It gives me great pleasure to invite our first speaker, Dr. Sravanti Parasar. She's from the Swedish gastro institution from Seattle, Washington. She will be speaking on performing a high-quality upper endoscopic exam. Thank you for the kind introduction, and thank you for the invitation. So I'm just going to get started with the basics, nothing crazy, nothing advanced endoscopy, but basics so that we can get started with high-quality exam, which is very important before we can get into diagnosis treatment and therapeutic stuff. So what am I going to cover today? Why do we need to perform a high-quality exam, right? We all know intuitively that we have to perform a high-quality exam, but sometimes we just, you know, in our busy practice, we might forget why we are doing what we are doing. And then what are the components of a high-quality exam? And then as we come into practice, we can have all these quality metrics and performance measures, but it's really hard to kind of keep up with them and implement them in our clinical practice. So how do we go about implementing those quality measures as well? So why should we perform a quality endoscopy, right? As endoscopists, the first thing that we do during an endoscopy is trying to find lesions or detect lesions, right? That's our first goal. Or maybe rule out lesions. That's the first thing that we want to do. So diagnosis is important. And based on that diagnosis, your entire pathway of treatment, whether it's endoscopic treatment, medical treatment, surgical, oncology, whatever it is, is pivoted based on those diagnosis that we do at the time of endoscopy. And of course, if, you know, there's no specific therapeutic option for that particular condition, we want to make sure if it's a precancerous condition, we need to provide the appropriate surveillance guidelines based on the degree of dysplasia and whatnot, based on the individual indications, right? So that is why we need to know how to perform a high-quality exam. Now it's very simple. I'm not going to talk about the consent process, the indications, and those kind of metrics. But we'll just focus on what do we need to do once we are with the patient with the scope in our hand. Most importantly, we no longer recommend any just white light endoscopy. But high-definition white light endoscopy is a minimum, at most. And then secondly, even if you have great cameras with great filters and optical enhancement technologies, it doesn't make sense if the lumen is not clear, right? If you have a lot of bubbles or food, or in terms of upper endoscopy, when you have bleeding, lots of clots and stuff like that, you need to wash them out. You need to clear them out. There's a lot of variability in the time of an upper endoscopy. It almost seems like an eye wash, right? In some cases, it is catching up between your colonoscopy exams, because these are shorter. But in reality, if you have to perform a high-quality upper endoscopy exam, it ranges somewhere between 10 to 15 minutes on an average. So I'll talk a little more about what are the agents we can use for clearing the mucosa for bubbles, and what kind of scores are available for tackling or standardizing in your endoscopy unit. I'll also talk about inspection time, because you need to spend time to see what you're seeing, even if you have high-quality cameras. And also, if you completely clean the mucosa, you need to know what you're looking for, and how do those lesions look, and so forth. So this is an example of what we need to do when we get in with the scope. The first thing is, you need to identify your landmarks. If we don't know how to identify the landmarks, then our hiatal hernias might be smaller or larger, our varicose esophagus might be smaller or larger, or we might be even missing visible lesions. So in this picture, what you're seeing is the junction of the esophagus and the gastric cardia. So your top of gastric folds are basically where your stomach ends, and that's where your esophagus starts, right? And then, in this video, what I'm showing is you're trying to wash the mucosa. You're trying to deflate your stomach to accurately identify the different landmarks of your apogee endoscopy. So that's very important. So a lot of times, we could be still heavily distended in the stomach and trying to identify the diaphragmatic pinch, the top of gastric folds. That's where your stomach ends. And the next part is your esophagus. So you need to know diaphragmatic pinch to the top of gastric folds. That's the length of your hiatal hernia, right? And then, from the top of gastric folds to your squamo-columnar junction is your barrett's esophagus, if it's present or not present, and that's your Z line. So identifying landmarks is very critical, and having your stomach deflated is important as well. Now moving on to, OK, you've gone in, you've washed your mucosa, you've tried to identify your landmarks. Now you're thinking of, OK, when do I use that additional switch on my upper endoscopy scope, right? So I've included three images, different technologies. Different companies have different technologies. The first image that you see up here, it's the barrett's mucosa. And this is blue light imaging. And then the next one is linked color imaging. Usually we can use it for, you know, when we get to the barrett's mucosa and we already start biopsying, you'll notice that there's a lot of blood and you no longer can identify visible lesions, which can be a hindrance because we focus a lot on identifying lesions. In LCI, that bloody battlefield is kind of reduced where you can still see the rest of the mucosa so that you can take more targeted biopsies and focus on visible lesions as well. The next image is an NBI image with a high focus and a zoom, looking specifically at the mucosal pattern so that you can understand the subtleties of irregularities in the mucosa that will allow you to take more targeted biopsies and also help with missed lesions. So what are