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View all the figures for this chapter.

Endoscopy Practice and Safety

Editor: Peter B. Cotton ed.


8. Risks, prevention, and management

Peter B. Cotton

Top of page Synopsis  Next section

This review emphasizes key issues for reducing the burden of risk inherently involved in all interventional procedures, and the need to ensure that patients are informed sufficiently to be able to participate in decisions about their care. Whilst each patient and each procedure may be unique, the principles of risk minimization and management are universal. Procedures must be done for appropriate indications, by well-trained endoscopists, assisted by expert staff, using the correct equipment. Known risk factors should be reviewed beforehand, and steps taken to accommodate them whenever necessary and possible. Patient consent exists only when there has been a meaningful educational process, adjusted appropriately to the individual patient and clinical situation. Unplanned events should be defined carefully and their occurrence monitored, so that standard methods for continuous quality improvement can be applied.

Top of page Introduction  Previous section Next section

Endoscopy ('looking inside') is invasive by definition, and therefore potentially hazardous. Therapeutic interventions add to the risk. The goal of everybody involved in an endoscopy procedure, not least the patient, is to maximize the benefits and to minimize the risks.

This contribution focuses on the potential risks of endoscopy in general. Specific risks of individual procedures (such as ERCP, and various therapeutic maneuvers) are covered in the relevant sections. However, the principles are the same. Endoscopists must understand the risks, the factors which affect them, the ways to reduce them, and how best to educate our patients about them. There have been many reviews of this topic [1–23].

Top of page The contract with the patient; informed consent  Previous section Next section

Endoscopy is normally conducted as part of a comprehensive evaluation by a gastroenterologist or by another digestive specialist. It is used mostly electively in the practice environment, or hospital outpatient clinic, but may sometimes be needed elsewhere (e.g. emergency room, intensive care unit). Sometimes, endoscopists offer an 'open access service' where the initial clinical assessment and continuing care is performed by another physician.

Responsibility  Previous section Next section

In all of these situations it is the responsibility of endoscopists to assure themselves that the potential benefits of the proposed procedure exceed the potential risks, and to convey that information clearly to their patients. Truly informed consent means that the patient really does understand the potential risks and benefits, as well as the possible limitations and any available alternative approaches [24]. That is our contract with the patient. Signing an 'informed consent form' is a medico-legal requirement in many institutions, but this is nothing more than confirmation of the education process.

Educational materials  Previous section Next section

Nothing can replace a detailed discussion between the endoscopist and the patient (and any accompanying persons), but this process can be enhanced with written, video-, or web-based educational materials. Suitable brochures are available from national organizations, and on many websites (e.g. http://www.ddc.musc.edu). They can be adapted for local conditions. Whatever the details of the education process, patients must be given the opportunity to ask questions of their endoscopist (and support staff) immediately before the procedure. The process of informed consent must be clearly documented, and preferably witnessed.

Humanity  Previous section Next section

It is appropriate here to emphasize also the importance of simple courtesies and common humanity in dealing with our customers. What is familiar and routine to the endoscopist and staff may be viewed by patients as a major ordeal—especially by those unfortunate enough to experience a significant adverse event.

Top of page What are 'risks' and 'complications'?  Previous section Next section

Definitions  Previous section Next section

Risks cannot be described, discussed, or monitored unless there is agreement about their definition. This has proved to be a challenge [25,26]. The word 'complication' has unfortunate medico-legal connotations. It suggests that something has 'gone wrong'. It seems preferable to use a more neutral term, like 'unplanned event', which simply indicates that the procedure has not gone completely 'according to plan', a subtle but important difference in emphasis. Some use the term 'adverse events' instead of complications. However, not all unplanned events are actually adverse; occasionally, things may go better than expected. The logic of using 'unplanned event' is that it ties directly in with the informed consent process. The truly informed patient knows what the plan is, and has specific expectations about what will happen before, during, and after the procedure, as well as the likely outcomes, both positive and negative.

Threshold for 'a complication'  Previous section Next section

Some unplanned events are relatively trivial, e.g. the need for sedation reversal during or after a procedure, or self-limited bleeding at the site of an endoscopic incision. These events should be adequately documented, so that quality improvement processes can be applied, but they are not significant enough clinically to be called complications. Mostly, patients are unaware of such events. However, there is a level of severity at which an 'unplanned event' does become clinically important, and where 'complication' is a legitimate descriptor. The question is where to place the threshold, i.e at what level of severity does an unplanned event become a complication? We attempted to define that threshold in 1991 at a consensus conference discussing outcomes of ERCP [27]. We stated that 'a complication is an unplanned event, related to the procedure, that requires the patient to be admitted to hospital, or to stay in hospital longer than expected, or to undergo other unplanned interventions'. By this definition, we do not count in our statistics of 'complications' any deviation that occurs during a procedure but which is not obvious to the patient afterwards (e.g. transient bleeding), or one which can be treated on an outpatient basis (e.g. localized thrombophlebitis at an infusion site). This definition is not an attempt to hide such events, merely an effort to provide a common language. This is essential if we are to collect data, for, without data, we cannot study our outcomes or improve them.

