Endoscopic Quality Research Articles

The gastrointestinal endoscopy satisfaction questionnaire captures patient satisfaction as a key quality indicator of gastrointestinal endoscopy.

Patient satisfaction is a crucial indicator of gastrointestinal endoscopy quality. The gastrointestinal endoscopy satisfaction questionnaire (GESQ) was validated for the assessment of patient satisfaction undergoing endoscopy in English with good validity. We translated and validated the GESQ in Dutch. The original GESQ was translated in Dutch according to the WHO guidelines. First, an internal validation of the Dutch GESQ (D-GESQ) was established by the think-aloud method and subsequent expert panel analysis. Next, the D-GESQ was embedded in the computer-based education (CBE) program in our unit, with 30-day interval after endoscopy. Adult patients, informed via CBE after undergone endoscopy, were included. Exclusion criteria were conscious sedation, limited language skills, no e-mail address available, dementia and visual impairment. For statistical analysis, several psychometric analyses were performed to identify the underlying dimensions and assessed the questionnaire for reliability and validity. In total, 227 of 1065 patients completed the D-GESQ, a response rate of 21.3%. Men comprised 52.6% (n = 129) of patients. Mean age was 62.7 ± 11.54 years. In total, 180 patients (79.3%) had previously undergone endoscopy, with 157 (87.2%) of them two or more times. The exploratory factor analysis showed the 21 questions could best be clustered into five clusters instead of four in the original GESQ. The D-GESQ had an overall Cronbach α of 0.88, confirming the high internal validity. The Dutch version of the GESQ showed high internal validity and practicality. We recommend the D-GESQ for routine use in endoscopy practice to improve quality of patient care.

Adequacy of EGD Reporting: a Review of 100 Reports from 100 Endoscopists

IntroductionEsophagogastroduodenoscopy (EGD) is commonly performed in patients with gastroesophageal reflux disease (GERD). An EGD report should document pertinent findings such as esophagitis, a columnar-lined esophagus (CLE), the location of the squamo-columnar and gastroesophageal junctions, the size and type of a hiatal hernia and the number and location of any biopsies. The aim of this study was to evaluate how commonly these findings were noted in the EGD reports of patients referred for antireflux surgery. MethodsA retrospective review was performed of patient charts from 2012 to 2015 to identify 100 consecutive EGD reports from different endoscopists in different patients. Each EGD report was reviewed for pertinent findings and the use of a classification system for esophagitis (Savory-Miller or Los Angeles) and for reporting a CLE (Prague). ResultsIn 100 EGD reports, esophagitis was noted in 33 patients, but was graded in only 14 (42%). A CLE was noted in 28 patients, but the length was reported in only 16 (57%) and no report used the Prague classification system. A hiatal hernia was noted in 61 patients, measured in 31 (51%) and the type classified in 26%. A biopsy was taken in 93 patients and the location noted in 86 patients (93%). The number of biopsies was recorded in only 20 patients (22%). In 12 patients the EGD was for Barrett’s surveillance, yet a Seattle biopsy protocol was reported to be used in only 3 patients. ConclusionEndoscopy reports frequently do not include the use of a grading system for esophagitis or the Prague system for CLE. This hampers the assessment of change with therapy or over time. The size of a hiatal hernia was typically reported in a subjective fashion and only infrequently was the type specified. Lack of clarity about the presence of a paraesophageal hernia can impede evaluation of acute symptoms. In patients with Barrett’s esophagus a standard biopsy protocol was infrequently reported to be used. These findings raise concern about the quality of upper endoscopy, both in the performance of the procedure and the documentation of findings. A consistent reporting system is recommended for routine use with upper endoscopy.

Effect of gastric lavage with hemostasis powder® on upper gastrointestinal bleeding (Conversion of emergency endoscopy to elective endoscopy).

