STANDING COMMITTEES
Education Committee:
Chairman: Jerome D Waye
650 Park Avenue
New York, NY 10021, USA
Fax: 1-212-2495349
Members: Daldiyono (Indonesia), R Fujita (Japan), Yesus Y Perez (Philippines), A Martin
(Italy), L.A. Simon (Hungary), C.B. Williams (UK), N Chopita (Argentina), H Espejo Romeo
(Peru), G Machado (Brazil)
Research Committee:
Chairman: Eamonn MM Quigley
University of Nebraska - Medical Ctr
Section of Gastroenterology & Hepatology
600 South 42nd Street
Box 982000
Omaha, NE 68198-2000, USA
Fax: 1-402-559 9004
Members: H.J. Choi (Korea), S Nakazawa (Japan), K Huibregtse (NL), R Lambert (France),
J.F. Riemann (Germany), T.H. Wang (ROC), Villa-Gomez (Bolivia), R.A. Kozarek, (USA), A
Abrao Neto, (Brazil)
Nominating Committee:
Chairman: T. Sakita (Japan)
Members: G Machado (Brazil), R Llanio (Cuba), H Niwa (Japan), M Crespi (Italy)
Financial Committee:
Chairman: A. Montori (Italy)
"AD HOC" COMMITTEES
Information Committee:
Chairman: Friedrich Hagenmüller
A.K. Altona
Paul-Ehrlich Str. 1
D-22763 Hamburg, GERMANY
Fax: 49-40-88224902
Members: B Krishna Rau (India), Y Oguro (Japan), J St. John (Australia), D Colin- Jones
(UK), A Nowak (Poland), W Roesch (Germany), A Celestino (Peru), M Paniagua (Cuba), A
Penaloza-Rosas (Colombia)
Terminology and Data Processing Committee:
Chairman: Zdenek Maratka
U5 baterie 40
16200 Praha 6, CZECH REPUBLIC
Fax: 4202-24314574
Members: WSC Chao (Hong Kong), MA Fujino (Japan), S Wilairatana (Thailand), S Brunati
(Italy), W Swobodnik (Germany), CW Venables (UK), LAG Juruena Mattos (Brazil), JE Segal
(Argentina), M Schapiro (USA)
Minimal Invasive Surgery Committee:
Chairman: Alberto Montori
III Dept. of Surgery
University La Sapienza
00161 Roma, ITALY
Fax: 39-06-44702412
Members: SC Sydney Chung (Hong Kong), Dayasiri Fernando (Sri Lanka), T Yamakawa (Japan), J
Perissat (France), A Cuschieri ( UK), G Buess (Germany), AL de Paula (Brazil), P Briceno
(Venezuela), J Ruiz (Cuba)
Electronic Communications Committee:
Chairman: J.R. Armengol-Mirò
Secretary: A. Grassi
National Cancer Institute Regina Elena
Viale Regina Elena 291 – 00161 Roma, ITALY
Fax: +39.06.44 57 086 e-mail: mc6512@mclink.it
Members: H.D. Allescher, M. Delvaux, M. Fujino, V. Tejedo Grafia, Cheng-Yi Wang
Ethics Committee (joint with the OMGE Ethics Committee):
Chairman: Jean Escourrou
Service de Gastroenterologie
Hopital de Rangueil
Avenue Jean Poulhes 1
31054 Toulouse Cedex, FRANCE
Fax:33-56132-2176
REPORTS OF STANDING COMMITTEE CHAIRMEN
Education Committee
Terminology and Data Processing Committee
Minimally Invasive Surgery Committee
Education Committee
Jerome D. Waye, Chairman (1994-1998)
OUTLINE OF THE ACTIVITIES OF THE OMED
EDUCATION COMMITTEE, MAY 1995
This Committee has set broad goals for
the next four years:
1. A set of teaching video tapes will be made available in each of the major endoscopic
specialties. OMED will maintain an up-to-date video library, and copies of tapes will be
presented to endoscopy societies, hospitals and chiefs of endoscopy training centers
throughout the world.
2. An attempt will be made to establish true "hands on" training programs for
beginner endoscopists and for learning advanced techniques. Intensive, short courses have
been successfully structured in upper intestinal endoscopy and colonoscopy by Dr. Charles
Swan in England. Although these provide only rudimentary entry-level knowledge and are not
acceptable in countries where full training programs exist, they will provide the concepts
of indications, contraindications and techniques to ensure a safe start in endoscopy.
3. OMED will collect from each national endoscopic society a copy of their constitution,
by-laws and guidelines to serve as an international reference source. Information can be
shared, and societies that are in the formative stages will no longer need to reinvent the
structure of their group anew, nor rewrite guidelines which have already been labored over
by other endoscopic societies.
All of these endeavors will need funding to be able to provide the services that are
necessary to introduce endoscopy to countries where it is undeveloped and underutilized,
to assist in continuing education and to ensure our patients of the safety of the
procedure.
ACTIONS BY THE OMED EDUCATION COMMITTEE, MAY 1997
Omed is embarking upon a two-part approach to teaching endoscopy in under developed countries. The overall plan is to present videotape demonstrations of endoscopic procedures to a national meeting at which all people who are interested in gastrointestinal endoscopy and gastroenterology will be invited. The group of people who express an interest in forming endoscopic centers will subsequently (within one year) be invited to attend a practical workshop on endoscopy in that country. Cases will be provided and experts will demonstrate various techniques of basic endoscopic procedures. Lectures and written material will be developed for those basic workshops. The first area contacted for this approach is Africa. Communication has been established with professor Simjee, president of the newly-formed African Federation of Gastroenterology. He has expressed an interest in this program and is currently contacting physicians who may be interested in this approach.
A cadre of teachers in endoscopy is being developed for purposes of teaching endoscopy in underdeveloped countries. If anyone would like to be nominated as a member of the Omed teaching faculty, please contact me with a brief resume detailing your endoscopic experience, the hospitals in which you were trained, a description of the level of expertise, and the types of endoscopy in which you are interested in teaching.
The education committee is attempting to act as a repository for the collection of constitution and by-laws of endoscopic societies throughout the world. This will allow us to know which organizations have established by-laws, and the languages in which they are written. Upon request from any group which is considering formation of an endoscopic society, or which would like further information on patterns which have been developed by other organizations, the names of the endoscopic societies and a specific contact person will be sent so that communications can be established between various endoscopic societies for the exchange of this information. At the present time, the education committee has received twelve responses. The committee has also requested information concerning teaching videotapes and guidelines which have been established for endoscopy. The American Society for Gastrointestinal Endoscopy, seems to have the best-developed set of guidelines. The British Society of Gastroenterology also has several endoscopic guidelines available.
In order to facilitate communication between endoscopic societies and endoscopists worldwide concerning items of interest, Omed is currently on the internet at: www.uni. net/omed. The E-mail address is OMED@uni.net.
Videotapes of the Post-graduate Courses of the last two World Congresses of Gastroenterology, held in Sydney and Los Angeles, are currently available at no cost for national organizations who request them from the Omed General Secretariat. The stipulation is that they will be shown at a National Congress of Gastroenterology within a year after their having been received by the national Society.
They will be also available to individual physicians by
request. They are in two formats, Pal and Ntsc. The price for the complete package of 13
videotapes is $ 100 US. This is to defray the cost of videotapes and mailing. The requests
should be addressed to Prof. Massimo Crespi, National Cancer Institute "Regina
Elena", Viale Regina Elena 291 - 00161 Roma, Italy
Fax: +39.06.4457086 E-mail: as stated above.
OMED EDUCATION COMMITTEE, OCTOBER 1997
The World Organization of Digestive Endoscopy represents
organized gastrointestinal endoscopy throughout the world. Many areas of the world are
well-served by endoscopic societies, endoscopic organizations, and gastroenterology
associations which have active endoscopic components. Each of the many endoscopic
organizations throughout the world are autonomous, and most endoscopic organizations or
groups of endoscopists develop their own rules, regulations, and organizational structures
to suit their particular needs, constituents, and geographic areas. For the most part,
rules, regulations, endoscopic guidelines, and organizational structures are developed
independently from any other endoscopic organizations. Associations which are well
established and have multitudes of members are the groups that characteristically take the
lead in the development of practice parameters, practice guidelines, and in the defining
of indications, techniques and contraindications for gastrointestinal endocopy. omed has
taken upon itself the collation of information from various sources throughout the world
and has redefined itself as being the stucture which scan knit the various worldwide
organizations into a cohesive array of societies. OMED is the link across all of endoscopy
and will disseminate knowledge and education to all of our members, from the highly
organized societies to te less-well-developed groups of endoscopists throughout the world.
In an attempt to transmit specific knowledge about endoscopy, OMED has made available the
endoscopy videotapes from the last two World Congress of Gastroenterology to any
member-constituent GI organization throughout the world. These are available in both PAL
and NTSC format, and merely have to be requested by the constituent societies. The intent
of OMED is to have these shown at any endoscopic congress held by the individual society,
or available to be loaned to any individual or group in that society. Any individual may
purchase the entire twelve-videotape packet of World Congress videotapes from the
endoscopy courses of the Australia World Congress of Gastroenterology (1990) as well as
from the Los Angeles World Congress of Gastroenterology (1994) for US$100 plus mailing.
These can be obtained by sending a check directly to: Massimo Crespi, MD - OMED acting
president.
The Education Committee has also requested information on constitutions and by-laws from
all of the constituent endoscopic organizations. Only a few of the many constituent
societies have submitted copies of their constitutions and by-laws, but a list of
countries which have sent printed by-laws, will be made available to any organizations who
request them.
Some of the larger and more advanced endoscopic societies have multiple guidelines and
practice parameters which are "state of the art" position papers. A list will be
sent upon request.
