The SAGES Manual of Flexible Endoscopy

This book addresses all aspects of endoscopy from scope and tower basics to the more advanced interventional procedures like endoscopic retrograde cholangiopancreatography, per-oral esophageal myotomy, and percutaneous endoscopic gastrostomy. It covers a broad range of topics in order to remain relevant to the surgical subspecialist, the community general surgeon, the surgical fellow interested in endolumenal and transluminal procedures, and the surgical resident interested in the very basics of endoscopy. The table of contents is intentionally designed to mirror the Flexible Endoscopy curriculum currently being implemented for all minimally invasive, advanced GI and surgical endoscopy fellowships. The chapters are broken up into five parts. The first part introduces the SAGES Masters Program, followed by parts that cover flexible endoscopy basics, flexible endoscopy procedures, and finally bariatric flexible endoscopy. Written by experts and thought leaders in their fields, The SAGES Manual of Flexible Endoscopy serves as a valuable resource for surgeons of all training and skill levels to better grasp an overview of modern endoscopy practice.

• Language: English
• Publisher: Springer
• Release date: Sep 24, 2019
• ISBN: 9783030235901

Book preview

Part ISAGES Masters Program

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Nau et al. (eds.)The SAGES Manual of Flexible Endoscopyhttps://doi.org/10.1007/978-3-030-23590-1_1

1. SAGES University Masters Program: Flexible Endoscopy Pathway

Daniel B. Jones¹  , Linda Schultz² and Brian P. Jacob³

(1)

Minimally Invasive Surgery and Bariatric Surgery, Beth Israel Deaconess Medical Center, Harvard University Medical School, Boston, MA, USA

(2)

SAGES: Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA, USA

(3)

The Mount Sinai Hospital, New York, NY, USA

Daniel B. Jones

Email: [e-mail]

Keywords

EndoscopyColonoscopyCompetencyProficiencyMastery

Adapted with permission of Springer International Publishers from Jones DB, Stefanidis D, Korndorffer JR Jr, Dimick JB, Jacob BP, Schultz L, et al. SAGES University MASTERS Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017 Aug;31(8):3061-3071.

Overview

The Society of American Gastrointestinal and Endoscopic Surgery (SAGES) Masters Program organizes educational materials along clinical pathways into discrete blocks of content which could be accessed by a surgeon attending the SAGES annual meeting or by logging into the online SAGES University (Fig. 1.1) [1]. The SAGES Masters Program currently has eight pathways including acute care, biliary, bariatrics, colon, foregut, hernia, flexible endoscopy, and robotic surgery (Fig. 1.2). Each pathway is divided into three levels of targeted performance: competency, proficiency, and mastery (Fig. 1.3). The levels originate from the Dreyfus model of skill acquisition [2], which has five stages: novice, advanced beginner, competency, proficiency, and expertise. The SAGES Masters Program is based on the three more advanced stages of skill acquisition: competency, proficiency, and expertise. Competency is defined as what a graduating general surgery chief resident or minimally invasive surgery (MIS) fellow should be able to achieve. Proficiency is what a surgeon approximately 3 years out from training should be able to accomplish. Mastery is what more experienced surgeons should be able to accomplish after several years in practice. Mastery is applicable to SAGES surgeons seeking in-depth knowledge in a pathway, including the following: areas of controversy, outcomes, best practice, and ability to mentor colleagues. Over time, with the utilization of coaching and participation in SAGES courses, this level should be obtainable by the majority of SAGES members. This edition of The SAGES Manual of Flexible Endoscopy aligns with the current version of the new SAGES University Masters Program Flexible Endoscopy pathway (Table 1.1). This chapter provides an overview of the key elements of the SAGES Masters Flexible Endoscopy Program.

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Figure 1.1

SAGES Masters Program logo

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Figure 1.2

SAGES Masters Program clinical pathways

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Figure 1.3

SAGES Masters Program progression

Table 1.1

Flexible endoscopy curriculum

Flexible Endoscopy Curriculum

The key elements of the flexible endoscopy curriculum include core lectures for the pathway, which provides a 45-minute general overview including basic anatomy, physiology, diagnostic workup, and surgical management. As of 2018, all lecture content of the SAGES annual meetings are labeled as follows: basic (100), intermediate (200), and advanced (300). This allows attendees to choose lectures that best fit their educational needs. Coding the content additionally facilitates online retrieval of specific educational material, with varying degrees of endoscopic complexity , ranging from introductory to complex endoscopic interventions.

