Publications by authors named "Matthew D Rutter"

84 Publications

Personalizing polypectomy techniques based on polyp characteristics. Authors reply.

Clin Gastroenterol Hepatol 2021 Feb 11. Epub 2021 Feb 11.

Servicio de Medina Digestiva. Hospital General Universitario de Alicante. Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain.

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http://dx.doi.org/10.1016/j.cgh.2021.02.019DOI Listing
February 2021

When and How To Use Endoscopic Tattooing in the Colon: An International Delphi Agreement.

Clin Gastroenterol Hepatol 2021 Jan 22. Epub 2021 Jan 22.

Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Biomédica ISABIAL, Alicante, Spain. Electronic address:

Background & Aims: There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process.

Methods: The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process.

Results: A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%).

Conclusions: This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done.
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http://dx.doi.org/10.1016/j.cgh.2021.01.024DOI Listing
January 2021

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a population-based study.

Lancet Gastroenterol Hepatol 2021 03 15;6(3):199-208. Epub 2021 Jan 15.

Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Big Data Institute, University of Oxford, Oxford, UK.

Background: There are concerns that the COVID-19 pandemic has had a negative effect on cancer care but there is little direct evidence to quantify any effect. This study aims to investigate the impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England.

Methods: Data were extracted from four population-based datasets spanning NHS England (the National Cancer Cancer Waiting Time Monitoring, Monthly Diagnostic, Secondary Uses Service Admitted Patient Care and the National Radiotherapy datasets) for all referrals, colonoscopies, surgical procedures, and courses of rectal radiotherapy from Jan 1, 2019, to Oct 31, 2020, related to colorectal cancer in England. Differences in patterns of care were investigated between 2019 and 2020. Percentage reductions in monthly numbers and proportions were calculated.

Findings: As compared to the monthly average in 2019, in April, 2020, there was a 63% (95% CI 53-71) reduction (from 36 274 to 13 440) in the monthly number of 2-week referrals for suspected cancer and a 92% (95% CI 89-95) reduction in the number of colonoscopies (from 46 441 to 3484). Numbers had just recovered by October, 2020. This resulted in a 22% (95% CI 8-34) relative reduction in the number of cases referred for treatment (from a monthly average of 2781 in 2019 to 2158 referrals in April, 2020). By October, 2020, the monthly rate had returned to 2019 levels but did not exceed it, suggesting that, from April to October, 2020, over 3500 fewer people had been diagnosed and treated for colorectal cancer in England than would have been expected. There was also a 31% (95% CI 19-42) relative reduction in the numbers receiving surgery in April, 2020, and a lower proportion of laparoscopic and a greater proportion of stoma-forming procedures, relative to the monthly average in 2019. By October, 2020, laparoscopic surgery and stoma rates were similar to 2019 levels. For rectal cancer, there was a 44% (95% CI 17-76) relative increase in the use of neoadjuvant radiotherapy in April, 2020, relative to the monthly average in 2019, due to greater use of short-course regimens. Although in June, 2020, there was a drop in the use of short-course regimens, rates remained above 2019 levels until October, 2020.

Interpretation: The COVID-19 pandemic has led to a sustained reduction in the number of people referred, diagnosed, and treated for colorectal cancer. By October, 2020, achievement of care pathway targets had returned to 2019 levels, albeit with smaller volumes of patients and with modifications to usual practice. As pressure grows in the NHS due to the second wave of COVID-19, urgent action is needed to address the growing burden of undetected and untreated colorectal cancer in England.

Funding: Cancer Research UK, the Medical Research Council, Public Health England, Health Data Research UK, NHS Digital, and the National Institute for Health Research Oxford Biomedical Research Centre.
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http://dx.doi.org/10.1016/S2468-1253(21)00005-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808901PMC
March 2021

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement.

Endoscopy 2021 Feb 7;53(2):196-202. Epub 2021 Jan 7.

Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. ESGE suggests that each national society should prioritize quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures are a local priority to their members and make measuring quality intrinsic to daily endoscopy practice.
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http://dx.doi.org/10.1055/a-1312-6389DOI Listing
February 2021

Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement.

United European Gastroenterol J 2021 Feb 10. Epub 2021 Feb 10.

Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal.

The European Society of Gastrointestinal Endoscopy (ESGE) has developed performance measures and established a framework for quality assessment for gastrointestinal endoscopy in Europe. Most national societies actively undertake initiatives to implement and explicitly endorse these quality indicators. Given this, the ESGE proposes that, at a national level, strong leadership should exist to disseminate and implement quality parameters. Thus, understanding the potential barriers that may vary locally is of paramount importance. The ESGE suggests that each national society should prioritise quality and standards of care in gastrointestinal endoscopy in their activities and should survey/understand which measures area local priority to their members and make measuring quality intrinsic to daily endoscopy practice.
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http://dx.doi.org/10.1177/2050640620981366DOI Listing
February 2021

WASh multicentre randomised controlled trial: water-assisted sigmoidoscopy in English NHS bowel scope screening.

