Cotton and Williams' Practical Gastrointestinal Endoscopy E-Book

Catharine M. Walsh

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 500

Veröffentlichungsjahr: 2023

Beschreibung

PRACTICAL GASTROINTESTINAL ENDOSCOPY The fundamental guide to gastrointestinal endoscopy returns in a fully updated new edition For over forty years, Cotton and Williams' Practical Gastrointestinal Endoscopy has offered a clear, accessible introduction to the fundamentals of endoscopy, from patient positioning to the range of available procedures. Now updated by a new authorial team to reflect the latest advances in endoscopic procedures, this text promises to serve a new generation of trainees and specialists as the essential introduction to upper and lower gastrointestinal endoscopy. Readers of the eighth edition of Cotton and Williams' Practical Gastrointestinal Endoscopy will also find: * Updated online resources including a downloadable bank of clinical images * High-quality videos illustrating endoscopic practices and procedures, linked to specific points in the text Cotton and Williams' Practical Gastrointestinal Endoscopy remains a must-own for all trainee and specialist gastroenterologists and endoscopists.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

List of Video Clips

Preface to the Eighth Edition

Preface to the First Edition

Acknowledgments

About the Companion Website

CHAPTER 1: Welcome to Endoscopy

Resources and links

CHAPTER 2: The Endoscopy Unit, Staff, and Management

Endoscopy units

Staff

Management, behavior, and teamwork

Documentation and quality improvement

Educational resources

Further reading

CHAPTER 3: Endoscopic Equipment

Endoscopes

Endoscopic accessories

Ancillary equipment

Electrosurgical units

Lasers and argon plasma coagulation

Equipment maintenance

Infection control

Cleaning and disinfection

Further reading

CHAPTER 4: Patient Care, Risks, and Safety

Patient assessment

Patient education and consent

Physical preparation

Sedation/anesthesia

Recovery and discharge

Managing adverse events

Further reading

CHAPTER 5: Upper Endoscopy: The Fundamentals

Patient position

Endoscopist position

Endoscope handling

Passing the endoscope

Routine diagnostic survey

Stomach

Problems during endoscopy

Recognition of lesions

Specimen collection

Diagnostic endoscopy under special circumstances

Further reading

CHAPTER 6: Therapeutic Upper Endoscopy

Benign esophageal strictures

Achalasia

Esophageal cancer palliation

Gastric and duodenal stenoses

Gastric and duodenal polyps and tumors

Foreign bodies

Acute bleeding

Enteral nutrition

Further reading

CHAPTER 7: Colonoscopy and Flexible Sigmoidoscopy

History

Indications and limitations, and alternatives

Informed consent

Contraindications and infective hazards

Patient preparation

Medication

Equipment—present and future

Anatomy

Insertion

Handling “single‐handed,” “two‐handed,” or two‐person?

Sigmoid colon—accurate steering

Endoscopic anatomy of the sigmoid and descending colon

Sigmoid colon—the bends

Sigmoid colon—the loops

Diverticular disease

Descending colon

Splenic flexure

Transverse colon

Hepatic flexure

Ascending colon and ileo‐cecal region

Overtubes and balloon colonoscopy

Examination of the colon

Stomas

Pediatric ileocolonoscopy

Per‐operative colonoscopy

Further reading

CHAPTER 8: Therapeutic Colonoscopy

Equipment

Principles of polyp electrosurgery

Approach to polypectomy

Selection of polypectomy technique

Polypectomy: Diminutive and small polyps

Polypectomy: Large polyps

Polypectomy: Problem polyps

Recovery of polypectomy specimens

Risks of polypectomy

Other therapeutic procedures

Further reading

CHAPTER 9: Advanced Endoscopic Procedures

Small bowel endoscopy

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic ultrasound (EUS)

Bariatric endoscopy

Anti‐reflux procedures

Third space procedures and NOTES

Epilogue: The Future? Comments from the Senior Authors

Intelligent endoscopes

Colonoscopy—boon or bubble?

Advanced therapeutics, cooperation, and multidisciplinary working

Quality and teaching

Index

End User License Agreement

List of Tables

Chapter 4

Table 4.1 Severity grading system for adverse events (ASGE, 2010)

Table 4.2 ASA classification—anesthesia risk classes

Table 4.3 Commonly used sedation/analgesic agents.

Chapter 6

Table 6.1 Retrieval devices

Table 6.2 Rockall Score

Table 6.3 Glasgow‐Blatchford Score

Chapter 7

Table 7.1 Colonoscopy: indications and yield

Chapter 8

Table 8.1 Key considerations for polypectomy

Table 8.2 Resection method for noninvasive polyps by size and shape

List of Illustrations

Chapter 2

Fig 2.1 Functional planning—showing logical separation of the spheres of act...

Chapter 3

Fig 3.1 Endoscope system.

Fig 3.2 Static red, green, and blue filters in the “color” chip.

Fig 3.3 Sequential color illumination.

Fig 3.4 Basic design of the endoscope.

Fig 3.5 The internal anatomy of a typical endoscope.

Fig 3.6 The tip of a forward‐viewing endoscope.

Fig 3.7 A side‐viewing endoscope with a deflectable elevator.

Fig 3.8 Biopsy cups open.

Fig 3.9 Control handle for biopsy forceps.

Fig 3.10 Cytology brush with outer sleeve.

Fig 3.11 A suction trap to collect fluid specimens.

Fig 3.12 An overtube with biteguard over a rubber lavage tube.

Fig 3.13 Argon plasma coagulation (APC).

Fig 3.14 Carry endoscopes carefully to avoid knocks to the optics in the con...

Fig 3.15 Mask, gowns, gloves, and eye/face protection should be worn.

Chapter 4

Fig 4.1 Sample patient information leaflet for upper endoscopy.

Fig 4.2 Sample patient information leaflet for colonoscopy.

Chapter 5

Fig 5.1 Preparing the patient correctly for upper gastrointestinal endoscopy...

Fig 5.2 A neutral body posture and balanced stance with a straight instrumen...

Fig 5.3 The thumb rests on the up/down angulation control knob with the firs...

Fig 5.4 The thumb can reach across to the left/right angulation control knob...

Fig 5.5 The endoscopist pre‐rehearses tip angulation in the correct axis bef...

Fig 5.6 (a) Follow the center of the tongue … (b) … past the uvula … (c) … a...

Fig 5.7 Sometimes “blind” insertion is helped by guiding the instrument betw...

Fig 5.8 Esophageal landmarks—with a small hiatal hernia.

Fig 5.9 (a) A sliding hiatus hernia. (b) A paraoesophageal hiatus hernia.

Fig 5.10 The Hill classification whereby the gastroesophageal flap valve is ...

Fig 5.11 The distal esophagus angles the scope into the posterior wall of th...

