Introduction

Recent data has suggested that discordance between surgeon sex and patient sex is associated with a negative postoperative outcome (1). It is as yet unknown whether this is also true for endoscopists’ performance in relation to endoscopist and patient sex. We aimed to assess if there is an association between endoscopist-patient sex discordance and colonoscopy outcome.

Aims & Methods

In a multicenter retrospective study all colonoscopy procedures performed between 2016 and 2020 in 17 hospitals were collected from a prospective endoscopy database. Coloscopies were categorized into colorectal cancer screening procedures and colonoscopies performed for other indications. Concordance sex was defined if endoscopist and patient had the same sex, discordance was defined if endoscopist and patient did not have the same sex. For each colonoscopy, patient discomfort (Gloucester comfort scale >4), cecal intubation, adenoma detection rate (ADR), and polyp detection rate (PDR) was recorded. We used generalized estimating equations accounting for endoscopist age and experience (years of experience), patient age, year of procedure, ASA classification, adequate bowel preparation (Boston bowel preparation score >6), type of hospital (academic vs. non-academic) and type of sedation. Random effects incorporated were patient ID, hospital and endoscopist.

Results

Out of 235,101 colonoscopies, 44,944 screening procedures were performed by 103 endoscopists, of which 23,990 were sex concordant and 20,954 were sex discordant. The other 190,157 colonoscopies were performed by 196 endoscopists, of which 95.662 were sex concordant and 94.495 were sex discordant. In screening colonoscopies, sex discordance was associated with significantly more discomfort (aOR: 1.19; 95%CI, 1.04-1.37), lower ADR (aOR: 0.86; 95%CI, 0.82-0.90), and lower PDR (adjusted Odds Ratio (aOR): 0.84; 95%CI, 0.80-0.88) but not with cecal intubation (aOR: 0.9; 95%CI, 0.76-1.07). In non-screening colonoscopies ,sex discordance was significantly associated with lower PDR (aOR: 0.95; 95%CI, 0.92-0.98) but not with discomfort (aOR: 0.99; 95%CI, 0.92-1.07), cecal intubation (aOR: 1.00; 95%CI, 0.94-1.06) and ADR (aOR: 1.00; 95% CI, 0.96-1.05). Subgroup analyses revealed no specific subgroup, and endoscopists’ sex and patients’ sex did not change this association (Table 1).

Table 1. Discordance vs concordance

		Colorectal Cancer Screening colonoscopies	Non-screening colonoscopy
	Outcome	OR (95% CI)	OR (95% CI)
Female patients	Significant discomfort	0.685 [0.446 – 1.052]	0.815 [0.604 – 1.100]
	Caecal intubation	0.992 [0.607 – 1.620]	1.219 [0.740 – 2.008]
	ADR	1.020 [0.875 – 1.188]	1.037 [0.742 – 1.450]
	PDR	1.040 [0.879 – 1.231]	0.916 [0.789 – 1.062]
Male patients	Significant discomfort	0.721 [0.441 – 1.177]	0.952 [0.673 – 1.348]
	Caecal intubation	0.965 [0.652 – 1.428]	1.250 [0.711 – 2.196]
	ADR	0.938 [0.804 – 1.095]	1.018 [0.696 – 1.488]
	PDR	0.976 [0.829 – 1.150]	0.870 [0.729 – 1.039]

Conclusion

Sex discordance between endoscopists and patients was associated with more discomfort, lower ADR, and lower PDR in screening colonoscopies, and lower PDR in non-screening colonoscopies. These findings do not seem to be driven by a specific subgroup or endoscopists’ sex, such as the case was in the study on the observed discordance between surgeon sex and patient sex and its associated negative postoperative outcome. Further studies are needed to confirm or invalidate these findings, as well as the clinical relevance.