Gut 2020 Sep 7. Epub 2020 Sep 7.

Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK.

Objectives: The English Bowel Cancer Screening Programme invites 55 year olds for a sigmoidoscopy (Bowel Scope Screening (BSS)), aiming to resect premalignant polyps, thus reducing cancer incidence. A national patient survey indicated higher procedural pain than anticipated, potentially impacting on screening compliance and effectiveness. We aimed to assess whether water-assisted sigmoidoscopy (WAS), as opposed to standard CO technique, improved procedural pain and detection of adenomatous polyps.

Design: The WASh (Water-Assisted Sigmoidoscopy) trial was a multicentre, single-blind, randomised control trial for people undergoing BSS. Participants were randomised to either receive WAS or CO from five sites across England. The primary outcome measure was patient-reported moderate/severe pain, as assessed by patients on a standard Likert scale post procedure prior to discharge. The key secondary outcome was adenoma detection rate (ADR). The costs of each technique were also measured.

Results: 1123 participants (50% women, mean age 55) were randomised (561 WAS, 562 CO). We found no difference in patient-reported moderate/severe pain between WAS and CO (14% in WAS, 15% in CO2; p=0.47). ADR was 15% in the CO arm and 11% in the WAS arm (p=0.03); however, it remained above the minimum national performance standard in both arms. There was no statistical difference in mean number of adenomas nor overall polyp detection rate. There was negligible cost difference between the two techniques.

Conclusion: In the context of enema-prepared unsedated screening sigmoidoscopies performed by screening-accredited endoscopists, no difference in patient-reported pain was seen when using either a CO or WAS intubation technique.

Trial Registration Number: ISRCTN81466870.
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http://dx.doi.org/10.1136/gutjnl-2020-321918DOI Listing
September 2020

Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis.

Gut 2021 03 20;70(3):537-543. Epub 2020 Jul 20.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.

Objective: The COVID-19 pandemic has had a major global impact on endoscopic services. This reduced capacity, along with public reluctance to undergo endoscopy during the pandemic, might result in excess mortality from delayed cancer diagnosis. Using the UK's National Endoscopy Database (NED), we performed the first national analysis of the impact of the pandemic on endoscopy services and endoscopic cancer diagnosis.

Design: We developed a NED COVID-19 module incorporating procedure-level data on all endoscopic procedures. Three periods were designated: pre-COVID (6 January 2020 to 15 March), transition (16-22 March) and COVID-impacted (23 March-31 May). National, regional and procedure-specific analyses were performed. The average weekly number of cancers, proportion of missing cancers and cancer detection rates were calculated.

Results: A weekly average of 35 478 endoscopy procedures were performed in the pre-COVID period. Activity in the COVID-impacted period reduced to 12% of pre-COVID levels; at its low point, activity was only 5%, recovering to 20% of pre-COVID activity by study end. Although more selective vetting significantly increased the per-procedure cancer detection rate (pre-COVID 1.91%; COVID-impacted 6.61%; p<0.001), the weekly number of cancers detected decreased by 58%. The proportion of missing cancers ranged from 19% (pancreatobiliary) to 72% (colorectal).

Conclusion: This national analysis demonstrates the remarkable impact that the pandemic has had on endoscopic services, which has resulted in a substantial and concerning reduction in cancer detection. Major, urgent efforts are required to restore endoscopy capacity to prevent an impending cancer healthcare crisis.
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http://dx.doi.org/10.1136/gutjnl-2020-322179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385747PMC
March 2021

BowelScope: Accuracy of Detection Using Endocuff Optimisation of Mucosal Abnormalities (the B-ADENOMA Study): a multicentre, randomised controlled flexible sigmoidoscopy trial.

Gut 2020 Nov 3;69(11):1959-1965. Epub 2020 Apr 3.

Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, South Tyneside, UK.

Objectives: Adenoma detection rate (ADR) is an important quality marker at lower GI endoscopy. Higher ADRs are associated with lower postcolonoscopy colorectal cancer rates. The English flexible sigmoidoscopy (FS) screening programme (BowelScope), offers a one-off FS to individuals aged 55 years. However, variation in ADR exists. Large studies have demonstrated improved ADR using Endocuff Vision (EV) within colonoscopy screening, but there are no studies within FS. We sought to test the effect of EV on ADR in a national FS screening population.

