Training In Therapeutic Endoscopy Research Articles

A279 EUS-GUIDED BILIARY DRAINAGE IN MALIGNANT DISTAL BILIARY OBSTRUCTION: AN INTERNATIONAL SURVEY TO IDENTIFY BARRIERS OF TECHNOLOGY IMPLEMENTATION

Abstract Background Endoscopic ultrasound-guided biliary drainage (EUS-BD) is a promising alternative to endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction (MDBO). Recent small randomized controlled trials comparing EUS-BD with ERCP suggest that EUS-BD achieves a similar technical success rate and safety profile while potentially being associated with lower rates of stent dysfunction However, its application in clinical practice has been impeded by various undefined barriers. Aims To evaluate the current practice of EUS-BD and the determinants for its clinical implementation in MDBO. Methods An online survey was generated using Google Forms. Five endoscopy societies have distributed the survey as of October 10th, 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers to implementation. Descriptive statistics were calculated using frequencies, chi-square statistics were used for inferential analysis, and a standard step-wise multivariable analysis was performed to identify independent variables for and against the use of EUS-BD. Results To date, 102 physicians have participated in the survey (response rate 7.97%). The majority of participants are from North America (39.2%), Asia (31.4%), and Europe (19.6%). Most participants are gastroenterologists with formal therapeutic endoscopy training (66.7%), though only 28.4% have received EUS-BD training. In unresectable cancer, 85.1% of respondents favoured EUS-BD over percutaneous biliary drainage following ERCP failure (p<0.0001), while in borderline resectable disease, 72.3% preferred EUS-BD. On multivariable analysis, male gender, formal training in EUS-BD, and unresectable cancer were independent variables for the use of EUS-BD. Conversely, independent discouraging factors for EUS-BD included fear of adverse events, limited high-quality data, lack of local expertise, and inadequate access to EUS technology. Conclusions In this international survey, it appears that EUS-BD is gaining traction, especially in the setting of unresectable disease following ERCP failure. However, barriers to implementation include the lack of high-quality data, fear for adverse events, limited experts in the field, and inadequate access to EUS technology. This suggest the need for high-quality clinical trials, increased endoscopist training in this field, and further technology development in EUS-BD in order to increase its uptake in clinical practice. Funding Agencies None

Stricter national standards are required for credentialing of endoscopic-retrograde-cholangiopancreatography in the United States.

Endoscopic-retrograde-cholangiopancreatography (ERCP) is now a vital modality with primarily therapeutic and occasionally solely diagnostic utility for numerous biliary/pancreatic disorders. It has a significantly steeper learning curve than that for other standard gastrointestinal (GI) endoscopies, such as esophagogastroduodenoscopy or colonoscopy, due to greater technical difficulty and higher risk of complications. Yet, GI fellows have limited exposure to ERCP during standard-three-year-GI-fellowships because ERCP is much less frequently performed than esophagogastroduodenoscopy/colonoscopy. This led to adding an optional year of training in therapeutic endoscopy. Yet many graduates from standard three-year-fellowships without advanced training intensely pursue independent/unsupervised ERCP privileges despite inadequate numbers of performed ERCPs and unacceptably low rates of successful selective cannulation of desired (biliary or pancreatic) duct. Hospital credentialing committees have traditionally performed ERCP credentialing, but this practice has led to widespread flouting of recommended guidelines (e.g., planned privileging of applicant with 20% successful cannulation rate, or after performing only 7 ERCPs); and intense politicking of committee members by applicants, their practice groups, and potential competitors. Consequently, some gastroenterologists upon completing standard fellowships train and learn ERCP “on the job” during independent/unsupervised practice, which can result in bad outcomes: high rates of failed bile duct cannulation. This severe clinical problem is indicated by publication of ≥ 12 ERCP competency studies/guidelines during last 5 years. However, lack of mandatory, quantitative, ERCP credentialing criteria has permitted neglect of recommended guidelines. This work comprehensively reviews literature on ERCP credentialing; reviews rationales for proposed guidelines; reports problems with current system; and proposes novel criteria for competency. This work advocates for mandatory, national, written, minimum, quantitative, standards, including cognitive skills (possibly assessed by a nationwide examination), and technical skills, assessed by number performed (≥ 200-250 ERCPs), types of ERCPs, success rate (approximately ≥ 90% cannulation of desired duct), and letters of recommendation by program director/ERCP mentor. Mandatory criteria should ideally not be monitored by a hospital committee subjected to intense politicking by applicants, their employers, and sometimes even competitors, but an independent national entity, like the National Board of Medical Examiners/American Board of Internal Medicine.

Radiation Training, Radiation Protection, and Fluoroscopy Utilization Practices Among US Therapeutic Endoscopists.

