Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope

Roles of nurse-surgeons in global surgical care: A scoping review

AIM

To identify the roles of nurse-surgeons in the provision of surgical care.

DESIGN

Scoping review.

METHODS

This scoping review adhered to the JBI guideline for scoping reviews and EQUATOR Network's PRISMA-ScR checklist. Searches were performed from May 2022 to July 2022 using a combination of MeSH headings, keywords and filters via database and hand searching based on the eligibility criteria. Keywords included nurse-surgeon, nurse endoscopist, nurse hysteroscopist and nurse cystoscopist. Data sources were CINAHL, Cochrane, Google Scholar, PubMed and Scopus. Descriptive analysis was used to report the findings.

RESULTS

Ninety-six included records indicated nurse-surgeon practice in 26 countries. Forty-one nurse-surgeon titles were found, the majority of which were types of nurse practitioner. A total of 5,684,198 surgeries were performed by nurse-surgeons varying from laparotomies to biopsies. Nine records reported that nurse-surgeons perform surgeries safely and on par with physicians with zero to minimal complications. Nineteen records reported improved surgical care efficiency by nurse-surgeons in terms of patient access to surgery, waiting times, surgery times, patient show rates, patient education, physician workload and junior physicians' training. Seven records reported high patient satisfaction. Nurse-surgeons were cost-effective according to five records. Thirteen records recommended the standardization of nurse-surgeon practice.

CONCLUSION

Nurse-surgeons performed millions of surgeries worldwide assisting in easing the global surgical burden. This review identified the roles and benefits nurse-surgeons play in global surgical care. Research gaps on nurse-surgeon roles were discovered including the ambiguity in nurse-surgeon titles and the need to regulate nurse-surgeon practice.

IMPACT

This research addressed the clinical safety, quality, contribution to timely surgical access and cost efficiency of nurse-surgeon performed surgeries, as well as the need to standardize nurse-surgeon practice and use a more consistent nurse-surgeon title to ensure role identification and monitoring.

Transnasal endoscopy: no gagging no panic!

BACKGROUND

Transnasal endoscopy (TNE) is performed with an ultrathin scope via the nasal passages and is increasingly used. This review covers the technical characteristics, tolerability, safety and acceptability of TNE and also diagnostic accuracy, use as a screening tool and therapeutic applications. It includes practical advice from an ear, nose, throat (ENT) specialist to optimise TNE practice, identify ENT pathology and manage complications.

METHODS

A Medline search was performed using the terms "transnasal", "ultrathin", "small calibre", "endoscopy", "EGD" to identify relevant literature.

RESULTS

There is increasing evidence that TNE is better tolerated than standard endoscopy as measured using visual analogue scales, and the main area of discomfort is nasal during insertion of the TN endoscope, which seems remediable with adequate topical anaesthesia. The diagnostic yield has been found to be similar for detection of Barrett's oesophagus, gastric cancer and GORD-associated diseases. There are some potential issues regarding the accuracy of TNE in detecting small early gastric malignant lesions, especially those in the proximal stomach. TNE is feasible and safe in a primary care population and is ideal for screening for upper gastrointestinal pathology. It has an advantage as a diagnostic tool in the elderly and those with multiple comorbidities due to fewer adverse effects on the cardiovascular system. It has significant advantages for therapeutic procedures, especially negotiating upper oesophageal strictures and insertion of nasoenteric feeding tubes.

CONCLUSIONS

TNE is well tolerated and a valuable diagnostic tool. Further evidence is required to establish its accuracy for the diagnosis of early and small gastric malignancies. There is an emerging role for TNE in therapeutic endoscopy, which needs further study.

Non-Physician Endoscopy: How Far Can We Go?

BACKGROUND

The delegation of medical tasks to trained nurses is still little discussed in Germany.

METHODS

To get a picture of the current extent of non-physician endoscopy worldwide, we performed a systematic literature research. The following databases were used: CINAHL®, Cochrane Library, the German National Library of Medicine (ZB MED), OPAC, DIMDI, PubMed and MEDLINE. The research words were: nurse and practitioners or nurse clinician and diagnosis and organization and administration. Actual journals and references were used to find relevant studies (hand research).

RESULTS

Non-physician endoscopy has been well established in some European countries, in the USA and in several other countries in the western world.

