A Longitudinal Study of Adenoma Detection Rate in Gastroenterology Fellowship Training

Multicenter evaluation of the impact of COVID-19 on the uptake of endoscopic skills by gastroenterology trainees

BACKGROUND AND AIMS

The COVID-19 pandemic significantly decreased procedural volume in 2020, thus limiting training opportunities. First-year fellows (1YF) are particularly susceptible to reduction in endoscopic volume as they build foundational endoscopic skills. We used an objective validated tool, the Assessment of Competency in Endoscopy (ACE), to determine the effect of the pandemic on endoscopy competency in gastroenterology fellows.

METHODS

This was a prospective cohort study conducted across two fellowship programs in New York City. Our primary outcome was the comparison of ACE scores of fellows starting gastroenterology fellowships in 2020 to the scores of those starting in 2016-2018. Our secondary outcome was to compare colonoscopy quality metrics and endoscopy volume between these cohorts.

RESULTS

ACE scores were available from 11 pandemic and 10 pre-pandemic 1YFs, and five pandemic and 19 pre-pandemic second (2YF) and third-year fellows (3YF). ACE scores for 1YFs showed significantly higher rating in the pre-pandemic cohort for 4 domains including knowledge of indications and medical issues (p = 0.03), effective and efficient use of air, water, and suction (p = 0.04), pathology identification (p = 0.001), and overall hands-on skills (p = 0.004). 2YFs showed no significant differences. 3YFs showed significantly lower scores in the pandemic cohort in the effective and efficient use of air, water, and suction (p = 0.03), fellows' knowledge of therapeutic tools (p = 0.05), and fellows overall cognitive skills (p = 0.05). There were no significant differences in quality metrics between the cohorts, except longer procedure time for the pandemic cohort (p < 0.01).

CONCLUSION

Following the COVID-19 pandemic, there was a decline in multiple aspects of endoscopic competency both at the beginning and the end of fellowship training. These trends are likely the result of a decrease in overall procedure volume early in training and highlight the need for supplementing trainee education with other modalities.

Effect of computer aided detection device on the adenoma detection rate and serrated detection rate among trainee fellows

Background and Aims

The utilization of artificial intelligence (AI) with computer-aided detection (CADe) has the potential to increase the adenoma detection rate (ADR) by up to 30% in expert settings and specialized centers. The impact of CADe on serrated polyp detection rates (SDR) and academic trainees ADR & SDR remains underexplored. We aim to investigate the effect of CADe on ADR and SDR at an academic center with various levels of providers' experience.

Methods

A single-center retrospective analysis was conducted on asymptomatic patients between the ages of 45 and 75 who underwent screening colonoscopy. Colonoscopy reports were reviewed for 3 months prior to the introduction of GI Genius™ (Medtronic, USA) and 3 months after its implementation. The primary outcome was ADR and SDR with and without CADe.

Results

Totally 658 colonoscopies were eligible for analysis. CADe resulted in statistically significant improvement in SDR from 8.92% to 14.1% (P = 0.037). The (ADR + SDR) with CADe and without CADe was 58% and 55.1%, respectively (P = 0.46). Average colonoscopy (CSC) withdrawal time was 17.33 min (SD 10) with the device compared with 17.35 min (SD 9) without the device (P = 0.98).

Conclusion

In this study, GI Genius™ was associated with a statistically significant increase in SDR alone, but not in ADR or (ADR + SDR), likely secondary to the more elusive nature of serrated polyps compared to adenomatous polyps. The use of CADe did not affect withdrawal time.

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.

Impact of an artificial intelligence-aided endoscopic diagnosis system on improving endoscopy quality for trainees in colonoscopy: Prospective, randomized, multicenter study

OBJECTIVE

This study was performed to evaluate whether the use of CAD EYE (Fujifilm, Tokyo, Japan) for colonoscopy improves colonoscopy quality in gastroenterology trainees.

METHODS

The patients in this multicenter randomized controlled trial were divided into Group A (observation using CAD EYE) and Group B (standard observation). Six trainees performed colonoscopies using a back-to-back method in pairs with gastroenterology experts. The primary end-point was the trainees' adenoma detection rate (ADR), and the secondary end-points were the trainees' adenoma miss rate (AMR) and Assessment of Competency in Endoscopy (ACE) tool scores. Each trainee's learning curve was evaluated using a cumulative sum (CUSUM) control chart.

