Prospective assessment of colonoscopic intubation skills in trainees

Can my surgeon scope? Trends in endoscopy training volume and experience among general surgery residents in the United States: a nationwide analysis

INTRODUCTION

Endoscopy is a major part of surgical training. Accreditation Council for Graduate Medical Education (ACGME) has set standards regarding the minimum volume of endoscopy cases required for graduation. However, there is paucity of high-quality data on the number of cases that most surgical graduates perform.

METHODS

We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from ACGME-accredited programs from 2010 to 2023. Data on mean number of endoscopy cases, including mean in each subcategory, were retrieved. Mann-Kendall trend test was used to investigate trends in endoscopy experience.

RESULTS

Between 2010 and 2023, the mean overall endoscopy procedures per resident remained stable, with 129.5 in 2010 and 132.1 in 2023 (t = 0.429; p-value = 0.037). The majority of these cases were performed as surgeon junior (76.6% in 2010; 80.9% in 2023), while the remaining cases were logged as surgeon chief. The most substantial contribution to the overall volume was from flexible colonoscopy (mean: 64.1 in 2010 and 67.2 in 2023). The volume for colonoscopy remained fairly stable (t = 0.429; p-value = 0.036). This was followed by esophagogastroduodenoscopy (mean: 35.3 in 2010 and 35.5 in 2023), which saw a significant increase in volume (t = 0.890; p-value ≤ 0.001). There was a significant increase in the number of overall upper endoscopic procedures (t = 0.791; p-value ≤ 0.001), while lower endoscopic procedures did not change significantly (t = 0.319; p-value = 0.125). The procedural volume for endoscopic retrograde cholangiography, sigmoidoscopy, cystoscopy/ureteroscopy, laryngoscopy, and bronchoscopy decreased significantly (p-value < 0.05 for all).

CONCLUSION

The overall endoscopy volume for general surgery residents has largely remained stable, with a minor increase in esophagogastroduodenoscopy and no change in colonoscopy. Future research should investigate whether simulation-based exercises can bridge the gap between procedural volume and learning curve requirements for endoscopy.

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.

Using computerized assessment in simulated colonoscopy: a validation study

Background and study aims  Patient safety during a colonoscopy highly depends on endoscopist competence. Endoscopic societies have been calling for an objective and regular assessment of the endoscopists, but existing assessment tools are time-consuming and prone to bias. We aimed to develop and gather evidence of validity for a computerized assessment tool delivering automatic and unbiased assessment of colonoscopy based on 3 dimensional coordinates from the colonoscope. Methods  Twenty-four participants were recruited and divided into two groups based on experience: 12 experienced and 12 novices. Participants performed twice on a physical phantom model with a standardized alpha loop in the sigmoid colon. Data was gathered directly from the Olympus ScopeGuide system providing XYZ-coordinates along the length of the colonoscope. Five different motor skill measures were developed based on the data, named: Travel Length, Tip Progression, Chase Efficiency, Shaft movement without tip progression, and Looping. Results  The experinced had a lower travel length ( P  < 0.001), tip progression ( P  < 0.001), chase efficiency ( P  = 0.001) and looping ( P  = 0.006), and a higher shaft movement without tip progression ( P  < 0.001) reaching the cecum compared with the novices. A composite score was developed based on the five measurements to create a combined score of progression, the 3D-Colonoscopy-Progression-Score (3D-CoPS). The 3D-CoPS revealed a significant difference between groups (experienced: 0.495 (SD 0.303) and novices -0.454 (SD 0.707), P  < 0.001). Conclusion  This study presents a novel, real-time computerized assessment tool for colonoscopy, and strong evidence of validity was gathered in a simulation-based setting. The system shows promising opportunities for automatic, unbiased and continuous assessment of colonoscopy performance.

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.

Trainee colonoscopy quality is influenced by the independent and unobserved performance characteristics of supervising physicians

Background  Endoscopy training remains an apprenticeship, and the characteristics that facilitate transfer of high quality procedural skills from role models to trainees are unknown. We sought to determine whether unobserved supervisor performance influences the quality of colonoscopy performed by trainees, by studying how supervisors perform alone and how trainees perform while under those same supervisors. Methods  This was a retrospective cross-sectional study conducted among ambulatory adults ≥ 50 years old who underwent colonoscopy for cancer screening or polyp surveillance from 2006 to 2015 at one academic medical center. The primary exposures were the colonoscopy withdrawal time (WT) and adenoma detection rate (ADR) of supervisors while performing colonoscopies alone. The primary outcomes were the WT and ADR of trainees performing colonoscopies under supervision. Results  Data were included from 22 attending gastroenterologist supervisors, 56 gastroenterology fellow trainees, and 2777 adults undergoing 3094 colonoscopy procedures. Among all supervised colonoscopies, mean trainee WT was 12.7 minutes (SD 4.9) and trainee ADR was 33.5 %. The trainee WT was 0.42 minutes longer (standard error = 0.16, P  = 0.01) per minute increase in supervisor WT. Similarly, trainee ADR was higher under a high ADR supervisor, and the odds ratio of high compared to low supervisor ADR category was 1.28 (95 %CI 1.01 - 1.62, P  = 0.04) after adjusting for other factors. Conclusions  The unobserved performance characteristics of supervising endoscopists may influence the quality of colonoscopy performed by trainees.

Education and Training Guidelines for the Board of the Korean Society of Gastrointestinal Endoscopy

The Korean Society of Gastrointestinal Endoscopy (KSGE) developed a gastrointestinal (GI) endoscopy board in 1995 and related regulations. Although the KSGE has acquired many specialists since then, the education and training aims and guidelines were insufficient. During GI fellowship training, obtaining sufficient exposure to some types of endoscopic procedures is difficult. Fellows should acquire endoscopic skills through supervised endoscopic procedures during GI fellowship training. Thus, the KSGE requires training guidelines for fellowships that allow fellows to perform independent endoscopic procedures without supervision. This document is intended to provide principles that the Committee of Education and Training of the KSGE can use to develop practical guidelines for granting privileges to perform accurate GI endoscopy safely. The KSGE will improve the quality of GI endoscopy by providing guidelines for fellowships and supervisors.

Correlation between obesity and metabolic syndrome-related factors and cecal intubation time during colonoscopy

Purpose

To investigate which colonoscopy (CS) cases should be presided over by endoscopists in training, using factors including obesity and metabolic syndrome.

