Injuries sustained by colorectal surgeons performing colonoscopy

Work-Related Musculoskeletal Injury Rates, Risk Factors, and Ergonomics in Different Endoscopic Specialties: A Review

Endoscopy-related musculoskeletal injuries (ERIs) are frequent among gastrointestinal, pulmonary, nasal, and urologic endoscopists, impacting the healthcare system. The present review aims to compare the ERI rates, risk factors, and ergonomic recommendations in the different endoscopic fields. A review was conducted using PubMed and Cochrane Library for articles based on surveys and published until 10 January 2024. Demographic, work, and ERI data from 46 publications were included, covering 10,539 responders. The ERI incidence ranged between 14% and 97%, highlighting the need of intervention independent of the specialties. The neck, back, and shoulder were the most frequent ERI locations, while gender, age, years of experience, and procedure volume the most common risk factors. Ergonomic recommendations suggest concentrating on endoscope design changes, especially in gastrointestinal endoscopy, to increase the comfort, adaptability of the equipment in the operating room, and workflow/institutional policy changes. The inclusion of an ergonomic timeout guarantees the correct equipment positioning, the neutralisation of the endoscopist's posture, and an indirect break between procedures. Ergonomic training to increase awareness and best practice should be promoted, also using new technologies. Future research should concentrate on intervention and comparative studies to evaluate to which extent prevention measures and newly designed equipment could reduce ERI incidence.

American Society for Gastrointestinal Endoscopy guideline on the role of ergonomics for prevention of endoscopy-related injury: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach to strategies to prevent endoscopy-related injury (ERI) in GI endoscopists. It is accompanied by the article subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline estimates the rates, sites, and predictors of ERI. Additionally, it addresses the role of ergonomics training, microbreaks and macrobreaks, monitor and table positions, antifatigue mats, and use of ancillary devices in decreasing the risk of ERI. We recommend formal ergonomics education and neutral posture during the performance of endoscopy, achieved through adjustable monitor and optimal procedure table position, to reduce the risk of ERI. We suggest taking microbreaks and scheduled macrobreaks and using antifatigue mats during procedures to prevent ERI. We suggest the use of ancillary devices in those with risk factors predisposing them to ERI.

The Relationship Between Colonoscopy Practice Style, Operator Ergonomics and Procedure Quality

OBJECTIVE

We aimed to compare three endoscopy operators who performed colonoscopy in three different styles in terms of procedure results, colonoscopy quality, and operator comfort during the procedure.

PATIENTS AND METHODS

A total of 246 patients, who underwent routine screening colonoscopy for precancerous lesions between May and December 2022 in Istanbul Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey, were prospectively analyzed. The results of three different styles (single operator sitting, single operator standing, and two operators standing) were compared with each other. The following criteria were examined: polyp/adenoma detection rate, number of polyps detected per patient, cecal intubation rate, total procedure time, number of endoscope corrective maneuvers, number of patient position corrections during the procedure, and the endoscopist's subjective pain scale after the procedure.

RESULTS

 The number of corrections and changes in scope position, rates of changing the patient's position during the procedure, and the postprocedural fatigue degree of the endoscopist were the highest for the single-operator standing style (p<0.001). The total processing time and post-procedure fatigue degree of the endoscopist were the lowest for the single-operator sitting style (p<0.001). The adenoma detection rate was the highest for single-operator standing style (37.8% vs 22.0% and 29.3%). The strongest predictive factors for the total procedure time were the colonoscopy style and patient age. The strongest predictive factors for the change in the total number of detected polyps were colonoscopy style, patient gender, and patient age. Independent of all other factors, the total detected number of polyps was statistically significantly higher for the single-operator standing style compared to other styles (B=-0.217, 95% confidence interval: -0.369 - -0.066 and p=0.005) (B=-0.172, 95% confidence interval: -0.326 - -0.017 and p=0.029).

CONCLUSIONS

Two conclusions were drawn from this study. For routine screening colonoscopy, the single-operator sitting style seems to be superior to other styles in terms of the shortest procedure time and the least tiring. However, the widely used single-operator standing style should be preferred over other styles in terms of the highest adenoma detection rate although it is most tiring and time-consuming.

Effect of Assisted Surgery on Work-Related Musculoskeletal Disorder Prevalence by Body Area among Surgeons: Systematic Review and Meta-Analysis

Surgeons are highly exposed to work-related musculoskeletal disorders (WMSDs). The objective of this review was to summarize the WMSD prevalence by body area with and without assistive devices. The underlying question was whether there is an effect of assistive device use (robot, video, or other) during surgery on WMSD prevalence by body area among surgeons, regardless of their specialty. The systematic review was conducted according to the PRISMA guidelines. The Google Scholar, Pubmed/Medline, and ScienceDirect databases were scanned to identify relevant studies. The article selection, review, critical appraisal, and data extraction were performed by two authors independently. Among the 34,854 unique identified records, 77 studies were included. They were divided into two groups: 35 focused on robotic- and video-assisted surgery (RVAS) and 48 concerning surgery without video/robotic assistance (WAS) (6 studies evaluated the prevalence for both groups). WMSD prevalence was reported for 13 body areas: the neck, back, upper back, mid-back, lower back, shoulders, elbows, wrists, fingers, thumbs, hips, knees, and ankles. The results showed that WMSD prevalence was significantly higher (unpaired t-test, p < 0.05) for RVAS in the shoulders (WAS: 28.3% vs. RVAS: 41.9%), wrists (WAS: 20.9% vs. RVAS: 31.5%), and thumbs (WAS: 9.9% vs. RVAS: 21.8%). A meta-analysis was performed for 10 body areas (with 4 areas including more than 25 studies). No sufficient data were available for the mid-back, thumbs, or hips. A high heterogeneity (Cochran's Q test and I² statistic) was observed. A random-effects model revealed that the highest worldwide prevalence was in the neck (WAS: 41% and RVAS: 45.3%), back (WAS: 37.7% and RVAS: 49.9%), lower back (WAS: 40.0% and RVAS: 37.8%), and shoulders (WAS: 27.3% and RVAS: 41.4%). Future work could focus on work environment design, particularly the positioning and adjustment of equipment, and on postural analysis to reduce the appearance of WMSDs. Recommendations are proposed for future reviews and meta-analyses.

An estimation of the endoscopist's musculoskeletal injury risk for right and left lateral decubitus positions during colonoscopy: a field-based ergonomic study

BACKGROUND

Colonoscopy exposes endoscopists to awkward postures and prolonged forces, which increases their risk of musculoskeletal injury. Patient positioning has a significant impact on the ergonomics of colonoscopy. Recent trials have found the right lateral decubitus position is associated with quicker insertion, higher adenoma detection rates, and greater patient comfort compared to the left lateral decubitus position. However, this patient position is perceived as more strenuous by endoscopists.

METHODS

Nineteen endoscopists were observed performing colonoscopies during a series of four-hour endoscopy clinics. Durations of each patient position (right lateral decubitus, left lateral decubitus, prone, and supine) were recorded for all observed procedures (n = 64). Endoscopist injury risk was estimated by a trained researcher for the first and last colonoscopies of the shifts (n = 34) using Rapid Upper Limb Assessment (RULA), an observational ergonomic tool that estimates risk of musculoskeletal injury by scoring postures of the upper body and factors such as muscle use, force, and load. The total RULA scores were compared with a Wilcoxon Signed-Rank test for patient position (right and left lateral decubitus) and time (first and last procedures) with significance taken at p < 0.05. Endoscopist preferences were also surveyed.

RESULTS

The right lateral decubitus position was associated with significantly higher RULA scores than the left lateral decubitus position (median 5 vs. 3, p < 0.001). RULA scores were not significantly different between the first and last procedures of the shifts (median 5 vs. 5, p = 0.816). 89% of endoscopists preferred the left lateral decubitus position, primarily due to superior ergonomics and comfort.

