Introduction

Musculoskeletal (MSK) injuries are frequent occupational hazards amongst endoscopists, partly attributed to the physically demanding nature and prolonged durations of endoscopic procedures. Understanding the prevalence and patterns of these injuries is crucial to improve the endoscopist’s occupational health by implementing appropriate preventive strategies.

Aims & Methods

Aim: The primary aim of this study was to determine the prevalence and distribution of MSK injuries among endoscopists. Endoscopists from across the world were surveyed regarding the types and frequencies of procedures they perform to evaluate the prevalence of MSK injuries among endoscopists with varying procedural type and frequency. The secondary aim was to investigate whether additional factors, such as exercise habits during adulthood and adolescence and the endoscopy environment, influence the frequency of reported MSK injuries.
Method: An international questionnaire-based study was conducted among endoscopists practising in numerous healthcare centres. Data gathered included the frequency and localisation of injuries, type of endoscopic procedures carried out, access to occupational health (OH) and ergonomics of the endoscopy theatre. Additionally, the study explored the potential impact of past and present exercise practice during adulthood and adolescence on the prevalence of MSK injuries.

Results

174 endoscopists participated in this study, from 25 countries. The most commonly reported MSK complaints were back, neck, shoulder and hand pain (table 1).

	Percentage of endoscopists reporting pain
Back Pain	23.6%
Neck Pain	19.5%
Shoulder Pain	16.0%
Hand Pain	14.9%
Thumb Pain	13.2%
Hip Pain	7.4%
Elbow Pain	6.7%
Finger Pain	5.1%

Table 1: Pain in endoscopists;
Endoscopists’ experience was as follows; 32.2% -0-5 years, 46% -5-20 years and 21.8% -20 years of experience. Only 35.1% of participants had formal training on scope handling at the start of training.
Participants reported to use 1, 2, 3 and 4 monitors respectively during endoscopy sessions: 37.9%, 56.0%, 4.6% and 0.6%. 75.9 % of participants ensure that their screen is at eye level during endoscopies, whilst 75.3% ensure that the monitor is the right distance away.
23% of participants stated that they have had a formal diagnosis of an occupation related injury or have been reviewed by a physiotherapist / orthopaedic surgeon because of an endoscopy related injury. In contrast, only 13.2% of patients have reported their occupational injury to OH services.
51.1% of participants have had MSK injuries that they think are attributable to current endoscopy practices. However, only 13.2% have sought help from the OH team. 74% of these felt they were supported by the OH team.
10.9% of participants have been diagnosed with osteoarthritis or an inflammatory arthropathy, unrelated to work.

Conclusion

This study provides a valuable insight into the relationship between endoscopic procedures and the occurrence of MSK injuries among endoscopists, offering opportunities for prevention to safeguard the health of endoscopists and to encourage them to seek help for such injuries.

Disclosure

The authors declare they have no conflict of interest.

Introduction

The ergonomics has been considered important in practicing surgical laparoscopy, and prior studies have shown significance of relevant factors e.g. operating room setup and design of surgical devices. However, little has been known in flexible endoscopy; How do endoscopists control flexible endoscopes? Which muscles are loaded during endoscopy? The deeper understanding of ergonomic aspects in flexible endoscopy is indispensable, since the number of endoscopies performed and its complexity are rapidly increasing.

Aims & Methods

We aimed to identify the differences of ergonomics between diagnostic endoscopy (EGD) and therapeutic endoscopy (ESD), by 1) multiple motion capture technology, and 2) wireless surface electromyography (EMG), in pre-clinical setting.
1) The multiple motion capture assessment
The control section of standard flexible endoscope (GIF-Q260J; Olympus, Tokyo, Japan), from the boot to the angulation knobs, was marked with 6 optical reflective markers. These markers were traced using a motion capture system (OptiTrack Flex13; NaturalPoint, OR) and the data were processed to generate 3-D coordinate data (The sternum manubrium of the endoscopist was setup as the coordinate origin; X: left-right axis, Y: cranio-caudal axis, Z: antero-posterior axis). EGD and ESD were performed with this motion capture system using live porcine models. For each endoscopist, mean±2SD for plotted coordinates from the origin was calculated in the three axes and described as a range of his/her arm/hand movement. The data were compared between EGD and ESD.
2) EMG assessment
Muscle activation of the left biceps brachii muscle, trapezius muscle, extensor carpi ulnaris muscle, flexor carpi radialis muscle, pronator teres muscle, thenar muscle, back neck muscle, and erector spinae muscle were recorded during endoscopic procedures using wireless surface EMG (BioLog DL-5500, DL-510A; S&ME, Tokyo, Japan). The maximal voluntary contraction (MVC) was obtained to normalize root-mean-square muscle activation as %MVC. We compared differences in muscle activity between EGD and ESD using %MVC.