Patients and methods

Items investigated were sex, age, body mass index (BMI), waist circumference, hypertension, diabetes, hyperlipidemia, history of abdominal surgery (excluding colectomy), colon diverticulosis, prescription of antithrombotic agents, and quality of bowel preparation. Expert physicians were defined as those with at least 9 years of endoscopy experience; all other physicians were defined as being in training. In a retrospective analysis, cases in which a physician in training reached the cecum within 15 minutes without requiring the involvement of the supervising physician were defined as eligible cases over which a physician in training should preside, while other cases were defined as non-eligible.

Results

Overall, 813 CS cases were analyzed. Males (P<0.0001), cases started by an expert physician (P<0.0001), cases of no fellow physician involvement (P<0.0001), and cases with good bowel preparation (P<0.0001) had significantly shorter cecal intubation times. Of the 562 cases presided over by a physician in training, 194 were deemed eligible and 368 non-eligible. The eligible cases had a higher proportion of males (P=0.017), younger age (P=0.033), higher BMI (P=0.034), and higher rates of hypertension (P=0.001) and good bowel preparation (P=0.001). In analysis by sex, males demonstrated significantly more eligible cases among younger patients (P=0.009) and those with good bowel preparation (P=0.008), while there were significantly more eligible cases among females with hypertension (P=0.004).

Conclusion

It may be useful to select CS cases for physicians considering sex, age, BMI, hypertension, and bowel preparation.

The efficacy of training insertion skill on a physical model colonoscopy simulator

Background and study aims: Prior research supports the validity of performance measures derived from the use of a physical model colonoscopy simulator - the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd., Kyoto, Japan) - for assessing insertion skill. However, its use as a training tool has received little research attention. We assessed the efficacy of a brief structured program to develop basic colonoscope insertion skill through unsupervised practice on the model. Participants and methods: This was a training study with pretesting and post-testing. Thirty-two colonoscopy novices completed an 11-hour training regime in which they practiced cases on the model in a colonoscopy simulation research laboratory. They also attempted a series of test cases before and after training. For each outcome measure (completion rates, time to cecum and peak force applied to the model), we compared trainees' post-test performance with the untrained novices and experienced colonoscopists from a previously-reported validation study. Results: Compared with untrained novices, trained novices had higher completion rates and shorter times to cecum overall (Ps < .001), but were out-performed by the experienced colono-scopists on these metrics (Ps < .001). Nevertheless, their performance was generally closer to that of the experienced group. Overall, trained novices did not differ from either experience-level comparison group in the peak forces they applied (P > .05). We also present the results broken down by case. Conclusions: The program can be used to teach trainees basic insertion skill in a more or less self-directed way. Individuals who have completed the program (or similar training on the model) are better prepared to progress to supervised live cases.

Does a Pre-Training Program Influence Colonoscopy Proficiency during Fellowship?

OBJECTIVES

The objective of this study was to determine whether a pre-training program influences the entire learning process and overall proficiency of colonoscopy during fellowship.

METHODS

From March 2011 to February 2013, a total of 28 first-year gastrointestinal fellows were trained in colonoscopy at a single tertiary center. Before entering their fellowship training, all fellows were board certified in internal medicine, but had no experience performing a full colonoscopy. Endoscopic quality indices were prospectively measured throughout the first training year and were compared between two groups, "pre-trained" fellows (n = 14), who had more than 100 cases of upper endoscopy experience and colonoscopy observation before starting their fellowship, and the "not pre-trained" group (n = 14), who had less experience.

RESULTS

A total of 15,494 colonoscopies were evaluated and 5,411 were screening colonoscopies. There were no significant differences in the overall quality index between the pre-trained and not pre-trained groups. However, the improvement in the adenoma detection rate (ADR) from the first half of the year to the latter half was significantly higher for the pre-trained group compared to the not pre-trained group (28.6% to 34.5% vs. 36.7% to 28.3%, respectively, P = 0.007). Multivariate analysis showed that pre-training before learning colonoscopy was the only significant factor for high ADR in the second half of the year (11.666 ± 4.251 [B±SE], P = 0.012).

CONCLUSION

Sufficient observation of colonoscopy and experience of upper endoscopy before colonoscopy training might facilitate improvement of fellows' manual and cognitive colonoscopic skills during the learning period.

Learning curve for endoscopy training: Is it all about numbers?

Endoscopy training is an important component of postgraduate gastroenterology and general surgery programs. Proficiency in endoscopy requires the development of several tangible and intangible skills. Much attention has traditionally been paid to establishing a threshold, or minimum procedural volume during the training period, which is necessary for a trainee to achieve competence in endoscopy by the conclusion of his or her program. However, despite several attempts to characterize this target, it has become clear in recent years that training programs need to consider other factors rather than relying on this measure as the sole marker of trainee competency. Here, we present a review of general concepts in endoscopy skills acquisition that affect the learning curve, the evolving definition of competency as it relates to procedural volume, the role of simulation in endoscopy training, and the concept of massed versus spaced delivery of endoscopy training.

In-training gastrointestinal endoscopy competency assessment tools: Types of tools, validation and impact

The ability to perform endoscopy procedures safely, effectively and efficiently is a core element of gastroenterology practice. Training programs strive to ensure learners demonstrate sufficient competence to deliver high quality endoscopic care independently at completion of training. In-training assessments are an essential component of gastrointestinal endoscopy education, required to support training and optimize learner's capabilities. There are several approaches to in-training endoscopy assessment from direct observation of procedural skills to monitoring of surrogate measures of endoscopy skills such as procedural volume and quality metrics. This review outlines the current state of evidence as it pertains to in-training assessment of competency in performing gastrointestinal endoscopy as part of an overall endoscopy quality and skills training program.

Training and competence assessment in GI endoscopy: a systematic review

INTRODUCTION

Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme.

AIMS

The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence.

METHODS

A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round.

RESULTS

The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance.

CONCLUSIONS

The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.

Training and Assessment in Pediatric Endoscopy

A key aspect of pediatric gastroenterology practice is the ability to perform endoscopy procedures safely, effectively, and efficiently. Similar to adult endoscopy, performance of pediatric endoscopy requires the acquisition of related technical, cognitive, and integrative competencies to effectively diagnose and manage gastrointestinal disorders in children. However, the distinctive requirements of pediatric patients and their families and the differential spectrum of disease highlight the need for a pediatric-specific training curriculum and assessment framework to ensure endoscopic procedures are performed safely and successfully in children. This review outlines the current state of evidence as it pertains to pediatric endoscopy training and assessment.

