Gastrointestinal Endoscopy Unit Research Articles

Experience of an interdisciplinary anaesthesiology and nursing team in a gastrointestinal endoscopy unit

Experience of an interdisciplinary anaesthesiology and nursing team in a gastrointestinal endoscopy unit

DEVELOPMENT OF GASTROINTESTINAL ENDOSCOPY IN MALAYSIA: A HISTORICAL PERSPECTIVE WITH SPECIAL REFERENCE TO THE EXPERIENCE AT THE UNIVERSITY OF MALAYA MEDICAL CENTRE

Gastrointestinal endoscopy started in the early 1970s in Malaysia with the help of Japanese doctors. It has evolved over the past 30 years. The gastrointestinal endoscopy unit at the University of Malaya Medical Centre has been in the forefront in providing endoscopy services to patients as well as training doctors in endoscopy in the country. In recent years, trainees have included those from neighboring countries in South-East Asia. Among our most significant achievements is the organization of regular international therapeutic endoscopy workshops since 1993 where leading endoscopists from throughout the world have accepted our invitation as teaching faculty. In 2008, the World Organization of Digestive Endoscopy accorded the high distinction of Centre of Excellence to the endoscopy unit of the University of Malaya Medical Centre.

Occupational risk prevention in endoscopy units: a pending issue

The degree of Knower and compliance with occupational risk prevention measures in the Spanish gastrointestinal endoscopy units is unknown. 1. To assess compliance with occupational risk prevention measures in GIE units. 2. To determine which factors influence the fulfillment of occupational risk prevention measures. a validated survey was supplied to 300 GIE units, including questions on: 1. General occupational risk prevention measures; 2. occupational risk prevention measures during disinfection; 3. occupational risk prevention measures during examination. The following Hospital or GIE Unit characteristics were evaluated: Type of hospital according to the Spanish National Health Service; Number of hospital beds; Advanced diagnostic and therapeutic procedures performed and; Centers providing training in the field of endoscopy. response: 196 GIE units (65%). 104 GIE units (53% CI95%: 46-60) fulfill less than 50% of the occupational risk prevention measures studied.The RR of less than 50% of the ORP measures being fulfilled is 1.975 times higher at public hospitals than at private facilities (CI95%: 1.11-3.52). None of the remaining factors analyzed proved to have a significant influence. compliance with occupational risk prevention measures in Spanish GIE units is inadequate and must be improved. Public hospitals in Spain comply with fewer occupational risk prevention measures than their private counterparts.

Quality improvement project eliminates falls in recovery area of high volume endoscopy unit

BackgroundThe authors' high-volume gastrointestinal endoscopy unit developed an infrastructure to track complications associated with endoscopic procedures in January of 2008. A result of this effort was the identification of a...

Narrow-band imaging without magnification for detecting early esophageal squamous cell carcinoma

To compare narrow-band imaging (NBI) without image magnification, and chromoendoscopy with Lugol's solution for detecting high-grade dysplasia and intramucosal esophageal squamous cell carcinoma (SCC) in patients with head and neck cancer. This was a prospective observational study of 129 patients with primary head and neck tumors consecutively referred to the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, São Paulo University Medical School, Brazil, between August 2006 and February 2007. Conventional examinations with NBI and Lugol chromoendoscopy were consecutively performed, and the discovered lesions were mapped, recorded and sent for biopsy. The results of the three methods were compared regarding sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood value and negative likelihood value. Of the 129 patients, nine (7%) were diagnosed with SCC, 5 of which were in situ and 4 which were intramucosal. All carcinomas were detected through NBI and Lugol chromoendoscopy. Only 4 lesions were diagnosed through conventional examination, all of which were larger than 10 mm. NBI technology with optical filters has high sensitivity and high negative predictive value for detecting superficial esophageal SCC, and produces results comparable to those obtained with 2.5% Lugol chromoendoscopy.

