João Pereira da Silva
Hospital dos Lusíadas
Serviço de Gastrenterologia
1. Missing the lesion altogether
The connection between a good bowel preparation and adenoma detection is well documented; data regarding upper GI preparation is less well validated, but simethicone-based upper GI preparation is a very low-cost-high yield trick worth implementing. There is also data correlating inspection time in colonoscopy and upper endoscopy and missing lesion rates, with recommended examination times and techniques for Barrett´s esophagus, esophageal squamous carcinoma and dysplasia in IBD patients. In short, make sure you have an adequate preparation and never rush an exam.
2. Inadequate characterization and photo/videodocumentation
There is no such thing as too much photos of a lesion; from personal experience in a high-volume centre in Japan, a normal upper GI or colonoscopy would be documented with at least 30 images; a lesion would increase this number to over 100. Close-up and long-distance photos in WLE should be taken, as well as digitally-enhanced chromoendoscopy (DEC) such as NBI or BLI; use Paris classification for morphological description in all locations, and familiarize yourself with location-specific DEC classifications: NICE or JNET for colon lesions, BING for Barrett´s, etc).
3. Being mindful of specificities regarding organ location and pathology
Circumferential involvement and distance to upper oesophageal sphincter or EG junction in oesophagus, clear identification of the duodenal papilla and relation to duodenal lesions, relation to ileo-cecal valve or appendicular orifice in cecal lesions; distance or involvement of the dentate line in low rectal lesions are just some examples of this.
4. Not choosing the right tools for the job
Increasing use of advanced techniques such as ESD and full-thickness resection (FTR) for en-bloc removal of digestive superficial lesions means making an informed decision when detecting a dysplastic lesion: Can this lesion be resected by conventional EMR or should it be resected by ESD or FTR (or surgery)? Criteria are different according to organ and histology, and by no means perfect; even so, the endoscopist is in the prime position to make this call, with abundant imaging documenting the chosen recommendation.
5. Not choosing the right tools for the job II
Cold snare polypectomy is currently the way to go in small adenomatous polyps in the colon; more recently, its use for resection of large flat/slightly elevated serrated lesions of the right colon or has proven effective and, crucially, safe, avoiding a potentially risky conventional EMR in the right colon. Its use for duodenal adenomas could also prevent complications in this high-risk area.
6. Not discussing with patients all treatment options, with its associated risk and benefits
Resecting a lesion is never an urgent matter. There is time to discuss treatment options as well as technique-associated risk; surgery should be mentioned. It´s crucial patients understand that procedures like ESD can result in the uneventful complete removal of a superficial lesion and still need salvage surgery because of an oncologically non-curative resection.
7. Biting more than you can chew
Be aware of your current skill level, and refer patients with lesions you cannot handle. Finding yourself unable to resect a lesion halfway through a procedure means a much harder rescue procedure later; finding yourself looking to the peritoneum after perforation because of inadequate technique is a serious complication, and potentially catastrophic because of the risk for peritoneal seeding.
8. Biting more than you can chew II
Even the most skilled endoscopist will eventually run into complications sometime. If you can´t handle them or if there is no on-site/on-call GI, urgent surgery or radiology consultation, undergoing complex procedures is really not an option.
9. Not reviewing your outcomes
Nowadays, every gastroenterologist will be required to review his/her pathology reports to document an adequate ADR. Furthermore, advanced lesions should be reviewed after (and ideally before) resection in a multidisciplinary team.
10. Not planning adequate follow-up
Current ESGE guidelines allow for long surveillance intervals in low-risk adenomas; inversely, patient with dysplastic/neoplastic lesion in the stomach or oesophagus have a high risk of metachronous lesions, and should be closely followed. If the patient was referred to you, there should be an agreed-upon follow-up program with and a recall system to deal with local recurrences, if and when they happen.