Gastroenterological Endoscopy. Группа авторов

      Modern GI endoscopy uses digital video endoscopy almost exclusively. While the analogue video signal (SVHS, RGB) is still available, most newly designed units use the digital high-definition video technique. Whether videos are stored centrally or in the local endoscopic documentation system depends on the video concept of the unit or the hospital. Increasingly, the Digital Imaging and Communications in Medicine (DICOM) standard is used to store endoscopic pictures in the PACS. This offers the advantage that all images are stored with the respective patient case in a central system which is generally accessible. A corresponding video standard is yet to be developed.

      As IT-based documentation of endoscopic procedures is standard, a specialized area for documentation within the procedure room has to be planned. This area should be located outside either the sterile or contaminated procedure area but should be close enough to access written or PC-documented information (Clinical Information System [KIS] or PACS information). In the radiographic procedure room, this documentation area must be located outside the radiation area.

      Various commercial endoscopic documentation systems with integrated report generation are available. As endoscopic terminology has been widely standardized, reports can be generated with these systems. Integrated systems also allow video streaming and video switching. For the integration of additional equipment, additional video inputs and video lines have to be planned and installed. It is advisable to have a separate video planning concept for a new unit. In most larger units, it is advisable to centralize video information to a central video switchboard which allows central video streaming or storage. Most integrated systems (EndoAlpha, OR-1) are based on such a concept.

      As already mentioned, IT documentation is also standard for sedation as well as for documentation of procedure parameters (endoscope and equipment and material used). Thus, in addition to the IT working place for the endoscopists, additional areas have to be planned for anesthetists and nursing staff. Recently, there have been attempts to switch the documentation process to handheld devices, which will then decrease space requirements. However, this emphasizes the need for high-speed WLAN connectivity in the endoscopic suite.

      5.8.5 Endoscopes and Endoscopic Equipment

      Sufficient endoscopes must be available within a endoscopic unit to allow a smooth sequence of the endoscopic procedures and to allow for optimal work efficiency of the endoscopists and endoscopic staff.

      The number of endoscopes needed is dependent on the reprocessing cycles, the number of procedures and rooms active in parallel, and the amount of specialized procedures that require specialized endoscopes and equipment (e.g., therapeutic endoscopes, large working channel, pediatric scopes).

      In addition to the equipment within the procedure room, a mobile endoscopy trolley carrying all essential instruments and endoscopic processors should always be on standby, as occasionally an endoscopic procedure has to be carried out in other parts of the hospital, such as the intensive care unit or the surgical or radiological department.

      5.9 Endoscopic Ultrasound and Laser Treatment Room, Radiography Room

      Large endoscopy units, from the so-called 4 + 2 room model and upward, should have a room dedicated to EUS, laser, or photodynamic therapy. Since such procedures tend to be time consuming, they should be scheduled and planned carefully so as to not interfere with general routine endoscopic activities. Radiographic facilities should be available when required during ERCP, dilation procedures, insertion of stents, etc. Such facilities avoid the inconvenience and waste of time involved in transporting patients and fragile equipment to and from the radiology department. An alternative for smaller endoscopy units is to modify one of the rooms in the radiography department to accommodate endoscopy.

      The choice of radiography system should consider the special needs of the endoscopist. In most modern units, a C-arm system with flexible X-ray planes is used. Digital X-ray with a pulse radiographic beam is preferable due to high image quality and low radiation exposure. A solid phase X-ray detector is a new X-ray standard which offers less respiration and movement artifacts, which is helpful especially for ERCP and percutaneous interventions (

Fig. 5.5). New technologies allow 3D imaging and image fusion of the ultrasound with DICOM CT and MR data. This technology involves magnetic field tracking, and prerequisites for such procedures can be planned in new procedure rooms.

      The radiographic procedure room is often used with additional imaging modalities such as endosonography and cholangiography. Therefore, the display capacity of this room must be versatile and flexible (see later). A “2 and 2” or “3 and 2” monitor system is recommended with flexible inputs to the various monitors, for example, by the use of a special switching device. The radiography monitor and the videoendoscopic monitor should be mounted together and positioned in such a way that the endoscopist and assistant personnel have a direct, unobstructed view. Preferentially, the main monitor system is composed of a radiographic and one endoscopic monitor, whereas the third monitor should be used for reference (X-ray) or additional imaging modalities (EUS, cholangiography, mother–baby endoscopy) (

Fig. 5.5). The second monitor system for the assistant personnel should be composed of one X-ray and one endoscopic monitor.

      Fig. 5.5 Modern multifunctional intervention room with X-ray and operative hygiene standard. Technical installations (e.g. for X-ray Siemens artis Zee with solid state detector) are in a separate room to gain space for anesthesiology and additional equipment. Modern video switching (Olympus Exera III with switching tool) allows versatile combination of video sources and distribution on the various procedure monitors. Ceiling supplies (Trumpf Medical) allow optimal hygiene standard and flexibility.

      The radiographic room should have enough space for the X-ray protection and shielding system and should be especially equipped for procedures performed under general anesthesia.

      5.10 Preparation and Recovery Room

      Preparation and recovery rooms should be located close to the endoscopy unit. In general, three beds per endoscopy room are required.^7,10 Seven square meters per bed is standard. The use of sedatives such as midazolam and/or propofol during upper or lower tract endoscopy requires recovery facilities (with nursing supervision), since it may be as long as an hour before these patients are able to leave the endoscopy unit. Oxygen and suction devices are essential in addition to pulse oximeters, electrocardiography monitoring, and resuscitation equipment.

      5.11 Cleaning and Disinfection Area

      Disinfection is a central problem in the endoscopic unit. Thus, the concepts for cleaning and reprocessing the endoscopes is of utmost importance and should be handled with local disinfection experts. Processing of the endoscopes can be done in a centralized area for the entire hospital, but requires elaborate logistics for transport to and from the unit. More commonly, a disinfection and reprocessing area is located within the endoscopic unit. When planning a new unit, there are two different concepts for the cleaning area. In one concept, the cleaning area is accessible directly from the procedure room. This is only practical in smaller units with few procedure rooms. In larger units with more than three procedure rooms, the cleaning area is best located centrally. For optimal hygiene, a one-way system for endoscope transport and processing has to be established. The cleaning and reprocessing area has to be divided into separate unclean and clean areas. These two areas should be completely separated by a separating wall and best by double side or load through washing and reprocessing machines, which act as separator