Results

1) The motion capture was performed on 15 board-certified endoscopists conducting EGD (n=13) and ESD (n=12). The movement range of endoscopist’s left hand/arm holding endoscope is shown in the Table. On all three axes, the range of movement was significantly narrower during ESD than during EGD (X, p<0.001; Y, p=0.015; Z, p<0.001).

	EGD			ESD
	X axis	Y axis	Z axis	X axis	Y axis	Z axis
Mean ± 2SD (cm)	-0.32±14.2	-24.3±11.0	12.8±11.6	-1.3±9.9	-22.8±9.8	7.9±8.9

2) The EMG was recorded during 15 EGDs and 8 ESDs. The %MVC was higher during ESD than EGD in an analysis including all muscles (LS-mean±SE; EGD, 28.9±1.5%; ESD, 34.1±2.6%; p=0.078). The comparison by each specific muscle showed that the extensor carpi ulnaris muscle (EGD, 34.6±3.5%; ESD, 47.8±5.8%; p=0.093) and the pronator teres muscle (EGD, 42.8±6.6%; ESD, 67.6±10.9%; p=0.092) had significantly larger %MVC during ESD (p<0.1 was considered statistically significant).

Conclusion

Our study has first shown that the range of endoscopis’s movement was significantly narrower in therapeutic endoscopy than in diagnostic endoscopy. Furthermore, it was demonstrated that muscle activity, especially in left forearm muscles, was larger during therapeutic endoscopy. These data may help understanding the ergonomics in flexible endoscopy, and potentially contribute to optimize its working environment and further development of relevant medical devices.

Introduction

Colorectal neuroendocrine tumors (NETs) and polyps have similar endoscopic manifestations and are easily misidentified. Due to the low incidence of NETs, it is difficult to obtain adequate images to fit deep-learning models. This study introduced a few-shot learning (FSL) model for the ternary classification of NETs and polyps on endoscopic images.

Aims & Methods

Three classes of endoscopic images (56 serrated lesions and polyps [SLPs], 86 traditional adenomas and 53 NETs) were collected from three datasets. First, three images from each class were randomly selected for Support Set (SS), while others for Query Set (QS). Second, ResNet50 V2 was pretrained based on ImageNet and then on esophageal endoscopic images Third, imaging eigenvectors were extracted based on a dual-pretrained model. Fourth, the Euclidean distances to the nine SS images were calculated for each QS image. Finally, a k-nearest neighbor classifier was used for classification based on Euclidean distances. The proposed FSL model was tested in three rounds.

Results

The performance of the FSL model (macro-area under the curve [AUC], 0.731; macro F1-score, 0.674; Matthews Correlation Coefficient [MCC], 0.526; Kappa, 0.523) was better than that of the traditional ResNet50 V2, junior endoscopist, and senior endoscopist. When identifying NETs, the proposed FSL model achieved the highest accuracy 0.823, sensitivity 0.653, precision 0.673 and F1-score 0.659, whereas the senior endoscopist achieved the highest specificity 0.904.

Conclusion

This study presented a FSL method based on transfer learning and metric learning to distinguish between SLPs, adenoma, and NETs on endoscopic images. This suggests that FSL might be an effective method for computer-aided diagnosis of rare diseases.

Introduction

Gastric adenoma is recognized as a premalignant lesion.¹Much of the literature lumps all adenomas together with different classifications. These are few western reports regarding the prevalence, associated risk factors and outcomes of endoscopic management of different subtypes of gastric adenoma.

Aims & Methods

Aims: The aim of this study is to determine the prevalence, potential predictors, and outcomes of endoscopic management of the different subtypes of gastric adenoma.
Methods: Of 162 consecutive patients who underwent endoscopic resection for gastric lesions between 2017 and 2022 at our center, 79 patients were enrolled. All the hyperplastic polyps (n=37) and subepithelial lesions (n=46) were excluded. The patient clinical characteristics, endoscopic and histopathological features of gastric lesions were retrospectively collected. Patients were divided according to the histological types of gastric adenoma into 4 groups: intestinal group (n= 49), foveolar group (n= 23),pyloric group (n= 6) and oxyntic group (n=1). We statistically compared the clinical and endoscopic features of the three groups. In addition to the analysis of the outcomes of endoscopic resection of gastric adenomas.

