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Discrepancy Between Gastroenterologists' and General RESEARCH • RECHERCHE Discrepancy between gastroenterologists’ and general surgeons’ perspectives on repeat endoscopy in colorectal cancer Arash Azin, MD Background: A myriad of localization options are available to endoscopists for M. Carolina Jimenez, MD, MSc colorectal cancer (CRC); however, little is known about the use of such techniques and their relation to repeat endoscopy before CRC surgery. We examined the local- Michelle C. Cleghorn, MSc ization practices of gastroenterologists and compared their perceptions toward repeat Timothy D. Jackson, MD, MPH endoscopy to those of general surgeons. Allan Okrainec, MD, MHPE Methods: We distributed a survey to practising gastroenterologists through a pro- vincial repository. Univariate analysis was performed using the χ2 test. Peter G. Rossos, MD, MBA Results: Gastroenterologists (n = 69) reported using anatomical landmarks (91.3%), Fayez A. Quereshy, MD, MBA tattooing (82.6%) and image capture (73.9%) for tumour localization. The majority said they would tattoo lesions that could not be removed by colonoscopy (91.3%), This work was presented at Digestive Disease high-risk polyps (95.7%) and large lesions (84.1%). They were equally likely to tattoo Week (American Society for Gastrointestinal lesions planned for laparoscopic (91.3%) or open (88.4%) resection. Rectal lesions Endoscopy), May 16–19, 2015. were less likely to be tattooed (20.3%) than left-sided (89.9%) or right-sided (85.5%) lesions. Only 1.4% agreed that repeat endoscopy is the standard of care, whereas 38.9% (n = 68) of general surgeons agreed (p < 0.001). General surgeons were more Accepted for publication likely to agree that an incomplete initial colonoscopy was an indication for repeat Feb. 23, 2015 endoscopy (p = 0.040). Further, 56% of general surgeons indicated that the findings of repeat endoscopy often lead to changes in the operative plan. Correspondence to: Conclusion: Discrepancies exist between gastroenterologists and general surgeons F.A. Quereshy with regards to perceptions toward repeat endoscopy and its indications. This is espe- Toronto Western Hospital cially significant given that repeat endoscopy often leads to change in surgical man- University Health Network agement. Further research is needed to formulate practice recommendations that 399 Bathurst St. guide the use of repeat endoscopy, tattoo localization and quality reporting. Rm 8MP-320 Toronto ON M5T 2S8 Contexte : De nombreuses options de repérage s’offrent aux endoscopistes dans les cas [email protected] de cancer colorectal; on en sait cependant peu sur l’utilisation de ces techniques et leur lien avec les endoscopies répétées avant les interventions chirurgicales de traitement de ce can- DOI: 10.1503/cjs.005115 cer. Nous avons étudié les pratiques de repérage employées par des gastroentérologues et comparé leurs perceptions des endoscopies répétées à celles des chirurgiens généralistes. Méthodes : Nous avons réalisé un sondage auprès de gastroentérologues en exercice figurant dans un répertoire provincial. Une analyse unidimensionnelle a été effectuée à l’aide du test χ². Résultats : Les gastroentérologues (n = 69) ont dit recourir à des repères anatomiques (91,3 %), au tatouage (82,6 %) et à des images (73,9 %) pour repérer les tumeurs. La majorité a dit tatouer les lésions ne pouvant être éliminées par coloscopie (91,3 %), les polypes à haut risque (95,7 %) et les lésions de grande taille (84,1 %). Ils étaient tout aussi susceptibles de tatouer les lésions devant être éliminées par résection laparoscopique (91,3 %) ou effractive (88,4 %). Ils étaient cependant moins susceptibles de tatouer les lésions rectales (20,3 %) que les lésions du côté gauche (89,9 %) ou du côté droit (85,5 %). Seul 1,4 % des gastroentérologues était d’avis que l’endoscopie répétée con- stitue une norme en matière de soins, contrairement à 38,9 % des chirurgiens généra- listes (n = 68; p < 0,001). Les chirurgiens généralistes étaient plus nombreux à penser qu’une coloscopie initiale incomplète était susceptible d’être associée à des endoscopies répétées (p = 0,040). En outre, 56 % d’entre eux ont indiqué que les résultats d’endoscopies répétées menaient souvent à des changements sur le plan chirurgical. Conclusion : Il existe des divergences entre les perceptions des gastroentérologues et des chirurgiens généralistes quant aux endoscopies répétées et à leur indication. Ces divergences sont particulièrement pertinentes, étant donné que les endoscopies répétées entraînent souvent des changements aux interventions chirurgicales qui sont pratiquées ultérieurement. Des recherches approfondies seront nécessaires pour formuler des recommandations liées aux pratiques et orienter le recours aux endoscopies répétées et au