CONCLUSION

RULA scores indicate an increased risk of musculoskeletal injury in both patient positions, with greater risk in the right lateral decubitus position.

Patient Factors Affect Ergonomic Strain of Endoscopists During Colonoscopy

INTRODUCTION

Endoscopic procedures place a great deal of muscular strain on providers, especially over the span of their careers. In this study we quantitatively analyzed the effects of patient factors such as age, body mass index, and sex on the ergonomics of endoscopists performing colonoscopies.

METHODS

Surface electromyography (sEMG) was used to measure ergonomic strain of physicians while performing colonoscopies in several key muscle groups. The percent of the maximum voluntary contraction (%MVC) was used as a measure of muscular strain. Data was then analyzed based on the patient characteristics above.

RESULTS

Endoscopists performing colonoscopies on female patients (n = 47) experienced significantly higher ergonomic strain in their right trapezius and right posterior forearm muscle groups when compared to colonoscopies performed on males (n = 35) (%MVC R-trapezius: Male: 8.2; Female: 8.9; p = 0.048); (%MVC R-posterior forearm: Male: 10.4; Female: 11.6; p = 0.0006). Operators experienced greater strain in the same muscle groups when performing colonoscopies on patients with BMI ≤ 25 (n = 25) when compared to patients with BMI > 25 (n = 57) (%MVC R-trapezius: BMI < 25: 9.7; BMI ≥ 25: 8.2; p = 0.0002); (%MVC R-posterior forearm: BMI < 25: 11.9; BMI ≥ 25: 10.8; p = 0.0001).

CONCLUSION

Physicians experienced greater ergonomic strain when performing colonoscopies on female patients and on patients with a BMI < 25. We believe that these factors potentially impact the tortuosity of the colon and therefore influence the difficulty of navigating the endoscope. These results may aid physicians in gauging the anticipated difficulty of colonoscopies based on patient factors. Increased awareness of their posturing and ergonomics during challenging cases will alleviate musculoskeletal injuries in the long run.

Musculoskeletal injury and ergonomics in pediatric gastrointestinal endoscopic practice

BACKGROUND AND AIMS

Endoscopy-related musculoskeletal injuries (ERI) are increasingly prevalent in adult endoscopists; however, there are no studies that have evaluated ERI and ergonomic practices among pediatric gastroenterologists and trainees. We aimed to examine the prevalence, nature, and impact of musculoskeletal injuries in pediatric endoscopic practice and assess attitudes towards ergonomic training needs.

METHODS

Pediatric gastroenterologists and trainees were surveyed to collect information on endoscopist and practice characteristics, the prevalence, nature, and impacts of ERI, ergonomics strategies employed in practice, previous ergonomics training, and perceptions of ergonomics training (elicited using a 1 (strongly disagree) to 5 (strongly agree) Likert scale). Responses were analyzed using descriptive statistics, and bivariate analyses were conducted to explore correlates of ERI.

RESULTS

Among 146 survey respondents, 50 (34.2%) were trainees and 96 (65.8%) were practicing endoscopists with a mean duration of endoscopic practice of 9.7 ± 9.4 years. Overall, 55.6% (n = 80/144) reported experiencing a musculoskeletal injury, with 34.7% (n = 50/144) reporting an injury attributable to endoscopy. Among those with ERI, the most common sites were the neck/upper back (44.0%), thumb (42.0%), hand/finger (38.0%), and lower back (36.0%). Women were more likely to experience ERI compared to men (43.4% vs. 23.4%; p = 0.013). Only 20.9% of participants had formal training in ergonomics. Respondents reported being motivated to implement practice changes to prevent ERI (4.41 ± 0.95) and perceived ergonomics training as important (4.37 ± 0.96).

CONCLUSIONS

Pediatric endoscopists, and particularly women, experience significant ERI; however, formal endoscopy ergonomics training is rare. Improved ergonomics training is needed for both practicing pediatric gastroenterologists and trainees.

Methods for Gastrointestinal Endoscopy Quantification: A Focus on Hands and Fingers Kinematics

Gastrointestinal endoscopy is a complex procedure requiring the mastery of several competencies and skills. This procedure is in increasing demand, but there exist important management and ethical issues regarding the training of new endoscopists. Nowadays, this requires the direct involvement of real patients and a high chance of the endoscopists themselves suffering from musculoskeletal conditions. Colonoscopy quantification can be useful for improving these two issues. This paper reviews the literature regarding efforts to quantify gastrointestinal procedures and focuses on the capture of hand and finger kinematics. Current technologies to support the capture of data from hand and finger movements are analyzed and tested, considering smart gloves and vision-based solutions. Manus VR Prime II and Stretch Sense MoCap reveal the main problems with smart gloves related to the adaptation of the gloves to different hand sizes and comfortability. Regarding vision-based solutions, Vero Vicon cameras show the main problem in gastrointestinal procedure scenarios: occlusion. In both cases, calibration and data interoperability are also key issues that limit possible applications. In conclusion, new advances are needed to quantify hand and finger kinematics in an appropriate way to support further developments.

Procedural and anthropometric factors associated with musculoskeletal injuries among gastroenterology endoscopists

BACKGROUND AND AIMS

Musculoskeletal (MSK) injuries among gastroenterologists are common. Our study describes risk factors and consequences of injury by comparing provider-specific anthropometric and objective procedural data to self-reported injury patterns.

METHODS

A validated MSK symptom survey was sent to gastroenterologists to gauge prevalence, distribution, and severity of active injury. Respondents' procedural activities over 7 years were collected via an endoscopic database.

RESULTS

64 surveys were completed. 54 respondents had active pain; 53.1% reported activity-limiting injury. Activity-limiting injuries lead to longer colonoscopy times (25.3 vs. 22.1 min, P = 0.03) and lower procedural volumes (532 vs. 807, P = 0.01). Hand/wrist injuries yielded longer colonoscopy insertion times (9.35 vs. 8.21 min, P = 0.03) and less hands-on scope hours (81.2 vs. 111.7 h, P = 0.04). Higher esophagogastroduodenoscopy volume corelated with shoulder injury (336.5 vs. 243.1 EGDs/year, P = 0.04). Females had more foot injuries (P = 0.04).

CONCLUSION

Activity-limiting MSK symptoms/injuries affect over 50% of endoscopists with negative impact on procedural volume and efficiency.

Assessment of muscle activity and fatigue during laparoscopic surgery

BACKGROUND

Cumulative musculoskeletal stress during operative procedures can contribute to the development of chronic musculoskeletal injury among surgeons. This is a concern in laparoscopic specialties where trainees may incur greater risk by learning poor operative posture or technique early in training. This study conducted an initial investigation of the physical stress encountered during the conduct of foregut laparoscopic surgery.

METHODS

Subjects were divided into two groups based on their surgical experience level, high experience (HE), consisting of two attending surgeons, and low experience (LE), consisting of two fellow surgeons and a surgical chief resident. Nine distinct foregut laparoscopic procedures were observed for data collection within these groups. Electromyographic (EMG) activity was collected at the bilateral neck, shoulders, biceps, triceps, and lower back for each procedure. Physical workload was measured using percent reference voluntary contractions (%RVC) for each surgeon's muscle activities. Fatigue development was assessed using the median frequency of EMG data between two consecutive cases. Subjects completed a NASA-TLX survey when surgery concluded.

RESULTS

LE surgeons experienced higher levels of %RVC in the lower back muscles compared to HE surgeons. LE fatigue level was also higher than HE surgeons across most muscle groups. A decrease in median frequency in six of the ten muscle groups after performing two consecutive cases, the largest decrements being in the biceps and triceps indicated fatigue development across consecutive cases for both surgeon groups.

