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The word endoscopy is derived from the Greek by combining the prefix endo-, meaning within, and the
verb skopein, meaning to view or observe. The result is an apt term for the procedure of peering into
the recesses of the living body. But there is more to the term than that. Skopein means not to merely
look at something but rather to view with a purpose, to observe with intent, to monitor. The ancient
Greeks had no equivalent for endoscopy, but being clever and wise, they would have understood its
modern meaning and likely would have admired its choice.

Inception of Gastrointestinal Endoscopy

The original concept of using a tube to peer into the hidden cavities of the living human body is easily
understood, but the impediments that confronted early experimenters may be difficult for today's
endoscopists to comprehend. First was the matter of design. Few channels and cavities in the living
body lend themselves to inspection by a simple, straight, rigid, hollow probe. Second was a lack of
materials suited to the construction of a proper endoscope. In the early 19th century, a variety of
metals was available, but machines to fashion metals of high tensile strength were relatively crude.
Rubber was known, but in short supply, and the process of vulcanizationwhereby rubber is rendered
strong and elasticwas not discovered until 1839. Plastics as we know them were unheard of. Third,
and the most serious impediment, was lack of adaptable light. Before the invention of the incandescent
bulb, the only convenient source of artificial light was a burning candle, the wick of an oil or gas lamp,
or an exposed, glowing, platinum wire. None of these was adequate. This was the setting in which
gastrointestinal endoscopy had its humble beginnings.1(1)
A footnote to these former times concerns the famous clinician William Osler who attended the August
1879 meeting of the American Association for the Advancement of Science where he encountered
Thomas Alva Edison. The prolific inventor had just demonstrated the marvel of his newly devised
incandescent bulb. Osler remarked that Edison, in conversation, expressed his belief that now "it would
be possible to illumine the interior of the body by passing a small electric burner into the stomach."2(2)
Osler may have given this only passing thought, but Edison's casual comment would prove prescient.
The earliest recorded attempt at endoscopy was by Phillip Bozzini3(3) of Mainz and Frankfurt who, in
1806, devised a tin tube illuminated by a wax candle fitted with a mirror. With this instrument, which he
called einer Lichtleiter (a light conductor), he tried to peer into the urinary tract. On hearing of this, the
medical faculty at Vienna derisively dismissed the preposterous idea of "a magic lantern in the human
Much of the subsequent development of the endoscope, before the advent of gastroscopy, took place
in France. In 1826, Pierre Salomon-Segalas introduced a "urethro-cystic speculum," the first
endoscope of any practical use in diagnosis.4(4) Unfortunately, faulty illumination hampered the utility
of Segalas' endoscope. Jean-Pierre Bonnafont, in the 1830s, offered technical changes that partially
solved this problem, and his designs were incorporated in the endoscope that Antonin-Jean
Desmoreaux devised in the 1850s.5,6(5)

Early Attempts at Gastroscopy

Adolf Kussmaul, a German physician who lived from 1822 to 1902 and who is perhaps more often
remembered for his description of air-hunger as a symptom of diabetic acidosis, is generally credited
with fashioning and employing in 1868 what might be hailed as the first gastroscope.7(6) In a plethora
of publications related to the gastrointestinal tract, it is curious that he hardly mentioned his efforts to
devise a gastroscope. For an account of Kussmaul's contribution to endoscopy, one must turn to the
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recollections of others.8(7)
Kussmaul's instrument was a straight, rigid, metal tube, passed over a previously inserted flexible
obturator (Figure 11A). The light source was a Desmoreaux lamp (Figure 11B) that burned a mixture
of alcohol and turpentine, illumination being concentrated by a reflector and lens. The first subjects for
experimentation were recruited from the ranks of sword-swallowers who performed at country fairs.
Legend has it that one of the first recruits balked when he saw the prototype instrument, exclaiming,
"I'll swallow a sword anytime, but I'll be damned if I'll swallow a trumpet!" Needless to say, Kussmaul's
tube, although marking an epoch, was hardly practical.

(8)Figure 11. A, Kussmaul's original simple tubular endoscope with obturator in place
(1868). B, Desmoreaux's lamp that provided endoscopic illumination, of a sort, before the
advent of the incandescent electric bulb. C, Mikulicz's rigid, angled gastroscope (1881); note
the provision of a rubber bulb for insufflation of air. (A-C, From Walk L. The history of
gastroscopy. Clio Med 1965; 1:20922.)
Kussmaul's interest in the gastroscope, despite his inability to produce a practical instrument, had a
direct and lasting influence on the design of early instruments. Joseph Leiter, the Viennese instrument
maker responsible for producing several variants of the esophagoscope and gastroscope, visited
Kussmaul at Strasbourg in 1876 and again in 1880 to confer on technical matters. Leiter returned to
Vienna impressed by Kussmaul's demonstration that a straight tube was preferable. When later he
collaborated with Mikulicz in the design of a gastroscope, Leiter recommended the straight form.7(9)
The first clinician to seriously consider the special requirements of a workable gastroscope was
Johann von Mikulicz-Radecki (18501905), a Polish surgeon more remembered for a variety of
innovative operations. Mikulicz understood that the longitudinal axis of the esophagus is not the same
as that of the stomach. Therefore, in 1881, he reported his design of a tube, 65 cm long and 14 mm in
diameter. With a slight angle in its distal fourth, this instrument employed an optical system and was
equipped to insufflate air (see Figure 11C).9(10) Illumination was originally supplied by an exposed,
electrically activated, glowing, platinum wire, but this was soon replaced by a miniature incandescent
globe (then called, by an odd coupling of French and German, a Mignon Lampchen; devised by Max
Nitze, developer of the first useful cystoscope). It was with this instrument, later refined by
othersnotably Rosenheim,10(11) Kelling,11(12) and Elsner12(13) (Figure 12A)that the first
informative views of the intact, living esophagus and stomach were obtained.

(14)Figure 12. Early gastroscopes devised by Elsner in 1911 (A), and modified by Schindler
in 1922 (B); the diameter of both was 11 mm. C, Schindler's semiflexible gastroscope
introduced in 1932. The original model had a sponge rubber ball at the tip, which Schindler
later found to be a hazard; it was replaced by a tapered, finger-like rubber tip. (A-C, From
Walk L. The history of gastroscopy. Clio Med 1965, 1:20922.)
A Cleveland surgeon, F. C. Herrick, in 1911 proposed intraoperative gastroscopyinserting a modified
cystoscope through a small gastrotomyas a means of locating a site of bleeding in the
stomach.13(15) Among the early accounts of peroral esophagogastroscopy in the United States are
those by Chevalier Jackson14(16) of Philadelphia and by Janeway and Green15(17) of New York.
To understand the compulsion of early investigators to find a means, however crude, of diagnosing
diseases of the stomach, one must remember that the earliest efforts to develop gastroscopy preceded
by decades the advent of gastrointestinal fluoroscopy and radiography. The remarkable power of
x-rays was discovered by Wilhelm Roentgen in 1895.
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At the juncture of the 19th and 20th centuries, the most notable accomplishments in endoscopy were
by German workers. The reason was the technical supremacy in optics and instrument fabrication by
German artisans. However, these skills were soon mastered by American craftsmen, among the
foremost being Reinhold Wappler of New York, who later organized the firm of American Cystoscope
Makers, Incorporated, now better known by the acronym ACMI.

The Remarkable Career of Rudolf Schindler

Beginning with the use of instruments such as those devised earlier by Mikulicz and by Elsner, Rudolf
Schindler embarked on his career of lifelong dedication to the advancement of gastroscopy. Why is the
career of Schindler so pivotal? Because this one man, almost single-handedly, provided an impetus for
the method when the ranks of erstwhile proponents were in disarray. Moreover, this same man
sparked the promotion of gastroscopy throughout Europe and, later, in the Americas. One can argue
that others, sooner or later, would have played the same role. True, but also beside the point. Schindler
was the man.
Rudolf Schindler was born in Berlin on May 10, 1888, the son of a banker and an artistically gifted
mother who encouraged his early interest in classical music, poetry, and natural history. Fascination
with marine biology led to collection of sea shells, a lifelong hobby. Young Schindler's decision to study
medicine, we are told by Audrey Davis16(18) (whose perceptive account of Schindler's career is
recommended to the reader, along with that by Martin Gordon and Joseph Kirsner17(19)), derived
from his respect and admiration of his maternal uncle Richard Simon, a Berlin ophthalmologist.
On graduation from the University of Berlin, Schindler undertook a rural practice that was soon
interrupted by service in the German army during World War I. In this bleak setting, he observed the
prevalence of alimentary ailments in both the military and the civilian populations, and he became
convinced that much digestive disability could be attributed to morbid changes in the gastric mucosa,
undetectable by conventional methods of diagnosis. An answer to the problem, Schindler concluded,
would emerge only from direct observation of the internal milieu of the living stomachin short, by
On his return to practice, Schindler attended patients at the Munich-Schwabing Hospital where, in
1920, he acquired a rigid Elsner gastroscope that had been discarded by someone whose interest had
flagged. With this instrument and a later model modified according to Schindler's own suggestions (see
Figure 12A and 12B)both constructed by the Munich firm of Reiniger, Gebbert, and
SchallSchindler performed hundreds of gastroscopic examinations, carefully documenting each
procedure. Often gastroscopy was repeated in the same subject so as to observe the evolution of
mucosal lesions. Nor did Schindler neglect to scrutinize the normal stomach. He is said to have
examined on a number of occasions the stomach of his surprisingly willing housekeeper. This early
work, conducted with meticulous care and often in an atmosphere of hostility toward the procedure,
culminated in the publication in 1923 of Schindler's monumental "Lehrbuch und Atlas der
Gastroskopie."18(20) This exposition, like none before it, elicited serious interest in gastroscopy by
clinicians the world over.
In the era before intragastric photography was feasible, gastroscopic images were vividly rendered by
colored drawings or paintings, usually by professional artists who were allowed glances through the
endoscope, but sometimes by the examining physicians themselves (Figure 13). Both Schindler's
1923 classic and the atlas compiled in 1937 by Kurt Gutzeit and Heinrich Teitge19(21) can still be
perused for delight and instruction, especially for their depiction of stomach lesions now seldom

(23)Figure 13. Color rendition of endoscopic views by an artist thought to have been
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employed by Dr. Rudolf Schindler. A, Cricopharyngeal sphincter in open and closed

positions. B, Gastric ulcers. (A and B, Courtesy of Dr. Eric R. Lee.)
Meanwhile, Schindler was far from satisfied with the efficacy and safety of the rigid gastroscope. He
devoted himself to the design of an instrument that could be inserted with less discomfort and risk to
the patient and that would provide clearer, more extensive images for the examiner. Schindler was
joined in this effort by Georg Wolf, a skilled Berlin instrument maker. The collaboration of Schindler
and Wolf, even though marked by occasional dissension, is an early and prime example of the alliance
between clinician and engineer needed to bring to fruition new and useful ideas in the advancement of
diagnostic and therapeutic instrumentation.
The idea shared by Wolf and Schindler was to construct an optical gastroscope wherein the light rays
that conveyed the image could be made to follow a flexible arc. The optical principle of articulated
prisms and lenses within a bendable tube had been established by Michael Hoffmann21(24) in 1911,
but its incorporation in a workable endoscope proved difficult. Wolf had contrived a prototype offered
for use in the inspection of condensing pipes in steam engines. (Flexible endoscopes are used to this
day to inspect otherwise inaccessible internal mechanisms of various types of machinery.) Wolf first
proposed and constructed an optical gastroscope that was flexible throughout its length, but Schindler
had the better idea of combining a rigid proximal half with a flexible distal half, thus producing a more
wieldy instrument that conveyed a brighter, clearer image. The result was the famous Wolf-Schindler
semiflexible gastroscope, first produced in 1932 (see Figure 12C). In retrospect, what was considered
"semiflexible" by the examiner more than likely was felt to be "semirigid" by the examinee.
With this instrument, Schindler22(25) was able to announce to the medical world the advent of an
acceptably safe, workable gastroscope capable of conveying informative images of the stomach's
interior to the eye of the examining physician (Figure 14). Schindler's achievement was readily
recognized, and clinicians flocked to Munich to observe and learn the new technique. Of these,
Schindler recognized the following workers as influential in propagating the method: Francois Moutier
of France (who published his own "Traite de gastroscopie et de pathologie endoscopique de
l'estomac"23(26) in 1935), Norbert Henning of Leipzig, and Kurt Gutzeit of Breslau. Among Schindler's
American students were Samuel Weiss, a New York gastroenterologist, and Edward Benedict, a
Boston ear-nose-and-throat surgeon. It should be mentioned that in certain prominent centers, such as
the University of Pennsylvania and the Mayo Clinic, peroral endoscopy in those early days was
considered to be solely in the province of the specialty then known as bronchoesophagology.

(27)Figure 14. A, Schindler's semiflexible gastroscope with accessories. B, Proximal

viewing end with insufflation bulb and electrical connection. C, Distal end of semiflexible
gastroscope. Note side-viewing optical design and tapered rubber tip. (C, Courtesy of Dr. Eric
R. Lee.)
With the darkening clouds of Nazism hovering over Germany, Rudolf Schindler, whose father was
Jewish, was subjected to increasing persecution by the anti-Semitic regime. He was befriended by two
American colleagues, Dr. Marie Ortmayer and Dr. Walter Lincoln Palmer of Chicago, who had visited
Schindler's clinic in the 1920s. Hearing of his plight, they invited Schindler to come to the University of
Chicago as a visiting professor. In 1934, Schindler managed his escape to the United States, where he
found an opportunity to practice and teach his endoscopic method at the Billings Hospital. His
publications, now in English, proliferated. Walter Palmer provided unstinting assistance to Schindler in
publishing his textbook Gastroscopy in 1937. This, with subsequently revised editions24(28) appearing
in 1950 and 1966, was the standard work on gastroscopy for a generation of clinicians. To be noted is
that Schindler subtitled his book The Endoscopic Study of Gastric Pathology. Thus, Schindler made
clear his belief in the endoscopic method as an approach to an understanding of diseases and to the
care of patients, not as an end in itself. Schindler always considered himself to be first a physician and
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only secondarily one who was skilled in technology.

On settling in Chicago, Schindler ever sought to improve the design and construction of the
gastroscope. He allied himself with William J. Cameron, whose Cameron Surgical Specialty (on
Instruments) Company became the world's largest supplier of illuminated instruments. On Cameron's
staff was a talented instrument maker, Louis Streifeneder, with whom Schindler developed a close
rapport. With the supply of German equipment cut off during World War II, the Cameron Omni-angle
gastroscope, modeled closely after the original Wolf-Schindler design, became the standard
instrument used in many clinics throughout the United States. Streifeneder later formed his own firm,
the Eder Instrument Company, that continues a tradition of meticulous workmanship, now mainly
directed to the production of laparoscopes.
In 1943, Schindler departed Chicago to reside in Los Angeles, where he taught at the College of
Medical Evangelists (now Loma Linda University). Later, he served as consultant at the Long Beach
Veterans Hospital, where his principal coworkers were Dr. Stephen Stempien and Dr. Angelo Dagradi.
At age 70, Schindler learned Portuguese and accepted appointment to the faculty of the University of
Minas Gerais at Belo Horizonte, Brazil. His wife's ill health necessitated their return to the United States
in 1960.
No account of Schindler's career would be complete without mention of his wife, Gabrielle (ne
Winkler), whom he wed in 1922. The use of the rigid and semiflexible gastroscopes required a capable
assistant who could hold and manipulate the patient's head. Moreover, it was the assistant who closely
monitored the patient's reaction to examination and who sought to soothe the patient's apprehension
and discomfort. Although untrained as a nurse, Gabrielle learned to perform the function of
gastroscopic assistant to perfection (Figure 15). It is said that on the rare occasion when Gabrielle
was unavailable to assist him, Schindler declined to perform gastroscopy.

(29)Figure 15. The Schindler team at work at the University of Chicago Clinics about 1940.
Rudolf Schindler peers through his semiflexible gastroscope as Gabrielle Schindler exhibits
her art of head-holding. Note that her left index finger aids the drainage of oropharyngeal
secretions. (Courtesy of Dr. Martin Gordon. From Gordon ME, Kirsner JB. Rudolf Schindler,
pioneer gastroscopist; glimpses of the man and his work. Gastroenterology 1979, 77:35461.)
From 1960 to 1965, Schindler again served as consultant at the Long Beach Veterans Hospital. On
him in 1962 was bestowed the first Schindler Award by the American Society for Gastrointestinal
Endoscopy (ASGE). That occasion was his last attendance at an annual meeting of the group he had
originally founded as the American Gastroscopic Club in 1941.25(30)
Schindler's beloved Gabrielle died in 1964. He then married Marie Koch, a friend of long standing from
Munich, and in 1965, he returned to that city where much of his early work had been accomplished. He
occupied himself by preparing an atlas based on his lifetime performance of 10,300 gastroscopic
examinations. Also, he found time to enjoy his music and his shell collection. Rudolf Schindler died of
heart disease in Munich in 1968.26(31)

Gastroscopy As It Was Performed During the Era of Rudolf Schindler

Perhaps the reader will find of interest a brief account of what it was like to perform gastroscopy in the
era before the advent of fully flexible instruments. In most centers, gastroscopy was perceived as an
extraordinary step to be undertaken only when all other diagnostic means had been found inadequate
or inconclusive. Properly trained and experienced gastroscopists were relatively few. The patient was
carefully selected, the need for gastroscopy always being predicated on a previous barium meal
radiographic examination. There was no talk of gastroscopy being a first-line venture in those days,
with the possible exception of the "vigorous diagnostic approach" to the bleeding patient as advocated
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by Dr. Eddy Palmer.27(32)

Premedication usually consisted of an intramuscular injection of a short-acting barbiturate. Atropine
was often added to reduce gastric secretion and motility. The lens system gastroscope was not
equipped with a suction channel, and for this reason, the stomach was first routinely emptied by use of
an Ewald tube. If one followed Schindler's carefully specified method, the patient's throat was
anesthetized by the injection of a numbing solution through a 25-cm rubber tube with side openings at
its distally tapered end. This tube, when fully inserted, extended through the upper esophageal
sphincter. This maneuver had the further advantage of slightly dilating the sphincter, thus facilitating
passage of the gastroscope.
The patient lay in the left lateral decubitus position, with an experienced and sturdy nurse-assistant
firmly gripping the sides of the patient's head. The operator's index and middle fingers guided the
tapered, soft rubber tip of the gastroscope into the proximal esophagus. The assistant then firmly and
fully extended the patient's head so as to provide a straight mouth-throat-esophageal channel, allowing
smooth passage of the endoscope into the stomach. Needless to say, one hoped for an edentulous
patient whose mouth would more easily accommodate the instrument and whose absent teeth would
not grate on the operator's fingers or the proximal steel rod of the fully inserted gastroscope.
Even the more advanced semiflexible gastroscopes (Figure 16) employed a side-viewing objective;
therefore, the examiner had no view of the esophagus on either insertion or withdrawal.
Esophagoscopy required a quite different instrument (Figure 17) and was an altogether separate

(33)Figure 16. A, Eder-Palmer semiflexible gastroscope. Note side-viewing optics. B,

Eder-Palmer instrument with tip deflected.

(34)Figure 17. A, Eder-Hufford rigid esophagoscope. Note, from top to bottom, the
obturator, lens assembly, examination tube, and illumination rod. B, Eder-Hufford rigid
esophagoscope assembled for use.
Once the gastroscope was within the stomach, air was insufflated. The distal half of the instrument,
with its lens and prisms in a rubber sheath, was partially flexible to accommodate the contour of the
stomach, but its flexion was uncontrollable by the examiner. One could, however, precisely manipulate
torque; the external handle, carrying electric current to the small (and sometimes unreliable)
incandescent light bulb at the distal end, always pointed in the direction of the objective. Thus,
orientation of the view in the stomach was exact. A problem was that inspection of the stomach lining
was somewhat limited. The pylorus was usually seen but never transgressed. The lesser curve of the
antrum was usually a "blind area," as was the area underlying the tip of the instrument.
The examiner had to be content with relatively fleeting glimpses. Discomfort to the patient, whose neck
was rigidly extended, hardly encouraged a leisurely look. The gastroscopist's own visual impression
usually had to suffice. Photographic documentation was managed by only a few accomplished
operators.28(35) There was no provision for insertion of a biopsy forceps, except in the special
"operating gastroscope" devised by Dr. Edward Benedict,29(36) an instrument found too cumbersome
by most gastroscopists.
Thus it was that gastroscopy was performed in the decades from the 1930s to the 1960s. Despite the
formidability of the instruments then available, complications were relatively rare,30(37) doubtless
because of the caution sternly inculcated by preceptors in those who would aspire to be practitioners of
the art. But such constraints may explain why, as late as 1966, there were only 268 members of the
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The Brief but Illuminating Era of the Gastrocamera

An impediment to the appreciation of early gastroscopy was that views of the internal milieu of the
stomachand such lesions as might be seenwere limited to the visual cognizance of the examiner
or to such fleeting glimpses as might be permitted an observer peering over the examiner's shoulder.
In a way, this was an advantage to the endoscopist, who could wax eloquently about what was seen,
and none could dispute it. As might be expected, skeptics abounded, especially when the topic was
The first challenge to endoscopic interpretation was the introduction in the late 1940s of the gastric
mucosal biopsy tube devised by Ian Wood and his Australian associates.31(38) Biopsy required a
separate procedure, but then the pathologist had a section of tissue with which to counter the
endoscopist's mental imageoften imperfectly recollected.
The 19th-century invention of photography provided a means of recording a permanent image, but
because of obvious technical inadequacies, it was long before photography could be adapted to
endoscopy. Lange and Meltzing,32(39) as early as 1898, actually tried to take black-and-white
photographs at gastroscopy, but lack of sufficient light and the slowness of the then-available film
emulsions discouraged further use of the method.
Another idea was to construct a miniature camera, small enough to be swallowed by the patient and
attached to a tube through which the camera could be actuated and then retrieved (Figure 18). This
concept was ideally suited to implementation by the Japanese. Thus was developed a workable
gastrocamera by Tatsuno Uji33(40) in collaboration with his engineering colleagues at the Olympus
Optical Company (Figures 19 and 110).

(41)Figure 18. Diagram of the disassembled distal tip of the gastrocamera apparatus; at the
proximal end of the connecting tube were a control unit and a rubber bulb for air insufflation
of the stomach. (From Perna G, Honda T, Morrissey JF. Gastrocamera photography. Arch
Intern Med 1965; 116:43441. Copyright 1965, American Medical Association.)

(42)Figure 19. Early model gastrocamera manufactured by the Olympus Optical Company.
(Courtesy of Olympus Optical Company, Ltd.)

(43)Figure 110. Later gastrocamera model GTF-A manufactured by the Olympus Optical
Company. Note small 5-mm film cartridge placed near the distal tip of the instrument.
(Courtesy of Olympus Optical Company, Ltd.)
Dr. John Morrissey has related the story34(44) of how Dr. Yoshio Hara brought the first gastrocamera
to the University of Wisconsin in 1962. Hara had come to the Madison campus to study cancer
chemotherapy. He happened to bring along a set of vivid, full-color photographs of lesions as they
appeared in the living stomach. He brought, too, the tiny camera that had captured them. Morrissey
was quick to recognize the utility of the instrument and became adept in its use. Soon scores of
clinicians journeyed to Madison, eager to become gastrophotographers. Gastrocameras,
gastroprojectors, and gastroscreens proliferated across the land (although never as many as in Japan,
where according to Morrissey, in 1966, there were 10,000 gastrocameras taking pictures in half a
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million subjects annually).

Although no finer photographs of the intact stomach have ever been obtained by any other means (the
reader is invited to inspect the color plates in Morrissey's 1965 article35(45)), the early gastrocameras
had a major disadvantage: The operator could not see what was photographed until the film was
developed. Pictures (32 exposures on a roll of 5 mm film) were taken in rote sequence (Figure
111).36(46) If all went well, the result was a fairly complete survey of the stomach's interior. However,
a gastroscope was still needed to provide a visual image. The solution: Attach the gastrocamera to a
gastroscope. This was done in 1963.

(47)Figure 111. Scheme of the prescribed sequence in which gastrocamera photographs

were taken. The tip of the tube containing the miniature camera was first placed in the gastric
antrum. N indicates the neutral position; U1, U2, D1, and D2 indicate flexion of the tip up or
down, 15 degrees or 35 degrees, respectively. The sequence was repeated as the tube was
moved proximally. (From Perna G, Honda T, Morrissey JF. Gastrocamera photography. Arch
Intern Med 1965; 116:43441. Copyright 1965, American Medical Association.)
Meanwhile, the acuity of the fiberoptic endoscope was rapidly improved, as were illumination and film,
and soon it was much easier for most endoscopists to simply attach an external 35 mm camera to the
eye piece of the gastroscope and thereby record the image conveyed by the fiber bundle. Insertion of
the miniature camera into the colon was suggested,37(48) but then came the fiberoptic colonoscope.
Ease of use prevailed. The gastrocamera, marvelous as it was, became obsolete.

The Advent of Fiberoptics

A Transatlantic Coalition
The era of fiberoptic gastrointestinal endoscopy might be said to have dawned on a wintry day in Ann
Arbor, Michigan, when Basil Hirschowitz picked up the January 1954 issue of Nature. What caught his
eye were two articles on the optical properties of fine glass fibers. One of them in particular, by
Hopkins and Kapany38(49) of the Imperial College of Science and Technology in England, fired his
imagination of how an endoscopic image might be transmitted by a coherent bundle of fully flexible
glass fibers from the alimentary tract of a patient to the eye of an examiner. The ensuing events have
been described in fascinating accounts by Hirschowitz39(50) and by Hopkins.40(51)
That light would follow the curved path of a stream of water pouring from a tank was first demonstrated
by John Tyndall, a British physicist, in 1870. The idea of using flexible glass fibers to propagate light
was proposed in patent applications by J. L. Baird of England in 1927 and by C. W. Hansell of the
United States in 1930. Schindler credited Heinrich Lamm41(52) with being the first to recommend the
adaptation of fiberoptics to gastroscopy. Unfortunately, Schindler gave no further thought to the matter,
as he was then preoccupied with developing his own system of lenses and prisms that he knew to be
Light-carrying bundles of glass fibers are of two types: incoherent and coherent. Incoherent or random
bundles intended only to transmit illumination are easily constructed. Quite another matter is
construction of a coherent bundle intended to convey an image, wherein many thousands of hair-thin
fibers must be in precisely the same array at both ends of the bundle. Any appreciable leakage of light
from one fiber to another defeats the purpose of a coherent bundle. This principal impediment to the
development of a fiberscope was overcome by Lawrence Curtiss, then an undergraduate physics
student at the University of Michigan. Curtiss devised a process whereby an individual fiber of optical
glass could be clad in a layer of glass of lower refractive index that then served as an insulating coat.
Hirschowitz, with whom Curtiss collaborated, credits this as the single most important innovation in the
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advent of fiberoptic endoscopy.39(53)

Development of the Fiberoptic Endoscope

A prototype fiberscope, adapted for gastroscopy, was finally constructed at Ann Arbor in January 1957
(Figure 112). A photograph of an image transmitted by this prototype is illustrated in Figure 113. The
photograph was made with an Exacta 35 mm camera that is still used by Dr. Hirschowitz (Figure
114). Hirschowitz manfully undertook to be the first to swallow this oversized worm. Unscathed by the
experience, within a few days at the University of Michigan Hospital he performed the first fiberoptic
gastroscopy, the examinee being a young woman who harbored a duodenal ulcer. Hirschowitz then
demonstrated his instrument to a small, polite, but less than enthusiastic audience later that year at the
annual session of the American Gastroenterological Association.42,43(54)

(55)Figure 112. First prototype flexible fiberoptic endoscope. (Courtesy of Dr. Basil

(56)Figure 113. Photograph of image seen with the first prototype fiberscope constructed by
Basil I. Hirschowitz, Larry Curtiss, and C. Wilbur Peters at the University of Michigan in
January 1957. (Courtesy of Dr. Basil Hirschowitz.)

(57)Figure 114. Exacta 35-mm camera attached to prototype flexible fiberoptic endoscope.
(Courtesy of Dr. Basil Hirschowitz.)
It was not until the latter 1960s that meticulous technicians, both Japanese and American, succeeded
in refining construction of the first workaday fiberoptic endoscopes. Notably improved were optical
clarity, wieldability, and control of the distal tip. Channels were provided for biopsy and therapeutic
maneuvers. The Japanese were especially intent on this work, largely because of their need to
precisely diagnose gastric cancer, so prevalent in their country.
The first fiberoptic instrument to gain widespread use in the United States was the esophagoscope with
a working length of 75 cm. This had the enormous advantage of an end-viewing objective rather than
the traditional side-viewing objective with which Hirschowitz' early fiberscope was equipped. To
clinicians previously obliged to attempt endoscopy of the esophagus by means of a straight, rigid, steel
tube, the fiberoptic esophagoscope was a marvel. Even more pleased with the new instrument, one
can be sure, were the patients. Soon thereafter, the coherent fiberoptic bundle was extended to a
working length of 110 cm, thus providing an easily insertable instrument with which the esophagus,
stomach, and duodenum could be thoroughly and unhurriedly examined, all at the same sitting.
Improvements in endoscope design were so numerous and so rapidly introduced during the early
1970s that one could hardly purchase a new instrument and become acquainted with its use before it
was rendered obsolete by a new model. The ungainly device that had its inauspicious beginning in the
corner of a physics laboratory in Ann Arbor was transformed into an invaluable instrument. In the
hands of a host of clinicians, for a full generation, fiberoptic endoscopy notably advanced the diagnosis
and management of patients with gastrointestinal disease.

The New Era of Video Endoscopy

The rapid pace of advancing technology is further illustrated by the observation that the same
generation that so benefited by the advent of fiberoptics also witnessed its evanescence. Fiberoptics
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dominated the field for barely a quarter century. The burgeoning technology of video endoscopy has
now largely superseded use of the coherent, image transmitting, fiberoptic bundle for most
gastroenterologic applications.
Vividly accurate documentation of a clear image has been a goal long sought by gastrointestinal
endoscopists. Earlier mention was made of determined efforts to capture by still or cine photography
what could otherwise be witnessed only by the endoscopist.28,44(58) The advent of television
cameras and monitors naturally suggested their adaptation to endoscopy. Black-and-white televised
images of bronchoscopy were reported in 1957.45(59) Rider and Hirschowitz collaborated in a
demonstration of televised images of upper gastrointestinal endoscopy at the 1963 meeting of the
ASGE. Television cameras were devised that could be attached to the eye piece of standard fiberoptic
gastrointestinal endoscopes,46(60) but the cameras were unwieldy and heavy (about 7 lbs) and had to
be suspended from a ceiling. What was needed was a means of incorporating within the endoscope
itself an electronic device capable of registering and transmitting a vivid image. This became feasible
with the innovation of the charge-coupled device.
The first video endoscope was introduced by Welch Allyn Inc. of Skaneateles, NY, a long-established
maker of illuminated diagnostic instruments. The earliest report of clinical experience with prototype
video endoscopes is that by Sivak and Fleischer47(61) in the United States, this being followed in short
order by those of Classen and Phillip,48(62) and Demling and Hagel49(63) in Europe.

Proctosigmoidoscopy and Colonoscopy

The success of the fiberoptic endoscope introduced through the mouth naturally led to its adaptation
for insertion at the nether end of the alimentary tract. Specula for examination of the anus and rectum
had been in wide use since the late 1800s. For practical purposes, the maximum length of a straight,
hollow, rigid proctosigmoidoscope had been found to be 25 cm. An instrument similar to the
semiflexible gastroscope would have been handy, but the tortuosity of the sigmoid colon was far
beyond the turning capacity of a lens-and-prism endoscope. Even the early fiberscope could not be
properly advanced in a retrograde manner into the colon, although a few venturesome examiners
tacitly tried to use the fiberoptic esophagoscope in this manner from time to time. For the development
of a workable fiberoptic colonoscope, we return to the University of Michigan.
According to Bergein F. Overholt,50(64) who pioneered development of fiberoptic colonoscopy, the
work was stimulated by an unusually disagreeable proctosigmoidoscopic examination suffered by the
person of Dr. J. Howard Gowan. In 1961, Overholt was an intern at the University Hospital in Ann
Arbor. As part of his application for a U.S. Public Heath Service fellowship, Overholt was interviewed by
Gowan, who had just undergone a somewhat trying physical checkup at the hospital. Overholt, being
well acquainted with the principles and promise of fiberoptics, commented on the prospect of a more
comfortable sigmoidoscopic procedure.
Meanwhile, others had been tempted to set aside esthetics and insert the fiberoptic gastroscope in the
anus, a procedure later reported.51(65) Also, all manner of contrivance had been suggested to pull
through the colon a fiberscope hooked onto the end of a swallowed string. But, just as the peculiar
anatomy of the proximal alimentary tract had posed a problem for Kussmaul and the earliest would-be
gastroscopists, so did the serpentine anatomy of the lower bowel present a problem to would-be
Overholt, with the support of his mentor, Dr. H. Marvin Pollard,52(66) strived to overcome this difficulty.
From a silicone-rubber cast, he devised a lifelike model of the human distal colon, thus enabling the
necessary adjustments in torque and control of a fiberoptic endoscope that resulted in a prototype
instrument first employed clinically in 1963 (Figures 115 and 116). Further refinement was required,
and it was not until the 1967 meeting of the ASGE that Overholt described, to a somewhat skeptical
audience, his experience in examining the first 40 patients.53(67) By coincidence, this event took place
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at the same locale, the Broadmoor Hotel in Colorado Springs, where Hirschowitz, also representing the
University of Michigan, had first described fiberoptic gastroscopy exactly 10 years earlier. Meanwhile,
Japanese workers were busily engaged in improving the colonoscope and advancing its clinical

(69)Figure 115. Early prototype fiberoptic sigmoidoscope developed at the University of

Michigan in conjunction with the Illinois Institute of Technology Research. (Courtesy of Dr.
Bergein Overholt.)

(70)Figure 116. Prototype fiberoptic sigmoidoscope made by the Eder Instrument Company.
(Courtesy of Dr. Bergein Overholt.)
Colonoscopy gained rapid acceptance by clinicians who had been recently introduced to the marvel of
fiberoptic gastroscopy, although most operators soon found that successful colonoscopy was much
more tedious and demanding than examination of the upper gastrointestinal tract. In England,
Christopher Williams,56(71) and in the United States, Hiromi Shinya,57(72) and Jerome Waye58(73)
and their colleagues were among the early proponents and most proficient teachers of the new art of
fiberoptic colonoscopy. Thereby, an additional, clinically important segment of the alimentary tract was
placed within the purview of gastrointestinal endoscopists.

Endoscopic Retrograde Cholangiopancreatography

The intricacies of the bile and pancreatic ducts had long intrigued physicians. The fascinating story of
visualizing the biliary tree begins in 1924 with the demonstration by surgeons Evarts Graham and
Warren Cole that intravenously administered iodinated phenolphthalein was selectively excreted in bile.
This served as the prototype of a contrast agent whereby the configuration of the biliary tree could be
recorded radiographically. However, even with the later use of improved agents, the radiographic
image was often indistinct, and the pancreatic duct defied demonstration. In 1955 Doubilet et al.59(74)
described intraoperative pancreatography, but what was needed was a means of obtaining a clear
image of the pancreatic duct without surgical intervention. In 1965, Ravinov and Simon60(75) reported
cannulation of the duodenal ampulla by a swallowed catheter manipulated under fluoroscopic
guidance. Their painstaking procedure was successful in only one of eight patients.
Why not guide a cannula into the ampulla under endoscopic control? This was first accomplished by
William S. McCune et al.61(76) at George Washington University in 1968. Again, it remained for the
Japanese to perfect the technique that was described by Oi et al.62,63(77) in 1970 and by Kasugai et
al.64(78) in 1972. Foremost among proponents of endoscopic retrograde cholangiopancreatography in
the United States were Jack Vennes et al.65(79) at the Minneapolis Veterans Administration Hospital.
For his masterful teaching of the method, Vennes received the 1978 Schindler Award of the

Just as early clinicians were stimulated to develop gastroscopy because of dissatisfaction with existing
means of diagnosis, so surgeons have sought a better means of detecting lesions within the biliary
ducts. To view inside the living common bile duct was first attempted in 1923 by Bakes,67(81) a
German surgeon better known for devising the graduated probes commonly used at operation to dilate
the bile ducts and the ampulla of Vater. A right-angled telescope specifically constructed for the
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common bile duct was reported by McIver68(82) in 1941, and improved instruments were described 20
years later by Wildegans69(83) and Berci.70(84) Predictably, fiberoptic technology was soon applied in
choledochoscopy,71(85) but there was then a return to the use of a rigid instrument equipped with
prisms and lenses,72(86) because it was more wieldy and conveyed a brighter, clearer image. This is
one of the few instances in the development of endoscopy wherein the rigid lens system prevailed, for
a while, over the flexible fiberoptic system. A more recent innovation, however, has been adaptation of
a video urethroscope for the purpose of both diagnostic and therapeutic choledochoscopy under
laparoscopic guidance.73(87)
With the demonstrated feasibility of endoscopically guided cannulation of the ampulla of Vater with a
catheter for the purpose of contrast radiography, it was inevitable that substitution of a small-caliber
fiberoptic endoscope would be proposed. Indeed, Nakajima et al.74(88) reported this remarkable feat
in 1978. They modified a duodenoscope (the "mother 'scope") by enlarging to 2.8 mm the bore of its
catheter channel through which they passed a 2.3-mm fiberoptic endoscope (the "baby 'scope") that, in
turn, could be guided under direct vision into either the common bile duct or the pancreatic duct.
Because the exceedingly fine caliber of the probing endoscope could accommodate only 3000 fibers
and because the view was through a fluid medium, the image lacked the clarity associated with other
endoscopic techniques. Peroral cholangiopancreatography has not gained wide use; nevertheless, its
accomplishment must be regarded as a tour de force.

Laparoscopy has been given almost as many names as there were early promoters. This method, by
which the contents of the abdomen and pelvic cavities can be visualized telescopically, has also been
termed peritoneoscopy, organoscopy, and coelioscopyall meaning the same thing. Laparoscopy has
the advantage of historical precedence and, largely because of adoption by gynecologists and
surgeons, this term has now achieved almost universal currency.
In 1902, Georg Kelling75(89) reported at Hamburgto the 73rd meeting of a group known as German
Natural Scientists and Physicianshis observations of the abdominal viscera of a dog by means of a
Nitze cystoscope. In the same year, Dimitri Ott,76(90) a Russian gynecologist, deliberately introduced
a speculum into the pelvic cavity of a female patient through an incision in the posterior vaginal fornix,
a procedure he referred to as ventroscopy. Working independently in Sweden, H. C.
Jacobaeus77,78(91) reported his percutaneous endoscopic examinations of the abdominal and
thoracic cavities, and in 1912, he proposed the term laparoscopy. Thereafter, Kelling and Jacobaeus
long disputed the priority of discovery. In what may have been one of the earliest efforts at cost
containment, Kelling,79(92) in 1923, wrote that he used what he called coelioscopy as a means of
sparing his poor German patients, then in an abyss of economic depression, the expense of surgical
Use of the procedure in the United States was first reported in 1911 by Bertram Bernheim,80(93) a
surgeon at the Johns Hopkins Hospital in Baltimore. He had inserted a proctoscope with a -inch bore
through the abdominal wall of a jaundiced patient to confirm the presence of a Courvoisier gallbladder.
Benjamin Orndorff81(94) of Chicago used a similar device and published the first report of an
extensive experience with what he called peritoneoscopy. Meanwhile, the procedure became widely
applied in Europe where Korbsch82(95) published his "Lehrbuch und Atlas der Laparound
Thorakoskopie" in 1923. Heinz Kalk, a renowned German proponent of laparoscopy, culminated a
series of publications with his own textbook and atlas, written in collaboration with Egmont Wildhirt in
1962,83(96) that emphasized the additional benefit of endoscopically guided liver biopsy.
John Ruddock84(97) of Los Angeles was almost a lone champion of the procedure in the United
States during the 1930s. Ruddock used a slightly modified cystoscope in hundreds of cases and
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proposed what was then an astonishing number of therapeutic applicationsproposals that were
greeted with derision by mainstream physicians and surgeons. After World War II, with resumed
importation of refined German instruments and the immigration of physicians trained in their use,
laparoscopy won new adherents. Quick to perceive the value of laparoscopy were gynecologists whose
specialty now encompasses a majority of laparoscopists in the United States. Prominent among
endoscopically oriented gynecologists was Peter Steptoe of England, who found laparoscopy essential
in his development of the technique that resulted in a "test-tube baby" boom.85(98)
Very recent years have seen an astonishing adaptation of the laparoscopic approach to numerous
intra-abdominal manipulations, notably those directed to treatment of calculus biliary tract disease.
Pioneered in France,86,87(99) laparoscopic cholecystectomy has come, in many centers, to largely
supersede open laparotomy and has caused to be rewritten entire chapters dealing with the surgical
management of gallstones.

Therapeutic Endoscopy
As the science and art of endoscopy evolved, its proponents well understood the meaning of Mark
Twain's complaint, "Everybody talks about the weather, but nobody does anything about it." In former
years, endoscopists could regale their colleagues with descriptions of what they saw but were relatively
powerless to employ their skill in beneficial intervention. The prospect was soon to brighten.88(100)
True, the early bronchoesophagologists were adept in extracting foreign objects inadvertently or
deliberately choked down by misguided patients. For years, there was an astonishing display of
trophies of incredible variety, extracted from various recesses, that lined the walls of the Chevalier
Jackson Clinic at the Graduate Hospital in Philadelphia. Endoscopists no longer so decorate their
workplaces (the array of foreign bodies extracted by Jackson and his associates is now part of the
Mutter Museum collection at the College of Physicians of Philadelphia), but the ingenious application of
a variety of techniques employing gastrointestinal endoscopy became widely promulgated.89(101)
The therapeutic procedure currently and most widely used by gastrointestinal endoscopists, and
probably that of benefit to the greatest number of patients, is polypectomy. In Miami at the 1971
session of the American Gastroenterological Association, Shinya and Wolf showed motion pictures
depicting the innovative technique of colonoscopic polypectomy.57(102) Viewers were enthralled as
they watched an improvised snare approach the polyp. The audience erupted in a spontaneous cheer
when the severed polyp was seen to topple from its pedicle. The number of patients who have since
been saved from carcinoma by having benign polyps extirpated from segments of the gastrointestinal
tract accessible to endoscopy is now becoming evident.
Control of active bleeding from lesions within the range of endoscopyby electrocoagulation, heater
probe, or laserwas accomplished as a result of intense investigation during the decade following
1970. Endoscopically guided percutaneous gastrotomy was first performed in 1979, using an
improvised appliance.90(103) No longer are strictures in the alimentary tract merely observed by the
endoscopist; they are now effectively dilated under endoscopic guidance. Obstructing neoplasms can
be obliterated under direct vision by endoscopically directed laser beams or electrodessicators. Even
more dramatic is endoscopic intervention in cases of calculus disease in the biliary and pancreatic
ducts, previously cited in these pages. Many of the pioneering and most knowledgeable investigators in
this field present their work in chapters to be found in this book.
Sometimes what looms on the horizon and may seem new turns out not to be new at all. Being aware
of what has gone before can improve one's perspective. This is exemplified by endoscopic
sclerotherapy of esophageal varices, thought by some to be a relatively recent innovation. It is
notinterest in the procedure has simply been renewed. This means of treatment was first reported by
Clarence Crafoord and Paul Frenckner91(104) in Europe in 1939, and a few years later, in the United
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States by Herman Moersch92(105) and by Cecil Patterson and Milford Rouse.93(106)

What can one learn from the history of endoscopy? Several recurring themes stand out.
First, almost without exception, advances in endoscopy have come about by virtue of close
collaboration between clinician and artisan; neither could have succeeded alone. One need only recall
the names of Mikulicz and Leiter, Schindler and Wolf, and Palmer or McCune and Streifeneder. It can
happen, too, that a notable advance issues from a merging of basically unrelated technologies. An
example is the advent of endoscopic ultrasonography reported in the mid-1980s94,95(107) and soon
after hailed by Sivak.96(108)
Second, those clinicians who have notably contributed to the advance of endoscopy were invariably
seeking an answer to a broader medical problem; none thought of himself as merely a technician
pursuing technology as a goal in itself. A case in point is the career of Rudolf Schindler.
Third, innovative instrumentation often has been prompted by technical advances made far afield of
the recognized domain of gastrointestinal endoscopy or even beyond the purview of medicine
generally. Instructive examples are the adaptation of fiberoptic technology and the charge-coupled
device to endoscopy.
Fourth, the progress of instrumentation and technique does not always proceed in a smoothly linear or
logical fashion, despite a semblance of order suggested by hindsight. Development often occurred in
repeated fits and starts. The pattern is familiar: astonishment at the first announcement, skepticism of
early enthusiastic reports, then a sorting out, with acceptance or rejection depending on the cautious
assessment by respected clinicians and one's own personal experience.
History is looked on as a humanistic discipline, but it has an essential role, too, in the understanding of
science. To know the history of endoscopy is to pay tribute to those who have cleared the path we now
tread, to recognize the impediments that have been overcome, to appreciate more fully the facility we
now enjoy, and to point to the prospect of still more marvelous advances to come.


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Cotton PB, Shorvon PJ, Lees WR. Endoscopic ultrasonography: A new look from within. BMJ
(Clin Res Ed) 1985;290:13734.
Sivak MV Jr. Is there an ultrasonographic endoscope in your future?. Gastrointest Endosc

Chapter 2 Flexible Endoscope Technology: The Fiberoptic

The flexible endoscope is a highly refined and complex instrument that may utilize one of two different
imaging systems: fiberoptic technology and semiconductor technology. A fiberoptic endoscope
(fiberscope) employs a glass fiber bundle that transmits images from the objective lens at the distal
end of the instrument to the ocular lens in the eye piece. A video endoscope (videoscope) uses a
charge-coupled device (CCD) to electronically transmit images from the endoscope to a television
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Mechanical Construction of the Flexible Endoscope

The major parts and controls of a typical fiberscope and videoscope are shown (Figure 21). The
mechanical components of these two types of endoscopes are basically the same. In this chapter,
aspects of the internal construction that are common to both types of instruments are discussed in

(110)Figure 21. Nomenclature of the various controls and components of a fiberscope (left)
and the control section of a videoscope (right).

Distal Tip
An end view and a cross section of the distal tip of a typical fiberscope and videoscope are shown in
Figure 22. On the faces of the tip, the following can be seen: (1) the channel opening for suction and
passage of accessories; (2) the complex illumination lens system, which distributes light from the light
guide (LG) fiber bundle into wide-angle, even illumination of the visual field; (3) the objective lens
system, which focuses an image of the mucosa onto the face of the image guide (IG) bundle; and (4)
an air/water nozzle, which provides air for insufflation of the organ being observed and water that
washes across the lens to remove substances such as secretions, mucus, and blood.

(111)Figure 22. End view and cross section of the distal tip of a fiberscope and a
videoscope. I.G.image guide; L.G.light guide; CCDcharge-coupled device.
Two cross sections of the distal tip of a side-viewing flexible endoscope (fiberscope) are illustrated in
Figure 23. A roof prism is used to produce a 90-degree change in direction of view. A forceps raiser is
also necessary to deflect the tip of various accessories passed through the channel to bring them
within the field of view.

(112)Figure 23. Cross section of the distal tip of a side-viewing flexible endoscope in two
different planes. L.G.light guide; I.G.image guide.

Bending Section and Angulation System

The design of the bending section, the portion that produces controlled deflection of the distal tip, was
originally developed in Japan for the gastrocamera. Four-way tip deflection was first introduced with the
Olympus Model CF-MB/LB colonoscope in 1970. Since then, a variety of different mechanisms have
been developed to control tip deflection.
A typical angulation system in current use is illustrated in Figure 24. The endoscope used for
gastrointestinal purposes generally has a built-in resistance or adjustable braking system to fix the
deflection of the tip, allowing the operator to remove the hand from the control knob and still maintain
tip deflection. To produce tip deflection, the operator rotates the control knob that is connected to a
sprocket within the control section. This sprocket moves a chain that, in turn, pulls on various wires
running the length of the insertion tube. As a wire is pulled, it produces tip deflection in that direction.
The bending section is constructed from interlocking metal rings. The pivot points between these rings
alternate by 90 degrees, thereby giving the bending section the ability to bend in any direction. A
cross-sectional view of the bending section is shown in Figure 25.

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(113)Figure 24. Bending section and angulation system of a flexible endoscope.

(114)Figure 25. Cross-sectional view of the bending section of a flexible endoscope.

L.G.light guide; I.G.image guide.
During an endoscopic procedure, the tip of the instrument is deflected many times. A tracking of total
movement during a procedure is shown in Figure 26. To withstand such repeated, complex
movements, the deflecting mechanism must be extremely durable and tested extensively to guarantee
that it is safe and reliable.

(115)Figure 26. Data showing the degree and direction of tip deflection during a typical
endoscopic procedure.

Insertion Tube
Although the insertion tube, excluding the bending section, is not capable of controlled deflection, its
carefully calculated flexibility and torque-free construction are of major importance in endoscope
The basic construction of the insertion tube is shown in Figure 27. Helical steel bands form the
supporting structure of the tube and give it its round shape. These bands are covered with a layer of
stainless steel wire mesh. Together, these components prevent the insertion tube from twisting or
stretching along its axis and also help shield the glass fiber bundles from damaging x-radiation.

(116)Figure 27. Internal components and construction of the insertion tube of the flexible
endoscope. L.G.light guide; I.G.image guide.
The outer plastic covering over the metal structure of the instrument also helps prevent twisting of the
insertion tube and compression along its axis. It is important that this final covering be waterproof and
able to withstand a variety of chemical agents from gastric acid to corrosive disinfectants. The
specifications for each component of the insertion tube are carefully chosen to ensure that the final
tube has the proper flexibility and elasticity to recover from repeated bending.

Control Section
The control section of the endoscope is designed to be held entirely by the left hand, leaving the right
hand free to hold and manipulate the insertion tube. The second, third, and fourth fingers grip the
instrument against the palm, leaving the left thumb free to control the up/down angulation knob and the
left index finger free to operate the air/water and suction valves. The right hand is used to torque and
advance the insertion tube, insert and operate accessories, control the right/left angulation knob,
operate the camera, adjust the diopter of the ocular lens, and focus the objective lens as necessary.
The technique of endoscopy is described in Chapter 38: Technique of Upper Gastrointestinal
Endoscopy; Chapter 57: Techniques of Endoscopic Retrograde Cholangiopancreatography; and
Chapter 81: Technique of Colonoscopy.

Air, Water, and Suction System

A cross section of the entire instrument (Figure 28) illustrates the various internal channels for air,
water, and suction. This type of design for automatic air, water, and suction originated in 1968 with the
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Olympus Model EF esophagoscope and has remained basically the same through succeeding
generations of instruments.

(117)Figure 28. Air, water, suction, and CO2 systems of a typical colonoscope.
Air supplied by a pump within the light source is emitted from the nozzle on the distal tip when the
opening in the air/water valve is covered. Air is used to insufflate the organ under observation and to
blow water off the objective lens. When the air/water valve is depressed, water is forced from the
pressurized water container through the endoscope and out the nozzle on the distal tip.
Aspiration of either air or fluid through the endoscope is accomplished by depressing the suction valve.
An external suction pump and collection bottle are connected to the endoscope and provide the
required negative pressure. When performing electrosurgery, the endoscopist may wish to introduce
CO2, as an inert gas, to reduce the risk of accidental explosion in the bowel, particularly the colon. This
is done by depressing the CO2 gas valve, which allows gas from an externally regulated tank to be
insufflated via the endoscope.
Valves are provided on all of these channels to check the backward flow of material from the various
openings on the distal tip into the air, water, and gas chan-nels within the endoscope. However, since
the endoscope is used in a pressurized environment owing to organ insufflation and because the air
within the channels of the endoscope is compressible, it is possible for small amounts of debris to work
their way slowly into the interior air, water, and gas tubing of the endoscope. To prevent occlusion of
these small tubes and for reasons of infection control, it is important to flush and disinfect these lines
when the instrument is cleaned.

Light Guide Connector

A cross section of the LG connector of the endoscope is shown in Figure 29. This portion of the
instrument connects to the light source and provides light and pressurized air. It also has connections
for a water container, a suction pump, and an electrical cord to safely return any electrosurgical
leakage current to the generator. A vent on the connector allows the interior of an airtight and fluid-tight
endoscope to be vented before the instrument is placed in an evacuated chamber for gas sterilization.

(118)Figure 29. Cross section of the light guide (L.G.) connector of an endoscope.

Principles of Fiberoptics
As described previously, one of two imaging technologies can be used in the flexible endoscope:
fiberoptic and CCD (video) technology. CCD technology is described in Chapter 3: Flexible Endoscope
Technology: The Video Image Endoscope; fiberoptic technology is discussed in this chapter.

Principle of Total Internal Reflection

The heart of the flexible fiberoptic endoscope (fiberscope) is the image-carrying fiber bundle, which
transmits the image through the instrument. This bundle contains tens of thousands of individual
ultra-thin glass fibers. The ability of an individual fiber to efficiently transmit light entering the distal end
of the fiberwithout substantial loss of brightness, change in color, or leakage of light to adjacent
fibersis basic to the development of fiberoptic instruments.
The phenomenon of refraction and reflection as shown in Figure 210 explains why light can be
transmitted through flexible glass fibers. This figure shows two transparent substances. The lower
substance can be assumed to be glass with a refractive index of n. The upper substance may be either
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air or glass of a different composition, possessing a lower refractive index of n. Line L represents the
boundary separating the two media of index n and n. A ray of light traveling through the lower medium
and hitting the boundary surface with incident angle A (Figure 210A) will be refracted and travel
through the upper transparent medium at angle B. The relationship between angle A and angle B is
given by the the equation:

n sin A = n' sin B

(119)Figure 210. A-C, Phenomenon of refraction and reflection of light by a plane surface.
See text for explanation.
As the angle of incidence A is increased, the angle of the refracted ray B also increases according to
the relationship given in the previous equation. When A equals AC (known as the critical angle of
incidence), the refracted ray will travel along the boundary surface (Figure 210B). The critical angle
for any two substances is found by setting B = 90 (sin B = 1). In this case,

If the angle of incidence is increased further to A0, A0 being greater than AC, the ray is totally reflected
at the boundary surface back into the lower medium (Figure 210C). The angle of reflection always
equals the angle of incidence. It is this condition of total internal reflection that enables glass fibers to
transmit light. Total internal reflection can occur only when the ray is incident on a medium whose
index is less than that of the medium in which the ray is traveling.

Optical Fibers
A long, cylindrical glass fiber will transmit light if its surface is clean and it is surrounded by a medium
with a lower refractive index (Figure 211). However, any debris on the surface of the fiber or any
contact of the fiber with adjacent fibers or other objects will disturb the boundary condition and prevent
total internal reflection from occurring at that point on the surface. These conditions will result in
leakage of light from the fiber, a loss in transmission, and the transfer of light from the fiber to other
objects with which it comes in contact. To prevent this and to ensure a proper boundary surface, all
glass fibers used for fiberoptics are clad with a very thin layer of glass (Figure 211B). The cladding
glass has a lower index than the core glass, a condition that guarantees total internal reflection of all
rays traveling through the core glass.

(120)Figure 211. Path of light ray through an unclad (A) and a clad (B) glass fiber.
A ray incident on the face of the fiber at angle 0 (Figure 212) will be refracted and travel through the
core at angle A0. At point P1 on the boundary surface, it undergoes total internal reflection. It
undergoes a second reflection at point P2, and continues onward down the fiber, reflecting each time it
hits the boundary surface. As the angle of incidence 0 on the face of the fiber is increased, the angle
of internal reflection decreases until A0 reaches AC, which is called the critical angle for internal
reflection (Figure 212). The angle representing the maximum incidence angle for total internal
reflection is referred to as the maximum acceptance angle C. AC is a function of n and n, the indices
of the glass used in the core and the cladding, respectively:

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(121)Figure 212. Total internal reflection and maximum acceptance angle of incidence, C.
See text for explanation.
A ray incident on the boundary at an angle less than AC will not undergo reflection but will be refracted
through the cladding, out through the side of the fiber, and will be lost.
A calculation of the value of C will show that it is dependent on the indices of the core, the cladding,
and the medium at the face of the fiber:

The value of N.A. is designated as the numerical aperture of the fiber and equals sin C when the face
of the fiber is in contact with air (n0 = 1 for air). The greater the difference between n and n, the
greater the numerical aperture and the larger the cone of light that the fiber will accept and transmit.
Because of production limitations on the glasses used for the core and cladding, the numerical
aperture of optical fibers is generally limited to 0.52. By calculation with the preceding formula, C (the
maximum acceptance angle) is 31 degrees for a fiber with this numerical aperture. Light entering at
angles greater than this will not undergo internal reflection, but will pass out through the side of the
In practice, not all light entering the face of the fiber at incident angles less than the maximum
acceptance angle of incidence (C) will be transmitted and exit the other end of the fiber. Light
transmission is also decreased by the following factors:
1. There is some absorption of light by the core glass. This loss is proportional to both the length of
the fiber and the length of the path light takes within the fiber.
2. Although the preceding discussion implies that at angles greater than AC the light will be totally
reflected, in practice this reflection is not 100%. The small amount of refraction or scattering that
takes place is insignificant for one reflection. However, because the light may be reflected tens of
thousands of times in traveling 1 m, a small loss at each reflection point results in a measurable
loss at the end of the fiber. Fibers of small diameter and long length suffer the greatest loss of this
3. Some of the light falling on the surface of the fiber will be reflected by the surface rather than
entering the fiber. The amount of loss is approximately 4% at each end.

Fiberoptic Bundles
An individual fiber cannot transmit an image. If one observes the end of an illuminated fiber, only a spot
of light of a certain color and intensity is seen. To create an image, a large number of fibers must be
grouped together. The pattern formed by the color and intensity of the individual fibers is perceived by
the observer as an image. For the image at one end of the bundle to duplicate the image at the other
end, it is necessary that the ends of each individual fiber occupy the same relative position in both ends
of the bundle. A bundle that is organized in this manner is called a coherent bundle (Figure 213). Only
coherent bundles are capable of producing an image. Therefore, they are also referred to as image
guide fiber bundles (IG bundles).

(122)Figure 213. Alignment of fibers on the face of a coherent fiber bundle.

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An important property of an IG bundle is its resolving power, that is, the amount of image detail the
bundle can convey. A bundle's resolving power depends on the diameter of the fiber core, the
thickness of the cladding, and the alignment and orderliness of the packing of the fibers within the
bundle faces. The smaller the fiber and the thinner the cladding, the greater the image resolution. In
practice, the thickness of the fiber cladding cannot be made less than 1.2 m for visible light because
of production limitations as well as physical optical theory.
The ratio of the total area occupied by the individual fiber cores to the total area of the fiber bundle is
referred to as the packing fraction. Since only the cores transmit light, it is advantageous to make the
packing fraction as large as possible. However, since there is a limit to the thickness of the cladding,
as the diameter of the core is reduced to improve resolution, a certain point is reached where the
packing fraction becomes unacceptably low. The high proportion of cladding area to core area results
in a very dark image. Owing to this limitation, the smallest practical fiber diameter (including cladding)
is generally approximately 6 m. A typical packing fraction is 60%.
The alignment of the fibers in the face of the bundle greatly affects the quality and resolution of the
image. Imperfect alignment will result in distorted images and annoying flaws or dark areas in the
The length and number of fibers within an IG vary greatly depending on the type and size of the
endoscope. The number of individual fibers in the IG bundle usually ranges between 5000 and 40,000.
The diameter of the bundle may vary between 0.5 mm and 3 mm.

Basic Optical System of a Fiberscope

A schematic of the type of optical system used in a fiberscope is shown in Figure 214. The objective
lens at the tip of the fiberscope forms an image of the object in view X0 on the distal face of the IG X0.
This miniature image is limited by the size of the fiber bundle. The light representing this image is
transmitted through the IG and a duplicate image is formed on the proximal face of the bundle near the
eye piece. Since the objective lens produces an inverted image on the distal face of the bundle, the
bundle must be twisted 180 degrees to produce an upright image at the proximal face. The ocular lens
(fiberscope eye piece) functions as a simple magnifying glass and creates an enlarged virtual image
representing the image resting on the tiny tip of the bundle.

(123)Figure 214. A basic fiberscope optical system. I.G.image guide.

Magnification of the viewed object is determined by several factors. Magnification produced by the
objective lens is variable and is determined by the distance between the objective lens (fiberscope tip)
and the object being viewed:

where M0 is usually much less than 1.

Magnification of the tiny image on the proximal face of the IG bundle is determined by the focal length
of the ocular lens:

where M1 typically ranges between 15 and 30.

The visual magnification of the fiberscope's entire optical system M is the product of M0 and M1:
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M = M0 X M1
The field of view () is given by:

where f is the focal length of the objective lens.

Progress in modern lens design technology has made it possible to obtain a maximum up to 140
All fiberscopes have a diopter adjustment on the eye piece. This allows focusing of the ocular lens to
compensate for the diopter of the individual endoscopist's eyesight.

Illumination System
An optical system used for endoscopic illumination is shown in Figure 215. An incoherent light guide
fiber bundle (LG bundle) is used to transmit light through the endoscope. Special lens systems on both
ends of the bundle are needed to effectively capture the maximum amount of light from the light source
lamp and to produce a wide angle for even illumination from the tip. Fibers used in the LG bundle are
designed for high a numerical aperture (N.A.) and a high transmission ratio. To produce the highest
possible packing fraction, LG fibers are made as large as possible without compromising their flexibility
and durability. At present, 30-m fibers are commonly used.

(124)Figure 215. Flexible endoscope illumination system. L.G.light guide.

Owing to the intense heat produced by the high-intensity light source used in endoscopy, dichroic
coatings and heat-absorbing filters are employed to cut out nonvisible radiation from the lamp output.
In addition, heat sinks and forced-air cooling systems in the light source prevent the LG bundle from

Production and Quality of the Image Guide

The following is a general description of an automated process that produces high-quality round
bundles, which is the method used to make the IG bundles found in the majority of fiberscopes today.

The individual fibers start out as single glass rods consisting of a core of high-quality optical glass, a
cladding of glass with a refractive index lower than that of the optical glass, and a second cladding of
acid-leachable glass (Figure 216). This original glass rod is many times larger in diameter than the
final flexible glass fiber.

(125)Figure 216. Composition of a glass rod that, after heating and elongation, will become
an individual glass fiber.
The necessary number of these single glass rods (usually tens of thousands) are perfectly aligned
within a larger cylinder made of acid-leachable glass. This large coherent bundle is called the master
IG (Figure 217).

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(126)Figure 217. Master IG bundle.

The master IG is then placed in an electric furnace and pulled (Figure 218). Owing to the heat and
tension, the bundle elongates and becomes thinner. This process is repeated many times until the
individual fibers are reduced to the desired size. A cross section of the bundle at this stage is shown in
Figure 219. Because of the tension of the pulling process, the acid-leachable glass is forced into a
hexagonal honeycomb pattern, fusing the individual glass rods into a single rigid bundle. The perfect
packing and coherence of the original master IG are maintained.

(127)Figure 218. Process of pulling a master IG bundle to reduce its diameter.

(128)Figure 219. Cross section of the fiber bundle after the pulling process, showing the
fusion of the acid-leachable glass.
Protective holders are placed over both ends of the bundle, which is then soaked in an acid solution
(Figure 220). Only the acid-leachable glass that fuses the fibers is affected by the acid. As this glass
is slowly dissolved, the fibers become free and flexible (Figure 221). At this point, the individual fibers
are freed from one another to convert the fragile, rigid bundle into a durable, flexible bundle.

(129)Figure 220. Rigid fiber bundle is soaked in an acid solution that dissolves the
acid-leachable glass and frees the individual fibers.

(130)Figure 221. Cross section of the fiber bundle after the acid leaching process.

Several factors can affect the quality of the final IG bundle. Some of these are shown in Figure 222
and include black dots caused by broken fibers; half-opaque (gray) dots caused by poor cladding or an
air bubble in the fiber; and disorders in fiber alignment or dust in the fiber inherent in the manufacturing

(131)Figure 222. Example of various forms of fiber bundle imperfections.

Ancillary Equipment
Endoscopic Light Sources
A variety of endoscopic light sources are available, ranging from simple low-power halogen light
sources to sophisticated high-intensity xenon units. The larger, more advanced light sources generally
have multiple features such as automatic flash photography, automatic brightness control for television
and video endoscopy, and the capability to accept rigid telescopes. A block diagram of the function of
the various components of a high-intensity xenon light source is shown in Figure 223).

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(132)Figure 223. Block diagram showing the function of various components of a xenon
light source.

Electrosurgical Generators
Only solid-state generators having isolated outputs should be used for endoscopic procedures.
Although almost any generator that operates within the proper power range can be adapted for
endoscopic use, electrosurgical units designed specifically for use with endoscopes have several
important additional safety features. One of these is a separate terminal to connect a safety return cord
(S-cord) from the endoscope (Figure 224). This S-cord returns any capacitance-induced "leakage"
current in the endoscope directly to the generator, thereby avoiding potentially dangerous circuiting
through the patient or physician. If proper electrical connections have not been made, a warning
system built into the generator will alert the operator and will prevent the unit from operating until these
connections are correct. A second safety feature is that the current returning through the S-cord is
continuously monitored by the generator and compared with the total output. If a significant amount of
current is detected in the S-cord, the generator automatically decreases power output to a substantial
degree in order to prevent possible injury. The principles of electrosurgery are discussed in Chapter 9:
Principles of Electrosurgery.

(133)Figure 224. Schematic diagram of endoscopic electrosurgery with a safety return cord
For safety, it is important that endoscopic electrosurgery be attempted only through the endoscope
specifically designed for this application. The endoscopes that have exposed metal bands on the
insertion tube, noninsulated distal tips, and nongrounded construction should never be used.

Imaging Apparatus
Various types of imaging apparatus (Figure 225) can be used with a fiberscope by connecting these
devices to the eye piece of the endoscope. These include full-automatic still camera (16-mm or 35-mm
film), instant still camera (Polaroid), motion picture camera (8-mm or 16-mm film), miniaturized
television camera, and video converter (connects to the video processor and allows the fiberscope to
be used as a video endoscope).

(134)Figure 225. Endoscopic system chart. A complete endoscopic system includes not only
a variety of fiberscopes but also a complete line of accessories and ancillary equipment.

Total Endoscopic System

A large variety of accessories and ancillary equipment are required for modern endoscopy. This total
endoscopic system is depicted schematically in Figure 225.

Cleaning, Sterilization, and Maintenance of the Endoscope and

Meticulous cleaning of the flexible endoscope immediately after use is important to keep the instrument
free of accumulated organic debris and in good mechanical working order. An improperly cleaned
instrument may also compromise subsequent disinfection or sterilization procedures, since the surface
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layer of debris may shield underlying microorganisms from the biocidal action of the disinfectant or
sterilization process. All detachable parts such as distal hoods, forcep valves, air/water and suction
valves, water containers, and tubes should be removed from the instrument, cleaned, and sterilized
separately. The majority of modern endoscopes are completely watertight and can be totally immersed.
The entire exterior surface and internal channels can be easily washed with a sponge or soft brush.
The most common disinfectant used for endoscopes is glutaraldehydes. Many different brands are
available. It is suggested that the user consult the endoscope manufacturer concerning the suitability of
particular disinfecting agents before using them to disinfect equipment. Instrument manufacturers can
suggest products that they have tested and have found not to damage their instruments after long-term
use. It is important that the instrument be thoroughly rinsed after using disinfectant solution and that all
interior channels be flushed with clean water and air-dried. Many disinfectants are irritating to body
tissue and must be completely rinsed from the instrument before its use on patients. It is also important
that the instrument be properly dried before storage. Moisture in the interior channels of the endoscope
can promote the growth of microorganisms, and water drops allowed to dry will leave a film or stain on
electrical contacts and lens surfaces.
Ethylene oxide gas (ETO) sterilization is suitable for sterilizing endoscopes. The endoscope must be
completely dry before ETO sterilization. The venting valve on airtight and fluid-tight fiberoptic
instruments must be opened before placing them in a gas sterilizer. This allows the pressure inside the
instrument to equilibrate with the chamber pressure. If the instrument is not vented, as the vacuum is
being drawn in the sterilization chamber the atmospheric pressure inside the endoscope will cause
expansion and bursting of the rubber sheath covering the bending section of the instrument. Generally,
videoscopes do not require this type of venting.
After exposure to ETO, the endoscope must be aerated to remove all residual ETO that has been
absorbed by the plastic and rubber parts of the instrument. The endoscope manufacturer should be
consulted concerning the maximum temperature, pressure, or vacuum the instrument can withstand
during the ETO sterilization and aeration cycles.
Although the flexible endoscope cannot be placed in an autoclave, many accessories such as biopsy
forceps, polypectomy snares, cytology brushes, water containers, and mouthpieces can be sterilized by
this method, which makes use of steam under pressure.
An automatic washing and disinfecting machine may be desirable in a busy endoscopy suite, since it
saves time in disinfecting endoscopes.

Mechanical Safety
As with any medical instrument, the endoscope must be manufactured according to specific national
standards such as the Good Manufacturing Practice standards of the U.S. Food and Drug
Administration. However, for the ultimate in safety, an endoscope manufacturer must consider all
possible types of malfunction and design an instrument such that it will not cause harm to the patient
should a malfunction occur. An example of this type of design philosophy would be an angulation
system that cannot jam or malfunction with locking of the tip of the instrument in a deflected position,
thereby preventing the removal of the instrument from the patient. Another example would be an
insufflation system that cannot malfunction in any manner that would produce a potentially dangerous
overinsufflation. A final example is the use of a braided wire consisting of numerous strands of
extremely fine wire in the angulation system of the instrument. A braided wire with only a few, thicker
wires could be used. However, if one of the strands became frayed or cut, a thick wire would be strong
enough to puncture the outer sheath of the insertion tube and injure the patient, whereas a thinner wire
would not.
With many mechanical devices, it is easy to increase the durability by simply increasing the size and
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weight of critical components, thereby strengthening them and preventing future failure. It is quite
possible to substantially increase the durability of the endoscope by also strengthening or redesigning
certain components. However, this would severely compromise the safety and effectiveness of the
instrument. For example, using larger, thicker wires in the angulation system would reduce the amount
of stretching that might occur. As explained earlier, this would compromise its mechanical safety.
Other changes to improve durability might be adding a thicker protective covering over delicate fiber
bundles to prevent fiber breakage, using a heavier supporting structure in the insertion tube to prevent
damage due to patient bites, reducing the amount of tip deflection to reduce stress on the internal
components, and increasing the thickness of the rubber sheath to eliminate water leakage owing to pin
holes. These and many more changes could be made to produce an instrument that would require little
or no repair during its lifetime. However, the results of these changes would be an endoscope with a
large, stiff insertion tube, limited tip deflection, reduced accessory channel size, and a larger, heavier
control section. Since these changes are unacceptable, modern endoscope design represents a
delicate balance between the various features the physician requires and the best design in terms of
ultimate durability.
Another important design factor is that the endoscope must "yield" before the patient does. The
flexibility of the instrument and the tactile feedback of the control knobs allow the physician to gauge
the force the instrument is exerting on the patient. This required "feel" of the instrument also puts
important limitations on the type of materials used in the endoscope and the manner in which the
instrument is constructed.

Electrical Safety
Underwriters Laboratories and International Electrotechnical Commission standards apply to the
ancillary electrical equipment used with an endoscope. The basic intent of these standards is to
prevent patient or operator shock due to leakage of line voltage, and to maintain electrical safety of the
equipment should some internal component fail or malfunction.
Endoscopes are now designed so that they are electrically isolated from ground. This is done to
prevent current from flowing through the endoscope and patient should a fault occur in attached
ancillary equipment. This also prevents the endoscope from acting as the return electrode should the
return electrode become dislodged or disconnected when performing electrosurgery with a
ground-referenced electrosurgical generator.
Owing to the nature of high-frequency current, it is impossible to totally eliminate capacitive coupling
between the endoscope and the electrosurgical accessory passed through it. Therefore, it is essential
that there be no unnecessary exposed metal parts on the insertion tube that could possibly result in an
electrosurgical burn to the patient. The use of a protective eye shield for the electrically nonisolated
metal eye pieces is also recommended. Despite all the safety features designed into modern
instruments, owing to the potential hazards of electrosurgery, the therapeutic endoscopist should be
thoroughly trained in electrosurgical procedures and aware of all possible complications (see Chapter
9: Principles of Electrosurgery).

Chapter 3 Flexible Endoscope Technology: The Video Image

The video image endoscope, referred to as "the most fundamental change in endoscope design since
the introduction of the fiberscope in 1957,"1(136) represents a new era for endoscopy. The clinical
advantages of the video image endoscope, or videoscope, are well documented.27(137) These
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include the ability to perform procedures with a natural, relaxed posture while observing a video
monitor; simultaneous viewing by the physician, trainee, endoscopy assistant, and even the patient;
enhancement of training through observation of procedures and videotape; and when the endoscope is
integrated with a computer, the assembly of a database of high-quality, easily accessible endoscopic
images for documentation, patient follow-up, and research.
Many of these advantages are not unique to the video image endoscope. In fact, by 1983, the year
Welch Allyn introduced the first commercial videoscope, many endoscopists were routinely performing
"video endoscopy" with small video cameras attached to fiberscopes. These external cameras
provided many of the benefits of the videoscope, including the provision for multiple observers,
enhanced training, and documentation. Despite these advantages, however, external cameras were
both bulky and heavy, and they had two insurmountable problems: (1) image resolution on the monitor
was limited by the resolution of the fiber bundle and (2) the image obtained through the fiber bundle
was further deteriorated by moir*(138) interference.
Moir interference is created when two regularly repeating patterns are superimposed (Figure 31).
When the honeycomb fiber bundle pattern of a fiberscope (see Chapter 2: Flexible Endoscope
Technology: The Fiberoptic Endoscope) is projected onto the image sensor of an external camera, a
disturbing moir pattern is likely to result. To prevent this, endoscopic camera designers typically
diffuse or slightly defocus the endoscopic image. The video image endoscope avoids this problem by
eliminating the fiber bundle and positioning the image sensor at the distal end of the instrument.

(139)Figure 31. A moir pattern is produced by the interference of two regularly repeating
patterns, such as the scan lines of a video camera and the fiber pattern of a fiberoptic bundle.

Charge-Coupled Device
The video image endoscope became a reality because of improvements in charge-coupled device
technology. The charge-coupled device (CCD or "chip") was invented in 1969 at Bell Laboratories by
W. S. Boyle and G. E. Smith. The CCD was first used in commercial cameras in 1981. Since then, an
array of remarkable machines has been built on the technology of the solid-state image sensor,
including facsimile machines, optical character readers, department store checkout wands,
surveillance cameras, and home video systems. The CCD also provides the "eyes" for robotic vision
systems and can be integrated with computers to automatically count parts, perform critical
measurements, and spot defects in manufacturing processes.
Solid-state image sensors have several important advantages over older technologies such as vacuum
tube imaging systems. They require much less power, are less susceptible to mechanical vibration and
shock, and are not damaged by bright illumination. They also do not "lag", that is, produce comet-like
tails trailing behind highlights when an image is moving.
Solid-state CCD image sensors have additional characteristics that make them particularly well suited
for certain unique applications. CCDs are commonly used in astronomy because their sensitivity to
light is more than 100 times greater than photographic film. They also have a dynamic range that is
more than 50 times greater than photographic film or tube cameras. They can be made to "stare" into
space for long periods of time to image faint celestial bodies that would otherwise be obscured by
bright nearby objects if they were recorded using conventional photographic techniques. At the
opposite extreme, the CCD can be electronically shuttered and operated at very short exposures to
capture images of fast-moving objects in as little as 1/10,000 second. For consumer applications, the
CCD's low power consumption, high resolution, and good color reproduction make it the sensor of
choice for home video cameras. For many of these same reasons, CCDs are found in most broadcast
video cameras as well.
Despite all of these inherent advantages as an imaging device, the CCD could not be used for
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endoscopic applications until solid-state technology evolved to the point that extremely small CCDs
could be manufactured to fit in the limited space at the distal tip of the endoscope.

Solid-State Imaging Technology

CCDs are solid-state image sensors made of silicon semiconductor material. The silicon on the
surface of the sensor is responsive to light and exhibits the photoelectric effect. When a photon of light
strikes this photosensitive surface, it displaces an electron from a silicon atom. This produces a free,
negatively charged electron and a positively charged "hole" created by the absence of the electron in
the regular crystalline structure of the silicon.
Although a single photosensitive element can be used to measure the brightness of the light falling on
the device (e.g., a light meter), it cannot reproduce an image. To do so, the photosensitive surface
must be divided into a matrix of small, independent photosites. When an image is focused on the
surface of such a sensor, the brightness of each discrete point in the image can be measured for later
The surface of a CCD is divided into an array of discrete photosites (Figure 32), individually referred
to as picture elements, or pixels. For simplicity, Figure 32 illustrates a pixel array of 10 rows by 10
columns (a total of 100 pixels). An actual endoscopic CCD may contain up to several hundred
thousand pixels.

(140)Figure 32. The photosensitive surface of a charge-coupled device (CCD) image sensor
is divided into a matrix of individual photosites called pixels.
In the video image endoscope, the CCD is located within the distal tip directly behind the objective lens
(Figure 33). The objective lens focuses a miniature picture of the observed area on the surface of the
CCD. (In some endoscopes, a prism reflects the image onto a CCD mounted at 90 degrees to the
optical axis of the instrument.) The pattern of light falling on the CCD is instantly converted into an
array of electrical charges owing to the photoelectric effect. Because charges created in each pixel are
isolated from neighboring charges, the CCD transforms the optical image into a faithful electrical
representation (Figure 34). The greatest number of charges is generated in those areas that are
brightest (Figure 34C).

(141)Figure 33. The components within a video endoscope's distal tip include a fiberoptic
light guide bundle for bringing light into the gastrointestinal tract, an objective lens for
focusing an image of the mucosa on the face of the image sensor, and a CCD image sensor
that captures the image for display on a video monitor.

(142)Figure 34. A, The photosensitive surface of a CCD is divided into electrically isolated
pixels. B, An endoscopic image is projected onto the CCD surface. C, A representation of the
image is created in the form of electrical charges. A detailed look at individual pixels indicates
that the charge developed is proportional to the brightness of the light falling on each pixel.
Each pixel can develop any amount of charge in a continuum from some minimum to some maximum
level, depending on the brightness of the incident light. The basic physics of the process is simple
and linear. Doubling the number of photons of light falling on a pixel doubles the number of charges
generated until the potential well (pixel) storing the electrons is finally full. Because of this linear
relationship, the charge developed at each photosite is the product of the brightness of the incident
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light and the exposure time.

After the exposure period, the charges developed in the CCD must be "read out" in an orderly manner
and processed to reproduce the image. The several methods used to transfer charges within and
finally out of a CCD include line, frame, and interline transmission systems.

Line Transfer CCD

The line transmission system is schematically illustrated in Figure 35. The charges within each
pixel are controlled and shifted via electrodes adjacent to each pixel (not shown in the figure). By
varying the voltages applied to these electrodes, the electrons within individual pixels are transferred
as "charge packets" from one pixel to another. Sequential voltage changes on these electrodes march
the charge packets toward one end of the CCD and into a horizontal shift register.