SAGES identified the need to develop targeted, complex content for its mastery level curriculum and created 25-minute lectures focused on specific topics. Mastery level content assumes that the attendee already has a good understanding of diseases and management from attending/watching competency- and proficiency-level lectures. Ideally, in order to supplement a chosen topic, the mastery lectures would also identify key prerequisite articles from Surgical Endoscopy and other journals, in addition to SAGES University videos. Many of these lectures will be forthcoming at future SAGES annual meetings.

The Masters Program has a self-assessment, multiple choice exam for each module to guide learner progression throughout the curriculum. Questions are submitted by core lecture speakers and SAGES annual meeting faculty. The goal of the questions is to use assessment for learning, with the assessment being criterion-referenced with the percent correct set at 80%. Learners will be able to review incorrect answers, review educational content, and retake the examination until a passing score is obtained.

The Masters Program flexible endoscopy curriculum utilizes SAGES existing educational products including the Fundamentals of Endoscopic Surgery (FES™) , the Fundamental Use of Surgical Energy (FUSE™), and SAGES Top 21 Videos and Pearls (Fig. 1.4a, b). The Curriculum Task Force has placed the aforementioned modules along a continuum of the curriculum pathway. For example, FES occurs during the competency level curriculum , whereas the Fundamental Use of Surgical Energy (FUSE) is required during the proficiency curriculum. The Fundamentals of Endoscopic Surgery (FES) (available at www.​fesprogram.​org) includes a multiple choice exam and a skills assessment conducted on an endoscopic simulator. Tasks include endoscopic target acquisition, loop reduction, and retroflex endoscope navigation. Since 2018, FES has been required of all US general surgery residents seeking to sit for the American Board of Surgery qualifying examinations. The Fundamental Use of Surgical Energy (available at www.​fuseprogram.​org) teaches about the safe use of electrosurgery in the endoscopy suite or operating room. After learners complete the self-paced modules, they may take the certifying examination.

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Figure 1.4

SAGES Educational Content: (a) FLS™; (b) FUSE™. (Trademarks by SAGES)

Top 21 Videos are edited videos of the most commonly performed diagnostic and therapeutic endoscopy procedures. Cases are straightforward with quality video and clear anatomy. Pearls are step-by-step video clips of endoscopic operations. The authors show different variations for each step. The learner should have a fundamental understanding of the operation.

SAGES Guidelines provide evidence-based recommendations for surgeons and are developed by the SAGES Guidelines Committee following the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine standards (formerly the Institute of Medicine) for guideline development [3]. Each clinical practice guideline has been systematically researched, reviewed, and revised by the SAGES Guidelines Committee and an appropriate multidisciplinary team. The strength of the provided recommendations is determined based on the quality of the available literature using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology [4]. SAGES Guidelines cover a wide range of topics relevant to the practice of SAGES surgeon members and are updated on a regular basis. Since the developed guidelines provide an appraisal of the available literature, they are included in the Masters Program.

The Curriculum Task Force identified the need to select required readings for the Masters Program based on key articles for the curriculum core procedures. Summaries of each of these articles follow the American College of Surgeons (ACS) Selected Readings format.

Facebook™ Groups

While there are many great platforms available to permit online collaboration by user-generated content, Facebook™ offers a unique, highly developed mobile platform that is ideal for global professional collaboration and daily continuing surgical education (Fig. 1.5). Eight unique vetted membership-only closed Facebook™ groups were created for the Masters Program, including a group for bariatrics, hernia, colorectal, biliary, acute care, flexible endoscopy, robotics, and foregut. The SAGES Flex Endo Masters Program Collaboration Facebook™ group (available at www.​facebook.​com/​groups/​SAGESFlexEndo) is independent of the other groups and is populated only by physicians, mostly surgeons, with training and/or interest in gastrointestinal endoscopy . The group allows for video assessment, feedback, and coaching as a tool to improve practice.