Severity  Previous section Next section

A complication is an unplanned event that reaches a certain level of severity. But not all complications are of equal importance. They vary from relatively minor episodes (e.g. one day of pancreatitis after ERCP) to those which are life threatening (e.g. perforation). It seems reasonable to stratify the severity of complications by the extent of the disturbance which they cause to the patient. The consensus conference settled on the following stratification of severity:

  • Mild; unplanned events requiring hospitalization of 1–3 days.
  • Moderate; needing 4–9 days in hospital.
  • Severe; more than 10 days in hospital, or needing surgery, or intensive care.
  • Fatal; death attributable to the procedure.

Attribution  Previous section Next section

Use of the terms 'attributable' and 'related to the procedure' (in the earlier general definition) introduces a regrettable element of subjectivity, with the potential for reporting bias. That could be avoided by counting everything adverse that occurs within a certain period (say 30 days, as used to be the case after surgery). However, this would not be appropriate. No one would causally connect a simple diagnostic endoscopy with a myocardial infarction which occurred 29 days afterwards, in an elderly patient with known heart disease, especially if they had undergone multiple other medical interventions in the meantime. However, attribution would seem reasonable if the same event had occurred only two days after the endoscopy, especially if aspirin had been discontinued, or if the patient had experienced transient hypotension or hypoxia. Other issues with unplanned events and complications are whether they cause the procedure to be interrupted or aborted, and whether they leave any permanent sequelae.

Timing of unplanned events  Previous section Next section

Most unplanned events occur during or immediately after the procedures. However, they can happen even before the endoscope is introduced (e.g. a reaction to prophylactic antibiotics or other preparation), during the procedure (e.g. transient bradycardia or hypoxia), immediately afterwards (e.g. pain due to perforation), a few hours later (e.g. pancreatitis after ERCP), or can be delayed for several days or weeks (e.g. aspiration pneumonia or delayed bleeding). Some events (e.g. viral transmission) may be so far delayed that the connection is difficult to make, or is missed completely. Keeping track of unplanned events which occur after patients leave the procedure unit is a challenge. Making routine follow-up phone calls is time-consuming, and not completely reliable. Perhaps automatic, computer-generated phone calls or e-mail will be useful in the future.

Direct and indirect events  Previous section Next section

When considering complications, most endoscopists think first about the obviously related direct events (such as bleeding and perforation) that occur in organs which are being traversed or treated. However, there are also many indirect events, which occur outside the digestive tract. Cardiopulmonary complications (often related to sedation) are probably the commonest of the unplanned events. Renal, neurological, and musculo-skeletal complications have all occurred. Indirect events are more likely to occur after the patient leaves the procedure unit, and are thus more often overlooked and under-reported.

Data set for unplanned events  Previous section Next section

A proposed data set for documentation of unplanned events, their consequences, and their severity is shown in Fig. 1[28].

Top of page General issues of causation and management  Previous section Next section

The issues impacting each specific type of event are discussed in detail below. However, there are some general risk factors, and important points to be made about the recognition and management of unplanned events.

Unplanned events may occur because of:

  • Poor technical or cognitive performance by the endoscopist or staff.
  • Patients' 'fitness' or, really, 'unfitness'. This is a combination of, and interaction between the complexity/severity of the presenting complaint and the patients' comorbidities (including allergies).
  • Non-compliance by patients and their helpers.

Technical and cognitive performance  Previous section Next section

The skill of the endoscopist (both clinical and technical) is probably the most important single factor determining the likelihood of unplanned events. As for certain surgeries, there is now good evidence that better-trained and more experienced endoscopists have higher success rates and fewer complications [29]. This raises the important and controversial issues of training, assessment of competence, report cards, recredentialling, and regionalization of specialist services [30]. However, endoscopists do not work on their own. Their specialist nursing and technical associates have much responsibility for many aspects of patient safety. The most important areas for them are the preparation of the patient, and the equipment, sedation, and monitoring of patients during and after the procedures.

Fitness for procedures  Previous section Next section

Defining a patient's 'fitness' for a procedure is a complex issue. Their 'unfitness', or degree of 'illness' is a combination of the presenting disease and any existing comorbidities (and their possible interactions, which are sometimes complex). As yet, there is no agreed and relatively simple score that can be used to compare the acuity of different patients and populations of patients undergoing endoscopic and related procedures.

ASA score  Previous section Next section

The American Society of Anaesthesiology grading system is well validated for operative procedures requiring anaesthesia [31]. It has some correlation with the cardiopulmonary responses to sedation during endoscopy, but other specific issues are more important.

Other risk indices  Previous section Next section

Many other risk indices are in use in other areas, e.g. APACHE, POSSUM, Charlson, but none measure the likely risk of endoscopic procedures [32–34]. Developing an overall (and procedure specific) risk score can be done only by collecting the data on large numbers of patients and procedures, and analysing the outcomes. This has been done in certain contexts, e.g. ERCP and sphincterotomy [28,35].

Prompt recognition and management  Previous section Next section

The keys to effective management of complications are early recognition and prompt focused action. Delay is dangerous both medically and legally [36]. Patients in pain and distress after procedures should always be examined carefully, and never simply 'reassured' without careful evaluation.

