UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS).

BACKGROUND AND AIMS: International endoscopy societies vary in their approach for credentialing individuals in endoscopic ultrasound (EUS) to enable independent practice; however, there is no consensus in this or its implementation. In 2019, the Joint Advisory Group on GI Endoscopy (JAG) commissioned a working group to examine the evidence relating to this process for EUS. The aim of this was to develop evidence-based recommendations for EUS training and certification in the UK. METHODS: Under the oversight of the JAG quality assurance team, a modified Delphi process was conducted which included major stakeholders from the UK and Ireland. A formal literature review was made, initial questions for study were proposed and recommendations for training and certification in EUS were formulated after a rigorous assessment using the Grading of Recommendation Assessment, Development and Evaluation tool and subjected to electronic voting to identify accepted statements. These were peer reviewed by JAG and relevant stakeholder societies before consensus on the final EUS certification pathway was achieved. RESULTS: 39 initial questions were proposed of which 33 were deemed worthy of assessment and finally formed the key recommendations. The statements covered four key domains, such as: definition of competence (13 statements), acquisition of competence (10), assessment of competence (5) and postcertification mentorship (5). Key recommendations include: (1) minimum of 250 hands-on cases before an assessment for competency can be made, (2) attendance at the JAG basic EUS course, (3) completing a minimum of one formative direct observation of procedural skills (DOPS) every 10 cases to allow the learning curve in EUS training to be adequately studied, (4) competent performance in summative DOPS assessments and (5) a period of mentorship over a 12-month period is recommended as minimum to support and mentor new service providers. CONCLUSIONS: An evidence-based certification pathway has been commissioned by JAG to support and quality assure EUS training. This will form the basis to improve quality of training and safety standards in EUS in the UK and Ireland.

Single slide assessment: A highly effective cytological rapid on-site evaluation technique for endobronchial and endoscopic ultrasound-guided fine needle aspiration.

No standardised, comprehensive approach to rapid on-site evaluation (ROSE) of cytology samples currently exists. Recent meta-analysis indicates variation in the effectiveness of ROSE, however, reviews commonly omit the details of how ROSE is conducted. This review demonstrates the clinical effectiveness of single slide assessment (SSA) for ROSE of cytology samples, providing a highly effective, standardised methodology, maximising cell yield and the diagnostic potential of samples obtained via endobronchial or endoscopic ultrasound. Advances in molecular testing and immunotherapy now allow patients to access sophisticated, targeted cancer treatments and, consequently, obtaining diagnostic material alone is no longer sufficient. SSA uses specific criteria, based on the morphological presentation, to ensure sufficient material is obtained through one procedure, allowing for all the molecular profiling and tumour expression testing required to provide the patient and clinicians with the optimal treatment options. In total, 450 endobronchial or endoscopic ultrasound procedures were conducted with ROSE SSA performed by a biomedical scientist between 2010 and 2017. In 97% of cases, ROSE SSA matched the final report (inadequate vs adequate-benign material vs malignancy). ROSE SSA provided sufficient material for immunocytochemistry in 200/208 cases (96%) and for additional molecular testing/tumour profiling in 92% (85/92) of cases. The median number of needle passes was three. ROSE SSA streamlines diagnostic pathways; minimising risk of complications to patients, reducing cost and delays to treatment associated with repeat or more invasive procedures. Using SSA, sufficient material for a comprehensive diagnosis can be obtained in one procedure.

Surgical admission secondary to perigastric appendagitis: an uncommon cause of acute epigastric pain.

A patient in her late 20s presented with severe epigastric pain. A CT scan of the abdomen and pelvis was performed to exclude an upper gastrointestinal perforation. This showed findings of perigastric appendagitis. This is a rare cause of severe upper abdominal pain. The patient was treated with oral and intravenous analgesia medication and discharged the next day. No surgical intervention was required.

Localising ingested metallic foreign bodies to guide surgical planning: A novel use for the CT metal artefact reduction algorithm.

We present the case of a 20-year-old female patient who presented following ingestion of multiple button magnets. She remained clinically well however serial abdominal radiographs demonstrated the magnets were not passing through the gastrointestinal tract and a CT was, therefore, performed for further assessment and to aid surgical planning. Artefact from the magnets made interpretation of the CT challenging. The use of a Metal Artefact Reduction (MAR) algorithm, however, enabled accurate localisation of the magnets thus guiding subsequent surgical intervention. Whilst MAR algorithms are usually used in the assessment of iatrogenic metallic devices (e.g., joint prostheses), this case demonstrates an example of their potential wider use.

The case of the mysterious vanishing spleen: autosplenectomy complicating pneumococcal sepsis.

A 57-year-old previously healthy fisherman was admitted in fulminant pneumococcal septic shock, with disseminated intravascular coagulation, requiring aggressive management including bilateral below-knee amputations for ischaemic necrosis. He began to recover and was discharged for rehabilitation, however during his convalescence was found to be hypercalcaemic. No malignancy was found on CT scan, but it was noted that his spleen was absent, replaced by a 4 cm smooth-walled, fluid-filled lesion. This was unexpected as an ultrasound in intensive care 10 weeks previously had demonstrated a normal spleen. Functional hyposplenism was confirmed on a peripheral blood film with evidence of target cells, spherocytes and Howell-Jolly bodies. A diagnosis of autosplenectomy complicating pneumococcal sepsis was therefore made, of which there is just one case previously reported. The patient continues to recover well and was discharged on penicillin prophylaxis after receiving vaccinations for hyposplenism.