Bowel preparation for colonoscopy: Enema versus Sodium Phosphate

Colonoscopy is considered to be the gold standard investigation for assessing the colonic mucosa. Good bowel preparation is essential in order to achieve optimal visualisation of the mucosa. Traditionally water enema is used for bowel preparation in most centres in Nigeria. This prospective study was performed at the Gastrointestinal Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between July 2008 and June 2009. This study compared patients' tolerability, adverse effects, efficacy and mean duration of colonoscopy of water enema and sodium phosphate (NaP) for bowel preparation toward colonoscopy. Standard structured questionnaire was completed by 64 patients and the colonoscopist assessing tolerability, adverse effect, efficacy and mean duration of the procedure. There were sixty four patients aged between 22 to 86 years. The mean age was 58.16 ± 15.790. Thirty eight (59.4%) patients were in patients and 26 (40.6%) were out patients. Forty one (64.1%) patients had water enema while 23 (35.9%) patients were included in the NaP group. The median age for patients in both groups was 62.0 years. Patients in NaP group rated their bowel preparation as more tolerable and found the dietary restriction much easier than those in water enema group (p < 0.0001). Better colon cleansing score was found in patient in NaP group as compared with those in water enema group in all region of the colon. The procedure took significantly longer time in patients in water enema group as compared with those in NaP group (p < 0.0001). NaP has a better bowel cleansing score for colonoscopy than water. It has better tolerability, side effect profile, efficacy and gives a shorter mean duration for the procedure.

Lactobacillus reuteri (DSM 17938) in Infants with Functional Chronic Constipation: A Double-Blind, Randomized, Placebo-Controlled Study

To evaluate the beneficial effects of Lactobacillus reuteri (DSM 17938) in infants with functional chronic constipation. A double-blind, placebo-controlled, randomized study was conducted from January 2008 to December 2008 in 44 consecutive infants at least 6 months old (mean age+/-SD, 8.2+/-2.4 SD; male/female, 24/20) admitted to the Gastrointestinal Endoscopy and Motility Unit of the Department of Pediatrics, University "Federico II" of Naples, with a diagnosis of functional chronic constipation. The 44 infants with chronic constipation were randomly assigned to 2 groups: group A (n=22) received supplementation with the probiotic L reuteri (DSM 17938) and group B (n=22) received an identical placebo. Primary outcome measures were frequency of bowel movements per week, stool consistency, and presence of inconsolable crying episodes, recorded in a daily diary by parents. Infants receiving L reuteri (DSM 17938) had a significantly higher frequency of bowel movements than infants receiving a placebo at week 2 (P=.042), week 4 (P=.008), and week 8 (P=.027) of supplementation. In the L reuteri group, the stool consistency was reported as hard in 19 infants (86.4%) at baseline, in 11 infants (50%) at week 2, and in 4 infants (18.2%) at weeks 4 and 8. However, there was no significant difference between L reuteri and placebo groups in the stool consistency at all weeks (P=.63, week 2; P=.38, week 4; P=.48, week 8). Similarly, there was no statistically difference in the 2 groups in the presence of inconsolable crying episodes. No adverse effects were reported. The administration of L reuteri (DSM 17938) in infants with chronic constipation had a positive effect on bowel frequency, even when there was no improvement in stool consistency and episodes of inconsolable crying episodes. Because of their safety profile, probiotics may be an attractive option in the treatment of functional constipation.

Lymphocytic colitis presenting as difficult diarrhoea in an African woman: a case report and review of the literature

IntroductionLymphocytic colitis is an uncommon intestinal disorder that presents with chronic diarrhoea. It is treatable, but in the developing world, its diagnosis may often prove difficult. Data and reports of this condition in Africa are scarce because most medical centres lack a functional gastrointestinal endoscopy unit that would aid in the diagnosis.Case presentationWe present the case of a 53-year-old Nigerian woman with pathogen-negative chronic diarrhoea and a family history of chronic diarrhoea. She responded well to treatment after colonoscopy and colonic biopsy successfully diagnosed her illness.ConclusionReferral of patients with pathogen-negative chronic diarrhoea to medical centres that have facilities for colonoscopy and biopsy is important in the developing world.