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Figure 1.5

SAGES Flex Endo Facebook™ Group (Trademark by Facebook)

Based on the anchoring procedures determined via group consensus (Table 1.2), participants in the Masters Program will submit video clips on closed Facebook™ groups, with other participants and/or SAGES members providing qualitative feedback . For the flexible endoscopy curriculum, surgeons would submit videos during diagnostic upper endoscopy or colonoscopy and complete videos of therapeutic procedures like percutaneous endoscopic gastrostomy. Using crowdsourcing, other surgeons would comment and provide feedback. However, for the mastery level, participants will submit a video of stricture dilation and stent placement to be evaluated by an expert panel. A standardized video assessment tool, depending on the specific procedure, will be used. A benchmark will also be utilized to determine when the participant has achieved the mastery level for that procedure.

Table 1.2

Anchoring procedures for flexible endoscopy pathway

The group provides an international platform for physicians interested in optimizing outcomes in flexible endoscopy to collaborate, share, discuss, and post photos, videos, and anything related to their specialty. By embracing social media as a collaborative forum, surgeons can more effectively and transparently obtain immediate global feedback that can potentially improve patient outcomes, as well as the quality of care provided, all while transforming the way SAGES members interact.

For the first two levels of the Masters Program, competency and proficiency, participants will be required to post videos of the anchoring procedures and will receive qualitative feedback from other participants. Once the participant has achieved mastery level, they will participate as a coach by providing feedback to participants in the first two levels. Masters Program participants will therefore need to learn the fundamental principles of surgical coaching. Key activities of coaching include goal setting, active listening, powerful inquiry, and constructive feedback [5, 6]. Importantly, peer coaching is much different than traditional education, where there is an expert and a learner. Peer coaching is a co-learning model where the coach is facilitating the development of the coachee by using inquiry/advocacy (i.e., open-ended questions) in a noncompetitive manner.

Surgical coaching skills are therefore a crucial part of the Masters curriculum. At the 2017 SAGES Annual Meeting, a postgraduate course on coaching skills was developed and video recorded. The goal is to develop a coaching culture within the SAGES Masters Program, wherein both participants and coaches are committed to lifelong learning and development.

The need for a more structured approach to the education of practicing surgeons as outlined by the SAGES Masters Program is well recognized [7]. Since performance feedback usually stops after training completion and current approaches to Maintenance of Certification are suboptimal, the need for peer coaching has recently received increased attention in surgery [5, 6]. SAGES has recognized this need, and its Masters Program embraces social media for surgical education to help provide a free, mobile, and easy-to-use platform to surgeons globally. Access to the Masters Program groups enables surgeons at all levels to partake in program curriculum and obtain feedback from peers, mentors, and experts. By creating physician-only private groups dedicated to this project, SAGES can now offer surgeons posting in these groups the ability to discuss preoperative, intraoperative, and postoperative issues with other SAGES colleagues and mentors. In addition, the platform permits transparent and responsive dialogue about technique, continuing the theme of deliberate, lifelong learning.

To accommodate the needs of this program, SAGES University is upgrading its web-based features. A new learning management system (LMS) will track participant progress and simplify access to SAGES University. The new LMS infrastructure will enable access to videos and lectures on demand and allow search functions in relation to content, level of difficulty, and author. Once enrolled in the Masters Program, the LMS will track lectures, educational products, continued medical education credits, and other completed requirements. Participants will be able to see where they stand in relation to module completion, and SAGES will alert learners to relevant content they may be interested in pursuing. Until the new LMS is operational, the SAGES Manual of Flexible Endoscopy will help guide learners through the Masters Program Curriculum for Flexible Endoscopy.

Conclusions

The Masters Program is an innovative, voluntary curriculum that embraces the concept of lifelong learning, and its curriculum is organized from basic principles to more complex content. The SAGES Masters Program Flexible Endoscopy pathway facilitates deliberate, focused postgraduate teaching and learning. Verified completion of the Masters Program indicates completion of the curriculum but is not meant to certify competency, proficiency, or mastery of surgeons.

References

1.

Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, et al. SAGES University Masters Program: a structured curriculum for deliberate, lifelong learning. Surg Endosc. 2017 Aug;31(8):3061–71.Crossref

2.

Dreyfus SE. The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177–81.Crossref

3.

Graham R, Mancher M, Miller Woman D, Greenfield S, Steinberg E, Institute of Medicine (US) Committee on standards for developing trustworthy clinical practice guidelines. Clinical practice guidelines we can trust. Washington, DC: National Academies Press (US); 2011.

4.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6.Crossref

5.

Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32–4.Crossref

6.

Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282–3.Crossref

7.

