Background and Aims Improving patient experience during endoscopy is crucial to improve patient attendance and feedback. We aim to explore the feasibility of virtual reality distraction and disassociation (VRDD) in patients having unsedated upper gastrointestinal (UGI) endoscopy and measure their experience. Methods 2-stage pilot feasibility trial at single site in North East England recruiting patients having elective diagnostic UGI endoscopy (transnasal or oral route). Patients having therapeutic or emergency procedures were excluded. Target sample size = 30 participants. Primary objective was to ascertain acceptability and tolerability of VRDD. In Stage 1, participants wore VR headset for 10 minutes pre-endoscopy and completed questionnaires about their experience. Participants having unsedated transnasal endoscopy progressed to Stage 2. They wore VR headset during endoscopy and completed questionnaires post procedure. Descriptive analyses were performed on collated questionnaire responses. Results Recruitment period spanned January to August 2024. 30 participants recruited, all completed their questionnaires. 93% of participants rated overall endoscopy experience as ‘very good’ or ‘excellent’. In Stage 1, 97% did not encounter issues during and after VR, with 83% finding VRDD acceptable and enjoyable. In Stage 2, 83% encountered no issues, 75% thought VRDD was acceptable and enjoyable and 67% thought it was a good distraction technique. 83% would choose VRDD again for future procedures. Conclusion Our pilot study suggests VRDD is acceptable and well tolerated by adults undergoing unsedated UGI endoscopy. We need future research involving larger controlled trials to determine if it is a suitable alternative for patients who cannot have sedation.

Objective This study aimed to explore patient experience and preferences for different investigation modalities for surveillance and assessment of disease activity and mucosal healing in patients with established Crohn's disease (CD). Method A qualitative interview study embedded within a UK-based pragmatic trial of panenteric capsule endoscopy (PillCam Crohn's capsule, PCC) compared with ileocolonoscopy (IC) and magnetic resonance enterography (MRE). Telephone semi-structured interviews were completed with 10 patients with established CD who had undergone all three modalities. Results A range of advantages and disadvantages relating to all three modalities were described. PCC was generally reported as being easy to swallow and associated with less discomfort, intrusiveness and pain than IC. Negative attributions associated with unpleasantness of IC were common; however, the intensity of associated emotions, rather than their presence, seems to have the greatest influence on procedure preference. Tolerance of investigative procedures can be moderated by acceptance and recognition of their necessity in management of CD and perceived effectiveness of the procedures. Other key influences include the importance of support and trust in clinical and nursing staff and the ability to manage procedure and appointment requirements within daily life and responsibilities. Conclusions Findings suggest that for many, although not all, patients with CD, there would be a clear preference for PCC over IC and MRE, if effectiveness is proven to be equivalent. This supports the need for further work to demonstrate use and effectiveness with a view to integration within current management guidelines and care pathways in line with patient preference.

Chapter 43 Transnasal gastrointestinal endoscopy Sara Koo, Search for more papers by this authorKristina Leinwand, Search for more papers by this authorSimon Panter, Search for more papers by this authorJoel A. Friedlander, Search for more papers by this author Sara Koo, Search for more papers by this authorKristina Leinwand, Search for more papers by this authorSimon Panter, Search for more papers by this authorJoel A. Friedlander, Search for more papers by this author Book Editor(s):George Gershman, Professor of Pediatrics, David Geffen School of Medicine Chief, Division of Pediatrics Gastroenterology, Hepatology and Nutrition Harbor-UCLA Medical Center, Torrance, California, USASearch for more papers by this authorMike Thomson, Professor of Paediatric Gastroenterology and Interventional Endoscopy Director of the International Academy for Paediatric Endoscopy Training Centre for Paediatric Gastroenterology, Nutrition and Haepatology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK Portland Hospital for Women and Children, London, UKSearch for more papers by this author First published: 05 March 2021 https://doi.org/10.1002/9781119423492.ch43 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Summary Transnasal gastrointestinal endoscopy (TNE) was first reported in 1994 by Shaker et al. as T-EGD with the advent of ultrathin (UT) endoscopes. In pediatrics, preparation for TNE is of the utmost importance because success depends on a cooperative child. The success rates for adult unsedated TNE are high. Esophagogastroduodenoscopy is associated with cardiopulmonary stress with increased heart rate and systolic blood pressure. TNE, on the other hand, does not have this effect, and patients undergoing TNE are noted to have a consistent heart rate and systolic blood pressure. The main common therapeutic use would be insertion of nasoenteric tubes. TNE-assisted insertion (either via guidewire assistance or pull-through method with biopsy forceps) was shown to be safe and comparable to fluoroscopic insertion. Practical Pediatric Gastrointestinal Endoscopy, Third Edition RelatedInformation

