Ouwendijk, R.J.T.

Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice (Article)

2011-09-12T00:00:00Z

Background: Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting. Objective: This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance. Design: Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department. Setting: Daily clinical practice in 12 Dutch endoscopy departments. Patients: Consecutive patients undergoing scheduled colonoscopy procedures. Main Outcome Measurements: Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR). Results: A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%). Limitations: Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist. Conclusion: Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved.

Predictors for neoplastic progression in patients with Barrett's esophagus: A prospective cohort study (Article)

2011-07-01T00:00:00Z

Objectives: Patients with Barrett's esophagus (BE) have an increased risk of developing esophageal adenocarcinoma (EAC). As the absolute risk remains low, there is a need for predictors of neoplastic progression to tailor more individualized surveillance programs. The aim of this study was to identify such predictors of progression to high-grade dysplasia (HGD) and EAC in patients with BE after 4 years of surveillance and to develop a prediction model based on these factors. Methods: We included 713 patients with BE (2 cm) with no dysplasia (ND) or low-grade dysplasia (LGD) in a multicenter, prospective cohort study. Data on age, gender, body mass index (BMI), reflux symptoms, tobacco and alcohol use, medication use, upper gastrointestinal (GI) endoscopy findings, and histology were prospectively collected. As part of this study, patients with ND underwent surveillance every 2 years, whereas those with LGD were followed on a yearly basis. Log linear regression analysis was performed to identify risk factors associated with the development of HGD or EAC during surveillance. Results: After 4 years of follow-up, 26/713 (3.4%) patients developed HGD or EAC, with the remaining 687 patients remaining stable with ND or LGD. Multivariable analysis showed that a known duration of BE of 10 years (risk ratio (RR) 3.2; 95% confidence interval (CI) 1.3-7.8), length of BE (RR 1.11 per cm increase in length; 95% CI 1.01-1.2), esophagitis (RR 3.5; 95% CI 1.3-9.5), and LGD (RR 9.7; 95% CI 4.4-21.5) were significant predictors of progression to HGD or EAC. In a prediction model, we found that the annual risk of developing HGD or EAC in BE varied between 0.3% and up to 40%. Patients with ND and no other risk factors had the lowest risk of developing HGD or EAC (1%), whereas those with LGD and at least one other risk factor had the highest risk of neoplastic progression (18-40%). Conclusions: In patients with BE, the risk of developing HGD or EAC is predominantly determined by the presence of LGD, a known duration of BE of 10 years, longer length of BE, and presence of esophagitis. One or combinations of these risk factors are able to identify patients with a low or high risk of neoplastic progression and could therefore be used to individualize surveillance intervals in BE.

Prevalence and prognosis of synchronous colorectal cancer: A Dutch population-based study (Article)

2011-04-05T00:00:00Z

Background: A noticeable proportion of colorectal cancer (CRC) patients are diagnosed with synchronous CRC. Large population-based studies on the incidence, risk factors and prognosis of synchronous CRC are, however, scarce, and are needed for better determination of risks of synchronous CRC in patients diagnosed with colonic neoplasia. Methods: All newly diagnosed CRC between 1995 and 2006 were obtained from the Rotterdam Cancer Registry in The Netherlands, and studied for synchronous CRC. Results: Of the 13,683 patients diagnosed with CRC, 534 patients (3.9%) were diagnosed with synchronous CRC. The risk of having synchronous CRC was significantly higher in men (OR 1.54, 95% CI 1.29-1.84) and in patients aged >70 years (OR 1.83, 95% CI 1.39-2.40). Synchronous CRC patients had a significantly higher risk of distant metastases (OR 1.69, 95% CI 1.27-2.26). In 34% (184/534) the two tumours were located in different surgical segments. Five-year relative survival of synchronous CRC was similar to patients with solitary CRC after multivariate adjustment for the presence of distant metastases. Conclusion: One out of 25 patients diagnosed with CRC presents with synchronous CRC. In the multivariate analysis, survival of patients with synchronous CRC was similar to patients with solitary CRC, when corrected for the presence of distant metastases at first presentation. One third of the synchronous CRC were located in different surgical segments, which stresses the importance of performing total colon examination preferably prior to surgery.