Sachdeva AK. Acquiring skills in new procedures and technology: the challenge and the opportunity. Arch Surg. 2005;140:387–9.Crossref

© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Nau et al. (eds.)The SAGES Manual of Flexible Endoscopyhttps://doi.org/10.1007/978-3-030-23590-1_2

2. Masters Program Flexible Endoscopy Pathway: Diagnostic Esophagogastroduodenoscopy

Consandre P. Romain¹  , Robert Joshua Bowles² and Jose M. Martinez²

(1)

Division of Laparoendoscopic Surgery, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA

(2)

Division of Laparoendoscopic Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Health System, University of Miami Miller School of Medicine, Miami, FL, USA

Consandre P. Romain

Keywords

Esophagogastroduodenoscopy (EGD)IndicationDiagnosticEsophagusStomachDuodenumEndoscopeEndoscopyWheelEvaluationScope maneuversDocumentation

Learning Objectives

1.

Applications of upper endoscopy

2.

Indications for diagnostic EGD

3.

Pre-procedure preparation

4.

Technical steps of EGD

5.

Documentation of EGD

Introduction

Since it was first performed in the 1950s, esophagogastroduodenoscopy (EGD) has been established as the primary modality for the diagnosis and treatment of a gamut of upper gastrointestinal conditions. An estimated 6.9 million EGDs were performed in 2009 [1]. The practical use of the endoscope has expanded exponentially over the past two decades. Due to standardization in patient preparation, procedural sedation, and advances in endoscopic equipment, EGD is increasingly valuable to the general surgeon.

The indications for EGD are numerous, and the list continues to grow as more clinical applications are established through the development of new accessories and equipment. The surgical endoscopist can not only perform a thorough mucosal evaluation but can also perform adequate tissue sampling, sclerotherapy, clipping for bleeding control or for the closure of mucosal or full-thickness defects, balloon dilation of strictures and stenting of partial obstructions, and enteral access procedures. Surgical endoscopists also perform a variety of other advanced procedures including minimally invasive tumor resection via endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) [2]. The flexible endoscope also allows us to treat surgical conditions that in the past were only achieved by a transabdominal approach. These include per-oral esophageal myotomy (POEM) for the treatment of achalasia and per-oral pyloromyotomy (POP) for the treatment of adult-onset pyloric stenosis and idiopathic refractory gastroparesis. Endoscopic bariatric procedures (e.g., balloon, sutured gastric plication) have also been adopted by bariatric surgeons as less-invasive options for weight loss in select patients [3]. Mucosal ablation for Barrett’s esophagus and endoscopic antireflux procedures are also well established [4]. This discussion will, however, focus on the indications, preoperative preparation, technical aspects, and surgical pearls and pitfalls of performing a diagnostic EGD.

Diagnostic EGD is routinely used as a primary tool to evaluate patients with suspected or established foregut pathology. EGD is the only modality to allow direct visualization of the upper gastrointestinal tract and obtain a tissue biopsy. The indications for diagnostic EGD include but are not limited to the evaluation of chronic abdominal pain, dysphagia, gastroesophageal reflux disease, anemia, gastrointestinal bleeding, neoplasms, ulcers, and a host of other foregut pathologies.

Patient evaluation and preparation prior to any endoscopy is of utmost importance. See Chap. 8 on patient preparation, sedation, and monitoring for a more detailed review of these aspects. Every patient should have a thorough history and physical exam to determine basic fitness and ability to undergo endoscopy in a way that will minimize adverse outcomes and complications. Several elements of the patient’s comprehensive history and physical exam will allow the endoscopist and anesthesiologist to make adequate preparations before the procedure. A review of the patient’s past medical history will reveal any potentially prohibitive cardiovascular or pulmonary disease, obesity, and obstructive sleep apnea. The past surgical history will reveal any prior neck, cervical spine, or oral surgery and any possible altered alimentary tract anatomy. A review of medications is crucial as it is important to be aware of any medications that may interact with sedatives and analgesics used during the procedure. The same goes for the patient’s social history and any ongoing substance abuse. Anticoagulants should be held for the appropriate recommended duration [5]. The patient should be made NPO prior to the procedure according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines [6]. Appropriate prophylactic antibiotics should be administered depending on the procedure to be performed and the patient’s medical history [7–9]. Finally, an informed consent should be obtained after a thorough discussion with the patient or their proxy regarding the risks and benefits of the procedure.