Communication  Previous section Next section

Poor communication is the basis for much unhappiness, and many lawsuits. Remember that the truly informed patient (and relatives) have been told already that complications can happen. This is an integral, important part of the consent process. So it is appropriate and correct to address suspected complications in that spirit. 'It looks as if we have a perforation here. We discussed that as a remote possibility beforehand, and I am sorry that it has occurred. Here is what I think we should do.'

Distress  Previous section Next section

Your distress is understandable and worthy, and it is important to be sympathetic, but equally important to be professional and matter of fact. Excessive apologies may give the impression that some avoidable mishap has occurred. Never, never, attempt to cover up the facts.

Document  Previous section Next section

Document what has happened and communicate widely, with the patient, interested relatives, referring physicians, supervisors, and your Risk Management advisors.

Act promptly  Previous section Next section

Get appropriate laboratory studies and radiographs, and consult other experts in the relevant fields, including a surgeon for anything that might remotely require surgical intervention. Sometimes it may be wise to offer to transfer the patient's care to a specialty colleague, or to a larger medical centre, but if this happens, try to keep in touch, and to show continuing interest and concern. Apparent abandonment alienates patients and their relatives, and may lead to initiation of legal action.

Specific unplanned events  Previous section Next section

Whilst cardiopulmonary events related to sedation are probably the commonest unplanned events, medico-legal claims arise more often from perforation and from failure to diagnose [37]. It is therefore smart to emphasize both of these risks in the informed consent process.

Failure to diagnose  Previous section Next section

Missing, or apparently missing, cancer and precursors is a particular risk in colonoscopy, but can occur in other organs [38]. Endoscopists have been faulted for failing to follow suspicious lesions (e.g. gastric ulcers), even when poor compliance of the patient has been the main issue.

Perforation  Previous section Next section

Perforation is the most feared complication of endoscopic procedures, because the consequences may be severe, and because its occurrence suggests (but does not prove) imperfect practice [39–43]. It can occur anywhere that endoscopes travel. It may be caused by the endoscope tip, or by pressure from the shaft in a tight loop, or by therapeutic dilatation or incision.

Risk factors  Previous section Next section

The risk of esophageal perforation is greater in the elderly, particularly in the presence of a Zenker's diverticulum. It is also markedly increased during esophageal dilatation, especially in patients with malignancy or achalasia [44]. Perforation of the stomach or duodenum is very unusual in patients without major focal pathology. Retroperitoneal perforation occurs after endoscopic sphincterotomy, particularly when the needle-knife or precut technique is used by inexperienced operators. Perforation of the afferent loop is a possibility during manipulations after Billroth II gastrectomy. Colonic perforation is the most severe complication of colonoscopy. The risk may be increased by focal disease, such as diverticula or tumours.

Recognition  Previous section Next section

Early recognition of perforation is essential. The endoscopic view may leave no room for doubt. Pain and distress are the hallmark symptoms. Patients with esophageal perforation may develop subcutaneous emphysema. Perforation at colonoscopy is often associated with dramatic abdominal distension. Tachycardia is common. Steps should be taken immediately to clarify the situation. Plain radiographs usually are diagnostic, but CT scanning is more sensitive and should be carried out quickly if perforation is suspected and standard radiographs are negative or equivocal. The retroperitoneal nature of perforation after endoscopic sphincterotomy may delay recognition and has few specific signs. The patient may appear to have pancreatitis. Severe pain without impressive elevation of serum amylase or lipase is suggestive of perforation, and early CT scan is advised.

Treatment  Previous section Next section

Treatment of perforation is sometimes controversial. Careful assessment, review of the available literature, and surgical advice are essential. Whilst prompt surgical intervention might seem to be the obvious solution (especially to surgeons), it is not always necessary. Intra-abdominal perforations are almost always treated surgically, although a few selected cases have been managed conservatively, and by endoscopic clipping or sewing. Many esophageal and most sphincterotomy perforations have been treated conservatively (nil by mouth, intravenous fluids, antibiotics, and sometimes with targeted drainage tubes). Collaborative management with specialist (surgical) colleagues is strongly recommended whatever strategy is proposed, with frequent review—and much communication with the patient and anxious relatives.

Bleeding  Previous section Next section

Bleeding may occur due to endoscopic manipulations (e.g. biopsy, polypectomy, or sphincterotomy), or can arise during procedures from existing lesions (e.g. an ulcer with a visible vessel), or occasionally due to retching (Mallory Weiss tear). The risk of bleeding is a balance between the technique of the endoscopist, the specific clinical lesion carried by the patient, and by the coagulation status.

Risk factors  Previous section Next section

Patients with poor coagulation and/or portal hypertension are clearly at increased risk. Coagulopathy should be normalized or improved wherever possible, preferably to achieve coagulation parameters like those usually accepted for percutaneous liver biopsy. Anticoagulation should be stopped ahead of time, and (if clinically necessary) replaced temporarily by intravenous heparin for the procedure, and during the phase of early recovery. The use of antiplatelet drugs also increases the risk of bleeding, although the extent is difficult to determine [45]. There is little evidence to support the widely held belief that aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) increase the risk, but many endoscopy units recommend that these agents be discontinued for five days or more before endoscopy (and for a week or so afterwards). It used to be common practice to measure coagulation parameters in all patients scheduled for therapeutic endoscopy. However, this practice is not supported by data, nor by the recent guidelines from the ASGE. A careful personal and family history of bleeding problems is more discriminating [46].