Advancements in endoscopic imaging for the detection of esophageal dysplasia and carcinoma

Advanced esophageal cancer, whether squamous cell or adenocarcinoma associated with Barrett's disease, carries a dismal prognosis. Dysplasia and early carcinoma, however, are amenable to surgery or endotherapy using techniques such as endoscopic resection, photodynamic therapy, and radiofrequency ablation. Therefore, the early detection of esophageal dysplasia and neoplasia is one of the most important goals of gastrointestinal endoscopy. This article will review several endoscopic imaging techniques and technologies that have been developed to enhance the visualization of mucosal glandular and vascular changes associated with early neoplasia, including the use of chromoendoscopy using vital dyes and stains. Also, reviewed in this article are endoscopic innovations that have received regulatory approval, are commercially available, and are supported by controlled clinical studies confirming their utility, such as high-resolution endoscopy and virtual chromendoscopy using narrow band imaging. The use of confocal laser endomicroscopy will be discussed, as this device provides real-time, histology-like information of cellular and vascular architecture. These technologies move us closer to the reality of an optical biopsy, with a tissue biopsy diagnosis made in the gastrointestinal endoscopy unit. In addition to emphasizing the practical aspects of these techniques, this article will summarize other advanced imaging technologies that await regulatory approval, commercial availability, and clinical validation.

Endoscopic Imaging for the Detection of Esophageal Dysplasia and Carcinoma

Numerous endoscopic imaging modalities have been developed and introduced into clinical practice to enhance diagnostic capabilities. In the past, detection of dysplasia and carcinoma of the esophagus has been dependent on biopsies taken during standard white-light endoscopy. Recent important developments in biophonotics have improved visualization of these subtle lesions sufficiently for cellular details to be seen in vivo during endoscopy. These improvements allow diagnosis to be made in gastrointestinal endoscopy units, thereby avoiding the cost, risk, and time delay involved in tissue biopsy and resection. Chromoendoscopy, narrow-band imaging, high-yield white-light endoscopy, Fujinon intelligent color enhancement, and point enhancement such as confocal laser endomicroscopy are examples of enhanced imaging technologies that are being used in daily practice. This article reviews endoscopic-based imaging techniques for the detection of esophageal dysplasia and carcinoma from the perspective of routine clinical practice.

Use of sedation in gastrointestinal endoscopy: a nationwide survey in Spain

Gastrointestinal endoscopy causes discomfort and pain in patients. Sedation reduces anxiety and pain. Its use, however, continues to be a controversial issue and it varies greatly from one country to another. The use of sedation in Spanish gastrointestinal endoscopy (GIE) units is unknown. To determine the use of sedation in Spanish GIE units. A 24-question survey on the use of sedation was distributed among 300 Spanish GIE units. Surveys were answered by 197 GIE units (65%), which had performed 588,326 endoscopies over the past 12 months. Sedation was used in more than 20% of gastroscopies performed at 55% of the GIE units, and more than 20% of colonoscopies were sedated at 71% of the units; endoscopic retrograde cholangiopancreatography (ERCP) is almost always performed under sedation. The most common drugs were midazolam for gastroscopy and midazolam and pethidine for colonoscopy and ERCP; propofol is used by anesthetists; pulse oximetry is used at 77% of GIE units; 42% of the GIE units fill in a nursing record; 52% of GIE units have recovery rooms and 91% have a cardiac arrest trolley. The use of sedation in endoscopy varies greatly in Spain. It is seldom used in gastroscopy; it is more frequent in colonoscopy, and in ERCP it is the norm. In most GIE units sedation is controlled by the endoscopist with pulse oximetry. The most commonly used drugs are benzodiazepines, on their own for gastroscopy and combined with opioids for colonoscopy and ERCP.

