Knowledge, attitudes, and practices of endoscopy among gastroenterologists in diagnosis and management of inflammatory bowel disease in China: a multicenter cross-sectional study.

BACKGROUND: The aim was to assess the knowledge, attitudes, and practices (KAPs) of endoscopy among gastroenterologists in the diagnosis and management of IBD in China. METHODS: A multicenter cross-sectional KAP study was performed. The questionnaire was developed and improved using feedback and opinions from a team of experienced IBD specialist professors and then distributed and collected online. In addition, eight fellow gastroenterologists participated in an IBD endoscopy training program were asked to review endoscopic images, and the consistency of the endoscopic scores before and after training was calculated. RESULTS: A total of 193 participants from 12 provincial-level administrative regions encompassing both the Northern and Southern parts of China completed the study questionnaire. The median age of the participants was 40 (36, 45) years, with the majority being female (70.5%). The median professional experience as gastroenterologists was 11 (7, 17) years, while the median experience as endoscopists was 8 (3, 15) years. The median knowledge score was 8 out of 10 points for single-choice questions; however, most gastroenterologists believed that some concepts in these endoscopic indices were vague, including those regarding deep ulcerations, ulcerated surfaces, affected surfaces and narrowing in open-answer questions. The UCEIS and SES-CD were considered most consistent with clinical activity score in the evaluation of UC and CD, respectively. IBD subspecialists and gastroenterologists who had previously received IBD endoscopy screening training were more likely to use endoscopic indices (p<0.001, p = 0.029, respectively). The Rutgeerts score demonstrated the most significant improvement in consistency before and after training, from 0.407 (95% CI: 0.025-0.999) to 0.909 (95% CI: 0.530-1.000). CONCLUSIONS: We propose the elucidation of ambiguous definitions in endoscopic indices, enhancement of training, and the application of innovative technology to enhance the application of endoscopic evaluation and endoscopic indices in clinical practice.

Perspectives and Advice from an Interventional Gastroenterologist at a Tertiary Academic Center.

PURPOSE OF THE REVIEW: The purpose of this review is to detail steps and strategies needed to have success as an interventional gastroenterologist at a tertiary care academic medical center. RECENT FINDINGS: Development of a specific niche within interventional endoscopy (IE), can allow an incoming academic interventional endoscopist to make a clinical and academic impact on a regional and national level. As the evolution of IE training continues, the development of a niche will become streamlined, supporting a more efficient academic progression for incoming IE faculty. By showcasing the experience of a junior academic interventional endoscopists, we demonstrate how expansion of a specific clinical interest within interventional endoscopy (IE), in conjunction with a mentoring environment, can facilitate academic and clinical progression at an academic medical center.

Benefits and barriers to accreditation of HPB center and fellowship programs in Europe: a strength-weakness-opportunity-and-threats (SWOT) analysis by an E-AHPBA-ESSO-UEMS ad hoc working committee.

BACKGROUND: Training in HPB surgery lacks uniformity across regions covered by the E-AHPBA. Accreditation has been in place for centers and fellowship programs, but with low uptake. The decision whether to continue, change or cease such accreditation is being discussed. Thus, a strengths, weaknesses, opportunities, and threats (SWOT) analysis was conducted. METHODS: A mixed-methods, cross-sectional study among stakeholders in E-AHPBA, ESSO and UEMS under the E-AHPBA executive council was founded, ensuring representation by gender and geographic distribution. RESULTS: Responses were collected from across E-AHPBA regions, with response from 15 of 24 subchapters. The most frequent and recurring themes are presented in a SWOT matrix which allows for paired evaluations of factors deemed to be helpful (Strengths and Opportunities), those that are harmful (Weaknesses and Threats). CONCLUSION: This study identified both helpful and harmful effects to an accreditation process of HPB centers or HPB fellowship training across the E-AHPBA membership region. Formal accreditation of centers is not within the scope, nor jurisdiction nor financial capacity for E-AHPBA in the current situation. A strong interest in formal HPB training should be capitalized into E-AHPBA strategic planning towards a structured accreditation system for HPB fellowship programs or HPB training tracks.