the mucosal patterns we are looking at? This is based off the BIN classification by Dr. Sharma's group. And it's an NBI image. So you see two images. The first image up here, you see, you know, circular, you're just looking at the mucosal pattern. You're not looking at the vascular pattern here. So you see the circular ridged villus tubular kind of pattern that kind of indicates that there's probably no dysplasia in that particular segment. The other part that you see here is very irregular. There's no pattern. It's kind of obvious that something's cooking up there. That is your visible lesion. So when you look at these kind of lesions, you are taking those targeted biopsies and keeping them in a separate jar. Because remember, we are first diagnosing and then we want to focus on treatment. If we don't know where this abnormal lesion is tomorrow, whether you're sending it to your colleagues or you're doing an ablation or an EMR, you need to know where exactly that particular lesion is, right? Now in terms of vascular patterns, so I'll make it very simple. When you're looking at advanced imaging, there are probably two different sets of characteristics that you're looking at. One is the mucosal patterns that we just discussed. And the second thing is the vascular patterns. So in vascular patterns, if there's kind of regularity between the ridges, so you're not looking at the mucosa anymore. You're looking at the patterns between those mucosa, these blood vessel patterns. So it's kind of a little normal. Now when I show you the abnormal ones, that's where you can identify that it's, you know, this is where the dysplastic lesion is. So coming to this level of visualization needs you to have a good endoscope. So that's why you need a high-def endoscope. You need to clean the mucosa and also learn to understand which are those abnormal areas so that you can get targeted biopsies. Now you know, there's a lot of buzz about what kind of mucolytics or proteolytics that we can use for upper endoscopy. There's a lot of research on the colonoscopy, right? We have the bubble score, you have the bowel preparation score, and so forth. But in terms of upper endoscopy, we don't talk as frequently as we talk about in colonoscopy for visualization of mucosa. But it's equally important, because if you don't see the mucosa, then there's no point of doing an endoscopy. So a couple of, I'm not going to go extensively into the literature review and stuff, a couple of practical points. You can use simethicone with water to flush through the endoscope, as you would do through the biopsy channel in a colonoscope, if you have a lot of bubbles, if your patient is complaining of bloating. The other option is NAC. You can add that with simethicone or just water that's a proteolytic. So it helps better visualization of your stomach. So that becomes very important if you're doing a lot of gastric intestinal metaplasia surveillance or gastric atrophy surveillance, and so forth. Of course, when you are going in with a bleeding case or you have a gastroparetic patient, there could be a lot of food and residue there. You know, if it's solid food, obviously, you can't suction it out. But you can use some techniques to kind of go around the solid food to reduce the residue. But a lot of times in acute conditions, when we see a lot of bleeding, there could be clots. You can use high-powered suction to get those clots out using a therapeutic scope as well. So going back to washing. So again, it's very important. Because we're talking about high-quality exam, we need to see what we are doing. So washing becomes very important. This is the degree of clarity you want to see when you're doing an endoscopy, when you're trying to identify your landmarks or trying to see where the abnormal lesions are, and so forth. OK, so a couple of data points on visualization. So when I started the presentation, I said, typically, a good upper endoscopic exam would be somewhere between a 10 and 15 minutes, right? The reason is, if you are going in for a surveillance endoscopy for a Barrett's patient, or you know there's a high-risk patient for gastric interstitial metaplasia based on their family history or ethnicity and so forth, or you already know that this patient has a history of gastric atrophy or gastric interstitial metaplasia, then you know that your exam should be at least 10 minutes, right? So first, you go in with your scope, identify the landmarks, do your usual thing, then make sure it's completely devoid of any debris, bubbles, food residue, and so forth. In terms of for Barrett's esophagus, the data suggests that for every centimeter of Barrett's, you need to be spending at least one minute per centimeter to closely look at it for these vascular abnormalities to identify abnormal lesions. When you do that, this data suggests that if you spend more than one minute per centimeter of Barrett's segment visualization, your high-grade dysplasia cancer detection rates go from like 54% to 6.7%. So that's the difference. So it's a significant improvement in your detection rate, and thereby leading to less interval cancer. For gastric inspection time, if you know you're going into surveillance for gastric interstitial metaplasia and the high-risk factors, it should be at least a minimum of seven minutes. And then we'll go over some overall guidelines on what kind of biopsies you need to take and so forth. So studies have shown that if you spend at least seven minutes in the stomach visualizing and inspecting, your chances of detecting dysplasia or high-grade dysplasia in gastric lesions is about 2 and 1⁄2 times. So when we think about looking at the upper endoscopy exam, let's say nobody has Barrett's, nobody has gastric interstitial metaplasia, it's a routine exam, you're just doing it for GERD, there's no esophagitis, there's no reason to report LA-grade or CA erosive esophagitis, things that are absolutely recommended for documentation, which is a photo