Features that may predict hospital admission following outpatient therapeutic ERCP

BACKGROUND

Some patients are admitted following outpatient therapeutic ERCP because of adverse events. This study aimed to identify factors that may predict such admissions.

METHODS

We prospectively studied admissions for post-ERCP adverse events in 415 consecutive patients undergoing outpatient therapeutic ERCP. Potentially relevant predictors of admission were assessed by univariate analysis and in case of significance included in a multivariate analysis.

RESULTS

Admission was necessary in 41 patients (9.9%) because of complications and in 63 (15.2%) for observation of adverse events that did not progress to definable complications. Potential predictors of admission were evaluated comparing patients who required more than an overnight admission (n = 63) with those who did not (n = 352). Multivariate analysis identified three factors that were significant: pain during the procedure (odds ratio 3.8: 95% CI [1.8, 7.9]), history of pancreatitis (odds ratio 2.3: 95% CI [1.1, 4.7]) and performance of sphincterotomy (odds ratio 2.2: 95% CI [1.1, 4.3]). The presence of all these features was associated with a 66.7% likelihood of admission, whereas the absence of pain during the procedure, history of pancreatitis and performance of sphincterotomy made admission likely in only 11.0%, 9.8% and 10.7%, respectively, of the cases.

CONCLUSIONS

The occurrence of pain during the procedure, a history of pancreatitis and the performance of sphincterotomy were independent predictors of admission following outpatient therapeutic ERCP.

Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial

BACKGROUND

Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain.

METHODS

Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1-4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat.

RESULTS

Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11-34) versus 18 (10-28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups.

CONCLUSION

Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).

A comparison of antibodies to tissue transglutaminase with conventional serological tests in the diagnosis of coeliac disease

BACKGROUND

Tissue transglutaminase is now recognized as the autoantigen for antiendomysial antibodies. Antibodies to tissue transglutaminase have been proposed as a valuable test for coeliac disease.

OBJECTIVE

To determine the value of antibodies to tissue transglutaminase in the diagnosis of coeliac disease in our outpatient population.

METHODS

Patients who underwent serological tests for coeliac disease during the first 18 months of the tissue transglutaminase antibody assay were retrospectively identified from the regional serology laboratory database. Patients' symptoms were noted, along with serological results and duodenal histology in those patients who underwent duodenal biopsy. RESULTS In total, 586 patients were identified as having been serologically tested for coeliac disease, of whom 92 patients (33 men; mean age 51.7 years) had been followed up with duodenal biopsies. Of these 92 patients, 29 (31%; 14 men; mean age 52.5 years) had histological features of coeliac disease. The 63 patients with normal histology (19 men; mean age 51.8 years) acted as controls. Weight loss was more frequent in coeliac disease patients compared to controls (7 vs 5; P = 0.04) whereas the frequency of anaemia (P = 0.85) and diarrhoea (P = 0.74) did not differ significantly between the two groups. The sensitivity and specificity of tissue transglutaminase antibodies (86%; 84%) were compared to those for antiendomysial antibodies (90%; 98%) and antigliadin antibodies (76%; 79%).

CONCLUSIONS

The diagnostic value of tissue transglutaminase antibodies was intermediate between that of antiendomysial antibodies and antigliadin antibodies. However, duodenal biopsy remains the gold standard diagnostic test for coeliac disease.

Effect of Helicobacter pylori eradication on antral somatostatin cell density in humans

OBJECTIVE

As Helicobacter pylori infection is associated with an elevation in plasma gastrin with normal antral gastrin cell counts, an abnormality in antral somatostatin cells may be associated with the infection. We evaluated the effect of eradication of H. pylori on antral somatostatin cell density in the light of antral gastrin cell density and plasma gastrin levels.

DESIGN

Prospective study.

METHODS

Of 25 dyspeptic patients with H. pylori infection, nine had H. pylori successfully eradicated and the rest remained infected. Antral biopsies were immunostained for somatostatin cells and plasma gastrin measured before and 4 weeks after H. pylori eradication therapy. Ten other dyspeptic patients without H. pylori infection had their somatostatin cell density evaluated as controls.

