Published online Mar 7, 2018. doi: 10.3748/wjg.v24.i9.1013
Peer-review started: November 25, 2017
First decision: December 27, 2017
Revised: January 15, 2018
Accepted: January 19, 2018
Article in press: January 19, 2018
Published online: March 7, 2018
The incidence of inflammatory bowel disease is on the rise worldwide, including in Asia. The gold standard for the diagnosis of inflammatory bowel disease is histologic confirmation from tissue biopsies obtained during esophago-gastro-duodenoscopy and colonoscopy. In particular, differentiating Crohn’s disease from ulcerative colitis is dependent upon inspection and biopsy of the terminal ileum. Thus, intubation of the terminal ileum is considered as an important quality indicator in pediatric colonoscopy. Current guidelines by the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition recommend the cecum examination and terminal ileum of 95%. This target should be used by pediatric gastroenterology centers worldwide to benchmark their performance.
Current literature showed that reported ileal intubation rate in pediatric colonoscopy from centers around Asia ranged from 75.6% to 77.5%. The performance of our unit, from an area where the incidence of inflammatory bowel disease is currently low but is on the rise, is unknown. Thus, we were motivated to benchmark our performance against current recommendation to identify areas for improvement to enhance the quality of our training program.
The main objective was to benchmark the performance of our unit, in particular the completeness of colonoscopic examination, i.e. cecal examination and ileal intubation, against current recommended guidelines. We also evaluated other indicators such as appropriateness of indications, level of bowel preparation, as well as safety and complications of the procedures encountered.
We conducted a retrospective analysis on all the pediatric colonoscopies performed in a pediatric gastroenterology training center in Malaysia over a period of 6 years. We included the following indicators: appropriateness of indications; quality of bowel preparation; safety and complications; as well as cecal examination and terminal ileum intubation rates. The performances of trainees in the cecal and ileal examination rates were ascertained separately.
We found that of the 177 colonoscopies performed, the diagnostic yield was 85%, quality of bowel preparation was good in 87%, while one of 177 procedures was complicated by perforation during the procedure. The overall cecum examination rate was 76.3% and ileal intubation rate was 54.2%. After excluding colonoscopy where full colonoscopic examination was either not indicated, not feasible because of poor bowel preparation or unsafe (severe colitis), the cecum examination rate was 95.0% and ileal intubation rate was 68.1%. Among four trainees who completed a minimum of 12 mo training, the overall cecum rate was 97% while the overall ileal intubation rate was 77%. The performance of all trainees was consistent. Thus, the cecum examination rate of our unit was satisfactory but the rate of terminal ileum intubation needs further improvement. To improve the rate of ileal intubation, the trainees would spend part of their training program in a center of excellence with adequate volume of pediatric colonoscopy.
The present study was the first attempt by a pediatric gastroenterology unit in Asia to benchmark its performance in pediatric colonoscopy against established international guidelines. Our study suggests that such a benchmark is both applicable and desirable. The study allows our unit to identify areas for further improvement. Trainees from our unit now routinely spend part of their training in a center of excellence to enhance their skills in colonoscopy.
Benchmarking against established guidelines has been adopted as part of quality assurance of our unit. We plan to conduct a prospective study to include other indicators of good practice not included in this retrospective review. These include anesthetic risk assessment, duration of procedure, ease of sedation, quality of mucosal biopsy sampling and patient recovery time.