Background We aimed to document international practices in small-bowel capsule endoscopy (SBCE), measuring adherence to European Society of Gastrointestinal Endoscopy (ESGE) technical and clinical recommendations. Methods Participants reached through the ESGE contact list completed a 52-item web-based survey. Results 217 responded from 47 countries (176 and 41, respectively, from countries with or without a national society affiliated to ESGE). Of respondents, 45% had undergone formal SBCE training. Among SBCE procedures, 91% were performed with an ESGE recommended indication, obscure gastrointestinal bleeding (OGIB), iron-deficiency anemia (IDA), and suspected/established Crohn's disease being the commonest and with higher rates of positive findings (49.4%, 38.2% and 53.5%, respectively). A watchful waiting strategy after a negative SBCE for OGIB or IDA was preferred by 46.7% and 70.3%, respectively. SBCE was a second-line exam for evaluation of extent of new Crohn's disease for 62.2% of respondents. Endoscopists adhered to varying extents to ESGE technical recommendations regarding bowel preparation (>60%), use in those with pacemaker holders (62.5%), patency capsule use (51.2%), and use of a validated scale for bowel preparation assessment (13.3%). Of the respondents, 67% read and interpreted the exams themselves and 84% classified exams findings as relevant or irrelevant. Two thirds anticipated future increase in SBCE demand. Inability to obtain tissue (78.3%) and high cost (68.1%) were regarded as the main limitations, and implementation of artificial intelligence as the top development priority (56.2%). Conclusions To some extent, endoscopists follow ESGE guidelines on using SBCE in clinical practice. However, variations in practice have been identified, whose implications require further evaluation.

The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Background Endoscopically defined mucosal healing in Crohn's disease is associated with improved outcomes. Panenteric capsule endoscopy enables a single non-invasive assessment of small and large bowel mucosal inflammation. Aims and methods: This multicentre observational study of patients with suspected and established Crohn's disease examined the feasibility, safety and impact on patient outcomes of panenteric capsule endoscopy in routine clinical practice. The potential role in assessment of disease severity and extent by a comparison with existing clinical and biochemical markers is examined. Results Panenteric capsule endoscopy was performed on 93 patients (71 with established and 22 with suspected Crohn's disease). A complete examination occurred in 85% (79/93). Two cases (2.8%) of capsule retention occurred in patients with established Crohn's disease. Panenteric capsule resulted in management change in 38.7% (36/93) patients, including 64.6% (32/48) of those with an established diagnosis whose disease was active, and all three patients with newly diagnosed Crohn's disease. Montreal classification was upstaged in 33.8% of patients with established Crohn's disease and mucosal healing was demonstrated in 15.5%. Proximal small bowel disease upstaged disease in 12.7% and predicted escalation of therapy (odds ratio 40.3, 95% confidence interval 3.6-450.2). Raised C-reactive protein and faecal calprotectin were poorly sensitive in detecting active disease (0.48 and 0.59 respectively). Conclusions Panenteric capsule endoscopy was feasible in routine practice and the ability to detect proximal small bowel disease may allow better estimation of prognosis and guide treatment intensification. Panenteric capsule endoscopy may be a suitable non-invasive endoscopic investigation in determining disease activity and supporting management decisions.