RESULTS

Somatostatin cell density in the patients without H. pylori infection at the outset was significantly higher than that in the patients with H. pylori infection at the outset (median 57 [18-83] vs. 37 [6-80] cells/mm) respectively (P <0.05). Somatostatin cell density increased after H. pylori eradication (before treatment, median 50 [15-72]; after treatment 71 [39-107] cells/mm) (P < 0.05) but was unchanged with persistent H. pylori infection. Plasma gastrin decreased after H. pylori eradication (before treatment, median 70 [45-100]; after treatment 30 [10-100] ng/l) (P < 0.05) but was unchanged with persistent H. pylori infection.

CONCLUSIONS

Following eradication of H. pylori, there is an increase in somatostatin cell density with a fall in plasma gastrin. This supports the theory that H. pylori infection results in a decrease in somatostatin cell density and, as the latter is an inhibitor of gastrin cells, this results in an increased plasma gastrin.

Assessment, endoscopy, and treatment in patients with acute severe ulcerative colitis during the COVID-19 pandemic (PROTECT-ASUC): a multicentre, observational, case-control study

BACKGROUND

There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes.

METHODS

The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov, NCT04411784.

FINDINGS

We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes.

INTERPRETATION

The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes.

FUNDING

None.

Percutaneous endoscopic gastrostomy sites infected by methicillin-resistant Staphylococcus aureus: impact on outcome

BACKGROUND

The impact of methicillin-resistant Staphylococcus aureus (MRSA) colonization of percutaneous endoscopic gastrostomy (PEG) sites on morbidity and mortality is uncertain.

AIM

We investigated the impact of known prior MRSA colonization on the incidence of symptomatic PEG site wound infection and mortality.

METHODS

Consecutive patients who had PEG tubes inserted recently at our hospital were identified. The presence or absence of MRSA colonization before PEG placement was noted. Patients were observed for wound infection, and swabs were taken from the site if there was clinical infection. Mortality within 30 days of PEG placement was determined.

RESULTS

A total of 83 patients underwent PEG placement; 23 (28%) of these patients had known MRSA colonization before PEG placement. Of these, 13 (57%) developed symptomatic MRSA infection of the PEG site. The remaining 60 patients (72%) had no known prior MRSA colonization. In these patients, 9 (15%) developed symptomatic MRSA infection of the PEG site. The overall incidence of wound infection was 37% (31) of the total undergoing PEG placement, of whom 71% (22) had developed MRSA infection. The mortality of those with symptomatic MRSA infection of the PEG site was 9% (2/22), whereas the mortality from non-MRSA-infected PEGs was 20% (12/61).

CONCLUSION

Patients with prior MRSA colonization had a significantly higher risk of developing symptomatic MRSA infection of the PEG site. However, there was still a significant risk (15%) of developing MRSA infection of the PEG site for patients with no known prior MRSA infection. MRSA infection of the PEG site did not affect mortality.

Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Endoscopic mucosal resection (EMR) is the standard of care for the complete removal of large (≥ 10 mm) nonpedunculated colorectal polyps (LNPCPs). Increased detection of LNPCPs owing to screening colonoscopy, plus high observed rates of incomplete resection and need for surgery call for a standardized approach to training in EMR. 1 : Trainees in EMR should have achieved basic competence in diagnostic colonoscopy, < 10-mm polypectomy, pedunculated polypectomy, and common methods of gastrointestinal endoscopic hemostasis. The role of formal training courses is emphasized. Training may then commence in vivo under the direct supervision of a trainer. 2 : Endoscopy units training endoscopists in EMR should have specific processes in place to support and facilitate training. 3: A trained EMR practitioner should have mastered theoretical knowledge including how to assess an LNPCP for risk of submucosal invasion, how to interpret the potential difficulty of a particular EMR procedure, how to decide whether to remove a particular LNPCP en bloc or piecemeal, whether the risks of electrosurgical energy can be avoided for a particular LNPCP, the different devices required for EMR, management of adverse events, and interpretation of reports provided by histopathologists. 4: Trained EMR practitioners should be familiar with the patient consent process for EMR. 5: The development of endoscopic non-technical skills (ENTS) and team interaction are important for trainees in EMR. 6: Differences in recommended technique exist between EMR performed with and without electrosurgical energy. Common to both is a standardized technique based upon dynamic injection, controlled and precise snare placement, safety checks prior to the application of tissue transection (cold snare) or electrosurgical energy (hot snare), and interpretation of the post-EMR resection defect. 7: A trained EMR practitioner must be able to manage adverse events associated with EMR including intraprocedural bleeding and perforation, and post-procedural bleeding. Delayed perforation should be avoided by correct interpretation of the post-EMR defect and treatment of deep mural injury. 8: A trained EMR practitioner must be able to communicate EMR procedural findings to patients and provide them with a plan in case of adverse events after discharge and a follow-up plan. 9: A trained EMR practitioner must be able to detect and interrogate a post-endoscopic resection scar for residual or recurrent adenoma and apply treatment if necessary. 10: Prior to independent practice, a minimum of 30 EMR procedures should be performed, culminating in a trainer-guided assessment of competency using a validated assessment tool, taking account of procedural difficulty (e. g. using the SMSA polyp score). 11: Trained practitioners should log their key performance indicators (KPIs) of polypectomy during independent practice. A guide for target KPIs is provided in this document.

