Endoscopic Training Research Articles

MP41-11 ANALYSIS OF FLEXIBLE URETEROSCOPIC MOTION AND KINEMATIC EFFICIENCY - A SIMULATION-BASED PILOT STUDY

You have accessJournal of UrologyCME1 May 2022MP41-11 ANALYSIS OF FLEXIBLE URETEROSCOPIC MOTION AND KINEMATIC EFFICIENCY - A SIMULATION-BASED PILOT STUDY Marie-Therese Valovska, Gricelda Gomez, Richard Fineman, William Woltmann, Leia Stirling, and Daniel Wollin Marie-Therese ValovskaMarie-Therese Valovska More articles by this author , Gricelda GomezGricelda Gomez More articles by this author , Richard FinemanRichard Fineman More articles by this author , William WoltmannWilliam Woltmann More articles by this author , Leia StirlingLeia Stirling More articles by this author , and Daniel WollinDaniel Wollin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002607.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Flexible ureteroscopy (fURS) is the most common surgical procedure for treatment of urolithiasis. Various surgical disciplines and subspecialties have examined surgeon kinematics to improve assessment and generate measures of skill. Despite frequency of utilization, there is no undisputed method for evaluating fURS skills. Our pilot study utilized kinematic evaluations of fURS simulation to determine whether specific surgeon movements, techniques, and strategies correlate with measures of ureteroscopic efficiency. METHODS: A motion capture system with 41 reflective markers and standard GoPro video camera were employed to characterize surgeon movement variables. A ureteroscopic simulation box was used by practicing urologists at various skill levels to perform a series of simple and complex ureteroscopic movement tasks. Two tasks were chosen for this initial pilot analysis. Body kinematics, time to task completion, and ureteroscopic movements were analyzed. Task efficiency was defined as quicker time to task completion and smaller ureteroscope end effector travel distance. A novel combined performance efficiency score (PES) was calculated using the root sum square of these two measures to characterize efficiency and skill. RESULTS: Twelve practicing urologists were enlisted. Average urologist age was 37 years with an average of 10.1 years of training; 50% were female, 50% were residents; and 33% had completed an Endourology fellowship. For the simple task, no kinematic data correlated with PES; for the complex task, participant head and torso movement correlated with PES (r=0.60, p=0.04 for head; r=0.65, p=0.02 for torso), with decreased body movement associated with higher efficiency. CONCLUSIONS: Our findings suggest that movement economy measures are associated with efficient ureteroscopic manipulation for complex tasks in a simulated setting. Decreased head and torso movement were associated with higher efficiency, suggesting that excess body movement may signal extraneous or improper ureteroscopic movements. Additional assessment of these variables, including analysis in a clinical setting, is warranted as this may serve as a basis for improvement in endoscopic training and evaluation. Source of Funding: The simulation box and single-use ureteroscopes were provided by Boston Scientific © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e723 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marie-Therese Valovska More articles by this author Gricelda Gomez More articles by this author Richard Fineman More articles by this author William Woltmann More articles by this author Leia Stirling More articles by this author Daniel Wollin More articles by this author Expand All Advertisement PDF DownloadLoading ...

Inter-observer and intra-observer agreement in drug-induced sedation endoscopy \u2014 a systematic approach

ObjectiveTo evaluate the feasibility of systematic observer training in drug-induced sedation endoscopy (DISE) interpretation.MethodsFifty DISE videos were randomly selected from a group of 200 videos of cohort of patients with OSA and/or snoring. The videos were assessed blindly and independently using a modified VOTE classification by an expert observer and by two novice observers starting their training. A systematic approach was initiated. Clusters of 10 videos were scored individually by each observer and then re-evaluated as the expert observer clarified the decision-making in plenum. Kappa coefficient (κ) was calculated as a measure of agreement.ResultsThe intra-observer variation for the total agreement and kappa values for the expert observer ranged between moderate to substantial agreement in VOTE classification, whereas the novices varied between “less than chance agreement” to “moderate agreement.” The inter-observer variation showed increased agreement and kappa values from day 1 to day 2 for both novice observers except at the velum level for observer C. The total agreement and kappa values for each site also improved compared to results of day 1, except at velum for observer C. The velum site seemed to be more difficult to evaluate. The learning curve varied during the study course for each site of the upper airways.ConclusionThis study shows that systematic intensive training is feasible, although expert level is not acquired after 100 evaluations. The learning curve for the expert observer showed “moderate to substantial agreement” but differed between the trainees.Level of evidence2

