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Flexible endoscopes: structure and function. The suction and biopsy channel.

Flexible endoscopes are complex medical instruments that are easily damaged. To maintain the flexible endoscope in optimum working condition, the user must have a thorough understanding of the structure and function of the instrument. This is the second in a series of articles presenting an in-depth look at the care and handling of the flexible endoscope. The first article discussed the air and water system. This article will focus specifically on the suction and biopsy channel system. The flexible endoscope is constructed of several systems that operate simultaneously to produce a highly technical, yet effective diagnostic and therapeutic medical device. These systems include the air and water system, the suction or operating channel system, the mechanical system, the endoscopic retrograde cholangiopancreatography (ERCP) elevator system, the optical system, and the electrical system. A review of the internal and external structure of the flexible endoscope and the functions of the channel system, including infection control issues, potential problems and evaluation, and prevention of minor problems to avoid expensive repairs, will be addressed.

Biopsy↗
PubMed1990

Hypoxia and hypotension during endoscopy and colonoscopy.

Sixty-three patients undergoing oesophagogastroduodenoscopy (OGD) (n = 24) or proctosigmoidocolonoscopy (PSC) (n = 39) had continuous monitoring of arterial oxygen saturation (SaO2), pulse and mean blood pressure (BP). The degree of patient distress, duration, dose of sedative and details of the endoscope and operator were recorded. Marked hypotensive (greater than 40% fall in BP) and hypoxic (greater than 8% fall in SaO2) changes occurred in 13% and 17% of the overall group, respectively. There were no significant differences in fall in BP, SaO2 or pulse between the OGD and PSC groups. The dose of sedative was significantly related to the fall in SaO2 (P less than 0.001) but not to the fall in BP. The falls in both SaO2 and BP were related to the duration of the procedure (P less than 0.001, P = 0.03, respectively). There were no correlations between the degree of hypoxia or hypotension and the patient's age or previous medical history. Hypotension and hypoxia occur in both colonoscopy and OGD and are neither predictable nor usually recognizable clinically. Pulse oximetric and BP monitoring throughout gastrointestinal endoscopy are recommended for maximal safety.

Adult↗
PubMed1993

Intracorporeal retrograde choledocholithotripsy or ESWL as a therapy for choledocholithiasis.

More than 90% of all common bile duct stones can be removed endoscopically following endoscopic sphincterotomy aided by the use of baskets, balloon catheters and mechanical lithotripsy. Oversized, very hard or impacted stones, however, often resist conventional endoscopic therapy. Promising new or improved approaches to the treatment of these stones are intracorporeal or extracorporeal shockwave lithotripsy. Shockwave lithotriptors for ESWL are currently available worldwide. However, to treat with the water-bath first generation devices general anaesthesia is required, since shockwaves are painful. Furthermore, an X-ray localization system is essential to visualize the stones after opacification of the bile duct via a nasobiliary catheter. On average, two shockwave treatments with a further one to four endoscopic sessions are required. Intracorporeal lithotripsy promises more comfort and less effort for the patient. Shockwaves are generated either by means of the spark gap principle (electrohydraulic probes) or by laser-induced plasma generation. Laser-induced shockwave lithotripsy appears to be the safer procedure, since with solid state lasers (Q-switched Nd: YAG, alexandrite) athermal, well controlled shockwaves can be generated without the risks of duct perforation (as described for the electrohydraulic system). Furthermore, a recently developed stone-tissue detection system integrated in a new dye laser system (Lithognost) enhances the safety of laser-induced lithotripsy. In consequence, laser lithotripsy without direct endoscopic control appears possible in selected cases.

Endoscopy, Digestive System↗
PubMed2000

Endoscopic management of the liver transplant patient.

