Altered Esophageal Smooth Muscle Phenotype in Achalasia.

Background/Aims: Achalasia is a disorder characterized by impairment in lower esophageal sphincter relaxation and esophageal aperistalsis, caused primarily by loss of inhibitory innervation. However, little is known about associated changes in esophageal smooth muscle. We examined the contractile phenotype and innervation of the circular smooth muscle, as well as inflammatory status, and correlated these with patient-specific parameters. Methods: Circular smooth muscle biopsies were obtained in consecutive patients with achalasia undergoing peroral endoscopic myotomy. Axonal innervation and neurotransmitter subtypes were determined with immunocytochemistry, and this was used with quantitative Polymerase Chain Reaction (qPCR) to characterize smooth muscle proliferation and cellular phenotype, as well as collagen expression. These were compared to control tissue obtained at esophagectomy and correlated with patient demographic factors including age, onset of symptoms, and Eckhardt score. Results: Biopsies of smooth muscle were obtained from 25 patients with achalasia. Overall, there was increased mast cell number and collagen deposition but increased smooth muscle cell proliferation vs control. There was a striking drop in axon density over controls, with no differences among subtypes of achalasia. Immunocytochemical analysis showed increased expression of the contractile marker α-smooth muscle actin, principally in Type 1 achalasia, that increased with disease duration, while qPCR identified increased mRNA for smoothelin with decreased myosin heavy chain and collagen 3a1, but not collagen 1a1. Conclusions: The thickened circular smooth muscle layer in achalasia is largely denervated, with an altered contractile phenotype and fibrosis. Biopsies obtained during peroral endoscopic myotomy provide a means to further study the pathophysiology of achalasia.

Achalasia: Current therapeutic options.

Achalasia is an esophageal motor disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absent peristalsis in the smooth muscle esophageal body. As a result, patients typically experience dysphagia, regurgitation, chest pain, and weight loss. Over the past 10-15 years, there has been a resurgence of interest in the evaluation of therapies for achalasia. Unfortunately, little progress in the development of effective pharmacological treatments has been made. Botulinum toxin injection provides some relief of symptoms in many patients but requires periodic reinjection that may provide progressively less benefit over time. There are now three well-established, safe, and effective therapies for the treatment of achalasia: pneumatic dilation (PD), laparoscopic Heller myotomy (LHM), and peroral endoscopic myotomy (POEM) which can lead to marked symptom improvement in most patients. Each treatment has a specific constellation of risks, benefits, and recurrence rate. The first-line treatment used will depend on patient preference, achalasia subtype, and local expertise. The recent impressive advances in both the art and science of achalasia therapy are explored with a comprehensive review of the various treatment modalities and comparative controlled clinical trials. In addition, key technical pearls of the procedural treatments are demonstrated.

Metabolic heat loss in southern elephant seals (Mirounga leonina) differs with stage of moult and between habitats.

The moult in southern elephant seals (Mirounga leonina) represents an especially energetically demanding period during which seals must maintain high skin temperature to facilitate complete replacement of body fur and upper dermis. In this study, heat flux from the body surface was measured on 18 moulting southern elephant seals to estimate metabolic heat loss in three different habitats (beach, wallow and vegetation). Temperature data loggers were also deployed on 10 southern elephant seals to monitor skin surface temperature. On average, heat loss of animals on the beach was greater than in wallows or vegetation, and greater in wallows than in vegetation. Heat loss across all habitats during the moult equated to 1.8 x resting metabolic rate (RMR). The greatest heat loss of animals was recorded in the beach habitat during the late moult, that represented 2.3 x RMR. Mass loss was 3.6 ± 0.3 kg day-1, resulting in changes in body condition as the moult progressed. As body condition declined, skin surface temperature also decreased, suggesting that as animals approached the end of the moult blood flow to the skin surface was no longer required for hair growth.

Increased Metabolic Rate of Hauled-Out Harbor Seals (Phoca vitulina) during the Molt.