The education committee has made initiatives for the
"hands-on" teaching of endoscopy in areas in which endoscopy is underdeveloped
or under-served. A cadre of teachers is currently available for teaching endoscopy in
underdeveloped countries. If any member would like to add their names to the list of
available endoscopists who may be requested to travel to foreign countries to begin
endoscopic instructions, please contact me with names, addresses, and a curriculum vitae
listing hospital affiliations, endoscopic training, current affiliations, and an outline
of the endoscopic teaching that you have performed.
All the members of the Education Committee have committed to submitting to the OMED
bulletin articles concerning endoscopy in their particular countries. Other endoscopists
are encouraged to send in their own experiences in individual countries, unusual
endoscopic situations, et cetera. Please send manuscripts directly to: Alberto Montori, MD
- OMED News Letter Editor.
OMED is currently on the worldwide web, and can be reached at: "uni.net/omed".
This website will be further developed in the future, and is intended to be a bulletin
board of worldwide interest in endoscopy. It is hoped that a "chat page" can be
formulated to allow interchange between endoscopists throughout the world.
The OMED bulletin will be published twice yearly, and an attempt will be made to
disseminate these at all major endoscopic meetings throughout the world; OMED is committed
to disseminating knowledge about endoscopy and being the leader in worldwide endoscopy
education. Please send in suggestions and comments concerning educational endeavours in
the field of gastrointestinal endoscopy.
REPORT OF THE EDUCATION COMMITTEE OMED, APRIL 1998
The Education Committee consists of the following members:
Nestor A. Chopita, MD
Daldiyono, MD
Rikiya Fujita, MD
Glaciomar Machado, MD
Alessandro Martin, MD
Jesus Y. Perez, MD
Herman Espejo Romeo, MD
Laszlo A. Simon, MD
Jerome D. Waye, MD (Chairman)
Christopher B. Williams, MD.
The Education Committee has applied itself over the past four years to several areas with
the purpose of bringing information concerning various aspects of endoscopy to
endoscopists throughout the world. The major thrust of the Education Committee is not in
the training of endoscopists in a formal fellowship program, but rather is focused on
bringing information to physicians who already perform endoscopy and educating doctors
about endoscopy in countries where there is a need for further endoscopic expertise.
Videotapes from the past two World Congresses of Gastroenterology (Australia, 1990 and
USA, 1994) are now available as a package. The price for the entire package is US$100.
This is available in either PAL or NTSC format, and is available upon request form Prof.
Massimo Crespi, President of OMED. Constituent member societies of OMED may acquire a copy
of these videotapes free of charge providing that they agree to show these videotapes at
national meetings of their endoscopic societies.
The Education Committee has arranged for a live demonstration endoscopy course to be held
in Moscow on April 23-24, 1998. This course will be presented in conjunction with the
Olympus Corporation, who will supply equipment and arrange for video transmission.
The Education Committee currently has a list of constitutions and by-laws which is
available on request. These constitutions and by-laws had been submitted by member
endoscopic societies of OMED three years ago. The Education Committee is currently seeking
information from every constituent endoscopic society as to the availability of
educational aids for gastrointestinal endoscopy. The aids would include slide series,
brochures, written material, and videotapes. A letter has been sent to every president of
each constituent endoscopic society throughout the world seeking such information.If any
individual members have knowledge of educational material which contain information
concerning gastrointestinal endoscopy, please contact Dr. Waye with a listing of this
information.
The Education Committee is currently working on developing a brochure for the performance
of live courses in endoscopy. Live tele-endoscopic courses are of great benefit in the
education of large numbers of physicians in the performance of endoscopic procedures. A
section of this brochure will address small, focused endoscopy courses. OMED desires to
establish standards for patient safety, patient selection, the performance of such live
courses, and patient privacy. The Education Committee is also concerned with the selection
of "experts" in endoscopic procedures, and desires to eliminate any risk to the
patient from being a subject in a "live" endoscopic course. Most physicians who
agree to produce such a course, are, in general, not knowledgeable about the various forms
of transmission to a nearby or remote location, and would benefit by having a
"primer" on the conduct of these courses. Anybody with a special expertise in
the development or production of live courses or is knowledgeable about the video
requirements should contact Dr. Waye with such information.
Stimulated by an excellent response from the Research Committee on a previous
questionnaire, the Education Committee is collaborating with the Research Committee to
distribute a questionnaire worldwide to collect further information on endoscopic
practices. The questionnaire is currently in the development phase, and will be
distributed during 1998.
MINUTES OF THE MEETING OF THE OMED EDUCATION, MAY 1998
OMED conducted a live endoscopy demonstration
in Moscow on April 23-24, 1998. The meeting was sponsored by Olympus and Wilson-Cook. The
local organizers were Drs. Poddubny and Fedorov. Approximately 400 Russian physicians
attended the two-day workshop, where they saw a wide range of endoscopic procedures
including ERCP, stone extraction, endoscopic ultrasound, endoscopic mucosal resection and
colonoscopic polypectomy. Several lectures were also given by the faculty members, which
consisted of Dr. Massimo Crespi, MD (President, OMED), Dr. Alberto Montori, MD (Treasurer,
OMED), Dr. Melvin Schapiro, MD (Vice President, OMED), Dr. Aksel Kruse, MD (Denmark), Dr.
Paul Fockens, MD (Amsterdam), Dr. J.R. Armengol Mirò, MD (Barcelona) and Dr. Jerome Waye,
MD (New York).
The meeting was a great success and was considered a great benefit to all of the
registrants who had traveled from all different parts of Russia to attend the workshop. At
the present time various locations are being explored for future workshops.
The committee has developed a list of all the guidelines and brochures concerning
endoscopy, as well as the video-educational material available throughout the world. The
United States, Japan and Australia have the largest number of published guidelines and
instructional videotape material concerning endoscopy. The Education Committee will try to
adapt currently published guidelines in English for use by the international fraternity of
endoscopy. Permission must be obtained from countries which already have developed
guidelines. Once the guidelines have been reformulated for their international
applicability, the will be published in the OMED bulletin and on the internet site. We
thank the individual societies who responded to our request for information.
OMED had made available a 12-pack packet of videotapes from the Sidney World Congress of
Gastroenterology and the Los Angeles World Congresses of Gastroenterology.
These videotapes are available without charge upon request by any of the constituent
endoscopic societies, and are available for $100 for anyone else who is interested. If
interested, contact Dr. Massimo Crespi and specify whether the video format desired il PAL
or NTSC.
The Research Committee, in conjunction with the Education Committee, has distributed a
questionnaire about "endoscopic practice and priorities throughout the world".
We urge all of the constituent societies to answer the survey promptly so that information
can be gathered on several topics, including the availability of endoscopy in various
parts of the world, the types of endoscopy which are considered to be of greatest benefit
throughout the world, and the degree of training required for performing endoscopy. The
information from this survey will serve to focus the future thrusts of endoscopy for both
educational purposes and research needs.
The Education Committee is currently developing a brochure on the requirements for live
courses in endoscopy. This will consist of two parts, a technical portion concerning types
of transmission, number of cameras, and the adequacy of facilities. The second part will
consist of patient selection, patients safeguards, and the role of the nurse/assistant
during live demonstration.
OMED has its own web page, which is found at www.uni.net/omed.
The E-mail address is OMED@uni.net.
TEACHING ENDOSCOPY BY INTERACTIVE
VIDEOTAPES, MAY 1997
(Melvin Schapiro, MD)
Teaching endoscopy has evolved from artist’s
reproduction of endoscopic findings, through the direct capture of high quality still and
video images. The limitations of teaching were primarily related to the need for a one on
one or very small group experience. The electronic endoscope brought large screen T-V to
the teaching environment and a large number of remote transmissions from international
centers soon evolved via satellite or telephone lines. The two most important limiting
factors to the remote, live transmission technology are the down time during complicated
cases, and the costs involved for a one time use.
A radically different approach has been developed by Advance Medical Ventures, a Hollywood
based company that utilizes professional motion picture production and editing crews as
well as state-of-the-art presentations designed to capture the "live
atmosphere".
The format is the presentation of a wide range of pretaped video sequences of procedures
actually performed by experts in their individual endoscopy units. In addition to large
screen projection, a high quality sound reproduction system and multiple high resolution
video monitors are spaced through out the presentation center allowing close-up
demonstrations of the technical aspects of complicated therapeutic endoscopic techniques
that were performed under real practice situations.
The direct video reproductions are enhanced by split screen technology allowing the
audience to focus on many aspects of the procedures with simultaneous visualization of the
high resolution endoscopic images. The use of stop-start and rapid rewind methods have
been combined with both recorded and live voice-over explanations by the on-site faculty
presenters who were filmed in their own units
The audience is further involved in the sessions through the use of interactive
"touch-pad" questions and the presence of an expert endoscopic
"facilitator" who anticipates questions and the need to review special technical
aspects of the presentations. The facilitator is as well scripted with time code
associated material so that by watching a special monitor he can amplify certain teaching
points agreed with by the faculty in pre-presentation rehearsal sessions.
A special teaching technique is further provided by "telestrator" technology
that allows the expert presenter to draw over or provide diagramming to emphasize
particular concepts.
This teaching concept was developed over five years ago and has been utilized at the World
Congresses of Gastroenterology Post-graduate Endoscopy course in Los Angeles in 1994 and
at the American Society for Gastrointestinal Endoscopy’s annual Post -graduate
teaching course in San Francisco in 1996. Parts of the program have been reproduced
internationally at the UEGW, and at regional society meetings. New endoscopic material is
provided every two years so that the latest in technology is provided as well as the
opportunity for individuals who have attended previous presentations to return for new
material. The attendance evaluations have universally indicated that the program is
extremely well received.