Polyp detection rates using magnification with narrow band imaging and white light

AIM: To compare the yield of adenomas between narrow band imaging and white light when using high definition/magnification.

METHODS: This prospective, non-randomized comparative study was performed at the endoscopy unit of veteran affairs medical center in Phoenix, Arizona. Consecutive patients undergoing first average risk colorectal cancer screening colonoscopy were selected. Two experienced gastroenterologists performed all the procedures that were blinded to each other’s findings. Demographic details were recorded. Data are presented as mean ± SEM. Proportional data were compared using the χ² test and means were compared using the Student’s t test. Tandem colonoscopy was performed in a sequential and segmental fashion using one of 3 strategies: white light followed by narrow band imaging [Group A: white light (WL) → narrow band imaging (NBI)]; narrow band imaging followed by white light (Group B: NBI → WL) and, white light followed by white light (Group C: WL → WL). Detection rate of missed polyps and adenomas were evaluated in all three groups.

RESULTS: Three hundred patients were studied (100 in each Group). Although the total time for the colonoscopy was similar in the 3 groups (23.8 ± 0.7, 22.2 ± 0.5 and 24.1 ± 0.7 min for Groups A, B and C, respectively), it reached statistical significance between Groups B and C (P < 0.05). The cecal intubation time in Groups B and C was longer than for Group A (6.5 ± 0.4 min and 6.5 ± 0.4 min vs 4.9 ± 0.3 min; P < 0.05). The withdrawal time for Groups A and C was longer than Group B (18.9 ± 0.7 min and 17.6 ± 0.6 min vs 15.7 ± 0.4 min; P < 0.05). Overall miss rate for polyps and adenomas detected in three groups during the second look was 18% and 17%, respectively (P = NS). Detection rate for polyps and adenomas after first look with white light was similar irrespective of the light used during the second look (WL → WL: 13.7% for polyps, 12.6% for adenomas; WL → NBI: 14.2% for polyps, 11.3% for adenomas). Miss rate of polyps and adenomas however was significantly higher when NBI was used first (29.3% and 30.3%, respectively; P < 0.05). Most missed adenomas were ≤ 5 mm in size. There was only one advanced neoplasia (defined by size only) missed during the first look.

CONCLUSION: Our data suggest that the tandem nature of the procedure rather than the optical techniques was associated with the detection of additional polyps’ and adenomas.

Technical skills assessment toolbox: a review using the unitary framework of validity

OBJECTIVE

The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity.

BACKGROUND

Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency.

METHODS

A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills.

RESULTS

A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables.

CONCLUSIONS

This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.

Trainee colonoscopists fulfil quality standards for the detection of adenomatous polyps

BACKGROUND

The detection of adenomatous lesions is a major indicator for quality and competence in colonoscopy. Little is known about adenoma detection rates (ADR) of endoscopy trainees. The aim of our study was to investigate the performance of trainee colonoscopists in detecting adenomas and to depict the shape of adenoma detection learning curves during apprenticeship.

METHODS

We retrospectively investigated a prospectively maintained database of a single tertiary referral center to reveal colonoscopies performed by trainee endoscopists during 2001 and 2013. Colonoscopy reports were chronologically retrieved and separately analyzed for each trainee. Using cumulative curves, courses of trainee's Adenoma detection rates (ADR) during apprenticeship were displayed. Additionally, procedural data including cecal intubation rate and occurrence of complications were assessed.

RESULTS

We retrospectively analyzed 4354 colonoscopies conducted by 10 trainee endoscopists (TE). A median number of 371 investigations were performed by each apprentice. Group ADR was 23%. No significant difference between aggregated ADRs at the beginning (23%) and at the end (22%) of apprenticeship could be determined (p = 0.70). However, individual learning curves showed considerable different slopes. Personal ADR values ranged between 17% and 31%. Overall cecum intubation rate was 99.0 %. Complication rates were low and fulfilled quality requirements recommended in guidelines.

CONCLUSION

From the beginning of education, trainee colonoscopists are capable to provide high-quality investigations considering the detection of adenomas as a benchmark quality indicator. Nevertheless, performance differs markedly between investigators. Therefore, individual detection rates should be reviewed regularly to reveal further need for training.

Predictors for cecal insertion time: the impact of abdominal visceral fat measured by computed tomography

BACKGROUND

Several factors affect the risk for longer cecal insertion time.

OBJECTIVE

The aim of this study was to identify the predictors of longer insertion time and to evaluate the effect of visceral fat measured by CT.

DESIGN

This is a retrospective observational study.

PATIENTS

Outpatients for colorectal cancer screening who underwent colonoscopies and CT were enrolled. Computed tomography was performed in individuals who requested cancer screening and in those with GI bleeding.

MAIN OUTCOME MEASURES

Information on obesity indices (BMI, visceral adipose tissue, and subcutaneous adipose tissue area), constipation score, history of abdominal surgery, poor preparation, fellow involvement, diverticulosis, patient discomfort, and the amount of sedation used was collected.

RESULTS

The cecal insertion rate was 95.2% (899/944), and 899 patients were analyzed. Multiple regression analysis showed that female sex, lower BMI, lower visceral adipose tissue area, lower subcutaneous adipose tissue area, higher constipation score, history of surgery, poor bowel preparation, and fellow involvement were independently associated with longer insertion time. When obesity indices were considered simultaneously, smaller subcutaneous adipose tissue area (p = 0.038), but not lower BMI (p = 0.802) or smaller visceral adipose tissue area (p = 0.856), was associated with longer insertion time; the other aforementioned factors remained associated with longer insertion time. In the subanalysis of normal-weight patients (BMI <25 kg/m), a smaller subcutaneous adipose tissue area (p = 0.002), but not a lower BMI (p = 0.782), was independently associated with a longer insertion time. Longer insertion time had a positive correlation with a higher patient discomfort score (ρ = 0.51, p < 0.001) and a greater amount of midazolam use (ρ = 0.32, p < 0.001).

LIMITATIONS

This single-center retrospective study includes a potential selection bias.

CONCLUSIONS

In addition to BMI and intra-abdominal fat, female sex, constipation, history of abdominal surgery, poor preparation, and fellow involvement were predictors of longer cecal insertion time. Among the obesity indices, high subcutaneous fat accumulation was the best predictive factor for easier passage of the colonoscope, even when body weight was normal.