CONCLUSION

Surgeons developed fatigue in consecutive cases while performing minimally invasive surgery (MIS). HE surgeons demonstrated a lower overall physical workload while also demonstrating different patterns in muscle work. The findings from this study can be used to inform further ergonomic studies and the data from this study can be used to develop surgical training programs focused on the importance of surgeon ergonomics and minimizing occupational injury risk.

Smaller hands and less experience are associated with greater ergonomic strain during endoscopic procedures

INTRODUCTION

Up to 89% of physicians who routinely perform endoscopy experience some type of musculoskeletal pain. In this study, we sought to quantitatively analyze provider factors that influence ergonomic strain during live endoscopic procedures.

METHODS

Surface electromyography (sEMG) was used to measure ergonomic strain on physicians while performing upper and lower endoscopies. EMG data were normalized to a maximal voluntary contraction (MVC) recording for each muscle group, yielding a %MVC value. Subgroup analyses were performed based on glove size, physician training level, specialty, and handedness.

RESULTS

A total of 165 upper (n = 68) and lower (n = 97) endoscopies were recorded. Endoscopists with small hand sizes had significantly higher ergonomic strain in the left anterior and posterior forearm muscle compartments as compared to endoscopists with medium or large hands (%MVC L-anterior: small: 9.1 ± 1.1; medium: 6.4 ± 1.2; large: 5.9 ± 1.6; p < 0.001); (%MVC L-posterior: small: 12.0 ± 0.8; medium: 9.4 ± 1.3; large: 8.8 ± 1.4; p < 0.001). Additionally, upper body muscle groups had significantly higher ergonomic strain in endoscopists with less lifetime endoscopic experience (%MVC R-trapezius: expert: 8.4 ± 1.2; novice: 9.3 ± 1.2; p < 0.05); (%MVC R-deltoid: expert: 6.1 ± 1.4; novice: 8.5 ± 1.3; p < 0.001). There were no significant ergonomic differences between surgeons or gastroenterologists and no differences between right- and left-handed dominant individuals.

CONCLUSIONS

Endoscopists with small hands experienced great ergonomic strain in their left forearm. Our data support the widely held belief that "one size does not fit all" and will hopefully spark change in the design of future endoscopes by device manufacturers. Our data also support that the experience level of the endoscopist contributed significantly to ergonomic performance, likely due to postural differences leading to decreased upper body strain. Therefore, it remains critically important to educate young proceduralists on strategies for ergonomic relief early in his or her endoscopic training program that can ameliorate ergonomic strain that accrues over the lifetime of a physician's career.

Effects of endoscopy-related procedure time on musculoskeletal disorders in Japanese endoscopists: a cross-sectional study

Background and study aims  There has been little evidence assessing the prevalence of musculoskeletal disorders (MSDs) among endoscopists performing recent diagnostic and therapeutic endoscopic procedures requiring prolonged procedural times. We evaluated the prevalence and identified the risk factors for developing MSDs, focusing on procedural time. Methods  An electronic survey of endoscopists (n = 213) employed at the Nagoya University Hospital and its affiliated hospitals was developed by a multidisciplinary group.  Results  Of the 110 endoscopists (51.6 %) who responded to the survey, eighty-seven endoscopists (79.1 %) had experienced endoscopy-related MSDs during the previous 1 year, and 49 endoscopists (44.5 %) had experienced these MSDs during the previous week. Nineteen endoscopists (17.3 %) reported absence from work due to severe MSDs. The most frequent sites of MSDs were neck, low back, and shoulders. Logistic regression analyses showed that longer upper endoscopic submucosal dissection ESD, (odds ratio: 5.7; 95 %CI: 1.3-25.0), lower ESD (odds ratio 4.9; 95 %CI: 1.1-22.0), and lower gastrointestinal treatment (odds ratio: 5.6; 95 %CI: 2.3-13.3) were significantly associated with the development of MSDs in the low back area. Moreover, longer lower ESD (odds ratio: 5.0; 95 % CI: 1.2-20.2) was a risk factor for symptoms in the left shoulder. Conclusion  This study suggests a correlation between the volume of therapeutic endoscopic procedures including ESD and the risk of MSDs mainly low back area and left shoulder. Managing monthly total endoscopic time, in light of organizational ergonomics, could contribute to minimizing such risks of endoscopy-related MSDs.

Ergonomic Injuries in Endoscopists and Their Risk Factors

BACKGROUND/AIMS

Prolonged repetitive strain caused by the continuous performance of complex endoscopic procedures enhances the risk of ergonomic injuries among health-care providers (HCPs), specifically endoscopists. This study aimed to assess the risk factors of ergonomic injuries among endoscopists and non-endoscopists.

METHODS

This cross-sectional study was conducted at the Gastroenterology Department of Liaquat National Hospital, Karachi, Pakistan. A total of 92 HCPs were enrolled, of whom 61 were involved in endoscopic procedures and 31 were non-endoscopists. Data were collected through a self-administered questionnaire during national gastroenterology conferences and analyzed using SPSS version 22 (IBM Corp. Chicago, IL, USA).

RESULTS

Of the total study population, 95.08% of endoscopists were observed to have ergonomic injuries, whereas only 54.83% of non-endoscopists had ergonomic injuries (p<0.00). The most common injury associated with musculoskeletal (MSK) pain sites was back (41%), leg (23%), and hand (19.7%) pain among endoscopists. Of 28 endoscopists performing ≥20 procedures/week, 26 had MSK injury. However, 95.08% of endoscopists had developed MSK injury irrespective of working hours (>5 or <5 hr/wk).

CONCLUSION

Endoscopists are at high risk of developing ergonomic injuries, representing the negative potential of the endoscopy-associated workload. To overcome these issues, an appropriate strategic framework needs to be designed to avoid occupational compromises.

Biomechanical risk factors associated with distal upper extremity musculoskeletal disorders in endoscopists performing colonoscopy

BACKGROUND AND AIMS

Endoscopists experience upper extremity musculoskeletal injuries. The primary aim of this study was to compare distal upper extremity biomechanical risk factors during colonoscopy with established risk thresholds. Secondary aims were to determine which subtasks during colonoscopy are associated with the greatest risk and to evaluate an intervention to reduce risks.

METHODS

Twelve endoscopists performed 2 to 4 colonoscopies while thumb pinch force and forearm muscle loads of extensor carpi radialis (ECR) and flexor digitorum superficialis (FDS) muscles were collected. Peak exertion values were analyzed using amplitude probability distribution functions. An endoscope support device was evaluated during simulated colonoscopy (n = 8).

RESULTS

Mean endoscopist age was 42.3 years; 67% were men. Peak thumb pinch force exceeded risk thresholds for pinch force (10 N) and percent of time spent in forceful pinch for all colonoscopy subtasks. Peak ECR and FDS muscle activity exceeded the action limit (10% maximum voluntary contraction [MVC]) in both forearms. Peak left FDS, left ECR, and right ECR activity exceeded the threshold limit value (>30% MVC). Peak left FDS and ECR activity were significantly greater during insertion than during withdrawal (P < .05). Peak right FDS and ECR activity were significantly greater during right colon insertion compared with withdrawal (P < .05). The endoscope support device reduced left ECR muscle activity (P = .02).

CONCLUSIONS

Thumb pinch forces and time spent in forceful pinch indicate high-risk exposures during colonoscopy. Left wrist extensor muscle activity exceeded established thresholds with the greatest risk occurring during insertion. An endoscope support device reduced loads to the left wrist extensors.

Are All Endoscopy-Related Musculoskeletal Injuries Created Equal? Results of a National Gender-Based Survey

INTRODUCTION

Endoscopy-related injury (ERI) is common in gastroenterologists (GI). The study aim was to assess the prevalence of self-reported ERI, patterns of injury, and endoscopist knowledge of preventative strategies in a nationally representative sample.

METHODS

A 38-item electronic survey was sent to 15,868 American College of Gastroenterology physician members. The survey was completed by 1,698 members and was included in analyses. Descriptive, univariate, and multivariate analyses were conducted to evaluate the likelihood of ERI based on workload parameters and gender.