Telemedicine use has expanded rapidly to cope with increasing demand on services by delivering remote clinical review and monitoring of long-term conditions. Triaging individual patients to determine their suitability for telephone, video or face-to-face consultations is necessary. This is crucial in the context of COVID-19 to ensure doctor-patient safety. Telemedicine was shown to be safe and feasible in managing certain chronic diseases and providing patient education. When reviewing newly referred or long-term patients, different specialty clinics have different requirements for physical examination. Clinicians prefer face-to-face consultations at the initial visit to establish a doctor-patient relationship; telephone or video consultations are reasonable options for long-term patients where physical examination may not be needed. Video consultations, often aided by sophisticated devices and apps or medical assistants, are useful to facilitate remote physical examination. Most patients prefer telemedicine as it saves time and travel cost and provides better access to appointments.

Aims ESGE published performance measures as benchmark for quality assessment in small-bowel capsule endoscopy (SBCE). The aim of this survey was to investigate the influence of ESGE guidelines in current SBCE practice.

Abstract Objective Identification of a cost-effective treatment strategy is an unmet need in Crohn’s disease (CD). Here we consider the patient outcomes and cost impact of pan-intestinal video capsule endoscopy (PVCE) in the English National Health Service (NHS). Design An analysis of a protocolized CD care pathway, informed by guidelines and expert consensus, was performed in Microsoft Excel. Population, efficacy and safety data of treatments and monitoring modalities were identified using a structured PubMed review with English data prioritized. Costs were taken from the NHS and Payer Provided Services (PSS) 2016–17 tariffs for England and otherwise literature. Analysis was via a discrete-individual simulation with discounting at 3.5% per annum. Setting NHS provider and PSS perspective Participants 4000 simulated CD patients Interventions PVCE versus colonoscopy ± magnetic resonance enterography (MRE) Main outcome measures Costs in 2017 GBP and quality-adjusted life years (QALY) Results The mean, total 20-year cost per patient was £42 266 with colonoscopy ± MRE and £38 043 with PVCE. PVCE incurred higher costs during the first 2 years due to higher treatment uptake. From year 3 onwards, costs were reduced due to fewer surgeries. Patients accrued 10.67 QALY with colonoscopy ± MRE and 10.96 with PVCE. PVCE dominated (less cost and higher QALY) colonoscopy ± MRE and was likely (>74%) to be considered cost-effective by the NHS. Results were similar if a lifetime time horizon was used. Conclusions PVCE is likely to be a cost-effective alternative to colonoscopy ± MRE for CD surveillance. Switching to PVCE resulted in lower treatment costs and gave patients better quality of life.

Background and study aims Nomenclature and descriptions of small bowel (SB) vascular lesions in capsule endoscopy (CE) are scarce in the medical literature. They are mostly based on the reader's opinion and thus differ between experts, with a potential negative impact on clinical care, teaching and research regarding SBCE. Our aim was to better define a nomenclature and to give a description of the most frequent vascular lesions in SBCE. Methods A panel of 18 European expert SBCE readers was formed during the UEGW 2016 meeting. Three experts constructed an Internet-based four-round Delphi consensus, but did not participate in the voting process. They built questionnaires that included various still frames of vascular lesions obtained with a third-generation SBCE system. The 15 remaining participants were asked to rate different proposals and description of the most common SB vascular lesions. A 6-point rating scale (varying from strongly disagree' to strongly agree') was used successive rounds. The consensus was reached when at least 80% voting members scored the statement within the agree' or strongly agree'. Results Consensual terms and descriptions were reached for angiectasia/angiodysplasia, erythematous patch, red spot/dot, and phlebectasia. A consensual description was reached for more subtle vascular lesions tentatively named diminutive angiectasia but no consensus was reached for this term. Conclusion An international group has reached a consensus on the nomenclature and descriptions of the most frequent and relevant SB vascular lesions in CE. These terms and descriptions are useful in daily practice, for teaching and for medical research purposes.