Validation study of automatically generated codes in colonoscopy using the endoscopic report system Endobase (Article)

2010-09-01T00:00:00Z

Objective. Gastrointestinal endoscopy databases are important for surveillance, epidemiology, quality control and research. A good quality of automatically generated databases to enable drawing justified conclusions based on the data is of key importance. The aim of this study is to validate the correctness of coding of a national automatically generated anonymous endoscopy database. Material and methods. We evaluated a total of 500 colonoscopies performed in five larger hospitals of the TRANS.IT project focusing on endoscopy reporting. Randomly 500 examinations were selected from a total of 5,000 examinations and their generated endoscopic terminology codes as well as complete reports were analysed. Indications for the examination and described findings were scored for correctness and clinical relevance of the coding that would be exported to the anonymous database. Results. Indications were correctly coded in 92% of all examinations (range 76100%) per hospital. Correct coding of findings ranged from 42% to 93% per hospital (mean 77%). Different correct coding proportions were seen varying with the diagnosis, with the highest correct coding rates in polyps, carcinoma and diverticular disease. Incorrect coded examinations were scored for clinical relevance. Overall 11% of the investigated examinations were incorrectly coded with clinical relevance. Conclusions. Accuracy of clinically relevant endoscopy data recorded in the TRANS.IT anonymous central database is high. Further improvement is desirable, which may be achieved by education of individual endoscopists and enhancement of the program.

Exposure to colorectal examinations before a colorectal cancer diagnosis: A case-control study (Article)

2010-04-01T00:00:00Z

Objectives: To assess the prior exposure to colorectal examinations between colorectal cancer (CRC) patients and matched control participants to estimate the effect of these examinations on the development of CRC and to obtain insight into the background incidence of colorectal examinations. Methods: A population-based case-control study was conducted within the Dutch Integrated Primary Care Information database over the period 1996-2005. All incident CRC cases were matched with up to 18 controls (n=7790) for age, sex, index date (date of CRC diagnosis) and follow-up before diagnosis. All colorectal examinations performed in symptomatic participants in the period 0.5-5 years before index date were considered in the analyses. Results: Within the source population of 457024 persons, we identified 594 incident cases of CRC. In the period 0.5-5 years before index date 2.9% (17 of 594) of the CRC cases had undergone colorectal examinations, compared with 4.4% (346 of 7790) in the control population [odds ratio (ORadj): 0.56, 95% confidence interval (CI): 0.33-0.94]. For left-sided CRC, significantly more controls than cases had undergone a colorectal examination (4.7 vs. 2.0%, respectively, ORadj: 0.36, 95% CI: 0.17-0.76), which was not seen for right-sided CRCs (3.3 vs. 3.9%, respectively, ORadj: 0.98, 95% CI: 0.42-2.25). Conclusion: Patients diagnosed with CRC were less likely than controls to have had a colorectal examination in previous years, being more pronounced in patients diagnosed with left-sided CRCs. If diagnostic examinations have a similar protective effect as screening examinations, this finding supports the concept that colorectal examination can have a major impact on the reduction of CRC risk.