The risk of adverse events during diagnostic EGD is low and complications are rare; however, the risk is not zero. Complications include aspiration pneumonia, bleeding, infection, perforation, and implant migration or impaction leading to injury [10]. The endoscopist can take several steps to minimize those complications. The patient is kept NPO prior to EGD to decrease the amount of stomach content during anesthesia and instrumentation and decrease the risk of aspiration. The patient is kept off anticoagulants, when appropriate, to decrease the risk of bleeding. Antibiotics are administered when necessary to decrease the risk of bacterial translocation. Specific maneuvers or patient positioning are employed throughout the procedure to minimize the risk of perforation and implant malposition or migration.

Preparation of the staff and the endoscopy suite is equally important to ensure the expected outcome of the procedure [11]. In the case of endoscopist-administered sedation, the provider should have a discussion with the staff prior to the procedure and verify that a suitable dose of medication, IV fluids, and resuscitative equipment are available in the room prior to the start of the procedure. Verification of a working pulse oximeter, sphygmomanometer, and heart rhythm monitors is essential. In the case of sedation by an anesthesia provider, the endoscopist should have a discussion with the anesthesia staff regarding the anticipated procedure including depth and duration of sedation and the need for endotracheal intubation for patients at increased risk of aspiration such as complete esophageal impaction or achalasia with megaesophagus. The endoscopist would also verify at this time that any equipment specific to the procedure, i.e., biopsy forceps, snares, baskets, clips, sclerotherapy needles, etc., is available.

For a diagnostic EGD, the patient is typically placed in the left lateral decubitus position with the head slightly elevated or on a pillow [12]. A mouthpiece or bite block is placed in the patient’s mouth prior to the induction of anesthesia in the case of conscious sedation or monitored anesthesia care (MAC) . The bite block is placed after induction and intubation in the scenario where general anesthesia is preferred or required. The endoscopist will ensure that all of the scope’s functions are working properly. Adequate connection of suction and insufflation tubing is checked. The functions can be checked by placing the tip of the endoscope in a cup of sterile water, and the suction button on the endoscope is depressed to verify function. The insufflation button is covered but not depressed to check for insufflation (bubbles are formed in the cup of water). The endoscope is then removed from the water as the insufflation button is depressed to demonstrate scope irrigation. White balancing of the scope is achieved as needed per scope manufacturer’s recommendations. The large (up/down) wheel and the small (left/right) wheel are turned to verify proper function. The small wheel is then placed in the neutral position and locked or unlocked per endoscopist’s preference. The examiner is now ready to start the endoscopy.

Scope Insertion

The endoscopist stands facing the patient with the endoscope connected to the scope tower behind and to the right of the endoscopist’s hip (Fig. 2.1). The flexible endoscope tip is lubricated with a water-soluble surgical lube from the tip to the 20 cm mark with care taken not to obscure the front-viewing lens with the lube. The scope is then held distal to the 20 cm mark and inserted through the patient’s bite block into the patient’s mouth. This can be done blindly until the scope passes through the upper esophageal sphincter; however, this maneuver tends to increase patient discomfort, the rate of inadvertent passage into the airway, and the potential risk for injury. A controlled passage of the endoscope under direct visualization through the mouth and oropharynx is preferred and recommended. Careful inspection of the oropharynx and hypopharynx during esophageal intubation will not only decrease patient discomfort and the rate of tracheal intubation but also aid in the identification of upper esophageal pathology. Common landmarks identified include the base of tongue, palate, uvula, epiglottis, arytenoid cartilages, and upper esophageal sphincter.

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Figure 2.1

With the patient in the left lateral decubitus position with a bite block in place, the scope is held with the tip in the neutral position and passed into the patient’s mouth. Note the scope tower behind and to the right of the endoscopist

With the tip of the scope in the neutral position, the scope is passed into the patient’s mouth over the tongue. This will produce an upside-down image on the screen with the tongue on top and the hard palate on the bottom (Fig. 2.2). The horizontal black line representing the horizon separating those two structures is targeted as the scope is advanced 5–7 cm in this fashion. Next, the endoscopist will perform a gentle upward tip deflection (big wheel down) to follow the curve of the base of the tongue to the uvula. The scope is advanced to 12–15 cm from the incisors with this maneuver and fall into the distal-most portion of the pharynx, the hypopharynx where the epiglottis and vocal cords are seen in the center top of the screen, the arytenoid cartilages in the midline, and the right and left piriformis sinuses on the bottom right and left corners (Fig. 2.3a, b). The scope is then gently straightened by releasing the big wheel in the neutral position while applying constant insufflation and gentle forward pressure. The patient under conscious sedation can be asked to swallow at this time. This will cause relaxation of the cricopharyngeus with passage of the scope into the upper esophagus (Fig. 2.4a, b).

