Colonoscopy learning curves for colorectal surgery fellow trainees: experiences with the 15-year colonoscopy training program

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

Outcome of Water Exchange and Air Insufflation Colonoscopy Performed by Supervised Trainee and Their Assessment of the Training Experience

GOALS

The hypotheses that supervised trainees would provide a more favorable assessment of the learning experience and could achieve superior results with water exchange (WE) compared with air insufflation were tested.

BACKGROUND

WE decreased pain, increased cecal intubation rate (CIR), and polyp detection rate (PDR).

STUDY

In a prospective pilot observational study, the trainees were taught WE in unsedated and WE and air insufflation in alternating order in sedated veterans. Trainee scores and procedural outcomes were tracked.

RESULTS

83 air insufflation and 119 WE cases were included. Trainee evaluations of the respective methods were scored based on a 5-point scale [1 (strongly agree) to 5 (strongly disagree, with lower scores being more favorable]. Evaluation scores [mean (SD)] were as follows: my colonoscopy experience was better than expected: WE 2.02 (1.00) versus air insufflation 2.43 (1.19), P =0.0087; I was confident with my technical skills using this method: WE 2.76 (0.91) versus air insufflation 2.85 (0.87), P =0.4822. Insertion time was 40 (21) min for WE and 30 (20) min for air insufflation ( P =0.0008). CIR were 95% (WE, unsedated); 99% (WE, overall), and 89% (air insufflation, overall). WE showed significantly higher CIR (99% vs. 89%, P =0.0031) and PDR (54% vs. 32%, P =0.0447).

CONCLUSIONS

The long air insufflation insertion time indicated the trainees were inexperienced. The significantly longer WE insertion time confirmed that learning WE required extra time. This pilot study revealed that supervised trainees reported more favorable learning experience with WE and equivalent confidence in technical skills scores. They completed both unsedated and sedated colonoscopy in over 89% of cases achieved significantly higher CIR and PDR with WE than air insufflation. It appeared that trainee education in WE might be an acceptable alternative to augment air insufflation to meet the challenges of training posed by traditional air insufflation colonoscopy.

JAG consensus statements for training and certification in colonoscopy

Introduction

In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.

Methods

Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.

Results

In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort <10% with moderate–severe discomfort); (2) minimum procedure count 280+; (3) performing 15+ procedures over the preceding 3 months; (4) attendance of the JAG Basic Skills in Colonoscopy course; (5) terminal ileal intubation rates of 60%+ in inflammatory bowel disease; (6) satisfying requirements for formative direct observation of procedure skills (DOPS) and direct observation of polypectomy skills (Size, Morphology, Site, Access (SMSA) level 2); (7) evidence of reflective practice as documented on the JAG Endoscopy Training System reflection tool; (8) successful performance in summative DOPS.

Conclusion

The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.

Continuous ADR50 monitoring through automated linkage between endoscopy and pathology: a quality improvement initiative in a Brussels public hospital

Background and study aim: Adenoma detection rate in patients aged 50 years or older (ADR50) is considered by the European Society of Gastrointestinal Endoscopy (ESGE) a key performance measures for lower gastrointestinal endoscopy. Technical and human resources constrain implementation of recording quality monitoring. The aim was to deploy an infrastructure for continuous monitoring of endoscopy quality indicators. And to evaluate its potential benefit on quality performance. Methods: A company reporting system was adapted by adding a dedicated tab for quality monitoring, including: preparation, progression, number of resected polyps. Automated linkage with the pathology database resulted in continuous monitoring of inter alia: rate of adequate bowel preparation, cecal intubation rate and ADR50. Continuous monitoring was done for all nine endoscopists working at our center, with individual feedback after 4, 9 and 28 months. Results: A total of 1434 colonoscopies were performed during the first 9 months of monitoring, 682 during the first 4 months, 752 during the following 5 months. Five months after feedback a global increase in ADR50 of 4.6% (22.9% to 27.5%) (P<0.05) was observed, compared to the first 4 months. Thus meeting the benchmark (≥25%) recommended by ESGE. A durable effect of monitoring and feedback was observed after 28 months (ADR50: 29.4%). Conclusions: An easy to use infrastructure for registration of quality monitoring in daily endoscopy practice, automatically linking the pathology database, facilitates continuous monitoring of endoscopy quality indicators. A global and durable ADR50 increase was observed after feedback, considered a quality improvement in performance of lower gastrointestinal endoscopy at our center.