A cost-benefit analysis of endoscopy reporting methods: Handwritten, dictated and computerized (Article)

2009-12-01T00:00:00Z

Background and study aims: Gastrointestinal endoscopy investigations are frequently requested by gastroenterologists, general practitioners and other physicians. In addition to the classic methods of report writing, several electronic endoscopic report systems are currently available. The aim of the study was to evaluate the costs of three different ways of producing reports; by hand, by dictation, or by computer. Methods: Three methods of report writing were compared, with special attention to costs. The endoscopy process was analyzed, from arrival of the patient to sending the report to the referring doctor, and including production of endoscopic images or video, logging of used endoscopes and their disinfection, and storage costs for endoscopy data. Results: During the first 5 years, the mean costs per procedure were C= 4.78 for handwritten, C= 6.39 for dictated and C= 8.90 for computerized reports. Due to depreciation, after this initial period, the respective costs declined to C= 4.37, C= 5.20 and C= 5.13, respectively. Despite high initial costs, a cost-benefit analysis already revealed a financial benefit from a computerized system after 3 years. Conclusions: The electronic production of an endoscopic report turned out to be the most expensive way of report writing during the first 5 years, due to high initial costs. After 5 years the costs of the different systems were comparable with each other. Cost-benefit analysis showed a positive financial benefit for computerized reports after 3 years.

Risk analyses for screening sigmoidoscopy based on a colorectal cancer (CRC) population (Article)

2009-02-01T00:00:00Z

Objective. Although colonoscopy can be effective in the prevention of colorectal cancer (CRC), it requires many endoscopic facilities, has a high patient burden and risk of complications, and it is expensive. The aim of this study was to determine the risk for proximal CRC and to identify subgroups in which screening sigmoidoscopy can be effective. Material and methods. A database search was carried out on all patients who underwent endoscopy of the lower gastrointestinal (GI) tract between 1997 and 2005. All patients diagnosed with CRC were included. Variables including age, gender and the presence of distal colonic neoplasia were used for risk analyses. Results. In total, 783 patients were diagnosed with CRC. Tumour was located in the proximal colon in 68/255 (27%) of the patients<65 years. Of the patients<65 years, 22% (57/255) had proximal CRC without synchronous distal lesions and would thus have been missed by sigmoidoscopy screening. Among patients >65 years, 41% (216/528) were diagnosed with proximal CRC, significantly more often in women than in men (p<0.001). In 35% of patients (185/528) proximal CRC without distal colonic neoplasia was found, significantly more than in those under 65 years of age (p<0.001). Conclusions. Significantly more proximal localized CRC would have been missed by sigmoidoscopy screening in elderly patients, especially in women. In subjects<65 years of age, sigmoidoscopy screening allows detection of almost 80% of CRC cases and might suffice as a screening method.

Proton pump inhibitor therapy in gastro-oesophageal reflux disease decreases the oesophageal immune response but does not reduce the formation of DNA adducts (Article)

2008-07-01T00:00:00Z

Background: Chronic oesophageal inflammation and related oxidative stress are important in the pathogenesis of erosive oesophagitis (EO) and its malignant progression. Aim: To study the effect of proton pump inhibitors (PPIs) on oesophageal cellular immune response and oxidative damage in EO patients. Methods: Forty gastro-oesophageal reflux disease (GERD) patients [non-erosive reflux disease (NERD): 15, EO: 25] were included, after 7 days off antisuppressive drugs. EO patients were randomized to 20-mg rabeprazole once daily for either 4 or 8 weeks with baseline and follow-up endoscopy with distal oesophageal biopsies. T lymphocytes, macrophages and mast cells were quantified by immunohistochemistry. DNA adducts were measured by analysis of 8-oxo-deoxyguanosine levels. Results: Erosive oesophagitis patients had more T lymphocytes and CD8+T lymphocytes in squamous epithelium than NERD patients (P = 0.001, P = 0.002, respectively). Levels of DNA adducts between both groups were, however, not different (P = 0.99). Four- and eight-week rabeprazole treatment in EO patients resulted in a significant decrease in number of T lymphocytes and CD8+T lymphocytes (all P < 0.05). PPIs did not, however, affect levels of DNA adducts. Conclusions: Short-term PPI therapy in EO patients reduces the oesophageal cellular immune response, but does not change oxidative damage. PPI therapy may therefore not be effective in reducing the risk of oesophageal cancer in GERD patients.

