JAG consensus statements for training and certification in colonoscopy

Development of 3D training models for the identification and classification of colorectal polyps

Colorectal cancers develop from pre-malignant polyps that can be removed during colonoscopy. Detection, assessment, and removal of polyps has a major role in bowel cancer prevention and is an important part of bowel cancer screening programmes. Trainee colonoscopists must acquire skills to recognise and classify colorectal polyps. Accurate classification is based on morphology, surface pit and capillary patterns. It is difficult to teach assessment skills because static polyp images are often of poor quality and cannot show all areas of interest. Based on anonymised, endoscopic reference images, 3D polyp models were created in ZBrush, demonstrating a variety of morphological forms. The models had detailed pit patterns to show the capillary structure, a key predictor of pathology. The models were subsequently uploaded to the online 3D repository and model viewer, Sketchfab, to create an interactive training resource for trainee colonoscopists. The digital models were evaluated by a panel of expert colonoscopists who scored them for realism and potential as aids for training. There was agreement that the digital polyp models would be useful for teaching. Polyp morphology was rated as realistic however representation of pit patterns received a mixed response, highlighting areas for further development.

Prospective assessment of learning curve and impact of intensive versus progressive training in colonoscopy competence among French residents

BACKGROUNDS

There are no existing data in the literature on the learning curve of French interns in colonoscopy or on the comparison between different frequencies of colonoscopy training modalities. We aimed to assess the number of procedures required for French residents in hepatogastroenterology to achieve competency in colonoscopy.

METHODS

The primary outcome was achieving greater than 90% cecal intubation rate (CIR90) competency using the Learning Curve-Cumulative Summation (LC-CUSUM) method. Participants with over 80 procedures were categorized into intensive and progressive training groups. We compared the proportion of residents reaching competency, the number of colonoscopies to reach it, and the speed of competency.

RESULTS

The study included 81 residents, totaling 6,259 procedures. 29 did more than 80 procedures: 12 in the progressive group and 17 in the intensive group. 204 colonoscopies were needed for reaching CIR90 competency (21% of residents). Achievement rates were similar across groups: 50% in the progressive and 65% in the intensive group (p = 0.50). LC competency was reached by 8.6% of residents after an average of 225 procedures, with no significant difference between groups (p = 0.21). Survival analysis showed no significant difference in the speed of competency acquisition between groups (p = 0.77 and p = 0.14, respectively). The Polyp Detection Rate (PDR) averaged 40%.

CONCLUSION

Given that only 21% reached CIR90, efforts are needed to increase the number of colonoscopies during training.

CLINICAL TRIAL NUMBER

Not applicable.

A multi-modal training environment for colonoscopy with pressure feedback

BACKGROUND

Colonoscopy is a complex procedure with a 3-5% failure rate even for experts. Mastering endoscopy skills and reducing complication rates extend well beyond the initial training phase for most endoscopists, and continues into their clinical experience. Thus, continuing efforts should focus on optimizing training methods to make them individualized with clear objective learning goals for trainees.

METHODS

A hybrid (physical and computer) colonoscopy training simulator was developed using a novel pressure-sensing sleeve covering the full length of a colonoscope, and a physical colon simulator (Kyoto Kagaku) along with custom-designed training software to visualize the color-mapped 3D pressure profile of the colonoscope during the simulated procedure and provide a visual and quantitative evaluation of the endoscopist's skills post-procedure. A system usability questionnaire and objective evaluation metrics were used to determine the model's effectiveness as a training tool.

RESULTS

Thirty-three participants were enrolled in the study, among which 8 were experts and 25 trainees. The interactive maximum and average pressures applied by the trainees were generally higher than those applied by experts, however, this difference was only statistically significant in the recto-sigmoid region. The mean average pressure applied in the rectum and the rectosigmoid region was 6.5 kPa for the experts compared to 13.7 kPa for the trainees, with a p-value of 0.011. Both groups agreed that the system is easy to understand and use, and would be helpful as a learning aid in training programs for colonoscopy skills.