Fig 5.12 With the gastroscope high on the lesser curve …

Fig 5.13 … the view is of the angulus in the distance, with the greater curv...

Fig 5.14 The route to pylorus and duodenum is a clockwise spiral around the ...

Fig 5.15 The angulus and antrum come into view …

Fig 5.16 … then angle down to see the pylorus in the axis of the antrum.

Fig 5.17 The scope passes from the antrum …

Fig 5.18 … to the pylorus and duodenal cap …

Fig 5.19 … and tends to impact in the duodenum.

Fig 5.20 Withdraw the scope to disimpact the tip and insufflate to see the s...

Fig 5.21 Corkscrew the tip clockwise around the superior duodenal angle, usi...

Fig 5.22 Trying to reach the third part by force simply forms a loop in the ...

Fig 5.23 … withdrawal helps to advance the scope into the second part of the...

Fig 5.24 Because of the loop in the greater curve …

Fig 5.25 Angulation of 180° (J maneuver) retroflexes the tip to see the less...

Fig 5.26 … and rotation of retroflexed tip (U‐turn) in both directions provi...

Fig 5.27 Angling right (rather than left) on entering the fundus can cause r...

Fig 5.28 Minor reflux changes above hiatus hernia—no need for biopsies.

Fig 5.29 Barrett’s esophagus—take biopsies.

Fig 5.30 Stages in placing biopsies onto the filter then fixing, sectioning,...

Fig 5.31 Cytology brush with outer sleeve.

Fig 5.32 A suction trap to collect fluid specimens.

Chapter 6

Fig 6.1 A balloon dilator exerts a radial force delivered simultaneously acr...

Fig 6.2 A deflated “through‐the‐scope” (TTS) balloon dilator and guidewire....

Fig 6.3 Tips of Savary‐Gilliard (above) and American Endoscopy (below) dilat...

Fig 6.4 A dilator guidewire positioned in the gastric antrum.

Fig 6.5 Advance the dilator with the left hand and the elbow extended to avo...

Fig 6.6 Achalasia dilating balloons (before full inflation) (a) checked fluo...

Fig 6.7 Covered metal mesh stent.

Fig 6.8 Endoscopic mucosal resection technique: (a) inject a saline cushion ...

Fig 6.9 An overtube with biteguard.

Fig 6.10 Remove sharp foreign bodies with a protecting overtube.

Fig 6.11 Latex hood for removal of small sharp objects.

Fig 6.12 Foreign body grasping (extraction) forceps.

Fig 6.13 A triprong grasping device.

Fig 6.14 Take a thread down with the forceps to pass through any object with...

Fig 6.15 Overtube with endoscope.

Fig 6.16 An esophageal banding device.

Fig 6.17 A retractable sclerotherapy needle.

Fig 6.18 Teflon‐coated tip of a heater probe with a water‐jet opening.

Fig 6.19 The tip of a multipolar probe with a central water jet.

Fig 6.20 (a) When an ulcer is actively bleeding, (b) probe pressure stops th...

Fig 6.21 Hemostatic clip.

Fig 6.22 The feeding tube and guidewire are passed through a large‐channel s...

Fig 6.23 A tube is carried alongside the scope by a thread grasped with a sn...

Fig 6.24 PEG insertion technique: (a) Grasp the wire; (b) pull the wire thro...

Chapter 7

Fig 7.1 Nitrous oxide/oxygen mixture is breathed through a mouthpiece.

Fig 7.2 (a) Variable‐stiffness colonoscopes have a twist control on the shaf...

Fig 7.3 Effect of using (a) gas or (b) water for colonoscope insertion in le...

Fig 7.4 Connect the CO

2

supply directly to the water bottle.

Fig 7.5 Positioning of foot pedals for electrosurgical unit and water pump. ...

Fig 7.6 Scope tip attachments: (a) cap; (b) cuff.

Fig 7.7 (a) Small coils within the scope generate magnetic fields, (b) energ...

Fig 7.8 (a) The fetal intestine and colon start on a longitudinal mesentery,...

Fig 7.9 (a) The embryonic colon extends on its mesentery, (b) then partial f...

Fig 7.10 Persistent descending mesocolon or mesentery.

Fig 7.11 Inverted cecum.

Fig 7.12 Mobile cecum.

Fig 7.13 The configuration of the colon when inflated, showing its attachmen...

Fig 7.14 Dynamic position changes to facilitate insertion of the colonoscope...

Fig 7.15 The longitudinal muscle bundles (teniae coli) can bulge visibly int...

Fig 7.16 (a) The distal colon appearance is usually circular, whereas (b) th...

Fig 7.17 Different methods of colonoscope insertion: (a) finger support of t...

Fig 7.18 Video‐proctoscopy (anoscopy).

Fig 7.19 The colonoscope suction/instrumentation port opens below and to the...

Fig 7.20 Angulate both controls, twist and

push in

to retrovert in the rectu...

Fig 7.21 Single‐handed maneuvering of the instrument shaft. The endoscope he...

Fig 7.22 The instrument shaft is held delicately between the thumb and finge...

Fig 7.23 Single‐handed control: the forefinger alone activates the air/water...

Fig 7.24 The thumb can reach the up/down and lateral angulation control if t...

Fig 7.25 With a clockwise shaft twist: (a) an up‐angulated tip moves toward ...

Fig 7.26 (a) Twist only affects the tip if the shaft is straight, (b) but it...

Fig 7.27 Lateral control angulation has little effect if the tip is maximall...

Fig 7.28 (a) The sigmoid colon is an elastic tube; (b) pushing causes loops ...

Fig 7.29 Aim at the convergence of folds.

Fig 7.30 Aim at the darkest area.

Fig 7.31 Aim at the center of the arc formed by folds.

Fig 7.32 At acute bends a longitudinal bulge (tenia coli) shows the axis to ...

Fig 7.33 Endoscopic view of an acute bend, with a bright fold on the angle, ...

Fig 7.34 Pre‐steer before pushing into an acute bend.

Fig 7.35 Pull back when lost—the mucosa slides away in the direction of the ...

Fig 7.36 (a) The sigmoid colon loops anteriorly, (b) then passes up into the...

Fig 7.37 Sigmoid loop—anterior view (clockwise spiral).

Fig 7.38 (a) A sigmoid spiral loop can be reduced with (b) clockwise torque ...

Fig 7.39 Fixed (iatrogenic) hairpin bend at the sigmoid‐descending colon jun...

Fig 7.40 The length of the mesentery and the extent of retroperitoneal fixat...

Fig 7.41 An alpha (clockwise) loop—a beneficial iatrogenic volvulus.

Fig 7.42 The endoscope may push a fully mobile distal colon up the midline t...

Fig 7.43 A reverse (counterclockwise) alpha loop due to a persistent descend...

Fig 7.44 Pulling back flattens out an acute bend and improves the view.