CONCLUSION

The implementation of such programs should be based on solid scientific consideration and evaluated within the framework of the 'delegation rights'.

Randomized crossover study comparing efficacy of transnasal endoscopy with that of standard endoscopy to detect Barrett's esophagus

BACKGROUND

Unsedated transnasal endoscopy (TNE) may be safer and less expensive than standard endoscopy (SE) for detecting Barrett's esophagus (BE). Emerging technologies require robust evaluation before routine use.

OBJECTIVE

To evaluate the sensitivity, specificity, and acceptability of TNE in diagnosing BE compared with those of SE.

DESIGN

Prospective, randomized, crossover study.

SETTING

Single, tertiary-care referral center.

PATIENTS

This study enrolled consecutive patients with BE or those referred for diagnostic assessment.

INTERVENTION

All patients underwent TNE followed by SE or the reverse. Spielberger State-Trait Anxiety Inventory short-form questionnaires, a visual analogue scale, and a single question addressing preference for endoscopy type were administered.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy and tolerability of TNE were compared with those of SE.

RESULTS

Of 95 patients randomized, 82 completed the study. We correctly diagnosed 48 of 49 BE cases by TNE for endoscopic findings of columnar lined esophagus compared with the criterion standard, SE, giving a sensitivity and specificity of 0.98 and 1.00, respectively. The BE median length was 3 cm (interquartile range [IQR] 1-5 cm) with SE and 3 cm (IQR 2-4 cm) with TNE, giving high correlations between the two modalities (R(2) = 0.97; P < .001). The sensitivity and specificity for detecting intestinal metaplasia by TNE compared with those by SE was 0.91 and 1.00, respectively. The mean (± standard deviation) post-endoscopy Spielberger State-Trait Anxiety Inventory short-form score for TNE (30.0 ± 1.10 standard error of the mean [SEM]) was lower than that for SE (30.7 ± 1.29 SEM), (P = .054). The visual analogue scale scores were no different (P = .07). The majority of patients (59%) expressed a preference for TNE.

LIMITATIONS

This is a small study, with limited generalizability, a high prevalence of patients with BE, differential drop-out between the two procedures, and use of sedation.

CONCLUSION

TNE is an accurate and well-tolerated method for diagnosing BE compared with SE. TNE warrants further evaluation as a screening tool for BE.

Screening for Barrett's Esophagus

Barrett's esophagus (BE) increases the risk for development of esophageal adenocarcinoma. Because of the rapid rise in incidence of esophageal adenocarcinoma, screening for BE with subsequent surveillance when found has been proposed as a method of early detection. Sedated endoscopy, however, is too expensive for wide spread screening. As a result, other techniques including unsedated transnasal esophagoscopy and capsule esophagoscopy have been proposed to expand screening programs.

Ultrathin esophagoscopy in screening for Barrett's esophagus at a Veterans Administration Hospital: easy access does not lead to referrals

OBJECTIVE

Unsedated, ultrathin esophagoscopy has been shown to be tolerable, safe, and accurate. Survey data have suggested that accessibility of unsedated esophagoscopy would increase referrals for Barrett's esophagus (BE) screening. Our purpose was to evaluate primary-care physician referrals for BE screening when unsedated esophagoscopy is made available.

METHODS

We studied primary-care referrals for unsedated esophagoscopy in a VA internal medicine clinic. Patients over age 45 with chronic heartburn for >5 yr or >3 times weekly and who had no previous EGD were eligible for screening with unsedated esophagoscopy. All primary providers received a 15-min education session on screening. Baseline referral rate was determined retrospectively. Longitudinal data were then collected during three phases of the study: (a) primary provider-initiated referrals, (b) primary provider-initiated referrals with weekly reminders from investigators, and (c) investigator recruitment.

RESULTS

Baseline referral rate averaged 0.5 patients per month. Availability of unsedated esophagoscopy and an education session increased the rate of referral to 0.66 patients per month. Weekly reminders to primary physicians further increased the rate to 1.33 referrals per month. Investigator recruitment produced a rate of 2.67 referrals per month. Of the 77 patients offered screening, 25 (32%) declined. Of the 52 patients screened, three (5.8%) were diagnosed with BE.

CONCLUSIONS

Accessibility of unsedated esophagoscopy itself does not lead to a large increase in the number of primary care referrals for BE screening. Factors that prevent primary care physicians from referring patients for screening need to be identified and effective interventions to change referral patterns need to be implemented for unsedated screening programs to be successful.