South Tyneside District Hospital had an underutilised simulation facility. Patient safety initiatives, Shape of Training and the subsequent development of the internal medicine (IM) curriculum[1][1] demonstrated that expansion of our simulation offering was necessary. The IM curriculum encourages

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Main recommendations Small-bowel capsule endoscopy (SBCE) 1 ESGE recommends that prior to SBCE patients ingest a purgative (2 L of polyethylene glycol [PEG]) for better visualization. Strong recommendation, high quality evidence.However, the optimal timing for taking purgatives is yet to be established. 2 ESGE recommends that SBCE should be performed as an outpatient procedure if possible, since completion rates are higher in outpatients than in inpatients. Strong recommendation, moderate quality evidence. 3 ESGE recommends that patients with pacemakers can safely undergo SBCE without special precautions. Strong recommendation, low quality evidence. 4 ESGE suggests that SBCE can also be safely performed in patients with implantable cardioverter defibrillators and left ventricular assist devices. Weak recommendation, low quality evidence. 5 ESGE recommends the acceptance of qualified nurses and trained technicians as prereaders of capsule endoscopy studies as their competency in identifying pathology is similar to that of medically qualified readers. The responsibility of establishing a diagnosis must however remain with the attending physician. Strong recommendation, moderate quality evidence. 6 ESGE recommends observation in cases of asymptomatic capsule retention. Strong recommendation, moderate quality evidence. In cases where capsule retrieval is indicated, ESGE recommends the use of device-assisted enteroscopy as the method of choice. Strong recommendation, moderate quality evidence. Device-assisted enteroscopy (DAE) 1 ESGE recommends performing diagnostic DAE as a day-case procedure in patients without significant underlying co-morbidities; in patients with co-morbidities and/or those undergoing a therapeutic procedure, an inpatient stay is recommended. Strong recommendation, low quality evidence The choice between different settings also depends on sedation protocols. Strong recommendation, low quality evidence. 2 ESGE suggests that conscious sedation, deep sedation, and general anesthesia are all acceptable alternatives: the choice between them should be governed by procedure complexity, clinical factors, and local organizational protocols. Weak recommendation, low quality evidence. 3 ESGE recommends that the findings of previous diagnostic investigations should guide the choice of insertion route.Strong recommendation, moderate quality evidence. If the location of the small-bowel lesion is unknown or uncertain, ESGE recommends that the antegrade route should be generally preferred.Strong recommendation, low quality evidence. In the setting of massive overt bleeding, ESGE recommends an initial antegrade approach. Strong recommendation, low quality evidence. 4 ESGE recommends that, for balloon-assisted enteroscopy (i. e., single-balloon enteroscopy [SBE] and double-balloon enteroscopy [DBE]), small-bowel insertion depth should be estimated by counting net advancement of the enteroscope during the insertion phase, with confirmation of this estimate during withdrawal. Strong recommendation, low quality evidence. ESGE recommends that, for spiral enteroscopy, insertion depth should be estimated during withdrawal. Strong recommendation, moderate quality evidence. Since the calculated insertion depth is only a rough estimate, ESGE recommends placing a tattoo to mark the identified lesion and/or the deepest point of insertion. Strong recommendation, low quality evidence. 5 ESGE recommends that all endoscopic therapeutic procedures can be undertaken at the time of DAE. Strong recommendation, moderate quality evidence. Moreover, when therapeutic interventions are performed, additional specific safety measures are needed to prevent complications. Strong recommendation, high quality evidence.