Development of the gastrointestinal endoscopy competency assessment tool for pediatric colonoscopy (GiECAT KIDS)

OBJECTIVES

Many aspects of pediatric colonoscopy differ from adult practice. To date, there is no validated measure of endoscopic competence for use in pediatrics. Using Delphi methodology, we aimed to determine expert consensus regarding items required on a checklist and global rating scale designed to assess the competence of clinicians performing colonoscopy on pediatric patients.

METHODS

A total of 41 North American pediatric endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform pediatric colonoscopy. Responses were analyzed and re-sent to the panel for further ratings until consensus was reached. Items that ≥ 80% of experts rated as ≥ 4 out of 5 were included in the final instrument. Consensus items were compared with those items deemed by adult endoscopy experts as fundamental to assessing the performance of adult colonoscopy.

RESULTS

Five rounds of surveys were completed with response rates ranging from 76% to 100%. Seventy-five checklist and 38 global rating items were reduced to 18 checklist and 7 global rating items that reached consensus. Three pediatric checklist items differed from those considered to be critical adult indicators, whereas 4 items on the latter did not reach consensus among pediatric experts.

CONCLUSIONS

Delphi methodology allowed for achievement of expert consensus regarding essential items to be included in the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECATKIDS), a measure of endoscopic competence specific to performing pediatric colonoscopy. Key differences in the checklist items, compared with items reaching consensus during a separate adult Delphi process using the same indicators, emphasize the need for a pediatric-specific tool.

Assessment of competence in pediatric gastrointestinal endoscopy

Gastrointestinal endoscopy is an invaluable tool for the diagnosis and treatment of upper and lower gastrointestinal diseases in children. Pediatric and adult endoscopy differ in several respects including differences in procedural indications, sedation practices, pre-procedure preparation, equipment, and the importance of routine tissue sampling and terminal ileum intubation. In the same way that performance of endoscopy in children requires pediatric-specific training, assessment of pediatric endoscopists requires an approach that is tailored to pediatric practice and the use of assessment methods and measures that have been developed and validated specifically within the pediatric context.

Development of a program to train physician extenders to perform transnasal esophagoscopy and screen for Barrett's esophagus

BACKGROUND & AIMS

Screening for Barrett's esophagus (BE) and esophageal adenocarcinoma is not recommended because it was not found to be cost effective. However, physician extenders (PEs) are able to perform unsedated procedures; their involvement might reduce the costs of BE screening. We examined the feasibility of training PEs to independently perform transnasal esophagoscopy (TNE) and screen patients for BE and measured their learning curve.

METHODS

Two PEs at a Veterans Affairs (VA) medical center underwent a structured didactic training program and observed nasopharyngoscopies before performing TNE under the supervision of attending endoscopists. Individual technical and cognitive components of TNE were rated on a 9-point structured scale. Learning curves were constructed using cumulative summation. Once the PEs were judged to be technically competent, each PE performed 10 independent videotaped TNEs, which were graded.

RESULTS

Both PEs identified anatomic landmarks after 18 consecutive procedures. PE1 and PE2 performed satisfactory nasal intubations after 20 and 25 procedures and esophageal intubations after 29 and 35 procedures, respectively. They acquired overall competence after supervised training on 43 and 47 procedures, respectively.

CONCLUSIONS

We developed a program at a VA medical center to train PEs to perform TNE to screen for BE. The PEs were able to perform TNE and recognize esophageal landmarks independently after a modest number of supervised procedures.

Gastrointestinal Endoscopy Competency Assessment Tool: development of a procedure-specific assessment tool for colonoscopy

BACKGROUND

Ensuring competence remains a seminal objective of endoscopy training programs, professional organizations, and accreditation bodies; however, no widely accepted measure of endoscopic competence currently exists.

OBJECTIVE

By using Delphi methodology, we aimed to develop and establish the content validity of the Gastrointestinal Endoscopy Competency Assessment Tool for colonoscopy.

DESIGN

An international panel of endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform colonoscopy. After each round, responses were analyzed and sent back to the experts for further ratings until consensus was reached.

MAIN OUTCOME MEASUREMENTS

Consensus was defined a priori as ≥80% of experts, in a given round, scoring ≥4 of 5 on all remaining items.

RESULTS

Fifty-five experts agreed to be part of the Delphi panel: 43 gastroenterologists, 10 surgeons, and 2 endoscopy managers. Seventy-three checklist and 34 global rating items were generated through a systematic literature review and survey of committee members. An additional 2 checklist and 4 global rating items were added by Delphi panelists. Five rounds of surveys were completed before consensus was achieved, with response rates ranging from 67% to 100%. Seven global ratings and 19 checklist items reached consensus as good indicators of the competence of clinicians performing colonoscopy.

LIMITATIONS

Further validation required.

CONCLUSION

Delphi methodology allowed for the rigorous development and content validation of a new measure of endoscopic competence, reflective of practice across institutions. Although further evaluation is required, it is a promising step toward the objective assessment of competency for use in colonoscopy training, practice, and research.

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.

Evaluation of Feedback Enabled Active Colonoscopy Training Model

The objective of this research is to evaluate the efficacy of an active colonoscopy training model (ACTM). Colonoscopy is a widely utilized procedure for diagnosing diseases of the lower gastrointestinal tract. Since colonoscopy is a difficult procedure to teach, as well as learn, simulators are often used to teach and practice the procedure. To make learning and assessing the procedural skills easy and interactive, an active training model was developed and evaluated. To measure the applied force and the time to complete the procedure, load cells and light detecting sensors were installed in the training model and were interfaced with a data acquisition system. The user interface was programmed in LabVIEW to record the force data and time taken to complete the procedure. Thirty medical students were recruited to perform a series of three colonoscopies on the ACTM. These students were instructed how to handle the equipment and perform the colonoscopy. The procedure was also performed by experienced endoscopists to establish a benchmark. The collected data were analyzed to determine the effectiveness of the device to (1) distinguish between the participants based on their level of expertise, and (2) to detect improvement in skill of the students with repetitive sessions with the device. The results of this research may be useful to show that the ACTM may be an effective tool to integrate in to the medical training program of medical studies. It can be possibly used for evaluating the skill sets, as well as practicing the procedure before a novice surgeon performs the procedure on a patient.

Predictive factors affecting cecal intubation failure in colonoscopy trainees

BACKGROUND

Successful cecal intubation (SCI) is not only a quality indicator but also an important marker in a colonoscopy trainee's progress. We conducted this study to determine factors predicting SCI in colonoscopy trainees, and to compare these factors before and after trainees achieve technical competence.

