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Original article Clinical endoscopy: Editorial| Volume 83, ISSUE 3, P542-544, March 2016

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It’s all about the loop: quality indicators in pediatric colonoscopy

      Abbreviations:

      IC (ileocecal), TI (terminal ileum)
      If you are a fan of “popular” music, you have likely heard a catchy song by Meghan Trainor called “All about that Bass,” which begins “Because you know I’m all about that bass, ‘bout that bass, no treble”… and repeats 3 times in the opening verse. Given the chance to pick the 1 measure that distinguishes a high-quality colonoscopy procedure in pediatric patients from the rest, it would likely be the formation of the loop or, more importantly, the lack thereof, hence a slightly modified tune “it’s all about the loop, ‘bout the loop, no trouble.”
      Pediatric colonoscopy, although similar in many ways to procedures performed in adults (similar albeit smaller equipment, need for a bowel preparation and sedation, potential adverse events, available techniques), is fundamentally a different procedure with differing indications, unique technical aspects, and different quality measures, especially when the “low hanging fruit” has already been managed. The 2 fundamental reasons relate largely to the differences in patient size and procedure indications. Despite these differences, complete colonoscopy can be performed in infants as young as 1 year of age or less with appropriate equipment, although this is infrequently required.
      The bulk of adult colonoscopy in the United States relates to colon cancer detection and management: initial screening, follow-up screening, follow-up of previously detected polyps at prior colonoscopy, screening because of a positive family history, and procedures related to colon cancer, once detected.
      • Ladabaum U.
      • Levin Z.
      • Mannalithara A.
      • et al.
      Colorectal testing utilization and payments in a large cohort of commercially insured US adults.
      • Lieberman D.A.
      • Williams J.L.
      • Holub J.L.
      • et al.
      Colonoscopy utilization and outcomes 2000 to 2011.
      Symptom-based screening in adult colonoscopy also largely revolves around colon cancer detection—colonoscopies done for rectal bleeding, unexplained weight loss, constipation, and so on to rule out malignancy. Adult patients have a variety of other conditions that warrant colonoscopy, although these represent a small fraction of procedure indications.
      • Ladabaum U.
      • Levin Z.
      • Mannalithara A.
      • et al.
      Colorectal testing utilization and payments in a large cohort of commercially insured US adults.
      • Lieberman D.A.
      • Williams J.L.
      • Holub J.L.
      • et al.
      Colonoscopy utilization and outcomes 2000 to 2011.
      • Rex D.K.
      • Schoenfeld P.S.
      • Cohen J.
      • et al.
      Quality indicators for colonoscopy.
      Indications for colonoscopy in pediatric patients, on the other hand, are largely symptom based, with surveillance procedures reserved for patients with a known or suspected polyposis syndrome and for those with a known history of inflammatory bowel disease. Except for rectal bleeding, isolated symptoms such as vague abdominal pain, constipation, and bloating without associated red flag signs on physical examination, abnormal laboratory examination, or other constitutional symptoms such as weight loss or failure to gain weight, growth failure, fatigue, or unexplained fever often warrant other evaluation before colonoscopy.
      In colonoscopy performed on adults, once the core quality indicators that apply to every GI procedure are satisfied, including consent, safety, preparation, sedation, monitoring, documentation, credentialing, communication of the procedure findings, and follow-up, current colonoscopy guidelines are really aimed at a very simple goal
      • Rizk M.K.
      • Sawhney M.S.
      • Cohen J.
      • et al.
      Quality indicators common to all GI endoscopic procedures.
      : did the endoscopist find and appropriately treat any lesion that was present, and was the entire colon examined in a safe manner? Because colon cancer is the primary target for adult endoscopists, surrogate measures for colon cancer detection and ensuring complete inspection (adenoma detection rate, identification of the cecum, percent mucosa visualized, and scope withdrawal time) have been studied and reported to correlate with high-quality colonoscopy.
      • Rex D.K.
