Computer-aided learning in capsule endoscopy leads to improvement in lesion recognition ability

Effect of an online educational module incorporating real-time feedback on accuracy of polyp sizing in trainees: a randomized controlled trial

BACKGROUND

Although polyp size dictates surveillance intervals, endoscopists often estimate polyp size inaccurately. We hypothesized that an intervention providing didactic instruction and real-time feedback could significantly improve polyp size classification.

METHODS

We conducted a multicenter randomized controlled trial to evaluate the impact of different components of an online educational module on polyp sizing. Participants were randomized to control (no video, no feedback), video only, feedback only, or video + feedback. The primary outcome was accuracy of polyp size classification into clinically relevant categories (diminutive [1-5mm], small [6-9mm], large [≥10mm]). Secondary outcomes included accuracy of exact polyp size (inmm), learning curves, and directionality of inaccuracy (over- vs. underestimation).

RESULTS

36 trainees from five training programs provided 1360 polyp size assessments. The feedback only (80.1%, P=0.01) and video + feedback (78.9%, P=0.02) groups had higher accuracy of polyp size classification compared with controls (71.6%). There was no significant difference in accuracy between the video only group (74.4%) and controls (P=0.42). Groups receiving feedback had higher accuracy of exact polyp size (inmm) and higher peak learning curves. Polyps were more likely to be overestimated than underestimated, and 29.3% of size inaccuracies impacted recommended surveillance intervals.

CONCLUSIONS

Our online educational module significantly improved polyp size classification. Real-time feedback appeared to be a critical component in improving accuracy. This scalable and no-cost educational module could significantly decrease under- and overutilization of colonoscopy, improving patient outcomes while increasing colonoscopy access.

The standardized training and assessment system for magnetically controlled capsule gastroscopy (with video)

BACKGROUND AND AIM

To explore the feasibility of a standardized training and assessment system for magnetically controlled capsule gastroscopy (MCCG).

METHODS

The results of 90 trainees who underwent the standardized training and assessment system of the MCCG at the First Affiliated Hospital of Xi'an Jiaotong University from May 2020 to November 2023 was retrospectively analyzed. The trainees were divided into three groups according to their medical backgrounds: doctor, nurse, and non-medical groups. The training and assessment system adopted the '7 + 2' mode, seven days of training plus two days of theoretical and operational assessment. The passing rates of theoretical, operational, and total assessment were the primary outcomes. Satisfaction and mastery of the MCCG was checked.

RESULTS

Ninety trainees were assessed; theoretical assessment's passing rates in the three groups were 100%. The operational and total assessment passing rates were 100% (25/25), 97.92% (47/48), and 94.12% (16/17), for the doctor, nurse, and non-doctor groups respectively, with no significant difference (χ2 = 1.741, p = 0.419). No bleeding or perforation occurred during the procedure. Approximately, 96.00% (24/25), 95.83% (46/48), and 94.12% (16/17) of the doctor, nurse and non-medical groups anonymously expressed great satisfaction, respectively, without statistically significant difference (χ2 = 0.565, p = 1.000). The average follow-up time was 4-36 months, and 87 trainees (96.67%) had mastered the operation of the MCCG in daily work.

CONCLUSIONS

Standardized training and assessment of magnetically controlled capsule endoscopists is effective and feasible. Additionally, a strict assessment system and long-term communication and learning can improve teaching effects.

Implementation of European Society of Gastrointestinal Endoscopy (ESGE) recommendations for small-bowel capsule endoscopy into clinical practice: Results of an official ESGE survey

BACKGROUND

We aimed to document international practices in small-bowel capsule endoscopy (SBCE), measuring adherence to European Society of Gastrointestinal Endoscopy (ESGE) technical and clinical recommendations.

METHODS

Participants reached through the ESGE contact list completed a 52-item web-based survey.