METHODS

Design of this study was a cross-sectional studies of two time series design for one year at a single center. From March 2011 to February 2012, a total 2,050 subjects who underwent colonoscopy by four first-year gastrointestinal fellows were enrolled at Christian hospital, Wonju, Republic of Korea. Four gastrointestinal fellows have filled out the colonoscopic documentation. Main outcome measurement was predictive factors affecting cecal intubation failure and learning curves.

RESULTS

Colonoscopy was successfully completed to the cecum in 1,720 patients (83.9%). Success rates gradually increased as trainees performed more colonoscopies: the rate of SCI was 62% in the first 50 cases, and grew to 93% by the 250th case. Logistic regression analysis of factors affecting cecal intubation failure showed that female gender, low BMI (BMI < 18.5 kg/m²), poor bowel preparation, and past history of stomach surgery were more often associated with cecal intubation failure, particularly before the trainees achieved technical competence.

CONCLUSION

Several patient characteristics were identified that may predict difficulty of cecal intubation in colonoscopy trainees. Particularly, low BMI, inadequate bowel cleansing, and previous stomach operation were predictors of cecal intubation failure before the trainees have reached technical competency. The results could be informative so that trainees enhance the success rate regarding better colonoscopy training programs.

Body mass index predicts cecal insertion time: the higher, the better

BACKGROUND

It is essential to determine the factors that predict prolonged procedural time during colonoscopy. The aim of this study was to determine the effect of body mass index (BMI) on cecal insertion time (CIT) during colonsocopy.

METHODS

Consecutive outpatients who received colonoscopies over a 10 month period (April-October 2007) were enrolled. Exclusion criteria included colonic resection, strictures or exophytic masses precluding colonic evaluation. Data were collected for age, sex, race, height, weight, BMI, waist circumference, prior history of abdominal or pelvic surgery, history of diverticulosis, participation of fellow, CIT, quality of colon cleansing and the amount of sedation used during the procedure.

RESULTS

A total of 1430 patients (586 men and 844 women; mean age 60.3 years) were included in the final analysis. The mean CIT was 648.5 seconds (SE = 11.47). Older age, female gender, fellow involvement, poor bowel preparation and lower BMI were associated with prolonged mean CIT on linear regression analysis ((R2) = 0.116; P < 0.001). Mean CIT declined linearly with increasing BMI.

CONCLUSION

A higher BMI is strongly associated with progressively shorter CIT.

Interim report of a randomized cross-over study comparing clinical performance of novice trainee endoscopists using conventional air insufflation versus warm water infusion colonoscopy

BACKGROUND

The applicability of water method colonoscopy in trainee education is not known.

AIM

To compare the water method vs. usual air method in teaching novice trainee colonoscopy.

METHOD

An IRB approved prospective randomized cross-over study (NCT01482546) in a university setting with diverse patient population.

DESIGN

Three first year GI fellows consented to participate in the study. Trainees were randomized to learn with either usual air method or the water method in performing colonoscopy with a dedicated endoscopy attending during their weekly outpatient endoscopy clinics for the initial six months of training and then cross-over to the other method for the remaining six months.

PATIENTS

Patients undergoing screening, surveillance or diagnostic colonoscopy.

RESULTS

The interim data revealed no significant difference in age, gender, and body mass index (BMI). Trainees rated the water method colonoscopy as significantly easier to learn compared to the air method (p=0.007).

CONCLUSIONS

The interim data demonstrate positive effects of using the water method in training novice endoscopists who reported a significant ease of learning colonoscopy using this method. Training programs could consider joining us in evaluating the use of warm water infusion in colonoscopy education.

Construct validation of a physical model colonoscopy simulator

BACKGROUND

Previous studies have demonstrated the construct validity of virtual reality colonoscopy simulators by showing that they can distinguish between users according to their level of endoscopic experience. Although physical model simulators are known to simulate looping more realistically than these devices, they lack published validation evidence.

OBJECTIVE

To assess the construct validity of a physical model simulator, the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd, Kyoto, Japan) and to determine its suitability for assessing the insertion skill of trainee colonoscopists.

DESIGN

Validation study; 21 experienced colonoscopists and 18 novices made 2 attempts at each of 4 standard cases on the Kyoto Kagaku physical model simulator, and we compared their performance on each case.

SETTING

A medical simulation center in a large tertiary hospital.

MAIN OUTCOME MEASUREMENTS

Completion rates, times to cecum, and peak forces applied to the colon model.

RESULTS

Compared with novices, experienced colonoscopists had significantly higher completion to cecum rates and shorter times to cecum for each of the 4 cases (all P < .005). For 2 cases, experienced colonoscopists also exerted significantly lower peak forces than did novices (both P = .01).

LIMITATIONS

Two of the model's 6 "standard cases" were not included in the study.

CONCLUSIONS

The 4 cases included in the study have construct validity in that they can distinguish between the performance of experienced colonoscopists and novices, reproducing experienced/novice differences found in real colonoscopy. These cases can be used to validly assess the insertion skill of colonoscopy trainees.

Magnetic endoscopic imaging saves abdominal compression and patient pain in routine colonoscopies

OBJECTIVE

Magnetic endoscope imaging (MEI) is a technique for the direct visualisation of endoscope configuration within the colon. This method may prevent loop formation by giving visual feedback of endoscope movement. This study aimed to evaluate the efficacy of MEI in improving colonoscopy performance.

METHODS

Overall 1000 consecutive patients who underwent a complete routine colonoscopy were randomized into two groups: in group A with MEI, while in group B without MEI. Sedation was performed according to local standards. In both groups time to reach the cecum, the number of positioning maneuvers and involvement of a second assistant nurse were recorded. Abdominal compression was graded from 1 to 4 according to the duration and intensity of compression was quantified using a scale from 1-3 according to compression form and patient reaction.

RESULTS

Patients were randomized (group A with MEI, n = 490; group B without MEI, n = 510) and a total colonoscopy was performed. Time to cecal intubation did not differ between the groups (507 s vs 538 s; NS). The duration of abdominal compression was significantly shorter in MEI guided colonoscopy. The intensity of abdominal compression was lower in group A and fewer turn maneuvers needed per patient. A trend towards a reduced need for assistance in MEI group was seen.