References

1. Wallis CJD, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. Bmj. 2017;359:j4366.

Disclosure

R.J.T. Ouwendijk received grants from Janssen Netherlands, Norgine and the Coolsingel foundation. M.J. Bruno serves as a consultant and receives support for industry and investigator-initiated studies from Boston Scientific and Cook Medical and receives support for investigator-initiated studies from Pentax Medical, 3 M, Interscope, and Mylan. P.D. Siersema received research grants from Norgine, Pentax, Microtech, Yakult, Lucid Diagnostics and Motus GI (ongoing). P.D. Siersema is a member on the advisory board of Motus GI and Boston Scientific.The other authors declare that they have no conflicts of interest.

Introduction

Fewer adenomas are detected at colonoscopy in women compared to men. Failure to detect adenomas and sessile serrated polyps is associated with an increased risk of post-colonoscopy colorectal cancer (PCCRC).There are differences between men and women that may influence different diagnostic yields by colonoscopy. Different attitudes towards the procedure may account for a lower attendance rate for colonoscopy in women. Colonoscopy can be technically more difficult in women than men, and women have an increased need of analgesia and sedation. Men and women have a different probability of complete examinations. A considerable variation in colonoscopy quality among different endoscopists has been observed in two randomized controlled clinical screening trials: the Nordic-European Initiative on Colorectal Cancer (NordICC) trial (1) and the SCREESCO (Screening of Swedish Colons) trial (2, 3). Endoscopist performance may affect male and female patients differently given the more technically challenging procedure in women. In previous studies, the adenoma detection rate tends has been higher in men while high-grade sessile serrated polyps, in particular those found in right colon, are more frequent in women , and the risk for post-colonoscopy CRC (PCCRC) within three years was lower in men (6.9%) than in women (7.6%) in Sweden and in England (7.0% vs 8.0%).

Aims & Methods

Aims: The aim of this study was to investigate whether this was in part due to the greater difficulty of conducting colonoscopy in women, with the difference being more apparent in colonoscopies conducted by less skilled endoscopists.
Methods: Cross-sectional exploratory analysis of data on 16,551 individuals undergoing a primary colonoscopy (PCOL group) or colonoscopy after positive fecal immunochemical test (FIT group) within the randomized controlled trial SCREESCO, Screening of Swedish Colons. Endoscopist skill (low or high) was determined based on each endoscopist’s adenoma detection rate in all first-time colonoscopies performed in SCREESCO. Colonoscopy yield was assessed by gender in each study group and by endoscopist adenoma skill. Effect modification of the gender difference by endoscopist adenoma detection rate (a measure of endoscopist skill) on colonoscopy yield was assessed by use of multiplicative interaction tests.

Results

​Most endoscopists performed equally many colonoscopies in men and women (median 52% men) and the adenoma detection rate was higher in male patients (median: 32.6%) compared to female patients (median: 22.9%). There were no signs of effect modification of the risk ratio of any finding (men vs women) by endoscopist skill in the PCOL group (p=0.33) and the FIT group (p=0.3). The proportion of incomplete index colonoscopies was lower in men than in women in both groups and there was no effect modification by endoscopist skill in neither the PCOL group (p=0.41) nor the FIT group (p=0.96).

Conclusion

Endoscopist skill affected yield similarly for men and women in both the PCOL group and the FIT group, both regarding diagnostic yield and caecal intubation rate. Differences in endoscopist adenoma detection rate in male and female patients suggest that quality indicators should be assessed by patient gender.

References

1. Bretthauer M, Kaminski MF, Loberg M, Zauber AG, Regula J, Kuipers EJ, et al. Population-Based Colonoscopy Screening for Colorectal Cancer: A Randomized Clinical Trial. JAMA Intern Med. 2016;176(7):894-902
2. Forsberg A, Westerberg M, Metcalfe C, Steele R, Blom J, Engstrand L, et al. Once-only colonoscopy or two rounds of faecal immunochemical testing 2 years apart for colorectal cancer screening (SCREESCO): preliminary report of a randomised controlled trial. Lancet Gastroenterol Hepatol. 2022;7(6):513-21.
3. Sekiguchi M, Westerber M, Ekbom A, Hultcrantz R, Forsberg A. Endoscopist Characteristics and Polyp Detection in Colonoscopy: Cross-Sectional Analyses of Screening of Swedish Colons. Gastroenterology. 2023;164(2):293-295.e4

Disclosure

No disclosores to report

Introduction

The quality of colonoscopy is influenced by patient and operator factors. Studies investigating operator attentional fatigue on adenoma detection rate (ADR) have yielded conflicting results.