Background:From many years ago, gastric lavage has been one of the main pillars of the classic treatment for upper gastrointestinal bleeding (UGIB). The present study investigated the effect of gastric lavage with hemostatic powder on the UGIB complications.Methods:This clinical trial study was performed on 54 patients who referred to the emergency department during 2017-2018. The subjects were divided into two groups (n=27 per group). Gastric lavage with saline and hemostasis powder® was performed in the control and experimental groups, respectively. The patients' information was collected and analyzed using SPSS software Version. 18. The significance level was set to p<0.05%.Results:In this study,59.2% and 18.5% of the patients in the gastric lavage with Hemostasis Powder® and saline required no treatment during the early endoscopy, respectively (p=0.002). The duration of endoscopy was shorter in the experimental group (p=0.001), (4.83±8.04 hours vs.6.73±14.12 hours, respectively) (p=0.001). Moreover, the gastric lavage with Hemostasis Powder® significantly improved the quality of endoscopy .There was no difference between the two groups in terms of their need for blood transfusion (p=0.4).Conclusion:Gastric lavage with hemostasis powder® is a useful measure in the primary treatment of patients with UGIB and can convert emergency therapeutic endoscopy to diagnostic elective endoscopy with higher quality.

Overutilization of Endoscopic Surveillance in Barrett's Esophagus: The Perils of Too Much of a Good Thing.

A cost-utility analysis in the current issue of AJG examines the ramifications of the overuse of surveillance endoscopy in Barrett's esophagus (BE). This study suggests that excess surveillance is expensive, increasing costs by 50% or more, with only nominal increases in quality-adjusted life expectancy. This study joins a growing literature of cost-utility analyses that suggest that more is not likely better when it comes to surveillance endoscopy. Given the plentiful literature showing overutilization of surveillance endoscopy in BE, the authors argue for a focus on the quality of endoscopy rather than increased frequency of surveillance to improve returns on our healthcare investment.

Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system

BackgroundNon-technical skills (NTS) are crucial to effective team working in endoscopy. Training in NTS has been shown to improve team performance and patient outcomes. As such, NTS training and assessment...

The Italian Society for Digestive Endoscopy (SIED) accreditation and quality improving project based on international standards.

Background and study aims Accreditation of endoscopy services, using valid quality indicators, may address failures to comply with quality standards between endoscopy services. The aim of this work was to present the Italian Society for Digestive Endoscopy (SIED) accreditation model and its effectiveness. Methods A team of eight endoscopists identified quality indicators derived from international guidelines and assessed them in each center voluntarily requesting accreditation. During a 1-day site visit, two expert endoscopists, the representative of the independent and international administrative certification body and a professional nurse evaluated the endoscopy center, by direct observation of the endoscopy team and examination of the medical records Results In all centers we noted shortcomings in instrument reprocessing. In 30 of 40 centers (75 %) the information in the nursing charts was incomplete. Sampling for Helicobacter pylori had not been done in 12 of 40 centers (30 %). In six of 40 centers (15 %) the adenoma detection rate for each endoscopist had not been evaluated. Post-polypectomy intervals were inappropriate in 12 of 40 centers (30 %). We noted a statistically significant difference ( P < 0.001) between the answers to the SIED checklist of indicators submitted to the inspection team for accreditation before the site visit and the situation found for colonoscopy on site. As of June 30, 2018, 18 endoscopy centers had been accredited and 10 centers had not yet being accredited because they had not completed the measures to correct points raised at the visits. Conclusions Numerous Italian endoscopy centers fail to meet important quality indicators. Our accreditation program can provide means for detecting these problems and correcting them by implementing SIED standards.

