Technical skills and training of upper gastrointestinal endoscopy for new beginners

Figure 15 Insertion from esophagus to stomach. A: Esophageal physiology, the second stenosis. If the scope is advanced 10 cm further after passing it through the sphincter of the upper esophagus, a high pressure zone caused by aortic arch (dotted line) on the left side, and another high pressure zone by the left main bronchus on the right side of the distal antrum can be seen. Depending on the examinees’s posture, or condition, state of air insufflation, there are some cases where such pressure marks are clearly visible; B: Pressure marks by the aortic arch and the left main bronchus, with a pressure zone caused by a vertebral body positioned in the 6 o’clock direction on the screen with a slightly rotation of the scope (knuckle line). The advancement direction inside the esophagus is usually described based on the condition that a high pressure zone by the vertebral body is positioned toward the 6 o’clock direction on the screen. However, if those pressure marks by the vertebral body are not clearly visible, the lumen of the esophagus is not wide enough. In that case, it is acceptable to describe their vertical locations (usually the insertion length from the incisor) unlike the description of directions inside the stomach; C: Pressure by a calcified aortic arc. A severe case of calcification can look like a submucosal tumor, due to the conspicuous appearance of pressure marks; D: Gastroesophageal junction (GEJ) before suctioning air. The boundaries of the GEJ (arrow mark) are not clearly visible; E: GEJ after suctioning air. As the GEJ unfolds, the boundaries of the GEJ become clear; F: The direction of the scope in the esophagus. The scope is inserted using a straight line progression (arrow mark) in the esophagus; G-I: An esophageal web around the GEJ. If the mucous membrane of the esophagus has a rather curved progression (arrow mark in I), it is recommended to insert the scope by slightly rotating the shaft rather than pushing it straight ahead forcefully; I: Esophageal diverticulum: it appears as though the progression of the esophagus has two different directions. If being pushed in a hurry, a scope can enter the esophageal diverticulum, which can cause a perforation; J: Esophageal diverticulum after pulling back the scope. After filming the entire entrance of the esophageal diverticulum by pulling back the scope, advance it into the lumen of the esophagus; K, L: Endoscopic image of a severe case of esophageal diverticulum. In the case of a patient with a severe esophageal varix, extra caution needs to be taken during the insertion and advancement of the scope into the esophagus. A massive hemorrhage here can lead to the death of an examinee.