RESULTS

ERI was reported by 75% of respondents. ERI was most common in the thumb (63.3%), neck (59%), hand/finger (56.5%), lower back (52.6%), shoulder (47%), and wrist (45%). There was no significant difference in the prevalence of ERI between men and women GI. However, women GI were significantly more likely to report upper extremity ERI while men were more likely to report lower-back pain-related ERI. Significant gender differences were noted in the reported mechanisms attributed to ERI. Most respondents did not discuss ergonomic strategies in their current practice (63%). ERI was less likely to be reported in GI who took breaks during endoscopy (P = 0.002).

DISCUSSION

ERI is highly prevalent in GI physicians. Significant gender differences regarding specific sites affected by ERI and the contributing mechanisms were observed. Results strongly support institution of training in ergonomics for all GI as a strategy to prevent its impact on providers of endoscopy.

Ergonomics in Endourology: Measurement of Force for Deflection in Contemporary Ureteroscopes

Introduction: Few studies have examined the ergonomic hazards to endourologists during endoscopic procedures. We have evaluated the forces required to deflect different flexible ureteroscopes across a range of measurements with several different standard instruments within the working channel. Methods: Five ureteroscopes were studied: the Uscope, Neoflex, LithoVue^™, URF-P6, and the Flex-X2^™. A pull-force meter (Nextech DFS 500) was attached to the thumb lever to deflect the tip from 30° to 210° at 30° intervals. Measurements were made with upward and downward deflection separately. The forces were reported in Newtons (N) to the nearest 10th, as positive values regardless of the direction of the force. Measurements were made with the channel empty or containing an instrument: a 365 μm laser fiber, a 2.4F Nitinol basket, 3F biopsy forceps, or a 0.038" guidewire using the flexible or the stiff tip. Results: The maximum downward deflection force, measured at 210° of deflection, with an empty channel range from a minimum of 5.7 N in one scope to a maximum of 33.4 N in another. The force necessary for deflection ranges from 2.0 to 7.0 N (0.45-1.57 foot-pounds) at 30° to 8.5 to 25.3 N (1.8-5.69) at 180°. Maximum upward deflection shows similar results with a minimum of 7.9 N in one scope and a maximum of 43.1 N of force in another. Working instruments in the channel increased the force needed for deflection. Conclusions: Forces required for steep deflection of the tip of a flexible ureteroscope reach extremely high levels or limit the deflection capability of the scope. The force is higher with increased deflection and with instruments within the channel.

The effectiveness of ergonomics interventions in reducing upper limb work-related musculoskeletal pain and dysfunction in sonographers, surgeons and dentists: a systematic review

The aim of this systematic review was to summarise the effects of ergonomics interventions on work-related upper limb musculoskeletal pain and dysfunction, and on productivity in sonographers, surgeons and dentists. A total of 31 studies were included. All studies reported effects on upper limb pain. Nine studies reported effects on dysfunction and only two studies reported effects on productivity. Moderately strong evidence in reducing upper limb pain was found for instigation of microbreaks into long duration surgical procedures, and the use of wider, lighter handles in dental instruments. Moderate evidence was also found for use of prismatic glasses and favourable positioning in reducing upper limb pain. Weak, inconsistent or no evidence was found for all other ergonomics interventions in reducing upper limb pain and dysfunction and increasing productivity. The lack of high quality research, particularly in sonographers and in the outcome of productivity, should be addressed. Practitioner summary: This systematic review investigates the effectiveness of ergonomics interventions on upper limb pain, dysfunction and productivity in sonographers, dentists and surgeons. Instigation of microbreaks during long duration procedures and the use of wider, lighter instrument handles were most effective in reducing upper limb work-related pain. Abbreviations: ANOVA: analysis of variance; CLS: conventional laparoscopic surgery; DMAIC: define, measure, analyze, improve and control; GRADE: grading of recommendations, assessment, development and evaluations; HD: high definition; PRISMA: preferred reporting items for systematic reviews and meta-analyses; PROSPERO: The International Prospective Register of Systematic Reviews; RCT: randomised control trial; SILS: single incision laparoscopic surgery; VITOM: video telescopic operative microscope; WNSWLHD: Western New South Wales Local Health District; WMSD: work related musculoskeletal disorder.

Musculoskeletal Pain Symptoms and Injuries Among Endoscopists Who Perform ERCP

BACKGROUND AND AIMS

The leaded protective gear worn, patient and endoscopist positioning, and longer average procedural time place endoscopists who perform endoscopic retrograde cholangiopancreatography (ERCP) at an increased risk of injuries as compared to other endoscopists. While multiple studies have investigated the prevalence of various pain symptoms and injuries among endoscopists, only one has been carried out in endoscopists who perform ERCP, and none have investigated potential predisposing risk factors. Our aim was thus to assess the prevalence of these pain symptoms, injuries, and potential risk factors.

METHODS

An anonymous electronic survey containing 23 questions was sent to 3276 gastroenterologists. Only providers that performed ERCPs were asked to respond.

RESULTS

A total of 203 surveys were completed. Of the 203 respondents, 91% reported a musculoskeletal pain symptom. The most prevalent pain symptoms were neck pain (24%) and lower back pain (17%). In total, 48% of respondents reported a musculoskeletal injury. In total, 32% attributed these injuries to performing ERCPs. The most prevalent musculoskeletal injuries were De Quervain's tenosynovitis (16%) and cervical radiculopathy (12%). Only 25% of participants had received any education/training on ergonomics in endoscopy.

CONCLUSIONS

The majority of endoscopists who perform ERCPs suffer from a musculoskeletal pain symptom, and almost half report a musculoskeletal injury. Further investigation regarding risk factors and preventative strategies is warranted. This information can then be incorporated into ergonomics education which only a small proportion of advanced endoscopists report having received any training in.

An Objective Ergonomic Risk Assessment of Surgeons in Real Time While Performing Endoscopic Sinus Surgery

There are increased reports of high prevalence of work related musculoskeletal symptoms in surgeons performing otolaryngology procedures. However, real time ergonomic risk assessment in the OR is difficult due to issues related to sterility, cooperation and acceptance from surgeons. Although such analyses can provide valid risk estimate and guide corrective actions, they are scarce. Hence, this study was undertaken to assess the postural ergonomic risk on RULA in otolaryngologists while performing Functional Endoscopic Sinus Surgery in OR, in real time. A cross sectional, observational multi-centric study was conducted in tertiary referral hospitals. Spinal, shoulder and elbow movements of 10 surgeons performing FESS were measured intraoperatively using orientation sensor-based, motion-analysis system (Noraxon myomotion). Postural ergonomic risk on RULA was computed using the motion analysis data. RULA is a method of quantifying the physical postural risk of the trunk and upper limb based on the postures adopted by an individual during work. 10 surgeons (9 males and 1 female) with the mean (± SD) age of 38 ± 7.5 years participated in the study. The motion analysis data results indicate that the surgeons often adopt awkward spinal and upper extremity postures during the surgery. All the surgeons scored higher than the acceptable RULA score (1 or 2) with the mean RULA scores being in the range of 6-7. The physical ergonomic risk in surgeons performing FESS is high (> 6 on RULA). There is a need for urgent ergonomic attention to the working environment of FESS surgeon.