Endoscopic incisions (e.g. for polypectomy or sphincterotomy) should be performed in a controlled manner, to provide sufficient coagulation of local vessels. The addition of epinephrine to a 'saline cushion' may be helpful when resecting sessile polyps. Polyps with large stalks often have large vessels. The risk of bleeding may be reduced by injecting epinephrine or sclerosant into the stalk, or by deploying a detachable loop. The risk of inducing immediate or delayed bleeding from lesions which have themselves recently bled (e.g. ulcers or varices) depends on the size of the vessel and the pressure within it, and on the precise endoscopic technique. Endoscopic ultrasound and Doppler techniques have been used to detect significant submucosal vessels.

Recognition  Previous section Next section

Recognition of bleeding is usually obvious, during or after endoscopy. Occasional patients may present later only with anaemia. Delayed bleeding should not be attributed to the treated area without endoscopic confirmation.

Treatment  Previous section Next section

Most endoscopically induced bleeding can be treated by standard medical means, with repeat endoscopic assessment and treatment when bleeding is persistent or severe. Expert angiographic investigation and treatment has been used successfully. Surgery is needed very rarely.

Cardiopulmonary and sedation complications  Previous section Next section

Cardiopulmonary problems and adverse reactions to sedation are the commonest cause of significant unplanned events attributable to endoscopy [47–66]. The stress of the procedures (and the presence of the tube itself) may provoke dysrhythmias or induce hypotension or hypoxia, especially in patients with established cardiac or pulmonary disease, and in the morbidly obese. Aggressive sedation (with inadequate monitoring) can be disastrous. The cardiopulmonary status of potential patients should be assessed carefully (and improved if possible), and the approach to sedation/anaesthesia should be cautious and intelligent. A history of toleration of past procedures may be helpful. Some patients can accept simple endoscopy procedures without any sedation or analgesia. Others with significant comorbidities, and predictable airway difficulties, are best managed by anaesthesiologists. Endoscopists and staff should be fully trained in sedation, monitoring, and resuscitation, with ready access to all necessary equipment. Cardiological consultation may be appropriate in patients with unusual rhythms (or medications), pacemakers and implantable defibrillators.

Infection  Previous section Next section

Endocarditis  Previous section Next section

Endoscopy can provoke bacteremia, especially during therapeutic procedures such as dilatation. This may be dangerous in a very small number of patients who are immunocompromised, or who have important cardiovascular lesions. Endoscopy-induced endocarditis is extremely rare (and therefore difficult to study). Hard facts are scarce, and there is certainly room for disagreements in practice [67]. Guidelines concerning the use of antibiotic prophylaxis have been developed by many cardiological and endoscopic authorities [68–71]. Most recommend giving antibiotics to certain 'high risk' patients undergoing the higher risk procedures, but leave much leeway for individual judgement.

Infections  Previous section Next section

Infections can be transmitted in the endoscopy unit [72]. Outbreaks of salmonella, shigella, pseudomonas, hepatitis and other infections have been reported [73]. Such patient-to-patient transmission should be prevented by assiduous attention to cleaning and disinfection regimes, and appropriate management of accessories, tissues, and fluids. Patient-to-staff transmission (e.g. of H. pylori) has probably occurred, when staff protection precautions are inadequate. Transmission of tuberculosis, and of prion diseases, is a cause for concern [73,75]. Staff-to-patient transmission is theoretically possible. Prevention of infection in the endoscopy unit clearly requires a comprehensive approach, involving appropriate 'universal precautions', assiduous cleaning and disinfection practice, and continuous monitoring. Selective immunization of staff is relevant.

Instrumentation  Previous section Next section

Instrumentation can stir up dormant colonization, e.g. when contrast is injected under pressure into a contaminated biliary tree. The same is theoretically true when endoscopy manipulates other infected areas, such as a small peridiverticular abscess.

Allergic reactions  Previous section Next section

Certain patients may react adversely to medications used during endoscopy procedures. Local anaesthetic agents, antibiotics, and iodine-containing contrast materials are most commonly cited. What to do about suspected iodine allergy before ERCP is controversial [76]. Some patients are allergic to latex rubber. Staff can become sensitized to gluteraldehyde. Obviously, a careful history of drug use and allergies is mandatory.

IV site issues  Previous section Next section

Blemishes and local phlebitis are common. Spreading infection is very rare.

Miscellaneous and rare events  Previous section Next section

There are many other theoretical and rare unplanned events. Patients may sustain injuries during sedation, by falling, or by pressure on nerves. Teeth have been damaged or lost, and more than one shoulder has been dislocated. Electrical injury can occur during diathermy, and there have been colonic explosions. Very rarely, endoscopes have become impacted, e.g. by retroversion up the esophagus, or have caused serious damage to adjacent structures, e.g. avulsion of the spleen.