(143)Figure 35. Schematic representation showing how charges are transferred and read out
of a CCD employing the line transmission system.
Figure 35 illustrates how the charges in the bottom row of the CCD are first transferred into the
horizontal shift register, leaving the bottom row empty. This starts the orderly transfer of charges from
each row to the row below it, starting at the bottom row and feeding from the top. After completing one
series of transfers (see Figure 35, Step 1 to Step 2), the electrical representation of the image has
shifted down by one row of pixels, with the charge packets from the bottom row of pixels now residing
in the horizontal shift register.
The quantity of charge in each charge packet within the horizontal shift register is then measured as
the packets progress one step at a time toward the amplifier at the left of the horizontal shift register.
The amplifier generates an output signal corresponding to the quantity of charges contained in each
charge packet. This output signal is later used to re-create the variation in brightness of the bottom row
of pixels.
Once the horizontal shift register is read out and emptied (see Figure 35, Step 3) the process repeats.
The charges in the bottom row of pixels are transferred into the horizontal shift register and the entire
image replica is shifted down one more row (see Figure 35, Step 4). The shift register is read out
again (see Figure 35, Step 5), and the process continues until the entire image has been read out and
the CCD surface is cleared for another exposure.
The "charge-coupling" processthe transfer of charges as packets from potential well to potential
wellgives the CCD its name. The charges in the furthermost corners of the CCD are actually moved
sequentially through several hundred potential wells before they finally reach the output of the
horizontal shift register. In current video image endoscopes, the CCD is exposed, read out, and
reexposed 60 to 90 times each second. To maintain image integrity during these repetitive transfers, it
is essential that these charge packets remain intact with no loss or gain in charge quantity as they
undergo hundreds of thousands of transfers per second as the CCD is read out.

Frame Transfer CCD

Some videoscopes utilize a frame transfer CCD (Figure 36). A frame transmission system uses two
separate pixel arrays. The first is a sensor array on which the endoscopic image is focused. This array
generates the charges during exposure. After exposure, the charges quickly transfer (as indicated by
the long vertical arrows in Figure 36) to a second storage array of identical size that is shielded from
light. The charges are held in this storage array until they are read out and processed. In the
meantime, the sensor array is reexposed to capture another image.

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(144)Figure 36. Schematic representation showing how charges are transferred through a
CCD employing the frame transmission system.
The processing of charges within the storage array is similar to that for the line transmission system.
Step-by-step (as indicated by the short arrows in Figure 36), each row of charge packets in the
storage array is transferred into the horizontal shift register and read out to the amplifier to generate
the output signal.
Because a frame transfer CCD contains both sensor and storage arrays, frame transfer CCDs tend to
be physically larger than line transfer CCDs. Although frame transfer CCDs have high light sensitivity,
their larger size is a disadvantage in many endoscopic applications.
The sensor arrays in both line and frame transfer CCDs generate charges whenever they are
illuminated. During the time period in which charges are transferred from the photosensitive area,
additional charges are generated by light still incident on the sensor pixels. These charges are added
to those being transferred through the sensor array. As a result, as the image is shifted through the
array, it becomes blurred by the incoming light, with especially bright areas of the scene producing
prominent vertical bands across the image. The solution to this problem is to prevent unnecessary light
from falling on the CCD while charges are being transferred out of the sensor array. Therefore, all
videoscopes using line or frame transfer CCDs must have a means of strobing the endoscope's
illumination so that light is present only during exposure and is absent during charge transfer.

Interline Transfer CCD

One type of CCD operates with nonstrobed, continuous illumination (Figure 37). Known as the
interline transmission system, this CCD has a vertical shift register adjacent to each column of
photosites. Immediately after exposure, charges developed at the photosites are transferred in one
quick step to the storage sites in the adjacent vertical shift registers. Owing to the rapid, one-step
transfer of these charges, illumination of the CCD need not be interrupted and the CCD can continue
to collect light. In the meantime, charges transferred to the storage sites in the vertical shift registers
move step-by-step down the vertical registers into the horizontal shift register, and then to the output
amplifier. The vertical shift registers are shielded from incident light, allowing them to be emptied while
the sensor array is exposed. When the vertical shift registers are empty, a new group of charges,
representing a new image, is transferred from the photosites.

(145)Figure 37. Schematic representation showing how charges are transferred through a
CCD employing the interline transmission system.
All three types of CCDs described previously have been used in commercial video image endoscopes.
Each type has its own advantages and disadvantages in terms of physical size, circuit complexity, light
sensitivity, and illumination requirements.

Shape of the Displayed Image

All endoscopes emit a conical beam of light from their distal tip. Likewise, the objective lens at the
distal end of the endoscope captures a round image. Because of these geometric considerations,
modern fiberoptic endoscopes typically use round image fiber bundles and present a round image in
the eye piece of the instrument. By contrast, commercially available videoscopes produce a wide
variety of image shapes on the observation monitor.
Because all CCDs use a matrix of rows and columns to transfer charges, the photosensitive surface of
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all CCDs is either square or rectangular. Because the objective lens of the endoscope projects a
circular image onto the photosensitive surface of the CCD, the videoscope engineer must make the
best use of the mismatch between the round image and the square sensor. The shape of the image on
the monitor screen is ultimately determined by the relative size of the projected endoscopic image on
the image sensor (Figure 38). If the endoscopic image is reduced to fit inside the borders of the
sensor, the CCD captures the entire illuminated area and a round image is displayed by the monitor. A
large number of pixels in the corners of the CCD, however, are not illuminated and therefore are not
used (Figure 38A).

(146)Figure 38. The size of the endoscopic image as projected on the CCD sensor
determines the ultimate shape of the endoscopic image on the monitor. A, The entire
endoscopic image is reduced to fit inside the CCD sensor, producing a round image. B, The
image is enlarged to cover the entire CCD surface, resulting in a square image. C, An
intermediate condition producing an eight-sided image.
If the projected image is enlarged to cover the corners of the CCD, the entire CCD is illuminated and a
square or rectangular image is displayed by the monitor. Since all pixels are illuminated, the CCD
sensor is used efficiently. A large portion of the endoscopic image, however, falls off the photosensitive
area of the CCD and is not detected and not displayed (see Figure 38B). The angle of view of the
displayed image is greatly reduced, and the endoscopist sees only the center portion of the illuminated
A compromise between these two extremes is to project an intermediate-sized image on the CCD to
minimize the number of unused pixels while capturing as much of the endoscopic image as possible.
This results in an eight-sided image shape (see Figure 38C). All three image shapes are used by
videoscope manufacturers.

Reproduction of Color
All solid-state image sensors are inherently monochromatic devices, that is, black-and-white (B/W)
sensors. Because the silicon photosites respond only to the intensity (brightness) of the light falling on
them, they cannot distinguish the actual wavelengths (color) of the incident light, and therefore cannot
provide direct information on the hue and saturation of each point in the image (HSI color space).
For the endoscope to reproduce colora capability essential for medical useit is necessary to further
electronically analyze the incident light to determine its color attributes.
To understand the process of color reproduction, it is first necessary to understand how the human eye
and brain perceive color. All photographic and electronic imaging systems attempt to mimic the
biologic imager, the eye. The sensitivity of the human eye to light varies with wavelength (Figure 39).
The eye is most sensitive to green, and less sensitive to reds, blues, and other colors. The CCD has a
similar sensitivity response curve, but it responds to a broader range of wavelengths, including infrared
light (wavelengths greater than 780 nm) and ultraviolet light (wavelengths less than 380 nm) that fall
outside the visible portion of the spectrum to which the eye responds.

(147)Figure 39. Comparison of the relative sensitivities of the human eye and the CCD to
various wavelengths of light.
Anyone who has mixed paints has observed that when two or more colors are mixed together, we no
longer perceive two independent colors, but instead see a single, newly created, third color. In any
mixture of colors, it is not possible for the eye to detect the exact component colors. The eye differs
from the ear in this respect. If two notes of different pitch are sounded simultaneously, the ear senses
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not a single intermediate tone but two clearly distinguishable notes. Our sense of hearing is analytical,
whereas our sense of color is not.

Trichromatic Vision
Nearly any color to which the human eye is sensitive can be matched by mixing light of three
colorsred, green, and blue (RGB). These are often referred to as the additive primary colors. If
three light projectors are fitted with red, green, and blue filters, and light from each is slightly
overlapped and projected simultaneously, the resulting image is similar to that shown in Figure 310.
Light reflected from the area where the red and green projectors overlap produces a mental sensation
indistinguishable from that produced by monochromatic yellow light. Likewise, overlapping red and blue
light produces magenta; blue and green light produces cyan. Where all three primary colors overlap at
the center, the eye perceives the combined reflected light as pure white with no hint of the component
colors. Thus, white light results from the mixture of all colors and is not the absence of color. By
varying the light intensities of the three individual projectors, it is possible to reproduce nearly any
spectral color.

(148)Figure 310. Additive primary colorsred, green, and bluecombine to form pure
The concept of human trichromatic vision was first proposed in the early 1800s by Thomas Young
based on his experiments with red, green, and blue light projectors. His experiments, and those that
followed, caused scientists to postulate that humans perceive color through the stimulation of three
different types of neural cells (cones) within the retina. These are presumed to have the approximate
sensitivity response curves shown in Figure 311.

(149)Figure 311. Hypothetical relative sensitivities of the suggested three types of retinal
cones to various wavelengths of light.
In many ways, it is fortunate that our eyes see color in the manner described. The additive and
subtractive properties of color make it possible for a printer to produce a full-color brochure using inks
of only three colors, for a chemist to manufacture color film using dyes of only three colors, and for
engineers to design color monitors that reproduce an unlimited variety of color using phosphors of only
three colors painted on the face of the picture tube.

Theory of Color Video

Video color reproduction is based on the concepts of trichromatic vision and additive color (RGB color
space). All video images are composed from the three component colors of red, green, and blue. As
mentioned, these are also the colors used in the phosphors for re-creating the video image on the face
of the color television (TV) monitor.
Three other colors commonly encountered in TV systems are the subtractive primary colors: yellow,
magenta, and cyan. Each of these is produced by mixing equal amounts of two additive primary colors
(see Figure 310). They are referred to as subtractive primaries because they are the colors that result
when an additive primary is subtracted from white. For example, filtering red light from white light
leaves cyan, that is, blue plus green. Since the additive and subtractive primary colors are basic to all
video reproduction, they commonly appear in the "color bar" displays used for adjusting video monitors
during setup.

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RGB Sequential Imaging Technology

All videoscopes may be categorized by the type of color imaging system they employ. Currently, two
types of videoscopes are commercially available: the RGB sequential videoscope and the color-chip
videoscope. Each has its own characteristics, advantages, and disadvantages.
The VideoEndoscope (the first commercial video image endoscope) introduced by Welch Allyn in
1983, as well as many videoscopes available today, employed an RGB sequential imaging system.
The components of the RGB sequential imaging system are shown in Figure 312. A monochromatic
CCD is mounted in the endoscope immediately behind the distal objective lens. The lens focuses a
miniature image of the endoscopic field on the CCD's photosensitive surface. Similar to the fiberoptic
endoscope, the video image endoscope employs a fiber bundle to bring light for illumination into the
gastrointestinal tract. However, in the case of an RGB sequential videoscope, the illumination is not the
ordinary white light as used for fiberoptic viewing; it is a pulsed or strobed, colored light.

(150)Figure 312. Schematic of an RGB sequential imaging system. A spinning filter wheel
within the video processor produces pulses of red, green, and blue light. Images captured
under this variously colored illumination are temporarily stored in the video processor prior to
simultaneous display on a monitor.
A xenon lamp within the video processor unit emits a conventional broad spectrum of white light.
However, positioned between the lamp and the fiber bundle of the endoscope is a rotating filter wheel
containing red, green, and blue filter segments (see Figure 312). As the filter wheel rotates,
alternating flashes of red, green, and blue light are emitted at the distal end of the endoscope. Owing
to the speed of filter wheel rotation, typically 20 to 30 revolutions/second (rps), these bursts of colored
light appear to the eye as a flickering white light, the phenomenon illustrated in Figure 310.
The imaging system creates three separate monochromatic images. During the fraction of a second in
which the red filter is in the light path, the CCD image sensor records an intensity (B/W) profile of the
endoscopic image as it appears under red illumination. Areas that appear reddish under natural white
light reflect heavily under red illumination and are therefore bright in the monochromatic image. Areas
of the image that are predominantly blue or green, or combinations thereof, appear dark under red
After an intensity profile is obtained under red illumination, the filter wheel rotates to one of the opaque
segments of the wheel that separate the filter components. This prevents light from entering the
endoscope and instantly causes the interior of the gastrointestinal tract to become dark. During this
instant, the image on the CCD is read out and directed through a switching circuit for storage in one of
the three solid-state memories within the video processor (e.g., the image information obtained under
red illumination is directed to the memory area reserved for "red images").
A second exposure is made under green illumination and the resulting B/W image replica is sent to the
"green image" memory in the video processor. Finally, a third image is obtained under blue illumination
and stored in the "blue image" memory. This sequence of capturing a separate set of images for each
of the three primary colors is repeated 20 to 30 times each second; with the exact rate being
determined by the video processor.
The face of a color video monitor is actually composed of an organized matrix of red, green, and blue
phosphor dots (circles or rectangles) (see Figure 312). The monitor also contains three electron guns,
each of which scans the face of the picture tube. The beam from the "red" gun hits and activates only
the red phosphor dots. The "green" and "blue" electron guns illuminate only the green and blue
phosphor dots, respectively.
By feeding the signal stored in the red memory of the video processor to the red electron gun, the
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monitor reproduces the endoscopic image as it appears under red illumination. Likewise, feeding the
signals stored in the green and blue memory arrays to the green and blue electron guns reproduces
the green and blue components of the image. (Although three guns are described here, some monitors
achieve the same results using a single electron gun.)
It is a phenomenon of human vision that when two or more sources of color are placed in close
proximity, but not overlapping, and are viewed at a sufficient distance, the colors blend together to form
a third color. This phenomenon, referred to as the juxtaposition of color sources, causes an observer to
perceive the three superimposed images from the red, green, and blue electron guns as blending
together to form a single, full-colored, natural-looking image, rather than a confusing collection of
multicolored dots. The RGB sequential imaging process is summarized in Figure 313.

(151)Figure 313. Illustration of color reproduction using additive primary color images.
Three monochrome (intensity profile) images are captured while the objects are illuminated
sequentially with red, green, and blue light. Note that all of these monochrome images are
different, indicating that the various objects illuminated absorb and reflect light differently,
depending on the wavelength of the incident light. To reproduce the image, the monochrome
images are converted into red, green, and blue component images. Superimposing these three
component images on a video monitor results in a final image of natural color.

Color-Chip Video Imaging Technology

A "color-chip" CCD is a B/W image sensor with a custom-fabricated, multicolored filter bonded to its
surface. This filter allows the CCD to directly and simultaneously resolve the color components of the
image. Often the term instantaneous single-plate color imaging system is used to emphasize that
all three color components are obtained concurrently by a single plate, or CCD.
There are many different ways to construct a color CCD. One of the simpler methods is to cover the
CCD with a precisely aligned RGB-striped filter (Figure 314A). When an image is projected onto the
photosensitive surface behind the striped filter (Figure 314B), and the information from all of the red
columns of pixels is combined, a basic red component image can be constructed. Likewise, combining
the information from pixels behind the green and blue filter stripes enables the reconstruction of the
green and blue component images, respectively.

(152)Figure 314. A, CCD with an RGB-striped filter. B, Combining the brightness

information of the individual red, green, and blue columns of pixels will allow re-creation of
the red, green, and blue image components, respectively.
In many respects, the basic components of the RGB sequential system described herein and the basic
components of an RGB-striped CCD are the same, except that the filters have changed size and
location. The filters that were previously located in the rotating filter wheel of the light source are now
miniaturized, cut into thin strips, and bonded to the surface of the CCD itself in the color-chip design.
Although RGB-striped CCDs (see Figure 314) are sometimes used in miniature TV cameras, they are
not commonly used in endoscopes. Rather, color-chip videoscopes typically employ a mosaic filter
arrangement of nonprimary colors owing to certain advantages that will be explained later.
When a mosaic filter is designed, a number of different filter patterns and color choices are available,
each with advantages and disadvantages. One of the more popular mosaic filter designs is shown in
Figure 315. In this example, the colors chosen for the filter elements are yellow, cyan, and white (no
filter). These segments are arranged in a 2 2 pixel pattern, regularly repeated over the face of the
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CCD. Since the final output signals sent to the monitor must be the standard red, green, and blue
component signals, the image produced behind this yellow/cyan/white mosaic filter must be converted
into its primary red, green, and blue components. A processing algorithm for doing this is also
illustrated in Figure 315.

(153)Figure 315. Mosaic filter composed of yellow, cyan, and white filter elements. An
analysis of a representative block of four pixels is shown. The relative intensities of the final
RGB components for this block of four pixels can be calculated using the processing
algorithm illustrated on the right.
A yellow filter element absorbs blue light but passes red and green light (see Figure 310). Therefore,
pixels behind all yellow elements receive both red and green image information. Likewise, pixels
behind the cyan filter elements receive light covering both the blue and the green portions of the color
spectrum (see Figure 310). The filter-free white pixels receive light covering all three primary colors.
Thus, in a representative block of four pixels (one yellow, one cyan, and two white), three pixels
receive red component information, four pixels receive green information, and three pixels receive blue
information (see Figure 315). By adding or subtracting the information obtained from adjacent pixels
using an appropriate algorithm (see Figure 315), it is possible to derive the individual red, green, and
blue component values for each block of (four) pixels.
A yellow/cyan/white mosaic filter (see Figure 315) has a significant brightness advantage over an
RGB stripe filter (see Figure 314). When red-, green-, and blue-striped filters are used, each pixel is
filtered to receive only one of the three primary colors. A cyan-filtered pixel, on the other hand, is
exposed to both blue and green light. It is therefore more heavily illuminated than a pure blue or pure
green pixel. Likewise, pixels behind a yellow filter (red plus green) or white filter (no filtration) receive
more photons (light) than pixels behind a pure red, green, or blue filter.
Because of the increase in light passing through the yellow/cyan/white mosaic filter, a CCD with this
construction exhibits greater light sensitivity than an RGB-striped CCD. The increase in brightness
achieved by using non-primary-colored filters is obtained at the expense of the additional processing
required to later separate the mixed color signals into their primary components. However, owing to
their increased light sensitivity, color mosaic CCDs allow the videoscope designer to construct an
endoscope with a smaller light guide fiber bundle, to maximize its angle of view, and to increase the
optical system's depth of field. All of these characteristics improve optical performance. Because of
these advantages, all commercial color-chip videoscopes use color mosaic rather than RGB-striped

Reproduction of Motion
The color-chip videoscope has an inherent advantage over the RGB sequential videoscope in
reproducing motion. The filter wheel in current RGB sequential video processors typically rotates at 20
to 30 rps. Since each of the color component images is captured individually in sequence, it takes 1/30
second (with a 30-rps filter wheel) to capture the three component images that make up a single video
image (Figure 316). If there is relative motion between the endoscope and the object being viewed,
as often occurs during endoscopy, the three component images may differ slightly with respect to
object size and position. When these three images are subsequently superimposed on the video
monitor, it is likely that they will be misaligned.

(154)Figure 316. RGB sequential videoscope requires 1/30 second to capture all three RGB
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This misalignment is clearly visible if the endoscopist happens to freeze the image when it is moving
rapidly. However, this color separation is continuously present, to a greater or lesser extent, throughout
the entire examination. It gives the images an unnatural, colorful, stroboscopic appearance when there
is rapid motion of the endoscope or the object being viewed, or both. This type of color separation is
especially apparent when water droplets are sprayed across the lens to clean it.
The color-chip videoscope, on the other hand, has an inherent advantage in imaging moving objects.
Because it captures all three color components of the image simultaneously, there is never any color
separation with either moving or "frozen" images. Since illumination is continuous and unstrobed, and
since the frame rate is consistent with customary TV standards, reproduction of moving images is
always smooth and looks natural.
Another unique advantage of the color-chip videoscope is that the effective shutter speed for capturing
still images can be shortened to increase the sharpness of frozen images. The color-chip system
normally captures a new video field every 1/60 second (Figure 317). Even though this time is
relatively short, quickly moving subjects, when frozen for observation or documentation, may appear to
be slightly blurred (but without color separation) owing to movement during this 1/60-second capture
period. However, this 1/60-second capture period can be electronically shortened to a fraction of its
normal time. Although the videoscope designer can choose any appropriate time period, a typical
"fast-shutter" exposure is 1/250 second. At this speed, sharp images of the fastest-moving endoscopic
subjects are obtainable.

(155)Figure 317. Color chip videoscope captures all color components simultaneously.
Capture time can be shortened to 1/250 second to eliminate blurring of fast-moving subjects.
As in traditional film photography, the shorter the exposure period, the more brightly the subject must
be illuminated to prevent underexposure. Therefore, the fast-shutter mode may not provide enough
light for distant panoramic images. However, in situations in which it is truly needed (e.g., close-up
viewing when there is likely to be a large amount of relative motion between the endoscope and the
mucosa), the fast-shutter capture mode is very effective at producing bright, sharp, frozen images.

Inherent Advantages of a Color-Chip Videoscope

The color-chip videoscope has several inherent advantages over the RGB sequential system. Those
discussed previously include: (1) smooth, natural reproduction of motion; (2) the absence of color
separation on frozen images; and (3) a fast-shutter mode that prevents image blur of even the fastest
moving subject.
A fourth advantage of the color-chip CCD is compatibility with standard (nonstrobing) xenon light
sources. This allows use of the same light source with both fiberoptic and video image endoscopes.
Increased transillumination is a fifth advantage. Since the color-chip videoscope operates with the
same intense white light used in fiberoptic instrument systems, transabdominal illumination is usually
possible without increasing the brightness of the light source. If additional light is needed, the light
source can be set to maximum. This may cause the video image to be overly bright, but there will be
no loss of color. With the RGB sequential system, transillumination is problematic, since its strobed
light output is substantially weaker than that of a fiberscope system. Therefore, many RGB sequential
systems have a means for temporarily removing the spinning filter wheel from the light path. This
produces a constant, intense white light for transillumination. Once the filter wheel is removed,
however, the image is lost, for in most cases the illumination is so intense that it saturates the CCD,
producing a totally white screen. Even if an image is visible, it will be in B/W, since the filter wheel must
be in proper position to reproduce color.
A sixth advantage of the color-chip system is superior performance when used in endoscopic laser
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therapy procedures (see later).

Laser Therapy Via the Videoscope

No video image endoscope can be effectively used with lasers that operate within the visible spectrum.
For example, it is impossible to use an argon-ion laser operating at approximately 500 nm with a video
image endoscope without distorting the image. Since the blue-green argon-ion beam is much more
intense than the background illumination of the video system, laser light completely saturates the CCD
whenever the laser is fired. The result is severe blooming and often a totally white screen with
complete loss of image detail. If the endoscope were constructed with a distal filter to eliminate the
blue-green laser light, similar blue-green image information would be removed from the endoscopic
images, resulting in abnormally colored mucosa on the monitor.
It is possible to efficiently adapt video image endoscopes for use with lasers that operate outside the
visible spectrum. For example, the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, which
produces near-infrared light at 1060 nm, is compatible with modified videoscopes. Since the Nd:YAG
laser output is outside the visible range, manufacturers commonly protect the endoscope CCD by
covering it with a filter that transmits visible light (the image) but heavily absorbs the reflected laser light
(near-infrared light). Whenever the laser is fired within the endoscopic field, the filter prevents the laser
output from reaching the CCD and leaves the image undisturbed.
Despite the addition of a filter over the CCD, RGB sequential videoscopes have two disadvantages
when used with an Nd:YAG laser. The first is a loss of the true color of the aiming beam (a conical
beam of visible light that approximates the geometry of the surgical laser beam and allows the
endoscopist to aim the invisible Nd:YAG laser at the target site). The helium-neon (He-Ne) aiming
beam used in almost all Nd:YAG lasers appears as a red spot when observed with a fiberscope or
color-chip videoscope. However, when observed by an RGB sequential videoscope, the beam is
always white. This is because the red aiming beam is illuminated continuously and therefore appears
equally bright to the CCD during all portions of the RGB imaging cycle. As a result, the RGB sequential
video processor interprets the light as being white. Because of this color loss, the bright, artificially
white aiming beam displayed on the monitor obscures the tissue effects produced by the Nd:YAG laser
and impairs observation of the laser's action. This loss of aiming beam color can be avoided by
strobing the aiming beam in synchrony with the light source filter wheel. This modification, however, is
complex and costly.
A second disadvantage of the RGB sequential endoscope for laser therapy is the relatively low
brightness of its strobed illumination. This causes two problems: (1) the intensity of the laser aiming
beam must be reduced because medical lasers have been traditionally designed to work with the
intense illumination produced by fiberoptic endoscopes, and (2) during periods of concentrated
treatment, tissue may glow at the point of laser impact. Since the burning tissue may be brighter than
the videoscope's background illumination, the glowing tissue also may cause the CCD to bloom and
mask the local tissue effects of the laser.
In contrast, the color-chip videoscope uses intense, nonstrobed white light illumination, similar to that
used with fiberscopes. The intensity of the laser aiming beam, therefore, is usually not a problem. Also,
the aiming beam always retains its red color. The result is a view similar to that seen through
fiberscopes. Because of these factors, the color-chip videoscope is usually the better choice for
endoscopic laser therapy.

Advantages of the RGB Sequential Videoscope

Having considered the advantages of the color-chip videoscope, it is now appropriate to review the
advantages of the RGB sequential videoscope. These can also be exploited when designing a video
image endoscope.
One of the major advantages of the RGB sequential videoscope is the opportunity for increased
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resolution. In simple terms, resolution relates directly to the number of pixels in an image. The
color-chip system requires that information from several different pixels be combined (added to or
subtracted from each other) to obtain the red, green, and blue component values for a single point
within the image (Figure 315). In the RGB sequential system, each pixel is illuminated by red, green,
and blue light in sequence and each provides information on each of the three color components. If the
number of pixels were unlimited, the resolution of the two technologies could be similar, but in
endoscopic applications the physical size of the CCD is restricted to the space available within the
distal end of the endoscope. This places limits on the size of the CCD and the number of pixels it can
contain. Since the color-chip CCD uses several pixels to provide the same information obtained from a
single pixel in the RGB system, the latter system can theoretically produce the greatest image
resolution, assuming pixel size and number are comparable.
Because the RGB sequential videoscope uses primary-colored filters, and since the color components
are captured and processed separately within the videoprocessor, this type of videoscope can provide
very accurate color information. Although both systems produce natural-looking images, the RGB
sequential system can theoretically produce a truer color signal, which may make it more suitable for
image analysis research.

Recent Advances in RGB Sequential Videoscopes

Recently introduced RGB sequential videoscope systems are engineered to overcome many of the
limitations of previous designs. To prevent the previously described problem of color separation of
frozen images, some new RGB sequential video processors incorporate an anti-color-slip circuit to
analyze images in real time and freeze the image at the moment when color separation is at a
minimum (Figure 318). In early RGB systems, the processor "froze" the image displayed on the
monitor at the exact instant when the image capture function was activated. Instead of capturing this
initial image, activation of the freeze function of newer RGB video processors triggers a special capture
circuit that analyzes the stream of images for the next 0.25-second, that is, the next 5 rotations of the
filter wheel (Figure 318). From these 5 complete images (a total of 15 RGB component images), the
circuit selects the set of RGB component images that exhibits the least amount of color separation. In
the example shown in Figure 318, the capture circuit found that relative motion was minimal during
RGB component images 8, 9, and 10, these being obtained during the third and fourth rotations of the
filter wheel. The circuit therefore holds these three RGB component images in memory as the best
possible still image of the subject, and displays this frame on the monitor as the best frozen image.
Even though the system is able to choose only from the images obtained within a 0.25-second period,
the circuit is remarkably effective in reducing color separation.

(156)Figure 318. EVIS-200 anti-color-slip capture circuit analyzes images obtained during a
0.25-second time period. RGB components 8, 9, and 10 exhibit the least amount of relative
motion and hence the best frozen image.

Designing for Compatibility

When endoscopy entered the video age, it left behind the compatibility advantages of fiberoptic
instruments. When designing a fiberscope, the designer can select a fiber bundle from a wide range of
sizes in order to make an optimum compromise among fiber bundle diameter, image resolution,
accessory channel diameter, and insertion tube diameter. Thus, a manufacturer's line of fiberscopes
frequently contains a wide range of optical systems with various levels of image resolution. All of these
instruments are fully compatible with a large number of light sources, still cameras, and ancillary
Videoscopes, on the other hand, greatly restrict optical design flexibility. As much as one half of the
circuitry in a video processor is designed around the specific CCD with which the processor is intended
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to operate. Until recently, no manufacturer had designed a video processor that would work with
several different CCDs. This meant that within a single videoscope system, all instrumentsfrom the
largest colonoscope to the slimmest gastroscopeused identical CCDs (although some
manufacturers modified the image display to hide this fact). Because video processors were tied to a
single CCD, the number of available videoscope models was limited when contrasted with the wide
range of comparable fiberoptic models.
The Olympus EVIS-200 system was the first video image endoscopy system designed around a family
of compatible CCDs. The CV-200 video processor drives three distinct CCDs, each of which differs in
size and image resolution capability. An advantage of this strategy is that a family of compatible CCDs
allows for development of a wide range of videoscopesincluding large-diameter high-resolution
instruments, specialty endoscopes, thin pediatric endoscopes, and large-channeled therapeutic
instrumentsall of which are compatible with the same videoprocessor. For a single video processor
to drive several different CCDs, the various CCDs usually must have similar electrical and physical
characteristics. In particular, the video processor must specifically compensate for differences in pixel
number, illumination requirements, data transfer rates, and drive circuitry.

Functions of a Typical Video Processor

Figure 319 schematically illustrates the functions of the various electrical circuits within a typical RGB
sequential video processor. The CCD image sensor (in the distal end of the endoscope) receives both
power and drive (timing) signals from the video processor. The timing signals control the readout of the
CCD and the transfer of charges to the horizontal shift register (see earlier discussion). From the shift
register, the image signal is fed through an amplifier on the CCD and into the preprocess circuitry of
the video processor.

(157)Figure 319. Simplified schematic illustrating some of the basic functions of an RGB
sequential video processor. A/Danalog to digital; D/Adigital to analog.
The preprocess circuitry is responsible for electrically isolating the patient from the potentially
dangerous high-voltage circuitry of the videoprocessor, for initiating automatic brightness control,
and for adjusting the chroma (color) and white balance of the image. The preprocess circuitry further
amplifies the signal and often performs additional image processing functions such as edge
The signal then passes through an analog-to-digital (A/D) converter that changes the signal from
analog to digital form. The digitized image is then directed through a switching circuit for storage in
one of the red, green, or blue segments of the image memory array. Images from the digital memories
are next passed through a size-correction circuit to adjust the relative size of the endoscopic image for
presentation on the video monitor. A second circuit then adjusts the relative position of the endoscopic
image and sizes and positions any subscreen image that may be added to the screen along with the
main image. An example of a typical subscreen image is a reduced display of the real-time endoscopic
image that is added to the screen whenever the main image is frozen.
At this point, the developing monitor image is still in digital form, but it has been adjusted in size and
position, with subscreen images (if any) added. The image then passes through a digital-to-analog
(D/A) converter to change the image back to analog form. The developing monitor image then passes
through a masking circuit that adds a mask (typically black) around the image(s) to provide a uniform
background color. Finally, the image passes through postprocessing circuitry to make the video signal
conform to a recognized video signal standard so that the image can be displayed on a standard video
Figure 319 also schematically illustrates some of the mechanical components of the video processor
and light source. Light from the source lamp first passes through an infrared absorption filter to remove
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nonvisible heat rays. The light then passes through a lens that focuses it on the tip of the fiberoptic light
guide bundle within the umbilical cord of the videoscope. An iris in the light path controls the brightness
of the light transmitted to the endoscope, and a filter wheel modifies the color of the light (described
previously). The motor rotating the filter wheel is regulated by a control circuit to ensure that the wheel
spins at the precise speed required by the video processor. Detectors placed adjacent to the filter
wheel identify at all times which filter segment (red, green, or blue) is in the light path.
Synchronization circuitry within the video processor ensures that all functions of the video processor
and light source are coordinated with the video output signal. These functions include synchronization
of filter wheel rotation, exposure and readout of the CCD, memory transfers within the video processor,
and image freeze control.
Video processors also generally require endoscope discrimination circuitry to identify the model (or
type) of endoscope connected to the processor. Endoscope discrimination allows the system to
compensate for differences in CCD type and endoscope length.
Although Figure 319 summarizes many of the basic functions of a video processor, for simplicity
some typical functions are not illustrated. Excluded are the connections to an external keyboard for text
input; circuitry for superimposing text on the monitor image; and circuitry for communicating with
external computers, printers, and image documentation devices.

Universal Light Source

The first commercial videoscope systems combined the video processor and light source in a single
unit. This was convenient given the close interaction required between the two devices. Recently,
however, "universal" light sources have been introduced. The concept of an all-purpose light source
originated from a desire to increase the flexibility of endoscopy systems. True universal light sources
are compatible with a wide variety of endoscopes, both fiberoptic and video, and also make it easier to
upgrade the endoscopic system as a whole. For example, the Olympus CLV-U20 universal light source
is compatible with fiberscopes (OES series), RGB sequential videoscopes (EVIS-200 series), and
color-chip videoscopes (EVIS-100 series). An effective universal light source has automatic brightness
control for both video and fiberoptic instruments, automatic flash photography capabilities for
fiberscopes, and the ability to remove the rotating RGB filter wheel from the light path when the light
source is used with color-chip and fiberoptic instruments.

Video Standards
All cathode ray tube (CRT) monitors, whether used for computer or video applications, "paint" an
image on a screen with a scanning electron beam. This beam typically starts in the upper left corner
and scans the monitor face, line by line, from top to bottom. The energy of this electron beam causes
the phosphors applied to the back of the screen to glow briefly, thus creating an image. The left-to-right
movement of the beam is referred to as horizontal scanning; top to bottom movement is referred to as
vertical scanning.
Figure 320 illustrates two scanning methods. One common protocol requires that the beam start at
the top of the monitor and scan the image downward on the screen, one line at a time, until it reaches
the bottom. Figure 320A illustrates the state of the monitor in the middle of such a process. (The red
arrow in the figure points to the last line scanned just before interrupting the process.) By the time the
beam reaches the bottom of the screen, the lines scanned first (those at the top) have begun to fade
away (Figure 320B). The monitor face is then repainted, starting again at the top and working down. If
each new image is slightly different from its predecessor, the system depicts motion, each newly
scanned image being the next frame in a motion sequence.

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(158)Figure 320. Comparison between the scanning protocols for non-interlaced (A and B)
and interlaced (C and D) video monitors.
A disadvantage of this simple scanning protocol is that the phosphors must decay very rapidly in order
that the screen just ahead of the scanning beam be continuously black for repainting. The quickly
fading phosphors cause an annoying rolling or flickering of the screen as a dark horizontal band
continuously precedes the area of the screen being repainted.
To address the problem of flickering, an interlaced scanning protocol was developed. An interlaced
scan starts at the top, scans line 1, skips line 2, scans lines 3, 5, 7, and so on, until all of the odd lines
are scanned (see Figure 320C). The beam then returns to the top and begins filling in the even lines.
By the time the even lines are completed, the odd lines have begun to fade away (see Figure 320D).
The odd lines are then refreshed as the entire process repeats. The advantage of this system is that
older lines, which are fading and being repainted, are interlaced with a full screen of brightly glowing,
recently scanned lines. Screen interlace, therefore, noticeably reduces screen flicker.
The TV signal for creating an interlaced screen must alternate between segments of video information
for scanning the odd lines and information for scanning the even lines. The odd lines represent the first
field of the image; the even lines represent the second field. Together, the two fields paint the entire
screen once and create a single video frame. The process then starts over again, first one field, then
the other, until a second complete picture or video frame is displayed.
The specifications of the interlace system described were standardized by the Electronic Institute of
America (EIA) and adopted by the U. S. Federal Communications Commission in 1941. Under the EIA
RS-170A standard, used for all broadcast and closed-circuit TV systems in the United States, a video
frame consists of 525 horizontal scan lines, of which 483 are actually observable on the screen.
Furthermore, the RS-170A standard requires that 60 fields (30 frames) be displayed during each
second of live video. Since a frame is composed of 525 lines, a total of 15,750 lines of information (30
525) are processed by the video system each second.
In 1953, the National Television System Committee (NTSC) proposed a color encoding method that
expanded on the RS-170A standard to become the first B/W-compatible, simultaneous color system
used for public broadcasting. The NTSC standard for color TV signals is the universal color encoding
method used in the United States, Canada, and Japan. In contrast to the NTSC standard, which is
based on 525 lines/frame and 30 frames/second, most European countries conform to the
incompatible PAL or SECAM color TV standards that specify 625 lines/frame and 25 frames/second.
Figure 321 displays a typical portion of an NTSC video signal for a single, active horizontal scan line.
The word active is emphasized, since out of the specified 525 scan lines required per frame,
approximately 35 do not contain any picture information. Instead, these are used by the inactive
electron beam as it travels in zigzag fashion from the bottom of the screen at the end of each field back
to the top. In addition to this loss, a portion of each horizontal scan line is also used for purposes other
than picture information. This nonpicture portion of the signal is used for synchronization and color
reference signals. Altogether, approximately 30% of the video signal used in the NTSC process is not
available for transmitting true picture information. The reference and synchronization segments of the
signal are essential, however, for reproducing true color and synchronizing the monitor scan that is
reconstructing the image with the device (e.g., video processor) that is generating the image.

(159)Figure 321. Representation of a portion of an NTSC composite video signal for

scanning a single horizontal line.
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Each horizontal line of the video signal is divided into two parts (see Figure 321): the active video
period, and a horizontal blanking (H-blanking) period. During the active video period, the electron
beam paints one horizontal line of the image. During the horizontal blanking and retrace interval, the
beam returns invisibly from the right to the left side of the screen to begin another line. The total time
allotted to the scan of a single horizontal line is approximately 63.6 sec, of which approximately 52
sec is spent generating a single horizontal line of glowing phosphor dots on the face of the picture
tube. The H-blanking period contains a horizontal sync pulse and a 3.58-MHz color burst signal. This
color burst signal establishes the reference phase and frequency of the color signal and serves as a
reference to the circuit that is decoding the color information.
The active video portion of the signal contains both a luminance (brightness) signal and a
chrominance (color) signal. The luminance signal describes the brightness of each point in the scan
line and is the only part of the signal used by B/W TV monitors. The luminance signal, the
low-frequency component of the active video signal, ranges between the signal levels representing
pure black and pure white. Superimposed on the luminance signal is the higher-frequency
chrominance signal. Whereas the luminance signal determines the brightness of each point in the
horizontal scan line, the chrominance signal establishes the colorspecifically the hue and saturation
of each point along the scan line. At any instant, the color saturation level is determined by the
amplitude of the chrominance signal, and the hue is determined by the phase difference between the
chrominance signal and the reference color burst. The chrominance signal and reference color burst
may be up to 360 degrees out of phase, all colors being encoded in this 0- to 360-degree phase range.
A signal similar to that represented in Figure 321 is repeated until 245.5 (262.5 - 17) lines are traced,
at which point the electron beam is at the bottom of the screen. Then a vertical blanking and retrace
(V-blanking) signal hides the beam as it zigzags from the bottom of the screen to the top. Once the
beam returns to the top, blanking stops and a horizontal scan signal (see Figure 321) returns to
create the first line of the next field.
The NTSC video signal (see Figure 321) is a composite video signalthat is, luminance
(brightness) and chrominance (color) information are combined in one signal. Although a composite
signal is convenient for broadcasting, image quality deteriorates to some extent as the color
information is encoded into and decoded from the brightness signal. Most videoscopes today also have
a means of outputting the image in a luminance/ chrominance (Y/C) video format. Y/C video
connections maintain the brightness and chrominance information on two separate wires. Monitors,
videocassette recorders (VCRs), and other peripheral equipment communicating with Y/C signals
provide better image reproduction than composite video equipment.
A third method of interconnecting video equipment is to use red, green, blue, sync (RGBS) cables. This
video communication method is the best means of preserving video image quality, since the
information for the red, green, and blue image components and synchronization is carried separately
over four different wires, so that the information is never mixed. Most videoscopes provide the option of
using any or all of these three video connection methods (NTSC composite, Y/C, or RGBS).

White Balance
The various lamps used in endoscopic light sources emit light ranging from a reddish tint (halogen
lamps operating at a color temperature of 3700 K) to white (xenon lamps operating at 5500 K) to a
bluish tint (metal halide lamps operating at 6000 K). In addition to the type of lamp used, the color of
the light emitted at the distal end of an endoscope is further affected by the length and optical
characteristics of the fiberoptic bundle carrying the light from the lamp. To reproduce white objects as
pure white on the monitor, regardless of the tint of the illuminating light, the video system must be
white balanced. This process produces a signal with equal parts of red, green, and blue, regardless of
the color temperature of the illumination. If, for example, the illumination system produces more red
light than blue or green, the video processor must proportionally reduce the red output signal to equal
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the blue and green signals. A videoscope can be white balanced by pointing the endoscope at a white
object and activating the automatic white balance circuitry. During white balance, the video processor
automatically adjusts its internal processing circuits to compensate for the color temperature of the
illumination system. Once this adjustment is made, the system is "white balanced." All colors will
remain true as long as the same endoscope and illumination source are used.
Although it was stated previously that white balance attempts to achieve equal amounts of red, green,
and blue light, this should be clarified. Video systems are designed to mimic human vision. The eye is
most sensitive to green and least sensitive to blue light (see Figure 311), a fact that must be
accounted for in the final video signal. When the RGB color information is combined into the final
composite signal in the NTSC system, the composite brightness signal is not the sum of equal parts of
the individual red, green, and blue brightness signals. Rather, the NTSC luminance signal equals 30%
of the red, plus 59% of the green, plus 11% of the blue luminance values (1 lumen white = 0.30 lumen
red + 0.59 lumen green + 0.11 lumen blue). When red, green, and blue video primary colors are mixed
in these proportions, the result appears to the eye to be pure white.

Field Versus Frame Capture

The distinction between a video field and a video frame is significant when images of rapidly moving
subjects are captured. In extreme conditions, the image may shift significantly during the time it takes
(1/30 second) to capture both fields of the video image. Because the fields are captured sequentially,
the image captured by the first video field may be slightly displaced from the image captured by the
second field. Owing to this offset, the edges of objects within the image may appear ragged when the
two images are interlaced. The faster an object is moving, the greater the difference between the
images in the two fields.
When these two frozen offset fields are displayed together, there may also be a disturbing flicker in the
image as the monitor alternately reproduces the two displaced fields. Flicker can be reduced in a
"frozen image" by switching the documentation device from the frame mode to the field capture mode.
In field mode, every other line is displayed (the second field is removed from the display), resulting in a
single, crisp, nonflickering image from the first field. However, because the displayed image lacks the
second field, vertical image resolution drops accordingly. It is often better to operate the videoscope in
frame mode and, if flickering occurs, to take a second photo while endoscope movement is minimized.

Video Resolution
The term resolution refers to the smallest element of an image visible to the human eye. In video,
resolution measurements are based on what a viewer with normal vision can distinguish when
positioned at a distance from the monitor that is approximately eight times the height of the picture on
the monitor screen. Vertical resolution is expressed as the maximum number of horizontally oriented
lines, from the top to the bottom of the screen or vice versa, that can be made visible to the observer.
NTSC TV images have an aspect ratio of 4:3. This indicates that the image is 4 units wide and 3 units
high. Horizontal resolution is specified in a manner comparable with that of vertical resolution by
determining the maximum number of vertically oriented lines that the viewer can distinguish over three
fourths of the TV screen width. Resolution therefore equals the maximum number of horizontal or
vertical lines that are distinguishable in a square area of the monitor covering 75% of the monitor's
width (Figure 322). (Although this description outlines the basic theory on which video resolution
specifications are based, manufacturers typically use standardized test patterns and electronic
instruments to determine video resolution.)

(160)Figure 322. Vertical resolution is determined by the maximum number of horizontal

lines the system can reproduce from the top of the screen to the bottom. Owing to the 4:3
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aspect ratio of an NTSC monitor, horizontal resolution is determined by the maximum number
of vertical lines reproducible within three quarters of the monitor's width.

Other Advances in Video Image Endoscopes

Video image endoscope technology has improved significantly since its introduction in 1983. Recent
advances in CCD manufacturing have reduced the physical size and increased the resolution of CCDs.
Smaller chip size allows the videoscope designer to reduce the physical dimensions of the videoscope
and thereby improve the handling and maneuverability of the instrument. The large size of early CCDs
necessitated larger insertion tube diameters or smaller working channels, or both. In addition, the rigid
distal tip housing the CCD in early videoscopes was typically quite long, making the instrument less
maneuverable than fiberoptic models. This was particularly true of video image duodenoscopes.
However, advances in CCD technology have allowed most current video image endoscopes to rival
their fiberoptic counterparts in all respects.
In contrast to first-generation videoscopes, current instruments offer simultaneous display of real-time
and frozen images, plus a wide range of options for displaying text and system information on the
monitor screen. In general, image brightness, dynamic range, angle of view, and image resolution have
all been improved. In addition, remote switches on the control body of current videoscopes provide the
endoscopist with direct operation of ancillary equipment.

Factors to Consider When Evaluating a Video Image Endoscope

The video image endoscope is a technologically advanced and complex clinical tool. Comparisons of
various models have been reported in the literature.810(161) It is difficult, however, to identify any
single design criterion as the deciding factor in selecting the best videoscope for a particular clinical
application. Each of the following criteria must be considered:
1. Image quality (wide angle of view and good depth of field, high image resolution, wide dynamic
range, a high signal-to-noise ratio, good image contrast, minimum blooming, accurate color,
and excellent frozen image quality).
2. Illumination characteristics (adequate image brightness under all clinical conditionseven
illumination from center to edge of the imageand automatic brightness adjustment as viewing
distances change).
3. Basic endoscope functions (responsive handling and appropriate insertion tube characteristics;
smooth tip angulation; a control section of appropriate shape and weight; well-positioned
angulation knobs and valves; and good suction, insufflation, and lens washing performance).
4. Basic specifications (appropriate insertion tube diameter, sufficient accessory channel capacity,
and availability of a full range of instrument models).
5. Suitability for special therapeutic procedures (good image protection from electrosurgical noise
and minimum laser interference).
6. System features (easy-to-understand video processor controls; adequate keyboard functions;
sufficient image and color controls; accessible endoscope switches for control of remote devices;
and acceptable equipment size, weight, and transportability).
7. System expansion and integration (full capability for interfacing the videoscope system with hard
copy devices, video tape recorders, and computers; the ability to combine endoscopic images
with database information; and compatibility with existing fiberoptic instrumentation).

Since the early 1990s, the video image endoscope has supplanted the fiberscope as the preferred
instrument for most clinical applications. The availability of two distinct video imaging technologies
allows the endoscopist a choice of systems according to clinical requirements. Recent improvements
in RGB sequential systems have increased image resolution, reduced the problem of color separation
in frozen images, and expanded the range of videoscope models. Of the two imaging technologies, the
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RGB sequential system has the potential for highest image resolution and purest color information
(perhaps useful in the future for computer analysis of endoscopic images). In contrast, the color-chip
system has inherent advantages in image reproduction when the subject is moving, offers a fast
shutter mode for sharp frozen images, produces better transillumination, provides improved
performance with Nd:YAG laser therapy, and is compatible with standard xenon light sources.

Additive primary colors

The colors red, green, and blue. These can be combined in

various proportions to reproduce all other spectral colors.

Aspect ratio

The ratio of width to height of the video image. In NTSC

systems, the video image is 4 units in width by 3 units in

Automatic brightness control

A combination of functions that continuously monitors and

automatically adjusts the light source and video signal
levels to maintain optimum image brightness on the video
monitor. Since the level of mucosal illumination is
inversely proportional to the square of the distance between
the illumination source (distal end of the endoscope) and
the mucosa, endoscopic images darken as the endoscope
moves away from an object or the gut wall. Automatic
brightness control compensates for this by (1) automatically
adjusting the brightness of the light source and (2) using an
automatic gain control circuit within the video processor to
electronically increase the amplitude of the video signal if
the image is below average brightness.


The process of cutting off the electron beam in the picture

tube during the retrace period to make the retrace of the
beam invisible on the monitor.


A condition in which image highlights become blurred or

defocused on the monitor owing to overexposure of a
pixel(s) to light (pixel saturation). The charges produced in
the saturated pixel(s) spill over into adjacent pixels,
enlarging the representation of the highlight on the monitor.


An abbreviation for charge-coupled device. A solid-state

device that, through the photoelectric effect, transforms
light (images) into finite quantities of electrical charges and
transfers the charges as packets through charge-coupling to
a processing circuit.

Chrominance signal

The portion of a composite video signal that contains the

color information.

Color burst

The portion of a composite video signal that establishes a

reference for decoding the chrominance signal. The color

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burst consists of several cycles of a sine wave at the

chrominance subcarrier frequency.
Color-chip videoscope

A common term for describing a video image endoscope

that employs an instantaneous single-plate imaging system.

Composite video

A video signal in which the elements of luminance

(brightness) and chrominance (color) are encoded into a
single signal. The luminance component of a composite
video signal is compatible with B/W video transmissions.


The range of light and dark values within a picture, or the

ratio between maximum and minimum brightness values.
Low-contrast images appear mainly as shades of gray, and
high-contrast images appear primarily as blacks and whites
with little gray.


Information quantified in discrete values. In contrast to

analog systems that handle continuously varying signals,
microprocessors and logic circuits require digital
information. Whereas the transmission and recording of
analog information (e.g., long-playing records, analog audio
tapes) is subject to deterioration and noise, digital-based
information (e.g., computer files, compact discs) can be
transmitted and duplicated completely free of degradation.
Although standard video monitors are analog devices, much
of the image processing that is performed in the endoscope
video processor is accomplished after the image has been
digitized. Endoscopic documentation systems that archive
endoscopic images via computer also store the image in a
digital format.

Dynamic range

The range in signal strength from a minimum level (dark

signal) determined by noise to a maximum level (bright
signal) beyond which the CCD does not output an increase
in signal level with a corresponding increase in incident
light. A videoscope with wide dynamic range produces
good image detail in both dark and brightly illuminated
regions of the image.


One of the two equal parts into which a television frame is

divided in an interlaced system of scanning. In the NTSC
system, a field consists of 262.5 horizontal scan lines.


The total amount of instantaneous picture information

perceived by the viewer, consisting of two interlaced odd
and even fields. An NTSC video frame consists of 525
horizontal lines.

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Frame transmission system

A CCD charge transfer system in which one frame of image

information is captured in a sensor array and is then
transmitted at one time to a separate storage array on the
CCD itself. The disadvantage of this design is that these
CCDs tend to be larger than other types of CCDs. Frame
transmission CCDs typically require that the endoscope has
a longer rigid distal tip or a larger diameter.


To display a single still image from an ongoing sequence.

When frozen, either one video field (field capture) or one
video frame (frame capture) is stored in digital memory or
displayed on the monitor.


Areas of maximum brightness within an image, occurring

in regions of highest illumination or greatest reflection.

Horizontal blanking and retrace

H-blanking) The blanking signal produced at the end of

each horizontal line while the electron beam invisibly
returns from the right to the left side of the monitor screen.

HSI color space

A method of analyzing and representing color based on the

attributes of hue, saturation, and intensity. (See also RGB
color space.)


A color attribute that describes a pure color, such as red,

yellow, green, purple, etc. Hue is typically what is meant by
the term "color." (See also HSI color space, Intensity, and

Incident light

Light falling directly on an object.

Instantaneous single-plate

A type of imaging system used in home video cameras

color imaging system

and some video image endoscopes. The system uses

standard white light for illumination. Light reflected from
the object under observation is passed through a colored
mosaic filter bonded to the CCD surface. The advantages of
this type of imaging system include smooth reproduction of
rapidly moving images without strobing or color separation
and compatability with standard white light sources. (See
also RGB sequential imaging system.)


A color attribute referring to the gray level (black and white

value) or relative brightness or darkness of the color.

Interlaced scanning

A scanning protocol in which the monitor generates a

complete image by first scanning all odd-numbered lines
(first field), followed by a second scan interleaving the
even-numbered lines (second field).

Interline transmission system

A commonly used CCD charge transfer system. Unlike the

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frame transmission system, in which one frame of

information is transmitted all at once, the interline system
transmits signals each time the horizontal direction of the
chip is scanned. The CCD structure is more complex, but
the size of the CCD is smaller than chips that use the frame
transmission system.
Line transmission system

A CCD charge transfer system that requires a smaller

number of input/output connections than other CCD
designs having an equal number of pixels. A line
transmission CCD allows miniaturization of electronic
circuitry, resulting in smaller endoscope diameters and
shorter rigid distal tip lengths.

Luminance signal

The portion of a composite video signal that represents the

brightness of the scan line.


A wavy or satiny effect produced by the convergence of

lines or patterns. Moir is often seen when a regularly
repeating pattern (such as a honeycomb fiberbundle pattern)
is projected on an imaging device (such as the pixel matrix
in a CCD).


Having only one color. Or alternately, a "black-and-white"

representation of the brightness profile of a color image.


A signal disturbance that obscures or reduces image clarity.

Noise can appear to be either random and incoherent or
fixed to the image.


An abbreviation for the National Television System

Committee. In 1953, the color encoding method proposed
by this committee was adopted by the Federal
Communications Commission as the first B/W-compatible,
simultaneous color system for public broadcast. The United
States, Canada, and Japan use the NTSC system for
broadcast television. (See also PAL and SECAM.)


An abbreviation for phase alternating line. The color video

transmission system used by the majority of European
countries. The PAL television standard uses more scan
lines (625 lines/frame versus 525 lines/frame) but a lower
frame rate (25 frames/second versus 30 frames/second)
than the NTSC system used in the United States and Japan.


An abbreviation for picture elements, the smallest unit

component of an image. The term also refers to the discrete
sensor elements that make up a solid-state image sensor.
The number of pixels on a CCD is one factor that

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determines the resolution of an imaging system.


A measure of a video system's ability to reproduce detail.

Image resolution is determined subjectively by the number
of lines that can be recognized on a television monitor
displaying an Electronic Institute of America (EIA)
Resolution Chart. Resolution is measured separately in the
horizontal and the vertical direction.

RGB color space

A method of representing color based on the relative

amounts of the three additive primary colors (red, green,
and blue) contained in the color under analysis. When
complex color image processing is performed, it is often
easier to convert the RGB representation of color into HSI
(hue, saturation, intensity) values. (See also HSI color

RGB sequential imaging system

The type of imaging system used by the majority of video

image endoscope manufacturers. The system requires a
strobed light source outfitted with three primary color
filters. The endoscopic field under observation is
sequentially imaged under red, green, and blue
illumination. The three sequentially obtained images are
then processed and recombined on the viewing monitor.
Color reproduction is excellent with this system; relative
motion, however, results in color separation in the
re-created image. RGB sequential imaging systems are also
able to use CCDs with fewer input/output connections,
which results in videoscopes with smaller diameters and
shorter rigid distal tips.

RGB sequential videoscope

A video image endoscope employing an RGB sequential

imaging system.


A video scanning standard developed by the EIA. It

specifies a video format of 525 total lines, a 2:1 interlaced
frame rate of 30 Hz, and a 15.734-KHz horizontal line scan


A color attribute that describes color purity, or the degree to

which a pure color is diluted with white. A high-saturated
color has a low white content (e.g., vivid red), whereas a
low-saturated color has a high white content (e.g., pink). In
composite video signals, color saturation is determined by
the amplitude of the chrominance signal.


The process in which a two-dimensional image is analyzed

and converted to line information. Scanning also refers to

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the opposite process in which lines of information are

reassembled to form an image. Monitor scanning is
performed from left to right, top to bottom. As the beam
scans across the face of the monitor, it causes the phosphors
coating the back of the monitor glass to glow in intensity
proportional to the intensity of the electron beam hitting the

An abbreviation for sequential color with memory, from the

French "sequential couleur avec mmoire." A color
broadcast system used in several parts of Eastern Europe.
The system, which is based on 625 lines/frame and 25
frames/second, features strong resistance to color changes
and good immunity to transmission interference, but
performs poorly in the presence of heavy electrical noise.


A measure of a video system's ability to produce usable

pictures in low light. The more sensitive a system is, the
less light it requires.

Signal-to-noise ratio

The ratio, expressed in logarithmic terms, between a useful

video signal and the unwanted noise or interference
superimposed on the signal. The higher the ratio, the
"cleaner" the picture. The signal-to-noise ratio is an
indicator of how fine details appear relative to background
noise. Noise typically appears as a spotty or grainy texture
within the image.

Subtractive primary colors

The colors yellow, magenta, and cyan. These colors are

referred to as subtractive primaries because they are the
colors that result when an additive primary color is
subtracted (filtered out) from white light.

Synchronization (sync)

Electronic pulses that are inserted in the video signal for the
purpose of timing and correctly assembling the picture
information. These timing signals synchronize the transfer
of image information from the camera to the processing
circuitry and video monitor.

Trichromatic vision

A theory that there are three unique types of receptor cells

(cones) in the eye, each of which has selective sensitivity to
photons of red, green, or blue wavelengths.

Vertical blanking and retrace


The invisible return of the electron beam to the top of the picture tube at the
completion of a field scan.

White balance

A procedure for adjusting the circuitry of a video camera or

video processor to compensate for the (nonwhite) color of
the incident light falling on the object being imaged.

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Morrissey JF. Thoughts on the VideoEndoscope. Gastrointest Endosc 1984;30:43.

Sivak MV Jr, Fleischer DE. Colonoscopy with a video endoscope. Preliminary experience.
Gastrointest Endosc 1984;30:15.
Schapiro M. Electronic video endoscopy. A comprehensive review of the newest technology
and techniques. Pract Gastroenterol 1986;10:818.
Graham DY, Smith JL, Schwartz JT. Endoscopic television: Traditional and video endoscopy.
Gastrointest Endosc 1986;32:4951.
Demling L, Hazel HJ. Video endoscopy: Fundamentals and problems. Endoscopy
Sivak MV. Video endoscopy. Clin Gastroenterol 1986;15:20534.
Schapiro M, Auslander M, Schapiro MB. The electronic video endoscope: Clinical experience
with 1200 diagnostic and therapeutic cases in the community hospital. Gastrointest Endosc
Knyrim K, Seidlitz H, Hagenmuller F, Classen M. Videoendoscopes in comparison with
fiberscopes: Quantitative measurement of optical resolution. Endoscopy 1987;4:1569.
Knyrim K, Seidlitz H, Vakil N, et al. Optical performance of electronic imaging systems for the
colon. Gastroenterology 1989;96:77682.
Video colonoscope systems. Health Devices 1994;23:151205.

Chapter 4 The Endoscopy Unit



This chapter does not attempt to define the ideal endoscopy unit. The operational characteristics of
every unit are so unique that there can never be a single design plan that would be suitable in every
case. Rather, our purpose is to define principles of design and function that can be applied in most
instances. By considering the endoscopy unit as a concept rather than as a place, certain general rules
and guidelines can be evolved that are applicable in many situations.
Once a decision has been made to construct a new unit or to modify an existing facility, there is a
natural compulsion to think in terms of diagrams and blueprints, rooms and walls. This is the wrong
place to begin. Instead, the first and most important step is to define very clear concepts as to how a
unit functions. In fact, there are general principles of function that are common to all units. But there
are also operational characteristics that are unique, so that the second step in the process of building a
unit, also vitally important, is a careful and detailed assessment of the requirements that have
determined that a new unit should be built. This has two aspects: an analysis of historical data
concerning endoscopy operations and a forecast of future requirements. Past experience is,
unfortunately, the least reliable frame of reference for the future. Its value, however, lies in the
discovery of simple principles that shape action and in the measure of confidence it inspires in the
existence of logical sequences of cause and effect.
Construction of an endoscopy unit frequently involves great expenditures of time, money, and effort.
Mistakes can lead to long-term inefficiency, high operational costs, loss of revenue, frustration on the
part of those who work in the unit, and dissatisfied patients. It is therefore imperative to remember two
axioms: As far as possible, form must fit function, and the fundamental purpose of the endoscopy unit
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is to care for patients.

Evolution of the Endoscopy Unit

It is germane to ask why we have endoscopy units and how they come about.
The practice of dedicating a specific area of a hospital, an outpatient clinic, or even a private office to
the performance of endoscopic procedures is relatively recent. Although many factors have made
allocation of dedicated space for gastrointestinal (GI) endoscopy inevitable, the driving force, operative
in virtually every health care facility, has been growth in the demand for endoscopic services.
In its early phases, the development of endoscopy was limited by a lack of technically adequate
means. With the advent of the coherent fiberoptic bundle and its incorporation into a flexible
endoscope, the stage was set for growth of truly exponential proportions. Not only were risk and
requisite levels of skill reduced by flexible instruments, but sustained technical improvement also
steadily expanded diagnostic capability. As a result of remarkable improvements in GI endoscopes
since the early 1970s, certain diagnostic procedures such as upper GI endoscopy have become
technically less difficult and are thus performed by greater numbers of physicians. The ready
availability of such procedures combined with their superior diagnostic accuracy has naturally led to
greater utilization.
GI diseases themselves have added impetus to the rapid evolution of the endoscopy unit. For
example, GI endoscopy developed rapidly in a country such as Japan where gastric carcinoma is a
significant problem. Colon cancer and the recognition of its relation to the colon polyp have promoted
the development of colonoscopy and flexible sigmoidoscopy in the United States and other countries in
which the prevalence of this disease is high. GI diseases such as these have thus contributed to
steady growth year by year in the number of endoscopic procedures performed.
Therapeutic endoscopy is a somewhat more recent invention. Colonoscopic polypectomy is without
doubt the prototypic therapeutic maneuver for the modern era of therapeutic endoscopy. Previously,
certain therapeutic maneuvers existed, such as the extraction of foreign bodies and sclerotherapy.
However, these were not performed in numbers that could remotely approximate the potential for
colonoscopic polypectomy. The further development of side-viewing endoscopes in the early 1970s
provided an important new approach to the investigation of diseases of the duodenal papilla, bile duct,
and pancreas. Although diagnostic endoscopic retrograde cholangiopancreatography (ERCP) has
been supplanted to a certain extent by other, less invasive imaging methods such as computed
tomography, the addition of an electrosurgical wire to the standard cannula provided endoscopic
access to the biliary system and pancreas, which became the basis for a variety of more complicated
therapeutic maneuvers. There are now numerous examples of complex endoscopic treatment
methods that require sophisticated instruments, multitudes of ancillary equipment and accessories,
and specially trained personnel.
At the onset of the fiberoptic era, endoscopic procedures were performed in almost any convenient
place. Descriptions of these "procedure rooms" suggest that most amounted to little more than closets.
In the course of time, two closets were required in order to meet demand. Eventually, the need for
additional ancillary and support spaces became obvious, and this collection of rooms and space began
to take on a functionality of its own. In time, it became customary to refer to this place as the
endoscopy unit.
The endoscopy unit concept came into its own when specific areas within health care facilities were
reserved for the performance of endoscopic procedures. This event was a long time in coming for
many institutions, but this was fortunate in one respect: a better understanding of the necessary
facilities could be deduced from the inadequate nature and shortcomings of existing rooms and space.
Somewhat later, those who had participated in several cycles of unit development began to derive
principles of unit design and function that could be applied to the construction of any unit. Because of
size and cost, the development of new units began to require higher levels of thought and careful
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planning. Many endoscopy units are now designed in conjunction with professional architects and with
careful attention to the unique nature and purpose of the proposed facility. Fortunately, there are now a
few excellent publications that are concerned with the construction and operation of endoscopy
The percentage of procedures performed on an ambulatory basis has steadily increased since the
mid-1980s. This shift toward outpatient-based endoscopy has been a nearly universal trend in most
countries. Although therapeutic endoscopy has relatively low, albeit definite, morbidity and mortality
rates, many interventional procedures as well as diagnostic endoscopy in general can be performed
safely and expeditiously on an outpatient basis. In the United States, this trend has been motivated by
cost containment and efforts to avoid hospitalization whenever possible. Moreover, the great majority
of patients clearly regard the outpatient setting as preferable and more convenient. This emphasis
influences the design and operation of an endoscopy unit; more space must be available for waiting
rooms, dressing, preprocedure holding, and postprocedure recovery and additional personnel are
The advent of the electronic endoscope has been another seminal event in the history of the
endoscopy unit. This occurred during the early part of the 1980s at a point when the fiberscope had
reached its apogee of technical sophistication. The introduction of this new technology had obvious
ramifications for clinical practice and teaching. Less evident at that time was the effect it would have on
the endoscopy unit. Few, if any, units were designed to accommodate this new instrument. It was
common, for example, to find television monitors in the most improbable and inefficient places, often
the only available location in an otherwise crowded room. Wires were strewn about the floor and ceiling
to such an extent that they became a physical danger for the unwary.
Although the physical adaptation of the endoscopy unit to the "new electronics" has been problematic,
of greater consequence for the unit has been the transition to the use of computers to manipulate and
store images that was triggered by the electronic endoscope.
Whether considering a large tertiary care center or a small community hospital, the two attributes of
growth in numbers of procedures and expanding complexity are common to virtually every endoscopy
unit. To date, these two elements have been the driving force in the development of the endoscopy

Current Status of the Endoscopy Unit

It would be gratifying to believe that the development of endoscopy units around the world has
proceeded in an orderly, logical fashion based on a thorough knowledge of well-defined general
principles of unit operations, and guided in every case by a thoughtful needs assessment.
Undoubtedly, this cannot be the case. However, it would be valuable to have some knowledge of the
actual status worldwide of the endoscopy unit. Given the tremendous numbers of procedures
performed and the importance of endoscopy in the diagnosis and treatment of digestive diseases, it is
important to inquire whether existing units approximate reasonable standards of patient care.
It is extremely difficult, perhaps impossible, to obtain an accurate assessment of the status of
endoscopy units throughout the world or even in a particular country. Seifert and Weismuller7(165)
stated in 1986 that a completely satisfactory GI endoscopy unit probably did not exist in the Federal
Republic of Germany. Based on a survey of 31 hospitals, this statement was remarkable, coming from
a country with high standards of endoscopic practice. The British Society of Gastroenterology has
published an excellent series of monographs that provide detailed analysis on the design, staffing, and
operation of endoscopy units.810(166)
The Olympus Optical Company (Tokyo, Japan) and KeyMed Ltd. (Southend-on-Sea, Essex, England)
in 1988 commissioned one of us (RM) to conduct an Ergonomics and Design Study that surveyed a
total of 41 endoscopic facilities in five countries.11(167) Included in this study were tertiary care
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institutions (n = 17), general hospitals (n = 18), and private offices (n = 6). Among the facilities visited,
13 were located in the United States, 14 in Japan, 3 in Germany, 7 in the United Kingdom and 4 in
The objective of the Ergonomics and Design Study was to gather information concerning the manner
whereby the work of an endoscopy unit is accomplished and the extent to which the infrastructure and
design of a unit either facilitate or interfere with the tasks to be accomplished. These data were
analyzed from several perspectives such as layout of procedure rooms, the overall design of the unit,
and the utilization of space and equipment. The survey was not intended to assess level of endoscopic
skill and technique, nor to evaluate the appropriateness of procedures, safety, diagnostic accuracy, or
effectiveness of endoscopic treatment. It did, however, assess the quality of patient care in terms of
the emotional and physical comforts, or the lack thereof, provided for the patient. Inasmuch as data
were collected by an individual with no medical background or training, the survey also provides a
unique impression of endoscopy and the endoscopy unit obtained, in essence, from the vantage of a
patient. Lastly, the survey was undertaken to assess future requirements and expectations for
endoscopy and the endoscopy unit.
During survey visits, data were collected by means of a questionnaire. When permitted, still
photographs and videotapes were made throughout the unit (videotaping was permitted in 26 units).
Photographs were assembled into storyboards for each facility. In addition to providing a simple
mechanism for understanding the layout of a unit and its procedure room(s), the storyboard also gave
a general impression of the decor and amenities as well as the types of equipment in use. Videotapes
were especially useful in providing an assessment of the way in which individual physicians and
gastrointestinal assistants (GIAs) performed their functions within the procedure room. In this fashion,
approximately 100 physicians were observed in the performance of both upper and lower GI
procedures. Diagrams were then drawn to illustrate the design of procedure rooms (Figure 41), types
of equipment present, placement of this equipment, and the range of activities performed by physicians
and GIAs within the room.

(168)Figure 41. Movement patterns that determine endoscopist and gastrointestinal assistant
(GIA) sectors within a procedure room with video endoscopy systems. The diagram is based
on a compilation of survey data from KeyMed Endoscopy Unit Ergonomics and Design Study.
Note the extreme variability in the positions of the light source, the videoprocessor, and the
television monitor.
Units were rated according to assessment parameters on a scale of effectiveness that ranged from
poor to fair, average, good, and very good. On this admittedly subjective scale, 26 units were rated as
below average or unacceptable, 9 were considered average/acceptable, and 14 were rated as above
average. It is of interest that there were few differences in quality of equipment between the highest
and the lowest rated units. Crowding and a basic disregard for the dignity of the patient were invariably
observed in the poorest rated units.
Although it is not possible or appropriate to present all of the data contained in the KeyMed survey,
some of which remain proprietary, certain salient points are of interest.
The equipment in use in the great majority of units was of high quality, relatively new, and in good
condition. Roentgenographic equipment (including C-arm machines) was utilized for endoscopic
procedures on a frequent and regular basis in 31 units. In 15 institutions, this equipment was available
within the endoscopy unit. It was necessary that endoscopic equipment be transported to the radiology
department in the remaining 16 institutions, and in many of these facilities usage was sufficient to
justify the presence of an x-ray machine within the endoscopy unit. Lasers were present in 13 units and
available within the institution in a further 2. Endoscopic ultrasound equipment was found in 15 units
surveyed. Fourteen units had a computer or computer system. This was rated as reasonably
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sophisticated in 7 institutions.
At the time of the survey, many units were in various stages of transition from the exclusive use of
fiberoptic instruments to video endoscopy systems. A failure to recognize the special requirements for
incorporation of such systems was evident in the layout of many units. Video processors, television
monitors, and associated cabling were found at virtually any location within the procedure room (see
Figure 41).
Among the endoscopy units surveyed, 21 had special or separate areas designated for cleaning and
disinfection; 18 were equipped with automatic washing machines. In 5 units, washing machines were
placed within procedure rooms. In many cases, the areas set aside for endoscope/accessory cleaning
and disinfection were crude, badly designed, and poorly organized.
For patients undergoing procedures, storage lockers or cabinets for clothes and changing facilities
varied considerably from poor or nonexistent to very good. The design and decor of some but not all
units incorporated features and amenities that provided for the comfort of patients, both physical and
emotional, and preserved their privacy and dignity.
Comparisons of the individual units that composed the KeyMed survey would be inappropriate and
unnecessary. Furthermore, no single unit could be considered as perfect; each had flaws as well as
attractive features. However, a number of general conclusions can be drawn from the collective data.
The most immediate and obvious conclusion is the existence of an enormous range in the quality of
endoscopy units in terms of layout and efficiency. Some were clearly well organized and efficient;
others were characterized by chaos and disarray. Marked differences were found between as well as
within countries. Although it is often assumed that limited space results in poor design, large size was
not necessarily synonymous with a satisfactory arrangement of rooms and spaces (layout). In fact, the
size of many units was comparatively small, but the layout was relatively good, whereas in some of the
large units, the layout was very poor and could be attributed only to bad planning.
In the planning and construction of the units surveyed, it was generally apparent that relatively little
attention was given to cleaning and disinfection functions, including handling of soiled instruments.
This aspect of the endoscopy unit stood out clearly as the area most in need of immediate
The comfort and dignity of patients were not a high priority in the design of many units. In this regard,
there was again a wide range in ratings for the units surveyed. Data assembled in the survey identified
this as another major area in need of substantial improvement.
Although difficult to measure, there was a definite correlation between good design, emphasis placed
on nursing skill, and attention to the comfort of patients. Conversely, when nursing skill was at a low
level, patients were treated poorly, as if objects, and the entire operation of the unit reflected this
unacceptable treatment. Units that exhibited high levels of nursing skill were generally rated high in
terms of the attention given to patient comfort. When these elements were present, the unit was
usually extremely well organized with efficient layout and use of available space. Invariably, these
achievements were the result of careful planning.

Endoscopy Unit Function

A large endoscopy unit (25 to 35 or more procedures per day) is a complicated place in which a great
number of different procedures are performed. It is no small task to organize the use of available
space, numerous pieces of equipment, and the activities of various staff members to accomplish a
heavy schedule of procedures with a minimum of confusion. By the same token, the operation of such
a unit becomes difficult to comprehend as the numbers and complexity of procedures increase.
Planning for future needs and growth becomes even more perplexing. Given the seeming complexity,
problem solving as well as establishing and achieving goals can be an arduous process that
sometimes amounts to a series of educated guesses. From the standpoint of daily operations, problem
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solving, and future goals, it is therefore essential to clearly understand the way in which a unit
functions. To this end, certain management tools can be used. These are actually abstract concepts,
but they provide insight into function as well as a workable apparatus for analysis and problem solving.
These devices are the procedure unit and the weighted scale.

The Procedure Unit

Most endoscopists regard an endoscopic procedure only in terms of the actual use of an endoscope in
a patient. From an operational standpoint, a procedure is more complicated. Nevertheless, any
endoscopic procedure can be reduced to a series of basic steps (Table 41) that can be
subcategorized into three components: preprocedural, procedural, and postprocedural. The basic
procedure components taken together are termed a procedure unit. From a managerial viewpoint, the
business of an endoscopy unit is to produce endoscopy procedure units.


Procedure Unit

Patient check-in
Patient instruction, interview
Patient preparation
Room/equipment preparation
(Handling of biopsy and other specimens)
Patient recovery
Postprocedure instructions/scheduling
Room/equipment cleaning, turn around
Charting/report generation*
Written chart notation
Report dictation
Typing report
Review/signature of typed report
Processing of report to chart
File copy of report
Data processing
* Non-computer-based system.
Variable activity. May not be performed in some
endoscopy units.

The actual endoscopic (procedural) component of the procedure unit is but one part of a relatively
complex process. The length of time required for each component varies according to the type of
endoscopic procedure, although the endoscopy itself may require only a short length of time relative to
that needed for the other steps. Diagnostic esophagogastroduodenoscopy (EGD), for example,
requires only 5 to 10 min. But the related components of scheduling, preparing the patient for the
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procedure, preparing the procedure room and equipment, administering sedative drugs,
cleaning/disinfecting, and report generating require the same amounts of time as those for a
colonoscopy, even though the time required to perform a colonoscopy versus that for an EGD may be
longer by a factor of three or four.

Weighted Scale
Although all procedure units are identical, actual endoscopic procedures differ in many respects. From
the managerial point of view, the fundamental variables are the time required, number of personnel,
and items of equipment. The procedure unit concept is useless unless it is adjusted for these factors.
It is impossible to assess the true amount of work performed in an endoscopy unit simply by counting
the number of procedures performed. This "raw count" does not take into consideration complicated
procedures that require more time, equipment, and personnel. One way to deal with this variability is to
develop a weighted scale for procedures, essentially an equivalent value system that adjusts total
procedure count for degree of complexity. The number assigned in the scale to each specific type of
procedure relates the complexity of that procedure to an arbitrarily selected reference procedure. The
best reference procedure for a weighted scale is diagnostic EGD (without biopsy or other ancillary
procedures) because this procedure should be the least time consuming and least complex in terms of
personnel and equipment required. Diagnostic EGD may be assigned a value of 1.0 in a weighted
scale. Giving the procedure unit an arbitrary reference value in the weighted scale facilitates
manipulation and analysis of data. One procedure unit therefore becomes equivalent to a simple
diagnostic EGD.
The next step is to determine an equivalent time value for the unit used in the weighted scale. For
example, a weighted scale value of 1.0 may be given a time value of 30 min. The time value assigned
must take into account all of the steps in the procedure unit. Although it may require only 10 min to
perform the endoscopic component of a diagnostic EGD, a large number of other tasks must be
accomplished before the procedure room can be "turned around" for the next examination. A
suggested equivalent value table for a hypothetical endoscopy unit is shown in Table 42.


Suggested Weighted Scale of Endoscopic

EGD with heat probe or Bicap probe
Other procedures with EGD
Variceal banding
Esophageal dilation (bougie)
Limited colonoscopy
Multiple polypectomies (710 polyps)
Colonoscopy with sequential biopsy for dysplasia
Colonoscopy with heat probe or Bicap probe
ERCP, spincterotomy, stent placement
Sphincter of Oddi manometry
Laser, all types
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Suggested Weighted Scale of Endoscopic

EUS with FNA cytology
Any major complication, any procedure (e.g.,
respiratory arrest, hemorrhage)
Any procedure done on hospital floor (except laser
and ERCP)
EGDesophagogastroduodenoscopy; ERCPendoscopic retrograde
cholangiopancreatography;PEGpercutaneous endoscopic gastrostomy;
EUSendoscopic ultrasonography; FNAfine-needle aspiration.
* For example, polypectomy, dilation over guidewire, insertion of endoprosthesis.

Each endoscopy unit must develop its own weighted scale for procedures if this device is to be utilized
effectively. This is because there are unique aspects in the way each unit functions that cannot be
accounted for in a universal scale. For example, it may be necessary in some units that lack x-ray
equipment to perform ERCP procedures in a radiology department. In this case, transport time and
additional time to place necessary equipment on carts must be calculated into the procedure
equivalent value for ERCP. In units that provide instruction to trainees, equivalent values should also
reflect the fact that teaching is almost always inefficient. As a rule, supervised instruction increases the
time required for a procedure by a factor of about one third, and this added time must be factored into
the scale. In a nonteaching institution, the time equivalent for a weighted scale value of 1.0 might be
reduced to 25 or 20 min.
The procedure unit/weighted scale methodology has many uses with respect to analysis, planning, and
problem solving. It can be used to accurately gauge the work output and performance of a unit. For
example, the average weighted value for all procedures performed during specific periods of time can
be calculated. An average value that increases over the course of time indicates increasing complexity
of procedures and workload. This may occur with or without a change in the total number of
procedures performed. If little or no increase in the total count of procedures is recorded, the overall
output of work has nevertheless increased if the average weighted value for procedures has increased.
Also, an estimate of total work is obtained by multiplying the average weighted value by the total
number of procedures performed. In effect, this converts the work output to an equivalent number of
diagnostic EGDs.
The weighted scale methodology can also be used to obtain an actual measurement of the time and
effort required of the GIAs within a unit. To do so, the GIAs record a weighted value for each procedure
performed according to the guidelines in Table 42. Adjustments are permitted for especially lengthy
and difficult procedures or those that require an unusual number of items of equipment. For any given
period of time, a total of the weighted values becomes a fairly accurate representation of the actual
output of work. Dividing this total by the number of procedures performed provides a precise measure
of the acuity of procedures performed within the unit.
The weighted scale method of analysis of procedure activity can be used in planning for acquisition of
space, equipment, and staff. The theoretical maximum capacity of a given endoscopy unit can be
assessed in terms of procedure units once the average weighted value and the time value for one
procedure unit are established. This calculation would be as follows:

where N is the number of procedure rooms available, Hrs is the number of working hours per day,
Days refers to the number of working days per year, T is the time value for 1.0 procedure unit (or a
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weighted scale value of 1.0), Avg is the average procedure equivalent value, and Eff is the expected
efficiency of the unit. The last value, expected efficiency, is somewhat arbitrary, but if this is not
included, the calculation assumes that every room in the unit operates at 100% efficiency, something
that is not attainable. A more reasonable efficiency factor would be about 70%. It is also easy to
calculate the actual efficiency of a unit by comparing the weighted procedure count with the theoretical
maximum of 100% efficiency.
The weighted scale methodology can be used to assess the level of GIA staffing needed in the unit.
Although an increase (or decrease) in numbers of procedures is easy to demonstrate, this "raw count"
alone might not be enough to justify additional personnel. However, in addition to increasing numbers
of procedures, there may also be a corresponding increase in procedure complexity that is not
reflected in the count. In essence, the workload of the GIAs may be increasing to a much greater
extent than a simple count of procedures would suggest.