The high quality video material has been reproduced on video cassettes for international
distribution, and lends itself to the new electronic formats such as DVD and CD-ROM. This
enables continued study outside of the presentation environment.
The teaching format has been used by small groups such as a hospital that invites 50
physicians to a meeting, or by large groups with attendance exceeding 2000. Further
information concerning presentations and materials are available on the AMV home page:
http:/www.amv.com.
" SURVEY ON ENDOSCOPIC PRACTICE AND
PRIORITIES THROUGHOUT THE WORLD"
All the member Societies already received the questionnaire.
Those which did not yet reply are invited to do so as soon as possible.
SURVEY ON ENDOSCOPIC PRACTICE AND PRIORITIES THROUGHOUT
THE WORLD DEVELOPED BY RESEARCH AND EDUCATION COMMITTEES OF OMED: CHAIRS EAMONN M.M.
QUIGLEY, M.D.,JEROME D. WAYE, M.D.
Please Submit Responses to: Eamonn M.M. Quigley, M.D. Gastroenterology and
Hepatology University of Nebraska Medical Center Omaha, NE 68198-2000, USA,
FAX.+001.402-559-9004, E-MAIL: equigley@mail.unmc.edu
1. Who performs endoscopy in your country? For each type of practitioner, please estimate the percentage of all endoscopy that is performed by these individuals.
A. Upper Gastrointestinal Endoscopy
------- % Family Practitioner
------- % General Internist/General Physician
------- % Gastroenterologist
------- % Surgeon
------- % Other (Please clarify)
B. Colonoscopy
------- % Family Practitioner
------- % General Internist/General Physician
------- % Gastroenterologist
------- % Surgeon
------- % Other (Please clarify)
C. ERCP and Other Interventional Procedures
------- % Family Practitioner
------- % General Internist/General Physician
------- % Gastroenterologist
--------% Surgeon
--------% Other (Please clarify)
2. In your country, please estimate the proportion (as %) of endoscopic examinations that are performed at the following sites:
% hospital inpatient
% hospital outpatient (ambulatory)
% private clinic, attached to a hospital
% free-standing private clinic, not associated with a hospitalSurgical Residency
Gastroenterology Fellowship
Fellowship training in endoscopy other than that provided in
Gastroenterology.
3. Which of the following endoscopic procedures are available in your country? For each, state whether they are
A. Not available
B. Available only at a few center
C. Available only at major referral hospitals or
D. Available widely in community-type hospitals or physician's offices.
A B C D
Esophago- gastroduodenoscopy/upper gastrointestinal endoscopy
Endoscopic therapy of gastrointestinal hemorrhage
Endoscopic therapy of esophageal/gastric varices
Endoscopic placement of gastrostomy/jejunostomy tubes
Colonoscopy
Colonoscopic Polypectomy
ERCP
ERCP with Sphincterotomy
ERCP with Sphincterotomy and placement of stents
Esophageal dilatation and placement of prosthesis
Enteroscopy
Endoscopic Ultrasound
Endoscopic laser therapy of tumors
4. What are the most common indications for the major endoscopic procedures in your country? For each procedure, list the top 3 indications:
A. Upper Gastrointestinal Endoscopy (diagnostic)
B. Upper Gastrointestinal Endoscopy (therapeutic)
C. ERCP
D. Colonoscopy (diagnostic)
E. Colonoscopy (therapeutic)
5. What is the prevailing practice of patient preparation/sedation/anesthesia in your country for:
A. Upper Gastrointestinal Endoscopy
No sedation
Conscious Sedation with Benzodizapine/Opiate/Other (please specify)
General Anesthesia
B. Colonoscopy
No sedation
Conscious Sedation with Benzodizapine/Opiate/Other (please specify)
General Anesthesia
If conscious sedation or anesthesia are employed, who administers these?
The endoscopist
An anesthesiologist
Other (please specify)
6. What are the guidelines for disinfection of endoscopes and accessories in your country?
No generally accepted guidelines - each institution has its own
National guidelines developed by national GI/endoscopic societies
National guidelines mandated by governmental agency
7. In general, would you regard the approach to the disinfection of endoscopes and accessories in your country as...
Adequate
Inadequate
8. What are the major problems in terms of the disinfection of endoscopes in your country?
A. Are there particular or unique infections or infectious agents that cause problems with disinfection in your country" Please specify
B. Do cost concerns limit the performance of disinfection of endoscopes and accessories? If so, please specify.
C. Is there access to adequately trained personnel for the disinfection of endoscopes and accessories?
9. What is the average time taken to clean and disinfect an instrument between uses in your country?
--------------- minutes.
10. What is the disinfectant most commonly used in your country?
11. What do you perceive to be the greatest unmet need in the area of endoscopy in your country? Please list
A. Clinical problems that you feel would benefit from additional endoscopic expertise or technology:
B. The endoscopic procedures that you would most like to see developed in
your country.
Research Committee
Eamonn M.M. Quigley, Chairman (1994-1996)
OMED RESEARCH COMMITTEE, SAPRIL 1997
Following the resignation of Dr. Stiel, it
was my great honor to be nominated to succeed him as Chair of the Research Committee,
which became effective in May 1996. I now have the pleasure of updating you on current and
planned activities of the Research Committee. Several activities are currently in hand.
A major priority for the Research Committee is the development of an international
database on endoscopic priorities. If the Research Committee is to serve as a voice for
endoscopic research in the future it is clear that we need data to indicate the important
priorities for the development of endoscopy in various parts of the world. Each member of
the Research Committee has, therefore, been charged with compiling a list of the most
important diagnostic and therapeutic uses of endoscopy in their part of the world. This
data will be collated and should be of considerable assistance in the development of
research and educational strategies appropriate to different parts of the world. It is my
impression that, contrary to popular belief, endoscopy may, in fact, be a very important
and almost basic medical tool in many parts of the world, including the developing world,
yet priorities may be quite different.
In the past, the Research Committee, Omed and the World Congress have addressed the issue
of endoscopic disinfection. I am pleased to announce that the Organizing Committee of the
Vienna World Congress have asked me to chair a working party on minimal standards for
endoscopic disinfection. While this will be performed within the auspices of a separate
working party, the results of this group should be of considerable value to Omed and its
Research Committee. Along similar lines, the Omed Research Committee is also working to
develop a consensus document on minimal standards for the performance of endoscopy. Our
goal here is to establish, through data generated by members of the Research Committee,
what are, indeed, the basic requirements for the performance of diagnostic and/or
therapeutic endoscopy in various parts of the world. This information should, again, help
to provide an appreciation of variations in endoscopic priorities throughout the world,
help delineate areas of mutual interest and also assist in developing specific protocols
for different parts of the world. Building on this, we also hope to address the
standardization of accessory equipment.
A proposal for a multicenter study of Barrett’s esophagus, intestinal metaplasia and
adenocarcinoma is under review and proposal in the area of endoscopic hemostasis and
laparoscopy will be considered.
The Research Committee will meet in Washington DC, at the time of Digestive Diseases Week
– we anticipate lively discussion, and I look forward to updating you of the
continuing activities of the Omed Research Committee.
ACTIVITIES OF RESEARCH COMMITTEE OF OMED, APRIL 1998
In association with Dr. Jerome Waye, Chair of the Education Committee of OMED, the Research Committee has been working over the past several months to develop a comprehensive questionnaire on endoscopic priorities throughout the world. This has now been finalized and is about to be distributed to the constituent national societies of OMED. This questionnaire will address several areas, including what endoscopic procedures are performed, who performs them and what has been their training. The purpose is to develop a database on endoscopic practice, training and facilities throughout the world, to provide a basis for further education, training and research initiative in this area. We look forward to the active participation of the constituent national societies in this process and we hope that all of you will complete this questionnaire and, also, that you will communicate with either Dr. Waye or Dr. Quigley regarding any comments or criticisms on the questionnaire. We believe that this is a vital prerequisite to developing short- and long-term strategies for OMED throughout the world.
SUMMARY OF THE SURVEY CONDUCTED BY THE RESEARCH COMMITTEE OF THE S.I.E.D.
During 1997, the Research Committee of the Interamerican
Society of Gastrointestinal Endoscopy (SIED), conducted a survey directed to all the
Societies of Gastrointestinal Endoscopy within the Latin-American area on "Endoscopic
equipment, Accessories, Disinfection and Endoscopy training". As illustrated by the
response rate, the survey was well received among constituent societies. A total of 58
endoscopy centers completed the survey: 19 from Brazil, 18 from Argentina, 9 from
Colombia, 5 from Uruguay, 4 from Bolivia, 2 from the Dominican Republic and 1 from Peru.
Endoscopic Examinations:
Regarding the frequency of the various endoscopic studies, there was only minor variation
between centers: the most frequent studies being esophagogastroduodenoscopy (comprising
65% to 70% of all studies), colonoscopy (20% to 23%) and duodenoscopy (10% to 15%).
Endoscopic Equipment:
Only four of the centers used videoendoscopes exclusively. Most (30) used both
videoendoscopes and fiberscopes; a significant number (20), also utilized videocameras,
i.e., an adaptor connection to transform a fiberoptic image into a video image. Only 3
centers did no possess video equipment. Fiberscopes are, therefore, still widely used in
Latin American countries, even though videoendoscopes are increasing in popularity.