CONCLUSIONS

The proposed system is expected to enhance the quality of colonoscopy procedures by enabling endoscopists to adopt safer and more efficient navigational skills. The evaluation metrics discussed in this research offer useful insights into the performance of endoscopists, and the ability of trainees to compare their performance against expert benchmarks will enable them to establish personalized objective training goals.

Exploring Endoscopic Competence in Gastroenterology Training: A Simulation-Based Comparative Analysis of GAGES, DOPS, and ACE Assessment Tools

Purpose

Accurate and convenient evaluation tools are essential to document endoscopic competence in Gastroenterology training programs. The Direct Observation of Procedural Skills (DOPS), Global Assessment of Gastrointestinal Endoscopic Skills (GAGES), and Assessment of Endoscopic Competency (ACE) are widely used validated competency assessment tools for gastrointestinal endoscopy. However, studies comparing these 3 tools are lacking, leading to lack of standardization in this assessment. Through simulation, this study seeks to determine the most reliable, comprehensive, and user-friendly tool for standardizing endoscopy competency assessment.

Methods

A mixed-methods quantitative-qualitative approach was utilized with sequential deductive design. All nine trainees in a gastroenterology training program were assessed on endoscopic procedural competence using the Simbionix Gi-bronch-mentor high-fidelity simulator, with 2 faculty raters independently completing the 3 assessment forms of DOPS, GAGES, and ACE. Psychometric analysis was used to evaluate the tools' reliability. Additionally, faculty trainers participated in a focused group discussion (FGD) to investigate their experience in using the tools.

Results

For upper GI endoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.8, and 0.87 for ACE, DOPS, and GAGES, respectively. Inter-rater reliability (IRR) scores were 0.79 (0.43-0.92) for ACE, 0.75 (-0.13-0.82) for DOPS, and 0.59 (-0.90-0.84) for GAGES. For colonoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.82, and 0.85 for ACE, DOPS, and GAGES, respectively. IRR scores were 0.72 (0.39-0.96) for ACE, 0.78 (-0.12-0.86) for DOPS, and 0.53 (-0.91-0.78) for GAGES. The FGD yielded three key themes: the ideal tool should be scientifically sound, comprehensive, and user-friendly.

Conclusion

The DOPS tool performed favourably in both the qualitative assessment and psychometric evaluation to be considered the most balanced amongst the three assessment tools. We propose that the DOPS tool be used for endoscopic skill assessment in gastroenterology training programs. However, gastroenterology training programs need to match their learning outcomes with the available assessment tools to determine the most appropriate one in their context.

Causes of intraprocedural discomfort in colonoscopy: a review and practical tips

Colonoscopy is a commonly performed procedure in the United Kingdom and the gold standard for diagnosis and therapy in the gastrointestinal tract. Increased levels of pain during colonoscopy have been associated with reduced completion rates and difficulties in maintaining attendance for repeat procedures. Multiple factors play a role in causing discomfort intra-procedurally: patient factors, such as gender, anatomy and pre-procedure anxiety; operator factors, such as patient position and level of experience and other factors, such as bowel preparation and total procedure time. A literature search was performed to identify papers that explained how patient, operator and endoscopy factors influenced pain and discomfort in endoscopy. A further search then also identified papers describing solutions to pain and discomfort that have been explored. After review of the literature, key methods are selected and discussed in this paper. Solutions and aids that can resolve and improve pain and discomfort include endoscopic methods such as variable stiffness and ultrathin scopes. Operator improvements in techniques and ergonomics alongside the use of newer technologies such as propelled endoscopy, computer-assisted endoscopy and task distraction. To improve patient experience and outcomes, the investigation and research into improving techniques to reduce pain is crucial. This review aims to identify the modifiable and non-modifiable factors associated with intra-procedural discomfort during colonoscopy. We discuss established methods of improving pain during colonoscopy, in addition to newer technologies to mitigate associated discomfort.