AbstractHarbor seals (Phoca vitulina) live in cold temperate or polar seas and molt annually, renewing their fur over a period of approximately 4 wk. Epidermal processes at this time require a warm skin; therefore, to avoid an excessive energy cost at sea during the molt, harbor seals and many other pinnipeds increase the proportion of time they are hauled out on land. We predicted that metabolic rate during haul-out would be greater during the molt to sustain an elevated skin temperature in order to optimize skin and hair growth. To examine this, we measured post-haul-out oxygen consumption (V˙O2) in captive harbor seals during molt and postmolt periods. We recorded greater V˙O2 of seals while they were molting than when the molt was complete. Post-haul-out V˙O2 increased faster and reached a greater maximum during the first 40 min. Thereafter, V˙O2 decreased but still remained greater, suggesting that while metabolic rate was relatively high throughout haul-outs, it was most pronounced in the first 40 min. Air temperature, estimated heat increment of feeding, and mass also explained 15.5% of V˙O2 variation over 180 min after haul-out, suggesting that the environment, feeding state, and body size influenced the metabolic rate of individual animals. These results show that molting seals have greater metabolic rates when hauled out, especially during the early stages of the haul-out period. As a consequence, human disturbance that changes the haul-out behavior of molting seals will increase their energy costs and potentially extend the duration of the molt.

Meeting the Motility Educational Requirements of the Gastroenterology Trainee in the 21st Century.

BACKGROUND: Gastrointestinal (GI) motility and functional disorders comprise over two-third of referrals to GI specialists yet training programs are disproportionately focused on endoscopy, inflammatory bowel disease and liver disease. Trainees at many centres receive minimal or no formal training in motility disorders and have little or no exposure to motility testing. Our purpose was to develop an educational intervention to address this learning need. METHODS: We designed a formal training program comprised of didactic sessions, workshops and hands-on motility sessions with live demonstrations designed to be held over the course of a weekend. Faculty for the course were experienced GI motility experts from across Canada. Resident trainees from all Canadian GI fellowship programs were invited to attend. Pre- and post-tests were administered to measure the baseline learning needs and the impact of the program. Course evaluations were completed by attendees. RESULTS: Three annual courses were offered over the past 3 years. Both adult and paediatric gastroenterology trainees attended the programs. The majority of training programs from Canada were represented. Baseline testing of attendees revealed a fundamental lack of understanding of GI motility concepts and their clinical implications. Postcourse test scores demonstrated a significant improvement in motility knowledge. Course evaluations of the content and faculty presentations received uniformly positive reviews. CONCLUSIONS: There is a pervasive lack of clinical knowledge of GI motility among Canadian GI subspecialty trainees. A focused weekend intensive course is one step in addressing this learning need.

Screening and Treatment Outcomes in Adults and Children With Type 1 Diabetes and Asymptomatic Celiac Disease: The CD-DIET Study.

OBJECTIVE: To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD. RESEARCH DESIGN AND METHODS: Asymptomatic patients (8-45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA1c and continuous glucose monitoring over 12 months. RESULTS: Adults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9-8.2%, N = 1,298] vs. 4.7% [95% CI 3.4-5.9%, N = 1,089], P = 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, P < 0.0001). Fifty-one participants were randomized to a GFD (N = 27) or GCD (N = 24). No HbA1c differences were seen between the groups (+0.14%, 1.5 mmol/mol; 95% CI -0.79 to 1.08; P = 0.76), although greater postprandial glucose increases (4-h +1.5 mmol/L; 95% CI 0.4-2.7; P = 0.014) emerged with a GFD. CONCLUSIONS: CD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.

MMS SITL Ground Loop: Automating the Burst Data Selection Process.

Global-scale energy flow throughout Earth's magnetosphere is catalyzed by processes that occur at Earth's magnetopause (MP). Magnetic reconnection is one process responsible for solar wind entry into and global convection within the magnetosphere, and the MP location, orientation, and motion have an impact on the dynamics. Statistical studies that focus on these and other MP phenomena and characteristics inherently require MP identification in their event search criteria, a task that can be automated using machine learning so that more man hours can be spent on research and analysis. We introduce a Long-Short Term Memory (LSTM) Recurrent Neural Network model to detect MP crossings and assist studies of energy transfer into the magnetosphere. As its first application, the LSTM has been implemented into the operational data stream of the Magnetospheric Multiscale (MMS) mission. MMS focuses on the electron diffusion region of reconnection, where electron dynamics break magnetic field lines and plasma is energized. MMS employs automated burst triggers onboard the spacecraft and a Scientist-in-the-Loop (SITL) on the ground to select intervals likely to contain diffusion regions. Only low-resolution survey data is available to the SITL, which is insufficient to resolve electron dynamics. A strategy for the SITL, then, is to select all MP crossings. Of all 219 SITL selections classified as MP crossings during the first five months of model operations, the model predicted 166 (76%) of them, and of all 360 model predictions, 257 (71%) were selected by the SITL. Most predictions that were not classified as MP crossings by the SITL were still MP-like, in that the intervals contained mixed magnetosheath and magnetospheric plasmas. The LSTM model and its predictions are public to ease the burden of arduous event searches involving the MP, including those for EDRs. For MMS, this helps free up mission operation costs by consolidating manual classification processes into automated routines.

