I'm going to give a talk about quality indicators in upper GI endoscopy. I'll try to click through here, those are my disclosures again. You know, and I was mentioning this to Eden before we started, you know, I think, you know, I think it's fair to say over the last 10 to 20 years, you know, we've really emphasized that the quality of colonoscopy to really push forward with optimizing this. But I think it really is important to realize that, you know, we're doing a lot of gastroscopies in North America and worldwide. Now, I wrote these because I'll be honest, I'm pretty sure I've said almost all of these comments at one point in time, you know, I'm sure from a nursing perspective as well. You've heard this from the endoscopist or if you're one of the managers, you've heard this from your endoscopist, you know, like, oh, this will only take a couple of minutes or this will be quick or, you know, we can catch up. I've got a few EGDs for the rest of my list or, you know, maybe subconsciously in your mind, you recognize that you're doing a combo procedure between a gastroscopy and colonoscopy and, you know, it's an opportunity for you to catch up, which, you know, to be frank, I think it's something that we need to move away from because just as we have, you know, quality associated with colonoscopy, we should also see gastroscopy through that lens as well. And so what makes us a high quality procedure or a high quality gastroscopy? There needs to be a clear indication. I think every endoscopist can admit that sometimes we do things that are maybe on the cusp of what's clearly indicated to facilitate patient care. You know, it's important that we are evaluating patients for relevant diagnoses and either establishing that they are present or if they're not. I'm just as guilty as sometimes writing quick notes and just saying, you know, duodenum normal, stomach normal, esophagus normal, but providing some detail around that is important. You know, obviously, if you're providing therapy during an upper endoscopy, that it's the appropriate therapy for the right indication and that you've effectively applied it. And then, as always, trying to mitigate harm or adverse events to our patients. So, yeah, as Sonali mentioned, it's actually really exciting. This actually hasn't been published yet. And so these are sort of truly, you know, a unique look at what's coming down the pipeline for quality indicators in upper GI endoscopy. You know, starting off in the in the pre-procedure aspects, I think that's probably relatively standard of care now with respect to the timing of upper GI endoscopy interventions for upper GI bleeding. But I think it is really important to highlight those boxes are not going to come up. That's OK. You know, essentially that we are doing procedures for the right indication. You know, this is a citation suggesting that, you know, an endoscopy without an appropriate indication can sometimes be upwards of 49 percent, which to me sounds extreme. But I definitely think this is something that we can optimize, ensuring, you know, appropriate patients are getting appropriate procedures. Now, next up, this is intraprocedural aspects more tailored towards general endoscopy, potentially reflux and eosinophilic esophagitis. And, you know, one of the important ones, I think, is the fact that we need to really start describing landmarks and providing photo documentation. So, for instance, of the esophagus gastroesophageal junction, you know, specific aspects of the stomach. Just as TR mentioned, there are areas in the colon and rectum that are commonly missed or overlooked. And same thing with the stomach, making sure that you're getting a good look at the incisora and specifically a body lesser curve or places where patients can or at least lesions can be missed alongside the duodenum. And then, you know, with this in mind, you know, taking appropriate samples in patients with dysphagia for EOE biopsies, you know, and alongside this appropriate classification of the LA classification for reflux or erosive esophagitis. Now, I don't know whether or not the picture will come up or not. Oh, they are now. OK, perfect. And so this is an example, right, of, you know, for instance, if you have images embedded in your endoscopy, you know, these are appropriate images for the different aspects that we've just aligned. And I think something to note is, is that, you know, if you are taking not just pictures, but high quality pictures, you know, essentially you've actually cleaned the stomach, not leaving, you know, all these bubbles and stuff like that in it. It essentially forces you into performing a high quality upper endoscopy. So next up is Barrett's esophagus. So I manage Barrett's esophagus. So this is sort of near and dear to my heart, you know, along the same lines of delineating appropriate images. It really is important that we delineate the anatomy of the upper GI tract. And so, you know, for instance, where is the diaphragmatic crux? Where's the top of the gastric folds? Where is the squamous glomerular junction? Because that's allowing us to identify, one, does the patient have a hiatal hernia? And on top of that, does the patient actually have Barrett's esophagus? Now, uncommonly, I get referred patients with a question of Barrett's esophagus. And although difficult for me, fortunate for the patient, I get to walk them back from this diagnosis and say, because you have, you know, for instance, a subcentimeter tongue above the top of the gastric folds that you technically, by definition, don't need this diagnosis. Alongside this, and I think this is something that we can really work to improving on, you know, just identifying that the patient has at least endoscopic features of Barrett's esophagus is important. But taking it