Stress and its causes in UK gastroenterologists: results of a national survey by the British Society of Gastroenterology

AIM

Evaluation of stress and its causes in UK gastroenterologists.

DESIGN

Questionnaire emailed to all 1932 medical members of the British Society of Gastroenterology.

RESULTS

Of 567 respondents (29%), 107 (20%) graded their stress level as 4 or 5 out of 5. Stress levels correlated inversely with self-reported happiness levels (r=-0.60; p<0.001) and with hours slept per night (r=-0.23; p<0.01) and correlated directly with % time off-duty thinking about work (r=0.46; p<0001) and with proportion of nights with broken sleep (r=0.30; p<0.01). Due to stress over the past year, 21% of respondents reported one of the following: consulting their general practitioner (7%), attending occupational health (5%), taking planned time off (7%), taking anxiolytics/antidepressants (6%) and considering suicide (5.5%). These respondents had higher stress and lower happiness levels than the remainder. Stress levels were higher in women and in those working full time but had no other demographic associations.The main causes of stress were excessive clinical work (ranked highest by 47% and most commonly patient-related administration), working conditions beyond control (ranked highest by 15% and most commonly inadequate information technology systems, workspace and secretarial staff) and conflict (ranked highest by 9%). Of eight potential factors, happiness with work showed the closest associations with overall happiness (positive) and overall stress (negative) levels. Talking to someone at work about stress was ranked difficult or impossible by 35%. The highest ranked suggested solutions were relief from some duties and mentoring.

CONCLUSIONS

Stress is common and has objective correlates in UK gastroenterologists. The main cause is excessive workload.

Evaluation of feedback given to trainees in medical specialties

The aim of this study was to evaluate the quality of feedback provided to specialty trainees (ST3 or higher) in medical specialties during their workplace-based assessments (WBAs). The feedback given in WBAs was examined in detail in a group of 50 ST3 or higher trainees randomly selected from those taking part in a pilot study of changes to the WBA system conducted by the Joint Royal Colleges of Physicians Training Board. They were based in Health Education Northeast (Northern Deanery) and Health Education East of England (Eastern Deanery). Thematic analysis was used to identify commonly occurring themes. Feedback was mainly positive but there were differences in quality between specialties. Problems with feedback included insufficient detail, such that it was not possible to map the progression of the trainee, insufficient action plans made and the timing of feedback not being contemporaneous (feedback not being given at the time of assessment). Recommendations included feedback should be more specific; there need to be more options in the feedback forms for the supervisor to compare the trainee's performance to what is expected and action plans need to be made.

Diagnosis of common bile duct stones by intravenous cholangiography: prediction by ultrasound and liver function tests compared with endoscopic retrograde cholangiography

BACKGROUND

Routine intravenous cholangiography using the safer contrast medium, meglumine iotroxate, may be a useful investigation prior to laparoscopic cholecystectomy for the detection of suspected common bile duct stones. We compared this with endoscopic cholangiography.

METHODS

Eighty-one consecutive nonjaundiced patients (mean age 62 years; range 20 to 90) with suspected common bile duct stones referred for endoscopic cholangiography to one center underwent intravenous cholangiography that was considered positive if it detected ductal stones. The ability of ultrasound scans and liver function tests to predict ductal stones was also assessed.