RESULTS

We analyzed data for 231 patients (Group A, n = 113; Group B, n = 118). The ADR was not significantly different between the two groups. Group A had a significantly lower AMR (25.6% vs. 38.6%, P = 0.033) and number of missed adenomas per patient (0.5 vs. 0.9, P = 0.004) than Group B. Group A also had significantly higher ACE tool scores for pathology identification (2.26 vs. 2.07, P = 0.030) and interpretation and identification of pathology location (2.18 vs. 2.00, P = 0.038). For the CUSUM learning curve, Group A showed a trend toward a lower number of cases of missed multiple adenomas by the six trainees.

CONCLUSION

CAD EYE did not improve ADR but decreased the AMR and improved the ability to accurately locate and identify colorectal adenomas. CAD EYE can be assumed to be beneficial for improving colonoscopy quality in gastroenterology trainees.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN000044031).

You are not lab rats at teaching hospitals: A systematic review of resident and fellow participation leads to improved colonoscopy

BACKGROUND

Participation in colonoscopies is an essential aspect of endoscopic training. The purpose of this study was to explore the impact of fellow/trainee participation on colonoscopy outcomes.

METHODS

This meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO). From database inception to July 2022, studies investigating fellow involvement and colonoscopy outcomes were searched across Cochrane library, PubMed, and other databases. The random-effects model was applied to generate more conservative estimates. Sensitive analysis was conducted to explore whether the result would depend on a particular study. Egger's test and Begg's test were used to estimate the potential for publication bias.

RESULTS

Seventeen studies including 30,062 participants were included. We found that fellow/trainee involvement enhanced the overall rates of adenoma detection and polyp detection (OR = 1.26, 95% CI = 1.14-1.40, p < 0.001; OR = 1.29, 95% CI = 1.02-1.63, p = 0.020, respectively). The mean number of adenoma/polyps per colonoscopy was also higher with fellow/trainee participation (MD = 0.12, 95% CI = 0.08-0.17, p < 0.001; MD = 0.15, 95% CI = 0.02-0.28, p = 0.020, respectively).

CONCLUSION

In addition to its educational purpose, fellow or trainee involvement is associated with beneficial effects on colonoscopy outcomes.

Colonoscopy quality improvement after initial training: A cross-sectional study of intensive short-term training

Background and study aims High-quality is crucial for the effectiveness of colonoscopy and can be achieved by high-quality training and verified with assessment of key performance indicators (KPIs) for colonoscopy such as cecum intubation rate (CIR), adenoma detection rate (ADR) and adequate polyp resection. Typically, trainees achieve adequate CIR after 275 procedures, but little is known about learning curves for KPIs after initial training. Methods This cross-sectional study includes work-up colonoscopies after a positive screening test with fecal occult blood testing (FIT) or sigmoidoscopy, performed by either trainees after 300 training colonoscopies or by consultants. Outcome measures were KPIs. We assessed inter-endoscopist variation in trainees and learning curves for trainees as a group. We also compared KPIs for trainees and consultants as a group.  Results Data from 6,655 colonoscopies performed by 21 trainees and 921 colonoscopies performed by 17 consultants were included. Most trainees achieved target standards for main KPIs. With time, trainees shortened cecum intubation time and withdrawal time without decreasing their ADR, reduced the proportion of painful colonoscopies, and increased the adequate polyp resection rate (all P  < 0.01). Compared to consultants, trainees had higher CIR (97.7 % vs. 96.3 %, P  = 0.02), ADR after positive FIT (57.6 % vs. 50.3 %, P  < 0.01), and proximal ADR after sigmoidoscopy screening (41.1 % vs. 29.8 %; P  < 0.01), higher adequate polyp resection rate (94.9 % vs. 93.1 %, P  = 0.01) and fewer serious adverse events (0.65 % vs. 1.41 %, P  = 0.02). Conclusions Trainees performed high-quality colonoscopies and achieved international target standards. Several KPIs continuously improved after initial training. Trainees outperformed consultants on several KPIs.