Design: BowelScope: Accuracy of Detection Using ENdocuff Optimisation of Mucosal Abnormalities was a multicentre, randomised controlled trial involving 16 English BowelScope screening centres. Individuals were randomised to Endocuff Vision-assisted BowelScope (EAB) or Standard BowelScope (SB). ADR, polyp detection rate (PDR), mean adenomas per procedure (MAP), polyp characteristics and location, participant experience, procedural time and adverse events were measured. Comparison of ADR within the trial with national BowelScope ADR was also undertaken.

Results: 3222 participants were randomised (53% male) to receive EAB (n=1610) or SB (n=1612). Baseline demographics were comparable between arms. ADR in the EAB arm was 13.3% and that in the SB arm was 12.2% (p=0.353). No statistically significant differences were found in PDR, MAP, polyp characteristics or location, participant experience, complications or procedural characteristics. ADR in the SB control arm was 3.1% higher than the national ADR.

Conclusion: EV did not improve BowelScope ADR when compared with SB. ADR in both arms was higher than the national ADR. Where detection rates are already high, EV is unable to improve detection further.

Trial Registration Numbers: NCT03072472, ISRCTN30005319 and CPMS ID 33224.
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http://dx.doi.org/10.1136/gutjnl-2019-319621DOI Listing
November 2020

Principles for Evaluation of Surveillance After Removal of Colorectal Polyps: Recommendations From the World Endoscopy Organization.

Gastroenterology 2020 May 30;158(6):1529-1533.e4. Epub 2020 Mar 30.

Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria ISABIAL, Alicante, Spain.

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http://dx.doi.org/10.1053/j.gastro.2019.12.052DOI Listing
May 2020

Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study.

Gut 2020 Sep 17;69(9):1645-1658. Epub 2020 Jan 17.

Cancer Screening and Prevention Research Group (CSPRG), Department of Surgery and Cancer, Imperial College London, London, UK.

Objective: Postpolypectomy colonoscopy surveillance aims to prevent colorectal cancer (CRC). The 2002 UK surveillance guidelines define low-risk, intermediate-risk and high-risk groups, recommending different strategies for each. Evidence supporting the guidelines is limited. We examined CRC incidence and effects of surveillance on incidence among each risk group.

Design: Retrospective study of 33 011 patients who underwent colonoscopy with adenoma removal at 17 UK hospitals, mostly (87%) from 2000 to 2010. Patients were followed up through 2016. Cox regression with time-varying covariates was used to estimate effects of surveillance on CRC incidence adjusted for patient, procedural and polyp characteristics. Standardised incidence ratios (SIRs) compared incidence with that in the general population.

Results: After exclusions, 28 972 patients were available for analysis; 14 401 (50%) were classed as low-risk, 11 852 (41%) as intermediate-risk and 2719 (9%) as high-risk. Median follow-up was 9.3 years. In the low-risk, intermediate-risk and high-risk groups, CRC incidence per 100 000 person-years was 140 (95% CI 122 to 162), 221 (195 to 251) and 366 (295 to 453), respectively. CRC incidence was 40%-50% lower with a single surveillance visit than with none: hazard ratios (HRs) were 0.56 (95% CI 0.39 to 0.80), 0.59 (0.43 to 0.81) and 0.49 (0.29 to 0.82) in the low-risk, intermediate-risk and high-risk groups, respectively. Compared with the general population, CRC incidence without surveillance was similar among low-risk (SIR 0.86, 95% CI 0.73 to 1.02) and intermediate-risk (1.16, 0.97 to 1.37) patients, but higher among high-risk patients (1.91, 1.39 to 2.56).

Conclusion: Postpolypectomy surveillance reduces CRC risk. However, even without surveillance, CRC risk in some low-risk and intermediate-risk patients is no higher than in the general population. These patients could be managed by screening rather than surveillance.
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http://dx.doi.org/10.1136/gutjnl-2019-320036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456728PMC
September 2020

Guidelines for the management of hereditary colorectal cancer from the British Society of Gastroenterology (BSG)/Association of Coloproctology of Great Britain and Ireland (ACPGBI)/United Kingdom Cancer Genetics Group (UKCGG).

Gut 2020 03 28;69(3):411-444. Epub 2019 Nov 28.

Genetic Medicine, Central Manchester University Hospitals Foundation Trust, Manchester, UK.