Of those centers that use fiberscopes, 80% use immersible equipment. Of importance in
relation to disinfection, 13% of all centers continue to use non-immersible endoscopes and
7% use both immersible and non-immersible. Given the fact that non-immersible equipment
has not been manufactured for several years, it can be concluded that a significant number
of centers still use this outdated equipment. Of all videoendoscope systems, 60% were
housed in endoscopy centers and 40% in public hospitals. This distribuction was similar in
all countries with the exception of Argentina where 75% of videoendoscopes were in private
and 25% in public centers. This difference in distribution may be explained by the fact
that, in Argentina, videoendoscopy is frequently reimbursed at a higher rate than
fiberoscopy. In 75% of responses from centers in all other countries, it was stated that
both types of endoscopy were reimbursed at a similar rate. It should be noted that 28% of
centers responding to the questionnaire did not answer this question; these conclusions
are, therefore, drawn from an incomplete sample.
Costs of Endoscopy:
Inquiries regarding fees charged for endoscopic studies provided widely variable
responses: charges for diagnostic videoesophagogastro-duodenoscopy ranged from U.S.$ 150
to 600, in various countries. In those countries where there was a difference in fees
between video and fiberoscopy (notably Argentina), fiberoscopy was reimbursed at half, or
even less, of the rate for videoendoscopy. In general, the fee quoted included the use of
the equipment and accessories, as well as, nursing support and other ancillary services.
The fee for therapeutic endoscopy varied widely and it was very difficult to draw any
conclusions.
Cleaning and Disinfection:
All centers performed manual cleasing of endoscopes and accessories with a neutral
detergent or an enzymatic soap and then disinfected with 2% glutataldehyde. Six centers
used ethylene oxide for accessories and only 4 used automated "washing
machines". Seventy-five percent disinfected equipment after each examination; 25%
performed this, only at the end of the day or following cases with known infectious
diseases.
With regard to who performs cleaning and disinfection, 41 centers stated that disinfection
is performed by trained paramedical personnel; 28 stated that disinfection is carried out
by the physician (in several centers both of those options were operative) and only 3
centers use operating room personnel who do not have specific training in endoscopic
cleaning and disinfection.
With regard to protection of staff: 100% of responders use gloves, 53,5% protective
goggles, 48,3% chin straps, 39,6% disposable aprons and 15,5% boots. Some centers took
precautions only in those cases where they knew that the patient was HIV (+).
Accessories:
With regard to access to accessories, 40 centers responded that accessories can be easily
obtained in their own countries; 15 experienced some difficulties and 3 did not answer
this question. The reasons for such difficulties included the following: high price,
absence of hospital budget, lack of stock in the country and a bureaucracy that hinders
purchase of accessories. When asked about what accessories are used in the different
centers, most (50) use well-known international brands; 12 (from Argentina and Brazil),
use national brands (domestically manufactured) and 9 (in Argentina, Bolivia and Brazil)
use self-manufactured accessories. Accessory prices vary widely. For example, the price of
a papillotomy knife ranged from U.S. $200 to 700 and a polypectomy snare from U.S. $65 to
500. In Argentina and Brazil, domestic brands are, on average, half the price. In Latin
America, accessories are, onaverage, twice or three times more expensive than in USA or
Europe and this is a major problem for endoscopy centers. All centers stated that they
re-use accessories that have previously been disinfected with 2% glutaraldehyde or
ethylene oxide.
Endoscopy Training and Certification:
With regard to gastrointestinal endoscopy training, all countries responded that their
gastroenterology residencies include training in gastrointestinal endoscopy; both
diagnostic and therapeutic. The location of such gastroenterology training is as follows:
University Center 51, Private Institution 19, Public Hospital 18. Thirty-five centers
responded that specialized, concentrated, endoscopic training experiences were available
in their country; in addition to a standard gastroenterology residency. The duration of
this additional endoscopy training is variable, but they generally last between one years
and two. With regard to the administration of these specialized endoscopic training
portions, 27 responses stated that these were administered by Universities, 12 by
Scientific Societies, 10 by private and 5 by other hospitals. When asked about wherether a
higher qualification in gastroenterology enables a physician to perform endoscopies, all
countries answered affirmatively except for Brazil where 14 Centers answered positively an
5 negatively.
With regard to the granting of certification in
gastroenterology and endoscopy, 25 answered that such certification is granted by
Scientific Societies, 20 by Universities, 16 by Medical Colleges and 9 by a giverment
Ministry. In some countries more that one mechanism was operative. In Peru, the Dominican
Republic and Uruguay, certification does not require a practival demonstration of
endoscopic skills. In other countries requirements appeared to vary. In Brazil 18 Centers
stated that a practical demonstration is required; one stated that it is not. In Colombia,
4 answered positively and 5 negatively; in Argentina, 2 answered positively and 16
negatively and in Bolivia, 2 answered positively and 2 negatively.
The last question was whether centers were prepared to receive foreign doctors for
endoscopy training. To this, 45 answered affirmatively, 6 negatively and 7 did not answer.
Nevertheless, in all countries that responded to the survey there is at least one center
willing to receive foreign trainees.
COMMENTARY BY EAMONN M.M. QUINGLEY, CHAIRMAN RESEARCH COMMITTEE OMED
Dr. Rainoldi and his colleagues are to be congratulated on
this important survey. This report illustrates that meaningful surveys are feasible an
worthwhile. Several important findings deserve emphasis. These include the persistence of
non-immersible endoscopes in a minority of centers and significant variations in policies
for cleaning, disinfection ,and staff protection.
Reflecting high costs and difficulties with accessory cleaning, re-use of accessories
following disinfection seems universal and should be contrasted with emerging policies
regarding single-use in Europe an North America. While the basic components of
gastroenterology training appear similar, the details of endoscopic training and
certification, in particular, vary considerably both between and within various countries.
Surveys such as this provide "real" data on endoscopic practive and should serve
as the basis for future projects in endoscopic research, training and education.
WORLD CONGRESS OF GASTOENTEREOLOGY, WORKING
PARTY
ON "MINIMAL STANDARD FOR ENDOSCOPIC DISINFECTION", May 1998
Intermediate Report
Present: Eamonn Quigley, MD (USA-Chair), Habib Ben
Khelifa, MD (Tunisia), Nestor Chopita, MD (Argentina), Axel Kruse, MD (Denmark), Kazuei
Ogoshi, MD (Japan), Rakesh Tandon, MD, PhD (India)
Excused Absence: Walter Bond, MS (USA), Alistair Cowen, MD, FRACP (Australia), Richard
Kozarek, MD (USA)
I)The following interns were distributed:
A. Monograph "Clinical Risks of Infection Associated with Endoscopy" by Dr. Cowen
B. Correspondence to Dr. Quigley from Dr. Bond, draft monograph, "Standard practice for the reprocessing of reusable, heat-stable endoscopic accessory instruments (EAI) used with flexible fiberoptic and video gastrointestinal endoscopes, Correspondence to Dr. Cowen from Dr. Bond regarding his monograph, monograph on "Disinfection, Sterilization and Antisepsis in Health Care", published by the Association for Professionals Infection Control in Epidemiology and draft from CDC on "Creutzfeldt-Jakob disease. Current epidemiology, risk factors and decontamination.
C. Comments on the draft proposal by Dr. Ben Khelifa
D. Comments on the experience in Latin America with endoscopic disinfection from Dr. Chopita
II) Dr. Quigley summarized the format and the order of presentation for the Working Party in Vienna. The presentation for the Working Party is scheduled between 4-6 pm on Monday afternoon September 7, 1998. Following a brief introduction by Dr. Quigley, three-20-minute presentations will follow as follows:
A. Walter W. Bond, MS "Microbiological Considerations in Disinfection and Endoscopy.
B. Alistai Cowen, MD "Clinical Risk of Infection Associated with Endoscop
C. Rakesh Tandon, MD "Endoscopic Disinfection – Practices and Recommendations for Endoscopes and Accessories"
1. This will be followed by a discussion within the panel with particular emphasis on experience in different parts of the world and on controversial issues, in particular, the reuse of accessories.
2. This will be followed by an open discussion and concluding remarks by Dr. Quigley.
III) The remainder of the meeting was taken up with a
detailed discussion of Prof. Tandon’s presentation on "Endoscopic Disinfection
– Practices and Recommendations for Endoscopes and Accessories". The details of
this presentation will be circulated to the members of the committee following receipt of
the complete document from Prof. Tandon. The most extensive discussion has surrounded a
number of areas which remain controversial.
These are as follows:
A. The issue of reuse of accessories. While it was agreed that some accessories such as sclerotherapy needles should never be reused, there was some divergence of opinion with regard to the reuse of some common accessories such as biopsy forceps and sphinctertomes, The problems here appears to be in relation to the cleaning of these accessories rather than their disinfection.
B. The other contentious issue related to the "soaking time" in disinfectant. This is clearly a major issue which has enormous impact, particularly in the developing world. Again, there was divergence of opinion varying from the 10 minutes recommended by the Gastroenterological Nurses Society of Australia and Gastroenterological Nurses Society of Australia to the 20 minutes recommended in Britain and Europe. Indeed, times of up to two hours had been recommended in some reports.
C. The issued of cleaning, manual vs. machine was discussed in some detail. With regard to manual cleaning, the importance of adequate training of personnel, adequate protection and adequate ventilation were emphasized. Some discussion took place with regard to automated systems, their potential benefits an limitations.
D. There was consensus that non-immersible instruments should not be recommended.
E. While most data relates to 2% glutaraldahyde, there are problems with its use, in particular, with the issue of sensitivity in personnel, which apparently has led to its prohibition in Germany and Denmark. What should the Working Party recommended as an alternative? Should this be paracetic acid or are there other possibilities?
F. Are there some infectious agents that we cannot protect against, in particular, prions and MAI? What should be our statement with regard to these?
G. What should be our position on alternative methods of disinfection such as thermal, superoxide water, etc? Should these be mentioned if there is insufficient data or availability?