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics

IMPORTANCE

Trainees routinely participate in colonoscopy procedures, yet whether their involvement is positively or negatively associated with procedural quality is unknown because prior studies involved small number of trainees and/or supervisors, lacked generalizability, and/or failed to adjust for potential confounders.

OBJECTIVE

To assess the association between trainee participation and colonoscopy quality metrics.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter population-based cohort study was conducted at 21 academic and community hospitals between April 1, 2017, and October 31, 2018, among consecutive adult patients undergoing colonoscopy. Procedures performed by endoscopists who did not supervise trainees were excluded. Statistical analysis was performed from April 3, 2017, to October 31, 2018.

EXPOSURE

Participation by a trainee, defined as a resident or fellow enrolled in a gastroenterology or general surgery training program.

MAIN OUTCOMES AND MEASURES

The primary outcome was the adenoma detection rate (ADR), and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate.

RESULTS

A total of 35 499 colonoscopies (18 989 women [53.5%]; mean [SD] patient age, 60.0 [14.1] years) were performed by 71 physicians (mean [SD] time in practice, 14.0 [9.3] years); 5941 colonoscopies (16.7%) involved trainees. There were no significant differences in the ADR (26.4% vs 27.3%; P = .19), CIR (96.7% vs 97.2%; P = .07), and perforation rate (0.05% vs 0.06%; P = .82) when trainees participated vs when they did not participate, whereas the the ssPDR (4.4% vs 5.2%; P = .009) and PDR (39.2% vs 42.0%; P < .001) were significantly lower when trainees participated vs when they did not. After adjustment for potential confounders, the ADR (risk ratio [RR], 0.97; 95% CI, 0.91-1.03; P = .30), PDR (RR, 0.98; 95% CI, 0.93-1.04; P = .47), and CIR (RR, 0.93; 95% CI, 0.78-1.10; P = .38) were not associated with trainee participation, although the ssPDR remained significantly lower (RR, 0.79; 95% CI, 0.64-0.98; P = .03).

CONCLUSIONS AND RELEVANCE

This study suggests that trainee involvement during colonoscopy was associated with reduced ssPDR but not other colonoscopy outcome measures. Extra care should be exercised when examining the right colon when trainees are involved.

Impact of Fellow Participation During Colonoscopy on Adenoma Detection Rates

BACKGROUND

An endoscopist's adenoma detection rate (ADR) is inversely related to interval colorectal cancer risk and cancer mortality. Previous studies evaluating the impact of gastroenterology fellow participation in colonoscopy on ADR have generated conflicting results.

AIMS

We aimed to determine the impact of fellow participation, duration of fellowship training, and physician sex on ADR and advanced ADR (AADR).

METHODS

We retrospectively analyzed average-risk patients undergoing screening colonoscopy at Veterans Affairs New York Harbor Healthcare System Brooklyn Campus and Kings County Hospital Center. Review of colonoscopy and pathology reports were performed to obtain adenoma-specific details, including the presence of advanced adenoma and adenoma location (right vs. left colon).

RESULTS

There were 893 colonoscopies performed by attending only and 502 performed with fellow participation. Fellow participation improved overall ADR (44.6% vs. 35.4%, p < 0.001), right-sided ADR (34.1% vs. 25.2%, p < 0.001), and AADR (15.3% vs. 8.3%, p < 0.001); however, these findings were institution-specific. Year of fellowship training did not impact overall ADR or overall AADR, but did significantly improve right-sided AADR (p-value for trend 0.03). Female attending physicians were associated with increased ADR (47.1% vs. 37.0%, p = 0.0037). Fellow sex did not impact ADR.

CONCLUSIONS

Fellow participation in colonoscopy improved overall ADR and AADR, and female attending physicians were associated with improved ADR. Year of fellowship training did not impact overall ADR or AADR.

Comprehensive evaluation of the learning curve to achieve satisfactory adenoma detection rate

BACKGROUND AND AIM

The number of colonoscopies required to reach satisfactory adenoma detection rate (ADR) is not well established. The aim of this study was to identify the appropriate number of procedures required to attain satisfactory ADR for those well-trained endoscopists who have a cecal intubation rate (CIR) ≥ 90% and start to perform colonoscopy independently.