Top of page Preventing unplanned events  Previous section Next section

The responsibility for safety (and any unplanned events) falls ultimately on the endoscopist, and there are very important issues of training, competence, and credentialling [76]. However, it is equally clear that the professionalism of nurses and other staff is crucial. Electronic monitoring of some aspects is helpful, but the personal involvement of educated staff is even more so. Emergency equipment must be readily available. Endoscopists should be trained in advanced cardiac life support techniques.

Endoscopy can never be completely safe. Keeping unplanned events to a minimum should be of the highest priority for the endoscopy team, and for the patient. Understanding the risks and risk factors is fundamental. Careful prospective monitoring of defined events allows continuous quality improvement.

Top of page Outstanding issues and future trends  Previous section Next section

Reducing the burden of unplanned events in the future will involve progress in many different areas, including:

  • Reducing the use of endoscopy for purely diagnostic purposes, using better patient selection (e.g. by fecal DNA testing), and alternative non-invasive methods (e.g. virtual colonoscopy).
  • Refining methods for therapeutic endoscopy.
  • Improving the training of endoscopists and support staff, with objective testing of competence for credentialling, and recredentialling.
  • Continuous quality improvement, through structured documentation of outcomes, and appropriate feedback.
  • Making endoscopes easier to clean and disinfect, even sterilize.
  • Fostering patient empowerment, through meaningful education and the widespread use of report cards.

Top of page References  Previous section

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45 Miller, AM, McGill, D & Bassett, ML. Anticoagulant therapy, anti-platelet agents and gastrointestinal endoscopy. J Gastroenterol Hepatol 1999; 14: 109–13. PubMed

46 Eisen, GM, Baron, TH, Dominitz, JA, Faigel, DO, Goldstein, JL & Johanson, JF et al. Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc 2002; 55 (7): 775–9. PubMed

47 Lipper, B, Simon, D & Cerrone, F. Pulmonary aspiration during emergency endoscopy in patients with upper gastrointestinal haemorrhage. Crit Care Med 1991; 19: 330–3. PubMed

48 Benjamin, SB. Complications of conscious sedation. Gastrointest Endosc Clin N Am 1996; 6 (2): 277–86. PubMed

49 Daneshmend, TK, Bell, GD & Logan, RFA. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991; 32: 12–15. PubMed

50 Eckardt, VF, Kanzler, G, Schmitt, T, Eckardt, AJ & Bernhard, G. Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc 1999; 49 (5): 560–5. PubMed

51 Freeman, ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 1994; 4 (3): 475–99. PubMed

52 Froehlich, F, Gonvers, JJ & Fried, M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland. Endoscopy 1994; 26 (2): 231–4. PubMed

53 Holm, C & Rosenberg, J. Pulse oximetry and supplemental oxygen during gastrointestinal endoscopy: a critical review. Endoscopy 1996; 28 (8): 703–11. PubMed

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55 Lazzaroni, M & Porro, GB. Preparation, Premedication, Surveillance Endoscopy 2001; 33 (2): 103–8.

56 McCloy, R. (1997) Safety, sedation and emergencies in endoscopy. In: Practical Endoscopy (eds. M Shephard and J Mason). p. 139. Chapman & Hall, London.

57 American Society for Gastrointestinal Endoscopy. Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. Gastrointest Endosc 1995; 42 (6): 626–9. PubMed

