Ian Gralnek: Hello everyone and welcome to episode one of Endoscopy Unplugged. My name is Ian Gralnick, past president of the ESGE and I'm your host. Today's podcast is titled, From Good to Great, How to Perform a High-Quality Upper Endoscopy. My guest is Dr. Miguel Areia from the Gastroenterology Department of the Portuguese Oncology Institute in Coimbra, and the Portuguese Oncology Institute of Porto. Dr. Areia is the lead author on ESGE's recently published performance measures for upper GI endoscopy update 2025. Welcome Miguel to the podcast.

Miguel Areia: Thank you Ian. It's a pleasure to be here. It's always a pleasure to have a talk with you and it's also a pleasure to collaborate with ESGE whenever you want to. So thank you. It's great to have you Miguel. Listen, before we get started, can you tell our listeners, how has endoscopy become the focus of your clinical practice? Okay Ian, so when I was a medical student I was looking for something that was not surgical because I was really never a fan of the operating room and surgical things. But I wanted to do something more than just prescribing some medication. So endoscopy was that field that I found that was in between and in fact, today with endoscopy, we can see things, we can treat things. Sometimes we are already more surgical than just medical, but that was the field that I found. Okay, great. Yes, we have definitely become more surgical endoscopists or endoscopic surgeons, however you want to say that. Yeah. Alright, so let's get at it. Can you tell our listeners really what today is considered to be a high quality upper endoscopy? So it seems a simple question, but it's not so easy to respond. So I would say that we need some things before and during the endoscopy to be a high-quality endoscopy. So before the endoscopy, we need to have an upper GI endoscopy under a proper indication. This will be the first thing. Then I think today, and that is recommended in the guideline, we should take at least 20 minutes to put the time slot in our busy department, And then...

00:02:55: Let me, I'm gonna stop you there for one second, because I wanna come back. So yeah, the indication for sure, that's appropriate indication, but what do you do in terms of instructions to the patient in terms of fasting? How long should they be fasting in terms of solids and liquids before the endoscopy? And then the other thing is, do you use anything such as, simethicone or do you give the patient some type of a mucolytic before upper endoscopy to try and make sure there's no bubbles and debris. Yeah, so starting on fasting, okay, I think it's quite clear for everybody that we should have some fasting for liquids and solids. And for many years that we are defending that two hours for liquids and six hours for solids, it's enough, in terms of visibility for ourselves, but also for comfort from the side of the patient.

00:03:54: I think what we have changed in the last years and it's now written in the guideline is that fasting is not enough for perfect visualization so we should do something else and this means using some medication. In Europe, mainly it would be Simethicone I would say that even in upper endoscopy, probably it's the only area where we have a lot of randomized controlled trials defending what we are saying. So in 2025, beyond fasting, you should use Simethicone. And I do it for every diagnostic endoscopy. Do you give that, do you tell the patient to drink a little bit of dilute simethicone before you even perform sedation? Yeah, so what we do in our department, when the patient is going to enter the endoscopy room, half an hour before, he will drink a small glass of water, 100 milliliters of water with Simethicone, and the dose that we use is 130 milligrams of Simethicone. So, depending on what you have in your country, so in Portugal we have a liquid solution, we put the drops on the water to achieve the 130mg of Simethicone and this is done half an hour before the procedure. So they're basically drinking 100 millilitres of water with a little bit of simethicone in it That will make the difference in terms of visualization of the mucosa, cleanliness and better visibility scores. And also there are some few studies that showing that because you see better, you will achieve to get more detection of lesions, which is what we want. Yeah exactly. Once you've put your scope in and there still may be residual bubbles, you can give more simethicone. My question is, do you give that using a syringe through the working channel? Because there's current recommendations we should be avoiding that through the water jet pump because of infectious issues. Can you tell our listeners about that? In my department, we always give Simethicone before, half an hour before, but then eventually if you still find some debris of some bubbles, we use Simethicone through the working channel, not in the water pump.

00:06:10: Okay, so now we'll get to where we were before. So you started to talk about the inspection time. I have to tell you, I think that we as gastroenterologists, endoscopists, surgeons who perform endoscopy, I think we've been so taken with colonoscopy over the last 20 years, I really think we've actually disregarded maybe to a certain extent the upper endoscopy exam. And I think it's really great that we're now starting to refocus on upper endoscopy and about inspection time. So tell us a little bit about what's like a minimum inspection time that's currently recommended. So now we have a few studies, not much, but a few studies suggesting that seven minutes time from intubation to extubation, so a little bit different from the concept of withdrawing during colonoscopy. So from the start until the end of the endoscopy, we should take seven minutes for diagnostic endoscopy. Okay. And this should be quite easy to measure because if you take the first picture by the moment you enter the oesophagus you do your whole inspection and then you take a last picture just before removing the scope then you can measure your seven minutes time and again it's the same seven minutes that you have in colonoscopy so it's easier to focus on seven minutes.

