So in the next 20 minutes, I have no relevant disclosures for this stuff. So I think it's interesting, first, you know, I'm really happy to be here. When he said 20 years, I just realized I was probably at the halfway mark, because when I was here for a first-year fellows course, it was 10 years ago. It's hard to believe. But so I'm going to give you an introduction to endoscopy, but the interesting thing here is that, I mean, I think when we're in training, a lot of our, you know, thoughts and processes and everything is so focused on the endoscopy part. When you're done with training and you're in attending, you come to appreciate how important everything that happens around the endoscopy part, how important that is, and sometimes how little we actually pay attention to that during our training. So my talk today on endoscopy is going to involve everything around endoscopy, what you do before, what you do after, give you some tips. Go through things a little bit quickly, because there's a lot to cover, but it's just really to give you an overview of certain topics that are relevant. Probably the most important, obviously, is the informed consent. This really is so much important. It doesn't really start, you know, when that patient's out in your pre-op room, when, you know, you're doing cases with your attending, you're meeting them for the first time, and you're saying, well, you're having a colonoscopy, or you're having an EMR for a large polyp, or you're having an ERCP. It really starts when that person's seen in the office, whether seen by you now with your attending or seen when you are attendings. And the key to that, really, the process is disclosure, and it's really even more than that is giving patients a sense of agency to what they're about to go through. Some of them are going through more complex procedures, some are simple. Even the simple procedure scares a lot of people sometimes. So really making them part of that process, making them feel like part of that process, that's really what the informed consent is about in its most basic sense, right? And then, obviously, the components of this is really more to prepare the patient mentally for the procedure, be mentally prepared for what to expect from the procedure, what they can expect to benefit from it, what they can expect. Give them sort of an idea of what could go wrong if they go wrong, and then, more importantly, what would happen if they did go wrong, how you would go about navigating that. So description of the procedure, you know, you talk to them, let them know what you're doing, why you're doing it. Benefits of the procedure is the same thing. You're sort of going over, it goes more than beyond that procedure itself. You're telling them they're coming in to you with a problem, they're coming to you with a problem, and you're hoping that this either helps diagnose it a little bit better or treat something that's bothering them. The risk and the adverse events are important, mostly because, you know, things happen with endoscopy, and it's a statistical certainty that if you do enough procedures that some things are going to go wrong. So it's important to, for patients to be aware that there are things that go wrong. They're a lot more accepting of adverse events when they're aware of it than, you know, well, you never told me this was going to happen, even if it's something mild as pain after a procedure, right? So it's very important to go over stuff like that. And then it's, you know, it's important to appreciate for ourselves, and then also to explain to the patient that there are alternative procedures, like an endoscopy may not be the answer for everything, and there may be other options. There may be other procedures that may be an option, and they should be allowed to sort of understand that and decide on whether they like the endoscopic option, they want the surgical option, they want the radiological option, whatever is presented to them or whatever is available to them. And then I think it's also important, because patients are going to ask you sometimes, which is a hard question to answer, well, if you were me, what would you do? It's always a hard question to answer, right? So I mean, you know, that's where, you know, you tell them, well, this is what you have, this is what I think I can do with this procedure. And if you don't have the procedure, well, these are the possible consequences. And sometimes that helps sort of patients, especially when they're nervous about something very invasive or more invasive, sort of contemplating their decision there. And then sort of when we talk about things that can happen during a procedure that, you know, they're sort of adverse events, but they're sort of part and parcel of doing anything with sedation really is, you know, if they don't have a breathing wall, it's safer to intubate them. So they may get intubated during the procedure. If they're hypotensive, they have an arrhythmia, those will be corrected usually pretty easily without any significant adverse results. You may need to be hospitalized after the procedure. Maybe nothing went wrong, but I'm a little worried about what that procedure itself. I'm worried that you're going to have some issues, so