Aims & Methods

This study aims to compare ADR, polyp detection rate (PDR) and sessile serrated lesion detection rate (SSLDR) and complication rates between elective colonoscopies performed early and late in the list, across multiple operators (n>15), over 10 years, in a tertiary Brisbane (Australia) hospital.
A retrospective study was conducted on elective colonoscopies performed between 2012 and 2022 at The Prince Charles Hospital. ‘Early procedures’ are defined as procedures starting in the first hour of the first procedure starting and ‘late procedures’ are defined as procedures starting within the last hour of the last procedure starting. This pre-defined early and late procedures were used as surrogate markers for operator fatigue, accounting for a possible non-linear relationship between time and onset of fatigue, as well as the variation in number of colonoscopies performed every hour. Timing and the order of colonoscopy were used as alternative surrogates, in a secondary analysis.
Logistic regression was performed on all categorical outcome variables, and Poisson regression was modelled on continuous outcome variables, due to their non-linear distribution. Multivariate analysis included all potential confounding variables related to outcomes of interest. Statistical significance was defined as a P-value less than 0.05. Statistical analyses were performed using the SAS® statistical software (SAS Institute Inc, USA).
Exclusion included; surveillance for IBD and elective ESD.

Results

In total, 15 proceduralist (11 gastroenterologists, 4 surgeons) performed 39, 206 elective colonoscopies from 2012 to 2022. The baseline characteristics of patients, year and procedure sessions are similarly distributed between the early and late groups.
Multivariant analysis found significant associations between late procedures and lower adenoma detection rates, polyp detection rates and SSL detection rates. After adjusting for age, gender, proceduralist, year, morning or afternoon procedure, and bowel preparation quality, PDR, ADR and SDR remain 20-28% lower in late colonoscopies compared with early ones. We also found that age, gender, proceduralist, year and bowel preparation independently affected ADR in multivariant analysis. However, morning or afternoon ADRs did not significantly differ after adjusting for other variables. Proceduralist were found to be the only additional significant variable for SDR in multivariant analysis. There was no significant association between timing of procedures and major adverse events.

Conclusion

This is the largest single-centre study on operator fatigue and its effect on colonoscopy quality. Although the minimum standards for ADR was achieved, ‘late procedures’ have statistically significant lower ADR, PDR and SSLDR compared to ‘early procedures’. There was no difference in the complication rates between ‘early procedures’ and ‘late procedures’.
This study highlights the detrimental effect of fatigue in later procedures affecting the quality of colonoscopies and may be applicable in principal to other procedural based clinical work. Importantly, this may or perhaps will or is having an impact on patient safety, satisfaction, outcomes and clinical KPI’s for the operators and hospital administrators.

Disclosure

None

Introduction

Differences between males and females were reported in digestive diseases and upper endoscopy.

Aims & Methods

The objective of the study was to investigate the similarities and differences in colonoscopy indications and findings between men and women. Multi-center, large cohort, retrospective study included all colonoscopies performed between 2016 and 2021. Multi-center study, data collected from seven Assuta endoscopy departments. All performed colonoscopies were included, and the indications and findings of the procedures were compared between men and women.

