How to improve the quality of upper gastrointestinal diagnostic endoscopy?

Mário Dinis-Ribeiro; Miguel Areia

doi:10.5946/ce.2024.339

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Review How to improve the quality of upper gastrointestinal diagnostic endoscopy?: Mário Dinis-Ribeiro^1,2, Miguel Areia³; DOI: https://doi.org/10.5946/ce.2024.339
Published online: April 8, 2025

¹Gastroenterology Department, Porto Comprehensive Cancer Center, Porto, Portugal

²Department of Community Medicine, Health Information, and Decision, Faculty of Medicine, University of Porto, Porto, Portugal

³Department of Gastroenterology, Instituto Português de Oncologia de Coimbra, Porto, Portugal

Correspondence: Mário Dinis-Ribeiro Department of Gastroenterology, Instituto Português de Oncologia de Coimbra, Rua Dr. Bernardino de Almeida, 4200-072 Porto, Portugal E-mail: mario.ribeiro@ipoporto.min-saude.pt

• Received: December 23, 2024 • Revised: January 18, 2025 • Accepted: January 24, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
BEFORE ENDOSCOPY: PREPARE YOUR MIND AND MUCOSA
DURING ENDOSCOPY: TAKE TIME AND “BEST” PICTURES
AFTER ENDOSCOPY: MEASURE PRACTICE
CONCLUSIONS
NOTES
REFERENCES

Abstract

Upper gastrointestinal endoscopy is commonly performed worldwide and is the gold standard for most upper gastrointestinal tract diseases, particularly cancer. This review will use gastric cancer as an example to tackle how providers can improve the quality of endoscopy being delivered to reduce the missing rate, which may reach up to 10% of cases. In brief, endoscopists must consider pre-, intra-, and post-procedural attitudes to achieve this purpose. “When planning endoscopy,” cancer as a possible diagnosis in all procedures should be thought. Fasting of patients and the use of mucosal cleaning solutions help ensure mucosal cleansing, while planned sedation increases comfort. During endoscopy, taking time for complete inspection and photodocumentation to assure completeness. Importantly, training and knowledge of cancer (superficial) endoscopic features, particularly using advanced imaging technologies, are of paramount importance, as they are regular post-endoscopy audits of practice that positively impact quality. Finally, human-machine interaction through artificial intelligence has been shown to improve photodocumentation, detection, and auditing, and it may well assure a more homogenous service, particularly among low-performing deliverers.
Keywords: Early detection of cancer; Gastroscopy; Quality improvement

INTRODUCTION

Upper gastrointestinal (GI) endoscopy (UGIE) is probably the most common technique used in GI endoscopy units worldwide and is the gold standard for most diseases affecting the esophagus, stomach, or duodenum. Patients undergoing UGIE expect a high-quality procedure to be delivered. A complete diagnosis explaining the individuals’ complaints, previous tests, or even neoplasm screening is usually possible. However, the missing rates of cancer are not negligible and may be as high as 9.8% to 11.3%.¹^,²

Under the natural assumption that a better UGIE results in a lower missing rate, efforts have been made to determine metrics for assessing the performance of UGIE.³^,⁴ This review briefly describes the evidence behind attitudes, including human-machine interactions, which may improve each of these key indicators towards an increased detection rate. Gastric cancer and conditions defining individuals at a higher risk of developing gastric cancer are used as examples.

BEFORE ENDOSCOPY: PREPARE YOUR MIND AND MUCOSA

Awareness of endoscopic features of early forms of cancer

At an early stage, upper GI cancer presents as flat, small, and subtle lesions. Recognition using white light endoscopy (WLE) may be improved by the steps described in this review. However, readers must understand that the inter-observer reliability of the Paris classification, which schematically describes these forms, is suboptimal,⁵ but it determines prognosis and therapeutic options.⁶ Therefore, as “we just recognize what we know” educational materials, atlas or videos can and must be used especially online.⁷

Understand the expected yield of upper gastrointestinal endoscopy

When planning any endoscopic procedure, its indication is highly relevant, and the final outcome must change the management and prognosis of patients. Moreover, the stratification of the risk of altered findings, particularly cancer, should be considered. This is even more important for UGIE, as a different risk profile exists for diverse neoplastic lesions (that is, squamous cell cancer, Barrett’s and its related esophageal adenocarcinoma, proximal and distal gastric cancer, and rarely duodenal neoplasms). The chances of detecting a lesion differ according to age, sex, ethnicity, prior data, and symptoms. For instance, a Western male smoker with reflux does not have the same chance of developing Barrett’s disease as an old Asian female complaining of dyspepsia.

Awareness, recognition of lesions, risk modeling, and artificial intelligence (AI) may be provided in the near future, improving forms of delivering high-quality endoscopy, for instance, by integrating different forms of metadata into imaging and processing.

Fasting for food and liquids, simethicone, and plan for sedation

Food and residues should not be present to allow complete observation of the mucosa. Thus, patients should be asked to fast for solids for 6 hours and consume liquids before 2 hours.³ Solids may be restrained for a longer period according to previous information regarding the incompleteness or use of medications that may delay emptying.⁸

Several randomized controlled trials have also demonstrated the benefits and safety of using simethicone diluted in water as a premedication. The best dose seems to be >133 mg in 100 mL of water 20 to 30 minutes before the procedure.⁹^,¹⁰ Liu et al.¹¹ demonstrated that simethicone may not be inferior to pronase (not available in the Western world).