I'd rather not send you three hours away and then bring you back or have you go to a local hospital. And then, you know, always bleeding is always a possibility with certain procedures and sort of being sure that one, that they're accepting of blood transfusions, so you know that beforehand. And then even if they are accepting that, they're okay getting it if it were to be needed. It does strengthen that relationship. I mean, like I said, when they feel part of that decision-making, they trust you more, they are forgiving of things that don't go wrong, they're appreciative of things that go right. I think it's an important part of that initial visit, you know, sort of informed consent, but it really encompasses that entire time, the entire process of seeing that patient for the first time. You know, again, you want to discuss the worst possible outcomes, but again, you're going over everything that can happen, including death, but you want to discuss misleasions. We do a lot of diagnostic procedures, whether it's upper endoscopies, colonoscopies, endoscopic ultrasounds, but we're not perfect either, neither are the procedures themselves. So it's important to explain to them, we do our best, but sometimes lesions can be missed. That's true of any diagnostic test, right, across the board in medicine. Have a witness there to sign your, to sort of corroborate your consent, and then document the process. I mean, most hospitals, most institutions require some kind of documentation that the patient was spoken to and consent was obtained before a procedure if not seen within the last 30 days or so, but that's important to document, not just have the consent in the chart, but document that you actually spoke to the patient, you discussed everything with them. When you do the informed consent, you know, keep it simple. I use descriptive terms, explain what you're doing. I think that whole process, especially, you know, when you're doing it just in your pre-op area, you know, simple things like I always sit down, it doesn't matter how bad my day is going, how backed up I am, how many cases I've got waiting for me to go next, I always sit down. Patients, you know, it just gives them the sense, if you're standing over them and being like, oh, Mr. Smith, I'm going to be doing an endoscopy, blah, blah, blah, blah, do you have any questions for me? And as, you know, you do that as you're walking, sort of walking away, it gives that, you know, you might be doing everything you need to do, you've probably done, gone through all those steps, but the only thing the patient remembers is like, this guy didn't even bother sitting down, he didn't even give me a chance to really communicate. So even if it takes less time, sitting down, just sit down, keep it quick, leave, they just feel like you took the time to actually talk to them and go over the procedure itself. Keep it simple, use descriptive terms, I use, you know, pictures, in our endo unit we have diagrams for ERCP, for EUS, so again, visually it's easier to understand stuff, we all have phones now, just pop up Google biliary tract and you'll get an image of an ERCP and a bile duct or a colon or a stomach. Always ask questions, if there's family around and you can tell someone's either nervous or maybe not comfortable on their own, get the family into the room with you there and then, you know, make them part of that process too. Always remember to ask the patient first if they're okay with doing that though. Some patients may not want other people in the room, but always ask and if they are, if they request them, have them in the room and then make that other person, their advocate part of that process, you know, do you have any questions, let them ask and if they ask questions, you know, address them. And then in the end, like I said, just always making sure that they know what they're getting into, why they're getting into it and what to expect from it. You know, just sort of from different papers, these are all retrospective, but, you know, you can give them sort of numbers, you know, it's easier for a patient when you say 1%, you know, what does that really mean, 2%, what does that really mean. So giving them sort of numbers like this, when you're telling them what the risks of certain procedures are, whether it's an endoscopy, colonoscopy, whether certain interventions is helpful. Like, you know, you say ERCP pancreatitis 5%, that sounds pretty small, but then you tell them it's 1 in 20 people, if you do a few hundred in a year, that's not that small risk, right? So sort of it gives you perspective when you give them in numbers. And these are sort of numbers that you can quote. I quote most of these all the time. So when it comes to patient preparation, again, this also starts way before the procedure ideally. You're going over what they have to do, but making sure in terms of oral intake, when they can stop, making sure they can take their medications that morning, because, you know, you tell them don't take anything by mouth, now they're worrying, well, do I take my medications because I'm taking that by mouth? So you can, you know, you always want to tell them no food, take your medication with a sip of water, especially the essential ones. The