Prime Time to Focus on Gastrointestinal Endoscopy Quality Improvement

“Continuous improvement is better than delayed perfection”

Mark Twain

With all the hard work and contribution by the authors and reviewers, Journal of Digestive Endoscopy (JDE), the official journal of Society of Gastrointestinal Endoscopy of India, has completed one more successful year with its impressive endoscopy-based articles under various categories. We should always take pride in how far we have come and have faith in how far we can go. We whole heartedly thank all the authors and reviewers who had sincerely contributed to JDE in 2022 and expect the same to continue for the coming year.

In the past four decades, endoscopy has evolved to become an important tool in diagnosis and management of several gastrointestinal (GI) diseases. The focus on endoscopy quality not only ensures proper and effective delivery of treatment but also ensures competency among endoscopists. Various national societies have endorsed the quality metrics that help define the areas of endoscopy quality improvement. Various societies like American Society for Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy have taken the initiatives to propose several quality metrics and performance measures for endoscopy procedures.[1] [2]

In the year 2022, we encouraged and published several articles directly or indirectly contributing to the literature on endoscopy quality improvement. Most commonly performed endoscopic procedure with wide variety of indications is esophagogastroduodenoscopy (EGD). Documentation of complete examination of esophagus, stomach, and duodenum and targeted biopsies of suspected and established lesions is very important part of EGD. It is very important to improve the detection rate of Barrett's esophagus (BE) in our busy endoscopy practice. In a review article, Dutta has highlighted the currently available and suitable options like acetic acid-based chromoendoscopy or image-enhanced endoscopy for the identification of dysplasia.[3] The detection of BE can be improved by performing adequate and systemic examination during EGD.

Among all quality metrics, the most studied and validated are related to colonoscopy. The proposed quality metrics for colonoscopy procedure are related to bowel preparation, cecal intubation rate, adenoma detection rate, and colonoscopy withdrawal time.[4] [5] [6] For identification of all possible lesions and improving the adenoma detection rate, the complete examination of large intestine with good bowel preparation is essential.[6] Poor bowel preparation not only increases the duration of procedure but also increases the chances of missing the lesions ultimately leading to increased healthcare cost due to repeat colonoscopy.[7] Constipation is one of the important reason for poor bowel preparation. Theoretically, prucalopride which is the agonist of serotonin type 4 receptors may augment the effect of polyethylene glycol preparation, which is considered as one of the safest and efficacious agents for bowel preparation. In a study, Singh et al, however, found that prucalopride has no additional benefit when added with standard bowel preparation in patients of constipation.[8] Negative studies like this are also important if properly conducted.

Training of endoscopy is an important task for the endoscopists in the teaching hospitals. Healthcare workers, especially the resident doctors, were on the frontline in the fight against coronavirus disease 2019 (COVID-19). Sonika et al in a survey found that the COVID-19 pandemic has affected the training of gastroenterology residents in our region immensely as the routine endoscopic services were completely disrupted in approximately 52% of institutions for varying periods during the pandemic.[9] Therefore, an additional effort has to be taken to compensate the loss occurred to these resident doctors.

Pancreaticobiliary endoscopy procedures that involve endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreaticography require robust and methodological process to increase the efficacy, reduce the complications, and ultimately to have a positive impact on clinically relevant outcomes. EUS-guided intervention for biliary drainage in patients with biliary obstruction is one of the relatively recently developed procedure that has got good clinical outcomes and at the same time has potential risk for the fatal complications. In a technical review, by Rana et al, various technical strategies to prevent serious adverse events during EUS-guided biliary drainage were discussed using a case-based approach.[10]

Maintaining good quality in GI endoscopy procedures is a dynamic process that requires several monitoring tools and techniques that cover all aspects of the procedure. Local and national societies need to develop educational tools and performance measures that will prioritize quality and standard of care in GI endoscopy.

Publication History

Article published online:
29 March 2023

• References

• 1 Bisschops R, Rutter MD, Areia M. et al. Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement. Endoscopy 2021; 53 (02) 196-202
• 2 Gurudu SR, Ramirez FC. Quality metrics in endoscopy. Gastroenterol Hepatol (N Y) 2013; 9 (04) 228-233
• 3 Dutta AK. Are we missing Barrett's esophagus in our busy endoscopy practice? Improving detection. J Digest Endosc 2022; 13: 36-43
• 4 Gurudu SR, Ramirez FC, Harrison ME. et al. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Am J Gastroenterol 2011; 106 (suppl (Suppl. 02) S417-S418
• 5 Marshall JB, Barthel JS. The frequency of total colonoscopy and terminal ileal intubation in the 1990s. Gastrointest Endosc 1993; 39 (04) 518-520
• 6 Baxter NN, Sutradhar R, Forbes SS, Paszat LF, Saskin R, Rabeneck L. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011; 140 (01) 65-72
• 7 Rex DK, Imperiale TF, Latinovich DR, Bratcher LL. Impact of bowel preparation on efficiency and cost of colonoscopy. Am J Gastroenterol 2002; 97 (07) 1696-1700
• 8 Singh GK, Chauhan SG, Lad SS. et al. Addition of prucalopride to standard bowel preparation does not improve colonic mucosa visualization—a retrospective observational cohort study. J Digest Endosc 2022; 13: 65-69
• 9 Sonika U, Sachdeva S, Kumar A. et al. Impact of the COVID-19 pandemic on gastroenterology training in India. J Digest Endosc 2022; 13: 77-81
• 10 Rana SS, Shah J, Bhujade H, Gorsi U, Kang M, Gupta R. Prevention of serious complications during endoscopic ultrasound-guided biliary drainage: a case-based technical review. J Digest Endosc 2022; 13: 82-88