Core curriculum for ergonomics in endoscopy

Endoscopy ergonomics: a survey-based study exploring gender differences

BACKGROUND AND AIMS

Women, on average, have smaller hand sizes as well as lower muscle mass and strength. With the increasing number of women entering training programs in gastroenterology, our aim was to study the subtle gender differences in endoscopy ergonomics.

METHODS

A survey instrument regarding demographic information, personal preferences in endoscopy styles and techniques, and endoscopy-related injury was sent to practicing gastroenterologists. Statistical analysis was performed on the data.

RESULTS

The survey was answered by 107 gastroenterologists, 41 (38.3%) female subjects and 66 (61.7%) male subjects. Female participants were shorter in height, had smaller hand sizes, and performed fewer weekly cases. More men (45.5%) than women (20%) performed advanced endoscopic procedures. Women preferred the following: (1) holding the endoscope with the umbilical cord outside the forearm; (2) using the right hand to turn the small wheel; and (3) using a pediatric colonoscope to perform colonoscopy in a petite patient or one with a low body mass index. Endoscopy-related injury was reported in 49.5% of all gastroenterologists, with women reporting a significantly higher risk of injury (63.4%) than men (40.9%) (P = .02). Although higher weekly case volumes and performance of advanced endoscopy procedures were not independent risk factors for endoscopy-related injury, female gender was found to be an independent risk factor for injury.

CONCLUSIONS

Gender differences exist in endoscopy styles and techniques, as well as endoscopy-related injury. Providing gender-specific training in endoscopy may improve ergonomics and decrease the risk of injury.

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024

1:  ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2:  ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3:  ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4:  ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5:  ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6:  ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7:  Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8:  ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9:  ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10:  ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11:  ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Sex differences impact ergonomic endoscopic training for gastroenterology fellows

BACKGROUND AND AIMS

Endoscopic-related injuries (ERIs) for gastroenterologists are common and can impact longevity of an endoscopic career. This study examines sex differences in the prevalence of ERIs and ergonomic training during gastroenterology fellowship.

METHODS

A 56-item anonymous survey was sent to 709 general and advanced endoscopy gastroenterology fellows at 73 U.S. training programs between May and June 2022. Demographic information was collected along with questions related to endoscopic environment, ergonomic instruction, technique, equipment availability, and ergonomic knowledge. Responses of female and male gastroenterology fellows were compared using χ2 and Fisher exact tests.

RESULTS

Of the 236 respondents (response rate, 33.9%), 113 (44.5%) were women and 123 (52.1%) were men. Female fellows reported on average smaller hand sizes and shorter heights. More female fellows reported endoscopic equipment was not ergonomically optimized for their use. Additionally, more female fellows voiced preference for same-gender teachers and access to dial extenders and well-fitting lead aprons. High rates of postendoscopy pain were reported by both sexes, with significantly more women experiencing neck and shoulder pain. Trainees of both sexes demonstrated poor ergonomic awareness with an average score of 68% on a 5-point knowledge-based assessment.

CONCLUSIONS

Physical differences exist between male and female trainees, and current endoscopic equipment may not be optimized for smaller hand sizes. This study highlights the urgent need for formal ergonomic training for trainees and trainers with consideration of stature and hand size to enhance safety, comfort, and equity in the training and practice of endoscopy.

Implementation and Evaluation of a Curriculum for Ergonomics Training During GI Fellowship

BACKGROUND AND AIMS

Training in ergonomics is either fragmented or lacking in most GI programs. There are limited real-world data on fellows' perceptions and change in practice after the delivery of a curriculum for ergonomics. We aim to implement a curriculum for endoscopy for our GI fellows and evaluate their response to the same.

METHODS

We devised and implemented a curriculum with three components, delivered over 6 months for all GI fellows in an academic hospital center. These were one, a comprehensive, hour-long didactics session conducted by an experienced faculty member; two, an interactive session with a physical therapist; and three, provision of free resistance bands and compression stockings to fellows. We conducted a pre- and post-curriculum test. Data are presented as proportions and medians with interquartile range.

RESULTS

We surveyed 23 fellows. At baseline, 13.6% (3) had sustained ERI during their training. Only 63.6% (14) of trainees reported confidence in being able to recognize signs and symptoms of ERI. Their median self-reported understanding of ergonomics was 3 on a Likert scale of 1-5, corresponding with "average understanding." The majority of trainees had never reviewed any material on ergonomics prior to this curriculum. In the post-test evaluation, the median self-reported understanding of ergonomics improved to 4, corresponding with "above average understanding." All fellows requested a repeat of the curriculum, either semi-annually or annually.

CONCLUSION

Our data show a positive perception of trainees of a practical, reproducible, and low-cost curriculum for endoscopy incorporated during GI fellowship.

Work-related musculoskeletal pain and discomfort in laparoscopic surgeons: an international multispecialty survey

INTRODUCTION

As laparoscopic surgery is used more widely across the globe and within multiple surgical specialties the potential impact on surgeons is yet to be fully quantified. Maintenance of uncomfortable body positions may lead to work-related musculoskeletal disorders (WMSD) in surgeons, with potential knock-on effects.

METHODS

An international open online survey of multispecialty laparoscopic surgeons was carried out, designed and reported in accordance with the CHERRIES checklist for internet e-survey research. There was no paid advertising and no incentives offered.