RESULTS

217 responded from 47 countries (176 and 41, respectively, from countries with or without a national society affiliated to ESGE). Of respondents, 45 % had undergone formal SBCE training. Among SBCE procedures, 91 % were performed with an ESGE recommended indication, obscure gastrointestinal bleeding (OGIB), iron-deficiency anemia (IDA), and suspected/established Crohn's disease being the commonest and with higher rates of positive findings (49.4 %, 38.2 % and 53.5 %, respectively). A watchful waiting strategy after a negative SBCE for OGIB or IDA was preferred by 46.7 % and 70.3 %, respectively. SBCE was a second-line exam for evaluation of extent of new Crohn's disease for 62.2 % of respondents. Endoscopists adhered to varying extents to ESGE technical recommendations regarding bowel preparation ( > 60 %), use in those with pacemaker holders (62.5 %), patency capsule use (51.2 %), and use of a validated scale for bowel preparation assessment (13.3 %). Of the respondents, 67 % read and interpreted the exams themselves and 84 % classified exams findings as relevant or irrelevant. Two thirds anticipated future increase in SBCE demand. Inability to obtain tissue (78.3 %) and high cost (68.1 %) were regarded as the main limitations, and implementation of artificial intelligence as the top development priority (56.2 %).

CONCLUSIONS

To some extent, endoscopists follow ESGE guidelines on using SBCE in clinical practice. However, variations in practice have been identified, whose implications require further evaluation.

Training pathway for small bowel capsule endoscopy in the UK

The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Training, Reading, and Reporting for Small Bowel Video Capsule Endoscopy

Video capsule endoscopy (VCE) is an established modality for examining the small bowel. Formal training in interpretation and reporting of VCE examinations, along with assessment of performance metrics, is advocated for all gastroenterology fellowship programs. This review provides an overview of VCE minimum training requirements and competency assessment, cognitive and technical aspects of interpretation, and standardized reporting of findings. In order to optimize and advance the clinical utility of VCE, efforts must continue to promote and encourage consensus and standardization of training, definition and assessment of competence, enhancements of VCE reading tools, and use of appropriate nomenclature in VCE reports.

Capsule endoscopy - Recent developments and future directions

INTRODUCTION

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.

AREAS COVERED

This review covers the role and recent advances of CE, as a non-invasive investigative tool.

EXPERT OPINION

The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Prospective multicenter study to evaluate capsule endoscopy competency using a validated assessment tool

BACKGROUND AND AIMS

Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are based primarily on guidelines and expert opinion. A validated tool to assess the competence of CE is lacking. In this prospective, multicenter study, we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience.

METHODS

We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score ≥90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on the number of previous endoscopies.

RESULTS

A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score ≥84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k = 0.85). There was no correlation between the scores and the number of endoscopies performed.

CONCLUSION

After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.

Training in video capsule endoscopy: Current status and unmet needs

Since its introduction to clinical practice nearly 20 years ago, wireless capsule endoscopy has revolutionized the landscape in the diagnosis and management of small bowel diseases. Over the past 10 years, capsule endoscopy has evolved beyond the small intestine and a range of capsules are now available to examine the esophagus, stomach and colon. Because of its ease of use, tolerability, paucity of complications and ability to visualize the entire gastrointestinal tract, capsule endoscopy has entered the mainstream of clinical practice. This review of the literature summarizes the current state of capsule training and highlights the limited data available to assess reader competence and standards expected of an independent practitioner. There are neither standardized teaching strategies nor national or international metrics for accreditation of physicians and non-physicians interested in mastering this examination. Summating the few publications, there appears to be consensus that diagnostic expertise improves with experience, and that trainees should be fully supervised for at least 20 full case studies. Formative and summative assessment is advisable and the number of taught cases should not be the sole determinant of competence. The review also highlights differences in recommendations from major national gastroenterology societies. Finally, the authors discuss areas of unmet needs in teaching and learning for capsule endoscopy.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

NASPGHAN Capsule Endoscopy Clinical Report

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Assessment of an electronic learning system for colon capsule endoscopy: a pilot study

BACKGROUND

Training for colon capsule endoscopy (CCE) procedures is currently performed as a lecture and hands-on seminar. The aims of this pilot study were to assess the utility of an electronic learning system for CCE (ELCCE) designed for the Japanese Association for Capsule Endoscopy using an objective scoring engine, and to evaluate the efficacy of ELCCE on the acquisition of CCE reading competence.

METHODS

ELCCE is an Internet-based learning system with the following steps: step 1, introduction; step 2, CCE reading competence assessment test (CCAT), which evaluates the competence of CCE reading prior to training; step 3, learning reading theory; step 4, training with guidance; step 5, training without guidance; step 6, final assessment; and step 7, the same as step 2. The CCAT, step 5 and step 6 were scored automatically according to: lesion detection, diagnosis (location, size, shape of lesion), management recommendations, and quality of view. Ten trainee endoscopists were initially recruited (cohort 1), followed by a validating cohort of 11 trainee endoscopists (cohort 2).