Heritable factors account for approximately 35% of colorectal cancer (CRC) risk, and almost 30% of the population in the UK have a family history of CRC. The quantification of an individual's lifetime risk of gastrointestinal cancer may incorporate clinical and molecular data, and depends on accurate phenotypic assessment and genetic diagnosis. In turn this may facilitate targeted risk-reducing interventions, including endoscopic surveillance, preventative surgery and chemoprophylaxis, which provide opportunities for cancer prevention. This guideline is an update from the 2010 British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland (BSG/ACPGBI) guidelines for colorectal screening and surveillance in moderate and high-risk groups; however, this guideline is concerned specifically with people who have increased lifetime risk of CRC due to hereditary factors, including those with Lynch syndrome, polyposis or a family history of CRC. On this occasion we invited the UK Cancer Genetics Group (UKCGG), a subgroup within the British Society of Genetic Medicine (BSGM), as a partner to BSG and ACPGBI in the multidisciplinary guideline development process. We also invited external review through the Delphi process by members of the public as well as the steering committees of the European Hereditary Tumour Group (EHTG) and the European Society of Gastrointestinal Endoscopy (ESGE). A systematic review of 10 189 publications was undertaken to develop 67 evidence and expert opinion-based recommendations for the management of hereditary CRC risk. Ten research recommendations are also prioritised to inform clinical management of people at hereditary CRC risk.
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http://dx.doi.org/10.1136/gutjnl-2019-319915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7034349PMC
March 2020

British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post-polypectomy and post-colorectal cancer resection surveillance guidelines.

Gut 2020 02 27;69(2):201-223. Epub 2019 Nov 27.

Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.

These consensus guidelines were jointly commissioned by the British Society of Gastroenterology (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and Public Health England (PHE). They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic colorectal imaging in people aged 18 years and over. They are the first guidelines that take into account the introduction of national bowel cancer screening. For the first time, they also incorporate surveillance of patients following resection of either adenomatous or serrated polyps and also post-colorectal cancer resection. They are primarily aimed at healthcare professionals, and aim to address:Which patients should commence surveillance post-polypectomy and post-cancer resection?What is the appropriate surveillance interval?When can surveillance be stopped? two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); five or more premalignant polyps The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument provided a methodological framework for the guidelines. The BSG's guideline development process was used, which is National Institute for Health and Care Excellence (NICE) compliant.two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); five or more premalignant polyps The key recommendations are that the high-risk criteria for future colorectal cancer (CRC) following polypectomy comprise :two or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10 mm in size or containing any grade of dysplasia, or an adenoma of at least 10 mm in size or containing high-grade dysplasia); five or more premalignant polyps This cohort should undergo a one-off surveillance colonoscopy at 3 years. Post-CRC resection patients should undergo a 1 year clearance colonoscopy, then a surveillance colonoscopy after 3 more years.
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http://dx.doi.org/10.1136/gutjnl-2019-319858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6984062PMC
February 2020

The WASh Trial: water-assisted sigmoidoscopy in the English Bowel Scope Screening Programme: study protocol for a randomized multicenter trial.

Endosc Int Open 2019 Nov 11;7(11):E1574-E1582. Epub 2019 Nov 11.

Department of Gastroenterology, University Hospital of North Tees, Stockton-On-Tees, UK.

 The English National Bowel Scope Screening Programme (BSSP) invites 55-year-olds for a one-off, unsedated flexible sigmoidoscopy (FSIG). Data from BSSP participant-reported experience studies shows 1 in 3 participants report moderate or severe discomfort. Water-assisted colonoscopy (WAS) may improve participants' comfort. The primary objective of this study is to ascertain if post-procedural participant-assessed pain is reduced in WAS compared with carbon dioxide (CO ) insufflation, in invitees undergoing FSIG in BSSP.  This is a multicenter, prospective, randomized, two-arm, single-blinded trial designed to evaluate the performance of WAS versus CO insufflation in BSSP. Participants will be randomized to either CO or WAS and will be asked to rate pain post-procedure. Key procedure-related data will be analyzed, including adenoma detection rates (ADR) and degree of sigmoid looping. A cost-effectiveness analysis of WAS versus CO and a discrete choice experiment exploring preferences of participants for attributes of sigmoidoscopy will also be performed.  This is the first trial in the United Kingdom (UK) to investigate the effects of WAS in a screening setting. If the trial shows WAS either reduces pain or increases ADR, this may result in a practice change to implement WAS in screening and non-screening endoscopic practice directly impacting on 256,000 people a year who will undergo BSSP FSIG by 2020. Trial funding came from National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) supported by the NIHR Clinical Research Network. The trial is actively recruiting. ID: 35866 ISRCTN: 81466870.
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http://dx.doi.org/10.1055/a-0953-1468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6847695PMC
November 2019

Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study.

BMJ 2019 11 13;367:l6090. Epub 2019 Nov 13.

Cancer Epidemiology Group, Institute of Cancer and Pathology and Institute of Data Analytics, University of Leeds, Leeds LS2 9JT, UK.

Objectives: To quantify post-colonoscopy colorectal cancer (PCCRC) rates in England by using recent World Endoscopy Organisation guidelines, compare incidence among colonoscopy providers, and explore associated factors that could benefit from quality improvement initiatives.

Design: Population based cohort study.

Setting: National Health Service in England between 2005 and 2013.