RESULTS

A total of 259 surgeons from 9 specialties and 32 countries answered the survey, with 90% reporting pain attributable to performing laparoscopic surgery. All training grades were represented. Longer average operative duration and a greater number of years in practice were both associated with a significantly higher prevalence of pain. Surgeons with a pre-existing injury were significantly more likely to report pain than those without. Twenty per cent of surgeons would consider early retirement owing to pain.

CONCLUSIONS

The impact on surgeons of performing laparoscopic surgery is significant, even given the limitations of an open survey. Innovations such as robotic surgery and improved ergonomic education may reduce the incidence of WMSD in surgeons, to mitigate both the personal effects on surgeons and the wider effect on the future surgical workforce.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Upskilling Pediatric Ileocolonoscopy

Upskilling in ileocolonoscopy is an important aspect of pediatric endoscopic practice as it enables endoscopists to learn additional skills through education and training to improve outcomes. With the advent of technologies, endoscopy is continuously evolving. Many devices can be applied to improve endoscopy quality and ergonomics. In addition, techniques such as dynamic position change can be employed to increase procedural efficiency and completeness. Key to upskilling is enhancing endoscopists' cognitive, technical and nontechnical skills and the concept of "training the trainer" to ensure trainers have the requisite skills to teach endoscopy effectively. This chapter details aspects of upskilling pediatric ileocolonoscopy.

Enhancing Ergonomics in Pediatric Endoscopy Training and Practice

Pediatric endoscopists are at risk of work-related injuries from overuse and repetitive motions during endoscopy. Recently, there has been increasing appreciation for the importance of ergonomics education and training to help build long-term habits that prevent injury. This article reviews the epidemiology of endoscopy-related injuries in pediatric practice, describes methods for controlling exposures in the workplace, discusses key ergonomic principles that can be used to mitigate injury risk, and outlines tips for integrating education on endoscopy ergonomics during training.

Musculoskeletal injury and ergonomics in pediatric gastrointestinal endoscopic practice

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

GIE Editorial Board Top 10: advances in GI endoscopy in 2021

The 9-member Editorial Board of the American Society for Gastrointestinal Endoscopy performed a systematic literature search of original articles published during 2021 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals on endoscopy-related topics. Votes from each editorial board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study, with a focus on 3 criteria: significance, novelty, and global impact on clinical practice. The 10 areas identified collectively represent advances in the following endoscopic topics: colonoscopy optimization, bariatric endoscopy, endoscopic needle sampling and drainage, peroral endoscopic myotomy, endoscopic defect closure, meeting systemic challenges in endoscopic training and practice, endohepatology, FNA versus fine-needle biopsy sampling, endoscopic mucosal and submucosal procedures, and cold snare polypectomy. Each board member contributed a summary of important articles relevant to 1 to 2 of the consensus topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2021.

Educational interventions to improve ergonomics in gastrointestinal endoscopy: a systematic review

Background and study aims  Endoscopists are at high risk of musculoskeletal pain and injuries (MSPI). Recently, ergonomics has emerged as an area of interest to reduce and prevent the incidence of MSPI in endoscopy. The aim of this systematic review was to determine educational interventions using ergonomic strategies that target reduction of endoscopist MSPI from gastrointestinal endoscopy. Methods  In December 2020, we conducted a systematic search in MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews for articles published from inception to December 16, 2020. Studies were included if they investigated educational interventions aimed at changing knowledge and/or behaviors related to ergonomics in gastrointestinal endoscopy. After screening and full-text review, we extracted data on study design, participants, type of training, and assessment of primary outcomes. We evaluated study quality with the Medical Education Research Study Quality Instrument (MERSQI). Results  Of the initial 575 records identified in the search, five met inclusion criteria for qualitative synthesis. We found that most studies (n = 4/5, 80 %) were single-arm interventional studies that were conducted in simulated and/or clinical settings. The most common types of interventions were didactic sessions and/or videos (n = 4/5, 80%). Two (40 %) studies used both standardized assessment studies and formal statistical analyses. The mean MERSQI score was 9.7. Conclusions  There is emerging literature demonstrating the effectiveness of interventions to improve ergonomics in gastrointestinal endoscopy.

Endoscopy-related injury among gastroenterology trainees

Background and study aims  Endoscopy-related injury (ERI) is widespread among practicing gastroenterologists. However, less is known about the incidence among trainees. This study assesses the rate of self-reported ERI occurrence, patterns of injury, and knowledge of preventive strategies in a nationally representative sample of gastroenterology fellows. Methods  A 38-item electronic survey was sent to members of the American College of Gastroenterology. One hundred and sixty-eight gastroenterology fellows were included in analyses. Descriptive and univariate analyses evaluated the likelihood of ERI by workload parameters and gender. Results  ERI was reported by 54.8 % of respondents. ERI was most common in the thumb (58.7 %), hand/finger (56.5 %), and wrist (47.8 %). There was no significant difference in the reported occurrence of ERI between male and female gastroenterology fellows. However, female fellows were significantly more likely to report a greater number of body areas affected by ERI, and male fellows were more likely to report elbow pain. Most respondents (85.1 %) reported discussion about, or training in, ergonomic strategies during gastroenterology fellowship. Conclusions  ERI is reported to occur as early as gastroenterology fellowship. Results of this study support this finding and highlight the need for ongoing implementation and monitoring of a formal ergonomics training program as well as development of ergonomically appropriate instruments. Implications of these findings likely extend to trainees in other procedural related specialties like orthopedics and general surgery, though further research is required. Ergonomics training in gastroenterology fellowship and monitoring of its impact on trainees reported ERI is important due to negative effects on productivity and career longevity.