anesthesia societies have, the ASA have guidelines on when, how long you need to be NPO for, and those are pretty standard in any unit. Certain things like patients with gastroparesis, now we have all these GLP-1 antagonists, a lot of those will sort of impact that. People getting colonoscopies, I mean, I think this really has to happen in the office, honestly. You have to emphasize the importance of inadequate prep and explaining why it's important, not just for doing a good thorough exam that is beneficial to the patient, but, you know, avoiding the need to repeat the procedure prematurely, having to go through, I tell people like, you know, it's going to be terrible, but you'd rather go through it once than have to go through it more than once when you don't need to. It does increase your procedure time, it does increase your risk, because if you can't see where you're going, you're trying to maneuver to an inadequately prepped colon, you do run the risk of increasing severity. So sort of just sort of, again, the same thing, just sort of emphasizing why it's important for them to participate as far as they're concerned, and, you know, it usually goes over well when they understand why they have to do certain things. Sorry, I just keep going through. This is not the poll thing, right? It is. All right. So, I guess, which of the following patients should have antibiotic prophylaxis prior to their GI procedures? Okay. So most of you got it right. So yeah, so among those choices, when you're placing a PEG is probably the time you really need antibiotic prophylaxis. The other ones you really don't. And it's good because those are very valid questions because they do come up, especially the joint replacements. Patients always ask, my surgeon told me I can't get any procedure without an antibiotic. So it's always a sense of anxiety for them. So it's important to know and then sort of be able to communicate to them whether it's necessary or not. Sort of basic principles. Antibiotics to prevent endocarditis is not recommended for, just not universally recommended for GI procedures. Just because someone gets one for dental procedures doesn't mean they need one for an endo procedure. And this is why. So if you can actually compare the risk of bacteremia when you have an endoscopic procedure versus something you do in your daily life, you can see the risk of bacteremia is significantly smaller and less concerning. So these are, you know, based on the article in GIE from a few years ago, this is where the ASG recommends. I think, you know, three of those are strong recommendations are PEG tubes, ERCPs with incomplete drainage. So when you have strictures and you don't feel like you're going to be able to drain the entire tree. And cirrhosis with acute GI bleeding. Those are strong recommendations. The others are, have sort of suggestions. That's how they word it. Most endosynographers for pancreatic cysts, I think, have gone away from giving antibiotics just because there's a lot of data showing that it doesn't make a difference. Mediastinal cysts, the data is small, but I think there is a risk, some studies showing even after antibiotics that they can get infection. So those are two sort of suggestions, but we haven't had updated guidelines in a while. So I think when we do that will change. This is probably the most, the thing you guys are going to deal with the most is like, I think it's very rare to have a patient in a day, not have a handful of patients who are not on either antiplatelet agents or anticoagulants, right? Just from the vast number of comorbidities that patients have, just AFib alone, I feel like everyone has AFib these days. So which of the following is a procedure that is high-risk for bleeding? So ERCP without sphincterotomy, EOS with final aspiration, EGD with biopsies, a push enteroscopy, colonoscopy with biopsies. All right. I see the majority have it again. So yeah, so fine needle aspiration does carry some risk of bleeding. The other is the risk of bleeding is really small. Often we do an ERCP without sphincterotomy specifically for that reason because we can't do a sphincterotomy because for whatever reason there's a risk of bleeding and they need that ERCP more urgently than electively. I mean, I think this is something to familiarize yourself with, knowing which procedures have a high risk of bleeding and some of which don't have, are not associated with a high risk of bleeding. Some of them are maybe surprising things like, you know, taking small polyps out, doing coagulation interventions like APC or deploying a stent or doing an ERCP without a sphincterotomy, for example, just so, I mean, and we'll go over in the next slides why this is important because a lot of times these patients are coming to you for a procedure and you're looking through their medical history, whether they're safe for a procedure. And then part of that is, to me is like, you know, I always ask patients, do you have any cardiac disease? Do you have any pulmonary disease? If you do have either one or the other, how bad are they? Are they stable? Are they sort of acute? And then the other question I always go over is anti-platelets and anti-coagulants because that's important for me for a