Results

Of the 79 patients with a mean follow-up of 2622 months, 51 patients were males (65 %) and 28 patients were females (35%). Forty-nine patients (49/79,62%) had intestinal adenoma, 23 patients (29%) showed foveolar adenoma, 6 patients (8%) developed pyloric adenoma and only 1 patient (1%) had oxyntic adenoma. The mean age was significantly older in the intestinal group (71 ± 13 years vs. 64 ± 16 years vs. 58 ± 18 years, p = 0.03). Intestinal adenomas were significantly associated with family history of gastric adenocarcinoma (14% vs. 4% vs. 0%, p = 0.01) and history of statin intake (39% vs. 26% vs. 0%, p = 0.04).Foveolar adenomas were significantly associated with multiple lesions (≥3 lesions) (p < 0.001) and 0-IIa+IIc Paris classification (6/23, 26%). the size of largest polyp was significantly higher among pyloric group (28 ±15, p= 0.00). Among intestinal group, 33/49 patients (67%) had atrophic gastritis. 82% of the adenomas were resected by ESD with histologically complete resection (R0) in 72/79 patients (91%). Although the difference was not statistically significant (p = 0.4), adenocarcinoma was most frequently encountered among the intestinal adenoma group (17/49, 35%). The post endoscopic resection outcome was comparable among 3 groups with overall recurrence rate (group1:8% vs. group 2:17% vs group 3:17%, P = 0.07) with a comparable mean time to recurrence among three groups (21 ± 17 months vs. 20±17months vs. 14 months, p=0.8). Family history of gastric adenocarcinoma (HR=1.33, p< 0.001) and active helicobacter pylori infection (HR=1.14, p < 0.001) were identified as independent predictors of recurrence after endoscopic resection of different gastric adenoma. Among baseline endoscopic characteristics, polyp size ³ 30mm(HR= 2.04, p< 0.001), more than 3 polyps (HR=1.51, p<0.001), lesser curvature as lesion location (HR=1.72, p< 0.001) and morphology as Paris classification IIc are potential predictors of post resection recurrence. In addition to specimen size ³ 15mm (HR=2.19, p< 0.001) and T1b as lesion histology (HR=2.07, p< 0.001), in the histopathological examination.

Conclusion

The present study clarifies the endoscopic and histopathological characteristics of different gastric adenomas, in addition to the potential predictive factors for each subtype. Potential predictors of recurrence after endoscopic resection emphazie the importance of endoscopic follow up.

References

1. Fujiwara, Y. et al. Diagnosis of borderline adenomas of the stomach by endoscopic mucosal resection. Endoscopy 28, 425–430 (1996).

Introduction

Though the burden of musculoskeletal injury(MSI) by long-term accumulation of endoscopy procedures is well known, there is little data on the techniques that can reduce or prevent MSI.

Aims & Methods

The purpose of this study is to develop a new method for MSI assessment in long-term endoscopy practitioners and to establish an individualized MSI restoration plan through the special 16-week intervention of Kinetic Ergonomics based on Movement Analysis(KEMA) program by physical therapists.
Fifteen volunteer endoscopists practicing more than 10 years from 4 tertiary medical centers, were evaluated by demographics, endoscopy burden, location and degree of pain, and endoscopy posture. A comprehensive functional evaluations of ergonomic position, posture, and MSI and load during endoscopy was made by the physical therapist and self-perception questionnaire for involved joints was also evaluated. Then personalized KEMA program (musculoskeletal function evaluation and customized exercise program based on ergonomics) was delivered for 16 weeks by physical therapists on a one to one basis. KEMA program included recommendations for individualized exercises, static and dynamic posture re-education during and between procedures, optimization of procedure suite set-up and pain education. The endoscopists were re-evaluated regarding their perception and adherence to ergonomics and subjective symptoms at the end of the program.

Results

Various ergonomic problems were found to varying degrees in all 15 long-term endoscopy practioners including ergonomic inefficiencies and suboptimal movement patterns. Among 12 areas evaluated, pain areas were most commonly found in the order of the low back, neck, shoulder, wrist, and thumb. In addition, cumulative endoscopy time and neck and thumb pain, cumulative number of endoscopy cases and neck, back, and hip pain scores, neck and shoulder pain, and wrist and elbow pain showed positive correlations with each other. After 16-weeks KEMA program, among these 5 main painful joints, the remaining 4 joints (80%) showed improvement in the intensity and frequency of pain, except for the shoulder. Before and after the program, the level of understanding of knowledge about ergonomics increased from an average of 28 points to 33.6 (5-point scale of 10 items), but unfortunately, ergonomic attitudes and performance did not show significant changes.

Conclusion

The evaluation of MSI based on kinetic ergonomics for endoscopists and customized exercise program helped to recognize one's own body condition and relieve pain and recovery of the MSI even with a relatively short-term management of 16 weeks. These ergonomic interventions used here could potentially contribute to career longevity, decreased burnout, reduce lost days of work and most importantly reduction in pain and fatigue among practitioners.