Cross-fellowship Inter-institutional Exchange: Answering the Call for Hepatopancreatobiliary Training Standardization.

OBJECTIVE: General surgery trainees interested in performing hepatopancreatobiliary (HPB) surgery can choose from multiple fellowship pathways, namely HPB, surgical oncology (SO), and abdominal transplant-HPB (TXP-HPB). Although focused on similar operations, each program offers distinct clinical and technical emphases. DESIGN: An annual inter-institutional exchange between TXP-HPB and SO fellowships, starting in 2014. SETTING AND PARTICIPANTS: TXP-HPB fellows from Washington University in St. Louis (WUSTL) and SO fellows from Memorial Sloan Kettering Cancer Center (MSKCC). RESULTS: About 14 fellows have participated in the exchange so far, 13 of whom responded to our survey. At MSKCC, TXP-HPB fellows performed a median of 24 cases, including 6 major pancreatic resections, 3 major hepatectomies, 4 hepatic artery infusion pump insertions, and 1 major biliary case. At WUSTL, SO fellows performed a median of 16 cases, including 5 liver transplants, 2 major pancreatic resections, 2 major hepatectomies, and 2 major biliary cases. About 92.3% of respondents stated they would repeat the rotation, with SO fellows emphasizing the exposure to vascular anastomoses and transplant-HPB fellows appreciating the oncologic focus. CONCLUSIONS: A monthlong inter-institutional exchange offers a unique opportunity to standardize and improve HPB education.

Ergonomic wellness for the trainee in gastrointestinal endoscopy.

PURPOSE OF REVIEW: Endoscopy-related injuries (ERIs) are prevalent in gastrointestinal endoscopy. The aim of this review is to address the growing concern of ERIs by evaluating the ergonomic risk factors and the efficacy of interventions and educational strategies aimed at mitigating these risks, including novel approaches. RECENT FINDINGS: ERIs are highly prevalent, exacerbated by factors such as repetitive strain, nonneutral postures, suboptimal equipment design, and the procedural learning curve. Female sex and smaller hand sizes have been identified as specific risk factors. Recent guidelines underscore the importance of ergonomic education and the integration of ergonomic principles into the foundational training of gastroenterology fellows. Advances in equipment design focus on adaptability to different hand sizes and ergonomic positions. Furthermore, the incorporation of microbreaks and macrobreaks, along with neutral monitor and bed positioning, has shown promise in reducing the incidence of ERIs. Wearable sensors may be helpful in monitoring and promoting ergonomic practices among trainees. SUMMARY: Ergonomic wellness is paramount for gastroenterology trainees to prevent ERIs and ensure a sustainable career. Effective strategies include ergonomic education integrated into curricula, equipment design improvements, and procedural adaptations such as scheduled breaks and optimal positioning. Sensor-based and camera-based systems may allow for education and feedback to be provided regarding ergonomics to trainees in the future.

What is the role of out of programme clinical fellowships in the era of Shape of Training? A single-centre cohort study.

BACKGROUND: The updated Shape of Training curriculum has shortened the duration of specialty training. We present the potential role of out of programme clinical fellowships. METHOD: An electronic online survey was sent to all current fellows to understand their experiences, training opportunities and motivations.Data were collected on fellows' endoscopic experiences and publications using PubMed for all previous doctors who have completed the Sheffield Fellowship Programme. RESULTS: Since 2004, 39 doctors have completed the Sheffield Fellowship.Endoscopic experience: current fellows completed a median average of 350 (IQR 150-500) gastroscopies and 150 (IQR 106-251) colonoscopies per year. Fellows with special interests completed either 428 hepato-pancreato-biliary procedures or 70 endoscopic mucosal resections per year.Medline publications: Median average 9 publications(IQR 4-17). They have also received multiple national or international awards and 91% achieved a doctoral degree.The seven current fellows in the new Shape of Training era (57% male, 29% Caucasian, aged 31-40 years) report high levels of enjoyment due to their research projects, supervisory teams and social aspects. The most cited reasons for undertaking the fellowship were to develop a subspecialty interest, take time off the on-call rota and develop endoscopic skills. The most reported drawback was a reduced income.All current fellows feel that the fellowship has enhanced their clinical confidence and prepared them to become consultants. CONCLUSION: Out of programme clinical fellowships offer the opportunity to develop the required training competencies, subspecialty expertise and research skills in a supportive environment.