Application of artificial intelligence in real-time monitoring of withdrawal speed of colonoscopy

Objective To construct a real-time monitoring system based on computer vision for monitoring withdrawal speed of colonoscopy and to validate its feasibility and performance. Methods A total of 35 938 images and 63 videos of colonoscopy were collected in endoscopic database of Renmin Hospital of Wuhan University from May to October 2018. The images were divided into two datasets, one dataset included in vitro, in vivo and unqualified colonoscopy images, and another dataset included ileocecal and non-cecal area images. And then 3 594 and 2 000 images were selected respectively from the two datasets for testing the deep learning model, and the remaining images were used to train the model. Three colonoscopy videos were selected to evaluate the feasibility of real-time monitoring system, and 60 colonoscopy videos were used to evaluate its performance. Results The accuracy rate of the deep learning model for classification for in vitro, in vivo, and unqualified colonoscopy images was 90.79% (897/988), 99.92% (1 300/1 301), and 99.08% (1 293/1 305), respectively, and the overall accuracy rate was 97.11% (3 490/3 594). The accuracy rate of identifying ileocecal and non-cecal area was 96.70% (967/1 000) and 94.90% (949/1 000), respectively, and the overall accuracy rate was 95.80% (1 916/2 000). In terms of feasibility evaluation, 3 colonoscopy videos data showed a linear relationship between the retraction speed and the image processing interval, which indicated that the real-time monitoring system automatically monitored the retraction speed during the colonoscopy withdrawal process. In terms of performance evaluation, the real-time monitoring system correctly predicted entry time and withdrawal time of all 60 examinations, and the results showed that the withdrawal speed and withdrawal time was significantly negative-related (R=-0.661, P<0.001). The 95% confidence interval of withdrawal speed for the colonoscopy with withdrawal time of less than 5 min, 5-6 min, and more than 6 min was 43.90-49.74, 40.19-45.43, and 34.89-39.11 respectively. Therefore, 39.11 was set as the safe withdrawal speed and 45.43 as the alarm withdrawal speed. Conclusion The real-time monitoring system we constructed can be used to monitor real-time withdrawal speed of colonoscopy and improve the quality of endoscopy. Key words: Quality control; Artificial intelligence; Colonoscopy; Withdrawal time; Withdrawal speed

Artificial intelligence in gastrointestinal endoscopy: general overview.

Artificial intelligence (AI) is now a trendy subject in clinical medicine and especially in gastrointestinal (GI) endoscopy. AI has the potential to improve the quality of GI endoscopy at all levels. It will compensate for humans’ errors and limited capabilities by bringing more accuracy, consistency, and higher speed, making endoscopic procedures more efficient and of higher quality. AI showed great results in diagnostic and therapeutic endoscopy in all parts of the GI tract. More studies are still needed before the introduction of this new technology in our daily practice and clinical guidelines. Furthermore, ethical clearance and new legislations might be needed. In conclusion, the introduction of AI will be a big breakthrough in the field of GI endoscopy in the upcoming years. It has the potential to bring major improvements to GI endoscopy at all levels.

A prospective randomized controlled trial comparing simethicone, N-acetylcysteine, sodium bicarbonate and peppermint for visualization in upper gastrointestinal endoscopy.

Early cancer detection is crucial in improving the patients' quality of life and upper gastrointestinal endoscopy (EGD) plays a key role in this detection. Many clearing mechanisms may be applied to create good endoscopic visualizations for the upper gastrointestinal tract using mucolytic agents, antifoaming agents, proteolytic enzymes and neutralizers. The aim of this study is to compare the effects of simethicone, N-acetylcysteine (NAC), sodium bicarbonate and peppermint as pre-medications for visualization of esophagogastroduodenoscopy (EGD). This study was a single center prospective randomized controlled trial. The patients were randomly allocated to one of four treatment groups. Group A: water; Group B: water with simethicone; Group C: water with simethicone plus NAC 600mg; Group D: water with simethicone, NAC, sodium bicarbonate and peppermint. A total of 128 patients were enrolled and evaluated in this study. Total visibility score (TVS) of Groups A, B, C, and D were 13.4 ± 1.86, 10.5 ± 1.45, 7.15 ± 0.98 and 6.4 ± 1.43, respectively. Group D showed lower TVS than other groups. The procedural durations of Groups C and D were significantly shorter than Group A. The volume of solution for mucosal cleansing of Groups C and D was significantly lower than Groups A and B. The application of simethicone plus NAC is safe, improves endoscopic visualization and requires a minimal amount of mucosal cleansing solution. The addition of sodium bicarbonate and peppermint further improved visualization for the upper and lower gastric body. Thai Clinical Trials Registry (TCTR) with a reference number; TCTR20190501002.