RESULTS

All but one participant finished ELCCE training within 7 weeks. In step 6, accuracy ranged from 53 to 98 % and was not impacted by step 2 pretest scores. The average CCAT scores significantly increased between step 2 pretest and step 7 in both cohorts, from 42 ± 18 % to 79 ± 15 % in cohort 1 (p = 0.0004), and from 52 ± 15 % to 79 ± 14 % in cohort 2 (p = 0.0003).

CONCLUSIONS

ELCCE is useful and effective for improving CCE reading competence.

Impact of the endoscopist's experience on the negative predictive value of capsule endoscopy

INTRODUCTION

The impact of the accumulated experience of the capsule endoscopy (CE) reader on the accuracy of this test is discussed.

AIM

To determine whether the negative predictive value of CE findings changes along the learning curve.

METHODS

We reviewed the first 900 CE read by 3 gastroenterologists experienced in endoscopy over 8 years. These 900 CE were divided into 3 groups (300 CE each): group 1 consisted of the sum of the first 100 CE read by each of the 3 endoscopists; group 2, the sum of the second 100 and groups 3, the sum of the third 100. Patients with normal CE were monitored for at least 28 months to estimate the negative predictive value.

RESULTS

A total of 54 (18%) CE in group 1, 58 (19.3%) in group 2 and 47 (15.6%) in group 3 were normal, although only 34 patients in group 1, 38 in group 2 and 36 in group 3 with normal CE completed follow up and were eventually studied. The negative predictive value was 88.2% in group 1, 89.5% in group 2 and 97% in group 3 (P>.05).

CONCLUSION

The negative predictive value tended to increase, but remained high and did not change significantly after the first 100 when readers are experienced in conventional endoscopy and have preliminary specific training.

The effectiveness of Internet-based e-learning on clinician behaviour and patient outcomes: A systematic review

BACKGROUND

The contemporary health workforce has a professional responsibility to maintain competency in practice. However, some difficulties exist with access to ongoing professional development opportunities, particularly for staff in rural and remote areas and those not enrolled in a formal programme of study. E-learning is at the nexus of overcoming these challenges. The benefits of e-learning have been reported in terms of increased accessibility to education, improved self-efficacy, knowledge generation, cost effectiveness, learner flexibility and interactivity. What is less clear, is whether improved self-efficacy or knowledge gained through e-learning influences healthcare professional behaviour or skill development, whether these changes are sustained, and whether these changes improve patient outcomes.

OBJECTIVE

To identify, appraise and synthesise the best available evidence for the effectiveness of e-learning programmes on health care professional behaviour and patient outcomes.

DESIGN

A systematic review of randomised controlled trials was conducted to assess the effectiveness of e-learning programmes on clinician behaviour and patient outcomes. Electronic databases including CINAHL, Embase, ERIC, MEDLINE, Mosby's Index, Scopus and Cochrane - CENTRAL were searched in July 2014 and again in July 2015.

QUALITY ASSESSMENT AND DATA EXTRACTION

Studies were reviewed and data extracted by two independent reviewers using the Joanna Briggs Institute standardised critical appraisal and data extraction instruments.

DATA SYNTHESIS

Seven trials met the inclusion criteria for the analysis. Due to substantial instructional design, subject matter, study population, and methodological variation between the identified studies, statistical pooling was not possible and a meta-analysis could not be performed. Consequently, the findings of this systematic review are presented as a narrative review.

RESULTS

The results suggest that e-learning was at least as effective as traditional learning approaches, and superior to no instruction at all in improving health care professional behaviour. There was variation in behavioural outcomes depending on the skill being taught, and the learning approach utilised. No papers were identified that reported the effectiveness of an e-learning programme on patient outcomes.

CONCLUSION

This review found insufficient evidence regarding the effectiveness of e-learning on healthcare professional behaviour or patient outcomes, consequently further research in this area is warranted. Future randomised controlled trials should adhere to the CONSORT reporting guidelines in order to improve the quality of reporting, to allow evaluation of the effectiveness of e-learning programmes on healthcare professional behaviour and patient outcomes.