Prevalence, risk factors and global impact of musculoskeletal injuries among endoscopists: a nationwide European study

Background and study aims  Previous studies have suggested a high prevalence of musculoskeletal injuries (MI) in endoscopists. Little evidence has come from European countries. Our main aim was to evaluate the prevalence, type, and impact of MI among Portuguese endoscopists. We also sought to identify risk factors for the development, severity and number of endoscopy-related MI. Material and methods  A 48-question electronic survey was developed by a multidisciplinary group. The electronic survey was sent to all members of Portuguese Society of Gastroenterology (n = 705) during May 2019. Study data were collected and managed using REDCap electronic data capture tools hosted at SPG - CEREGA. Results  The survey was completed by 171 endoscopists (response rate of 24.3 %), 55.0 % female with a median age of 36 years (range 26-78). The prevalence of at least one MI related to endoscopy was 69.6 % (n = 119), the most frequent being neck pain (30.4 %) and thumb pain (29.2 %). The median time for MI development was 6 years (range 2 months-30 years). Severe pain was reported by 19.3 %. Change in endoscopic technique was undertaken by 61.3 % and reduction in endoscopic caseload was undertaken by 22.7 %. Missing work was reported by 10.1 %, with the median time off from work being 30 days (range 1-90). Female gender and ≥ 15 years in practice were independently associated with MI and severe pain. Years in practice, weekly-time performing endoscopy, and gender were significant predictors of the number of MI. Conclusions  Prevalence of MI was significant among Portuguese endoscopists and had a relevant impact on regular and professional activities.

Ergonomic endoscopy: An oxymoron or realistic goal?

The current endoscope design is not ergonomic. There is a high prevalence of endoscopy-related injury reported in the literature, and studies have demonstrated high-risk biomechanical exposures during the performance of routine colonoscopy. Endoscopy ergonomics focuses on understanding the endoscopist's interaction with the endoscope and the endoscopy unit and re-designing these tasks to minimize the risk of endoscopy-related injury. The discussion to date has focused on what the endoscopist can do to minimize his or her risk of injury. It is imperative that we re-frame that discussion because the implication that physicians are responsible for implementing personal or workplace interventions places an undue burden on physicians and will be the least effective exposure control method. Endoscope companies need to consider the endoscopist in their design process. As a profession, we need to collectively advocate for endoscopist safety. We offer a perspective on how ergonomic endoscopy can become a realistic and achievable goal.

Musculoskeletal Injuries Are Commonly Reported Among Gastroenterology Trainees: Results of a National Survey

BACKGROUND

Endoscopy-related musculoskeletal injuries are increasingly recognized among gastroenterologists. While injury rates and risk factors have been studied among practicing gastroenterologists, little is known about rates among trainees during fellowship.

AIMS

This study analyzes the prevalence of endoscopy-related overuse injuries and risk factors for injuries among a national sample of gastroenterology (GI) fellows. We also surveyed GI fellowship program directors and fellows about perceptions of overuse injuries during GI training.

METHODS

We distributed a 29-item electronic survey to GI fellows at accredited programs in the USA in April 2016. Survey items included demographic information, questions pertaining to injuries, and level of agreement on the importance of ergonomics training in GI fellowship. Additionally, we distributed a 7-item electronic survey to fellowship program directors evaluating perception of overuse injuries and prevention during fellowship training. Fisher's exact test determined factors associated with sustaining an injury.

RESULTS

An estimated 1509 fellows received the survey. Eleven percent (n = 165) of gastroenterology fellows completed the survey. Twenty percent reported having a musculoskeletal injury. Female gender was the only factor associated with a higher rate of reported injury (p < 0.01). The most common injuries reported were thumb and other hand-related pain (n = 28 [64%]).

CONCLUSIONS

Musculoskeletal injuries may affect up to 20% of GI fellows. Female fellows more frequently report injuries and may be at particularly high risk which has not been found in previously reported surveys of practicing gastroenterologists. Standardized curricula on ergonomic considerations and injury prevention are needed to enhance GI fellowship training and reduce injury rates.

Endoscopy-related musculoskeletal injuries in gastroenterology fellows

Background and study aims  Gastroenterologists are at high risk for work-related musculoskeletal injuries. Studies have shown that 37 % to 89 % of endoscopists have work-related musculoskeletal injuries. While all surveys until now have focused on practicing endoscopists, there have been no publications assessing the prevalence of musculoskeletal injuries among gastrointerology fellows, which we sought to investigate. Methods  A 22-question survey about ergonomics and work-related musculoskeletal injuries was sent to 114 gastroenterology fellows in different programs across the United States in June 2016, and an additional 103 surveys were distributed at Digestive Disease Week in May 2017. Responses were collected, and data were analyzed. Results  A total of 156 surveys were collected. Of these, 74 fellows (47 %) reported a new musculoskeletal injury related to endoscopy. Injuries occurred mostly in the first year of fellowship (85 %, P  < 0.001). The most common sites of injury were the right wrist (53 %), left thumb (42 %), back (27 %), and neck (22 %). Only 26 % those who had endoscopy-related musculoskeletal injuries had received training in ergonomics compared to 45 % of those who did not have injury ( P  = 0.012), and ergonomics training was highly desirable among respondents, particularly among those with previous injuries ( P  = 0.0030) Conclusion  Musculoskeletal injuries related to endoscopy are very common among gastroenterology fellows, particularly during the first year of fellowship. While the overall percentage of fellows who received training in ergonomics was low, those who did receive training were less like to report a musculoskeletal injury. There is an urgent need for ergonomics training among Gastroenterology fellows.

Occupation-associated health hazards for the gastroenterologist/endoscopist

Advances in the field of endoscopy have allowed gastroenterologists to obtain detailed imaging of anatomical structures and to treat gastrointestinal diseases with endoscopic therapies. However, these technological developments have exposed endoscopists and staff to hazards such as musculoskeletal injuries, exposure to infectious agents, and ionizing radiation. We aimed to review the occupational hazards for the gastroenterologist and endoscopist. Using PubMed, Medline, Medscape, and Google Scholar, we identified peer-reviewed articles with the keywords “occupational hazards,” “health hazards,” “occupational health hazards,” “endoscopy,” “gastroenterologist,” “infectious agents,” “musculoskeletal injuries,” and “radiation.” Strategies for reducing exposure to infectious agents, radiation, and the risk of musculoskeletal injuries related to gastroenterology include compliance with established standard measures, the use of thyroid shields and radioprotective eyewear, and ergonomic practices. We conclude that educating endoscopic personnel and trainees in these practices, in addition to further research in these areas, will likely lead to the development of more efficient and user-friendly workspaces that are safer for patients and personnel.

Prevalence of Work-Related Musculoskeletal Disorders Among Surgeons and Interventionalists: A Systematic Review and Meta-analysis

Importance

Physicians in procedural specialties are at high risk for work-related musculoskeletal disorders (MSDs). This has been called "an impending epidemic" in the context of the looming workforce shortage; however, prevalence estimates vary by study.

Objectives

To estimate the prevalence of work-related MSDs among at-risk physicians and to evaluate the scope of preventive efforts.

Data Sources and Study Selection

Systematic search in MEDLINE (Ovid), Embase (Elsevier), Web of Science, PubMed (National Center for Biotechnology Information), and 2 clinical trial registries, without language restriction, for studies reporting on the prevalence and prevention of work-related MSDs among at-risk physicians published until December 2016. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for meta-analyses and systematic reviews of observational studies were used. At-risk physicians were defined as surgeons and medical interventionalists. Studies reporting on specific disorders or pain assessed with validated instruments were included.

Data Extraction and Synthesis

Study characteristics; disease prevalence for the neck, shoulder, back, and upper extremity; and measures of resulting disability were recorded. Study estimates were pooled using random-effects meta-analytic models.

Main Outcomes and Measures

Career prevalence of injuries and 12-month prevalence of pain.

