Standards for Upper GI Endoscopy Released

Pam Harrison

September 19, 2017

Recommendations on upper gastrointestinal (GI) endoscopy were jointly released by the British Society of Gastroenterology (BSG) and the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. The groups seek to improve the overall performance of upper GI endoscopy and image quality and reduce the risk for missed cancer on the initial test. This is the first position statement from the two groups.

"In the last 10 to 15 years we've made a dramatic improvement in the quality of colonoscopy in the United Kingdom but upper gastrointestinal endoscopy hasn't really changed," senior author, Andrew Veitch, MD, consultant gastroenterologist, Wolverhampton National Health Service Trust, United Kingdom, told Medscape Medical News.

"[O]ne of the biggest drivers to do this quality improvement initiative is to improve early cancer detection, and the one thing that will really improve quality overall is all about mucosal visualization," he said.

The position statement was published online August 18 in Gut.

The position paper includes quality standards that endoscopists need to follow before and after the procedure, including the need to provide patients with a report of the main findings before discharge. Written consent is mandatory.

In accordance with the "Safe Surgery Saves Lives" initiative, the authors recommend that practitioners complete a safety checklist to assess patients for medications or conditions that may render the procedure too risky to proceed.

"Only an endoscopist with appropriate training and the relevant competencies should independently perform [esophago-gastro-duodenoscopy] OGD," the authors state. "[E]ndoscopists should aim to perform a minimum of 100 OGDs a year, to maintain a high-quality examination standard," they add.

Visualization, Photo-documentation Key

Clinicians should use "high-definition video endoscopy systems, with the ability to capture images and take biopsies" and should adhere to and document a standardized set of anatomic landmarks and high-risk stations to ensure the examination is complete, the authors write. "The practice of photo-documentation...encourages mucosal cleansing, mucosal inspection and ensures a complete examination," they explain.

Requiring photo-documentation "encourages" practitioners to acquire a good photograph because it will, by default, prompt them to wash the mucosa to get a better picture for their records, Dr Veitch noted.  A combination of air insufflation, aspiration, and mucosal cleansing helps guarantee adequate mucosal visualization, and the use of mucolytic and defoaming agents enables the dispersion of bubbles and mucous. "We would not expect to find small polyps in a dirty colon, yet we look at the upper gastrointestinal tract and it's covered in mucus that is not routinely washed away in most practices," Dr Veitch said.

"[I]t really is about taking time — cleaning the mucosa — the same as we do in colonoscopy and all of the measures we have taken to improve colonoscopy is what we are trying to do in upper gastrointestinal endoscopy," he added.

A complete OGD should take about 7 minutes, during which time endoscopists need to describe any lesion detected and its anatomic location; targeted biopsy should also be done. At times, achieving a high-quality examination may require sedation or analgesia, and all endoscopy units need to follow safe sedation guidelines.

The authors encourage the use of intravenous sedation or local anesthetic throat sprays to enhance patient comfort.

Facilities must have a method in place for ensuring processing of histologic results. Results should be reviewed promptly, and "[w]here an unsuspected case of high-grade dysplasia or malignancy is detected on histological review,

this should also be highlighted to the relevant multidisciplinary team by the histopathologist," the authors write.

Disease-Specific Standards

Disease-specific quality standards include Barrett's esophagitis, esophageal ulcers, grade D or atypical esophagitis, hiatus hernias, eosinophilic esophagitis, esophageal varices, gastric or duodenal ulcers, gastric atrophy or metaplasia, gastric polyps, and celiac disease.

There is a small but "unacceptable" risk that an esophageal stricture is malignant, and histology should be obtained before dilatation to avoid transforming what might be a localized tumor into disseminated disease, "should a malignant stricture perforate secondary to endoscopic therapy," the authors say. 

Any lesion that looks malignant should be described and photo-documented, as well as biopsied a minimum of six times. "An UGI [upper gastrointestinal] cancer detected within 3 years of an OGD should be considered as a failure to diagnose the cancer earlier (termed post OGD UGI cancer or POUGIC)," the authors conclude.

"We recommend that units audit performance data to ensure that POUGIC rates do not exceed 10% and a root cause analysis of factors contributing to individual cases is performed," they suggest.

ASGE Comments

Jonathan Cohen, MD, spokesman for the American Society for Gastrointestinal Endoscopy (ASGE) and clinical professor of medicine at NYU Langone School of Medicine in New York City, told Medscape Medical News that the drive to improve upper GI endoscopy quality similarly motivated his society to update quality indicators. They released their own position paper in 2015 to ensure that quality continues to improve over time. "A number of things stand out in common," Dr Cohen noted. For example, both documents emphasize the importance of obtaining informed consent and properly documenting the procedure as it is being performed.

"Both documents also highlight those indicators that we felt would be associated with better outcomes, and that ought to be measured and practiced," he added. The ASGE authors also tried to create priorities that they felt were especially important for endoscopists to be aware of and improve upon if they were found lacking in proficiency.

In their recommendations, the ASGE prioritized indicators for which the evidence is strong, not only those on which consensus members strongly agreed. "We also set targets," Dr Cohen observed, "so that people could see how well they were meeting these targets, and then if they weren't reaching them for some reason, they would know what to shoot for," he added.

The authors and Dr Cohen have disclosed no relevant financial relationships.

Gut. Published online August 18, 2017. Full text

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