Endoscopy ergonomics: a survey-based study exploring gender differences.

BACKGROUND AND AIMS: Women, on average, have smaller hand sizes as well as lower muscle mass and strength. With the increasing number of women entering training programs in gastroenterology, our aim was to study the subtle gender differences in endoscopy ergonomics. METHODS: A survey instrument regarding demographic information, personal preferences in endoscopy styles and techniques, and endoscopy-related injury was sent to practicing gastroenterologists. Statistical analysis was performed on the data. RESULTS: The survey was answered by 107 gastroenterologists, 41 (38.3%) female subjects and 66 (61.7%) male subjects. Female participants were shorter in height, had smaller hand sizes, and performed fewer weekly cases. More men (45.5%) than women (20%) performed advanced endoscopic procedures. Women preferred the following: (1) holding the endoscope with the umbilical cord outside the forearm; (2) using the right hand to turn the small wheel; and (3) using a pediatric colonoscope to perform colonoscopy in a petite patient or one with a low body mass index. Endoscopy-related injury was reported in 49.5% of all gastroenterologists, with women reporting a significantly higher risk of injury (63.4%) than men (40.9%) (P = .02). Although higher weekly case volumes and performance of advanced endoscopy procedures were not independent risk factors for endoscopy-related injury, female gender was found to be an independent risk factor for injury. CONCLUSIONS: Gender differences exist in endoscopy styles and techniques, as well as endoscopy-related injury. Providing gender-specific training in endoscopy may improve ergonomics and decrease the risk of injury.

Sex differences impact ergonomic endoscopic training for gastroenterology fellows.

BACKGROUND AND AIMS: Endoscopic-related injuries (ERIs) for gastroenterologists are common and can impact longevity of an endoscopic career. This study examines sex differences in the prevalence of ERIs and ergonomic training during gastroenterology fellowship. METHODS: A 56-item anonymous survey was sent to 709 general and advanced endoscopy gastroenterology fellows at 73 U.S. training programs between May and June 2022. Demographic information was collected along with questions related to endoscopic environment, ergonomic instruction, technique, equipment availability, and ergonomic knowledge. Responses of female and male gastroenterology fellows were compared using χ2 and Fisher exact tests. RESULTS: Of the 236 respondents (response rate, 33.9%), 113 (44.5%) were women and 123 (52.1%) were men. Female fellows reported on average smaller hand sizes and shorter heights. More female fellows reported endoscopic equipment was not ergonomically optimized for their use. Additionally, more female fellows voiced preference for same-gender teachers and access to dial extenders and well-fitting lead aprons. High rates of postendoscopy pain were reported by both sexes, with significantly more women experiencing neck and shoulder pain. Trainees of both sexes demonstrated poor ergonomic awareness with an average score of 68% on a 5-point knowledge-based assessment. CONCLUSIONS: Physical differences exist between male and female trainees, and current endoscopic equipment may not be optimized for smaller hand sizes. This study highlights the urgent need for formal ergonomic training for trainees and trainers with consideration of stature and hand size to enhance safety, comfort, and equity in the training and practice of endoscopy.

A National Survey of the Training and Practice Patterns of Practicing Pediatric Advanced Endoscopists in the United States.

