes, cancer and polyp detection in FIT positive patients in BCSP are notable. Understanding patient’s perspectives on tests, preferences over TC or F2F and SSP education on health assessment for colonoscopy may improve uptake of diagnostic tests within the BCSP.

Background: Colonoscopy surveillance is recommended for some patients post polypectomy. The 2002 UK surveillance guidelines classify post-polypectomy patients into low, intermediate and high risk, and recommend different strategies for each classification. Limited evidence supports these guidelines. Objectives: To examine, for each risk group, long-term colorectal cancer incidence by baseline characteristics and the number of surveillance visits; the effects of interval length on detection rates of advanced adenomas and colorectal cancer at first surveillance; and the cost-effectiveness of surveillance compared with no surveillance. Design: A retrospective cohort study and economic evaluation. Setting: Seventeen NHS hospitals. Participants: Patients with a colonoscopy and at least one adenoma at baseline. Main outcome measures: Long-term colorectal cancer incidence after baseline and detection rates of advanced adenomas and colorectal cancer at first surveillance. Data sources: Hospital databases, NHS Digital, the Office for National Statistics, National Services Scotland and Public Health England. Methods: Cox regression was used to compare colorectal cancer incidence in the presence and absence of surveillance and to identify colorectal cancer risk factors. Risk factors were used to stratify risk groups into higher- and lower-risk subgroups. We examined detection rates of advanced adenomas and colorectal cancer at first surveillance by interval length. Cost-effectiveness of surveillance compared with no surveillance was evaluated in terms of incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained. Results: Our study included 28,972 patients, of whom 14,401 (50%), 11,852 (41%) and 2719 (9%) were classed as low, intermediate and high risk, respectively. The median follow-up time was 9.3 years. Colorectal cancer incidence was 140, 221 and 366 per 100,000 person-years among low-, intermediate- and high-risk patients, respectively. Attendance at one surveillance visit was associated with reduced colorectal cancer incidence among low-, intermediate- and high-risk patients [hazard ratios were 0.56 (95% confidence interval 0.39 to 0.80), 0.59 (95% confidence interval 0.43 to 0.81) and 0.49 (95% confidence interval 0.29 to 0.82), respectively]. Compared with the general population, colorectal cancer incidence without surveillance was similar among low-risk patients and higher among high-risk patients [standardised incidence ratios were 0.86 (95% confidence interval 0.73 to 1.02) and 1.91 (95% confidence interval 1.39 to 2.56), respectively]. For intermediate-risk patients, standardised incidence ratios differed for the lower- (0.70, 95% confidence interval 0.48 to 0.99) and higher-risk (1.46, 95% confidence interval 1.19 to 1.78) subgroups. In each risk group, incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained with surveillance were lower for the higher-risk subgroup than for the lower-risk subgroup. Incremental costs per quality-adjusted life-year gained were lowest for the higher-risk subgroup of high-risk patients at £7821. Limitations: The observational design means that we cannot assume that surveillance caused the reductions in cancer incidence. The fact that some cancer staging data were missing places uncertainty on our cost-effectiveness estimates. Conclusions: Surveillance was associated with reduced colorectal cancer incidence in all risk groups. However, in low-risk patients and the lower-risk subgroup of intermediate-risk patients, colorectal cancer incidence was no higher than in the general population without surveillance, indicating that surveillance might not be necessary. Surveillance was most cost-effective for the higher-risk subgroup of high-risk patients. Future work: Studies should examine the clinical effectiveness and cost-effectiveness of post-polypectomy surveillance without prior classification of patients into risk groups. Trial registration: This trial is registered as ISRCTN15213649. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 26. See the NIHR Journals Library website for further project information.

There is a global climate emergency, and also a global health concern related to climate change. The British Society of Gastroenterology (BSG) acknowledges these issues, and supports the concerns of its members to address them. Climate change has adverse effects on gastroenterological and liver disease, and on healthcare systems. The healthcare industry, itself, is also a major contributor to greenhouse gases. BSG has developed a strategy on Climate Change and Sustainability, which encompasses all of the activities of the society, and its members: personal, professional, organisational, political, international and research.

Introduction Training and quality assurance in oesophagogastroduodenoscopy (OGD) is important to ensure competent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for OGD training and certification. Methods Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted with stakeholder representation from British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons, trainees and trainers. Recommendations on OGD training and certification were formulated following literature review and appraised using Grading of Recommendations Assessment, Development and Evaluation. These were subjected to electronic voting to achieve consensus. Accepted statements were incorporated into the updated certification pathway. Results In total, 32 recommendation statements were generated for the following domains: definition of competence (4 statements), acquisition of competence (12 statements), assessment of competence (10 statements) and post-certification support (6 statements). The consensus process led to following certification criteria: (1) performing ≥250 hands-on procedures; (2) attending a JAG-accredited basic skills course; (3) attainment of relevant minimal performance standards defined by British Society of Gastroenterology/Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, (4) achieving physically unassisted D2 intubation and J-manoeuvre in ≥95% of recent procedures, (5) satisfactory performance in formative and summative direct observation of procedural skills assessments. Conclusion The JAG standards for diagnostic OGD have been updated following evidence-based consensus. These standards are intended to support training, improve competency assessment to uphold standards of practice and provide support to the newly-independent practitioner.