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  A (very) brief history of endoscopy
  Professionalism and quality
Synopsis
Introduction
Unit design
  Space planning
   Daily room volumes
   Procedure room size
   Preparation and recovery ratios
   Separate entrances
   Common space problems
  Physical infrastructure
  Intake and recovery areas
   Intake areas
   Managing clothes and valuables
   Recovery facilities
  Procedure room reprocessing and storage
   Standard procedure rooms
   Scope reprocessing and storage
   Patient flow issues
   Complex procedure rooms
   Storage of supplies and medications
   Travel carts for emergencies
Unit management
  Major areas of responsibility
  Staffing design
   Staffing emergencies
  Procedure schedules
   Relative time requirements
   Barriers to efficiency
  Purchasing
   Endoscopes
   How many endoscopes?
   Endoscope repair costs
   Databases
   Devices
  Endoscope reprocessing
  Coding and billing
  Accreditation
Outstanding issues and future trends
  Capsule endoscopy
  Colon screening technologies
  Endoscopy by non-specialists
  Growth of advanced endoscopy
Summary
References
Synopsis
Introduction
  Moderate sedation
  Deep sedation/analgesia
Advances in monitoring during sedation
  Standard pulse oximetry
  CO2 monitoring
   Transcutaneous CO2 monitoring
   Capnography
  BIS monitoring
Topical anesthetics: are they worth the effort?
Titration vs. bolus administration of sedation and analgesia
Propofol
  Problems with propofol
  Specific training for use of propofol
  Contraindications of propofol
  Clinical trials of propofol
   Propofol or midazolam?
   Upper endoscopy
   ERCP
   Upper endoscopy and colonoscopy
   Propofol with or without midazolam
   Patient-controlled administration of propofol
   Nurse-administered propofol
   Gastroenterologist-administered propofol
Droperidol
  Complications
Outstanding issues and future trends
References
Synopsis
Gastrointestinal endoscopes
  Endoscope design
   Control section
   Insertion tube
   Connector section
  Imaging
   Light source/processors
  Endoscope equipment compatibility
  Endoscope categories
   Esophagogastroduodenoscope (gastroscope)
   Enteroscope
   Duodenoscope
   Choledochoscope
   Echoendoscopes
   Colonoscope
   Sigmoidoscope
   Wireless capsule endoscopy
Gastrointestinal endoscopic accessories
  Tissue sampling
   Biopsy forceps
   Single-bite cold-biopsy forceps
   Biopsy cup jaws
   Multi-bite forceps
   Other specialty forceps
   Monopolar hot biopsy forceps
   Reusable vs. disposable biopsy
   Cytology brushes
   Needle aspiration
  Polypectomy snares
  Retrieval devices
  Injection devices
   Injection needles
   Spray catheters
   ERCP catheters
  Hemostatic and ablation devices
   Contact and non-contact thermal devices
   Heater probe
   Laser fibers
   Argon plasma beam coagulator
   Mechanical hemostatic devices
   Band ligation
   Metallic clip application via flexible endoscopes
   Marking with clips
   Detachable loops
  Transparent cap
  Dilation devices
   Push-type fixed-diameter dilators
   Hurst and Maloney dilators
   Savary-type dilators
   American Dilation System dilators
   TTS fixed diameter dilators
   Threaded-tip stent retrievers
   Radial expanding balloon dilators
   TTS dilators
  Achalasia balloon dilators
Conclusion
Outstanding issues and future trends
References
Synopsis
  Fiberoptic imaging
   Teaching attachments and photography
  Videoscopes
   Image capture
   Standardized image terminology
   Structured reporting
   The opportunities and challenges of the digital revolution
Digital imaging
  Imaging the gastrointestinal tract using a videoendoscope requires several steps
  Color models
   RGB
   CMYK
   HSB
Digitization of color
Color depth
Pixel density
File size
  What detail is needed?
  File compression
  Compression techniques
   Lossless compression
   Lossy compression
  Image file formats
  Color and black and white compression
  JPEG 2000 and beyond
DICOM standard
  Information Objects
   Patient name attributes
  DICOM conformance
  DICOM in endoscopy
  Expanding the scope of DICOM
How much compression is clinically acceptable?
  Studies of compression acceptability
   Vakil and Bourgeois
   Kim (personal communication)
  Developments in compression
Still pictures or live video?
  Video storage developments
What images should be recorded in practice?
  Lesion documentation
  Recording negative examinations
  Structured image documentation
  Costs of image documentation
Image enhancement
  Color manipulation
  Narrow band imaging and spectroscopy
Terminology standardization
  OMED standardized terminology
  Minimal standard terminology—MST
   Problems with MST
Outstanding issues and future trends
Acknowledgments
References
Editor's note
Introduction
Relevant thermal effects in biological tissues
  Thermal devitalization
  Thermal coagulation
  Thermal desiccation
  Thermal carbonization
  Thermal vaporization
Generation of temperature in thermal tissue
  Heater probe
  High-frequency surgery
   General principles of high-frequency electric devices
   Electric arcs
Principles of high-frequency surgical coagulation
  Monopolar coagulation instruments
  Electro-hydro-thermo probes
  Bipolar coagulation instruments
Principles of high-frequency surgical cutting with particular regard to polypectomy
Technical aspects of polypectomy
  Polypectomy snares
  The polypectomy snare handle
  Polypectomy snare catheters
Safety aspects of high-frequency surgery
Argon plasma coagulation
  The principle of argon plasma coagulation
  Equipment for argon plasma coagulation
  Safety aspects of argon plasma coagulation
Laser
  Principle of Nd:YAG laser
  Specific characteristics of Nd:YAG lasers in flexible endoscopy
Safety aspects of Nd:YAG laser in flexible endoscopy
Summary
References
Synopsis
Sterilization and disinfection