lot of the procedures that I do. And then, you know, a lot of times there's things that are simple enough that you can sort of guide patients on your own, but you have to know sort of what you're doing, what the risk is, and then you have to know what their risk is for thromboembolism. So why are they on the blood thinner? Is it for a DVT that they had 20 years ago because they were on a flight? Or was it because they're on a-fib and they had a stroke in the last three years? So you know, what's their CHA2DS2-VASc score or what's their CHA2DS2-VASc2 score? Do they still have blood clots? Do they have recurrent blood clots? So these are all questions that sort of determine that the patient's individual thrombotic risk, and then you have to compare that to the risk of bleeding. And that's what helps you decide what you're going to do with the anti-coagulants. And sometimes you can take the help of your colleagues. You know, if they're seeing a cardiologist or hematologist, nothing wrong in conferring with them and saying, hey, listen to me, I have this patient, this is what I'm planning to do, this is how long I need them to be off a blood thinner, you know, how can we work this out? So even speaking to your colleagues about these things, I think, is an important aspect of the preoperative care of these patients. So in general, I'm not going to go through all of this, but in general, you're comparing always the risk of the procedure is low or high, and the risk of thromboembolism in the patient where it's low or high. And then whether they're on anti-platelets alone, one or two anti-platelets, are they on anti-coagulants alone, are they on both anti-platelets and anti-coagulants? In general, just remember aspirin, you really don't need to stop it. You really shouldn't be stopping it for any procedure, right? And then even for NSAIDs, there's really no great data on stopping NSAIDs, like continuing NSAIDs actually increases your risk of bleeding. With everything else, again, it depends on their risks. So if you have a low bleeding risk procedure, you really don't need to hold aspirin, I mean, sorry, Coumadin, Warfarin, or your newer, your heparin anti-platelet agents. If it's, with Coumadin, obviously, you want to check to make sure they're not super therapeutic before their procedure. If they are, you may want to consider pushing it off, pushing off your procedure. If they have a high bleeding risk procedure and a low thromboembolic risk, then you can stop anticoagulation for three to five days, depending on what the anticoagulant is. Heparin for eight hours, anti-platelet agents, if they're on two, you can stop the non-aspirin one. If they're high bleeding risk and they have a high thromboembolic risk, these are the patients that are a little bit more trickier to manage. But most of these patients probably need some kind of bridging anticoagulation to prevent anything happening during that procedure, whether it's with a drip when they're in the hospital. But low molecular weight heparins are easy to use as an outpatient. You really need to hold it for about eight hours before your procedure, and you should be fine to do almost any endoscopic intervention or diagnostic procedure. It's just part of the reason why this is important, and this is a little old from a few years ago, but it doesn't happen that much now because I think the awareness among the gastroenterologists in general in terms of stopping aspirin, not stopping aspirin, has gotten better. It's not perfect, but it has gotten better. In general, if you're on two anti-platelet agents, it really depends on, if they've had a stent recently, for example, you're doing an elective procedure, postpone it to when it's safe to hold one of the anti-platelet agents. If there's a risk of stent thrombosis in the past, if they've had stent thrombosis in the past and their cardiologist doesn't want them off the medication, that's something else you can work with their cardiologist for. And then in general, if you're doing an elective endoscopic procedure, you're probably better off holding off for at least a year for most patients with either a stroke or a recent ECS with a PCI or some kind of coronary intervention. Sedation monitoring, I think all procedures now are done with sedation, either with propofol or concious sedation in most places. Timeout is important in any operative setting. Making sure you have the right patient, you're doing the right procedure, and you have all your equipment that you need, and you've sort of reconciled any medication-related issues. Making sure you have the right monitoring equipment, I think, is important. A lot of this is usually done by your anesthesiologist. If you're in a setting where you have an anesthesiologist, they do this sort of their pre-anesthesia setup, which is basically trying to determine if there's any risk of any respiratory compromise during the procedure, just from anatomical or comorbidity standpoint. But again, when you're in the office and you're seeing these patients, you want to think of that too. If you have someone with severe COPD, you want to start thinking about how that's going to impact your ability to do certain procedures in these patients. Again, depending on the setting