The Endoscopy Unit

Acquisition of Space
Until recently, few endoscopy units were specifically designed for GI endoscopy. Rather, portions of a
hospital or clinic were converted for this purpose. To a certain extent, this means that function must fit
form; that is, the design of the unit must conform to the physical dimensions of the space allocated.
Fitting the basic components of the unit into available space frequently leads to a less than ideal design
with respect to the flow of activities within the unit. All too often, sufficient time is not allocated for
planning and problem solving at the outset, so that end users are frequently disappointed with the final
Another liability inherent in the renovation of existing space is a lack of flexibility. The space available is
usually subdivided according to specific functions, and rooms are constructed for highly specific
purposes. However, it often becomes necessary to change the function of a specific room or rooms as
the demand for endoscopic services changes and new procedures and newly developed equipment
are added. Shifts in emphasis will be possible to the degree that foresight is exercised in designing
adaptability into the unit. It is therefore critical that the planners or design team allow sufficient time to
research current trends and future requirements before final acceptance of the proposed scheme.
An endoscopy unit is usually developed in response to problems that have arisen in meeting an
increasing demand for services. The unswerving desire of administrators to economize wherever
possible often leads to construction of a unit that is adequate for current needs, but poorly positioned
for future growth. Existing problems are solved to a large extent, but there is little anticipation of future
needs and potential problems. This leads to an obsolescence cycle in which a series of units will have
been constructed that meet the needs of the moment or at best the immediate future. This will prove to
be a false economy, as the subsequent efforts to accommodate future growth and change invariably
consume resources over and above those that would have been needed at the outset. Unfortunately,
the capacity for growth in numbers and complexity of procedures is often seen as a distinct luxury, and
built-in provisions for growth are seldom encountered. Rather, it is more usual that growth is
compromised in a fashion that is, based on past performance, predictable.

Principles of Design
All endoscopic procedures are alike in the sense that the same basic steps are required to complete
one procedure unit (see Table 41). From this standpoint, endoscopic procedures can be considered
uniform and interchangeable when designing an endoscopy unit. From another perspective, they are
dissimilar. In relation to the design and function of the unit, the differences in procedures relate to
requirements for diverse items of equipment and variation in procedure room size.
The Procedure Room
At least two persons are required for every endoscopic procedure (in addition to a patient): an
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endoscopist and a GIA. The procedure table should be considered the central focus of the room. It so
happens that for most procedures, the GIA and the endoscopist take different positions in relation to
the table as they perform their respective tasks. The basic rule of specific places within the room is
thus established by the way in which endoscopic procedures are performed.
It is necessary to have access to the procedure table from at least three and preferably four sides, so
that it is almost always placed at or near the center of the room. The next logical step conceptually is to
divide the room into sectors or work zones for the GIA and the endoscopist, based on their relationship
to the procedure table and the tasks they perform. Although the location of the endoscopist sector is
relatively fixed, GIA sectors vary with the type of procedure being performed. A well-designed
procedure room takes greatest advantage of this simple but valuable principle of dividing the room into
three basic sectors according to the position of the patient (table) and the activities of the GIA and the
The sectors within the procedure room are interactive. Considerable foresight and planning are
therefore needed before the layout of a room is finalized. In some cases, the size and location of the
sectors for the endoscopist and GIA may be dependent on the size and shape of the room where these
parameters have been defined by other considerations, as for example the need to construct a unit
within an existing structure.
The relatively fixed work sector for the endoscopist is smaller in terms of actual space than that for the
GIA. Obviously, this sector includes the position taken by the endoscopist for performance of the
procedure. The area immediately surrounding the endoscopist within his or her sector should provide
storage for commonplace procedural items such as lubricating jelly, gloves, and gauze pads. A second
satellite sector may be provided within the procedure room for the endoscopist for charting, dictating,
reviewing x-rays, accessing computer data, reviewing other types of records, and making telephone
calls. In larger units, a separate area outside the procedure room but in close proximity may be
provided for these functions.
The organizational routine of the GIA requires the most careful analysis in order that a procedure room
layout be designed that allows the assistant to work with maximum effectiveness. The GIA work sector
is far more complex than that of the endoscopist. It has three functional parts. The first is a work
surface immediately within the primary work sector of the GIA. Generally placed near the head of the
patient, this surface is designated for storage of endoscopic accessories, paraphernalia for handling
tissue specimens, gloves, and any other items that are likely to be needed during the procedure. The
second is a satellite area, close at hand, that includes storage space and an additional work surface.
Accessories, all of the drugs that are likely to be required, and other equipment that is less likely to be
needed during the procedure can be kept in this area. The third component to the GIA work sector is
designated for storage. It usually consists of cupboards and drawers as well as an extra work surface
when possible.
The procedure room as well as the endoscopist and GIA will come into contact with a wide array of
body fluids and tissues during endoscopic procedures. It is essential, therefore, that the distribution of
potentially infectious tissues and fluids within the procedure room be controlled as rigidly as possible.
For example, tissue samples should be handled in an area that is separate from that designated for
sedative and other drugs that may be administered to the patient. Endoscopes and accessories used
in a procedure should never be placed in an area designated as clean. There should be adherence to
this principle of strict separation of clean and dirty areas throughout the unit. A sink basin should be
provided in each procedure room for hand washing.
Two variables that must be considered in the design of a procedure room are size and shape. Opinion
varies somewhat as to an acceptable minimum size for a procedure room. Our recommendations are:
172 ft2 (16 m2) (RM); 192 ft2 (17.8 m2) (MER); 300 ft2 (27.9 m2) (MVS). These recommendations
refer to gross as opposed to net size, which takes into account installed cabinets. They pertain to the
floor space required for a basic procedure room. The recommendations at the smaller end of the range
are satisfactory for the basic standard procedures such as EGD and colonoscopy, whereas the larger
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recommendation provides contingency space for additional items of equipment such as a laser or an
endoscopic ultrasonography (EUS) unit. Rooms designated for these special procedures should have
a minimum of 200 net ft2. Larger rooms tend to be more adaptable and can be used for more than one
special procedure or for the development of new and highly technical procedures. Furthermore, rooms
of larger dimension are more suitable in teaching units where there are likely to be additional personnel
within the procedure room.
The shape of the room is another consideration. Unfortunately, this is sometimes dictated by the
overall dimensions of the building, placement of stairwells, elevators, plumbing, ducting, and a host of
other factors. When possible, however, a somewhat re 20 ft (4.5 6 m). In a room of rectangular
proportions, the work surfaces, cupboards, and storage facilities should be within convenient and
comfortable reach for the endoscopist and GIA. Diagrams of several hypothetical procedure rooms
based on these concepts are shown in Figure 42.

(169)Figure 42. Schematic diagrams of hypothetical procedure rooms. A and B, Rooms

designed for routine procedures such as esophagogastroduodenoscopy (EGD) and
colonoscopy. C and D, Rooms designed for endosonography and laser treatment. E, Procedure
room design with C-arm fluoroscope suitable for endoscopic retrograde
cholangiopancreatography (ERCP) and other procedures that require fluoroscopy.
Ooxygen; Vvacuum (suction); Aair (medical).
Division of Floor Space
The physical layout of an endoscopy unit must accommodate the basic steps in the procedure unit
(see Table 41). Space must be allotted to each component whether the endoscopy unit consists of a
single procedure room or has multiple rooms. Thus, any floor plan must subdivide available space
according to the fundamental functions listed in Table 43. In assigning available space(s) to specific
function(s), some areas may serve dual purposes. Areas can be set aside in the procedure room for
instrument storage and charting; scheduling, secretarial, and reception functions can be located in a
single area.

Basic Functions That

Require Allocation of Space in the Endoscopy

Patient reception
Patient interview room(s)
Patient dressing/recovery
Procedure room(s)

With maximum consolidation, the simplest possible endoscopy unit must consist of five room groups or
areas designated as follows: (1) patient reception, (2) scheduling/secretarial, (3) procedure room (with
areas for instrument storage and charting/report generation), (4) cleaning and disinfection of
instruments, and (5) patient dressing/recovery room or area. At the opposite extreme is the tertiary
center unit that is substantially larger than the simplest model, there being much greater floor space
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and many more rooms. Although available space is much greater in such a unit, it is nevertheless
allocated according to the same basic functional plan (see Table 43). In a unit in a sizable referral
center, separate, larger areas, even actual rooms, are provided for the basic functions listed
Independent and Interdependent Procedure Rooms
The degree to which the procedure rooms of a large unit will function independently of one another is
an important design decision.
In the simplest unit model (or single-room unit), the procedure room can serve several functions. To
the maximum possible extent, the elements of the procedure unit (see Table 41) are contained and
accomplished within this room. With this approach, the procedure room functions in a
semiautonomous fashion that is relatively independent of the other procedure rooms and support
areas. Even in a larger unit, this design can be preserved by placing as many elements of the
procedure unit as possible in the procedure room. For the large unit, however, such a system is usually
less efficient and is likely to increase the operational cost of running the unit.
The opposite approach is to accomplish as many procedure unit elements (see Table 41) away from
the procedure room as possible. The only activity performed in the procedure room is therefore the
endoscopic procedure itself. Because the procedure room represents a relatively large fraction of the
cost of development of a unit, it is usually more cost effective to restrict its use to the performance of
procedures. Other areas and rooms in the unit are provided and designated for other components of
the procedure unit. A single room or area for cleaning/disinfection and one for storage could serve
many or all procedure rooms. Centralized patterns for cleaning/disinfection and for storage versus a
more dispersed scheme with more than one area or room for cleaning/disinfection and for storage
(e.g., between two procedure rooms) is one of the main differences in design among units.
Centralization of storage and cleaning/disinfection functions provides flexibility in the use of procedure
rooms because the same equipment can be used in more than one room. Administration of sedative
drugs can also be accomplished outside the procedure room with the use of a cart exchange system.
In a completely interdependent system, the sole purpose of the procedure room will be the procedure
A unit built on the interdependent design concept is inherently more complex but potentially more
efficient from an operational standpoint. For example, procedure scheduling becomes more intricate
because care must be taken to avoid simultaneous procedures that require the same item of
equipment. The efficient operation of such a unit demands tight organization and teamwork on the part
of all personnel. The arrangement of the physical counterparts of the various procedure unit elements
also has a bearing on staffing. For example, with centralized cleaning/disinfection and storage, it may
be efficient to assign a GIA to this task alone, perhaps on a daily rotating basis.
Although the interdependent design concept offers the greatest prospect for efficiency and cost
effectiveness, extremely careful planning is required to realize this potential. By the same token, a
single design error or miscalculation becomes magnified throughout the entire unit and any gain in
efficiency is thereby eliminated. In particular, the size and functional capacity of support areas, such as
recovery and cleaning/disinfection, must be adequate to handle the maximum output from procedure
rooms. Otherwise, these ancillary and support functions can adversely affect efficiency and thereby
limit the overall productivity of the unit.
Multifunctional Versus Dedicated Procedure Rooms
An endoscopy unit takes on its unique character as various purposes are assigned to procedure
rooms. The balance between multifunctional versus dedicated procedure rooms is another of the major
differences between units.
In the simplest model (one procedure room), all pro-cedures in the repertoire are necessarily
performed in one room. As the number of procedure rooms increases, an independent room
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philosophy can be maintained; however, if carried to its logical conclusion, this results in a group of
extraordinarily well-equipped, functionally autonomous procedure rooms, any one of which could serve
alone as a respectable endoscopy unit. This is, of course, exaggerated, and in practice, such a unit
would be highly unusual. In fact, as procedure rooms become more numerous, they are diversified
according to various functions, each room being designed, equipped, and arranged with an emphasis
on one or a few types of procedures.
The way in which different procedures are diversified among available procedure rooms is another
major difference between endoscopy units. To a large extent, this reflects the pattern of procedures
performed in the unit, which in turn depends on referral patterns, the demand for particular procedures,
and the interests and expertise of the professional staff. Thus, in one unit, an emphasis on laser
procedures might require a room designated for this purpose. A center with a large referral base for
ERCP would logically require a separate room for this purpose. It is essential to bear in mind that none
of the factors that influence the pattern of the types of procedures performed in a unit is static. Rather,
the pattern always changes over the course of time, especially as new techniques are developed. It is
probably safe to predict, for example, that the demand for colonoscopy procedures will continue to
accelerate in coming years. At the same time, the demand for laser procedures has declined, although
this may change again with the further development of photodynamic therapy.
A tradeoff necessarily occurs when a room is designated for a precise function. When altered for a
specific purpose by the way it is scheduled and equipped, perhaps even with respect to physical
changes in layout, the room becomes less suitable for other procedures. Essentially, the unit as a
whole becomes less flexible and less adaptable to changes in the pattern of procedures. A unit in
which rules for room utilization are relatively inflexible tends to be inefficient. Certain functions such as
scheduling are simplified, but procedure rooms may stand idle. If demand for endoscopic services is
high, this may translate to limitations on access, delays in scheduling procedures, dissatisfied patients,
and disgruntled referring physicians. At the other extreme is the concept that there should be the
capability to perform virtually any procedure in any room. The difficulty here is frequently the need to
move equipment from room to room. Scheduling actually may become more complex, and there is a
greater tendency toward disorganization in the management of the daily activities unless each room is
so well equipped that procedures can be scheduled ad lib in any room without concern for availability of
GIAs and equipment. The problem with this approach is the high cost for duplicate staff and
Special and Routine Procedures
One method of establishing a balance in a unit between dedicated and multifunctional procedure
rooms is to divide procedures into "routine" and "special" types. Routine procedures have the following

Usually but not always high volume

Performed by most endoscopists working in the unit
Usually diagnostic
Require fairly standard, relatively unsophisticated equipment that is readily available in the unit
Significant day to day (even hour to hour) variation in demand

Special procedures tend to have the following attributes:

1. Performed by a relatively small number of endoscopists
2. Usually require special, often expensive equipment that is frequently a one-of-a-kind item within
the unit
3. Lower volume relative to that for routine procedures
4. Frequently more time consuming
5. Often require more than one GIA
It can be useful to divide routine procedures into high and low volume. The definition of a high-volume
procedure is arbitrary, but this label generally applies to any procedure that constitutes 20% or more of
the total volume of procedures.
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The division of procedures into routine and special categories is unique in each unit. Although EGD
and colonoscopy would typically be categorized as routine in most units, large units might include
ERCP and even EUS. This depends on the pattern and numbers of procedures performed and on the
availability of equipment. It is unusual to find the capability to perform ERCP in more than one room in
any given unit, so that by default ERCP becomes a special procedure with a designated room. In the
unit at University Hospitals of Cleveland, ERCP (diagnostic and therapeutic), laser endoscopy, EUS,
certain dilation procedures, and esophageal prosthesis placement are special, whereas all other
procedures are routine and can be performed in any room. EGD, colonoscopy, polypectomy, some
types of dilation, and most methods for control of bleeding including sclerotherapy and variceal banding
can be performed in any room.
Achieving Balance
As a general rule, specific rooms should be designated for special category procedures. Usually this
follows without much deliberation because the availability of special equipment is limited. However, as
far as possible, routine procedures should not be restricted to specific procedure rooms. For maximum
efficiency, it should be feasible to conduct routine procedures in any room, even rooms designated for
special procedures. A large referral center unit should have adequate equipment to carry out routine,
high-volume procedures simultaneously in most or all procedure rooms, including those designated for
special purposes.
Because by definition certain routine procedures are high volume, it might seem logical to assign
specific rooms for such procedures while excluding other activities from these rooms. Depending on
circumstances, this may be efficient or restrictive. If the number of routine procedures of one type,
EGD, for example, is sufficient to reasonably expect that a room will be fully utilized in the performance
of this one procedure, then it may be efficient to designate one or more procedure rooms for this
purpose alone. However, another characteristic of the routine procedure is that the demand for this
type of service varies a great deal on a day-to-day basis (even hour to hour in a highly active unit).
Over longer periods of time, there will be changes in the numbers and patterns of procedures
In deciding the mix of multifunctional and dedicated rooms within a unit, it is important to analyze
efficiency and the effect that limiting room usage has on the scheduling process.
A retrospective approach to assessing efficiency is to determine the average number of hours per day
that a unifunctional, designated room is not in use in relation to the desired overall efficiency of room
utilization in the unit. If, for example, this is greater than about 30%, then the use of the room for a
single specific function may be inefficient; that is, the procedure activity in question does not justify
restrictions on the use of a room. Conversely, utilization of the room at greater than targeted efficiency
may mean that demand exceeds capacity. If, at the same time, other rooms designated specifically for
other procedures are not in use more than about 30% of the time, the unit overall is not functioning at
maximum efficiency.
There is a further element in balancing dedicated versus multifunctional room usage that is potentially
more damaging to the orderly function of the endoscopy unit. Rigid adherence to specific room
designations may restrict patient access. One way to determine this is to track overall scheduling
activity of the unit with special attention to schedule lag. This is the length of time required to complete
a procedure unit beginning with the moment of contact between the endoscopy unit and the patient or
the referring physician. It is important to consider all types of procedures performed in the unit because
the time required for completion of one type may be within expectations, whereas that for another may
be unsatisfactory. The many possible reasons for such an imbalance include limited staff availability.
However, in some cases, it may be due entirely to or at least compounded by an inflexible adherence
to a policy of dedicated room usage.
The uncontemplated "trigger" reaction to apparently excessive demand for a routine procedure is to
acquire another designated room. A more discerning approach is to first determine whether the way in
which the unit functions is the problem. This emphasizes the basic importance of trying to think about
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the endoscopy unit from an abstract conceptual point of view rather than as a physical cluster of
The blend of unifunctional, special procedure rooms and multifunctional, routine procedure rooms
should never become absolute and unchangeable. If past experience is any guide, it can be assumed
that the pattern, numbers, complexity, and general mix of procedures will continue to change.
Therefore, it is important that a unit be constructed in such a way that the function of any room can be
altered when necessary. Designing a "few small rooms" for EGD, for example, is very imprudent. A unit
cannot be set up today that will serve all the foreseeable and unforeseeable needs of the next decade.
The only answer to this problem is flexibility in design.
Ultra-High-Volume Procedures
Certain procedures may be performed in such numbers that the sheer volume is overwhelming to the
point that the functionality and efficiency of the unit are compromised. It usually becomes necessary to
consider such ultra-high-volume procedures as separate categories in relation to other endoscopic
procedures. The only procedure that potentially qualifies in this respect at present is screening flexible
Flexible sigmoidoscopy does not fit the procedure unit concept; that is, it differs significantly from other
endoscopic procedures with respect to scheduling, patient preparation and recovery, and the amount
of time required. These differences in relation to other procedures would not be so important were it
not for the high volume of procedures. In great numbers, the special characteristics of an
ultra-high-volume procedure tend to dominate the function of the unit. It would seem to be not only
efficient but also responsive to patient needs to design a specific room or rooms in the endoscopy unit
for this purpose. It may also be sensible to divorce the truly ultra-high-volume procedure physically and
functionally from the rest of the endoscopy unit.
The dissociation of flexible sigmoidoscopy from the rest of the endoscopy unit need not be absolute.
For example, scheduling might be done in the same place and by the same personnel for this and
other procedures. Staff can rotate from one unit to the other. However, at any point in time, the function
of the flexible sigmoidoscopy unit should be independent of the endoscopy unit. Patient flow patterns
should not intersect nor should patients use the same dressing facilities. To some degree, toilet
facilities might be shared in a well-designed unit, but in this case, care must be taken that the
requirements for flexible sigmoidoscopy preparation do not overwhelm the capacity to prepare patients
for colonoscopy.
Ultra-high-volume could become problematic with respect to EGD in relation to the growing utilization
of this examination as a primary diagnostic procedure in place of the upper GI x-ray series. From a
conceptual and operational point of view, it may be reasonable to separate facilities for primary upper
GI diagnostic endoscopy from the other procedure activities. Such a separation can be physical or
functional to greater or lesser degrees. Another possible concept is to separate special (frequently
therapeutic) procedures from routine high-volume diagnostic procedures. Thus, laser, ERCP (with a
high volume of therapeutic endoscopy), EUS, endoscopic methods of hemostasis, and other
therapeutic procedures might be performed in one area of the unit, while EGD and colonoscopy are
performed in another. Operationally, these two areas would work at different paces and require
different methods of scheduling, different types of equipment, and different levels of staffing.
The Multidisciplinary Unit
It is possible to dispense with specific GI endoscopy scheduling/secretarial, reception, and patient
dressing/ recovery areas in a multidisciplinary unit in which a variety of other nongastrointestinal
diagnostic and therapeutic procedures are performed. This is not germane here, since a GI endoscopy
unit as an entity does not exist in this type of unit. However, this plan has the advantage of cost
containment in that some equipment, staff, and spaces are shared among disciplines, but it can be
extremely restrictive in terms of growth, in both numbers and complexity of procedures. Furthermore,
the similarity between different types of endoscopy is superficial with regard to the instruments required
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and to the actual procedures, so that cross training of assistants for more than one discipline has its
limits. Shared units frequently lead to scheduling conflicts and apportionment of time and room
availability to the various specialties that use the unit, a practice that in effect means that each
specialty has its own unit but that it is operated at something less than full time.
Certain expensive pieces of equipment, a C-arm fluoroscope or neodymium:yttrium-aluminum-garnet
laser, for example, might be shared between two or more specialties if the volume of cases for all
users is small and the demand for use of a machine is expected to remain static. However, when two
or more departments must combine their patient activity to justify the acquisition of an expensive
device, a laser, for example, there is reason to ask whether this represents an improvement in patient
care, because the number of procedures in any category of usage is by definition small. Nevertheless,
cost is a significant factor in the function of a unit. Except where the volume of procedures is very high,
ERCP is usually performed away from the endoscopy unit in a radiology suite because of the cost of
x-ray equipment. In general, however, the efficiency of an endoscopy unit decreases in proportion to
the number of procedures performed away from the unit.
Another design principle, often overlooked and sometimes even ignored, is that the endoscopy unit
exists first and foremost for the care of patients. Too often a unit will have been designed to suit the
needs of physicians or nurses with little attention to the physical and emotional well-being of the
patients. A unit may be a model of factory-like efficiency, while patients find it detestable. Although it is
difficult for patients to accurately assess medical expertise, they nonetheless make judgments,
consciously and unconsciously, about the quality of care they receive. These are based on such purely
human considerations as cleanliness, attractiveness of surroundings, privacy, courtesy, respect,
efficiency, availability, and physical comforts.
The best endoscopy units are based on a total design approach, that is, one that accounts for the
well-being of the patient, GIA, and endoscopist. In the planning process, the GIA and endoscopist are
usually well represented, whereas the patient may not have an advocate. As the process proceeds, it is
therefore advisable to take time to look at the developing plan from the viewpoint of the patient. From
this perspective, two factors are especially important: preservation of privacy and dignity and the
aesthetics of the unit.
When a unit is aesthetically pleasing, patients feel more comfortable and relaxed. This is beneficial for
the patient about to undergo a procedure, but it also facilitates the tasks to be performed by the GIA
and endoscopist. Furthermore, an attractive decor also has a positive effect on all who work in the unit
in terms of morale, motivation, teamwork, and general performance.

The location of an endoscopy unit in the hospital setting is not inconsequential. Although options as to
site are often not available (see "Acquisition of Space," earlier in this chapter), placement of the unit in
relation to other hospital departments has a direct bearing on efficiency. The hospital-based endoscopy
unit has a natural relation with many other areas of a hospital, including the emergency room, radiology
department, and intensive care units, because it is frequently necessary to perform endoscopic
procedures in these areas. At the same time, the unit must be convenient to hospital wards. When
certain beds are reserved for specific types of disease or for specific hospital departments, placement
of the endoscopy unit near wards set aside for patients with GI diseases is advantageous.
Because more and more endoscopic procedures are being performed on an outpatient basis,
convenient outpatient access becomes a necessity. In hospital units built at a time when there was less
emphasis on outpatient procedures, patients must endure a series of signs, maps, and conflicting
directions that begin at the hospital front door, a symbolic portal that is not necessarily "patient
A location for a unit that is desirable in every way is an impossibility that would require that the hospital
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be built around the unit. Fortunately, close spatial relationships within the hospital have relative
degrees of importance that are determined largely by practice methods. As a general rule, however,
proximity to the radiology suite and easy outpatient access should be given precedence in determining
unit location. In addition to the fact that ERCP and related procedures may be performed in the
radiology suite, many radiologic and endoscopic procedures are complementary. This facilitates patient
evaluation in that patients may undergo a series of procedures in each of the two units without
returning to a hospital ward between diagnostic studies. Proximity also facilitates a cooperative
professional relationship between radiologist and endoscopist that enhances patient care.

Number of Procedure Rooms

The number of procedure rooms that will be required is a very basic consideration in planning an
endoscopy unit. It is a simple matter to calculate the needs of the moment, but the future, be it further
growth in numbers and complexity or contraction of growth, is more difficult to predict. Past experience
helps to some extent, and in this respect records of unit activity are extremely helpful. But there are no
formulas for future activity and forecasts are at best educated guesses. Some variables in this
calculation are common to all units, such as the socioeconomic factors and other trends described
later. However, each unit faces unique questions peculiar to its environment. Such an analysis can be
far-reaching and can include factors as diverse as the quality of competing organizations and the
demographic characteristics of the population that the unit serves. In the final analysis, however,
growth is strongly related to the quality of the unit. Is it innovative in a critical way? Is it responsive to
the needs of patients and referring physicians? Is the proficiency of its staff high? Does it function
The theoretical maximum capacity of an endoscopy room can be calculated in procedure units using
the weighted scale. It is first necessary to calculate the number of working days per year
(approximately 256 days based on a 5-day work week and five or six holidays per year) and the
working hours of the unit (usually 7 hr, with time being permitted for lunch breaks for GIAs). The time
corresponding to a 1.0 procedural equivalent is a relative value that must be estimated for each
individual unit (1.0 equals about 30 min in our unit). Thus, the theoretical maximum number of
procedure units (diagnostic EGD equivalents) that can be performed in one room during 1 year is 3584
(256 2.0 7). However, this is a theoretical value that assumes that all procedures performed are
diagnostic EGD. To arrive at a more realistic number, it is necessary to allow for the average acuity
(degree of difficulty) of the procedures performed. For example, if the average weighted acuity value of
all procedures is 1.53, the theoretical maximum number of procedures that a single room can
accommodate is 2342 (3584 1.53). This, however, assumes 100% efficiency in the use of the room,
a level that is not possible. A more attainable efficiency for use of a room would be about 60 to 70%, in
which case the capacity of one procedure room is about 1500 procedure units per year.

Support Rooms
Although the procedure room(s) is the nucleus of every endoscopy unit, many other kinds of rooms or
designated areas are also necessary. A relatively complete list of possibilities is given in Table 44. It
is doubtful that the majority of units are so complete. However, such a complement of rooms is a
reasonable goal for a large tertiary referral unit.

Endoscopy Unit Rooms

(Full Complement)

Procedure room(s)
Appointment desk
Dressing room
Toilet facilities (women/men)
Interview room(s)
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Endoscopy Unit Rooms

(Full Complement)

Director of unit
Medical staff
Head nurse
Word processing
Computer facilities
Staff changing, toilet facilities, locker room
Nurse base area, utility room
Conference roomstaff, students
Storage room(s)

Dressing Rooms
The term dressing room is preferred for the preprocedure holding and postprocedure recovery area for
patients, although in some units this is termed the recovery room. In most units, a single dressing room
serves all procedure rooms. This arrangement is most common because it allows for the most efficient
use of space and staff. However, other plans are possible such as a dressing/recovery area for each
procedure room, although this is usually impractical. There are other potentially useful modifications of
the basic arrangement, provided space and equipment are adequate. One would be separate areas or
even separate rooms for preprocedure holding and postprocedure recovery (inefficient for most units
with respect to utilization of staff). Another would be separate areas for inpatients and outpatients.
Hospitalized patients do not require extensive dressing facilities, although they often require closer
postprocedure monitoring while awaiting transport to a hospital ward. Conversely, outpatients generally
require more elaborate dressing facilities. Furthermore, it is somewhat inconsiderate to mix relatively
healthy patients with those who are seriously ill. Separation of inpatients and outpatients in the
dressing room does require some duplication of space because the ratio of inpatient to outpatient
procedures will fluctuate from day to day (in our unit, this may change by as much as 30 to 40% from
one day to the next).
The major concern with respect to the dressing room is its size; that is, what is the required ratio of bed
spaces to procedure rooms. There are various formulas but these can be deceptive because an ideal
ratio depends greatly on methods of practice. For example, the types and dosages of sedative drugs
used may necessitate more prolonged observation. Another major factor is the number of outpatient
therapeutic procedures that require protracted postprocedure observation. Just as there is a trend
toward performance of routine diagnostic procedures on an outpatient basis, there is also a trend in
favor of performing therapeutic procedures on an ambulatory basis. Thus, any formula for dressing
room bed space must be modified according to individual circumstances.
One basis for determining the number of beds needed is the average time a patient spends in the
dressing room. This depends in part on how the room is used. Usually, patients are brought to the
dressing room and assigned a space to be utilized throughout the procedure. Because ambulatory
patients require a place for personal belongings and to gown for the procedure, assignment of a
dressing room space on arrival is most satisfactory. Clothes and other personal belongings can be
placed in a lockable cabinet, the key to which the patient retains throughout the procedure (e.g., on a
bracelet). The result of this method, however, is that a certain number of bed spaces are reserved but
unoccupied while patients are in the procedure room. It is possible to circumvent this by simply not
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assigning a space until after the procedure. Theoretically, this would be more efficient and allow a
reduction in the ratio of dressing room bed spaces to procedure rooms. However, in a large unit, the
flow of patients to and from multiple procedure rooms is always so unpredictable that this method
allows for only a slight reduction at best in the ratio of recovery beds to procedure rooms. Furthermore,
it makes changing clothes and handling personal belongings more difficult, and it usually deprives the
patient of some privacy.
The average time required for recovery after procedure can be determined by actual observation (e.g.,
a dressing room log). For many routine procedures, however, the recovery time is about equal to the
length of the procedure. For routine diagnostic EGD, for example, this is usually about 30 to 45 min.
For maximum efficiency, at least two dressing room spaces should be available for each procedure
room; a patient should be ready and waiting in one bed while the second bed awaits the patient
undergoing the procedure. After the first procedure has been performed, one bed will be occupied by a
recovering patient while the other contains a patient who is awaiting a procedure. One procedure room
at 100% efficiency can sustain about 14.0 procedure units per day. At 70% efficiency, this decreases to
9.8 procedure units per day. Because two bed spaces are always occupied (by a recovering patient
and a patient awaiting a procedure), the number of required bed spaces is approximately twice the
number of procedure units that will be performed in the procedure room. This would mean that under
ideal circumstances about 19.6 hr of dressing room time would be required to service one procedure
room that generates 9.8 procedure units per day. Based on an 8-hr working day, about 2.45 beds
would therefore be required to support one procedure room. However, the average weighted value for
procedures performed in a unit is never 1.0, since all procedures other than basic EGD are by
definition longer or more complex and therefore given a higher value in the weighted scale. If the
average weighted value for procedures in a unit were 1.5, then the actual number of procedures
performed in one room in 1 day could be as low as 6.5. Theoretically, only 1.6 dressing room spaces
would be needed for this level of activity, although this does not take into account the length and
difficulty of the procedure or the fact that more extended periods of recovery are required for some
procedures. Thus, the ideal ratio of beds for a unit operating rooms at 70% efficiency with a average
weighted scale value of 1.5 would be between 1.6 and 2.45 beds per procedure room. A unit with four
procedure rooms would therefore require between 8 and 10 recovery beds.
A cart exchange system has been adopted in many units. This requires the use of mobile beds or carts
(trolleys or stretchers, if you prefer). When properly gowned, the patient is placed on a cart in the
dressing room. The cart is wheeled to the procedure room where the examination takes place with the
patient on the same cart. On completion of the procedure, the cart is moved back to the dressing
room, where the recovery component of the procedure unit is completed. This very efficient method of
moving patients about in the unit also adds a measure of safety, in that it is not necessary to transfer
patients to and from a procedure table. Suitable carts are available from a number of manufacturers.
An essential feature is the ability to alter the height of the cart to accommodate short as well as tall
endoscopists. In many units, the patient's clothes and personal belongings are placed underneath the
cart (although some patients may find this less desirable compared with placing clothes and personal
effects in a locked wardrobe). This system works well for virtually all types of procedures with the
exception of ERCP where it is still necessary to transfer the patient to the x-ray table.
Lavatory Facilities
The number of toilets required depends in part on methods of preparation for colonoscopy. Colon
lavage is the preferred method of preparation in many units. In some units, the lavage is performed
within the unit under the supervision of a GIA. This markedly reduces the number of procedures
terminated because of poor preparation. Of all possible methods, however, this requires the maximum
lavatory facilities. About 3 to 4 hr is required to complete this type of preparation. It is mandatory that
one toilet be available during this period of time for each patient undergoing colon lavage. There must
be duplicate facilities for men and women. Because this approach is the most labor intensive and
requires installation of a large number of toilets within the endoscopy unit, most units rely on
self-preparation by patients. Nevertheless, it is extremely unwise to stint on toilet facilities in designing
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a unit where large numbers of colonoscopy and sigmoidoscopy procedures will be performed.
Interview Rooms
The requirements for preprocedure and postprocedure interview rooms relate for the most part to the
level of outpatient activity in the unit. When this is high (e.g., 70% of procedures), more rooms will be
needed. In a unit with this level of outpatient procedure activity, a ratio of about one interview room to
every two procedure rooms is usually satisfactory.
Other Rooms
Requirements for other types of rooms shown in Table 44 depend on size and the range of functions
of the unit.
The reception area or room generally serves as a waiting room for family and friends. It may also serve
as a step-down recovery unit following certain procedures when extended close monitoring is not
necessary but it is still desirable that a patient remain in the unit for several hours.
As the endoscopy unit increases in size, it usually becomes necessary to separate the appointment
desk from other functions such as reception. In a large unit, scheduling can be so complex and
essential to orderly operations that a separate area for appointment secretaries is needed.
With increasing size comes increasing administrative complexity and a more intricate administrative
structure that requires a director, ideally a physician, and a chief GIA who should be a registered nurse,
preferably with managerial experience. These individuals make up the nucleus of a management team,
and their offices should be near, if not within, the endoscopy unit. It may be prudent to allocate office
space for other physicians within the unit, depending on the amount of time they spend in endoscopic
activities. Consultation/examination rooms must also be provided in this case.
A conference room, although not absolutely essential, is of great value, especially in teaching units.
Many different meetings may be scheduled in an endoscopy unit, such as demonstrations of new
equipment, management conferences, problem-solving discussions, and teaching conferences for
attending physicians, trainees, and GIAs. A pleasantly appointed conference room not only provides a
convenient, time-saving meeting place but also helps to promote esprit de corps simply by virtue of the
fact that there is a common ground.
A library is essential where endoscopy is taught. This is not a library in the ordinary sense, although
some books on endoscopy should be provided. Rather it should contain audiovisual materials such as
television tapes that demonstrate and illustrate endoscopic procedures and findings.
Photodocumentation changed dramatically with the inception of video endoscopy. Whereas 35 mm
slide photographs obtained with a camera attached to the ocular of a fiberoptic endoscope were once
the preferred method for photodocumentation, the advent of video endoscopy systems has made
videotape the standard for retention of endoscopic images. Computer systems have made retention of
images fast and easy. However, these static digital images are relatively unsatisfactory compared with
a videotaped segment of a procedure. Static EUS photographs, whether obtained using instant film or
a thermal printer, are especially unsatisfactory for review of findings inasmuch as EUS diagnosis is
based on real-time continuous observations. In the past, 35 mm slides were problematic because of
the need for handling, labeling, filing, and storing the slides or filmstrips. Extensive use of videotape
presents virtually the same problems. Because these are compounded over time, it is usually prudent
to set aside a small area in the unit for handling, storing, and labeling of videotapes when there is a
need to retain this type of information.
Report generation and record keeping are integral to the operation of any unit, large or small. These
basic functions can be either paper-based or computer-based; some combination of these is frequently
found within an endoscopy unit. The least sophisticated method is the handwritten procedure note.
This is sometimes combined with some form of computerized record-keeping system. Other units may
use a central dictating system accessed via a telephone. The least labor-intensive approach to report
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generation and record keeping is an interactive computer system. Given their potential for speed,
accuracy, and savings in terms of cost and labor, computer-based systems are becoming the norm.
Whatever the reporting and record-archiving system, provision must be made in the design of a unit to
accommodate these functions. The exact requirements depend on the type of system adopted. For
example, it might be necessary to consider inclusion of a secretarial area. If a computer network
system is envisioned, it may be necessary to include conduits for wiring.
Unusable Space
In designing an endoscopy unit, it is important to realize that all the floor space allocated for the unit
cannot be used for the various rooms that one wishes to construct. About 30 to 35% of the available
space will be taken up by corridors, walls, building supports, stairwells, ductwork, and the like.

Floor Plan
The last step in designing an endoscopy unit is the arrangement of the desired rooms in a floor plan. In
all probability, these will fall into one of the following configurations: procedure rooms grouped in one
area, procedure rooms arranged around the dressing/recovery area, procedure rooms placed on
opposite sides of a central dressing/recovery area, or procedure rooms arranged around a central
cleaning/disinfection room. Often an ideal arrangement is prevented by the configuration of a building.
Even when floor space is adequate, the shape of the building may not accommodate the desired plan.
The compromises made at this stage determine what is good and bad about the layout of a unit, and
every unit has a little of each.
The arrangement of rooms should be made with traffic flow patterns in mind. For an ambulatory
patient, for example, the major flow is from reception to dressing room to procedure room and back
again to dressing room and then reception. Thus, the dressing room should be relatively close to the
procedure rooms. If at all possible, there should be separate routes to and from the procedure room. If
a separate room(s) for cleaning and storage of equipment is used, it should be located near the
procedure rooms. As a general principle, it is highly desirable that heavy traffic flow patterns not
Procedure rooms are often grouped in one area of the unit. This is not absolutely necessary. Arranging
the procedure rooms around the dressing room or at opposite sides of a central dressing room can
have advantages. However, this usually makes it difficult to place cleaning and storage functions
Support roomsother than the dressing, cleaning, and storage roomscan usually be located away
from the more active areas of the unit. However, personnel, equipment, and rooms for report
generation should be clustered if at all possible. Appointment and reception areas should also be close
together because communication between these areas is often needed.

Endoscopy Unit Profiles

The authors have engaged in an exercise that illustrates the principles and process of endoscopy unit
design presented in this chapter. One of us (MVS) developed imaginary profiles for four units. Using
the information provided in these fictional scenarios, another of the authors (MER), an architect with
extensive experience in the design of endoscopy units, developed schematic diagrams to fit these
hypothetical profiles. These are arranged as Figures 43, 44, 45 and 46. Each figure consists of a
profile (A), a design layout (B), and an inventory of rooms (C). The inventory for each profile unit lists
room category (description), dimensions, size (in square feet), numbers of such rooms, number of
persons that the room can accommodate, and the total area within the unit occupied by rooms of each
description. Numbers within the descriptive notes refer to a table of notes (Table 45). The design
layouts (B) represent design concepts and not actual architectural plans.


Descriptive Notes for Endoscopy Unit Profiles

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Descriptive Notes for Endoscopy Unit Profiles

1. Remote monitors on procedure imaging network. Cables that run in ceiling areas
should be housed in metal piping or conduits, to shield video signals from
interference caused by fluorescent light ballasts, motors, or other potential
2. Walls that surround the procedure rooms, as well as doors to these rooms, should
have acoustic ratings to contain procedure sounds. Walls should have a minimum 55
sound transmission coefficient (STC) rating and doors should have 40 STC.
3. The procedure rooms should be designed with two modes of lighting. In a two-mode
system, fluorescent fixtures should provide the required level of work light (100
foot-candles), and adjustable low-voltage or mini-spotlights should be positioned to
provide low levels of light during procedures.
4. A double monitor system should be planned for the procedure rooms. In a
two-monitor system, both physician and assistant can have a comfortable view of the
procedure image.
5. Procedure spaces should be equipped with a means of exhaust and ventilation to
remove odors. A total air change capability should be designed. Potentially irritating
chemical fumes from washing disinfectants must be mechanically removed from the
cleaning/disinfection room. Provide 15 air changes per hour with direct exhaust of
used air to outside.
6. In cleaning rooms, exhaust grills should be located near the floor and at counter
7. Endoscope washing rooms should be located in clusters with pairs of procedure
8. Oxygen, suction, and medical air should be located in procedure rooms, recovery
areas, etc.
9. Emergency call button.
10. Lead lining in walls and doors. Anesthesia capability. Open hanging wall storage for
snares, etc.
11. Locked cabinets for drugs.
12. Emergency communication system.
13. Smoke exhaust system at laser procedure room.
14. Emergency (crash) cart.

(170)Figure 43. (For Parts A and C, see below Figure 43A and Figure 43C) Endoscopy
procedure suite: Endoscopy procedure suite: Profile ITertiary center. B, Design layout
(overall dimensions 126.5 85.6 feet; scale 1/16 inch = 1 foot). HMOhealth maintenance
cholangiopancreatography; EUSendoscopic ultrasonography; FNAfine-needle aspiration;
M/Fmale/female; Jan.janitor's; Mmen's; Wwomen's; sfsquare feet; Gengeneral.
Endoscopy procedure suite:
Figure 4-3A.

Profile ITertiary center. (See table below) A, Profile. HMOhealth maintenance

cholangiopancreatography; EUSendoscopic ultrasonography; FNAfine-needle aspiration;

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M/Fmale/female; Jan.janitor's; Mmen's; Wwomen's; sfsquare feet; Gengeneral.

Figure 43 Part A
LOCATION: Large, growing metropolitan area, population approximately 3 million.
CATEGORY: Unit is based in a tertiary level (teaching) hospital of 950 beds. Hospital is the central
element in a large integrated health care system that includes numerous primary care providers
throughout the community, three smaller peripherally located hospitals, and several free-standing
clinics that provide both primary and specialty care. By design, tertiary level care is provided only at the
central hospital. Two thousand five hundred physicians work within the system. System is medical
school affiliated.
Care for about 25% of the population is governed by managed care contracts. This percentage is
increasing at 7% per year. About 35% of the population is Medicare eligible; this group is also
increasing by 7% per year. Fee-for-service insurance contracts cover about 15% of care provided
(expected to remain stable). The integrated system has its own insurance plan and an HMO. About
15% of patients who undergo procedures in the endoscopy unit are referred from outside the system
specifically for endoscopy. About 10% of care is provided to indigent persons.
No. of Procedures per Year

7000 Case Acuity: 1.58

3000 (10% pediatric cases; 75 laser cases)
2000 (10% pediatric cases)
900 (mostly screening)
900 (80% therapeutic)
200 (includes FNA)

PROFILE: The unit is staffed by a closed faculty of gastroenterologists (includes three pediatric
gastroenterologists) and surgeons. Two physicians devote most of their professional effort to
endoscopy. Nine other physicians perform various endoscopic procedures. Nonendoscopic GI
procedures (e.g., esophageal manometry, liver biopsy) are also performed in the unit. There is a GI
fellowship program; surgery residents and pediatric GI fellows also receive endoscopic training.
Between two and five fellows are working in the unit at any given time. One is an advanced trainee in
endoscopy. A range of research projects are conducted in the unit including the evaluation of prototype
endoscopic equipment. Other types of endoscopic procedures (e.g., bronchoscopy) are not performed
in the unit. Seventy-five percent of procedures are performed on an ambulatory basis. The volume of
cases has increased 13% per year over the last 3 years.
The unit manager is a nurse administrator who reports to the GI Division Chief. There is also a
physician/endoscopist section head for endoscopy. There is a well-developed and functional matrix
management system. The unit operates at 75% efficiency.
Figure 4-3C.

(See table above) Profile ITertiary center. C, Inventory of rooms (numbers within
Descriptive Notes refer to Table 45). HMOhealth maintenance organization;
cholangiopancreatography; EUSendoscopic ultrasonography; FNAfine-needle aspiration;
M/Fmale/female; Jan.janitor's; Mmen's; Wwomen's; sfsquare feet; Gengeneral.

Figure 43 Part C
Room Name

Room Size




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Descriptive Notes

Room Name

Room Size




Descriptive Notes

15 35

525 sf


Individual seating for 35 persons

8 9

72 sf

Administration Areas
Waiting room
Patient interview area

Discussion, examination, desk,



6 8

48 sf

Disabled accessible

Reception station

7 12

84 sf

Scheduling and appointments

Computer station

6 8

48 sf

Billing area

Files and records

8 10

80 sf


6 8

48 sf


8 12

96 sf

Head nurses office

8 10

80 sf

Computer-server, imaging

12 18

216 sf

Computer image manager (1)

Conference room

16 26

416 sf



Fellows work area

8 16

128 sf

Computer, coat storage, desk


6 6

36 sf

Male, female

Locker area

6 12

72 sf

Male, female

Patient toilets

6 6

36 sf

Endoscopy [general]

17 17

289 sf

Gen, EGD, colonoscopy


Endoscopy [manometry]

12 15

180 sf

Gen, motility (2,3,4,5,8,12)

Endoscopy [fluoroscopy]

14 20

280 sf

ERCP, dilation (2,3,4,5,8,10,12)

Endoscopy [laser]

17 17

289 sf

Gen, laser (2,3,4,5,8,12,13)

Endoscopy [ultrasound]

17 17

289 sf

Gen, ultrasonography (2,3,4,5,

High-density filing
Monitors (1)

Procedure Areas

Nurses station

8 8

64 sf

Equipment storage

10 17

170 sf

Dictation area

7 12

84 sf

8 15

120 sf

5 12

60 sf

6 12

72 sf



Curtain cubicles (8,

Isolation holding area

6 12

72 sf

Acoustic separation (8,9)


6 6

36 sf

Nurses station

10 15

150 sf

Scope washing
Scope storage

Handwashing sink

Mobile endoscopy cart, crash ca


Washing closet
12 sf
3 4
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Automatic scope washer


Centrally located, good view (14

Bedpan hopper

Room Name

Room Size




Descriptive Notes

Staff roomM/F

12 14

168 sf


Refrigerator, microwave, etc.

Staff toilet

6 6

36 sf

Doctors and staff lockers

6 8

48 sf

Storage supplies/utility

10 12

120 sf

Soiled area

8 10

80 sf

Janitors closet

4 4

16 sf

Support Services

Space Total

Shower stalls


Bulk style carts

Subtotal area

Circulation factor 35% (corridors, shafts, columns, etc.)

Measurement excludes space occupied by stairs, elevators, electrical closets, and mechanical spaces

(171)Figure 44. Endoscopy procedure suite: Profile IICommunity hospital. A, Profile

(click to see Part A below). B, Design layout (overall dimensions 85 70 feet; scale 1/16 inch
= 1 foot). HMOhealth maintenance organization; EGDesophagogastroduodenoscopy;
ERCPendoscopic retrograde cholangiopancreatography; PEGpercutaneous endoscopic
gastrostomy; GIgastrointestinal; Ttoilet; M/Fmale/female; Jan.janitor's; sfsquare
feet; Gengeneral; Broncbronchoscopy. Endoscopy procedure suite: Profile
IICommunity hospital. C, (click to see Part C below)

Figure 44 Part A
LOCATION: Medium-sized city with a population of about 500,000.
CATEGORY: Unit is in a hospital of 300 beds. Hospital is affiliated with two other hospitals, and this
group competes with another system that is slightly smaller in size.
Health care for about 10% of the population is governed by managed care contracts. This percentage
is increasing at around 2% per year. About 40% of the population is Medicare eligible, and this is
increasing by 10% per year. About 20% of care is covered by fee-for-service insurance contracts.
There is a large indigent population which accounts for about 15% of care provided. Both of the
competition belong to HMOs. About 20% of the population belong to HMOs. The hospital operates an
extended care facility as well as a long term nursing home.
No. of Procedures per Year:

3640 Case Acuity: 1.39

2100 (2% pediatric cases)
1200 (2% pediatric cases)
1000 (mostly screening)
75 (40% therapeutic)

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65 (includes bronchoscopy)

PROFILE: Procedures are performed in the unit by various physicians ans physician groups who have
been credentialed by the hospital. Twenty-two physicians have credentials to perform endoscopy.
Eleven of these 22 physicians perform procedures on a regular basis. Nonendoscopic GI procedures
(e.g., esophageal manometry, liver biopsy, paracentesis) are performed in the unit. The hospital offers
training in family practice as part of its affiliation with a medical school. Family practice residents
receive training in sigmoidoscopy. There are no GI fellows. Research is not part of the mission
statement of the unit. The unit is multidisciplinary with pulmonary medicine; bronchoscopy and
pulmonary function studies are performed in the unit. Eighty-five percent of procedures are performed
on an ambulatory basis. The volume of procedures has been relatively steady over the last 3 years.
The unit manager is a nurse administrator who reports to the Director of Nursing. There is a physician
advisor. The unit operates at 60% of efficiency.
Figure 4-4C.

(Ssee table below) C, Inventory of rooms (numbers within Descriptive Notes refer to Table
45). HMOhealth maintenance organization; EGDesophagogastroduodenoscopy;
ERCPendoscopic retrograde cholangiopancreatography; PEGpercutaneous endoscopic
gastrostomy; GIgastrointestinal; Ttoilet; M/Fmale/female; Jan.janitor's; sfsquare
feet; Gengeneral; Broncbronchoscopy.

Figure 44 Part C
Room Name

Room Size




Descriptive Note

15 30

450 sf


Individual seating

Consultation room

8 9

72 sf

Discussion, exam


6 8

48 sf

Disabled accessib

7 12

84 sf

Computer station

6 8

48 sf

Files and records

8 10

80 sf

8 12

96 sf

Monitors (1)

Preparation area

6 6

36 sf

Male, female

Locker area

6 12

72 sf

Male, female

Patient toilet

Administration Areas
Waiting room

Reception station

Nurses office

Scheduling and a

Procedure Areas

6 6

36 sf

Endoscopy [general]

17 17

289 sf

Gen, EGD, colono

Endoscopy [manometry]

12 12

144 sf

Gen, motility (2,3,

Endoscopy [fluoroscopy]

14 20

280 sf

Bronc, ERCP, dila


Dictation area

7 12

84 sf

Nurses station

7 10

70 sf

12 15

180 sf

5 10

50 sf

6 10

60 sf


Scope washing
Scope storage

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Automatic scope

Curtain cubicles (

Room Name

Room Size




Descriptive Note

Holding area

6 10

60 sf

Acoustic separati


5 6

30 sf

8 8

64 sf

Centrally located,

12 10

120 sf


Refrigerator, micr

Staff toilet

6 6

36 sf

Doctors and staff lockers

10 10

100 sf

8 12

96 sf

Clean area

6 8

48 sf

Soiled area

8 8

64 sf

Janitors closet

4 4

16 sf

Nurses station
Support Services
Staff roomM/F

Storage supplies

Space Total

Shower stall


Bulk style carts

Subtotal area

Circulation factor 35% (corridors, shafts, columns, etc.)

Measurement excludes space occupied by stairs, elevators, electrical closets, and mechanical spaces.

(172)Figure 45. Endoscopy procedure suite: Profile IIIAmbulatory center. A, Profile

(click to see Part A below). B, Design layout (overall dimensions 157 54 feet; scale 1/16
cholangiopancreatography; PEGpercutaneous endoscopic gastrostomy; EUSendoscopic
ultrasonography; Ttoilet; M/Fmale/female; Jan.janitor's; sfsquare feet;
Gengeneral. Part C, (click to se Part C below).

Figure 45 Part A
LOCATION: Large, growing metropolitan area, population approximately 3 million people.
CATEGORY: Unit is free-standing in a multispecialty ambulatory care facility. The facility is part of a
large integrated health care system that includes a 950-bed tertiary level (teaching) hospital, three
smaller hospitals, and numerous primary care providers throughout the community. By design, tertiary
level care is provided only at the central hospital. Two thousand five hundred physicians work within
the system. System is medical school affiliated.
Care for about 25% of the population is governed by managed care contracts. This percentage is
increasing at 7% per year. About 35% of the population is Medicare eligible; this group is also
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increasing by 7% per year. Fee-for-service insurance contracts cover about 20% of care provided, and
this is expected to remain stable. Facility is in an affluent suburb; there is no indigent care. The
integrated system has its own insurance plan and an HMO.
No. of Procedures per Year:

2500 Case Acuity: 1.19

1100 (no pediatric cases)
800 (no pediatric cases)
550 (mostly screening)

PROFILE: The unit is staffed by closed faculty of three gastroenterologists. Nonendoscopic

procedures (e.g., esophageal manometry, liver biopsy) are also performed in the unit. ERCP, EUS,
and PEG procedures are referred to the central hospital. No endoscopic training or research is
conducted in the unit. Other types of endoscopic procedures (e.g., bronchoscopy) are performed in the
unit. All procedures are performed on an ambulatory basis. The volume of cases has increased 20%
per year over the last 3 years. the unit manager is a nurse administrator who reports to the
Administrator (nonphysician). the unit operates at 80% efficiency.
Figure 45C.

(See table below). Endoscopy procedure suite: Profile IIIAmbulatory center. C, Inventory
of rooms (numbers within Descriptive Notes refer to Table 45). HMOhealth maintenance
cholangiopancreatography; PEGpercutaneous endoscopic gastrostomy; EUSendoscopic
ultrasonography; Ttoilet; M/Fmale/female; Jan.janitor's; sfsquare feet;

Figure 45 Part C
Room Name

Room Size




Descriptive Notes

20 30

600 sf


Individual seating for 30 persons


6 8

48 sf

Patient education area

7 9

63 sf

8 12

96 sf

Scheduling and appointments

Computer station

6 8

48 sf

Billing area

Files and records

12 20

240 sf


6 8

48 sf

Offices, physicians

12 15

180 sf

Nurses office

8 10

80 sf

Computer server

12 18

216 sf

Computer image manager (1)

Conference room

13 16

208 sf


Video monitor

Examination rooms

8 10

80 sf

Patient toilets

6 6

36 sf

6 8

48 sf

Administration Areas
Waiting room

Reception station

Disabled accessible

High-density filing
Monitors (1)

Discussion, examination, desk,


Procedure Areas

Male, female

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Locker area

6 12

72 sf

Patient toilets

6 6

36 sf


10 14

140 sf

Nurses desk

6 10

60 sf

15 18

270 sf

Gen, EGD, colonoscopy


Nurses station

8 8

64 sf

Handwashing sink


12 17

204 sf

Dictation area

7 12

84 sf

8 15

120 sf

5 12

60 sf


6 12

72 sf


5 6

30 sf

Nurses station

8 12

96 sf

Centrally located, good view (14)

12 14

168 sf


Refrigerator, microwave, etc.

Staff toilet

6 6

36 sf

Staff lockers

10 12

120 sf

Storage supplies

8 12

96 sf

Clean area

6 10

60 sf

Soiled area

8 10

80 sf

Janitors closet

4 4

16 sf

Endoscopy [general]

Scope washing
Scope storage

Male, female

Automatic scope washer

Curtain cubicles (8,9)

Support Services
Staff roomM/F

Space Total


Shower stall
Bulk style carts

Subtotal area

Circulation factor 35% (corridors, shafts, columns, etc.)

Measurement excludes space occupied by stairs, elevators, electrical closets, and mechanical spaces.

(173)Figure 46. Endoscopy procedure suite: Profile IVPrivate office. A, Profile (Click to
see Part A below). B, Design layout (overall dimensions 77 60 feet; scale 1/16 inch = 1
foot). HMOhealth maintenance organization; EGDesophagogastroduodenoscopy;
GIgastrointestinal; CEOchief executive officer; Ttoilet; sfsquare feet; Gengeneral.
C, (Click to see Part C below).

Figure 46 Part A
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LOCATION: Medium-sized city with a population of about 1 million.

CATEGORY: Unit is within a physician office complex. It is owned by a group of physicians that
includes four gastroenterologists. Physicians attend at several different hospitals.
Health care for about 10% of the population is governed by managed care contracts. This percentage
is increasing at around 5% per year. About 40% of the population is Medicare eligible, and this is
increasing by 10% per year. About 20% of care is covered by fee-for-service insurance contracts.
About 20% of the population belongs to HMOs.
No. of Procedures per Year:

3500 Case Acuity: 1.30

1900 (no pediatric cases)
1200 (no pediatric cases)
300 (mostly screening)
100 (includes bronchoscopy)

PROFILE: Procedures are performed in the unit by four gastroenterologists. Nonendoscopic GI

procedures (e.g., esophageal manometry) are performed in the unit. There is no training or research.
The unit is multidisciplinary with pulmonary medicine; bronchoscopy and pulmonary function studies
are performed in the unit. All procedures are performed on an ambulatory basis. The volume of
procedures has been increasing at 10% per year over the last three years.
The unit manager is a nurse administrator who reports to the Facility Manager (nurse) who reports to
the CEO of the corporation (physician). The unit operates at 70% efficiency.
Figure 46C

Endoscopy procedure suite: Profile IVPrivate office. C, Inventory of rooms (numbers

within Descriptive Notes refer to Table 45). HMOhealth maintenance organization;
EGDesophagogastroduodenoscopy; GIgastrointestinal; CEOchief executive officer;
Ttoilet; sfsquare feet; Gengeneral.

Figure 46 Part C
Room Name

Room Size




Descriptive Note

13 20

260 sf


Individual seating

Administration Areas
Waiting room


6 8

48 sf

Disabled accessib

Reception station

8 12

96 sf

Scheduling and a

Computer station

Billing area

6 8

48 sf

Files and records

12 15

180 sf


6 6

36 sf

Physicians consultation

12 12

144 sf

Patient education

7 12

84 sf

Nurse manager

12 13

156 sf


6 6

36 sf

6 10

60 sf

High-density filing
Monitors (1)


Procedure areas
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Male, female

Room Name

Room Size




Patient toilet

6 6

36 sf

Examination rooms

8 10

80 sf

Descriptive Note

Discussion, exam

Endoscopy [general]

12 15

180 sf

Gen, EGD, colono


Nurses station

3 10

30 sf


10 10

100 sf

Scope washing

8 15

120 sf

Handwashing sin

Automatic scope

Scope storage

5 5

25 sf

Staff lounge

9 12

108 sf

Storage supplies

6 10

60 sf

Clean area

6 10

60 sf

Janitors closet

4 4

16 sf

Support Services

Space Total


Subtotal area

Circulation factor 30% (corridors, shafts, columns, etc.)

Measurement excludes space occupied by stairs, elevators, electrical closets, and mechanical spaces.

Endoscopy Unit Management

Capital Equipment
The number of endoscopes necessary for routine procedures depends on how the unit functions. It has
been suggested that at least three upper GI endoscopes should be available for each room in which
EGD is performed (one being cleaned, one as backup, and one in use).12(174) This ratio is too high
and one backup instrument for every room is unnecessary, unless a simultaneous malfunction of every
instrument is expected. Two upper GI endoscopes for each multifunctional procedure room in which
EGD is performed should be adequate.
In a large unit (5000 or more procedures per year), repair costs are a significant operational cost item.
The actual cost of repairs will again depend on the skill and care exercised in using the instruments.
With careful record keeping, it is possible to cost-account major repairs.
The life expectancy of a GI endoscope might be expressed in number of procedures. This information
would be of great value, but unfortunately, there are no such data. The number of times an endoscope
can be used depends entirely on the manner in which it is used.13(175) In units where there are
numerous endoscopists with varying levels of skill, and where endoscopic procedures are taught, an
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endoscope may not last very long. If, however, an endoscopy unit has an efficient record-keeping
system that tracks the usage of an instrument as well as its repair record, it is not too difficult to
determine the average lifespan of an endoscope within the unit.13(176)

Systematic methods for directing daily activities are crucial to orderly operations. Such systems are
also based on management concepts. Two of the most important systems are scheduling and record
If the procedure room is the heart of the endoscopy unit, the daily schedule is its nervous system.
When 25 or more procedures requiring numerous different pieces of equipment and procedural skills
are being performed daily by several physicians, obviously an enormous potential for disorder and
confusion exists. The extent to which this potential remains latent and unrealized is a direct measure of
managerial skill in designing a scheduling system.
The primary task in devising a method of scheduling is to determine which procedure component will
be most restrictive. There may be an abundance of procedure rooms but limited numbers of
endoscopists, GIAs, or instruments. Some deficiencies and imbalances are easier to correct than
others. When there are adequate numbers of staff, the overriding factors that control the schedule are
availability of procedure rooms and, to a lesser extent, availability of equipment for special procedures.
These two factors necessarily govern the schedule.
The endoscopy schedule also reflects the basic philosophy for procedure room utilization. The
efficiency and capacity of the unit increase in proportion to the number of procedure rooms that are
considered multifunctional, although greater numbers of multifunctional rooms increase the complexity
of the schedule. When there is dogmatic restriction of procedure types to specific rooms, scheduling is
uncomplicated, but there is a loss of flexibility in responding to day-by-day fluctuations in the demand
for procedures.
The first step in devising a schedule is to set up a timetable for each available procedure room. This
timetable should be divided into units of time that equal one procedure unit (e.g., 1.0 procedure unit =
30 min). Special procedures (see definition earlier in this chapter) should then be restricted to specific
rooms to the extent that necessary items of equipment are limited or unique in the unit. Thus, one
room might be designated for ERCP (more desirable would be the simple designation fluoroscopy),
another for laser endoscopy, and perhaps another for EUS. These designated rooms, however, should
not stand idle in the absence of special procedure activity. If properly designed and equipped, a
laser-designated room or EUS-designated room will serve nicely for EGD and colonoscopy and any
number of other procedures. Even an ERCP room can be used for other procedures when necessary.
A multifunctional-room scheduling scheme requires careful thought and judgment by the appointment
secretary. In effect, this individual must have a basic insight as to the function of the unit. Such an
individual must be a tactician with the ability to effectively deploy and coordinate staff, equipment, and
rooms. In a highly multifunctional room system, close cooperation between the appointment secretary
and the GIA in charge is essential for success. With such cooperation, it is entirely possible to shift and
adjust staff, rooms, and equipment on an hour-to-hour basis to achieve a highly flexible system that
adapts quickly to delays in one or more procedure rooms, urgent requests for examinations, equipment
breakdown, and a variety of other foreseen and unforeseen circumstances.
The work habits of physicians can be one of the more difficult problems in scheduling. Although most
physicians are not only hard working but also productive, their schedules and work habits may be at
odds with those of the unit as a whole. Therefore, an important stratagem is to induce the endoscopists
to think in terms of overall productivity and goals of the endoscopy unit. One step in this direction is to
persuade them to accept assigned, regularly scheduled work periods in the unit. In medical
communities where primary diagnostic endoscopy is accepted, certain procedures can be scheduled
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with any endoscopist working in the unit at the time requested by the patient or referring physician.
Records, Statistics, and Computers
The administration and, hence, the operation of an endoscopy unit are facilitated by reliable and readily
available statistical data. In a large unit, such data are critical to the decision-making process.
Certain types of information (e.g., complications) are relevant to the maintenance of high standards of
patient care. When the volume of cases is high and numerous endoscopists and GIAs are performing
procedures, a pattern of recurring complications as a result of a breakdown in technique may become
evident only by reference to data gathered over an extended period. Accurate methods of endoscopy
record keeping can also be used to support and promote scientific inquiry.
A record-keeping system is a management tool. Data and statistics may seem mundane and irrelevant
in a small unit where standards of care are readily assessed, scientific inquiry has a low priority, and
management is a relatively simple, part-time business. However, recall and subjective assessment are
crude administrative techniques that are poorly suited, not only for recognizing and dealing with
problems but also for guiding the unit toward its goals. When problems such as low staff morale,
confusion and delays in scheduling, poor condition of instruments, high cost, low productivity, obsolete
equipment, inadequate numbers of or poorly trained GIAs, excessive delays between procedures,
shortages of supplies, declining referrals, dissatisfied referring physicians, dissatisfied patients, an
insufficient number of procedure rooms, crowded working conditions, and incompetent personnel
arise, the first query is whether fault lies in the system of management or perhaps the lack of a system.
When problems are numerous and interrelated, there may be a basic inability to define and understand
the difficulty. This is often due to a lack of pertinent information.
A computer can perform three operations in the endoscopy unit: report generation, image
management, and data management. The relative importance of each will depend on the objectives of
the individual endoscopy unit. For almost all facilities, however, a computer-generated report is likely to
be of benefit. A glance at Table 41 and a rudimentary knowledge of computers lead to the inevitable
conclusion that the procedure unit could be streamlined by delegating as many "secretarial/clerical"
tasks as possible to the computer. With proper software and a relatively inexpensive computer, it is
entirely possible to dispense with handwritten chart notes, report dictation and typing, and all file
copies. Rather, the endoscopist interacts with the computer by responding to a series of questions.
Based on these responses, the computer can produce an accurate, "hard-copy," English language (or
any language) report that can be placed in the patient's chart within minutes. Best of all, the patient's
record then becomes part of a computerized endoscopy database (eliminating the file copy) that can
be accessed to provide information that has a bearing on the management of the endoscopy unit.
There can be no doubt that computer technology has had, and will continue to have, a profound effect
on virtually all aspects of modern society. However, evidence of this is not to be found in the average
endoscopy unit. Many unit operations could be accomplished by computers with greater efficiency and
at lower cost. However, the transition to such automated systems has been slow to develop by
comparison with virtually any other field in which large amounts of data are processed. In fact, the
technology required to transform even a large endoscopy unit into a fully automated, state-of-the-art,
data-processing machine is relatively mundane by modern standards. The missing factor has been
appropriate and acceptable software. The potential and the problems entailed in the transition of the
endoscopy unit to a computer-based operation are discussed in detail in Chapter 6: Medical
Informatics and Chapter 7: Electronic Image Management.
The electronic endoscope is a significant driving force behind the effort to bring the computer into the
endoscopy unit. It is logical to believe that the combination of computers and electronic endoscopes
can provide great benefit to the operation of endoscopy units. Whether this will occur is difficult to
predict. The lack of a truly well-designed computer/software system with the flexibility to meet the
objectives of diverse endoscopy units at reasonable cost may remain a limiting factor for some time to
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come. However, GI endoscopy has become a huge and growing field of medicine, and size alone may
be the technologic imperative of greatest significance to the realization of the potential benefits of the

Staffing Levels
From a managerial viewpoint, it is necessary to know how many endoscopists work in an endoscopy
unit. This is not the same as the number of physicians who perform procedures because most will not
be full-time endoscopists. However, it is useful to calculate the equivalent number of full-time
endoscopists using the part-time contributions of each of the staff members, that is, to express the
availability of endoscopists in terms of full-time equivalents (FTEs).
It is easy to estimate the number of procedures (using the weighted scale method to allow for more
complex procedures) that one full-time endoscopist can perform in 1 year based on 256 working days
per year and a 7-hr day. This number should then be modified by taking into account scheduled staff
meetings, conferences, vacation and meeting time, and perhaps a day or two for illness. Furthermore,
time is inevitably consumed in a variety of procedure-related activities such as review of x-ray films,
chart maintenance, discussions with patients and family members, and unavoidable interruptions. An
estimate of the efficiency of the unit should be added because the endoscopist cannot be more
efficient than the least efficient component of the system. This works out to about 1800 procedure
units. This computation should not be used out of context because it is based on a hypothetical
institution that has three or four conferences per week, 30 days vacation and meeting days per year for
a tired, middle-aged endoscopist, an expected endoscopy unit efficiency of 70%, and other
assumptions. The actual maximum output of a full-time endoscopist in terms of procedure units can,
however, be calculated for any institution. The actual number of procedures will also be less because
the endoscopist usually performs a variety of procedures that are more complex, that is, have a higher
weighted scale value, than a simple EGD.
It is important to note that a calculation of the number of procedure units that one FTE endoscopist
performs will always exceed the maximum theoretical capacity of one procedure room, usually by
about 300 to 500 procedures per year.
The purpose of these computations is to determine whether there are sufficient numbers of procedure
rooms, items of equipment, and GIAs in relation to the number of endoscopists. The staff of few if any
units is made up by full-time endoscopists. However, the part-time contributions of the actual members
of the staff can be converted to the number of FTEs. The easiest method is to determine how much
time each endoscopist spends in the unit during an average week. Because there are 10 half days in a
week, a full-time individual would have a score of 10. Often, an endoscopist will perform procedures on
a half-day basis. A physician who performs procedures 3 mornings per week would have a score of 3;
someone working 3 mornings and 2 afternoons would score 5. Totaling the scores for all endoscopists
and dividing by 10 yields the number of FTEs performing endoscopy. This analysis assumes that the
unit is fully operational and that procedures are performed throughout the day (idle rooms and GIAs
are very expensive). There are other ways to use this method of analysis. For example, when it
appears that limited space is restricting procedural activity and acquisition of additional rooms or even
construction of a new unit is contemplated, a similar calculation can be made based on the amount of
time that each endoscopist thinks she or he needs to perform procedures.
Gastrointestinal Assistants
The number of GIAs needed in a unit is a very important determination. Of all the types of personnel
that contribute to one procedure unit, the GIA has the most functions and duties. The maximum
capacity of 1 GIA in terms of procedure units per year will be lower than that of the endoscopist or the
procedure room itself. Applying the methods of analysis used throughout this chapter results in a figure
of about 1000 procedure units per year. This therefore translates to a ratio of about 1.5 GIAs per
procedure room or 1.8 GIAs per FTE endoscopist.
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The role of the GIA in the endoscopy unit is discussed in Chapter 5: The Gastrointestinal Assistant. In
terms of management of the unit, there are many ways to deploy GIAs. These methods are also
considered in Chapter 5.
Other Personnel
There are many other important personnel in a well-organized endoscopy unit. A process of
redelegating responsibilities in relation to the procedure unit becomes more necessary as the volume
and complexity of procedures increase. The easiest way to conceptualize this is to think in terms of
one procedure unit (see Table 41) and the various types of personnel needed to accomplish one unit
of work. Early in the development of the unit, one employee may be responsible for more than one
component. With growth, more employees will be required and each will be responsible for a smaller
number of components in the procedure unit. For example, in a small unit (not more than 1000
procedure units per year), one secretary might handle appointments, report generation, statistics, and
filing. However, as volume increases, the number of employees required to accomplish each of the
steps in the procedure unit increases, and each employee must focus on a smaller number of
After the head nurse and director of the unit, one of the most important members of the team is the
appointment secretary, especially in a unit that has a flexible method of scheduling as described
previously. At a level of about 2500 to 3000 procedure units per year, an endoscopy unit should have
one person assigned to this job.

Quality and Efficiency

As a rule, it is not possible to eliminate any of the basic elements in the procedure unit (see Table 41).
To assess the quality and efficiency of an endoscopy unit, it is only necessary to study the way in which
each of the basic steps in the procedure unit are accomplished. There are numerous definitions of
efficiency, all of which depend on overall objectives.
Quality and Standards of Patient Care
A high standard of patient care should be an obvious goal. Generally, this pertains to certain aspects of
the endoscopy procedure itself that can be assessed by reviewing factors such as appropriateness of
indications, complication rates, and numbers of unsuccessful procedures. For example: How often are
colonoscopy procedures canceled because of poor preparation? Is there a high incidence of sepsis in
association with ERCP? What percentage of colonoscopy procedures are not accomplished to the
cecum? Additional, less tangible but no less consequential considerations are the qualifications,
training, and morale of the staff, including the GIA.
Efficiency and the Business of Endoscopy
From the administrative standpoint, two interrelated factors determine efficiency: time and cost.
It is very much in vogue in the United States to believe that solutions to health care problems are to be
found in disciplines that are remote to the practice of medicine. It is thought, for example, that the
application of principles and methods from fields such as business, finance, marketing, and
management will encourage the delivery of care that is more effective and less costly. These solutions
become conflicts, however, when applied in an overly rigorous fashion to health care. Nevertheless,
there is much to be gained in trying to look at medical practice from new perspectives.
For better or worse, the modern endoscopy unit is in many respects a business, not by analogy but in
point of fact. In simple terms, resources (personnel, supplies, physical plant, and equipment) are used
to produce a product (a procedure unit). This means that there are costs involved (payroll, capital
equipment, repairs, and the like) and that the services provided to health care consumers (sometimes
referred to as patients) generate income. The operation of any endoscopy unit, therefore, can be
expressed as an operating statement, that is, a breakdown of cost versus revenue. It would be
intriguing, perhaps provocative, to develop this theme of the endoscopy unit as a business, but it is
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sufficient for the subsequent discussion if the veracity of this concept is accepted, even if only
In the remaining years before the 21st century and no doubt beyond, it is no great feat to predict that
the overriding consideration in health care will be cost. Any description of the endoscopy unit of the
future is ill conceived if it does not take this into consideration.
From the standpoint of the endoscopy unit as a business, it is appropriate to inquire as to the costs of
doing business. After the physical plant itself (in reality, a fixed asset that depreciates long term), there
are four major cost factors: supplies, capital equipment (also a fixed asset), repairs, and personnel. For
purposes of cost analysis, the first of these, supplies, gains in significance as the numbers of
procedures increase, especially those with a high complexity (weighted) value. Capital costs are
obviously significant, especially if maintenance of equipment is included, and cannot be totally ignored.
However, the cost of equipment is relatively small compared with the cost of labor. From a long-range
accounting point of view, the financial commitment to a staff member in terms of salary and benefits far
exceeds that of almost any piece of equipment. Even the most expensive laser or fluoroscope
represents a one-time cost that can be amortized over several years, even with allowances for periodic
repair. With proper care, many endoscopes can be used for 1000 or more procedures before a major
overhaul is necessary. A member of the endoscopy unit staff, however, represents a repeated cost
year to year that will only increase with periodic salary increases and seniority. Control of labor costs is
therefore axiomatic.
The efficiency and productivity of any endoscopy unit can be estimated quickly by comparing the
number of procedures performed (with allowances for complexity) with the number of people
(nonphysicians) required to generate these procedures. Complex procedures that consume many
resources may not be very productive from the business point of view. Furthermore, such procedures
are often difficult to perform and, therefore, most likely to require extended periods of time and
additional supplies that, from the business standpoint, amount to a cost overrun.
Every endoscopy procedure requires a certain minimum number of support personnel below which the
quality and safety of the examination are compromised. This would suggest that labor costs in the
endoscopy unit have a relatively fixed relation to the number of procedures performed. It is often
argued, therefore, that the only way to control cost is to reduce service. However, a better answer to
this dilemma is to maximize the productivity of the unit, that is, greater numbers of procedure units in
relation to the number of personnel available. The productivity of a unit can be defined as the ratio of
the number of procedures performed per number of personnel multiplied by a constant that reflects the
overall mix of procedures in terms of complexity.
How much time is required to accomplish one procedure unit? This also has a direct bearing on patient
care. If the time required is excessive, delays in scheduling are the usual result. This can be extremely
costly for hospitalized patients. Delays in scheduling can be a major restricting factor in the growth of
an endoscopy unit. In some cases, growth is restricted by limitations on space or staff. But in others, it
may seem that space and staffing should be more than adequate for continued growth. When such
growth is not apparent, there are many possible reasons, including a declining referral base and
poor-quality patient services. However, another factor, often more difficult to define, is inefficient use of
existing resources.
Productivity is influenced to a substantial extent by the design of an endoscopy unit. Design determines
functionality, that is, the ease with which required tasks are accomplished. Numerous small errors in
the organization of procedure rooms or the overall layout of a unit increase the time and effort required
for a procedure. With growth, the "cost" of such small errors is magnified. In order to achieve the
highest possible levels of productivity, efficiency must be one of the guiding principles of design in the
endoscopy unit of the future.

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The Endoscopy Unit of the Future

The endoscopy unit of the 21st century will be larger than its predecessors. The present growth in
numbers of procedures will be sustained over the next several decades. Although new endoscopic
methods will be developed and applied to clinical problems, most of the growth will occur in procedures
that are already well established. Barium contrast x-ray procedures will be supplanted, for most
purposes, by endoscopy. The most dramatic increase in numbers of procedures will be noted for
colonoscopy. In many countries, large portions of the endoscopy unit will be reserved for colon cancer
screening and the care of patients with colon cancer and polyps.

Socioeconomic Factors
It is essential to recognize that endoscopy alone, in the sense of technologic advancements, will no
longer be the single, dominant factor shaping the endoscopy unit. Rather, other forces will define the
unit and dictate to a greater extent the course of development of endoscopy; a subtle but nevertheless
profound shift in emphasis will occur. These new elements, not medical in the sense of individual
patient care, will usually be socioeconomic in nature. They differ greatly from country to country, so that
attempts at generalizations become problematic. Nonetheless, it cannot be denied that GI endoscopy
and thus the GI endoscopy unit of the 21st century will be influenced to a marked degree by new,
largely external forces.
When systems of health care are centrally planned by government agencies, it is common that
complex procedures requiring high levels of skill and expensive equipment are performed by a
relatively small number of individuals in a few centers. Economic issues are a major driving force in
such a system, so that the allocation of funds for staff and equipment determines the pattern of
medical practice.
Economic forces are becoming increasingly important in health care delivery in the United States and
most other countries, although these forces operate differently. In the United States, the trend is toward
a competitive, marketplace strategy in which health care delivery systems must vie for fixed or even
reduced health care dollars. To an ever-increasing extent, the health care dollar is spent by
organizations, the so-called third-party payers, rather than individuals. The third party has traditionally
been an insurance company or government agency, but increasingly, other third parties such as
corporations will negotiate for health care benefits, frequently with other for-profit corporations.
Economic factors such as these favor larger, efficient, flexible, and responsive institutions that have an
economy of scale. The large, for-profit health care company is a derivative of these changes. Another
result is the consolidation of smaller health care institutions to achieve an economy of scale. Thus,
there are hospital mergers and acquisitions, as well as affiliations and amalgamations as "networks," to
provide total health care systems. The essence of competition is that over the course of time there are
fewer competitors.
It is impossible to know the long-range consequences of these socioeconomic forces with regard to an
endoscopy unit. One net result may be that within any health care systema network of hospitals, for
exampleendoscopic services may also be consolidated. It is logical to expect that specialized
endoscopic procedures will be concentrated at one or a few locations within an organization. The end
result may be a system that more closely resembles those in which governmental agencies are
responsible for centralized planning of health care; that is, complex procedures that require high levels
of skill and expensive equipment will be performed by a relatively small number of individuals in a few
The need to control costs will lead to better designed and more efficient units that require fewer
support personnel. Much of this will be accomplished by application of technology, especially
computers. Most of the clerical functions such as scheduling, report generation, recall of patients, data
processing, record keeping, image management, supply, and many managerial functions related to the
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operation of the unit will be streamlined by computer programs designed specifically for endoscopy.
As manufacturers recognize the need for efficiency and cost control, they will develop complete
endoscopy procedure rooms that can be purchased as modular units. These will comprise
interchangeable components that can be arranged in different patterns to fit into available space. The
modular procedure room will be designed for optimum efficiency with particular emphasis on the tasks
performed by the GIA.

Ambulatory Endoscopy Services

The endoscopy unit of the next century will continue to provide services to hospitalized patients, but the
number of such patients will continue to decline in relation to the number of ambulatory patients
undergoing procedures. In most respects, the endoscopy unit will be an outpatient facility. As such,
more space will be allocated to patient waiting and recovery areas, and greater attention to the comfort
and convenience of the patient will be evident throughout the unit.

