Core curriculum for EUS

Gastrointestinal endoscopy training in the United States: Program structure and competence assessment

The general principles of gastrointestinal endoscopy training in the United States were formulated and summarized more than a decade ago and the principles have been consistent until now. To summarize, trainees should be prepared to (i) appropriately recommend endoscopic procedures as indicated by the findings of the consultative evaluation, with an explicit understanding of accepted specific indications, contraindications, and diagnostic/therapeutic alternatives, (ii) perform procedures safely, completely, and expeditiously, including possessing a thorough understanding of the principles of conscious sedation/analgesia techniques, the use of anesthesia-assisted sedation where appropriate, and pre-procedure clinical assessment and patient monitoring, (iii) correctly interpret endoscopic findings and integrate them into medical or endoscopic therapy, (iv) identify risk factors for each procedure, understand how to minimize each, and recognize and appropriately manage complications when they occur, (v) acknowledge the limitations of endoscopic procedures and personal skills and know when to request help, and (vi) understand the principles of quality measurement and improvement. This article provides an overview of the endoscopy training system and structure, evaluation scheme, and competence and credentialing process in the United States.

Development of American Society for Gastrointestinal Endoscopy standards for training in advanced endoscopy within dedicated advanced endoscopy fellowship programs

BACKGROUND AND AIMS

Training in interventional endoscopy is offered by nonaccredited advanced endoscopy fellowship programs (AEFPs). The number of these programs has increased dramatically with a concurrent increase in the breadth and complexity of interventional endoscopy procedures. Accreditation is governed by competency-based education, yet what constitutes a "high-quality" nonaccredited AEFP has not been defined. Using an evidence-based consensus process, we aimed to establish standards for AEFPs.

METHODS

The RAND UCLA appropriateness method, a well-described modified Delphi process to develop quality indicators, was used. A task force established by the American Society for Gastrointestinal Endoscopy drafted potential quality indicators (structure, process, and outcome) in 6 categories: activity preceding training; structure of AEFPs; training in ERCP, EUS, and EMR; and luminal stent placement. Three rounds of iterative feedback from 20 experts were conducted. Round 0 involved discussion of project details. In round 1, experts independently ranked proposed quality indicators on a 9-point interval scale ranging from highly inappropriate (1) to highly appropriate (9). Next, proposed quality indicators were discussed and reworded in a group meeting followed by round 2, in which experts independently reranked proposed quality indicators and provided benchmarks (when applicable). The median score for each quality indicator was calculated. Mean absolute deviation from the median was calculated, and appropriateness of potential quality indicators was assessed using the BIOMED concerted action on appropriateness definition, P value method, and interpercentile range adjusted for symmetry definition. A quality indicator was deemed appropriate if the median score was ≥7 and met criteria for appropriateness using all 3 defined statistical methods.

RESULTS

Of 89 proposed quality indicators, 37 statements met criteria as appropriate for a quality indicator (activity preceding training, 2; structure of AEFPs, 10; training in ERCP, 7; training in EUS, 8; training in EMR, 7; luminal stent placement, 3). Minimum thresholds were defined for 19 relevant quality indicators for number of trainers, procedures during fellowship, and procedures before assessment of competence. Among the final appropriate quality indicators were that all trainees should undergo qualitative and quantitative competence assessments using validated tools at least quarterly with documented feedback throughout the training period and that trainees should track outcomes and relevant quality metrics for specific procedures.

CONCLUSIONS

This consensus process using validated methodology established standards for an AEFP in an effort to ensure adequate training in the most commonly taught interventional endoscopic procedures (ERCP, EUS, EMR, and luminal stent placement) during fellowship. An important component of an AEFP is the use of competency-based assessments that are compliant with the Accreditation Council for Graduate Medical Education's Next Accreditation System, with the goal of ensuring that trainees achieve specific milestones in their progression to achieving cognitive and technical competency.

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.