Fig 7.45 Rotation of the vessel pattern (from (a) to (b)) indicates rotation...

Fig 7.46 De‐angulate at the splenic flexure to avoid “walking‐stick handle” ...

Fig 7.47 A very long sigmoid may allow the scope to “push though” and avoid ...

Fig 7.48 (a) Pull back and deflate to keep the sigmoid short, (b) which may ...

Fig 7.49 An “N”‐loop stretching up the sigmoid colon.

Fig 7.50 (a) An “N” loop with the tip hooked into the retroperitoneal descen...

Fig 7.51 (a) An “N”‐spiral loop with the tip at the sigmoid‐descending junct...

Fig 7.52 In an alpha loop the scope runs through the fluid‐filled descending...

Fig 7.53 An alpha loop.

Fig 7.54 Many “N”‐loops (a), if also seen in lateral view (b), are actually ...

Fig 7.55 “The alpha maneuver”: (a) during sigmoidal insertion, (b) try count...

Fig 7.56 (a) An alpha loop (b) derotates with clockwise torque and withdrawa...

Fig 7.57 Shaft loops forming outside the patient can be transferred to the u...

Fig 7.58 (a) Choosing the correct path can be difficult in diverticular dise...

Fig 7.59 If the tip is fixed it cannot be steered (the shaft moves instead)....

Fig 7.60 Fluid levels in the left lateral position.

Fig 7.61 The phrenicocolic ligament.

Fig 7.62 The splenic flexure can pull back to 40 cm if there is a free phren...

Fig 7.63 (a) In the left lateral position the transverse colon flops down, m...

Fig 7.64 The transverse colon is usually triangular.

Fig 7.65 Sigmoid colon buckling.

Fig 7.66 Torque clockwise while advancing to keep the sigmoid straight.

Fig 7.67 Control sigmoid looping by hand‐pressure to help pass the splenic f...

Fig 7.68 A “reversed” splenic flexure will result in a deep transverse loop....

Fig 7.69 (a) Counterclockwise rotation (b) swings a mobile colon back to the...

Fig 7.70 The transverse colon is anterior, over the duodenum and pancreas. T...

Fig 7.71 Colon mesenteries—the transverse and sigmoid mesocolons.

Fig 7.72 (a) Transverse mesocolon. (b) A gamma loop.

Fig 7.73 The triangular configuration is due to the three teniae coli.

Fig 7.74 Similar “knife‐like” haustra are seen at the mid‐transverse colon a...

Fig 7.75 The longitudinal bulge of a tenia coli shows the axis of the colon....

Fig 7.76 Follow the longitudinal bulge (tenia coli) round an acute bend.

Fig 7.77 (a) If the passage up the proximal transverse colon is difficult, (...

Fig 7.78 (a) If the phrenicocolic ligament is lax, withdrawal maneuvers are ...

Fig 7.79 A gamma loop in a redundant transverse colon.

Fig 7.80 “Specific” hand pressure can be used to elevate the transverse colo...

Fig 7.81 Aspirate to shrink the hepatic flexure toward the scope.

Fig 7.82 Suction toward, then angle acutely (180°) around the acute hepatic ...

Fig 7.83 (a) When around the hepatic flexure and viewing the ascending colon...

Fig 7.84 Appendix orifice at the fusion of the three teniae coli.

Fig 7.85 Transillumination deep in the iliac fossa suggests the cecum.

Fig 7.86 Finger‐pressure in the right iliac fossa indents the cecum.

Fig 7.87 (a) Angle in the direction of the appendix lumen (b), and (c) pull ...

Fig 7.88 The ileo‐cecal valve is a bulge on the ileo‐cecal fold—a flattening...

Fig 7.89 (a) Locate the ileo‐cecal valve, (b) insert beyond, angulate, and d...

Fig 7.90 The biopsy forceps can be used to locate the slit of the valve, and...

Fig 7.91 A slit‐like valve may only be visible in retroversion (in a large c...

Fig 7.92 (a) If necessary, retroflex to see the valve, (b) pull back to impa...

Fig 7.93 Entering the ileo‐cecal valve. (a) Distant view of the valve slit. ...

Fig 7.94 Potential blind spots for colonoscopic visualization.

Fig 7.95 Dynamic position change during withdrawal is essential for optimal ...

Fig 7.96 Pulling back the scope shortens the colon.

Fig 7.97 If the scope is in the cecum at 70–80 cm, other anatomical sites ar...

Fig 7.98 Fluid distribution in (a) the left lateral position and (b) the rig...

Fig 7.99 Per‐operative straightening of the stomach and duodenum.

Chapter 8

Fig 8.1 Use one commercial snare type for familiarity.

Fig 8.2 (a) Appropriate snare closure with the wire loop 15mm into the outer...

Fig 8.3 Mark the handle when the loop is fully closed.

Fig 8.4 Polyp tissue can be trapped in the snare, reducing its efficiency.

Fig 8.5 (a) Argon plasma coagulation (APC) catheter with internal wire elect...

Fig 8.6 Nylon polyp retrieval net.

Fig 8.7 (a) An old‐style mucus trap. (b) A filtered polyp suction trap.

Fig 8.8 Gauze inserted over suction connector for polyp retrieval.

Fig 8.9 Heat is generated by electricity (electrons) passing through resista...

Fig 8.10 An electrosurgical current alternates 1,000,000 times per second, p...

Fig 8.11 A household current alternates 50–60 times per second, producing he...

Fig 8.12 Cutting current—continuous (high‐power) low‐voltage pulses cannot p...

Fig 8.13 Coagulating current—intermittent high‐voltage pulses can pass desic...

Fig 8.14 Blended current combines the characteristics of both cutting and co...

Fig 8.15 Current flows more easily through larger areas of tissue resistance...

Fig 8.16 Current density results from constricting tissue and greatly increa...

Fig 8.17 Heating occurs at the closed snare but not at the plate.

Fig 8.18 The whole plexus of stalk vessels must be electrocoagulated before ...

Fig 8.19 Heat produced is directly proportional to power …

Fig 8.20 … and directly proportional to time …

Fig 8.21 … but

increases

as the

cube

of snare closure.

Fig 8.22 When snaring a thick stalk (a) the plastic sheath may crumple befor...

Fig 8.23 Cold snare polypectomy whereby (a) a small polyp is identified, (b)...

Fig 8.24 (a) Thick stalks can bleed—think of pre‐injection. (b) The distance...

Fig 8.25 Backward snaring is sometimes useful.

Fig 8.26 (a) Bad position for snare placement. (b) Rotate the instrument to ...

Fig 8.27 (a) To avoid the snare pulling off during closure, (b) push the loo...

Fig 8.28 Snare at the narrowest part of the stalk.

Fig 8.29 To disengage a trapped snare, push it upstream over the polyp head....