Primary Diagnostic Endoscopy

Another emerging trend is that of providing endoscopic services on request. In the future, a substantial
portion of relatively simple diagnostic procedures such as EGD will be performed at the request of a
referring physician without prior consultation, much the same as a radiologist performs an upper GI
x-ray series. This practice is referred to by a variety of names, such as primary diagnostic endoscopy,
primary panendoscopy, and open access endoscopy. Frequently controversial, this concept offers
certain advantages but also has potential problems (see Chapter 37: Indications, Contraindications,
and Complications of Upper Gastrointestinal Endoscopy). Such a system presently works best in a
closed staff environment in which there is an established referral pattern of patients for endoscopy and
in which the endoscopist has an existing professional relationship as well as direct communication with
physicians who request endoscopy.

New Technology
GI endoscopy since the early 1970s has been a masterpiece built on two complementary themes:
technical development and the clinical application of technology. To a significant extent, the endoscopy
unit has evolved to accommodate this progress. Its existence is in fact secondary to the more
fundamental purpose of performing procedures of ever-increasing sophistication in greater numbers of
patients. If the future could be modeled on the past, then the endoscopy unit of the 21st century would
be a truly remarkable place, a technologic tour de force. Unfortunately, the old formulas will not be
quite so reliable in the future.
Over the next decade, there will be relatively few technologic developments in the field of endoscopy
that are truly innovative with respect to endoscopic diagnosis and therapy. New devices and methods
will tend to be more costly in terms of the time required for development and their complexity. These
will address a narrower range of clinical problems and will be less applicable to large groups of
patients, so that the overall effect on numbers of procedures and the functional nature of the
endoscopy unit will be relatively small.
Developmental advances in the field of endoscopy since the mid-1960s have come at relatively low
cost. Future technologic gains that require computers, videosystems, lasers, specialized endoscopes,
and other instruments will have a higher monetary cost. Currently, EUS is the best example of this
trend. It is doubtful, therefore, that every hospital will be able to afford a state-of-the-art endoscopy unit
in the future.

The endoscopy unit of the 21st century will be all electronic. In addition to new methods of diagnosis,
the electronic instrument will link the procedure itself to the computer that runs the unit. Computer
systems for image management will be commonplace, as will electronic communication between units
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for consultation and patient referral. In systems of health care that comprise multiple facilities, the
paper record will be a relic of the past. Because patients may be seen in more than one facility within
the system, the patient record that consists of pieces of paper must be replaced by electronic systems
of computer databases and networks. The computer system that serves the endoscopy unit will be but
one part of a much larger network of computers.

It is virtually certain that a full range of endoscopic services will not be found in every unit. Decisions for
new technology will be more difficult because of cost and uncertainty as to the clinical applications of
new devices. In many cases, choices will have to be made as to a range of technical capability, and it
will be difficult or impossible to offer full endoscopic services. In the coming years, the numerous
institutions that make up the delivery of health care will continue to consolidate. There will be smaller
numbers of health care systems, but these will consist of multiple hospitals and other facilities. Within
each system, a state-of-the-art endoscopy unit for each component facility will not be cost effective.
The net result of this line of reasoning is the separation of endoscopy units into two categories, tertiary
and primary.

Regulation and Oversight

It would be unrealistic to deny that the policies of government regulatory agencies will continue to
influence endoscopy and, therefore, the endoscopy unit, at least in the United States. It is impossible to
explore in this essay the impact of each and every regulatory body on the endoscopy unit of the future.
Whether this will enhance the quality of care and reduce costs is a matter of some speculation.
Furthermore, there is a real concern that regulatory policy can adversely affect the development of new

The Consumer Movement

There is a growing demand for objective measurements of the quality of medical care. This is driven in
part by concerns over the cost of care, but also by more fundamental questions as to the true value of
care. This movement has many facets and ramifications, but for the endoscopy unit, it will mean more
rigorous standards of practice in terms of appropriate use, outcome, and safety of procedures. There
will be a great need for accurate data in these three areas. Added emphasis will be given to proper
training and credentials, for physicians as well as GIAs.
Greater emphasis will be given to assessing the benefit to patients of new technology. That a new
device or method can be demonstrated to work as declared will be insufficient justification for
acceptance as standard practice. Rather, every invention and new application of existing technology
must be shown to improve outcomes for patients. The time required for the development and
implementation of new techniques will therefore be longer.

The authors gratefully acknowledge the assistance of Mr. S. M. Greengrass, Research and
Development Director, KeyMed, Ltd. (Southend-on-Sea, Essex, England), for his assistance in
providing data from the KeyMed study for this chapter.


Overholt BF, Chobanian SJ. Office Endoscopy. Baltimore: Williams & Wilkins. 1990.
Waye JD, Rich ME. Planning an endoscopy suite for office and hospital. New York,
Igaku-Shoin. 1990.
Gostout CJ, Ott BJ, Burton D, DiMagno EP. Design of the endoscopy procedure room.
Gastrointest Endosc Clin N Am 1993;3:50924.
Burton D, Ott BJ, Gostout CJ, DiMagno EP. Approach to designing a gastrointestinal
endoscopy unit. Gastrointest Endosc Clin N Am 1993;3:52540.

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Gostout CJ. Unit management. Gastrointest Endosc Clin N Am 1993;3:54147.

The American Society for Gastrointestinal Endoscopy. Guidelines for establishment of
gastrointestinal endoscopy areas. Gastrointest Endosc 1988;34(suppl 3):3S.
7. Seifert E, Weismuller J. How to run an endoscopy unit? Experience in the Federal Republic of
Germany. Results of a survey of 31 centers. Endoscopy 1986;18:204.
The British Society of Gastroenterology. Design of gastrointestinal endoscopy units. The
British Society of Gastroenterology, 1984;128.
The British Society of Gastroenterology. Report of a working party on the staffing of
endoscopy units. The British Society of Gastroenterology, 1987;139.
10. The British Society of Gastroenterology. Provision of gastrointestinal endoscopy and related
services for a district general hospital. Working Party of the Clinical Services Committee of
the British Society of Gastroenterology. Gut 1991;32:95105.
Manoy R. Ergonomics and Design Study. Personal communication. 1989.
12. Larson DE, Ott BJ. The structure and function of the outpatient endoscopy unit. Gastrointest
Endosc 1986;32:104.
13. Urayama S, Kozarek R, Raltz S. Evaluation of per-procedure equipment costs in an outpatient
endoscopy center. Gastrointest Endosc 1996;44:12932.

Chapter 5 The Gastrointestinal Assistant



Evolution of the Gastrointestinal Assistant Concept

The comfort and safety of a patient undergoing gastrointestinal endoscopy in the era of the rigid
endoscope depended largely on the skill and attention of the endoscopy assistant. Just as rigid
endoscopy is no longer widely practiced, few gastrointestinal assistants (GIAs) today are cognizant of
the role of the "head-holder." This is unfortunate because the present-day GIA has little awareness of
the background and early development of this form of nursing. Although an appreciation of the role of
the assistant from a historical perspective is not essential, it adds greatly to the sense of profession
and of participation in the development of gastrointestinal endoscopy.
Although much has changed for the endoscopist and GIA, the fundamental relationship remains the
same. During the early days of endoscopy, the assistant had two basic functions, which have remained
essentially unaltered: custody and preparation of endoscopic instruments and a role in the comfort and
safety of the patient. The specific ways in which these functions are carried out, however, have
changed substantially. Responsibility for only the endoscopic instruments now encompasses a large
endoscopy unit and numerous items of equipment. Patients today undergo many types of procedures
that require numerous and different items of equipment; each procedure has unique potential
complications, and each presents special difficulties for patients. Most procedures are now performed
on an ambulatory basis, so that patient education and assessment of the patient's status before
discharge are integral to the role of the GIA.
The remarkable increase in the number of procedures performed presents new problems for the GIA
with respect to patient comfort and safety. Heretofore, the assistant might have been responsible for
the postprocedure recovery of one or a few patients, whereas the GIA now has responsibility for
numerous patients with various disorders who have undergone any number of different procedures.
Safety in rigid endoscopy once depended on holding the patient's head properly and monitoring
respiratory and cardiac function. Although exact positioning of the patient is perhaps less important
now, attention to the patient's vital functions is no less essential. When large numbers of procedures
are performed, they become "routine." This plus the inherent low complication rate for most
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endoscopic procedures can lead to a false sense of security. In a busy unit, the many tasks to be
performed can distract attention from the most critical function of patient monitoring.
The GIA's custody of the instruments also has a direct bearing on patient safety. The endoscopist and
the patient both expect that all instruments will be in working order and that the success and safety of
the procedure will not be compromised by poor condition of the equipment or by disorganization. This
has ramifications ranging from instrument malfunction during a critical stage of a procedure to disease
transmission by inadequately cleaned instruments. A high volume of procedures can also compound
problems with respect to proper cleaning and maintenance of equipment.
The avoidance of pain, discomfort, and injury to the patient as a direct result of a procedure is
essentially the responsibility of the endoscopist. In many respects, however, the GIA shares in this
responsibility. For example, most patients approach a procedure with trepidation. The size and intense
activity of a large endoscopy unit can increase this anxiety by virtue of a seeming lack of individual
attention. These factors make the role of the GIA even more crucial with respect to the emotional
preparation of the patient and require highly developed skills.
The relationship of nursing to gastrointestinal endoscopy in the past was usually that of a part-time
assistant, since the volume and variety of procedures performed did not fully occupy a nurse in most
institutions. Growth and evolution of gastrointestinal endoscopy have changed this relationship to the
extent that the role of the GIA has become a highly specialized area within the field of nursing. It is
appropriate that this full-time profession with its special requirements and qualifications be given its
own designation; hence, the term gastrointestinal assistant. This specialty has grown to the point that
the Society of Gastroenterology Nurses and Associates now offers professional certification to both
nurses and GIAs.

Certain fundamental qualifications are required for an individual to become a GIA. The candidate
should be trained in the basic aspects of patient care; prior experience involving contact with patients is
desirable. Most gastrointestinal endoscopy procedures require administration of conscious sedation.
The GIA must be familiar with the essential aspects of cardiovascular and respiratory physiology and
must be able to quickly and accurately assess the cardiopulmonary status of any patient. Certification
in cardiopulmonary resuscitation (CPR) should be required, including a thorough knowledge of all
drugs and equipment used in CPR.
Medications are administered in most endoscopic procedures, so that the GIA must be knowledgeable
about dosages, methods of administration, side effects, and interactions of the various drugs used.
Since the medications used in endoscopy are often controlled substances, the GIA must be licensed
and qualified to handle these agents.
For the GIA with no previous experience, it is helpful to understand that gastrointestinal endoscopy has
a large technical component and that a certain amount of manual dexterity and mechanical ability are
necessary. The amount of equipment that must be put in place, maintained, cleaned, and inventoried
is far more than that found in most other patient care situations. Candidates with experience in the
operating room, emergency room, cardiac catheterization laboratory, intensive care areas, or other
procedurally oriented settings may acclimate to gastrointestinal endoscopy more easily than those
whose background is general medical surgical nursing.
An endoscopic procedure encompasses many tasks that must be accomplished, sometimes
simultaneously. These include monitoring and reassuring the patient, assisting with the administration
of medications, processing specimens, and keeping records and documentation, in addition to working
with the endoscopy equipment.
The GIA must be flexible and able to adapt. Abrupt changes in the schedule of procedures are
common. Level scheduling is problematic in most active units, busy periods alternate with lighter ones,
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and frequently the daily schedule of procedures does not conclude on time. The GIA must also be able
to adapt to changing needs for equipment. As a procedure progresses, accessories and instruments
may be required that could not be anticipated at the beginning of the procedure.
Of all the special attributes required of the GIA, attention to detail is perhaps the most important. The
difference between an adequate and an excellent GIA is the quality of thoroughness and punctilious
attention to the numerous small aspects of patient care, procedures, and equipment. By virtue of their
education, nurses are uniquely qualified for this position.

Functions of the GIA

The Procedure Unit
The endoscopy "procedure unit" is described in Chapter 4: The Endoscopy Unit. Conceptionally, the
essential elements derive from all endoscopic procedures being alike in many respects, since all have
certain steps in common, and the actual endoscopic component of the procedure unit being only one
part of a more complex process (Table 51). The GIA has responsibility for more steps and for the
accomplishment of more tasks within the endoscopy procedure unit than any of the other personnel,
including the endoscopist (Table 51).

Functions of the
Gastrointestinal Assistant in the Procedure

Patient check-in*
Patient instruction, interview*
Patient preparation*
Room/equipment preparation*
Handling of biopsy and other specimens
Patient recovery
Postprocedure instructions/scheduling*
Room/equipment cleaning, turn-around*
Charting/report generation
Written chart notation
Report dictation
Report typing
Review/signature of typed report
Process report to chart
File copy of report
Data processing
* Functions normally performed by GIA.

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Functions of the
Gastrointestinal Assistant in the Procedure

Functions that may or may not be performed by GIA,

depending on unit.

The length of time required for the endoscopic component of the procedure unit is highly variable and
depends on the type of the procedure, whether any abnormalities are encountered, and the skill of the
endoscopist. Thus, a routine diagnostic upper gastrointestinal endoscopy can be accomplished in 5 to
10 minutes, whereas a complex colonoscopic polypectomy may require a significantly longer period of
time. As a general rule, there is less variation in the time required for the steps in the procedure unit
that are accomplished by the GIA. The time necessary for preparation of instruments and the
procedure room, cleaning, and postprocedure monitoring of the patient is relatively fixed regardless of
the type of procedure performed.
Preprocedure Functions
The principal duties of the GIA prior to a procedure include preparation of the patient, proper
arrangement of the procedure room, and preparation of the endoscopic equipment. In some units, the
GIA may also have a partial role in the scheduling of procedures, a function that is usually the
responsibility of the GIA supervisor or scheduling personnel. The supervisor's role is discussed later in
this chapter. Preparing the patient for endoscopy has several facets that may differ according to the
type of procedure to be performed.
First Contact
If the procedure is to be performed on an ambulatory or outpatient basis, the patient must be brought
to the dressing room and shown the place he or she will occupy before and after the procedure. In
some units, the patient's belongings are placed on a tray beneath the cart or gurney that the patient
occupies before, during, and after the procedure. This practice effectively saves time by eliminating the
need for the patient to move from cart to cart after sedation is given. It also keeps clothes and other
personal belongings with the patient (Figure 51). The GIA can explain what must be done in
preparation for the procedure, such as disrobing and gowning (some patients require assistance).
Although these details are seemingly mundane and unimportant, they offer the GIA an ideal
opportunity to meet with the patient and to establish a rapport.

(179)Figure 51. Preprocedure preparation area and recovery area (Cleveland Clinic). Carts
are equipped with storage trays underneath to hold the patient's belongings. Monitoring
equipment, "sharps" containers, gloves, tissue, basins, and other frequently needed supplies
are found between bedspaces. Side rails on carts can be positioned to provide a flat surface for
starting intravenous lines. A rocking chair, toys, and books are available for pediatric patients.
Whether a patient is an inpatient or an outpatient, it should be verified that all the necessary steps in
the preparation process have been accomplished. For example, when preparation for colonoscopy has
been carried out by the patient, it is useful for the GIA to review the process with the patient to confirm
that cleansing of the colon is adequate for the examination. It is not unusual to discover that the patient
has encountered difficulty with some aspect of the preparation. An alert GIA can sometimes salvage
this situation with additional enemas and thereby avoid loss of valuable time.
Medical History
It is of value to inquire about any recent change in the patient's overall medical status. As a general
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rule, this line of questioning can be based on chart notes and should focus on the patient's
cardiovascular and pulmonary status, any change in gastrointestinal symptoms, and the use of
medication. Recent changes in gastrointestinal symptoms such as the onset of protracted vomiting,
worsening or prolonged abdominal pain, and the appearance of bloody diarrhea sometimes
necessitate changes in the investigative plan.
The use of medications prior to a procedure is a common area of confusion for patients. Essential
drugs may have been discontinued in the mistaken belief that this was a necessary part of fasting.
Conversely, the patient may have continued the use of an agent that she or he did not consider to be
medication, for example, a liquid antacid. Some patients continue to take iron preparations orally
during the standard preparation for colonoscopy, which often compromises the preparation of the
The GIA should be particularly careful with the insulin-dependent diabetic patient. In our units, we
usually ask the diabetic patient to administer half the morning dose of insulin at the usual time.
Procedures are scheduled early in the day for these patients, and the second half of the usual insulin
dose is given along with a morning meal after the patient recovers from the procedure. However, errors
can still occur with this simple plan, especially in patients on a stable dosage who have a consistent
routine for insulin administration.
The GIA should also ask about the use of sedative and hypnotic drugs, as this may have a bearing on
the selection of medications and their dosages for the procedure. The anxiety-prone patient may find it
necessary to take such a drug before coming to the endoscopy unit. Chronic users of this type of
medication may also have a tolerance to some agents. Finally, it is essential to ask about any drug
allergies, especially if antibiotic prophylaxis will be used for the procedure.
Description of the Endoscopic Procedure
In our units, all patients receive a written description of the procedure they are to undergo. Ideally, they
receive this far enough in advance so that they can express any concerns or questions that arise after
studying the written outline. The printed material contains information on the goals of the study, steps
the patient must take to prepare for the procedure, a general description of the way in which the
endoscopy will be performed, and some basic facts concerning complications including signs and
symptoms along with specific instructions should the patient encounter symptoms of a complication
after discharge. This type of instruction serves as a point of reference for the patient and often fills in
gaps in the patient's memory regarding the physician's instructions. Although the printed description is
necessary and valuable, it is impersonal and may strike some patients as legalistic. It seldom offers the
patient a sense of confidence or reassurance. Regardless of how well it is written, it is unrealistic to
believe that all the information it contains will be correctly interpreted by every patient. Therefore, it can
never totally substitute for an informed consent or serve as the sole vehicle for conveying instructions
and information.
In some units, the responsibility for the formal explanation of the endoscopic procedure is delegated to
the GIA. However, the primary responsibility for advising the patient of the indication(s), methodology,
and possible complications of the endoscopic procedure remains with the endoscopist. Patients,
however, are sometimes reluctant to discuss with the physician concerns and questions that they may
consider trivial or unimportant, and often questions arise in their minds some time after contact with the
physician. For some patients, it may be necessary for signifiant points in the description to be repeated,
especially when the information has become distorted by anxiety. The GIA plays an essential role in
this process. The GIA is usually the first person with a medical background that a patient encounters
immediately before a procedure. At this time, the sense of uneasiness is greatest and the patient is
most likely to ask questions. Furthermore, the patient often recognizes the GIA not only as someone
with knowledge of the endoscopy procedure but also as someone to relate to in a more personal and
direct way than may occur in the traditional doctor-patient relationship.
The patient's most common questions and predictable comments can be anticipated by the
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experienced GIA"Will it hurt?" "Is it dangerous?" "Will I gag?" "Will I be able to breathe?" "I don't like
needles!" "How long will it take?" The GIA should answer questions forthrightly. However, because of
the natural human tendency to offer support to a person in emotional distress, the GIA must be careful
not to offer excessive reassurance. The GIA should never attempt to completely dismiss from the
patient's mind any of the potentially unpleasant parts or aspects of a procedure and, equally important,
should not overly stress these factors.
Psychologic Preparation
Almost all patients are apprehensive to some degree. Many patients control this well, but in others
there is overt fear and aversion. The way this is dealt with can influence the course and outcome of the
procedure. If the patient is at ease, the procedure will be better tolerated, the endoscopist will have
adequate time to complete it, and smaller amounts of sedative drugs will be required. Although the
value of this psychologic preparation in addition to the pharmacologic preparation is easily recognized,
the emotional needs of patients may be difficult to resolve. Success is in some measure dependent on
the natural attributes and personality of the GIA. The patient would not permit the procedure under
normal circumstances if she or he did not regard the physician as a benefactor. But sometimes the
patient is not always at ease and comfortable with the physician as the "authority figure" during the
procedure. In contrast, the GIA is in a less formal, more personal position to offer the type of
reassurance that leads to the patient's emotional confidence in all the personnel involved in the
procedure. The patient needs to know that her or his welfare is first and foremost. The simple phrase "I
am ... , I will be with you through the procedure" can be as effective as any drug, the key words being I,
with, and you.
Sedative drugs are usually administered before endoscopic procedures, although this varies in extent
from country to country. The two most widespread classes in use are narcotic and benzodiazepine
agents. These may be given in a variety of ways, although intravenous administration is probably
preferred. Anticholinergic drugs are rarely used for most routine endoscopic procedures with the
exception of laparoscopy. In almost all cases, the dosage of medication is calculated according to the
patient's age, weight, and general medical condition, and it is administered slowly while the patient's
response is observed. Endoscopists also differ with respect to methods of intravenous administration.
For a relatively short diagnostic procedure with a motivated patient, some endos-copists administer no
sedation at all or only small dose(s) by direct intravenous injection. For a more prolonged procedure in
which some discomfort is expected, the endoscopist may prefer to maintain constant intravenous
access, so that additional amounts of sedative drugs may be administered. Generally, a heparin lock is
adequate for this purpose, although a slowly running intravenous infusion is sometimes requested,
especially for procedures that involve some risk such as bleeding. In our units, direct intravenous
injection of drugs is performed only by a physician or by a registered nurse under the direct supervision
and observation of a physician.
In some units, sedative and other drugs are administered prior to bringing the patient to the endoscopy
room. Generally, this requires a cart-exchange system between the dressing room and the procedure
room; that is, the patient remains on one cart during all steps of the procedure. In most units,
intravenous sedation is given in the procedure room immediately before a procedure.
The GIA has primary responsibility for the drugs used in the endoscopy unit. This includes the
maintenance of a proper inventory of agents commonly used and the handling of controlled substances
as prescribed by law. In addition, the GIA is also responsible for preparing correct dosages of drugs for
use during procedures.
Preparation of the Procedure Room and Equipment
An important duty of the GIA is to prepare the procedure room for each endoscopy. The room must be
maintained in a clean and orderly fashion. Surfaces that may be contaminated are cleaned with an
appropriate disinfecting agent between cases. The need for various items of equipment is anticipated.
Our scheduling systems are based on room availability. The master schedule sheet can be easily
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separated into individual sections that outline activity within each room on a daily basis. A copy of this
is placed in each procedure room and the dressing room station. A master schedule is kept by the GIA
supervisor. Using this schedule, the GIA working in each room can plan ahead with respect to the
equipment needed for each procedure and, since the physician's name is also listed on the schedule,
can also anticipate the special preferences of each endoscopist. When appropriate, marginal notes
and remarks are included on the schedule to indicate special requirements, especially with respect to
therapeutic endoscopy.
The ability to organize all equipment and to keep the procedure room and unit functioning smoothly is
based on a thorough understanding of endoscopic procedures, and this can only be learned by actual
practice. Thus, it is impractical to list all the items of equipment needed for the many different
diagnostic and therapeutic endoscopic procedures. Moreover, there are differences among institutions
in the way procedures are performed, and these modifications often necessitate additional accessories
and pieces of equipment.
Functions During Endoscopy
It is impossible to address every variation in the activity of the GIA that may be encountered during
every kind of procedure. However, it is appropriate to comment on the more prominent aspects of the
functions of the GIA during the main types of endoscopic procedures.
It is necessary for an ambulatory patient to only partially disrobe for esophagogastroduodenoscopy
(EGD). It is ordinarily sufficient to remove outer garments above the waist, but not undergarments, and
then put on a hospital gown. Eye glasses and dentures should be removed.
Some but not all endoscopists prefer topical pharyngeal anesthesia (see Chapter 38: Technique of
Upper Gastrointestinal Endoscopy). Several methods of accomplishing this include the GIA's
administering an anesthetic spray or having the patient gargle with a viscous anesthetic agent. It is
advisable to inquire again about any drug allergies the patient may have before any medication is
administered in the procedure room.
The patient is then positioned on the examination table. One or two pillows should be available. The
patient usually first assumes a supine position if sedative drugs are to be given, although she or he
may be placed directly in the left decubitus position for endoscopy if there is convenient intravenous
access. Once the medication is given, the GIA places the patient in the proper position for the
procedure. For upper gastrointestinal endoscopy, the patient is generally on the left side, knees flexed,
left arm under pillow, right arm on the right side, with head and chin tilted slightly downward toward the
Except in the case of edentulous patients, a mouthguard is placed between the patient's teeth to
protect both the instrument and the teeth during the examination. One of the GIA's responsibilities is to
ensure that the mouthguard remains in proper position. It may fall out or be pushed out by the patient
during the procedure. Some endoscopists prefer to lubricate the insertion tube of the endoscope, and a
supply of lubricant should be at hand. Because the insertion tube also becomes coated with secretions,
gastric juice, and mucus during the procedure, it may become slippery and difficult to handle.
Therefore, a few gauze sponges are kept on a washcloth on the pillow near the patient's head for the
endoscopist to use to grasp the instrument.
Most endoscopists pass the endoscope under direct observation without inserting a finger into the
patient's mouth (see Chapter 38: Technique of Upper Gastrointestial Endoscopy). During direct vision
passage of the endoscope through the pharynx and cricopharyngeus, the GIA must keep the patient's
head in proper position, which is a slight flexion of the neck. There is a natural tendency for patients to
extend the neck and to move away from the instrument. Gentle words of reassurance and
encouragement offered by the GIA are frequently helpful as the instrument is being passed. Just as the
instrument enters the esophagus, a disposable oral suction catheter can be placed in the left side of
the patient's mouth next to the mouthguard. This has a blunt tip and can be bent to fit comfortably in
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the corner of the mouth. This will allow removal of any regurgitated fluid and oral secretions.
During the endoscopic procedure, the GIA must keep the patient in proper position on the examination
table and must monitor cardiopulmonary status, especially respiration. Some endoscopists prefer that
the lights be dimmed in the room, others do not. The room should never be so dark, however, that it
becomes difficult to monitor the patient. The GIA must also ensure that the mouthguard and suction
device remain in proper position and must be alert for unexpected vomiting, as aspiration is a serious
potential complication of EGD.
The GIA has several functions with regard to the various types of specimens collected during the
procedure. These include tissues (biopsies), cells (cytology specimens), and secretions or exudate
(e.g., potassium hydroxide preparation). The GIA should prepare the necessary accessories and
equipment and assist in the actual collection of specimens. The GIA usually takes care of the handling
of the specimens including proper labeling of containers and preparation of the necessary forms that
must accompany specimens to the laboratory. The GIA also cleans certain accessories.
When the endoscope is set out for use (or replaced in storage), its appropriate set of accessories
should always be included. It should never be necessary to interrupt a procedure to search for the
correct accessory. In particular, although all endoscopic biopsy forceps have the same basic design,
there are significant differences. The most important are the differences in diameter necessitated by
variations in accessory channel diameter according to the type and manufacture of an endoscope. This
can be a problem, albeit minor, in a large unit where there are many endoscopes. This can be avoided
if each endoscope and its related accessories are stored in the same place. Biopsy forceps may also
differ slightly in some other respects; they may have open (fenestrated) or closed forceps cups, or
there may be a bayonet spike enclosed within the cups. The GIA must determine the type of forceps
preferred by the endoscopist.
Most often, the endoscopist directs the GIA to open and close the biopsy forceps. It is important that
the GIA and endoscopist agree on specific and simple directions for operation of the biopsy forceps
(e.g., "open" and "close"). The forceps should always be checked to be certain that it works properly
before it is given to the endoscopist. The forceps can be broken if it is opened or closed too forcefully.
The endoscope may be damaged as well as the forceps if the latter is opened within the accessory
channel or if it is withdrawn into the channel while it is open. An alert and experienced GIA can
recognize that the forceps is partially or completely within the channel if an unusual opposing force is
encountered when attempting to open the device. This may save expensive repair and replacement
costs and is particularly important when trainees obtain biopsies. Even an experienced endoscopist
may attempt to open the forceps when it is partially within the channel if she or he encounters difficulty
in obtaining a specimen and must work close to a lesion. Closure of the forceps should not be abrupt
or forceful. Brusque closure sometimes causes the forceps cups to recoil from a firm lesion without
obtaining a specimen. An experienced GIA can often appreciate that a lesion is unusually firm or hard
as the forceps is closed; this tactile perception is frequently associated with malignancy. As the forceps
is removed from the accessory channel of the instrument, simultaneous wiping with a gauze pad will
prevent splashing and dripping of fluid. This also cleans and dries the coil somewhat and makes it
easier to handle.
The GIA is also responsible for proper handling of tissue and cytologic specimens. The methods of
doing this should be specified by the pathology and cytology laboratories. These requirements vary
from hospital to hospital. In the Cleveland Clinic endoscopy unit, biopsy specimens are gently teased
out of the forceps cup and on to a small disk of filter paper (one paper disk per biopsy) using a
toothpick. The paper and specimen are then placed in a bottle containing Hollande's fixative solution.
No attempt is made to orient the specimen, as most endoscopic biopsy specimens are small and
attempts to rearrange the specimen on the paper damage the tissue. By contrast, pathologists at
University Hospitals of Cleveland prefer that the specimen for biopsy be simply dropped into a small
bottle of fixative, which is accomplished by opening the forceps within the solution and gently moving it
back and forth several times.
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Proper procedures should always be observed in handling bodily tissues and fluids, as these are
potentially infectious.
Probably the second most commonly used accessory is the sheathed cytology brush. In some cases,
this may be used to obtain specimens such as exudate from the esophageal surface to determine the
presence of Candida albicans. However, it is most commonly used to obtain cells from the surface of a
lesion for cytologic study. Since this accessory cannot be adequately cleaned and disinfected, a new
cytology brush should be used for each procedure and then discarded, Furthermore, reuse may permit
malignant cells to be transferred from one patient's sample to another's. Commercially available
disposable cytology brushes are relatively inexpensive.
Cytologic specimens obtained by brushing are placed on a microscope slide by simply brushing the
specimen on to the glass. With a good specimen, there is usually enough material for two slides. The
slide is then placed in a fixative solution (e.g., Carnoy's solution).
The GIA is usually responsible for proper identification of the biopsy specimens. In some units, the
endoscopist may direct that the GIA complete the pathology request forms. This obligation should
never be taken lightly, since mislabeling or confusing specimens from one patient with those from
another may have serious consequences. Therefore, the procedures and methods for handling
specimens should be firmly established and rigidly adhered to in every unit.
Sclerotherapy of esophageal varices is a therapeutic procedure commonly performed in conjunction
with EGD. Injection of the sclerosant solution is almost always performed by the GIA and requires
precise communication between the GIA and the endoscopist. The directions given by the endoscopist
should be unambiguous, and a single set of terms should be used. The GIA reports the volume of
sclerosant injected in increments of 0.5 ml to allow the endoscopist to control the rate and volume of
the injection. Injections may be intravariceal or paravariceal, according to the technique of the
endoscopist (see Chapter 32: Technique of Endoscopic Sclerotherapy). When intravariceal technique
is employed, it is usually possible for an experienced GIA to recognize that the needle is not within a
vessel or that the vessel is thrombosed, according to the degree of resistance encountered while
injecting. A 10-ml syringe is the easiest to use, since it contains enough sclerosant for several
injections and it allows for relatively precise control of the rate and volume of injections. Since most
sclerosants are injurious to the eyes, care must be taken that the syringe not be abruptly disconnected
from the injector needle. If this should occur, the sclerosant may be sprayed into the eyes of the
physician, patient, or GIA. To prevent this, it is advisable to wrap a gauze sponge around the
connection while injecting. The total volume used during sclerotherapy and the number of injections
are recorded by the GIA.
Certain complications are possible with sclerotherapy. Those that may occur suddenly during the
procedure include the vomiting and aspiration of blood and gastric contents during acute hemorrhage
and the onset of active bleeding during the procedure. In rare instances, balloon tamponade has been
necessary for control of acute bleeding. Therefore, it is advisable to keep the necessary equipment at
The functions of the GIA during colonoscopy differ somewhat from those attendant to EGD. It may be
necessary, for example, to assist the patient in changing position during the procedure. Additional
lubricant may also be needed to be applied to the insertion tube near the patient's anus intermittently
during the procedure (e.g., a small amount of lubricant may be placed on a gauze pad or other
methods may be used). In addition to the usual monitoring of the patient, it is essential in this
procedure to observe the patient for signs of excess discomfort or pain and evidence of abdominal
The GIA should be aware that there are substantial variations in colonoscopy technique among
endoscopists (see Chapter 81: Technique of Colonoscopy). The endoscopist may request that the GIA
hold the instrument at the anus as the endoscopist shifts his or her hand from the insertion tube to the
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lateral deflection knob. As a general rule, most expert colonoscopists do not permit the GIA to advance
or withdraw the colonoscope. Many endoscopists use external counterpressure on the patient's
abdominal wall during the procedure. Generally, pressure is applied to the mobile segments of the
colon that are on the mesentery (see Chapter 81: Technique of Colonoscopy). There are many
individual variations for this part of the procedure. If external counterpressure is requested, the GIA
should ask the endoscopist to indicate the place and direction to apply pressure on the abdominal wall,
especially if the GIA is not familiar with the endoscopist's methods. The patient should be forewarned
of this maneuver and should be observed for evidence of pain or excessive discomfort. The
suctionaccessory channel of the colonoscope sometimes becomes clogged during colonoscopy. This
can often be cleared by forcing water or air, or both, back through the channel. During this maneuver, it
is necessary that the endoscopist depress the suction valve.
The GIA usually has several important functions in the process of polypectomy. Modern electrically
isolated electrosurgical generators provide a margin of safety for endoscopic polypectomy (see
Chapter 9: Principles of Electrosurgery). In addition, the patient is almost always awake, albeit sedated,
during the procedure, so that it is unlikely that an inadvertent burn will lead to tissue necrosis. But these
built-in safety factors do not reduce the responsibility of the GIA for the overall safety of this procedure.
All connections between the active electrode (snare) and the generator, as well as those for the
dispersive electrode (plate), must be made correctly. This equipment must be inspected periodically to
be sure that the wires and connections are not worn or broken. In addition, the GIA must be certain at
all times that there is a good contact between the plate and the patient, especially if the patient's
position has been changed between successive polypectomies. Braided polypectomy snare wires
should be checked carefully for any small broken wires in the braid. A broken strand can result in stray
electrosurgical currents. These are usually difficult to see but can be found by gently running a gauze
sponge over the open snare loop.
The generator output is usually set by the GIA. The settings should always be verified before
proceeding with polypectomy and never assumed to be correct, especially if the generator is used for a
variety of procedures by different endoscopists. Even if the GIA is thoroughly familiar with an
endoscopist's particular technique, it is always wise to announce the settings before proceeding. It is
best also that the GIA have an understanding with every endoscopist that polypectomy must not begin
until the GIA announces that everything is ready.
Closure of the snare loop is a critical phase of endoscopic polypectomy. Since the GIA and the
endoscopist must cooperate closely in this maneuver, it is essential that the directions that the
endoscopist will use be established and clearly understood by the GIA in advance. As with biopsy
technique, simple directions work best: for example, "close" to close the loop, "open," "open slightly,"
"open full," "open half," to open the loop. The endoscopist may repeat the direction to "close" until the
loop is against the stalk of the polyp. Electrosurgical polypectomy encompasses several variations in
technique (see Chapter 9: Principles of Electrosurgery, and Chapter 85: Polyps and Tumors of the
Colon) that determine how tightly the snare loop must be closed. Excessive force may guillotine the
polyp and result in bleeding, or it may inhibit the sparking necessary to produce electrosurgical cutting.
Inadequate closure may also prevent adequate coagulation or cutting. It is virtually impossible to
describe the correct amount of tension to be applied to the snare wire; the GIA can learn this only
through experience, and this learning process is based entirely on close cooperation and
communication with the endoscopist. As the snare is closed, the GIA can often appreciate that viable
tissue is still present within the loop because the effort to close meets with a certain resistance. It is
also possible to sense the point that the snare cuts through tissue. The degree of closure of the loop
can also be gauged by observing the control handle.
Endoscopic Retrograde Cholangiopancreatography
The tasks associated with endoscopic retrograde cholangiopancreatography (ERCP) are similar to
those for EGD with some additions, such as the injection of contrast medium. Therapeutic ERCP
usually requires a greater variety of accessories than most other procedures. Certain ERCP
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procedures have a higher risk of complications, depending on the nature of the disease. In some
clinical situations, there is a higher risk of sepsis.
As with biopsy, polypectomy, sclerotherapy, and any cooperative therapeutic procedure, injection of
radiographic contrast material requires precise communication between endoscopist and assistant.
Excessive force with an increased rate and volume of injection usually causes discomfort and in the
pancreatic duct may contribute to postprocedure pancreatitis. Generally, the endoscopist controls the
rate of injection by reference to the fluoroscopic image. The GIA should also watch the filling of the
ductal systems fluoroscopically, although instructions from the endoscopist should primarily direct the
filling procedure. Some special types of ERCP catheters may be used such as those with a tapered tip
and those with a small metal tip for cannulation of a stenotic papilla or the minor papilla (see Chapter
57: Technique of Endoscopic Retrograde Cholangiopancreatography).
Aseptic technique is mandatory in ERCP, since in some clinical situations, contrast medium may be
injected into a closed space such as a pancreatic pseudocyst or beyond a tight stricture in the bile duct.
The introduction of bacteria into a closed space without proper drainage can lead to septicemia and
abscess formation. One of the major sources of contamination is the light source water bottle. Because
of this danger, water bottles should be sterilized and changed between procedures. All catheters and
other accessories are gas sterilized. Although it is not possible to make ERCP a sterile procedure,
measures such as these are known to reduce the incidence of serious infection (see Chapter 8:
Disinfection of Endoscopes and Accessories).
Endoscopic sphincterotomy (ES), along with its ancillary therapeutic maneuvers in the bile and
pancreatic ducts, is one of the most demanding of all therapeutic procedures for both the endoscopist
and the GIA. The papillotome is usually operated by the GIA in response to established instructions. It
is necessary that the GIA be thoroughly familiar with the technique of sphincterotomy. There are also a
number of variations of ES, most of which require special papillotomy devices (see Chapter 60:
Endoscopic Papillotomy). Extraction of bile duct stones may require different devices during a
procedure including various baskets, mechanical lithotriptors, and balloons. Breakage of certain
accessories commonly occurs, so backup equipment must always be available. Biliary stenting
requires that a number of different types of stents be available in different lengths and diameters.
Insertion of a large-diameter prosthesis requires not only an endoscope with a large accessory channel
but also several types of catheters and guidewires (see Chapter 64: Diagnosis and Management of
Malignant Biliary Obstruction). Many other pieces of equipment may be needed during any given
procedure. The GIA must know the names and understand the use of each of these items. As virtually
any accessory may be called for quickly and unexpectedly, the entire complement of devices and
accessories must be well organized and within easy reach.
Pediatric Endoscopy
There are some important differences in the role of the GIA in pediatric endoscopy and in endoscopy in
adults (see Chapter 53: Esophagogastroduodenoscopy in the Pediatric Patient, Chapter 79:
Esophagogastroduodenoscopy in Infants and Children, and Chapter 90: Colonoscopy in the Pediatric
Patient). For example, in most children, endoscopy requires two assistants. One performs those
functions normally associated with adult procedures while the other holds and comforts the child.
Generally, the endoscopes used are the same as those for adults, except that in small children,
smaller-diameter instruments must be used. Dosages of medications differ in some cases.
Certain additional supplies are required when pediatric endoscopy is performed in an endoscopy unit.
These include diapers, small gowns, and toys. CPR also differs slightly in infants and children. For
example, certain items of equipment must be available in smaller sizes.
The requirements for charting have increased over recent years. In general, baseline vital signs,
allergies, relevant medical history, and current medications should be documented preprocedurally.
Intraprocedurally, vital signs are recorded at least every 15 minutes, medications are recorded as they
are given, and changes in patient status are documented. The use of blood or blood products is
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recorded according to institutional policy. Postprocedure documentation includes vital signs, any
unusual event(s) or complication(s), intervention(s), and patient response, as well as patient teaching,
taking into account the patient's level of understanding. All discharge criteria must be met and
Postprocedure Functions
The GIA has three main tasks after endoscopy: monitoring the patient's recovery, educating the
patient, and cleaning the instruments.
Patient Monitoring
The length of time that a patient must remain under observation depends on the type and dosage of
the sedative drugs administered and the nature of the procedure. Even after a patient recovers from
the medication, it may be necessary to continue observation after therapeutic procedures that carry a
risk of complications. Generally, proper postprocedure monitoring requires determination of vital signs
and observation of the patient for any signs of pain or discomfort. In our units, the GIA is permitted to
discharge patients from the recovery area after specific discharge criteria are met (Table 52).


Discharge Criteria

1. Patient alert and oriented to time and place or mentation equal to that at admission.
Mobility similar to admission status.
2. Vital signs are obtained prior to the procedure, immediately after the procedure, and
15 and 30 minutes after the procedure completion in the recovery room.
a. Discharge blood pressure
Should not be less than 90 mm Hg, unless accompanied by a physician's note of
Should not be more than 30 mm Hg below the preprocedure or baseline* systolic
blood pressure.
b. Discharge pulse rate
Should not be less than 50 bpm or greater than 120 bpm.
Should not be more than 30 bpm different from the preprocedure or baseline*
c. Respiration rate
Should not be less than 12 or greater than 26 per minute.
Should not be more than 8 per minute different from the preprocedure or
baseline* value.
3. Discomfort, nausea, vomiting and dizziness at a minimum. Swallow, cough, and gag
reflexes present.
4. Verbal instructions pertinent to the procedure given to the patient along with a written
copy. Prescriptions given to the patient are reviewed, and the presence of a
responsible adult to accompany the patient is confirmed.
* Baseline value recorded in the hospital record within 3 months of procedure

Patient Education
Discharge instructions are given by the GIA in many units; this can include a printed sheet that
provides information on possible delayed complications and instructions for the patient should a
complication develop. Whenever possible, another person, such as the patient's spouse, should also
receive instructions.
Cleaning and Disinfection
In addition to cleaning and preparing the room, following procedures the GIA must clean the
endoscope and other equipment used during the procedure. Any disinfecting or sterilization process
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will be ineffective if mechanical cleaning of the instrument has not been thorough.
Water and then air should be flushed through the air/water channel of the endoscope immediately after
the procedure, using the special flush valve. Clean water should also be drawn through the suction
channel, followed by room air. Use of transparent suction tubing makes it possible to see the color and
the contents of the suctioned water. The cleaning brush is then passed through the accessory suction
channel(s) of the endoscope and through the universal cord suction channel.
Proper cleaning requires the use of a sink with a fairly large basin. In addition, a rack on the wall above
the sink on which the instrument may be hung is extremely useful. This allows the insertion tube of the
instrument to hang down into the basin (see "Procedure Room Organization," later in this chapter).
Gloves and an appropriate gown or jacket should always be worn during the cleaning procedure.
Debris and secretions should be removed from the opening of the accessory channel valve with a
cotton-tipped applicator. The control section of the endoscope should then be cleaned, especially
around the suction and air/water valves, deflection locks, and deflection knobs. A gauze sponge
moistened with enzymatic detergent is usually adequate for this purpose.
Disinfection of endoscopes and accessories is discussed in Chapter 2: Flexible Endoscope
Technology: The Fiberoptic Endoscope, and Chapter 8: Disinfection of Endoscopes and Accessories.

GIA Productivity and Staffing Level

Procedure Unit/Weighted Scale
Although the procedure unit concept considers endoscopic procedures in terms of their similarities, in
fact from the GIA's perspective, endoscopic procedures differ significantly. From a systems
management viewpoint, the major differences among procedures relate to the number of personnel
required, the time required for the endoscopic portion of the procedure, and the time required for
assembling and cleaning needed items of equipment.
The concept of a rating system for procedures based on a weighted scale is presented in Chapter 4:
The Endoscopy Unit. All procedures are converted to a weighted number of simple diagnostic EGDs.
This procedure unit/weighted scale system has many applications with regard to analysis, planning,
and problem solving, but it was developed mainly as a method for assessing productivity.
The output of work in an endoscopy unit (as an entity including all personnel and resources) may be
substantial, but this may not be totally reflected in a simple count of procedures performed over a given
period of time. If an increase in the complexity of procedures has occurred, productivity may actually
be at a much higher level than is suggested by a simple count. The workload of the GIA may have
therefore increased to a greater degree than can be determined from existing data. The subjective
impression by the unit's staff of an increasing workload may be correct, but this can be difficult to
substantiate for those who do not understand the function of an endoscopy unit and the nature of
endoscopic procedures. Therefore, an objective method of analysis more accurately reflects the actual
performance and productivity of a unit.
The GIA plays a central role in the procedure unit/weighted scale system's methodology. As noted, the
GIA has responsibility for more steps in the procedure unit than any other participant, including the
endos-copist. In developing the weighted procedure scale, the time and effort of the GIA were primary
considerations. At the conclusion of every procedure, a weighted scale value is calculated by the GIA
using a set of guidelines (see Chapter 4: The Endoscopy Unit). The assistant can also adjust the value
within certain limits for uncommonly long and difficult procedures or those that require an unusual
amount of equipment.
From the standpoint of productivity, especially cost effectiveness, it is of great importance to know the
actual number of GIAs that an endoscopy unit requires. Although equipment can be expensive, the
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greater cost factor over the course of time is usually the payroll. The basic problem in determining the
number of GIAs required is an imbalance in the amount of time required of the GIA, the endoscopist,
and the procedure room to accomplish one procedure unit. In terms of procedure units, one GIA is not
equivalent to one endoscopist or one procedure room.
The maximum number of procedure units that one GIA can produce in a given time can be calculated.
This will always be fewer than the maximum capability of one endoscopist, and it is always less than
the maximum capacity of one procedure room, this being due principally to the need to monitor
patients after procedures. A GIA who assists with the endoscopic portion of a procedure may not be
the one who performs postprocedure functions such as cleaning and patient monitoring. Nevertheless,
these tasks require GIA time, a factor that must be considered. Other adjustments must be included in
calculating maximum productivity such as vacation days, conferences, and the expected efficiency for
the unit as a whole.
Expected efficiency is difficult to analyze. Individuals almost always assume that they function at a level
approaching 100%, but it is difficult to exceed the maximum possible efficiency of the endoscopy unit
as a whole. No unit functions at 100% efficiency, since this requires that every procedure be performed
with virtually no delay and that all equipment and personnel be fully occupied at all times. A more
attainable goal would be about 70% of the theoretical maximum capacity. This would also, therefore,
be a reasonable expectation for GIA productivity. Taking into account these factors, a reasonable
expectation for the productivity of one GIA is 1000 procedure units per year.
To determine the required level of GIA staffing for a unit, however, it is also necessary to know the
maximum capacity (in terms of procedure units) of the available procedure rooms and the number of
full-time equivalent endoscopists working in the unit along with the maximum number of procedure
units that each full-time equivalent endoscopist can produce. It is possible to calculate the equivalent
number of full-time endoscopists based on estimates of the part-time (or in a few cases the full-time)
contributions of each staff member. This is usually not equivalent to the number of physicians who
perform endoscopy, since most physicians are not full-time endoscopists and perform procedures only
during a portion of a working day or week. These various calculations indicate that there should be a
ratio of about 1.5 GIAs per procedure room or 1.8 GIAs per equivalent full-time endoscopist.
The final step in calculating the level of GIA staffing required is to determine whether the number of
endos-copists or number of procedure rooms will be the limiting factor on productivity. If the number of
full-time endoscopist equivalents exceeds the capacity of all of the unit's procedure rooms, then GIA
staffing should be based on the number of rooms available. Conversely, if the limiting factor is the
number of full-time equivalent endoscopists, GIA staffing should be based on the number of equivalent
full-time endoscopists available. In practice, other factors must also be considered, such as the
demand for procedures.
Many small, seemingly unimportant tasks must be performed in an endoscopy unit. Many of these
tasks pertain to supply and logistics (see later in this chapter). Time and effort are required to keep a
unit clean and orderly. The morale of the GIA staff requires that time be set aside for discussions,
in-service meetings pertaining to new procedures and equipment, and continuing education. Rigid
calculations of the required staffing level often ignore these less tangible, less noticeable, but
nevertheless important activities of the GIA. In the long run, the efficiency and the quality of the work
produced by a unit will be greater if some estimate of the time and personnel needed for these tasks is
included when determining the level of staffing appropriate for a unit.
In almost any endoscopy unit, it is necessary that some procedures be performed away from the unit.
Some of the reasons for this are the type of practice (e.g., a large number of procedures for acute
hemorrhage), the need to share expensive equipment such as a laser with other departments, and the
need to have the services of a radiologist and an x-ray suite available for certain procedures such as
ERCP. The types and quantity of procedures performed away from the endoscopy unit have a bearing
on the number of assistants needed. Transporting equipment to and from the endoscopy unit is always
time-consuming. In a large medical center, travel time may be significant. When two or more off-unit
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sites are used routinely, travel time during a day can be equivalent to two or three procedure units. For
complex procedures, such as therapeutic biliary endoscopy, the variety and amount of equipment in
itself would prohibit transportnot just the fact that x-ray equipment is often available only in a
radiology department. Although a full complement of equipment could be maintained in the radiology
suite, this would provide only a partial solution. Certain useful pieces of equipment, such as a light
source, would be unemployed for significant periods of time. Consequently, the GIA has the problems
of cleaning, storing, and restocking supplies as they are consumed and refurbishing worn equipment at
these additional sites. From a managerial viewpoint, this approach means in essence that any
part-time procedure rooms accompanied by a large number of procedures performed away from the
unit require additional GIA staffing.
Another factor to consider when staffing a unit is the need to match the procedure to the skill level of
the GIA. Nurse Practice Acts vary from state to state, and it is therefore important to be familiar with
restrictions for licensed practical nurses and other nonnursing personnel. Temporary or "float"
personnel who work in the unit infrequently are best utilized in relatively simple diagnostic procedures.

The GIA Supervisor

Just as the growth of gastrointestinal endoscopy has brought forth the position of GIA, so the growth of
the endoscopy unit has brought about the position of GIA supervisor. Sustained increases in the
numbers and complexity of procedures have also resulted in a substantial increase in the staff of most
units. During the early development of endoscopy, a single individual usually accomplished most of the
GIA tasks entailed in a single procedure unit. In the modern unit, there is often a substantial division of
labor because of the greater numbers of procedures. Thus, one GIA may assist with the endoscopic
portion of a procedure, another is responsible for instrument cleaning and preparation, and still another
is concerned only with postprocedure patient monitoring. Various assignments are often rotated among
the GIA staff. Because of the intricacy of new therapeutic techniques, more than one GIA is often
needed for certain procedures. An operation of such complexity has a high potential for disorder and
confusion, a point strongly in favor of the need for a specific supervisor of GIA personnel.
Extensive experience in gastrointestinal endoscopy and a thorough knowledge of all procedures are
major qualifications for the position of GIA supervisor. However, a comprehensive background in
endoscopy is only one of the required qualifications. Such an individual occupies a pivotal position in
the organizational structure of the unit. In this role, the GIA supervisor is directly and most immediately
involved in the allocation of the resources of personnel, equipment, and procedure rooms. This central
role obligates the supervisor to participate in the day-to-day scheduling of procedures. The GIA
supervisor also shares responsibility for meeting the endoscopy unit's standards of quality, for
maintaining plant and equipment, for training GIAs, for developing and evaluating new procedures and
equipment, and for tracking consumable supplies. The GIA supervisor directs the activities of the GIA
staff throughout the working day and also interacts with many people who support the operation of the
unit but who are not staff members, such as manufacturer's representatives, biomedical engineers,
radiation safety officers, and pharmacists. Thus, it is highly desirable that the GIA supervisor have
managerial and organizational skills in addition to a total grasp of the field of gastrointestinal
The GIA supervisor is frequently the representative of the unit and must interact with many other
groups within an institution. The supervisor must remain abreast of changes in standards of practice
through organizations such as the Society of Gastroenterology Nurses and Associates, Association of
Practitioners of Infection Control, and American Operating Room Nurses' Association. The GIA
supervisor should play an active role in the quality improvement program for the endoscopy unit and
has significant responsibility for the implementation of guidelines and standards as promulgated by the
Joint Commission on Accreditation of Healthcare Organizations.
It is mandatory that the importance of the GIA supervisor's many functions be clearly recognized and
that these functions be considered apart from the activities of other GIA personnel. The GIA supervisor
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and the physician head of the unit form the nucleus of the unit's management team. It is unrealistic to
expect that a single individual can accomplish these managerial tasks and still perform the more usual
duties of a GIA. Paradoxically, therefore, the GIA supervisor must become less involved with the actual
steps of the procedure unit.

Endoscopy unit efficiency requires a systematic approach to the scheduling of procedures. Certain
aspects of this are discussed in Chapter 4: The Endoscopy Unit. As a guiding principle, the design of
any system should be based on the most restrictive factor. This may be any one or more of the
following: procedure rooms, endos-copists, assistants, or instruments. In our units, the schedule is
based on the procedure rooms. The scheduling system will also reflect a basic philosophy of room
utilizationthat is, to what extent a room can accommodate various procedures. The complexity of a
scheduling process increases in proportion to the degree to which procedure rooms are
multifunctional. Multifunctional rooms increase efficiency and flexibility, but they also demand more
sophisticated scheduling methods. There is usually a mixture of multipurpose and dedicated or
semidedicated rooms in every unit.
Virtually no scheduling system can anticipate the minute-to-minute changes in the daily activity of a
large endoscopy unit unless a superficial orderliness is achieved at the expense of productivity. Ways
in which the daily activities can be disrupted include unanticipated delays in patient preparation,
last-minute cancellations, mistakes in scheduling, procedures prolonged beyond the allotted time,
complications, equipment breakdown, urgent and emergency requests for service, absence of staff
members owing to illness, and delays in starting procedures for any number of reasons. When there is
a close working relationship and communication between an appointment secretary and the GIA
supervisor, the resources of the unit can be quickly redeployed to adjust the schedule to changing
circumstances on an hour-to-hour basis, the result of which is a flexible, efficient, and productive

An incredible amount and variety of equipment are required for the efficient function of an endoscopy
unit. The capital equipment (e.g., endoscopes, light sources, lasers, x-ray machines) is the most
obvious. However, a less evident but no less important category of equipment is that of consumable
supplies, a seemingly endless listfor example, antibiotics, arm boards, aspirin, bandages, batteries,
biliary stents, biopsy channel valves, cleaning solutions of all types, coffee, colon lavage solutions,
cytology brushes, dental suction devices, diapers, emesis basins, enemas, facial tissues, gauze
sponges, glass slides, hospital gowns, intravenous tubing and solutions, laboratory requisition forms,
light source lamps, lubricants, nasobiliary tubes, needles, paper towels, photographic film (various
types), sedative drugs, sheets, silicon lubricants, specimen bottles, suction tubing, syringes, tape,
tongue depressors, toothpicks, toys, videotapes, washcloths, and x-ray monitoring badges. Another
category of equipment that must be replaced periodically is endoscopic accessories, including items
such as snare wires, papillotomes, biopsy forceps, multipolar cautery and heat probes, and stone
extraction balloons. Although much of this seems mundane, it must not be taken for granted. Every
endoscopy unit, if it is to function smoothly, must have an inventory-supply system, which should also
be the responsibility of the GIA supervisor. The establishment of par levels makes maintenance of
appropriate levels of critical items manageable.

Deployment of GIA Staff

Once the number of GIAs needed for a specific unit's function and design is known, it is necessary to
deploy them effectively. The physical design of an endoscopy unit must accommodate the basic steps
of the procedure unit. Since space must be allocated for each fundamental component of the
procedure unit, the floor plan of the unit also locates the work stations of the GIAs.
It is highly inefficient for a GIA who assists at the endoscopic segment of the procedure unit to also
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perform postprocedure monitoring, since this would result in a significant lapse of time between
procedures. Furthermore, the simplest possible endoscopy unit must be divided into four rooms or
areas: patient reception, scheduling/secretarial, and procedure room (with cleaning, storage, charting
areas), and patient dressing/recovery area. These factors dictate that, at a minimum, all but the
smallest units with a single procedure room will require at least two GIAs.
As the size of an endoscopy unit increases, many more questions of design must be answered. The
degree to which procedure rooms function independently of one another must be resolved. Even in a
unit with many procedure rooms and a large amount of floor space, the individual procedure rooms can
remain semiautonomous by retaining many of the procedure unit steps. In practical terms, this means
that the procedure room must contain facilities for cleaning and storage as well as all drugs,
accessories, and other paraphernalia required for a variety of procedures. This endoscopy unit
"philosophy" also demands some duplication of equipment. In essence, however, each procedure
room in such a scheme will have its own daily schedule of cases. In general, this system requires one
GIA for each active procedure room. When procedure room utilization approaches 75%, at least one
GIA will be required for each procedure room in the unit.
A design that utilizes an interdependent room concept is another option. In such a system, as many
elements of the procedure unit as possible are removed from the procedure room and performed in
other areas provided for these purposes. A unit design might use a single space for cleaning and
storage of instruments that is central to all of the procedure rooms. To utilize such a plan to maximum
advantage, it is necessary to assign at least one GIA to the cleaning and preparation of endoscopes.
Consolidation of the cleaning and storage functions for groups of two or more procedure rooms within
the unit is another possibility. The advantages of this are space savings and a simplified interchange of
equipment between the associated rooms. Since cleaning and storage for the unit as a whole are not
truly centralized in such a plan, however, it is usually impractical to assign an individual exclusively to
these duties unless the unit is exceptionally large and a GIA can be fully occupied at each of the
cleaning-storage substations.
Preparation, cleaning, and storage of endoscopes and accessories are relatively uncomplicated tasks.
It is possible, therefore, to hire a less highly trained individual to perform only these functions. In such
cases, this activity is usually regarded as a separate job description that is not filled by a GIA. This has
certain advantages and disadvantages. One view is that it is desirable that a GIA be familiar with all
aspects of endoscopy, that expensive equipment is better cared for by individuals who understand and
respect its purposes, and that these tasks will be performed with greater care by someone more
directly involved with the patients for whom the equipment is intended. Although it is essential that this
type of work be performed in a careful and expeditious manner, it is nevertheless relatively routine and
perhaps unexciting. If the activity of a fully qualified GIA is to be limited to this work, then it is best to
rotate this assignment among the GIA staff. The opposite view is that hiring a person with lesser
qualifications for this position is economical and also frees GIAs for activities that are more concerned
with direct patient contact.
The basic task elements of the procedure unit can be subdivided in other ways. Patient preparation for
procedures can also be accomplished outside the procedure room. This method usually requires a cart
exchange system between the procedure rooms and dressing room. Since sedative drugs are
administered before the patient reaches the procedure room, the patient must be attended by a GIA. It
can be efficient in a large unit that uses such a system to assign a GIA exclusively to the patient
exchange function. This function could also include an assisting role in postprocedure observation in
the recovery area in conjunction with another GIA assigned only to monitoring. The patient exchange
GIA could also be responsible for preparation of the procedure roomexcept for instruments and
equipmentbetween cases.
The number of GIAs required in the recovery room depends on the number of patients that can be
accommodated, which in turn should relate to the number of procedure rooms (see Chapter 4: The
Endoscopy Unit). The number of GIAs also depends on the types of procedures being performed. The
length and intensity of postprocedure monitoring are less if a high percentage of procedures are simple
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diagnostic EGDs. If, however, there are many outpatient therapeutic procedures that require closer
observation for more extended periods of time, then the workload of the GIA will be greater.
Various types of procedures are performed in most endoscopy units. Many of these procedures will be
considered "routine," whereas others might be termed "special" procedures. Those in the special
category tend to be therapeutic and are usually performed less frequently relative to the number of
routine examinations. This mix will be reflected in the design of the unit, specifically with respect to the
ratio of dedicated rooms for specific procedures to multifunctional rooms. From a managerial
viewpoint, it is important that individual GIAs not become identified with certain procedures. Although it
can be argued that the result of restricting certain procedures to one or a few GIAs improves the quality
of the procedure, this tends to segregate the GIAs into groups. The implication of this is a hierarchy
within the GIA staffthat some members have greater importance than others. This managerial
stancethat only certain individuals are capable of performing particular procedurescan be
inefficient and may be a source of friction within the GIA staff. In this same context, it is essential that
GIA assignments be rotated among the endoscopists who work in a unit. Allowing an endoscopist to
identify those GIAs she or he will work with, or permitting GIAs to select endoscopists to work with
according to their preferences, makes it impossible to develop and maintain a team approach. Such a
predicament may be inadvertent and its consequences may only become evident as it impedes growth
of the unit. It must always be the primary goal of the GIA supervisor that the GIA staff function as a
The attributes of "routine" and "special" procedures are discussed in Chapter 4: The Endoscopy Unit.
Special category procedures are usually therapeutic and often require distinctive, expensive,
one-of-a-kind equipment within the unit. Some special procedures require relatively large amounts of
equipment. These factors increase the magnitude of preparation for the procedure as well as the
amount of postprocedure work of the GIA. Depending on the skill of the endoscopist, special
procedures can be more time-consuming. In addition, they are intrinsically more complex for both the
endoscopist and the GIA. The assistant must often perform a number of tasks, including patient
monitoring, at the same time. Although one GIA is the minimum requirement for a special procedure, in
some cases the difficulty of the procedure, patient safety requirements, and the need to perform a
number of tasks simultaneously justify the presence of a second and sometimes a third GIA. ES,
especially with additional therapeutic maneuvers such as insertion of a biliary stent, is an example of
such a procedure.

GIA Training
In-Service Conferences
Associated with the increase in the scope and complexity of endoscopic procedures is a corresponding
increase in the quantity and intricacy of items of endoscopic equipment. New procedures are
constantly being developed. Another aspect of this change and growth is that the GIA must acquire
new knowledge and skill concurrently. There is considerable value, therefore, in regularly scheduled
in-service conferences.
Method of Training
Much of the present knowledge and skills that the GIA requires is based on practical experience. A
formal preceptor program works well in this setting. Learning to be a GIA has a large psychomotor
component, and therefore, guided hands-on experience is essential.
The fact that the knowledge and skills that qualify a nurse as a GIA reside with relatively few individuals
is inauspicious for the future development of gastrointestinal endoscopy. The method of training GIAs
is essentially that of passing information and experience from one individual to another. Even the
methods and techniques used in training new GIAs, as well as the actual experience of teaching those
who undertake this activity, are known to relatively few nurses. Thus, in many large units, the training
of GIAs is the responsibility of one nurse with a number of years of service and experience. The loss of
this individualthrough retirement, for exampleis equivalent to a substantial loss of ability to train
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new GIAs.
The training of GIAs is a stepwise process. It is first necessary to provide an overview, through
observation, of the way in which endoscopy is performed. The student GIA must learn the primary
parts of a gastrointestinal endoscope along with the correct methods of handling this type of
instrument, especially with respect to proper techniques for cleaning and storage.
In our experience, GIA training is best conducted by teaching one procedure at a timeEGD serving
as the initial, basic procedure. This method of instruction is similar to systems for training
gastrointestinal endos-copists. The use of one fundamental procedure as a prototype in instruction
simplifies the learning process. Rather than confronting the trainee with many different endoscopes,
accessories, and procedures, the subject matter is broken down into modules that fit into a natural
progression in which the information and knowledge acquired in earlier stages of training can be built
on and modified as the GIA is introduced to colonoscopy and, later, ERCP. In this respect, it is also
best to introduce therapeutic procedures only after the assistant is thoroughly familiar with basic
diagnostic endoscopy.
In order to properly assist at endoscopy, it is essential that a GIA have a basic understanding of the
way in which endoscopic procedures are performed. This knowledge of the procedure itself should
include the indications and contraindications and, in particular, its major complications and the signs
and symptoms of untoward events. Familiarity with the procedure allows the GIA to be alert to possible
patient discomfort and to recognize potential hazards and difficulties for the endoscopist. Furthermore,
it also allows the GIA to anticipate the need for accessories, other items of equipment, and medication.
A well-designed procedure room supports the performance of endoscopic procedures in a number of
waysfor example, items of equipment, the examination table, work surfaces, storage spaces, and
sink are located according to the role they play in the procedure unit (see Chapter 4: The Endoscopy
Unit). The organization of the procedure room should be presented early in the course of training at a
time when the new GIA is learning about the endoscopy procedure itself. An understanding of the
objectives and actual performance of an endoscopic procedure makes it relatively easy to comprehend
the seemingly complex organization of a procedure room. As the relationship between form and
function of the procedure room becomes more apparent, the new GIA is also better able to understand
and recognize his or her role in the procedure unit.

The GIA supervisor plays an essential role in maintaining equipment within the endoscopy unit. The
quality of the procedures performed in the unit, the safety of the patients, and the overall efficiency of
the unit depend substantially on the cleanliness and condition of the equipment. The growth of
endoscopy has also fostered growth in the commercial sector, so that many manufacturers now sell
endoscopic equipment. Although competition is desirable in many respects, it also leads to differences
in price, quality, durability, design, safety, and availability. Consideration must also be given to
provisions for maintenance and compatibility with existing equipment. The choice of equipment can,
therefore, be difficult; proper selection requires a thorough familiarity with available items.
Manufacturers also make improvements in their products, so that equipment must be continuously
reevaluated. The GIA supervisor plays an essential role in this process and collects and synthesizes
the opinions and experience of the unit's staff.
New endoscopic procedures are constantly being developed. Each new technique requires further
skills and knowledge on the part of the GIA. In a large unit, one GIA, often the GIA supervisor but not
necessarily the same individual in each case, can be assigned to assist in the development of new
procedures and to evaluate new equipment. The knowledge and information derived in this process
must then be disseminated to other GIA staff members.

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The methods of experienced GIAs differ in many ways. This applies not only to the specific process of
assisting at procedures but also to the general activities within the endoscopy unit. There are different
systems for cleaning and storage of instruments, for preparation of patients for procedures, for moving
patients to and from the procedure room, for handling emergency situations, and for a great variety of
other functions. It is uncertain whether these differences are important and whether the approach of
one individual to a given procedure is more satisfactory than that of another. Most likely, there are
unique aspects of each experienced GIA's methods that will be useful to others.
The Society of Gastroenterology Nurses and Associates has made progress toward standardized
techniques for GIAs. The purpose in this is not to define recommended or approved methods, either
arbitrarily or by consensus, nor to impose uniformity. Rather, the value of a more standardized
approach lies in the establishment of a frame of reference and guiding principles for future GIAs.
Considering the many methods and techniques used by the GIA, it is appropriate to emphasize only
the most universal aspects.

Procedure Room Organization

The arrangement of the contents of the procedure room follows naturally from the general manner in
which endoscopic procedures are performed. A simple but useful plan of organization for the roomas
discussed in Chapter 4: The Endoscopy Unitis one that provides specific work areas for the GIA and
the endoscopist, with the examination table placed centrally. Ideally, the GIA's area should have a
large countertop work surface as well as adequate storage areas, all within easy reach during a
Some features in the layout of a procedure room that pertain to the GIA's functions can be illustrated
by reference to a procedure room (Figure 52). During a procedure, the GIA works in the section of the
room between the examination table and the power column. The power column keeps necessary
equipment conveniently organized in a place that the GIA can reach without leaving the patient (Figure
53). Monitoring equipment, oxygen, suction, biopsy bottles, suction tubing, nasal cannula, irrigation
basin, and other items are found on the power column. A countertop work surface is behind the GIA,
attached to the power column, and another work surface that is the top of a cart is to the GIA's side.
During the procedure, this arrangement provides a natural separation for clean and contaminated
accessories (Figure 53). The cart located at the head of the table also holds various items of
equipment (e.g., electrosurgical generator). The position of this cart allows the GIA to perform certain
tasksworking with specimens, for examplewithout turning her or his back to the patient or the
endos-copist. Cleaning and storage facilities are provided in one area within the room. Instrument
storage cupboards are equipped with an inventory log board that lists the endoscopes assigned to that
cupboard and accounts for instruments that are away for repairs (Figure 54). Behind the power
column and to the left of the endoscope storage cupboard is a double sink with a rack for hanging
instruments while they are being cleaned (Figure 52).

(180)Figure 52. Typical endoscopy procedure room (Cleveland Clinic). An imaginary

diagonal line separates the gastrointestinal assistant's (GIA's) work area from the physician's.
The GIA's equipment is located on the left side of the power column. The endoscope washing
area behind the power column is complete with a double sink, a rack for holding endoscopes,
and an automatic endoscope washer (not shown). Ample cupboard space is provided.

(181)Figure 53. Close-up view of the GIA's work area. Frequently used equipment is stored
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or housed on the power column. The GIA rarely has to leave the patient's side to gather

(182)Figure 54. Instrument storage cupboard. Endoscopes are stored so that their distal ends
hang freely. Accessories are also stored in this cupboard.

Some Special Equipment

Regardless of how well an endoscopy unit and a hospital are equipped, certain endoscopic procedures
must be performed away from the unit. This means that virtually every item of equipment needed for
the procedure must be transported. The best method of transferring the functions of the procedure to
another site is by using a cart. The type and amount of equipment needed will vary according to the
nature of the procedure. The procedures include emergency endoscopy for gastrointestinal bleeding
with endoscopic methods of hemostasis, ERCP with ES, laser endoscopy, and bedside
sigmoidoscopy. It is difficult to set up a general purpose cart that would be suitable for all of these
A single cart may be equipped and maintained for procedures that are frequently performed away from
the unit. The usual example is the emergency cart for EGD for acute upper gastrointestinal bleeding
(Figure 55). The equipment on the emergency cart used routinely in the Cleveland Clinic unit is listed
in Table 53. A relatively simple cart with open shelves and large wheels is preferable. This allows for
the interchange of assorted items of equipment, so that the cart can be used for various purposes.
Certain items commonly used in the endoscopy unit can also be placed on small carts with wheels, so
that they can be moved from one procedure room to another. It is often useful to place an
electrosurgical generator on such a cart.


Emergency Cart Equipment

Basin for water

Plastic cups
Gauze sponges (4" 4")
Cytology brush
Cleaning brush
Biopsy forceps
Light source
Fiberoptic panendoscope
Lecturescope ("teaching attachment")
Heater probe (with large and small probes)
Suction machines (2)
Viscous lidocaine (Xylocaine) spray
50-ml syringe with blunt needle
Gastric lavage kit
Sclerosing needles (2)
Introducer (for accessory channel valve)
Additional items:
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Emergency Cart Equipment

3% sodium tetradecyl sulfate (Sotradecol) (one 2-ml

Sterile 95% alcohol
12-ml syringes (6)
Normal saline solution (two 10-ml vials for injection)

(183)Figure 55. Emergency cart. Items maintained on this cart are listed in Table 53.
(Courtesy of Olympus Optical Company, Ltd.; and Allied Healthcare Products.)
Certain small and frequently disposable items of equipment are required for specific parts of the
procedure unit. Such items are often used at the same time. An example would be the needles,
tourniquets, bandages, alcohol preparation sponges, and syringes for premedicating patients. One
method of organizing items of equipment that are used together is to put them in small boxes or

Chapter 6 Medical Informatics



Hospitals and large clinics have long recognized the utility of computers. Nowadays, it is difficult to
conceive of handling the vast amount of information generated in the delivery of health care without
computers. Technologic advances, the proliferation of hardware and software companies, market
competition, and the resulting decline in cost have all led to greater interest in computer systems.
Furthermore, the initial fear of a novel science and the reluctance to confront unfamiliar methods and
complicated machines are being replaced by the acquisition of personal skills, the confidence of a
growing experience, and the ready availability of qualified professionals.
The advantages of computers are indisputable (Table 61). 1 However, their ubiquity in medical
centers is not a measure of optimum utilization. The diversity of existing equipment (hardware,
operating systems, networking) gives rise to numerous options for the configuration of a system, which
can be confusing. The many criteria include processing power, memory allocation, data distribution,
accessibility, and transfer, as well as cost.2(186) When a platform is found that best serves the
data-processing requirements of an individual enterprise, the choice of software becomes the issue.
Usually, the data to be processed are readily evident or else easily defined. Unfortunately, this is not
true of medicine.


Advantages of a Database

Compactness (minimizes storage problems)

Speed (optimizes retrieval time)
Currency (immediate availability of new data)
Efficiency (ease of maintenance)

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Computerization in Medicine
The introduction of computerization to medicine was inspired by its use in the corporate world. Initially,
computers dealt with only administrative aspects of medical care. Within a few years, a large
assortment of software programs became available for the electronic filing of patient demographics,
scheduling, and the tracking of charges and collections. The volume of patients at any particular
institution and the complexity of billing have virtually mandated the use of computers for these
purposes. Even relatively small office practices have come to rely on computers for routine
administrative tasks. To date, these activities still make up the bulk of computer use in medical

The use of computers in medicine, however, has quickly expanded to encompass many other activities
related to clinical practice and research.3(187) These range from simple computations (e.g., drug
dosages) to elaborate statistical packages; from warnings and reminders (e.g., drug interactions) to the
interpretation of clinical tests (e.g., electrocardiography); from the transcription of chart notes ("the
computerized medical record")4(188) to analysis (e.g., quality assurance), discovery of clinical
associations, and the inference of new knowledge (e.g., cancer chemotherapy protocols); from
reference libraries (e.g., Medline) to diagnostic tools and medical decision making (e.g., expert
systems).5,6(189) This set of developments constitutes the world of medical informatics.
The discipline of medical informatics grew from the awareness that the application of computer science
to medicine requires unique constructs and special techniques. In science, knowledge is usually
focused and structured, its elements easily defined, and its interrelationships readily formulated.
Hypotheses can be tested, reasoning is logical, and decision making is methodical. Conclusions are
definite or carry a calculable uncertainty. Conversely, medical knowledge is vast and fragmentary,
disparate and unorganized. Much is unknown, cogent observations may be irrelevant, and
redundancies abound. Complex relationships between elements are incompletely understood and
change as scientific knowledge accrues. Hypotheses derive from personal experience rather than
established facts. Thus, reasoning is tainted by subjectivity, and decision making is largely
probabilistic. Much rests on convention, and conclusions are typically arguable.
In summary, the elements and nuances that constitute medical thinking are diverse and often elusive.
Nevertheless, they must be explicitly stated in order to be incorporated into a computer program. For
these reasons, many software programs that address a single issue or a limited purview have been
very effective. Conversely, the difficulty in formalizing medical thinking has resulted in a comparative
lack of success with respect to broader, more extensive systems.

Gastrointestinal Endoscopy
Many different aspects of endoscopy can benefit from the use of informatics;7(190) few have been
The success of an endoscopic practice can be measured by various factors besides competence in
the performance of procedures. Many of these can be enhanced by computers, including
administrative and clinical factors.8(191)
Management of an endoscopy suite begins with the purchase of endoscopic equipment, its distribution
among procedure rooms, and its maintenance and replacement. It involves allocation of room time to
various endoscopists, which itself entails the assignment of nursing or other personnel to procedure
rooms and waiting and recovery areas. Patient scheduling is another complex task, as is billing for
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In an era when advancing endoscopic technology and ever-increasing regulation have combined to
increase expenses while the health care dollar inexorably shrinks, overhead costs have all but
mandated optimum use of time in the endoscopy unit. Given the many variables in the management of
a large and busy endoscopy suite, this is best achieved by a well-designed computer system. When a
suite consists of only one or two rooms or is sparsely used, optimum management is rarely a concern.
Computerization then becomes unnecessary and is likely burdensome.
At the very least, the clinical aspects of endoscopic practice include preparation of an endoscopic
report and retention of clinical data for patient follow-up. The endoscopic report is frequently intended
as the vehicle for communication with the referring physician. Often it also takes the place of the chart
note. The clinical data constitute the contents of the report. Other important uses for reports and
clinical data, depending on the size and interests of the particular institution, include quality
improvement and clinical research.
For a number of years, the perception in the endoscopic community has been that reporting methods
and data management could be greatly facilitated by the use of informatics. This has led to much
interest in the development of software intended for these purposes. Several programs now exist that
purport to perform many of the intended tasks, but none has gained wide acceptance and none is used
with any consistency. The luster of a new software product typically derives from some novel and
attractive feature such as the use of color and graphics or voice-recognition technology. Initial
enthusiasm quickly fades, however, and the product is abandoned as soon as closer scrutiny reveals
its weaknesses and limitations.

Why Have Software Programs Failed?

The first parameter for success of a computer system is the willingness of its intended clients to use it.
The second, equally important parameter is performance: Are the proposed goals being met, and at
what price?

Physician Resistance
Physician resistance was seen for many years as the principal obstacle to the success of computer
systems in medical practice.9(192) The emergence of a complex technology in a largely uneducated
medical community created a predictable aversion on the part of physicians. That the intricacies of
medical thinking could be processed by a machine was viewed by many as preposterous.10(193)
Perceptions have changed, however, and the period since the mid-1980s has witnessed a proliferation
of computer systems in medical institutions and private offices. Many physicians have become adept at
using them effectively and are eager to exploit their possibilities. The demand for more powerful
systems constantly increases, and expectations outdistance technologic feasibility. Yet no system for
gastrointestinal endoscopy has to date been embraced and applied broadly despite concerted efforts,
by researchers and industry, to develop a suitable product.

The costs of acquisition, maintenance, and operation have been touted as obstacles to the widespread
acceptance of computer systems.11(194) High price may be a cause for concern (current systems
including hardware and software cost between $20,000 and $50,000) but must be considered in
relation to potential benefits.12(195) Most systems provide, at a minimum, a report-generating
function, that is, the ability to print an endoscopic report based on data entered by the user. This
replaces the conventional report dictated by the endoscopist and typed by a secretary. Unlike the
conventional report, it is available immediately after the procedure. In a busy endoscopic practice,
automated reporting frees secretarial time and may result in savings large enough to offset the entire
cost of the system within the first year or two after purchase. Computer-assisted scheduling, billing,
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and management of the endoscopy suite, when available, also contribute to efficiency and save clerical
time, resulting in additional savings.
Several auxiliary benefits provided by most commercial systems can enhance the functioning of an
endoscopic practice, although they do not lend themselves to comparative calculations of cost
effectiveness. For example, medical information is compactly stored and can be retrieved rapidly. This
saves time and space and facilitates patient follow-up. Reports of billing accounts, quality
improvement, and other desired information can be produced periodically, obviating manual
computations. Computer storage of digital endoscopic images preserves their integrity, provides a
safeguard against misplacement, and allows simultaneous cataloging by multiple attributesfor
example, type of lesion, anatomic location, therapeutic maneuvers, date, and patient demographics.
Computer retention also provides the physician with an extensive library of endoscopic images for
research, publication, and education.13(196)

Perception of Utility
To date, the utility of clinical systems remains in doubt. A clinical system is one that handles
information strictly relevant to patient care. In endoscopy, this information consists primarily of
endoscopic findings but also includes all the other facts deemed necessary to the complete
endoscopic report: indication(s) for the procedure, relevant medical history, description of the
procedure (e.g., endoscopist, assistants, type of instrument, accessories, medication, time and length
of the procedure), and complications, if any.
Two fundamental considerations enter into the decision to use a computer system for endoscopy. First,
the system must provide an adequate format for expression of endoscopic observations, that is,
without loss of content and with maximum observance of nuance and appropriate detail. Second, data
entry must be rapid. The time required to enter the substance of a procedure in the system should be
comparable to that spent in dictating a report. Despite the many advantages of informatics, dictation
will prevail as long as it is faster than entering data into a computer. Only after the challenges of
expressivity and speed of data entry have been resolved (and physicians are motivated to use a
computer system) will other benefits of a computer system be probed and appreciated.

For physicians to entrust their narration of clinical events to computers, they must be able to articulate
their thoughts with factual completeness and little deviation from their customary organization and style
of expression. They may find it useful to incorporate descriptive details, not strictly scientific, that impart
a general flavor to the report or convey an impression otherwise difficult to communicate. Insofar as
endoscopy is essentially observation, it entails interobserver variation and personal bias.