The endoscopic evaluation of the asymptomatic liver transplant patient is essential to risk-stratify the patient for future complications related to portal hypertensive bleeding (i.e., presence of large varices), and to exclude findings (e.g., malignancy) that might preclude the patient from consideration of OLT. Because waiting times for transplant are longer after listing, preventive management becomes imperative to diminish attrition on the waiting list and maintain long-term success. Following OLT, endoscopy may be performed to assess a number of common problems: gastrointestinal blood loss that may be caused by anastomotic lesions; persistent portal hypertensive bleeding; biliary complications, including leaks and strictures; and systemic processes (e.g., infectious diseases or lymphoproliferative disorder (LPD). Clearly, endoscopy plays an integral role in the successful management of the patient before and after OLT.

Endoscopy, Digestive System↗
PubMed2003

Gastroesophageal reflux as a possible co-promoting factor in the development of the squamous-cell carcinoma of the oral cavity, of the larynx and of the pharynx.

According to recent advances it is assumed that the gastroesophageal reflux (GER) is a possible co-promoting factor of the squamous-cell carcinoma development in the upper parts of the gastro-intestinal and respiratory systems, considering the higher frequency of lesions due to acid in the studied population interested by GER. The aim of this study is to investigate 274 patients with malignant neoplasm of the oral cavity, of the pharynx and of the larynx, by esophago-gastro-duodenoscopy (EGD) and to compare the incidence of GER in this group with a control group of healthy patients from their hospital. Acid exposure in the upper level of the esophagus often remains unknown using traditional pH-monitoring, especially if no pharyngeal probe is used. When necessary a good diagnostic test is EGD with mucosa biopsy; it allows to directly examine the lesion. We retrospectively studied the data of 274 patients suffering from a cancer of the upper aero-digestive tracts by EGD in order to diagnose lesions caused by GER. We compared non-smoking patients affected by GER and tumours a control group of healthy patients. Statistical analysis revealed a significant difference between the two groups using the z-Test (p = 0.0001). In our study, based on endoscopic data, we observed a high percentage of non-smoking patients affected by GER and squamous-cell carcinoma of the upper parts of the airways and the gastrointestinal system. For this reason we consider GER as a possible co-promoting factor of cancer in some patients.

Adult↗
PubMed1992

Technical failure of biliary metal stent deployment in a series of 116 applications.

Biliary metal stents are thought to offer improved long-term palliation of malignant biliary obstruction due to a lower incidence of migration and clogging. Placement of these stents is technically more complicated than that of plastic endoprostheses and requires two experienced physicians. We report the incidence and reasons for apparent malfunction of expandable metal stent deployment (Wallstents and Strecker stents). In 116 applications of 82 Wallstents (endoscopic approach: n = 33, transhepatic approach: n = 49), we observed 19 cases of stent malfunction due to technical problems of stent delivery. In 13 cases (15.8%), the restraining membrane of the Wallstent could not be retracted sufficiently to deliver the stent. There were 6 (17.6%) failures in 34 cases of Strecker stent deployment. In 3 cases, we noted difficult balloon removal, including avulsion of the balloon catheter shaft within the endoscope during attempted balloon removal in one case. In one case, the Strecker stent could only be released partially, requiring subsequent endoscopic extraction. In two patients, only partial expansion of one end of the Strecker stent could be achieved. Given the significant malfunction rate of expandable metal stents during stent delivery, further improvements in the delivery system of the metal stents are required.

Cholestasis, Extrahepatic↗
PubMed1992

Endoscopic laser lithotripsy with an automatic stone recognition system for basket impaction in the common bile duct.

In a patient with a common bile duct stone 28 mm in diameter, the traction wires of two basket catheters fractured during endoscopic mechanical lithotripsy. Disintegration of the concrement and removal of the impacted baskets failed even after extracorporeal application of 8,000 shockwaves. Pulsed dye laser lithotripsy was carried out via a 250 microns fiber which was advanced to the stone through a 6 French ERCP guiding catheter. Lithotripsy could be safely performed under fluoroscopic control since the laser used provides an automatic cut-out system upon tissue contact. 3,600 of 11,800 applied pulses were emitted with the total power setting and complete disintegration of the calculus was achieved. The baskets and the fragments could be removed endoscopically in the same session. Laser lithotripsy with a stone recognition system would seem to improve the applicability and safety of intracorporeal lithotripsy even when performed without direct visual guidance.