Fig 8.30 (a) Bad view of a polyp? (b) Change the patient’s position to let g...

Fig 8.31 (a) Inject broad‐stalked polyps with epinephrine before snaring to ...

Fig 8.32 “Leak” current can result in contralateral burns.

Fig 8.33 A large area of contact reduces the risk of contralateral burn, but...

Fig 8.34 (a) A 20 mm sessile polyp … (b) … is elevated by submucosal saline ...

Fig 8.35 (a) First inject

proximally

to a larger sessile polyp … (b) … then ...

Fig 8.36 Conventional piecemeal EMR whereby (a) a larger polyp is elevated b...

Fig 8.37 (a) Large sessile polyps can be risky to snare in one portion … (b)...

Fig 8.38 (a) Clips across top of stalk. (b) Clips placed perpendicular to st...

Fig 8.39 (a) A nylon self‐retaining loop can be placed over a large stalk … ...

Fig 8.40 A 1 mL India ink tattoo marks a polypectomy site permanently.

Fig 8.41 The target sign.

Fig 8.42 A deflation tube can be carried up alongside the colonoscope.

Guide

Cover Page

Title Page

Copyright Page

Table of Contents

List of Video Clips

Preface to the Eighth Edition

Preface to the First Edition

Acknowledgments

About the Companion Website

Begin Reading

Epilogue: The Future? Comments from the Senior Authors

Index

WILEY END USER LICENSE AGREEMENT

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Cotton and Williams' Practical Gastrointestinal Endoscopy

The Fundamentals

Eighth Edition

Catharine M. Walsh MD MEd PhD FRCPC

Associate Professor

Division of Gastroenterology, Hepatology and Nutrition

Department of Paediatrics, The Hospital for Sick Children

Temerty Faculty of Medicine, University of Toronto

Toronto, Canada

Ahmir Ahmad MBBS BSc MRCP PhD

Consultant Gastroenterologist

Wolfson Unit for Endoscopy

St Mark’s Hospital (The National Bowel Hospital)

London, UK

Brian P. Saunders MD FRCP FRCS

Consultant Gastroenterologist

St Mark’s Hospital (The National Bowel Hospital)

Professor of Endoscopy Practice

Imperial College

London, UK

Jonathan Cohen MD FASGE FACG

Clinical Professor of Medicine

Division of Gastroenterology

NYU Grossman School of Medicine

New York, USA

Peter B. Cotton MD FRCP FRCS

Professor of Medicine

Digestive Disease Center

Medical University of South Carolina

Charleston, South Carolina, USA

Christopher B. Williams BM FRCP FRCS

Retired Physician

Wolfson Unit for Endoscopy

St Mark’s Hospital (The National Bowel Hospital)

London, UK

Videos supplied by Stephen Preston

Multimedia Consultant

St Mark’s Hospital (The National Bowel Hospital)

London, UK

This eighth edition first published 2024© 2024 John Wiley & Sons Ltd

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Library of Congress Cataloging‐in‐Publication Data Names: Walsh, Catharine M., author. | Haycock, Adam. Cotton and Williams’ practical gastrointestinal endoscopy. Title: Cotton and Williams’ practical gastrointestinal endoscopy : the fundamentals / Catharine M. Walsh, Ahmir Ahmad, Brian P. Saunders, Jonathan Cohen, Peter B. Cotton, Christopher B. Williams ; videos supplied by Stephen Preston. Other titles: Practical gastrointestinal endoscopy Description: Eighth edition. | Hoboken, NJ : Wiley Blackwell, 2024. | Preceded by: Cotton and Williams’ practical gastrointestinal endoscopy / Adam Haycock, Jonathan Cohen, Brian P. Saunders, Peter B. Cotton, Christopher B. Williams. Seventh edition. [2014]. | Includes bibliographical references and index. Identifiers: LCCN 2023028999 (print) | LCCN 2023029000 (ebook) | ISBN 9781119525202 (hardback) | ISBN 9781119525189 (adobe pdf) | ISBN 9781119525158 (epub) Subjects: MESH: Gastrointestinal Diseases–diagnosis | Gastrointestinal Diseases–surgery | Endoscopy–methodsClassification: LCC RC804.E6 (print) | LCC RC804.E6 (ebook) | NLM WI 141 | DDC 616.3/307545–dc23/eng/20231027 LC record available at https://lccn.loc.gov/2023028999 LC ebook record available at https://lccn.loc.gov/2023029000

Cover Design: WileyCover Image: © David Gardner

List of Video Clips

Chapter 5

Video 5.1

Endoscopic view of direct vision insertion

Video 5.2

Full insertion and examination

Chapter 7

Video 7.1

History of colonoscopy

Video 7.2

Variable shaft stiffness

Video 7.3

Water‐assisted colonoscopy

Video 7.4

ScopeGuide

®

magnetic imager: The principles

Video 7.5

Embryology of the colon & its consequences

Video 7.6

Position change

Video 7.7

Insertion and handling of the colonoscope

Video 7.8

Steering the colonoscope

Video 7.9

Magnetic imager: An easy spiral loop

Video 7.10

Sigmoid loops

Video 7.11

Magnetic imager: Short and long “N”‐loops

Video 7.12

Magnetic imager: “Alpha” spiral loops

Video 7.13

Magnetic imager: “Lateral view” spiral loop

Video 7.14

Magnetic imager: Flat “S”‐loop in a long sigmoid

Video 7.15

Transferring shaft loops to the umbilical

Video 7.16

Descending colon

Video 7.17

Splenic flexure

Video 7.18

Transverse colon

Video 7.19

Magnetic imager: Shortening transverse loops

Video 7.20

Magnetic imager: Deep transverse loops

Video 7.21

Magnetic imager: “Gamma” looping of the transverse colon

Video 7.22

Hepatic flexure

Video 7.23

Ileo‐cecal valve

Video 7.24

Examination of the colon

Video 7.25

Normal appearances

Video 7.26

Abnormal appearances

Video 7.27

Post‐surgical appearances

Video 7.28

Infective colitis

Video 7.29

Crohn’s disease

Chapter 8

Video 8.1

Cold snare polypectomy

Video 8.2

Stalked polypectomy

Video 8.3

En‐bloc injection‐assisted endoscopic mucosal resection (EMR)

Video 8.4

Underwater EMR

Video 8.5

Piecemeal injection‐assisted EMR

Video 8.6

Clipping post‐polypectomy defect

Video 8.7

Tattoo

Video 8.8

Post‐polypectomy bleeding with therapy

Video 8.9

Post‐polypectomy perforation with therapy

Preface to the Eighth Edition

In recent decades, there have been major advances in endoscopic techniques and technology. Improvements in endoscope resolution and image‐enhancing modalities, as well as the emergence of artificial intelligence, are transforming endoscopic practice. The demand for endoscopy has never been greater. Yet, despite these changes, the fundamental principles of high‐quality endoscopy remain constant.