Patient Engagement and Multidisciplinary Involvement Has an Impact on Clinical Guideline Development and Decisions: A Comparison of Two Irritable Bowel Syndrome Guidelines Using the Same Data.

BACKGROUND AND AIM: The value of a multidisciplinary group and patient engagement in guideline groups is uncertain. We compared the recommendations of two guidelines that used the same data during the same time frame but with different participants to obtain a "real world" perspective on influence of the composition of guideline groups. METHODS: The Canadian Association of Gastroenterology (CAG) and the American College of Gastroenterology (ACG) recently updated their clinical practice guidelines for the management of Irritable Bowel Syndrome (IBS). Both the CAG and ACG used the same methodology and methodologist and were presented with the same data for interpretation. The ACG group consisted of predominantly academic gastroenterologists, while the CAG group also included general practitioners, a psychiatrist, a psychologist and a patient representative. The CAG group were also asked what components of the group were valuable. RESULTS: There were 14 statements with the same or similar recommendations. There were 10 statements in the CAG guideline not addressed by the ACG guideline and five recommendations where the opposite was the case. There was one statement that the two groups both addressed, but each group came to different conclusions. CAG members were in 100% agreement that involving a patient and having a multidisciplinary team was valuable and may have played a role in these differing interpretations of the same data in an IBS guideline. CONCLUSIONS: There has been little uptake of patient involvement and multidisciplinary teams in guideline groups. However, this study provides a unique example of added benefit through broader group representation.

Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS).

BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is one of the most common gastrointestinal (GI) disorders, affecting about 10% of the general population globally. The aim of this consensus was to develop guidelines for the management of IBS. METHODS: A systematic literature search identified studies on the management of IBS. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach. Statements were developed through an iterative online platform and then finalized and voted on by a multidisciplinary group of clinicians and a patient. RESULTS: Consensus was reached on 28 of 31 statements. Irritable bowel syndrome is diagnosed based on symptoms; serological testing is suggested to exclude celiac disease, but routine testing for C-reactive protein (CRP), fecal calprotectin or food allergies is not recommended. A trial of a low fermentable oligosaccharides, disaccharides, monosaccharides, polyols (FODMAP) diet is suggested, while a gluten-free diet is not. Psyllium, but not wheat bran, supplementation may help reduce symptoms. Alternative therapies such as peppermint oil and probiotics are suggested, while herbal therapies and acupuncture are not. Cognitive behavioural therapy and hypnotherapy are suggested psychological therapies. Among the suggested or recommended pharmacological therapies are antispasmodics, certain antidepressants, eluxadoline, lubiprostone, and linaclotide. Loperamide, cholestyramine and osmotic laxatives are not recommended for overall IBS symptoms. The nature of the IBS symptoms (diarrhea-predominant or constipation-predominant) should be considered in the choice of pharmacological treatments. CONCLUSIONS: Patients with IBS may benefit from a multipronged, individualized approach to treatment, including dietary modifications, psychological and pharmacological therapies.

Environmental and physiological determinants of huddling behavior of molting female southern elephant seals (Mirounga leonina).