Fluoroscopy use during ERCP exposes patients and providers to deleterious effects of radiation. Formal training in fluoroscopy/radiation protection is not widely emphasized during therapeutic endoscopy training, and radiation use during GI endoscopy has not previously been characterized in the USA. In this study, we evaluated radiation training, fluoroscopy use patterns, and radiation protection practices among US therapeutic endoscopists. An anonymous electronic survey was distributed to US therapeutic endoscopists, and responses were analyzed using descriptive statistics. State-specific requirements for fluoroscopy utilization were determined from state radiologic health branches. A total of 159 endoscopists (response rate 67.8%) predominantly those working in university hospitals (69.2%) with > 5years of experience performing ERCP (74.9%) completed the questionnaire. Although the majority of endoscopists (61.6%) reported that they personally controlled fluoroscopy during ERCP, most (56.6%) had not received training on operating their fluoroscopy system. Only a minority (18-31%) of all respondents reported consistently utilizing modifiable fluoroscopy system parameters that minimize patient radiation exposure (pulsed fluoroscopy, frame rate modification or collimation). Endoscopists appear to undertake adequate personal radiation protective measures although use of a dosimeter was not consistent in half of respondents. The majority of states (56.8%) do not have any stated requirement for certification of non-radiologist physicians who intend to operate fluoroscopy. Most US gastroenterologists performing ERCP have not received formal training in operating their fluoroscopy system or in minimizing radiation exposure to themselves and to their patients. Such formal training should be included in all therapeutic endoscopy training programs, and fluoroscopy system-specific training should be offered at all hospitals.

PTH-010 Uk training in therapeutic endoscopy – are we achieving the basics? results of the bsg national training survey

Introduction Colonoscopic polypectomy and endoscopic treatment of acute upper gastrointestinal bleeding (AUGIB) are key skills for the majority of consultant gastroenterologists. Competence in polypectomy is assessed by direct observation of polypectomy skills (DOPyS) with 4 competent level 2 (>1 cm) polypectomies required for full colonoscopy certification. Measures for defining competence in endoscopic treatment of AUGIB are in development. There is evidence of slow rates of progression to achieve basic endoscopic skills amongst gastroenterology trainees due to other service and training pressures. 1 Method The BSG national training survey was open to all UK gastroenterology trainees from June–August 2014. Data on exposure to polypectomy and endoscopic treatment of AUGIB was analysed as well as trainees desire to train in advanced endoscopic techniques. Results 32.6% (263/806) of UK trainees completed the survey. 68% of ST6 (year 4) trainees and 38% of final year trainees have performed senior trainees ) wish to formally train in endoscopic mucosal resection (EMR), with corresponding figures of 40% for ERCP, 29% for EUS, and 33% for enteroscopy. 28% of senior trainees report having the opportunity to perform endoscopy in a patient with AUGIB either monthly or less often (less than once per month/never). >95% of senior trainees feel they will be competent to perform variceal and non-variceal AUGIB endoscopic treatment as a newly qualified consultant. 91% feel they will be competent to place a Sengstaken-Blakemore tube if required. Conclusion Exposure to level 2 polypectomy amongst senior gastroenterology trainees is limited, which may explain slow rates of progression to full colonoscopy certification. 1 Over a quarter of senior trainees have limited opportunity to perform endoscopy in cases of AUGIB. Virtually all trainees feel they will be competent in the endoscopic management of AUGIB as a new consultant, but the documented lack of exposure for some trainees suggests this may not be the case. Despite slow progression to basic endoscopy competencies, large numbers of trainees wish to train in advanced endoscopic techniques. These results suggest the need for focused training lists to develop key therapeutic endoscopic skills such as removal of level 2 polyps, and systems to guarantee dedicated supervised exposure to AUGIB cases. Disclosure of interest None Declared. Reference Neale JR, Basford PJ. General medical training in gastroenterology: views from specialist trainees on the challenges of dual accreditation. Clin Med. 2015;15(1):35–9

Gastroenterology fellowship programs: the fellows' perspective.

Gastroenterology fellowship programs: the fellows' perspective.