RESULTS

Sixty patients had both endoscopic and intravenous cholangiograms performed. Thirteen out of 27 patients with ductal stones confirmed by endoscopic cholangiography had positive intravenous cholangiograms, and 29 out of 30 with no stones had negative intravenous cholangiograms. The sensitivity for intravenous cholangiography was 48%, specificity 97%, positive predictive value 93%, negative predictive value 67%, and accuracy 73%. For ultrasound scans the positive predictive value was 69%; negative predictive value was 78%. For liver function tests the positive predictive value was 68%; negative predictive value was 93%.

CONCLUSIONS

Intravenous cholangiography cannot be recommended instead of endoscopic cholangiography except in situations where the latter is not readily available. Ultrasound and liver function tests are useful in predicting ductal stones.

Are accelerated infliximab infusions safe in patients with inflammatory bowel disease?

BACKGROUND

Infliximab is a monoclonal antibody used in the treatment of inflammatory bowel disease (IBD). The manufacturer-recommended administration is over 2 hours followed by 2 hours of patient observation. The data relating to adverse outcomes in patients receiving accelerated infusions for IBD are limited.

METHODS

Our unit utilizes an accelerated protocol for infliximab infusion in selected patients with IBD (those with no adverse reaction in their first four standard infusions). Our aim was to assess if the accelerated infusion protocol (infusion over 1 hour or 30 minutes with 1 hour or no monitoring according to protocol) was associated with any increase in adverse outcomes. Data were collected retrospectively on protocol used and adverse outcomes for all infliximab infusions between October 2005 and June 2008.

RESULTS

Out of 69 patients, 27 received the accelerated protocol (130 infusions). All patients received a total of 306 infusions on the standard protocol. No adverse reactions were reported in the accelerated protocol patients. In patients on the standard protocol, 16 adverse reactions were observed: seven were acute (occurring during infusion); nine were delayed (occurring within 1-7 days following infusion). No patient required intramuscular adrenaline or hospitalization.

CONCLUSIONS

Our findings suggest that an accelerated protocol for infliximab infusion is well tolerated in selected patients. The monitoring period following infusion may not be necessary, as all acute reactions occurred within an hour of initiating infusion and did not warrant hospitalization. The accelerated infusion may allow more efficient utilization of hospital resources and reduce patient inconvenience.

Long-term follow-up of patients with iron deficiency anaemia after a negative gastrointestinal evaluation

OBJECTIVES

Our aim was to determine whether patients who have had a negative gastrointestinal evaluation (i.e. oesophagogastroduodenoscopy and a colonic examination) for iron deficiency anaemia are subsequently found to have recurrent anaemia or significant pathology.

METHODS

From a prospectively entered endoscopy database, we identified a cohort of patients who had negative upper and lower gastrointestinal (GI) investigations for iron deficiency anaemia. We carried out a retrospective chart review of these patients to determine their outcome after a GI evaluation. In particular, we wished to determine the proportion of patients who had recurrent anaemia, became transfusion dependent or were found to have significant pathology.

RESULTS

Sixty-nine patients, with an average age of 65.8 years (range 29-87), were followed up for a median of 5 years and 10 months (range 7-109). In 57 patients (83%), the anaemia resolved after the initial treatment period. Fifteen patients (22%) died during the follow-up period, two from a GI cancer and 13 from non-GI-related causes. Six patients (9%) developed persistent anaemia severe enough to require recurrent blood or iron transfusions. Seventeen patients (25%) had a transient recurrent anaemia and four (6%) were diagnosed with GI malignancies during the follow-up.

CONCLUSION

For the majority of patients with the iron deficiency anaemia and a negative GI evaluation the outcome is favourable, although a proportion (6%) may subsequently be found to have significant GI pathology. We believe that this number could be minimized by the use of colonoscopy rather than barium enema. In addition, small bowel investigations should not be limited to those who are transfusion dependent, as is currently recommended.

Differences in the diagnostic yield of upper gastrointestinal endoscopy in dyspeptic patients receiving proton-pump inhibitors and H2-receptor antagonists

BACKGROUND AND STUDY AIMS

Patients attending for diagnostic oesophagogastroduodenoscopy (OGD) for dyspeptic symptoms are often receiving acid-suppression therapy that has not been discontinued prior to endoscopy, and this may reduce the diagnostic yield of endoscopy. The aim of this study was to compare the diagnostic yield of OGD in uncomplicated dyspepsia in patients receiving no medication, those receiving acid-suppression therapy, and those receiving nonsteroidal anti-inflammatory drugs (NSAIDs) at the time of endoscopy.