  Sterilization
  High-level disinfection
  What level of disinfection is required?
   Critical items
   Semi-critical items
  The practical problem
  Biocides
  The organisms
  The critical points in reprocessing
Risks of infections associated with endoscopic procedures
  Mechanisms of infection
  Clinical infections
   Infecting organisms
   Bacteria
   Vegetative bacteria
   Clostridium difficile
   Mycobacterium tuberculosis
   Atypical mycobacteria
   Serratia marcescens
   Helicobacter pylori
   Pseudomonas
   Viruses
   Human immunodeficiency virus (HIV)
   Hepatitis B
   Hepatitis C (HCV)
   Prions
   CJD
   What to do in practice about CJD?
   New variant CJD (vCJD)
   Other infections
  The endoscopic procedures
   Upper gastrointestinal endoscopy
   Lower gastrointestinal endoscopy
   Endoscopic retrograde cholangiopancreatography
   Percutaneous endoscopic gastrostomy
   Endoscopic ultrasound
   Mucosectomy
  Host factors
   Immune competence
   The degree of tissue damage
   Intrinsic sources of infection
   Damaged valves and implants
Antibiotic prophylaxis for endoscopic procedures
  Principles of prevention of bacterial endocarditis
  High risk cardiovascular conditions [43]
  Moderate risk cardiovascular conditions [43]
  Recommendations for antibiotic prophylaxis
   Who should receive antibiotics?
   Clinical problems where opinions diverge
   What antibiotic regimen?
Antibiotic prophylaxis for ERCP
  Prophylactic antibiotic regimens for ERCP
Principles of effective decontamination protocols
  Cleaning is essential
  Effectiveness of recommended protocols
  Endoscope structure
   Common features
   External features
   Common internal features
   Special internal features
   Cleaning equipment
   Cleaning fluids
   Rinsing
   Disinfectants
   Soaking time
   General maintenance
   Lubrication
  Recommendations
   Work areas
Reprocessing regimens
  Disinfect before and after procedures
  Manual cleaning
  Manual disinfection
  At the end of the list
  Endoscopic accessory equipment
   Cleaning accessories
   Disinfection
   Special accessory items
   Sclerotherapy needles
   Water bottles and connectors
   Dilators
Problem areas in endoscope reprocessing
  Rinsing water
   Poor quality water
   Infections from rinsing water
   Bacteria free water
   Water testing
   Recommendations for rinsing water
Variation in cleaning and disinfection regimens depending upon the supposed infective status of the patient
Compliance with cleaning and disinfection protocols
The investigation of possible endoscopy infection transmission incidents
  Common causes
  Golden rules for investigating potential infection incidents
  The investigation process
  Transmission of viral disease
Automatic flexible endoscope reprocessors (AFERs)
  Machine design and principles
   Contamination
   Water supply
   Alarm function
   Self-sterilization
   Fume containment
   Disinfectant supply
   Reprocessing time
   AFERs cannot guarantee to sterilize endoscopes
   Cost
   Plumbing pathway
   Rinse and dry cycle
   Regular bacteriological surveillance
Quality control in endoscope reprocessing
  Quality control measures
Microbiological surveillance in endoscopy
  Duodenoscopes
  Bronchoscopes
  Recommendations
  Testing procedures
  Interpretation of cultures
  Microbiological surveillance of AFERs
Outstanding issues and future trends
References
Synopsis
Introduction
The contract with the patient; informed consent
  Responsibility
  Educational materials
  Humanity
What are 'risks' and 'complications'?
  Definitions
  Threshold for 'a complication'
  Severity
  Attribution
  Timing of unplanned events
  Direct and indirect events
  Data set for unplanned events
General issues of causation and management
  Technical and cognitive performance
  Fitness for procedures
   ASA score
   Other risk indices
  Prompt recognition and management
   Communication
   Distress
   Document
   Act promptly
  Specific unplanned events
   Failure to diagnose
   Perforation
   Risk factors
   Recognition
   Treatment
   Bleeding
   Risk factors
   Recognition
   Treatment
   Cardiopulmonary and sedation complications
   Infection
   Endocarditis
   Infections
   Instrumentation
   Allergic reactions
   IV site issues
   Miscellaneous and rare events
Preventing unplanned events
Outstanding issues and future trends
References
Synopsis
Introduction
Gastroenterologist–pathologist communication
  Endoscopist communication responsibility
  Pathologist communication responsibility
  Question-orientated approach
  Common terminology
Endoscopic biopsy specimens
  Specimen handling and interpretation issues
   Orientation
   Fixation
   Number of biopsies per container
   Tissue processing
   Prep-induced artifact
   Endoscopy-induced artifacts
   Biopsy-induced artifacts
   Crush artifact
   Burn/cautery artifact
   Polypectomy
   Endoscopic mucosal resection
   Core biopsy
  Regular stains
Exfoliative and fine-needle cytology
  Specimen handling; staining and fixation
   Artifacts
   Cytological diagnosis
  Fine-needle aspiration
Organ system overview
  Esophagus
   Where and when to biopsy
   Gastroesophageal reflux disease
   Barrett's esophagus
   Infective esophagitis
   Candida
   Herpes simplex virus
   Cytomegalovirus
   Adenocarcinoma and squamous cell carcinoma
  Stomach
   Where and when to biopsy
   Inflammatory conditions; gastritis
   NSAIDS
   H.pylori gastritis
   Hypertrophic folds
   Polyps
   Mass lesions
  Small bowel
   Celiac sprue
   Infective enteropathies
   Whipple's disease
   Mycobacterium avium–intracellulare
   Giardia lamblia
   Polyps
   Mass lesions
  Colon
   Defining 'normal'
   Inflammatory colitides
   Normal colonoscopy
   Abnormal colonoscopy
   Inflammatory bowel disease
   Pseudomembranous colitis
   Ischemic colitis
   Polyps
   Adenomatous
   Hyperplastic
   Mass lesions
 