A deep learning-based system for mediastinum station localization in linear EUS (with video)

Background and Objectives

EUS is a crucial diagnostic and therapeutic method for many anatomical regions, especially in the evaluation of mediastinal diseases and related pathologies. Rapidly finding the standard stations is the key to achieving efficient and complete mediastinal EUS imaging. However, it requires substantial technical skills and extensive knowledge of mediastinal anatomy. We constructed a system, named EUS-MPS (EUS-mediastinal position system), for real-time mediastinal EUS station recognition.

Methods

The standard scanning of mediastinum EUS was divided into 7 stations. There were 33 010 images in mediastinum EUS examination collected to construct a station classification model. Then, we used 151 videos clips for video validation and used 1212 EUS images from 2 other hospitals for external validation. An independent data set containing 230 EUS images was applied for the man-machine contest. We conducted a crossover study to evaluate the effectiveness of this system in reducing the difficulty of mediastinal ultrasound image interpretation.

Results

For station classification, the model achieved an accuracy of 90.49% in image validation and 83.80% in video validation. At external validation, the models achieved 89.85% accuracy. In the man-machine contest, the model achieved an accuracy of 84.78%, which was comparable to that of expert (83.91%). The accuracy of the trainees' station recognition was significantly improved in the crossover study, with an increase of 13.26% (95% confidence interval, 11.04%-15.48%; P < 0.05).

Conclusions

This deep learning-based system shows great performance in mediastinum station localization, having the potential to play an important role in shortening the learning curve and establishing standard mediastinal scanning in the future.

Quality of reporting in endoscopic ultrasound: Results of an international multicenter survey (the QUOREUS study)

Background and study aims  The endoscopic report has a key role in quality improvement for gastrointestinal endoscopy. High quality standards have been set by the endoscopic societies in this field. Unlike other digestive endoscopy procedures, the quality of reporting in endoscopic ultrasound (EUS) has not been thoroughly evaluated and a reference standard is lacking. Methods  We performed an international online survey concerning the attitudes of endosonographers towards EUS reports in order to understand the needs for standardization and quality improvement. Endosonographers from different countries and institutional setting, with varying case volume and experience were invited to take part to complete a structured questionnaire. Results  We collected replies from 171 endosonographers. Overall analysis of results according to case volume, experience and working environment of respondents (academic, public hospital, private) are provided. In brief, everyone agreed on the need for standardization of EUS reporting. The use of minimal standard terminology and a structured tree with mandatory items was considered of primary importance. Image documentation was also deemed fundamental in complementing EUS reports both for patient documentation and research purposes. A strong demand for connection and consultation among endosonographers for clinical and training needs was also found. In this respect, a formal expert consultation network was advocated in order to improve the quality of reporting in EUS. Conclusions  Our survey showed a strong agreement among endosonographers who expressed the need for a standardization in order to improve the report and, as a consequence, the quality of EUS.

Per-oral endoscopic myotomy (POEM) training and skills evaluation tool: a pilot study

Background and study aims  Hands-on training for per-oral endoscopic myotomy (POEM) in the United States is limited and without a structured curriculum or assessment tool. Training to competency in POEM is critical and POEM trainees must acquire multiple cognitive and technical skills to achieve proficiency. The aim of this study was to develop a POEM training and skills evaluation tool. Patients and methods  The training protocol included initial explant porcine models followed by live human cases, proctored by a single endoscopist experienced in POEM who prospectively graded trainees for each step ("skill") of the procedure on a 5-point scale. Procedural skills were divided into cognitive and technical skills. Acceptable passing level was considered a score ≥ 4 for each skill. Results  Three trainees completed a total of 18 cases (8 cases on animal explant models and 10 human cases). Overall, cognitive skills were acquired early in training with scores of ≥ 4 achieved by ≤ 3 cases. Technical skills required more cases and direction with scores ≥ 4 in technical skills achieved by three porcine and eight human cases. Entry of the endoscope into the submucosal space and submucosal tunneling were the most challenging steps followed by myotomy. Conclusion  This pilot study introduces a POEM training and skills evaluation tool for training to competency. Submucosal entry, tunneling, and myotomy were the most challenging to learn while cognitive skills were learned early in training. Evaluation of more trainees at multiple sites will be necessary to further validate the utility of this tool.