Table 1.
Summary of of key recommendations for improving quality in diagnostic endoscopy
| Pre endoscopic preparation |
| Premedication with simethicone or simethicone and N-acetylcysteine improves visualisation in the stomach and oesophagus |
| Pronase, a proteolytic agent, increases gastric visibility scores |
| Allowing clear liquids up to 2 h of endoscopy improves patient anxiety and patient comfort |
| Use of antispasmodic agents to enhance detection of high risk superficial neoplasms is recommended |
| Sedation |
| Patients should be counselled adequately regarding sedation options. Reported satisfaction is higher after endoscopy with sedation |
| Propofol sedation decreases sedation time and improves the detection of early stage pharyngeal and upper gastrointestinal cancers |
| Propofol use is associated with better inspection during oesophageogastroduodenoscopy (OGD) and hence offers better quality examination compared to midazolam |
| In patients undergoing sedation with midazolam, routine fentanyl use reduces additional midazolam doses and shortens procedural times and reduces patient retching |
| In low risk patients and procedures, the use of a target controlled infusion of propofol and alfentanil administered by a nurse anesthetist has been shown to be safe and improves anesthesia quality |
| In patients who prefer not to undergo sedation, small caliber OGD performed via transnasal or transoral route may offer better patient tolerability with similar level of diagnostic accuracy |
| Systemic examination |
| A mandatory set of systemic images in endoscopy reports may increase quality of reports and reduce variability in interpretation |
| There is currently no consensus how many pictures should be recorded for an adequate OGD |
| The use of systemic alphanumeric coded endoscopy approach during endoscopy increases yield of high risk lesions |
| Endoscopists with high rates of ampulla photo documentation were more likely to detect upper gastrointestinal neoplasms and dysplasia and ampulla photo documentation may be used a quality indicator for thorough gastroscopy |
| Duration of examination |
| Endoscopists with average Barrett’s inspection time (BIT) exceeding 1 min per centimeter detected more endoscopically suspicious lesions; A longer BIT correlated with high grade dysplasia and adenocarcinoma detection |
| Endoscopists with a mean examination time exceeding 7 min for a normal examination were twice as likely to detect high risk lesions and neoplastic lesions compared to their faster counterparts |
| The effect of longer examination time may be diminished in very experienced endoscopists who are able to readily recognise neoplastic lesions |
| Various societies and consensus guidelines now recommend at least 7–8 min for an adequate upper endoscopic examination |
| Routine endoscopy biopsy |
| No studies have demonstrated that routine biopsy improves detection of high risk lesions during endoscopy |
| Endoscopists with high biopsy rates were less likely to miss a cancer in patients who undergo interval endoscopy |
| Image enhanced endoscopy |
| Detection of oesophageal lesions |
| Absence of iodine staining on chromoendoscopy, even when negative for dysplasia on initial histology, identifies esophageal lesions with high sensitivity for dysplasia or cancer in later follow ups |
| Non-magnifying narrow band imaging (NBI) was found to have similar sensitivity with superior accuracy and specificity compared to iodine staining for early squamous cell carcinoma |
| Endoscopists should be trained in the NBI use. NBI Sensitivity was higher in the hands of more experienced endoscopists |
| Blue laser imaging (BLI) is comparable to magnifying NBI as well as Lugol iodine chromoendoscopy for detection of early esophageal cancer |
| Detection of gastric lesions |
| Newer generation NBI improves pick up rate of focal gastric lesions and intestinal metaplasia compared to high definition white light endoscopy |
| The magnifying endoscopy simple diagnostic algorithm guideline should be followed to identify early cancers |
| In the presence of a demarcation line as well as irregular micro surface and/or irregular microvascular pattern, a diagnosis of early gastric cancer can be confidently made |
| High specificity in excluding gastric neoplasms may reduce the need for unnecessary biopsies if magnifying endoscopy (ME) and NBI is employed |
| ME-NBI improves visualization of the horizontal margin of early gastric cancer compared to low magnification NBI and chromoendoscopy |
| BLI- Bright was demonstrated to be superior to white light endoscopy (WLE) in the real-time detection of early gastric cancers |
| Linked color imaging (LCI) identifies confidently Helicobacter pylori infection, gastric intestinal metaplasia and early gastric cancer |
| The diagnostic accuracy of magnifying LCI with indigo carmine for small depressed gastric lesions has been shown to be better than both conventional WLE and magnifying BLI |
| Future developments |
| Raman spectroscopy differentiates normal gastric tissue from premalignant and malignant tissue and allows real time diagnosis and reduces need for biopsy |
| Endocytoscopy allows real time diagnosis of Helicobacter pylori positivity, intestinal metaplasia, atrophic gastritis and early gastric cancer. There is good interobserver agreement between endoscopists and pathologists |
| Neural network based artificial intelligence can now be trained to identify oesophageal squamous cell carcinoma and gastric cancer with high sensitivity and specificity |