Nurses working in GI and endoscopic practice: a review

BACKGROUND

Over the last 10 years, nurses increasingly perform tasks and procedures that were previously performed by physicians.

OBJECTIVE

In this review, we investigated what types of GI care and endoscopic procedures nurses presently perform and reviewed the available evidence regarding the benefits of these activities.

DESIGN

Review of published articles on nurses' involvement in GI and endoscopic practice.

RESULTS

In total, 19 studies were identified that evaluated performance and participation of nurses in GI and endoscopic practice. Of these, 3 were randomized trials on the performance of nurses in flexible sigmoidoscopy (n = 2) and upper endoscopy (n = 1). Fourteen nonrandomized studies evaluated performance in upper endoscopy (n = 2), EUS (n = 1), flexible sigmoidoscopy (n = 7), capsule endoscopy (n = 2), and percutaneous endoscopic gastrostomy placement (n = 2). In all studies, it was found that nurses accurately and safely performed these procedures. Two further studies demonstrated that nurses adequately managed follow-up of patients with Barrett's esophagus and inflammatory bowel disease. Four of the 19 studies showed that patients were satisfied with the type of care nurses provided. Finally, it was suggested that costs were reduced if nurses performed a sigmoidoscopy and evaluated capsule endoscopy examinations compared with physicians performing these activities.

CONCLUSIONS

The findings of this review support the involvement of nurses in diagnostic endoscopy and follow-up of patients with chronic GI disorders. Further randomized trials, however, are needed to demonstrate whether this involvement compares at least as favorably with gastroenterologists in terms of medical outcomes, patient satisfaction, and costs.

Feasibility and safety of string wireless capsule endoscopy in the diagnosis of esophageal varices

OBJECTIVE

To assess the feasibility, safety, accuracy, and acceptability of "string-capsule endoscopy" in the evaluation of esophageal varices.

MATERIAL AND METHODS

Strings were attached to the wireless capsule endoscopy device to allow its controlled movement up and down the esophagus. Time of recording and discomfort associated with the procedure was documented. Patient's preference compared to conventional esophago-gastro-duodenoscopy (EGD) was recorded. An independent endoscopist blinded to EGD diagnoses assessed the diagnostic accuracy of pictures obtained.

RESULTS

Thirty patients with clinical liver cirrhosis (mean age: 54.4 yr; mean MELD score: 12.5, and mean Child-Pugh score: 6.3) were enrolled; 19 for surveillance and 11 for screening purposes. The procedure was safe (no strings were disrupted and no capsule was lost). The mean recording time was 5.8 min (2.9-8.7), the accuracy 96.7%, and discomfort was minimal. The majority (83.3%) of patients preferred string-capsule endoscopy to EGD.

CONCLUSIONS

String-capsule endoscopy was feasible, safe, accurate, highly acceptable, and preferred by cirrhotic patients undergoing screening/surveillance of esophageal varices. The technique may prove to be more cost effective than conventional EGD.

Office-based unsedated ultrathin esophagoscopy in a primary care setting

PURPOSE

Gastroesophageal reflux disease is common and with time may be complicated by Barrett's esophagus and esophageal adenocarcinoma. Upper gastrointestinal endoscopy, including esophagoscopy, is the procedure of choice to diagnose Barrett's esophagus and other esophageal disease. The use of unsedated ultrathin esophagoscopy (UUE) has been reported by gastroenterologists in specialized endoscopy units and otolaryngologists in outpatient otolaryngology offices, but UUE has not been previously described in a primary care setting. This study examines the feasibility of office-based UUE in primary care.

METHODS

This study is a retrospective chart review in a university-based family medicine clinic in the southeastern United States. Charts were reviewed of 56 adult outpatients who were referred for further evaluation of reflux symptoms that persisted after at least 4 weeks of therapy with histamine(2) receptor agonists or proton pump inhibitors and who elected to undergo UUE in the primary care setting. Patient demographics, procedure indications and findings, changes in clinical management, and procedure times were recorded.

RESULTS

One hundred percent of patients asked to participate in UUE were willing to undergo the procedure (mean age 48.3 +/- 1.6 y, 57.1% women); 95% of the patients tolerated UUE. Barrett's esophagus was diagnosed in 5.7% (n = 3) of the patients. Mean procedure time was 5.5 +/- 1.7 min. No complications were reported in this series.

