This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. 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, 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.

endoscopy procedure

consent

ergonomics

abnormalities

biopsy protocols