ABC OF ENDOSCOPY FOR THE SURGEON IN EASY STEPS

Endoscopy for the surgeon - basics

1. www.anurag-hospital.com ABC of ENDOSCOPY Dr John AC Thanakumar MS,MNAMS,FRCS(Ed),FRCS(G),Dip MIS(Stras)

2. If the process is imprecise or incorrectly performed, it can cause severe complications, endangering the patient's health or life Diagnostic upper gastrointestinal endoscopy is the most basic of endoscopy procedures It is used to directly access the upper part of the gastrointestinal (GI) tract, which includes the esophagus, the stomach, and the duodenum

3. Indications Unexplained discomfort or pain in the upper abdomen. Gastroesophageal reflux disease Persistent nausea and vomiting. Upper gastrointestinal bleeding .Bleeding can be treated during the endoscopy. Iron deficiency anemia Dysphagia Abnormal or unclear findings on an upper GI X-ray, CT scan, or MRI. Removal of a foreign body To check healing or progress on previously found polyps, tumors, or ulcers.

4. Instruction to patient - not to eat or drink anything for up to eight hours before the test. It is important to decrease the possibility of food or fluid being aspirated into the lungs while under sedation. to adjust the dose of medications (such as insulin) or to stop specific medications (such as blood thinners) temporarily before the examination. a friend or family member to escort patient home after the examination. Usually no sedation apart from surface analgesia is needed To avoid oral intake till the effect of the anesthetic spray wears off.

5. ANIMATION VIDEO

6. FOR THE OPERATOR The most important point for proper insertion is for the operator to have a stable posture. Commonly used endoscope grips include the two-finger method, in which the ring and little fingers hold the endoscope and the index and middle fingers operate the suction and aspiration valves The three-finger method, in which the middle, ring, and little fingers hold the endoscope and only the index finger is used for the suction and aspiration valves small hands, because the two-finger method leads to insufficient endoscope stability and can easily cause problems of the wrist and arm, the three-finger method is more appropriate.

7. INSERTION For endoscope insertion, the insertion tube should be held lightly with the ends of the fingers of the right hand and proceed so almost no resistance is felt from the distal end. Operator should hold the endoscope in the right hand 25 to 30 cm from the distal end. MOUTH PROP Bigger wheel down by 60 deg may help get the scope across the tongue and the teeth beyond the soft palate arriveS at the left pyriform sinus without difficulty by watching the screen

8. Video AT PYRIFORM SINUS A t the left pyriform sinus as seen on the left side of the screen, its tip is maneuvered so that it faces the center . The endoscope may need slightly clockwise turn & it is possible to insert the endoscope through the left pyriform sinus without difficulty. Right pyriform sinus used also. Patient swallowing relaxes upper esophageal sphincter to aid insertion.

9. IN THE ESOPHAGUS After the endoscope passes the upper esophageal sphincter and enters the esophagus, there should be no further difficulty Apart from the upper and lower esophageal sphincters in the esophagus, pressure from the aortic arch (23 to 25 cm from the incisors in adults) and the left bronchus (27 to 29 cm from the incisors) can form physiological strictures. Compression from the spine or left atrium (32 to 34 cm from the incisors) can be observed COMPRESSION FROM SPINE VIDEO

10. IN THE STOMACH While the insertion tube passes through the lower esophagus at 40 to 42 cm from the incisors, the gastroesophageal junction can be observed. Precise observation of this area is very important in the diagnosis of gastroesophageal reflux disease. As the tube enters the stomach, gastric folds can be observed in the 10 and 4 o'clock positions P roceed easily to the antrum if the operator naturally rotates the endoscope by turning their body and arm clockwise while infusing air to adjust their position so that the gastric folds flow in the 6 and 12 o'clock directions

11. DUODENUM Systematic observation of all regions without missing any points. As soon as the endoscope passes through the pylorus, the duodenal bulb is observed, with the anterior wall and the lesser curvature observed simultaneously in the 8 and 11 o'clock positions, respectively As the left arm is rotated clockwise, the posterior wall and greater curvature are observed simultaneously in the 2 and 5 o'clock positions The rotation of the left arm in a clockwise direction rotates the endoscope toward the posterior wall to enable easier observation of the posterior wall in both the stomach and the duodenum………… The passage connecting to the second portion of the duodenum is located in the 3 to 4 o'clock position, and the second portion of the duodenum can be entered by placement of the tip of the endoscope in this part, In the second portion of the duodenum, after observation of the ampulla, which usually appears at the 9 o'clock position VIDEO

12. STOMACH While removing from the duodenum, the anterior wall and lesser curvature of the antrum as well as the posterior wall and greater curvature are observed. Endoscope is deflected up at the appropriate position (called a "J-turn"), the gastric angle can be observable at the front of the field of view If the endoscope is pulled back gradually, maintaining it in the J-turn position, the lesser curvature of the lower, middle, and upper body can be observed In contrast, rotation of the left arm in the clockwise direction while the J-turn position is maintained is called the "U-turn," which enables observation of the fundus. After the J-turn is released in the gastric angle, with the endoscope straightened, it is pulled back and the lower, middle, and upper parts of the body can be observed. Usually, the anterior wall and lesser curvature are observed simultaneously and the endoscope is rotated posteriorly by clockwise rotation of left arm for simultaneous observation of the posterior wall and greater curvature. VIDEO

13. PHOTOS - Tips SITE OF INTEREST IN THE MIDDLE NOT TOO DARK OR TOO BRIGHT HIGH QUALITY IMAGE KEEP THE COPY AND PRINT IMAGE TAKE LESION WITH SURROUNDING FIELD

14. IMPORTANT SITES FOR PHOTOS (1) upper esophagus, 20 cm from the incisors (2) lower esophagus, 2 cm superior to the gastroesophageal junction (this site is important when checking for Barrett's esophagus or reflux esophagitis (3) cardia and fundus in the U-turn position (4) lesser curvature of the upper body (5) gastric angle in the J-turn position (6) entire gastric antrum (7) entire duodenal bulb and (8) second portion of the duodenum. The tip of the endoscope should be positioned at the ampulla.

15. CHROMOENDOSCOPY Indigo carmine helps visualize minute depressions by a contrast method, while Lugol's solution helps to confirm suspected esophageal dysplasia or esophageal cancer lesions and to determine their extent. Narrow band Imaging (NBI) at endoscopy, which uses a light source of a particular wavelength, are frequently used instead of chromoendoscopy. VIDEO

16. Complications of endoscopy Aspiration Reactions to the sedative medications The medications may produce -Thrombophlebitis Bleeding can occur from biopsies or the removal of polyps Perforation Difficulty swallowing or severe throat pain A crunching feeling under the skin of the neck Passage of red blood or black material in vomit or stool

17. Therapeutic Endoscopy Oesophageal Dilatation Variceal injection, banding, glue Endoscopic Mucosal Resection Stenting Esophageal therapy

18. Therapeutic Endoscopy Foreign body Pyloric Dilatation Polypectomy Gastric Varices GERD - Stretta Esophyx-Z Overstich Gastric Therapy

19. Oesophageal Therapy Esophyx-Z for GERD Foreign Body Removal from Esophagus Stretta

20. Endoscopy for obesity Overstitch - Olympus Overstitch - Endoscopic Endoscopic Balloon

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