Results

287,930 were included, 151,411(52.5%) women and 136,519 men, aged 56.54±12.9 years and 56.59±12.7, with no difference in cecal intubation (95.6% vs 95.5%, p=0.251). 71.4% of the females had excellent or good bowel preparation, while 65.6% of the males had the same grade of quality. 22,650 (15%) of the females had Abdominal pain as the indication compared to 13,568 (9.9%) of males, while 11,846 (7.8%) had positive fecal occult testing compared to 12,955 (9.5), p<0.001.
Higher rates of change in Bowel habits, constipation, diarrhea, family history of colon cancer and Anemia were found among females compared to males (4.3% vs 3.7%, 3.9% vs 2.2%, 12.6% vs 11.4% and 7.6% vs 4.9%, p<0.001, respectively), while rectal bleeding, weight loss, polyp follow up and screening colonoscopy were more among males (10.7% vs 7.8%, 1.5% vs 1.3%, 10.8% vs 7.1% and 23.4% vs 20.6%, p<0.001, respectively. The colonoscopy findings showed that males had significantly higher rates of colon cancer, polyp detection rates, Crohn’s disease, ulcerative colitis and diverticulosis (0.5% vs 0.4%, 35.1% vs 24.6%, 1.5% vs 1.3%, 1.6% vs 1.5%, and 14.9% vs 12.8%.

Conclusion

We found significant differences between men and women regarding the indications and pathological findings of colonoscopy; these findings highlighted the need of the identification of factors contributing to these differences and the development of sex-specific approaches for the diagnosis and management of gastrointestinal diseases.

Introduction

Previous case reports and studies have shown frailty to be a risk factor for complications and poor outcomes following surgeries and endoscopic procedures. However, limited studies have examined the impact of frailty on endoscopic retrograde cholangiopancreatography (ERCP). Our study aims to compare patients undergoing ERCP with frailty to those without ERCP to understand the impact of frailty on ERCP better.

Aims & Methods

The NIS is a large, publicly available all-payer inpatient care database in the USA and was queried. We retrospectively analyzed the Nationwide Inpatient Sample (NIS) database for 2015-2019. Patients with a principal diagnosis of ERCP with and without frailty were identified using the ICD-10 codes. Multivariate regression analysis was used to calculate the odds ratios of in-hospital mortality, the average length of hospital stay (LOS), and hospital charges (TOTHC) using STATA 17 MP.

Results

Our study identified approximately 1,088,175 patients undergoing ERCP, of which 1,700 were frail.

On multivariate analysis, in patients undergoing ERCP and frailty as a co-morbidity, positive predictors of increased mortality were the following: sepsis (OR: 9.95, p<0.0001, 95% CI: 2.95 - 16.95), acute kidney injury (AKI) (OR 5.63, p<0.0001, CI 4.64 - 6.82), malnutrition (OR 3.28, p<0.0001, CI 2.66 - 4.04), post-procedural bleeding (OR 2.85, p<0.0069, CI 1.95 - 3.70), aspiration (OR 4.94, p<0.0001, CI 2.59 - 6.80), congestive heart failure (CHF) (OR 1.48, p<0.001, CI 1.19 - 1.86).

LOS was increased if patients had any of the following complications: sepsis (+2.86 days, p<0.0001, 95% CI: 2.59 - 3.13), AKI (+3.44 days, p<0.0001, 95% CI: 3.16 - 3.73), malnutrition (+6.44 days, p<0.0001, CI 5.89 - 6.99), post-procedural bleeding (+4.99 days, p<0.0001, CI 3.29 - 6.68), aspiration (+9.87 days, p<0.0001, 95% CI 7.48 - 12.27), or CHF (+1.87 days, p<0.0001, CI 1.53 - 2.22).

TOTHC were increased in patients who had the following complications: sepsis ($46,978, p<0.0001, CI $41,364 - $52,593), AKI ($53,007, p<0.0001, CI $44,221 - $61,793), malnutrition ($85,454, p<0.0001, $64,515 - $106,393), post-procedural bleeding ($114,168, p<0.0001, $61,465 - $166,871), aspiration ($198,071, p<0.0001, $113,911 - $282,230) or CHF ($20,191, p<0.0001, $12,983 - $27,398).

Conclusion

Based on our study results, those with ERCP who had a co-morbidity of frailty had increased mortality, LOS, and TOTHC with the following complications: sepsis, AKI, malnutrition, post-procedural bleeding, aspiration, and CHF. While frailty is not a contraindication to doing an ERCP, our study demonstrates that there must be close monitoring and preparation of these patients before ERCP to avoid complications because many complications significantly increase mortality. This is a high-risk patient population. Randomized trials will be required to further study the impact of frailty on ERCP.