CONCLUSIONS

Initial data suggest that UUE is feasible in primary care, with the majority of patients tolerating the procedure. UUE may be an efficient method of examining the distal esophagus.

Unsedated endoscopy

Unsedated endoscopy will likely play an increasingly important role in the daily practice of GI endoscopy. Although there is adequate evidence that un-sedated endoscopy is technically feasible in selected patient populations, there area number of obstacles preventing its widespread adoption. Small-caliber endoscopy is not as accurate as conventional EGD. This may be remedied as improvements in endoscope technology emerge. Many patients refuse to consider an unsedated examination, and those who do participate report more symptoms of discomfort than patients undergoing conventional endoscopy. Whether patients will accept mild discomfort in exchange for substantial cost savings has not been evaluated. Finally, although unsedated endoscopy seems to have a low complication rate, its safety has not been formally addressed in large studies. Large, randomized, controlled studies are needed to better determine the role of un-sedated small-caliber endoscopy in daily practice. Unsedated colonoscopy may follow the footsteps of unsedated upper endoscopy with even more obstacles to overcome before its widespread application.

Is esophagoscopy alone sufficient for patients with reflux symptoms?

BACKGROUND

Unsedated esophagoscopy with ultrathin endoscopes is a valuable screening modality for Barrett's esophagus, but the stomach and the duodenum cannot be examined completely with the smallest and best tolerated of these endoscopes. There are no data as to how often disease in the stomach and the duodenum would be missed when using this screening strategy. Our hypothesis is that patients with reflux symptoms, in the absence of daily abdominal pain, nausea, or history of ulcer, were unlikely to have clinically significant gastroduodenal disease.

METHODS

Patients scheduled for upper endoscopy at a single outpatient endoscopy unit in a tertiary referral center were screened. The inclusion criterion was reflux symptoms as the primary indication for upper endoscopy. Patients with another valid indication were excluded. A detailed history was recorded and symptom questionnaire completed for each patient before endoscopy; these data were compared with the endoscopy findings.

RESULTS

A total of 175 patients were included. Indications for upper endoscopy were the following: worsening symptoms (n=74), ongoing reflux despite therapy (n=27), and long-standing reflux (n=74). Major esophageal findings were discovered in 95 patients. In 10 patients, major gastric or duodenal findings were detected as follows: erosive gastritis (n=8), gastric ulcer (n=2), duodenal ulcer (n=2), erosive duodenitis (n=2), and duodenal polyp (n=1). Daily abdominal pain (p=0.014) or possibly daily nausea (p=0.028 unadjusted, 0.197 adjusted) was associated with major gastric/duodenal disease. Patients without daily abdominal pain, nausea, or a history of gastric/duodenal ulcer were much less likely to have major disease (0.9%) than patients with one of these predictors (13.2%, p=0.00097).

CONCLUSIONS

Daily abdominal pain and nausea, in combination with a history of ulcer disease, are strong predictors of major gastric or duodenal disease. Patients with reflux without these predictors are highly unlikely to have a major disease involving the stomach or duodenum, and are suitable candidates for esophagoscopy alone.

Interventional endoscopy

PURPOSE OF REVIEW

This review provides an updated summary of gastric interventional endoscopy. Relevant original articles and topic reviews are highlighted in the areas of infection control, light sedation, hemostasis, endoscopic mucosal resection, and endoscopic placement of enteric devices.

RECENT FINDINGS

Several key findings are worth noting: the increased use of propofol by nonanesthesiologists for deep sedation with minimal adverse side effects, the adaptation of tissue adhesive agents for the treatment of bleeding gastric varices, the successful treatment of early gastric cancer by endoscopic mucosal resection, and the development of direct percutaneous endoscopic jejunostomy tubes for patients at high risk of aspiration.

SUMMARY

These recent developments in the field of interventional endoscopy have already made a great impact on clinical care. More advanced procedures can be performed safely while the patient is under deep sedation. Yet, these developments have not slowed down the need for improvement in interventional endoscopy. Researchers continue to look for smaller instruments, better optics, and more advanced accessories. This constant state of flux marks the field of interventional endoscopy and ensures its progress.