PATIENTS AND METHODS

A total of 6825 diagnostic OGDs performed in our unit between 1993 and 2001 were analysed. Patients were excluded if they had sinister symptoms, were receiving NSAIDs, or were undergoing repeat or surveillance endoscopy.

RESULTS

A total of 4233 OGDs (62 %) fulfilled the criteria for uncomplicated dyspepsia. Of the patients examined in these procedures, 1367 (32 %) were receiving acid-suppression therapy. A total of 724 patients (53 % of those on therapy) were receiving proton-pump inhibitors (PPIs), 393 of whom (54 %) had positive endoscopic findings (oesophagitis 31 %, gastritis 16 %, duodenal ulcer/duodenitis 16 %). A total of 643 (47 % of the patients on therapy) were receiving H 2 -receptor antagonists, 443 of whom (69 % of this group) had positive endoscopic findings (oesophagitis 30 %, gastritis 21 %, duodenal ulcer/duodenitis 31 %). A total of 2866 patients were not receiving acid-suppression therapy, 1805 of whom (63 %) had endoscopic findings (oesophagitis 37 %, gastritis 14 %, duodenal ulcer/duodenitis 24 %). The endoscopic yield was significantly lowest in the PPI group, except for the diagnosis of oesophagitis. Overall, 17 carcinomas were detected in patients referred with simple dyspepsia, and in five of these cases the patients were receiving acid suppression.

CONCLUSIONS

The widespread use of acid suppression in the treatment of simple dyspepsia prior to endoscopy leads to a reduction in the endoscopic recognition of mucosal lesions caused by acid-peptic disease, but not to a high healing rate for these lesions, and it may mask malignancy.

Artificial intelligence and inflammatory bowel disease: practicalities and future prospects

Artificial intelligence (AI) is an emerging technology predicted to have significant applications in healthcare. This review highlights AI applications that impact the patient journey in inflammatory bowel disease (IBD), from genomics to endoscopic applications in disease classification, stratification and self-monitoring to risk stratification for personalised management. We discuss the practical AI applications currently in use while giving a balanced view of concerns and pitfalls and look to the future with the potential of where AI can provide significant value to the care of the patient with IBD.

Curriculum for diagnostic endoscopic ultrasound training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in diagnostic endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in diagnostic EUS. This curriculum is set out in terms of the prerequisites prior to training; the recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1:  Trainees should have achieved competence in upper gastrointestinal endoscopy before training in diagnostic EUS. 2:  The development of diagnostic EUS skills by methods that do not involve patients is advisable, but not mandatory, prior to commencing formal training in diagnostic EUS. 3:  A trainee's principal trainer should be performing adequate volumes of diagnostic EUSs to demonstrate maintenance of their own competence. 4:  Training centers for diagnostic EUS should offer expertise, as well as a high volume of procedures per year, to ensure an optimal level of quality for training. Under these conditions, training centers should be able to provide trainees with a sufficient wealth of experience in diagnostic EUS for at least 12 months. 5:  Trainees should engage in formal training and supplement this with a range of learning resources for diagnostic EUS, including EUS-guided fine-needle aspiration and biopsy (FNA/FNB). 6:  EUS training should follow a structured syllabus to guide the learning program. 7:  A minimum procedure volume should be offered to trainees during diagnostic EUS training to ensure that they have the opportunity to achieve competence in the technique. To evaluate competence in diagnostic EUS, trainees should have completed a minimum of 250 supervised EUS procedures: 80 for luminal tumors, 20 for subepithelial lesions, and 150 for pancreaticobiliary lesions. At least 75 EUS-FNA/FNBs should be performed, including mostly pancreaticobiliary lesions. 8:  Competence assessment in diagnostic EUS should take into consideration not only technical skills, but also cognitive and integrative skills. A reliable valid assessment tool should be used regularly during diagnostic EUS training to track the acquisition of competence and to support trainee feedback. 9:  A period of supervised practice should follow the start of independent activity. Supervision can be delivered either on site if other colleagues are already practicing EUS or by maintaining contacts with the training center and/or other EUS experts. 10:  Key performance measures including the annual number of procedures, frequency of obtaining a diagnostic sample during EUS-FNA/FNB, and adverse events should be recorded within an electronic documentation system and evaluated.