METHODS

All endoscopists with compelete independent colonoscopy data during career in our database were enrolled. The number of procedures required to achieve ADR ≥ 20% was identified by cumulative summation (Cusum), learning curve Cusum (LC-Cusum), and moving average method. Mixed effect logistic regression model was developed to determine the relationship between endoscopist as well as patient-related factors and adenoma detection.

RESULTS

A total of 24 943 procedures and 14 endoscopists were enrolled. By Cusum analysis, the interest point was at 207 procedures. By LC-Cusum analysis, 71% (10/14) and 86% (12/14) of endoscopists had attained satisfactory ADR after 200 and 300 procedures, respectively. By moving average method, endoscopists reached a mean ADR of 20% at 216 and 261 procedures over blocks of 50 and 100 procedures, respectively. The total number of procedures, number of daily procedures, patient age and gender, bowel preparation, sedation, and diverticulosis were significantly associated with adenoma detection.

CONCLUSIONS

This is the first study to investigate the learning curve of ADR for those well-trained endoscopists who have a CIR ≥ 90% and start to perform colonoscopy independently. Two hundred procedures might be an optimal number required to reach an ADR ≥ 20%.

Trainee participation during screening colonoscopy does not affect ADR at subsequent surveillance, but may result in early follow-up

Background and study aims  Training future endoscopists is essential to meet rising demands for screening and surveillance colonoscopies. Studies have shown conflicting results regarding the influence of trainees on adenoma detection rates (ADR). It is unclear whether trainee participation during screening adversely affects ADR at subsequent surveillance and whether it alters surveillance recommendations. Patients and methods  A retrospective analysis of average-risk screening colonoscopies and surveillance exams over a subsequent 10-year period was performed. The initial inclusion criteria were met by 5208 screening and 2285 surveillance exams. Patients with poor preparation were excluded. The final analysis included 7106 procedures, including 4922 screening colonoscopies and 2184 surveillance exams. Data were collected from pathology and endoscopy electronic databases. The primary outcome was the ADR with and without trainee participation. Surveillance recommendations were analyzed as a secondary outcome. Results  Trainees participated in 1131 (23 %) screening and in 232 (11 %) surveillance exams. ADR did not significantly differ ( P  = 0.19) for screening exams with trainee participation (19.5 %) or those without (21.4 %). ADRs were higher at surveillance exams with (22.4 %) and without (27.5 %) trainee participation. ADR at surveillance was not adversely affected by trainee participation during the previous colonoscopy. Shorter surveillance intervals were given more frequently if trainees participated during the initial screening procedure ( P  = 0.0001). Conclusions  ADR did not significantly differ in screening or surveillance colonoscopies with or without trainee participation. ADR at surveillance was not adversely affected by trainee participation during the previous screening exam. However, trainee participation may result in shorter surveillance recommendations.

Impact of fellow participation on colon adenoma detection rates: a multicenter randomized trial

BACKGROUND AND AIMS

There are limited and conflicting data on the impact of fellow participation in improving the colon adenoma detection rate. We performed a multicenter randomized controlled trial to evaluate whether fellow involvement might have a beneficial effect on adenoma detection rate.

METHODS

The trial was conducted at 4 tertiary hospitals between April and December 2019. Eight hundred twelve patients were randomized to undergo colonoscopy performed by a fellow under the supervision of a staff endoscopist or by an attending physician alone.

RESULTS

No significant differences in demographic or adenoma risk factors were detected between the 2 groups. The adenoma detection rate in the intervention group was 44.8% versus 37.1% in the control arm (P = .02). The mean number of adenomas per colonoscopy was significantly higher in the intervention group (0.65 ± 0.3 vs 0.53 ± 0.2 in the control arm, P < .001). The polyp detection rate was 69.7% in the intervention group and 62.5% in the control arm (P = .03), whereas rates of advanced and sessile/serrated adenoma detection were not different between the trial arms (P = .50 and .42, respectively). In the subgroup of more experienced fellows, the adenoma detection rate and polyp detection rate were 49.5% and 75.7%, respectively. No difference was observed between less-experienced fellows and attending physicians alone (P = .53 and 0.86, respectively). The level of bowel preparation and fellow involvement were significant predictors of increased adenoma detection rate in a multivariate analysis.

