The Four Pillars: Why Endoscopic Complications Aren't Bad Luck

The Thesis

Complications are predictable. They cluster around the same four gaps in operator preparation. They are preventable at unacceptable rates only when one of four things is missing — theoretical understanding, familiarity with materials, preparation and equipment, or procedural excellence.

The complication rate is not a feature of the procedure. It is a feature of the operator.

Pillar 1 — Theoretical Understanding

Knowing what to look for is theory. The lesion you missed was not a hand problem. It was a knowledge problem.

In Issue 5, Dr Alžběta Hujova, with Dr Gianluca Esposito, Dr João António Cunha Neves and Dr David Roser, defines misdiagnosis as an adverse event in the same category as a perforation. Their closing line:

Not all adverse events bleed. Some are simply missed.

Their segment walks through the ESGE 2025 performance measures (≥20-min procedure slot, ≥7-min inspection), the new GREY visibility scale, simethicone pre-medication, and symptom-driven biopsy strategy — including the detail almost everybody gets wrong on coeliac disease: at least six biopsies, and at least two of them must come from the duodenal bulb, or you will miss ultra-short coeliac.

Pillar 2 — Familiarity With Your Materials

Dr Maria Eva Argenziano leads the lower GI segment on perforation management. She does not talk about clips in the abstract — she talks about which clip: its rotability, jaw width, stem length, whether it is single-use or reloadable, the cost, the environmental footprint.

That is what familiarity looks like.

The defect chooses the tool, not the other way around. She uses the Deep Mural Injury (DMI) classification 0–5 and the zipper closure technique: align the stem with the perforation line, push and suction together, mind gravity, place the defect on the anti-gravity side. When through-the-scope clips will not approximate, she has a salvage hierarchy ready: anchor-prong clips, clip + wire, over-the-scope clip, suturing, surgery as last resort.

One good clip beats three placed badly. Do less, but do it well.

That sentence is not a slogan. It is what familiarity sounds like.

Pillar 3 — Preparation and Equipment in the Room

Preparation is what panic looks like in slow motion, done in advance.

This pillar runs through Dr Argenziano's segment and through Dr Roos E. Pouw's group on iatrogenic oesophageal perforation (with Dr Francesco Vito Mandarino, Dr Michele Montori, Dr Ernesto Fasulo and Dr Robert Bechara).

• CO₂ insufflation always on — switched before you start, not after the perforation
• Capnoperitoneum decompression kit (14G IV cannula, 10 mL syringe, saline) in the room before any therapeutic case. Not in a cupboard down the corridor. In the room.
• Broad-spectrum IV antibiotics drawn up — given the moment recognition happens, not five minutes later
• Suction lines clear; nasogastric access ready; a colleague within calling distance
• Imaging pathway pre-arranged — low threshold for chest CT if doubt

The first second of a complication is no time to start looking for tools.

Pillar 4 — Procedural Excellence: A. B. C.

Dr Pouw and her group give the framework every endoscopist should be able to recite — the ABC of iatrogenic perforation management:

• A — Assess. Size, location, depth, degree of contamination. Document the perforation before treating it.
• B — Breathe. Stay calm. Confirm CO₂ is on. Suck the fluids. Start the antibiotics. Check for pneumothorax or pneumoperitoneum, decompress if found. Call a colleague.
• C — Close. Through-the-scope clip. Over-the-scope clip. Stent. Endoscopic suture. Vacuum therapy. Surgery. The choice is driven by the assessment in A — not by the device you happen to know.

ABC is not a slogan. It is a discipline that survives the moment. It works because it forces you to slow down at the precise moment your instinct is telling you to speed up.

The most important part of pillar four is the part nobody trains: recognise your limits. Escalate before the patient deteriorates, not after. The strongest endoscopists pick up the phone first, not last.

The Hard Line

If you put the work into all four pillars, your complication rate is the rate the procedure dictates. If you skip any one of them, your patients experience complications at rates that are not acceptable. And in that case the rate is no longer a feature of the procedure. It is a feature of you.

There is only one thing that closes those gaps.

Training. Training. Training.

Watch all of Issue 5 on the ESGE Academy

Issue 5 of the ESGE Academy Video Journal is themed Adverse Events in Endoscopy. The Lower GI and Upper GI sections are available now; ERCP and EUS will follow.

Open the ESGE Academy →