Author:

Thomas Archer, Clinical Fellow, Leeds Teaching Hospitals NHS Trust

Acknowledgments:

Arlyn Usama

Imran Iqbal

Umair Akbani

Vivek Goodoory

Conchubhair Winters

Ruchit Sood

Noor Mohammed

Introduction

Submucosal endoscopy has opened up a new paradigm in the management of gastrointestinal diseases with minimally invasive and short stay elective admissions for conditions previously managed with more invasive surgical interventions.  At Leeds Teaching Hospital NHS Trust 100-150 submucosal procedures are performed per year.  

Endoscopic submucosal dissection (ESD) is a highly effective, minimally invasive technique for removing complex colorectal polyps. It offers an alternative to surgery, reducing hospital stays, lowering costs, and minimizing complications associated with surgical interventions. However, a relatively high frequency of complications are observed, with post polypectomy bleeding seen in 3% and perforation seen in 5%. While it provides significant benefits over surgery, these potential complications require early identification to ensure patient safety.

Per oral endoscopic myotomy (POEM) in contrast offers a minimally invasive alternative to surgical myotomy for benign conditions of the oesophagus and stomach.  This allows short stay admissions with a reduced recovery period with equivalent efficacy.  Complications are less commonly seen following POEM, however, they can be severe, with potential sequalae of significant infections and mediastinitis amongst other complications. 

Prior to April 2024, post-ESD and POEM follow-up in our unit was inconsistent, which raised the possibility of delayed recognition of complications and limited communication with patients.  The introduction of a dedicated Endoscopy Clinical Nurse Specialist (ECNS) aimed to address these challenges by providing structured monitoring, early complication detection, and improved patient communication. 

Challenges and Need for Change

A retrospective review of our colorectal ESD follow up at our trust was conducted.  124 cases were reviewed, of which 12 (9.9%) had a complication requiring readmission.  During this period the median number of days from procedure to first review was 28 days (IQR 43).

A clear opportunity to improve the care of patients undergoing complex submucosal endoscopy with consistent follow up was identified.  As well as structured cohesive follow up, other areas of improvement were identified; a consistent point of contact for patients pre, during and following the procedure, as well as support in administrative and governance associated with submucosal endoscopy.

Methods & Approach

A dedicated ECNS was introduced in April 2024 to provide structured post-procedural monitoring.   The ECNS followed a standard follow up, reviewing patients at days 3,7 and 28 post procedure.  Patients were also provided with a contact number for the ECNS in the event of queries or the development of concerning symptoms.

As well as this primary role, other tasks within the team were identified. The ECNS attended the dedicated endoscopy clinic, to support patients pre procedure, as well as the upper gastrointestinal and polyp multidisciplinary team (MDT) meetings. The ECNS reviewed governance and protocols relating to submucosal endoscopy.

Outcomes

Following the introduction of the ECNS an initial cohort of patients undergoing ESD was reviewed.  Between May 2024 and September 2024, 22 patients underwent colorectal ESD.   All patients were contacted by the ECNS with a median number of days to first review of 3 days (IQR = 1). All patients were also reviewed at 7 and 28 days. 2/22 (9%) patients were readmitted to hospital following ECNS review. One patient had a post polypectomy bleed that was managed conservatively, and one patient had a delayed perforation requiring surgical washout and intravenous antibiotics.

An ECNS feedback form was completed by 11/22 (50%) patients. Patients rated ECNS as excellent with respect to communication in 72.7%, timeliness in 63.6%, and overall care in 81.8% of responses. 90.9% of patients would recommend the centre for those undergoing a similar procedure.

The ECNS routinely attended the weekly endoscopy clinic.  This gave her the opportunity to meet patients referred for submucosal endoscopic procedures.  She was able to support them through additional information as well as being a point of contact prior to their procedure so that further queries could be addressed and any deterioration in their condition could be considered by the clinical team.  

The ECNS has also improved the efficiency of MDT meetings, supporting administrative tasks such as ordering tests and contacting patients with outcomes.  Furthermore, the ECNS has supported a supplementary polyp MDT that reviewed polyp resection and histology and planned further follow up, improving the efficiency of the primary polyp MDT to review new referrals.

Within the endoscopy department the ECNS improved efficiency by ensuring early arrival of patients for their procedures, undertaking prompt patient assessment and coordinating the team, ensuring a timely start of procedures.  She also provides education of endoscopy staff to improve understanding of submucosal endoscopy and training in the role of assistant to the submucosal endoscopist.

The ECNS has reviewed the governance and protocols relating to endoscopic procedures completing 7 standard operating procedures introduced to ensure standardised care and utilisation of the endoscopy team.

Table 1 demonstrates the standard operating procedures spearheaded by ECNS

Learning points & applicability to other teams

We have identified the potential for a dedicated ECNS, whose role centres around wrap around care for patients undergoing submucosal endoscopy.  This helps to guarantee effective pre and post procedural communication with patients, ensuring that they are both fully informed regarding their complex intervention and well-supported post procedure.  Patients have a supported recovery and a consistent point of contact if complications develop.  Such complications can potentially be life changing; prompt identification gives the opportunity to offer early rescue therapy and offer the best chance of recovery.

We have found that the ECNS’s role has grown to cover other aspects of management of complex mucosal endoscopy with ancillary roles that have improved the cohesion and efficiency of the team.

Furthermore, service innovations such as SOP development, patient education materials, and workflow efficiencies have contributed to the sustainability and effectiveness of this initiative. In the future her role will also incorporate non-medical prescribing.

Submucosal endoscopy is a growing field with an increasing workload across the country. This model demonstrates the potential to improve the care at other centres with a high volume of submucosal endoscopy. Furthermore, a similar role could be incorporated into other high risk endoscopic therapies such as biliary and pancreatic endoscopy. By bringing healthcare closer to patients and ensuring direct, personalized support, this model should be considered for wider implementation in endoscopy services to improve care standards and patient experiences.