Before exposing a patient to this invasive procedure, we must ensure that there is an appropriate indication and truly informed consent for it. Patient activity should be optimized to minimize any avoidable risk. The endoscopist should be skilled, or supervised if training, to ensure that accurate diagnosis and definitive therapy are performed with minimal patient discomfort or anxiety. When adverse events occur, they must be quickly recognized and appropriately managed.

It is a huge honor, and responsibility, to take forward the incredible legacy of Peter Cotton and Christopher Williams, the pioneering authors of this textbook first published in 1980. It is their commitment and dedication to the field of endoscopy that has made this text an invaluable resource for endoscopists all over the world. We are very grateful for their support, feedback and endorsement of this revised edition. The key word in the title, “Fundamentals,” encapsulates the essence and differentiating aspect of this book. For decades, it has served to guide novices through their early days of learning to perform high‐quality endoscopy. It remains focused on helping those in their first few years of experience advance more quickly along the endoscopic learning curve through competency toward excellence.

In this eighth edition of Practical Gastrointestinal Endoscopy: The Fundamentals, we have made updates and enhancements to reflect current practice to ensure that the text remains relevant and accessible for future generations of endoscopists. In doing so, we hope to maintain the original vision of Peter Cotton and Christopher Williams to help make skillful endoscopy easier and safer, ultimately improving patient care.

October 2023

Catharine M. Walsh

Ahmir Ahmad

Brian P. Saunders

Jonathan Cohen

Preface to the First Edition

This book is concerned with endoscopic techniques and says little about their clinical relevance. It does so unashamedly because no comparable manual was available at the time of its conception and because the explosive growth of endoscopy has far outstripped facilities for individual training in endoscopic technique. For the same reason we have made no mention of rigid endoscopes (oesophagoscopes, sigmoidoscopes and laparoscopes) which rightly remain popular tools in gastroenterology, nor have we discussed the great potential of the flexible endoscope in gastrointestinal research.

Our concentration on techniques should not be taken to denote a lack of interest in results and real indications. As gastroenterologists we believe that procedures can only be useful if they improve our clinical management; clever techniques are not indicated simply because they are possible, and some endoscopic procedures will become obsolete with improvements in less invasive methods. Indeed we are moving into a self‐critical phase in which the main interest in gastrointestinal endoscopy is in the assessment of its real role and cost‐effectiveness.

Gastrointestinal endoscopy should be only one of the tools of specialists trained in gastrointestinal disease—whether they are primarily physicians, surgeons or radiologists. Only with broad training and knowledge is it possible to place obscure endoscopic findings in their relevant clinical perspective, to make realistic judgements in the selection of complex investigations from different disciplines, and to balance the benefits and risks of new therapeutic applications. Some specialists will become more expert and committed than others, but we do not favor the widespread development of pure endoscopists or of endoscopy as a subspecialty.

Skillful endoscopy can often provide a definitive diagnosis and lead quickly to correct management, which may save patients from months or years of unnecessary illness or anxiety. We hope that this little book may help to make that process easier and safer.

April 1979

Peter B. Cotton

Christopher B. Williams

Acknowledgments

The authors are grateful to the dedicated collaborators who have embellished or enabled the production of this book. The artistic prowess and great patience of David Gardner has been crucial in enhancing the drawings and figures in this edition and several previous ones. The skills of Steve Preston have been invaluable in producing the online videos. The authors appreciate the input of Catherine Bauer from a nursing perspective in reviewing several chapters. At Wiley publishers, the guidance of Mandy Collison and Moyuri Handique’s formidable editorial talents have made the production process seamless and even enjoyable. The authors also wish to register indebtedness to their respective life‐partners (Geoff, Amina, Annie, Cori, Marion, and Christina) for their unending support—despite intrusions into personal and family time.

About the Companion Website

This book is accompanied by a website:

www.wiley.com/go/cottonwilliams8e 

The website includes:

40 videos showing procedures described in the book

All videos are referenced in the text where you see this logo

A clinical photo imagebank

CHAPTER 1Welcome to Endoscopy

If you are reading this book, you have likely just embarked on a journey to master the art and science of gastrointestinal endoscopy. Many of the experienced teachers you encounter along the way will sail through their examinations as if the scope is an extension of their hands, with a myriad of unconscious maneuvers and fast‐thinking visual processing of what appears on the screen. They will make what appear to you to be near‐instantaneous assessment and judgment calls as to how to respond to the information that comes into view. It can be easy for them to forget the wonderment of the first exposure to endoscopy that drew them into the field and now hopefully excites you to follow suit. At the same time, it is understandable for you to feel a bit overwhelmed by the apparent magnitude of the challenge you face to reach their level of proficiency.

Here are some reassuring thoughts to accompany your introduction to endoscopy. With time, practice, self‐challenge, reflection, good role models, and feedback, you will be able to master what initially appears so daunting. By breaking down the many technical, cognitive, and non‐technical skills into the components detailed in this book, and with equal doses of patience and persistence, becoming a high‐quality endoscopist is well within your reach. Knowing that you will eventually develop the skills is comforting, but another source of support is the many resources available to you to make this learning trajectory far less bumpy and more expeditious. Several of these are listed at the end of this chapter. Hopefully, this book on the fundamentals of endoscopy will demystify the first steps of the learning process for you by clearly outlining the skills to learn and will make the path forward far less intimidating.

What general skills, knowledge, and mindset do you need to best set off to learn endoscopy? Contrary to common belief, you do not need to be a master video gamer or star athlete with already honed hand‐eye coordination, although such skills may come in handy early in the learning curve for technical skills. Perhaps the most essential ingredient is having eagerness and motivation to learn. In doing so, you will also need to combine parallel threads of knowledge. This characteristic of endoscopy education is common to all medical specialties and highlights the importance of building one’s fund of knowledge and making connections within it. You will no doubt have some of this understanding when you start to learn endoscopy, but the key to making progress is to use the circumstances of each patient endoscopic encounter to augment your knowledge as it relates to the particular case at hand.

The technical skills required to navigate the endoscopic instruments and accessories, covered in detail in subsequent chapters in this book, are a second layer of knowledge that must be learned via observation, demonstration, deconstruction into component maneuvers, practice, feedback, reflection, and refinement. You will find this aspect to be novel and to require your full attention in the early phase of learning. A common mistake of teachers is to overload clinical training with lessons about visual image interpretation while a novice is focusing on mastering the basic manipulative physical aspects of performing endoscopy. Key to success in this effort is the attitude and understanding that progress is incremental, and one can always improve. Great teachers are themselves always striving to refine their skills and asking themselves the question “How can I do better?” Once you find yourself successfully completing components of the technical procedures without assistance, avoid complacency and push yourself to perform them better: more precise movements, less loop formation in the colon, smoother intubation of the oropharynx, etc. This will be the way to excel at endoscopy. Expertise is not innate; it is achieved by continually engaging in deliberate practice that is purposeful, feedback‐informed, and conducted with the specific goal of improving performance.