Population: All people undergoing colonoscopy and subsequently diagnosed as having colorectal cancer up to three years after their investigation (PCCRC-3yr).

Main Outcome Measures: National trends in incidence of PCCRC (within 6-36 months of colonoscopy), univariable and multivariable analyses to explore factors associated with occurrence, and funnel plots to measure variation among providers.

Results: The overall unadjusted PCCRC-3yr rate was 7.4% (9317/126 152), which decreased from 9.0% in 2005 to 6.5% in 2013 (P<0.01). Rates were lower for colonoscopies performed under the NHS bowel cancer screening programme (593/16 640, 3.6%), while they were higher for those conducted by non-NHS providers (187/2009, 9.3%). Rates were higher in women, in older age groups, and in people with inflammatory bowel disease or diverticular disease, in those with higher comorbidity scores, and in people with previous cancers. Substantial variation in rates among colonoscopy providers remained after adjustment for case mix.

Conclusions: Wide variation exists in PCCRC-3yr rates across NHS colonoscopy providers in England. The lowest incidence was seen in colonoscopies performed under the NHS bowel cancer screening programme. Quality improvement initiatives are needed to address this variation in rates and prevent colorectal cancer by enabling earlier diagnosis, removing premalignant polyps, and therefore improving outcomes.
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http://dx.doi.org/10.1136/bmj.l6090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6849511PMC
November 2019

Personalizing Polypectomy Techniques Based on Polyp Characteristics.

Clin Gastroenterol Hepatol 2020 Dec 26;18(13):2859-2867. Epub 2019 Sep 26.

Servicio de Medina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. Electronic address:

Polypectomy is an essential skill for all endoscopists performing lower gastrointestinal endoscopy. Different polypectomy tools and techniques have evolved and it is important that endoscopists are familiar with these so they can select the most appropriate technique for each polyp. This narrative review updates the different concepts in tailoring polypectomy technique to the characteristics of polyps. Effective polypectomy requires different components, including the following: careful evaluation of the polyp; decision making about optimal polyp management; actual polypectomy, which includes careful positioning of the endoscope and polyp; and postpolypectomy evaluation of the results (for completeness of resection and prophylaxis of complications).
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http://dx.doi.org/10.1016/j.cgh.2019.09.025DOI Listing
December 2020

Development of a national automated endoscopy database: The United Kingdom National Endoscopy Database (NED).

United European Gastroenterol J 2019 07 2;7(6):798-806. Epub 2019 Apr 2.

Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK.

Background: The National Endoscopy Database (NED) project commenced in 2013 under the auspices of the Joint Advisory Group. The aim is to upload endoscopy procedure data from all units across the United Kingdom to a centralised database. The database can be used to facilitate quality assurance, research and training in endoscopy.

Objective: This article describes the development and implementation process of NED from its inception to date.

Methods: NED utilises automated data uploading of a minimum dataset from local endoscopy reporting systems to a central national database via the internet. Currently all data are anonymised. Key performance indicators are presented to endoscopists and organisations on a web-based platform for quality assurance purposes.

Results: As of October 2018, 295 endoscopy services out of a total of 529 known services in the UK (56%) are actively uploading to NED. Data from more than 400,000 endoscopic procedures have been uploaded.

Conclusion: UK-wide data collection from endoscopy units to a central database is feasible using an automated upload system. This has the potential to facilitate endoscopy quality assurance and research.
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http://dx.doi.org/10.1177/2050640619841539DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620868PMC
July 2019

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

United European Gastroenterol J 2019 06 15;7(5):614-641. Epub 2019 May 15.

Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.

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.
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http://dx.doi.org/10.1177/2050640619850365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545716PMC
June 2019

Performance measures for small-bowel endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

Endoscopy 2019 06 10;51(6):574-598. Epub 2019 May 10.

Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.

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 for both 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, where performance measures had already been identified, this is the first time that small-bowel endoscopy quality measures have been proposed.
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http://dx.doi.org/10.1055/a-0889-9586DOI Listing
June 2019

Predictions of an individual's chance of postcolonoscopy colorectal cancer gives false reassurance both within and outside the United States.

Gastrointest Endosc 2019 04;89(4):896

Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.

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http://dx.doi.org/10.1016/j.gie.2018.09.029DOI Listing
April 2019

Variability in cecal intubation rate by calculation method: a call for standardization of key performance indicators in endoscopy.

Gastrointest Endosc 2019 05 17;89(5):1026-1036.e2. Epub 2019 Jan 17.

Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, United Kingdom; Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom.

Background And Aims: The cecal intubation rate (CIR) is a widely accepted key performance indicator (KPI) in colonoscopy but lacks a universal calculation method. We aimed to assess whether differences in CIR calculation methods could have an impact on perceived trainee outcomes.

