Hopefully, this will just set the stage for the remainder of the speakers and also we thought that this would be an important primer for all our young trainees as well as junior faculty who are joining us from all around the country is just talking about that. And what I thought for this is I would just use, you know, these top 10 tips for how all of us can improve our quality, you know, upper endoscopic examination. While the focus all along has been on colonoscopy, I think everyone's now realizing that we probably need to step back and talk about quality in upper endoscopy as well. So the first few tips are very simple and I think or the majority I'd say are very simple, but yet sometimes simple or simplicity is the key. So again, the prior to endoscopy always ensure that you have a consent form from the patient, you've evaluated the patient's personal medical history, and that all of this has been documented. And again, although may sound mundane, if there is a complication, which were to unfortunately happen during the procedure, everything goes back to this is that what were the medications? Did the patient actually require the procedure? And were all the risks and benefits discussed with the patient? So once you've done that the patients in the room, ergonomics and the technique of intubation becomes important. And here's an example is that make sure that we are using our best posture. The head of the bed is at the level of where you feel comfortable with your height. And then of course, that you're holding the endoscope in such a way that the ergonomics don't lead to any sort of wrist injuries, which are very common in all endoscopists performing not just upper endoscopy, but as well as any sort of procedures. Then of course, that you have checked your up down and your left, right knobs. And before you insert the endoscope, that it's absolutely straight. And when you bring your big dial down, that it moves forward downwards in a perpendicular fashion. This is the initial part, which trainees as well as folks in practice sometimes hesitate in doing and do a very quick examination here. And you can see that you can actually go in very slowly when you're doing that, get a good look at the vocal cords and decide which piriform sinus you want to intubate and gradually go in through there. So this is a technique of intubation that I think is extremely important rather than just a blind intubation in which the first landmark you see is that you're already inside the esophagus or the patient is gagging while you're doing that. Now, once you're inside and before you start any of your inspection, it's key that you use your water channel button or your foot pedal, as well as your suction area to clean the mucosa and make sure that you are getting a prep, which is extremely clean. And this is what I call sort of like the esophageal or the gastric bowel prep in which you're cleaning it. And then you have all the saliva, bile and debris, which is removed before you start your inspection. So that's the first thing. So you've done that. Now you can take your time to inspect as you're doing this. And there's enough evidence now showing both for Barrett's esophagus, as well as for gastric neoplasia, that the more time you spend, the more likely you are to detect lesions. Now, during today's masterclass, we are not going to be discussing Barrett's esophagus, esophageal cancer. But, you know, you will be encountering these patients during your upper endoscopic examination. This is a study which shows that the more time you spend in inspecting the Barrett's mucosa, the more likely you are to diagnose not just patients with high grade dysplasia and cancer, but more lesions will be detected as well as you are doing that. So we usually recommend a time of about a centimeter per minute or a minute per centimeter of Barrett's esophagus. And for gastric inspection, which Madha will be talking about, it's been shown that you have at least about six to seven minutes of examination of the stomach for gastric preneoplastic and cancerous lesions. So once you've inspected, and if you find something abnormal, you need to start looking at the biopsy protocol. Now, just a few words of just different disease states. Of course, Iko will be discussing eosinophilic esophagitis in detail, but just to tell you where these different recommendations come from. These are data from the Northwestern group looking at the number of biopsies to take for eosinophilic esophagitis and its sensitivity. And there's where the recommendation of obtaining at least five biopsies from all segments of the esophagus come about is to make sure that it's a patchy disease and that you're getting the biggest bang for your buck by taking adequate number of biopsies. Now, this is the biopsy protocol for Barrett's esophagus. And you can again see that the mucosa has been cleaned very thoroughly. You've inspected. And then you start doing your four quadrant biopsies every two centimeters as recommended by the guidelines after any visible lesions have been biopsied. For gastric intestinal metaplasia, again, we'll be getting into this detail during session three. But nevertheless, just to show you that you again need to follow these different guidelines and be familiar with the landmarks, for example, here in the stomach, where's the antrum, where's the lesser curve, the greater curve, the body. And again, very important for all our fellows that as you are doing this in your practice, that you're very familiar with the landmarks and the anatomy before you start taking these biopsies as have been recommended. Now, a full examination is never complete until you've done a good retroflection. And this is very important when you are dealing with patients with gastroesophageal reflux disease or trying to screen for Barrett's esophagus and also in those patients who have a known history of Barrett's esophagus for surveillance. Here is an early cardiac adenocarcinoma, which is very clearly visible in the retroflexed view. You have to take your endoscope retroflex, get into the hernia sac, and then do a very good examination within the hernia sac in a retroflex position to do that. After you've done that, make sure that you are obtaining high quality images of key landmarks and that you're documenting abnormal findings and looking for it. Here's, for example, looking at Barrett's esophagus very carefully and grading the landmark, the gastroesophageal junction, and this patient has a C0M2 Barrett's esophagus. On the other hand, this patient has a very small hiatus hernia, but there is no Barrett's esophagus endoscopically at best. It's an irregular Z line. Here are some examples endoscopically how you can make a diagnosis, or more importantly, don't overcall a diagnosis in that situation. This is something very important, and I'll try and pause here for a second also. Here's as