CONCLUSION

Although MEI does not generally accelerate colonoscope advancement, it significantly reduces the force and the duration of abdominal compression by assistant personnel, thus minimizing patient discomfort and decreasing the need for additional staff.

Training to competency in colonoscopy: assessing and defining competency standards

BACKGROUND

How to define competency in colonoscopy, how to assess it, and how much training is required are questions that experts in endoscopy have grappled with since the advent of the procedure.

OBJECTIVE

To describe methods to assess core endoscopy skills in trainees and learning curves for these parameters and to define competency thresholds for these skills.

DESIGN

A prospective descriptive assessment of trainee colonoscopy performance.

SETTING

Mayo Clinic, Rochester, Minnesota.

SUBJECTS

Gastroenterology fellows undergoing endoscopy training.

INTERVENTION

From July 2007 through June 2010, fellows' core cognitive and motor colonoscopy skills were assessed by using the Mayo Colonoscopy Skills Assessment Tool (MCSAT).

MAIN OUTCOME MEASUREMENTS

Average MCSAT item scores and learning curves are described. Minimal competence thresholds for each MSCAT item are established by using the contrasting groups method.

RESULTS

Forty-one GI fellows performed 6635 colonoscopies; 4103 procedures (62%) were assessed by using the MCSAT. Average scores of 3.5 set the competency bar for each of the core skills and were reached by 275 procedures on average. Independent cecal intubation rates of 85% and cecal intubation times of 16 minutes or less were also achieved at 275 procedures on average.

LIMITATIONS

Limited to a single center.

CONCLUSIONS

Learning curves for core colonoscopy skills are described. MCSAT scores of 3.5, cecal intubation rates of 85%, and intubation times of less than 16 minutes are recommended as minimal competency criteria. It takes on average 275 procedures to achieve competence in colonoscopy. This is more than previous gastroenterology training recommendations and far more than current training requirements in other specialties.

Observational tools for assessment of procedural skills: a systematic review

BACKGROUND

Assessment by direct observation of procedural skills is an important source of constructive feedback. The aim of this study was to identify observational tools for technical skill assessment, to assess characteristics of these tools, and to assess their usefulness for assessment.

METHODS

Included studies reported tools for observational assessment of technical skills. A total of 106 articles were included.

RESULTS

Three main categories included global assessment scales evaluating generic skills (n = 29), task-specific methods assessing procedure-specific skills (n = 30), and combinations of tools evaluating both generic and task-specific skills (n = 47). In most studies, content validity was not evaluated using an accepted scientific method. All tools were assessed for inter-rater reliability and construct validity. Data on feasibility, acceptability, and educational impact were sparse.

CONCLUSIONS

There is evidence of validity and reliability for observational assessment tools at the trainee level. In most studies a comprehensive analysis of the tools was not achieved. Evaluation of technical skill using current observational assessment tools is not reliable and valid at the specialist level. Future research needs to focus on further systematic tool development and analysis, especially at the specialist level.

Overview of methods for flexible endoscopic training and description of a simple explant model

The question of how to train surgeons in flexible endoscopy has been debated over the years as these skills have become an essential part of residency and practice. As many as two-thirds of surgeons perform flexible endoscopy, and for many, endoscopy represents up to 50% of their practice. Training in flexible endoscopy has evolved over many decades from an apprenticeship-type model to a more formal training program. Surgical residencies vary widely in their approach, with some having dedicated endoscopy rotations and others using an integrated approach. Innate to a good training program are faculty dedicated to teaching, an established curriculum, and adequate exposure of residents to proper training tools, whether as patient-based learning or supplemented by simulators. Hands-on models for teaching surgical endoscopy include mechanical, animal, and computer-based platforms. Herein, we describe our experience with a low-cost approach using porcine stomach explants that offers a breadth of endoscopic training including scope navigation, band ligation, endoscopic mucosal resection, hemostasis management, esophageal stenting, foreign body extraction, and ERCP. Simulation-based learning must be validated from a construct and internal validity perspective to be considered useful. Correlation between simulator learning and improvement in clinically relevant skills must then be shown using a validated scale, such as the Global Assessment of Gastrointestinal Endoscopy Skills. Competency in flexible endoscopy, which is currently measured by case volume, may be replaced by objective programs, such as Fundamentals of Endoscopic Surgery, that combine didactic teaching, cognitive assessment, and hands-on technical skills evaluation to determine a minimum level of proficiency.

The Mayo Colonoscopy Skills Assessment Tool: validation of a unique instrument to assess colonoscopy skills in trainees

BACKGROUND

Defining competence in colonoscopy is elusive because there is no objective means by which to assess skills.

OBJECTIVE

We describe the development and validation of the Mayo Colonoscopy Skills Assessment Tool (MCSAT) designed for the assessment of cognitive and motor skills during colonoscopy training.

DESIGN

Prospective development and analysis of the validity evidence of a unique colonoscopy skills assessment tool.

SETTING

Outpatient endoscopy center, Mayo Clinic in Rochester, Minn, from July 2007 through May 2010.

SUBJECTS

All gastroenterology fellows in training at this institution during the study period.

INTERVENTION

The MCSAT was developed and used to assess fellow performance over a 3-year period.

MAIN OUTCOME MEASUREMENTS

A descriptive report of the form's development, correlation of each MCSAT assessment parameter with overall competency scores, and a comparison of MCSAT scores at various stages of training.

RESULTS

There is strong individual item correlation to overall skills assessment for many of the parameters as well as significant improvement in all parameter scoring at increasing stages of experience.

LIMITATIONS

Compliance with MCSAT completion was 62% of all colonoscopies performed.

CONCLUSIONS

The MCSAT provides a valid means to objectively assess individual cognitive and motor skills in a continuous manner throughout colonoscopy training. The resultant data can eventually be used to establish average learning curves in colonoscopic skills and define competency thresholds based on performance scores rather than basing assessment simply on numbers of procedures performed.

Morning-only one-gallon polyethylene glycol improves bowel cleansing for afternoon colonoscopies: a randomized endoscopist-blinded prospective study

OBJECTIVES

Inadequate bowel preparation is a known factor associated with increased failure rates of afternoon colonoscopy and lower adenoma detection rates. The aim of our study was to compare the efficacy of bowel cleansing achieved by administering 1-gallon (4 l) polyethylene glycol (PEG) preparation to patients in the morning of an afternoon colonoscopy with that of the traditional evening regimen.