A nationwide survey evaluating adherence to guidelines for follow-up after polypectomy or treatment for colorectal cancer (Article)

2008-05-01T00:00:00Z

BACKGROUND: Endoscopic follow-up (FU) in patients treated for colorectal adenomas or cancer (CRC) is intended to reduce the incidence of CRC. In the Dutch postpolypectomy guidelines, the FU interval is solely determined by the number of previous adenomas, whereas in other countries size and histology are also taken into account. Whether this difference in policy is also reflected in clinical practice is unknown. Furthermore, FU guidelines after CRC are not standardized in The Netherlands, even though national recommendations are available. GOAL: To assess the adherence to the current Dutch postpolypectomy guidelines and to evaluate the FU policy after CRC resection. STUDY: A survey was sent to all Gastrointestinal Departments in The Netherlands. The survey consisted of questions on logistic organization of FU, postpolypectomy FU intervals, and FU after CRC. RESULTS: The response rate was 85%. In contrast to the national guidelines, size and histology of the adenomas were often taken into account, leading to shortening of the FU interval. With respect to the CRC cases, 52% of the respondents advised shorter FU intervals than advised by the national recommendations. CONCLUSIONS: Despite recent Dutch postpolypectomy guidelines, clinicians incorporate histology and size into their clinical strategy. Either further education on the guidelines is needed, or the guidelines need to be reconsidered. Furthermore, evidence-based guidelines for FU after CRC should be formulated.

Tumor pyruvate kinase isoenzyme type M2 and immunochemical fecal occult blood test: Performance in screening for colorectal cancer (Article)

2007-10-01T00:00:00Z

OBJECTIVES: Immunochemical fecal occult blood test (FOBT) and determination of tumor pyruvate kinase isoenzyme type M2 (TuM2-PK) in stool samples may be valuable new screening tools for colorectal cancer (CRC). The aim of this study was to compare the accuracy of fecal TuM2-PK testing with immunochemical FOBT in patients with CRC or adenomas. METHODS: A total of 52 patients with CRC were analyzed, 47 with colorectal adenomas, and 63 matched controls with a normal colonoscopy. Nineteen additional patients with inflammatory bowel disease were tested to determine influence of inflammation. Stool samples were analyzed with two immunochemical FOBTs, Immo-care and OC-Light, and with a commercial enzyme-linked immunosorbent assay for TuM2-PK. RESULTS: In patients with CRC, the sensitivity of TuM2-PK, Immo-care and OC-Light was respectively 85, 92 and 94%. In patients with adenomas, the sensitivity was respectively 28, 40 and 34%. Specificity for these tests was 90% for TuM2-PK and 97% for both immunochemical FOBTs. All tests showed a high positivity rate in patients with inflammatory bowel disease (79% for TuM2-PK and Immo-care, and 89% for OC-Light). CONCLUSION: Both immunochemical FOBTs appear valuable and are sensitive tests for CRC screening. TuM2-PK does not have supplemental value for screening for CRC because of a lower sensitivity and specificity. None of these tests is sensitive enough for detection of advanced adenomas. Patients with inflammatory bowel disease should be excluded from CRC screening when using immunochemical FOBT or TuM2-PK.

Computerized endoscopic reporting is no more time-consuming than reporting with conventional methods (Article)

2007-07-01T00:00:00Z

Background: Endoscopists use different methods for reporting their findings after a gastrointestinal endoscopy. These may result in handwritten, dictated, or computerized reports. The time needed to create the report is an important parameter for acceptance of the method used. It is also important to be aware of the possible advantages and disadvantages of these different methods. The aim of this study was to compare time aspects of different methods of report writing. Methods: Three different methods of report writing, i.e., handwritten, dictated, and computerized, were compared. In three different endoscopy departments, one investigator recorded the time needed to compose the report and to send it to the referring doctor. The time needed to describe different diagnoses at endoscopy was compared between the systems. Results: Handwritten reports were completed in an average time of 113 s, free text dictated reports by the endoscopist in 65 s with an additional 172 s allowed for the typist, and computerized, pre-defined reports were completed in 86 s. The incidences of abnormalities found in the reports of the different hospitals were comparable. Conclusion: To a large extent, computerized, pre-defined reports could be composed in almost the same amount of time as handwritten and dictated reports. Free text dictated and computerized, pre-defined reports are both stored in the hospital information system, but only computerized, pre-defined reports including endoscopic pictures are stored in a structured database, which makes statistical analysis possible.