While endotherms can rely on their insulation to reduce heat loss to adapt to cold environments, renewing of fur during molt impairs insulation while they have to perfuse the periphery to support epidermal tissues. The southern elephant seal Mirounga leonina undertakes an annual catastrophic molt while fasting on land in a wet, windy and cold environment. However, southern elephant seals show characteristic aggregation patterns that are predicted to reduce high metabolic costs during the molt. Between 2012 and 2016, 59 female elephant seals were tracked on land during their molt to study their aggregation behavior in relation to molt stage, habitat type and local weather conditions. Infrared thermography and stomach temperature loggers were used to observe variation in body surface and internal temperature in relation to molt stage and aggregation behavior. We found that thermal constraints varied during the molt, with a peak in surface temperature during the mid-stage of the molt. Wallows (mud pools) appear as favorable habitat to aggregate while molting. Indeed, wallows offered a warmer microclimate with greater ground temperature and lower wind speed. Moreover, there was a greater proportion of aggregated seals and larger group size in wallows. These aggregation patterns in wallows were influenced by local weather such that a greater proportion of seals were located in the center of the aggregation, and larger group size occurred during days of unfavorable meteorological conditions. We also observed a higher proportion of seals at mid-stage of molt amongst aggregated seals compared to isolated individuals. This aggregation behavior may reduce the cost of thermogenesis as surface body temperature and stomach temperature were cooler by 1.0 °C and 1.5 °C, respectively, in aggregated compared to isolated seals. As a consequence, huddling behavior may be thermally advantageous for female southern elephant seals during the molt.

Energy partitioning constraints at kinetic scales in low-ß turbulence.

Turbulence is a fundamental physical process through which energy injected into a system at large scales cascades to smaller scales. In collisionless plasmas, turbulence provides a critical mechanism for dissipating electromagnetic energy. Here we present observations of plasma fluctuations in low-ß turbulence using data from NASA's Magnetospheric Multiscale mission in Earth's magnetosheath. We provide constraints on the partitioning of turbulent energy density in the fluid, ion-kinetic, and electron-kinetic ranges. Magnetic field fluctuations dominated the energy density spectrum throughout the fluid and ion-kinetic ranges, consistent with previous observations of turbulence in similar plasma regimes. However, at scales shorter than the electron inertial length, fluctuation power in electron kinetic energy significantly exceeded that of the magnetic field, resulting in an electron-motion-regulated cascade at small scales. This dominance should be highly relevant for the study of turbulence in highly magnetized laboratory and astrophysical plasmas.

Two-year retrospective analysis of patients undergoing direct to procedure flexible sigmoidoscopy investigation with rectal bleeding as a primary complaint.

BACKGROUND AND AIMS: Rectal bleeding affects ~15 % of the general population and is a common reason for referral to gastroenterologists by primary care physicians. Direct to procedure flexible sigmoidoscopy is an appealing modality to investigate rectal bleeding due its diagnostic yield, safety profile, and accessibility. Patients referred on a routine basis for direct to procedure clinic by primary care physicians with the sole complaint of rectal bleeding have not previously been studied. Our study aims to explore the spectrum of diagnoses and evaluate for potential clinical predictors of underlying pathology in this specific patient population. METHODS: In total, 528 charts of patients referred to the Kingston General Hospital and Hotel Dieu Hospital endoscopy units (Kingston, Canada) with the sole complaint of rectal bleeding were reviewed. All of these patients were referred on a routine basis to direct to procedure clinic from primary care physicians. The performance of various clinical variables in predicting significant pathology was assessed by univariate analysis. RESULTS: The diagnostic spectrum of the cohort studied included hemorrhoids (75.5 %), anal fissures (4 %), ulcerative colitis (3.2 %), Crohn's disease (1.1 %), indeterminate proctitis/colitis (1.7 %), and colorectal malignancy (2.7 %). Of the various clinical variables assessed, only male sex predicted significant pathology (25.2 % of males vs 17.6 % of females, P  < 0.05). CONCLUSION: Our study highlights the need for a thorough investigation of rectal bleeding given the lack of clinical predictors. Future prospective studies with more patients are needed to fully assess the utility of various clinical variables in predicting pathology in this patient population. This would allow for more effective triaging of a routine rectal bleeding, a very common reason for patient referral to gastroenterologists by primary care physicians. Flexible sigmoidoscopy was not associated with complications or missed diagnosis in our study. As such, the technique appears to be a suitable initial investigative modality for patients with rectal bleeding.

Local weather and body condition influence habitat use and movements on land of molting female southern elephant seals (Mirounga leonina).