repérage des lésions par tatouage ainsi que la production de rapports sur la qualité. ©2016 8872147 Canada Inc. Can J Surg, Vol. 59, No. 1, February 2016 29 RECHERCHE olorectal cancer (CRC) is the third most commonly often recommended for colonic lesions suspicious for diagnosed cancer in Canada. In 2014, an estimated malignancy,17 the use of tattooing in different clinical 24 300 individuals will have CRC diagnosed and an scen arios remains unclear. C 1 estimated 9300 will die of the disease. Colonoscopy is Given the limited evidence available on the localization considered the gold standard for detection of CRC, with a practices of endoscopists, including the use of tattoo local- specificity of 90.0% and a sensitivity of 95.0%.2 Over the ization, the primary objective of our study was to identify past decade, the rise of minimally invasive surgical (MIS) the colonoscopic localization practices of gastroenterolo- techniques has made endoscopic lesion localization critical gists and to clarify the role of tattoo localization in this set- to surgical planning. However, little is known about the ting. The secondary objective was to assess the attitudes localization practices of gastroenterologists and general and perceptions of gastroenterologists toward repeat surgeons. endoscopy and to compare their perceptions to those of Although colonoscopy demonstrates excellent detection general surgeons identified by a recent survey. rates for both malignancies and adenomas, its ability to provide precise localization information is less clear. In the METHODS literature, estimates of the error rate in tumour localization vary from as low as 4% to as high as 21%.3–10 These errors Instrument design can have a dramatic impact on surgical management, espe- cially in laparoscopic cases where the surgeon lacks the tac- We developed a preliminary questionnaire based on a tile ability to palpate the colon for the lesion. This may Medline literature review to ascertain the current local- result in conversion from a laparoscopic to open approach, ization practices and attitudes of gastroenterologists intraoperative colonoscopies and removal of incorrect seg- toward repeat endoscopy before CRC surgery. The pre- ments of colon. To help surgical planning and prevent liminary survey was reviewed by a focus group consisting such complications, surgeons often perform repeat colon- of 2 academic gastroenterologists, a community gastroen- oscopy before CRC surgery to verify lesion location. terologist, a gastroenterology resident and a practising In a recent study by Al Abbasi and colleagues,11 the general surgeon. repeat endoscopy rate at a large tertiary academic centre The final questionnaire comprised 16 questions that before CRC surgery was estimated to be up to 40.5%. addressed demographic items, general localization prac- Factors associated with preoperative repeat endoscopy tices, tattoo localization practices and indications for repeat by the operating surgeon were left-sided colonic neo- endoscopy as well as attitudes and perceptions toward plasms, planned laparoscopic resection and failure to repeat endoscopy. The survey evaluated the frequency of tattoo the lesion on the initial colonoscopy.11 However, 5 localization techniques used over the previous 12 months to our knowledge, no studies have assessed the percep- using a 5-point Likert scale (with possible responses being tions of gastroenterologists toward repeat endoscopy never, rarely, sometimes, frequently and always). Tattoo and its indications. localization practices under 10 clinical scenarios were When a lesion is detected by colonoscopy, endosco- assessed using the same 5-point Likert scale. The 5 most pists have a myriad of localization techniques at their dis- common indications for repeat endoscopy were ranked posal. They include use of anatomic landmarks, distance from most to least frequent.11 from the anal verge, image capture if the lesion is near an identifiable landmark, hemoclips and tattooing. No for- Data collection and analysis mal protocols exist to guide endoscopists in choosing the appropriate localization technique, and little is known We disseminated the questionnaire in an online, elec- about current use of these practices as they relate to tronic format using QuestionPro. Participants were iden- repeat endoscopy before CRC surgery. Localization tified and recruited via the membership directory of the based on anatomic landmarks is often reported in the vast Ontario Association of Gastroenterology (OAG) and majority of polypectomies;12 however, this technique has among attendees of the 17th Annual OAG Conference. been associated with error rates as high as 21%.3–10 Less We performed statistical analyses using SPSS Statistics clear is the practice of colonoscopic image capture,
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