IV) Dr. Quigley undertook to distribute the three
draft documents to all of the Working Party once these have been received.
There being no further business, the meeting was adjourned.
REPORT OF "AD HOC" COMMITTEES CHAIRMEN
Terminology and Data Processing Committee
Zdnek Maratka, Chairman (1994-1998)
TERMINOLOGY COMMITTEE REPORT, July 1993
The Committee of Terminology in Digestive Endoscopy was founded in 1976 by the European Scociety for Gastrointestinal Endoscopy (ESGE) and was raised to a Committee of the World Society (OMED) in 1978. Its activity has included regular meetings at the European and World Congresses of ESGE and OMED and elaboration of a standard endoscopic terminology suitable for daily practice and computer-aided endoscopic reports. The collaboration within the Committees in the three zones of OMED as well as continuing discussions have resulted in a series of publications, especially the manual of standard endoscopic terminology: Terminology, Definitions and Diagnostic Criteria in Digestive Endoscopy, 1st ed. [Scan J Gastroenterol 1984, 19 (suppl 103): 1–74]. The 2nd revised edition appeared in English (1989), German (1989), Italian (1989), Czech (1989), French (1990); all published by Normed Verlag, Bod Homburg, Germany. The Spanish, Portuguese and Norwegian editions are in preparation as well as the 3rd English edition. This book has been complemented by an atlas of endoscopic pictures presenting the most common findings with a standard description and interpretation (by the same publisher). Five video films have been produced by F. Costentino) documenting standard terminology in upper and lower digestive endoscopy (so far published in English, Italian and German). The publications and video films have been included in the educational programmes of endoscopic and gastroenterological societies.
TWENTY YEAR ANNIVERSARY OF THE OMED
TERMINOLOGY COMMITTEE, April 1998
The evolution of endoscopic terminology and nomenclature has been mentioned in previcus reports (1) but a 20 years anniversary of the committee gives the opportunity to recall the story shortly.
In the seventies the need for a standardized endoscopic terminology became more and more apparent and with the advent of computers was urgent. One of the first innovations which I introduced after being elected President of the European Society for Gastrointestinal Endoscopy (ESGE) in 1976 was founding the Terminology Committee. A round table conference was organized at the IV World Congress of Digestive Endoscopy in Madrid (1978) which aroused unexpected interest and incited inviting representatives of the other zones to participate in future activities. Thus the ESGE Committee was raised to an OMED Committee and since then bore the name Committee for Terminology and Computerization in Digestive Fndoscopy of the World Society of Digestive Endoscopy (OMED).The achievements of this committee during its 20 years existence can be summarized as follows.
First it was necessary to establish basic rules for endoscopic terminology. Three essential requirements were put forward:
1) Endoscopic terminology must be based on visual
perception and denomination of macroscopic features as seen through the scope.
2) Accepted terms must be classified and arranged in a system according to the character
of the finding; OMED’s classification distinguished nine categories of findings
referring to lumen, contents, wall, peristalsis, mucosa,
hemorrhage, flat changes, protrusions and depressed/excavated lesions. The list of all
terms belonging to the discipline represents a comprehensive database: the OMED
nomenclature.
3) The endoscope findings designated by appropriate terms specific for the endoscopic
method are interpreted in terms of clinical diagnosis by means of accessory methods like
biopsy, if necessary.
Developing a consistent endoscopic terminology was
considered to be the primary goal of endeavor. A draft was prepared and repeatedly
circulated to the members of the Committee and relevant experts to insure the greatest
possible consensus. At all international Congresses symposia and round table conferences
were held and the present state of the document was discussed and comments respected.
In 1984 the first publication appeared and gained wide acceptance; it was quickly
translated in other languages and updated in further editions (2). At present the forth
English edition is ready-to-print. In addition to the book, an atlas (3) and videos (4)
were published. A CD-ROM in 5 languages presenting gastroenterology as a discipline viewed
by the eyes of the endoscopist and using the OMED nomenclature was published under the
name Normedia-Gastro (5). All this work was accomplished thanks to sponsoring by
pharmaceutical and endoscopic industry companies as well as by perfect collaboration with
Normed Verlag, Bad Homburg.
The OMED nomenclature aims at being a possibly complete list of terms used in digestive
endoscopy organized in a hierarchical system and provided by definitions and diagnostic
criteria. Being such it should represent a fundamental database. For practical purposes
this exhaustive list can be tailored to suit different computer programs, e.g. Minimal
Standards for a computerized endoscopic database (6) facilitating a correct formulation of
endoscopic records. Customized databases of this kind, however, should use the
standardized nomenclature and should not depart from agreed categorization and
terminology.
It has been a privilege to chair the OMED Terminology Committee for these 20 years and to see its achievements being accepted by the endoscopic community and further developed by the ESGE Committee for Minimal Standards for Tenninology and Documentation in Digestive Endoscopy.
REFERENCES
Minimally Invasive Surgery Committee
Alberto Montori, Chairman (1994-1998)
THE IMPACT OF ENDOSCOPY
ON DIGESTIVE SURGERY
Having been trained as a surgeon in the
so-called pre-endoscopic era, I have no doubt that the impact of endoscopy on digestive
surgery has been tremendous. In an attempt to identify and analyse the key points of such
tremendous impact, I draw my readers’ attention to three different aspects.
The importance of endoscopy in obtaining early diagnosis, its influence on clinical
judgement and its role in surgery, by suggesting the most
appropriate surgical approach and technique through a correct diagnosis of the lesion.
The contribution of digestive endoscopy to a better knowledge of the pathophysiology
of several gastrointestinal diseases with enormous consequent benefit in the surgical
decision-making process.
The host of therapeutic applications which have become more and more widespread and
sophisticated and which have arisen because of the direct visual inspection that endoscopy
allows.
Therapeutic endoscopy has perhaps had the most visible impact in terms of reducing
morbidity and mortality in the emergency as well as in the high-risk patient. Its
application and the consequent refinement of indications for surgery has also produced a
reduction in the number of surgical operations performed and has shortened hospitalization
periods, thus producing a reduction in the cost of management of surgical patients.
In my opinion, endoscopy has also had an impact on the evolution of digestive surgery. In
fact, the same principles of flexible endoscopy have inspired the diffusion of
"minimal access surgery" via laparoscopy, which represents a great progress in
gastrointestinal surgery.
On the basis of these brief observations, I recommend that gastrointestinal endoscopy be
considered a complementary aid to surgery and not a contrasting technique. It has led to a
multidisciplinary approach to the gastroenterological patient and to a better co-operation
between physicians and surgeons.
FIRST CLINICAL APPLICATIONS IN TELESURGERY
PRESENTED AT 6TH WORLD CONGRESS OF ENDOSCOPIC
SURGERY IN ROME, JUNE 1998
Based on recent scientific and clinical experience of the
first applications in telesurgery, the 6th World Congress of Endoscopic Surgery in Rome
added two special sessions to include presentations by Professor Guy-Bernard Cadiere, of
St. Pierre Hospital in Belgium, and Doctor Anno Diegeler, of the Leipzig Heart Center in
Germany. These two surgeons were invited to present their initial results and experience
using the Intuitive computer-enhanced surgery system.
Professor Cadiere performed the world’s first computer-enhanced Nissen Fundoplication
procedure and Doctor Diegeler and his team performed the world’s first videoscopic
coronary artery bypass surgery.
The World Congress of Endoscopic Surgery provides a scientific forum in which to debate
and exchange scientific experiences in the field of Minimally Invasive Surgery. While
moving toward the next millennium, technologies such as this system will be one of the
most significant advancements in endoscopy, helping to redefine minimally invasive surgery
as we know it today.
Intuitive is developing a computer-enhanced minimally invasive surgery system that uses
proprietary electronics, advanced robotics, and enhanced visualization to greatly improve
surgical technique and take surgical precision far beyond what is possible today.
The system is a new surgical technology intended to eliminate the major obstacles to
widespread adoption of Minimally Invasive Surgery. It is designed to transform a broad
range of open procedures to Minimally Invasive Procedures by making MIS more precise and
easier to perform.
Using state-of-the-art computing, sophisticated software and highly-specialized
micro-surgical instruments, this system combines the natural hand movements used in
traditional open surgery, with the less traumatic approach of Minimally Invasive Surgery
– thereby delivering the best of both techniques.
Using this system, surgeons will perform procedures seated at the console while viewing a
high-resolution 3-D video image of the surgical field.
The surgeon’s hands rest below the monitor and hold instruments that provide the
flexibility of those used in open surgery. Highly-specialized technology simultaneous
transfers the surgeon’s exact hand movements made at the console to precise
microsurgical movements of the instruments at the operative site.
With this remote control it is nowadays possible to operate with precision and these
surgical procedures can be done based on scientific and clinical experience of the
application in telesurgery.
ULTRACISION – THE ARMONIC SCALPEL
As we know, electrosurgical units are more often based on
monopolar energy sources which transmit the electrical power to the patient by means of a
metallic pad placed on the skin. Once the surgeon activates the unit, a flow of electrical
energy passes through the patient tissues and, according to the frequency and intensity,
cauterisation or cutting is obtained.
Complications from the diffusion of energy to healthy structures or skin burns are
frequently reported. Armonic dissection is a totally different approach to obtain
sectioning of tissue and simultaneous hemostasis with no risks of inadvertent injury to
the surrounding structures.