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Figure 2.2

Adequate orientation of the scope once in the patient’s mouth reveals an image where the patient’s tongue is seen at the top of the screen and the hard palate at the bottom. The black line or horizon is followed as the scope is advanced to the oropharynx

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Figure 2.3

(a, b) A gentle upward tip deflection (big wheel down) to follow the curve of the base of the tongue to the uvula. The scope is advanced to 12–15 cm from the incisors with this maneuver and falls into the distal-most portion of the pharynx, the hypopharynx where the epiglottis (a) and vocal cords (b) are seen in the center top of the screen, the arytenoid cartilages in the midline, and the right and left piriformis sinuses (b) on the bottom right and left corners

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Figure 2.4

(a, b) The scope is then gently straightened by releasing the big wheel in the neutral position while applying constant insufflation and gentle forward pressure. The patient under conscious sedation can be asked to swallow at this time. This will cause relaxation of the cricopharyngeus (red-out) (a), with passage of the scope into the upper esophagus (b)

Once beyond the upper esophageal sphincter , the lumen is distended with insufflation, and a global survey of the esophagus is performed to rule out any mucosal abnormalities including fungal or reflux esophagitis, mucosal tears, ulcerations, webs, Schatzki’s rings or strictures, and mucosal/submucosal lesions. Other pertinent findings include diverticula , varices, hiatal hernia, and Barrett’s esophagus . Photo documentation of a bird’s-eye view of the esophagus and then of the Z line is obtained. The location of the Z line from the incisors is measured and noted.

Stomach

The scope is then advanced into the stomach. With continued insufflation, a global survey of the stomach body is performed. Masses, mucosal lesions or ulcerations, varices, retained gastric contents, or bile reflux into the stomach would be noted at this time. The scope is methodically advanced through the body of the stomach towards the antrum and pylorus using the lesser curve on the right of the video screen as a landmark. Any identified pathology should be clearly documented with respect to size and location. Anterior/posterior gastric wall , lesser or greater curvature, and proximity to pylorus or gastroesophageal junction are common landmarks used to document location of a lesion. The antrum , a common location for gastritis and ulcerations, should be meticulously examined. Photo documentation of a bird’s-eye view of the stomach, the antrum, and the pylorus and any other positive findings should be obtained at this time.

Duodenum

The scope is passed through the pylorus into the duodenal bulb. A global survey of the bulb will reveal any mucosal or submucosal lesions, ulceration, or diverticula. The duodenal bulb must be carefully evaluated upon initial scope insertion as visualization is usually limited on scope withdrawal. Duodenal ulcers are most commonly found in the duodenal bulb; however, one must also inspect for duodenitis, polyps, as well as diverticula. A specific maneuver will then assist scope passage into the second portion of the duodenum while minimizing scope trauma to the duodenal mucosa and retraction of the scope back into the stomach. The scope is advanced to the end of the duodenal bulb where the turn into the second portion of the duodenum is encountered. Rightward deflection of the tip (small wheel), clockwise rotation of the scope handle with simultaneous upward tip deflection, and advancement of endoscope will reveal the second portion of the duodenum. After the scope is advanced to the second portion of the duodenum, the area of the ampulla of Vater will be identified. The ampulla may not be completely visible using a forward viewing gastroscope, but one should be able to identify periampullary diverticula as well as large ampullary lesions. The third portion of the duodenum is inspected for similar mucosal and submucosal abnormalities. It is usually reached by scope withdrawal causing a paradoxical effect of the scope tip advancing into the third portion of the duodenum. The fourth portion of the duodenum and proximal jejunum are not part of a diagnostic upper endoscopy. Further scope insertion is required to reach this area; thus, a longer endoscope is usually required. With both hands on the handle to maneuver the knobs, the endoscopist takes a few steps back, withdrawing the scope from the duodenum, using the knobs and scope rotation to examine the entire lumen of the second and third portion of the duodenum. Photo documentation of the duodenal bulb, periampullary region, and second and third portion of the duodenum is obtained. Biopsy of any lesions or random biopsy to rule out celiac disease and any other indicated therapeutic intervention can be performed at this time.