Results

Among 21 articles (5828 physicians [mean age, 46.0 years; 78.5% male; 12.8 years in practice; 14.4 hours performing procedures per week]) included in this systematic review and meta-analysis, pooled crude prevalence estimates of the most common work-related MSDs were degenerative cervical spine disease in 17% (457 of 2406 physicians) (95% CI, 12%-25%), rotator cuff pathology in 18% (300 of 1513 physicians) (95% CI, 13%-25%), degenerative lumbar spine disease in 19% (544 of 2449 physicians) (95% CI, 5%-16%), and carpal tunnel syndrome in 9% (256 of 2449 physicians) (95% CI, 5%-16%). From 1997 to 2015, the prevalence of degenerative cervical spine disease and degenerative lumbar spine disease increased by 18.3% and 27%, respectively. Pooled prevalence estimates for pain ranged from 35% to 60% and differed by assessment instrument. Of those with a work-related MSD, 12% (277 of 2319 physicians) (95% CI, 7%-18%) required a leave of absence, practice restriction or modification, or early retirement. Heterogeneity was considerable for all crude analyses (mean I2 = 93.5%) but was lower for sensitivity analyses (mean I2 = 72.3%). Interventions focused on products and behaviors. Twelve at-risk specialties described a gross lack of awareness and an unmet need for ergonomics education.

Conclusions and Relevance

Prevalence estimates of work-related MSDs among at-risk physicians appear to be high. Further research is needed to develop and validate an evidence-based applied ergonomics program aimed at preventing these disorders in this population.

Musculoskeletal injuries in gastrointestinal endoscopists: a systematic review

Gastrointestinal(GI) endoscopy forms a significant proportion of clinicians' workloads. However, little attention is given to the ergonomic aspects of endoscopy. This systematic review of musculoskeletal pain and/or injuries in GI endoscopists aims to better understand the types of occupational injuries resulting from endoscopic procedures and associated risk factors. Areas covered: Systematic literature search conducted for articles evaluating prevalence, risk factors and mechanism of musculoskeletal pain and/or injuries related to GI endoscopy. In 13 included studies, 39-89% of surveyed endoscopists reported pain and/or injuries related to endoscopy. Common areas of pain were the back(15-57%), neck(9-46%), shoulders(9-19%), elbows(8-15%) and hands/fingers(14-82%). Risk factors included procedure volume, time spent doing endoscopy, cumulative time in practice and endoscopist age. Experimental studies showed that forces and loads placed on endoscopists' bodies during procedures place them at risk of occupational injury. Areas of pain differed between novice and experienced endoscopists implying separate mechanisms of injury. Expert commentary: Comprehensive investigation into the prevalence, types, pathophysiology and methods to minimise endoscopy-related musculoskeletal injuries is vital to ensure the continued efficient provision of endoscopy services in the face of rising demands worldwide. A paradigm shift is required in endoscopic devices and techniques to improve safety and comfort.

Assessing work-related musculoskeletal symptoms among otolaryngology residents

PURPOSE

Previous studies have suggested that musculoskeletal symptoms are common among practicing otolaryngologists. Early training can be the ideal time to foster knowledge of ergonomics and develop safe work habits, however, little data exists regarding musculoskeletal symptoms in residents. The purpose of this study was to identify and characterize musculoskeletal symptoms in a preliminary sample of otolaryngology residents.

MATERIALS AND METHODS

A cross-sectional survey incorporating the Nordic Musculoskeletal Questionnaire was sent to 30 Otolaryngology-Head and Neck Surgery residencies to examine musculoskeletal symptoms among residents. A two-sample test of proportions was performed to compare symptoms between male and female residents.

RESULTS

In total, 141 respondents (response rate=34.7%) completed the survey. Fifty-five percent of survey respondents were male and 45% were female. Musculoskeletal symptoms were most frequently reported in the neck (82.3%), followed by the lower back (56%), upper back (40.4%), and shoulders (40.4%). The most common symptoms were stiffness in the neck (71.6%), pain in the neck (61.7%), and pain in the lower back (48.2%). In total, 6.4% of residents missed work and 16.3% of residents stopped during an operation at some point due to their symptoms. Most residents (88.3%) believed their musculoskeletal symptoms were attributed to their surgical training. Female residents were significantly more likely to experience neck (p<0.0001) and wrist/hand (p=0.019) discomfort compared to male residents.

CONCLUSIONS

Musculoskeletal symptoms were common among residents, approaching rates similar to those previously identified in practicing otolaryngologists. Increased emphasis on surgical ergonomics is warranted to improve workplace safety and prevent future injury.

Prevalence and risk factors for musculoskeletal injuries related to endoscopy

BACKGROUND

There are limited data regarding work-related injury among endoscopists.

OBJECTIVE

To define the prevalence of endoscopy-related musculoskeletal injuries and their impact on clinical practice and to identify physician and practice characteristics associated with their development.

DESIGN

Survey.

SETTING

Electronic survey of active members of the American Society for Gastrointestinal Endoscopy with registered e-mail addresses.

PARTICIPANTS

Physicians who currently or ever performed endoscopy and responded to the survey between February 2013 and November 2013.

INTERVENTION

A 25-question, self-administered, electronic survey.

MAIN OUTCOME MEASUREMENTS

Prevalence, location, and ramifications of work-related injuries and endoscopist characteristics and workload parameters associated with endoscopy-related injury.

RESULTS

The survey was completed by 684 endoscopists. Of those, 362 (53%) experienced a musculoskeletal injury perceived definitely (n = 204) or possibly (n = 158) related to endoscopy. Factors associated with a higher rate of endoscopy-related injury included higher procedure volume (>20 cases/week; P < .001), greater number of hours per week spent performing endoscopy (>16 hours/week; P < .001), and total number of years performing endoscopy (P = .004). The most common sites of injury were neck and/or upper back (29%) and thumb (28%). Only 55% of injured endoscopists used practice modifications in response to injuries. Specific treatments included medications (57%), steroid injection (27%), physiotherapy (45%), rest (34%), splinting (23%), and surgery (13%).

LIMITATIONS

Self-reported data of endoscopy-related injury.

CONCLUSION

Among endoscopists there is a high prevalence of injuries definitely or potentially related to endoscopy. Higher procedure volume, more time doing endoscopy per week, and cumulative years performing endoscopy are associated with more work-related injuries.

Review of musculoskeletal injuries and prevention in the endoscopy practitioner

Practitioners of endoscopy often experience musculoskeletal pain and injury (most often in the back, neck, shoulders, hands, wrists, and thumbs) that are associated with the minute and repetitive strain that is placed on these areas during endoscopic procedures. This review of the current documentation of endoscopy-related pain and injuries among practitioners finds that such problems are widespread and specific in kind as well as strongly correlated with high procedure volume and procedure duration. Research on the nature and impact of cumulative trauma and overuse syndromes in other professions such as dentistry, pianists, production labor, and athletics is brought to bear on the work of the endoscopist. A more thorough understanding of the nature and prevalence of work-related pain and injury sustained by endoscopists should inform further development of ergonomic practices and equipment design. This article reviews current recommendations for ergonomic design in the endoscopy procedure space and finds that reported compliance with those recommendations is quite low. Strategies for the management of the risk of musculoskeletal injuries related to the practice of endoscopy include compliance with currently recommended ergonomic practices, education of trainees in ergonomic technique when practicing endoscopy, and research toward the modification and development of more ergonomic endoscopes and procedure spaces.

Characterization of right wrist posture during simulated colonoscopy: an application of kinematic analysis to the study of endoscopic maneuvers

BACKGROUND

Endoscopic maneuvers are associated with a high incidence of musculoskeletal injuries.

OBJECTIVE

To quantify wrist motion patterns during simulated endoscopic procedures to identify potential causes of endoscopy-related overuse injury.

DESIGN

Twelve endoscopists with different levels of experience were tested on 2 simulated endoscopic procedures that differed in their level of difficulty.

SETTING

Right wrist movement patterns were recorded during simulated colonoscopies by using a magnetic motion-tracking device. Analysis focused on 3 wrist degrees of freedom: abduction/adduction, flexion/extension, and pronation/supination.

INTERVENTIONS

Subjects were tested on 2 GI lower endoscopies (colonoscopies) on a simulator.

MAIN OUTCOME MEASUREMENTS

Time spent within ranges of the entire wrist range of motion for 3 wrist degrees of freedom.

