Best practices

Endoscopy units are specific areas in a hospital (or physician's office) in which all endoscopic procedures are performed. For this unit to be functional and effective, according to the American Society for Gastrointestinal Endoscopy (ASGE), certain conditions must be met, [7, 8] including the following:

Properly trained endoscopist and nursing staff

Functioning and adequately maintained equipment

Availability of an endoscope cleaning area

Personnel trained to perform cardiopulmonary resuscitation

Quality improvement program in place

Open-access endoscopy is a system designed to offset the cost of endoscopy in stable patients without significant comorbidities who have clear indications for upper GI endoscopy. [9] The responsibilities of the referring physician are to have a complete understanding of the patient's condition and to be fully aware of the accepted indications for endoscopy. If the patient is on anticoagulation or if antibiotic prophylaxis is required, these issues must be addressed via proper communication between the referring physician and the endoscopist.

According to ASGE recommendations, training in upper GI endoscopy should include an understanding of indications, limitations, contraindications, alternatives, principles of conscious sedation, and correct interpretation of endoscopic findings. [10] A minimum of 100 upper GI endoscopic procedures is recommended for trainees to become competent in diagnostic upper GI endoscopy.

Therapeutic upper GI endoscopy requires further training and experience to gain competency. The recommendations of the ASGE for the number of procedures required to gain competency in various therapeutic upper GI endoscopic procedures are available through the society Web site (see American Society for Gastrointestinal Endoscopy).

Procedural planning

Transnasal EGD (TN-EGD) has certain limitations in bending, which can make approaching certain gastric regions difficult. Rhee et al evaluated whether the quality and quantity of two-directional TN-EGD biopsied gastric specimens were affected by this limitation. [11] Specimen quantity was assessed on the basis of diameter and depth (μm), as well as presence of tissue layers (superficial mucosa, deep mucosa, muscularis mucosa, and submucosa). Specimen quality was assessed on the basis of anatomic orientation (good, intermediate, or poor), presence of crush artifact (none to minimal, mild, or moderate), and overall diagnostic adequacy (adequate, suboptimal, or inadequate).

Of 289 TN-EGD gastric biopsy specimens, 33 (11.4%) were of poor orientation, 26 (9.0%) revealed the presence of crush, and 37 (12.8%) demonstrated overall diagnostic inadequacy. [11] In 211 (73.0%), deep mucosa was present, but only 75 specimens (26.0%) had muscularis mucosa. The posterior aspect of the cardia had the greatest limitations in specimen quantity and quality, with the shallowest depth, poorest orientation, and poorest diagnostic adequacy. The investigators recommended paying special attention to gastric lesions located on the posterior aspect of the cardia when using two-directional TN-EGD.

In a two-part study, Japanese investigators attempted to find a good washing solution to counter the known limitations of the small-caliber water-jet nozzles of TN-EGDs for cleaning lenses. [12] Komazawa et al compared oolong tea, barley tea, and distilled water as washing solutions for the endoscopic lenses. In the first part of the study, the TN-EGD lenses were soiled by lard and then washed with one of the three washing solutions. When the image quality of photographs were judged, lenses washed with oolong tea resulted in a significantly higher image quality than did lenses washed with barley tea or distilled water solutions.

In the second part of the study, 982 patients scheduled to undergo TN-EGD were randomly assigned to groups in which the endoscope lens was washed with one of the three washing solutions. The investigators found that the level of lens cleansing was significantly greater and the overall time required for endoscopy was significantly shorter in the oolong tea group than in the other two groups. [12] When the volume of washing solution used for lens cleansing was compared, significantly less was used in the oolong group compared with the distilled water group. On the basis of their findings, Komazawa et al recommended oolong tea rather than water for cleaning TN small-caliber EGD lenses.

Complication prevention

Despite the large number of endoscopic procedures performed each day, the incidence of infection transmission via endoscopes remains very low. [13] Methods of reprocessing endoscopes include mechanical cleaning, high-level disinfection, rinsing, and drying. Proper and diligent care during reprocessing of endoscopes, with attention to quality control, cannot be overstated for minimizing the risk of spreading infection via endoscopic procedures. [14]