CONCLUSIONS

Our multicenter trial represents the first prospective validation of the beneficial role of fellow involvement in colonoscopy procedures. (Clinical trial registration number: NCT03908229.).

Anesthesia Assistance in Screening Colonoscopy and Adenoma Detection Rate Among Trainees

BACKGROUND AND AIMS

The use of anesthesia assistance (AA) for screening colonoscopy has been increasing substantially over the past decade, raising concerns about procedure safety and cost without demonstrating a proven improvement in overall quality indicators such as adenoma detection rate (ADR). The effect of AA on ADR has not been extensively studied among trainees learning colonoscopy. We aimed to determine whether type of sedation used during screening colonoscopy affects trainee ADR.

METHODS

Using the electronic endoscopy databases of two hospitals in our medical center, we identified colonoscopies performed by 15 trainees from 2014 through 2018, including all screening examinations in which the cecum was reached. Multivariable logistic regression was used to determine factors associated with adenoma detection.

RESULTS

We identified 1420 unique patients who underwent screening colonoscopy by a trainee meeting the inclusion criteria. Of these, 459 (32.3%) were performed with AA. Overall trainee ADR was 39.6%, with ADR increasing from 35.0% in year one of training to 42.8% in year three (p = 0.047). ADR for cases with AA was 37.9%, while ADR for conscious sedation cases was 32.0% (p = 0.374). Despite this 5.9% absolute difference, the use of AA was not associated with finding an adenoma on multivariable analysis when controlling for patient age, sex, smoking status, body mass index, trainee year of training, mean withdrawal time, supervising attending ADR, and bowel preparation quality (OR 0.85; 95% CI 0.67-1.09).

CONCLUSIONS

Despite providing the ability to more consistently sedate patients, the use of AA did not affect trainee ADR. These results on trainee ADR and sedation type suggest that the overall lack of association between AA use and ADR is applicable to the trainee setting.

Endocuff-Assisted versus Cap-Assisted Colonoscopy Performed by Trainees: A Retrospective Study

Background/Aims

The adenoma detection rate (ADR) of screening colonoscopies performed by trainees is often lower than that of colonoscopies performed by experts. The effcacy of cap-assisted colonoscopy (CAC) in adenoma detection is well documented, especially that of CACs performed by trainees. Endocuff, a new endoscopic cap, is reportedly useful for adenoma detection; however, no trials have compared the effcacy of Endocuff-assisted colonoscopy (EAC) and CAC conducted by trainees. Therefore, the present study retrospectively compared the effcacy between EAC and CAC in trainees.

Methods

This was a single-center, retrospective study involving 305 patients who underwent either EAC or CAC performed by three trainees between January and December 2018. We evaluated the ADR, mean number of adenomas detected per patient (MAP), cecal intubation rate, cecal intubation time, and occurrence of complications between the EAC and CAC groups.

Results

The ADR was significantly higher in the EAC group than in the CAC group (54.3% vs. 37.3%, p=0.019), as was the MAP (1.36 vs. 0.74, p=0.003). No significant differences were found between the groups with respect to the cecal intubation rate or cecal intubation time. No major complications occurred in either group.

Conclusions

Our results suggest that EAC exhibits increased ADR and MAP compared to CAC when performed by trainees.

Linked color imaging versus narrow-band imaging for colorectal polyp detection: a prospective randomized tandem colonoscopy study

BACKGROUND AND AIMS

Linked color imaging (LCI) is a newly available image-enhanced endoscopy (IEE) system that emphasizes the red mucosal color. No study has yet compared LCI with other available IEE systems. Our aim was to investigate polyp detection rates using LCI compared with narrow-band imaging (NBI).

METHODS

This is a prospective randomized tandem colonoscopy study. Eligible patients who underwent colonoscopy for symptoms or screening/surveillance were randomized in a 1:1 ratio to receive tandem colonoscopy with both colonoscope withdrawals using LCI or NBI. The primary outcome was the polyp detection rate.