Antrum to GE Junction

Usually performed after the duodenal inspection, the scope is retroflexed by upward deflection of the tip of the scope (large wheel up) and by turning the small wheel to the left to examine the lesser curve of the stomach, the incisura, the gastric cardia, and gastroesophageal junction. The scope is pulled back to advance its tip closer to the cardia and GE junction for better visualization of those structures. Pertinent pathology to be noted includes hiatal or paraesophageal hernia, ulcers at incisura and other mucosal or submucosal lesions. Photo documentation of the incisura and gastroesophageal junction is obtained. The scope straightened and biopsies of the antrum, random gastric biopsies, or any other diagnostic or therapeutic procedures can be performed at this time. The endoscopist should avoid overdistention of the stomach as this precludes adequate biopsy specimen from the stretched-out mucosa.

Scope Withdrawal

Once all indicated procedures are performed, the stomach is decompressed, and the scope is withdrawn. The esophagus is again examined on the way out and suctioned only above the level of the upper esophageal sphincter to remove any excess saliva from the oropharynx prior to terminating the procedure. Limited evaluation of the external vocal cords may be performed quickly at this time without inciting the patient’s gag reflex. The bite block is removed and the patient monitored until awake from anesthesia.

The quality of endoscopic exam is inherently related to the quality of the post-procedure documentation. Pertinent positive and negative findings should be noted, and photographs should be referenced when applicable. The endoscopist should provide a detailed description of positive findings. This will help other providers in the healthcare team better care for the patient by taking the appropriate next steps. It will also serve as a reference for future exams to monitor the progression or stability of findings. For example, when a hiatal hernia is encountered, it is important to note the location of the Z line and the diaphragmatic pinch from the incisors. Adequate description of Barrett’s changes, esophagitis, ulcers, varices, etc., are equally important in dictating further management.

The indications for flexible endoscope are broad, and endoscopists continue to find more applications for it. A diagnostic EGD allows us to directly visualize and promptly treat many conditions of the upper gastrointestinal tract. Though complications can arise from an upper endoscopy, a thorough understanding of how to prepare the ancillary staff and the patient and a comprehensive handle on the maneuverability of the endoscope will limit adverse events. It is, however, essential that the endoscopist has direct communication with the surgeon when a complication does occur. It is also paramount that the general surgeon familiarizes themselves with the flexible endoscope as this will open many avenues for ways to care for patients in a minimally invasive fashion.

Pearls/Pitfalls

1.

Know the many indications for EGD and the wealth of information that can be obtained during a short examination.

2.

Patient, staff, and equipment preparation prior to the procedure are essential.

3.

Major complications are rare; however, the endoscopist should follow several guidelines to ensure the expected outcome every time.

4.

A controlled passage under direct visualization is key on scope entry.

5.

Controlled movement of scope, suction, and insufflation allow for a complete and expeditious examination.

6.

Adequate documentation allows for appropriate patient management and follow-up endoscopy.

References

1.

Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. (e1-3). Gastroenterology. 2012;143:1179–87.Crossref

2.

ASGE Standards of Practice Committee, Sharaf RN, Shergill AK, Odze RD, Krinsky ML, Fukami N, et al. Endoscopic mucosal tissue sampling. Gastrointest Endosc. 2013;78(2):216–24.Crossref

3.

American Society for Gastrointestinal Endoscopy Standards of Practice Committee, Evans JA, Muthusamy VR, Acosta RD, Bruining DH, Chandrasekhara V, et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;81(5):1063–72.Crossref

4.

Standards of Practice Committee, Wani S, Qumseya B, Sultan S, Agrawal D, Chandrasekhara V, et al. Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer. Gastrointest Endosc. 2018;87(4):907–931.e9.Crossref

5.

