Endoscopic full thickness resection (EFTR) is an evolving procedure along the spectrum of lesion resection. It encompasses a wide range of various clinical applications and indications, with evolving devices for resection and defect closure. The rapidly changing landscape of EFTR over the past years, alongside the potential for new developments, necessitates a better understanding of this field and its’ required training. This review summarizes a brief history of EFTR over time, while highlighting the goals and steps of training for this emerging procedure.
With the emergence of advanced endoscopic technologies and techniques, endoscopic resection has emerged as an important therapeutic modality. However, endoscopic full-thickness resection can be limited by concerns for R0 resection, margins, potential for seeding the peritoneal cavity, perforation, or difficulty in closing the full-thickness defect. Combined laparoscopic surgery with endoscopic-full thickness resection has become an important cooperative strategy that leverages the unique skillsets of both the endoscopist and the laparoscopic surgeon. Several techniques have emerged that range from endoscopic resection with laparoscopic assistance, laparoscopic resection with endoscopic assistance, and finally to truly cooperative laparoendoscopic surgery. The application of combined laparoscopic surgery and endoscopic full-thickness resection shows great promise especially for subepithelial tumors of the upper gastrointestinal tract, but more widespread applications need to be tempered by focusing on clinical benefit to the patient.
The way endoscopists hold and manipulate the endoscope during examination varies. The lack of a standard manual on how to hold and manipulate the endoscope has perhaps contributed to the variation seen in practice. Unfortunately, the knowledge of how to properly hold the endoscope is not innate. What seems to be the simplest form may actually be incorrect. Developing the ability to hold and to manipulate the endoscope correctly requires practice and time. We are very pleased to contribute to this chapter given the paucity of literature and the importance of this foundational technique when performing endoscopy.
Endoscopic full-thickness resection (EFTR) is the cutting edge of therapeutic endoscopy. It is a minimally invasive method designed to remove gastrointestinal subepithelial tumors originating from the muscularis propria. In this review we will focus on pure EFTR, a technique that evolved from endoscopic submucosal dissection and utilizes endoscopic submucosal dissection skills and equipment. Pure EFTR differs from device-assisted or laparoscopy-assisted EFTR. It has fewer limitations in terms of tumor location and size and is a true embodiment of the natural orifice transluminal endoscopic surgery concept. Here we will review the development, applications, equipment, technique, and outcomes of pure EFTR, as well as give a brief overview of the current state of the art featuring both the worldwide literature and data from our large referral center.
Proper reprocessing of flexible endoscopes in gastroenterology practice is a critical element of a comprehensive patient safety and infection control strategy in both the inpatient and outpatient healthcare setting. This effort requires an interprofessional approach consisting of collaboration between the endoscopist and multiple other facility stakeholders including reprocessing professionals, nursing, infection prevention and control, biomedical engineering, and patient safety professionals. Recent advancements in human factors engineering has demonstrated a high reliability in validated and standardized reprocessing efforts for flexible endoscopes with properly trained reprocessing personnel and appropriate resources to execute the overall reprocessing process. A continued and concerted effort must be paid to maintaining the safety of these devices through focus on personnel, processes, and a continued innovative engineering of the devices themselves. While flexible endoscopes play a pivotal role in delivering diagnostic and therapeutic medical capabilities to endoscopists, their use is not without risk and require a comprehensive approach to medical device hygiene and integrated infection prevention and control.
Outbreaks of infections related to duodenoscope use have brought attention to the important topic of endoscope reprocessing. Much work has been done to understand why these outbreaks occurred and how to prevent them; however, the adequacy of duodenoscope reprocessing has not been ensured to date. This review summarizes current techniques in duodenoscope reprocessing and future directions to eradicate endoscopically transmitted infections.