A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

A critical analysis of the effect of view mode and frame rate on reading time and lesion detection during capsule endoscopy

BACKGROUND AND AIM

Factors influencing reading time and detection of lesions include the view mode (VM) and frame rate (FR) applied during reading of small bowel capsule endoscopy images. The aims of this study were to examine the impact of VM and FR on reading time and lesion detection using a standardized, single-type lesion model.

METHODS

A selected video clip containing a known number of positive images (n = 60) of small bowel angioectasias was read using nine different combinations of VM and FR (VM1, VM2, and VM4 × FR10, FR15, and FR25) in randomized order by six capsule endoscopists. Readers were asked to count all positive images of angioectasias (maximum number of positive images, MPIs) seen during reading. The main outcome measurements were effect of VM and FR on reading time and lesion detection.

RESULTS

Mean MPIs for all VM2 and VM4 were 36 (60 %) and 38 (64 %). They were significantly higher than VM1 of 24 (40 %) (P = 0.011, 0.008). A statistical difference was found when the total MPIs at FR10 were compared to FR15 (P = 0.008) and to FR25 (P < 0.001).

CONCLUSIONS

Both VM and FR significantly influence lesion detection during capsule endoscopy reading.

Practical aspects of delivering a small bowel endoscopy service in the UK

Capsule endoscopy remains at the forefront of small bowel investigation, offering the only non-invasive means of directly imaging the mucosa of the small bowel. Recommended for the investigation of obscure gastrointestinal bleeding, Crohn's disease, coeliac disease, small bowel tumours and hereditary polyposis syndromes, the uptake of small bowel capsule endoscopy has been widespread in the UK. However, despite a wealth of published literature supporting the utility of capsule endoscopy in clinical practice, there are limited data regarding the actual practical aspects of service delivery, training and quality assurance. In this article, we attempt to address this by considering specific factors that contribute to provision of a high-quality capsule service. The role of formal training, accreditation and quality assurance measures is also discussed.

Optimizing lesion detection in small-bowel capsule endoscopy: from present problems to future solutions

This review presents issues pertaining to lesion detection in small-bowel capsule endoscopy (SBCE). The use of prokinetics, chromoendoscopy, diagnostic yield indicators, localization issues and the use of 3D reconstruction are presented. The authors also review the current status (and future expectations) in automatic lesion detection software development. Automatic lesion detection and reporting, and development of an accurate lesion localization system are the main software challenges of our time. The 'smart', selective and judicious use (before as well as during SBCE) of prokinetics in combination with other modalities (such as real time and/or purge) improves the completion rate of SBCE. The tracking of the capsule within the body is important for the localization of abnormal findings and planning of further therapeutic interventions. Currently, localization is based on transit time. Recently proposed software and hardware solutions are proposed herein. Moreover, the feasibility of software-based 3D representation (attempt for 3D reconstruction) is examined.

Usefulness of flexible spectral imaging color enhancement for the detection and diagnosis of small intestinal lesions found by capsule endoscopy

OBJECTIVE

Capsule endoscopy (CE) is an established technique for the detection and diagnosis of obscure gastrointestinal bleeding (OGIB). Flexible spectral imaging color enhancement (FICE) is a software feature of RAPID 6.5. This study assessed the value of FICE for accurate identification of red lesions during CE.

METHODS

We randomly selected 10 patients who underwent CE for OGIB at Juntendo University. The CE images were read by five endoscopists. Small bowel videos, which were recorded by regular CE devices (PillCam SB2, Given Imaging), were evaluated on RAPID 6.5. We standardized the reading condition to a dual view, at a speed of 20 frames/s in manual mode. This interpreted FICE-CE images obtained at settings 1-3. Both conventional and FICE images were read at random. We defined a conventional image as standard and investigated the potential of FICE in detecting small intestinal lesions by the Steel-Dwass test.

RESULTS

We considered that conventional images represented baseline (100). On this basis, detection rates for FICE images were as follows: FICE1 = 266.4 ± 33.1 (p < 0.0001); FICE2 = 255.4 ± 25.6 (p < 0.0001); and FICE3 = 117.0 ± 12.3 (p = 0.9447). Detection rates using FICE1 and FICE2 images were significantly higher than conventional CE images. FICE1 and FICE2 were more useful in detecting erosions than conventional CE (p < 0.0001) and FICE3 (p < 0.0001).

