Quality assurance in colonoscopy: role of endomucosal clips

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ObjectiveQuality assurance in colonoscopy is important, and subjective assessment of completion based on endoscopic signs can be inaccurate leading to missed lesions. We aimed to determine the technique of endomucosal clips with follow-up X-rays in objectively documenting completion and correlation with pathology miss rates.MethodA total of 82 patients undergoing colonoscopy by trained colonoscopists had an endomucosal clip applied to the most proximal bowel reached. A plain abdominal X-ray was performed while there was still a pneumocolon, and the clip position was assessed by a blinded radiologist to determine objective completion rates. Repeat colonoscopies were performed in patients with incomplete procedures. Pathology and endoscopy database were also reviewed to identify missed lesions at a median follow-up of 6 years. These were correlated with colonoscopy completions.ResultsThe clip was found in caecum of 76 (93%), ascending-colon in three (3.6%), hepatic flexure in one (1.2%) and splenic flexure in two (2.4%) patients. The endoscopist opinion was incorrect in six incomplete colonoscopies. A total of 33 patients underwent repeat colonoscopies over the median 6-year follow-up. Three adenomas and one carcinoma were missed in the incomplete group and were subsequently picked up in repeat endoscopies. Only one adenoma was truly missed in complete colonoscopies, providing an overall miss rate of 1.3%.ConclusionUse of endomucosal clips with follow-on abdominal X-ray is a safe and effective method of determining completion of colonoscopy. This technique is also an excellent objective measure of quality assurance of completion and miss rates in colonoscopy, especially when combined with an audit to determine the missed lesions at two years postprocedure.

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