The duodenoscope, a complex endoscopic instrument, is frequently utilized to accomplish the increasing demand for minimally invasive treatments of pancreatic and biliary diseases. It is, in addition, the fundamental tool used to perform endoscopic retrograde cholangiopancreatography (ERCP). However, outbreaks of multidrug resistance organism transmission have occurred in patients undergoing ERCP while adherent to current endoscope manufacturers’ reprocessing guidelines. Evolving evidence suggests that implementation of the current protocols is inadequate to guarantee a pathogen-free duodenoscope. In spite of infection risk, ERCP remains a critical platform in the management of patients with pancreaticobiliary diseases. This manuscript reviews the history and epidemiology of recent duodenoscope-related infections, current challenges to scope reprocessing, and recommendations by regulatory agencies.
In the wake of several highly publicized endoscope-associated multidrug-resistant organism (MDRO) outbreaks, healthcare providers have focused on understanding and improving endoscope reprocessing practices. Microbiological culture of endoscopes has emerged as a critical tool in support of these efforts. As healthcare providers increasingly rely on microbiological culture results to make decisions that impact patient safety, it is important to understand the limitations of the methodology as well as the factors that may impact results. The use of traditional cultures in combination with molecular methods has enabled the investigation of disease transmission during outbreaks. With increased prevalence of MDROs, advanced molecular techniques like whole-genome sequencing provide high resolution data and information on the entire bacterial genome that are needed for thorough investigations and management of transmission events. Elucidation of the true burden of postprocedure patient colonization and infection would benefit from improved clinical lab access to molecular biology tools. Molecular biology tools would facilitate detection of emerging MDROs and ever-increasing diversity of antibiotic resistance genes. Implementation of postprocedure surveillance programs aimed at early recognition of colonized and infected patients could improve appropriate management of endoscope infected patients and guide infection prevention measures to prevent the spread of MDROs.
Endoscopic Retrograde Cholangiopancreatography (ERCP) provides an important medical procedure for patients in a generally safe and effective manner. It can be technically complex, often performed during serious illness, and has the highest potential complication rate of procedures commonly performed by gastroenterologists. The issue of duodenoscope-related infections has been more recently added the list of potential ERCP adverse events. This chapter will take a risk management approach to help the endoscopists understand and manage the risks associated with ERCP, with particular concentration on duodenoscope-related infections. This chapter is written for educational purposes only and cannot be considered legal advice. For specific legal advice, one should consult a health care attorney.
Gastroenterologists are at increased risk for musculoskeletal injuries from overuse and repetitive motions during endoscopy. Recently there has been more awareness of ergonomics in endoscopy and strategies for improvement since an injury can be shocking to a physician's career. This article reviews common injuries seen in those who practice endoscopy, steps in managing an injury, guidelines for ergonomic design of a procedure suite, and a basic primer on disability insurance. Incorporation of ergonomic principles in the endoscopy suite and during use of electronic health record can minimize risk of work-related injuries.
During a visit to the Hiroshima University Hospital in April of 2018, an endoscopist (GSR) observed and learned several facets from an ergonomically designed endoscopy unit which opened its doors to service in 2013. This review is a reflection of those observations during that visit, which might be helpful to a Western endoscopist.
The quality of the endoscopy training varies greatly around the world. Some of this variation may be due to a lack of conscious competence of the trainer, but also the lack of appreciation of how early ergonomic training can influence learning and skills acquisition for the trainee. Ergonomics can either facilitate or negatively impact performance during training and influence potential in independent practice. This chapter focuses on the importance of human factors and ergonomics training to the early endoscopist to optimizing patient outcomes and minimizing risk to the endoscopist. Effective training requires preparation and structure; an educational contract helps create this. Integral to this is ensuring that the agendas of both trainer and the trainee are aligned, along with an approach to the development of realistic learning objectives. These principles are covered in addition to exploring the methods of teaching optimal scope handling. Trainee progression is linked to effective, performance-enhancing feedback. A pragmatic approach to providing effective feedback is suggested. Crown Copyright (C) 2019 Published by Elsevier Inc. All rights reserved.