The Ultracision – Armonic Scalpel is composed by a current generator connected to a
piezoelectric transducer which is located inside the handle used by the surgeon. The
transducer transforms the electric power into mechanic energy, then transferred to a
blade. The blade vibrates linerly for a distance varying between 50 and 100 microns at a
frequency of about 55,000 times per second. The blade is incorporated in a mechanism in
the shape of scissors. Only tissues incorporated by the surgeons between the two blades
undergo the mechanical dissection energy. Low temperature heath is generated, which
contributes to vessel coagulation without carbonisation of tissue, a normal effect of most
monopolar electrosurgical units.
Therefore, Armonic Dissection and Ultracision guarantee one of the most precise and less
invasive dissection methods available today provided by Ethicon Endo-Surgery a Johnson
& Johnson Company.
OMED POSTGRADUATE COURSE ORGANIZED
WITHIN THE 6th WORLD CONGRESS OF ENDOSCOPIC SURGERY Rome, JUNE 1998
The Postgraduate Course was organized under
the auspices of the OMED, the EAES and the SAGES. The coordinators were J.R. Armengol
Mirò, M.D. and M. Crespi, M.D. for OMED, Sir A. Cuschieri, M.D. and J.J. Jakimowicz, M.D.
for EAES and J. Ponsky, M.D. and G. Van Stiegman, M.D. for SAGES
This interesting and successful Course was followed by 322 participants for 10 hours a
day.
This Postgraduate Course with live interactive demonstrations (16 patients operated in 2
days) with Satellite connection with the Auditoruim of Alitalia where the Nurses’
Seminar took place and with the Hospitals in Milan and Taranto.
The Postgraduate Course was dedicated to "Diagnostic and Interventional Flexible
Endoscopy; Interventional Radiology and Endoscopic Surgery: Competing, Complementary,
Combined?". The contribution and participation of about 40 specialists in the
different minimally invasive methods has brought up the possibility of managing patients
through a cooperative efforts. When involved in the management of patients, only the
knowledge of the possibilities and limits of each diagnostic and therapeutic approach
makes it possible to achieve the best outcome with the lowest morbidity and costs. The
Postgraduate Course has been focused mainly on all management options of digestive
diseases of surgical interest, including interventional radiology and flexible endoscopy,
with updating of all new-coming technologies, from the ultimate imaging technologies to
the future role of telerobotics and virtual reality. The technological evolution has been
indicated as the path for future wider and wider application of the principles of
Minimally Invasive Surgery.
Nonetheless, technology has not been the only commitment of the Course, where special regard has been given to the study and treatment of pre-cancerous lesions, early cancers and other malignancies. Therefore, at the end of the Course, the new profile for the Surgeons of the 3rd millennium has been drawn: an expert in sophisticated technology; good hand skills but also deep cultural roots.
Ethics Committee
Endoscopy and ethics, May 1996
ENDOSCOPY AND ETHICS, MAY 1996
Hippocrate’s Oath has been considered as the
physicians’ legal and moral code in the whole world for twenty two centuries.
The Code of Nuremberg defines the conditions in which experiments on human subjects may be
authorited. The difterent Ethics Committees, and more recently, Laws about Bio-Ethics
attest of the fundamental questions that science and medical technics improvements bring,
modifying continuously what gives the worth to life and death to Human being Endoscopy in
Gastroenterology, and the permanent development of its diagnostic and therapeutic
possibilities, raise new questioning about medical power and medical know how.
Concerning this invasive procedure, Ethics defines collective rules of "logic"
and "good practice" that can’t be limited in their dimensions by an
individual choice.
These measures allow to establish some rules of conduct we must respect to avoid drifts
regarding the patient and the technique.
Even if these basic principles seem obvious and established, to ensure patient’s security ancl cornfolt before, during and after intervention.
ETHICS COMMITTEE REPORT
Among the activities of the Committee, is the publication
of the book "Medical Ethics in Gastroenterology and Digestive Endoscopy: changing
concepts in a changing world" Editor J. Escourrou, with articles from N Antaki
(Syria), Ben Khelifa
- A. Kilani (Tunisie), M.A. Latorzeff - J. Escourrou (France), J. Campos (Colombia), F.
Villardell (Spain), M.C. Milano (Argentina), J.H. Solhaug (Norway), B.H. Novis (Israel),
C. Francesconi (Brazil) - C. Stanciu (Romania).
The passionate and competent work of Professor Escourrou during his chairmanship of the
OMED Ethics Committee has produced a booklet which will be, for several years, a reference
text for gastroenterologists and endoscopists. This book is distributed at the World
Congress in Vienna and is available through the OMED Secretariat.
In a changing medical world, characterized by an
increasing confrontation with administrative rules, budget restrictions, litigations, but
also with a decrease of compassion and distorted human relationships, the doctors are
confronted too often with difficult and sometimes painful decisions. This publication,
which faces these problems from different points of view, will refresh to all of us our
duties and obligations and give us the opportunity to stop for a while and ask ourselves:
where we are?
We may be proud that Professor Jean Escourrou and his co-authors, under the auspices of
OMED, were able to produce such a valuable reference work.
Medical Ethics, Gastroenterology and Digestive Endoscopy : changing concepts in a changing world
Editor Prof. Jean Escourrou, Chairman of the OMED Ethics
Committee
An OMED Newsletter Publication
Editor: Prof. Alberto Montori
Co-Editor: Prof. Massimo Crespi
Rome, Italy 1998
The passionate and competent work of Professor Escourrou
during his chairmanship of the OMED Ethics Committee has produced the present booklet
which will be, for several years, a reference text for gastroenterologists and
endoscopists.
In a changing medical world, characterized by an increasing confrontation with
administrative rules, budget restrictions, litigations, but also with a decrease of
compassion and distorted human relationships, the doctors are confronted too often with
difficult and sometimes painful decisions. This publication, which faces these problems
from different points of view, will refresh to all of us our duties and obligations and
give us the opportunity to stop for a while and ask ourselves: where we are?
I am proud that Professor Jean Escourrou and his co-authors, under the auspices of OMED, were able to produce such a valuable reference work. Thank you Jean, thank you all.
Professor Massimo Crespi President OMED
FOREWORD
Sir Thomas Percival was the first to recognize the necessity of collective thought on the
development of new medical procedures back in 1803. The first " Ethical
code " concerning research on human beings was developed after the Nuremberg
trial, and has since been completed at different meetings.
As Greenberger said, Ethics is a domain of truth or error,
where intelligent and sensitive people can sincerely differ. Indeed, countries can have a
different conception of Ethics according to the different social values and/or religions
in a given society. This concept is constantly questioned due to progress in the fields of
biology and medicine. It is not uniform or static, and doesn’t concern medicine
alone. Contrary to morals which are based on individual conscience, the notion of ethics
is decided on, is arbitrary and must correspond to a collectif consensus ;
In this work, the reader will find the reflections of authors from different countries on
existing ethical relationships in numerous fields. Thus, N. Antaki (Allepo, Syria) has
analysed particularly well the link between ethics - the goal of which is the common well
- being, and morals, which correspond to personal obligations. Habib Ben Khalifa (Tunis)
has developed the duties of the gastroenterologist, especially as regards the need to
follow the procedure according to the rules, yet respecting the ethical aspect. From this
point of view informed consent is the basis of the respect of the patient. The evolution
of means of communication and data-processing mean that new problems concerning the
respect of the medical secret have arisen. These two aspects have been particularly well
analysed by J. Campos (Bogota) and F. Villardell (Barcelona). The limitation of financial
means generates a real conflict when it comes to respecting ethics. The same is true for
ethics and scientific progress, dealt with by Claudia Milano (Buenos -Aires) and J.
Solhaug (Oslo) Numerous practical elements concerning Helicobacter Pylori are illustrated
in the chapter by B. Novis (Tel-Aviv). Finally I would like to thank C. Stanciu (Roumania)
President of the Ethical Committee of the WGO (World Gastoenterological Organization)
together with Carlos Francisconi (Porto Alegre, Brasil) for having dealt with the
responsibilities of Ethical Committees when faced with the different problems that
transgress this notion. This notion of ethics that requires each thing and every act to be
in the right place. This book should enable physicians in general, and gastroenterologists
in particular, to exerce their activity whilst respecting restraints and the four basic
principles which are the very backbone of Ethics : -the respect of the invidivual,
-the respect of knowledge, -the responsability of the researcher and -the refusal of
profit.
Jean Escourrou, France
AUTHORS
ANTAKI Nabil MD. President of the endoscopy section of the
Syrian Society of Gastroenterology,
PO BOX 6448 Aleppo - SYRIA
BEN KHELIFA Habib MD. Gastroenterology Unit – Hopital Habib Thameur Tunis - TUNISIA
CAMPOS Jaime M.D. Associate Professor, Dean,Faculty of
Medicine. National University of Colombia
Bogota - COLOMBIA
ESCOURROU Jean M.D. Professor of Hepatogastroenterology,
University Hospital Rangueil
31403 Toulouse - FRANCE
FRANCISCONI Carlos M.D., FACG, Chief, Gastroenterology
Division, Hospital de Clínicas de Porto Alegre,
BRAZIL
KILANI A. MD. Gastroenterology Unit – Hopital Habib Thameur, Tunis - TUNISIA
LATORZEFF Marie Ange MD. Hospital LA GRAVE,Toulouse - FRANCE
MILANO Claudia, M.D. Specialist in
Gastroenterology.Specialist in Clinical Oncology.
Hospital Nacional Profesor Alejandro Posadas, Buenos Aires - ARGENTINA.