How to Manage a Patient With Gastric Intestinal Metaplasia: An International Perspective

How to Manage a Patient With Gastric Intestinal Metaplasia: An International Perspective

Acute Exacerbations in Recurrent Acute Rhinosinusitis: Differences in Quality of Life and Endoscopy.

Research surrounding outcome differences for patients with recurrent acute rhinosinusitis (RARS) is scarce. This investigation explored quality of life (QOL) and sinonasal attributes in patients during acute episodes (AEs) and in-between AEs of RARS. Retrospective outcomes research. Data from patients with RARS were collected from two academic institutions between 2009 and 2017 using prospective and retrospective methodology. During clinical presentation, subjects were classified as with or without an AEs using guideline definitions of acute bacterial rhinosinusitis (ABRS). Between-group differences in 22-item Sino-Nasal Outcome Test (SNOT-22) survey and Lund-Kennedy (LK) endoscopy scores were assessed. Four hundred twenty-three clinical visits from 202 patients were included. Visits during an AE (168/423, 40%) were associated with significantly worse SNOT-22 total scores compared to between AEs (255/423, 60%; median = 53.0 [interquartile range (IQR) = 24.0] vs. 34.0 [IQR = 29.5]) and all SNOT-22 subdomain scores (all P < .001). LK scores were available for 167 visits, with 56 (34%) completed during an AE. Compared to visits without an AE, endoscopy findings associated with an AE were less frequently normal (LK score = 0, 45% vs. 62%, P = .031) with worse median LK scores (2.0 [IQR = 4.0] vs. 0.0 [IQR = 2.0], P = .005). AEs are associated with significantly worse QOL and mildly worse endoscopic findings. Almost half of visits during AEs had negative endoscopy, identifying a disparity between patient symptoms and objective findings and calling into question alternative or concomitant diagnoses. Diagnostic criteria for ABRS or AEs in RARS do not require objective confirmation of inflammation, presenting a conundrum for clinicians. The potential for overdiagnosis of ABRS and AEs should be considered when determining the risk/benefit ratio of treatments for RARS. 2c Laryngoscope, 2019.

Quality in Biliary and Pancreatic Endoscopy Meeting – Critical Appraisal

The Portuguese Society of Digestive Endoscopy (SPED) organized its’ second Quality Meeting in 20th September 2019. This one-day meeting debated some of the performance measures suggested in the 2018 publication “Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative” [1]. The initial conference, “How to audit quality in pancreatobiliary endoscopy” was presented by Lars Aabaken. During the day the 134 participants debated multiple other themes about ERCP and Endoscopic Ultrasonography. A final Quizz was won by three participants that received an inscription in the 3rd Quality Meeting that will take place in 18th September 2020, and colonoscopy will be the main focus.

Acceptability of endoscopic procedures and patients' willingness to repeat them: a single-centre nursing study of influential factors

Background: Patient satisfaction and factors that influence it have become an important indicator of the quality of digestive endoscopy. Aims: This study aimed to define variables that make endoscopic procedures acceptable and those that predispose patients to repeat them under the same conditions. Methods: Consecutive outpatients undergoing endoscopic examinations completed questionnaires, administered by the nursing staff, before and after the procedure. Univariate analysis and multivariate logistic regression models were designed to investigate independent variables associated with the following outcomes of interest. Findings: Most patients experienced pain and anxiety before and during the procedure, considered the procedure unacceptable and felt unwilling to repeat it. Conclusion: Symptoms strictly related to the patient, specifically anxiety and pain and type of sedation received, were the main factors related to satisfaction and willingness to repeat the procedure under the same conditions.