Free Text: a Viable Option?

To capture the subtlety of observation and preserve the endoscopist's organization of thoughts and
style of expression, free text would seem to be ideal. This is the strategy adopted by the COSTAR
system used within the Harvard Health Plan.14(197) Text dictated by the physician is transcribed by a
typist directly into the global database. When needed, a "hard copy" can be produced. This process is
identical to that for a standard dictated report, although the medium is electronic rather than paper. The
advantages of a free text system are limited to compactness of storage, accessibility, and availability of
data at remote locations. Any cost savings deriving from automated report generation are forfeited
because full-length text must be transcribed at a keyboard. Furthermore, free text does not lend itself
to systematic computer searches. Searching for the random appearance of certain words or groups of
words is exceedingly timeconsuming and fraught with errors owing to omissions, redundancies, varying
styles of expression, and the widespread use of synonyms in medical parlance. The value and
efficiency of a computer search depend directly on the structure of the stored elements.

Structure: Help or Hindrance?

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In computer applications, structure exists at different levels: physical, logical, and user
interface.15(198) Structure at the physical level denotes the actual location of data in computer
memory. It is generally unknown to the user, although it is important from the standpoint of software
development. It determines the speed with which related data can be accessed and therefore plays a
significant role in the efficiency of a program.
Structure at the logical level reflects the cognitive basis of the field, in this case our understanding of
the art and science of endoscopy. Logical structure defines the elements of a body of knowledge and
their interrelationships. It might appear that this is fixed and immutable. This would be true if
endoscopic knowledge were stationary. In actual fact, the logical structure represents only our
conceptual interpretation of the field, this being subject to change as the field evolves.16(199) Although
impervious to the average system user, logical structure is critical for search and analysis of
accumulated data.
Finally, and most obviously, structure at the level of the user interface establishes the format of data
acquisition and display. It is conceived on the basis of various factors: user perception of the relative
importance of data and their utility, the usual sequence in which data are collected, a suitable order for
data viewing, synoptic value, and screen appeal, to mention but a few. For purposes of the present
discussion, the notion of structure is strictly confined to that of the user interface. It is the proposed
framework that the endoscopist must observe and that dictates the manner in which thoughts must be
If imposition of structure limits expressivity, it also offers distinct advantages over free text. It reduces
error, suppresses duplication, minimizes oversight, and virtually eliminates verbiage. It also provides
the necessary skeleton for automation of the endoscopic report. The latter systematically molds itself
around data collected according to the existing structure. As discussed, when automated report
generation is satisfactory, cost savings can be considerable. Furthermore, structure at the user
interface ensures standardization of reporting and consistency in reported data. The counterpart of
such uniformity at the logical level is data analysis.17(200)

Unsatisfactory Design
Structure that is too restrictive for the effective expression of ideas is likely to be rejected by users,
whereas lack of structure in the organization of data offsets many of the benefits of
computerization.18(201) The challenge that has faced developers since the first efforts to computerize
endoscopic data and reporting is to maximize expressivity while minimizing reporting time and retaining
the advantages of structure.
Fixed structure imposes an order of data acquisition that is not necessarily that which the endoscopist
might choose or regard as most appropriate for a particular procedure.19(202) For example, some
systems divide an esophagogastroduodenoscopy (EGD) report into three headings, corresponding to
the component organs of the upper gastrointestinal tract (esophagus, stomach, duodenum), and force
the user to follow this sequence.20(203) This offers the advantage of clarity in simple cases but
detracts from important findings in others. The difficulties with this structure are illustrated by several
If a bleeding duodenal ulcer is found and coagulated, the system requires that findings pertaining to the
esophagus and stomach, however inconsequential, be mentioned first. This is not only clumsy but the
emphasis is also wrongly placed. The following scenario illustrates a different pitfall. Consider an EGD
performed to search for a bleeding source in the upper gastrointestinal tract. Although the examination
findings are negative, the uncomfortable patient retches sufficiently to suffer a Mallory-Weiss tear.
Reporting this under the heading "esophagus" suggests that the tear is the bleeding source rather than
a complication of the procedure.
Localizing a lesion only to an organ is often too vague. Generally, it is important to specify its site with
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greater precision. For example, the significance of an esophageal diverticulum depends on its level
within the esophagus. An antral ulcer and one in the body of the stomach have different clinical
It seems that the problem of specifying location could be resolved by partitioning organs. Unfortunately,
suitable partitions are not readily evident. One set might be convenient for characterizing certain
endoscopic findings but not others. For example, the stomach can be divided histologically into body
and antrum or anatomically into body, fundus, cardia, antrum, and pylorus. The second option is better
for the description of ulcers and masses (e.g., to distinguish a pyloric channel ulcer from one in the
midantrum). However, this option is clumsy for the characterization of gastritis. Type A gastritis would
be listed in three distinct partitions (body, fundus, and cardia) instead of one (body). Similarly, the
esophagus could be arbitrarily divided into thirds (upper, middle, lower). Although adequate for
diverticula, such a scheme is cumbersome for describing esophagitis and localizing complex
esophageal strictures.
Despite the degree of detail achieved, partitioning may still be imprecise. For instance, it may be
important to note that a gastric ulcer is on the lesser or greater curvature. Unfortunately, further
partitioning of organs creates new problems. For one, it is onerous and exacting; it forces a degree of
precision that is only occasionally needed. Moreover, it is likely to introduce errors when lesions span
more than one partition.
Another issue relating to the anatomic partitioning of organs is that patients do not exhibit a uniform
anatomy.21(204) In certain cases, albeit rare, aberrant anatomy is congenital (e.g., pyloric duplication)
or merely an anatomic variant (e.g., pancreas divisum). In the majority, however, anatomic variability is
due to prior surgery. This creates a world of new possibilities. Not only are organs or portions of organs
removed or rearranged (e.g., gastric stapling, right hemicolectomy with ileotransverse anastomosis)
but also organs are interposed that do not ordinarily lend themselves to examination (e.g., jejunum in
Billroth II or Roux-en-Y anastomosis). Furthermore, a new set of pathologic findings becomes germane
(e.g., afferent loop syndrome, pouchitis in colectomy with ileoanal anastomosis). Structured
endoscopic reporting must accommodate all possible cases.
Descriptive reporting of lesions according to a preestablished sequence implies a static picture. Such a
format deals effectively with the majority of endoscopic procedures that are exclusively diagnostic. It
fails, however, to capture the dynamic aspect of endoscopy, which is most evident with therapeutic
maneuvers. Failure to recount the steps of a procedure in order of occurrence may result in loss of
valuable clinical information. It may also produce substantial inaccuracies in case studies intended for
quality assurance and for medical-legal concerns. Consider, for example, post-endoscopic retrograde
cholangiopancreatography (ERCP) pancreatitis. Although pancreatitis is a recognized complication of
ERCP, contributing events remain a matter of some controversy. A critical factor may be the repetitive
cannulation of the pancreatic duct that results from frustrated attempts to enter the biliary system. To
confirm or disprove this theory by retrospective review requires, at the very least, that the order of
ductal cannulation be explicitly stated. Tracking each step becomes quite elaborate, and other
variables must be taken into account (e.g., therapeutic maneuvers).

Voice-Recognition Technology: a Solution?

Despite the appeal of generating an endoscopy report with a computer program, the many drawbacks
of current systems have kept endoscopists from abandoning the dictated report. Fortuitously, the
emergence of voice-recognition technology seems promising in bridging the gap between dictation and
a computer-generated report.22(205)
Voice-recognition technology dispenses with the typist. A voice-recognition board in the computer
possesses a vocabulary from which words spoken by the user are recognized and stored in memory.
Sentences are formed by the system around the words chosen by the user to produce the report.
Unfortunately, systems using early voice-recognition technology have been disappointing. The training
period required of each user is lengthy, and mistakes in word recognition tend to occur frequently.
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Recent advances have produced boards that are more accurate, eliminate user training, and possess
a much larger vocabulary.23(206)
Technology for the automatic transcription of freely enunciated sentences belongs to the future.
Voice-recognition systems cannot emulate the stylistic ease of free text dictation. However, they
provide ample latitude for text editing such that the adherence to a strict model for data entry becomes
less critical. Although this strategy may avoid some of the problems inherent in a rigid, structured
format for data collection, it does not address the issue of organization of the stored data. As
mentioned, the structure of the stored data is what determines the value of a computerized database
as a research tool.

If computerization eliminates verbiage in medical reports, by the same token it requires that the
operating vocabulary be comprehensive and unambiguous. Several problems exist with respect to
verbal expression in medicine and are not unique to gastroenterology. Synonyms must be eliminated to
ensure that searches produce accurate results. For example, Crohn's disease and regional enteritis or
diverticulosis and diverticular disease cannot be used interchangeably.
Identification of lesions is also problematic. Those recognized by their appearance (e.g., ulcers,
diverticula) are usually reported as diagnostic entities. When a diagnosis cannot be ascertained from
the visual aspect of a lesion, the lesion is named by a descriptive term (e.g., polyp). Any elevation
above the mucosal surface may be technically identified as a polyp, even though the lesion may be
hyperplastic, inflammatory, adenomatous, or lipomatous. Some elevations are preferentially termed
nodules; other larger lesions may be designated masses. Nonetheless, the distinction between polyps,
nodules, and masses is blurred. The endoscopist may be unable to decide if a mucosal elevation is a
polyp or a prominent fold and may wish to express this uncertainty in the report. It seems appropriate,
in such cases, that the computerized report have the capacity to reflect such doubt by indicating
different possibilities. An alternative, more objective, approach would be a brief qualitative description
of the abnormality (e.g., erythematous, smooth mucosal elevation). This issue is even more evident
with diffuse lesions that have a similar appearance. It may be impossible, for example, to distinguish
chronic hemorrhagic gastritis from portal hypertensive gastropathy in a cirrhotic patient. Moreover, a
depiction of findings is often necessary, even when the nature of the lesion is evident, in order to
convey its type, extent, and severity. It is important to note not only the location of an ulcer but also its
size, its depth, and the presence of a visible vessel, adherent clot, or active bleeding. Varices may be
barely visible within the distal few centimeters of the esophagus, or they may be large, engorged, and
exhibiting red color signs or ongoing hemorrhage.
A qualitative description must use terminology that is meaningful and standardized. To achieve this
objective, it is necessary not only to classify each and every endoscopic finding according to a uniform
nomenclature but also to formulate precisely the list of attributes required for characterization of each
finding, each with its corresponding set of variables. Only then is it possible to draw conclusions by
comparison and analysis of data with the aid of a computer.24(207)

Endoscopic Images: a Solution?

Electronic endoscopy makes it possible to acquire and store high-resolution images. Photographs
saved on disk can be retrieved for illustration, case comparisons, patient follow-up, education, and
documentation. A suitably designed computer system can also relate an image to a specific finding
(e.g., an ulcer with a visible vessel) or a therapeutic maneuver (e.g., coagulation of that vessel).
The widespread availability of endoscopic photography would seem to obviate precise, albeit tedious
and imperfect, verbal descriptions of lesions. A few photographs obtained during a procedure would
circumvent the need for a comprehensive dictionary of findings and an explicit vocabulary of related
attributes. Indeed, this solution is adequate for day-to-day clinical practice. However, images without
data fall short in providing the basic structure needed for analysis and are not suitable alone for a wide
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variety of purposes, including research. Unfortunately, despite advances of image understandinga

branch of artificial intelligenceit is not yet possible to analyze photographs without verbal definitions.
Some preliminary attempts have been made to explore the possibility of image processing in
endoscopy. Although they are encouraging, their scope remains narrow (e.g., the estimation of ulcer
size).25(208) In order to compare findings and conduct analyses to discover clinical associations and
successful therapies, objective cognitive features must be diligently elucidated, defined, itemized, and
evaluated. Any study conducted on a large number of elements possessing multiple attributes and
variables is best done with the assistance of a properly conceived computerized database.

A Computerized Database for Gastrointestinal Endoscopy

A database is a record-keeping system.26(209) It stores and catalogs information and facilitates
retrieval. As in any record-keeping system, the data must be organized so as to best serve the needs
of its intended users. Data organization may be thought of as a problem of optimum indexing, for it is
the indexing of data that permits their rapid retrieval and maximizes their utility. For example, if clinical
information regarding patients is always accessed by the patient's name, a single index, in this case a
name index, suffices. If information must also be accessed by date, patient age, type of procedure, or
diagnosis, then additional indexing is needed. If information is to be accessed by a combination of such
parameters, a data structure that supports complex requests becomes essential.27(210)
The term database is used loosely to refer to three distinct entities. First, a database is the aggregate
of collected data pertaining to some field of interest. Second, the term database may apply to the
conceptual framework devised expressly to accommodate that set of data. The framework defines
data items and their interrelationships and organizes the data according to a theoretical model, known
as the data model. Third, the term database may designate the database management system
(DBMS), a software program that facilitates the collection, storage, and manipulation of the data. A
DBMS is specific to a data model.

Data Models
Three principal data models exist, each with special properties that make it suitable to certain tasks:
network, hierarchical, and relational. When creation of a database is contemplated, it is most important
to make its purpose explicit. This not only indicates which data to collect but also makes evident the
best data model.28(211)
The network model is procedural. It is ideal for repetitious tasks. It is the most efficient of the three
models because items operated on are connected physically such that their simultaneous retrieval is
extremely rapid (Figure 61). For example, it is the model used by airline companies for reservations.
However, it lacks flexibility. Tasks that are not anticipated and planned cannot be executed (Figure

(212)Figure 61. A network database. EGDesophagogastroduodenoscopy.

(213)Figure 62. A network model.

The hierarchical model has been the most popular model for medical databases.29(214) Conceptual
simplicity and efficiency in data retrieval make it attractive. Unfortunately, lack of flexibility limits its
The conceptual simplicity of the hierarchical model is reflected by its simple graphic representation: an
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inverted tree. The trunk of the tree, which constitutes the key element, gives rise to branches, each
representing some feature related to the key element. Every branch may generate its own branches,
meant to identify selected properties. This process continues until all relevant data are included (Figure
63). The multilevel structure thus achieved seems particularly well suited for the representation of
medical information in that clinical occurrences (e.g., an endoscopic procedure) typically bring about
observations (e.g., organs examined, lesions), which invite finer characterization (e.g., description of
lesions, photography, biopsies), in turn necessitating specialized interpretation (e.g., histology, image

(215)Figure 63. A hierarchical database. EGDesophagogastroduodenoscopy.

From an operational standpoint, the main advantage of the hierarchical model lies in efficiency of data
retrieval. All data belonging to a particular record (i.e., an inverted tree) are physically linked in
computer memory, thereby minimizing access time. This requires, however, that data be accessed
according to the prescribed path, that is, by starting at the trunk of the tree. This arrangement is
satisfactory for the clinical follow-up of patients. The hierarchical model is used in the COSTAR system
(see earlier in this chapter) as well as in other databases for gastrointestinal endoscopy.
The advantage with the hierarchical model of rapid data retrieval becomes a drawback, however, if the
database is used as a research tool. Data that reside at deeper levels (farthest branches) of the
hierarchy cannot, as a rule, be accessed directly. Certain data items, judged to be of particular
importance when the database is designed, may be flagged and pointers drawn between them to
facilitate their independent recovery. This strategy is akin to having separate indexes for selected data.
Nonetheless, random queries on the vast majority of items in the hierarchical database remain
problematic. It is very impractical, if not impossible, to compare homologous data belonging to different
records, that is, corresponding branches of different trees. Moreover, the system collapses with
searches that use as parameters multiple attributes deeply embedded in the tree structure. Relatively
straightforward queries are unmanageable, as for example the following: "What is the percentage of
patients under 50 years of age without familial polyposis coli who, having been found to have one or
more adenomatous colonic polyps at a first colonoscopy, are found to have at least one other
adenomatous polyp within the ensuing 3 years?" Here the parameters include patient age, diagnosis,
procedure type, finding, and histology, each occupying a distinct level in the hierarchy. Searches in
hierarchical databases are therefore limited to simple queries. This severely limits their usefulness as
research tools (Figure 64). Attempts to extract new knowledge in gastrointestinal endoscopy from
existing hierarchical databases30(216) have been sparse31,32(217) and their results often

(219)Figure 64. A hierarchical model.

Another serious disadvantage of hierarchical databases is predictable obsolescence. The design of a
hierarchical database is fixed. Once data items are defined and their interrelationships established,
they cannot be changed.34(220) Moreover, new data items cannot be easily incorporated, particularly if
they disrupt the existing structure. Suppose, for example, that location and maneuver are considered
qualifiers of a lesion (a maneuver is any action taken in relation to a lesion such as a biopsy, brushing,
or dilation). A gastric ulcer of which biopsies are obtained is easily expressed in such a structure. Now
suppose that new evidence emerges to suggest that duodenal ulcers associated with the presence of
Helicobacter pylori in the gastric antrum respond preferentially to some unconventional therapy.
Identification of such ulcers would require that biopsies be systematically obtained from the stomach.
To indicate that the biopsies are from the stomach when the ulcer is in the duodenum, the structure
would have to be amended. Indeed, the existing structure would suggest that the biopsies are from the
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ulcer itself. Because a hierarchical database is static, it quickly becomes obsolete as knowledge
The third and most robust model is the relational model.35(221) Its principal strength lies in the
absence of fixed relationships among data items, a property known as data independence.36(222)
Broadly speaking, each data item is represented by a table (Figure 65). A table is composed of fields,
one of which is the primary key. The primary key is a unique identifier of the data item itself, the
remaining fields being attributes directly related to it and characterizing it. For example, a patient table
could have a unique number ("patient #") as its primary key and first name, last name, sex, race, and
date of birth as its associated fields (Figure 65). An endoscopist table could have endoscopist number
as its primary key and first name, last name, pager number, and phone number as its associated
fields. Tables are independent of each other but can be joined by common fields known as foreign
keys. For example, it would be useful to have a field in the table called "procedure" (Figure 65) to
identify the corresponding endoscopist. Such a field, "endoscopist #", can be added to the procedure
table. It then functions as a foreign key to link that table to the table called "endoscopist" and to obtain
from the latter the desired information. The patient-procedure table serves to itemize the various
procedures undergone by each patient. Similarly, the indications table identifies the indications relevant
to the performance of each procedure.

(223)Figure 65. A relational database.

In the relational model, retrieval of data does not have to follow a preset path, as in the hierarchical
model. Rather, the access path depends on the particular query, and various techniques are used to
optimize that path.37(224) Complex queries can be accommodated without difficulty regardless of the
diversity and number of parameters involved (Figure 66).

(225)Figure 66. A relational model.

Tables and fields can be added to the relational model as medical knowledge advances. The previous
example of H. pylori-related duodenal ulcers serves to illustrate this point. In a properly designed
relational database, the data items "lesion" and "maneuver" are represented by separate tables. It is
then easy to add a field that indicates the location of the maneuver to the maneuver table. The location
of the maneuver is therefore distinguished from that of the lesion. In this case, it would indicate that
biopsies are obtained from the stomach and not the duodenum.
In summary, relational databases are the most flexible and powerful for research, and they offer the
potential for growth. They are also the most challenging from the standpoint of database design in that
they require in-depth understanding of the sphere of medical knowledge that is to be transformed into a

A Global System
It is possible to conceive of several separate systems for gastrointestinal endoscopy, each assuming a
segment of the total work to be accomplished. However, a global system is far more efficient and
economical. Such a system ensures a unique vocabulary, minimizes redundancies and unnecessary
duplication of data, and eliminates errors associated with data transfer, particularly in the case of
updates. It greatly simplifies technical maintenance and facilitates the maturation of the software. It is
imperative, however, as the global system is conceived, that each and every task be considered
separately and guaranteed optimum efficiency.

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Chapter 7 Electronic Image Management



The history of gastroenterologic endoscopy begins with attempts to peer into the gastrointestinal tract,
that is, the first rudimentary efforts to obtain images from within the lumen of the digestive tract.
Because endoscopic images have always been an invaluable asset to the gastroenterologic
endoscopist, the history of endoscopy can be viewed as a history of image acquisition and
In the beginning, endoscopic images were documented as drawings made by an artist at the side of
the endoscopist. Attempts at photographic documentation date to the earliest phases of development
of cameras and photographic film, but endoscopic photographs of acceptable quality were not possible
until the 1950s. The development of the gastrocamera by Uji1(228) symbolizes the opening of the era
of gastroenterologic endoscopic photography (see Chapter 1: History of Endoscopy).
The accuracy of image documentation markedly improved with the introduction of photography, but
photographic materials were not easy to manage. Review of images on film strips through a projector,
as with gastrocamera systems, often resulted in damage to the film. Discoloration inevitably occurred
over long periods of time. In general, image degradation was a significant problem. Retrieval of a
desired image on a film strip or a 35 mm slide from among large numbers of images in storage was
not always easy, and the loss of images, particularly of important cases, was most annoying.2,3(229)
Supported by the advances in computers and related fields, electronic management of images became
a promising technology in the 1980s.110(230) In particular, the advent of the electronic endoscope by
Welch-Allyn Inc. (Skaneateles Falls, NY) in 1983 made feasible the electronic management of
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endoscopic images.11(231) With the incorporation of the charge-coupled device (CCD) into an
endoscope, images of the digestive tract can be converted instantly to electric signals that are readily
managed by computers (see Chapter 3: Flexible Endoscope Technology: The Video Image
Endoscope). Advances in the development of computer memory media are occurring with amazing
speed.3(232) Image transmission technology is redefining the environment of the endoscopy unit, and
electronic image management is one of the newest developments. It is reasonable to believe that
these revolutionary changes will continue into the foreseeable future.

Technology of Image Management

Image management consists of acquisition and storage of images, together with related information,
and the organization of these data for specific purposes. Images are acquired by endoscopic
instrument systems, the ideal technology for image management. Once captured, images are archived
and organized according to requirements for patient care, research, or education.

The Digital Image

Before we analyze the detailed aspects of image management, it is essential to note the difference
between analog and digital images. This relates to the fact that computers are usually designed to
function by the use of binary coding systems.
An endoscopic image in its original state is a color picture that can be conceptualized as a set of
two-dimensionally arranged picture elements that are continuous in space and continuous in
brightness (i.e., amplitude) of color components. In reality, such an image cannot be represented with
absolute accuracy by numerical elements; rather, they comprise a continuous series of transitions from
point to point. A mathematical representation of this concept is a graph of a line with multiple curves
rather than a series of numbers. An image constituted by these continuous transitions in space and
amplitude is classified as an analog image.
When an endoscopic image is captured electronically by a CCD, the CCD generates, at each pixel, an
electric charge in proportion to the intensity of light that the pixel receives within a specified period of
time. The original image is sampled spatially according to the distribution of pixels on the CCD. The
image is transformed by the CCD into a set of electric signals, discrete in space but continuous in
amplitude (space-discrete signals). These signals are forwarded to the video processor (essentially a
computer), where the amplitude of the electric charge from each pixel is measured and converted to a
number, which is in turn represented by binary digits (i.e., 0 and 1). In this way, the original analog
image (a series of continuous transitions in space and amplitude) is converted to a digital or binary
image (i.e., one described by binary code). The waveform (analog) signal has, in effect, been reduced
to a series of numbers. This analog-to-digital process can never be so detailed that a digital image
becomes an exact duplicate of an analog image (although the digital representation becomes more
precise as the number of pixels increases). Nevertheless, the image that results from the
analog-to-digital conversion is suitable for most practical applications.
Because a digital image is essentially binary code, it has characteristics common to all digital data. For
example, it can be altered by specific software programs and transferred within a computer network
(see later in this chapter) or over telephone lines. It is helpful to conceptualize the digital image as
existing in a computer file comparable to the document file of a word processing computer program
(software). Whereas the latter file typically "contains" several "pages" of text, a digital image file
contains a single image. The term image can therefore denote a single digital image file. Although that
file may be a composite of several different pictures, it is nevertheless a single image file.
The digital image can be conceptualized as a matrix in much the same way as a CCD, that is, a
three-dimensional Cartesian coordinate system specified by three intersecting, perpendicular lines. In
the flat (two-dimensional) plane (defined by x- and y-axes), the CCD and digital images are both
composed of pixels. The location of each pixel in a digital image is therefore specified by two
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coordinates (referred to as x and y coordinates). The third or vertical coordinate in the CCD image
matrix is the value of the electric charges that develop in the pixels. In the digital image, however, the
vertical axis is constituted by a binary code that specifies either color values or shades of gray (i.e., a
gray scale image).
The meaning of the term pixel changes depending on the context in which the word is used. Pixel
indicates an element on a CCD as well as a component of a digital image. The former is an actual
physical structure, whereas the latter is an abstract mathematical concept. Pixel can also refer to a
group of phosphor dots on the screen of a color television monitor. The potential for confusion is
compounded by the interrelationships among these several frames of reference. In effect, the number
and planar arrangement of pixels on the CCD determine the number and arrangement in the CCD
image. Because the television monitor must reproduce the image, the number and arrangement of
pixels it contains must conform to the digital image.
The smallest data element that a computer can distinguish is known as a bit. The number of colors (or
shades of gray) a pixel can display is specified by the number of bits it can contain (a factor termed bit
depth). As the number of bits increases, more colors or shades of gray can be represented. Bit depth
is a function of computing power. If the bit depth is one, only two colors or gray shades are possible,
that is, black and white. If the bit depth is increased to four, 16 colors or shades of gray are possible
(i.e., 2 to the fourth exponential power).
A CCD measures light intensity but not wavelength; that is, it detects brightness but not color. Several
ingenious methods have been developed to obtain color images with a CCD. These are discussed in
Chapter 3: Flexible Endoscope Technology: The Video Image Endoscope. A basic knowledge of the
trichromatic theory of color reproduction using the primary colorsred, blue, and greenis essential to
the following discussion of digital color images (see Chapter 3: Flexible Endoscope Technology: The
Video Image Endoscope).
Digital images are classified according to bit depth as follows: bilevel (1-bit, black and white), gray
scale (usually 8-bit), pseudocolor (usually 4-bit or 8-bit), and true color (24-bit). In a sense, bit depth
specifies the resolution of color or shades of gray in an image, that is, the number of different colors or
shades that can be distinguished.
Bilevel Images
Bilevel images are not germane to endoscopic image management systems because digital x-ray
images are composed of shades of gray, whereas endoscopic images must be rendered in color.
Bilevel images are used in printing, and clever methods have been developed to represent an image
using only the colors black and white.
Gray Scale Images
Gray scale images are composed of shades of gray ranging from absolute white to completely black.
Usually these are 8-bit images, which means that each pixel can display up to 256 shades of gray. The
"brightness" of a pixel is sometimes referred to as its gray value. A gray value of 0 is black; that for
pure white is 256. A gray scale image is analogous to a black-and-white photograph.
Pseudocolor Images
A 4-bit pseudocolor image can represent 16 colors; an 8-bit image of this class offers 256 colors. The
term pseudocolor is used to indicate that the color displayed in a pixel is not a direct function of its
value. Rather, a color is assigned to the pixel value from an index table of colors (referred to as a
palette) in the computer program. Usually, the palette table is stored with the image. Most
image-processing software supports 8-bit pseudocolor images. Commercially available electronic
endoscopic systems are based on 8-bit pseudocolor images.
True Color Images
Images of this class have 24 bits per pixel, that is, 8 bits for each of the three primary colors (see
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Chapter 3: Flexible Endoscope Technology: The Video Image Endoscope). Therefore, as many as
16.7 million colors are possible with a true color image. This is well in excess of the number of
separate and distinct colors that can be distinguished by the human eye.
It is possible, within certain limits, to convert a digital image of one class to another of lesser bit depth.
An image of lesser bit depth can be converted to a class with greater depth, but this does not increase
the number of data available in the image; that is, the color and resolution remain the same.
Conversion of images from one class to another can sometimes be advantageous. For example, a
standard, commercially available (color) television camera can be used to capture digital images of
radiographic films. Because radiographs are black-and-white images, conversion of the pseudocolor
8-bit image to a gray scale image enhances detail and contrast.
Spatial Resolution
Spatial resolution is a second attribute of a digital image in addition to bit depth (brightness resolution).
This is specified by the number of pixels and expressed according to the two-dimensional coordinate
system, that is, the number of pixels on the x-axis multiplied by the number on the y-axis. For example,
an image with a resolution of 640 480 pixels contains 307,200 pixels; an image with a resolution of
1024 768 has 786,432 pixels.
Bit depth and spatial resolution are the main determinants of the quality of a digital image. Resolution
defines the amount of detail that can be seen in an image. The higher the resolution (number of
pixels), the better the definition and sharpness of the image.

Digital Versus Analog Images

Most image management systems use both digital and analog images. The digital image is
reconverted to an analog signal by the video processor so that it can be displayed on a standard
television monitor. Because television technology for consumers was originally developed for analog
signals, analog equipment is generally available at a lower price than digital equipment. Because of
financial considerations, analog devices have been used more widely for storage of endoscopic
images as, for example, by means of videotape or analog filing devices.12(233)
Some degradation in image quality usually occurs as a result of loss of information when analog
images are repeatedly stored and recovered for viewing. It is preferable, therefore, that images be
stored digitally.13(234) However, a permanently stored analog image is not degraded while in storage.
Some loss of data occurs when the image is initially stored and some additional loss occurs each time
it is recovered from storage, but the stored image itself remains essentially unchanged.
The difference between digital and analog signals can be illustrated using the analogy of a compact
audio disk (CD) compared with a long-playing phonograph record (LP). Sound is recorded on the LP
as a wave along a circular track; the amplitude of the wave (width of the lateral movement of the
pickup) specifies the intensity of the sound, and pitch is given by the frequency of the wave. On the
CD, amplitude of the sound wave is sampled at regular intervals, and these values are expressed as
binary code (i.e., a representation of any number by means of series of two digits, 0 and 1). Binary
code is represented on the CD itself by the presence or absence of a pit; the pickup of the CD player
detects the latter by means of a laser beam. On the CD, sound is thus recorded as digital signals.
Original sounds are easily reconstructed from binary code. Because the signals are represented by
discrete numbers, the shape of the analog signal wave is of no consequence when the "sound" (binary
code) is reproduced; distortion of the replayed sound (corresponding to the degradation of a
reproduced image) is unlikely to occur. Furthermore, copying the binary code (e.g., from one CD to
another) or long-distance transmission is unlikely to be associated with distortion. Little interference is
produced by noise (stray electric signals inherent to any electronic device); lost data can be recovered;
and methods are available for error correction. Although a sound signal is a function of time and
amplitude, the preceding discussion applies also to an image signal in which space replaces time.
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Digitally recorded images are qualitatively superior to analog images. A digital image is also more
suitable for image processing by means of computer programs. Compared with an analog image,
however, a digital image (if uncompressed) requires more time for recording, for transmission, and for
recovery and redisplay from a memory storage device. When a memory medium of a given capacity is
used for recording, the number of uncompressed digital images that can be stored is much less than
the number of analog images; that is, a larger segment of the available memory of the device is
required. Technical problems also occur with storage of multiple digital images in series in order to
display motion.
Because the technology for storage of digital images is more involved, storing an image in digital as
opposed to analog format is more expensive. The cost is expected to be less problematic in the near
future as the use of digital technology becomes more widespread. The price will undoubtedly decrease
with increasing demand; at the current level of technology, however, digital storage of images is more
An additional problem with the choice of the digital format for image management is speed of
transmission. For integrated image management, communication is vital, but the speed of digital image
transmissionas, for example, through a standard local area network (LAN)is limited.
The characteristics of analog and digital images are summarized and compared in Table 71.


Analog Versus Digital Images

Image recording
Recording capacity
Image search
Image transmission
Quality of recorded image
Transmitted image
Copied image

Quick (instantaneous with
Large (108,000 images/300
mm optical disk)*
Quick (<1 sec/image*
Associated with image
Associated with image

Moving image recording

Application for image
MOmagneto optical disk.
* Data from the authors' system.

Slow (instantaneous with
Small (5000 images/130 mm
Slow (<3 sec/image)*
No image degradation
No image degradation

Image Acquisition
Various types of images are appropriate and suitable for image management. Images acquired with
electronic or video endoscopes are obvious choices. However, images obtained through a fiberscope
can also be converted to a digital system by means of a video converter. However, resolution (the
ability to distinguish fine detail) in images obtained in this fashion is inferior to that of electronic
endoscope images and even that of photographs made by attaching a camera to a fiberscope.
In addition to endoscopic images, relevant images to be archived include ultrasound images obtained
by extracorporeal scanning and endoscopic ultrasonography, conventional radiographs, including plain
radiographs and contrast studies such as ERCP (endoscopic retrograde cholangiopancreatography)
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radiographs as well as computed tomography (CT) and magnetic resonance imaging (MRI) scans.
Images in the form of photographs and radiographs can be "digitized" and incorporated into a digital
format storage system by means of a high-resolution image scanner. A complete system might include
images obtained by light or even electron microscopy (of biopsy specimens, for instance). Images of
resected specimens can also be important; macroscopic images can be acquired through a standard
video camera.

Data Formats
Data format is problematic with regard to all aspects of image management. This is somewhat
analogous to the situation that exists with text files generated by word processing software programs.
Text is stored in a computer memory (e.g., a hard drive or floppy disk) in a particular format that is
unique to each word processing program. This means that a text file stored in a format specific to one
program cannot be manipulated without difficulty by another word processing program. By means of a
uniform standard for text characters (i.e., American Standard Code for Information Interchange
[ASCII]), a text file written to a memory device can be read and manipulated by all word processing
programs. However, much of the usefulness that the word processing program adds to a text file is lost
when the digital data are written to memory using the ASCII format.
Formats for writing a digital image (file) to a memory device depend on the process by which the
manufacturer of the software acquired the digital image. In general, each format is unique to the
software and is proprietary in nature. Unlike the ASCII format for text files, no universal common
standard format exists for image files. Converting the format of a text file from that of one word
processing program to another (or to ASCII format) is relatively uncomplicated. Image files can also be
converted from one format to another, but conversion of this type is much more complex than that of
text files. To begin with, the number of data (binary code) in a text file, even a very large one, is
relatively small compared with that of a file containing a color image. Furthermore, exact conversions
between image formats are often technically difficult or impossible because images may become
distorted by the conversion process. The data format problem is compounded by the fact that all
images (e.g., endoscopic, radiographic, ultrasound) to be incorporated into a software-hardware image
management system must be in the same data format.
The type of file format is indicated by a file extension (i.e., a period followed by three letters after the
name of the file; e.g., FILENAME.TIF or FILENAME.TGA). Some commonly used file formats (and
corresponding software) are given in Table 72.


Examples of File Formats Used for Digital



Tagged information file format: A widely used general-purpose

format developed by Aldus Corporation and Microsoft
Corporation. Specifically designed for image processing (file
extension is .TIF).
Developed for image processing with TIPS software by
TrueVision Corporation. Works with TARGA series of frame
grabbers (extension is .TGA).
Used with Windows and OS/2 (extension is .BMP).
Developed by Media Cybernetics. Works with a program known
as Halo Paint Package (extension is .CUT).
Graphics interchange format: Developed by CompuServe, Inc.
(extension is .GIF).
Developed by Digital Research. Used in certain desktop
publishing programs (extension is .IMG).
Developed by Microsoft for a program called Microsoft Paint
(extension is .MSP).

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Examples of File Formats Used for Digital


Developed by ZSoft Corporation (extension is .bmp).

The conventional (quick and easy) solution to the data format problem has been to use the format of
video signals as the interface; these consumer product television technology standards are NTSC
(National Television System Committee) for North America and Japan and PAL (phase-alternation line)
for Europe. Although this approach is economical, these standards are for analog signals. For storage
and retrieval, therefore, a digital image must undergo repeated digital-to-analog and analog-to-digital
conversions. Theoretically, this process results in subtle image degradation. Although one such
transfer (as occurs each time the image is recalled from memory) may be of no consequence in terms
of image quality, many such conversions result in an appreciable decrease in quality.
Efforts are under way to develop device-independent standards for diagnostic images; digital imaging
and communications in medicine (DICOM) standards for endoscopic images are being developed in
the United States of America by a joint working group.14(235)

Image Compression
A large amount of computer memory is needed to store an image with a high spatial resolution and bit
depth. For example, an 8-bit pseudocolor image with a spatial resolution of 480 640 requires about
300 kilobytes (K) of memory; a 24-bit true color image with the same spatial resolution requires almost
1 megabyte (MB) of storage capacity. Image "size" in terms of bits needed to represent the image also
influences the speed at which it can be transmitted, as in a FAX message. To deal with these
problems, standard methods of image encoding, also known as compression, have been developed.
Even with compression, however, a color digital image still requires a relatively large memory for
Image compression is fundamentally a mathematical technique that identifies redundant image data
and replaces them with codes that consist of smaller numbers of data bits. With elimination of
irrelevant and repetitious data, less memory is needed to store the image and speed of transmission
Several steps are required to encode an image. The first is known as mapping. In this step, the input
data from the pixels are transformed to reduce redundancy. Mapping may be of two types: destructive
(which eliminates varying amounts of data) and nondestructive (in which all data in an image are
preserved). Methods of compression that preserve all data are called lossless; those that do not are
referred to as lossy.
Discrete cosine transform (DCT), a commonly used compression for digital image storage and retrieval
in the Joint Photographic Experts Group (JPEG) format, is an example of destructive mapping. This
method divides an image into blocks where the spatial frequency components are extracted and
compressed by coarsely quantizing the high-frequency components (that slightly affect the image
quality). All methods of destructive (lossy) compression are nonreversible and degrade an image with
each compression.
Run length encoding (RLE) is a commonly used type of nondestructive mapping. This method is based
on the assumption that adjacent pixels frequently have the same brightness or value. RLE assigns a
number pair to each sequence or "run" of pixels that are alike. Typically, the first number of the pair
signifies the brightness of the first pixel in the run (which is equal to that of all of the other pixels in the
run). The second number specifies how many pixels the run contains. RLE is especially suitable for
images with large areas in which a color is constant.
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Image Storage
Recording or storage of images is the essential element of image management. Two important
aspects of image storage are the selection of a memory medium and the security of the stored data.
Memory Media
Currently available memory media relevant to image storage are of three types: magnetic, optical, and
Magnetic memory media include the hard disk, floppy disk, and digital audio tape recorder (DAT). All of
these are rewritable; that is, it is possible to erase existing data. A hard disk consists of a substrate
coated with a thin metallic plating of a magnetic alloy. Characteristics of a hard disk include relatively
large memory capacity (40 to 4280 MB/disk) and high-speed access (less than 10 ms) to data. A floppy
disk is a flexible, lightweight disk made of ferric oxide-coated polyester, 3.5 or 5.25 inches in diameter.
The usual storage capacity is limited (approximately 1.4 MB per formatted disk), but the low price and
convenience of the floppy disk in an office environment are attractive features. DAT can be used for
archival storage.
Currently, three types of optical memory media are available: rewritable (i.e., erasable), write-once (i.e.,
non-rewritable), and read-many-times, or read-only. A magneto optical disk (Figures 71 and 72) is
rewritable and portable (90 to 130 mm in diameter) and has a large memory capacity (128 to 1000
MB/disk, double-sided). The write-once type of optical disk (occasionally abbreviated WORM for
write-once, read-many-times) (Figure 72) is non-rewritable and usually large (300 mm in diameter),
with a large capacity of memory (up to 7 gigabytes/disk, double-sided). The WORM disk is suitable for
archival storage of large numbers of data such as color images. It will replace the magnetic tape. A
compact disk with read-only memory (CD-ROM) is a portable optical disk with a memory capacity of
540 MB; the CD-ROM disk is especially suitable for atlases of endoscopic images.

(236)Figure 71. A magneto optical disk and its drive unit. A 130-mm, rewritable, magneto
optical disk (left) holds 646 megabytes. A disk stores more than 5000 endoscopic images in
one-tenth compression (irreversible).

(237)Figure 72. A 300-mm write-once type optical disk and a 130-mm magneto optical disk.
In the authors' system, the 300-mm write-once optical disk is used for backup storage. It
records 108,000 analog images per disk. (Courtesy of Olympus Optical Company, Ltd.)
IC memory cards are lightweight, credit card-shaped devices measuring 54 86 3.3 mm that
incorporate a microcomputer. Characteristics of the IC memory card relevant to image storage include
a large-capacity static random-access memory and quick access time (counted in nanoseconds). An
IC memory card may be used for temporary image storage or as a personal data file for an individual
patient. It can be used as a cache, that is, a type of quick access memory inserted between the central
processing unit and the main memory when the same data are read repeatedly. Data (e.g., an image)
retrieved for the first time from memory are "written" or transferred to the quick access memory, that is,
a cache file. Thereafter, these data are retrieved not from the main memory but from the quick access
memory or cache. This provides a solution to the problem of slowness in displaying digital images.
Security of Stored Data
Endoscopic images are as much a part of a patient's record as laboratory tests and chart notations. As
with all such records, patients have a legitimate expectation that this information will be kept
confidential. Endoscopic images and related information (e.g., procedure reports) must therefore be
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protected against loss, theft, and unauthorized manipulation or modification. Data in any memory
medium must be physically protected from accidental erasure or overwriting. In this regard, the
write-once types of media are ideal. Nevertheless, it is mandatory that backup capability be
incorporated into the design of every system for image storage. To avoid violation of patient privacy,
access to data must be restricted to authorized personnel only. Generally, this can be accomplished by
use of passwords.

Image Retrieval and Display

Stored images are usually indexed and identified by patient identification (ID) code and demographic
information, date and sequence number of the procedure, and type of procedure. In most systems,
images captured successively during a procedure are assigned sequential frame numbers. Other
diagnostic information, such as biopsy results, must also be entered into the system. This is usually
accomplished by keyboard entry into a corresponding database.
Retrieval of endoscopic images is done for three basic purposes: patient care, education, and
research. It is frequently useful to compare endoscopic findings from a previous examination when
procedures are performed in follow-up. The ability to retrieve endoscopic images greatly enhances
endoscopy conferences, including case presentations. In addition, endoscopic images have numerous
uses with regard to endoscopic and other types of research.
Required images are retrieved by reference to a denominator (usually items of demographic
information), such as diagnosis, patient's date of birth, date of the procedure, and the patient's ID
number. A unique number is usually assigned to each patient by a hospital or health care system;
sometimes the patient's social security number is used. In general, use of the patient's name as a
denominator is unsatisfactory because two or more patients sometimes have the same name.
Because ID numbers may be entered incorrectly into a computer system, it is best to use a second
denominator to verify that the file(s) and images of the correct patient have been selected. The
patient's date of birth is usually suitable for this purpose.

Image Transmission
An endoscopy unit usually consists of a number of procedure rooms as well as other support rooms
that serve various purposes. It becomes necessary, therefore, to link these rooms and their equipment
into a common system for image management. This can be accomplished in a number of ways. In
most endoscopy units, the various components of an image management system are interconnected
by wire or fiberoptic cable. In such a design, software programs are needed to direct and regulate the
flow of images and other data. This type of system is generally referred to as a local area network
(LAN). Most commercially available systems provide software and other components needed to
establish a LAN.
It is not possible to discuss all aspects of LAN technology within the context of this chapter. However,
reference to a commonly used technology for LAN, called Ethernet, serves to illustrate certain essential
points. Ethernet refers to standards developed for a LAN mainly for connection of devices to the net
and transmission of data within a LAN. It was developed jointly by the Digital Equipment Corporation,
Xerox, and Intel.
The Ethernet LAN system can transmit data at the rate of 10 megabits/sec over coaxial cable with a
data link control protocol of carrier sense multiple access/collision detection (CSMA/CD). The
CSMA/CD is the software that prevents collisions of data files (images) when simultaneous requests
are made for transmission of data over the LAN, such as to or from a memory device. The CSMA/CD
protocol allows the various stations (nodes) on the system (e.g., several procedure rooms) to detect
the presence of transmitted messages on the network by sensing the carrier of the transmission. In
effect, CSMA/CD makes each station wait its turn to transmit until no other station is transmitting. As
the number of stations or nodes on a system increases, the chance of a collision also increases,
thereby making the waiting time longer. In general, digital image transmission is slower when many
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stations are present.

Every procedure room in an endoscopy unit, as well as a central control room or area, must have a
station for transmission and display of images if the advantages of an image management system are
to be realized. This is the essential minimum. Beyond this point, many possible enhancements of the
system can increase its utility and improve the quality and efficiency of the endoscopy unit. Display
stations can be placed in consultation rooms to show patients their own endoscopic images. Stations in
physician work areas are useful. In particular, conference rooms and lecture theaters should have
display stations. Each operating room in the surgical theater should have access to stored endoscopic
images. All of these rooms (nodes, stations) must be connected by a LAN.

A System for Electronic Image Management

The system for electronic image management at the authors' hospital illustrates the process of design,
essential points that must be considered in building a system, and some possibilities for choices of
hardware and software.

The Environment
As a first step in designing and planning an electronic image management system, it is necessary to
consider the nature of the environment as well as the objectives of the system.
The authors' institution has a hospital with 600 beds distributed as 13 wards. Approximately 700
outpatient clinic visits occur each day; approximately 5000 digestive endoscopy procedures are
performed each year.15(238) The number of images acquired during a typical
esophagogastroduodenoscopy (EGD) is about 40.16(239) Most of the endoscopy procedures are
performed in the endoscopy unit, which has five examination tables, but ERCP and other procedures
that require fluoroscopy are performed in the radiology unit. Laparoscopy is performed in the operating
theater. The radiology unit and operating theater are both on different floors from the endoscopy unit.

Design of the System

A block diagram of the endoscopy image management system is shown in Figure 73.2,3,1725(240)
In this system, the endoscopy procedure tables in the endoscopy unit are connected on-line with the
main computer in a central control room, where images can be stored in both analog and digital
formats. The 130-mm magneto optical disks recorded with digital images are carried to distant
subsystems for display and review of images. All disks are kept in storage in the central control room.

(241)Figure 73. Block diagram of the authors' image management system. Within the
endoscopy unit, there is a central control room that houses equipment that stores images in
both analog and digital formats. All endoscopy tables are connected on-line with the central
analog image storage device through the multi-input unit. At the same time, all the endoscopy
tables have, both within and distant from the endoscopy unit, an individual digital image
recording device. Lecture theater and conference rooms have digital image display stations.
GIgastrointestinal; NTSCNational Television System Committee.
The flow of endoscopic images from the endoscopy procedure tables is diagrammed in Figure 74.
The images are recorded simultaneously as digital images at the endoscopy table and as analog
images centrally through the multi-input unit. An endoscopy station with procedure table is shown in
Figure 75, and the central control room is shown in Figure 76.

(242)Figure 74. Block diagram of endoscopy station at each endoscopy table. Endoscopic
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images acquired with the electronic endoscope are sent to the video processor. The images are
further sent to both the digital image storage device that records images on the 130-mm
magneto optical disk and to the multi-input unit in the central control room. VTRvideo tape

(243)Figure 75. View of an endoscopy station. A cable running from behind the television
monitor toward the ceiling connects the video processor via the multi-input unit with the
analog image storage device. In the bottom two sections of the rack, the digital image
recording devices are seen. These are an image compressor/decompressor (above) and a
magneto optical disk drive with its controlling computer (below). (Courtesy of Olympus
Optical Company, Ltd.)

(244)Figure 76. View of central control room. Equipment on the desk to the left is for digital
image display; that on the desk to the right is for data control and analog image recording and
display. The cables in the bundle seen in the right upper corner run to individual endoscopy
tables. In the front of the whitish box is the multi-input unit; below the right desk, in the lower
right corner, is the computer that controls the 300-mm optical disk recorder at the bottom. The
large television monitor at the extreme left of the left desk is a high-resolution computer
graphic monitor used for multiple image display of digital images. To its right is another
monitor showing the indices of the multiple display images; using these indices as a guide, it is
possible to choose an image for enlargement on the monitor above. Between the two lower
monitors (left desk) are two magneto optical disk drive units.

Multiple Image Display

An endoscopy conference in our department is shown in Figure 77. At the display station, an enlarged
endoscopic image (seen on the monitor on the left) is being discussed.21(245) The magneto optical
disks on which the required images are recorded have been brought to the conference room.

(246)Figure 77. Endoscopy conference using a display station. An enlarged endoscopic

image displayed on the left monitor is being discussed. The monitor on the right is a
high-resolution computer graphic monitor for displaying multiple images simultaneously; it is
possible to display up to 42 images simultaneously. The box above the left monitor is a
compression/decompression unit for digital images. Above the right monitor are four magneto
optical disk drive units that can search four disks in parallel for images.
Necessary images are retrieved through keyboard entry of a denominator, such as the patient's ID
number. If searched by patient ID number, all of the procedures performed on that particular patient
are listed first in chronologic order; a certain procedure performed on a given date is selected. Then all
of the images stored during that procedure are displayed, together with their indices, on the monitor
designated for multiple image display. If necessary, any particular image may be selected for
enlargement and detailed study. Figures 78, 79 and 710 are examples of images being displayed
on the monitors, including simultaneous display of multiple images on a computer graphic monitor
(Figure 78), selection of an image (image 26) for enlargement, display of this enlarged image on the
NTSC monitor (Figure 79), and a combination of different types of images (colonoscopic,
endosonographic, and microscopic) from a single patient, which are being edited for presentation
(Figure 710).
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(247)Figure 78. Multiple image display on a computer graphic color monitor. Image 26 is
chosen for enlarged display. This is a case of acute gastric ulceration developing after
transcatheter arterial embolization therapy for hepatocellular carcinoma.

(248)Figure 79. Enlarged image display on the (NTSC) color television monitor. Image 26
(Figure 78) is shown enlarged for detailed analysis.

(249)Figure 710. Display of different kinds of color images. For presentation of a case of
colonic carcinoma, a colonoscopic image, two endosonographic images on the left, and a
histologic image of a resected specimen are displayed together. The histologic image was
input by attaching a television camera to a microscope.

Analog-To-Digital and On-Line/Off-Line Dual Hybrid System

A personal computer-based endoscopic image management system was developed by the authors to
minimize the implementation costs (Figure 711). In studying the picture archiving and communication
systems (PACS) in other university hospitals, we discovered that the delay in digital image
transmission was so marked that images to be reviewed during a conference had to be transferred to
the display unit in a conference room throughout the night preceding the meeting. We considered this
a serious problem because the average number of images captured during a procedure in Japan is
40,16(250) many more than are obtained in a conventional radiologic examination. Furthermore, the
number of endoscopic procedures far exceeds that of radiologic examinations. To circumvent this
problem, we developed an analog-to-digital and on-line/off-line dual hybrid system rather than the
standard on-line digital image management system. This system is integrated with the information
system of the hospital. When the shortcomings of the on-line digital image management system are
overcome, our dual hybrid system has the flexibility to be altered without difficulty to an on-line system.

(251)Figure 711. Analog/digital hybrid system for image management. The concept of
analog/digital and on-line/off-line dual hybrid system is used in the current system. The solid
lines show on-line signal flow, the broken line shows off-line signal flow.

Importance and Future Development

An electronic image management system organizes and integrates endoscopic images and makes
them readily available for a variety of purposes. Such a system offers a substantial degree of security
and safety and avoids problems of image degradation that are common to older methods of archiving
images. An electronic system facilitates image processing and analysis and increases the efficiency of
the endoscopy unit, especially those units in which photodocumentation is considered
essential.26(252) A tremendous library of images covering a wide variety of endoscopic findings and
diagnoses can be built within a relatively short period of time, and a properly designed system brings
together the many different types of images that pertain to each patient. All of this has a very favorable
influence on training programs and serves to elevate the level of endoscopic knowledge throughout the
endoscopy unit. With the further standardization of endoscopic terminology and the assimilation of
these terms into computer programs for the generation of endoscopy reports and retention of
endoscopic data, the endoscopy unit will truly enter the modern age of computers.27(253) Among the
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remarkable changes that may be foreseen are the development of methods of image communication
between institutions. In this way, endoscopic images can become common assets within health care
systems. Computer networks will make it possible to transfer images from country to country for
consultation, research, and teaching.


Uji T. Studies on photography of gastric mucosa and its application. Tokyo Igaku Zasshi
2. Fujino MA, Ikeda M, Yamamoto Y, et al. Development of an integrated filing system for
endoscopic images. Endoscopy 1991;23:115.
Fujino MA, Morozumi A, Kawai T, et al. Management of endoscopic images and advances in
optical disk technology. Gastrointest Endosc Clin North Am 1992;2:31334.
4. Dwyer SJ III, Templeton AW, Martin NL, et al. The cost of managing digital diagnostic images.
Radiology 1982;144:3138.
5. James AE Jr, Erickson JJ, Carrol FE, et al. Medical image management: Practical, legal and
ethical considerations. Comput Biol Med 1986;16:24757.
Cox GG, Templeton AW, Dwyer SJ III. Digital image management: Networking, display, and
archiving. Radiol Clin North Am 1986;24:20619.
7. Seshadri SB, Arenson RL, van der Voorde F, et al. Design of a medical image management
system: A practical cost-effective approach. Comput Methods Programs Biomed
8. Rozen P. Computer assistance in gastroenterology: An update. Am J Gastroenterol
9. Iber FL, Kruss DM. Computer storage of gastrointestinal procedures. Am J Gastroenterol
10. Publig W, Zandl Ch, Czitober H. EDV-gestutzte Dokumentation in der gastroenterologischen
Endoskopie. Simultane Archivierung und Befundausgabe. Wien Klin Wochenschr
11. Sivak MV Jr, Fleischer DE. Colonoscopy with a videoendoscope: Preliminary experience.
Gastrointest Endosc 1984;30:15.
Yamagata S, Oida M, Imaizumi H, et al. Management of endoscopic pictures using analog
filing system. Endoscopia Digestiva 1993;5:7318.
13. Classen M, Wagner F, Swobodnik W. Electronic data base in gastroenterological endoscopy.
Endoscopy 1991;23:2931.
Endoscopic Image Exchange Ad Hoc Committee. Digital imaging and communications in
medicine (DICOM). Personal communication. .
Fujino MA, Ikeda M, Yamamoto Y, et al. Introduction of endoscopy units (endoscopy centres).
A series: No. 45. Gastroenterol Endosc 1990;32:22834.
Takasu Y, Kitamura A. Practice of panendoscopy. Stomach Intestine 1984;19:4754.
Fujino MA, Ikeda M, Yamamoto Y, et al. Filing network of electronic endoscopic images. With
reference to a newly developed system. Image Technol Inf Disp Med 1990;22:117781.
18. Fujino MA, Ikeda M, Yamamoto Y, et al. Digital/analog hybrid system for filing of endoscopic
images. Comput Methods Programs Biomed 1992;37:2918.
Fujino MA. Image management in video endoscopy. Organisation Mondiale d'Endoscopie
Digestive Newsletter 1994;1:7.
Morozumi A, Fujino MA. Personal computer-based endoscopic picture archiving and
communication system (PACS). Image Technol Inf Disp Med 1992;24:68993.
Otaka M, Fujino MA, Ikeda M, et al. Development of image display stations for endoscopic
conferences. Endoscopia Digestiva 1992;4:152933.
Fujino MA, Morozumi A, Nakamura T, et al. Analysis on an off-line system for endoscopic
image management. Image Technol Inf Disp Med 1993;25:599602.
Ikeda M, Fujino MA, Morozumi A, et al. Management of endoscopic images using digital
images. Off-line system/hybrid system. Endoscopia Digestiva 1993;5:73945.
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Fujino MA, Morozumi A, Nakamura T, et al. Future outlook for digestive endoscopy in the
context of computerisation. Endoscopia Digestiva 1993;5:7915.
25. Fujino MA, Ikeda M, Morozumi A, et al. Electronic endoscopy in perspective. J Gastroenterol
1994;29(suppl 7):8590.
26. Fujino MA, Kawai T, Morozumi A, et al. Endoscopic image manipulation: State of the art.
Endoscopy 1992;24(suppl):455550.
27. Crespi M, Delvaux M, Schapiro M, et al. Minimal standards for computerized endoscopic
database. Am J Gastroenterol 1994;89(suppl):S14453.

Chapter 8 Disinfection of Endoscopes and Accessories



Since the mid-1980s, there has been a quickening of interest in the disinfection of endoscopes and
accessories. The recognition that serious infection may be transmitted endoscopically and that patients
have died as a result of inadequately disinfected equipment has caused endoscopists to review their
working practices. Interest has been further stimulated by the acquired immunodeficiency syndrome
(AIDS) epidemic, not only because of the risk that the human immunodeficiency virus (HIV) might be
transmitted to normal individuals but also because immunocompromised patients may harbor unusual
and potentially pathogenic organisms that may be passed to others.
The enormous increase in the number of patients undergoing endoscopy has meant that nurses and
endoscopy assistants are under pressure to "turn around" equipment more rapidly. They have
recognized that this can lead to unacceptable compromises in cleaning and disinfection, and they have
been attracted to mechanical aids to alleviate the pressure and tedium of these activities. The fact that
only aldehyde-based disinfectants appear at present to be totally reliable for safe disinfection has
meant that increasing numbers of endoscopists and staff have become sensitive to these toxic
chemicals. This has given rise to concern about safety at work and has led to litigation by affected
individuals against their employers. On the one hand, strong pressure is placed on endoscopists to
ensure that all equipment used is completely safe for all patients, whatever their immune status and
whoever underwent endoscopy before them. On the other hand, concern exists about the time taken to
disinfect equipment and the expense required to provide the necessary staff as well as added
resources to ensure that they are working in a safe environment.
These considerations stimulated a number of national endoscopy societies to produce guidelines for
the disinfection of equipment,15(256) and the World Congresses of Gastroenterology have made
similar recommendations on disinfection practice.6(257)

Potential Risks of Inadequately Disinfected Equipment

Infection Carried by Patients
A significant minority of patients referred for endoscopy are infected with pathogenic bacteria. This
applies particularly to individuals who undergo emergency endoscopy. A proportion have acute
infection, such as salmonellosis, that may have given rise to the upper or lower gastrointestinal
symptoms that prompted investigation; others are carriers of infectious disease. Infection with hepatitis
A and B is more common among individuals coming to endoscopy than in the population at large, and
a particularly high percentage of patients are infected with Helicobacter pylori. Because this latter
organism is now considered to be a pathogen (see Chapter 46: Peptic Diseases of the Stomach and
Duodenum), the majority of patients referred for endoscopy in most communities can be considered to
be infectious.
Patients who are immunocompromised frequently develop viral, bacterial, and fungal infections that
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may lead to esophagitis, gastric symptoms, or diarrhea and require examination. Some of these
individuals are infected with the HIV virus; others, such as those undergoing chemo-therapy, although
not infected with a primary pathogen, nevertheless harbor other potential pathogens, especially atypical
mycobacteria, spore-forming organisms, and fungi. Although these may not be dangerous to normal
individuals, they may be devastating to other patients with an immune deficiency.711(258)
One of the major protections against enteric infection is gastric acid. The hypochlorhydric stomach
rapidly becomes colonized with a variety of enteric organisms. Many patients referred for endoscopy
are taking H2 receptor antagonists or proton pump inhibitors; others have achlorhydria as a result of
longstanding gastric pathology. Not only may these organisms be transmitted to others, but
hypochlorhydric patients are in greater danger of contracting infection from organisms transmitted to
them at endoscopy.

Infection Generated by Equipment

Endoscopic equipment is contaminated by use in patients, but it also becomes colonized by
saprophytic organisms during storage.1216(259) Opportunistic organisms present in the general
environment are able to colonize stagnant water, detergent, and even certain disinfectants. The warm,
moist channels of an endoscope left in the humid environment of an endoscopy cupboard in a centrally
heated room are rapidly colonized. Similar contamination occurs in ancillary endoscopic equipment
such as catheters and in endoscope washing machines. From these reservoirs of infection, the air
suction channel, the water channel, and the channel that contains the elevating mechanism for the
biopsy forceps may all become contaminated, leading to further spread within the endoscopy room.
The major risk of this contamination occurs with endoscopic retrograde cholangiopancreatography
(ERCP). However, in addition, these organisms, which are often antibiotic resistant, may be introduced
into a succession of patients, who may become colonized and transmit the infection after leaving the
endoscopy room.17,18(260) If they are introduced into patients who are immunologically
compromised, more serious problems may arise.

The best-documented cases of endoscopic transmission involve salmonella.1927(261) A number of
epidemics have been reported in which infection with this organism has been transmitted from one
patient to a succession of others. In each reported epidemic, the disinfection techniques used by the
units affected were below the standard now generally recommended. The size of this problem is
difficult to estimate because undoubtedly only a minority of epidemics are recorded in the scientific
literature. Some go unrecognized, others unreported. Most infection has arisen from
esophagogastroduodenoscopy (EGD), but one well-documented series of infections arose in patients
who had undergone colonoscopy with a variety of instruments. The source of infection was eventually
traced to the spiral spring of one pair of biopsy forceps.28(262) It follows that infection may be
transmitted not only by the endoscope but also by ancillary equipment used with the endoscope. It is
not necessary for the organism to be ingested by mouth; effective colonic seeding is also possible. The
fact that the colon is a con-taminated organ does not imply that less rigorous disinfection techniques
should be practiced with the colonoscope or flexible sigmoidoscope.

Helicobacter pylori
The most common pathogenic organism encountered at endoscopy is H. pylori, which infects 95% of
individuals with duodenal ulcer and more than 50% of patients with nonulcer dyspepsia.29(263) When
introduced into a normal stomach, the organism gives rise to an acute gastritic illness;3032(264) in
the majority of cases, that illness progresses to chronic active gastritis, which often persists throughout
life (see Chapter 46: Peptic Diseases of the Stomach and Duodenum). Infection is associated with an
increased risk of duodenal ulcer, gastric ulcer, and gastric cancer.
Two epidemics of helicobacter infection have been reported in volunteers undergoing experimental
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intubation for gastric secretion studies.33,34(265) The infection was attributed to inadequately
sterilized pH probes, and although the cause of hypochlorhydria was not recognized at the time, it is
now believed that both were due to H. pylori. Well-documented cases have been reported of
helicobacter transmission by endoscopy in which individual patients became infected with the same
strain of organism as a patient who had undergone prior endoscopy.35(266) The disinfection technique
being practiced at that time did not meet the standards now generally recommended.
More recently, a study from Japan described a postendoscopy syndrome in which patients developed
upper gastrointestinal symptoms following endoscopy. This condition appears to be acute
helicobacter-associated gastritis as a direct result of the endoscopic transmission of the
organism.36(267) Unless equipment is properly disinfected, transmission rates may be as high as 1%
of all endoscopic examinations.

The fear that hepatitis B might be transmitted by endoscopy has been a constant concern because
asymptomatic carriage of hepatitis B virus (HBV) is well recognized, and inevitably, many affected
patients undergo endoscopy without the clinician being aware of the hazard. It is surprising, therefore,
that only one case of HBV transmission has been reported.37(268) A number of longitudinal studies
have been done on individuals who inadvertently underwent endoscopy immediately following a carrier
who had undergone the same procedure.3846(269) None of these has demonstrated cross-infection,
and transmission of HBV by endoscopy appears to be an exceedingly rare occurrence.

Human Immunodeficiency Virus

To date, no cases of transmission of HIV by endoscopy have been reported. Patients with AIDS often
undergo endoscopy because they are prone to gastrointestinal complications. Fortunately, HIV is
labile4750(270) and less infective than HBV.5155(271) The fact that the latter organism has not
caused serious problems suggests that the danger of HIV transmission by means of endoscopy is very
low. If units follow appropriate disinfection procedures, the risk of transmission can be virtually

Opportunistic Organisms
Opportunistic organisms, particularly pseudomonas, are present throughout the environment and
readily colonize endoscopic equipment and ancillary apparatus. In 1974, Pseudomonas aeruginosa,
Pseudomonas fluorescens, atypical P. aeruginosa, and Pseudomonas maltophilia were isolated from
endoscopes following storage.12(273) At that time, it was recommended that equipment be disinfected
at the beginning of the endoscopy session as well as between each case. In the same year, fatal
pseudomonas septicemia was described following endoscopy in two patients with leukemia, and it was
confirmed that the infecting organism had come from the endoscope.7(274) In 1975, polymicrobial
sepsis was reported following ERCP, and the endoscopy equipment was again thought to be the
source.58(275) A further four patients with sepsis following ERCP were also described, one of whom
had a pseudocyst that was infected with pseudomonas.59(276) In 1976, two cases of fatal septicemia
following ERCP were described in which pseudomonas was the responsible organism.
In 1979, Parker et al.60(277) prospectively analyzed fever and bacteremia following ERCP. Ten of 50
patients became febrile. Organisms were grown from the blood in 7, and the source of infection was
the endoscope in at least 4. In 1980, Noy et al.16(278) reported three patients who became colonized
after EGD with a strain of P. aeruginosa identified as having come from the endoscope. The authors
believed that pseudomonas sepsis had contributed materially to the deaths of these patients and may
have been a major factor in determining their unsatisfactory response to surgery (they had been
admitted to the intensive therapy unit with gastrointestinal hemorrhage). These authors recommended
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disinfection before each session. A prospective assessment of bacterial complications following ERCP
was performed in 101 endoscopies.61(279) Aspirates from the pancreaticobiliary duct after injection of
contrast material yielded growth of P. aeruginosa in 14. These had all come from the endoscope.
In 1982, Gerding et al.62(280) drew attention to the importance of 2% glutaraldehyde disinfection
followed by forced-air drying prior to storage. Using this technique, they were able to reduce overnight
contamination, but even in their hands and in a careful study, they still found contamination after
overnight storage in 4 of 63 instruments (6%). In the same year, another case of pseudomonas
septicemia was reported following ERCP,63(281) the organisms again coming from the endoscope. In
1987, pseudomonas infection was described in 12 patients undergoing ERCP.64,65(282) Davion et
al.66(283) reported multiple liver abscesses due to pseudomonas, and Allen et al.64(284) reported 10
patients in whom pseudomonas was cultured from bile following ERCP. Classen et al.,67(285) in 1988,
observed a single case of P. aeruginosa bacteremia following ERCP and then retrospectively reviewed
the cases of the previous year and identified six other infections. In all seven, the infection had
developed within 5 days of ERCP. In each case, the pseudomonas isolate was from equipment, and
each of the patients had received the first scheduled ERCP of the day. The mean duration between
cleaning of the ERCP endoscope and its subsequent use was significantly longer in these cases than
in matched controls. The authors emphasized that all gastrointestinal endoscopes were disinfected
according to American Society of Gastroenterologists and Centers for Disease Control guidelines for
high-level disinfection. At the end of the day endoscopes were washed, disinfected, dried, and
suspended, but "endoscopes were not washed or disinfected again before subsequent use."
In the same year, Godiwala et al.68(286) reported two cases of Serratia marcescens infection following
ERCP (death occurred in one case). The source of the infection was the endoscope. This organism is
usually regarded as a saprophyte and does not normally inhabit the gut. The two cases occurred 3
days apart. The authors of this paper draw attention to three other papers that describe S. marcescens
infection following ERCP.59,69,70(287)
Pseudomonas not only colonizes endoscopic equipment but may also infect tubes and water
bottles,12,13,15,71(288) disinfectant solution, and even full-strength disinfectant.18,72(289) Ancillary
equipment and reservoirs of fluids used in the endoscopy unit should be changed regularly and
cultured periodically. Once pseudomonas has colonized equipment, it may be difficult to eradicate,
particularly if it contaminates washing machines and cleaning apparatus, leading to contamination of
equipment by the machine during the rinsing program (see later in this chapter).

Other Organisms
Theoretical dangers exist that organisms such as fungi, mycobacteria, other bacteria, and viruses may
contribute to cross-infection. However, no reports have been published of transmitted disease at
digestive endoscopy, although fungal contamination of equipment has been described.73(290) In the
developing parts of the world,5(291) other organisms such as Giardia lamblia, amoebae, helminths,
and those associated with cholera represent further hazards, but no confirmed reports of their
transmission have been found in the readily available literature.

Immunocompromised Patients
With the increasing number of patients with AIDS, the use of immunosuppression for the treatment of
malignancy, the ability of physicians to manage patients with advanced liver and renal disease who
would previously have died, and an increase in the number of elderly patients, many patients referred
for endoscopy fall into a particularly vulnerable group with respect to infection. Not only are these
individuals at greater risk of developing disease from pathogenic organisms, but they may become
desperately ill when infected with organisms that would present no major difficulty for healthier people.
Some national societies have recommended that special precautions be taken to protect these patients
at endoscopy. The working party of the World Congresses of Gastroenterology, having taken account
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of the published literature on this subject, took the view that if equipment is properly cleaned
mechanically and then totally submersed for 10 minutes in a disinfectant of equivalent power to 2%
activated glutaraldehyde, it should subsequently be safe for use in any individual.6(292)

Special Precautions to Be Taken in Patients Known to Be Infectious

Certain authorities have suggested that patients known to be infected with HIV, HBV, or other
infectious disease should be treated differently from other patients on the grounds that they could be a
risk to endoscopy staff or other patients. Suggestions include reserving a single endoscope for use
only on infectious patients, leaving "dangerous" patients to the end of the schedule of procedures, and
leaving endoscopic equipment in disinfectant fluid for a prolonged period after examination of such
patients. These special precautions are illogical and even dangerous. The implication of taking special
precautions is that standard disinfection practice is inadequate and those patients who carry HIV or
HBV, unknown to themselves and their medical attendants, represent a continual risk to staff and other
patients. Every patient submitted for endoscopy must be considered to be potentially infectious. Staff
must take universal precautions against needle-stick injury and must always employ a safe disinfection
protocol. Furthermore, in order to ensure that everyone is examined with properly disinfected
equipment, the principle of equality of safety must be employed. Whether a patient is the first on the
list, in the middle, or last, no benefit or detriment to safety should apply; that is, no patient must be
placed at greater risk than another, and this implies that no patient should be put at greater safety than

Endoscopic Retrograde Cholangiopancreatography

Infective complications are especially important in ERCP because mortality is high when they occur.
Cholangitis and pancreatic sepsis may occur after ERCP because organisms already within the
pancreaticobiliary system are disturbed or may be disseminated by the procedure. Sanctuary areas in
the pancreas or in biliary calculi may be opened by the injection of contrast or by mechanical
manipulation. Alternatively, the injection pressure during retrograde cholangiography may cause a
backwash of infected bile into the bloodstream. Sometimes, following the procedure, a partial
obstruction may become complete owing to trauma, bleeding, or edema, in which case infection may
occur. The most common cause of sepsis, however, is none of these; rather, it is the injection of
contaminated radiographic contrast material into an obstructed duct.16,58,59,61,6368,71,7477(293)
Numerous examples have been reported of pseudomonas septicemia occurring after ERCP in which
the organism, grown from the blood, was the same as that identified in the endoscope. Sepsis is the
most common cause of death following ERCP,78(294) and, in the majority, the condition is iatrogenic.
Post-ERCP sepsis has become more of a problem since the introduction of stenting for malignant
disease. A recent study has shown that patients who underwent ERCP in another unit, before referral,
had a greater chance of developing pseudomonas septicemia than those who underwent the
procedure at the specialist unit.79(295) The explanation advanced for this finding is that the less
experienced units had not been as meticulous with their disinfection technique.
The patient first on the ERCP list is the one most likely to develop sepsis. The reason for this is that
many endoscopy units disinfect their equipment at the end of the day, leave it in storage overnight, but
do not disinfect it before use the following morning. This practice is dangerous. Pseudomonas colonize
equipment overnight, and although colonization does not occur if the equipment is thoroughly dried, it
is very difficult to be sure that all water has been eliminated from every channel. Even in those units
where great care was taken to follow these recommendations, colonization occurred in some of the
instruments. It is essential to observe the universal standards advocated previously. Endoscopic
equipment must be disinfected immediately before use in each patient. Failure to do this leads to
deaths, particularly in patients undergoing ERCP.

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Principles of Disinfection and Sterilization

The principles of disinfection and sterilization have been reviewed by Bond.80(296) The process of
sterilization destroys all microbial life, including viruses, vegetative bacterial organisms, mycobacteria,
and spores. All equipment used in general surgery in which an epithelium is breached should be
sterilized. The same applies to needles used for parenteral injection or therapy. Some medical
equipment, however, having been sterilized or disinfected, may be left on an examination table for long
periods before use; such items include tongue depressors, cotton-tipped swabs, otoscopes, and nasal
specula. This equipment does not breach an epithelium, and the environmental organisms that
contaminate them are not pathogenic or are present in small, noninfective numbers. Furthermore,
these instruments are used in areas already contaminated by microorganisms. It is illogical to insist on
sterilization for a tongue depressor, for example, when people regularly ingest unsterile food and suck
the tips of pencils, cigarettes, knives, forks, digits, and other unsterile items. It is perhaps for this
reason that when upper digestive endoscopy was first introduced, relatively little attention was paid to
disinfection and sterilization.
Unlike the instruments used in general surgery, endoscopes are used in nonsterile areas. As soon as
the instrument is introduced into the mouth or anus, it becomes contaminated with microorganisms. It
is therefore illogical to demand "sterility" for endoscopes. Nevertheless, endoscopes and their related
equipment are increasingly used for therapeutic procedures that do breach the gastrointestinal
mucosa, and bleeding may even occur occasionally during diagnostic endoscopy. Unlike a tongue
depressor, however, the equipment is not disposable and is used in a succession of patients, often
with a very short turnaround time. Many patients are potentially infectious, and it is not necessary to
breach the epithelium to transmit their infectious organisms. The need to "disinfect" endoscopic
equipment is therefore apparent, but it is not necessary to "sterilize" it.
The process of disinfection is arbitrarily divided into high-, intermediate-, and low-level disinfection.
High-level disinfection implies that all vegetative organisms are destroyed, together with the majority of
spores. Intermediate-level disinfection is the destruction of all vegetative organisms, including
Mycobacterium tuberculosis var. bovis, but not spores. In low-level disinfection, mycobacteria may not
all be destroyed. Disinfection should be distinguished from antisepsis, a process in which gross
contamination is eradicated but not all vegetative organisms are destroyed. Examples of antisepsis are
the use of iodine on the skin and the wiping of a table top with a disinfectant. The distinction between
high-level disinfection and sterilization is essentially one of confidence. Certain processes inevitably
destroy all microbial life, such as autoclaving and some forms of radiation. Many of the chemicals used
for disinfection, for example, 2% activated glutaraldehyde, are capable of sterilization if left in contact
for a sufficient length of time. Any chemical that is used for high-level disinfection must, by definition,
be capable of sterilization.
The length of time needed for a disinfectant to produce high-level disinfection or sterilization depends
on a number of factors. Of great importance is the nature of the surface to be disinfected. Porous,
absorbent, or convoluted surfaces where disinfectant has greater difficulty in penetration require a
longer period of time than does a smooth, flat, nonporous surface. The penetration of certain
disinfectants may be enhanced by the use of surfactants, which increase the "wettability" of the
surface. Of particular importance is the "cleanliness" of the surface to be disinfected. If equipment is
adequately cleaned before the disinfection processthat is, all organic matter such as blood, mucus,
and other debris is removed, the length of time needed to disinfect that surface is less than if it
remained contaminated.
The cleanliness of the surface depends to some extent on its nature. A plastic lining, for example, may
be more difficult to clean than a smooth metallic surface. Some surfaces lend themselves to the
development of a biofilm, which may render disinfection particularly difficult, especially if the surface
itself is irregular or has discontinuities. Equipment comprising convoluted tubing is a particular
problem, not only because of the difficulty in mechanical cleaning but also because airlocks may
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develop that prevent disinfectant from reaching the whole surface.

Access of the disinfectant to the surface is not the only factor that determines the rate at which
organisms are destroyed. In addition to the concentration of the disinfectant and length of time in
contact, the nature of the organism to be destroyed is important. Disinfectants vary in their
effectiveness toward different organisms. In general terms, certain organisms are recognized to be
more resistant to chemical disinfection than others. Spore-forming organisms are particularly resistant.
Certain fungi and mycobacteria are relatively resistant, and a league table of resistance can be drawn
up (Table 81).6(297)

Descending Order of Resistance to

Germicidal Chemicals*

Baccilus subtilis
Clostridium sporogenes
Mycobacterium tuberculosis var. bovis
Trichophyton spp.
Cryptococcus spp.
Candida spp.
Pseudomonas aeruginosa
Staphylococcus aureus
Salmonella choleraesuis
Herpes simplex virus
Respiratory syncytial virus
Hepatitis B virus (HBV)
Human immunodeficiency virus (HIV)
From Axon ATR, Bond WW, Bottrill PW, et al. Disinfection and endoscopy.
Working Party Report of the World Congress of Gastroenterology,
Sydney, 1990. J Gastroenterol Hepatol 1991; 6:2347.
* With the exception of HBV, the microorganisms listed under each heading
may be used in standardized laboratory tests to determine the germicidal
activity spectrum of a selected disinfectant chemical.

Fortunately, the two viruses that particularly worry endoscopists are among those most easily
destroyed. However, other factors also influence the effectiveness of disinfection. The presence of
organic matter, or "soil," within a piece of equipment materially reduces the effectiveness of a
disinfectant. Not only does organic matter inhibit or neutralize a disinfectant and prevent access of the
disinfectant to the surface, but organic material may become fixed by the disinfectant itself and form a
shell around other organic particles, which then remain in a sanctuary zone that the disinfectant is
unable to penetrate.
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Endoscopic equipment presents particularly unsatisfactory surfaces for disinfection. It is fragile and
heat labile. It is made of glass, which precludes the use of irradiation. The channels within the
endoscope are made of a plastic material and are subject to the trauma of biopsy forceps and
therapeutic equipment, all of which may cause damage and give rise to surface irregularity. The
channels have bends and blind alleys. The air/water channel is too narrow to take a cleaning brush.
Finally, the equipment is used in circumstances in which patients undergo endoscopy one after
another, leaving little time for disinfection procedures to be carried out.
The shapes and compositions of the various ancillary equipment used in endoscopy are also
unsatisfactory for disinfection. Balloons and some catheters cannot be autoclaved. Biopsy forceps are
constructed from coiled wire, which has numerous interstices in which organic material and organisms
may reside and is difficult to clean. Dormia baskets and polypectomy snares comprise metallic wires
within a plastic sheath. The valves used in endoscopes are often heat labile and have a complicated
internal structure. Plastic water bottles, which represent a reservoir of potential infection, are linked to
the endoscope by plastic tubing. In short, the designs of endoscopes and ancillary equipment make
disinfection very difficult.