Methods: A systematic review of CIR calculation methods was conducted on major societal guidelines (United Kingdom, European Society of Gastrointestinal Endoscopy [ESGE] and American Society for Gastrointestinal Endoscopy [ASGE]) and trainee-inclusive studies. Trainees awarded colonoscopy certification between June 2011 and 2016 were identified from the United Kingdom e-portfolio and selected as a validation cohort. For each trainee, both the crude and unassisted CIR were calculated for 50 post-certification procedures using definitions from the 3 international guidelines. The resulting CIRs, and the proportions of endoscopists failing to meet the minimum standard of CIR ≥90%, were then compared across these definitions.

Results: Across the 3 guidelines and 37 eligible studies identified, differences in CIR calculation methodology were demonstrated. These related to adjustment criteria (18 studies) and whether unassisted CIR was stipulated (18 studies). In the validation cohort of 733 trainees (36,650 procedures), the median crude CIR ranged from 96% (ESGE) to 98% (ASGE) (P < .001) and whether unassisted CIR was specified (ESGE, 94%; ASGE, 96%; P < .001). The proportion of trainees failing to achieve CIR ≥90% varied significantly across the different definitions, from 4.9% for the crude ASGE definition to 18.6% for the unassisted ESGE definition (P < .001).

Conclusions: CIR calculation methods vary among guidelines and research studies; this has an impact on trainee performance measures. With CIR used as an example, this study highlights the need for standardized definitions and calculations of KPIs in endoscopy.
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http://dx.doi.org/10.1016/j.gie.2018.12.026DOI Listing
May 2019

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

United European Gastroenterol J 2018 Dec 19;6(10):1448-1460. Epub 2018 Oct 19.

Northern Institute for Cancer Research, Newcastle University, Newcastle, UK.

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); bile duct cannulation rate (key performance measure, at least 90%); tissue sampling during EUS (key performance measure, at least 85%); appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); bile duct stone extraction (key performance measure, at least 90%); post-ERCP pancreatitis (key performance measure, less than 10%); and adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.
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http://dx.doi.org/10.1177/2050640618808157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297928PMC
December 2018

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

Endoscopy 2018 11 19;50(11):1116-1127. Epub 2018 Oct 19.

Northern Institute for Cancer Research, Newcastle University, Newcastle, United Kingdom.

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.
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http://dx.doi.org/10.1055/a-0749-8767DOI Listing
November 2018

World Endoscopy Organization Consensus Statements on Post-Colonoscopy and Post-Imaging Colorectal Cancer.

Gastroenterology 2018 09 27;155(3):909-925.e3. Epub 2018 Jun 27.

Maastricht University Medical Center, Maastricht, The Netherlands.

Background & Aims: Colonoscopy examination does not always detect colorectal cancer (CRC)- some patients develop CRC after negative findings from an examination. When this occurs before the next recommended examination, it is called interval cancer. From a colonoscopy quality assurance perspective, that term is too restrictive, so the term post-colonoscopy colorectal cancer (PCCRC) was created in 2010. However, PCCRC definitions and methods for calculating rates vary among studies, making it impossible to compare results. We aimed to standardize the terminology, identification, analysis, and reporting of PCCRCs and CRCs detected after other whole-colon imaging evaluations (post-imaging colorectal cancers [PICRCs]).

Methods: A 20-member international team of gastroenterologists, pathologists, and epidemiologists; a radiologist; and a non-medical professional met to formulate a series of recommendations, standardize definitions and categories (to align with interval cancer terminology), develop an algorithm to determine most-plausible etiologies, and develop standardized methodology to calculate rates of PCCRC and PICRC. The team followed the Appraisal of Guidelines for Research and Evaluation II tool. A literature review provided 401 articles to support proposed statements; evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The statements were voted on anonymously by team members, using a modified Delphi approach.

Results: The team produced 21 statements that provide comprehensive guidance on PCCRCs and PICRCs. The statements present standardized definitions and terms, as well as methods for qualitative review, determination of etiology, calculation of PCCRC rates, and non-colonoscopic imaging of the colon.

Conclusions: A 20-member international team has provided standardized methods for analysis of etiologies of PCCRCs and PICRCs and defines its use as a quality indicator. The team provides recommendations for clinicians, organizations, researchers, policy makers, and patients.
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http://dx.doi.org/10.1053/j.gastro.2018.05.038DOI Listing
September 2018

Colonoscopic perforations in the English National Health Service Bowel Cancer Screening Programme.

Endoscopy 2018 09 28;50(9):861-870. Epub 2018 Mar 28.

Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom.

Background: Perforation is the most serious adverse event associated with colonoscopy. In this study of data from the English National Health Service Bowel Cancer Screening Programme, we aimed to describe the presentation and management of perforations, and to determine factors associated with poorer outcomes post-perforation.