Does Colon Polyp Surveillance Improve Patient Outcomes?

Colon polyp surveillance now accounts for 25% of all colonoscopies performed. The evidence that colonoscopy surveillance reduces colorectal cancer (CRC) incidence or mortality is weak. The biology of the baseline lesions and quality of the baseline exam are two primary factors contributing to post-colonoscopy CRC. Prior recommendations for surveillance were based largely on the likelihood that patients with adenomas would develop advanced adenomas, a surrogate for CRC. There is now evidence that baseline colonoscopy findings are strongly associated with the risk of incidence or death from CRC. This evidence provides a basis for updated evidence-based recommendations for surveillance. In addition, there is also growing evidence that the quality of the baseline exam is an important predictor of the likelihood of developing post-colonoscopy CRC.

Chinese consensus of early colorectal cancer screening (2019, Shanghai)

The patients with colorectal cancer in Chinese population are increasing, which is a serious threat to human life and health. In order to improve the high incidence, high mortality and low early diagnosis rate of colorectal cancer and promote cancer screening program in China, leading by the National Clinical Research Center for Digestive Disease (Shanghai), relying on Gastrointestinal-Cancer Prevention & Treatment Center Alliance, in conjunction with a number of related societies, we organized multidisciplinary experts including gastroenterology, digestive endoscopy, oncology, health management and endoscopic quality control to jointly develop this consensus. This consensus aims to establish and refine early colorectal cancer screening protocol adapting to our national conditions and guide the screening practice.

1858 Corneal Injury After Routine Gastrointestinal (GI) Endoscopy With Moderate Sedation

INTRODUCTION: Corneal abrasion is the most common ocular adverse event from deep sedation and general anesthesia. Its occurrence during moderate sedation for gastrointestinal (GI) endoscopy has not been previously reported. We report 5 cases of corneal abrasion following standard GI endoscopy under moderate sedation. CASE DESCRIPTION/METHODS: Retrospective chart review of ocular adverse events during endoscopy collected prospectively from our endoscopy quality system. 5 cases were identified from May 2013 to January 2019. All patients (4 men, 1 woman; age 45-76) underwent routine endoscopy (2 upper endoscopies, 2 colonoscopies, 1 upper endoscopy and colonoscopy) and noted ocular discomfort during recovery from the procedure. All procedures were performed under moderate sedation with 4 patients receiving non-anesthesiologist administered propofol sedation in our hospital endoscopy lab and the 5th patient receiving monitored anesthesia care (MAC) propofol sedation in the medical ICU. Procedure times ranged from 15 minutes to 2 hours 18 minutes. Oxygenation methods included two by nasal cannula (4L/min and 6L/min), two by non-rebreather mask (12 L/min), and one by Bilevel positive airway pressure mask (BiPAP). Ophthalmological examination confirmed the presence of a corneal abrasion in all cases. No patients had prior ocular disease or injury. DISCUSSION: Moderate sedation for GI endoscopy is very safe, but there exists a risk for corneal injury which has not been previously reported. Endoscopists and unit staff should be made aware of this complication, which is likely underrecognized. Training to ensure patient’s eyelids are fully closed during procedure, supplemental oxygen delivery systems are properly fitted and that there is no direct contact between the dependent eye and underlying head support can prevent this complication.

Updates on the Disinfection and Infection Control Process of the Accredited Endoscopy Unit.

A thorough disinfection and infection control process associated with gastrointestinal endoscopy is highly important for the health and safety of the examinee and the medical staff involved in the procedure. Endoscopic reprocessing and disinfection are two of the most important steps in quality control of endoscopy. In 2019, the Korean Society of Gastrointestinal Endoscopy updated the Accreditation of Qualified Endoscopy Unit assessment items for these quality indicators. Assessment of disinfection and infection control comprises 28 mandatory items in the categories of disinfection education, pre-cleaning, cleaning, disinfection, rinsing, drying, reprocessing, storage, endoscopic accessories, water bottle and connectors, space/facilities, personal protective equipment, disinfection ledger, and regulations regarding infection control and disinfection.The updated Accreditation of Qualified Endoscopy Unit assessment items are useful for improving the quality of endoscopy by ensuring thorough inspection of endoscopic disinfection and infection control.