RESULTS

Endoscopists spent up to 30% of the duration of the procedures at the extremes of the wrist joint range of motion. Endoscopic experience did not affect the time spent at the extremes of the wrist joint of motion. The time spent within each range of motion differed depending on the wrist degrees of freedom and difficulty of procedure.

LIMITATIONS

This study examined only 1 upper limb joint in a limited number of subjects and did not measure interaction forces with endoscopic tools.

CONCLUSIONS

We identified wrist movement patterns that can potentially contribute to the occurrence of musculoskeletal injury in endoscopists. This study lays the foundation for future work on establishing links between upper limb movement patterns and the occurrence of overuse injury caused by repetitive performance of endoscopic procedures.

Prevalence and impact of musculoskeletal pain in Japanese gastrointestinal endoscopists: A controlled study

AIM: To examine the frequency and prevention of musculoskeletal pain in Japanese gastrointestinal endoscopists and non-endoscopist physicians.

METHODS: Questionnaires were sent to 275 endoscopists and 173 non-endoscopists working in Hiroshima University Hospital and its affiliated hospitals.

RESULTS: The completed questionnaires were returned by 190 (69%) endoscopists and 120 (69%) non-endoscopists. The frequency of pain in the hand and wrist, and especially the left thumb, was significantly higher in endoscopists than in non-endoscopists (17% vs 6%, P = 0.004). Using multivariate analysis, the only significant factor associated with this pain was the age of the endoscopist (odds ratio 2.77, 95% confidence interval, 1.23-6.71, P = 0.018). Interestingly, endoscopists had made significantly fewer modifications to their endoscopic practices than non-endoscopists (12% vs 33%, P < 0.0001) to prevent pain.

CONCLUSION: Pain in the hand and wrist may be endoscopy-related. However, endoscopists made little modifications in practice to prevent such pain. More attention to prevention appears necessary.

Multicenter study of robotic thyroidectomy: short-term postoperative outcomes and surgeon ergonomic considerations

BACKGROUND

Robotic thyroidectomy (RT) has recently emerged as a viable approach to thyroid surgery, resulting in better functional and cosmetic outcomes than afforded by open thyroidectomy (OT). The present multicenter study assessed the perioperative outcomes of RT and compared physician perspectives on the musculoskeletal ergonomic parameters associated with OT, endoscopic thyroidectomy (ET), and RT.

MATERIALS AND METHODS

We reviewed the medical records of 2014 consecutive patients who underwent RT, conducted by 7 surgeons, at 4 centers between October 2007 and June 2010. Patient characteristics, perioperative clinical results, complications, and pathologic outcomes were analyzed. Moreover, surgeons were surveyed to gather data on musculoskeletal discomfort experienced during OT, ET, and RT.

RESULTS

Of the 2014 patients, 740 underwent total and 1274 subtotal thyroidectomy. Mean tumor diameter was 0.8 cm, and the mean number of retrieved central lymph nodes was 4.5 ± 3.9 (range 0-28). The rates of permanent recurrent laryngeal nerve injury and permanent hypocalcemia were 0.4 and 0.05%, respectively. Neck and/or back pain after OT, ET, and RT was experienced by 100, 85.7, and 28.6% of surgeons, respectively. When surgeons ranked the operative approaches in decreasing order of associated pain, 57.1% indicated ET > OT > RT, 28.6% selected OT > ET > RT, and 14.3% responded ET > RT > OT.

CONCLUSION

RT is a feasible and safe procedure that may facilitate radical cervical lymph node dissection. Moreover, for surgeons, the RT resulted in less musculoskeletal discomfort than did OT or ET. A larger prospective study, with a longer follow-up, is needed to determine whether RT offers real benefits for both patients and surgeons.

Accidental occupational injuries to endoscopy personnel in a high-volume endoscopy suite during the last decade: mechanisms, workplace hazards, and proposed remediation

INTRODUCTION

Scant data exist about accidental occupational injuries in endoscopy suites. This work systematically analyzes injuries, identifies workplace hazards, and proposes hazard remediation to potentially reduce risks.

METHODS

A retrospective study was performed on 14 previously unreported injuries among 120 endoscopy suite personnel in a high-volume endoscopy suite during 2000-2010, identified by medical records, employee records, and interviews. Injuries, mechanisms, outcomes, and workplace hazards were analyzed.

RESULTS

Seventeen endoscopy personnel suffered occupational accidents in an endoscopy suite, including three previously reported cases of tripping on exposed wires (rate = 1.35/100 worker-years). The 14 newly reported accidents include: hand crushed against narrow doorway while transporting patients, 4; striking head against ceiling-mounted video monitors, 3; slip and fall on wet floor, 3; injury while breaking patient's fall, 2; injury while turning patient during colonoscopy, 1; and tripping over misplaced wheelchair, 1. Injuries included: hand-crush injury, 4; myofascial back strain, 2; scalp laceration, 2; knee contusion, 2; and other, 4 (mean = 6.1 ± 15.5 lost workdays, 6.1 ± 10.1 restricted workdays). Two gastroenterologists suffered a torn tendon or coccyx fracture from slip and falls while working in the hospital. Proposed hazard remediation includes: replace bulky, heavy CRT video monitors with sleek, light LCD-flat-panel-screens to reduce likelihood and impact of head collisions; eliminate sharp edges on video monitor supports; widen doorways to accommodate extra-wide stretchers; slip-resistant flooring for rooms with frequent liquid spills; and parking wheelchairs away from traffic areas.

CONCLUSIONS

Potentially correctable design flaws may frequently contribute to accidents in endoscopy suites, including: bulky overhead video monitors, too narrow doors for extra-wide stretchers, absence of slip-resistant flooring, and wires exposed above the floor.

Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics

The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, by using a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to personal protection equipment by using the key words "personal protection equipment" (exp Protective Clothing/ or exp Protective Devices/ or exp Masks/ or exp Occupational Exposure/'') "infection control" paired with "Endoscopy." For the radiation section, the following key words were used: "radiation and endoscopy," "radiation and ERCP," and "radiation safety." For the ergonomics section, the following key words were used: "ergonomics of endoscopy," "endoscopist injury," "medical ergonomics," "endoscopy and musculoskeletal strain," "musculoskeletal injury and endoscopists," "occupational diseases and endoscopy," "cumulative trauma disorder and endoscopy," "repetitive strain injury and endoscopy." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Injury to endoscopic personnel from tripping over exposed cords, wires, and tubing in the endoscopy suite: a preventable cause of potentially severe workplace injury

BACKGROUND The endoscopy unit before remediation may be a high-risk area for slip and fall injuries due to a large number of exposed above-the-floor wires in the endoscopy rooms, dimmed lighting during endoscopic procedures, and staff inattention to obstacles due to preoccupation with the endoscopic patient. AIM To describe a novel, previously unappreciated workplace hazard to endoscopic personnel: Exposed wires in the endoscopy unit.METHODS This study is a retrospective review of 110,000 endoscopic procedures performed during the last 5 years at an academic, teaching hospital with a high-volume endoscopy unit. All significant orthopedic injuries to endoscopic personnel from slips, twists, and falls from tripping over exposed cords in the endoscopy unit were reviewed. The severity of injury was documented based on roentgenographic findings, number of days of missed work, number of days with a modified work schedule, and requirement for orthopedic surgery. The number of potentially exposed cords per endoscopy room was determined. RESULTS During the 5-year study period, three endoscopic personnel suffered significant orthopedic injuries from slips, twists, and falls from tripping over cords, wires, or tubing lying exposed over the floor in the endoscopy suite: The resulting injuries consisted of fourth and fifth metacarpal hand fractures due to a fall after tripping on oxygen tubing; a rib fracture due to tripping on electrical wires trailing from an endoscopy cart; and a grade II ankle sprain due to the foot becoming entangled in oxygen tubing. All injuries resulted in lost days of work [mean 9.3 +/- 11.0 (SD) days] and in additional days of restricted work (mean 41.7 +/- 31.8 days). One injury required orthopedic surgery. Hospital review revealed a mean of 35.3 +/- 7.5 cords, wires, or tubing per endoscopy procedure room, the majority of which were exposed above the floor before remediation (n = 10 rooms). Remediation of exposed wires included: bundling related wires together in a cable to reduce the number of independent wires, covering exposed wires on the floor with a nonslip heavy mat, and running wires from ceiling outlets to equipment high above ground (e.g. mounted endoscopy video monitors). CONCLUSIONS Tripping, slipping, and falling over exposed wires can cause significant injury to endoscopic personnel. This previously undescribed hazard should be preventable by simple remediation, and all endoscopic personnel, hospital architects, hospital administrators, and governmental regulators should be alerted to this potential hazard