Aged↗
PubMed1990

[Hemorrhages of the upper gastrointestinal tract. A comparison of the diagnostic accuracy between endoscopic and radiological examinations].

One hundred and forty-eight patients admitted for upper gastrointestinal hemorrhage, but excluding esophageal varices, underwent optic fibre gastroscopy at the time of admission and were then examined using a barium meal after a 24-48 h interval. The aim of the study was to compare the sensitivity, specificity and diagnostic accuracy of the two tests. A correct diagnosis was obtained using both procedures in 58.2% of cases. Endoscopy provided an accurate diagnosis in 35.1% of patients, whereas gastrointestinal x-rays showed the exact site of the lesion in only 6.7% of cases. Endoscopy had a sensitivity of 92.5% compared with 60.7% for the barium meal. Endoscopy also had a higher level of specificity (100%) versus the barium meal (33.3%). The results obtained from the pathological examination of specimens confirmed the accuracy of endoscopy. In conclusion, early endoscopy is a reliable procedure in the emergency assessment of the hemorrhaging patient; routine x-ray examination does not appear to add additional information and may be reserved for subsequent use if endoscopy gives doubtful or misleading indications of the site of bleeding.

Barium Sulfate↗
PubMed1991

Longitudinal comparative study on the influence of computers on reporting of clinical data.

The impact of the clinical database system SISCOPE on medical services was evaluated and objective data compiled on the quality of information recording and reporting using a fully structured data entry system compared to traditional free text reporting. 1565 upper endoscopy reports produced with SISCOPE over a period of 12 months were assessed for completeness and compared to 152 and 208 free text reports done 4 months before and 1 month after the study period, respectively. Data on four common gastrointestinal findings (esophageal varices, ulcers, polyps and tumors) were evaluated. Physicians' compliance with the new system was good, as reflected by a constant level of quality of reporting over time, although a very slight decline in the ratio of computer generated reports to the total number of examinations was noted. Structured reports had an 18% missing data rate and contained 60% more relevant information than free text reports, which had a 48% missing data rate. No educational effect of the system was seen as missing data rates returned to pre-computerization levels just one month after the end of the study. It is concluded that menu-driven structured data entry systems result in production of far superior reports as compared to free text systems, probably due to their reminder effect.

Endoscopy, Digestive System↗
PubMed1994

Observer variation in the assessment of chronic gastritis according to the Sydney system.

The main aims of the Sydney system for the classification of gastritis are to improve uniformity in histopathological reporting and to provide a flexible matrix of rules for grading the histological features. We sought to determine the level of interobserver agreement between pathologists in the application of the Sydney system. Three histopathologists independently examined H & E, alcian blue/PAS and modified Giemsa stained sections of two antral and two corpus gastric biopsies from 69 consecutive dyspeptic patients. After elimination of five unsuitable cases, each observer graded chronic inflammation, polymorph activity, atrophy, intestinal metaplasia and Helicobacter pylori density in the antrum and corpus on a 0-3 scale according to the Sydney system criteria. The pairwise agreement on final diagnosis and the overall and conditional agreement on histological grades were examined by kappa statistics. Agreement on the final diagnosis ranged from 83-94% with kappa values of 0.699 ('good') to 0.887 ('excellent'). Conditional probability of agreement on a diagnosis of H. pylori positive gastritis was 99%, but wider disagreements were apparent in the recognition of H. pylori negative gastritis, reactive gastritis and even normal biopsies. Overall agreement for grade ranged from 70% for antral atrophy to 94% for intestinal metaplasia in the corpus with 'moderate' or 'good' kappa values. We conclude that the diagnostic and grading criteria described in the Sydney system can be applied consistently by histopathologists. The findings underline its potential usefulness in routine practice.