00:07:28: So, and what about photo documentation? What's currently recommended? What images should I be capturing and should be a part of the endoscopy report that we give to the patient? It should be standard by now and this is what we are suggesting in the last update that you should take at least 10 pictures of what we call standard normal landmarks that you should document with a picture. we suggested 10. There was some discussion because some people tend to say more. Some people say it's too much. I think it's a good balance between taking 20 or 30 pictures or just taking two or three. And so, and what we also put in the last update. So we suggested how you should take 10 pictures in a sequence that you can mechanize the procedure and you don't forget to take those 10 pictures. So I can briefly tell you, so it should be the upper oesophagus, the lower oesophagus, then one of the Z-line. Then we usually clean everything in the stomach and you move to the duodenum. You take one of the bulb and one of the second portion of the duodenum. So you have five by now. And then you go to the stomach and you take the last five. So you take one from the antrum, you retroflex, you go until the fundus, you take picture number seven, then you start going down and you take one of the lesser curvature of the corpus, number eight. You take one of the incisora, number nine. And then you come back and you take one of the greater curvature of the corpus and this is number 10. And so if you put these 10 pictures in sequence and you get used to do it in every endoscopy, you will not miss. Okay, so it's sort of like a radiologist scan pattern. You're standardizing how you're going take the images. And if you get used, then it becomes mechanical. You don't think about it anymore. But by the end, when you are going to write your report, you have at least those 10 pictures there. And then if you find any lesion, of course that you have, you should have a picture of the lesion. Like you take a picture of the polyp in the colonoscopy or tumour or whatever. Of course, so those are additional images if there's some type of a lesion that's found you need to photodocument that as well. Yeah, exactly beyond the normal landmarks.

00:09:41: So you've completed your upper endoscopy. What should be going into the endoscopy report? And I know that the ESGE just came out. I think it was a position statement if I remember correctly. Or maybe it was a quality document. What should be within the endoscopy report itself. Can you tell us about that? Okay, yeah, so we have published two main manuscripts regarding this issue. So one is the quality update, regarding the quality measures. And the other one is what we call the STAR project, meaning what should be in a standardized reporting regarding upper GI in this specific case. And so before the procedure, doing the procedure and after the procedure there are several things that should be there and in the normal endoscopy is not correct just to write normal. Let's put it like this. So you should have the identification of the patient, you should put the fasting and the pre-medication like the SIMATICON, you should write the main anticoagulants or medication that people were taking and if they stopped or not. And during the report, it should be minimal to write, describe the oesophagus, the stomach and the duodenum. The stomach you should divide in the fundus and the corpus and the entrum and second portion of the duodenum you should describe the bowl and second portion of the duodenum. And you should write normal, if everything is normal, normal oesophagus, normal corpus, normal duodenum. Then you should describe any lesion and for this you should use the proper standardized classifications. Again, in the quality guideline, we are at least five that are more common and more validated. Los Angeles classification for erosive esophagitis, Baveno classification for varices, the Paris classification for lesions, the Forrest classification for ulcers, and the Prague classification for Barrett’s. So these five are more or less common among our normal diagnostic endoscopies and these five should be used whenever it's applicable. Okay. And then finally, by the end of the report, if it was a therapeutic procedure, some indications regarding eventual side effects and what should be done, and depending on the condition, if there's any indication for surveillance. Are you able to put the endoscopic photos onto the endoscopy report? Yeah, should be possible. I think it will depend on your local conditions and your software. If you can put the 10 pictures plus the lesions in the report or at least print a few of them. But even if you don't print the 10, you should have the 10 in your software report storage. Yeah, so Absolutely. Do you give your patients a copy of the endoscopy report? I think it will depend on the country on how software interconnect with themselves. But in Portugal, at least in my department, so it is stored on the national software database, but we still give in paper because we might assume that our report will be available in the computer for the referring doctor, but it might not. And eventually in a case of a serious adverse event, going to the emergency room, it's easier to bring a paper and say, I had done this endoscopy and I'm not feeling well. And in paper, it's clear for everybody what happened. Yeah, we do the same thing. We give a hard copy to the patient, including the photos that we've taken, and we tell them that they should bring this back to their referring physician. Yeah, I think for safety issues and also if the patient might want to have his own report. Do you have any formal follow-up with patients after they leave the endoscopy unit? They've gone home, you know, they've been in the post-endoscopy recovery area, given the report, they leave. Is there any formal system where you're checking on patients 24 hours later, 72 hours later to see if they've had any type of adverse events, if they've had to go to the emergency department because of some type of a quote unquote adverse event after the upper endoscopy? So in our experience in my department, only a diagnostic endoscopy without any biopsies, whatever, so we don't have that formal assessment because the rate of adverse events for a pure diagnostic endoscopy is almost zero. But for every therapeutic endoscopy, whatever it is, is a polypectomy, a dissection, a dilation, whatever, we always schedule an appointment 30 days after. It might be just on a call But for therapeutic procedures, we always have a surveillance follow-up after 30 days. And then if you take biopsies or if you take lesions, you should have also that appointment after 30 days for adverse events, but also to adequate your surveillance if applicable.

