BSG CSSC Service Development Prize 2022 highly commended submission by Prof Owen Epstein.

Current Post Held: Honorary Consultant Gastroenterologist.

Names of team involved: Owen Epstein, Hansa Palmer, Timothy Rayne.

In the spring of 2020, the COVID-19 pandemic struck, imposing considerable strain on endoscopy units. Traditional endoscopy takes place in a closed room, with close physical contact between the patient and staff. At the height of each wave, only emergency endoscopy was possible, and endoscopy waiting lists rapidly expanded.

Colon capsule endoscopy (CCE) has similar sensitivity and specificity as traditional colonoscopy for polyps and inflammatory bowel disease. Its ease of use, tolerability, and paucity of complications, positions CCE as a screening device that can ask and answer the question, “who needs an interventional colonoscopy?”. CCE does not require day-case hospital admission and is readily delivered with social distancing. Swallowing the capsule with a sip of water mitigates droplet spread and there is no requirement for intravenous sedation, analgesia, oxygen supplementation, monitoring, or recovery. After swallowing the capsule patients can return home to complete the procedure, after which the recorder is returned, and the video file downloaded for rendering, review and reporting. In March 2021, recognising the potential for safely delivering colon capsule endoscopy (CCE) as part of the Covid-19 endoscopy recovery programme, NHS England commissioned an evaluation of 11,000 CCE’s for patients referred for investigation of cancer alarm symptoms, or a positive quantitative faecal immunochemical test within the range of 10-100. Forty-six English colon cancer alliances were invited to participate, and each was resourced with capsules and kit. However, the pressing need to deliver thousands of colon capsules was met by a dearth of trained and experienced CCE readers.

During a time of lockdown, training had to rapidly transform from occasional 1- or 2-day residential courses, attracting small numbers of capsule enthusiasts, to a turbo-charged cyberspace curriculum designed to mentor over a hundred endoscopists, most of whom had no prior experience of capsule endoscopy. Currently there are no widely agreed CCE accreditation guidelines. In 2019, a literature review recommended a consensus for mentoring novice capsule practitioners. The learning curve suggests that trainees should read and report a minimum of 20 full case studies, graded with increasing complexity, with each report individually mentored. A sequence of formative video cases should conclude with a summative assessment to determine adequacy of progress. The curriculum should also include a series of lectures on the safe practice of capsule endoscopy.

In advance of the pandemic, we had developed a colon capsule curriculum, delivered on-line, comprising a smartphone App-primer, an animated lecture series, five live Zoom workshops and 15 full length formative and 5 summative colon capsule videos. The curriculum was endorsed by the Royal College of Physicians (30 hours CME) and NHS England, and the course program received BSG endorsement. Each video was accessed using a web-based rapid reader simulator (PillCam Web supplied by GIVEN /Medtronic). This platform does not require software installation as the videos play from within a web browser. Presented with a menu of graded videos, the trainee clicks the appropriate video and reviews the study in the same manner as a locally installed reader program. The case studies are read sequentially from “easy” to “difficult”. The reporting template is submitted electronically to a content management system. Trainees are asked to timestamp the major anatomical landmarks and identify abnormal findings, indicating the timestamp, and which of the two cameras located the finding. On submission of each formative video, the CMS automatically returns a model answer and an edited video displaying the expected findings. In addition, each report is forwarded for personalised appraisal and feedback by one of two experienced colon capsule mentors (OE and HP), both of whom have read and reported at least 200 colon capsules and taught on residential colon capsule courses both in the UK and abroad. On completion of the formative video review, trainees gained access to the 5 summative cases. These are reported as usual, but without model answer or summary video feedback. Each anonymous report is assessed and designated a “pass” or “repeat”. A “pass” requires reporting all clinically significant pathology (e.g. polyps >5mm, cancer, inflammation, oozing angiodysplasias), and at least 90% of incidental findings (diverticulosis, diminutive polyps, incidental angiodysplasia, haemorrhoids).

Trainees failing to meet the required standard for any of the 5 summative video cases are asked to repeat a review of the segment of colon where pathology was unreported. On successful course completion, trainees are issued with a certificate of completion. At this point, they are considered ready to embark on independent reading, with a caveat that increasing competence requires continuous reporting and sharing uncertainty. Between June 2020 and end of December 2021, 226 participants had enrolled in 11 CCE reading courses (Table 1). The Trainees included consultant physicians (53%), clinical nurse specialists (37%) and consultant surgeons (10%). Twenty three (10%) registrants either withdrew or failed to start. Of the remaining participants 81% have completed the course. The shortest time taken to complete the course was 18 days, and the longest 288 days (median 61 days). The proportion of trainees asked to repeat at least 1 summative video is indicated in Table 2 Conclusion Gaining proficiency in colonoscopy requires considerable technical skill and a long period of mentoring. CCE delivery requires little technical knowhow and the capsule practitioner’s skillset resides solely in image recognition and interpretation.

On average, candidates working in their own spare time, successfully completed the course in 8 to 10 weeks. Over 18 months, 183 novice CCE trainees achieved the expected NHS England reporting standard. Currently 116 are participating in the 11,000-capsule pathway evaluation. Filtering patients with a normal study or small and diminutive polyps, from the minority with advanced neoplasia, will markedly reduce pressure on screening and surveillance programs. Currently, the UK has the world’s largest faculty of colon capsule endoscopists and assuming each practitioner reports 8 reviews weekly, around 77,000 patients could be offered a minimally invasive examination annually.