BACKGROUND AND AIMS: Pediatric advanced endoscopy consists primarily of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) and is becoming more common in pediatrics. This study aims to characterize the current landscape of pediatric advanced endoscopy training and practice by directly surveying independently practicing pediatric advanced endoscopists (PAEs). We also aim to ascertain expert opinion on competency in pediatric ERCP and EUS. METHODS: A 66-question REDCap survey and a 73-question Qualtrics survey were distributed to members of the ERCP Special Interest Group of North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition. Respondents currently performing ERCP or EUS independently in children were included. Statistical analysis was performed using Mann-Whitney U test. RESULTS: Of 41 PAEs surveyed, 38 (92.7%) responded and 27 independent practitioners were included. Thirteen respondents performed EUS. PAEs who completed an advanced endoscopy fellowship (AEF) were more comfortable performing American Society for Gastrointestinal Endoscopy grade 3 or grade 4 ERCPs ( P < 0.0008) and felt more prepared to practice EUS independently than other trainees. Expert opinion of PAEs felt a threshold of 200 procedures was needed to attain competency in either ERCP or EUS. Pediatric duodenoscope exposure improved comfort in performing ERCP in children <10 kg ( P = 0.009). CONCLUSIONS: Training of pediatric gastroenterologists in ERCP and EUS are highly variable, though the skills attained are similar. AEF-trained specialists reported greater training volumes and felt more prepared to practice independently than those who did not. Competency thresholds determined by expert PAEs for ERCP and EUS agree with American Society for Gastrointestinal Endoscopy guidelines for adult advanced endoscopy trainees.

Anatomical endoscopic retrograde cholangiopancreatography simulator using moulded meshed silicone: A novel simulator pilot study.

INTRODUCTION: Endoscopic retrograde cholangio-pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient-based training in ERCP however models to date have been unconvincing. METHODS: This ERCP simulation model was constructed from moulded meshed silicone by co-designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists. RESULTS: From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009). CONCLUSIONS: The simulator showed statistically significant results in face, content, and construct validity. A follow-up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.

Evidence-Based Cognitive Endoscopy Simulators: Do They Exist? A Systematic Search and Evaluation of Existing Platforms.

BACKGROUND: The development of guidelines by gastroenterology societies increasingly stresses evidence-based endoscopic practice. AIMS: We performed a systematic assessment to determine whether endoscopic video teaching platforms incorporate evidence-based educational strategies and methods in order to disseminate guideline-based endoscopic management strategies. METHODS: Platforms with a video component were systematically identified using the Google search engine, Apple and Android application stores, and searching four major gastroenterology society websites and three known platforms, to identify all relevant platforms. Two video samples from each teaching platform were reviewed independently by two authors and assessed for use of a priori defined principles of evidence-based medicine, as determined by consensus agreement and for the use of simulation. RESULTS: Fourteen platforms were included in the final analysis, and two videos from each were analyzed. One of the 14 platforms used simulation and incorporated evidence-based medicine principles consistently. Nine of the 14 platforms were not transparent in regard to citation. None of the platforms consistently cited the certainty of evidence or explained how evidence was selected. CONCLUSIONS: Education of guideline-based endoscopic management strategies using principles of evidence-based medicine is under-utilized in endoscopic videos. In addition, the use of cognitive simulation is absent in this arena. There is a paucity of evidence-based cognitive endoscopy simulators designed for fellows that incorporate systematic evaluation, and efforts should be made to create this platform.

[The Present Status and Improvement Directions for Gastrointestinal Fellows and Residents in Korea].

The Korean Society of Gastroenterology (KSG) and the Korean Society of Gastrointestinal Endoscopy (KSGE) have tried to promote high-quality patient care, and safety in the field of gastrointestinal (GI) diseases. In 2017, the training guidelines for GI fellows have been made, and the education board of KSGE revised 2 year- program of GI fellows. The guideline includes the total number of assigned patients, the number of GI endoscopy procedures, attendance of academic conferences, and research presentations. The traditional training model of GI fellowship is known as an "apprenticeship". Unfortunately, it might increase confusion between what trainees are observing and prior information. Now, practical hands-on training system using simulator helps to provide a support program for GI fellowship education. In order to facilitate training program, trainers will need to carefully plan the teaching. Therefore, it improves knowledge and performance for trainers. What we should keep in mind is that this hands-on program has the goal of making a good gastroenterologist, not just making an endoscopist. At same time, the application of cognitive education in GI fellow training must be performed. On the other side, the privileging and credentialing for endoscopic subspecialty should be made. The provision of benefits could serve as an important foundation for maintaining GI specialist board system.