A review of quality metrics in colonoscopy

Colonoscopy is a commonly performed procedure with increasing use across medical specialties including gastroenterology, general surgery, colorectal surgery, and primary care. Over the past several decades, studies have demonstrated variation in colonoscopy quality with regard to adenoma detection rate and missed colorectal cancers among endoscopists within the same specialty and more significantly, across specialties. There is mixed literature suggesting that gastroenterologists may have better adenoma detection rates and colonoscopy completion rates than other specialists including surgeons, possibly related to practice volume and training. In an effort to standardize colonoscopy and improve overall outcomes, the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology Task Force on Quality in Endoscopy (ASGE/ACG) published a list of pre-, intra-, and post-procedure quality metrics in colonoscopy with associated performance targets. Surgeon endoscopists should be prepared to evaluate their performance based on these quality metrics. There is ongoing investigation into various new possible performance metrics in an effort to define exactly which metrics best correlate with clinical outcomes. In addition, the method to most accurately and efficiently document colonoscopy performance metrics and outcomes is not standardized, but the use of video recording especially in the era of the electronic medical record may be of value.

The Effect of Midyear Report Cards on Colonoscopy Quality Measures.

Introduction Since 2011, our institution has distributed annual reports, in June, to providers with personalized data regarding adenoma detection rate (ADR), colonoscope withdrawal time (CW), and cecal intubation (CI) rate, using standardized reporting systems. We examined the impact of distribution of individualized reports at the midpoint of each year on colonoscopy outcomes in the latter half of each year. Methods Providers with endoscopy privileges, performing ≥20 colonoscopies/year, at our center throughout a five-year period (2011-2015) were included. The three metrics recorded and reported were ADR, CW, and CI using standard benchmark rates. The mean values of each metric from January through June (1st half) and July through December (2nd half) were calculated. Curve estimation test was used to determine the significance of ADR in the respective time period. Results Fifteen providers were eligible for the study. Collective ADR in the 1st half of all years was 26.9% and in the second half of all years was 28.1% (p = 0.476). CW for all years was more than 9 minutes while CI was above 90% for all providers. There was no significant increase in the CI and CW during the 5-year study period. Overall, ADR increased from 26.43% (2011) to 33.47% (2015) (p = 0.137). When examining ADR during each of the 12 months following the June report cards, there was no month-to-month trend observed (p = 0.893). Conclusion Endoscopists at our institutions met/exceeded the quality metrics in the first half of each year from the beginning of the study. Routine reporting may maintain, but not improve, outcomes. Long-term studies to determine if periodic feedback to endoscopists improves the quality of endoscopy as per national standards for detection of early colorectal cancers are required.

Development of a national automated endoscopy database: The United Kingdom National Endoscopy Database (NED).

The National Endoscopy Database (NED) project commenced in 2013 under the auspices of the Joint Advisory Group. The aim is to upload endoscopy procedure data from all units across the United Kingdom to a centralised database. The database can be used to facilitate quality assurance, research and training in endoscopy. This article describes the development and implementation process of NED from its inception to date. NED utilises automated data uploading of a minimum dataset from local endoscopy reporting systems to a central national database via the internet. Currently all data are anonymised. Key performance indicators are presented to endoscopists and organisations on a web-based platform for quality assurance purposes. As of October 2018, 295 endoscopy services out of a total of 529 known services in the UK (56%) are actively uploading to NED. Data from more than 400,000 endoscopic procedures have been uploaded. UK-wide data collection from endoscopy units to a central database is feasible using an automated upload system. This has the potential to facilitate endoscopy quality assurance and research.