METHODS

A prospective endoscopist-blinded study was conducted, in which patients undergoing afternoon colonoscopy were randomized to receive either 1 gallon of PEG the evening before the procedure or the morning of the colonoscopy. Bowel cleansing efficacy was scored by a blinded endoscopist using the Ottawa scale and each participant filled out a satisfaction survey. Mean scores for each bowel segment, composite mean scores, and rates of "good prep" interpreted from the Ottawa scale were compared between the two groups.

RESULTS

A total of 136 patients (mean age 51.8 years, 52.2% men) evenly distributed between the two groups formed the study sample. Patients in the morning group had significantly lower Ottawa scale scores and were more likely to have a good preparation for each bowel segment and overall when compared with the evening group (P<0.01). Moreover, patients in the morning group were over 50% less likely to lose sleep or have bloating compared with the evening group (P<0.05). There was no difference in the study groups on overall polyp detection rate, adenomatous polyps, or number of patients with adenomas.

CONCLUSIONS

This study shows that the bowel cleansing efficacy of morning-only 1-gallon PEG is superior and better tolerated compared with consumption of 1-gallon PEG in the evening before the day of an afternoon colonoscopy. Thus, administering 1-gallon PEG solution in the morning of an afternoon colonoscopy is a feasible option that can improve the quality of an afternoon colonoscopy.

Fellow perceptions of training using computer-based endoscopy simulators

BACKGROUND

Integrating procedural training by using computer-based endoscopic simulators (CBES) into gastroenterology fellowships may facilitate technical skill development, while posing no additional risk to patients.

OBJECTIVE

The aim of our study was to survey pediatric gastroenterology fellows about their experiences with and perceptions of CBES as compared with actual procedures, prior to and after exposure to both types of endoscopic learning.

DESIGN AND SETTING

All first-year trainees at Children's Hospital Boston (2003-2008) were invited to complete a written, pretraining questionnaire and then perform at least 10 each of CBES endoscopies and colonoscopies prior to performing actual procedures. Fellows completed a written, posttraining questionnaire after 4 months.

MAIN OUTCOME MEASUREMENTS

Survey responses.

RESULTS

All 25 first-year fellows (12 male, median age 30 years) over the 5-year period participated. Four months into their fellowships, fellows reported simulation to be helpful in increasing procedural skill and confidence. The number of sessions on the simulator was associated with reported increased colonoscopic skill and confidence (P = .032 and P = .007, respectively). All fellows reported it difficult to incorporate CBES into their work schedules. Only 28% of fellows reported performing 20 total CBES procedures, with most simulation sessions reportedly lasting less than 30 minutes. All participants rated faculty instruction with CBES as very helpful.

LIMITATIONS

This was a single-site study of pediatric trainees and may be limited in generalizability.

CONCLUSION

A few short sessions with CBES may be perceived as useful for endoscopic skill acquisition by pediatric gastroenterology trainees. Further exploration into how to assimilate CBES into busy gastroenterology training programs may be warranted.

Surgical resident's training in colonoscopy: numbers, competency, and perceptions

BACKGROUND

There is currently great discrepancy in the training requirements between medical societies regarding the recommended threshold number of colonoscopies needed to assess for technical competence. Our goal was to determine the number of colonoscopies performed by surgical residents, rate of cecal intubation, as well as trainee perceptions of colonoscopy training after completion of their training period.

METHODS

This study consisted of a 12-item electronic survey completed by 21 surgical residents after their 2-month endoscopy rotation at a tertiary care, urban referral center. This survey assessed numbers of colonoscopies performed, number successful to the cecum, and perceptions of training in colonoscopy. The cecal intubation rate was used as a surrogate marker of technical competence.

RESULTS

Twenty-one surgical residents performed a mean of 80 ± 35 total colonoscopies during the 2-month rotation. The average cecal intubation rate was 47% (range 9-78%). Resident comfort level for independently performing a total colonoscopy was scored a mean 3.6 on scale of 1-5 (5 = most comfortable), and 43% of the surgical residents planned on performing colonoscopy after residency training.

CONCLUSIONS

Surgical residents can obtain the recommended threshold for colonoscopy (N = 50) during a standard 2-month rotation. However, no resident was able to achieve technical competence in colonoscopy as defined by a 90% cecal intubation rate. These data suggest that the method of training of general surgery residents in colonoscopy may need reappraisal.

Evaluating changes in gastrointestinal endoscopy training over 5 years: closing the audit loop

BACKGROUND

An audit in 2002 showed that colonoscopy training in a large London training region was poorly structured, with the quality of supervision below recommendations and high reported complication rates. In 2004, the UK National Endoscopy Training Programme introduced centrally funded, accredited courses and new assessment tools to standardize training and raise the quality of colonoscopy by improving the skills of practicing endoscopists.

AIM

To evaluate the changes in the standard of colonoscopy training over the last 5 years.

METHODS

Questionnaires used in the earlier study were updated and e-mailed to all gastroenterology trainees in the region and those who participated in the earlier study. Trainees completed and returned the forms electronically.

RESULTS

Twenty-six out of 37 gastroenterology trainees responded (70.3%). Significantly more trainees said that they had been formally taught the principles of colonoscopy (91 vs. 65%; P = 0.02), polypectomy (81 vs. 52%; P = 0.02) and extubation (88 vs. 56%; P = 0.01) than in 2002, and reported that complication rates were lower. Trainers displayed more appropriate teaching strategies and course attendance had significantly increased (84 vs. 48%, P = 0.003). Eighty-seven percent of the trainees thought that their training had been adequate or better than adequate, compared with 25% in 2002.

CONCLUSION

In the 2007 survey, trainees reported a significant improvement both in colonoscopy training at base hospitals and in access to specialist courses compared with those in the 2002 survey. The centrally funded training programme has made a significantly positive impact in this large training region that is likely to be reflected elsewhere in England. The loss of such investment may have a detrimental effect on future colonoscopy training and the quality of service provision.

Colonoscopy training in gastroenterology fellowships: determining competence

BACKGROUND

Although 140 colonoscopies is the recommended minimal requirement for gastroenterology fellows, it is unclear whether this minimum is a surrogate for competence.

OBJECTIVE

To assess whether 140 colonoscopies is an adequate threshold to determine > or =90% colonoscopy performance independence.

DESIGN

Retrospective analysis on a database constructed for quality control/improvement.

SETTING

Gastroenterology fellowship training program at a veterans hospital.