that you're in, conscious sedation often is just the endoscopist and a nurse. If you're doing deeper sedation, you usually have an anesthesiologist in the room or an anesthetist of some sort, and they usually know where this is. But knowing where you have your rescue equipment, God forbid if something should go wrong, is always a good idea. And knowing what the complications are, again, these are sort of part of your informed consent. And complications are related to the endoscopy in general. I think, again, part of your informed consent, which is that you talk to the patient, but also to be able to do that consent, you have to be aware of what the possible complications are when you're doing certain things. So you know there are certain people where certain patients may have a higher risk just because of what they're doing. Maybe they're older, maybe they have underlying pulmonary disease, maybe what you're doing itself has a higher risk. Maybe they're on blood thinners, and maybe they have a coagulopathy of some sort. So know your patient, know your procedure, and you know, don't be a hero, I don't know if I would put it that way, but the point being, understand where your skill set is, especially if you're in an institution where you have colleagues, knowing who your colleagues are on the day. So let's say you need help or you anticipate that you may need help, knowing that those people are there, whether it's a fellow gastroenterologist, whether it's a surgeon, whether it's a radiologist, just being wary of where you're having contingencies with things that might go wrong. And if it's contingencies that you can't fix yourself, then knowing having people who can help you fix problems, I think that's important. Being aware of what's going on and detecting, being able to identify when something's not right, I think that's really important, comes with experience. Always keeping an eye on the patient, keeping an eye on what's going on on your screen, communicating with your team in the room, whether it's the nurse, the anesthetist, or anyone else that you're doing your procedures with. In the post-op period, if you feel like something's not right, get the appropriate testing. If you need an x-ray or a CT scan, no harm in doing it. Get one, see what's happening, especially if it's a patient you intend to send home and it's not an inpatient. Always better to know that the patient's safe to go home before they're actually discharged. And then some complications, obviously, we're capable of treating now. With overtime, we've gotten better at managing our own complications, not that we can manage all of them. But again, identifying what those are and what your capability is, what resources are available to you within your unit or locally. In terms of how you deal with the patient, communication, I think, is the most important thing. So detection, communication, and then action, I think those are the three parts of dealing with any complication. So if you don't know there's a problem, then everything else is kind of moot. So being able to identify a problem, being able to communicate with the patient or their family truthfully, say, listen, I think this is going on. This is what I'm going to do. This is how I'm going to figure it out. And depending on what it is, if it's x, y, or z, these are the options we have to manage that. Or I'm going to call my colleague who's going to be able to help us deal with this. I think that communication is extremely important. Being just very straightforward about these with the patient, I think, is of paramount importance. It'll work well. It'll work in your favor in the long term, just if you're honest with them about everything. You know, making sure they have the adequate resuscitation, right? I mean, fluids, antibiotics when needed. Speaking to your colleagues that you may need, that you think you may need, even if it's not evident at the time that they need an intervention. Just if there's a possibility, sort of keep making them aware and bringing them on board sooner rather than later. It's always helpful. So in the last 15 seconds, so like I said, the introduction to endoscopy really is about everything around endoscopy. And it's really, like I said, once you start going into practice on your own, you really appreciate how important this is. It really is extremely important. Making sure you do that informed consent, which is really part of your initial meeting with that patient. Going over everything from what's going on with them, what you think is going on with them, to what you think your options are to help either diagnose or manage those problems. And sort of going over everything in a way that they understand and they feel involved with. Making sure you do everything you need to prepare the patient in terms of instructions to the patient, instructions to your staff, to yourself, making sure you have equipment, things like that. Preparing antibiotics in terms of who needs them, who doesn't need them, which procedures you should be giving them. It really should be part of your time out every time you do that is whether or not antibiotics are required.

endoscopy

informed consent

patient agency

medical decisions

complications

patient safety