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Practical Gastrointestinal Endoscopy


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Table of Contents

Preface to the Sixth Edition, vii Acknowledgments, ix 1 The Endoscopy Unit and Staff, 1 Staff, 1 Facilities, 1 Management and behavior, 3 Documentation, 4 Educational resources, 5 2 Endoscopic Equipment, 7 Endoscopes, 7 Endoscopic accessories, 11 Ancillary equipment, 12 Electrosurgical units, 12 Lasers and argon plasma coagulation, 13 Equipment maintenance, 14 Infection control, 15 Cleaning and disinfection, 16 3 Patient Care, Risks, and Safety, 22 Patient assessment, 22 Patient education and consent, 26 Physical preparation, 31 Monitoring, 31 Medications and sedation practice, 32 Recovery and discharge, 34 Managing an adverse event, 35 4 Upper Endoscopy: Diagnostic Techniques, 37 Patient position, 37 Endoscope handling, 38 Passing the endoscope, 39 Routine diagnostic survey, 42 Problems during endoscopy, 49 Recognition of lesions, 50 Specimen collection, 55 Diagnostic endoscopy under special circumstances, 58 5 Therapeutic Upper Endoscopy, 61 Benign esophageal strictures, 61 Achalasia, 65 Esophageal cancer palliation, 66 Gastric and duodenal stenoses, 70 Gastric and duodenal polyps and tumors, 70 Foreign bodies, 70 Acute bleeding, 74 Enteral nutrition, 80 6 Colonoscopy and Flexible Sigmoidoscopy, 87 History, 87 Indications and limitations, 88 Informed consent, 93 Contraindications and infective hazards, 94 Patient preparation, 95 Medication, 105 Equipment-present and future, 111 Anatomy, 116 Insertion, 120 Handling-"single-handed," "two-handed," or twoperson?, 123 Sigmoidoscopy-accurate steering, 128 Endoscopic anatomy of the sigmoid and descending colon, 131 Sigmoidoscopy-the bends, 133 Sigmoidoscopy-the loops, 134 Diverticular disease, 143 Descending colon, 144 Splenic flexure, 145 Transverse colon, 152 Hepatic flexure, 155 Ascending colon and ileo-cecal region, 158 Examination of the colon, 164 Stomas, 172 Pediatric colonoscopy, 172 Per-operative colonoscopy, 173 7 Therapeutic Colonoscopy, 176 Equipment, 176 Polypectomy, 182 Other therapeutic procedures, 202 8 Resources and Links, 208 Web sites, 208 Endoscopy books, 208 Journals with major endoscopy/clinical focus, 209 Index, 211