NOVIS B.H. MD. Meir Hospital, Kfar Saba and the Sackler
School of Medicine, Tel Aviv University
ISRAEL
SOLHAUG Jan Helge M.D. Dept of Surgery, Diakonhjemmets Sykehus, Oslo - NORWAY
STANCIU Carol, MD. University Hospital " St. Spiridon " Iind Medical Clinic Gastroenterology B-dul Independentei 6600 Iasi - ROMANIA
VILLARDELL Francisco, MD DSc FRCP FACP Postgraduate School
of Gastroenterology,
Autonomous University, Hospital Sant Pau Barcelona - SPAIN
CONTENT |
|
| ETHICS AND RELIGION N. Antaki |
1 |
| DUTIES OF THE ENDOSCOPIST Ben Khelifa - A. Kilani |
6 |
| DOCTRINE OF INFORMED CONSENT M.A. Latorzeff - J. Escourrou |
18 |
| ETHICS AND MEDIA Campos |
23 |
| ETHICS, ENDOSCOPY AND COMPUTERS Villardell |
29 |
| ETHICS AND MONEY A view of ethics, money and collective resources. M.C. Milano |
40 |
| ENDOSCOPY AND CLINICAL TRIALS J.H. Solhaug |
47 |
| HELICOBACTER PYLORI DIAGNOSTIC AND THERAPEUTIC MEASURES : ETHICAL ASPECTS B.H. Novis |
60 |
| BIOETHICS COMMITTEES C. Francesconi - C. Stanciu |
66 |
ETHICS AND RELIGION
N. ANTAKI
Ethics and Morals have etymologically the same meaning,
Ethics stemming from the Greek ethos and morals from the Latin adjective moralis (1). But,
in reality, these two words convey two different concepts. For a long time, morals,
defining the good and the bad, were used as a reference, as a rule of conduct for science
which had to abstain from everything that was morally bad. It can be of religious or
philosophical inspiration. Religious morals, taking its roots in faith, doctrine, sacred
texts and tradition, can differ according to the different religions; this is why there
are several religious morals as opposed to just one. For the catholic religion, for
example, moral conscience urges to love, to call upon the good and avoid the bad (2). It
prescribes to man the ways and rules of conduct leading to the promised beatitude (3).
Morals takes its roots in the faith that man was created as the image of God, and that God
made the total gift of himself in Jesus his son; this faith is the basis of catholic moral
precepts which respect life and human dignity.
Morals concerns what "should be" as opposed to "what is". It is
defined by four essential lines (4-5): inwardness: which calls upon one's own conviction,
one's own implication. It is not a simple exterior conformity.
Idealism: Morals is demanding, it suggests an ideal, it leads to a better self. It even
demands heroism in certain cases.
Universality: its precepts and authority extend to all men.
Immutability: it is permanent whatever the changes in history. But with the passing of centuries, societies no longer had in common à unanimous religious tradition nor a belief in the universality of moral faith inscribed in the heart of human nature, which replaced it since the age of enlightenment. we cannot assume that we all have the same concept of what is good.
Medical ethics were born because, on the one hand, the
world and societies became pluralists and one cannot impose à specific moral to all. We
have been lead to tolerate, for moral reasons, what we sometimes ourselves condemn for
moral reasons (6); and on the other hand because religious morals have sometimes been
unable to face new situations in the biomedical field.
It was attempted to set up the rules of common morals, named ethics, applicable to all,
ranging from the texts of the Human Rights to the rules established in Nuremberg and in
Helsinki. Then the legislator intervened by voting the bioethic laws.
These ethics are the putting into practice of principles of different origins and place
themselves downstream from morals. Instead of being à moral of conviction (religious) it
has become a moral of compromise (7). For some, it represents the smallest common
denominator acceptable by all. For others, this compromise is meant to bring the different
elements of society together on demanding issues (8)
Civil ethics have replaced, in the biomedical field,
religious morals. If morals is defined by inwardness, idealism, universality and
immutability, bioethics is on the contrary (9): pluralist = aiming to protect diversities.
minimalist = it is realistic. A law which is inapplicable is a bad law
exteriorized - it demands exterior obedience and does not care about personal feelings.
circumstantial = it addresses particular communities at a given time.
Bioethics presents itself as an alternative, although
complementary, to indifference or the incapability of morals to establish a dialogue with
the sciences of life (10). But it is admitted as evidence that ethical decisions are
precarious and in a large measure arbitrary because they are the result of negotiations
which can be challenged as new generations of speakers take part in the debate (11).
Religion and ethics meet on many issues. They can nevertheless diverge on important
matters such as voluntary interruption of pregnancy, contraception, in vitro fertilization
... In gastroenterology and in digestive endoscopy, ethics and religions have identical
positions on many issues.
Ethics and religion in gastroenterology
Many issues in the practice of gastroenterology and digestive endoscopy raise ethical
problems such as organ transplants, blood transfusion, medical responsibility, clinical
research and experimentation on humans, euthanasia and informed consent. 0n many of these
issues, the different religions have a similar approach and a similar attitude. The
religious approach considers that issues relating to the respect of the human being, its
integrity and life cannot be resolved by simple reference to conscience, be it common or
universal, but by reference to Faith, doctrine and sacred texts.
As far as the position of the different religions on gastroenterology ethics is concerned,
it varies according to the problems. The different religions are unanimous in allowing clinical
research and experimentation on man as long as they do not represent a threat
to the life or health of the volunteer, that he has given his free and informed consent
and that their aims are therapeutic.
They are unanimous in prohibiting active euthanasia
as nobody has the right to take away life even if the person concerned is in a vegetative
state of life, because as stipulated in the Jewish Theology, a fraction of infinity stays
infinity (12). If there are controversies on passive euthanasia, all religions
nevertheless agree not to confuse the maintenance of life and therapeutic relentlessness.
Informed consent and medical responsibility also make unanimity and medical ethics meet
the morals of the different religions on these issues. Blood transfusion is
acceptable and even desirable for all religions except, for Jehovah’s witnesses
(13-16). Even in 1927, well before the perfecting of transfusion techniques,
Jehovah’s witnesses explained that according to the Alliance concluded between
Jehovah and Humanity, no blood should be consumed in order to respect the sacred character
of life. Based on this doctrine they quoted the formal command given by God to Noah:
"Everything that moves and has life will be your nourishment. But you will not eat
flesh with its soul, that is to say blood. You will be answerable to me for your blood
" (GN 9:3 . 5). According to them, this ban was permanent and involved all those
wanting to remain faithful to the Alliance. It is for Jehovah’s witnesses a
fundamental belief, à conviction with profound implications as it touches their eternal
salvation.
During the decades following the declaration of these principles by their religious leaders, the witnesses have remained attached to the belief that one cannot accept blood even in life-threatening situations. They have rejected most of the new techniques refusing not only total blood but also red cells concentrates, plasma, white blood cells and platelets.
However there are a few methods on which their position is not as clear. It is the case of albumin, immunoglobulins, and preparation for hemophiliacs. Laws and jurisprudence are currently clear enough to allow Jehovah’s witnesses to refuse transfusions and to clear hospitals and doctors of their responsibility. The position is clear and without ambiguity: the patient’s will must be respected on condition that it is freely expressed. The discovery of the hepatic virus .B, C and G and the ravages of Aids have given more arguments to those who reprove transfusion against somebody's will, transfusion not being as safe as doctors once thought. Refusal of transfusion can go against the personal morals of the doctor, telling him to do everything to preserve the life and health of his patient, but bioethics bases itself on the immutable principle of respecting the wish of the person who has the right to refuse a treatment even at the cost of his life.
Let us now talk about organ transplants. Religious morals
and medical ethics admit that transplants should be a gift, clear, free and anonymous. In
addition, most religions have in common (17):
- The respect of the wishes of the deceased.
- The certainty of the irreversible character of death.
- The respect of the appearance of the corpse.
Unanimously a preliminary consent is requested from the donor (free consent and revocable
at any time), that the gift is free, based on the principle of the non patrimoniality of
the human-body (free, anonymous and non- patentability of the body and its parts) (18). In
addition, they proclaim that transplants should only be carried out with the therapeutic
aim to save a human life and not to experiment.
On all these points, the Catholic, 0rthodox, Protestant, Muslim, Buddhist and part of
Judaism religions agree. 0n the other hand, Hinduism and Shintoism are against
transplants, this is why there are virtually no hepatic transplants in Japan except from
partial transplants from live donors (19-23). The problem lies with the criteria of the
definition of death. For the above mentioned religions and for ethics, the death criteria
is cerebral death, which allows the taking of viable organs. 0n the other hand, for Islam,
the death criteria is not the cerebral death, but the definitive stopping of the heart
(24), therefore making it impracticable to transplant from dead donors. But a progressive
tendency (rejected by the strict Islam) accepts, since the Amman Conference of 1986,
cerebral death as an alternative to the definitive stopping of theheart in the definition
of death.
For strict Judaism, death is defined as the simultaneous abolition, total and
irreversible, of the respiratory, cardiac and neurologic functions, making transplants
impossible. But the favorable tendency towards transplants has increased thanks to two
ideas (25):
- The kidney taken and transplanted is alive again due to the transplant and therefore outside the laws on the respect of the body.
- The transplant aims at saving the life of the receiver and it prevails on all the interdictions of the Torah.
Remains the problem of the consent. If the informed, clear and revocable consent is an essential condition for all religions, two divergent points emerge:
- For Islam, even if a donor has given his consent while
still alive, it is the right of his heirs to dispose of his body after his death. They can
annul the consent given and refuse the organ donation expressed by the deceased (26). On
the other hand, to increase the number of organs to be transplanted, some laws no longer
request a clear or active consent and accept a presumed consent, i.e. the non-refusal of
transplant by the donor while still alive.
As far as organ transplants from a live donor are concerned (partial liver), religions and
ethics accept this as long as there are no other alternatives and if there is no negative
impact on the life or health of the donor and if the consent is given freely (quid
psychological pressure on a parent donor to his child?).
Finally we are heading for the concept of the death of the Brainstem as opposed to
cerebral death.