A wide variety of commercial preparations is available for disinfection, but claims made by the
manufacturers are not always reliable. Assessing a disinfectant preparation adequately is an expensive
undertaking. Not only should the chemical be tested against a variety of organisms, including viruses
(the infectivity of which may be difficult to assess), but the compound should be tested "in the field"
before being accepted as a reliable preparation for use in endoscopy. Any disinfectant used in
endoscopy should be capable of "sterilization," should not be affected by the presence of organic "soil,"
must have good penetration, and should be rapidly effective. At the present time, the only generally
recommended disinfectants are aldehyde-based. The accepted standard is 2% activated
glutaraldehyde. This disinfectant destroys most vegetative organisms and viruses within 2 min.
However, in order to destroy mycobacteria and spores, the exposure time should be longer. An
international working party has recommended that if an endoscope has been properly cleaned, full
immersion of the endoscope and all channels in 2% activated glutaraldehyde for 10 min should be
sufficient to render the equipment safe for use in any patient.6(298)
Other disinfectant preparations may be equally efficacious, but proof of their efficacy should be sought
before they are recommended for use. Other available disinfectants include hydrogen peroxide, a
difficult compound to work with, and organic iodide-based preparations, to which some organisms may
be resistant81,82(299) and which may discolor the equipment.83(300) Other compounds have been
advocated, but they show a low level of activity against pseudomonas7,72,84,85(301) and
salmonella,2126(302) they lack tuberculocidal86(303) and virucidal activity, or they are rapidly
inactivated by organic material.83, 87(304) The alcohols have been suggested as an alternative to the
aldehydes. However, several studies have shown that they do not effectively eradicate
pseudomonas.12,14(305) In addition, owing to their flammability, they represent an environmental
hazard both within the endoscopy unit and with their disposal. Furthermore, they damage endoscopic
equipment after prolonged immersion.
For the reasons presented previously, only aldehyde-based disinfectants are recommended for use in
endoscopy at present. However, their major disadvantage lies in the environmental hazard they pose
to endoscopists and endoscopy assistants. Sensitivity to glutaraldehyde is a major problem in many
endoscopy units. The chemical causes conjunctivitis, rhinitis, asthma, and dermatitis;8890(306) some
individuals complain of general malaise when they are in contact with it. The disinfectant is volatile;
once sensitized, staff may develop symptoms when only trace amounts are present in the
environment. For these reasons, it is essential to take special precautions when it is used. Ideally, the
disinfection process should be carried out in a room that is completely isolated from both the
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endoscopy area and the internal environment. Within that area, staff should be protected by masks
and special clothing. If this is not possible, a closed system should be used, with special attention given
to ventilation. Open troughs should never be used except in a specially constructed fume cupboard
with ventilation extraction to the outside. Special garments and gloves should always be used to avoid
skin contact. Ordinary surgical and disposable gloves are often not satisfactory, and the penetration of
glutaraldehyde through glove material is being assessed.9193(307)

Disinfection Technique
The most important part of disinfection is mechanical cleaning. Unless the endoscope and its
accessories are properly cleaned, the disinfection process cannot be effective. The presence of
organic debris within the endoscope channels or on the surface of the instrument causes problems in a
number of ways. Organic material exposed directly to most disinfectants denatures and becomes fixed
and hard within the endoscope channel. This leads to an irregularity that interferes with subsequent
cleaning and leads to a gradual build-up of an irregular film inside the endoscope channel. This porous,
organic matrix forms a nidus for colonization and provides sanctuary zones for organisms within it.
Particular problems arise at Y junctions, valve housings, biopsy ports, and exit ports, to which
particular attention must be directed.

Immediately following removal from the patient, the endoscope channels should be flushed by a
suction of water through the suction channel and ejection of clean water through the air/water channel.
This procedure should be performed by the endoscopist before handing the equipment to the
endoscopy assistant. The endoscope is then usually removed to a cleaning area, where it should be
totally immersed in warm water and detergent. The outside should be washed thoroughly with
disposable swabs. The distal end is brushed with a soft toothbrush, particular attention being paid to
the air/water outlet nozzle and the bridge elevator where appropriate. All of the valves should be
removed, disassembled, cleaned, and disinfected separately. The biopsy channel opening and suction
ports should be cleaned with a cotton-tipped swab.
Next, attention should be directed to the suction/ biopsy channel, which should be brushed through
using a cleaning brush of appropriate size for the specific instrument channel. This should be done
several times from top to bottom, and the cleaning brush should itself be washed in detergent using a
soft toothbrush each time it emerges from the distal end. Initially, the brush should be introduced
through the biopsy port; then it should be passed through the suction valve port, down through the
insertion tube, and lastly from the valve suction port proximally through the umbilical cord. Each
procedure should be carried out at least three times to ensure adequate cleansing of the channels.
If an automatic cleaning/disinfection machine is available, the equipment can then be transferred to it.
If such equipment is not available, however, manual cleaning should be continued. Each internal
channel should be flushed with detergent fluid. It is important to remember that some instruments have
more channels than others. This is particularly important in equipment with a raiser bridge (e.g.,
side-viewing duodenoscopes). After this cleaning has been done, all channels and the outside of the
instrument should be rinsed with tap water. Then the outside of the instrument should be dried and the
internal channels each flushed with air in order to expel as much water as possible prior to the
disinfection procedure.

The cleaning process reduces the number of contaminating organisms to a very low level. The
purpose of disinfection is to further reduce the number of organisms. The endoscope and all internal
channels should be soaked in 2% glutaraldehyde or disinfectant of similar potency for at least 10 min.
This prepares an instrument for use in any patient about to undergo endoscopy, no matter who has
been previously examined or whether the next patient on the list is immunocompromised.
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Some authorities recommend 5 min of disinfection, which destroys viruses and vegetative bacterial
organisms. A number of spore-forming organisms and mycobacteria may remain; although these are
not a danger to most patients, they may represent a hazard to those who are immunocompromised.
For this reason the International Working Party6(308) recommends a 10-min soak.
Following disinfection, the equipment must be rinsed thoroughly, both internally and externally, with
drinking-quality water in order to remove all traces of the disinfectant. The outside of the endoscope is
then dried and air is flushed through the channels. The instrument is then ready for use.

Overnight Storage
In order to reduce overgrowth of commensal organisms in stored equipment, it is essential to follow
several procedures. At the end of the endoscopy session, the equipment needs to be cleaned and
disinfected in the usual manner. Following this, 70% alcohol should be introduced into each channel,
which should then be thoroughly dried using compressed air. After these procedures, the instrument
must be hung in a well-ventilated cupboard, not coiled in a closed case.

Washing Machines
Manual cleaning and disinfection of endoscopes are tedious, repetitive, and time-consuming activities.
Endoscopy assistants are under pressure from endoscopists to reduce the turnaround time to allow
more patients to undergo endoscopy per unit time, and staff may be tempted to take short cuts with
both the completeness of mechanical cleaning and the length of time equipment is in contact with
disinfectant. Most units use aldehyde-based disinfectants in endoscopy. These compounds are toxic to
staff, and small quantities of vapor in the environment may trigger unpleasant symptoms in sensitive
individuals. For all of these reasons, many endoscopy units have turned to automatic
washing/disinfection equipment to alleviate the workload. In addition, it is hoped that confining the
disinfectant to a closed system will decrease the likehood of its giving rise to sensitivity in staff
Most endoscope washing machines are designed along the lines of a dishwasher, but without the
heating element. The apparatus does not "clean" the endoscope mechanically; it perfuses the internal
channels but does not introduce a brush, which is essential to mechanically dislodge organic material.
It is essential, therefore, that all endoscopic equipment be thoroughly cleaned mechanically, as
described previously, before being placed in the machine. Washing machines usually run on a
computerized cycle. Initially, detergent and water are flushed through the channels and the outside of
the equipment is sprayed. Then it is drained and rinsed. Following this, the endoscope is immersed in
disinfectant, the channels are filled, and the equipment is left in contact with the disinfectant for a
preprogrammed period of time. The disinfectant is then returned to a reservoir, and a rinsing cycle with
water completes the process. At the end of the cycle, the equipment is usually wet and needs to be
manually dried internally and externally.
A number of endoscope washing machines are available commercially, but unfortunately, most are
flawed in design; some actually represent serious danger to both patients and staff. Most of the
equipment marketed is bulky and immobile. Some are noisy and cannot be comfortably located within
the endoscopy unit. Most are very expensive, being priced at the level of a superior family automobile.
Some are designed to take only one endoscope at a time; others are limited to a single manufacturer's
endoscopic equipment.
Perhaps the most important flaw is that the majority have no satisfactory way to disinfect the machine
itself. Even a cursory examination reveals areas of stagnant water, which provides the potential for
commensals to multiply. Unless the autodisinfection mechanism is designed to perfuse every area of
tubing, including the detergent reservoir, the risk of serial endoscope contamination remains. The
particular area most commonly neglected is the piping between the main water supply and the inlet
valve. In many machines, the disinfectant follows a different pathway and exits through different
nozzles from the water used to rinse the equipment.
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Several machines have a spray mechanism that, in the initial washing phase, splashes contaminated
water onto the inside of a perspex cover. This cover does not come in contact with the disinfectant in
the second phase. Thus, in the rinse cycle, the contaminated droplets are sprayed back onto the "clean
equipment" to be used for the next procedure. One machine was initially designed with an "oral" and an
"anal" program, presumably to ensure that disinfectant from colonoscopes would not become mixed
with disinfectant from upper gastrointestinal endoscopes. The thought process behind this
arrangement reveals a lack of understanding of the nature of "disinfection."
An effective autodisinfection cycle is essential, but in nearly all machines, it is either ineffective or
incomplete or requires such labor-intensive activity as to negate the advantage of having a machine in
the first place. Furthermore, attempting to autodisinfect some machines creates considerable risk of
spillage of disinfectant and atmospheric pollution by the vapor. Indeed, although endoscope washing
machines are said to be "closed," aldehyde vapor can be readily detected in the immediate
environment of most machines.
At present, no commercially available washing machine can be regarded as satisfactory. At least two
models, which have been shown to be unsafe, have been removed from the market in the United
States, although they continue to be marketed in other parts of the world.

Dilution of Disinfectant
With usage, the disinfectant becomes diluted and therefore inactive. It is very important for staff to be
aware that disinfectant should be regularly changed. The frequency depends more on the number of
times it has been used than on the length of time it has been in service. The effectiveness of the
disinfectant should be regularly monitored.

Ancillary Equipment
Ancillary equipment provides a potential source of cross-infection in endoscopy, so wherever possible
it is desirable to use disposable or sterilizable equipment. A particular problem relates to coiled springs
and cannulae, from which it may be difficult to dislodge organic matter. Endoscope valves should be
dismantled for cleaning purposes, and an ultrasonic cleaning device should be employed with this
equipment to ensure that mechanical cleansing is as complete as possible prior to sterilization.

Endoscopy Room Design

Design of the endoscopy room must take into consideration the cleaning, disinfection, and
maintenance of the equipment (see Chapter 4: The Endoscopy Unit). A purpose-designed cleaning
area separate from the rest of the unit should be provided so that toxic fumes are isolated. The
disinfection room should be well ventilated and contain a fume cupboard, so that if open troughs of
glutaraldehyde are required they can be isolated from the staff. Good ventilation is essential.
Depending on the policies of the unit, a bench-top autoclave or ultrasonic cleaning machine may be
incorporated along with the usual sinks and disinfection apparatus. In a large endoscopy unit, two-way
cupboards may be helpful so that dirty equipment can be delivered at one entry and clean equipment
collected from another without having to enter the disinfection room itself. Within the disinfection area,
staff safety is paramount. Apart from good ventilation, there should be enclosed systems, protective
clothing, and masks if necessary.

Endoscopists and endoscopy assistants should receive instruction about the risk of infection to
themselves and to patients, and they must learn how to clean and disinfect endoscopic equipment and
ancillaries. Suitable guidelines should be laid down for each unit, and a designated individual should be
responsible for ensuring that endoscopic cleaning protocols are followed and kept up to date. He or
she should ensure that other employees within the department are properly trained and understand the
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disinfection policies that have been laid down. Disinfection practice must be regularly audited.
All endoscopy staff must be made aware of the dangers of contact with disinfectants and should take
care to avoid such contact. It is most important that precautions do not become relaxed in this regard.

Staffing numbers should be commensurate with the needs of the endoscopy facility, taking account of
the time and expertise needed to ensure that equipment is properly cleaned and maintained. The
scheduling of endoscopy sessions should correlate with the number of staff available and the
turnaround time required for disinfection; if necessary, extra endoscopic equipment or staff, or both,
must be provided so that each instrument is given the attention it requires. Using the "procedure
unit/weighted scale" system of analysis (discussed in Chapter 4: The Endoscopy Unit), an objective
assessment to determine the specific needs of a given facility can be made.


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Chapter 9 Principles of Electrosurgery

True electrocautery uses direct current from a battery to heat a wire, which in turn coagulates bleeding
tissue; however, electrocautery cannot cut tissue. In contrast, electrosurgery employs radio frequency
(RF) alternating currents that flow through the tissue to produce heat and cause both cutting and
coagulating effects. Electrosurgery is used in more than 18 million surgical procedures each year in the
United States and is discussed in this chapter.

Many scientists experimented with the effects of alternating currents on tissue, but the initial
development of electrosurgery is generally credited to d'Arsonval, who demonstrated in 1891 that
high-frequency alternating currents could be passed through living tissue, causing desiccation without
producing muscle and nerve stimulation.1(310) In the early 1900s various researchers such as
Riviere,2(311) Clark,3(312) and Nagelschmidt4(313) reported the use of electrosurgery in treating a
wide variety of clinical problems, such as the coagulation of intractable ulcers and the removal of
benign and malignant tumors of the head, neck, breast, and cervix. At the same time, Edwin Beer
initiated his pioneering effort to employ electrosurgery through a cystoscope to remove bladder
tumors.5(314) It was not until the late 1920s, however, that electrosurgery was accepted in surgical
Although several inventors produced electrosurgical machines for clinical use,6(315) only those
developed by William Bovie gained prominence. Bovie, a Harvard physicist, developed two separate
electrosurgical generators, one for cutting and another for coagulation. The acceptance of these
generators by surgeons was actively promoted by neurosurgeon Harvey Cushing. Cushing, Director of
Surgery at Boston's Peter Bent Brigham Hospital, performed various intracranial surgeries such as
removing meningiomas, vascular myelomas, and astrocytomas on patients who were previously
considered inoperable.7(316) By 1928, the Liebel-Flarsheim Company was producing the "Bovie" unit
commercially. Solid-state electrosurgical units, developed in the early 1970s, now offer reduced
generator size, added options, and enhanced electrosurgical safety for both patient and operator.
However, the principles of high-frequency alternating current effects developed by the work of early
pioneers have remained unchanged.

Electrosurgical Variables
The surgical action of electrosurgery is produced by passing alternating currents through tissue.
Because the tissue resists current flow, heat is produced. If heating is sufficiently high and rapid,
intracellular and extracellular fluids are vaporized and a cutting action is produced. If the amount of
heat produced is less and heating is slower, the cells are desiccated and the action produced is
coagulation. The quantity and time course of tissue heating are controlled in part by the generator
voltage and current output, waveform of the generator output, size of the active electrode, tissue
resistance, and application time.
The operating frequency of the electrosurgical generator is also important but not critical in relation to
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tissue heating. Muscles and nerves are easily stimulated by alternating currents with frequencies of 2
KHz (2 kilohertz, i.e., 2000 cycles/sec) or less. Although muscles and nerves can be stimulated by
alternating currents as high as 1 MHz (1 megahertz, i.e., 1 million cycles/sec), the currents required are
extremely large and are not used in electrosurgery.8,9(317) Based on such neuromuscular stimulation
data, electrosurgical generators typically use frequencies between 400 KHz and 3 MHz. Generators
cause virtually no direct stimulation at these frequencies because they do not supply the necessary
high-current amplitude; the effect, therefore, is only thermal. The electrosurgery operating frequency
range is in the radio band, and thus the currents are referred to as radio frequency currents.

Voltage (measured in volts, V) is the force required to push current (electrons or charged ions) through
a resistance. The voltage produced by an electrosurgical generator alternates between positive and
negative values, similar to household voltage except in the RF band. The number of volts from the
maximum to minimum value is termed the peak-to-peak voltage (Vp-p). The higher the voltage, the
more force is available to push current into tissue. Therefore, higher voltages cause deeper thermal
destruction (Figure 91).

(318)Figure 91. Tissue effect of increasing peak-to-peak voltage (Vp-p). As the voltage
increases, the arc intensity increases and thermal damage (shaded area) becomes deeper. At
high voltage, charring is seen on the tissue.

Tissue Resistance
As electric current (measured in amperes, A) flows through tissue, the tissue resists the flow; the
amount of tissue resistance is measured in ohms. The electrolyte content of tissue is directly
proportional to its resistance. Therefore, tissue such as liver with a high content of blood has a low
resistance, whereas fat and bone have high resistances.
Some typical tissue resistance values are blood, 30 to 50 ohms; skeletal muscle, 200 to 400 ohms;
bowel wall, 150 to 250 ohms; fat, 800 to 1000 ohms; bone, 1000 to 2000 ohms; and skin, 10K to 50K
ohms. (To be precise, these values should be in terms of resistivity, which is characteristic of a
material rather than of a particular specimen of a material; the unit of resistivity is ohm-cm). During
electrosurgery, the resistance of tissue varies dramatically: Prior to RF current flow, the tissue
resistance may be only 200 to 400 ohms; after a few seconds of desiccation or coagulation, the value
may rise to 1000 to 3000 ohms.
The term resistance, to be exact, applies only to direct current flow. When referring to alternating
currents, the term impedance is technically correct. Impedance consists of two components:
magnitude and a phase angle, because tissue has membrane capacitances as well as resistance. At
electrosurgical frequencies, however, the phase angles are small, and simply using resistance
measurements introduces only small errors.

Current Density and Power Density

The most important variable affecting clinical outcome that is directly under the control of the physician
during electrosurgery is current density. This is simply the RF current (I) that flows through a specific
cross-sectional area (a) and is expressed as I/a. The current density can be controlled by changing the
surface contact area between tissue and an active electrode, such as a snare for polypectomy,
specifically the diameter of the snare wire.
The amount of heat produced in the tissue by RF current flow is directly proportional to the power
dissipated in the tissue. Power density (P) is related to the current density (I/a) and the tissue
resistance (R) by:
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The effect of current density on power delivered to the tissue is illustrated in Figure 92. Near the
snare, the cross-sectional area of the polyp tissue is 0.25 cm2. If 0.25 A flows from the snare to the
tissue, the current density is 1.0 A/cm2 (0.25 A/0.25 cm2). At the bowel wall, the area is 1.0 cm2.
Because the same current flows through this area, the current density is four times less than that at the
snare, or 0.25 A/cm2 (0.25 A/1.0 cm2). At the patient return electrode, the 0.25 A of RF current is
collected on an area of 100 cm2. Thus, the current density is 400 times less than that at the snare
(0.25 A/100 cm2, or 0.0025 A/cm2). Because the power delivered to the tissue is proportional to the
square of the current density, the power at the bowel wall and that at the return electrode are reduced
by factors of 16 (42) and 160,000 (4002), respectively, compared with the power at the snare. The
small power level at the patient return electrode causes virtually no rise in temperature; the power level
at the bowel wall (1/16 the level at the snare) causes a temperature rise. At high generator settings,
this could cause clinically significant thermal damage to the tissue.

(319)Figure 92. Effect of area on current density during polypectomy. The small
cross-sectional area of the polyp stalk near the snare (A) creates a high current density and
high temperature. At the bowel wall (B), the area through which the current flows (arrows) is
larger and the current density less. The large surface area of the return electrode (C) results in
a small current density and little rise in temperature.
The situation depicted in Figure 92 is idealized. Tissue resistance is not uniform; the polyp and bowel
wall consist of low-resistance tissues such as blood in vessels surrounded by higher-resistance
muscle. Current does not flow uniformly through actual tissue but through multiple paths of various
resistances. For example, current leaves the snare wire on at least two parallel paths: a blood vessel
with 50 ohms resistance and the surrounding muscle with 500 ohms resistance. The majority of the
current flows through the path of least resistance, approximately 90% through the low-resistance
vessel and the remaining 10% through the muscle.

Time and Energy

Electrosurgical effects are further complicated by changes that occur over time; conditions vary from
microsecond to microsecond. As RF current heats tissue, resistance increases, thus changing the path
of least resistance and the current flow. These changes directly affect the heat produced in a given
area. As the tissue resistance changes, generator power output also varies. The situation becomes
more complex as heat is removed from high-temperature areas by blood flow and tissue conduction.
Although the detailed time course of many electrosurgical conditions cannot be controlled by the
physician, methods are available by which the time course can be manipulated.
It is possible to control the duration of RF current application. The power level (P) multiplied by the time
(t) current flows through tissue is defined as the energy (E) dissipated in the tissue:

where E is measured in joules (J).
Although the total energy delivered to the tissue has a direct relation to thermal necrosis,10(320) the
time course of power delivery must also be considered. For example, 1 watt delivered over 20 sec (20
J) causes less destruction than 20 watts delivered over 1 sec (also 20 J) because blood flow removes
heat that is delivered slowly. Unfortunately, specific guidelines for relating the time course of power
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delivered to tissue versus necrosis are complex because other variables such as blood flow have
significant effects. However, even at low levels of a few watts, power delivered through a small area
over a long time can cause tissue destruction.

Electrosurgical Waveforms
Another way to control the time course and clinical effect of electrosurgery is by choice of waveform.
Generator waveforms differ in their voltage and current characteristics over time, and these in turn
affect the physical electrosurgical effect. The electrosurgical action of the cutting waveform is produced
by heating tissue to a high temperature, that is, above 100 C, to vaporize water and explode cells.
Coagulation is produced by heating above 70 C but below 100 C in order to dry the tissue.
Coagulation is accomplished by desiccation or fulguration. In desiccation, the active electrode is in firm
contact with the tissue, whereas in fulguration, it does not touch the tissue and sparks jump from the
electrode to the tissue. The generator waveforms are optimized to accomplish these desired clinical
To some extent, the terms cut waveform and coagulate waveform are misleading. Low power settings
(low heat) in the cut mode (waveform) produce excellent contact desiccation, and high power settings
(high heat) in the coagulation mode produce a cutting action.

Pure Cutting
Cutting is typically accomplished with a sine waveform (Figure 93A). The generator voltage must be
sufficiently high to cause ionic breakdown of air with arcing between the active electrode and the
tissue. These arcs produce high current density, causing rapid heating and tissue vaporization. If the
active electrode is placed firmly in contact with the tissue, cutting is delayed and is not initiated until the
tissue is desiccated and shrinks slightly from contact with the active electrode; at this point, arcing can
occur and the cut action begins. The cut progresses as arcing from active electrode to tissue allows
the electrode to move through the tissue.

(321)Figure 93. Typical electrosurgical waveforms over time (t): A, pure cut; B, blended cut;
C, coagulation; and D, fulguration.
Voltages of approximately 500 Vp-p are necessary to ionize air and establish arcing. Arcs occur twice
each cycle at approximately the maximum and minimum voltage of the sine wave; this produces one
arc each microsecond for a generator operating at 500 kHz. At this high arcing rate, ions produced in
the air gap between electrode and tissue and from the vaporized tissue have little opportunity to diffuse
away from the site. Therefore, the arcing occurs as a tight packet and produces a clean cut.11(322) As
the voltage is increased, the intensity of the arcing increases with greater current density; this produces
higher temperatures and greater thermal effects on the tissue adjacent to the cut. The depth of thermal
damage increases with the increasing voltage (see Figure 91), and at high voltages and current
densities, the tissue at the side walls of the cut becomes charred and the volume of necrotic tissue
becomes larger.
Blended Cutting
One method of obtaining adjacent sidewall coagulation and minimizing charring during cutting is to use
a blended cut waveform. These waveforms use higher voltages than pure cut waveforms, but the
generator does not supply current continuously as in cut mode (Figure 93B). Blended waveforms are
intermittent or interrupted; that is, the generator supplies current only part of the time during which it is
activated. Some generators have multiple blended settings. Typically, in the blended mode, the
generator supplies current during only 50 to 80% of the activation period. The term for this is duty
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cycle. At 100% duty cycle, the generator supplies current in a continuous waveform, as in the pure cut
mode; at 50% duty cycle the generator supplies current during only 50% of the activation period. If
power is kept constant, lower duty cycles use higher voltages. The lower the duty cycle and the higher
the voltage, the greater the hemostatic effect. The higher voltages force current deep into the tissue,
causing increased sidewall coagulation; the lower duty cycle allows heat to be removed by blood flow
and tissue so that cutting occurs without unnecessary charring.
Figure 94 shows a comparison of waveform, voltage, and tissue effect of a pure cut and two blended
cut waveforms. All three have the same average voltage (Vavg) over time, and the average power is
therefore similar. However, because the blended cut waveforms are not supplying continuous current
yet employ higher voltages, the coagulation is deeper without charring than is the high-voltage pure cut
waveform. The ratio of peak voltage (Vp) to the Vavg (root mean square) is termed the crest factor.

(323)Figure 94. Tissue effect of various waveforms with the same average voltage (Vavg)
and increasing peak voltage (Vp): 1, pure cut; 2, blended one; and 3, blended two. Increasing
Vp increases the depth of thermal damage (d).

Coagulation waveforms have lower duty cycles than blended cut waveforms. Coagulation is
accomplished by two methods: (1) contact coagulation or desiccation, in which the active electrode is
touching the tissue, and (2) fulguration or spray coagulation, in which the active electrode is not
touching the tissue but rather sparks are generated between electrode and tissue. Typical coagulation
waveforms have a duty cycle less than 50% and as low as 5%.
Contact Coagulation
If an electrode is in contact with a tissue to be desiccated, a cut waveform (100% duty cycle) can be
used for coagulation provided that the peak-to-peak voltage (Vp-p) is less than 500 V (low generator
setting), so that coagulation is produced without sparking, cutting, or accompanying tissue
carbonization. In this case, the pure cut waveform produces excellent tissue desiccation; deep tissue
desiccation is produced with longer application times. This effect points out the misleading nature of
the names cut and coagulation waveforms.
The typical coagulation waveform (see Figure 93C) is also used for contact coagulation. The higher
voltage coagulation waveforms cause relatively deep tissue desiccation. As the surface tissue
desiccates, tissue resistance rapidly increases. If low settings are used, sparking does not occur. If
high voltage is used, however, sparking occurs from the electrode to the tissue, increasing the depth of
The sparking that occurs with the coagulation waveform differs in character from that that occurs in the
cut mode. Specifically, coagulation sparks are not confined to a compact area, but spray from the
active electrode may strike the tissue at many different points.11(324) The low duty cycle or
intermittence of the waveform is believed to be responsible for this phenomenon, as it allows the ions
to disperse between sparks; this requires the establishment of new ions and new spark paths, in
contrast to the cut mode, in which sparks follow the same ion cloud.12(325) If the voltage is sufficiently
high, carbonization of the tissue also occurs. Usually voltages vary from 500 Vp-p to several thousand
Fulguration or Spray Coagulation
Fulguration is used to treat large bleeding areas, typically multiple small vessels, such as occur in liver
resection or when retracted vessels become hidden in fissures and are not directly accessible. The
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very large Vp-ps, up to 10,000 V (10 KV), create long sparks between the electrode and the tissue.
Although the voltage is extremely high (greater than 10 KV), the depth of tissue destruction is typically
shallow owing to the low duty cycle, about 5% (see Figure 93D), and lack of contact between the
electrode and the tissue. Clinically, fulguration is not as effective as contact coagulation for control of
bleeding from large vessels because tamponade or vessel coaptation cannot be achieved. The
sparking that occurs with fulguration is highly random, primarily because of the very low duty cycle. As
a spark strikes tissue, a high resistance area is created; therefore, the next spark is more likely to
strike a low-resistance area on the tissue.

Electrosurgical Generators and their Ramifications

Monopolar Systems
In monopolar electrosurgery, RF currents flow from the generator to an active electrode and then to the
surgical site. When tissue is entered, the current disperses, flows through the patient to a return
electrode with a large surface area, and then returns to the generator to complete the circuit.
Initially, all generators were ground referenced; that is, the return electrode was connected to earth
ground. As current seeks to return to the generator to complete the circuit, any break in the connection
between the patient return electrode and the generator causes current to flow through any ground path
back to the generator. These early grounded systems caused alternate-site burns if the RF
electrosurgical current returned to ground via unintentional paths (e.g., electrodes for
electrocardiography, conductive components of the operating table; Figure 95). Modern
ground-referenced generators have circuitry that monitors the integrity of the return electrode
connections. For example, a generator such as the Valleylab Force 4 compares the currents in the
active and return electrode leads and disables the generator if a substantial difference occurs.

(326)Figure 95. A ground-referenced electrosurgical generator can create alternate paths to

ground through other equipment, e.g., electrocardiography (ECG) electrodes.
Late-model electrosurgical generators are typically isolated; that is, the patient return electrode is not
connected to earth ground (Figure 96). If a break occurs in the return electrode connections, the
generator output is reduced virtually to zero and RF current does not flow through the patient to ground
by alternate paths. Alternate-site burns through ground paths are therefore eliminated. If care is not
taken to avoid inadvertently grounding the return electrode of an isolated generator, the system acts as
if it were grounded and all advantages of isolation are lost. Isolating the generator from earth ground
does increase the problem of capacitive coupling of stray RF currents in other nearby conductors (see
later in this chapter).

(327)Figure 96. An isolated electrosurgical generator eliminates alternate current paths to

ground. ECGelectrocardiography.
To avoid potential problems and complications of electrosurgery, the endoscopist should always
become familiar with the generator being used and its associated safety features.

Bipolar Systems
The patient return electrode is eliminated in bipolar electrosurgery by placing a second electrode a
small distance (several millimeters) from the active electrode. Current flows from the first electrode to
the tissue at the surgical site, through the tissue to the second electrode, and then returns to the
generator to complete the circuit. Therefore, bipolar electrosurgery confines the RF current flow to a
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small volume of tissue between the two electrodes.

Classically, bipolar electrodes have been used only for coagulation and are well accepted by
endoscopists for this purpose. New bipolar electrodes have been developed for cutting. These have
met with varying degrees of clinical acceptance, however. Animal studies have demonstrated that
bipolar electrodes cut with reduced power and destroy less tissue than their monopolar counterparts
when electrodes of similar area are compared. Bipolar electrodes for clinical fulguration have not yet
been produced.

Generator Outputs
Power output and other characteristics of electrosurgical generators vary from model to model.
Endoscopists must therefore be fully aware of the output characteristics of the generator used for a
particular procedure. Many generators have arbitrary front panel output power settings, that is, a dial
marked from 0 to 10. The output at the maximum setting of 10 for monopolar cutting may be as low as
50 watts for one generator and as high as 400 watts for another. Although newer generators allow
selection of a specific power level, such as 50 watts, it must be remembered that even this is not
constant over time during cutting or coagulating.
Figure 97 shows the actual power output versus resistance for a typical multipurpose generator
(Valleylab SSE2L) in monopolar cut, blended, and coagulate modes with the generator set at 5, the
midpoint of the range of possible dial settings. Peak powers are produced in the typical tissue
impedance range, 300 to 500 ohms. However, the power output decreases for all modes of operation
as tissue impedance rises to several thousand ohms. In order to achieve cutting, cut and blended
modes produce higher powers at higher resistances than does the coagulation mode. In cut mode, the
RF current path resistances include tissue resistance at the surgical site, tissue resistance between the
surgical site and the return electrode, contact resistance of the return electrode and the patient's skin,
and all electric connections. Also included is the resistance of the arc from active electrode to tissue,
this being approximately 1100 ohms.13(328) Although spray coagulation also includes this arc
impedance, cutting action requires the delivery of higher power at high resistance in order to heat the
tissue to vaporization temperature. In contact coagulation without sparks, the power can decrease after
the tissue has been sufficiently desiccated (a tissue resistance of approximately 2000 ohms). In fact,
this effect is desirable to avoid excessive coagulation and deep necrosis.

(329)Figure 97. Generator power output (Valleylab SSE2L at a setting of 5) versus

resistance for cut, blended, and coagulation (Coag) modes.
The bipolar mode of a typical multipurpose generator has a very different power versus resistance
characteristic than does the monopolar mode. The peak power is generated at lower resistances, for
example, 100 to 150 ohms, these values being typical for the resistance of bleeding tissue between the
tines of a bipolar forceps. The power output of such a bipolar mode decreases much faster with
increasing resistance (Figure 98) than that of the monopolar mode, thus avoiding high heating and
complete vaporization of the tissue between the tines.

(330)Figure 98. Power output versus resistance for a typical multipurpose generator for
monopolar and bipolar applications. The curves were obtained at a setting of 3 in blend for the
monopolar output and a setting of 5 in the bipolar.
Special-purpose bipolar generators specific for endoscopic coagulation are available. The outputs of
these generators (e.g., CIRCON/ACMI, Stamford, CT) are optimized to coagulate bleeding tissue
between electrodes separated by several millimeters. These generators produce a maximum power
output of approximately 50 watts at 50 to 100 ohms and very little power at resistances greater than
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1000 ohms (Figure 99).

(331)Figure 99. The power output versus resistance for the ACMI BICAP generator
designed for a bipolar coagulating electrode.
The bipolar output of either a multipurpose generator or a bipolar coagulation generator is
inappropriate for true bipolar cutting in endoscopy. Because the arc resistance is high and cutting
requires significant power output, effective bipolar cutting requires a power versus resistance curve
similar to that of a monopolar multipurpose generator. Several new bipolar generators are available
that are optimum for bipolar cutting (e.g., Everest Medical, Minneapolis, MN; Meditron, Hackensack,
NJ). These generators have bipolar power versus resistance characteristics analogous to those of
monopolar generators (Figure 910).

(332)Figure 910. The power output versus resistance for a bipolar generator (Everest
Medical) designed for bipolar cutting and coagulating electrodes.

Clinical Utilization
Although it is possible to give general guidelines for the clinical use of RF current to cut and coagulate
tissue, these techniques are largely a part of the art of medicine. They require subjective assessments
such as the appropriate amount of coagulation and the speed of cutting. Although understanding the
biophysics of electrosurgery aids in avoiding complications and achieving the desired outcome, the
technical art must be learned from a skilled endoscopist. It is prudent for the novice to utilize the same
equipment, settings, and techniques employed by their instructors until they develop the necessary
judgment and experience in a variety of clinical settings. The following sections are intended to
emphasize the role of electrosurgery in endoscopy and not to be a complete description of clinical

Electrosurgical polypectomy is accomplished by using one of the many commercially available
colonoscopes and a wire loop that is placed around the polyp and tightened. Three techniques are
commonly used to remove polyps with RF current:14,15(333) (1) desiccation followed by mechanical
cutting with the loop, (2) desiccation followed by electrosurgical cutting, and (3) a single-maneuver
electrosurgical cut. Some endoscopists open and close the polypectomy snare themselves, whereas
others have an assistant do this for them. The latter approach requires a substantial degree of
cooperation between endoscopist and assistant (see Chapter 5: The Gastrointestinal Assistant).
Probably the most common method of polypectomy is desiccation, at a relatively low generator setting,
of the entrapped tissue with a coagulation or blended cut waveform, followed by simple mechanical
transection with the wire loop. The necessary tissue desiccation is visually quantified by the amount of
mucosal blanching around the wire. Too little desiccation leads to bleeding during mechanical
transection; overdesiccation leads to dehydrated tissue that can be difficult to transect mechanically
and may cause snare entrapment.
The second polypectomy method is similar to the first except that the mechanical cut is replaced by
electrosurgical cutting. The initial step of coagulation is the same, and again, care must be taken to
avoid overdesiccation, which limits the ability to cut the tissue electrosurgically and may cause snare
entrapment. Endoscopists use pure cut, blended cut, and coagulation waveforms to accomplish
electrosurgical cutting. Because electrosurgical cutting requires arcing from electrode to tissue, an
excessively tight grasp of the polyp with the snare actually prevents the initiation of cutting. Therefore,
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loosening the snare slightly enhances the cutting action. Although this is not intuitively obvious,
loosening the snare decreases the electrode-tissue contact area and thus increases the current
Polypectomies are also performed in a single maneuver by an electrosurgical cut using a blended or
coagulation waveform without prior desiccation. With this technique, cutting speed strongly influences
the outcome; fast cutting yields less hemostatic effect than slow cutting. As discussed earlier, optimum
cutting is produced when the snare is in loose contact with the polyp to allow arcing.
All polypectomy techniques are influenced by the physical diameter of the wire used in making the
snare. A direct relationship exists between wire diameter and current density; that is, the current
density varies with the surface area of the contact between electrode and tissue. Popular commercial
snare wire diameters vary from 0.012 to 0.040 inch (0.3 to 1.0 mm). At a given power setting and a
given polyp size, a small-diameter wire results in a significantly higher current density and yields faster
cutting and coagulating than a large-diameter wire. If the diameter of the snare wire is changed, the
clinical resultintentional or unintentionalcan be different from that expected. Therefore, a change in
wire diameter may require a change in generator settings, depending on the desired result.
No typical generator power settings were given in the preceding discussion. Guidelines are general at
best, given the multiple variables involved in polypectomy. In fact, detailed power settings appropriate
to every situation cannot be given. At a specific power setting, voltage and type of waveform influence
clinical outcome. The correct power setting also depends on the amount of tissue trapped within the
snare; large polyps require higher power settings to achieve similar current densities than do small
polyps. When an equipment change is made (snare or generator), the endoscopist should seek advice
from manufacturers and other experienced endoscopists on ranges of power settings suitable to
particular clinical situations.
The polypectomy techniques discussed thus far are monopolar; current flowing from the snare to the
polyp continues flowing to the distant return electrode to complete the circuit. If the power setting is
high, the current density at the polyp base may be sufficient to cause full-thickness desiccation of the
bowel wall. Depending on the extent of necrosis, this injury can lead to the so-called postpolypectomy
syndrome or perforation. Another type of injury can also result from monopolar current flowing to the
return electrode. If the head of the polyp is in contact with the wall of the colon, the current effectively
has two paths to the return electrodean intended path through the snared tissue and an unintended
one through the head of the polyp to the opposite bowel wall (Figure 911). The current flow through
the unintended path increases as the tissue within the snare, typically the polyp stalk, is desiccated and
increases in resistance. This problem can be minimized by moving the snared polyp back and forth
during activation of the generator so that either contact with the opposite wall does not occur or the
duration of contact at any given point is not prolonged.

(334)Figure 911. Diagram of unintended current flow through the head of a polyp to the
opposite bowel wall. If the contact area is sufficiently small, a burn (darkened area) can
Bipolar snares have been developed in an effort to eliminate or reduce the complications that occur in
monopolar polypectomy (e.g., contralateral wall burns and perforations). These are commercially
available from several sources (Bard, Tewksbury, MA; Everest Medical; and Meditron). Although
designs differ, all bipolar snares are composed of two wire electrodes separated by an insulator. RF
current passes from one electrode (segment or part of the snare loop) through the polyp to the second
electrode to complete the circuit. This design completely eliminates burns to the contralateral bowel
wall. Because bipolar snares cut with less power and the extent of tissue necrosis is significantly less
than with monopolar snares, the incidence of postpolypectomy syndrome and perforation may be
decreased.16(335) However, bipolar snares have not been available long enough to allow completion
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of clinical comparison studies.

Endoscopic retrograde sphincterotomy has become widely accepted since the mid-1970s. Cutting of
the sphincter of Oddi is performed by endoscopic cannulation of the papilla of Vater and passing of RF
current from a wire electrode on the cannulating catheter to a distant return electrode. This monopolar
electrosurgical procedure has become the treatment of choice for the removal of retained common
duct stones following cholecystectomy or with the gallbladder in situ (see Chapter 60: Endoscopic
Papillotomy, and Chapter 62: Calculus Disease of the Bile Ducts).
The cannulating catheter, known as a papillotome or sphincterotome, may be single or double lumen.
The single-lumen catheter carries only the electrosurgical wire electrode. A wire electrode occupies
one lumen of the double-lumen catheter and the second may be used for injection of a contrast agent
or passage of a guidewire to aid in difficult cannulations. In both catheter types, the distal end of the
catheter is bent into a bow when tension is applied to the cutting electrode wire so that the externally
located portion of the wire becomes the string of the bow (see Chapter 60: Endoscopic Papillotomy).
Sphincterotome cutting wires are available in a wide variety of designs. Wires may be stranded or
monofilament; diameters vary from 0.008 to 0.012 inch. The physical characteristics of the wire affect
its cutting characteristics. Monofilament wires have less surface area than stranded wires and for a
given diameter produce greater current density and faster cutting. Similarly, smaller-diameter wires
also produce greater current density and cut faster than those of larger diameter.
Cutting is typically performed in the blended cut mode. Because the risks of rapid cutting are bleeding
and perforation, use of more than 70 watts of power is uncommon. Many endoscopists cut with short
applications of electrosurgical current and only slight bending of the sphincterotome to achieve added
control. If cutting is slow, retraction of the wire electrode to shorten the length of wire in contact with the
papilla increases the current density and the speed of cutting. Slow cutting may also be encountered if
the papilla is fibrotic or a ductal calculus (having high electric resistance) is touching the active wire.
Repositioning the electrode in these cases usually enables cutting. Repeated application of ineffective
cutting current should be avoided, as this desiccates the tissue and raises the tissue resistance to high
levels, further slowing the cutting action. The practicing endoscopist should be familiar with both the
electric output of the generator and the cutting characteristics of the sphincterotome being used.

Gastrointestinal Bleeding
Endoscopic monopolar electrosurgical electrodes have been used for several decades to stop bleeding
from various sources in the upper gastrointestinal tract (see Chapter 28: Thermal Contact Methods for
Endoscopic Hemostasis). Although early attempts at electrosurgical control of bleeding were
associated with complications, including perforation and death,17(336) techniques and equipment
have been improved. Various distal tip configurations of monopolar coagulating electrodes are
available, but all of these are applied in a similar fashion. The electrode is used to tamponade the
bleeding vessel and coapt its walls; coagulation current then "welds" the vessel closed, producing
hemostasis. Excessive desiccation of the bowel wall can cause full-thickness burns, leading to
immediate or delayed perforation.
Bipolar electrodes were developed to reduce the tissue necrosis that occurs during monopolar
coagulation and to decrease the likelihood of a perforation. A bipolar coagulator typically consists of a
small (approximately 5 mm in length) ceramic shaft with a rounded end. Most have a central irrigation
channel. The electrodes at the distal end of the shaft have various configurations, the two most
common being (1) four or six metallic strips (about 1 mm wide) arranged longitudinally and equally
spaced around the end of the shaft with opposing strips electrically connected to form two sets of
electrodes and (2) two metallic strip electrodes equally spaced in a spiral pattern that winds around the
ceramic shaft. These endoscopic bipolar electrodes confine current flow to a much smaller volume of
tissue than do monopolar electrodes. Generators for use with bipolar electrodes have power versus
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resistance curves that are optimized for the low resistance of blood; that is, maximum power output
occurs at approximately 50 ohms. The waveforms are pure sine wave (cut) with low voltage to
minimize the development of sparks and thus to provide contact desiccation. Bipolar systems have
been widely accepted by endoscopists.
Other thermal probes (e.g., "heat probe") are available for treatment of gastrointestinal bleeding
lesions. However, these are not actually electrosurgical devices because current does not flow in any
manner from the probe to the tissue, although the device is heated electrically (see Chapter 28:
Thermal Contact Methods for Endoscopic Hemostasis).

Complications of Electrosurgery
Alternate-Site Burns and Return Electrode Burns
The likelihood of producing a serious electrosurgical burn is minimized during endoscopy because
patients are awake and can experience pain. However, such burns can occur in patients who are
heavily sedated or unconscious or have spinal cord injuries.
As stated earlier, ground-referenced generators have the return electrode connected to earth ground.
Any discontinuity from the return electrode to the generator causes the electrosurgical current to flow
through any alternate path to ground in order to complete the circuit. Virtually any conductive material
can become incorporated into an alternate path, including metal tables, electrocardiographic
electrodes, and other monitoring equipment. Most newer grounded generators provide circuits that
monitor current in the return electrode and sound an alarm or disable the generator if any fault occurs
in the return circuit. Isolated machines were developed to eliminate alternate-site burns that result from
unintended ground paths. Because the return circuit is isolated from ground by a transformer, any
break in this circuit that prevents completion of the normal current path stops the generator output.
Ground-referenced generators and many isolated generators do not monitor the patient return
electrode contact. The surface area of the return electrode in contact with the patient must be relatively
large if current density is to remain low in the adjacent tissue. If the area of contact is small, as may
occur if the return electrode is placed improperly, all of the electrosurgical current flows through a
confined area, markedly increasing the probability of an RF burn. Some newer-model isolated
generators monitor the contact area between the return electrode and the patient by means of circuits
called return electrode monitors, or REMs. An REM electrode is actually two electrodes; that is, the pad
is split. The electrode-to-patient contact resistance is compared between the two separate return
electrode sections of the pad; if a significant difference exists, the generator is disabled. Thus, if the
return electrode is only partially in contact with the patient, a situation in which current density could be
high enough to cause a burn, the REM circuit eliminates all power output. REM generators and REM
return electrodes virtually eliminate return electrode burns. However, care must be taken not to use a
standard return electrode with an REM generator, as this defeats the monitor circuit and increases the
potential for burns.

Capacitive Coupled or Stray Currents

An RF current flowing through a conductor can induce an RF current on nearby conductors, even with
intact insulation and no direct electric connection between the two conductors. This phenomenon is
termed capacitive coupling. A capacitor is composed of two conductors separated by an insulator.
Alternating voltages across such a structure causes currents to flow through it. In endoscopy, several
capacitors have the potential to create deleterious effects for the patient and the endoscopist.
One capacitor is always present during endoscopic electrosurgery. This comprises the active wire lead
(e.g., polypectomy snare or sphincterotome) and the inner metal frame of the endoscope.18(337) As
current flows through the active lead within the endoscope, RF currents are induced in the metal frame
of the instrument. Because these appear to leak from the active wire, they are often called leakage or
stray currents. The induced currents may then flow from any exposed metal on the endoscope to the
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endoscopist, who is unknowingly part of the path to the return electrode. Stray currents can result in
burns to the endoscopist, most likely from the eye piece of older fiberoptic endoscopes. The stray
currents can exceed 0.1 A. Given this high value, it is surprising that such burns do not occur more
often. However, another capacitive path couples most of the endoscope frame current to the patient.
This capacitor comprises the endoscope frame, the covering insulation of the instrument, and the
conductive patient tissue. Therefore, the majority of the stray current is coupled to the patient. Most
endoscopists have at times received a small burn or "shock" from these stray currents. (Although RF
currents cannot "shock," small burns are often described as a "shocklike" sensation.)
Patients are also at risk for a burn from stray currents if any part of the endoscope metal frame is
exposed by a small crack in the covering insulation. To reduce the potential for burns to endoscopists
and patient, a safety cord is used; this connects the endoscope to the patient return electrode and
removes all the stray currents induced on the endoscope and returns them safely to the generator.
However, if the return electrode is not properly in place on the patient, the endoscope becomes the
return electrode and current flows from patient to endoscope and returns to the generator via the safety
cord. Any point of contact between the patient and the metal endoscope frame is likely to result in a
serious burn. Therefore, the use of safety cords is no longer common and is not recommended.
Another capacitor that has the potential to create RF burns is found during guidewire-assisted
sphincterotomy.19(338) Many endoscopists prefer to cannulate the papilla using a guidewire,
especially in technically difficult cases. A double-lumen sphincterotome (one lumen for the cutting wire
and the other for the guidewire) can be advanced into the bile duct over the guidewire. The capacitor is
composed of the sphincterotome cutting wire, the insulating septum between the two lumens of the
catheter, and the metal guidewire. As current flows in the cutting wire, current is induced in the
guidewire by capacitive coupling; the resistance (impedance) for this capacitive coupling is as low as
2000 ohms. Many endoscopists leave the guidewire in the common bile duct during sphincterotomy in
order to maintain access. Only an insulated guidewire intended for use during electrosurgery is suitable
for this purpose; other types of guidewires must not be used during electrosurgery.
Any flaw in the insulation of a guidewire that exposes the metal wire to tissue during sphincterotomy
allows induced currents to flow to the patient. At typical operating settings in the blended mode, only a
few watts are induced from the guidewire. However, if the cutting wire is not in contact with tissue when
the generator is activated (open-circuit activation), up to 15 watts may be induced in the guidewire.
Although 1 or 2 watts can probably be tolerated, larger values over the small area of the flaw in the
guidewire insulation can yield power densities that may perforate the common bile duct. Therefore, if
the guidewire is to be left in the common bile duct during electrosurgery, high power settings,
prolonged generator activation, and activation with the active wire not in contact with the tissue must be
Coupled currents between the active wire and the guidewire are reduced by thicker guidewire
insulation. Thus, sheathed guidewires offer an increased margin of safety if a guidewire is to be left in
the common bile duct during sphincterotomy. Some guidewires are simply spray coated with Teflon.
Although Teflon is an insulator, the coating has many imperfections that expose the underlying
metal.20(339) All guidewires to be left in place during cutting should be thoroughly examined for
defects in insulation.
A more serious potential clinical problem is the direct electric connection (shorting) between active wire
and guidewire; this may place full generator output power onto the guidewire. This cannot occur
without insulation failure on the guidewire, and sheathed guidewires are significantly less susceptible to
shorting. A guidewire should never be placed in the same channel of the sphincterotome as the cutting
wire because this invites electric shorting between the two wires. Unfortunately, even double-channel
catheters do not provide total isolation between the wires. In fact, new double-channel catheters have
been shown to have a significant incidence of septum defects that allow electric connection between
active wires and guidewires. Therefore, it is prudent not to leave a Teflon spray-coated guidewire or a
guidewire with any exposed metal in the common duct during electrosurgical cutting.
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Demodulation Current
Although typical electrosurgical currents do not cause muscle or nerve stimulation, all surgeons are
aware that striated muscle fasciculations occur during electrosurgery. Endoscopists also report that
sedated patients occasionally complain of uncomfortable sensations during electrosurgical cutting even
though the bowel does not possess the necessary pain receptors. Both phenomena are explained by
the demodulation of RF currents, that is, the changing of high-frequency current into low-frequency or
direct current, both of which can stimulate muscle and nerve.21(340)
Demodulation occurs when RF current flows through nonlinear circuits. The most important of these
during electrosurgery is sparking. (Although tissue is also nonlinear, its contribution to demodulated
currents is minor). Therefore, occasional muscle and nerve stimulation should be expected during
electrosurgical cutting and fulguration. Unfortunately, such stimulation is inherent to RF currents and
cannot be prevented. However, no long-term consequences occur as a result of these demodulated
low-frequency and direct currents.

Electric Interference
Electrosurgical generators are essentially radio transmitters and therefore radiate small amounts of
radio waves into the atmosphere. These radiated waves as well as capacitively coupled currents may
interfere with other electronic devices. Electronic devices used in the same area with electrosurgical
generators usually have circuits designed to filter any RF interference. Interference may occasionally
occur with some video systems, but it is usually minor. However, in three clinical situations, RF
interference has potentially deleterious effects. These involve patients with pacemakers, implanted
defibrillators, and intracardiac catheters. Although patients undergoing open heart surgery are at
greatest risk for problems related to RF interference, endoscopists should be aware of these potential
Cardiac pacemakers are of two types: demand and fixed rate. Demand pacemakers sense the cardiac
cycle and deliver a stimulating pulse in the absence of an R wave. Because electrosurgical currents
may be interpreted as R waves, the pacemaker may thereby be inhibited. Demand pacemakers placed
in asynchronous mode are less susceptible to electrosurgical interference, although failures can occur
even in this mode.22(341) Fixed-rate pacemakers deliver stimulus at a predetermined rate, but their
internal circuitry can also be susceptible to RF interference generated during electrosurgery.
Although modern pacemakers have protective circuitry, programming to control RF interference, or
both, any pacemaker may have its intended output modified during electrosurgery. However,
endoscopic procedures can be performed safely on patients with pacemakers provided that several
simple precautions are observed. The return electrode should be placed away from the heart, that is, in
such a way that the current flow from the surgical site to the return electrode does not include the
heart. Endoscopists are encouraged to use low-power and low-voltage waveforms on patients with
pacemakers to reduce possible interference. Bipolar electrosurgery also decreases the potential for
pacemaker-associated problems. Electrocardiographic monitoring of patients with pacemakers is also
strongly recommended. Manufacturers can also provide specific details on the susceptibility of their
products to electrosurgical interference.
Potential RF interference complications also exist for patients with defibrillator implants. Electrosurgical
interference can cause unnecessary shocks or defibrillator output failure. Usually, inactivation of the
defibrillator and close patient monitoring are recommended. As with pacemakers, endoscopists are
encouraged to seek advice from the specific manufacturer and consultation with the patient's
cardiologist before performing an electrosurgical procedure.
Cases of ventricular fibrillation during electrosurgery have been reported in patients undergoing
thoracic surgery with its associated multiple monitoring systems, including central venous lines.23(342)
It has been demonstrated that ventricular fibrillation and a myocardial burn can occur via a
pressure-sensing catheter acting as the RF return for a grounded generator after a break in the patient
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return circuit. Although such a situation is uncommon during endoscopy, it could occur when
electrosurgery is performed in patients with severe bleeding who are connected to various central
catheters and monitoring devices.

Bowel Gas Explosion

Although uncommon, injuries from bowel gas explosion during polypectomy have been reported since
this procedure was first introduced (see Chapter 80: Indications, Contraindications, and Complications
of Colonoscopy).24,25(343) Bowel gas is composed of carbon dioxide, nitrogen, oxygen, hydrogen,
and methane. The proportions of these gases are quite variable among individuals and depend in part
on diet and disease state. The combustible constituents of bowel gas result from swallowed air
(oxygen) and bacterial metabolism (hydrogen and methane).26(344) Nearly half of all patients with
unprepared colons have an explosive mixture of bowel gases.27(345) Therefore, preventive measures
to decrease concentrations of combustible gases must be taken prior to electrosurgical sparking.
Carbon dioxide insufflation during colonoscopy decreases the risk of explosion by decreasing the
concentration of combustible gases. However, meticulous bowel preparation prior to electrosurgery
results in extremely low concentrations of combustible gases. Several methods are available (see
Chapter 81: Technique of Colonoscopy). Only the use of carbohydrate alcohols (e.g., mannitol,
sorbitol) is contraindicated for bowel preparation because chemical breakdown by colonic bacteria
produces large amounts of hydrogen gas.28(346)


d'Arsonval MA. Action physiologique des courants alternatits. Comp Rend Soc Biol Paris
Riviere AJ. Action des courants de haute frequence et des efflures du resonateur Oudin sur
certaines tumeurs malignes. J Med Interne 1900;4:7767.
Clark WL. Oscillatory desiccation in the treatment of accessible malignant growths and minor
surgical conditions. J Adv Therapy 1911;29:16983.
Nagelschmidt CF. Lehrbuch der Diathermie fr rzte und Studierende. Berlin: J Springer.
Beer E. Removal of neoplasms of the urinary bladder. A new method employing high
frequency (Oudin) currents through a catheterizing cystoscope. JAMA 1910;54:176874.
Wyeth GA. The endotherm. Am J Electrother Radiol 1924;42:1867.
Cushing H, Bovie WT. Electrosurgery as an aid to the removal of intracranial tumors. Surg
Gynecol Obstet 1928;47:75184.
Hill AV, Foulerton RS, Katz B, et al. Nerve excitation by alternating current. Proc Roy Soc
Lond [Biol] 1936;121:74133.
9. LaCourse JR, Miller WT, Vogt M, et al. Effects of high frequency current on nerve and muscle
tissue. IEEE Trans Biomed Eng 1985;32:826.
10. Tucker RD, Kramolowski EV, Bedell E, et al. A comparison of urologic application of bipolar
versus monopolar five French electrosurgical probes. J Urol 1989;141:6625.
McLean AJ. The Bovie electrosurgical current generator: Some underlying principles and
results. Arch Surg 1929;18:186373.
Kelly HA, Ward GE. Electrosurgery. Philadelphia, London: WB Saunders, 1932;3944.
Peares JA. Electrosurgery. Medical Instrumentation and Clinical Engineering Series. London:
Chapman & Hall 1986;87.
14. Cohen LB, Waye JD. Treatment of colonic polypsPractical considerations. Clin
Gastroenterol 1986;15:35976.
Tedesco FJ. Colonic polypectomy. In Silvis SE (ed). Therapeutic Gastrointestinal Endoscopy.
New York: Igaku Shoin, 1985;26988.
16. Tucker RD, Platz CE, Sievert CE, et al. In vivo evaluation of monopolar versus bipolar
electrosurgical polypectomy snares. Am J Gastroenterol 1990;85:138690.
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Koch H, Pesch HJ, Bauerle H, et al. Experimentelle Untersuchugen und klinische Erfahrunge
zur electrodogulation blutende Laisonan im oberen Gastrointestinaltrakt. Fortschr Endosk
Barlow DE. Endoscopic application of electrosurgery: A review of basic principles.
Gastrointest Endosc 1982;28:736.
Tucker RD, Voyles CR, Silvis SE. Capacitive coupled stray currents during laparoscopic and
endoscopic electrosurgical procedures. Biomed Instrum Technol 1992;26:30311.
Johlin FC, Tucker RD, Ferguson SD. The effect of guide wires during electrosurgical
sphincterotomy. Gastrointest Endosc 1992;38:53640.
Tucker RD, Schmitt OH, Sievert CE, et al. Demodulated low frequency currents from
electrosurgical procedures. Surg Gynecol Obstet 1984;159:3943.
Mangar D, Atlas GM, Kane PB. Electrocautery induced pacemaker malfunction during
surgery. Can J Anaesth 1991;38:6168.
Hungerbuhler RF, Swope JP. Ventricular fibrillation associated with use of electrocautery.
JAMA 1974;230:4325.
Geddes LA, Tacker WA, Cabler P. A new electrical hazard associated with electrocautery.
Med Instrum 1975;9:1123.
Carter HG. Explosion in the colon during electrodesiccation of polyps. Am J Surg
Bigard MA, Gaucher P, Lassalle C. Fatal colonic explosion during colonoscopic polypectomy.
Gastroenterology 1979;77:130710.
Levitt MD, Lasser RB, Schwartz MA, et al. Studies on a flatulent patient. N Engl J Med
Ragins H, Shinya H, Wolf WI. The explosive potential of colonic gas during colonoscopic
electrosurgical polypectomy. Surg Gynecol Obstet 1974;138:5546.

Chapter 10 Laser Physics and Laser-Tissue Interactions



The first brilliant flash of deep red laser light emitted from a perfect crystal of ruby at Hughes Research
Laboratories in 1960 marked the beginning of a renaissance in the study of light and its applications in
science, technology, and medicine.
Emerging from its origins in atomic physics, the laser has come to pervade disciplines ranging from
biophysics to satellite communications. Lasers are now used routinely in medical practice to cut,
shape, remove, and examine biologic tissue. Commercialization of lasers and delivery systems
specifically designed for particular applications has kept pace with the transformation from research
tool to clinical necessity. Increasing interest in lasers and optical techniques in medicine is due to a
synergism among the unique capabilities of lasers, rapid technologic advances in optoelectronic
technologies, and trends in clinical medicine.
The matchless qualities of lasers that make the light they generate especially attractive for medical
applications include high directionality (spatial coherence), wavelength selectivity and tunability, and
the generation of high peak and average optical powers. Indeed, specific laser sources can exhibit
each of these characteristics individually as well as simultaneously to a higher degree than any other
known sources of radiation.1(349)
The directionality of laser light is important for beam handling, shaping, focusing, and efficient coupling
into optical fibers. This characteristic makes possible the direct linkage of lasers to the rapidly
advancing optical fiber technology. That technology is critically important to the development of modern
clinical methods that are less invasive and more economical such as endoscopy and laparoscopy. The
tunability of laser light makes possible the selection of optimum wavelengths for specific applications,
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in effect tuning the absorption and scattering properties of the tissue to match the problem at hand.
This characteristic complements recent advances in optical detector technology such as
charge-coupled devices and intensified detector arrays and enables real-time spectroscopic imaging of
tissue surfaces. The development of high-speed computers and related information technologies
permits the use of elaborate algorithms for therapy, imaging, and diagnostics in real time, thereby
amplifying the impact of advances in optoelectronic technology and matching new developments in
medical instrumentation and informatics.
In many medical applications, the use of laser light provides unique benefits over conventional
techniques for diagnosis and therapy. Therapeutic applications include ablation (vaporization) (see
Chapter 43: Palliation of Malignant Obstruction: Lasers and Tumor Probes), coagulation and
cauterization (see Chapter 29: Laser Therapy), and laser-induced photochemistry (see Chapter 19:
Photodynamic Therapy). Although it is a capital-intensive technology, use of lasers nevertheless offers
compelling advantages under the proper circumstances. Because no contact is required between the
light delivery system and the target tissue, the risk of infection is greatly reduced. For ablation and
coagulation, lasers generate significantly less radio frequency interference than alternative techniques
and are thus compatible with other medical devices such as pacemakers. For cutting applications,
laser ablation exerts only minimum pressure on tissue, in contrast to the scalpel blade, which cuts by
exerting pressure in excess of the local tissue tensile strength. The activation with laser light of
phototoxic exogenous chromophores, although still in the early phases of research and development,
is a promising technique for the treatment of cancer and some immune disorders.
Novel applications of lasers are also being developed for diagnosis. Laser scattering and fluorescence
techniques are the basis for sensors that monitor blood flow, local tissue temperatures, and blood gas
concentrations. Laser scanning confocal microscopy permits high-resolution "optical sectioning" of
microorganism preparations and tissue, enabling detailed subcellular examination without tissue
sectioning. It has been demonstrated that laser-induced fluorescence spectroscopy can be used in
tissue to indicate compositional and architectural changes associated with the onset and development
of atherosclerotic plaques and dysplastic tissue in the urinary bladder and gastrointestinal tract (see
Chapter 17: Biomedical Tissue Spectroscopy, and Chapter 18: Spectroscopic Diagnosis and
Treatment of Gastric Cancer). This most recent category of medical laser applications is in many ways
the most promising. When merged with other sophisticated diagnostic technologies, it has the potential
to elucidate the origins of certain diseases and to pinpoint their earliest manifestations.

Historical Background
Albert Einstein first suggested the theoretical concept of coherent "negative absorption" or amplification
of light in atomic systems in 1917.2(350) Because this idea arose before full development of the
quantum theory, which is necessary for accurately describing atomic systems, it remained only a
tantalizing speculation for many years. During the 1950s, groups in the United States and the Soviet
Union demonstrated weak microwave amplification in gases.3(351) Then, in 1958, Arthur Schawlow
and Charles Townes4(352) published an influential paper suggesting the possibility of amplification of
optical radiation. This initiated a flurry of research to demonstrate and expand this important concept
that continues to this day.
The first operational lasers were demonstrated in 1960 by Theodore Maiman et al.5(353) at Hughes
Research Laboratories (using ruby exposed to powerful flashlamps to produce red laser light) and Ali
Javan et al.6(354) at the Bell Telephone Laboratories (using an electric discharge in a gaseous mixture
of helium and neon to produce infrared, and later red, light). In the subsequent years, thousands of
different laser systems have been developed, generating perhaps more than 1 million discrete optical
Attempts to use lasers for medical purposes occurred almost immediately after development of the first
operational devices. In 1961, Zaret et al.7(355) performed iris and retinal photocoagulation using the
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ruby laser in rabbit eyes, and by 1963, several groups had developed ruby laser delivery systems for
retinal photocoagulation.8,9(356) Following development of the argon-ion laser, it was recognized to be
a superior source for achieving controlled photocoagulation, owing to its continuous wave nature and
strong absorption by melanin and hemoglobin (Figure 101).10,11(357) Clinicians quickly realized that
high-power lasers could be used for tissue removal or ablation, and by 1965, several groups had
begun using ruby and neodymium:yttrium-aluminum-garnet (Nd:YAG) lasers to vaporize melanomas,
sarcomas, and carcinomas in animal models.1218(358)

(359)Figure 101. Absorption spectrum of several important tissue chromophores, together

with the wavelength positions of the most widely used medical lasers. ArFargon-fluoride;
GaAsgallium-arsenic; Er:YAGerbium:yttrium-aluminum-garnet; CO2carbon dioxide;
HbO2oxyhemoglobin; HPDhematoporphyrin derivative. (Data from Boulnois J-L.
Photophysical processes in recent medical laser developments: A review. Lasers Med Sci
1986; 1:4766; data for the ultraviolet portion of the H2O spectrum is from Hale GM, Querry
MR. Optical constants of water in the 200nm to 2000nm wavelength region. Appl Opt 1973;
The first attempt to use a photocoagulative effect to achieve hemostasis in the gastrointestinal tract
was by Goodale et al.19(360) in 1970, who reported success at delivering CO2 laser light at 10.6 mm
through a rigid gastroscope for control of bleeding from gastric erosions. Similar results were achieved
shortly afterward by the groups of Dwyer,20,21(361) Kiefhaber,22(362) and Frhmorgen23(363) using
argon-ion and Nd:YAG lasers coupled to optical fibers that were passed through flexible endoscopes.
Many controlled studies have since been published detailing efficacy of photocoagulative laser therapy
in the treatment of actively bleeding lesions2427(364) and angiodysplasia28,29(365) (see Chapter 29:
Laser Therapy).
The second prominent application of lasers in gastroenterologic practice is endoscopic laser ablation
(photoablation, vaporization) of neoplastic tissue. Although related conceptually to animal experiments
conducted 20 years previously, photoablation of malignant tumors in humans was not substantially
achieved until the technology for convenient delivery of high-power Nd:YAG laser light through flexible
endoscopes became commercially available in the early 1980s. Mostly palliative in intent, laser
vaporization has been well characterized for treatment of neoplasms of the esophagus,30(366)
stomach,31,32(367) duodenum, ampulla of Vater, colon, and rectum33(368) (see Chapter 43:
Palliation of Malignant Obstruction: Lasers and Tumor Probes.25(369)).
Two additional applications of lasers with relevance to gastrointestinal disease deserve mention.
Although the concept of photodynamic therapy was decades old, several groups began in the early
1970s to use lasers as directed light sources to activate toxicity in tumor-localized drugs, primarily
porphyrin derivatives.3438(370) Interest in this field has been heightened by the development of new
phototoxic drugs with improved selectivity for dysplastic tissue and reduced side effects such as skin
photosensitivity (see Chapter 19: Photodynamic Therapy). In addition, scattered and tentative reports
have described the use of very small doses of laser light for selective destruction of malignancy in
tissue cultures and animal models, a process termed biostimulation.3942(371) The mechanisms
underlying these effects remain poorly understood.

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Laser Principles
Light Amplification by Stimulated Emission of Radiation
A laser is a device that generates and amplifies light by use of energy level transitions of quantum
mechanical systems enclosed within an electromagnetic resonant cavity.1,43,44(372) The word laser
is an acronym for light amplification by stimulated emission of radiation. Light in this context is defined
as the portion of the electromagnetic spectrum that the human eye perceives as colors, plus
neighboring frequencies in the ultraviolet and infrared ranges. Visible light frequencies range from
about 4.3 to 7 1014 cycles/sec, with corresponding wavelengths of about 400 to 700 nm (1 nm =
10-9 meter; see Figure 101). The essential components of a laser are illustrated in Figure 102.
These are (1) a lasing or gain medium, (2) a process for pumping or exciting the gain medium, and (3)
an electromagnetic oscillator or cavity enclosing the ends of the gain medium that intercepts and
recirculates light through the medium.

(373)Figure 102. Schematic diagram of a laser. Light amplified through the process of
stimulated emission is recirculated through the laser cavity (i.e., the gain or lasing medium) by
the end mirrors. Light partially transmitted through one end mirror constitutes the output laser
The gain (lasing) medium is the heart of the laser. The active elements of the gain medium are
quantum mechanical particles that exhibit discrete energy levels and absorb or emit radiation when
changing energy levels according to Planck's Law:

where E is the energy shift of the transition (in Joules [J]), h is Planck's constant (h = 6.626 10-34
J-sec), and is the frequency of the radiation (in cycles/sec). Wavelength () is related to frequency
through the relation

where c is the speed of light in the medium (c = 3 108 m/sec in air). Lasing action has been
demonstrated with many different types of particles, including free electrons, atoms, molecules, and
electron-hole pairs in semiconductors. Although the details of a particle's energy level structure depend
on the type of particle and its surroundings, the underlying principles of laser action do not. Therefore,
for the purposes of this discussion, atom is used as a generic term for whatever species exhibits laser
Microscopic processes occurring within the lasing medium are illustrated schematically in Figure 102.
A pumping process such as an electric discharge is used to excite some of the atoms from their
ground state into higher energy states. Each excited state has a characteristic lifetime, which can be
thought of as the average time until the atom decays to a lower energy state or back to the ground
state. Several avenues are available for decay. The atom can simply release the excess energy in the
form of heat, this being termed nonradiative decay. The atom can also decay by emitting a photon, a
unit of radiation with energy equal to the transition energy and thus a frequency determined by Planck's
Law. This emission process, termed spontaneous emission, is responsible for the glow from
fluorescent lights, neon signs, and cathode-ray tubes. Light produced in this process is emitted in all
directions and can either escape the laser medium, scatter off other atoms or particles, be absorbed by
unexcited atoms, or if it encounters another excited atom, induce that atom to emit a second photon
through a process termed stimulated emission. This last process is unique in that the resulting pair of
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photons is perfectly matched in frequency and phase and propagate together in precisely the same
direction. They can be conceptualized as an electromagnetic wave with the same frequency and phase
as the incident photon but with twice the amplitude.
The basic concept of laser action, as suggested by Einstein in 1917, is as follows: If a collection of
atoms could be specially prepared such that the population division between two of their energy states
is "inverted," that is, with the majority in the upper state, then through the process of stimulated
emission, the medium could produce and amplify a light beam of remarkable directionality, spectral
purity, and intensity. Physically, this means that the collection of atoms must be coaxed into a state in
which the probability of an incident photon of a given energy inducing stimulated emission is higher
than the sum of the probabilities of that same photon being absorbed, scattered, or otherwise lost. This
is a very unlikely situation in nature (in fact, it can be described as a condition of negative temperature),
and the difficulty of developing a means to trick a collection of atoms into this state was in large part
responsible for the long delay between Einstein's conceptualization of stimulated emission gain and the
first operational lasers in 1960.
One of the simplest and most practical methods for establishing the population inversion necessary for
laser action is the so-called four-level pumping scheme, as illustrated in Figure 103. Atoms in their
ground energy state are excited by a pump source into a highly excited state or group of states with
very short lifetimes for nonradiative transition to the upper lasing state, E2. The state E2 has a very
long lifetime, so that atoms tend to collect there and to be available for stimulated emission. Initial
photons emitted through spontaneous emission that encounter particles in this E2 state induce
stimulated emission, thereby reducing the particle's energy to the lower excited state E1 and producing
amplified light with a frequency of

(374)Figure 103. A four-level laser energy level diagram. Atoms are induced into a
condition of population inversion between two discrete energy levels by taking advantage of
differences between the lifetimes of states E1 and E2.
The state E1 has a short lifetime for deexcitation to the ground state, so that atoms do not collect in
this state and reabsorb the precious laser light. There must also be no other energy levels available at
an energy E2 - E1 above the ground state, or else absorption from the ground state would overwhelm
laser emission.
Laser action occurs when a few photons initially produced by spontaneous emission are amplified
many times by stimulated emission. If the condition of population inversion could be established in a
large enough collection of atoms, lasing would occur spontaneously. This has in fact been observed in
huge interstellar gas clouds and planetary atmospheres.45(375) A more practical laser, and one that
better preserves and enhances the directional and spectral purity of stimulated emission, is made by
enclosing a relatively small volume of particles within an optically resonant cavity. In a typical laser
oscillator (see Figure 102), mirrors placed at the ends of a lasing medium redirect only light emitted
within a limited solid angle back through the lasing medium to induce formation of a highly directional
laser beam. Laser light is extracted from the laser cavity either by allowing one of the mirrors to
transmit a slight fraction so that some light escapes with every round trip or by some other means such
as the use of very fast optical switches that periodically open the laser cavity to permit escape of short
pulses of light.

Unique Properties of Laser Light

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Several qualities of laser light distinguish it from light from any other source and make it particularly
useful in medical applications. These qualities, illustrated in Figure 104, all result from the directional
and phase-maintaining characteristics of the stimulated emission process, preserved and enhanced by
the surrounding optical resonant cavity.

(376)Figure 104. Unique properties of laser light.

Spatial Characteristics
The spatial characteristics of laser beams are largely determined by the laser optical cavity. Typical
simple lasers emit relatively narrow beams (a few millimeters in diameter) with an intensity profile that
decays radially as a Gaussian function (see Figure 104). The regenerative feedback mechanism
inherent in laser gain lends laser beams the property of being highly collimated; that is, the beam
diverges very slowly with distance. A typical collimated laser beam has a divergence on the order of 1
milliradian, although lasers can be constructed with microradian divergence. The directionality of laser
light makes it easy to direct laser beams with mirrors and to manipulate them with inexpensive,
low-numerical-aperture optics. The collimation of laser light is also directly related to the minimum
attainable focused spot size; a well-collimated beam can be focused with an appropriate lens to a spot
with a diameter comparable to a single wavelength. This degree of spatial coherence allows for laser
beams to be coupled into optical fibers and to be used for very high resolution microscopy.
Frequency Characteristics
Lasers emit light over a very narrow wavelength range, owing both to the limited gain bandwidth
intrinsic to the stimulated emission process and to the restricted number of discrete electromagnetic
modes that can oscillate within the resonant optical cavity. Although the visible spectrum extends over
approximately 300 nm, the spectral width of a gas laser line can be narrower than 0.01 nm. The
spectral purity or monochromaticity of laser light, defined as the ratio of the frequency spread of the
emitted light to the frequency of the emitted light itself, can thus range as high as 1 part in 106. In
optical systems, this property eliminates chromatic aberration as a design consideration and aids in
focusing the beam to the smallest spot sizes. In medical applications, this feature can be used to excite
or target very specific species (ranging down to specific molecules) in biologic tissue in order to identify
them or alter their function.
Radiometric Characteristics
For many medical applications, the most important property of a laser beam is the power or energy it
carries. Radiometry is the quantitative measurement of electromagnetic radiation; definitions of
radiometric terminology for medical lasers are summarized in Figure 104. Pulsed lasers are rated in
terms of their energy per pulse, termed radiant energy (in Joules). Continuous-wave lasers are rated in
terms of radiant power, which is energy per unit time (1 watt = 1 J/sec). The radiant power in a typical
continuous-wave laser beam available in an operating room, although not exceptional in itself (a few
watts are comparable to the optical output of an incandescent light bulb), is truly remarkable in that all
of this power resides within a highly collimated beam and a very narrow spectral line width. Typical
laser radiant powers range from less than 1 milliwatt for compact disk player or laser printer
semiconductor lasers, to kilowatts of power in industrial CO2 lasers used for materials processing. The
highest reported laser powers have occurred only instantaneously during extremely short laser pulses.
Research lasers have generated in excess of 1015 watts of instantaneous power,46(377) a factor
more than 100 times the total installed electric generating capacity of the United Statesalthough only
for a few tenths of femtoseconds, equal to 1 millionth of 1 billionth sec.
The extent of laser effects on materials usually depends on the area over which the laser beam has
been focused. Thus, irradiance is defined as the laser radiant power divided by the beam area.
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Specific Laser Systems

During the past several decades of laser development, the total number of discrete laser wavelengths
demonstrated probably exceeds 1 million. In terms of sheer numbers of wavelengths available,
molecular systems represent the largest category by far of laser gain media owing to their large and
complicated energy level structures. However, the number of laser systems that are commercially
viable for specific applications is much smaller, and a relative handful of systems are the workhorses
for medical and industrial applications.47,48(378) A selection of laser systems relevant to medical
applications and their key characteristics are provided in Table 101. Although relatively few types of
lasers are in current use, it is important to note that appropriate laser designs can often be
implemented very rapidly as new applications are developed that require novel laser wavelengths and
other special characteristics.


Argon ion (cw)

Dye (pulsed or
(pulsed or cw)
Nd:YAG (pulsed
or cw)

Laser Systems Used in Medical Applications



Excited dimers
Argon ions

193, 249,
308, 351
488, 514

Dye molecules
pairs (solid)
ions (solid)



1 mm

Ablation with little

thermal damage


110 mm

Tunable absorption


110 mm


5 mm

1100 m

CO2 (pulsed or
CO2 molecules 10,600
10 m
cwcontinuous wave; Nd:YAGneodymium:yttrium-aluminum-garnet.

Sensitizer triggering
Deep penetration
Volume heating
Plasma and shock
Precise cutting

Corneal surgery
Laser angioplasty
Panretinal photocoagulation
Cancer palliation
Pigmented lesions
Photodynamic therapy
Photodynamic t
Optical tomography
Cancer palliation
Laser microsurg
Tissue debulking

Extensions of Laser Technology

Lasers, because of their remarkable qualities, have since their discovery stimulated a renaissance in
the field of optics. Many phenomena would not have been discovered without the use of laser sources;
some of these phenomena form the basis of useful extensions of laser technology itself. Examples
include developments in electro-optics, acousto-optics, nonlinear optical phenomena, and fiberoptics.
The first two of these provide techniques now commonly used to perform optical switching within lasers
to create short pulses as well as techniques to direct, shift, and examine the frequency of laser
beams.1,49(379) The third category, nonlinear optics, encompasses a large range of very useful
phenomena that have substantial commercial applications.50,51(380)
Nonlinear optics describes the unusual phenomena that occur when very intense radiation propagates
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through materials, including the generation of new frequencies from one laser beam and frequency
mixing of more than one laser beam. These important effects make available a wider range of
wavelengths from established laser systems and play a large role in medical devices.
The basic principle of nonlinear optics is illustrated by the example of second-harmonic generation
(Figure 105). When an electromagnetic wave propagates through a clear medium such as a crystal,
electrons within the crystal are induced to oscillate along with the wave. The induced oscillations are
termed the optical polarization of the material, and this polarization in turn induces reradiation, as is
generated by any oscillating charge. When the incident intensity is small enough that the induced
motion of the electrons is small and their motion is unencumbered by the surrounding crystal lattice,
then the electron motions are proportional to the incident field, following the sinusoidal oscillations of
the incident wave. In this case, the reradiated field is indistinguishable from the incident field, and the
light propagates unchanged through the crystal. When the incident intensity becomes high enough,
however, electrons are driven beyond their linear range of motion, and the induced polarization is no
longer sinusoidal and acquires frequency components other than the incident field frequency.

(381)Figure 105. Schematic representation of second-harmonic generation, an example of

nonlinear optics. Incident electromagnetic (EM) radiation generates asymmetric oscillation of
electrons in crystal lattices that have the appropriate symmetry properties. The oscillating
electrons reradiate at both the incident light frequency and its second harmonic.
Second-harmonic generation occurs in crystals that lack so-called inversion symmetry. In these
crystals, the structure in which the electrons are located is asymmetric, with the result that the
electrons are freer to oscillate with larger amplitudes in one direction than in the opposite. As illustrated
in Figure 105, the excursion of the electrons is different for the positive-going wave than for the
negative-going wave. In this case, Fourier analysis demonstrates that the induced polarization can be
constructed from the sum of two sinusoidal waves, one at the incident oscillating frequency and a
second at twice that frequency, plus a small direct current offset. As a result, the oscillating electrons
reradiate at both the incident wave frequency and its second harmonic. When the incident radiation is
an intense laser beam and the crystal is oriented at just the right direction so that all of the radiating
electrons are in phase for both the incident frequency and the second harmonic, a second beam at
twice the frequency of the incident light (i.e., half the wavelength) can be generated, with a significant
proportion of the power converted from one frequency to the other. Similar effects can be used for
generating higher harmonics of a laser frequency or for adding or subtracting frequencies of more than
one laser beam.