you're doing a standardized pullback, and this is during the pullback when I do all my measurements. If you see my mouse, the first area that you see, the pinch that you're seeing, is the diaphragmatic pinch. You always measure this extent from the incisors. Then as you're coming back, what you will see is that the top of the gastric folds are coming back and they will be converging here. This top of the gastric folds right here, if you see, this is the gastroesophageal junction. From the gastroesophageal junction to this diaphragmatic pinch, this is your endoscopic measurement of the hiatus, which you should be doing in all patients rather than just saying that there was a hiatus hernia or that there was a small hernia or a large hernia. Just measure and say where there is. Now let's look at this example. Again, you're doing your standardized pullback, you're coming back, and there is no diaphragmatic pinch here and no impression here. All you will see directly are the top of the gastric folds and the squamous columnar junction. In this situation, the patient does not have a hiatal hernia. You can see that this is the GE junction. If it's at 40 centimeters in your endoscopy report, just write that the gastroesophageal junction was at 40 centimeters. What you don't want to do is that even if the endoscopy is normal, just say normal EGD, and that's the only thing in your endoscopy report. Please take the time to measure the landmarks and report that in your endoscopy report. It's a clear idea that you should be doing. You could start seeing the presence of a Schatzky's ring here, which is shown as well as multiple erosions. What you will do in that situation also, and let's try to play the video again, is that you will measure your landmarks, the presence of a hernia, and then report endoscopically what you're seeing. You can again see in all of these that the picture is very clear and there is no bile or debris which is in the way of you doing your examination. Once you've done that, I've alluded to this, is that you use standardized classification systems for your abnormal findings. I'll just go over a couple of them. Here's using the Prague CNM criteria. What you do is measure the GE junction and then the circumferential extent. If the circumferential extent is from this area to the GE junction, this is a C2 and then M5 Barrett's. Rather than saying this patient has a short Barrett's or a long Barrett's or an ultra long Barrett's, whatever you might think, that's great, but just mention using standardized classification systems. For example, for Barrett's using the Prague classification. For EOE, ECO will be going over the EREF. Again, make sure that you're using that. If you see reflux esophagitis, I think we are all tempted to call it mild esophagitis or severe esophagitis. These are, again, very arbitrary terms. Use the Los Angeles classification, which is shown here, both in the cartoon form on the left and pictorially on an endoscopic image on the right with some markings on it for you as well. Look at these different grades of esophagitis and then call it LA grade A, B, C, or D. Again, it will help you not just standardize it, but we know that LA grade C and D are more difficult to treat endoscopically. Those patients may need a repeat endoscopy after healing to rule out the presence of Barrett's esophagus. It's not only something, just a fancy tool to use, but it also dictates management and patient outcomes. That's how you should be doing it. Again, this is talking about the EREFs and saying that this is how you should be looking. These are pictures of edema, rings, exudate, furrows, and strictures that you should be doing. Now, something that I think we don't use enough of is the Paris classification. This is for any luminal GI tract lesions that you see. Always in your mind, and in our endo unit, we've put this up in our dictation room as well as in one of our endoscopy suites. This is important to recognize. On the left, just keep this in mind when we say, oh, this is a pedunculated polyp or a pedunculated lesion. Just look at it as, is it a 1P, is it a 1SP, or is it a 1S? Always look at protruded lesions and report it as such. If you see flat lesions, is it a 2A, which is a flat elevation? Is it a 2A plus C, which has a flat depression in it? Is it a 2B, which is absolutely flat, so something with Barrett's esophagus that you may see only on NBI or BLI or eye scan? If there is a depression, it is a 2C, and if it's an ulcerator excavated lesion, it's a 3. Remember these and try to use this as part of your vocabulary as well as part of your looking at lesions and starting to report based on this. Because we're all used to saying that, oh, I saw a flat lesion. Well, I mean, is it a flat elevated lesion or an absolutely flat? I think that will help you whether it's a 2A or a 2B. I think it's important to recognize the Paris classification for that. Finally, upper endoscopy. We may think, let's go ahead and do a very quick EGD. That's what most people say. I think that's, of course, a not good thing to do, but also be mindful that there are adverse events and things could go bad even after doing upper endoscopy. Do not ignore signs and symptoms of possible adverse events. Depending whether it's a diagnostic EGD or whether you're doing EMR or tight stricture dilation, your risk may vary between these patients. Always look for these different signs and symptoms. Again, just be aware of these different problems which may happen related to perforation, bleeding after the procedure that you've done. For example, you can see here is that after a stricture dilation, you could sometimes unfortunately have a perforation. Then again, on the right, you can see is that after resection, there is bleeding, which has happened, so do that. Finally, don't overuse upper endoscopy. I think this is true for all endoscopic procedures because we have to be mindful. Are we doing the right thing for our patients? Set up endoscopy surveillance schedules appropriately and don't overuse it. Here is a good list of things that do not require a repeat endoscopy. Again, if you see an inlet patch, that doesn't need it. If there's LA grade A or B or less than a centimeter of columnar line esophagus, we will be hearing about different gastric lesions which don't require a follow-up endoscopy. Duodenal ulcer, for example. Be mindful of what the guidelines are saying and use that in your practice to do that. Hopefully, I set up the stage for all our other experts and given you some tips for how to perform an upper endoscopy to the best of your ability. That will improve your detection rate as well as lead to better utilization and better patient outcomes. Thank you all for your attention. I'm going to turn it back to Vani Honda to head it off again. Vani.

upper endoscopy

quality

improve examination

patient consent

lesion detection