REFERENCES:
- GOLD F,, Ethique, éthique medical, bioéthique. Repères et situation
éthiques en médecine. Ellipses, 1996. 10-18.- GAUDIUM et SPES, Ch, 16, Concile Vatican II
- CATECHISME DE L'EGLISE CATHOLIQUE, Mame/Pl on, 1992;405
- CATECHISME DE L'EGLISE CATHOLIQUE, Mame/Plon, 1992;406-407
- DURANT G La bioéthique, méthodes et fondement, Les cahiers scientifiques,
Montréal, ACFAS, 1989; p.87-96- FAGOT.LARGEAULT A., La réflexion philosophique en bioéthique. Les fondements de la bioéthique, De Boeck, Université, 1992, p, 11-26
- GOLD F., Ethique, éthique médicale, bioéthique. Repères et situations
éthiques en médecine. Ellipses, 1996,p,10-18- GOLD F., Idem
- DURANT G Ethique, droit et régulation alternative. Les fondements de la
bioéthique, De Boech Université, 1992, p.63-75- DOUCET H., la contribution du théologien en bioéthique. Les fondements de la
bioéthique. De Boech Université, 1992, p.49-62- FAGOT.LARGEAULT A., La réflexion philosophique en bioéthique, Les cahiers
scientifiques, Montréal, ACFAS, 1989, p. 3-16- GUEDJ P; La recherche médicale dans le Judaïsme, la lettre de RAMBAM, Medica Judaica 23:11
- DEVINE R., Save the Body-Lose the Soul; Health Progress, June 1989
- THOMAS J.M. Meeting the surgical and ethical challenge presented by Jehovah's
Witnesses, Canadian medical association journal, vol 128 1153-1154, 1983- GARAY A., GONI P., La valeur juridique de l'attestation de refus de
transfusion sanguine. Les petites Affiches, N 97, p.14-18, 1993- JAMA, vol. 246,2471-2472, 1981
- JACOB I., prélèvements d'organes, Revivre, N° 54, 1992
- Loi N 94-654 du 29 Juillet 1994, le dictionnaire permanent Bioéthique e
Biotechnologies, Editions législatives.- KREIS H., Ethique et transplantation, Administration numéro spécial,
p;37-49, 1997- VERSPIEREN P. Transplantation et catholicisme, Administration numéro spécial p.51-53, 1997
- BOUBAKEUR D., l'Islam et la transplantation, Administration numéro spécial,
p.57-60, 1997- BOTBOL E., Ethique Juive et transplantation d'organes, Administration numéro
spécial, p.61-64, 1997- ABEL 0., l'éthique protestante, Administration numéro spécial p.65-66, 1997
- .ALBOUTI S.R., kadaya fikhiye mouassira, edition Farabi-Damas p.128-131,1994
- NAJMAN A., Greffes d'organes, une éthique de la décision, la lettre de RAMBAM, Médica Judaica N° 20, p.11-13
- ALBOUTI S.R., kadaya fikhiye mouassira, edition Farabi.Damas p.132, 1994
- THOUVENIN D., Les règles juridiques organisant l'activité de transplantation
- d'organes, Administration p.29-36, 1997
DUTIES OF THE ENDOSCOPIST
H. BEN KHELIFA, A. KILANI
INTRODUCTION
PRIMUM NON NOCERE
Gastro intestinal endoscopy (G.I) is neither infallible nor absolutely safe, and thus
becomes a subject of medical ethics which rely on 2 principles (1) :
1/Autonomy of the endoscopist,
2/Beneficence, nonmaleficence and justice for the patient.
The endoscopist must always consider the patient’s best interest and keep in mind
that diagnostic and therapeutic safety are foremost, and that endoscopy is not solely
guiding the endoscope. So, the duties of the endoscopist play in 3 ways :
COMPETENCE OF THE ENDOSCOPIST
Competence in endoscopy assumes a combination of technical and cognitive skills, and
requires correct interpretation of abnormal findings. In most countries the proper
background is considered to be a formal postgraduate training in gastroenterology.
a)Training :The trainee must learn when
endoscopy is indicated
(2 , 3 ) , how to reduce the possible danger of a false diagnosis, and of an iatrogenic
lesion, and how to use endoscopically derived informations in clinical practice ( 4
). An ethical problem arises in teaching endoscopy (8). The welfare of the patient must
always be ensured , so that he is never endangered or exposed to excessive discomfort by
the teaching process.
b) Maintaining competency in endoscopic skills is mandatory ,and so, the
learning process does not stop at the end of the training period, but should be an ongoing
educational process (6-7-8). It is imperative that the endoscopist documents his
continuing education effort in the rapidly developing field of GI endoscopy. Self training
must occur on a background of basic endoscopic skills , and each endoscopist must
assess when additional formal training is necessary before undertaking a new kind of
endoscopic procedure (6).
THE ENDOSCOPY UNIT
The endoscopy unit should be properly designed and establish guidelines to render the
examination efficient and safe (1O) with :
PREPROCEDURAL ASSESSMENT
a) Endoscopic competence of the endoscopist and his staff and appropriate endoscopy suite. These problems were discussed above.
b) Infection control,
c) Sedation and monitoring ,
d) Personal and expanded duty ,
e) Endoscopic complications, claims and risk management ,
f) Quality assurance.
The endoscopic devices must be considered semi-critical
material and should therefore be sterilized or at least receive high level disinfection.
Liquid chemical agents are used almost exclusively for disinfection. Several alternative
preparations are recommended : Of these glutaraldehyde at 2 % concentration is
the disinfectant most used and recommended as a first choice in various International
guidelines (2O). The disinfection of accessories must be of a high level. The re-use of
accessories labelled " for single use only " as a potential means to
reduce costs has not been carefully evaluated, but should be allowed only if disinfection
is effective (22).
A recent study was reported about the use of acidic electrolytic water potency for
endoscope disinfection, safety for the tissues of the subject, and low cost (19 ).
As regards the time of contact between the disinfectant and the endoscope, not less than
1O minutes are recommended. Mechanical cleaning is the first and most important step,
followed by high-level disinfection .The protection of the personnel is also important.
Standards to prevent contact with infectious blood or body fluids must be maintained.
Recent document on disinfection has been published on behalf of the ESGE (19).
Prophylactic antibiotics are recommended by ASGE (21) in patients with prothetic valves
and surgically constructed systemic pulmonary shunts. For the British Society of
Gastroenterology (16), it is also recommended when the patient is at a high risk of
endocarditis, or of symptomatic bacteraemia as a consequence of immunosuppression or
neutropenia. In most circumstances, parenteral Amoxicillline and Gentamycin are
recommended. The addition of Metronidazole is needed in patients with neutropenia.
Antibiotics prophlaxis is also recommended for all patients undergoing ERCP with evidence
of biliary stasis or pancreatic pseudo-cyst ( 22 ).
a) Sedation : consists in reducing the level of
consciousness induced by medications used to facilitate acceptance of endoscopic
procedures and to increase the comfort and safety of the examination (2). Benzodiazepines
are the most commonly used agents in endoscopy and the most frequently prescribed drugs
are Diazepam and Midozolam. Analgesia is almost associated, induced by the use of
medications primarily opiates. Intravenous sedation is certainly worth recommending,
especially for therapeutic endoscopic procedures ; however, it has been clearly shown
that it carries significant risks ( 26, 33).
b) Monitoring : ( 27,29) is mandatory and prudent, and consists in the continuous
assessment of the patient’s status, before, during, and after the administration of
sedatives. It improves the outcome, by decreasing the risks of sedation and of the
procedure, and should detect early signs of patient distress, before compromise to vital
functions occurs. Most endoscopists are currently employing electronic monitoring
equipment , but the best monitors of a patient’s safety are the physicians and
skilled assistants working as a team. Nothing replaces clinical assessment, and it is
important to underline that the ultimate responsibility for protecting patients lies with
the endoscopist and cannot be assigned to an assistant or an electronic monitoring device.
However, both may greatly improve the ability to detect patient distress in time ,
when intervention will prevent an otherwise adverse outcome.
Emergency assistance, as well as transport to local intensive care units should be readily
available. Whenever possible and appropriate the cooperation of an anesthesiologist will
avoid a lot of problems and reduce the responsibilities of the endoscopist .
c) Standard clinical monitoring should include heart rate, blood pressure and respiratory
rate, before sedation, during the procedure and immediately after , as well as before
discharge from the recovery area. Oxymetry is useful for detecting decrease in oxygen
saturation which usually carries little clinical risk. Continuous electrocardiographic
rhythm is also used. Devices are now available to monitor all these parameters.
d) Out patient and sedation :
The standard practice as documented by multiple surveys ( 25, 27) is to carry out
digestive endoscopy as a routine on an outpatient basis. It is also important to note that
one half of the world regards upper G.I endoscopy without sedation as being the
norm , and some authors suggest that endoscopy without sedation should be encouraged
for routine examinations ( 32). The safety aspects point strongly to increased use of
topical pharyngeal anesthesia and the reduction in the use of sedation ( 24). The use of
throat spray for diagnostic endoscopy is quite acceptable to patients in routine
diagnostic uppergastrointestinal endoscopy as it improves tolerance and facilitates
examination (28, 29).
In fact, the vast majority of endoscopic procedures can be performed without sedation (
32).
a) Define instances that place the endoscopist at risk
b) Determine the frequency and significance of these instances,
c) Apply risk treatment to individual cases,
d) Develop remedial and preventive measures.
There are several simple and easy risk techniques which can be incorporated into practice routine (47).
The occurrence of complications is not malpractice per se, whereas the failure to make a timely diagnosis of the complication, may be. Documentation is the shield against malpractice claims.