Medical Laser Delivery Systems

Developments in fiberoptic technology have greatly accelerated the use of lasers for medical
procedures. Early laser delivery systems required awkward articulated arms containing folding mirrors.
Optical fibers capable of transmitting substantial amounts of energy are now available for wavelengths
from about 300 nm to 2.5 m.48(382) Unfortunately, this wavelength range excludes CO2 radiation at
10.6 m as well as 2.9 m, where water and hence tissue absorption are even stronger (see Figure
101). Some optical fibers and hollow flexible wave guides are available for these infrared
wavelengths, but current versions tend to be unacceptably lossy and inflexible. There is an intense
effort to develop fibers suitable for this important wavelength range.
Optical fibers modify the properties of laser light that they conduct depending on their construction and
size. Most commercially available optical fibers trap light by means of total internal reflection at the
interface between cylindrical glass layers with dissimilar indices of refraction (Figure 106). The inner
cylinder in such "stepindex" fibers is termed the core, and the surrounding glass is termed the cladding
(see also Chapter 2: Flexible Endoscope Technology: The Fiberoptic Endoscope). Total internal
reflection occurs over a range of angles of incidence at the core-cladding interface if the index of
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refraction of the core is greater than that of the cladding. Two major classes of fibers are available.
Single-mode fibers have very small core diameters (<10 m) and fully preserve the spatial coherence
of fully coherent laser beams; that is, the light exiting the fiber can be recollimated by a lens to a beam
with diffraction-limited divergence and Gaussian cross section. Unfortunately, single-mode fibers are
delicate and can conduct only limited optical powers. Also, the laser beam coupling site is very
sensitive to shocks and vibrations. For these reasons, the majority of medical laser delivery systems
use multimode fibers with core diameters of 50, 100, or 200 m or larger. Laser light propagating in a
multimode fiber loses a substantial portion of its spatial coherence and, if the fiber is long enough,
emerges with the optical power evenly spread over the surface of the output core face and at the
maximum angle allowed by the fiber. A plot of the distribution of laser energy emerging from a bare
multimode fiber is provided in Figure 107. Various focusing and diffusing tips for medical use are
available, the choice depending on the application.

(383)Figure 106. Schematic of a step-index optical fiber in cross (a) and longitudinal (b)
section. Light incident on the core-cladding interface at angles less than the critical angle () is
totally internally reflected throughout the length of the fiber (see Chapter 2: Flexible
Endoscope Technology: The Fiberoptic Endoscope). the index of glass used in the core
and cladding.

(384)Figure 107. Plots of the spot size and light irradiance as a function of distance from a
fiber tip. The calculations are performed for a 600-m core, 0.2 numerical aperture multimode
fiber carrying a total radiant power of 1 watt.

Laser-Tissue Interactions
Laser-Tissue Interaction Regimes
The interaction of laser light with biologic tissue is a complex process that depends on many factors:
the wavelength, power, and illuminating geometry of the incident laser beam; the optical, thermal, and
mechanical properties of the tissue; and the biologic host response.48,52(385) Laser-tissue interaction
processes may be grossly divided into qualitative regimes that are determined primarily by the intensity
of the laser beam and its interaction time with the tissue (Figure 108).48,53(386) Within each of these
regimes, variations in the resultant effects can be observed, depending mostly on the laser wavelength
and the optical properties of the specific tissue type.

(387)Figure 108. Laser-tissue interactions map including the primary laser-tissue interaction
regimes. CWcontinuous wave. (Data from Boulnois J-L. Photophysical processes in recent
medical laser developments: A review. Lasers Med Sci 1986; 1:4766.)
Very high laser intensities combined with short laser pulses (<10-6 sec) result in ionization of tissue
(and the air or water above it) and the formation of a plasma. This process, termed photodisruption in
ophthalmology, is useful for cutting of transparent membranes within transparent media in intraocular
surgery.47(388) It is also the mechanism responsible for the initiation of photoacoustic fracturing of
urinary calculi with pulsed dye lasers.54(389) However, this regime is not optimum for soft tissue
vaporization because it has poor efficiency, the light can damage optical fibers, and dosage is difficult
to control because the initiation mechanism is very sensitive to tissue and medium impurities.
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The physical basis of many surgical applications of lasers is tissue ablation. The use of moderately
high laser beam intensities with exposure times of milliseconds to seconds results in rapid deposition
of heat and subsequent tissue vaporization or decomposition, processes that characterize thermal and
thermoacoustic ablation. The ablation process depends substantially on the thermodynamic properties
of water, the primary constituent of tissue. For short laser pulses, the thermodynamics of water
specifies that under conditions of inertial confinement, when not enough time is available for material to
move, the energy densities typically deposited during ablation can lead to the generation of
tremendous pressure. Ablation occurs when this pressure exceeds a threshold that depends on the
structural properties of the tissue.55(390) For longer pulses or quasicontinuous-wave exposures,
inertial confinement is not achieved, but ablation can be modeled as a rapidly moving vaporization front
at relatively constant pressure.56(391)
Low-intensity or defocused laser beams used for periods of a few seconds have a more gentle effect
of simply heating without tissue removal. This regime is used for tissue coagulation and cauterization.
Careful modeling of heat deposition and diffusion has led to the prediction and observation of specific
tissue transformations that occur at particular temperatures (Table 102).

( C)

Relationship Between Temperatures and Tissue Event

Cell death, edema, endothelial
damage, vasodilation
Protein coagulates
Denatured collagen contracts,
blood vessels constrict
Tissue water boils
Dehydrated tissue burns

Erythema, edema cuff
Tissue turns gray-brown, blood turns black
Tissue "puckers"

Vaporization causes divot

Blackened tissue disappears, leaves glowing
From Fleischer D. Lasers in gastroenterology. Am J Gastroenterol 1984; 79(5):40615.

Finally, nonthermal interactions are produced at low laser intensity levels delivered over minutes or
hours. These interactions are strongly coupled to the tissue history and host response and include
various forms of photochemically mediated reactions such as photodynamic therapy. This regime is
also used in laser-tissue diagnostics, including tissue spectroscopy and imaging.

Laser-Tissue Interaction Processes

The laser-tissue interaction regimes relevant to gastroenterologic practice and research are those
occurring at moderate to low laser powers and exposure times (see Figure 108), that is, vaporization,
coagulation, photochemistry, and tissue diagnostics. Each of the regimes depend on many component
processes, including tissue optics, heat diffusion, ablation, and ionization; in general, the higher the
intensity, the greater the complexity of the processes and correspondingly less knowledge of the
mechanisms involved. The topics of tissue optics and heat diffusion are indispensable to a basic
understanding of any laser-tissue interaction and are discussed in the following sections. The
remaining topics are beyond the scope of this chapter; interested readers are directed to the
references concerning these very active areas of research.
Tissue Optics
All of the laser-tissue interaction processes depicted in Figure 108 are initiated by the deposition of
light within tissue. Many tissue components absorb laser light, the absorbing tissue species being
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termed chromophores. The absorption spectra of some important tissue chromophores are included in
Figure 101. Light is absorbed in tissue through the action of a variety of chromophores, including
water, various proteins, the hemoglobin in blood, and tissue pigments such as melanin.48(392)
Because absorption of almost all tissue constituents is lowin the 600- to 1300-nm region of the
spectrumlaser light within this wavelength range penetrates more deeply into tissue. This range of
wavelengths is therefore referred to as the therapeutic window. Chromophore absorption spectra are
typically a strong function of the laser wavelength and have relatively sharp features because they
depend on the details of the atomic or molecular structure of the absorbing species (see Figure 101).
The strength of light absorption in tissue, which is proportional to the sum of the concentration of all of
the chromophores at a given wavelength, can be characterized by an absorption coefficient, a, which
is related to the probability of absorption per unit length in the tissue. The inverse of a is the
mean-free-path for absorption, la, which can be interpreted as the average distance an incident photon
propagates in the tissue before being absorbed.
Just as in the laser medium itself, absorption of an incident photon leads to excitation of the absorbing
species, and several avenues are available for deexcitation. Excited chromophores can release their
energy as heat, this being the basis for tissue heating and ablation. Alternatively, excited
chromophores can release part of their energy as photons of a lower frequency than the laser beam.
This is the process of fluorescence. Monitoring of emitted fluorescence can be used to detect and
measure the concentrations of chromophores specific to particular disease states.
Laser light is also scattered in biologic tissue.57(393) In scattering events, incident laser photons
essentially bounce off tissue components, losing in this process little or none of their energy. The
amplitude of scattering in tissue varies less strongly with wavelength than does absorption by tissue
chromophores, and it does not exhibit such sharp features. The direction in which photons are
scattered, however, depends very strongly on the size of the scattering particle and its orientation with
respect to the incident photon. In bulk tissue, the average scattering direction is effectively randomized
and can be characterized statistically only as the average deviation from the forward direction. The
strength of scattering in a tissue type can also be characterized by a scattering coefficient (s) and its
inverse (ls), the mean-free-path for scattering. This latter quantity represents the average distance a
photon travels in tissue between scattering events.
A significant characteristic of tissue optics is the fact that in almost all tissues except the clear part of
the eye, la is much longer than ls; that is, scattering dominates absorption. The ratio of scattering
length to absorption length in tissue is typically in the range of 0.01 to 0.1, indicating that photons
average 10 to 100 scattering events before being absorbed. The dominance of scattering over
absorption indicates that incident laser light is drastically redistributed within tissue, typically taking on a
roughly exponential shape, as illustrated in Figure 109. The exponential constant or penetration depth
of the laser light within the tissue is a complicated function of the absorption and scattering
mean-free-paths as well as the mean scattering deviation angle and is very difficult to predict
theoretically as a function of chromophore and scattered concentrations.58,59(394) For this reason,
the best estimations of light distribution profiles are obtained using Monte Carlo calculations on
computers (the profiles in Figure 109 were generated in this way).60(395)

(396)Figure 109. Contour plot of light irradiance levels in tissue resulting from illumination
with a flat-profile laser beam of diameter 5 mm with 10 watts radiant power. The calculation
was performed using a Monte Carlo computer program with absorption and scattering
coefficients of a = 1 cm-1 and s = 100 cm-1 as parameters. The data summarize the
simulated trajectories of 10,000 photons.
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Typical measured values for tissue optical properties as well as theoretically predicted values for the
penetration depth and other tissue physical properties are listed in Table 103. Measured optical
penetration depths in most tissues of clinical interest range from fractions of a micron in the deep
ultraviolet and mid-infrared regions, up to several millimeters in the near-infrared. An excellent
tabulation of all known published tissue optical properties as of 1990 may be found in Cheong et


Summary of Tissue Physical Properties


Absorption coefficient
Absorption mean-free-path
Scattering coefficient
Scattering mean-free-path
Total attenuation coefficient
Penetration depth



Optical Properties
Typical values in therapeutic window (
~ 6001300 nm)
0.01 mm-1
1 - 100 mm


1 - 100 mm-1
0.01 - 1 mm

s / (a + s)

1 - 100 mm-1
0.5 - 0.99

Specific heat per unit volume

Heat diffusivity

Speed of sound
Maximum elongation
Maximum stress


Thermal Properties
3.96 x 10-3 (J/ C-mm3)
0.106 mm2/sec
Mechanical Properties
Soft Tissue
Calcified Tissue
1500 m/s
2800 m/s
600 bars
5002500 bars

Tissue Thermal Processes

Absorption of visible and near-ultraviolet light in tissue occurs by exciting electronic transitions in tissue
molecules, primarily proteins and lipids. Near-infrared and mid-infrared light is absorbed via
vibrational-rotational excitations in biomolecules and in water. The lifetimes of both the electronic and
the vibrational-rotational states are much less than laser pulse durations of hundreds of nanoseconds
or longer. As soon as the initial excited state distributions thermalize, the energy deposited by the laser
pulse may be considered to be heat, and its dissipation is described by classic thermal diffusion. Thus,
once an estimate of a laser light deposition profile has been secured, centuries-old analytical
techniques developed for thermal diffusion may be used to describe the subsequent heat flow.62(398)
A very useful prediction of heat diffusion theory provides an approximate prediction of the characteristic
time for heat diffusion in tissue. This quantity , indicates how short a laser pulse duration must be to
ablate without causing thermal damage in peripheral tissue; its inverse determines the maximum
repetition rate for avoiding a cumulative rise in local temperature with successive laser exposures. The
expression for is calculated under the assumption that the diameter of the tissue spot under
irradiation is larger than the penetration depth of the laser light in the tissue.48(399) It is
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where is the heat diffusivity of tissue, provided in Table 103. A plot of this characteristic time as a
function of penetration depth and the heat diffusion regimes it defines is provided in Figure 1010.

(400)Figure 1010. Illustration of laser pulse duration thermal regimes. For pulses longer
than the characteristic thermal diffusion time (solid line), thermal diffusion occurs during the
pulse and can lead to significant heat damage peripheral to the illuminated spot.

Laser technology offers distinct advantages in many medical applications, both diagnostic and
therapeutic. Commercialization of lasers and delivery systems specifically designed for particular
applications plays an important role in acceptance of new techniques as well as in the laser
marketplace itself. Although technology for laser applications in many medical disciplines is maturing,
an abundance of exciting prospects for significant advances remain. The rapid development of
semiconductor lasers, which have already redefined much of the optoelectronics industry, will be soon
be felt in medical therapy as new low-cost devices begin to supplant older technology. New
developments in tissue imaging and spectroscopy coincide with rapid integration of optics and lasers
into the sensor industry in general. These have the potential to deliver significant new diagnostic
capabilities in a cost-effective manner.


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oxyhemoglobin. Lasers Lif Sci 1988;2:24955.
Marcuse D. Principles of Quantum Electronics. New York: Academic Press. 1980.
Yariv A. Quantum Electronics. 3rd ed. New York: John Wiley & Sons. 1989.
Elitzur M. Physical characteristics of astronomical masers. Rev Mod Phys 1982;54:122560.
Ditmire T, Perry MD. Terawatt Cr:LiSrAlF6 laser system. Opt Lett 1993;18:4268.
Steinert RF, Puliafito CA. The Nd:YAG Laser in Ophthalmology. Philadelphia: WB Saunders.
Katzir A. Lasers and Optical Fibers in Medicine. New York: Academic Press. 1993.
Yariv A. Optical Electronics. 2nd ed. New York: Holt, Reinhart, and Winston. 1985.
Bloembergen N. Nonlinear Optics. New York: Benjamin. 1965.
Shen YR. Principles of Nonlinear Optics. New York: John Wiley & Sons. 1984.
Muller G (ed). Medical Optical Tomography: Functional Imaging and Monitoring. Bellingham,
WA: Society of Photo-Instrumentation Engineers. 1993.
Boulnois J-L. Photophysical processes in recent medical laser developments: A review.
Lasers Med Sci 1986;1:4766.
Teng P, Nishioka NS, Anderson RR, Deutsch TF. Optical studies of pulsed laser
fragmentation of biliary calculi. Appl Phys B 1987;42:738.
Albagli D, Dark M, Perelman LT, et al. Photomechanical basis of laser ablation of biological
tissue. Opt Lett 1994;19:16846.
56. Partortovi F, Izatt JA, Cothren RM, et al. A model for laser ablation of biological tissue using
laser radiation. Lasers Surg Med 1987;7:14154.
Ishimaru A. Wave Propagation and Scattering in Random Media. New York: Academic Press.
58. Jacques SL, Prahl S. Modeling optical and thermal distributions in tissue during laser
irradiation. Lasers Surg Med 1987;6:494503.
59. Welch AJ, Yoon G, van Gemert MJC. Practical models for light distribution in laser-irradiated
tissue. Lasers Surg Med 1987;6:48893.
Wang L, Jacques SL. Monte Carlo Modeling of Light Transport in Multi-Layered Tissues in
Standard C. Houston: M D Anderson Cancer Center. 1992.
Cheong WF, Prahl SA, Welch AJ. A review of the optical properties of biological tissues. IEEE
J Quant Elect 1990;QE-26:216685.
Carslaw HS, Jaeger JC. Conduction of Heat in Solids. Oxford: Clarendon Press. 1947.

Chapter 11 Principles of Endoscopic Ultrasonography

Endoscopic ultrasonography is a technologic development of extraordinary application for the
endoscopist. It requires, however, a considerable degree of endoscopic expertise, along with additional
knowledge of the anatomy and ultrasonographic representations of the chest and abdomen. To be
able to integrate this information and perform the procedure competently, the endoscopist must begin
with a practical knowledge of ultrasonography.1(402)

Properties of Ultrasound Waves

Ultrasound waves within the human body are mechanical pressure waves that are propagated in
longitudinal fashion. They are characterized by their frequency (the distance between successive
waves) and their wavelength (the span of a wave in space). The speed of ultrasound waves in a
medium is called the acoustic velocity and is the product of the wavelength times the frequency.
Therefore, of necessity, ultrasound waves of high frequency must have short acoustic wavelengths.
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The acoustic velocity of ultrasound waves in the human body is relatively constant, measuring 1540
m/sec. As shall be seen later, variations in acoustic velocity have great import for ultrasound imaging.
The acoustic impedance of a tissue is related to the tissue's mechanical properties and is defined as
its density times the acoustic velocity. Acoustic impedance is a primary predictor of echo reflection
between two different tissues.
Ultrasound imaging is accomplished when pulsed ultrasound is produced by a transducer and is
reflected by tissue interfaces in the human body. Reflected sound is received by the transducer.
Because acoustic velocity within soft tissues is assumed to be constant at 1540 m/sec and the time
between sound pulse transmission and reception is known, the distance between the transducer and
the reflecting object or surface may be calculated. In this sense, time is equated to distance in
ultrasound imaging.
In addition to the positional information provided by the time delay between sound transmission and
reception, the strength or amplitude of the received echoes is displayed on a monitor. Typically, a black
background is used, with a gray scale shading toward white representing increasing echo amplitude.

Interaction of Ultrasound with Matter

Displayed echoes on an ultrasound screen are created by an acoustic impedance mismatch between
adjacent tissues. Large, smooth surfaces, such as the liver capsule, are specular reflectors that
transmit a portion of the ultrasound beam into deeper soft tissues and reflect the rest. Specular
reflectors are visualized only when the incident ultrasound beam is perpendicular to the reflector
surface (Figure 111). Smaller reflectors result in more diffuse echoes that are scattered in all
directions, with a small proportion returning to the transducer receiver (Figure 112). These diffuse
reflectors form the basis for imaging organs and organ boundaries within the human body.24(403)

(404)Figure 111. Specular reflector. A, When sound leaving the transducer (T) strikes a
specular reflectorsuch as that which occurs between two tissue interfaces (T1Tr)in a
perpendicular fashion, a portion of beam will be propagated distally and a portion will be
reflected back to the transducer for display (dashed arrow). B, If the incident beam is not
perpendicular to the specular reflector, the reflected portion of the beam will not be returned
to the transducer (dashed arrow), and the angle of incidence will equal the angle of reflection.

(405)Figure 112. Smaller reflectors. Scattering from smaller tissue reflectors occurs in all
directions. A small portion of the beam will be reflected back to the transducer (T) for display.
When sound enters the human body, it can be absorbed, refracted, or reflected. Attenuation of the
ultrasound beam is due primarily to tissue absorption, with energy conversion to a small amount of
heat.24(406) Refraction is the change in direction of an ultrasound beam that occurs as it crosses
different tissues with different acoustic velocities. Refraction, which may occur at a soft tissue-fat
interface within the abdomen, results in a misregistration of the reflector position on the ultrasound
monitor (Figure 113).

(407)Figure 113. Refraction. Sound waves (arrows) traveling through two tissues (T1, T2)
with differing acoustic velocities may misregister the position of a reflector on the television
monitor owing to refraction. Light graytissue interface; black ovalactual reflector
position; dark gray ovalprojected position on monitor.
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Attenuation of the ultrasound beam is directly related to transducer frequency; the reduction in intensity
with increasing frequency is logarithmic. Therefore, evaluation of deeper structures within the human
body requires lower-frequency transducers despite their limited resolving powers. Ultrasound
equipment compensates for ultrasound beam attenuation by boosting echoes returning to the
transducer from deeper tissues. This represents the time-gain compensation (TGC) curve, which can
be manipulated by the operator. The TGC curve prevents echoes arising in deeper structures from
appearing as decreased in amplitude owing to beam attenuation. In addition, the amplitude of returning
echoes is often compressed because of ultrasound monitor limitations. The degree of compression
can be manipulated in a postprocessing fashion to enhance subtle echo amplitude differences
between tissues.

Originally, ultrasound information was displayed in amplitude mode (A-mode), with a vertical axis
representing the amplitude of returning echoes and the horizontal axis distance. Current ultrasound
equipment uses a brightness (B-mode) display on the cathode ray or television tube, with brightness
representing received echo amplitude. Representation of echo amplitudes in shades of gray is called
gray scale imaging. Returning echoes are stored and processed by a scan converter, which then
displays the spatial origin of echoes and gray scale amplitude on the monitor screen.4(408)
The original B-mode scanners stored information on spatial location of echoes and echo amplitude
formed during a prolonged scan time. The image was displayed in a static fashion. All modern
ultrasound equipment is capable of acquiring data at a rate fast enough to produce a real-time image
with true temporal resolution. Because all echoes from a pulse of ultrasound must be returned to the
transducer before the next pulse is generated, a limitation is imposed on the information that can be
displayed. As the frame rate increases, temporal resolution is improved but spatial resolution
decreases. Therefore, real-time ultrasound imaging represents a compromise between spatial and
temporal information.2,3(409)

Transducer Technology
Ultrasound transducers contain piezoelectric crystals that are deformed when a voltage is applied.
Therefore, ultrasound waves are produced with a frequency corresponding to the alternating voltage
source. Of equal importance are the returning echoes from the human body. These exert mechanical
pressure on the piezoelectric crystals, which in turn induces a voltage. This voltage, when amplified, is
the basis for echo display on a television monitor. Most piezoelectric crystals are manufactured and
can be shaped for different transducer specifications.24(410)
Many types of ultrasound units and transducers are available for real-time imaging. The simplest is a
mechanical sector that usually employs a single oscillating element and a traditional triangular field of
view. The element motion may be expanded to 360 degrees in certain transducers for specific
purposes, such as endoscopic ultrasonography.
A linear array transducer is composed of multiple elements that are fired sequentially along a relatively
broad surface. Focusing of the ultrasound beam is better than with mechanical sector transducers, and
visualization of the tissues adjacent to the transducer is improved. The curved linear array is similar but
provides a more accessible scan head than does linear array equipment.
Phased array transducers use time delays between excitation of adjacent elements and reception of
returning echoes to electronically steer the ultrasound beam. Phased array transducers produce a
sector-shaped field of view and have the advantages of a relatively small size and electronic focusing.
Annular array transducers employ concentric ring elements with mechanical scanning. This
arrangement also allows electronic focusing, which is not possible with single-crystal transducers.
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Determinants of Image Quality

Spatial resolution of an ultrasound image is determined by the number of lines per displayed frame. As
previously noted, the lines per frame and therefore spatial resolution must decrease as frame rate
increases. Imaging blurring occurs as a result of echo averaging of smaller reflectors and reception of
echoes from strong receptors at multiple points. Small sample volumes diminish blur inherent in
ultrasound images and improve spatial resolution.
Resolution has both axial and lateral components. Axial resolution refers to the ability to distinguish
echo reflectors in the same direction of the ultrasound beam. Axial resolution is improved by
shortening or damping the ultrasound pulse (Figure 114). High-frequency transducers produce brief
pulses and thus improve axial resolution. Lateral resolution refers to the ability to separate echo
reflectors that are perpendicular to the ultrasound beam. Lateral resolution is intimately related to
transducer beam width. As the beam width decreases, the sample volume and lateral resolution
improve. Narrower beam patterns are achieved with higher-frequency transducers, resulting in an
increase in lateral resolution.

(411)Figure 114. Axial resolution. A, A short ultrasound pulse is able to distinguish two
echo reflectors oriented in the same direction as the ultrasound beam. B, With a longer
ultrasound pulse, axial resolution is degraded, and the two echo reflectors are displayed as a
single, elongated echo complex on the monitor. Ttransducer.
The resolution of an ultrasound beam is not constant through its field of view. Although axial resolution
does not vary substantially throughout the image, the width of the ultrasound beam changes and
results in perceptible changes in lateral resolution (Figure 115). The transducer focal zone represents
the portion of the ultrasound beam that produces the best spatial resolution (Figure 116). The focal
length is the distance from the transducer face to the narrowest portion of the focal zone. The near
field represents the distance from the transducer face to the start of the focal zone (Figure 117). In
the near field, returning echo information is distorted for unfocused transducers and does not represent
the actual pattern of reflectors in this region.24(412)

(413)Figure 115. Lateral resolution. Two reflectors perpendicular to the ultrasound beam
axis are best discriminated when beam width is minimized. In the widest portion of the beam,
two echo reflectors may be displayed on the monitor as a single echo complex. Ttransducer.

(414)Figure 116. Focused transducer. The focal zone represents the narrower portion of the
ultrasound beam with optimum spatial resolution. The focal length is the distance from the
transducer (T) to the narrowest portion of the focal zone.

(415)Figure 117. Unfocused transducer. The ultrasound beam is composed of a near field
and a far field. Reflector information obtained in the near field may be distorted.
Although the focal length and focal zone can be manipulated, the length of the focal zone increases
with increasing focal length. As the transducer aperture increases, the transducer focus improves with
a narrower beam, but focal length decreases. These principles have important implications for
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transducer design and selection for clinical applications. A transducer designed with a short focal
length to evaluate structures close to the transducer has a correspondingly short focal zone.
Single-crystal transducers are limited by a fixed focal zone; therefore, good spatial resolution is
achieved in only a very narrow range of depths. Single-element transducers are focused by means of
an acoustic lens or curved piezoelectric crystal design. Multielement transducers allow the operator to
select the focus zone most appropriate to the structures being interrogated. More complex focusing
techniques provide optimum focusing characteristics throughout all depths of the ultrasound image.

Ultrasound Artifacts
Artifacts occur commonly in ultrasound imaging and must be recognized by the operator in order to
produce accurate, high-quality images and avoid interpretive errors. In addition, artifacts often provide
useful information that helps to characterize structures visualized during the course of the examination.
Shadowing occurs when the ultrasound beam is completely reflected or absorbed at a tissue interface.
Typically, this is seen with gallstones and is represented by a lack of sound or a black streak deep to
the reflecting structure (Figure 118). Gas also may produce acoustic shadowing that is characterized
as "dirty" owing to reverberation and ring-down artifact. Reverberation occurs when a pulse of
ultrasound is reflected multiple times, therefore delaying its return to the transducer. This is displayed
as artifactual echoes in the region of shadowing. A ring-down or "comet-tail" artifact occurs when a
reflector prolongs the train of echoes returning to the transducer. This type of artifact is typically seen
with air or metal and has also been described with cholesterol deposits and adenomyomatosis
involving the gallbladder.

(416)Figure 118. Shadowing. When the ultrasound beam is completely reflected or absorbed
at a tissue interface, such as calcification (Ca), absence of sound distally will result in acoustic
shadowing compared with surrounding tissues (long arrows).
Fluid-filled structures produce enhanced transmission of sound. In essence, fluid attenuates the sound
beam less than adjacent tissues; therefore, an increase in transmitted sound deep to the fluid structure
is seen (Figure 119). This results in increased amplitude of returning echoes, with a width
corresponding to the width of the fluid collection. Fluid structures also cause refraction of the
ultrasound beam with bending inward of the sound. This also produces brighter echoes deep to a fluid
structure. At the edges of a cyst or other well-defined fluid collection, refractive shadowing occurs
owing to bending of the edge of the sound beam away from the center of the beam and a resultant
decrease in echo intensity.

(417)Figure 119. Increased sound transmission. Sound originating from the transducer
(black arrows) is not significantly attenuated by fluid as is sound in surrounding tissues (gray
arrows). This results in apparent increased echo amplitude beyond a fluid collection.
A mirror-image artifact occurs at highly reflective interfaces. A portion of the returning ultrasound beam
may be delayed in returning to the transducer and produce a mirror image of the reflecting surface
displayed at a different depth. If the ultrasound beam is wider than an interrogated fluid collection,
external reflectors may be projected into the fluid. This is commonly seen as artifactual sludge within
the gallbladder. Although the speed of ultrasound is assumed to be constant in soft tissues, acoustic
velocity does vary and can produce misregistration of reflector positions. Fat within the human body
has an acoustic velocity approximately 6% less than that of other soft tissues. The location of the fatty
reflectors is misrepresented in the ultrasound image, and reflectors deep to the fat are also
misregistered owing to prolonged ultrasound beam transit time.
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Finally, owing to inhomogeneity in the ultrasound beam, off-axis artifacts may occur where reflectors
outside the beam return echoes to the transducer. This results in an artifactual display of these
reflectors within the ultrasound image.

Principles of Doppler/Duplex Sonography

When ultrasound waves strike moving reflectors, such as red blood cells, the returning frequency of
the reflected wave is shifted. Such Doppler-shifted frequencies are measured in the kilohertz range, as
opposed to frequencies in the megahertz range in diagnostic ultrasound imaging. Doppler equipment
can measure these frequency shifts and, by application of the Doppler equation, produce an accurate
estimate of blood velocity.
Continuous-wave Doppler ultrasound produces a continuous signal, and a separate receiving
transducer receives this signal for Doppler-shifted frequencies. These Doppler-shifted frequencies are
displayed graphically as frequency versus time. Continuous-wave Doppler ultrasound provides no
positional information and may interrogate multiple blood vessels in its course simultaneously.
Pulsed Doppler ultrasound works on the same principle as ultrasound imaging: A limited pulse of
ultrasound is transmitted and received by a single transducer, and the time delay of the returning pulse
provides positional information. This gives the operator the ability to select a particular sample volume
depth but cannot provide exact positional information unless it is coupled with ultrasound imaging.
Duplex sonography is a combination of pulsed Doppler ultrasound and real-time imaging. This allows a
visual depiction of sample volume location, and the size of the sample is adjustable as well. By directly
visualizing sampled vasculature, the angle between the transmitted ultrasound beam and the blood
flow axis, termed the Doppler angle, can be accurately characterized, thus producing highly accurate
velocity tracings. Duplex sonography systems rapidly oscillate between imaging and Doppler
capabilities to provide apparent real-time characteristics, but competition between these two
components causes loss of detail.5,6(418)

Color Doppler Imaging

Color Doppler imaging provides a visual, color-encoded representation of flow superimposed on a
two-dimensional ultrasound image. A process of autocorrelation is usually used in color Doppler
imaging to detect relative motion over time. This approximates pulsed Doppler sampling, in which the
entire field of view is summated by multiple gates to provide a large sample volume.
Color Doppler imaging provides visual information on relative direction of blood flow and mean blood
velocity (see Chapter 25: Endoscopic Blood Flow Analysis). Color encoding is used to depict the
direction of blood flow, with flow toward the transducer conventionally portrayed as red and flow away
from the transducer as blue. In addition, Doppler-shifted frequency information is used to display mean
velocity of flow as color shading or hue; this may vary, for example, from deep red for slower-moving
blood to white for higher-velocity systems.7(419)
Color Doppler imaging has several advantages in the evaluation of vascular structures. It provides a
rapid assessment of vascular patency and flow directionality. For small vessels or diseased vessels
with off-axis flow streams, color Doppler imaging may improve estimation of the Doppler angle for
pulsed Doppler sampling and provide more accurate velocity information. Color Doppler imaging allows
visualization of small vessels not seen with gray scale imaging, which is particularly important in the
evaluation of smaller branch vasculature. The addition of color Doppler imaging often decreases
examination time and increases operator confidence by visually depicting normal and abnormal flow
The information provided by color Doppler imaging is, however, limited. In many clinical circumstances,
detailed information on the characteristics of blood flow is needed, such as absolute blood velocity and
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resistance in the vascular system. In these instances, information obtained by pulsed Doppler imaging
is critical, and color Doppler imaging provides guidance for pulsed Doppler sampling.


Kremkau FW. Diagnostic Ultrasound: Principles, Instruments and Exercises. 3rd ed.
Philadelphia: WB Saunders. 1989.
Goldstein A. Physics of ultrasound. In Rumack CM, Wilson SR, Charboneau JW (eds).
Diagnostic Ultrasound. St. Louis: Mosby-Year Book, 1991;218.
Sprawls P. Physical Principles of Medical Imaging. Gaithersburg, MD: Aspen Publishers.
Curry ST III, Dowdey JE, Murry RC. Christensen's Physics of Diagnostic Radiology.
Philadelphia: Lea & Febiger. 1990.
Nelson TR, Pretorius DH. The Doppler signal: Where does it come from and what does it
mean?. AJR 1988;151:43947.
Taylor KJW, Holland S. Doppler US: Part I. Basic principles, instrumentations, and pitfalls.
Radiology 1990;174:297307.
Mitchell DG. Color Doppler imaging: Principles, limitations, and artifacts. Radiology
Foley WD, Erickson SJ. Color Doppler flow imaging. AJR Am J Roentgenol 1991;156:313.

Chapter 12 Chromoscopy


Esophagus, Stomach, and Duodenum

Chromoscopy, a unique method of accurate diagnosis of many gastrointestinal disorders, provides a
variety of new findings and information that cannot be obtained by standard endoscopy.1,2(423)

No special premedication is necessary for chromoscopy except for examination of the stomach.
Gastric mucosa is covered with large quantities of mucus that inhibits observation. Therefore,
procedures for the elimination of mucus are always necessary for chromoscopy of the stomach.
An anticholinergic agent is given intramuscularly to suppress evacuation of the mucus-clearing solution
from the stomach. The gastric mucus-clearing solution consists of dimethylpolysiloxan, Pronase (a
proteinase enzyme) (Kaken Pharmaceutical Co., Ltd.), and sodium bicarbonate (Figure 121). The
temperature of the solution should be about 40 C, as this promotes the activity of the enzyme. Sodium
bicarbonate maintains the Pronase solution at an optimum pH value. The mucus-clearing solution
must wash over all gastric mucosal surfaces. This may be accomplished by asking the recumbent
patient to roll over once every minute for about 10 or 15 min.

(424)Figure 121. Procedure for elimination of gastric mucus using a proteinase enzyme.

Methods for Spraying the Dye Solution

Two spraying methods are used: direct and indirect. With the direct method, which can be used
throughout the gastrointestinal tract, a dye solution is simply sprayed over the mucosa during
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endoscopic observation by means of a syringe and a catheter inserted through the accessory channel
of the endoscope. The indirect method is used only in the stomach. After premedication and the gastric
mucus-clearing procedure have been completed, the patient takes the dye orally and once again
repeatedly changes position by rolling over, so that the dye reaches all gastric mucosal surfaces. At the
conclusion of the examination, any remaining pools of dye should be aspirated.

Technique and Application

Three basic types of chromoscopy are used in gastrointestinal endoscopy at present: contrast,
staining, and reaction methods (Table 121).




Dye collects in
Absorption or
permeation of



More precise

Indigo carmine

intestinal and
colonic diseases

Methylene blue


Lugol's solution

Reaction with cell

constituent or

Congo red

Congo red

Contrast Method
The contrast method highlights irregularities in the mucosal architecture by pooling of a blue dye
solution in mucosal grooves and other interstices. This improves the precision of endoscopic diagnosis
by defining minute and inconspicuous lesions and structures that might otherwise be overlooked with
conventional endoscopic methods. Some of the applications of this method are:
1. Observation of the minute structure of the gastrointestinal tract, such as areae gastricae,
duodenal villi, and colonic areas.
2. Confirmation of the existence of a very small lesion, such as a gastric erosion or a small colonic
3. Differentiation of certain lesions as either benign or malignant.
4. Determination of the extent of infiltration of a malignant lesion.
5. Certain applications in conjunction with magnifying endoscopy.
Dye spraying may be either direct or indirect with the contrast method (Figure 122). In the direct
method, a 0.2% indigo carmine solution is sprayed after the standard endoscopic evaluation has been
completed. If the stomach is to be examined, the mucus-clearing procedure must be completed before
endoscopy. In the indirect method, which is applied in the stomach and the duodenal bulb, 10 ml of a
3% indigo carmine solution is given orally at the same time that the patient takes the mucus-clearing
solution. We prefer the simple indirect method.

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(425)Figure 122. Contrast method using indigo carmine solution.

Staining Method
The staining method is based on absorption of dye by epithelial cells or permeation of the dye into
necrotic tissue.3(426)
Staining can be used to diagnose certain diseases, pathologic conditions, and states of the mucosa
that are difficult to recognize with certainty by conventional endoscopic observation. Some examples
are gastric intestinal metaplasia and the status of the colonic mucosa in ulcerative colitis, that is,
whether the inflammatory process is active or healed.
Direct and indirect methods of dye application may be used in the stomach as outlined in Table 122,
but the indirect method is preferable because directly sprayed dye promptly flows away and is not fully
absorbed. In the duodenum, small intestine, and colon, however, a 0.1 to 0.5% dye solution is sprayed
directly over the mucosa. After 1 to 2 min, the mucosa must be washed with water to observe the
stained surface.

Staining Method Using

Methylene Blue Dye

1. Procedure for elimination of gastric mucus
2. Conventional endoscopic evaluation
3. Spray 0.1 to 0.5% methylene blue solution on mucosa
4. Wash mucosa with water 1 to 2 min later
5. Endoscopic chromoscopic observation
1. Procedure for elimination of gastric mucus
2. Oral administration of 20 ml of 0.5 to 0.7% methylene
blue solution in conjunction with the gastric
mucus-eliminating solution
3. Patient rolls over once every minute for 10 to 15 min
4. Endoscopic chromoscopic observation

Reaction Method
In the reaction method, a dye applied to a mucosal surface reacts with a constituent of the epithelial
cell or with some mucosal secretion. There are two types: the Lugol method and the Congo red
Lugol's Method
Nonkeratinized squamous epithelial cells contain abundant glycogen that reacts with Lugol's
solution.4(427) This reaction has been used in the diagnosis of esophageal diseases such as
esophagitis and carcinoma.5(428) After standard endoscopic evaluation, 1.5 to 3.0% Lugol's solution is
sprayed directly over the entire esophageal mucosal surface. Normally, the mucosa turns brown within
1 to 2 sec.
Congo Red Method
The Congo red method is based on the reaction that occurs between this dye and secreted
hydrochloric acid.6(429) It is therefore useful in defining the extent of the acid-secreting fundic mucosa.
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The fundic mucosa changes from red to dark blue; the antral mucosal surface does not change color.
The original technique for the Congo red method is as follows: After conventional endoscopic
observation, a mixture of 0.3% Congo red and 5% sodium bicarbonate solution is sprayed over the
gastric mucosa. Tetragastrin, 5 g/kg, is then injected intramuscularly. The mucosa is then observed
for 15 to 30 min until no further extension of discolored areas occurs. This method is not suitable for
morphologic observation.

Endoscopic Appearance
Reaction Method
After direct spraying with Lugol's solution, the normal esophageal mucosa stains brown or dark brown
and has a fine mucosal pattern suggesting a wrinkled texture. Areas of leukoplakia stain a striking dark
brown. Esophagitis with or without erosions and esophageal cancer are not stained by Lugol's solution.
This method is useful for detecting early cancer and for defining the boundaries of invasive cancer. A
superficial esophageal carcinoma, shown in Figure 123A, is well delineated as a whitish lesion after
spraying with Lugol's solution (Figure 123B).

(430)Figure 123. Superficial cancer of the esophagus. A, Conventional endoscopy. B, After

being sprayed with Lugol's solution, the cancer is more clearly delineated.

Stomach and Duodenum

Contrast Method
With the contrast method, the normalthat is, acid-secretingfundic mucosa of the proximal stomach
is thick and reddish, whereas the pyloric (antral) mucosa and non-acid-secreting fundic mucosa that
are affected by fundal gastritis are thin and yellowish (Table 123).7(431) Nonsecreting mucosa
observed in the proximal stomach corresponds to atrophic gastritis.

Chromoscopic Features of Fundic

and Pyloric (Antral) Mucosa

Areae Gastricae





Well defined
Close, regular

Poorly defined

The term areae gastrica, it will be recalled, refers to a small area superimposed on the gastric mucosa
by a system of furrows. These grooves subdivide the mucosa into areas (areae gastricae) of 1 to 5 mm
in diameter. The areae gastricae of the fundic mucosa are usually regular in size and arrangement;
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those of the other non-acid-secreting fundic mucosa and pyloric mucosa are generally irregular. The
former are called Type F and the latter Type P. Each type is divided, based on appearance, into four
subtypes (Figures 124, 125 and 126). At the higher end of the scale, that is, F3 or P3, the mucosa
is atrophic. Areae gastricae express histopathologic findings that can be diagnostic for atrophic

(432)Figure 124. Classification of areae gastricae.

(433)Figure 125. Examples of classification of areae gastricae in the fundic mucosa. A, F0;
B, F2.

(434)Figure 126. Examples of classification of areae gastricae in the pyloric (antral) mucosa.
A, P1; B, P2.
The distal border of the acid-secreting fundic mucosa in the stomach can be easily recognized
because of the differences in mucosal characteristics and the pattern of the areae gastricae. The
border is not uniform in position in the stomach from individual to individual, especially along the lesser
curvature. Two general types are recognized. In the open type, the lesser curvature of the gastric body
is covered with non-acid-secreting fundic mucosa; in the closed type, the lesser curvature mucosa is
acid-secreting fundus (Figure 127). The open and closed types are subdivided into three subtypes
according to the extent of the pyloric type of mucosa; that is, in the order of Type C0 to O3 the extent
of the normal fundic mucosa progressively decreases, with a corresponding decrease in acid
secretion. An example of a patient with a Type C2 pattern is shown in Figure 128.

(435)Figure 127. Schematic diagram illustrating closed and open types of (fundic-pyloric)
mucosal border patterns in the stomach as well as the subclassification of each type. The top
row of figures represents the entire stomach opened as a gross specimen along the greater
curvature. The bottom row of figures illustrates endoscopic views of the stomach
corresponding to the figures in the top row.

(436)Figure 128. Fundic-pyloric mucosal border. A, Region of the stomach proximal to the
angulus in a patient with the closed type of distribution. B, Mucosal border on the greater
curvature of the antrum.
The contrast method is very effective in detecting early gastric cancer, especially minute and Type IIb
carcinomas (Japanese classification of early gastric cancer), and in recognizing the extent of
cancerous infiltration in the mucosa.8(437) An example of early gastric cancer in the body of the
stomach (Type IIc, similar to IIb) is shown in Figure 129.

(438)Figure 129. Early gastric cancer (Type IIc, similar to Type IIb). A, Conventional
endoscopy. B, Direct contrast method demonstrates irregular erosion, greater extent of
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involvement, spread into the surrounding mucosa, abnormal red granulation, and tapered
folds. All findings indicate malignancy.
The contrast method is useful in differentiating benign from malignant ulcers. A small erosion that
produces a very shallow depression without elevation of the surrounding mucosa is very difficult to
detect endoscopically. However, with the contrast method, recognizing such lesions and defining their
size, shape, number, and distribution are not difficult (Figure 1210).

(439)Figure 1210. Erosive gastritis, antrum. A, Conventional endoscopy showing a few red
spots. B, Multiple small erosions demonstrated by contrast chromoscopy with indigo carmine
Precise endoscopic evaluation of peptic ulcer healing is extremely important because the approach to
treatment may be significantly altered by endoscopic findings. Chromoscopy using the contrast method
provides a very accurate assessment. Even when conventional endoscopy evaluation indicates that
the ulcer has healed, in the majority of cases, the contrast method reveals a small depression
consisting of a defect in the regenerated epithelium (Figure 1211). In the strict sense of the term, the
ulcer has not yet healed and may recur. Therefore, evaluation of ulcer healing should be performed
using the contrast method and detailed observation.

(440)Figure 1211. Evaluation of gastric ulcer healing. A, Conventional endoscopy suggests a

healed ulcer. B, Chromoscopy (indirect method) performed immediately after conventional
endoscopy reveals a depression in the center that indicates incomplete healing.
Chronic active gastritis can accompany gastric erosions, which are thought by some investigators to
produce a variety of symptoms, including epigastric discomfort. Chronic active gastritis may be
manifest as redness of the mucosa. This may have a comblike patternthat is, multiple, long,
frequently narrow red lines in the fundic mucosa that are arranged in parallel fashion (Figure 1212).
The use of contrast chromoscopy reveals associated erosions in many patients with comblike redness
and unexplained epigastric discomfort or pain.

(441)Figure 1212. Comblike redness and linear erosions, gastric body. A, Comblike redness
by conventional endoscopy. B, Linear erosion on a reddened fold are revealed by contrast
The villous pattern of the duodenum and individual villi are clearly defined by the contrast method. In
the example shown (Figure 1213), two microerosions are present in a duodenal bulb where the
mucosal pattern has an otherwise normal villous appearance. Such erosions are found frequently. The
contrast method is also helpful in determining whether a duodenal ulcer has healed completely.

(442)Figure 1213. Normal villi and two microerosions in the duodenal bulb (contrast
Staining Method
Two groups of stomach lesions are defined by in vivo staining chromoscopy. Group 1 comprises the
lesions that have absorptive cells and regular papillae; like villi, they are stainable by spraying
methylene blue on their surface. The papillae thus stained can be seen when the tip of the endoscope
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is close to the mucosal surface or when high-magnification endoscopy is used (Figure 1214). The
lesions in Group 2 do not have stainable, regular papillae. The staining method in this group is based
on permeation of methylene blue into tumor tissue. The lesions in Group 1 include intestinal
metaplasia, adenoma, and polyps consisting of intestinalized mucosal tissue. Group 2 lesions
comprise protruded gastric cancers that are covered by necrotic tissue and debris.

(443)Figure 1214. Close-up view of intestinal metaplasia stained with methylene blue.
Reaction MethodCongo Red
The Congo red method demonstrates the extent of acid-secreting mucosa (Figure 1215). Once
discoloration takes place, the junction of the acid-secreting and non-acid-secreting mucosal areas is
sharply defined.

(444)Figure 1215. Endoscopic appearance after Congo red method. Very dark purple color
develops in acid-secreting mucosa.
Mucosal Border and Gastroduodenal Disease
As noted previously, the distribution pattern for acid-secreting fundic mucosa and the
non-acid-secreting mucosa in the stomach and hence the border between these two areas differ from
individual to individual. In general, the demarcation between the two types of mucosa moves in an oral
direction with increasing age; that is, in a group of patients, the predominant classification changes
from C0 toward O3 as age increases (Figure 1216). Gastric cancer and polyp formation, within this
classification, are found with highest frequency in patients with the greatest proximal extent of the
pyloric (antral) type of mucosa, that is, those in Type O3. Furthermore, the frequency of these
disorders gradually increases as the classification changes from C0 toward O3. Conversely, the
frequency of duodenal ulcer, gastric erosions, and superficial gastritis decreases as the border moves
in a distal direction; that is, the highest incidence is found with the C0 classification.

(445)Figure 1216. Types of mucosal border by age group.

The more proximal the location of a peptic ulcer, the more proximal the demarcation between the two
types of mucosa. In other words, an ulcer in a proximal position is found in fundic mucosa, which
occupies a relatively small percentage of the total gastric mucosal surface area, and generally the acid
output of the stomach is low. More than 90% of patients with active duodenal ulcers have a closed-type
mucosal pattern, and open types O2 and O3 are not found. The comblike redness characteristic of
chronic active fundal gastritis, as expected, is more often found when the mucosal pattern is the closed

Small Intestine
The mucosal surface of the small intestine is covered by numerous minute villi of various shapes. The
villi of the duodenal bulb and ileocecal valve have a ridgelike form, but those of the distal parts of the
duodenum, jejunum, and ileum have a regularly arranged finger shape.
Application of chromoscopy in the small intestine focuses mainly on observation of the villi;
high-magnification fiberscopes are frequently used in conjunction with chromoscopy (see Chapter 13:
Magnification Endoscopy). Two of the various magnifying endoscopes suitable for close observation of
the villi are the SIF-M and the SIF-HM (both Olympus Optical Company, Ltd.) (Table 124). Use of the
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SIF-M and SIF-HM for close observation permits photography at magnifications of 10 to 35.9(446)


Optical system
Angle of view field
Range of observation
Magnifying rate

Insertion tube
Outer diameter (mm)
Angle mechanism
Up, down

Technical Specifications of Magnifying Endoscopes

















180, 90












Right, left
Biopsy channel
Inner diameter (mm)
Working length (mm)
Whole length (mm)
* Magnifying optical system.

The magnifying enteroscope is introduced into the small intestine via the anus or mouth. With the
instrument in place, and after the standard inspection, 10 ml of 0.1% methylene blue solution is
sprayed on the mucosa. Staining of the villi occurs rapidly.
The villi have any of several different shapes or forms.10(447) In almost all parts of the small intestine
they are finger-like. A few villi with a wider form (tonguelike) may be found among the finger-shaped
villi, but these are thought to be a variation of normal.
The villi of normal duodenal mucosa are well stained with methylene blue. This method reveals
complete or incomplete healing of a duodenal ulcer and demonstrates complete versus incomplete
reepithelialization. An ulcer scar takes the same stain as surrounding mucosa, and this indicates
complete reepithelialization and therefore complete healing, with the likelihood that a particular ulcer
will not recur.
The villi are irregular in shape and arrangement in inflammatory bowel disease and are sometimes lost
completely. In an area of tuberculous scarring of the intestine, the villi are finger-shaped or leaf-shaped
but vary in size, and their arrangement is irregular and sporadic (Figure 1217); also, the absorption of
methylene blue in the area of the scar is less than that of normal villi. In Crohn's disease, the villous
pattern is irregular with a leaf or ridge convolution form (Figure 1218). It is interesting that in Crohn's
disease the villi that are distant from an obvious inflammatory focus and seem to be intact by
endoscopic observation actually have an atrophic appearance when studied by magnification

(448)Figure 1217. Atrophic villi of intestinal tuberculosis.

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(449)Figure 1218. Irregular villi of the ileum in Crohn's disease.

When a villus becomes abnormal, a striking reduction occurs in the total number of constituent
epithelial cells. Thus, a leaf-shaped villus has only about one fourth the number of epithelial cells of a
normal finger-shaped villus; those with a convolution form have only one eighth the normal number.
Such morphologic abnormalities can be found, for example, in the intestinal villi of postgastrectomy
patients. These and similar abnormalities are thought to correspond to a malabsorptive condition in the
mucosa and to reflect the pathophysiologic state of the small intestine.

The surface of the colonic mucosa has a granular appearance and is demarcated by innominate
grooves; demarcated regions are called the colon area on the basis of radiologic and endoscopic
findings. The innominate grooves circumscribe areas on the colonic mucosa that contain numerous
pits, representing the glands or crypts of Lieberkhn. These minute pits are arranged in a regular
pattern and are round or somewhat oval. The diameter of each pit is 40 to 50 m. About 40 to 60 pits
are present in one colon area.
When a blue dye such as indigo carmine or methylene blue is sprayed on the surface of the colonic
mucosa, the colon areas as defined by grooves are observable without difficulty.11(450) Several
normal variations in the shape of the colonic mucosal areas can be seen: spindle, oval, and so on.
The minute structures of the colonic mucosa can be observed as a fine network pattern with the aid of
chromoscopy, but smaller pits cannot be seen. Observation of such minute pits requires the use of a
magnifying colonoscope. Several instrument types have now been devised (Table 124).11,12(451)
Magnifying colonoscopes have almost the same characteristics as conventional colonoscopes except
that their optical systems can provide mucosal images that are magnified from about 35 to 170.
With the use of chromoscopy and a magnifying colonoscope, numerous minute pits, which represent
the glands of Lieberkhn, are seen in the colonic mucosal areas circumscribed by the innominate
grooves (Figure 1219). These minute pits are arranged regularly and are round and oval.

(452)Figure 1219. Magnified view of the normal colon mucosa using CF-200HM (50).
Minute round pits are arranged regularly.
Polypoid Lesions
The surface appearance of a polyp or the margin of a flat or diminutive polyp is more clearly observed
with chromoscopy than with conventional colonoscopy alone. The minute structure of polypoid lesions
can also be observed with a magnifying colonoscope.
Polyps are classified into four categories according to the shape or arrangement of pits (Table 125):
circular, tubular, sulcus, and irregular (Figure 1220). Metaplastic polyps belong to the circular type;
adenomatous polyps may be circular, tubular, or sulcus types and are quite regular in shape and
arrangement. All cases of advanced cancer fall into the irregular type. Almost all cases of early cancer
also belong to the irregular type. However, some have a tubular or sulcus pattern like that of the benign
adenoma. The diagnosis of early or diminutive cancer with the magnifying colonoscope remains
problematic, and further improvements in both magnifying capabilities of endoscopes and
chromoscopy are required.

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adenoma. The diagnosis of early or diminutive cancer with the magnifying colonoscope remains
problematic, and further improvements in both magnifying capabilities of endoscopes and
chromoscopy are required.

Classification of Minute Structure

of Polypoid Lesions of the Colon
Round type
Tubular type
Sulcus type
Irregular type

Regular round or narrowly deformed pits; a little

larger than normal mucosal pits
Various patterns from circular to oval pits
No pits; formation of cerebral gyrus-like sinuses
Surface shows cauliflower-like, rough, irregular or
nonstructured appearance

(453)Figure 1220. Various types of minute structures of the colon polyp. A, Round type;
round or very nearly round pits that are slightly larger than normal mucosal pits. B, Tubular
type; various patterns from circular to oval. C, Sulcus type; no pits but sinus formation like
cerebral gyrus. D, Irregular type of early cancer; surface shows a cauliflower-like, rough,
irregular pattern.
Ultra-Magnifying Endoscopy
The ultra-high-magnification colonoscope was introduced in 1982 to enhance the recognition of small
colonic cancers.12(454) This instrument, the CF-UHM, which has undergone improvements, has a
magnification capability of 170.
Ultra-high magnification with the aid of chromoscopic techniques offers endoscopic views of the minute
structure of the pits in flat, normal mucosa (Figure 1221). The pits are round or somewhat oval.
Nuclei of the cells are arranged peripherally around the pits, each nucleus being round and regular in
shape. Nuclei of the stroma around the intestinal gland are also visualized clearly.

(455)Figure 1221. Ultra-magnified view of the normal colon mucosa, using CF-UHM
The pits of adenomatous polyps are enlarged and elongated. Nuclei of the gland cells are arranged
peripherally as in flat, normal mucosa. Each nucleus is regular in its arrangement and size. The stroma
is displaced by the glands and reduced in size.
The minute surface structure of early cancer differs from that of both benign polypoid lesions and
normal, flat mucosa (Figure 1222). Pits are displaced by irregular sulcus formation. Nuclei are also
irregular in shape and can be easily differentiated from those of benign colon polyps. Thus, colon
cancer can be accurately diagnosed in its early or diminutive stage with the ultra-magnifying
colonoscope. It is expected that more diminutive cancers will be diagnosed at the stage in which
cancer shows only cellular atypism and not structural atypism.

(456)Figure 1222. Ultra-magnified view of early cancer.

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Yamakawa K, Naito S, Kanai J, et al. Superficial staining of gastric lesions by fiberscopy. In

Proceedings of the First Congress of the International Society of Endoscopy. Tokyo,
Ida K, Misaki J, Kohli Y, Kawai K. Fundamental studies on the dye scattering method for
endoscopy. Jpn J Gastroenterol Endosc 1972;14:2616.
Ida K, Hashimoto Y, Kawai K. In vivo staining of gastric mucosa. Its application to endoscopic
diagnosis of intestinal metaplasia. Endoscopy 1975;7:1824.
Schiller W. Early diagnosis of carcinoma of the cervix. Surg Gynecol Obstet 1933;56:21022.
5. Nothmann BJ, Wright JR, Schuster MM. In vivo vital staining as an aid to identification of
esophagogastric mucosal junction in man. Am J Dig Dis 1972;17:91924.
Okuda S, Saegusa T, Ito T, et al. An endoscopic method to investigate the gastric acid
secretion. In Proceedings of the First Congress of the International Society of Endoscopy.
Tokyo, 1966;2216.
Ida K, Kohli Y, Shimamoto K, et al. Endoscopical findings of fundic and pyloric gland area
using dye scattering method. Endoscopy 1973;5:216.
8. Ida K, Hashimoto Y, Takeda S, et al. Endoscopic diagnosis of gastric cancer with dye
scattering. Am J Gastroenterol 1975;63:31620.
Tada M, Kawai K. Small-bowel endoscopy. Scand J Gastroenterol 1984;19(suppl 102):3952.
10. Tada M, Misaki F, Kawai K. Endoscopic observation of villi with magnifying
enterocolonoscopes. Gastrointest Endosc 1982;28:179.
11. Tada M, Misaki F, Kawai K. A new approach to the observation of minute changes of the
colonic mucosa by means of magnifying colonoscope, type CF-MB-M (Olympus). Gastrointest
Endosc 1978;24:1467.
Tada M, Nishimura S, Kawai K. A new method for the ultra-magnifying observation of the
colon mucosa. J Kyoto Pref Univ Med 1982;91:34954.

Chapter 13 Magnification Endoscopy



Magnification endoscopy refers to a diagnostic endoscopic system for observing changes that occur in
the pits (openings of glands) and the villi of the digestive tract. Diagnosis by observation of morphologic
changes must be based on an established frame of reference. Standard endoscopic diagnosis is
equivalent to observation of findings visible to the naked eye. The frame of reference in magnification
endoscopy is the fine structure formed by punctiform or linearly arranged recesses in the mucosa of
the digestive tract of about 0.1 mm in size. As such, magnification endoscopy is intermediate between
macroscopic and microscopic observation. The structures and findings observable by magnification
endoscopy correspond to those that may be seen by means of a dissecting (stereoscopic) microscope.
Although all endoscopes provide some magnification, the power of standard instruments is insufficient
for observation of fine detail such as pit patterns. Special magnifying endoscopes have been
developed for this purpose. Use of these instruments also requires new systems of endoscopic
diagnosis, such as that which we developed for observation of the gastric mucosa.1(459) This system
of gastroscopy and its related instrumentation were introduced in the first edition of this book.
Excellent resolving power as well as computer processing of digital images (e.g., edge enhancement)
makes detailed observations possible with modern electronic endoscopes (see Chapter 3: Flexible
Endoscope Technology: The Video Image Endoscope). However, the development in Japan of
endoscopic mucosectomy (strip biopsy) for mucosal cancers and its associated requirement for
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detailed diagnosis have redirected attention to the need for magnifying instruments (see Chapter 24:
Early Colorectal Cancer and Endoscopic Resection). The fundamentals of magnification endoscopy
and its application to endoscopic diagnosis using magnifying electronic endoscopes are described in
this chapter.

History of Magnification Endoscopy

Early Development
The origin of magnification endoscopy, that is, the first attempt to observe gastric pits, dates to the era
of rigid gastroscopes. Gutzeit and Teitige2(460) observed foveolae in the body of the stomach and
published their findings in 1954. Subsequently, a diagnostic system based on the shapes of the gastric
pits was developed within the field of pathology. This made use of the dissecting microscope. Salem
and Truelove3(461) in 1964 stressed the value of this system for examination of gastric biopsies,
especially in the diagnosis of gastritis. In Japan, Matsumoto4(462) reported that normal gastric pit
patterns are destroyed and replaced by pseudo-pit patterns in cases of gastric ulcer and gastric
cancer, each having its own characteristic pattern. Yoshii5(463) described normal fine mucosal
patterns (foveolate, foveolate-sulciform, and sulciform) as well as the changes that occur in these
patterns in certain disorders. These types of investigation provide the basis for the diagnostic system of
magnification endoscopy.

The Magnifying Fiberscope

Special fiberscopes for magnification endoscopy have been produced in Japan since l967. Although
many prototypes were produced (Table 131), detailed study1,6,7(464) of the fine mucosal patterns of
the gastrointestinal tract awaited development of the most powerful magnifying fiberscopes such as the
ML series offered by Machida Endoscope Company in 1977 and the HM series offered by Olympus
Optical Company, Ltd. in 1980. High-magnification gastroscopy was performed with the FGS-ML II and
GIF-HM instruments (Figures 131 and 132); the FCS-ML II and CF-HM instruments were used for
magnification colonoscopy. In general, these instruments were forward-viewing fiberscopes with
magnification capabilities ranging from 30 to 35. They provided excellent images of pit patterns, but
they were not popular for clinical applications owing to certain limitations in their handling
characteristics. Production was discontinued in the mid-1980s.


Development of Magnifying Fiberscopes


FGS-ML type 1
FGS-ML, type 2
* Magmagnification capability.


Suzaki and Miyake
Maruyama and Takemoto
Ida and Kawai
Sakaki and Takemoto
Ooida and Okabe
Tada and Kawai
Nishizawa and Kobayashi

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(465)Figure 131. Magnified view of the gastric mucosa at the greater curvature of gastric
angle, using the FGS-ML II model endoscope offered by Machida Endoscope Company.

(466)Figure 132. Magnified view of the gastric mucosa at the greater curvature of the gastric
angle, using the GIF-HM endoscope offered by Olympus Optical Company, Ltd.
An ultra-high-magnification instrument, CF-UHM (Olympus Optical Company, Ltd.), with a magnifying
capacity of 170, was developed by Tada et al.8(467) in 1982. Another system that we9(468)
developed was the FGS-SML (Machida Endoscope Company) with 170 magnification. Cellular
features and the nucleus are considered the frame of reference for these ultra-high-magnification
fiberscopes (Figure 133).

(469)Figure 133. Magnified view (170) of a colonic cancer, using an

ultra-high-magnification endoscope (CF-UHM, Olympus Optical Company, Ltd.). (Courtesy
of Dr. M. Tada.)

Magnifying Endoscopy with Electronic Endoscopes

When electronic endoscopes were initially developed, their excellent resolution, based on high
numbers of picture elements (pixels), was used to advantage as in the TGS-50D introduced by
Toshiba Corporation-Machida Endoscope Company in 1986 (Figure 134). Similar high-resolution
instrument models were offered by the Fuji Photo Optical Company (HR2 series) in 1988 (Figure 135)
in response to interest in observing mucosal pit patterns. Further improvements in resolution were
achieved with the introduction by the Toshiba Corporation in 1992 of instruments (TRE-3000 series)
with a "color" charge-coupled device (CCD) having a high pixel density (Figure 136). All of these are
practical endoscopes that offer not only magnification but also a wide angle of view (more than 100
degrees), features that usually represent conflicting design specifications in a single instrument.
Although the degree of magnification with these instruments is low, it is nevertheless satisfactory for
the observation of pit patterns.

(470)Figure 134. Close-up view of a minute Type IIc early gastric cancer, using the
TGS-50D model endoscope (Toshiba Corporation-Machida Endoscope Company) after
spraying a solution of indigo carmine dye.

(471)Figure 135. View of Type IIa + IIc early gastric cancer, using an EG7-HR2 model
endoscope (Fuji Photo Optical Company).

(472)Figure 136. View of a gastric ulcer scar, using the TGI-3000D endoscope (Toshiba
Corporation). (Courtesy of Dr. Y. Hoshihara.)
Another approach to magnification endoscopy has been to place a movable lens with variable
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magnification between the objective lens and the CCD of an electronic endoscope, the first such
instrument being the GIF-V10Z offered by the Olympus Optical Company, Ltd. This company
subsequently introduced the model GIF-200Z instrument in 1991. After observation in the standard
mode, this instrument is placed close to the mucosa for magnified observation. Once the objective lens
is close to the area of interest, a magnified view is produced by twisting a ring that is incorporated into
the control section of the instrument. Maximum magnification is 35; the magnified image is displayed
as a 1-inch image on a television monitor. Pit patterns can be observed clearly with these endoscopes
(Figure 137). However, the range of focus at magnified views is very narrow; that is, the image is out
of focus unless the objective lens remains within a narrow range of distance from the mucosal surface.
For this reason, time and effort are required to learn the technique of magnification endoscopy with this
type of instrument.

(473)Figure 137. Magnified view of fundic gastric mucosa, using the GIF-200Z model
magnifying endoscope (Olympus Optical Company, Ltd.).
The fine gastric mucosal pattern consists of gastric pits; the diameter of the elements in this pattern is
about 0.1 mm. High resolving power, that is, the ability to distinguish structures as small as 0.01 mm,
such as that offered by FGS-ML and GIF-HM instruments, is required to observe the detailed
morphology of pit patterns. In our experience, a resolving power of less than 0.5 mm, such as that
available with recently introduced electronic endoscopes, is sufficient only for low-magnification
endoscopy, although this allows for recognition of characteristics and differences in pit patterns. The
resolving power of standard endoscopes is about 0.1 cm by our measurements with a metal test plate
of the type used in roentgenography (Micro-chart, Micromedical Company).

Fundamentals of High-Magnification Gastroscopy

The gastric mucosal surface, when observed with magnifying fiberscopes, has a pattern composed of
variously shaped gastric pits. Areas that are slightly reddish are elevated parts of the mucosal surface;
whitish yellow dots and lines are recesses, the former being the gastric pits. We named this
appearance the fine gastric mucosal pattern.
The fine gastric mucosal pattern is divided into two main patterns of depression: discontinuous and
continuous. We have classified these two main patterns as follows: The discontinuous pattern may be
Type A, which has "dotted" depressions (Figure 138), and Type B, which has short linear depressions
(Figure 139). The continuous pattern is divided into Type C, in which the elevated areas are
surrounded by depressions that are characterized as striped (Figure 1310), and Type D, which has
circular depressions (Figure 1311). Three intermediate patterns are also recognized, so that the
combination of Types A and B is named Type AB, the combination of Types B and C is Type BC, and
the combination of Types C and D is Type CD. Therefore, seven pattern types are possible (Figure

(474)Figure 138. Type A fine gastric mucosal pattern (dotted depressions) under
magnification view, using the FGS-ML II model instrument (Machida Endoscope Company).

(475)Figure 139. Type B fine gastric mucosal pattern (short linear depressions).

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(476)Figure 1310. Type C fine gastric mucosa pattern (striped continuous depressions).

(477)Figure 1311. Type D fine gastric mucosal pattern (circular continuous depressions).

(478)Figure 1312. Classification schema of the fine gastric mucosal patterns for
magnification endoscopy.
The fine gastric mucosal pattern is altered in various disease states. The Type A pattern is
characteristic of normal fundic mucosa. This is transformed into the Types B and C patterns with
mucosal atrophy. The normal pyloric mucosa has a fine Type C pattern that transforms to a coarse
Type C pattern when the mucosa is atrophic. Well-differentiated (intestinal) cancer has a characteristic
Type C pattern (Figure 1313), but poorly differentiated (diffuse) cancer shows an uneven surface with
no pit pattern. The Type D pattern indicates previous mucosal destruction and regeneration and is
observed mainly with scarring from ulcers and erosions. The pattern of a hyperplastic polyp is the
same as that of the surrounding mucosa.

(479)Figure 1313. Characteristic irregular type C pattern of a well-differentiated tubular

adenocarcinoma (FGS-ML II, Machida Endoscope Company).

Small Gastric Cancers

Gastric carcinoma can be recognized by its characteristic pit pattern in magnified views. With
advanced carcinoma, however, it is difficult to observe the characteristic pit pattern owing to tissue
destruction and regeneration. Standard observation is more appropriate for the clinical diagnosis of
advanced carcinoma.

Endoscopic Diagnosis
The diagnosis of a small (diameter up to 1 cm) or minute (diameter up to 5 mm) gastric cancers is
difficult by standard methods of observation. Detailed observation using the dye-contrast method
(chromoscopy) is usually required (Figure 1314) (see Chapter 12: Chromoscopy). These small
lesions, in which the characteristic pit patterns are well preserved, are good subjects for magnification
endoscopy (Figure 1315). They have been treated in Japan by endoscopic mucosectomy using the
technique of strip biopsy devised by Tada et al. in 1984.10(480) Well-differentiated mucosal
carcinomas in the stomach with diameters less than 2 cm are considered in Japan to be good
indications for endoscopic mucosectomy, which also has applications in the colon and esophagus (see
Chapter 24: Early Colorectal Cancer and Endoscopic Resection). Flat or depressed cancers can be
resected safely, along with a portion of surrounding normal mucosa. The spread of carcinoma in an
endoscopically resected specimen is assessed by differences in pit patterns observed with a dissecting
microscope (Figure 1316) prior to standard histologic evaluation.

(481)Figure 1314. Close-up view with a conventional fiberscope (GIF-P20, Olympus

Optical Company, Ltd.) of a minute gastric cancer sprayed with indigo carmine dye.
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(482)Figure 1315. Magnified view of the margin of the characteristic pit pattern of a minute
gastric cancer (same lesion as in Figure 1314). (GIF-200Z, Olympus Optical Company,

(483)Figure 1316. Spread of a mucosal gastric cancer as assessed by difference in pit

patterns observed with a dissecting microscope in an endoscopically resected specimen.
(Courtesy of Dr. Y. Iwasaki.)
An early gastric cancer of the papillary type is recognized as a reddish lesion with a characteristic Type
C pattern that can be likened to a tree branch (Figure 1317). A fine striped pattern is characteristic in
well-differentiated tubular adenocarcinoma. In these cases, background atrophic gastric mucosa also
exhibits a Type C pattern. However, this has a coarse appearance and can be differentiated from the
labyrinth-like pattern with irregular alignment of the carcinomatous area (Figure 1318).

(484)Figure 1317. Papillary adenocarcinoma with characteristic tree branch-like type C

pattern (TGS-50D, Toshiba Corporation-Machida Endoscope Company).

(485)Figure 1318. Well-differentiated tubular adenocarcinoma with labyrinth-like Type C

pattern aligned irregularly (GIF-200Z, Olympus Optical Company, Ltd.).
Moderately differentiated tubular adenocarcinoma has the same fine mucosal pattern as background
atrophic gastric mucosa. Therefore, diagnosis of this type of cancer is difficult even with magnifying
endoscopic observation. A Type IIb (flat) early gastric cancer with a diameter of 1.5 cm is shown in
Figure 1319. Recognition of this lesion as an early gastric cancer was difficult because of the
unevenness in the mucosal surface and color tone as well as a lack of differences in pit patterns
between the cancerous and the benign mucosa.

(486)Figure 1319. Type IIb (flat) moderately differentiated tubular adenocarcinoma that
exhibits the same fine mucosal pattern as the surrounding atrophic mucosa (TGS-50D,
Toshiba Corporation-Machida Endoscope Company).
Correct diagnosis of signet-ring cell carcinoma or poorly differentiated tubular adenocarcinoma, which
do not form defined glandular ducts, is difficult by observation of the fine mucosal pattern alone. These
lesions are for the most part eroded so that the pit pattern is lost and replaced by a flat area (Figure
1320). Occasionally, the eroded area is surrounded by mucosa with irregularly shaped Type D
patterns of various sizes (Figure 1321). Although considered to be characteristic of diffuse (poorly
differentiated) carcinoma, this finding may not be present. When cancer cells are scattered in the
mucosa around the margin of the eroded area, the fine mucosal structure is the same as that of
surrounding normal mucosa and is difficult to recognize (Figure 1322).

(487)Figure 1320. Type IIc type signet-ring cell carcinoma that was observed as a
nonspecific erosion without a pit pattern (TGS-50D, Toshiba Corporation-Machida
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Endoscope Company).

(488)Figure 1321. Type IIc poorly differentiated adenocarcinoma in which irregularly

shaped Type D patterns of various sizes surround the eroded area (EG7-FP3, Fuji Photo
Optical Company).

(489)Figure 1322. Marginal area of Type IIc + IIb signet-ring cell carcinoma in which
cancer cells are scattered. The pit pattern is the same as that of the surrounding mucosa
(GIF-300Z, Olympus Optical Company, Ltd.).

Differential Diagnosis
Elevated submucosal lesions have a fine mucosal pattern that is the same as that of surrounding
mucosa. An erosion with associated edema and fibrosis on the surface of a small elevated
submucosal lesion is seen as a defect or as mucosa with a regenerated Type D pattern. On rare
occasion, it is necessary to differentiate a hyperplastic polyp from a papillary carcinoma. This is not
difficult because the former lesion has a coarse Type B or C pattern (Figure 1323).

(490)Figure 1323. Hyperplastic polyp that exhibited a coarse Type BC pattern (GIF-200Z,
Olympus Optical Company, Ltd.).
The elevated Type IIa early neoplastic lesion has a well-demarcated characteristic pattern.
Well-differentiated tubu-lar adenocarcinoma is recognized by a labyrinth-like Type C pattern with a
sharp boundary; a coarse Type C pattern is noted in the surrounding atrophic mucosa. However, it is
difficult to differentiate this lesion from an adenoma.
Small red spots can be divided into surface redness and erosions by magnification endoscopy (Figure
1324). If a fine gastric mucosal pattern is preserved in a reddish area, it is referred to as a redness, a
descriptive term that includes angiodysplasia. An erosion, if acute, is seen as a shallow depression
without a pit pattern; if it has healed, a regenerated Type D pattern is observed. For differential
diagnosis of small depressed lesions, assessment of the fine mucosal pattern in the depressed area
and the adjacent mucosa is important. If the area exhibits a coarse Type D regenerating mucosal
pattern without variation in size, it is an ulcer scar or the remnant of an erosion, especially when the
boundary is not clearly defined. A depressed Type IIc early gastric cancer is easily recognized by the
characteristic pit pattern of the differentiated cell type as seen by magnification endoscopy.

(491)Figure 1324. Classification of gastric red spots using magnification endoscopy.

Gastric Ulcer Healing

Magnification endoscopy can be used to study the healing process of gastric ulcers, including the
morphologic changes that occur during regeneration of the mucosal surface. A magnified view of the
initial stages of healing of an ulcer in the body of the stomach 2 weeks after initiation of treatment is
shown in Figure 1325. A narrow reddish belt without mucosal structure surrounds a white coating,
and an enlarged pit pattern due to edema is present. At 4 weeks, regenerated mucosa in a Type C
pattern, with a radial alignment, was observed (Figure 1326). This ulcer became a scar that showed a
coarse granular regenerated mucosal pattern and transformed subsequently to a fine granular pattern,
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similar to that of the surrounding mucosa (Figure 1327).

(492)Figure 1325. Gastric ulcer in the initial stage of healing (R0 stage) at 2 weeks after
treatment (GIF-D10, Olympus Optical Company, Ltd.).

(493)Figure 1326. Gastric ulcer in the initial stage of healing (R2 stage) at 4 weeks after
treatment (GIF-D10, Olympus Optical Company, Ltd.).

(494)Figure 1327. Gastric ulcer scar (Sc scar) at 36 weeks after treatment (GIF-D10,
Olympus Optical Company, Ltd.).
A recurrent gastric ulcer exhibits a different morphology. A Type C regenerating mucosal pattern was
observed at 4 weeks; after 6 weeks, the pattern tended to be more granular (Figure 1328). A coarse
Type C regenerated mucosal pattern with a central depression was observed (Figure 1329) after
disappearance of the white coating. This transformed into a coarse granular regenerated mucosal
pattern with a central depression (Figure 1330).

(495)Figure 1328. Recurrent gastric ulcer (R2 stage) at 6 weeks after treatment (GIF-D10,
Olympus Optical Company, Ltd.).

(496)Figure 1329. Recurrent gastric ulcer scar (Sa scar) at 8 weeks after treatment
(GIF-D10, Olympus Optical Company, Ltd.).

(497)Figure 1330. Recurrent gastric ulcer scar (Sa scar) at 36 weeks after treatment
(GIF-D10, Olympus Optical Company, Ltd.).
We proposed a classification of the phases of gastric ulcer healing in 1984 based on our experience
with magnification endoscopy and pathologic studies;11(498) this was modified for application to
standard endoscopy in 1988.12(499) In our classification, the healing process is divided into two main
phases: a regenerating phase with white coating and a scar phase (Figure 1331). The regenerating
phase is divided into three stages based on regenerated mucosal patterns: R0 (no regenerating
mucosal pattern), R1 (fine regenerating mucosal pattern), and R2 (coarse regenerating mucosal
pattern). The scar phase is divided into three stages: Sa (coarse regenerated mucosal pattern with
central depression), Sb (central coarse regenerating mucosal pattern), and Sc (fine pattern similar to
that of the surrounding mucosa).

(500)Figure 1331. Classification of the time phase of the healing process of gastric ulcers by
magnification endoscopy. (From Sakaki N, Takemoto T. Endoscopic study on stage of healing
process of duodenal ulcer [Japanese, English abstract]. Gastroenterol Endosc 1988;
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The scar pattern as seen at endoscopy correlates with the degree of histologic regeneration and
healing.13(501) Histologic regeneration is inadequate if the Sa and Sb patterns persist, even if these
remain present over long periods of time. Transformations in the scar pattern are also related to the
depth of the ulcer defect as noted at endoscopy.14(502) When the ulcer defect is no deeper than the
submucosal layer, only the Sc pattern is seen. When the defect penetrates into the muscularis propria,
regeneration occurs by transformation from the Sa or Sb pattern to the Sc pattern.
We investigated the relationship between our endoscopic classification of ulcer scars and ulcer relapse
in a prospective endoscopic follow-up study of 77 patients who received maintenance therapy with an
H2 blocker (at half the therapeutic dosage).14(503) Transformation of scar patterns and ulcer relapses
during the 2-year follow-up period are shown in Table 132. A high rate of relapse (84%) was observed
in patients with persistence of the Sa scar. The relapse rate for patients with an Sb scar pattern was
also high (33%) but less than with persistence of the Sa pattern. By contrast, relapses did not occur in
the group with the Sc pattern. We concluded that ulcer scar patterns as seen at endoscopy relate to
the depth of the ulcer defect and can be correlated with the likelihood of ulcer recurrence.

Transformation of Scar Patterns and Ulcer Relapses*





Sc Sc
Sa, Sb Sc
5/15 (33%)
23.2 months
Sa, Sb Sb
27/32 (84%)
11.6 months
Sa Sa
From Sakaki N, Takemoto T. The relationship between endoscopic finding of gastric ulcer scar
and ulcer relapse. J Clin Gastroenterol 1993; 17(suppl 1): S649.
* Prospective 2-year follow-up study in 77 patients with maintenance H2-blocker therapy at half
P < .01: Sc vs. Sb, Sc vs. Sa, and Sb vs. Sa.

Other Digestive Tract Organs

The diagnostic unit (frame of reference) for magnification colonoscopy is the colonic pit. These
structures are actually the orifices of the crypts of Lieberkhn. Chromoscopy is useful for endoscopic
observation of the colonic pits, and the normal colonic mucosa stains deeply with methylene blue (see
Chapter 12: Chromoscopy, and Chapter 24: Early Colorectal Cancer and Endoscopic Resection). The
shapes of colonic pits change under the influence of certain disease states and show characteristic
patterns. However, these are very similar to those seen in the stomach and can be described by our
classification. Fundamentally, normal colonic pits are characterized by a Type A pattern. During the
healing process of inflammatory bowel disease, a Type B pattern is transiently observed. A Type C
pattern is characteristic of neoplastic lesions.

Small Intestine
The villi of the small intestinal mucosa range in size from 0.2 to 1.0 mm. They are easily observed with
low magnification and are often clearly seen with standard instruments. Normal villi show Types C and
D patterns in magnified views. A coarse Type D pattern is characteristic of regeneration.
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Magnification endoscopy of esophageal mucosa can be performed using the technique of iodine
staining (see Chapter 12: Chromoscopy). However, the technique of magnification esophagoscopy is
not well developed, and information on the magnified view of esophageal epithelium is lacking.


Sakaki N, Iida Y, Okazaki Y, et al. Magnifying endoscopic observation of the gastric mucosa,
particularly in patients with atrophic gastritis. Endoscopy 1978;10:26974.
Gutzeit H, Teitige H. Die Gastroskopie, Lehrbuch und Atlas. Munchen: Urban &
Schwarzenberg. 1954.
Salem SN, Truelove SC. Dissection microscope appearance of the gastric mucosa. BMJ
Matsumoto M. Dissecting microscopic study of gastric ulcer and gastric cancer. Gastroenterol
Endosc 1973;15:63965.
Yoshii T. Staining dissecting microscopic observation and its application for endoscopy. In
Takemoto T, Kawai K (eds). Gastrointestinal Endoscopy With Application of Dye. Tokyo:
Igaku Shoin, 1974;1120.
6. Nishizawa M, Kariya A, Kobayashi S, Shirakabe H. Clinical application of an improved
magnifying fiber-colonoscope (FCS-ML II) with special reference to the remission features of
ulcerative colitis. Endoscopy 1980;12:7680.
7. Tada M, Misaki F, Kawai K. Endoscopic observation of villi with magnifying
enterocolonoscopes. Gastrointest Endosc 1982;28:179.
Tada M, Nishimura S, Watanabe Y, et al. A new method for the ultra-magnifying observation
of colonic mucosa. J Kyoto Pref Univ Med 1982;91:34954.
Sakaki N, Takeuchi K, Saito M, et al. Study for development of ultra-high magnifying
fibergastroscope [Japanese, English abstract]. Gastroenterol Endosc 1985;27:659.
Tada M, Shimada M, Murakami F, et al. Development of the strip-off biopsy [Japanese,
English abstract]. Gastroenterol Endosc 1984;26:8339.
Sakaki N, Harada H, Takeuchi K, et al. Magnifying and endoscopic diagnosis of gastric ulcer
healing [Japanese, English abstract]. Stomach Intestine 1984;19:97986.
Sakaki N, Takemoto T. Endoscopic study on stage of healing process of duodenal ulcer
[Japanese, English abstract]. Gastroenterol Endosc 1988;30:19149.
13. Takemoto T, Sakaki N, Tada M, et al. Evaluation of peptic ulcer healing with a highly
magnifying endoscope: Potential prognostic and therapeutic implications. J Clin Gastroenterol
1991;13(suppl 1):S1258.
14. Sakaki N, Takemoto T. The relationship between endoscopic finding of gastric ulcer scar and
ulcer relapse. J Clin Gastroenterol 1993;17(suppl 1):S649.