Visual gaze patterns in trainee endoscopists – a novel assessment tool

Background Colonoscopy proficiency is significantly influenced by skills achieved during training. Although assessment scores exist, they do not evaluate the impact of visual search strategies and their use is time and labour intensive. Eye-tracking has shown significant differences in visual gaze patterns (VGPs) between expert endoscopists with varying polyp detection rates, so may provide a means of automated assessment and guidance for trainees. This study aimed to assess the feasibility of eye-tracking as a novel assessment method for trainee endoscopists. Methods Eye-tracking glasses were used to record 26 colonoscopies from 12 endoscopy trainees who were assessed with directly observed procedural scores (DOPS), devised by the Joint Advisory Group (JAG) on GI endoscopy, and a visual analogue score of overall competence. A ‘total weighted procedure score’ (TWPS) was calculated from 1 to 20. Primary outcomes of fixation duration (FixD) and fixation frequency (FixF) were analysed according to areas of interest (AOIs) with the bowel surface and lumen represented by three concentric rings. Correlation was assessed using Pearson’s coefficient. Significance was set at p<.050. Results Trainees displayed a significant positive correlation between TWPS and FixD (R = 0.943, p<.0001) and FixF (R = 0.936, p<.0001) in the anatomical bowel mucosa peripheries. Conversely, they had significant negative correlations between TWPS and the anatomical bowel lumen (FixD: R= −0.546, p=.004; FixF: R= −0.568, p=.002). Conclusions Higher objective performance scores were associated with VGPs focussing on bowel mucosa. This is consistent with prior analysis showing peripheral VGPs correspond with higher polyp detection rates. Analysis of VGPs, therefore, has potential for training and assessment in colonoscopy.

Endoscopic resection of superficial bowel neoplasia: The unmet needs in the Egyptian practice.

BACKGROUNDManagement of superficial bowel neoplasia (SBN) in early stages is associated with better outcomes. The last few decades experienced a paradigm shift in the management of SBN with the introduction of advanced endoscopic resection techniques (ERTs). However, there are no clear data about the aspects of ERTs in Egypt despite the growing gastroenterology practice.AIMTo investigate the knowledge, attitude, and practice of ERTs toward management of SBN among Egyptian practitioners and the suitability of the endoscopy units’ infrastructures toward these techniques.METHODSAn online 2-pages questionnaire was used. The first page comprised demographic data, and questions for all physicians, about the knowledge (11 questions) of and attitude (5 questions) toward ERTs as a therapeutic option for SBN. The second page investigated the practice of ERTs by endoscopists (6 questions) and the infrastructures of their endoscopy units (14 questions). The survey was disseminated through July 2021 and the data were collected in an excel sheet and later analyzed anonymously.RESULTSThe complete responses were 833/2300 (36.2%). The majority of the participants were males (n = 560, 67.2%), middle-aged (n = 366, 43.9%), consultants (n = 464, 55.7%), gastroenterologists (n = 678, 81.4%), spending ≥ 15 years in practice (n = 368, 44.2%), and were working in university hospitals (n = 569, 68.3%). The majority correctly identified the definition of SBN (88.4%) and the terms polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) (92.1%, 90.2%, and 89.1% respectively). However, 26.9%, 43.2% and 49.5% did not recognize the clear indication of polypectomy, EMR, and ESD respectively. Although 68.1% of physicians are convinced about the ERTs for management of SBN; only 8.9% referred all candidate cases for ERTs. About 76.5% of endoscopists had formal training in the basic polypectomy techniques while formal training for EMR and ESD was encountered only in 31.9% and 7.2% respectively. About 71.6% and 88.4% of endoscopists did not perform EMR or ESD in the last one year. Consequently, the complication rate reported by endoscopists was limited to 18.1% (n = 103) of endoscopists. Only 25.8% of endoscopists feel confident in the management of ERTs-related complications and a half (49.9%) were not sure about their competency. Regarding the endoscopy units’ infrastructures, only 4.2% of the centers had their endoscopes 100% armed with optical enhancements and 54.4% considered their institutions ready for managing ERTs-related complications. Only 18.3% (n = 104) of endoscopists treated their complicated cases surgically because the most frequent ERTs-related complications were procedural bleeding (26.7%), and perforations (17%).CONCLUSIONA significant deficiency was reported in the knowledge and attitude of Egyptian practitioners caring for patients with SBN toward ERTs. The lack of trained endoscopists in both EMR and ESD in part is due to unsuitable infrastructures of many endoscopy units.

