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El Menabawey T, McCrudden R, Shetty D, Hopper AD, Huggett MT, Bekkali N, Carroll NR, Henry E, Johnson GJ, Keane MG, Love M, McKay CJ, Norton S, Oppong K, Penman I, Ramesh J, Ryan B, Siau K, Nayar M. UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS). Gut 2023; 73:118-130. [PMID: 37739777 PMCID: PMC10715553 DOI: 10.1136/gutjnl-2023-329800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/02/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS 39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.
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Affiliation(s)
- Tareq El Menabawey
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Gastroenterology, Homerton University Hospital, London, UK
| | - Raymond McCrudden
- Department of Gastroenterology, University Hospitals Dorset NHS Trust, Bournemouth, UK
| | - Dushyant Shetty
- Department of Radiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Andrew D Hopper
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Noor Bekkali
- Department of Gastroenterology and Hepatology, University of Oxford, Translational Gastroenterology Unit, Oxford, UK
| | - Nicholas R Carroll
- Radiology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Henry
- Department of Gastroenterology, NHS Tayside, Dundee, UK
| | - Gavin J Johnson
- Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK
| | - Margaret G Keane
- Gastroenterology and Hepatology, Johns Hopkins, Baltimore, Maryland, USA
| | - Mark Love
- Radiology, Belfast City Hospital, Belfast, UK
| | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Sally Norton
- Upper Gastrointestinal Surgery, Bristol Royal Infirmary, Bristol, UK
| | - Kofi Oppong
- HPB Unit & Department of Gastroenterology, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Ian Penman
- Centre for Liver & Digestive Disorders, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Jayapal Ramesh
- Department of Gastroenterology, Royal Liverpool Hospital NHS Trust, Liverpool, UK
| | - Barbara Ryan
- Department of Gastroenterology, Trinity College Dublin, Dublin, Ireland
| | - Keith Siau
- Gastroenterology, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Chiba M, Kato M, Kinoshita Y, Akasu T, Matsui H, Shimamoto N, Tomita Y, Abe T, Kanazawa K, Tsukinaga S, Nakano M, Torisu Y, Toyoizumi H, Suka M, Sumiyama K. Analysis of the variation in learning curves for achieving competency in convex EUS training: a prospective cohort study using a standardized assessment tool. Gastrointest Endosc 2023; 97:722-731.e7. [PMID: 36343675 DOI: 10.1016/j.gie.2022.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/29/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIMS The need for mastering standard imaging techniques for convex EUS in the biliopancreatic regions has been increasing; however, large variations in the aptitude for achieving EUS competency hinder expert development. Therefore, we investigated the factors influencing the achievement of expert competency in EUS using a new assessment tool for multiple imaging items. METHODS Between January 2018 and February 2022, 3277 consecutive EUS procedures conducted by 5 beginners (EUS procedures <250), 7 intermediate trainees (250-749), and 2 experts (≥750) were prospectively evaluated. Immediately after each EUS procedure, the success or failure of imaging for each item was recorded using a newly developed EUS assessment tool that requires 17 items to be photographed. After correcting for missing values using multiple imputation, learning curves of EUS scores were created, and a competency was set based on expert scores. Finally, a comparative analysis between high and low performers was performed to extract factors influencing EUS scores. RESULTS Although 3 of 7 intermediates (43%; mean, 317 cases) achieved competency, none of the beginners achieved competency. During a comparative analysis, although no significant difference in the number of EUS procedures performed was observed between the high and low performers, the former had significantly higher scores in the written test (theoretical knowledge). CONCLUSIONS Our results showed that theoretical knowledge, rather than the number of EUS cases, may be a possible influencing factor for distinguishing high and low performers after treating 250 cases. (Clinical trial registration number: UMIN 000043271.).
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Affiliation(s)
- Masafumi Chiba
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masayuki Kato
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuji Kinoshita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takafumi Akasu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroaki Matsui
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Nana Shimamoto
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Youichi Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Abe
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Keisuke Kanazawa
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Shintaro Tsukinaga
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Masanori Nakano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirobumi Toyoizumi
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Machi Suka
- Department of Public Health and Environmental Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
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Oh S, Kim YJ, Park YT, Kim KG. Automatic Pancreatic Cyst Lesion Segmentation on EUS Images Using a Deep-Learning Approach. SENSORS (BASEL, SWITZERLAND) 2021; 22:s22010245. [PMID: 35009788 PMCID: PMC8749636 DOI: 10.3390/s22010245] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 05/05/2023]
Abstract
The automatic segmentation of the pancreatic cyst lesion (PCL) is essential for the automated diagnosis of pancreatic cyst lesions on endoscopic ultrasonography (EUS) images. In this study, we proposed a deep-learning approach for PCL segmentation on EUS images. We employed the Attention U-Net model for automatic PCL segmentation. The Attention U-Net was compared with the Basic U-Net, Residual U-Net, and U-Net++ models. The Attention U-Net showed a better dice similarity coefficient (DSC) and intersection over union (IoU) scores than the other models on the internal test. Although the Basic U-Net showed a higher DSC and IoU scores on the external test than the Attention U-Net, there was no statistically significant difference. On the internal test of the cross-over study, the Attention U-Net showed the highest DSC and IoU scores. However, there was no significant difference between the Attention U-Net and Residual U-Net or between the Attention U-Net and U-Net++. On the external test of the cross-over study, all models showed no significant difference from each other. To the best of our knowledge, this is the first study implementing segmentation of PCL on EUS images using a deep-learning approach. Our experimental results show that a deep-learning approach can be applied successfully for PCL segmentation on EUS images.