PATIENTS

Consecutive patients who underwent colonoscopy primarily for symptoms, previous polyps, or family history of cancer (a minority were performed for screening only) from April 2007 to September 2008. This study involved 11 gastroenterology fellows who performed 770 colonoscopies during 18 individual month-long rotations.

INTERVENTION

Assessment of various procedure-related parameters.

MAIN OUTCOME MEASUREMENTS

Determining when > or =90% independence in colonoscopy performance was reached.

RESULTS

Total colonoscopy time, time to cecal intubation, withdrawal time, and independent completion rates all significantly improved when first and third years of training were compared (P < .001 for all comparisons). The adenoma detection rate did not change between years of training. Independent completion was achieved in > or =90% of cases for all fellows after 500 colonoscopies, whereas no fellow reached a > or =90% independent colonoscopy completion rate after 140 colonoscopies.

LIMITATIONS

Number of participants, single center.

CONCLUSIONS

Becoming a competent colonoscopist requires repeated practice. Our study suggests that, although there is variability between a trainee's ability to become colonoscopy independent, 500 colonoscopies are likely required to ensure reliable (> or =90%) independent completion rates. Competency requires more than a single parameter.

Global Assessment of Gastrointestinal Endoscopic Skills (GAGES): a valid measurement tool for technical skills in flexible endoscopy

BACKGROUND

Simulators may improve the efficiency, safety, and quality of endoscopic training. However, no objective, reliable, and valid tool exists to assess clinical endoscopic skills. Such a tool to measure the outcomes of educational strategies is a necessity. This multicenter, multidisciplinary trial aimed to develop instruments for evaluating basic flexible endoscopic skills and to demonstrate their reliability and validity.

METHODS

The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) Upper Endoscopy (GAGES-UE) and Colonoscopy (GAGES-C) are rating scales developed by expert endoscopists. The GAGES scale was completed by the attending endoscopist (A) and an observer (O) in self-assessment (S) during procedures to establish interrater reliability (IRR, using the intraclass correlation coefficient [ICC]) and internal consistency (IC, using Cronbach's alpha). Instrumentation was evaluated when possible and correlated with total scores. Construct and external validity were examined by comparing novice (NOV) and experienced (EXP) endoscopists (Student's t-test). Correlations were calculated for GAGES-UE and GAGES-C with participants who had performed both.

RESULTS

For the 139 completed evaluations (60 NOV, 79 EXP), IRR (A vs. O) was 0.96 for GAGES-UE and 0.97 for GAGES-C. The IRR between S and A was 0.78 for GAGES-UE and 0.89 for GAGES-C. The IC was 0.89 for GAGES-UE, and 0.95 for GAGES-C. There were mean differences between the NOV and the EXP endoscopists for GAGE-UE (14.4 +/- 3.7 vs. 18.5 +/- 1.6; p < 0.001) and GAGE-C (11.8 +/- 3.8 vs. 18.8 +/- 1.3; p < 0.001). Good correlation was found between the scores for the GAGE-UE and the GAGE-C (r = 0.75; n = 37). Instrumentation, when performed, demonstrated correlations with total scores of 0.84 (GAGE-UE; n = 73) and 0.86 (GAGE-C; n = 45).

CONCLUSIONS

The GAGES-UE and GAGES-C are easy to administer and consistent and meet high standards of reliability and validity. They can be used to measure the effectiveness of simulator training and to provide specific feedback. The GAGES results can be generalized to North American and European endoscopists and may contribute to the definition of technical proficiency in endoscopy.

Pilot feasibility study of the method of water infusion without air insufflation in sedated colonoscopy

One study in sedated patients demonstrated a reduction in pain score but not midazolam dosage when warm water infusion was used to manage colonic spasm. We describe pilot data with a modified warm water infusion technique. We tested the hypothesis that patients receiving even only half of the usual dose of sedation medications would have acceptable cecal intubation and tolerate the procedure well, based on retrospective review of prospectively collected data from a single Veterans Affairs (VA) medical center. Group 1 included 32 consecutive patients who received full-dose and group 2 included 43 consecutive patients who received half-dose premedication. Insertion of colonoscope was aided by warm water infusion in lieu of air insufflation. Pain scores during insertion, cecal intubation rate, and total amount of medications were monitored. The novel technique permitted equal cecal intubation rate at reduced total dose of medications. Pain scores were not significantly different. The uncontrolled nonrandomized observational nature of the data is one limitation. The nonsignificant difference in pain scores may be affected by a type II error. These pilot data suggest that insertion is feasible without air when water infusion is used. The novel technique may be a useful adjunct for minimizing the dosage of sedation medications without adversely affecting cecal intubation. Further study is needed to compare air insufflation and water infusion with regard to patient tolerance and success, particularly in the presence of an on-demand sedation policy.

Effect of GI endoscopy nurse experience on screening colonoscopy outcomes

BACKGROUND

The effect of the GI endoscopy nurse experience on colonoscopy outcomes is unknown.

OBJECTIVE

To determine whether the nurse experience was associated with screening colonoscopy complications, procedure length, and cecal intubation.

DESIGN

A retrospective analysis of screening colonoscopies performed by attending physicians between August 2003 and August 2005. Nurse experience was measured in weeks.

SETTING

University of North Carolina Hospitals.

SUBJECTS

Twenty-nine nurses were employed during the study period, 19 of whom were newly hired. A total of 3631 eligible screening colonoscopies were analyzed.

MAIN OUTCOME MEASUREMENTS

The primary outcome was any immediate complication; secondary outcomes included time to cecum, total procedure time, and cecal intubation rate.

RESULTS

In procedures staffed by nurses with 2 weeks of experience or less, 3.2% had complications compared with 0.3% for procedures with more experienced nurses (odds ratio [OR] 10.4 [95% CI, 3.55-30.2]). For nurses with 6 months or less of experience, 18% of procedures had cecal-intubation times more than 1 standard deviation above the mean compared with 12% for more experienced nurses (OR 1.60 [95% CI, 1.30-1.97]). Similar results were seen for the total procedure duration (OR 1.61 [95% CI, 1.32-1.97]) and cecal-intubation rates (OR 1.81 [95% CI, 1.37-2.39]). All relationships held after adjusting for potential confounding factors.

LIMITATIONS

A retrospective, single-center study.

CONCLUSIONS

GI endoscopy nurse inexperience is associated with an increase in immediate complications, prolonged procedure times, and decreased cecal-intubation rates for screening colonoscopies. These findings have implications for nurse training, procedure efficiency, colonoscopy quality assessment, and patient safety.