Impact of a Continuous Quality Improvement Program on Infection Control of Endoscopes

Bolak Eldakror Hospital is a secondary care governmental hospital in Giza, Egypt. the Gastrointestinal endoscopy unit was founded in 1999. A written protocol for endoscope decontamination based on international standards was implemented and an ongoing quality assurance program was established in 2003 when we commenced bacteriological monitoring of endoscopes. Pseudomonas aeruginosa was found in a specimen obtained from a colonoscope. the unit guidelines were reviewed. the cause of contamination was a breach in reprocessing technique. A nurse admitted that she did not remove or clean the cap in the distal tip of the colonoscope at the end of a long busy day. We reprocessed and sampled the colonoscope. the new specimen yielded no growth. the staffing system was changed to secure a balance between the number of cases and work hours. A disinfection logbook and reprocessing checklists were provided for the nurses to record decontamination procedures.

A Quality Initiative to Decrease Pathology Specimen–Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center

Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen-labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site and correct patient by both the endoscopy nursing staff and the endoscopist for each specimen bottle. We reviewed the number of specimen-labeling errors from our endoscopy unit for the first 3 months of 2007, before the implementation of the initiative, and for the first 3 months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two-provider confirmation of correct site, correct patient specimen labeling. The RFID system we used was an off-the-shelf 3M (St. Paul, MN) Library Sciences RFID system modified and installed for our purposes. Specimen-labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) or Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen-bottle labeling errors before and after the initiation of this new system. In the first 3 months of 2007, our endoscopy unit sent 8,231 specimen bottles to our pathology laboratory for evaluation; 8,539 bottles were sent in the first 3 months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P<0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and 10 (0.12%) in the first quarter of 2008 (P<0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected before the processing of the specimens in the pathology laboratory (P=0.001). These data confirm that the initiation of a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by two health-care providers significantly decreased specimen-labeling errors at every level in a high-volume endoscopy center.

NOTES oder endoskopische Chirurgie über natürliche Körperöffnungen – Training und Ausbildung

In NOTES natural orifices are used to enter the abdominal cavity. Extensive training is required and mentioned by the NOSCAR Consortium in the white paper as an important precondition prior to any introduction of this technique in clinical practice. These techniques also require certain skills and experience such as flexible endoscopic as well as advanced laparoscopic experience and extensive knowledge in abdominal surgery. These Skills and this knowledge is trained in modern gastrointestinal surgery units and gastroenterologic endoscopy units. Only when NOTES techniques are extensively trained in the box-model and the trainee has gotten acquainted with all the special instruments, a training in an animal model is justified. In addition, training within the team, starting with the box-work is important to prepare the team for the clinical step.

Satisfacción del paciente con la endoscopia digestiva: resultados de un estudio multicéntrico

The aim of this study was to determine the main quality problems perceived by patients in gastrointestinal endoscopy through a satisfaction survey. A total of 321 patients from five gastrointestinal endoscopy units were included. Telephone interviews using a previously validated questionnaire on several aspects related to the procedure were carried out. Pareto analyses were performed to pinpoint the most common aspects among the vital few causes at each medical center. Based on the questionnaire, the satisfaction indicators were calculated for each center: the overall satisfaction score (the sum of the responses to the eight questions) and the rate of perceived problems (number of questions with a negative response divided by the number of questions asked). The most frequent aspects among the vital few were waiting time for an appointment and discomfort during the examination, since both factors were included in the vital few in four of the five medical centers. Significant differences were found among centers in the overall satisfaction score (questionnaire score) (p < 0.001) and for the rate of perceived problems (p < 0.001). According to the patients, the most problematic aspects were waiting time until the day of the appointment and discomfort during the examination. Perceived quality differed among the participating centers.

A Quality Initiative to Decrease Pathology Specimen Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center

