Mistakes in... 2022 - 35

ueg education
Mistakes in... 2022
Mistake 3 Not spending enough time
investigating the mucosa
In the case of colonoscopy, data clearly show the
benefit of a minimum withdrawal time to increase
adenoma- and polyp detection.9,10
Data from EGD
demonstrate similar findings. The number of
patients identified with premalignant conditions
(intestinal metaplasia and atrophy) increases
with time spent in the stomach.11-13
In a study
by Park et al., 100.000 endoscopies were
retrospectively analysed. Endoscopists with
longer investigation times found more
preneoplastic and neoplastic lesions.11
In this study, the authors chose three minutes
as a cut-off value. However, The et al., the
cut-off value of gastric mucosal inspection
was calculated to be at least seven minutes, to
increase the diagnostic yield of preneoplastic
lesions.12
Investigation of Barrett's mucosa to
screen for dysplasia should be performed while
spending at least a minute for each centimetre
length of Barrett's mucosa. These time frames are
not mandatory but underline the importance of
detailed, careful, and sophisticated inspection of
the mucosal surface.
Mistake 4 Not adhering to commonly used
classification systems
Endoscopic classification systems are widely
available and can help in classifying endoscopic
findings. In most cases, the description is the
core basis of endoscopic diagnosis through the
prediction of histology. First, it is essential to
strictly adhere to the classification systems to
obtain reliable results. Second, it is helpful to
guarantee transferable reports to others.
In other cases, the description of lesions
according to distinguished classification systems
such as the Paris Classification can predict
further diagnostic, therapeutic steps and
endoscopic resectability.
Disease
GORD
Barrett's Metaplasia
IPCL in early Squamous cell cancer
Chronic gastritis
Tumour lesions
Early gastric cancer
Peptic ulcer bleeding
Oesophageal varices
FAP
Oesophago-gastric-junction adenocarcinoma
Gastric Varices
Global lesion description
Table 2 | Endoscopic classification systems
The following table shows the most crucial
classification systems for upper GI endoscopy.
Mistake 5 Not reporting landmarks
In case of significant findings, the investigator
should give detailed information about the
anatomy. The findings should be recorded in
the oesophagus at a distance to the incisors.
Important landmarks are the upper oesophageal
sphincter, oral tumour/lesion margin and
aboral tumour/lesion margin. If tumours cross
the oesophagogastric junction (OGJ), the extent
into the stomach should be given. In Barrett's,
the most proximal extent of metaplasia should be
given, and the beginning of the circular Barrett's,
if present, needs to be given. Both extents are
needed for the Prague classification, which
additionally utilises the beginning of the rugal
folds and the diaphragm pinch. With these
landmarks, the exact extent of Barrett and the
presence of hiatal hernia is described. These
landmarks may have high relevance in the
case of risk stratification, especially in surgery.
Tumour locations can be given as left-right
anterior-posterior. It should be stated whether a
tumour is transversal to the scope or not. In the
stomach, the locations can be given as anterior/
posterior wall, pylorus /antrum/corpus/fundus
and cardia, greater and lesser curvature and
incisura. In contrast, the corpus may be divided
into proximal, distal, and middle parts.
Understanding the difference between the
Z-Line and the oesophagogastric junction is
essential. The Z-Line is located at the same
height as the OGJ only in case of absent Barrett's
metaplasia. OG junction is defined as the
beginning of the rugal folds. However, sometimes
it is not easy to determine the exact beginning
because of air insufflation and distension. We
recommend sucking out air and determining the
landmarks during the insertion of the endoscope
rather than at the end of the examination. In case
Classification System
Los Angeles classification
Prague classification
Inoue classification
Modified Sydney classification
Paris classification
VS classification
Forrest classification
Modified Paquet classification
Spigelman classification
Siewert classification
Sarin classification
Paris classification
of bad visibility, the beginning of the circular veins
at the OGJ can be used as an alternative marker.14
The Z-Line is defined as the junction between
the squamous epithelium and the cylindrical
epithelium and thus is a paradox to give a height
in centimetres for the Z-line in the description of
landmarks in Barrett's metaplasia.
Mistake 6 Not taking (enough) pictures
Reporting of endoscopic findings should include
detailed information about the mucosa and
lesions. However, the description in words may
never be as good as an image, a short video,
or the combination of both. Any finding of the
mucosa should therefore be documented as a
still image (at least). This guarantees that changes
in diagnosis, exact anatomic circumstances and
classification can be reviewed, justified, and may
be revised. Also, for patient referral, imaging can
be crucial since during the clinical course, new
aspects may appear that may not be answered
with the descriptive report, thus avoiding second
endoscopic investigations.
Taking standard endoscopic images can
also facilitate the performance of complete
investigations. Recent trials using artificial
intelligence to investigate the completeness of
gastric mucosal inspection have shown that the
chances of incomplete inspection are accurate,
and that AI can reduce blind spots.15
Pictures should show key anatomic
landmarks: middle oesophagus, duodenal bulb,
body-antrum transition, GOJ junction/Z-line,
antrum, incisura, and retroflexion, duodenum d2,
pylorus fundus and cardia in retroflexion, greater
curvature antegrade.
Whenever additional focal findings are
present, the documentation should contain an
overview image with visible lesions and borders
and, if possible, magnification images with image
enhancement like NBI or BLI. Good endoscopic
images are taken without coverage of blood or
other contents like mucus or food remnants.
Images are cantered to the lesions and contain
only a few light reflections.
Mistake 7 Pulling out too fast
In clinical reality, many investigators end their
examination too early. The scope is often pulled
out fast through the tubular oesophagus. This
leads to ignoring the mid and proximal parts of
this organ. In consequence, specific lesions
of the oesophagus are at risk of being
overlooked. Especially early squamous cell
cancer or dysplasia, heterotopic gastric inlet
patches, intramural diverticula or even Zenker's
diverticula are frequently missed.
For heterotopic gastric inlet patches, the
prevalence of endoscopic diagnosis varies
from 0.1% to 10%. Recent data documents that
endoscopic detection strongly depends on the
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