Hospital compound-level endoscopy training quality performance: scoping the spectrum.

Background and study aims This study aimed to assess the quality of endoscopy training in a UK Statutory Educational Body compared with Joint Advisory Group on Gastrointestinal Endoscopy Training standards (JETS). Methods A total of 28,298 training procedures recorded by 211 consecutive cross-specialty trainee endoscopists registered with JETS in 18 hospitals during 2019 were analyzed. Data included trainer and trainee numbers, training list frequency, procedures, direct observation of procedural skills (DOPS) completion, and key performance indicators. Results Annual median training procedures per hospital were 1395 (interquartile range (IQR) 465–2365). Median trainers and trainees per unit were 11 (6–18) and 12 (7–16), respectively, (ratio 0.8 [0.7–1.3]). Annual training list frequency per trainee was 13 (10–17), 35.0 % short of Joint Advisory Group (JAG) standard (n = 20, P = 0.001, effect size –0.56). Median points per adjusted training list were 11 (5–18). Median DOPS per trainee and trainer were three (1–6) and four (1–7) respectively; completing 0.2 DOPS (0.1–0.4) per list and amounting to six (2–12) per 200 procedures: fewer than half of the JAG standard (20 per 200) (P < 0.001, –0.61). Esophagogastroduodenoscopy median KPI: J maneuver 94 % (90–96), D2 intubation 93 % (91–96); Colonoscopy KPI: cecal intubation 82 % (72–90), polyp detection rate 25 % (18–34). Compound hospital score ranged from nine to 26 (median 17 [14–20]). Conclusions Important performance disparity emerged with three-fold variation in compound hospital training quality and most units underperforming compared with JAG standards. Trainees and training program directors should be aware of such metrics to improve quality endoscopy educational programs and consider formal adjuncts to optimize training.

The Cost of Setting Up an ENT Endoscopic Practice in Lower Middle-Income Countries of Sub-Saharan Africa.

Ear, nose, and throat (ENT) surgeons in developing countries are constrained to practicing with lower technology, lower cost surgery, and reliance on outdated surgical techniques carried out with improvised instruments when compared with their counterparts in the developed world. In this review, we planned to lay open the bottle necks militating against setting up an ENT endoscopy practice in our setting with possible outcomes. The literature search was carried out to retrieve relevant published articles, books, and guidelines. Unpublished literatures were excluded. The search was limited to articles in English. ENT clinical practice in lower middle-income countries (LMICs) where there are limited or no ENT endoscopic setup due to high cost of procurement and maintenance, human resources, lack of subspecialty training, and inadequate funding by policy makers poses major challenges that can militate against the provision of adequate and effective surgical management. A continually improved management practices will positively affect the organisational structure, efficiency, and safety of a system. That is, an affordable and standard ENT endoscopic setup will go a long way to improve the access to training and practice for both ENT clinical and surgical purposes. The expansion of ENT endoscopic specialist training will improve both the diagnostic and therapeutic acumen in ENT practice in LMICs. The budget for health and the health-funding systems of our institutions must receive special and specific attentions tailored towards putting our health facilities in better shapes, subspecialty training, and procurement of state-of-the-art endoscopic equipment with proper plans on maintenance culture.