The next major novel frontier for the student of endoscopy is re‐learning how to look at images. By the time a prospective endoscopist passes an endoscope for the first time, the mechanics of assessing visual inputs has long since become automatic and immediate. For instance, imagine a hike through a forest. As you walk along the trail, you may notice some of the rocks and trees and the occasional bird as you pass by, but seldom do you stop and analyze the frames presented as you pass to truly notice patterns, assess the content, discern when something stands out as novel or atypical from the norm, decide what that unusual feature might signify, and choose whether to take a photo (or sample) or move on. Unless you happen to be a naturalist, you have probably become used to viewing your surroundings in a much more passive manner.

As you begin your endoscopy education, you will find it advantageous to consciously change the way you look. In the endoscopy suite, when your trainer asks you what you see on the screen, resist the temptation to blurt out a label or an interpretation, but rather start with a simple description. This requires you to notice and appreciate the features—the color, the contours, changes in the surface pattern, and the topography of the surface layer (bumpy or smooth, raised or depressed). Even when you learn the features associated with normal versus abnormal mucosa in various organs and with specific pathological diagnoses, pattern recognition begins with detailed observation and appreciation of the images that come into view. This is a learned skill that can be overlooked in the rush to label and correctly name what you see. Once you characterize the features, you will start to match what you are seeing to what you expect to find in a particular organ under normal circumstances and in various common disease states. This analytical type of data collection and processing is no different from that used by a novice botany student learning to recognize and name the vegetation along a hike through the forest. With practice, you will rapidly be able to detect when something is abnormal and figure out what the abnormality is. You will learn, too, how to respond to what you see as you progress in your cognitive skill development. Just as important a habit to form at the beginning of your training is a meticulous tendency to inspect completely and leave no blind spots in your examinations. To some extent, this overlaps with the technical skills required to maneuver your endoscope to visualize any hard‐to‐reach areas. The chapters in this book will guide you in how best to do this. However, the diligence that drives you not to overlook any area, and to go back and reinspect regions that you did not get a great look at the first time around, is a critically important practice.

As you get your first exposure to patients undergoing endoscopy, whether initially as an observer or with scope in hand, be mindful of everything happening in the suite. When you are observing a case in which the instructor is handling the endoscope, the tendency is to stare intently at the video monitor to see what the scope is imaging. However, it is often equally or more important to notice what your teacher is doing with their hands. Another key aspect to appreciate is how they are communicating and interacting with the rest of the staff in the suite. We all learn by reading, watching, listening to verbal instructions, and manually practicing and refining skills by tactile feedback. Trainees rely on each of these modes of learning to varying extents. You will soon figure out what works best for you.

Once you come to appreciate the magnitude of the different technical, cognitive, and non‐technical skills you must master to perform high‐quality endoscopy, you may again become overwhelmed. You certainly cannot learn all the skills at once, and the concept of cognitive overload will be discussed later in this book. A good rule of thumb that will help keep you on track and avoid becoming disheartened is to ensure that each procedure in which you participate provides you with at least one take‐home lesson or opportunity to improve one skill, technical, non‐technical, cognitive, or otherwise. After each case, review in your mind or with your trainer what you have just learned. Focused feedback discussions are essential to promote learning. Before each case, ensure that you set one to two learning goals, which may need to be adjusted depending on what you encounter during the actual procedure. For example, if you hoped to work on passing a gastroscope into the duodenum, but the patient has a large ulcer in the stomach, the main lessons from the case will necessarily deviate from the original plan. You may still try to achieve duodenal intubation, but the educational value of the experience will shift according to the circumstances that arise. This opportunity‐based education is in contrast to a didactic A‐to‐Z learning agenda and remains an exciting aspect of proctored live endoscopy performance as a principal teaching tool in endoscopy.

You will soon appreciate that learning to perform endoscopy is a highly iterative process. Repetition, reflection, assessment, feedback, and monitoring progress are key features. You will notice that your best teachers will not only enjoy teaching but will themselves still be striving to continually improve and learn throughout their career. You will also see that they are always thinking about the patient and putting patient care first. Keeping these attitudes foremost in mind will serve you well, both as you learn to become an excellent endoscopist and as you progress throughout your professional career.

If this “welcome to endoscopy” seems to be more of a pep talk, well … that is what this is!

Resources and links

Websites

There is a huge amount of valuable material on the internet, posted largely by the main endoscopy societies around the world. These include many thoughtful guidelines for practice and training.

The main (Western) society resources are:

American College of Gastroenterology (ACG):

www.gi.org

American Gastroenterological Association (AGA):

www.gastro.org

American Society for Gastrointestinal Endoscopy (ASGE):

www.asge.org

British Society of Gastroenterology (BSG):

www.bsg.org.uk

Canadian Association of Gastroenterology (CAG):

www.cag‐acg.org

European Society for Gastrointestinal Endoscopy (ESGE):

www.esge.com

European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN):

www.espghan.org

North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN):

www.naspghan.org

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):

www.sages.org

World Endoscopy Organization (WEO):

www.worldendo.org

Online endoscopy educational resources include:

American Society for Gastrointestinal Endoscopy (ASGE) core curricula:

www.asge.org

European Society for Gastrointestinal Endoscopy (ESGE) core curricula:

www.esge.com

ImageSIM (endoscopy image cognitive simulation tool):

www.imagesim.com

The Gastrointestinal Endoscopy Quality and Safety (GIEQs) Foundation:

www.gieqs.com

Endoscopy books

Adler DG.

Upper Endoscopy for GI Fellows

. Cham, Switzerland: Springer International Publishing, 2017.

Chandrasekhara V, Elmunzer BJ, Khashab MA, Muthusamy VR.

Clinical Gastrointestinal Endoscopy

(3rd edition). Philadelphia, PA: Elsevier, 2019.

Chun HJ, Yang SK, Choi MG.

Clinical Gastrointestinal Endoscopy: A Comprehensive Atlas

(2nd edition). Singapore: Springer Singapore, 2018.

Cohen J.

Comprehensive Atlas of High‐Resolution Endoscopy and Narrowband Imaging

(2nd edition). Chichester, United Kingdom: Wiley Blackwell, 2017.

Cohen J.

Successful Training in Gastrointestinal Endoscopy

(2nd edition). Hoboken, NJ: John Wiley & Sons, 2022.

Gershman G, Thomson M.

Practical Pediatric Gastrointestinal Endoscopy

(3rd edition). Hoboken, NJ: Wiley Blackwell, 2021.