Introduction Guidelines support endoscopic assessment of mucosal healing in Crohn’s disease before a change in therapy. [Gomollon, J Crohn’s Colitis 2016] A recent study has shown that the PillCam Crohn’s (PCC, Medtronic, Dublin, Ireland) has a better diagnostic yield than ileocolonoscopy [Leighton, Gastrointest Endosc 2017] and that colon capsule (for which the same bowel preparation is used) is better tolerated [Ojidu, European J Gastroenterol Hepatol, in press ]. We report the first experience of PCC in routine clinical practice. Methods Data was collected prospectively in Sheffield and South Tyneside hospitals. Montreal classification was used (ileal:L1; colonic: L2; ileocolonic: L3; upper GI: L4; B1: non-stricturing/penetrating; B2: stricturing; B3: penetrating). All patients passed an Agile patency capsule (Medtronic). Results Eighteen patients (median age 35 years, 38.9% male, known Crohn’s in 83%) had PCC. Indications were: symptom assessment (77.8%), assess response to treatment (11.1%), consideration of stepping down therapy (16.7%). Patients with established Crohn’s had L1 (53.3%), L2 (13.3%), and L3 disease (33.3%) which was uncomplicated (40%), stricturing (46.7%) and penetrating (13.3%). Patients were on medical treatment in 73.3%. PCC changed staging of disease in 33% of cases (L1 to L3 n=1, B2 to B1 n=3 and B1 to B2 n=1). One of three patients with suspected Crohn’s disease subsequently had endoscopic confirmation (L3 B1). PCC was normal (5/18), revealed L1 disease alone (8/18), L2 disease alone (1/18) and L3 disease (5/18). There were three incomplete procedures, all with an otherwise normal visualised colon. No capsule retentions occurred. Follow up data was available in 11 patients. Of eight patients with symptoms, five had active disease and three no or minimal activity. Of the five, three had a step-up in treatment, one had adalimumab temporarily suspended due to a perianal abscess and management continues to be discussed in one patient on maximal medical therapy. Other causes of symptoms were sought in the patients with inactive disease. Three patients had no symptoms, one had active disease and a step up in treatment, two had no or minimal activity of whom one continued therapy due to poor prognostic factors and one was already on no treatment (PCC being performed to provide supportive evidence of a diagnosis made in childhood). No patient known to have Crohn’s has been referred for further small bowel imaging or colonoscopy. Conclusion PCC provides a single visit assessment of both small and large bowel which was useful in guiding patient management without complications.

Out of programme (OOP) opportunities are to be encouraged. This article gives an insightful view of the Sheffield Clinical Research Fellowship Programme. Unique trainee feedback is provided. The take home message is clear - trainees should grab OOP experiences with both hands! For consultants the logistics described are potentially transferrable to their own regions.

Introduction Increasing demands on healthcare systems mean that nurses are taking on more roles as physician extenders. Capsule endoscopy (CE) is a laborious procedure where specialist nurses could reduce physician workload and rationalise resource utilisation. The aim of this review and meta-analysis is to consolidate data on nurses' performance in small bowel CE (SBCE). Materials and methods A comprehensive literature search was conducted for randomised controlled trials and comparative studies on nurses in SBCE reading compared to physicians. We examined the performance of nurses compared to SBCE-trained physicians. Results Sixteen relevant studies were identified, with 820 SBCE examinations involving 20 nurses. 11/16 studies reported the numbers of SBCE findings detected. Overall, the pooled proportion of all findings reported by physicians and nurses was 86%. Studies involving nurses with endoscopic experience showed a summative detection rate of 89%. 7/16 studies reported the number of videos where there was agreement between the nurse and physicians for overall findings/diagnosis. The overall proportion of videos with agreement was 68%. In studies where nurses had endoscopy experience, the proportion of videos with agreement was 71%. Conclusion Our meta-analysis supports a more active role for nurses in SBCE reading. We suggest nurses can function as independent CE readers in general, given adequate training and formal credentialing.