Educación virtual y simulación en endoscopía

The American Society of Gastrointestinal Endoscopy (ASGE) defines competency as the minimum level of skill, knowledge, and/or experience derived from training that will enable the proficient performance of a task or procedure.1 Training in gastrointestinal endoscopy, for most of us who are involved in it, was performed in hospitals during our residency or fellowship. The acquisition of competence required and still requires continuous supervision by tutors or mentors trained as teachers, and takes a long time to avoid errors or adverse events during the development of the learning curve. The greater the complexity of the procedure, the greater the need for close supervision. Continuous supervision prolongs the procedures, thus reducing the number of procedures that can be programmed on a daily basis. This has financial implications for the institution and results in shift delays. It also has a cost in terms of equipment performance: when operated by inexperienced personnel, it encourages breakage due to incorrect use. On the other hand, current standards prevent, from an ethical point of view, doctors in training from using patients for training. What is the reason that makes guardianship necessary? For the patient who is the object of the procedure, the procedure is unique and unrepeatable - in general - and should be performed in the best possible way. That event for the individual patient is in principle unique.

Effect of a Surgical Endoscopy Training Program on Postgraduate Daily Practice: Results from a Single- Center

Effect of a Surgical Endoscopy Training Program on Postgraduate Daily Practice: Results from a Single- Center

Development and Validation of a Deep Neural Network for Accurate Identification of Endoscopic Images From Patients With Ulcerative Colitis and Crohn's Disease.

Background and AimThe identification of ulcerative colitis (UC) and Crohn's disease (CD) is a key element interfering with therapeutic response, but it is often difficult for less experienced endoscopists to identify UC and CD. Therefore, we aimed to develop and validate a deep learning diagnostic system trained on a large number of colonoscopy images to distinguish UC and CD.MethodsThis multicenter, diagnostic study was performed in 5 hospitals in China. Normal individuals and active patients with inflammatory bowel disease (IBD) were enrolled. A dataset of 1,772 participants with 49,154 colonoscopy images was obtained between January 2018 and November 2020. We developed a deep learning model based on a deep convolutional neural network (CNN) in the examination. To generalize the applicability of the deep learning model in clinical practice, we compared the deep model with 10 endoscopists and applied it in 3 hospitals across China.ResultsThe identification accuracy obtained by the deep model was superior to that of experienced endoscopists per patient (deep model vs. trainee endoscopist, 99.1% vs. 78.0%; deep model vs. competent endoscopist, 99.1% vs. 92.2%, P < 0.001) and per lesion (deep model vs. trainee endoscopist, 90.4% vs. 59.7%; deep model vs. competent endoscopist 90.4% vs. 69.9%, P < 0.001). In addition, the mean reading time was reduced by the deep model (deep model vs. endoscopists, 6.20 s vs. 2,425.00 s, P < 0.001).ConclusionWe developed a deep model to assist with the clinical diagnosis of IBD. This provides a diagnostic device for medical education and clinicians to improve the efficiency of diagnosis and treatment.

A system for real-time multivariate feature combination of endoscopic mitral valve simulator training data