a step further, it's not just to say, okay, there is Barrett's esophagus, I'm going to take biopsies, but actually doing a careful evaluation with high definition, white light, and some form of chromoendoscopy. I suspect in North America, this is predominantly going to be virtual chromoendoscopy, like NBI or like BLI-LCI. And why this is so important is, at least within my practice, like I know uncommonly get referred patients, you know, for instance, consideration for radiofrequency evasion, for Barrett's endotherapy. And maybe upwards of about 50% of the time, I'm actually identifying a lesion that requires endoscopic resection. And then alongside this, you know, appropriately managing patients with respective biopsy protocols and management of dysplasia within the esophagus. For upper GI bleeding, you know, my hope would be is that a lot of centers now are really, really quite competent in the management of upper GI bleeding, you know, risk stratification of lesions that require therapy and the appropriate use of therapy. And, you know, we might be now moving to sort of those outcome type measures of saying, you know, when you have a patient with upper GI bleeding, how often is this patient being effectively managed? And so, at least within my center, I think this is the thing now that we've moved towards evaluating. And I think for me, this may be the most exciting area of the up-kinding guidelines, because I think it's something that specifically North America continues to strive to improve. Like, I think we have a relatively good appreciation for GI bleeding and, for instance, Barrett's esophagus and reflux and EOE. But something that the East has a lot more experience in is gastric cancer prevention. So, for instance, you know, how often are you taking appropriate biopsies in patients? You know, how do you actually evaluate the stomach? And sort of going back to some of those pictures I showed, you know, for instance, like really copiously irrigating the stomach, cleaning the stomach, and carefully evaluating it under white light and, you know, virtual chromoendoscopy to try to detect features of, for instance, atrophy, intestinal metaplasia, dysplasia, and other forms of polyps in the stomach. And then on top of that, you know, sampling issues and stuff like that. And so, I have pictures here. Oh, I think I threw this in. You know, like, I think alongside this, we're going to start moving towards terms that maybe not as many endoscopists or, for instance, physicians feel comfortable with. So, for instance, like things like evaluating GAP syndrome, which is an APC variant in patients who have, you know, numerous fundigal polyps. And so, here's a nice example, again, of, you know, potential biopsy protocols to really try to tease out patients who are at higher risk of gastric cancer. So, patients who, for instance, have atrophy or intestinal metaplasia in the proximal stomach, you know, specifically people with distal intestinal metaplasia or atrophy in high-risk ethnic populations. And obviously, people who have started to develop dysplasias in their stomach need to be put on different surveillance protocols than the average NWC undergoing gastroscopies. And you can see in the guidelines. Now, they're starting to delineate, for instance, you know, what polyps look like. I think most endoscopists will feel very comfortable with fundigland polyps. The authors chose a very interesting polyp here. This is almost for surely a prolapse-related polyp in the antrum. You may or may not know there's, you know, three different types of hyperplastic polyps, hypovolar, hyperplasia, prolapse-related polyps in the antrum, and then sort of conventional hyperplastic polyps that are more confined to the gastric body. And then on top of that, you know, starting to recognize adenomatous lesions, the most challenging being these sort of subtle flat lesions that we find in high-risk patients, sort of training our eyes the same way we've trained our eyes to look at serrated class lesions, we now need to start training ourselves to pick up these lesions in the stomach. We now have also recommendations for celiac disease, specifically taking biopsies, not just in D2, but also in the bulb. And then lastly, it goes to the post-procedural aspects of care. And, you know, some of these, again, I think are really important. So, for instance, you know, relook of patients who have really severe esophagitis, you know, I'm sure every unit has these types of patients coming in. Specifically, I find on on-call patients and ensuring they're coming back to rule out that they don't have esophageal cancer or Barrett's esophagus, so that could definitely change management. You know, speaking to, again, you know, efficiency of endoscopy, you know, making sure that patients are, one, if they're high-risk, they're being brought back. For instance, patients with, you know, squamous neoplasia of the esophagus, Barrett's esophagus, duodenal neoplasia, or patients with a high-risk stomach, but also remembering that not all patients need aggressive endoscopic surveillance. So, for instance, in Barrett's esophagus, the length may dictate how frequently you want to perform endoscopic surveillance. And then, again, as I mentioned before, you know, really starting to drill down on these patients who do have high-risk stomachs and identifying surveillance protocols. And we're now starting to see a lot of Western organizations, ASG, I think with the last couple of years, have come out with respect to management of upper GI tract lesions, similar to Europe and as well as the East. That's it for me with respect to the sort of quality indicators for upper GI tract endoscopy.

upper GI endoscopy

quality indicators

Barrett's esophagus

biopsy protocols

gastric cancer prevention