Biopsy↗
PubMed1982

Fentanyl and diazepam in endoscopy of the upper gastrointestinal tract.

To compare the effect of fentanyl, a short-acting narcotic analgesic, with that of diazepam as intravenous premedication for endoscopy of the upper gastrointestinal tract, we allocated at random 200 consecutive outpatients requiring elective endoscopy to receive either fentanyl or diazepam; the procedure was evaluated both by the endoscopist and by the patient. The endoscopists' opinion of the ease of the procedure was significantly better for the group of patients who received fentanyl than for the group who received diazepam (P less than 0.001). The patients' opinion of the procedure was not influenced by the premedication used. No serious side effects were observed in either patient group. We concluded that fentanyl has significant advantages over diazepam as premedication for endoscopy of the upper gastrointestinal tract.

Aged↗
PubMed2003

Temporally and spectrally resolved fluorescence spectroscopy for the detection of high grade dysplasia in Barrett's esophagus.

BACKGROUND AND OBJECTIVES: Temporal and spectral fluorescence spectroscopy can identify adenomatous colonic polyps accurately. In this study, these techniques were examined as a potential means of improving the surveillance of high grade dysplasia (HGD) in Barrett's esophagus (BE). STUDY DESIGN/MATERIALS AND METHODS: Using excitation wavelengths of 337 and 400 nm, 148 fluorescence spectra, and 108 transient decay profiles (at 550 +/- 20 nm) were obtained endoscopically in 37 patients. Corresponding biopsies were collected and classified as carcinoma, HGD, or low risk tissue (LRT) [non-dysplastic BE, indefinite for dysplasia (IFD), and low grade dysplasia (LGD)]. Diagnostic algorithms were developed retrospectively using linear discriminant analysis (LDA) to separate LRT from HGD. RESULTS: LDA produced diagnostic algorithms based solely on spectral data. Moderate levels of sensitivity (Se) and specificity (Sp) were obtained for both 337 nm (Se = 74%, Sp = 67%) and 400 nm (Se = 74%, Sp = 85%) excitation. CONCLUSIONS: In the diagnosis of HGD in BE, steady-state fluorescence was more effective than time-resolved data, and excitation at 400 nm excitation was more effective than 337 nm. While fluorescence-targeted biopsy is approaching clinical usefulness, increased sensitivity to dysplastic changes-possibly through modification of system parameters-is needed to improve accuracy levels.

Adenocarcinoma↗
PubMed1980

A critical look at the accuracy of endoscopy and double-contrast radiography of the upper gastrointestinal (UGI) tract in patients with substantial UGI hemorrhage.

Double-contrast radiography and endoscopy were compared in a prospective study of 100 patients with substantial hemorrhage of the upper gastrointestinal (UGI) tract. Endoscopy enabled detection of the primary bleeding site in 93% of the patients and correct diagnosis of 91% of all UGI lesions present. Double-contrast radiography detected 80% of primary bleeding sites and 76% of all UGI lesions present; whether the double-contrast examination was performed before or after endoscopy did not change its ability to detect lesions. Radiography demonstrated 68% (esophagitis) to 86% (duodenitis) of all superficial lesions. Endoscopy missed lesions in the duodenum and esophagus most frequently, while double-contrast radiography missed lesions in the esophagus most frequently. With the two modalities combined, the overall diagnostic accuracy for all lestions was 99%. Endoscopy and double-contrast radiography are complementary techniques for detecting acute bleeding sites of the UGI tract.

Adult↗
PubMed1995

The use of pancreatic ductoscopy in the operative management of benign and malignant pancreatic disorders.