At least one prospective study has shown that the detection rate of cancer or high-grade dysplasia increases when patients are subjected to sedated UGIE.¹² Sedation may have this effect by allowing a comfortable and timely procedure with proper further cleaning of the mucosa and advanced imaging technologies.

DURING ENDOSCOPY: TAKE TIME AND “BEST” PICTURES

Take time

Mucosal inspection and observation are time consuming. Three retrospective studies showed that the longer the time endoscopists spend observing, the more high-risk lesions or cancers they detect.¹³^-¹⁵ Based on these studies, the European guidelines suggest a minimum of 7 minutes to examine the entire upper GI mucosa from intubation to extubation.³

In addition, we may foresee that human-machine interaction may at least change this threshold, as completeness and detection rate may be improvable and, most of all, adjustable to patients’ risk and eventually the endoscopist’s previous case load and training (see below).

Properly and completely photodocument, report cleaning, and use validated classifications

After cleaning the mucosa, systematic inspection must ensure that all landmarks and spots are not missed.¹⁶ No evidence exists on the threshold number of images that may correlate with an improved detection rate or a lower missing rate. However, to ensure that high-risk areas are observed, the European Society of Gastrointestinal Endoscopy (ESGE) recommends at least ten pictures from all major landmarks, plus any abnormal findings, if present.³

All altered anatomical landmarks and detected lesions should be described according to standard and validated classifications (Los Angeles, Prague, Baveno, Paris, and Forrest). Moreover, a visibility scale should be used to describe the quality of mucosa visualization; recently, the gastroscopy rate of cleanliness evaluation (GRACE) scale describing mucosal cleaning was derived and validated¹⁷ and should become a regular practice to report, similar to what we do with the Boston scale for reporting bowel preparation quality.

This is a specific point emphasized by ESGE¹⁸ when specifically comparing or exposing expectations of AI. The level of mucosal inspection with AI should be comparable to that assessed by experienced endoscopists (obtained in ≥90% of the procedures). In fact, different preclinical studies¹⁹^-²¹ and real-time trials²² have already achieved this goal using AI systems.

Use the best technology

Although the use of WLE may need to be revisited with the most recent developments by the main scope providers, it has been shown that the use of high-definition and virtual chromoendoscopy improves the detection and characterization of neoplastic lesions and those at risk. For instance, one meta-analysis concluded that narrow-band imaging is more accurate than WLE for early gastric cancer diagnosis.²¹^,²² Despite these results, training and expertise are still required.¹⁶

AI may play a role. In a real-time randomized controlled trial, Zhou et al.²³ demonstrated that the detection rate increased from 2.3% to 6.1%. However, these results may have resulted from a relatively high a priori risk (6.1%) and level of expertise (this study did not demonstrate what others have proposed, that AI may improve those with a lower detection rate more significantly). Moreover, even though preclinical and clinical results are promising, they are probably below the threshold of 90% suggested by ESGE¹⁸ and also discussed by Libanio et al.²⁴ to become cost-effective in Europe.

Perform biopsies according to guidelines

The ESGE standardizes the role, site, and number of biopsies performed on the upper GI tract.²⁵ Specifically, for the stomach, all guidelines are consistent with the need to stratify the risk for each individual to adjust surveillance to prevent gastric cancer.²⁶ All guidelines published in this field agree that individuals must be identified as those at an increased risk of gastric cancer, as their follow-up has been shown to be cost-effective.²⁷ In addition, the number of biopsies must be sufficient to determine the diagnosis, especially when the early forms are diagnosed.

AFTER ENDOSCOPY: MEASURE PRACTICE

Several reports have shown that adherence to these guidelines improves patient outcomes. Antony et al.²⁸ demonstrated a higher detection of dysplasia when American Gastroenterological Association and American Society for Gastrointestinal Endoscopy statements on pictures and terminology were observed. Consequently, the following two observations were made. The use of standard terminology to describe the findings (anatomy, Paris classification, virtual chromoendoscopy descriptors, and cleanliness) may facilitate audits and benchmarks. AI would clearly be of major utility here.²⁹ By automatically generating photodocumentation and increasing everyday endoscopy completeness, AI elevates UGIE quality to and above the threshold considered by international guidelines but still needs further validation in larger populations.

CONCLUSIONS

To improve the quality of UGIE, providers must deal with the esophagus, stomach, and duodenum as they do during colonoscopy, aiming to reach the cecum, taking time to improve polyp detection, and properly describe bowel preparation, among other quality indicators.

With an expected increase in the number of cases of upper GI cancer due to persistent risk factors and aging, citizens should expect that with the current high-quality imaging devices and AI, the best standards will improve, and the missing rate that we described in the first sentences of this manuscript will decrease in the coming years.

Figure 1 summarizes this review. In the commonly used separation of attitudes, pre-, intra-, and post-procedural measures have been shown to increase the detection of significant lesions. AI will probably not substitute endoscopists' role but will most likely be a powerful adjunct (“an expert on the shoulder”), simplifying or revising quality metrics as we know them.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: all authors; Visualization: all authors; Writing–original draft: all authors; Writing–review & editing: all authors.

Fig. 1.

Steps to improve the quality of upper gastrointestinal endoscopy. VCE, virtual chromoendoscopy.

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