Special stains
  Histochemical stains
  Immunohistochemical stains
  In situ hybridization
  Flow cytometry
  Electron microscopy
  Cytogenetics
  Molecular pathology
Outstanding issues and future trends
References
Synopsis
Introduction
The endoscopy facility and personnel
  Endoscopy facility
  Equipment
   Endoscopes
   Endoscopy instruments
   Ancillary equipment
  Personnel
   The endoscopist
   Nursing and ancillary personnel
The pediatric patient and procedural preparation
  Patient preparation
   Psychological preparation
   Medical preparation
   Recommendations for fasting
   Bowel preparation
   Antibiotic prophylaxis
  Informed consent
Endoscopic procedures currently performed in pediatric patients
  Indications and limitations
  Patient sedation
  Endoscopic technique
   Esophagogastroduodenoscopy
   Colonoscopy
   Sigmoidoscopy
   Therapeutic endoscopy
   Other endoscopic modalities
   Small bowel enteroscopy
   Wireless capsule endoscopy
   Endoscopic ultrasonography
   Endoscopic retrograde cholangiopancreatography (ERCP)
Selected gastrointestinal pathologies in pediatric patients
  Eosinophilic esophagitis
  Food allergic enteropathy and colitis
  Foreign body ingestion
  Helicobacter pylori gastritis
  Polyps in the pediatric patient
  Lymphonodular hyperplasia
Outstanding issues and future directions
References
Synopsis
General principles of endoscopy training
  Traditional standard means of instruction
   Teachers
   Environment
   Is self-teaching still acceptable?
  What to teach and how to teach it
  Defining competency and how to access it
   Linking diagnosis and therapy
   How competent?
   Varying rates of learning
   Outcomes
   Learning beyond the training period
Training and competency in specific endoscopic procedures
  Esophagogastroduodenoscopy (EGD)
   Published guidelines for training in EGD
   Defining competence for EGD
   Data on acquisition of competency in diagnostic EGD
   Competency and EGD outcome
  Therapeutic EGD techniques
   Standard upper GI endoscopy techniques
   Hemostasis techniques
   Simulation
   Bleeding team
   Retaining competence
   Other specialized therapeutic upper GI endoscopy techniques
  Flexible sigmoidoscopy
   Published guidelines for training in flexible sigmoidoscopy
  Colonoscopy
   Published guidelines for training in colonoscopy
   Defining competence for colonoscopy
   Technical components
   Cognitive objectives
   Minimum training requirements to achieve competency for colonoscopy
   The Cass study
   Conclusion
   Competency and colonoscopy outcome
   Acceptable outcomes
   Non-gastroenterologists
   Rate of skills acquisition for colonoscopy
   Cases per week
   Too many cases?
  Therapeutic colonoscopy (biopsy, polypectomy, hemostasis techniques, stricture dilation, stent deployment)
   Standard therapeutic techniques (integral to performance of diagnostic colonoscopy)
   Advanced therapeutic colonoscopy techniques
  Diagnostic and therapeutic ERCP
   Published guidelines for training in ERCP
   Non-technical training
   Defining competence for ERCP
   Technical success
   Varying case difficulty
   Judgement
   Minimum training requirements to achieve competency for ERCP
   Case numbers
   What is a case?
   Competency and ERCP outcome
   Improving after training
   Annual volume
   Competence affects complication rates
   Rate of acquisition of ERCP skills
   Therapeutic ERCP
   Rate of acquisition of therapeutic skills
  Diagnostic and therapeutic EUS
   Defining competency in EUS
   Learning curve for EUS
   Therapeutic EUS
   EUS training opportunities
Complementary methods for instructions in GI endoscopy
  Advances in didactic methods
   Self-instruction
   Group instruction
   Laboratory demonstrations
  Endoscopy simulators
   Static models
   Courses with static models
   Ex vivo artificial tissue models: the 'phantom' Tübingen models
   Ex vivo animal tissue simulators: EASIE and Erlangen models
   Live animals
   Computer simulation
   AccuTouch®
   GI Mentor™
   Current status of simulators
   Costs of simulators
   EUS models and simulators
  Use of training resources: summary
Endoscopy training 2010—a glimpse into the future
Credentialing and granting of privileges
  Credentialing
  Privileging
  Proctoring
   ASGE guidelines
Renewal of privileges and privileging in new procedures
  New procedures
Privileging for non-gastroenterologists and non-physician providers
The future of credentialing and privileging
  The use of new technology for credentialing
The role of endoscopic societies in training and credentialing
  Guidelines
  Society courses
  Materials
  Hands-on courses
  Research in training
  Influencing credentialing
Outstanding issues and future trends
References
Synopsis
Introduction
Achieving competence—the goal of training
What experience is necessary in training? The fallacy of numbers
Beyond numbers: tools to measure competence
What level of competence is good enough? How is it recognized?
Endoscopic performance beyond training
Issues in measuring endoscopic performance
The report card agenda
Benchmarking
The quality of endoscopy units
Conclusion
Outstanding issues and future trends
References
Synopsis
Most endoscopists are not interested
Is the problem declining?
Newly recognized infections
Compliance with guidelines
What can be done to remedy this sorry state of affairs?
  Infection control staff
  Microbiological surveillance
   British practice
The role of industry
Manual cleaning is key
References

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