RESULTS

Two hundred seventy-two patients were randomized (mean age, 62 years; 48.2% male; colonoscopy for symptoms, 72.8%) with 136 in each arm. During the first colonoscopy, the polyp detection rate (71.3% vs 55.9%; P = .008), serrated lesion detection rate (34.6% vs 22.1%; P = .02), and mean number of polyps detected (2.04 vs 1.35; P = .02) were significantly higher in the NBI group than in the LCI group. There was also a trend of higher adenoma detection rate in the NBI group compared with the LCI group (51.5% vs 39.7%, respectively; P = .05). Multivariable analysis confirmed that use of NBI (adjusted odds ratio, 1.99; 95% confidence interval, 1.09-3.68) and withdrawal time >8 minutes (adjusted odds ratio, 5.11; 95% confidence interval, 2.79-9.67) were associated with polyp detection. Overall, 20.5% of polyps and 18.1% of adenomas were missed by the first colonoscopy, but there was no significant difference in the miss rates between the 2 groups.

CONCLUSION

NBI was significantly better than LCI for colorectal polyp detection. However, both LCI and NBI missed 20.5% of polyps. (Clinical trial registration number: NCT03336359.).

Colorectal Surgery Resident Participation in Screening Colonoscopies: How Does It Impact Quality?

BACKGROUND

Performing colonoscopies is an integral component of colorectal surgery residency training. There exists a paucity of literature regarding colonoscopy quality metrics with colorectal trainee involvement.

OBJECTIVE

This study aimed to investigate the effect of colorectal surgery resident participation on quality metrics in screening colonoscopy.

DESIGN

Screening colonoscopies performed between August 1, 2016, and July 31, 2018, were queried from a prospectively maintained institutional database. Data were cross-checked with resident case logs to verify colonoscopies with resident participation.

SETTING

This study was conducted by the colorectal surgery department at a tertiary level hospital in the United States.

PATIENTS

Consecutive, asymptomatic patients aged ≥45 years, undergoing screening colonoscopy, were selected.

MAIN OUTCOME MEASURES

The quality parameters measured included overall, male, and female adenoma detection rates; total examination time; withdrawal time; cecal intubation rate; quality of bowel preparation; complications; and medication dosage.

RESULTS

A total of 4594 patients were included in the study with a mean age of 60.5 ± 8.4 years (range, 45-91); 51.7% were women. Overall, 4186 of the colonoscopies were performed without resident participation, and 408 were performed with resident participation. Scope insertion, withdrawal, and total examination times were longer in the resident group. Cecal intubation rate, polypectomy rate, sex-specific and overall adenoma detection rates, and complication rates were similar between the groups. In the multivariate model, trainee involvement had no significant impact on adenoma detection rate. In addition, the trainee group utilized a higher mean dose of fentanyl.

LIMITATIONS

The retrospective nature of the data with possible coding errors of the database and the inability to quantify the amount of resident participation and to clarify the degree of attending surgeon assistance and oversight were limitations of the study.