CONCLUSIONS

FICE-CE has a high level of visibility by transparentizing bile or enhancing the color difference associated with reddish mucosa. We found that FICE-CE images were useful in the diagnosing of small intestinal lesions.

Training in small-bowel capsule endoscopy: assessing and defining competency

BACKGROUND

Minimum training for capsule endoscopy (CE) is based on societal guidelines and expert opinion. Objective measures of competence are lacking.

OBJECTIVES

Our objectives were to (1) establish structured CE training curriculum during a gastroenterology fellowship, (2) develop a formalized assessment tool to evaluate CE competency, (3) prospectively analyze trainee CE competency, (4) define metrics for trainee CE competence by using comparative data from CE staff, and (5) determine the correlation between CE competence and previous endoscopy experience.

DESIGN

Single-center, prospective analysis over 6 years.

SETTING

Tertiary academic center.

SUBJECTS

Gastroenterology fellows and CE staff.

INTERVENTIONS

Structured CE training was implemented with supervised CE interpretation. Capsule Competency Test (CapCT) was developed and data were collected on the number of CEs, upper endoscopies, colonoscopies, and push enteroscopies performed.

MAIN OUTCOME MEASUREMENTS

Trainee competence defined as CapCT score 90% or higher of the mean staff score.

RESULTS

A total of 39 fellows completed CE training and CapCT. Fellows were grouped according to number of completed CE interpretations: 10 or fewer (n = 13), 11 to 20 (n = 19), and 21 to 35 (n = 7). Eight CE staff completed CapCT with a mean score of 91%. Mean scores for trainees with fewer than 10, 11 to 20, and 21 to 35 CE interpretations were 79%, 79%, and 85%, respectively. A significant difference was seen between staff and fellow scores with 10 or fewer and 11 to 20 interpretations (P < .001). No correlation was found between trainee scores and previous endoscopy experience.

LIMITATIONS

Single center.

CONCLUSION

Using a structured CE training curriculum, we defined competency in CE interpretation by using the CapCT. Based on these findings, trainees should complete more than 20 CE studies before assessing competence, regardless of previous endoscopy experience.

Endoscopic assessment and grading of Barrett's esophagus using magnification endoscopy and narrow band imaging: impact of structured learning and experience on the accuracy of the Amsterdam classification system

OBJECTIVE

Several classification systems have been launched to characterize Barrett's esophagus (BE) mucosa using magnification endoscopy with narrow band imaging (ME-NBI). The good accuracy and interobserver agreement described in the early reports were not reproduced subsequently. Recently, we reported somewhat higher accuracy of the classification developed by the Amsterdam group. The critical question then formulated was whether a structured learning program and the level of experience would affect the clinical usefulness of this classification.

MATERIAL & METHODS

Two hundred and nine videos were prospectively captured from patients with BE using ME-NBI. From these, 70 were randomly selected and evaluated by six endoscopists with different levels of expertise, using a dedicated software application. First, an educational set was studied. Thereafter, the 70 test videos were evaluated. After classification of each video, the respective histological feedback was automatically given.

RESULTS

Within the learning process, there was a decrease in the time needed for evaluation and an increase in the certainty of prediction. The accuracy did not increase with the learning process. The sensitivity for detection of intestinal metaplasia ranged between 39% and 57%, and for neoplasia between 62% and 90%, irrespective of assessor's expertise. The kappa coefficient for the interobserver agreement ranged from 0.25 to 0.30 for intestinal metaplasia, and from 0.39 to 0.48 for neoplasia.

CONCLUSION

Using a dedicated learning program, the ME-NBI Amsterdam classification system is suboptimal in terms of accuracy and inter- and intraobserver agreements. These results reiterate the questionable utility of corresponding classification system in clinical routine practice.

Can we improve the detection rate and interobserver agreement in capsule endoscopy?

BACKGROUND

Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking.

AIM

(1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters.

METHODS

17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard).

RESULTS

The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience.

CONCLUSIONS

Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.