Gastrointestinal Endoscopic Terminology Coding (GET-C): A WHO-approved extension of the ICD-10 (Article)

2007-04-01T00:00:00Z

Technological developments have greatly promoted interest in the use of computer systems for recording findings and images at endoscopy and creating databases. The aim of this study was to develop a comprehensive WHO-approved code system for gastrointestinal endoscopic terminology. The International Classification of Diseases, 10th edition (ICD-10), and the ICD-10 clinical modification (ICD-10-CM) were expanded to allow description of every possible gastrointestinal endoscopic term under conditions defined by the WHO. Classifications of specific gastrointestinal disorders and endoscopic locations were added. A new chapter was developed for frequently used terminology that could not be classified in the existing ICD-10, such as descriptions of therapeutic procedures. The new extended code system was named Gastrointestinal Endoscopic Terminology Coding (GET-C). The GET-C is a complete ICD-10-related code system that can be used within every endoscopic database program for all specific endoscopic terms. The GET-C is available for free at http://www.trans-it.org/.

Attendance at surveillance endoscopy of patients with adenoma or colorectal cancer (Article)

2007-01-01T00:00:00Z

Objective. Surveillance of patients treated for adenoma or colorectal cancer (CRC) is intended to reduce the incidence of CRC. Responsibility for the adherence to surveillance advice is often left to the patients and family physician. It is not known whether this type of passive policy affects the efficacy of surveillance. The aim of this study was to determine the yield of surveillance without active invitation to follow-up endoscopy. Material andmethods. The study comprised a cohort follow-up of patients under 75 years of age with adenomas or CRC at index endoscopy in the period 1997-99. Adherence and intervals of follow-up endoscopy were determined up to December 2004. Results. During the inclusion period 2946 patients underwent lower endoscopy. In total, 393 patients were newly diagnosed with colorectal polyps (n=280) or CRC (n=113). Polyps were classified as adenomas in 167/280 (61%) patients. Forty-five (27%) of the adenoma patients underwent surveillance endoscopy within the guideline interval, 63 (38%) underwent delayed endoscopy, and 59 (35%) did not have any follow-up at all. CRC was diagnosed in 113 patients. Thirty-six patients who died during the first year or were diagnosed with metastases were excluded from the analysis. Twenty-three (30%) of the remaining 77 patients underwent endoscopic surveillance according to the guidelines, 40 (52%) had delayed surveillance endoscopy, and 14/77 (18%) did not undergo surveillance endoscopy at all. Conclusions. In surveillance for colorectal neoplasia, active follow-up invitation is important. Given the low follow-up rate in our series, passive follow-up policies may lead to underperformance of surveillance programs. An active and controlled follow-up is advisable.

Computerisation of endoscopy reports using standard reports and text blocks (Article)