Purpose: Our institution has had problems with mislabeling of tissue specimens in our gastrointestinal and colorectal surgery endoscopy units. Most labeling errors have been due to either the wrong patient label or no label being affixed to a specimen bottle. As a result, an initiative was created to reduce the number of specimen labeling errors. This initiative involved the application of radiofrequency identification (RFID) technology to specimen bottles, moving to a paperless pathology requisition system and confirmation of the correct site, correct patient by both the endoscopy nursing staff and the endoscopist on each specimen bottle. Methods: We reviewed the number of specimen labeling errors from our endoscopy unit for the first three months of 2007, prior to the implementation of the initiative and the first three months of 2008, 6 months after the initiation of RFID specimen labeling with paperless requisition and two provider confirmation of correct site, correct patient specimen labeling. Specimen labeling errors were categorized as Class 1 (only typographical with no potential clinical consequences), Class 2 (minor error, unlikely to have clinical consequences) and Class 3 (significant error that has the potential to detrimentally impact patient care). The Fischer's exact test was used to compare the rate of specimen bottle labeling errors before and after the initiation of this new system. Results: In the first three months of 2007, our endoscopy unit sent 8231 specimen bottles to our pathology laboratory for evaluation and 8539 bottles in the first three months of 2008. There were 646 (7.85%) Class 1 errors in the first quarter of 2007 and 35 (0.41%) in the first quarter of 2008 (P < 0.001). There were 112 (1.36%) Class 2 errors in the first quarter of 2007 and ten (0.12%) in the first quarter of 2008 (P < 0.001). Finally, in the first quarter of 2007 there were seven (0.09%) Class 3 errors and in the first quarter of 2008, there were two (0.02%) Class 3 errors. However, with the new system in place, both Class 3 errors in the first quarter of 2008 were recognized and corrected prior to the processing of the specimens in the pathology laboratory (P= .001). Conclusion: These data suggest that the initiation of a new specimen labeling system that uses RFID technology, a paperless requisition process and confirmation of the correct site correct patient by two health-care providers significantly decreased specimen labeling errors of every level in a high volume endoscopy center.

Reprocessing in digestive endoscopy units in Lombardy: Results of a regional survey

Inadequate disinfection of endoscopes and associated instrumentation can result in transmission of infections to patients. The aim of this study is to assess cleaning and disinfection practice in gastrointestinal endoscopy units in public and private institutions in the Lombardy region. We drafted a questionnaire which we e-mailed to all gastrointestinal centers in Lombardy. A total of 79 centers responded (77%). All endoscopy units perform manual cleaning before disinfection. Automated endoscope reprocessors are available in 84.4% of the centers. Glutaraldehyde-based disinfectants are the most common employed (67% of centers). The time of exposure to the disinfectant is of 10 min in only 9.8% of the centers. The majority of endoscopy units modify their disinfection procedures in the case of infectious disease patients. In 59% of centers disposable material is only used once. In 37% of the endoscopy units instruments are dried with propanol. The data collected suggest that cleaning and disinfection practices have improved in recent years, and that there is a good compliance with standard guidelines. There is still room for improvement in equipment, disinfection protocols, and traceability of instruments in order to improve safety for patients and staff.

Évaluation de la qualité des soins en endoscopie digestive : étude de 202 coloscopies totales consécutives

The aim of this study was to evaluate the quality of the medical care associated with the colonoscopies performed in our gastrointestinal endoscopy unit. This 6-month prospective, comparative study used process and result indicators. Its long-term objective was to improve the quality of care and to select a few pertinent quality indicators for continual monitoring. An audit was conducted of all total colonoscopies performed at our general hospital from November 2005 through May 2006. It assessed the principal published process and result indicators for the medical aspects of the procedure as well as patient satisfaction (indication, procedure itself, results, complications, satisfaction). These indicators were also compared between endoscopists. During the 6-month study period, 202 total colonoscopies were performed. Waiting time for the procedure, appropriateness of the indication, proportion of colonoscopies completed, proportion of neoplastic lesions found, adequacy of bowel preparation, frequency of complications, and patient satisfaction were similar to and even above the standard values. However, patient information and the completeness of the legal documents were insufficient. Although the mean values were satisfactory, detailed individual analysis showed statistically significant differences between endoscopists. For example, the proportion of withdrawal times exceeding 6 minutes was 16.3%, 25.0% and 86.4% according to endoscopist. The mean number of polyps each removed per procedure was respectively 1, 2, and 3 (p<0.05). An improvement plan was implemented in view of these results, and appropriate simple indicators were selected for prospective monitoring. Despite the overall results, which essentially complied with standard guidelines, our prospective and comparative audit of colonoscopies pointed out significant variations between individual endoscopists and helped us to define improvement actions and indicators.