Southern elephant seals (Mirounga leonina) are known to move and aggregate while molting, but little is known about their behavior on land during this time. In this study, 60 adult females were monitored (23 with GPS tags) during four molting seasons, between 2012 and 2016 at Kerguelen Archipelago, Indian Ocean. Population surveys were recorded each year (N = 230 daily counts), and habitat use was analyzed in relation to the stage of the molt and local weather. Based on stage of molt, habitat use, and movements on land, we classified the molt of elephant seals into three phases: (1) a "search phase" at the initial stage of molt when grass and wallow habitats were used and characterized by greater mean distances travelled on land per day compared with the two other phases; (2) a "resident phase": during initial and mid-stage of molt when animals were found in grass and wallow habitats but with less distance moved on land; and (3) a "termination phase" at the final stage of molt where grass and beach habitats were occupied with no change in distances. Windchill and solar radiation influenced individual distances moved per day (mean 590 ± 237.0 m) at the mid- and final stage of molt such that animals travelled greater distances on days of low windchill or high solar radiation. Individual variation in distance moved and relative habitat use were also linked to body mass index (BMI) at arrival on the colony, as females with higher BMI moved less and preferred beach habitat. Moreover, the individual rate of molt increased with the use of wallows. Aggregation rate tended to be negatively correlated with distances moved. We therefore suggest that individuals face an energetic trade-off while molting, balancing energy expenditure between movement and thermoregulation.

Clinical Practice Guidelines for the Assessment of Uninvestigated Esophageal Dysphagia.

BACKGROUND AND AIMS: Our aim is to review the literature and provide guidelines for the assessment of uninvestigated dysphagia. METHODS: A systematic literature search identified studies on dysphagia. The quality of evidence and strength of recommendations were rated according to the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Statements were discussed and revised via small group meetings, teleconferences, and a web-based platform until consensus was reached by the full group. RESULTS: The consensus includes 13 statements focused on the role of strategies for the assessment of esophageal dysphagia. In patients presenting with dysphagia, oropharyngeal dysphagia should be identified promptly because of the risk of aspiration. For patients with esophageal dysphagia, history can be used to help differentiate structural from motility disorders and to elicit alarm features. An empiric trial of proton pump inhibitor therapy should be limited to four weeks in patients with esophageal dysphagia who have reflux symptoms and no additional alarm features. For patients with persistent dysphagia, endoscopy, including esophageal biopsy, was recommended over barium esophagram for the assessment of structural and mucosal esophageal disease. Barium esophagram may be useful when the availability of endoscopy is limited. Esophageal manometry was recommended for diagnosis of esophageal motility disorders, and high-resolution was recommended over conventional manometry. CONCLUSIONS: Once oropharyngeal dysphagia is ruled out, patients with symptoms of esophageal dysphagia should be assessed by history and physical examination, followed by endoscopy to identify structural and inflammatory lesions. If these are ruled out, then manometry is recommended for the diagnosis of esophageal dysmotility.

Comparison of Flexible Sigmoidoscopy Screening in Average Risk Patients Performed by Nurses Versus Gastroenterologists.

BACKGROUND: Screening sigmoidoscopy is effective in reducing mortality from colorectal cancer. In 2009, Cancer Care Ontario (CCO) launched a nurse-performed screening flexible sigmoidoscopy program at Hotel Dieu Hospital, Kingston, Ontario. Prior to this program, there was a pilot sigmoidoscopy screening program by gastroenterologists in a similar average risk cohort. AIM: To compare neoplasia detection rates and associated costs of screening sigmoidoscopy performed by nurses and gastroenterologists. METHOD: A retrospective chart review was conducted on flexible sigmoidoscopies performed as part of two average risk screening programs performed by gastroenterologists and nurse-endoscopists. Detected polyps were categorized as hyperplastic, low-risk adenomas or high-risk adenomas. Average cost per procedure was estimated based on physician fee for service charges, nurse wage and benefits, physician supervisory fees, pathology costs and administrative expenses. RESULTS: There were 538 procedures performed by nurses and 174 by physicians. Adenomas were detected in 18% of nurse-performed procedures versus 9% in physician-performed procedures (p=0.003), with the higher adenoma detection rate restricted to low risk adenomas. One cancer was found in the physician group. Seven physicians performed the 174 sigmoidoscopies, with one physician performing the majority. This physician's adenoma detection rate was 4.5%, whereas detection rate for the remaining physicians combined was 16.5%. Nurses biopsied more polyps per case (0.96 versus 0.18). Average estimated cost per case was greater for nurses ($387.54 versus $309.37). CONCLUSION: Well-trained nurse-endoscopists can provide an effective service for colorectal cancer screening, but as currently structured in Ontario, the associated cost is higher for nurse-performed procedures.