2006-01-01T00:00:00Z

BACKGROUND: The widespread use of gastrointestinal endoscopy for diagnosis and treatment requires effective, standardised report systems. This need is further increased by the limited storage of images, and by the need for structured databases for surveillance and epidemiology. We therefore aimed for a report system which would be quick, easy to learn, and suitable for use in busy daily practice. METHODS: Endobase III is an endoscopy information system offering three different ways of report writing, i.e. standard reports, text blocks and Minimal Standard Terminology (MST). A working group of two university and four general hospitals worked as a reference group for the development of standard reports and text blocks. Guidelines from various gastrointestinal endoscopy societies were followed to compose the reports. RESULTS: Standard reports were based on a list of distinct diagnoses; text blocks were based on anatomic landmarks and individual procedures. As such, 316 standard reports were developed for upper and lower gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). In this way selecting one diagnosis produces a complete report. A total of 1571 different text blocks were additionally developed for each part of the gastrointestinal tract and for procedures during endoscopy. This module allowed generation of a full report on the combination of text blocks. Reports could be composed and printed within two minutes for 90% of cases. CONCLUSION: Standard reports and text blocks are a quick, user-friendly way of report writing accepted and used by a number of gastroenterologists in the Netherlands.

Severe hypokalaemic paralysis and rhabdomyolysis due to ingestion of liquorice (Article)

2005-01-01T00:00:00Z

Chronic ingestion of liquorice induces a syndrome with findings similar to those in primary hyperaldosteronism. We describe a patient who, with a plasma K+ of 1.8 mmol/l, showed a paralysis and severe rhabdomyolysis after the habitual consumption of natural liquorice. Liquorice has become widely available as a flavouring agent in foods and drugs. It is important for physicians to keep liquorice consumption in mind as a cause for hypokalaemic paralysis and rhabdomyolysis.

Effect of losartan on microalbuminuria in normotensive patients with type 2 diabetes mellitus. A randomized clinical trial (Article)

2003-01-01T00:00:00Z

BACKGROUND: Angiotensin-converting enzyme inhibitors have shown antiproteinuric effects in normotensive and hypertensive diabetic patients. Angiotensin-receptor antagonists reduce urinary albumin excretion and the risk for renal and cardiovascular complications in hypertensive patients with type 2 diabetes mellitus. The effect of angiotensin-receptor antagonists in normotensive diabetic patients with microalbuminuria has not yet been reported. OBJECTIVE: To assess the antiproteinuric effects of losartan in normotensive patients with type 2 diabetes and microalbuminuria. DESIGN: Multicenter randomized, double-blind, placebo-controlled clinical trial. SETTING: 19 outpatient clinics in the Netherlands. PATIENTS: 147 normotensive patients with type 2 diabetes mellitus and microalbuminuria. INTERVENTION: 74 patients were randomly assigned to receive losartan and 73 patients were assigned to receive placebo for 10 weeks; 71 patients in each group completed the study. The losartan dose was 50 mg during the first 5 weeks and 100 mg during the subsequent 5 weeks. MEASUREMENTS: Change in urinary albumin excretion rate after 5 and 10 weeks, change in creatinine clearance and blood pressure, and safety and tolerability of losartan. RESULTS: A significant 25% relative reduction in the albumin excretion rate occurred after 5 weeks of the 50-mg losartan dose, with further improvement over the subsequent 5 weeks with the 100-mg dose (relative reduction, 34%). In the losartan group, creatinine clearance did not improve and blood pressure decreased slightly. Side effects did not differ between treatment groups. CONCLUSIONS: The angiotensin-receptor antagonist losartan reduces urinary albumin excretion in normotensive patients with type 2 diabetes and microalbuminuria. In multivariate analysis, the antiproteinuric effect of losartan was independent of the associated reduction in blood pressure. Losartan was safe and well tolerated in these normotensive patients.

Eicosanoids, endotoxins and liver disease (Doctoral Thesis)

1985-12-13T00:00:00Z

Endotoxins are cell wall lipopolysacharides of gram negative bacteria. The gut contains large numbers of bacteria and is generally accepted to be a large reservoir of endotoxins. In the normal state absorbed endotoxins are rapidly removed from the portal blood by especially the reticulo-endothelial cells of the liver. In patients with liver disease there is a diminished function of the reticulo-endothelial system, resulting in a raised frequency of systemic endotoxemia. Systemic endotoxemia in liver disease, as measured by the Limulus lysate test, correlates with a higher frequency of clotting disorders, renal failure and a high mortality rate