Flexible endoscopy: basic technique

Edward J. Hall

doi:10.22233/9781905319572.3

British Small Animal Veterinary Association , 31 (2008); https://doi.org/10.22233/9781905319572.3

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Flexible endoscopy: basic technique

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Author: Edward J. Hall
From: BSAVA Manual of Canine and Feline Endoscopy and Endosurgery
Item: Chapter 3, pp 31 - 41
DOI: 10.22233/9781905319572.3
Copyright: © 2013 British Small Animal Veterinary Association
Publication Date: January 2008

Abstract

PLEASE NOTE THAT A MORE RECENT EDITION OF THIS TITLE IS AVAILABLE IN THE LIBRARY

With skill and the right flexible endoscopic equipment, most parts of the gastrointestinal tract, major airways and lower urinary tract are now accessible, and many patients have benefitted from such endoscopic investigations. However, in some cases endoscopy may be unhelpful. Regrettably, endoscopy can result in serious complications, such as hypoxia during respiratory endoscopy and GI perforation during GI endoscopy. Minimum standards are applied to endoscopic proficiency in human medicine, and the veterinary profession should aspire to the same level. This chapter explains Safe use of the endoscope; Preparation for endoscopy; Handling the flexible endoscope; Using the controls; Using the endoscope in a patient; Biopsy techniques, handling and preparation; and Image recording.

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Figures

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3.1

Damage to a flexible endoscope can make it unusable. (a) Compression damage to the bending section of a gastroscope caused by a trolley being wheeled over the tip as it trailed on the floor. (b) Breakage of the biopsy forceps due to over-vigorous closure of the cups; excessive pressure does not improve the biopsy quality, but stretches and ultimately breaks the operating wire. © 2008 British Small Animal Veterinary Association

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3.1 Damage to a flexible endoscope can make it unusable. (a) Compression damage to the bending section of a gastroscope caused by a trolley being wheeled over the tip as it trailed on the floor. (b) Breakage of the biopsy forceps due to over-vigorous closure of the cups; excessive pressure does not improve the biopsy quality, but stretches and ultimately breaks the operating wire.

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3.2

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3.2 Endoscopes should be carried securely in (a) one or (b) both hands to avoid accidental damage.

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3.3

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3.3 Holding the handpiece correctly in the left hand whilst guiding the insertion tube with the right.

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3.4

Holding the handpiece. The handpiece is held in the palm of the left hand with the umbilical cord running between the thumb and forefinger down the back of the hand, allowing the fingers to reach the buttons and control wheels. © 2008 British Small Animal Veterinary Association

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3.4 Holding the handpiece. The handpiece is held in the palm of the left hand with the umbilical cord running between the thumb and forefinger down the back of the hand, allowing the fingers to reach the buttons and control wheels.

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3.5

Gripping the endoscope handpiece. (a) Using the fourth and fifth fingers to stabilize the endoscope handpiece, the left index and middle fingers are free to operate the air/water and suction buttons, respectively. (b) Using a three finger grip to stabilize the handpiece, the left index finger is used to operate the valves, whilst the thumb controls the up/down steering wheel. (c) Rotation of the handpiece of a video-endoscope once almost full insertion has been achieved allows the left thumb to work the valves, and the right thumb and fingers to manipulate the steering wheels. © 2008 British Small Animal Veterinary Association

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3.5 Gripping the endoscope handpiece. (a) Using the fourth and fifth fingers to stabilize the endoscope handpiece, the left index and middle fingers are free to operate the air/water and suction buttons, respectively. (b) Using a three finger grip to stabilize the handpiece, the left index finger is used to operate the valves, whilst the thumb controls the up/down steering wheel. (c) Rotation of the handpiece of a video-endoscope once almost full insertion has been achieved allows the left thumb to work the valves, and the right thumb and fingers to manipulate the steering wheels.

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3.6

The red dot in the mucosa (arrowed) is a suction artefact caused by tissue being sucked up accidentally, and must not be mistaken for a lesion. (Courtesy of S Warman) © 2008 British Small Animal Veterinary Association

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3.6 The red dot in the mucosa (arrowed) is a suction artefact caused by tissue being sucked up accidentally, and must not be mistaken for a lesion. (Courtesy of S Warman)

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3.7

Holding the handpiece of a bronchoscope; the lever for 2-way tip deflection is operated by the left thumb, and the suction button by a finger. There is no air/water channel in bronchoscopes. © 2008 British Small Animal Veterinary Association

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3.7 Holding the handpiece of a bronchoscope; the lever for 2-way tip deflection is operated by the left thumb, and the suction button by a finger. There is no air/water channel in bronchoscopes.