Effectiveness of the echoendoscopic puncture in the diagnosis of solid pancreatic mass

BACKGROUND: Echoendoscopy is a mixed technique which adds the advantages of endoscopy to those of transabdominal ultrasonography through an endoscope with transductor in its distal extremity, allowing for the evaluation of the abdominal organs reached by the endoscope and in contact with the intestinal wall. AIM: To verify the positivity rate of the echoendoscopy with puncture with thin needle (EEPTN) or (EE-PAF) in solid pancreatic mass based on the technique used in the Gastrointestinal Endoscopy Unit of Hospital das Clínicas, University of São Paulo. METHODS: Retrospective evaluation - cohort study - of 138 patients who were submitted to echoendoscopy through aspiration puncture between May 2004 and June 2007. The data were collected through the medical charts present in the medical files of Hospital das Clínicas (Clinical Hospital) of the University of São Paulo, having as inclusion criterion the presence of solid pancreatic mass in computerized tomography and as exclusion criterion the presence of non solid pancreatic tumor. The routine technique was the one used in the Gastrointestinal Endoscopy Unit focusing the following variables: mass characteristics (size, location, presence of peripancreatic lymph node, presence of lymph node in celiac trunk); number of punctures to obtain microfragment for cytology, and experience of the professional in charge. The equipment used was an echoendoscopy device model Olympus EUS (EYES) Exera EU - C60, with electronic sectorial transductor and 22 gauges Wilson-Cook needles. RESULTS: Seventy six (55,4 %) male patients and 61 (44.5 %) female were enrolled. Age ranged from 16 to 87 years and means 59,9 years. The lesions were cephalic in 94 (68,1 %). Mass larger than 4 cm had a higher percentage of positivity reaching 40%, but lesions smaller than 2 cm had a percentage of 43% of inconclusive. Microfragments were obtained in 100% of the positive cases and only 73,1 % when negative (P=0,004). There was no statistic difference regarding the experience of the endoscopy professional. Only 80 patients had the number of punctures written down and it was noticed that there is better performance as the number of punctures was increased. The definitive histopathologycal diagnosis of pancreatic neoplasia occurred in only 41(29,7 %) patients. CONCLUSIONS: Regarding mass characteristics, when larger is the mass, larger is the positivity of the method; the location didn't correlate with higher positivity; when the lymph nodes were present, there was a tendency to positivity; concerning the number of punctures, the higher number, higher positivity; in relationship to the professional experience in endoscopy, there was no difference in the rate of positivity of the puncture of the solid pancreatic mass.

Evaluation of patient satisfaction in gastrointestinal endoscopy

Patient satisfaction questionnaires are a useful method for detecting opportunities for improvement on the basis of patient opinion. The aim of this study was to identify by means of a satisfaction questionnaire the main reasons for dissatisfaction in patients undergoing gastrointestinal endoscopy. Five hundred and thirty-seven patients (age 49+/-15 years, 53% women) who attended a gastrointestinal endoscopy unit were interviewed 3 weeks after undergoing upper endoscopy or colonoscopy, using a previously translated and validated GHAA-9 questionnaire modified for use in gastrointestinal endoscopy. In each case, the overall score median and the percentage of patients who gave negative (poor or fair) appraisals on each of the seven main questions were estimated. These data were used to perform a Pareto analysis. The overall questionnaire score median was 29 (interquartiles 25 and 75 over 26 and 32, respectively). Negative appraisal percentages for each of the seven questions were: waiting time until the appointment, 9.3%; waiting time on the day of examination, 3.5%; explanations, 3.9%; personal manner of staff, 0.5%; personal manner of the physician, 0.6%; discomfort, 3.5%; overall rating, 1.9%. The vital few found by Pareto analysis were questions regarding waiting time for appointment and adequacy of explanations regarding procedure. These questions accounted for 61% of the total number of problems encountered by patients. Questionnaires on satisfaction or quality perceived by patients allow the most frequent causes for dissatisfaction to be identified. The main problems patients encountered were waiting time until the appointment and explanations.