Gastroenterologists are at risk for endoscopic- injuries due to higher endoscopic volume, repetitive movements, poor posture, and limited education on endoscopic ergonomics. Limited studies however have investigated how to best educate gastroenterologists and other staff on proper endoscopic ergonomics to help reduce endoscopic-related injuries. The following is a review of a division-wide ergonomics educational quality improvement project at our endoscopy center and a discussion on how to obtain buy in from key stakeholders to make meaningful long-term changes in the endoscopy unit.
Physician burnout is an increasingly recognized syndrome which not only negatively affects physicians but has a detrimental impact on the overall healthcare system; similar to other physicians, gastroenterologists are susceptible to burnout due to multiple competing responsibilities. Avoiding and treating burnout must utilize a multifaceted approach to enhance recognition among physicians and peers, identify triggers and potential solutions, promote optimal coping mechanisms, and correct systemic issues. While as a medical community we have raised awareness regarding burnout, continued efforts are needed to develop modalities to prevent and mitigate burnout.
The endoscopy suite is the central hub of activity where most gastroenterologists spend a majority of their time in clinical practice. With the evolution of more complex diagnostic and therapeutic procedures, an ergonomically designed and dedicated gastrointestinal endoscopic unit is not only desirable but a necessity. Such a unit will ensure optimal workflow efficiency and throughput, as well as both patient and physician safety. It is important to plan meticulously upfront by seeking input from all stakeholders including engineers, physicians, nurses, technicians and architects. This will ensure a highly desirable work environment including procedural areas and the scope cleaning/sterilization section while optimizing patient and instrument flow. The procedure room should be ergonomically designed to allow for adjustability and optimize utilization of space for endoscopists, technicians, nurses, anesthesiologists, and trainees as well as the equipment required to perform the endoscopic procedures. This article provides practical tips on how to plan and develop an endoscopy suite, taking into consideration ergonomic and regulatory aspects, and is based on real life experience with designing a modern gastroenterology procedural suite.
The rates of women entering the field of gastroenterology have been increasing over the past several years. Most of these women enter the field during childbearing years. At the same time, the procedural demands placed on endoscopists have been increasing as well. With these changes in demographics to the physicians performing endoscopy, more attention should be paid to the physical demands of scoping while pregnant. In this paper, we focus on several common, overlapping injuries that are frequently encountered during pregnancy and while performing endoscopy. Additionally, ergonomic modifications and strategies are outlined for both the pregnant and postpartum endoscopist. Given the lack of data in this area, dedicated studies aimed at this specific population would help guide further recommendations.
A preponderance of evidence, primarily from surveys, has shown that gastroenterologists suffer from overuse injuries and pain of hand/fingers, wrist, forearm, shoulder, and back due to awkward postures, high forces, and repetitive movements during endoscopy. Although flexible endoscopes are brilliantly designed compact instruments that include light and image guides, irrigation channels, suction channel, biopsy channels and are the result of many technological advancements and iterations in the last 5 decades, not much has changed in their basic functions, layout, ergonomic design, and usability. The required hand-tool interaction in order to maneuver the endoscope inside the intestinal lumen, such as stabilizing the control section while manipulating dials with the left hand while simultaneously torqueing, pushing, and/or pulling the insertion tube with the right hand, are still unchanged. It is imperative that the scope manufacturers understand the ergonomic areas of concern in the design of current endoscopes and incorporate ergonomic principles in future designs to optimize the interface between the instrument and the physician. In addition, it is as important for the physicians to be educated on ergonomic principles to minimize the risk for endoscopy-related injuries. This chapter reviews the design of current endoscopes and the ergonomic areas of concern. We review endoscope design changes that are needed to mitigate risk of injury during endoscopy, possible innovations that may improve endoscope ergonomics in the future, and barriers to implementation of any intervention that will address these shortcomings.