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3.8

(a) Upward deflection of the endoscope tip and (b) longitudinal rotation effectively allow the endoscopist to look left or right, without having to manipulate the left/right steering wheel. © 2008 British Small Animal Veterinary Association

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3.8 (a) Upward deflection of the endoscope tip and (b) longitudinal rotation effectively allow the endoscopist to look left or right, without having to manipulate the left/right steering wheel.

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3.9

Application of the deflection brakes permit the endoscope tip to be held in a deflected position without the need to control the steering wheels. (a) Friction brakes ‘off’. (b) Friction brakes ‘on’. © 2008 British Small Animal Veterinary Association

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3.9 Application of the deflection brakes permit the endoscope tip to be held in a deflected position without the need to control the steering wheels. (a) Friction brakes ‘off’. (b) Friction brakes ‘on’.

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3.10

Red-out. Loss of a clear image occurs when the endoscope lens is too close to the GI mucosa. It is corrected by withdrawing the endoscope, deflecting the tip slightly and insufflating. (Reproduced from the BSAVA Manual of Canine and Feline Gastroenterology, 2nd edition ) © 2008 British Small Animal Veterinary Association

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3.10 Red-out. Loss of a clear image occurs when the endoscope lens is too close to the GI mucosa. It is corrected by withdrawing the endoscope, deflecting the tip slightly and insufflating. (Reproduced from the BSAVA Manual of Canine and Feline Gastroenterology, 2nd edition )

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3.11

Slide-by technique for advancing the endoscope around flexures. Red-out occurs as the endoscope tip passes along the wall until the next straight length of intestine is reached. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. © 2008 British Small Animal Veterinary Association

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3.11 Slide-by technique for advancing the endoscope around flexures. Red-out occurs as the endoscope tip passes along the wall until the next straight length of intestine is reached. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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3.12

(a) Linear haemorrhages at a small intestinal flexture are artefactual and caused by the endoscope tip scraping the mucosa of the outer curvature of the flexture. (b) Pre-deflection of the tip before reaching a flexure allows visualization along the next length of intestine and avoids slide-by induced artefacts. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission. © 2008 British Small Animal Veterinary Association

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3.12 (a) Linear haemorrhages at a small intestinal flexture are artefactual and caused by the endoscope tip scraping the mucosa of the outer curvature of the flexture. (b) Pre-deflection of the tip before reaching a flexure allows visualization along the next length of intestine and avoids slide-by induced artefacts. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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3.13

Correct (a) opening and (b) closing of biopsy forceps. The thumb is inserted in the handle and the fingers clasp the slider. As the palm of the hand is clenched, the cups close. © 2008 British Small Animal Veterinary Association

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3.13 Correct (a) opening and (b) closing of biopsy forceps. The thumb is inserted in the handle and the fingers clasp the slider. As the palm of the hand is clenched, the cups close.

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3.14

(a) As ‘swing-jaw’ biopsy forceps are opened (b) the cups tilt towards the tissue. This aids taking biopsy samples when the forceps are not perpendicular to the tissue surface. © 2008 British Small Animal Veterinary Association

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3.14 (a) As ‘swing-jaw’ biopsy forceps are opened (b) the cups tilt towards the tissue. This aids taking biopsy samples when the forceps are not perpendicular to the tissue surface.

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3.15

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3.15 Tissue cassette with foam insert for collecting biopsy specimens before fixation in formalin and processing.

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3.16

Sections of endoscopic biopsy samples demonstrating common artefacts. (a) Crush artefact with loss of discernible tissue and cellular structure. (b) Cross-section of isolated villi when tissue is not oriented in a perpendicular fashion. (c) Fragmentation of a small tissue biopsy sample. H&E stained sections. (Reproduced from the BSAVA Manual of Canine and Feline Gastroenterology, 2nd edition ) © 2008 British Small Animal Veterinary Association

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3.16 Sections of endoscopic biopsy samples demonstrating common artefacts. (a) Crush artefact with loss of discernible tissue and cellular structure. (b) Cross-section of isolated villi when tissue is not oriented in a perpendicular fashion. (c) Fragmentation of a small tissue biopsy sample. H&E stained sections. (Reproduced from the BSAVA Manual of Canine and Feline Gastroenterology, 2nd edition )