Chapter 14 The Use of Histoacryl Tissue Adhesive for the Treatment

of Variceal Bleeding


Since the mid-1980s, endoscopic sclerotherapy has become a routine treatment for acute esophageal
variceal bleeding. A major advantage of sclerotherapy is that it can be performed at the same time as a
diagnostic endoscopy. Randomized controlled studies comparing sclerotherapy with balloon
tamponade and vasopressin infusion have shown sclerotherapy to be more efficacious in arresting
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variceal hemorrhage and to have lower complication rates.14(506) However, sclerotherapy is not a
panacea for the treatment of bleeding varices. In particular, the treatment of gastric varices has been
problematic, and studies have shown poor results and high complication rates.5,6(507) Further, early
recurrence of bleeding after sclerotherapy of esophageal varices still occurs, approaching 30% or more
of patients in some studies.1,2,7(508) In several trials comparing sclerotherapy with balloon
tamponade and vasopressin infusion, no significant difference was found in early recurrence of
bleeding or in mortality rates among the treatment groups.1,2(509)
Endoscopic variceal obliteration with the polymer tissue adhesives isobutyl-2-cyanoacrylate (bucrylate,
not available commercially) and N-butyl-2-cyanoacrylate (Histoacryl, Braun, Melsungen, Germany) is
one answer to the shortcomings of sclerotherapy. The fundamental technique for tissue adhesive
injection is the same as that for sclerotherapy. This chapter describes the use of tissue adhesives for
the management of bleeding gastroesophageal varices and describes the role of these agents in
relation to conventional sclerotherapy.

Historical Perspective
Since their discovery in 1949, cyanoacrylate polymers have been widely studied and applied clinically
in various surgical subspecialties as tissue adhesives. Since the mid-1970s, interventional radiologists
have used the polymers for embolization of aneurysms, arteriovenous malformations, fistulas, and
vascular lacerations.8,9(510) Martin et al.10(511) used a tissue adhesive
(trifluoro-2-propyl-2-cyanoacrylate) at endoscopy in an effort to control hemorrhage in six patients with
a variety of bleeding lesions (esophagitis, malignant tumor, varix, duodenal ulcer). However, Protell et
al.11(512) found that use of this agent was not very effective in controlling hemorrhage from ulcers in
an experimental animal model. Vallieres et al.12(513) reported injection of N-butyl-2-cyanoacrylate
monomer into a bleeding duodenal ulcer. Although bleeding was controlled initially, pancreatoduodenal
necrosis developed within a matter of hours and the patient underwent pancreatoduodenectomy.
In 1974, Rsch et al.13(514) proposed the use of bucrylate for the management of gastroesophageal
varices following successful embolization of the gastric coronary vein in an animal model. The first
clinical obliteration of gastric and esophageal varices was reported by Lunderquist et al.14(515) (1978)
via a percutaneous transhepatic approach. Gotlib and Zimmermann15(516) (1984) described the first
use of bucrylate for the endoscopic obliteration of esophageal varices and Soehendra et al.16(517)
(1986) discussed its use for gastric varices. Whereas Gotlib and Zimmermann used bucrylate in lieu of
a sclerosant for the elective treatment of varices, Soehendra et al. (1987)17(518) proposed that
bucrylate treatment be restricted to acutely bleeding varices and the elective treatment of gastric

Properties of Cyanoacrylate Polymers

The cyanoacrylate polymers have a viscosity and appearance similar to those of water. Polymerization
occurs on contact with water to form a solid complex tightly bound with any underlying tissue.
Polymerization is almost instantaneous in blood. Experimental and clinical studies have shown that
cyanoacrylate polymers have both bacteriostatic and hemostatic activity.18,19(519) Half-life,
biodegradability, and tissue reactivity vary according to the alkyl chain length of the different homologs;
half-life increases and tissue toxicity decreases with lengthening of the alkyl chain. Longer alkyl chain
homologs have less bacteriostatic activity. Histoacryl, which has a long alkyl chain, is the least
histotoxic of the cyanoacrylate polymers currently available commercially.20(520) The use of Histoacryl
in the treatment of varices is described.

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Technique and Indications for Variceal Obliteration

Preparation and Instruments
Patient preparation for Histoacryl injection is the same as that for conventional sclerotherapy. The use
of Histoacryl does not require any special laboratory tests or monitoring. All personnel working with
Histoacryl should wear eye protection as a precaution against inadvertent spraying of the tissue
adhesive during injection. The patient's eyes should also be protected during injection.
An endoscope with a large working channel (at least 3.7 mm in diameter) is recommended to allow for
suction after inserting the injection catheter. Several injection catheters should be on hand. We use an
injection needle measuring 7 mm in length and 0.7 mm in diameter. The needle should be checked
before use, ensuring that it can be fully retracted and extended from the covering sheath. Two suction
outlets should be available, one for oropharyngeal and the other for endoscopic suction.
The liquid tissue adhesive can instantaneously solidify at the tip of the endoscope or within the working
channel, thereby damaging the instrument. This can be avoided by lubricating the insertion tube
liberally with silicone oil and aspirating oil through the accessory channel. With this precautionary
measure, we have not experienced any damage to an endoscope.
To prevent premature solidification during injection, Histoacryl is diluted with the oily contrast agent
Lipiodol (Byk Gulden, Konstanz, Germany). When Histoacryl is mixed in a ratio of 0.5 ml (volume per
tube of Histoacryl) to 0.8 ml Lipiodol (total volume, 1.3 ml per syringe), hardening is delayed by
approximately 20 sec.21(521) The two components are drawn up together into a 2-ml plastic syringe
and then mixed by inverting the syringe several times. To help prevent Histoacryl from adhering to the
catheter wall, several milliliters of Lipiodol are injected into the catheter, followed by a syringe full of air.
This coats the inner wall of the catheter with Lipiodol.
Although Histoacryl has a viscosity similar to that of water, the addition of Lipiodol increases the
viscosity considerably. Rapid injection of the Histoacryl mixture may therefore require considerable
injection pressure. Use of a large-bore sclerotherapy needle (0.7 mm in diameter) makes the injection
easier. We also recommend 2-ml syringes for the injection of Histoacryl. Use of a syringe with a
Luer-Lok prevents inadvertent spraying of Histoacryl during injection.
Most of the Histoacryl is retained in the dead space of the injection catheter following injection. To
ensure that the total volume of Histoacryl injected is actually deposited in the varix, it is necessary to
follow the Histoacryl injection with a second injection of distilled water. The volume injected should be
equal to the dead space of the catheter, about 0.7 ml for standard catheters. Several 2-ml syringes
filled with distilled water should be prepared for this purpose.

Injection Technique
Once localized, the bleeding varix is punctured in the usual manner for intravariceal injection (Figures
141 and 142). Theoretically, the tissue adhesive should be injected distal to the bleeding point
because of the direction of venous blood flow in portal hypertension. However, we have found this to
be irrelevant as long as the injection is intravariceal and the puncture is close to the bleeding point.
Paravariceal injection may lead to severe ulceration. Intravariceal position can be verified by first
injecting a small volume of distilled water into the varix. This should not cause mucosal swelling.
Because Lipiodol is radiopaque, the injection can also be monitored fluoroscopically. This is a distinct
advantage if the equipment is available.

(522)Figure 141. Endoscopic photographs of Histoacryl injection of esophageal varices. A,

Actively bleeding esophageal varix. B, Intravariceal injection of Histoacryl. C, Cessation of
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bleeding after injection of Histoacryl.

(523)Figure 142. Endoscopic photographs of Histoacryl injection of gastric (fundic) varices.

A, Conglomerate of polypoid varices in the gastric fundus as seen in retroflexion. B,
Intravariceal injection of Histoacryl. Histoacryl is seen emerging from the varix rupture site
(arrow). C, Magnified view showing plugging of the rupture site with solidified Histoacryl.
The Histoacryl-Lipiodol mixture is injected in small aliquots into esophageal (0.5 ml) and gastric (1 ml)
varices, followed immediately by an injection of distilled water to flush out any Histoacryl retained in the
catheter (see earlier in this chapter). After injecting the tissue adhesive, the injection catheter is
advanced several centimeters beyond the endoscope tip and flushed continuously with distilled water
to keep it patent for further injections. As a precautionary measure to prevent endoscope damage, one
should not aspirate through the accessory channel during and for about 20 sec after the injection of the
tissue adhesive.

Treatment of Nonbleeding Varices

Active bleeding from gastroesophageal varices can usually be arrested with one or two injections of
Histoacryl. After hemostasis is achieved, nonbleeding varices are treated at the same session to
decrease the risk of further variceal bleeding.
We use Histoacryl or a conventional sclerosant to treat nonbleeding esophageal varices. Although
Histoacryl can obliterate varices more rapidly than sclerotherapy, it may cause ulcerations when
inadvertently injected paravariceally. Therefore, we limit its use to patients judged to be at higher risk
for variceal bleeding and those who have a higher risk of death from a variceal bleed. These subsets of
patients are more likely to benefit from rapid varix obliteration. We use endoscopic criteria (size,
presence of red color signs) as well as the clinical severity of underlying liver disease to judge the risk
for variceal bleeding.22(524) Patients with varices at low risk for bleeding are treated with conventional
We perform sclerotherapy with 1% polidocanol (Aethoxysclerol, Kreussler, Wiesbaden, Germany), but
no sclerosant has been shown to be superior to another. No consensus exists as to the optimum
injection technique. We have found a combined perivariceal and intravariceal technique to be the most
efficacious (Figure 143).21(525) A maximum of 5 ml of sclerosant is first injected immediately
adjacent to the varices to produce submucosal wheals that compress the varix. The injection needle is
then introduced intravariceally and, while injecting 1 to 2 ml of the sclerosant, the needle is shifted to
and fro in a deliberate attempt to damage the intima of the varix. Both injury to the intima and
compression of the varix by submucosal deposits of sclerosant are thought to aid in securing
thrombosis of the varix. Recommended volumes for injection apply only to 1% polidocanol; the
selection of a different sclerosant may dictate a different injection volume.

(526)Figure 143. Diagram demonstrating the sequence of combined intravariceal and

perivariceal sclerotherapy technique. A, Perivariceal injection on both sides of the varix
produces visible submucosal wheals. B, Intravariceal injection. While the sclerosant is
injected, the needle is shifted back and forth in an attempt to damage the intima of the varix.
C, Submucosal deposits of sclerosant produce varix compression on all sides.
We treat gastric varices exclusively with Histoacryl. This includes varices located immediately distal to
the gastroesophageal junction without extension into the gastric fundus, which we prefer to call
junctional varices. Junctional varices deserve special mention because they are easily overlooked.
Junctional varices may appear during or after the eradication of esophageal varices and may cause
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recurrent bleeding. When bleeding occurs, these varices may be more difficult to treat than esophageal
or fundic varices owing to their location at the cardia.
We categorize fundal varices into three groups according to endoscopic appearance (Figure 144).
Type I is a single polypoid varix with feeding tributaries (Figure 145). The appearance may mimic that
of a large polyp. This type is easily obliterated with Histoacryl, usually requiring only a single injection.
Varix obliteration can be tested for by gentle probing with the tip of the injection catheter (needle
withdrawn); the structure should be firm and noncompressible. A radiograph may also be taken to
verify varix obliteration (Figure 146). Type II is a conglomerate of large, polypoid varices that tend to
be confluent. Several Histoacryl injections into different varices are required, and more than one
treatment session may be necessary. Type III varices are slender, serpiginous varices that tend to be
widely distributed in the gastric fundus and body. Varices with this morphology rarely bleed, and
therefore we do not treat them. Intravariceal injection with Histoacryl may also be difficult owing to the
slender caliber.

(527)Figure 144. Diagram representing the morphologic classification of fundal varices as

outlined in the text. A, Type I: a single polypoid varix. B, Type II: a conglomerate of large
polypoid varices. C, Type III: slender, serpiginous varices.

(528)Figure 145. Endoscopic photographs of fundal varices (Type I) after injection with
Histoacryl. A, Fundal varix with feeding tributaries. B, Same patient 3 months following
treatment showing obliteration of varices with some residual scarring.

(529)Figure 146. Roentgenographic views corresponding to Figure 145. A, Histoacryl

filling a Type I fundal varix and feeding tributaries. B, No residual Histoacryl is seen 3 months
after treatment.
Although controversial, our policy is to treat nonbleeding gastric varices following the treatment of
bleeding esophageal varices. Similarly, we treat any nonbleeding esophageal varices that may
accompany bleeding gastric varices.

Patient Follow-Up
Esophagogastroscopy is performed 4 days after the index episode of bleeding and at weekly intervals
thereafter until all varices are obliterated. Gastric varices are checked for obliteration in the manner
described previously. Incompletely obliterated varices are reinjected with Histoacryl. The number of
injection sessions using Histoacryl depends on the morphology of the gastric varices. Sclerotherapy for
esophageal varices is continued on a weekly basis until all varices are eradicated and the inner wall of
the esophagus is fibrosed (Figure 147).

(530)Figure 147. Large esophageal varices. A, Before sclerotherapy with 1% polidocanol. B,

After sclerotherapy with 1% polidocanol.

Published reports of experience with the cyanoacrylate polymer adhesives in the management of
gastroesophageal varices stem primarily from centers in France and Germany.
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Gotlib and Zimmermann15(531) reported the first results of esophageal varix obliteration with bucrylate
in 96 patients. Bucrylate was used during active bleeding in 21 patients, and hemostasis was achieved
in 20 (95% success rate). Bleeding recurred in 6 patients (30%) within 8 days of treatment. Of 75
patients treated electively with bucrylate within 8 to 20 days of a bleeding episode, 32 patients (43.2%)
experienced recurrent bleeding during a mean follow-up of 9 months.
Ramond et al.23(532) reported the results of a study of bucrylate in 49 patients with bleeding
gastroesophageal varices, 12 of whom had active bleeding at initial endoscopy. Bleeding was
controlled in 14 of 15 bleeding episodes. The cumulative rate of recurrent bleeding was 37% at 6
months and 42% at 1 year. In a second study by these investigators, 27 patients with large or actively
bleeding gastric varices were treated with either bucrylate or Histoacryl.24(533) The polymer adhesives
stopped bleeding in all 6 patients treated, but bleeding recurred within 6 hours in 2 patients. The
cumulative rate of recurrent bleeding was 37%. Feretis et al.25(534) performed Histoacryl injections in
23 patients with actively bleeding esophageal (19 patients) or gastric (4 patients) varices; hemostasis
was achieved in 22 patients after a single injection of Histoacryl. During a mean 2.4-month follow-up
period, patients with esophageal varices underwent conventional serial sclerotherapy, and only 1
episode of recurrent bleeding was encountered.
We began using Histoacryl in 1985 as part of an empirical treatment protocol for actively bleeding
gastroesophageal varices and nonbleeding gastric varices.21(535) Over a 6-year period (1985 to
1991), a total of 283 patients were treated with Histoacryl, 139 of whom had acute variceal bleeding at
endoscopy. Among the patients with acute bleeding, 61 had bleeding esophageal varices, 52 bleeding
"junctional" varices, and 26 bleeding fundic varices. Hemostasis was achieved with Histoacryl in all
patients. In the Histoacryl-treated group of patients, 17 (12.2%) experienced early recurrence of
bleeding (13 from esophageal varices and 4 from gastric varices). The in-hospital mortality rate was
7.2%. Causes of death were related primarily to hepatic failure, and no deaths were directly attributable
to bleeding. When the periods before and after the introduction of Histoacryl for acute variceal bleeding
are compared, the tissue adhesive substantially improved the results of treatment (Table 141).
Reflecting this improvement, balloon tamponade and decompressive shunt surgery have become
obsolete treatments for variceal bleeding in our unit.

Results of Sclerotherapy in
Patients With Acute Variceal Bleeding*

(n = 168)
n (%)

(n = 119)
n (%)

Initial hemostasis
With Histoacryl

98 (82.4%)
With polidocanol
124 (73.8%)
21 (17.6%)
With polidocanol and
40 (23.8%)

balloon tamponade
4 (2.4%)

Early recurrence of bleeding

50 (30.5%)
17 (14.3%)
Hospital mortality
53 (31.5%)
13 (10.9%)
* Comparison of two treatment periods at the University
Hospital, Hamburg. Includes only patients undergoing initial

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Adverse Effects and Complications

Local inflammatory reactions and neural toxicity were reported in surgical series that evaluated some
of the early smaller-chain monomers for wound closure. Recent surgical studies have shown markedly
reduced tissue toxicity when Histoacryl is used for blepharoplasty and other surgical wounds.20(536)
Endoscopic obliteration of varices with bucrylate was found to cause acute ulcerations of the
esophageal wall in autopsy studies.26(537) However, we have not observed ulceration to occur when
Histoacryl injections are strictly intravariceal, in contrast to inadvertent paravariceal injection, which can
cause extensive ulceration.
A concern has been raised regarding potential carcinogenicity of the polymer cyanoacrylates. In
experimental studies, polymer cyanoacrylates have been shown to induce sarcomas when implanted
into rat peritoneum.27(538) However, the dose used was 100 times that used in humans, and the rat
species selected for this study is known to have a predisposition to sarcoma formation. These findings
have not been reproduced in other experimental models or in humans. In particular, extensive clinical
experience with intraperitoneal implantation of cyanoacrylates has not shown carcinogenicity; in more
than 2000 patients treated with intravascular instillation of bucrylate, none has been reported to have
associated or concomitant neoplasm.28(539)
In the application of Histoacryl for the obliteration of varices, the tissue adhesive is injected into the
varix, solidifies, and is gradually extruded en masse over a period of weeks into the lumen and passed
in the feces (Figures 148 and 149). As shown in Figure 146, the complete disappearance of
Histoacryl can be demonstrated roentgenographically. This minimizes a long-term foreign body

(540)Figure 148. Endoscopic photograph showing extrusion of a Histoacryl cast 1 month

after varix obliteration.

(541)Figure 149. Photograph of an extruded Histoacryl venous cast.

Serious side effects of endoscopic injection of polymer cyanoacrylates have been limited to two cases
(one fatal) of cerebrovascular stroke resulting from acute embolization.29(542) It is thought that
anomalous right-to-left shunting predisposed to this rare complication. Other complications have been
minor and self-limited. In a review of 317 patients treated with bucrylate or Histoacryl over a 5-year
period, Gotlib30(543) reported no procedure-related mortality and only minor complications, including
dysphagia without stenosis, esophageal stenosis, bacteremia (2 cases), and pyrexia (1 case). In our
hands, the intravariceal injection of Histoacryl has not been associated with any serious complications.
These excellent results may be due to the technique and the doses used. In contrast to our findings,
the serious complications occurred with the use of larger-injection aliquots (1 to 2 ml) and two or three
injections per varix.
Approximately 1 week after intravariceal injection of Histoacryl, the mucosa overlying the obliterated
varix begins to slough. As mentioned earlier, the tissue adhesive is treated as a foreign body and is
gradually expelled into the lumen (see Figures 148 and 149). Several months may elapse before it is
completely eliminated from the wall. This usual sequence of events following Histoacryl injection is not
associated with increased bleeding or other adverse effects.

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Endoscopic variceal injection is widely accepted as the treatment of choice for acutely bleeding
esophageal varices. The availability and simplicity of the method have contributed to its popularity.
However, high rates of recurrent bleeding and technical difficulty treating bleeding gastric varices have
been major shortcomings of the technique. Endoscopic variceal obliteration with polymer
cyanoacrylates addresses these shortcomings. In a limited number of centers, Histoacryl has been
shown to be safe and highly effective in arresting acute gastroesophageal variceal bleeding and
permanently obliterating varices. These encouraging results indicate a need for further multicenter
clinical trials. The polymer cyanoacrylates do not replace conventional sclerotherapy, which is well
suited for eradicating nonbleeding varices and has the final aim of fibrosis of the inner esophageal wall.
Techniques for the use of polymer cyanoacrylates are still in a state of evolution, and the ultimate role
of each remains to be determined.31(544)

The authors would like to thank Dr. J. McCarthy, for his assistance in the preparation of this
manuscript, as well as the support of the nursing staff during these studies.


Westaby D, Hayes PC, Gimson AES, et al. Controlled clinical trial of injection sclerotherapy
for active variceal bleeding. Hepatology 1989;9:2747.
2. Sderlund C, Ihre T. Endoscopic sclerotherapy v. conservative management of bleeding
oesophageal varices. Acta Chir Scand 1985;151:44956.
3. Larson AW, Cohen H, Zweiban B, et al. Acute esophageal variceal sclerotherapy: Results of a
prospective randomized controlled trial. JAMA 1986;255:497500.
4. Barsoum MS, Bolous FI, El-Rooby AA, et al. Tamponade and injection sclerotherapy in the
management of bleeding oesophageal varices. Br J Surg 1982;69:768.
5. Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.
Gastrointest Endosc 1986;32:2648.
Yassin ZM, Eita MS, Hussein A. Endoscopic sclerotherapy for bleeding gastric varices. Gut
7. Copenhagen Esophageal Varices Sclerotherapy Project. Sclerotherapy after first variceal
hemorrhage in cirrhosis. N Engl J Med 1984;311:15941600.
8. Zanetti PH, Sherman FE. Experimental evaluation of a tissue adhesive as an agent for the
treatment of aneurysms and arteriovenous anomalies. J Neurosurg 1972;36:729.
Lehman RA, Hayes GJ. The toxicity of 2-cyanoacrylate tissue adhesives: Brain and blood
vessels. Surgery 1967;91522.
10. Martin TR, Onstad GR, Silvis SE. Endoscopic control of massive upper gastrointestinal
bleeding with a tissue adhesive (MBR4197). Gastrointest Endosc 1977;24:746.
Protell RL, Silverstein FE, Gulacsik C, et al. Failure of cyanoacrylate tissue glue (Flucrylate,
MBR4197) to stop bleeding from experimental canine gastric ulcers. Dig Dis 1978;23:9038.
12. Vallieres E, Jamieson C, Haber GB, Mackenzie RL. Pancreatoduodenal necrosis after
endoscopic injection of cyanoacrylate to treat a bleeding duodenal ulcer: A case report.
Surgery 1989;106:9013.
13. Rsch J, Goldman ML, Dotter CT. Experimental catheter obstruction of the gastric coronary
vein. Possible technique for percutaneous intravascular tamponade of the gastroesophageal
varices. Invest Radiol 1975;10:20611.
Lunderquist A, Borjesson B, Owman T, et al. Isobutyl 2-cyanoacrylate (Bucrylate) in
obliteration of gastric coronary vein and esophageal varices. AJR 1978;130:16.
Gotlib JP, Zimmermann P. Une nouvelle technique de traitement endoscopique des varices
oesophagiennes: L'obliteration. Endoscopia Digestiva 1984;7:102.
16. Soehendra N, Nam V Ch, Grimm H, et al. Endoscopic obliteration of large esophagogastric
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varices with Bucrylate. Endoscopy 1986;18:256.

17. Soehendra N, Grimm H, Nam V Ch, et al. N-Butyl-2-cyanoacrylate: A supplement to
endoscopic sclerotherapy. Endoscopy 1987;19:2214.
18. Eiferman RA, Snyder JW. Antibacterial effect of cyanoacrylate glue. Arch Ophthalmol
19. Matsumoto T, Hardaway RM, Heisterkamp CA, et al. Cyanoacrylate adhesive and
hemostasis. Arch Surg 1967;94:85860.
20. Kamer FM, Joseph JH. Histoacryl. Its use in aesthetic facial plastic surgery. Arch Otolaryngol
Head Neck Surg 1989;115:1937.
21. Soehendra N, Grimm H, Maydeo A, et al. Endoscopic sclerotherapyPersonal experience.
Hepatogastroenterology 1991;38:2203.
22. The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices.
Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and
esophageal varices. A prospective multicenter study. N Engl J Med 1988;319:9839.
23. Ramond MJ, Valla D, Gotlib JP, et al. Obturation endoscopique des varices oeso-gastriques
par le Bucrylate. Itude clinique de 49 malades. Gastroenterol Clin Biol 1986;10:5759.
24. Ramond MJ, Valla D, Mosnier JF, et al. Successful endoscopic obturation of gastric varices
with butyl cyanoacrylate. Hepatology 1989;10:48893.
25. Feretis C, Tabakopoulos D, Benakis P, et al. Endoscopic hemostasis of esophageal and
gastric variceal bleeding with Histoacryl. Endoscopy 1990;22:2824.
26. Fabiani B, Degott C, Ramond MJ, et al. Obturation endoscopique des varices oeso-gastriques
par le Bucrylate. IItude morphologique a partir de 12 cas autopsies. Gastroenterol Clin
Biol 1986;10:5803.
Reiter A. Sarkomerzeugende Wirkung des Gewebeklebers Histoacrylblau an der Ratte. Z Exp
Chir Transplant Knstliche Organe 1987;20:5560.
28. Samson D, Marshall D. Clinical versus experimental use of isobutyl-2-cyanoacrylate. J
Neurosurg 1987;67:3189.
29. See A, Florent C, Lamy P, et al. Accidents vascularies cerebraux apres obturation
endoscopique des varices oesophagiennes par l'isobutyl-2-cyanoacrylate chez deux malades.
Gastroenterol Clin Biol 1986;10:6047.
Gotlib JP. Endoscopic obturation of esophageal and gastric varices with a cyanoacrylic tissue
adhesive. Can J Gastroenterol 1990;9:6378.
31. Binmoeller KF, Soehendra N. Endoscopic sclerotherapy in 1991: Still evolving [Editorial].
Endoscopy 1991;23:2868.

Chapter 15 Tissue Glue for Fistulas



Interventional endoscopy is frequently an alternative to surgery. Injection techniques for gastrointestinal

hemorrhage, endoscopically assisted dilation, and prosthesis insertion have replaced more complex
and hazardous methods of surgical intervention. In recent years, endoscopic techniques have been
developed for treating defects and fistulas of the gastrointestinal tract by application of a variety of
agents, including artificial glues and quick-hardening substances.
Cyanoacrylate (Histoacryl), a rapidly polymerizing substance, can induce the formation of granulation
tissue in a fistula by foreign body reaction.1,2(547) Initially, this agent functions like an external clamp
that only briefly seals the opening of the fistula and is then rejected. Cyanoacrylate was first used
successfully for gluing recurrent congenital tracheoesophageal fistulas (in esophageal atresia).3,4(548)
Frequent failures, complicated revisions, and equipment defects caused by the glue were
counterbalanced by successful treatment in some cases.5(549) If injected intramucosally or
submucosally, polidocanol (Aethoxysclerol, Kreussler, Wiesbaden, Germany) causes occlusive edema
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and severe, partially destructive inflammation of the tissue. In individual cases, the local inflammatory
stimulus has been used to close defects.6,7(550) Electrocoagulation induces similar tissue changes
and has been used to induce local wound healing.8(551) Prolamin sulfate (Ethibloc), a curing amino
mixture, has been used mainly for blocking the pancreatic duct.9,10(552) Cases have also been
reported of successful precipitation of this agent in necrotic tumor cavities involving the esophagus and
rectum, in addition to gluing of gastrointestinal fistulas.1113(553) High viscosity and hardening times
of up to 30 min, however, have limited the use of this substance.14(554)
None of the agents or gluing techniques described previously has proved to be entirely satisfactory. In
recent years, interest has therefore focused on fibrin glues, biologic substances that meet diverse
prerequisites for gluing and healing defects (Tissucol/Tisseel, Immuno, Heidelberg/Vienna; Beriplast,
Behringwerke, Marburg).15(555)

Theoretical Aspects of Fibrin Gluing

Fibrin glues were used in surgery for the first time in 1943 by Michael and Abbott16(556) for skin
transplantation. A year later, Cronkite et al.17(557) used them for gluing nerves and for skin
transplantation. Today, surgical indications are myriad: establishing hemostasis, securing
anastomoses, gluing of ruptured parenchymatous organs, and treating fistulas.18,19(558)
Fibrin gluing imitates the last phase of plasmatic coagulation, whereby wound healing is stimulated in a
physiologic fashion.20(559) The gluing system incorporates two separate intermediary substances,
namely, highly concentrated human fibrinogen, fibronectin, and Factor XIII, as well as thrombin in
different concentrations dissolved in calcium chloride (4 IU/ml or 500 IU/ml; Tissucol, Immuno,
Heidelberg). The components are drawn up separately into two different syringes and attached to a
specially designed syringe holder. Mixing the substances together causes fibrinogen to convert to
fibrin. Activation by Factor XIII induces the cross-linking of fibrin with fibronectin. On the macroscopic
level, this combination results in a gray, ultimately white clot that develops, depending on the thrombin
component, within 30 to 120 sec (rapid or slow gluing) (Figure 151). Factor XIII is relevant for the
cross-linking of fibrin by means of covalent bonding to the fibrin molecule. This plays a crucial role in
the graft's resistance to tearing. Endogenous fibrinolysis is impeded by adding aprotinin (approximately
3000 KIU/ml) to the glue mixture.

(560)Figure 151. The forming fibrin clot. Note the color change from gray to white.
For use in practice, both agents required for gluing are supplied in a double-syringe system (Duploject
system- application catheter Duplocath, Immuno, Heidelberg) that separates them until application, at
which time they are combined via a Y-shaped end piece (Figure 152). In this way, the two
components are not united until they reach the end of the carrier channel where the fibrin plug forms.

(561)Figure 152. Double syringe (Duploject) with adapted catheter. The catheter for fibrin
glue instillation is passed through the channel of a flexible bronchoscope with an insertion
tube diameter of 6 mm (BF 1T10, Olympus Optical Company, Ltd.).
By interconnecting with local tissue, the glue initially forms a seal. Subsequently, granulation tissue
grows. Because the percentage of fibrin is 30 times higher than in a naturally formed blood clot, the
resulting fibrin clot has much greater resistance to tearing.20(562)
Comparative studies of gluing agents currently in use suggest that they have physicochemical and
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electron microscopic differences.21(563) Solubility patterns and the osmotic pressures of the
fibrinogen and thrombin solutions differ within specific limits. Apparently, the Tisseel clot most closely
approximates physiologic fibrin cross-linking.
Because human fibrinogen is a component of the fibrin glue, the glue components must be obtained
from the pooled human plasma of controlled long-term donors. At every plasmapheresis, the donor
plasma is tested for viral genomes of human immunodeficiency virus (HIV), hepatitis B virus, and
hepatitis C virus, and any significant elevations in transaminases. The manufacturing procedure
requires six logarithmic levels, so that no transmission of HIV is possible.22(564) No infections induced
by fibrin glue have been reported.

Application Technique
Fibrin glue (Tissucol) is available as a deep-frozen, lyophilized substance in a double syringe. Before
use, the components must be thawed. Application must be performed at a temperature of 37 C, with
both components in a completely dissolved form. Application at temperatures other than the optimum
of 37 C results in instability of the clot and inadequate therapy. In interventional endoscopy, the
comparatively long pathways that the components must travel through the endoscope must be
considered. Double-lumen catheters can be used to guide the injection of the components separately
to the tissue surface. However, consecutive injection of the two components with single-lumen
catheters is also a reliable technique for gluing.15(565) A spray-type catheter is not required.

Successful gluing in the digestive tract requires contact with tissue that has the capability of local
regeneration. Because this is necessary for the development and adaptation of the fibrin clot, the
tissue surrounding a fistula must have the capacity for wound healing. The glue does not function
exclusively as a sealing plug but provides a substrate for the migration of fibroblasts. Ideally, the glued
surface is replaced by scar tissue and the fibrin glue completely decomposes.23(566) At least 4 weeks
are required to reach this stage.
A standardized, generally accepted endoscopic technique for gluing is outlined in Table 151. After
endoscopic visualization and cannulation of the defect, deepithelialization should first be performed by
electrocoagulation of the margins or by roughening the fistulous canal with a brush. Mild bleeding is
desirable. These measures improve adhesion of the fibrin clot. The actual gluing is performed by
completely filling the defect with glue and sealing the inner defect with a clot. After 3 to 5 min, the clot
attains about 70% of its maximum strength.24(567) Thereafter, mechanical stress to the glued surface
should be avoided. Patients with esophageal leakage and fistulas are fed enterally via a nasoduodenal
tube until the wound has completely healed. Administration of antibiotics is recommended. The fistula
is then assessed once per week endoscopically and radiologically (Gastrografin swallow), and gluing
sessions are repeated until the fistula has closed completely.


Technique for Endoscopic Fibrin

Drain fistula-connecting cavity (pleural, abdominal)
Localize fistula endoscopically and radiologically
Deepithelialize margins and canal of fistula (electrocoagulation,
cytology brush)
Instill fibrin glue into canal and around borders of fistula
Avoid mechanical stress to glued surface
Reevaluate endoscopic and radiologic control (weekly)
Further gluing sessions (up to five if necessary)
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The general indications for endoscopic gluing are outlined in Table 152. Wound sealing is most
successful if the fistula is tubular and short. Endoscopic gluing is not indicated for broad, window-like
openings between the esophagus and the trachea. Therapy may fail for tissue that is chronically
infected or damaged by radiation therapy owing to the lack of regenerative capacity.25,26(568) The
clot rarely sticks to malignant fistulas.

General Indications for Endoscopic

Tissue Gluing in the Digestive Tract
Not indicated

Small, tubular defects that can be well visualized

and are not connected to the abdominal cavity
Postoperative leaks, inflammatory fistulas,
instrumental perforations involving esophagus,
trachea, and bronchus
Defects induced by radiation therapy
Chronic, infectious fistulas
Tumor fistulas

Defects and leaks involving the esophagus that can be reached using a flexible endoscope represent
the primary indications for gluing. The best results are achieved for this indication with favorable
anatomic position of the esophagus in the posterior and middle mediastinum and its complete
separation from the pleura and abdomen. Fistula penetration in an extraesophageal cavity (e.g.,
pleural space, abdomen) requires that the cavity be drained to relieve pressure prior to gluing.
Likewise, fistulas due to breakdown of a bronchial stump and bronchopleural fistulas can be glued after
primary thoracic drainage.7,15,27(569)

The main indications for endoscopic gluing are recurrent congenital tracheoesophageal fistulas in the
case of esophageal atresia, anastomotic breakdown and leakage (esophagogastrostomy,
esophagojejunostomy), spontaneous inflammatory fistulas, and traumatic or instrumental perforations
of the esophagus.24,2831(570) The extent and the speed of wound healing depend primarily on the
degree of local tissue irritation. Fistulas involving malignant tumors and those induced by radiation
therapy are equally problematic; multiple glue applications are rarely successful. The therapy of choice
for tracheoesophageal fistulas that develop in association with malignant tumors is implantation of an
endoprosthesis (see Chapter 40: Benign and Malignant Tumors of the Esophagus). Occasionally, the
use of glue (fibrin or artificial glue) can be of assistance in cases in which prosthetic bridging is
The more comprehensive reports on successful gluing refer mostly to esophageal leakage and
fistulas.26,30,31(572) The success rates for treatment of esophageal wounds are stated to be 80 to
90% (Table 153). The conservative endoscopic treatment of esophageal perforations should
therefore include the therapeutic concept of fibrin gluing (Figures 153, 154 and 155).


Results of Endoscopic Fibrin Sealing in the Gastrointestinal (GI) Tract




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Results of Endoscopic Fibrin Sealing in the Gastrointestinal (GI) Tract







(2 x Histoacryl)
Radiation induced




Adapted from Jung M, Manegold BC, Brands W. Endoscopic therapy of gastrointestinal fistulae with fibrin tissue sealant.
Waclawiczek HW (ed). Progress in Fibrin Sealing. Heidelberg: Springer-Verlag, 1989; 4352

(573)Figure 153. Gastrografin swallow x-ray demonstrating a high-grade esophageal

stenosis caused by mediastinal lymph node metastasis in a 60-year-old woman with breast

(574)Figure 154. A, Gastrografin x-ray demonstrating implantation of an endoprosthesis for

relief of dysphagia in the same patient as in Figure 153. B, Gastrografin x-ray demonstrating
a large perforation (arrows) into the mediastinum. C and D, Endoscopic views of the

(575)Figure 155. A and B, Endoscopic views showing the technique of fibrin sealing of the
perforation (same patient as in Figures 153 and 154). C and D, Endoscopic views of the
fibrin seal (same patient as in Figures 153 and 154). E, Gastrografin x-ray demonstrating
complete healing of the perforation at 3 weeks after initiation of gluing therapy. The patient
had no further dysphagia.

The treatment of fistulas involving the stomach and duodenum is difficult as long as a connection to the
abdominal cavity exists. However, success has been repeatedly achieved in gluing even the toughest
of putrid, fistulizing anastomotic failures (Figures 156 and 157).6,3336(576) The strategy for
management of such cases often starts with endoscopic visualization of the fistula (fistuloscopy) to
establish the degree of leakage and the nature of fistulous communications.37,38(577) For purulent
fistulas, abscess drainage, antibiotic therapy, and treatment of the fistula with a
streptokinase/streptodornase solution are necessary before gluing is attempted.

(578)Figure 156. A, Barium contrast x-ray demonstrating leakage at the

esophagojejunostomy site in a 37-year-old woman who underwent gastrectomy for early
gastric cancer in the cardia of the stomach. B, Endoscopic views of the anastomosis showing
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suture material and small anastomotic fistula. C, Endoscopic fistula cannulation.

(579)Figure 157. A and B, Endoscopic views of fibrin clot occluding the inner opening of
fistula (same patient as in Figure 156). C, Barium contrast x-ray of the anastomotic region 10
days after endoscopic fibrin sealing demonstrating complete healing of the fistula.
Cases of perforated ulcers successfully treated by endoscopic plus intraabdominal (laparoscopic)
applications of fibrin glue have been reported.39,40(580)

Biliary Tract and Pancreas

It is possible to glue fistulas in the region of the biliary tract. After rinsing with an antibiotic solution and
administering somatostatin, the biliary and pancreatic secretions can be reduced and a clot
successfully attached to the epithelialized tissue.36,41,42(581)
Endoscopic pancreatic duct occlusion with prolamin solution has been used to control the pain
associated with chronic pancreatitis. Occlusion, however, can damage the exocrine cellular system
and lead to atrophy of the exocrine pancreas and subsequent pancreatic fibrosis. The results of this
form of treatment are not very satisfactory.9,10(582)
Fibrin glues remain only briefly in the pancreatic ductal system. Owing to the copious pancreatic
secretion with its high fibrinolytic activity, the clot dissolves within 12 to 24 hours.43(583) Short-term
blockage can be used, however, to help protect pancreatic anastomoses. When somatostatin is
administered, cutaneopancreatic fistulas can be satisfactorily sealed with fibrin glue, although
documented success is limited to individual case reports.

Fibrin gluing of enterocutaneous and enteral fistulas in Crohn's enterocolitis is controversial. It is
performed after complicated pretreatment by peroral lavage, enteral tubal feeding, systemic
administration of antibiotics (metronidazole), medication with Factor XIII (1250 IU/day), and
7-S-immunoglobulin for 5 days with local antibiotic rinsing.44(584) The few reports of successful
outcomes are regarded with skepticism because convincing follow-up studies are lacking.
Furthermore, fibrin gluing for chronic inflammatory fistulas is known to be predominantly unsuccessful.
The healing of deep fistulas from colorectal anastomoses can be accelerated by endoscopic
application of gluing agents, provided that the defect is located below the peritoneal reflection.
Similarly, dehiscence and rupture following endoscopic bougienage of fibrous rectal strictures can be
treated successfully by gluing. As in the esophagus, improved wound healing with reduced scar
formation has been impressive.15,45(585)

Endoscopic gluing techniques play an increasing role in the definitive treatment of gastrointestinal
fistulas and leaks. The main targets for gluing are postoperative fistulas and iatrogenic defects
involving the esophagus. Compared with all other agents, fibrin glue is the most attractive because it
promotes natural wound healing. To date, the results of gluing techniques have been reported only as
case series, although the results have been spectacular in relatively large numbers of patients. Proof in
the form of randomized studies that fibrin gluing is superior to other conservative forms of treatment is
not available. Implementation of such studies poses considerable difficulties because the patient
populations that may benefit from gluing are mainly the severely ill. These issues are compounded by
the fact that the agents used for fibrin gluing are very expensive. Nevertheless, alternative therapies
may be poorly effective or nonexistent for many of the patients in whom gluing may be appropriate. For
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these reasons, the further refinement of endoscopic gluing techniques and their investigation in
patients with suitable indications are clearly warranted.



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sealant: An experimental study. In Waclawiczek HW (ed). Progress in Fibrin Sealing.
Heidelberg: Springer-Verlag, 1989;1119.

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Eimiller A, Berg P, Born P, et al. Fibrin sealing of fistulas in Crohn's disease. In Waclawiczek
HW (ed). Progress in Fibrin Sealing. Heidelberg: Springer-Verlag, 1989;614.
Liedgens P, Joppich I, Brands W. Endoskopische Behandlung tiefer Rektum
anastomosenstenosen im Kindesalter. In Manegold BC, Jung M (Hrsg). Fibrinklebung in der
Endoskopie. Berlin, New York: Springer-Verlag 1988;1647.

Chapter 16 Endoscopic Sewing Machine

The development of endoscopically controlled sewing and stapling machines might enable
endoscopists and surgeons to perform a range of surgical procedures without making external
incisions. Clinical applications for such devices might include the following:
1. Endoscopic treatment of gastrointestinal hemorrhage by oversewing or stapling of bleeding ulcers
and varices. Such improved endoscopic technology is needed for treatment of gastrointestinal
hemorrhage because existing methods (lasers, diathermy, heater probe, injection) are less
effective for terminating bleeding from large arteries than mechanical methods such as ligation or
2. Development of new, less invasive surgical methods such as creation of anastomoses, closure of
perforation, collection of full-thickness gastrointestinal biopsy samples using flexible endoscopes,
antireflux procedures, and operations for control of obesity. Endoscopic delivery of these
techniques might avoid the need for laparotomy, thus lessening discomfort to patients, shortening
hospital stay, and perhaps improving survival.
3. Attachment of devices to the gastrointestinal wall might offer new opportunities for diagnosis,
monitoring, and treatment. Placement of radiotelemetry capsules (RTCs) for measurements of pH
and pressure at the intestinal wall may allow detailed long-term monitoring of the gastrointestinal
environment. The ability to attach tubes to the stomach wall might make nasogastric feeding a
more reliable prospect. Drugs in membrane-bound form for topical treatment of lesions or in
slow-release form, if attachable to specific sites in the gastrointestinal tract, might offer the
prospect of new methods of treatment.
The design problems involved in developing such machines are not trivial. Access is available to only
one side of the tissue to be sewn and stapled. The suture or staple depth must be precisely controlled
to limit the risk of damage to other organs. The machines must be sufficiently small to be swallowed.
Power to and control of the machines occur via a small-diameter flexible channel either within or
parallel to the flexible endoscope.

Sewing Machines
Chain-Stitch Sewing Machines Using Thread
Sewing machines as developed in the 18th and perfected in the 19th century were designed to allow
stitches to be sewn faster than could be achieved by the human hand holding a threaded needle. The
aim of sewing in flexible endoscopy differs in that the technique should allow access to an inaccessible
site in the human body for placement of stitches without recourse to laparotomy. Conventional sewing
machines require access to both sides of the material to be sewn, a circumstance not available at
One method of overcoming this difficulty is to pleat the tissue so that the needle can pierce a double
thickness.1(587) This allows the needle pushing and catch mechanisms to remain within the bowel
lumen without requiring access to the serosal surface. This principle was used in the design of the first
endoscopic sewing machine (Figure 161).
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(588)Figure 161. Chain-stitch endoscopic sewing machine. A prototype endoscopic sewing

machine of transparent acrylic showing needle, thread, hooked catch mechanism, and
The pleat or double fold of tissue can be formed by using suction to bring a fold of tissue into a cavity in
the machine. A needle threaded through an eye close to the needle tip pierces the double layer of
tissue. A catch mechanism retains the loop of thread, and the machine is moved to the site of the next
stitch. The needle pierces tissue and then the first loop with the next loop, which in turn is retained by
the catch mechanism to form a chain of stitches (Figure 162). The machine is then withdrawn through
the mouth, pulling the loop of thread through the tissue until the threads passing through the tissue can
be detached at the mouth from the sewing machine. The thread may then be tied and a knot run down
to the sewn tissue.

(589)Figure 162. Mechanism of action of an endoscopic sewing machine. A, Sewing

machine and its relationship to the endoscope are shown, indicating tissue, needle, thread,
catch mechanism, and control wires. B, Fold of tissue is sucked into the cavity while the
threaded needle pierces a double layer of tissue. C, Catch mechanism retains the loop of
thread that has been passed through the tissue. D, A row of chain stitches is formed in the
tissue by the machine.
Rows of chain stitches were formed using this machine at endoscopy in the postmortem human
esophagus and stomach (Figure 163). A modular design of an endoscopic sewing machine (Figure
164), having interchangeable cavity sizes to provide adjustment of suture length and depth, has been
used at endoscopy to form single stitches and chains of stitches at the cardioesophageal junction and
stomach in survival studies in dogs with and without laparotomy.

(590)Figure 163. A chain of stitches in a postmortem human stomach formed by a prototype

endoscopic sewing machine.

(591)Figure 164. Modular sewing machine. A modular design of the sewing machine with
hand controls and a two-channel endoscope.
Acute ulcers of 1 cm diameter (n = 10) were formed with a suction biopsy device (Quinton ulcer maker)
in canine mucosa and then oversewn using the endoscopic sewing machine. The machine was
positioned over the ulcer, and the entire ulcer was sucked into the cavity. Suction pressure exerted by
the machine was usually sufficient to terminate bleeding. The threaded needle was then passed from
one side of the ulcer through the muscularis propria or serosa to appear at the other side of the ulcer.
The loop of thread was then caught and the ulcer oversewn; bleeding was terminated by compressing
the vessels with a single stitch or a chain of stitches that was subsequently tied at endoscopy.
This method can be simplified to deliver one loop of thread that can be tied by means of half-hitches or
other knots formed externally to the patient.

Single-Stitch Hollow-Needle Sewing Machine

A different approach to forming stitches in tissue is possible using a hollow needle that is passed
through tissue. Part of a preformed stitch is forced through the needle to appear on the far side of the
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tissue while another part is released on the proximal side (Figures 165 and 166).

(592)Figure 165. Mechanism of action of a single-stitch sewing machine. A, Cross-sectional

view of the machine positioned above the target tissue. One end of a preformed nylon stitch is
loaded into the hollow needle. B, Full-thickness double layer of tissue has been sucked into the
machine's cavity and pierced by the needle. C, The tilting arm of the preformed nylon stitch
has been forced out of the needle beyond the tissue, and the radiotelemetry capsule (RTC) is
being ejected from its cavity. D, Needle and pushing rod have been returned to their starting
positions, and the suction has been turned off to allow the tissue to slip out of the machine's
cavity, leaving the RTC secured to the nylon stitch sewn through a full-thickness double layer
of gastric tissue.

(593)Figure 166. Close-up preformed nylon stitches in postmortem human tissue.

The single-stitch hollow-needle sewing machine was designed to deliver a preformed nylon H-shaped
"tilt" stitch through a full-thickness double layer of gastrointestinal tissue (Figure 167; see also Figure
165).2(594) It is possible to attach objects to this stitch, leaving them secured to the wall of the gut.
The preformed stitch, attached for example to an RTC (Figure 168), is preloaded into the machine,
passing one end into the hollow needle and securing the stitch under a retainer that can release the
stitch in due course. A double layer of tissue is pierced by the hollow needle by pulling on a wire within
a wire-wound flexible cable. The leading part of the stitch is then forced by another wire through the
hollow needle by a pushing rod to a point beyond the fold of tissue where it adopts a T shape that
prevents it from coming back through the tissue. The movement of the pushing rod component of the
machine simultaneously releases the following part of the stitch on the near side of the tissue fold. The
needle and pushing rod are returned to their starting position, and the suction vacuum is released to
allow the tissue with the nylon stitch through it to slide out of the cavity of the machine. The RTC is
ejected from the body of the machine by pulling on a third wire, which forces it out.

(595)Figure 167. Single-stitch endoscopic sewing machine.

(596)Figure 168. RTC attached to a stomach by a preformed stitch.

The sewing machine can be front-loaded with its control cables passing through the accessory
channels of a conventional endoscope, or it can be guided using an endoscope positioned alongside
the control cables. To facilitate insertion and multiple stitch placements, the machine was designed to
be passed optionally through an esophageal overtube with an 11.5-mm internal diameter. One
thousand stitches were delivered in 25 postmortem human stomachs, 50 in 5 esophagi, 20 in 2 small
bowel specimens, and 20 in 2 colon specimens. The nylon stitch had a 6.6-lb breaking strain. Stitches
through muscularis propria required a 4.5-lb force to pull them out; stitches extending only through
muscularis mucosa required 2.1 lb of force.
The single-stitch sewing machine was used to implant pH-sensitive RTCs on 14 occasions for up to 87
days in the stomachs of unrestrained beagle dogs.3(597) Continuous recordings were made in 48-hr
periods using a belt aerial and solid-state recorder worn in a jacket. Studies were carried out during
normal feeding and with 20 and 40 mg (2 to 4 mg/kg) omeprazole (OM) once daily. There were no
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complications (hemorrhage or perforation) during the period of implantation, and follow-up

endoscopies disclosed no evidence of ulceration or focal gastritis. The median (range) intragastric
control pH (C) was 3.4 (2.8 to 7.2). Median pH during acid inhibition after 5 days dosing with 20 mg OM
was 4.2 (1.2 to 7.6), and 5.2 (2.0 to 7.6) after a similar period on 40 mg OM (p = .01 C vs. OM 20 and
OM 40, p = ns OM 20 vs. OM 40). After the drug was stopped, the median pH returned to 2.8 (1.0 to
6.8) on days 1 to 3 but fell to 1.2 (1.0 to 3.2) by days 5 to 7 (p < .001 C vs. period 5 to 7 days). This
technique, for the first time, has allowed monitoring of gastric pH for long periods of time without the
use of wires or tubes.
The single-stitch endoscopic sewing machine has been used to achieve continuous noninvasive
monitoring of gastric pH in humans.4(598) Using an endoscopic sewing machine, an RTC was sewn
into the stomach of one of its inventors with some help from his friends. An 11.5-mm outer diameter
endoscopic sewing machine was used to sew an RTC to the wall of the body of the stomach at 56 cm
from the teeth without laparotomy using a single transmural nylon stitch (Figure 169).

(599)Figure 169. Stitch in a human stomach.

The RTC stayed in position for 159 days and transmitted a radiofrequency signal indicating gastric pH
for the whole time. A total of 1200 hr of ambulatory recordings of gastric pH, that is, 50 24-hr periods,
were made using a body-borne aerial belt and portable pH recorder. A consecutive series of
experiments was carried out comparing the effect of regular antacids (Asilone; Maalox; Gaviscon, 40
ml qid with food; OM 20 mg; OM 40 mg; ranitidine [RAN] 300 mg nocte; RAN 300 mg twice a day), with
a control period of 1 week between each dose regimen. These studies were carried out without loss of
time at work; indeed, the subject was at work on an endoscopy list less than 1 hr after the RTC was
sewn into place. No discomfort was experienced; weight did not alter. No ulceration or inflammation
was observed at the site of the stitch at endoscopy on day 0 or day 14. Acid suppression was
expressed as the percent pH greater than 4.
These experiments showed that antacids altered gastric pH only marginally compared with control data
(control < pH 4: 50%, Gaviscon 51%, Maalox 66%, Asilone 49%). OM 40 mg and RAN 600 mg caused
significantly more acid inhibition (OM 40 mg < pH 4: 94%; RAN 600 mg 100%) than OM 20 mg and
RAN 300 mg (OM 20 mg 79%, RAN 300 mg 73%). Stressful events were not associated with alteration
of baseline pH in this study. This is by far the longest period of continuous monitoring of gastric pH in
humans, and this technique is far more comfortable than measurement by means of a nasogastric pH
probe. Long-term monitoring of gastrointestinal function by means of biosensors implanted at flexible
endoscopy is possible in humans.

Stapling Machine
This instrument is the first flexible, remotely controlled device designed to place multiple transmural
staples in double rows through gastrointestinal tissue without requiring laparotomy.5(600)
The stapler is mounted in front of a conventional endoscope, with a control cable passing through the
accessory channel of the endoscope. The dimensions of the stapler were 16 mm outer diameter and 8
cm long. The staples were made of stainless steel or titanium wire (0.25 mm) and measured 3.5 3.5
The stapler works in the following sequence (Figure 1610): Gastrointestinal tissue to be stapled is
sucked into a cavity within the stapling device to form a double layer (Figure 1610A). The dimensions
of the cavity determine the depth of staple penetration, and the device was designed to deliver staples
that penetrate mucosa and muscularis propria to serosa. The mechanism of action requires three
movements of parts within the stapling device. The tissue must be compressed after suction into an
optimum thickness for staple closure (Figure 1610B). The second movement (Figure 1610C)
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pushes the staples through their location slots by means of staple rammers, so that the staples
penetrate the double layer of tissue to engage shaped anvils that cause them to bend inward and
backward on themselves (into a B conformation) to exert compressive force on the tissue once they
have pierced it (producing an audible "clunk"). The considerable force of 12 to 15 lb required to close
these staples through tissue is exerted by means of strong steel wires inside a wire-wound flexible
(Bowden) cable similar to a bicycle brake cable. The third action (Figure 1610D) is to release the
tension transmitted to the staples through these wires to allow a release spring within the body of the
stapling device to open the cavity and permit the stapled tissue to slide out of the device.

(601)Figure 1610. Mechanism of action of the endoscopic stapling device. A, Fold of tissue
is sucked into the cavity of the stapler. B, The tissue is compressed to an optimum thickness
prior to stapling. C, The staple rammers force the staples through the tissue onto shaped anvils
that bend the staples into a B configuration. D, Spring opens the cavity to allow the stapled
tissue to slide out of the stapling device. Note: This diagram has been simplified to show the
closure of only two staples. In the device, the staples were arranged in an overlapping double
layer forming a semicircle 1 mm from the outer circumference of the stapler.
Two 1-cm-wide strips of postmortem human tissue were stapled together, and the force required to
tear the anastomosis apart was measured. Strips joined with five staples could support weights of up
to 2 lb.
The stapling machine (Figures 1611 and 1612) was used in the postmortem human stomach (35
stomachs, 120 stapling experiments), esophagus (20 esophagi, 40 stapling experiments), and colon
(15 colons, 30 stapling experiments). The force required to close rows of staples varied with the organ
being stapled. An average of 2 lb more force was needed to close rows of staples in the esophagus
than in the stomach. The device was also used to seal experimental 1-cm full-thickness perforating
wounds in postmortem human gastrointestinal tissue (10 experiments).

(602)Figure 1611. Endoscopic stapling machine in opened position.

(603)Figure 1612. Endoscopic stapling machine in closed position.

The stapler was used at endoscopy, with and without laparotomy, to deliver rows of staples in survival
studies in the canine esophagus (12 experiments) and porcine stomach (4 experiments). It was used
at laparotomy to terminate bleeding from standard experimental bleeding gastric ulcers in dogs (10
experiments) and to close 1-cm full-thickness perforating scalpel incisions (4 experiments) in
uncomplicated survival experiments. The stapler was used to oversew experimental bleeding ulcers
and to close small, full-thickness incisions in the canine stomach.
The stapling device is similar in some respects to the endoscopic sewing machine and also to existing
surgical anastomotic stapling guns.611(604) However, it is the first flexible, endoscopically controlled
device for remote placement of multiple staples through gastrointestinal tissue that does not require
laparotomy. Potential applications of such a device include the stapling of bleeding varices (the present
model has been specifically designed for this application and offers a prospect of improved
hemostasis), closure of internal wounds or fistulas, assistance in the removal of normal or abnormal
tissue, safe procurement of full-thickness biopsies of gastrointestinal tissue, and stapling across
bleeding or perforating ulcers. Modifications of the device could be used to assist in the formation of
anastomoses and for antireflux procedures and surgery for the control of obesity.
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Other Mechanical Devices for Attaching Material to Tissue at Endoscopy

A number of related mechanical methods for attaching things to tissue have also been devised. An
elegant clip-fixing device that can be passed through the accessory channel of an endoscope was
developed in 1975 by Hayashi et al.12(605) This has been used to treat bleeding ulcers, to mark the
site of insertion of a colonoscope, and to secure pH electrodes in the stomach. The Sakura J clip,
designed in the mid-1970s by Hayashi et al.12,13(606) and modified by Hachisu,14(607) can now be
passed through the accessory channel (2.8 mm diameter) of a conventional endoscope. This clip is
opened and then closed (Figure 1613) tight on the bleeding point by pulling the proximal loop of a
compressible metal clip into a metal ring, so that the clip closes in the shape of the number 8 to
compress a bleeding vessel.13(608) This device was reported as effective in controlling bleeding from
22 of 24 gastric ulcers and 3 of 4 duodenal ulcers. Dislodgment was relatively frequent (28%), and
further bleeding was noted in 23%.

(609)Figure 1613. Clip-fixing device. The clips are shown open and closed on tissue.
The invention of a rubber-band ligation device (Figures 1614 and 1615) for use at flexible
endoscopy, similar to that for treatment of hemorrhoids, was first reported in 198515(610) and has
subsequently been applied by Stiegmann et al. in the treatment of esophageal variceal bleeding (see
Chapter 36: Endoscopic Elastic Band Ligation for Bleeding Esophageal Varices).16,17(611)

(612)Figure 1614. Rubber-band ligation device.

(613)Figure 1615. Rubber-band placed on tissue.

An ulcer clamp (Figure 1616), which sucks tissue into a cavity to which compression can be exerted
by means of a spring, was developed and reported in 1985.15(614)

(615)Figure 1616. Ulcer clamp.

An instrument that exerts sufficient rotational torque to screw a corkscrew-like device into tissue at high
speed (600,000 rpm) was developed and has been used to treat bleeding gastric ulcers in two clinical
A suturing device for use with rigid endoscopes has been reported by Da Silva.19(617) A long plastic
needle is restrained within a curved track that allows it to be passed through tissue at the end of the
rigid open tube and the thread retrieved once it has passed through the tissue.

Anastomosis at Flexible Endoscopy

In 1892, Murphy20(618) popularized anastomosis at laparotomy by a compression button method in
which circular gastrointestinal anastomoses were formed by ischemic compression of tissue between
two buttons held together by a spring. This technique has been modified to allow the formation of
anastomoses at flexible endoscopy.
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The compression buttons used were circular with a raised rim designed to introduce a thin circle of
ischemia in the intervening tissue when the two buttons were pressed together. Both buttons had a
central locating hole through which a threaded needle could be passed, and one (the female part) had
a locking mechanism composed of a sprung wire that could catch a serrated hollow locating pin
passed through the other (the male part). When locked, the two buttons were pressed together by a
compression spring positioned over the locating pin (Figures 1617 and 1618).

(619)Figure 1617. Compression buttons open.

(620)Figure 1618. Compression buttons closed.

Gastrojejunostomies were formed at flexible endoscopy in six adult greyhounds in the following
fashion.21(621) Through a 2-cm minilaparotomy incision, a suitable loop of jejunum adjacent to the
stomach was identified. One flexible endoscope was passed by mouth into the stomach. Meanwhile, a
small incision was made in the jejunum to allow a second flexible endoscope to be passed a few
centimeters into the jejunum. By maneuvering the tip of this second endoscope, the jejunal wall could
be brought into close proximity to the stomach. Transillumination and indentation of the stomach wall
by the jejunal endoscope could be observed (Figure 1619). A needle with thread attached was
pushed through the jejunal and stomach walls and caught by a wire loop snare. Both endoscopes were
removed, leaving the thread passing through the abdominal incision into the jejunum, then through into
the stomach to emerge through the mouth. The male button was passed over the thread into the
jejunum. A knot was tied on the abdominal side, so that the force exerted on the thread at the mouth
would pull the jejunal male button in a cephalad direction. The second, female button was passed over
the thread and pushed into the stomach by the gastroscope. When the gastric button was in apposition
with the gastric wall, the thread was pulled so as to force the serrated pin of the male button through
the jejunal and gastric walls and into the female button. The two buttons were thus locked together
under compression and the intervening tissues squeezed between the raised circumferential rims. The
endoscope in the stomach was held steady, so that its tip could act as a stop to hold the female button
in place as the central serrated pin on the male button was pulled by means of the thread passing
through the accessory channel. Once the buttons were locked into position, a white rim indicating
ischemia could be seen around the edge of the buttons and bile-stained jejunal juice refluxed through
the hollow central pin (Figure 1619). The endoscopes were withdrawn, and the thread was removed
by pulling it out of the jejunal and abdominal incisions, which were then closed.

(622)Figure 1619. Compression buttons at endoscopy. A rim of ischemic necrosis can be

seen at the edge of the button. A drop of bile from the jejunum has run through the needle into
the stomach.
Using the preceding technique, eight gastrojejunostomies were formed in six animals without
complications (in two experiments adjacent double anastomoses were formed). The buttons left the
stomach and emerged in the stool at 48 to 96 hr after placement. Endoscopies at 7 days demonstrated
that the gastroenterostomies could be crossed by a 9-mm-diameter endoscope. The anastomoses
were still present and patent 9 months later (Figure 1620).

(623)Figure 1620. Formed gastrojejunal anastomosis at 9 months.

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A need remains for further development and application of technology for sewing, stapling, and forming
anastomoses. Knot tying at rigid and flexible endoscopy remains cumbersome although
feasible.22(624) Despite these difficulties, further technical development, together with the use of the
techniques and instruments described above in combination, has made it possible to perform relatively
complex operations without resorting to laparotomy.23(625) Moreover, continued technical
development will lead to simplified devices with potential clinical utility.24(626) Considerable scope
exists for joint endoscopic and laparoscopic projects involving sewing and stapling, and it is a pity that
so little crossover of technology occurs between the domains of rigid and flexible endoscopy.
Surgery has three basic technical aspects: cutting, controlling bleeding, and joining living tissue with
materials or other living tissue. Striking advances have been made in the clinical application of
endoscopic surgical techniques for cutting tissue and controlling bleeding. If the problems of sewing
and joining tissue and material at flexible endoscopy can be overcome, it is possible to consider the
advent of a new gastrointestinal surgery in which laparotomy is rarely required and the transabdominal
and transthoracic insertion of rigid instruments is much reduced.


Swain CP, Mills TN. An endoscopic sewing machine. Gastrointest Endosc 1986;32:367.
Swain CP, Brown G, Van Someren N, et al. Design and testing of a single stitch endoscopic
sewing machine. Gut 1989;30:A15145.
Evans DF, Brown G, Kalabakas A, et al. Acid breakthrough with high dose omeprazole
revealed by a new non-invasive method of continuous pH monitoring from implanted
telemetry capsules. Gastroenterology 1991;100:A62.
Swain CP, Evans DF, Glynn M, et al. Endoscopic sewing machine used to achieve continuous
non-invasive monitoring of gastric pH for three months in man. Gastrointest Endosc
5. Swain CP, Brown GJ, Mills TN. An endoscopic stapling device: The development of a new
flexible endoscopically controlled device for placing multiple transmural staples in
gastrointestinal tissue. Gastrointest Endosc 1989;35:3389.
6. Rohscek F. The birth of the surgical stapler. Surg Gynecol Obstet 1980;150:57982.
Fraser I. An historical perspective on mechanical aids in intestinal anastomosis. The
surgeon's library. Surg Gynecol Obstet 1982;155:55674.
Ravisch MM, Steichen FM. Technics of staple suture in the gastrointestinal tract. Ann Surg
9. Goliger JC. Recent trends in the practice of sphincter-saving excision for rectal cancer. Ann R
Coll Surg Engl 1979;61:16976.
Ravisch MM, Steichen FM. Contemporary stapling instruments and basic mechanical suture
techniques. Surgical stapling techniques. Surg Clin North Am 1984;634:42540.
11. Waxman BP. Large bowel anastomosis II. The surgical staplers. Br J Surg 1983;70:647.
Hayashi T, Yonezawa M, Kuwabara T, et al. The study on staunch clips for treatment by
endoscopy. Gastroenterol Endosc 1975;17:92101.
Hayashi J. The study of endoscopic staunching clips for bleeding of the exposed vessel end
of the ulcer. In Okabe M, Honda T, Oshiba S (eds). Endoscopic Surgery. New York: Elsevier,
14. Hachisu T. Evaluation of endoscopic hemostasis using an improved clipping apparatus. Surg
Endosc 1988;2:137.
Swain CP, Mills TN, Northfield TC. Experimental studies of new mechanical methods of
endoscopic haemostasis: Stitching, banding, clamping and ulcer removal. Gut
16. Stiegmann GV, Cambre T, Sun JH. A new endoscopic elastic band ligating device.

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Gastrointest Endosc 1986;32:2303.

17. Stiegman GV, Goff JS. Endoscopic esophageal varix ligation: Preliminary clinical experience.
Gastrointest Endosc 1988;34:1137.
18. Escourrou J, Delvaux M, Buscail L, et al. First clinical evaluation and experimental study of a
new mechanical suture device for endoscopic hemostasis. Gastrointest Endosc
19. Da Silva EG. Suturoscope: A new device that allows endoscopic sutures to be performed with
traditional threads. Surg Endosc 1990;4:2203.
Murphy JB. Cholecystointestinal, gastrointestinal, enterointestinal anastomoses and
approximation without suture (original research). Med Rec NY 1892;42:66576.
21. Swain CP, Mills TN. Anastomosis at flexible endoscopy: An experimental study of
compression button gastrojejunostomy. Gastrointest Endosc 1991;37:62831.
22. Swain CP, Kadirkamanathan SS, Gong F, et al. Knot tying at flexible endoscopy. Gastrointest
Endosc 1994;40:7229.
23. Kadirkamanathan SS, Evans DF, Gong F, et al. Antireflux operations at flexible endoscopy
using endoluminal stitching techniques: an experimental study. Gastrointest Endosc
24. Swain CP, Brown GJ, Gong F, Mills TN. An endoscopically deliverable tissue-transfixing
device for securing biosensors in the gastrointestinal tract. Gastrointest Endosc

Chapter 17 Biomedical Tissue Spectroscopy



The visual sensation of colors of light and their variations have long played a fundamental role in the
interaction of humans with nature. Our most highly developed special sense, vision, is a sophisticated
and versatile tool for analyzing the spatial and spectral distributions of light in our environment. Optical
spectroscopy, the quantitative study of the colors of light, has stimulated many of the great discoveries
in the history of science. Isaac Newton first stipulated that colors of light correspond to frequencies of
vibration of waves, and he demonstrated color separation with prisms.1(629) Late in the 19th century,
when it was determined that light waves correspond to vibrations of coupled electric and magnetic
fields, it became apparent that light spectra could be used to probe the elementary structure of matter.
This is because electromagnetic waves interact with atoms and molecules at characteristic frequencies
(i.e., colors) that are highly specific to their internal composition and microenvironment. Early in the
20th century, observations of optical spectra of simple atoms and molecules demonstrated that the
frequencies of light that are absorbed and emitted are quantized; that is, they occur only at discrete
energy intervals. These observations led directly to the development of quantum theory, the theoretical
tool needed to understand and predict atomic and molecular spectra. Many other developments in
science and technology in the 20th century can be traced to the study or use of optical spectra. Optical
and radio spectroscopy of radiation from the heavens provides the only available direct experimental
evidence concerning the origins and history of the universe.
Various forms of optical spectroscopy have been applied in the identification and monitoring of
physical, chemical, and biologic processes. Qualitative optical spectroscopy has also played a
fundamental role in medicine. From earliest to present practitioners, visual assessment of color, hue,
and pallor has been an essential element of physical diagnosis. These indicators have only increased
in value with the development of modern, minimally invasive diagnostic technology, which allows for
visual assessment of tissue surfaces in previously inaccessible regions of the body. Despite the
availability of these imaging modalities of unparalleled sophistication, diagnosis is still based largely on
qualitative visual observations. Unfortunately, the highly sensitive and specific optical biochemical
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assays developed in other disciplines using previously available technologies have not been directly
transferable to diagnostic applications in humans. In any case, these are insufficiently sophisticated in
relation to the complexity of clinical diagnosis.
Rapid advances in optical and photonic technologies over recent decades have led to the development
of new techniques that make possible the application of quantitative optical spectroscopy to the early
detection and staging of human disease. The fundamental advance that stimulated the renaissance of
optics in science, technology, industry, and now medicine was the invention of the laser (see Chapter
10: Laser Physics and Laser-Tissue Interactions). When used in conjunction with low-loss flexible
optical fibers, lasers make it possible to apply quantitative spectroscopic techniques within the human
Two additional technologies developed in the last decade are of critical importance to making real-time
quantitative spectroscopic diagnosis a reality: (1) highly sensitive, large-area multipixel imaging
detectors (e.g., charge-coupled devices [CCDs]) that enable collection of quantitative spectra through
optical fibers in near real time; and (2) fast, inexpensive computers that can rapidly collect, process,
and display imaging and spectral information.
Current research also holds promise in the near future of capabilities even greater than those provided
by imaging detectors and computers. Ultrafast optical technologies, for example, can potentially
combine spectroscopic characterization of disease with high-resolution, three-dimensional imaging of
tissue microstructure.2,3(630) Advances in the understanding of human visual processing may lead to
minimally invasive technologies for visualization of and interaction with unique three-dimensional

Light-Tissue Interactions
The interaction of light with tissue is a special case of the interaction of light with matter. This
interaction is a particularly difficult system to describe in detail, as it involves a complex interplay
among many component processes. Some of these processes act to change the frequency distribution
of light, whereas others act to redistribute light spatially once it has entered the tissue.57(632) Two
other intensively studied physical systems that involve simultaneous spatial and spectral redistribution
of radiation are the scattering of light in planetary atmospheres8(633) and the scattering of neutrons in
nuclear reactors.9(634) Many of the mathematical foundations underlying current studies of light-tissue
interactions had their origins in the study of these phenomena.7(635)
Although the light-tissue interaction process as a whole is complex, its components are well
understood (Figure 171). At its basis, the interaction of light with matter depends on the transfer of
energy between particles of light (photons) and particles of matter. Particles of matter include
submicroscopic components such as electrons, atoms, and molecules, as well as larger (microscopic)
particles such as cells, granules, and organelles. Although the latter may scatter photons (described
later), a quantum description is necessary only to describe interactions that occur between photons
and submicroscopic particles.

(636)Figure 171. Spectroscopic light-tissue interactions of diagnostic significance.

Molecules are the submicroscopic particles that have the richest spectral content and thus are the
primary concern of this discussion. Both photons and molecules exhibit a strong quantum nature,
having characteristics of both particles and waves. Light photons carry energy proportional to their
frequency, according to Planck's Law (see Chapter 10: Laser Physics and Laser-Tissue Interactions).
The wavelength of light () is inversely proportional to its frequency () according to the relation = c/,
where c is the velocity of light.
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According to quantum mechanics, only discrete amounts of energy may be stored in molecules. This
quantization applies to the electron orbitals, which may be occupied in the molecule's constituent
atoms, as well as to vibrations between constituent atoms, rotations of parts of the molecule with
respect to other parts, and rotations of the whole molecule. Vibrational and rotational energies are
typically small compared with electron energy levels (Figure 172). A photon can interact with a
molecule only if the photon energy corresponds to an available energy level difference in the molecule.
Similarly, if a molecule occupies an energy level above that of its ground state (having been excited, for
example, by a previous photon), it may relax to a lower state, accompanied by emission of a photon
with a frequency corresponding to the energy level difference. Molecules also interact with their
environment in other ways. They can be excited by other energy sources such as chemical reactions,
heat, or sound, and they may relax from excited states by emission of any of these or other forms of

(637)Figure 172. Schematic diagram of the energy level of a molecule. Solid horizontal
lines represent atomic energy levels that are surrounded by closely spaced
vibrational-rotational energy levels (horizontal dashed lines) with lower energy spacing. The
horizontal dotted line represents virtual energy levels, which only occur in the presence of
high-intensity light. Horizontal sinusoidal lines represent photons with energy hf, where f
represents the type of interaction. hPlanck's constant; frequency. Vertical solid lines
represent energy level transitions resulting in the absorption or emission of photons, and the
diagonal dashed line represents energy level transitions by other means, such as simple
Several light-tissue interaction processes have significance for optical diagnosis (Figure 173; see also
Figure 171). These can be described by several fundamental properties. Interactions can be elastic or
inelastic. In elastic scattering processes, the frequency of the incident radiation and the energy state of
the molecule remain largely unchanged, but the direction of light propagation may be altered. Two
important categories of elastic scattering include Rayleigh and Mie scattering.7,10(638) Rayleigh
scattering refers to scattering of light by particles much smaller than a wavelength, with the result that
(unpolarized) incident light is scattered essentially uniformly in all directions. Mie scattering theory
describes the scattering of light by particles of a size comparable to or larger than a wavelength; its
theoretical description is much more complicated. In Mie scattering, most photons are scattered into a
relatively small cone in the same direction as that of the incident photon; however, some photons are
scattered at high angles to that direction with a distribution that is highly sensitive to the exact size and
shape of the particle. Thus, small shifts in the wavelength of the incident light can lead to large
changes in the scattered light distribution for Mie-sized particles. Most (>90%) of the scattering of
visible wavelengths of light by tissue falls into the Mie scattering category.11(639)

(640)Figure 173. Schematic diagram of several possible light-tissue interactions processes.

In inelastic scattering processes, part or all of the energy carried by a photon may be absorbed by the
particle. The absorbed energy may be dissipated to the local surroundings in the form of heat, or
reemitted as another photon, generally with a lower frequency. Cases of both elastic and inelastic
scattering are frequency dependent; thus, by monitoring the frequencies that are preferentially
absorbed and scattered, as well as monitoring the emission of light at secondary frequencies,
information may be obtained about the size distribution and composition of tissue particles.
Figures 172 and 173 include energy level diagrams as a shorthand notation for keeping track of the
transfer of energy that characterizes light-matter interactions. These can be interpreted as progressing
from left to right; a photon approaches an atom from the left and interacts with it, and another photon
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may be emitted and exit to the right. The time dependence of an interaction is typically
noninstantaneous only when an atom occupies an intermediary excited state for some period of time
before emitting the final photon. The quantum yield of a specific interaction is defined here as that
fraction of the photons involved in interactions that are products of that specific interaction, compared
with the total number of photons incident on the medium. Elastic scattering (see Figure 171) is by far
the most likely light-tissue interaction in the visible and near-infrared wavelength regions of the
spectrum. This property of tissue, which accounts for its translucence, implies that each photon is likely
to be scattered many times (hundreds or thousands) before and between inelastic collisions. This
property also makes it particularly challenging to identify the spatial origins of photons reemitted from
tissues on a microscopic scale. Biologic specificity is a qualitative measure of how distinctive a given
type of interaction is in relation to biologic activity.

Optical Spectroscopy in Biomedicine

The earlier technical introduction to the physics of tissue spectroscopy forms the basis for a discussion
of specific approaches to spectroscopic characterization of normal and diseased tissue. The following
represents the current state of research in this field.

Absorption Spectroscopy
The most common application by far of spectroscopy in biomedicine is the routine analytical
characterization of biochemical compounds by spectrophotometry. Absorption spectra of compounds
extracted from human tissues can serve as indicators of metabolic state or the presence of
disease.1214(641) Absorption spectroscopy is performed by monitoring the attenuation of light in
samples of known thickness in order to detect and quantify the concentrations of specific molecules
with known quantum transition energy levels. These transition energies vary with the state and
microenvironment of the molecule (e.g., pH or oxidation-reduction state). It is well established that
hemoglobin, for example, exhibits distinct shifts in absorption spectra between its oxygenated and its
deoxygenated states (Figure 174).15,16(642) Deoxyhemoglobin absorbs strongly in the
red-wavelength region, thus causing deoxygenated blood to appear blue, whereas oxyhemoglobin
absorbs very little in the red region and thus causes oxygenated blood to reflect red colors and appear
bright red.

(643)Figure 174. Optical absorption spectra of oxyhemoglobin (HbO2) and

deoxyhemoglobin (Hb) in the visible and near-infrared wavelength ranges. (From Szaflarski
NL, Cohen NH. Use of pulse oximetry in critically ill adults. Heart Lung 1989; 18:44455.)
Although absorption spectroscopy has a long, rich history as the mainstay of analytical and clinical
chemistry, it is very difficult to apply quantitatively in highly scattering biologic tissues, primarily for two
reasons: (1) Native tissue contains such an abundance of biochemical compounds, each having
distinct but overlapping visible absorption spectra, that it is virtually impossible to separate the
contributions of the individual component molecules of interest. This is especially true in the lower
wavelength regions of the visible spectrum, where most biomolecules absorb and fluoresce.17(644) (2)
Even when abundant molecules with characteristic spectra in the infrared region (e.g., hemoglobin,
porphyrin compounds) can be identified, the prevalence of scattering in the tissue makes it virtually
impossible to accurately determine the path length of a light source shining through the tissue. For this
reason, quantitative determinations of molecular concentration cannot be performed.
Although quantitative measurements of chromophore concentration are very difficult to achieve using
absorbance measurements, fractional concentrations may still be measured using ratio
measurements. An example of this technique is pulse oximetry, in which the oxygen saturation, which
is the relative concentration of oxyhemoglobin to the total hemoglobin concentration, is
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measured.18,19(645) This is accomplished by measuring absorbance at two separate wavelengths in

the red and infrared regions of the spectrum (see Figure 174). Measurements are performed at
systole and diastole in rapid succession to separate out absorbance due to arterial blood only in the
finger tip or earlobe. Another use of absorption spectroscopy in diagnosis lies in the administration of
drugs with an increased affinity for diseased tissues, unique spectral signatures, and sufficient tissue
concentrations to overwhelm other tissue chromophores within their characteristic wavelength regions.
Porphyrin compounds, which preferentially concentrate in neoplastic tissues, are under investigation as
potential optical markers for disease.14,2027(646)
Despite its limitations for obtaining definitive diagnostic information, absorption does play an important
role in other forms of spectroscopy, including reflectance and fluorescence, by spectrally filtering
light.28,29(647) Because absorption is an established standard for biochemical measurements,
considerable effort has been devoted to the development of sophisticated techniques for extraction of
quantitative absorbance information from other optical tissue-probing techniques. Some of the
experimental techniques used to discriminate tissue optical properties, including absorption and
scattering coefficients, are attenuated total reflectance spectroscopy,30(648) coherent backscatter
spectroscopy,31(649) low-coherence interferometry,32(650) and various time-resolved3335(651) and
frequency-domain36(652) methods. Analytical and numerical theoretical techniques have also been
used in attempts to obtain tissue optical properties from reflectance spectra.11,37,38(653