      Some might suggest that these measures are only the beginning, and adult patients would be well served by additional quality markers for which expert pediatric and adult endoscopists strive.
      In this issue of Gastrointestinal Endoscopy, Thakkar et al
      • Thakkar K.
      • Holub J.L.
      • Gilger M.A.
      • et al.
      Quality indicators for pediatric colonoscopy: results from a multicenter consortium.
      report their analysis of the pediatric clinical outcomes research initiative database to examine almost 22,000 colonoscopies performed at 14 centers over an 11-year period. The database limitations are well known because data are entered at the time of the procedure and postprocedure or sedation-related adverse events may be under-reported because of a lack of data entry or management of the adverse event by another provider or at another institution. With this type of database, estimates regarding “rough” measures such as procedure duration may vary widely based on additional procedural components, such as mucosal biopsy sampling and polypectomy, and other factors, including trainee participation and sedation efficacy. The authors identified substantial intercenter variability in sedation administration, bowel preparation adequacy, fellow participation, and extent of examination with significant variability in the ileal intubation rate. The authors are to be congratulated for looking at this large series of colonoscopies and encouraging the conversation about what matters in pediatric colonoscopy.
      However, with any study of this type, what is not sought and the unanswered questions may ultimately be more revealing as to how to advance the field in performing high-quality pediatric colonoscopy. As in adults, once the usual indicators are met, what is really important may emerge. How do we achieve a great bowel preparation in pediatric patients in whom it is more of a challenge to persuade to take an unpalatable preparation but as equally important to achieve complete mucosal visualization? How do we minimize patient discomfort and risk especially in very small patients where by comparison we are using relatively large and stiff instruments? The approach to this may be 2-fold. Working with industry is essential to develop appropriately sized colonoscopic equipment with an adequate channel size to perform therapeutic interventions and appropriate flexibility characteristics for small pediatric patients as well as better bowel preparation regimens. Industry has started to collaborate with pediatric gastroenterologists in these areas, but there is significant work to do. The other critical aspect is development of excellent endoscopic skills for individuals performing pediatric endoscopy. Pediatric patients, given their size and physical characteristics as well as their different sedation tolerance and requirements, require a more refined approach than may be appropriate in the typical adult patient. Ideally, the procedure would be completed with minimal loop formation and smooth advancement that takes advantage of shaft torque and wheel movements as the scope is smoothly advanced while minimizing air insufflation. Distension of the bowel wall or rapid movements by the endoscopist lead to patient agitation and discomfort, complicating the procedure for all those involved.
      How do we as endoscopists and endoscopic teachers strive to not create the loop and, if created, not push through the loop and reduce any loops formed as rapidly as possible? This one measure, perhaps more than anything else, could be used to predict the “success” of a pediatric colonoscopy. A colonoscope with a loop in place has a different feel, lacks one-to-one movement, and moves paradoxically distally with scope insertion. And if the “dreaded” double alpha loop is not reduced, complete colonoscopy is virtually impossible. A small amount of extra time spent to navigate the rectosigmoid colon without loop formation is easily made up by a shortened time to navigate the rest of the colon and into the terminal ileum (TI).
      Scope length when the scope has reached the cecal base is also a surrogate marker for colonoscopy success. Full colonoscopy can typically be performed in an adolescent with the bowel telescoped on the colonoscope reaching the cecum with an insertion tube length between 70 and 80 cm at the anal verge. In smaller pediatric patients, 60 cm or less may represent the correct length. More length indicates looping, failure to telescope, and higher risk of patient discomfort or trauma to the bowel wall. Quality outcomes for pediatric colonoscopy could be proposed to include time to intubation of the TI documented by confirmation with an ileal biopsy sample, and in distinction to the adult measure of scope withdrawal time, shorter times are better, presuming complete mucosal visualization.
      TI intubation is another surrogate marker of high-quality pediatric colonoscopy. The article by Thakkar et al
      • Thakkar K.
      • Holub J.L.