CONCLUSIONS

Colorectal surgery resident participation in screening colonoscopy takes longer and appears safe, while achieving all national quality metrics without compromising adenoma detection rates. Changes in colonoscopy scheduling in regard to length of time may prove beneficial when there is resident participation. See Video Abstract at http://links.lww.com/DCR/B43. PARTICIPACIÓN DE LOS RESIDENTES DE CIRUGÍA COLORRECTAL EN COLONOSCOPIAS DE CRIBADO: ¿CÓMO AFECTA LA CALIDAD?: La realización de colonoscopias es un componente integral del entrenamiento de residencia en cirugía colorrectal. Existe una escasez de literatura con respecto a las medidas de calidad de la colonoscopia con la participación de los aprendices colorrectales.Investigar el efecto de la participación de residentes de cirugía colorrectal en las medidas de calidad en la colonoscopia de cribado.Las colonoscopias de cribado realizadas entre el 1 de agosto de 2016 y el 31 de julio de 2018 se consultaron desde una base de datos institucional mantenida prospectivamente. Los datos se cotejaron con registros de casos de residentes para verificar las colonoscopias con participación de residentes.Departamento de cirugía colorrectal en un hospital de tercer nivel de los Estados Unidos.Pacientes consecutivos, asintomáticos, edad ≥45 años, sometidos a colonoscopia de detección.Parámetros de calidad que incluyen tasas generales de detección de adenoma en hombres y mujeres, tiempo total de examen, tiempo de retiro, tasa de intubación cecal, calidad de la preparación intestinal, complicaciones y dosis de medicamentos.Se incluyeron un total de 4.594 pacientes en el estudio con una edad media de 60,5 ± 8,4 años (rango, 45-91) y 51,7% mujeres. En total 4,186 de las colonoscopias se realizaron sin participación de los residentes y 408 se realizaron con la participación de los residentes. Los tiempos de inserción, retiro y examen total del alcance fueron más largos en el grupo residentes. La tasa de intubación cecal, la tasa de polipectomía, las tasas de detección de adenoma específicos de género y generales, y las tasas de complicaciones fueron similares entre los grupos. En el modelo multivariado, la participación de los aprendices no tuvo un impacto significativo en la tasa de detección de adenoma. Además, el grupo de aprendices utilizó una dosis media más alta de fentanilo.Carácter retrospectivo de los datos con posibles errores de codificación de la base de datos. Incapacidad para cuantificar la cantidad de participación de los residentes y para aclarar el grado de asistencia y supervisión del cirujano.La participación de los residentes de cirugía colorrectal en la colonoscopia de cribado lleva más tiempo y parece segura, mientras se logran todas las medidas de calidad nacionales sin comprometer las tasas de detección de adenoma. Los cambios en la programación de la colonoscopia con respecto al período de tiempo pueden ser beneficiosos cuando hay participación de residentes. Vea el resumen del video en http://links.lww.com/DCR/B43.

Effect of fellow involvement on colonoscopy outcomes: A systematic review and meta-analysis

BACKGROUND AND AIMS

The effect of fellow involvement on colonoscopy outcomes is controversial. Thus, we evaluated this effect on adenoma detection rate (ADR) and on other colonoscopy quality indicators.

METHODS

MEDLINE and Cochrane central register of controlled trials were searched up to September 2018 for studies evaluating fellow-involved colonoscopies vs. attending physicians-only examinations in terms of colonoscopy outcomes. Primary outcome was ADR, while advanced ADR (AADR), mean number of adenomas per colonoscopy (MAC), cecum intubation rate (CIR) and adverse events rate comprised the secondary outcomes. The effect size on study outcomes was calculated using random-effects model and it is presented as Odds Ratio (OR) or Mean Difference (MD) with 95% confidence interval (CI).

RESULTS

Nineteen observational studies involving 34,059 patients (fellow-involved 16,875, attending physician-only 17,184) were included. Compared to the attending physician-only group, fellow involvement marginally increased ADR [OR (95%CI) = 1.12 (1.00-1.26); p = 0.06, I2 = 76%]. Attending physicians with low-to-moderate ADR (<35%) benefited most from fellow's participation [OR (95%CI): 1.26 (1.13-1.40) vs. 1.12 (1.00-1.26); p = 0.03 when ADR < 35% and OR (95%CI): 1.29 (1.13-1.46) vs. 0.95 (0.78-1.16); p = 0.01 when ADR < 30%, respectively]. Moreover, fellow-involved group had higher MAC compared to attending-only group [MD (95%CI) = 0.12 (0.04-0.20); p = 0.002, I2 = 53%]. No benefit from fellow involvement was detected either for AADR, CIR or adverse events rate.

CONCLUSIONS

Fellow involvement during colonoscopy is associated with more adenomas detected per procedure and with higher ADR when the attending physician-only group ADR is less than 35%.

Carbon Dioxide Insufflation Increases Colonoscopic Adenoma Detection Rate Compared With Air Insufflation

GOALS

To determine the effect of carbon dioxide insufflation on the most important outcome measure of colonoscopic quality: adenoma detection rate (ADR).

BACKGROUND

Bowel cancer is the second most common cause of cancer deaths in males and females in Australia. Carbon dioxide has in recent times become the insufflation methodology of choice for screening colonoscopy for bowel cancer, as this has been shown to have significant advantages when compared with traditional air insufflation.