Methods: The medical records of patients with a perforation following the national screening colonoscopy were retrospectively examined. All colonoscopies performed from 02/08/2006 to 13/03/2014 were studied. Bowel Cancer Screening Centres across England were contacted and asked to complete a detailed dataset relating to perforation presentation, management, and outcome.

Results: 263 129 colonoscopies were analyzed, and the rate of perforation was 0.06 %. Complete data were reviewed for 117 perforations: 70.1 % of perforations (82/117) occurred during therapeutic colonoscopies; 54.9 % (62/113) of patients with perforations who were admitted to hospital and in whom data were complete underwent surgery; 26.1 % (30/115) of hospitalized patients left the hospital with a stoma and 19.1 % (22/115) developed post-perforation morbidity. Perforations not detected during colonoscopy were significantly more likely to require surgery ( = 0.03). Diagnostic perforations were significantly more likely to require surgery ( = 0.002) and were associated with higher rates of post-perforation morbidity ( = 0.01). At presentation, the presence of abdominal pain ( = 0.01), a pulse rate > 100 beats per minute ( = 0.049), and a respiratory rate > 20 breaths per minute ( = 0.01) were significantly associated with the patient having surgery.

Conclusions: This is the largest retrospective observational case series in Europe to describe post-perforation presentation, management, and outcomes. We have confirmed that perforation leads to surgical intervention, stoma formation, and post-perforation morbidity. Perforations not recognized during the colonoscopy were significantly more likely to require surgery. Diagnostic perforations were at greater risk of requiring surgery and developing post-perforation morbidity.
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http://dx.doi.org/10.1055/a-0584-7138DOI Listing
September 2018

Implementing endoscopy checklists - a step in the right direction?

Endoscopy 2018 03 26;50(3):191-193. Epub 2018 Feb 26.

Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom.

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http://dx.doi.org/10.1055/s-0043-125208DOI Listing
March 2018

Colorectal Cancer Screening-Who, How, and When?

Clin Endosc 2018 Jan 31;51(1):37-49. Epub 2018 Jan 31.

Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, Durham, UK.

Colorectal cancer (CRC) is the third most common cancer worldwide. It is amenable to screening as it occurs in premalignant, latent, early, and curable stages. PubMed, Cochrane Database of Systematic Reviews, and national and international CRC screening guidelines were searched for CRC screening methods, populations, and timing. CRC screening can use direct or indirect tests, delivered opportunistically or via organized programs. Most CRCs are diagnosed after 60 years of age; most screening programs apply to individuals 50-75 years of age. Screening may reduce disease-specific mortality by detecting CRC in earlier stages, and CRC incidence by detecting premalignant polyps, which can subsequently be removed. In randomized controlled trials (RCTs) guaiac fecal occult blood testing (gFOBt) was found to reduce CRC mortality by 13%-33%. Fecal immunochemical testing (FIT) has no RCT data comparing it to no screening, but is superior to gFOBt. Flexible sigmoidoscopy (FS) trials demonstrated an 18% reduction in CRC incidence and a 28% reduction in CRC mortality. Currently, RCT evidence for colonoscopy screening is scarce. Although not yet corroborated by RCTs, it is likely that colonoscopy is the best screening modality for an individual. From a population perspective, organized programs are superior to opportunistic screening. However, no nation can offer organized population-wide colonoscopy screening. Thus, organized programs using cheaper modalities, such as FS/FIT, can be tailored to budget and capacity.
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http://dx.doi.org/10.5946/ce.2017.141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806924PMC
January 2018

Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial.

Gut 2019 02 23;68(2):280-288. Epub 2018 Jan 23.

Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK.

Objective: Low adenoma detection rates (ADR) are linked to increased postcolonoscopy colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation such as Endocuff Vision (EV) may improve ADR. This multicentre randomised controlled trial compared ADR between EV-assisted colonoscopy (EAC) and standard colonoscopy (SC).

Design: Patients referred because of symptoms, surveillance or following a positive faecal occult blood test (FOBt) as part of the Bowel Cancer Screening Programme were recruited from seven hospitals. ADR, mean adenomas per procedure, size and location of adenomas, sessile serrated polyps, EV removal rate, caecal intubation rate, procedural time, patient experience, effect of EV on workload and adverse events were measured.

Results: 1772 patients (57% male, mean age 62 years) were recruited over 16 months with 45% recruited through screening. EAC increased ADR globally from 36.2% to 40.9% (P=0.02). The increase was driven by a 10.8% increase in FOBt-positive screening patients (50.9% SC vs 61.7% EAC, P<0.001). EV patients had higher detection of mean adenomas per procedure, sessile serrated polyps, left-sided, diminutive, small adenomas and cancers (cancer 4.1% vs 2.3%, P=0.02). EV removal rate was 4.1%. Median intubation was a minute quicker with EAC (P=0.001), with no difference in caecal intubation rate or withdrawal time. EAC was well tolerated but caused a minor increase in discomfort on anal intubation in patients undergoing colonoscopy with no or minimal sedation. There were no significant EV adverse events.