Work-related musculoskeletal symptoms in surgeons

INTRODUCTION

Surgeons are a unique group of healthcare professionals who are at risk for developing work-related musculoskeletal symptoms (WMS). The diversity of operating skills for laparoscopic and endovascular procedures impose different physical demands on surgeons, who also work under time pressure. The present study aims to examine the physical and psychosocial factors and their association with WMS among general surgeons in Hong Kong.

METHOD

A survey was conducted among surgeons working in the General Surgery departments in public hospitals of Hong Kong. Over 500 questionnaires were mailed and 135 surgeons completed the survey successfully (response rate 27%). Questions included demographics, workload, ergonomic and psychosocial factors. The relationship of these factors with WMS symptoms in the past 12 months was examined.

RESULTS

Results indicated a high prevalence rate of WMS symptoms in surgeons, mainly in the neck (82.9%), low back (68.1%), shoulder (57.8%) and upper back (52.6%) regions. Sustained static and/or awkward posture was perceived as the factor most commonly associated with neck symptoms by 88.9% of respondents. Logistic regression showed the total score for physical ergonomic factors was the most significant predictor for all 4 body regions of musculoskeletal symptoms, with OR of 2.028 (95%CI 1.29-3.19) for the neck, 1.809 (1.34-2.43) for shoulder and 1.716 (1.24-2.37) for the lower back. Workstyle score was significantly associated with the symptom severity in the low back region (P = .003) but not with the other regions.

CONCLUSION

These results confirmed a strong association of physical and psychosocial factors with the musculoskeletal symptoms in surgeons. There is a potential for such musculoskeletal symptoms to escalate in the future, with rapid advances and increasing application of minimally invasive surgery.

Prevalence and impact of musculoskeletal injury among endoscopists: a controlled pilot study

BACKGROUND

Endoscopy-associated musculoskeletal injury has not been well studied. Our aim was to identify the frequency and significance of musculoskeletal injury among gastroenterologists compared with a similar group of nonprocedure-oriented internal medicine specialists and subspecialists.

METHODS

An electronic survey was developed and administered to all gastroenterologists and hepatologists [gastroenterologists (GI) group] and a sampling of nonprocedure-oriented internal medicine specialists and subspecialists (non-GI group) employed by Mayo Clinic. The questionnaire assessed several areas including current or past pain injury associated with performing endoscopy, location and description of pain or injury, impact of pain or injury, and prevention strategies. A modified survey was sent to the control group.

RESULTS

The response rate was 63% in the GI group and 45% in the non-GI group. The 2 groups were of similar age and level of physical activity. The frequency of musculoskeletal injury was higher in the GI group (74% vs. 35%; P<0.001). The most common sites of injury among the GI group were the thumb (19%), low back (19%), hand (17%), and neck (10%). There was no significant association between volume of endoscopy or years performing endoscopy and injury. Most of the GI group made modifications in their endoscopic practice to reduce injury risk.

CONCLUSIONS

Musculoskeletal injury occurs more commonly among gastroenterologists than nonprocedure-oriented internal medicine specialists. Most reported minor injuries, but members of the GI group tended to have more severe repercussions relating to ability to work. More attention to injury prevention is needed among gastroenterologists.

Pinch force and forearm-muscle load during routine colonoscopy: a pilot study

BACKGROUND AND OBJECTIVE

Overuse injuries of the hand, wrist, forearm, and shoulder are common among endoscopists and may be from repetitive pinching and gripping forces or awkward posturing. In this pilot study, we evaluated distal upper-extremity musculoskeletal load during colonoscopy (1) to confirm the feasibility of performing ergonomic measurements in endoscopists and (2) to identify tasks that may contribute to overuse injuries.

DESIGN AND SUBJECTS

Three experienced gastroenterologists were evaluated during 3 colonoscopies each.

SETTING

Veterans Affairs Medical Center, San Francisco, California.

MAIN OUTCOME MEASUREMENT

Right-thumb pinch force using a thumb-force sensor and bilateral forearm-muscle activity using electromyography.

RESULTS

The mean duration of the 9 colonoscopies was 19.5 minutes. The highest mean (SD) right-thumb peak pinch forces occurred during left (10.4 [4.1] N) and right (10.1 [4.5] N) colon insertion, which exceeded the injury threshold of 10 N. Mean peak forearm-muscle activity was also greatest during left and right colon insertion. Activity of the left abductor pollicis longus, left extensor carpi radialis, and right extensor carpi radialis exceeded the American Conference of Industrial Hygienists (ACGIH) hand activity level (HAL) action limit. The left extensor carpi radialis was at the ACGIH HAL threshold limit.

LIMITATIONS

The small sample size, no force measurement for the left thumb, and all the gastroenterologists were men.

CONCLUSION

The pinch forces and forearm-muscle loads applied during routine colonoscopy may pose a risk for overuse injuries at the elbow and wrist.

Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea

AIM: To determine the prevalence and risk factors of work-related musculoskeletal disorders in gastrointestinal endoscopists in Korea.

METHODS: A survey of musculoskeletal symptoms, using a self-administered questionnaire, was conducted on 55 endoscopists practicing in general hospitals or health promotion centers.

RESULTS: Forty-nine (89.1%) endoscopists reported musculoskeletal pain on at least one anatomic location and 37 (67.3%) endoscopists complained of pain at rest. Twenty-six (47.3%) endoscopists had severe musculoskeletal pain defined as a visual analogue score greater than 5.5. Factors related to the development of severe pain were (1) standing position during upper endoscopy, (2) specific posture/habit during endoscopic procedures, and (3) multiple symptomatic areas. Finger pain was more common in beginners, whereas shoulder pain was more common in experienced endoscopists. Sixteen percent of symptomatic endoscopists have modified their practice or reduced the number of endoscopic examinations. Only a few symptomatic endoscopists had sought professional consultation with related specialists.

CONCLUSION: The prevalence of musculoskeletal pain in endoscopists is very high. The location of pain was different between beginners and experienced endoscopists. Measures for the prevention and adequate management of endoscopy-related musculoskeletal symptoms are necessary.

The perception of gastroenterology fellows towards the relationship between hand size and endoscopic training

Some endoscopic trainees find it difficult to manipulate an endoscope's controls, possibly due to small hand size. To assess this, a survey was mailed to all gastroenterology fellows in the US. Two hundred twenty-seven of 1,295 (17.5%) fellows responded. Median surgical glove size was 7.5. Ninety-three respondents (41.0%) considered their hand too small for a standard endoscope's handle; 176 (78.2%) felt that hand size affects the ability to learn endoscopy. Seventy-seven (34.2%) would use smaller handled endoscopes if available. Of the 38 respondents with glove sizes < or =6.5, 37 (97.4%) were female. These respondents were more likely to consider their hand too small (P < 0.001), want to use smaller handled endoscopes (P < 0.001), and feel that training programs should offer them (P = 0.009). These results suggest that a significant number of trainees, especially women, perceive that their hands are too small for standard endoscopes and believe that hand size plays a role in learning and performing endoscopy.