Wave-particle energy exchange directly observed in a kinetic Alfvén-branch wave.

Alfvén waves are fundamental plasma wave modes that permeate the universe. At small kinetic scales, they provide a critical mechanism for the transfer of energy between electromagnetic fields and charged particles. These waves are important not only in planetary magnetospheres, heliospheres and astrophysical systems but also in laboratory plasma experiments and fusion reactors. Through measurement of charged particles and electromagnetic fields with NASA's Magnetospheric Multiscale (MMS) mission, we utilize Earth's magnetosphere as a plasma physics laboratory. Here we confirm the conservative energy exchange between the electromagnetic field fluctuations and the charged particles that comprise an undamped kinetic Alfvén wave. Electrons confined between adjacent wave peaks may have contributed to saturation of damping effects via nonlinear particle trapping. The investigation of these detailed wave dynamics has been unexplored territory in experimental plasma physics and is only recently enabled by high-resolution MMS observations.

Lack of benefit of active preparation compared with a clear fluid-only diet in small-bowel visualization for video capsule endoscopy: results of a randomized, blinded, controlled trial.

BACKGROUND AND AIMS: Controversy remains regarding the type and amount of precapsule bowel cleansing required for small-bowel video capsule endoscopy (VCE). This study aims to assess the efficacy and tolerance of 2 active preparations and a control group of clear fluids only. METHODS: Patients with clinical indications for VCE were randomized to (1) clear fluids only the evening before VCE, (2) 2 sachets of sodium picosulfate plus magnesium sulfate (P/MC) the evening before, or (3) 2 L of polyethylene glycol (PEG) the evening before. Diet instructions were the same for all 3 groups. Small-bowel cleansing was assessed in 3 ways: a 5-point ordinal scale (primary outcome), the percentage of time the small-bowel view was clear, and a validated computerized assessment of cleansing. RESULTS: In total, 198 patients were randomized and 175 patients completed the trial with a mean age of 49.2 years. There was no clear benefit of active preparation with either P/MC or PEG over clear fluids only in the overall 5-point rating scale or in the distal fourth of each examination. There was no difference in diagnostic yield between groups. Significant differences were seen concerning tolerance of the preparations, with a higher proportion rating it as easy or very easy in the clear fluids-only group (93%) and the P/MC group (67%) than in the PEG group (13%) (P < .0001). CONCLUSIONS: Small-bowel cleansing for VCE remains a controversial topic. This randomized control trial demonstrates no benefit in overall or distal small-bowel visualization with active preparation using either PEG or P/MC compared with clear fluids only. (Clinical trial registration number: NCT00677794.).

A Patient Flow Analysis: Identification of Process Inefficiencies and Workflow Metrics at an Ambulatory Endoscopy Unit.

Background. The increasing demand for endoscopic procedures coincides with the paradigm shift in health care delivery that emphasizes efficient use of existing resources. However, there is limited literature on the range of endoscopy unit efficiencies. Methods. A time and motion analysis of patient flow through the Hotel-Dieu Hospital (Kingston, Ontario) endoscopy unit was followed by qualitative interviews. Procedures were directly observed in three segments: individual endoscopy room use, preprocedure/recovery room, and overall endoscopy unit utilization. Results. Data were collected for 137 procedures in the endoscopy room, 139 procedures in the preprocedure room, and 143 procedures for overall room utilization. The mean duration spent in the endoscopy room was 31.47 min for an esophagogastroduodenoscopy, 52.93 min for a colonoscopy, 30.47 min for a flexible sigmoidoscopy, and 66.88 min for a double procedure. The procedure itself accounted for 8.11 min, 34.24 min, 9.02 min, and 39.13 min for the above procedures, respectively. The focused interviews identified the scheduling template as a major area of operational inefficiency. Conclusions. Despite reasonable procedure times for all except colonoscopies, the endoscopy room durations exceed the allocated times, reflecting the impact of non-procedure-related factors and the need for a revised scheduling template. Endoscopy units have unique operational characteristics and identification of process inefficiencies can lead to targeted quality improvement initiatives.