Identification of gaze pattern and blind spots by upper gastrointestinal endoscopy using an eye-tracking technique

BACKGROUND

The lesion detection rate of esophagogastroduodenoscopy (EGD) varies depending on the degree of experience of the endoscopist and anatomical blind spots. This study aimed to identify gaze patterns and blind spots by analyzing the endoscopist's gaze during real-time EGD.

METHODS

Five endoscopists were enrolled in this study. The endoscopist's eye gaze tracked by an eye tracker was selected from the esophagogastric junction to the second portion of the duodenum without the esophagus during insertion and withdrawal, and then matched with photos. Gaze patterns were visualized as a gaze plot, blind spot detection as a heatmap, observation time (OT), fixation duration (FD), and FD-to-OT ratio.

RESULTS

The mean OT and FD were 11.10 ± 11.14 min and 8.37 ± 9.95 min, respectively, and the FD-to-OT ratio was 72.5%. A total of 34.3% of the time was spent observing the antrum. When observing the body of the stomach, it took longer to observe the high body in the retroflexion view and the low-to-mid body in the forward view.

CONCLUSIONS

It is necessary to minimize gaze distraction and observe the posterior wall in the retroflexion view. Our results suggest that eye-tracking techniques may be useful for future endoscopic training and education.

Guidelines for accreditation of endoscopy units: quality measures from the Korean Society of Coloproctology

Purpose

Colonoscopy is an effective method of screening for colorectal cancer (CRC), and it can prevent CRC by detection and removal of precancerous lesions. The most important considerations when performing colonoscopy screening are the safety and satisfaction of the patient and the diagnostic accuracy. Accordingly, the Korean Society of Coloproctology (KSCP) herein proposes an optimal level of standard performance to be used in endoscopy units and by individual colonoscopists for screening colonoscopy. These guidelines establish specific criteria for assessment of safety and quality in screening colonoscopy.

Methods

The Colonoscopy Committee of the KSCP commissioned this Position Statement. Expert gastrointestinal surgeons representing the KSCP reviewed the published evidence to identify acceptable quality indicators and indicators that lacked sufficient evidence.

Results

The KSCP recommends an optimal standard list for quality control of screening colonoscopy in the following 6 categories: training and competency of the colonoscopist, procedural quality, facilities and equipment, performance indicators and auditable outcomes, disinfection of equipment, and sedation and recovery of the patient.

Conclusion

The KSCP recommends that endoscopy units performing CRC screening evaluate 6 key performance measures during daily practice.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Validation of an automated adenoma detection rate calculating system for quality improvement of colonoscopy

Purpose

This study aimed to validate an automated calculating system developed for determining the adenoma detection rate (ADR).

Methods

To calculate the automated ADR, the data linking processes were as follows: (1) matching the selected colonoscopy results with the pathological results, (2) matching the polyp number from colonoscopy with that from pathology and confirming the histopathological results of each colonic polyp, and (3) confirming the histopathological results, especially the adenoma status of each colonic polyp. To verify the accuracy of the automated ADR calculating system, we manually calculated the ADR for 3 months through medical record review. Accuracy was calculated by measuring the error rate for each value. The cause of error was analyzed by additional order and chart review.

Results

After excluding 318 cases, 2,543 patients (1,351 men and 1,192 women; median age, 57.9 years) who underwent colonoscopy were included in this study. When the automated calculating system was used, polyps were found in 1,336 cases (52.6%) and adenomas were found in 1,003 cases (39.4%). When the manual calculating system was used, polyps were found in 1,327 cases (52.2%) and adenomas were found in 1,003 cases (39.4%). The accuracies of the polyp detection rate and ADR according to the automated calculating system were 99.3% and 100%, respectively.

Conclusion

We developed a system to automatically calculate the ADR by extracting hospital electronic medical record results and verified that it provided satisfactory results. It may help to improve colonoscopy quality.