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Excellence is a habit, not an act
  1. Anton V Emmanuel
  1. Correspondence to Dr Anton V Emmanuel, Physiology Unit, University College Hospital, London NW1 2BU, UK; a.emmanuel{at}

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A 2014 blog in Nature ( identified that scientific publications double in volume every 9 years. Gastroenterology and hepatology being both technical and academic specialties have seen major increases in manuscript volume, and for the clinician it is a challenge to remain up to date with this expansion in literature. The intention of Frontline Gastroenterology has been to present the impact of this emerging evidence on practice and to provide tools which allow its adoption. The journal adheres to the Aristotlean view that excellence and competence arises from correctly implementing evidence. At the journal we focus on the relevant evidence that improves outcomes for the patients we look after. In this edition we are proud to highlight manuscripts on standardisation of practice in occasional and common conditions, integration of multimodal investigation in endoscopy and surveillance, and also an article on gastroenterologists’ views of a future therapy (faecal microbial transplantation).

Standardising pouchoscopy and capsule endoscopy

It is exactly 40 years since the first description of the ileonanal pouch by Sir Alan Parkes and John Nicholls from St Mark’s. With over 5000 pouch patients described in the most recent UK Pouch report it is certain that every reader of Frontline Gastroenterology looks after such cases. Endoscopic procedures are common in these patients given the approximately 20% experiencing complications. The variability in reporting of endoscopic procedures is well recognised in colonoscopy; reduction of this variation has potentially greatest clinical impact in low volume centres. It is fitting that van der Ploeg and colleagues at St Mark’s have developed a consensus tool to improve reporting of pouchoscopy, and then gone on to prospectively study the value of this tool.1 The template is included in the manuscript, and we look forward to seeing this being widely used in future research publications, in addition to the value in standardising monitoring of patients with chronic pouch problems, structural and functional.

Video capsule endoscopy of the small bowel has a more recent history than pouch surgery, and the uptake of the technology has been such that almost all specialists now have this modality as a key component of the investigation armamentarium. However, standards in capsule endoscopy reporting remain to be defined – relating both to the optimal methodology of reading the investigation as well as what level of quality control is required to monitor clinician competence. In this edition Beg and colleagues comprehensively review the evidence to address these issues.2 The paper spans the range of the topic from patient preparation to choice of equipment, reporting and maintenance of competence.

Integrating stool and radiology testing in endoscopy

What is the clinical significance of the Faecal Immunochemical Test (FIT) for haemoglobin in a screening population with small adenomas. Gibson et al describe a study from Dublin in which they undertook a second colonoscopy 40 days after the index ’FIT positive' colonoscopy.3 The paper provides insight into the relationship between FIT concentration and adenoma size. The data presented also increases understanding of the effect of colonoscopy on FIT testing. One key take away is that alternative sources of a positive FIT should be sought when only small adenomas are detected at colonoscopy.

As abdominal radiological assessment becomes ever more widely undertaken, the uncovering of potentially incidental abnormalities has emerged as a clinical conundrum. Thickened colonic mucosa identified at CT is a particular challenge as the finding may occur in a patient group who are too frail to undergo bowel preparation for colonoscopic examination. Chandrapalan and colleagues have undertaken a meta-analysis encompassing 1250 such patients and a key emerging message is that three-quarter of them had an abnormal colonoscopy.4 Another important theme is that the index of suspicion before the original CT predicts the colonoscopic findings: when undertaken for possible inflammation, there was an over 90% of such being found at colonoscopy.

Screening for hepatocellular carcinoma after treatment with direct acting antivirals

Direct acting antivirals (DAAs) have an unquestioned place in the management of chronic hepatitis C, however there is conflicting evidence on the association between these drugs and the development of hepatocellular carcinoma. Singh et al have undertaken a meta-analysis with a subtle message for surveillance after treatment with DAAs are highlighted.5 The data reveals a low proportion of incident hepatocellular cancer, but high proportion of recurrent cancers following treatment with DAAs. The implications for surveillance of hepatocellular carcinoma.

Attitudes to the future: faecal microbial transplantation for inflammatory bowel disease

Faecal microbial transplantation (FMT) is positively regarded as a therapy for Clostridium difficile infection. Now that there are published randomised controlled trials in ulcerative colitis, McIlroy et al undertook a survey study to assess attitudes towards FMT for this indication.6 The results reveal a lack of access to the therapy in the face of significant levels of interest in the therapy. Coupled with a lack of clarity about what control therapy should be in future studies, this is an ideal combination for a future Frontline Gastroenterology type study. We look forward to seeing such manuscripts of this emerging therapy as applied in practice.



  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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