Conclusion: EV significantly improved ADR in bowel cancer screening patients and should be used to improve colonoscopic detection.

Trial Registration Number: NCT02552017, Results; ISRCTN11821044, Results.
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http://dx.doi.org/10.1136/gutjnl-2017-314889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352411PMC
February 2019

Cumulative burden of inflammation predicts colorectal neoplasia risk in ulcerative colitis: a large single-centre study.

Gut 2019 03 17;68(3):414-422. Epub 2017 Nov 17.

St Mark's Hospital, London, UK.

Objective: Ulcerative colitis (UC) is a dynamic disease with its severity continuously changing over time. We hypothesised that the risk of colorectal neoplasia (CRN) in UC closely follows an actuarial accumulative inflammatory burden, which is inadequately represented by current risk stratification strategies.

Design: This was a retrospective single-centre study. Patients with extensive UC who were under colonoscopic surveillance between 2003 and 2012 were studied. Each surveillance episode was scored for a severity of microscopic inflammation (0=no activity; 1=mild; 2=moderate; 3=severe activity). The cumulative inflammatory burden (CIB) was defined as sum of: average score between each pair of surveillance episodes multiplied by the surveillance interval in years. Potential predictors were correlated with CRN outcome using time-dependent Cox regression.

Results: A total of 987 patients were followed for a median of 13 years (IQR, 9-18), 97 (9.8%) of whom developed CRN. Multivariate analysis showed that the CIB was significantly associated with CRN development (HR, 2.1 per 10-unit increase in CIB (equivalent of 10, 5 or 3.3 years of continuous mild, moderate or severe active microscopic inflammation); 95% CI 1.4 to 3.0; P<0.001). Reflecting this, while inflammation severity based on the most recent colonoscopy alone was not significant (HR, 0.9 per-1-unit increase in severity; 95% CI 0.7 to 1.2; P=0.5), a mean severity score calculated from all colonoscopies performed in preceding 5 years was significantly associated with CRN risk (HR, 2.2 per-1-unit increase; 95% CI 1.6 to 3.1; P<0.001).

Conclusion: The risk of CRN in UC is significantly associated with accumulative inflammatory burden. An accurate CRN risk stratification should involve assessment of multiple surveillance episodes to take this into account.
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http://dx.doi.org/10.1136/gutjnl-2017-314190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6581019PMC
March 2019

Post-polypectomy bleeding in the English National Health Service Bowel Cancer Screening Programme.

Endoscopy 2017 Sep 28;49(9):899-908. Epub 2017 Jul 28.

Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, United Kingdom.

 Colonoscopic polypectomy reduces colorectal cancer incidence, but is associated with complications including post-polypectomy bleeding (PPB). PPB ranges in severity from minor to life-threatening, making interpretation and comparison difficult. No previous studies have examined PPB rate according to a standardized severity grading system. We aimed to determine the PPB rate stratified by severity grading, explore factors that contribute to PPB severity grading, and describe PPB management.  Data relating to PPB were prospectively collected from all colonoscopies performed in one region of the English NHS Bowel Cancer Screening Programme (BCSP) from 06/12/2010 to 15/07/2014. PPB was defined and stratified into major, intermediate, and minor according to BCSP standardized definitions based on the American Society for Gastrointestinal Endoscopy adverse events lexicon.  A total of 15 285 colonoscopies (23 766 polypectomies) were analyzed. The PPB rate per colonoscopy was 0.44 % (95 % confidence interval [CI] 0.34 - 0.54) and the rate per polypectomy was 0.29 % (95 %CI 0.20 - 0.38); 2.9 % of PPBs were major and 42.6 % were intermediate. Repeat endoscopy occurred in 27.9 % and was the most common reason for bleeding being categorized as of intermediate severity, although therapy was applied in only 36.8 % of these cases. A therapeutic intervention was significantly more common in patients with PPB who had either a hemoglobin drop ≥ 2 g/dL and/or a blood transfusion ( = 0.04, relative risk 3.47, 95 %CI 1.05 - 11.52).  This study specifically examined colonoscopic PPB rate, stratified using standardized criteria. The rates of PPB were low, with the majority of PPB being of minor severity. Current stratification of PPB severity combines measures of bleed severity with interventions. Using only hemoglobin drop ≥ 2 g/dL and/or blood transfusion as markers of PPB severity may simplify stratification, and allow a better assessment of the necessity and impact of an intervention.
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http://dx.doi.org/10.1055/s-0043-113442DOI Listing
September 2017