Schiller KFR, Cockel R, Hunt RH, Warren BF.

Atlas of Gastrointestinal Endoscopy and Related Pathology

(2nd edition). Oxford, United Kingdom: Blackwell Science, 2002.

Schoenwolf GC, Bleyl SB, Brauer PR, Francis‐West PH.

Larsen’s Human Embryology

(6th edition). Philadelphia, PA: Elsevier, 2021.

Wallace MB, Fockens P, Sung JJY.

Gastroenterological Endoscopy

(3rd edition). New York, NY: Thieme, 2018.

Wang TC, Camilleri M.

Yamada’s Atlas of Gastroenterology

(6th edition). Hoboken, NJ: John Wiley & Sons, 2022.

Waye JD, Aisenberg J, Rubin PH.

Practical Colonoscopy

. Chichester, United Kingdom: John Wiley & Sons, 2013.

Waye JD, Rex DK, Williams CB.

Colonoscopy: Principles and Practice

(2nd edition). Hoboken, NJ: Wiley Blackwell, 2009.

Wilcox CM, Muñoz‐Navas M, Sung JJY.

Atlas of Clinical Gastrointestinal Endoscopy

(3rd edition). Philadelphia, PA: Saunders Elsevier, 2012.

Journals with major endoscopy focus

American Journal of Gastroenterology. Official journal of the American College of Gastroenterology.

Digestive Endoscopy. Official journal of the Japan Gastroenterological Endoscopy Society.

Endoscopy. Official journal of the European Society of Gastrointestinal Endoscopy, and 20 affiliated national societies.

Gastrointestinal Endoscopy. The official journal of the American Society for Gastrointestinal Endoscopy.

Gastrointestinal Endoscopy Clinics of North America. Quarterly publication of state‐of‐the‐art reviews on the use of endoscopic procedures for the diagnosis and treatment of digestive diseases.

Gut. Official journal of the British Society of Gastroenterology.

Journal of Pediatric Gastroenterology and Nutrition. Official journal of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and European Society for Paediatric Gastroenterology, Hepatology and Nutrition.

Surgical Endoscopy. Official journal of the Society of American Gastrointestinal Endoscopic Surgeons and European Association for Endoscopic Surgery.

CHAPTER 2The Endoscopy Unit, Staff, and Management

Most endoscopists, and especially beginners, focus on the individual endoscopic procedures and have little appreciation of the extensive infrastructure that is necessary for efficient and safe activity. From humble beginnings in adapted single rooms, most of us are lucky enough now to work in large units with multiple procedure rooms full of complex electronic equipment, with additional space dedicated to preparation, recovery, and reporting.

Endoscopy is a team activity, requiring the collaborative talents of many people with different backgrounds and training. It is difficult to overstate the importance of appropriate facilities and adequate professional support staff, to maintain patient comfort and safety, and to optimize clinical outcomes.

Endoscopic procedures can be performed almost anywhere when necessary (e.g. in an intensive care unit), but the vast majority take place in purpose‐designed “endoscopy units.”

Endoscopy units

Details of endoscopy unit design are beyond the scope of this book, but certain principles are important to understand.

There are two types of endoscopy units:

Stand‐alone, office‐based procedure facilities

(called ambulatory endoscopy or surgical centers in North America) that deal mainly with healthy (or relatively healthy) outpatients, and generally resemble cheerful modern dental suites.

Hospital‐based units

which must also provide a safe environment for managing sick inpatients, more complex procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), and the whole range of therapeutic techniques. These units more closely resemble operating suites.

Functional planning

Units that serve both the above functions should be designed to separate patient flows as far as possible. The modern unit has areas designed for many different functions. Like a hotel or an airport (or a Victorian household), the endoscopy unit should have a smart public face (“upstairs”), and a more functional back hall (“downstairs”). From the patient’s perspective, the suite consists of areas devoted to reception, preparation, procedure, recovery, and discharge. Supporting these activities are many other “back hall” functions, which include scheduling, endoscope reprocessing, preparation, maintenance and storage of equipment, reporting and archiving, education and training, and staff management.

There should be spheres of activity for the endoscopist and assistants, as well as clean and dirty regions. One side of the room should be dedicated to endoscopy assistants who have easy access to accessories, supplies, and medications in cabinets directly behind them. On the other side of the room, the endoscopist should have a hand‐washing area and workstation available to them. If anesthesia is used, the associated medication and supplies should be located at the head of the bed.

Procedure rooms

The rooms used for endoscopic procedures should:

not be cluttered or intimidating

as most patients are not sedated when they enter, so it is better for the room to feel warm and comfortable rather than like an operating room.

be large enough

to allow a patient stretcher/trolley to be rotated on its axis, and to accommodate all of the equipment and staff (and any emergency team), but also compact enough for efficient function.

be laid out with function in mind

, keeping nursing, endoscopist, and anesthesiologist (when present) spheres of activity separate (

Fig 2.1

), and minimizing exposed trailing electrical cables and pipes (best by ceiling‐mounted beams).

Each room should have:

piped oxygen, CO

2

, suction, a water supply, and electrical outlets for ancillary equipment

;

Fig 2.1 Functional planning—showing logical separation of the spheres of activity for endoscopy team members.

lighting

planned to illuminate nursing activities but not overstimulate the patient or disrupt the endoscopist’s line of vision;

adjustable video monitors

placed ergonomically, directly in front of the endoscopist to allow for neutral neck and back postures, with adjustable height and location to accommodate varying heights and the endoscopist’s preferred viewing distance, ideally one on each side of the patient to allow all staff to view and respond during the procedure and enable the patient to view, if wished;

adequate counter space

for accessories, with hand‐washing facilities and a large sink or receptacle for dirty equipment;

storage space

for equipment, supplies, and medications required on a daily basis to assure items are available when needed;

systems of communication

with the charge nurse desk, and emergency call;

workstation with computer system

that enables data capture and management, recording and reporting of endoscopic procedures and audit of quality indicators, and, ideally, is integrated into the electronic health record system;

two doors

to allow for easy access and simultaneous entry of clean instruments and removal of used equipment;

disposal systems

for hazardous materials.

Units serving children should have age/size/weight‐appropriate equipment and pediatric‐specific, patient‐ and family‐centered processes for pre‐procedure and recovery phases of care with a goal to reduce anxiety and provide age‐appropriate care.

Patient preparation and recovery areas

Patients need a private place for initial preparation (undressing, safety checks, intravenous [IV] access), and a similar place in which to recover from any sedation or anesthesia. In some units these functions are separate, but can be combined to maximize flexibility. Many units have simple curtained bays, but rooms with solid side walls and a movable front curtain or door are preferable. They should be large enough to accommodate at least two people in addition to the patient on the stretcher, and all necessary monitoring equipment.