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Affiliation(s)
- Seok Oh
- Gil Medical Center, Department of Biomedical Engineering, Gachon University College of Medicine, Incheon 21565, Korea; (S.O.); (Y.-J.K.)
| | - Young-Jae Kim
- Gil Medical Center, Department of Biomedical Engineering, Gachon University College of Medicine, Incheon 21565, Korea; (S.O.); (Y.-J.K.)
| | - Young-Taek Park
- HIRA Research Institute, Health Insurance Review & Assessment Service (HIRA), Wonju-si 26465, Korea;
| | - Kwang-Gi Kim
- Gil Medical Center, Department of Biomedical Engineering, Gachon University College of Medicine, Incheon 21565, Korea; (S.O.); (Y.-J.K.)
- Correspondence:
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Hedenström P, Marasco G, Eusebi LH, Lindkvist B, Sadik R. GAPS-EUS: a new and reliable tool for the assessment of basic skills and performance in EUS among endosonography trainees. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000660. [PMID: 34108134 PMCID: PMC8191616 DOI: 10.1136/bmjgast-2021-000660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/08/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Endosonography (EUS) is a useful but complex diagnostic modality which requires advanced endoscopy training and guidance by a supervisor. Since learning curves vary among individuals, assessment of the actual competence among EUS trainees is important. Design/methods We designed a novel assessment tool entitled Global Assessment of Performance and Skills in EUS (GAPS-EUS) for assessing skills among EUS trainees. Five quality indicators were marked on a five-grade scale by the supervisor (Observer Score) and by the trainee (Trainee Score). Trainees were included in two high-volume centres (Gothenburg, Sweden, and Bologna, Italy). Outcomes were feasibility, patient safety, reliability, and validity of GAPS-EUS in trainee-performed EUS procedures. Results Twenty-two EUS-trainees were assessed in a total of 157 EUS procedures with a completion rate of 157/157 (100 %) and a patient adverse event rate of 2/157 (1.3 %; gastroenteritis n=1, fever n=1). GAPS-EUS showed a high measurement reliability (Cronbach’s alpha coefficient=0.87) and a high inter-rater reliability comparing the supervisor and the trainee (r=0.83, r2=0.69, p<0.001). The construct of GAPS-EUS was verified by comparing low-level and high-level performance procedures and the content validity by recording that the EUS-FNA manoeuvre resulted in a lower score than other aspects of EUS 3.07 (95% CI 2.91 to 3.23) vs 3.51 (95% CI 3.37 to 3.65) (p<0.001). External validity was confirmed via similar findings in both centres. Conclusion GAPS-EUS is an easy-to-use and reliable tool with a recorded high validity for the assessment of competence among trainees in EUS. It can be recommended to centres involved in the education of future endosonographers. Trial registration number NCT02455570.
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Affiliation(s)
- Per Hedenström
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden .,Department of Internal Medicine, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Leonardo Henry Eusebi
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Bjorn Lindkvist
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Riadh Sadik
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden.,Department of Internal Medicine, Sahlgrenska University Hospital, Goteborg, Sweden
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DE Angelis CG, Rizza S, Rizzi F, Debernardi-Venon W, Caronna S, Gaia S, Bruno M. Training in advanced bilio-pancreatic endoscopy. Minerva Gastroenterol (Torino) 2021; 68:121-132. [PMID: 33793163 DOI: 10.23736/s2724-5985.21.02869-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As the clinical applications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) take more and more root in everyday practice and these endoscopic procedures become increasingly more complex and interventional with a higher chance for complications, the demand for expert bilio-pancreatic endoscopists continues to increase. In response to this growing need, specific postgraduate fellowships have been developed, however the standardization of training programs and the assessment of the achieved competence still remains an open debate. ERCP and EUS competency often requires training beyond the scope of a standard GI fellowship program, which lasts at least 1-2 years, and there are some differences in the way to face the issues of advanced bilio-pancreatic endoscopy training between Europe, America and the Asian regions. Today there is no role for the self-teaching of ERCP and EUS through trial and error without supervision and, in the near future, it is necessary to critically revise current training guidelines, to establish a standardized curriculum for advanced bilio-pancreatic endoscopists and to implement universally validated skill assessment tools, able to ensure constant and targeted feedback to trainees.
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Affiliation(s)
- Claudio G DE Angelis
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy -
| | - Stefano Rizza
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy.,Gastroenterology and Digestive Endoscopy Unit, FPO-IRCCS Candiolo Cancer Institute, Candiolo, Turin, Italy
| | - Felice Rizzi
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Wilma Debernardi-Venon
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Stefania Caronna
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Silvia Gaia
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Bruno
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
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The Role of Endoscopic Ultrasound for Esophageal Varices. Diagnostics (Basel) 2020; 10:diagnostics10121007. [PMID: 33255736 PMCID: PMC7760989 DOI: 10.3390/diagnostics10121007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/12/2020] [Accepted: 11/23/2020] [Indexed: 12/11/2022] Open
Abstract
Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care.
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