Challenges in Meeting Fellowship Procedural Guidelines in Pediatric Therapeutic Endoscopy and Liver Biopsy

The aims of this study were to assess the opportunities for therapeutic endoscopy, liver biopsies, and percutaneous endoscopic gastrostomy (PEG) placements available to fellows during a 3-year pediatric gastroenterology fellowship, and to evaluate access to ancillary procedural-training opportunities. Data were collected from 12 pediatric gastroenterology fellowship programs in the United States. Procedures completed in the years 2009-2011 were queried using CPT codes and endoscopy databases. The maximal opportunity for procedures was based on the total procedures performed by the institution in 3 years divided by the total number of fellows in the program. The centers completed a questionnaire regarding ancillary opportunities for endoscopic training. There is significant variability in pediatric endoscopic training opportunities in specialized gastrointestinal (GI) procedures. Under the 1999 guidelines, no centers were able to meet the thresholds for polypectomy and control of nonvariceal bleeding. The 2013 guidelines allowed the number of programs reaching polypectomy thresholds to increase by 67% but made no difference for control of bleeding despite a decrease in the threshold. Training in PEG placement was not available in 42% of the surveyed centers. Elective ancillary procedural training is offered by 92% of the surveyed centers. Most training programs do not have the volume of therapeutic endoscopy procedures for all of the fellows to meet the training guidelines. Training in therapeutic endoscopy, PEG placement, and liver biopsy in pediatric GI fellowships should be supplemented using all of the possible options including rotations with adult GI providers and hands-on endoscopy courses. A shift toward evaluating competency via quality measures may be more appropriate.

Magnetic imaging-assisted colonoscopyvsconventional colonoscopy: A randomized controlled trial

To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC). Magnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as "usual" or "difficult" by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications. Two hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist. Although the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.

PTU-042 Endoscocopic Training in upper Gastrointestinal Bleeding (Ugib): a BSG Regional and National Audit

IntroductionUGIB is a common emergency frequently requiring endoscopic intervention. Training in therapeutic endoscopy for UGIB is not mandatory. Furthermore UGIB endoscopic experience may be diminished by the European Working Time...

Creation of a therapeutic digestive endoscopy suite in Senegal: renovation, training and university certification. Results of a Belgian–Senegalese inter-university project

Therapeutic digestive endoscopy did not exist in sub-Saharan Africa before 2005. However, the prevalence of digestive diseases that could potentially benefit from basic endoscopic treatment is very high in this region. Portal hypertension with variceal bleeding and severe dysphagia associated with benign or malignant upper gastrointestinal tract diseases are prominent in these countries. The aim of the Project described in this report was to create a digestive endoscopy facility in Dakar (Senegal, West Africa), that would also provide local training in therapeutic endoscopy to doctors and nurses and facilitate regional autonomy with the opening of a University Certification in Gastroenterology. It took about 10 years to achieve these targets - 5 years to prepare realistic aims that took into account local needs, available local resources, and funding, and 4 years for the Project itself (2005-2009). At the present time, Senegalese colleagues and nurses are autonomous for basic therapeutic procedures in the upper and lower gastrointestinal tract. Two years after the end of funding, the rate of therapeutic activity has increased from 0% in 2005 to 12 % of digestive endoscopic activity in 2011. Key points of success were preparation, confidence of medical personnel, university involvement, shared funding, local multidisciplinary training, and facilitation of autonomy. Belgian healthcare workers were present on-site in Dakar for a total of about 6 months over the 4-year Project period, with an annual budget of less than € 80000. The Project has enabled an efficient North-South collaboration with a minimal budget, which has changed the healthcare provision of digestive endoscopy in Senegal, and has also provided autonomy, and facilitated the development of South-South cooperation.

Prevention of gastrointestinal cancer by surveillance endoscopy.

The classification of the endoscopic appearance of superficial neoplastic lesions of the digestive mucosa aims to evaluate the risk of progression to advanced neoplasia in 3° (low, intermediate, high) and to predict appropriate treatment and corresponding surveillance. The privileged position of endoscopy results from its double impact on prevention of digestive cancer through reduction in incidence after early detection and eradication of precursors; and through reduction of mortality after detection and treatment of cancer at an early and curable stage. However the efficacy of diagnostic endoscopy still requires improvement and quality control on the following points: (1) technology, with a generalized use of the recently introduced high-resolution endoscopes. (2) diagnosis of poorly visible nonpolypoid precursors: this applies to small depressed lesions and large slightly elevated or sessile serrated and non-serrated precursors, particularly in the proximal colon. (3) treatment and training in therapeutic endoscopy, including the most recent techniques of mucosal resection of nonpolypoid lesions.

314p: Endoscopic Ultrasound in Children: Applications and Pitfalls. the UC Davis Experience

There is very limited data on the indications, applications and risks of performing endoscopic ultrasound (EUS) in children. Major limiting factor has been lack of clear indications and difficulty in obtaining adequate training. EUS has a role both as a diagnostic tool and also guiding therapeutic interventions. In this role EUS can have the most impact. One provider (AQ) completed a dedicated adult therapeutic endoscopy training program at a high volume EUS center. Between 2005 and 2008 we performed 175 EUS examinations in children.

Mid-Point Results of a Randomized Blinded Controlled Study of Hands-On Therapeutic Endoscopy Training

Mid-Point Results of a Randomized Blinded Controlled Study of Hands-On Therapeutic Endoscopy Training