The “prep and/or recovery bays” should be adjacent to a central nursing workstation. Like the bridge of a ship, this is where the nurse captain of the day controls and steers the whole operation, and from which recovering patients can be monitored.

All units should have at least one private room for sensitive interviews/consultations before and after procedures.

Negative pressure rooms are preferred to help mitigate infection‐related risks, particularly related to coronavirus disease 2019 (COVID‐19), and to permit efficient air changeover between procedures. In resource‐limited settings, industrial‐grade high‐efficiency particulate (HEPA) filters may be a reasonable alternative.

Equipment management and storage

There must be designated areas for endoscope and accessory reprocessing, and storage of medications and all equipment, including an emergency resuscitation cart (or trolley). Many units also have fully equipped mobile carts to travel to other sites when needed, preferably in a designated storage area near the procedure rooms to avoid obstructing the hallways, as required by regulations.

Staff

Specially trained endoscopy assistants have many important functions. They:

prepare patients

for their procedures, physically and mentally;

set up

all necessary equipment;

assist

endoscopists during procedures;

monitor

patients’ safety, sedation, and recovery;

clean

, disinfect, and process equipment;

maintain quality control

.

Most endoscopy assistants are trained nurses, but technicians and nursing aides also have roles (e.g. in equipment processing). Large units need a variety of other staff, to handle reception, transport, reporting, and equipment management, including informatics.

Members of staff need places to change, store their clothes and valuables, and a break area for refreshments and meals.

Procedure reports

There are three broad areas of procedural documentation: nursing documentation before, during, and after the procedure, the endoscopy report, and a sedation record if a separate provider administers sedation. Space and workstations in the room are essential to maintain efficiency for the endoscopist and supporting team members.

Nursing record

The nurse’s report usually takes the form of a preprinted “flow sheet,” with places to record all of the pre‐procedure safety checks, personnel present, vital signs, use of sedation/analgesia and other medications, monitoring of vital signs and patient responses, equipment and accessory usage, and image documentation. It concludes with post‐sedation monitoring, documentation of the requirements for discharge, and discharge instructions given to the patient.

Procedure report

In many units, the endoscopist’s report is generated in the procedure rooms. In larger ones, there may need to be a separate work area designed for this purpose.

The report includes the patient’s demographics, reasons for the procedure (indications), specific medical risks and precautions, sedation/analgesia, findings, specimens, treatments, conclusions, follow‐up plans, and any adverse events. Endoscopists use many reporting methods—handwritten notes, preprinted forms, free dictation, and electronic endoscopy reporting systems. Recommended endoscopy reporting elements have been set out by endoscopy‐related societies, including the World Endoscopy Organization, the American Society for Gastrointestinal Endoscopy (ASGE), the Canadian Association of Gastroenterology, the European Society of Gastrointestinal Endoscopy, and the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition.

The paperless endoscopy unit

In many units nowadays, all reporting and photo‐documentation (nursing, administrative, and endoscopic) is incorporated into a comprehensive electronic endoscopy reporting system. Such systems substantially reduce the paperwork burden, facilitate standardized documentation, enable integration of histopathology, allow tracking and tracing of equipment, and increase both efficiency and quality assurance.

Management, behavior, and teamwork

Complex organizations require efficient management and leadership. This works best as a collaborative exercise between the medical director of endoscopy and the chief nurse or endoscopy nurse manager. The biggest units will also have a separate administrator. These individuals must be skilled in handling people (endoscopists, staff, and patients), complex equipment, and significant financial resources. They must develop and maintain good working relationships with many departments within the hospital (such as radiology, pathology, sterile processing, infection control, anesthesia, bioengineering), as well as numerous manufacturers and vendors. They also need to be fully cognizant of all of the many local and national regulations that now impact on endoscopic practice.

The wise endoscopist will embrace the team approach, and realize that maintaining an atmosphere of collegiality and mutual respect is essential for efficiency, job satisfaction, and staff retention, and for optimal patient outcomes.

It is also essential to ensure that the push for efficiency does not drive out humanity. Patients should not be packaged as mere commodities during the endoscopy process. Treating our patients (and those who accompany them) with respect and courtesy is fundamental. Always assume that patients are listening, even if they are apparently sedated, so never chatter about irrelevances in their presence. Maintain infection control practices and never eat or drink in patient areas. Background music is appreciated by many patients and staff but may potentially cognitively overload more novice endoscopists.

Documentation and quality improvement

The agreed policies of the unit (including regulations dictated by the hospital and national organizations) are enshrined in an Endoscopy Unit Procedure Manual. This must be easily available, constantly updated, and frequently consulted.

Day‐to‐day documentation includes details of staff and room usage, disinfection processes, medications, instrument and accessory use, as well as the procedure reports.

A formal quality assessment and improvement process is essential for maximizing the quality, safety and efficiency of endoscopy services. Professional societies have recommended methods and metrics for units to assess or demonstrate whether the services they provide are patient‐centered, safe, high‐quality, and appropriate. The ASGE has incorporated these into its Endoscopy Unit Recognition Program, and the benefit of concentrating on and documenting quality is well exemplified by the success of the endoscopy Global Rating Scale as a patient‐centered quality improvement tool in the United Kingdom and Canada.

The Society of Gastroenterology Nurses and Associates (SGNA) in the United States has an Infection Prevention Champion Program to guide units on ways of improving quality and helps to ensure that most current and safe practices are followed. SGNA recognizes endoscopy units that have shown a commitment to infection prevention, a supportive and educational work environment and positive patient outcomes through the Flame Award for Unit Excellence.

Educational resources

Endoscopy units should offer educational resources for all of its users, including patients, staff, and endoscopists. Clinical staff need a selection of relevant books, atlases, journals, and publications of professional societies. Many organizations also produce useful educational videos. Increasingly, many of these materials are available online, so easy internet access is essential.

Teaching units should embrace endoscopy simulators, which are valuable tools for training and assessment. Units should have dedicated time for education, and regular staff meetings.

Further reading

Armstrong D, Barkun A, Bridges R, et al. Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy.

Can J Gastroenterol

2012; 26(1):17–31.

Bretthauer M, Aabakken L, Dekker E, et al. Reporting systems in gastrointestinal endoscopy: Requirements and standards facilitating quality improvement: European Society of Gastrointestinal Endoscopy position statement.

United Eur Gastroenterol J

2016; 4(1):172–6.

Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: Report of an ASGE workshop.

Gastrointest Endosc

2010; 71(3):446–54.

Day LW, Muthusamy VR, Collins, J, et al. Multisociety guideline on reprocessing flexible GI endoscopes and accessories.

Gastrointest Endosc

2021; 93(1):11–33.

Hitchins CR, Metzner M, Edworthy J, et al. Non‐technical skills and gastrointestinal endoscopy: A review of the literature.

Frontline Gastroenterol

2018; 9(2):129–34.