Capsule endoscopy with flexible spectral imaging color enhancement reduces the bile pigment effect and improves the detectability of small bowel lesions

BACKGROUND

Capsule endoscopy with flexible spectral imaging color enhancement (CE-FICE) has been reported to improve the visualization and detection of small-bowel lesions, however, its clinical usefulness is still not established. Therefore, we conducted a study to evaluate whether CE-FICE contributes to improve the detectability of small-bowel lesions by CE trainees.

METHODS

Four gastroenterology trainees without prior CE experience were asked to read and interpret 12 CE videos. Each of the videos was read by conventional visualization method and under three different FICE settings. To evaluate whether the lesion recognition ability of the CE trainees could be improved by the FICE technology, the lesion detection rate under each of the three FICE settings was compared with that by conventional CE. CE trainees tend to miss small-bowel lesions in bile-pigment-positive condition, therefore we evaluated whether CE-FICE contributes to reducing the bile-pigment effect. The bile-pigment condition was determined by the color values around the small-bowel lesions according to the results of the receiver-operating-characteristic analysis. Moreover, we also evaluated whether poor bowel preparion might affect the accuracy of lesion recognition by CE-FICE.

RESULTS

Of a total of 60 angioectasias, CE trainees identified 26 by conventional CE, 40 under FICE setting 1, 38 under FICE setting 2, and 31 under FICE setting 3. Of a total of 82 erosions/ulcerations, CE trainees identified 38 by conventional CE, 62 under FICE setting 1, 60 under FICE setting 2, and 20 under FICE setting 3. Compared with conventional CE, FICE settings 1 and 2 significantly improved the detectability of angioectasia (P = 0.0017 and P = 0.014, respectively) and erosions/ulcerations (P = 0.0012 and P = 0.0094, respectively). Although the detectability of small-bowel lesions by conventional CE (P = 0.020) and under FICE setting 2 (P = 0.0023) was reduced by the presence of bile-pigments, that under FICE setting 1 was not affected (P = 0.59). Our results also revealed that in poor bowel visibility conditions, CE-FICE yielded a high rate of false-positive findings.

CONCLUSIONS

CE-FICE may reduce the bile-pigment effect and improve the detectability of small-bowel lesions by CE trainees; the reliability of CE-FICE may be improved by good bowel preparation.

Training in Capsule Endoscopy: Are We Lagging behind?

Capsule endoscopy (CE) is a new modality to investigate the small bowel. Since it was invented in 1999, CE has been adopted in the algorithm of small bowel investigations worldwide. Reporting a CE video requires identification of landmarks and interpretation of pathology to formulate a management plan. There is established training infrastructure in place for most endoscopic procedures in Europe; however despite its wide use, there is a lack of structured training for CE. This paper focuses on the current available evidence and makes recommendations to standardise training in CE.

Provision of service and training for small bowel endoscopy in the UK

OBJECTIVE

To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery.

DESIGN

Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training.

RESULTS

45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses.

CONCLUSIONS

Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

Evaluations of capsule endoscopy software in reducing the reading time and the rate of false negatives by inexperienced endoscopists

BACKGROUND AND OBJECTIVE

Capsule endoscopy (CE) is a comfortable for the patients; however, CE review is time-consuming. The aim of this study was (1) to evaluate the effectiveness of the CE software in reducing the CE reading time and the number of false negatives by beginners, and (2) to determine the learning curve for reading CE images.

METHODS

Capsule endoscopic images were captured by Pillcam SB (Given Imaging Ltd, Tokyo, Japan), and analyzed using the proprietary RAPID 5 software. Comparison of CE reading using different software modes: manual mode, automatic mode, and QuickView (QV) mode. Three trainee endoscopists participated as CE readers. Each participant watched CE videos in which positive findings had been predefined by trained endoscopists. Each participant read the same CE record by using one of three different software modes. These were blinded on clinical history of patients. CE reading time was recorded, and the number of false negatives was counted. Each trainee endoscopist read a total of 45 CE videos, in five steps divided into nine videos per step.

RESULTS

There was no significant reader associated difference between the results for the different modes. The QV software did miss some positive findings. Therefore, the total number of instances of FN by the software plus the reader in the QV mode was significantly higher than the others. The reading times in the automatic mode and the QV mode were significantly shorter than that in the manual mode. After the second step, the number of instances of false negatives significantly decreased.

CONCLUSIONS

CE software is useful for reducing the reading time. Experience of approximately 20 CE readings can be considered as the first step to becoming an expert.