documentation in your endoscopy report, include proximal esophagus, then your distal esophagus, then clear picture of your Z-line where you show where the Z-line is and the diaphragmatic pinch and so forth, a retroflex view of the gastric fundus, and then also, if you're thinking about GERD patients, you want to make sure you've documented the hill grade as well, because that will help you understand the reason why they're having persistent reflux and for surgical and other therapeutic options as well. You need to have a nice forward view of the whole stomach with the greater and lesser curvature. You want to do a retroflex view, not just of the cardia, but also the lesser curvature and greater curvature. Incisura, don't forget that. That's a common place where you can have high grade dysplasia in gastric cancer and so forth. And then, of course, the antrum, pylorus, deodenal bulb, second part of deodenum. The last picture, which shows the major papilla, is optional. You will get a stellar point if you get to the major papilla using a straightforward viewing scope. Now, I'll just quickly go over some of the diagnostic protocols. Just a quick refresher, not that we don't know what to do, but it's always important to know what indication you're going in for. Let's say it's dysphagia, so you take your E biopsies. It should be in two separate jars, at least two to four. One would be from your distal esophagus, the other one from proximal or mid-esophagus in two separate jars. So for Barrett's, it is every 2 centimeters. It's the Seattle protocol. If you're using WATS, then you can use the brush along with the Seattle protocol biopsy. So you have the brush biopsies as well as the standard Seattle protocol biopsies. That's every 2 centimeters. And also, if it's just the columnar epithelium and not the full circumference, then you take biopsy of that particular column of Barrett's esophagus as well. Then for gastric premalignant disorders, which is gastric atrophy or gastric intestinal metaplasia, you take the five biopsies, two from the antrum, a lesser and greater curvature, one from the incisor, and two from the body for surveillance as well as detection for high-risk patients with gastric cancer. For celiac disease, you need a minimum of four biopsies. You can take three of them from D2, one from the duodenal bulb. You can put them in separate jars to differentiate some of the disorders where you'll see inflammation in the duodenal bulb as well. So coming back to implementation, we have about three minutes left before I can go in for questions. So a lot of times, implementation is a huge, huge factor. The current ASGE guidelines almost report about 45 different types of metrics for just upper endoscopy. So it's impossible to kind of document all that and audit and track in your practice. So as a group, you can decide which are the things that make more sense from a practical standpoint. Is it the visualization? Is it making sure you have documentation that shows great visualization of the standard pain points and probable areas where you would see high-risk lesions, including your Barrett's lesions as well as gastric lesions and duodenal lesions, and if you see any adenomas, what you need to do, and so forth. The second thing is photo documentation of all those lesions as well as providing guidance as to when these patients need to come back for surveillance endoscopies, right? So that's the second thing. And always remember, if you are getting these patients, you need to know where these abnormal lesions are if you're doing ablation, EMRs, or ESDs, and so forth. So documenting where exactly, which, like, is it 36 centimeters in your Barrett's or is it in the lesser curvature that you're seeing this abnormal lesion, you need to mention that. And then I know all this is very complicated. It always helps if you have some automated machine that does all of these kind of metrics. There is some data using computer vision for AI and also standardizing some of these quality metrics where you're just going in with a scope, and the scope automatically detects the high-importance areas that algorithms are trained for those 10 different pictures that we want our report to have, and it automatically documents that. If there is a deficiency, it will give you live feedback so that you can change your practice at that time. That's all I have for today. Thank you. If you have any questions, is it after? No, we have time for one or two questions. Thank you for that amazing presentation and a guide to, you know, a very nice jumpstart to our day. So just a quick question, Sramanthi. How often on an upper-end dioscopy do you try to look at the major ampulla in the D2 or push to get into the D3 and take a look? For me, because I don't use a side-view scope, I typically don't. That's not my major focus. Of course, I get to the D2 and try to go beyond, but whether I visualize the ampulla or not is very hard. It always depends on the technique, but that's why I said it's optional. If you see, it's great because you are actually looking at the ampulla, but the rest of the 10 landmarks have to be documented and have to be looked at carefully. I have a question. Very nice presentation. You know, a lot of us who do a lot of Barrett's esophagus surveillance and screening use a distal attachment cap. What's your thought on that? Do you use it? Do you not? Do you think it's an added cost? So for routine exam, in my practice, I do not use a distal cap, but if I know I'm going in for an EMR or an ablation, it's going to be a therapeutic case, then I always have a distal cap so that I can clearly, you know, rub through them because I look for that abnormal area. Spend some time. You can zoom in in those specific areas as well. And a cap also helps with the EMR, so. Yes. I do, too. I love my clear cap on the Barrett's cases.

mucosa visualization

high-definition white light endoscopy

advanced imaging techniques

biopsy protocols

Sravanthi Parasa