PurposeFor an in-depth analysis of the learning benefits that a stereoscopic view presents during endoscopic training, surgeons required a custom surgical evaluation system enabling simulator independent evaluation of endoscopic skills. Automated surgical skill assessment is in dire need since supervised training sessions and video analysis of recorded endoscope data are very time-consuming. This paper presents a first step towards a multimodal training evaluation system, which is not restricted to certain training setups and fixed evaluation metrics.MethodsWith our system we performed data fusion of motion and muscle-action measurements during multiple endoscopic exercises. The exercises were performed by medical experts with different surgical skill levels, using either two or three-dimensional endoscopic imaging. Based on the multi-modal measurements, training features were calculated and their significance assessed by distance and variance analysis. Finally, the features were used automatic classification of the used endoscope modes.ResultsDuring the study, 324 datasets from 12 participating volunteers were recorded, consisting of spatial information from the participants’ joint and right forearm electromyographic information. Feature significance analysis showed distinctive significance differences, with amplitude-related muscle information and velocity information from hand and wrist being among the most significant ones. The analyzed and generated classification models exceeded a correct prediction rate of used endoscope type accuracy rate of 90%.ConclusionThe results support the validity of our setup and feature calculation, while their analysis shows significant distinctions and can be used to identify the used endoscopic view mode, something not apparent when analyzing time tables of each exercise attempt. The presented work is therefore a first step toward future developments, with which multivariate feature vectors can be classified automatically in real-time to evaluate endoscopic training and track learning progress.

Software Analysis of Colonoscopy Videos Enhances Teaching and Quality Metrics.

PurposeMachine learning algorithms were hypothesized as being able to predict the quality of colonoscopy luminal images. This is to enhance training and quality indicators in endoscopy.MethodsA separate study involving a randomized controlled trial of capped vs. un-capped colonoscopies provided the colonoscopy videos for this study. Videos were analyzed with an algorithm devised by the Australian Institute for Machine Learning. The image analysis validated focus measure, steerable filters-based metrics (SFIL), was used to assess luminal visualization quality and was compared with two independent clinician assessments (C1 and C2). Goodman and Kruskal's gamma (G) measure was used to assess rank correlation data using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY).ResultsA total of 500 random colonoscopy video clips were extracted and analyzed, 88 being excluded. SFIL scores matched with C1 in 45% and C2 in 42% of cases, respectively. There was a significant correlation between SFIL and C1 (G = 0.644, p < 0.005) and SFIL and C2 (G = 0.734, p < 0.005).ConclusionThis study demonstrates that machine learning algorithms can recognize the quality of luminal visualization during colonoscopy. We intend to apply this in the future to enhance colonoscopy training and as a metric for quality assessment.

Democratizing Flexible Endoscopy Training: Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam.

A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness has never been compared with higher-cost virtual reality simulators (VRSs). In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam or a validated BT-the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex vivo models. The primary endpoint was FESms improvement at 1 week. Secondary endpoints were FESms improvement at 2 weeks, FESms pass rates, ex vivo tests performance, and trainees' feedback. Seventy-seven trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16 ± 14.29 vs 25.58 ± 11.75 FESms points, respectively; p = 0.89), FESms pass rates (76.32% vs 61.54%, respectively; p = 0.16) and total ex vivo tasks completion times (365.76 ± 237.56 vs 322.68 ± 186.04 seconds, respectively; p = 0.55) after 1 week. Performances were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97 ± 1.20 vs 4.81 ± 0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p < 0.001). Simulation-based training is an effective means to develop competency in endoscopy, especially at the beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training.

Simulation training in endoscopic skull base surgery: A scoping review.

ObjectiveProficiency in endoscopic endonasal skull base surgery requires both substantial baseline training and progressive lifelong learning. Endoscopic simulation models continue to evolve in an effort to optimize trainee education and preoperative preparation and improve surgical outcomes. The current scoping review systematically reviews all available literature and synthesizes the current paradigms of simulation models for endoscopic skull base surgery training and skill enhancement.MethodsIn accordance with Preferred Reporting Items for Systemic Review and Meta‐Analyses guidelines, we systematically searched PubMed, Embase, CINAHL, and Cochrane databases. Studies were categorized according to the type of simulation models investigated.ResultsWe identified 238 unique references, with 55 studies ultimately meeting inclusion criteria. Of these, 19 studies described cadaveric dissection models, 17 discussed three‐dimensional (3D) printed models, 14 examined virtual surgical planning and augmented reality‐based models, and five 5 articles described task trainers.ConclusionsThere are a wide variety of simulation models for endoscopic skull base surgery, including high‐fidelity cadaveric, virtual reality, and 3D‐printed models. These models are an asset for trainee development and preoperative surgical preparation.