STUDY

Endoscopies performed over a period of 9 months immediately before and after the implementation of carbon dioxide insufflation at endoscopy centers were eligible for inclusion.

RESULTS

The difference in ADR between the carbon dioxide and air insufflation methods was statistically significant, with an increased ADR in the carbon dioxide group. The superiority of carbon dioxide insufflation was sustained with a logistic regression model, which showed ADR was significantly impacted by insufflation method.

CONCLUSIONS

Carbon dioxide insufflation is known to reduce abdominal pain, postprocedural duration of abdominal pain, abdominal distension, and analgesic requirements. This study represents for the first time the beneficial effect of carbon dioxide insufflation upon the key quality colonoscopy indicator of ADR.

Impact of fellowship training level on colonoscopy quality and efficiency metrics

BACKGROUND AND AIMS

Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the "fellow effect" on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use.

METHODS

We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal.

RESULTS

Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively).

CONCLUSIONS

ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.

Should We Measure Adenoma Detection Rate for Gastroenterology Fellows in Training?

Background

Adenoma detection rate (ADR) is a proven quality metric for colonoscopy. The value of ADR for the evaluation of gastroenterology fellows is not well established. The aim of this study is to calculate and evaluate the utility of ADR as a measure of competency for gastroenterology fellows.

Methods

Colonoscopies for the purposes of screening and surveillance, on which gastroenterology fellows participated at the Richard L. Roudebush VAMC (one of the primary training sites at Indiana University), during a 9-month period, were included. ADR, cecal intubation rate, and indirect withdrawal time were measured. These metrics were compared between the levels of training.

Results

A total of 591 screening and surveillance colonoscopies were performed by 14 fellows. This included six, four and four fellows, in the first, second and third year of clinical training, respectively. Fellows were on rotation at the VAMC for a mean of 1.9 months (range 1 to 3 months) during the study period. The average ADR was 68.8% (95% CI 65.37 - 72.24). The average withdrawal time was 27.59 min (95% CI 23.45 - 31.73). The average cecal intubation rate was 99% (95% CI 98-100%). There was no significant difference between ADRs, cecal intubation rates, and withdrawal times at different levels of training; however, a trend toward swifter withdrawal times with advancing training was noted.

Conclusions

ADR appears not to be a useful measure of competency for gastroenterology fellows. Consideration should be given to alternative metrics that could avoid bias and confounders.

Colonoscopy procedural volume increases adenoma and polyp detection rates in gastroenterologytrainees

AIM

To investigate changes in polyp detection throughout fellowship training, and estimate colonoscopy volume required to achieve the adenoma detection rate (ADRs) and polyp detection rate (PDRs) of attending gastroenterologists.

METHODS

We reviewed colonoscopies from July 1, 2009 to June 30, 2014. Fellows’ procedural logs were used to retrieve colonoscopy procedural volumes, and these were treated as the time variable. Findings from screening colonoscopies were used to calculate colonoscopy outcomes for each fellow for the prior 50 colonoscopies at each time point. ADR and PDR were plotted against colonoscopy procedural volumes to produce individual longitudinal graphs. Repeated measures linear mixed effects models were used to study the change of ADR and PDR with increasing procedural volume.

RESULTS

During the study period, 12 fellows completed full three years of training and were included in the analysis. The average ADR and PDR were, respectively, 31.5% and 41.9% for all fellows, and 28.9% and 38.2% for attendings alone. There was a statistically significant increase in ADR with increasing procedural volume (1.8%/100 colonoscopies, P = 0.002). Similarly, PDR increased 2.8%/100 colonoscopies (P = 0.0001), while there was no significant change in advanced ADR (0.04%/100 colonoscopies, P = 0.92). The ADR increase was limited to the right side of the colon, while the PDR increased in both the right and left colon. The adenoma per colon and polyp per colon also increased throughout training. Fellows reached the attendings’ ADR and PDR after 265 and 292 colonoscopies, respectively.

CONCLUSION

We found that the ADR and PDR increase with increasing colonoscopy volume throughout fellowship. Our findings support recent recommendations of ≥ 275 colonoscopies for colonoscopy credentialing.