Direct visualization of the pancreatic duct was helpful in decision making during complex pancreaticobiliary operations. Two-, 3-, or 5-mm scopes were introduced into the pancreatic ducts of 32 patients with pancreatic disorders. Scopes were passed into the ductal system of: (1) 16 patients undergoing pancreaticojejunostomy; (2) six patients undergoing pancreaticoduodenectomy; (3) four patients with pancreatic pseudocysts or choledochal cysts: (4) two patients undergoing resection of the pancreatic tail; and (5) two patients undergoing accessory ductoplasty for pancreas divism or stricture. Eight patients had calculi removed utilizing the scope, and multiple strictures were identified and filleted. Pancreatic ductoscopy was used in two patients to document successful sphincteroplasty of an accessory duct. In two instances benign pancreatic duct tumors were removed. Pancreatic ductoscopy was used to search for coexistent duct neoplasms in the eight patients who underwent resection. The technique permits intraoperative inspection, biopsy, and removal of lesions intrinsic to the ductal system. Combined with surgical procedures this endoscopic method proved a useful adjunct in difficult cases.

Adult↗
PubMed2003

Endoscopic ultrasonography for upper gastrointestinal submucosal lesions: a cost minimization analysis with an international perspective.

OBJECTIVES: Our prospective clinical study of prospectively compared physicians' management of submucosal tumors (SMTs) with and without endoscopic ultrasound (EUS). It showed that EUS reduced further tests by more than 50%, but it is unclear whether it reduced the overall costs. The aim of this study was to determine whether EUS would reduce costs. METHODS: Based on the data from the clinical study, a decision analysis was created to compare the direct hospital costs for diagnosing SMTs with and without EUS. Cost data from Germany, Canada, Japan, France, and the United States were used. Costs were expressed as a ratio of the cost of esophagogastroduodenoscopy (EGD). Average cost ratios for each procedure were as follows (sensitivity analysis ranges are 95% CIs): EGD = 1; large particle biopsy (LPB) 0.75 (0.22-1.24); endoscopic ultrasound (EUS) 2.0 (1.22-2.79); abdominal ultrasound (US) 0.77 (0.31-1.24); computed tomography (CT) 1.79 (0.64-2.95); magnetic resonance imaging (MRI) 3.54 (1.28-5.79); and ERCP 3.45 (0.82-6.07). RESULTS: Initial inputs show the "no EUS" strategy is less costly when cost data for all countries are averaged (expected cost 2.13 vs 2.71, expressed as a ratio of the cost of EGD]) and for all countries individually except Germany. In descending order, overall management costs were most sensitive to the relative costs of CT and EUS, the cost of LPB, and to the probability of no further testing when the "no EUS" strategy is used. However, threshold analysis showed that changes in only one variable, the ratio of the cost of EUS compared to CT (the "EUS/CT ratio"), were able to shift the optimal strategy from "no EUS" to "EUS." "EUS" becomes less costly only if the EUS/CT cost ratio is <0.85 (i.e., if the cost of EUS is <85% that of CT). If the potential for EUS to reduce severe complications caused by LPB of high risk lesions is incorporated, "EUS" is less costly if this risk is >2% (range 1-5%). CONCLUSIONS: When used to diagnose SMTs, EUS may reduce the need for further tests but not necessarily costs. For this indication, the relative cost of EUS compared with CT is what most limits its potential value as a cost-minimizing test. The costs, economic impact, and hence the relative appropriateness of EUS and other procedures may vary in different health care systems.

Adult↗
PubMed1976

Topical lidocaine in preendoscopic medication.

A double blind study of 111 consecutive elective upper gastrointestinal endoscopies performed with a flexible fiberoptic esophagogastroduodenoscope was made to determine the efficacy of topical pharyngeal anesthesia with lidocaine as an adjunct to intramuscular meperidine, intramuscular atropine, and intravenous diazepam. Patients who received lidocaine rated the over-all endoscopy and passage of the endoscope significantly easier than did those receiving placebo. The endoscopist found that patients who received lidocaine tolerated endoscopy significantly better, although gagging was not affected.

Adolescent↗