Women in gastroenterology: the UK trainee experience

IntroductionCompared with other medical specialties, there are lower numbers of female trainees and lower rates of flexible working in gastroenterology. This study aims to examine the experience of male and...

How to Approach Submucosal Lesions in the Gastrointestinal Tract: Different Ideas between China and USA.

Between 2019 and 2020, the author Gao pursued advanced endoscopic training at the University of Mississippi Medical Center in the USA. She experienced certain different ideas between the East (China) and the West (USA) in terms of endoscopic approach to the submucosal tumors (SMTs) or lesions in the gastrointestinal (GI) tract. In the West (USA), when SMTs are found on gastroscopy, the main goal of endoscopists is to obtain a tissue diagnosis through endoscopic ultrasound-guided fine-needle aspiration or biopsy (EUS-FNA or FNB) or single incision needle-knife biopsy (SINK); if immunohistochemical tests confirmed the GISTs, the first-line treatment is local surgery, that is, diagnosis before treatment, whereas in China, SMTs will be completely resected with endoscopic technology for those with no lymph node metastasis or extremely low risk of lymph node metastasis. There may not be pathological tissue at first, that is, treatment before diagnosis.

Colonoscope "Looping" During Ileo-Colonoscopy in Children is Significantly Different to that Observed in Adult Practice.

Ileo-colonoscopy (IC) can be technically challenging because of unpredictable colonoscope loop formation. Aims of this study were to assess the risk of loop formation and to attempt to understand which factors were likely to predispose to which subtype of loop. Prospective study conducted on children referred for an IC at Sheffield Children's Hospital. Presence and type of loop was objectively assessed using the magnetic endoscope imaging tool. Three hundred procedures were prospectively evaluated. Only 9% of paediatric ICs were loop-free. Alpha loops were the most common loop in children older than 5, whereas reverse alpha loops and a wider variety of complex and repetitive loops were observed in younger patients. Once a specific type of loop has formed, the risk of re-looping in a different way or in a different position of the colon is reduced. Left lateral starting position was found to increase the risk of reverse alpha loops and re-looping. Challenging loops, such as reverse alpha, were more frequent in males. Higher body mass index (BMI) was associated with an increased risk of alpha and deep transverse loops formation, while lower BMI with a higher incidence of reverse alpha and N loop. Loop formation did not prevent 100% ileal intubation. This study represents the first attempt to describe loop formation according to patient characteristics in a large paediatric series. Further studies are needed in order to establish if these findings could be helpful in simplifying the execution of IC procedures in children and facilitate the learning curve during endoscopy training programs.

A168 UTILITY OF FOLLOW-UP PANCOLONIC DYE SPRAY CHROMOENDOSCOPY FOR THE DETECTION AND TREATMENT OF DYSPLASTIC LESIONS IDENTIFIED DURING HIGH-DEFINITION WHITE-LIGHT ENDOSCOPY IN PATIENTS WITH COLONIC INFLAMMATORY BOWEL DISEASE