      • Gilger M.A.
      • et al.
      Quality indicators for pediatric colonoscopy: results from a multicenter consortium.
      had a high intercenter variability in the rate of cecal and especially ileal intubation. Although in part this may relate to documentation issues, it is an area in which we need to focus our training efforts to achieve high-level results. This standard has received increased attention in the most recent pediatric endoscopy training guidelines, which specify at least a 90% to 95% cecal intubation rate and a goal for a comparable TI intubation rate.
      • Leichtner A.M.
      • Gillis L.A.
      • Gupta S.
      • et al.
      NASPGHAN guidelines for training in pediatric gastroenterology.
      TI intubation and biopsy sampling is considered a core objective for 2 reasons, both of which may also apply to adult patients. Pediatric patients with Crohn’s disease have a very high rate of TI disease with or without associated colonic disease, in the range of 70% at diagnosis or early in their course.
      • Van L.
      • Russell R.K.
      • Drummond H.E.
      • et al.
      Definition of phenotypic characteristics of childhood-onset inflammatory bowel disease.
      • Vernier-Massouille G.
      • Balde M.
      • Salleron J.
      • et al.
      Natural history of pediatric Crohn's disease: a population-based cohort study.
      Colonoscopy with biopsy sampling performed to rule out inflammatory bowel disease requires TI intubation if possible. In some cases of Crohn’s disease this cannot be performed due to an ileocecal (IC) valve lumen that has been compromised by inflammation that prohibits passage of the endoscope into the small bowel. This limitation is why the rates will likely not reach 100%.
      The other reason is one the adult gastroenterologists are actively working toward by other measures. An endoscopist cannot intubate the TI unless the scope is in the cecum in a patient without prior surgery or a fistula. Therefore, TI intubation and biopsy sampling for confirmation indicates that the scope has reached the cecal base. As a side note, in a relatively loopless colonoscopy, the IC valve is typically located in the 7 o’clock position and is relatively easy to intubate indirectly, in some cases directly by gently nudging the lips of the valve open and insufflating a small amount of air with subsequent advancement of the colonoscope. Abnormal positioning of the IC valve can be a surrogate marker of the presence of looping.
      Most likely all endoscopists have encountered at some point, or many times, a characteristic view frequently seen at a flexure where the endoscopist believes he or she is “around and seeing the cecal base/Mercedes Benz sign” and appendiceal opening only to realize that in fact there is more colon to be examined. This phenomenon of misperceived complete colon examination if unrecognized by the endoscopist may in part contribute to some of the significant issues with right-sided colon cancers and polyps missed at prior examination and why higher adenoma detection rates (and presumably better technique) have been associated with a lower rate of interval cancer development.
      • Rex D.K.
      With TI intubation there is reliable confidence that the scope is fully inserted as long as the cecal base proximal to the IC is also examined.
      A note about mucosal biopsies and scope withdrawal times: the frequency and extent of mucosal biopsies is commonly much higher in pediatric colonoscopy compared with adults based on the differing procedure indications. As such, scope withdrawal times are typically longer in pediatric patients than adults but for different reasons.
      Additional potential measures of high-quality pediatric colonoscopy include minimization of air insufflation, atraumatic technique, ease of patient sedation, duration of procedure (shorter is generally better), performance of mucosal biopsy sampling, diagnostic yield, patient recovery time, and ongoing procedural competency assessment. Some of these may be driven by external forces such as reference/value-based pricing and reimbursement currently applied to procedures in many related fields such as orthopedics, cardiac catheterizations, and cardiac surgery, including bypass graft and valve procedures.
      The authors are to be congratulated on their article, which advances the conversation about what represents a good-quality pediatric colonoscopy. It is essential that adult and pediatric endoscopists maintain this dialogue and develop the next steps, learning from each other how to improve the quality of our endoscopy procedures and adapt them to our unique patient population. It’s all ‘bout the loop, and the valve, and the air…no trouble.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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