About the Author

Peter Cotton is Professor of Medicine, and Director of the Digestive Disease Center, at the Medical University of South Carolina in Charleston. He was born and educated in England, where his father was a rural family physician. He graduated in 1963 from Cambridge University and St. Thomas Hospital Medical School (London). During a year of bench research as part of his GI training, he came across a paper describing the first fiberoptic gastroscope with a biopsy capability. The instrument was acquired, and a career was born. He developed the Endoscopy Laboratory at St. Thomas' Hospital whilst still officially in training, and wrote many of the first European papers on the use of endoscopy in the investigation of dyspepsia, bleeding and other contexts. After a 6 month spell in Iran (during which he introduced endoscopy to the Middle East), he went to Japan to see pioneer Kazuei Ogoshi cannulating the pancreatic duct, a huge breakthrough at a time before there were any abdominal scans. Believing the Japanese name for the procedure to be rather cumbersome, he coined the term Endoscopic Retrograde Cholangio Pancreatography, which has stuck. He brought ERCP back to England in 1971, and his first paper on the subject was published in January 1972. In 1973 he was appointed to the faculty of the Middlesex Hospital and Medical School (London), where he worked closely with Surgical and Radiology colleagues to develop and evaluate the rapidly growing portfolio of endoscopic procedures. He initiated the first randomized controlled trials of laser therapy for bleeding, and other trials comparing endoscopic, radiologic and surgical approaches to biliary obstruction. There was strong emphasis on teaching, which attracted postgraduates from all over the world. He pioneered live endoscopy teaching workshops in 1975, and opened a video-conferencing center in 1982. With colleagues in London he developed the first computer-based endoscopy reporting system, and maintains a strong interest in the slow march towards paperless GI and endoscopic practice. Dr. Cotton left England in 1986 to become Professor of Medicine and Chief of Endoscopy at Duke University in North Carolina. He developed a state of the art endoscopy center. He maintained his interests in teaching (mainly through live video courses), new techniques, and careful outcome evaluation. He moved to Charleston, South Carolina in 1994 to initiate the Digestive Disease Center. The mission of the Digestive Disease Center is to provide multidisciplinary patient-friendly, cost-effective patient care, and to pursue the research and teaching necessary to enhance it. Approximately 40 full-time faculty from Gastroenterology, Surgery, Radiology, Oncology and other specialties work together. Dr Cotton has maintained his enthusiasm for teaching postgraduates, especially in ERCP, and many from overseas. He continues to practice consultative gastroenterology, focusing on pancreatic and biliary problems, and personally performs about 400 complex ERCP procedures each year. Dr. Cotton has been active in many National and International organizations, and has given invited lectures and demonstrations in almost 50 countries. He helped to form the British Society for Digestive Endoscopy, became its President, and served the British Society of Gastroenterology as its vice president and treasurer. He was secretary of the European Society for Gastrointestinal Endoscopy, and president of the Pancreatic Society of Great Britain. He was elected Fellow of the Royal College of Physicians (London) in 1978, Fellow of the Royal College of Physicians and Surgeons (Glasgow) in 1997, and Fellow of the Royal College of Surgeons (London) in 2002. He has honorary memberships of the British Society of Gastroenterology, the Hong Kong Society for Digestive Endoscopy, and the South African Gastroenterology Society. His long association with ASGE began in 1974 when he was invited to give the Roche keynote lecture at DDW. He and his group have made innumerable original presentations at ASGE, and participated as faculty in many postgraduate courses. He was given the 2004 ASGE Rudolph Schindler award for services to Endoscopy. He has been on the editorial boards of 12 gastroenterology and endoscopy journals, and was the first international editor of Gastrointestinal Endoscopy. His bibliography includes more than 800 publications, including 232 original contributions in peer reviewed journals. He has not been shy to express strong opinions in many editorials. His book, "Practical Gastrointestinal Endoscopy" (co-authored with Christopher Williams ) is a well-known teaching text. Now in its 5th Edition, (with CDRoms), it has been translated into 7 languages. He is involved with the educational website www.Gastrohep.com, where he has recently edited an innovative new ebook/annual on Advanced Digestive Endoscopy. Christopher Williams is Consultant Physician in Gastrointestinal Endoscopy at St. Mark's and Northwick Park Hospitals in London, England. He is Director (with Brian Saunders) of the Wolfson Unit for Endoscopy and its associated Kennedy Leigh Academic Centre. This focuses on development of new approaches to colonoscopy, its teaching, and aspects of colorectal cancer prevention. He has private practice at the London Clinic and is Honorary Consultant at several other hospitals. The son of two physicians, Christopher Williams was born in 1938 in Norwich, England. From 1940 to 1944 he stayed with a medical family in Boston, Massachusetts, USA, as a war evacuee. His pre-clinical education and physiology degree was at Oxford University. He qualified from University College Hospital, London where he did internships, with medical residencies, there and at other leading London Hospitals. In 1970 Dr Williams moved to St Mark's Hospital as Senior Resident, to work with the distinguished gastroenterologist Professor John Lennard-Jones. Following a Research Fellowship at St Mark's, the post of Consultant Physician in GI Endoscopy was created in 1975, between St Mark's and St Bartholomew's Hospitals. He conducted pediatric colonoscopy at St Bartholomew's, the Hospital for Sick Children, and the Royal Free Hospital. Since 1970 Christopher Williams has had experience of most forms of GI endoscopy, especially colonoscopy and polypectomy (around 35,000 procedures), a field in which he has taught, published, demonstrated, and lectured widely. He has written numerous articles on colonoscopy, colonic neoplasia, and related topics, and is co-author (with Peter Cotton) or editor of five books relating to the colon and endoscopy. He gave the endoscopy Foundation Lectures of the British Society of Gastroenterology in 1976 and 1996, and was Endoscopy Vice-President of the Society in 1987. In 1999 Dr Williams was elected Fellow of the Royal College of Surgeons in recognition of his work on colonoscopy. His particular interests include teaching and television teaching of colonoscopy, and the application of new approaches and technology to facilitate the technique. This has included development of the hot-biopsy forceps, variable-stiffness colonoscope, 3-D-imager technology, and computer simulation. Robert 'Rob' Hawes is Professor of Medicine at the Medical University of South Carolina in Charleston, USA, and is an adjunct Professor of Bioengineering at Clemson University. He was born in 1954 in Berkley, California, and some attribute his 'radical' nature to his place of birth. His father was professor of theatre and drama at Indiana University in Bloomington, Indiana, where he learned to love the game of basketball, hung out in the quarries made famous by the movie Breaking Away and, under the tutelage of his father, learned to project his voice to the far reaches of the universe. His undergraduate education and medical training were completed at Indiana University. He went on to obtain his internal medicine training at Indiana University followed by a gastroenterology fellowship at the same institution. He joined the faculty at Indiana University in 1985 and was extremely fortunate to receive an immediate sabbatical to spend a year training with Peter Cotton at The Middlesex Hospital in London, UK, where he refined his skills in ERCP and laser therapies. He remained on faculty at Indiana University from 1985 until 1994, during which time he was promoted from assistant to associate and ultimately to full professor. In 1994, he joined Peter Cotton to help establish a comprehensive Digestive Disease Center at the Medical University of South Carolina. Rob Hawes' fundamental interest is diagnostic and therapeutic endoscopy. Three areas of special interest include pancreaticobiliary endoscopy, endoscopic ultrasound and experimental endoscopic procedures. Dr Hawes has served on the Governing Board of the American Society of Gastrointestinal Endoscopy and is vice-chairman of the Investigation Review Board at the Medical University of South Carolina. Dr Brian Saunders is Senior Lecturer and Honorary Consultant Physician at St Mark's and Northwick Park Hospitals, and is head of the hospital's newly formed Academic Department of Endoscopy. His main research interests include therapeutic colonoscopy, endoscopy teaching, and the development and evaluation of novel endoscopic technology. Brian Saunders qualified in medicine from University College Hospital, London in 1988. He trained in General Medicine in the North East of England and in Gastroenterology in London at St Mark's, Guy's, and Lewisham Hospitals. In 1996 he completed his MD thesis on Advances in Colonoscopic Practice and was also awarded the Hopkin's Endoscopy Prize from the British Society of Gastroenterology.


"For young endoscopists, this book is a wonderful introduction to the principles of endoscopy, from the design of the endoscopic unit all the way through to patient discharge. It also has great descriptions of how understanding torque, patient positioning, and managing scope length will transform one into an excellent endoscopist". (Doody's, 31 December 2010)

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