Abstract Background Patients with inflammatory bowel disease (IBD) involving the colorectum are at higher risk for the development of flat and poorly delineated dysplastic lesions. Pancolonic dye spray chromoendoscopy (DCE) can represent an adjunct to white light endoscopy (WLE) that enhances detection and delineation of such lesions. Aims We evaluated the utility of follow-up DCE for lesion detection and treatment in patients with IBD who had visible (polypoid or flat lesions) or invisible (identified in non-targeted biopsies) dysplasia detected during high-definition (HD)-WLE. Methods We retrospectively studied patients with colonic IBD from The Ottawa Hospital who underwent DCE by a trained endoscopist, as follow-up for dysplasia detected during HD-WLE, over a 7-year time period (2013–2020). We collected demographic and disease-specific variables. Results Twenty-four patients were included (mean age 56.7±13.8 years, 50.0% male, 70.8% ulcerative colitis, mean disease duration 18.0±11.0 years, 70.8% moderate or severe disease activity historically, and 41.7% remote history of dysplasia). Seventeen (70.8%) patients were referred following detection of invisible dysplasia; the remainder (29.2%) were referred for surveillance of poorly defined visible dysplastic lesions. For those referred following detection of invisible dysplasia, DCE identified visible dysplasia at the same site in 8/17 (47.1%) patients, at a different site in 6/17 (35.3%) patients, and no dysplasia in 3/17 (17.6%) patients. DCE identified 1.39±1.50 new visible dysplastic lesions per patient that were not identified on index HD-WLE. DCE upgraded the highest grade of dysplasia and diagnosed colorectal cancer in 2/24 (8.3%) patients, which was missed on index HD-WLE. Endoscopic resection was successful in 23/34 (76.7%) dysplastic lesions identified on DCE. However, DCE was unable to facilitate lesion resection in three patients due to advanced lesion characteristics. Follow-up data was available for 17/24 (70.8%) patients (mean 0.88±0.58 years). Of these patients, 7/17 (41.2%) developed subsequent dysplasia, including 4/17 (23.5%) at a site of prior invisible dysplasia, 2/17 (11.8%) at sites of prior visible dysplasia, and 1/17 (5.88%) at a different site. One of these patients developed high-grade dysplasia requiring resection. Conclusions In this study, DCE is a valuable tool for dysplasia detection and treatment in persons with colonic IBD who have ill-defined dysplasia identified during HD-WLE. Given some patients developed dysplasia following DCE in our cohort, it is important to maintain close follow-up and obtain biopsies around sites of prior invisible and visible dysplasia. Further studies are required to validate our findings. Funding Agencies None

A124 INITIAL EXPERIENCES AND OUTCOMES IN LAUNCHING AN ESD PROGRAM IN CANADA

BackgroundEndoscopic submucosal dissection (ESD) is emerging as the preferred modality for curative resection of certain gastrointestinal lesions, yet it has a steep learning curve. Formal ESD training in Canada is limited, thus several endoscopists have sought training abroad. There are no data on the initial outcomes of ESD in Canada.AimsTo describe the experience of a single advanced endoscopist (P.B.) who completed a mentor-apprentice model of ESD training in Europe and recently launched an ESD service in Canada.MethodsFormal training in submucosal endoscopy was completed over a 12-month period (Sep 2018-Aug 2019) in Milan, Italy involving a stepwise progression through case observation (n=40), use of animal models (n=10), partial completion of human cases under direct supervision (n=25), and independent completion of human cases (n=19). Upon return to Calgary, AB, the program was promoted via grand rounds, an evening launch event and word-of-mouth. Patient and lesion characteristics, as well as procedure details and ESD outcomes were recorded prospectively in a database and used to complete a practice audit. Cases were divided into two timeframes (first 18 vs second 18 cases) and then compared with respect to specimen size, resection speed, R0 resection rate, and adverse event (AE) rate using the Mann-Whitney U and two-proportion Z-tests.ResultsFrom Nov 2019 to Sep 2021, 36 lesions were treated by ESD in 34 patients (mean (SD) age=66.5 (13.5) years). Most lesions were located in the rectum (44.4%) or stomach (41.7%); 21 (58.3%) were neoplastic, of which 5 (23.8%) were submucosal carcinomas, 11 (52.3%) were mucosal carcinomas (7 m1/Tis, 4 m2-3/T1a), and 5 (23.8%) were neuroendocrine tumors. The overall en bloc resection rate was 97.2% (35/36 lesions). In comparing the first 18 cases to the second 18 cases (Table 1), there were non-significant trends toward increases in mean specimen size (5.4 to 8.6 cm2, P=0.07) and R0 resection rate (62.5% to 84.6%, P=0.24). Resection speed increased significantly (2.97 to 6.25 cm2/hr, P=0.04), while AE rates remained the same (11.1%); namely 2 episodes of bleeding requiring repeat endoscopy in each set of cases. There were no perforations or intra-abdominal infections.ConclusionsWith appropriate training and support, ESD can be performed safely and effectively in a Canadian context. Proficiency can be expected to improve significantly within the first 2 years of independent ESD practice without compromising safety.Table 1.ALL LOCATIONS1st 18 cases2nd 18 casesAll 36 casesPElliptical area (cm2)5.358.597.740.07Total ESD time (min)94.2897.7296.000.70Resection speed (cm2/hr)2.976.254.610.04*R0 resection (%)62.5084.6276.190.24Adverse events (%)11.1111.1111.111Funding AgenciesNone