00:14:40: Okay, and what about, do you measure patient satisfaction with the experience? I know there's some places that actually do that. What we do is once a year in my department, we start measuring and we measure 100 consecutive patients. It might be in January, in August, whatever. So, but 100 consecutive we do it and then we assess it. once a year. And sometimes we find interesting things. So people can complain not of the procedure itself, but they had some difficulties in finding the department or the air conditioning was not so good or whatever. It's not because it's not just the endoscopy performance itself, but everything that surrounds it. And sometimes you get better replies from the patients if you can improve these things that you don't think about it because it's not pure endoscopy, but it's relevant for the patients and they Yeah, yeah. It's all part of the patient experience, right? I think that's not commonly done. Our hospital system does that, but it comes from the hospital itself. They contact patients afterwards. It doesn't come from our own unit. So kudos to you if you guys are doing that on a regular basis. think it's very important to better understand the patient experience, and we can improve it. It's not just the endoscopy, as you say. It's everything else in addition.

00:16:08: I want to before we because we're getting towards the end of the podcast. I want to circle back to something you had talked about at the beginning that really today in 2025, 2026, we should be working with up to date high definition endoscopes. Yeah. Now there are depends on resources in different places, not just in Europe, but all over the world. But let's say in theory, a provider doesn't have those. Are there data, are there recommendations currently that that's really what needs to be for high quality exams today, whether it's upper or lower endoscopy, that they can actually take potentially to their hospital administration to say, look, we're not up to standard, we really need to get this equipment. Can you tell our listeners about that? Yeah Ian. So like we are saying, so many things to get the high quality endoscopy do not demand money. But I think two of them really do, which is high definition scopes and the good reporting system because it's straightforward and standardize the reporting and it should help you on getting the quality measures for your own assessment. So for any diagnostic endoscopy, I think you should have high-definition scopes because in the oesophagus and in the stomach, we have data showing that you will see better and you will detect more. If you want to do a proper inspection of a stomach or an oesophagus or a Barrett’s oesophagus or to see if it's an extensive gastritis, you need high definition. You have data saying that you need high definition to see better and detect more. Is that actually a recommendation in the updated performance measures? So it's not as a recommendation in one statement, but when you read the statements, when you read the statements about oesophagus, you say that you need high definition and the chromoendoscopy. When you read the statements on evaluating the risk of gastric cancer and assessing the extensive of the gastritis, again, you need high-definition scopes and you need the chromo. So it's there. Okay, I think it's a very, very important point and hopefully this may be able to stimulate those who may not be working with high definition scopes to be able to go get the high-definition scopes and provide higher quality endoscopy for their patients.

00:18:28: Before we conclude here, Miguel, first of all, was great to have you. Thank you thank you it’s always a pleasure. It was a great conversation, but I do want to ask again a little bit more personal questions. I'm still an avid sports fan. follow American sports, my home teams, the Minnesota Vikings and the Minnesota Twins who have not been doing well as of late. Did you play sports or do you follow? I know that football is a big deal in Portugal. Tell our listeners about that. Yeah, so a Portuguese guy has to follow the Portuguese national team at least Yeah, so I have two main hobbies, let's say it. So I like to see football but live. I don't like to sit on the couch. I like to go to the stadium and watch live. So I have a team in my own town. Unfortunately, it's on the third league by now, ah okay, but that's what happens. And also my second hobby is to play the violin. Yeah, so it helped me a lot to distress a little bit from work and yeah. How long have you been playing violin for? Well, since I was young, but then you have your family and you have your job, but it helps me a lot, at least on weekends to get a clear mind a little bit. So you know, Fado is a Portuguese song for those who know it. People associate Fado from Portugal, but we have the Fado from Lisbon and we have the Fado from Quimber, which is my town. And so I have a small group that works around the Quimber Fado. Yeah. That's very cool. Okay, so I learned something new about Miguel Area. Yeah thank you thank you. All right, well listen, Miguel, thank you again for being here. It's been great. I'm sure our listeners have loved this podcast and have a wonderful rest of the day. You too. And congratulations to the initiative of ESGE and hi to everybody. Thank you, thank you very much. It was a pleasure. Outro: Thank you for listening to this episode of Endoscopy Unplugged. If you’ve found this podcast useful, please subscribe wherever you get your podcasts. To find out more about the European Society of Gastrointestinal Endoscopy, for example to browse our scientific publications, interact with our online learning portal, The ESGE Academy, or learn about becoming a member of ESGE, visit our website www.esge.com. And of course, your feedback is always valuable to us – so send us your thoughts via office@esge.com. Thanks for listening – and join us next time!