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© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2020

P. Nau et al. (eds.)The SAGES Manual of Flexible Endoscopyhttps://doi.org/10.1007/978-3-030-23590-1_3

3. Masters Program Flexible Endoscopy Pathway: Diagnostic Colonoscopy

Emily Huang¹, ² and Syed G. Husain², ³  

(1)

The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, OH, USA

(2)

The Ohio State University College of Medicine, Department of Surgery, Columbus, OH, USA

(3)

The Ohio State University Wexner Medical Center, Department of Surgery, Division of Colon and Rectal Surgery, Columbus, OH, USA

Syed G. Husain

Email: [e-mail]

Keywords

BleedingAnemiaMelenaColon cancerRectal cancerIschemic Colitis C. difficile Toxic megacolonObstruction

Learning Objectives

1.

Describe the indications for diagnostic colonoscopy

2.

Describe the appropriate setup for diagnostic colonoscopy

3.

Describe principles for appropriate documentation of visual findings in diagnostic colonoscopy

4.

Apply principles of safe endoscopy to specific diagnostic situations, including choice of insufflation, extent of endoscope insertion, and choice of sedation technique

5.

Apply specific techniques for making progress in the course of diagnostic colonoscopy, such as insertion-withdrawal, torqueing, and suctioning

6.

Utilize appropriate diagnostic tools in special circumstances, such as biopsy in inflammatory bowel disease surveillance or in patients suspected to have microscopic colitis

Introduction

Diagnostic colonoscopy is an endoscopic examination performed for evaluating a specific symptom, as opposed to screening colonoscopy, which is performed to search for polyps or cancer in an asymptomatic individual. Out of the estimated 15 million colonoscopies performed in the United States in 2012, approximately 6.3 million were for screening purposes while the remainder were diagnostic exams [1]. Diagnostic colonoscopy may be performed under emergent or non-emergent conditions, and because of this, the patient’s functional status or medical comorbidities can have a significant impact on decision-making and procedural considerations. Diagnostic colonoscopy not only attempts to provide valuable insight into the underlying etiology but also provides a vehicle for treatment of the problem via endoscopic intervention.

This chapter discusses indications for and performance of diagnostic colonoscopy under a number of different circumstances. Screening and surveillance of colorectal neoplasia and endoscopic therapeutic interventions are beyond the scope of this chapter and will not be addressed here.

Indications and Contraindications

By far the most common indication for diagnostic colonoscopy is rectal bleeding. As many as 35% of all colonoscopic exams performed in patients 50 years or younger are for evaluation of hematochezia [2]. In addition to hematochezia , colonoscopy is often indicated for evaluation of occult gastrointestinal bleeding (hemoccult-positive stool), melena, or unexplained iron deficiency anemia . Other indications include evaluation for a change in bowel habits, abdominal pain, and large bowel obstruction or diagnosis of ischemic colitis. Patients with inflammatory bowel disease often require repeated endoscopic evaluation for disease staging, treatment planning, or assessment of response to a particular therapy. Likewise, many postoperative patients require an endoscopic evaluation of the anastomosis prior to proceeding reversal of a protective stoma.

Contraindications to diagnostic colonoscopy include symptoms suggestive of perforation (e.g., peritonitis) or situations that expose patients to an unacceptable risk of iatrogenic perforation such as acute diverticulitis, fulminant colitis, or toxic megacolon and complete or near complete obstruction. The patient’s overall medical condition and hemodynamic stability should also be taken into account; the patient must be able to tolerate transient increments in intra-abdominal pressure, positioning and/or abdominal manipulation, and enteric insufflation.

Materials and Setup

The operational details of the endoscopy tower and scope controls, patient preparation, sedation, and monitoring for diagnostic colonoscopy are generally similar to those during screening colonoscopy. That being said, diagnostic colonoscopy differs from screening procedures in several key aspects, often mandating significant modifications to pre-procedure preparations. A thorough understanding of the patient’s history and medical condition will inform appropriate decision-making, allowing the operator to modify the setup appropriately for a specific diagnostic indication. By considering all of the potential contingencies and preparing for them, one can optimize the chances of a good outcome.

While the endoscopy suite offers the greatest ergonomic ease for the endoscopist coupled with prompt access to a variety of endoscopic tools, a bedside exam using a portable tower may be ideal for a critically ill or unstable patient. However, the very virtue that makes a tower portable also limits the armamentarium at the endoscopist’s disposal. Therefore, a detailed knowledge of the limitations of the portable endoscopy tower is essential for a seamless bedside exam. The endoscopist should be able to anticipate and request the required equipment to minimize interruptions during the course of an exam. Examples of indication-based endoscopic setup are discussed in the ensuing section titled, "Specific