The Distribution and Composition of Colonoscopy Providers in Australia

Introduction: Colorectal cancer is a common cause of cancer in Australia. Also, patients living in regional and rural areas are diagnosed later and have poorer outcomes compared to their metropolitan counterparts. The purpose of this study is to determine the distribution of the workforce providing colonoscopies for the Australian population.Methods: A cross-sectional observational study of the medical practitioners certified by the conjoint committee for the recognition of training in gastrointestinal endoscopy (CCRTGE) was performed. Data regarding their specialty and principal place of practice was collected. The principal place of practice was stratified with the Modified Monash Model (MMM) of rurality and the local government association’s classifications of rural and urban areas.Results: As of March 2021, there were 2698 medical practitioners listed as being recognised in the field of adult colonoscopies by the CCRTGE. Of these, 2123 were found to still have active specialist registration with the Australian Health Practitioner Regulation Agency (AHPRA). In the capital city Local Government Areas (LGAs), there was an endoscopist every 0.33 km2 to 62.05 km2. In the rural LGAs, there was an endoscopist every 23,382 km2 to 267,780 km2. In metropolitan areas, the most common specialty of the endoscopist was gastroenterology whereas in regional cities and remote towns it was general surgery. In very remote towns, general practitioners provided colonoscopy services.

Transfer of virtual reality endoscopy training to live animal colonoscopy: a randomized control trial of proficiency vs. repetition-based training.

BackgroundLow first-time pass rates of the Fundamentals of Endoscopic Surgery (FES) exam stimulated development of virtual reality (VR) simulation curricula for test preparation. This study evaluates the transfer of VR endoscopy training to live porcine endoscopy performance and compares the relative effectiveness of a proficiency-based vs repetition-based VR training curriculum.MethodsNovice endoscopists completed pretesting including the FES manual skills examination and Global Assessment of GI Endoscopic Skills (GAGES) assessment of porcine upper and lower endoscopy. Participants were randomly assigned one of two curricula: proficiency-based or repetition-based. Following curriculum completion, participants post-tested via repeat FES examination and GAGES porcine endoscopy assessments. The two cohorts pre-to-post-test differences were compared using ANCOVA.ResultsTwenty-two residents completed the curricula. There were no differences in demographics or clinical endoscopy experience between the groups. The repetition group spent significantly more time on the simulator (repetition: 242.2 min, SD 48.6) compared to the proficiency group (proficiency: 170.0 min, SD 66.3; p = 0.013). There was a significant improvement in porcine endoscopy (pre: 10.6, SD 2.8, post: 16.6, SD 3.4; p < 0.001) and colonoscopy (pre: 10.4, SD 2.7, post: 16.4, SD 4.2; p < 0.001) GAGES scores as well as FES manual skills performance (pre: 270.9, SD 105.5, post: 477.4, SD 68.9; p < 0.001) for the total cohort. There was no difference in post-test GAGES performance or FES manual skills exam performance between the two groups. Both the proficiency and repetition group had a 100% pass rate on the FES skills exam following VR curriculum completion.ConclusionA VR endoscopy curriculum translates to improved performance in upper and lower endoscopy in a live animal model. VR curricula type did not affect FES manual skills examination or live colonoscopy outcomes; however, a proficiency curriculum is less time-consuming and can provide a structured approach to prepare for both the FES exam and clinical endoscopy.