Defining the learning curves of colorectal surgical trainees in colonoscopy using the Assessment of Competency in Endoscopy tool.

BACKGROUND AND AIMS: Gastroenterology fellows require on average 250 to 275 colonoscopies to achieve competency. For surgical trainees, 50 colonoscopies is deemed adequate. Two training pathways using different assessment methods make any direct comparison impossible. At the Mayo Clinic colonoscopy training of gastroenterology and colorectal surgery (CRS) fellows were merged in 2017, providing a unique opportunity to define the learning curves of CRS trainees using the Assessment of Competency in Endoscopy (ACE) evaluation tool. METHODS: In a single-center retrospective descriptive study, ACE scores were collected on colonoscopies performed by CRS fellows over a period of 4 academic years. By calculating the average scores at every 25 procedures of experience, the CRS colonoscopy learning curves were described for each core cognitive and motor skill. RESULTS: Twelve CRS fellows (men, 8; women, 4) had an average prior experience of 123 colonoscopies (range, 50-266) during the general surgical residency. During CRS fellowship, an average of 136 colonoscopies (range, 116-173) were graded per fellow. Although the competency goals for a few metrics were met earlier, most motor and cognitive ACE metrics reached the minimum competency thresholds at 275 to 300 procedures. CONCLUSIONS: CRS fellows reached competency in colonoscopy at around 275 to 300 procedures of experience, a trajectory similar to previously reported data for gastroenterology fellows, suggesting little difference in the learning curves between these 2 groups. In addition, no trainee was deemed competent at the onset of training despite an average experience well over the 50 colonoscopies required during residency.

Impact of Fellow Participation During Colonoscopy on Adenoma Detection Rates.

BACKGROUND: An endoscopist's adenoma detection rate (ADR) is inversely related to interval colorectal cancer risk and cancer mortality. Previous studies evaluating the impact of gastroenterology fellow participation in colonoscopy on ADR have generated conflicting results. AIMS: We aimed to determine the impact of fellow participation, duration of fellowship training, and physician sex on ADR and advanced ADR (AADR). METHODS: We retrospectively analyzed average-risk patients undergoing screening colonoscopy at Veterans Affairs New York Harbor Healthcare System Brooklyn Campus and Kings County Hospital Center. Review of colonoscopy and pathology reports were performed to obtain adenoma-specific details, including the presence of advanced adenoma and adenoma location (right vs. left colon). RESULTS: There were 893 colonoscopies performed by attending only and 502 performed with fellow participation. Fellow participation improved overall ADR (44.6% vs. 35.4%, p < 0.001), right-sided ADR (34.1% vs. 25.2%, p < 0.001), and AADR (15.3% vs. 8.3%, p < 0.001); however, these findings were institution-specific. Year of fellowship training did not impact overall ADR or overall AADR, but did significantly improve right-sided AADR (p-value for trend 0.03). Female attending physicians were associated with increased ADR (47.1% vs. 37.0%, p = 0.0037). Fellow sex did not impact ADR. CONCLUSIONS: Fellow participation in colonoscopy improved overall ADR and AADR, and female attending physicians were associated with improved ADR. Year of fellowship training did not impact overall ADR or AADR.

Gender and Other Factors Associated with Endoscopy Volume Among U.S. Gastroenterology Fellows.

Gastroenterology (GI) fellows' ability to perform procedures are evaluated by the level of competency in the cognitive and technical components of procedures in Accreditation Council for Graduate Medical Education-accredited fellowship programs.1 However, competency in endoscopic procedures correlates with the number of procedures performed.2 The American Society for Gastrointestinal Endoscopy has recommended that a minimum of 130 esophagogastroduodenoscopies (EGDs) and 275 colonoscopies be performed before procedural competency can be assessed.3 Few studies have examined program or trainee-related factors, such as trainee gender, that may influence procedural volume. In other procedural subspecialties, a gender gap exists in trainee procedural volumes, with female residents performing fewer surgical cases than males.4,5 However, whether gender-related disparities exist in endoscopy volume among GI trainees is unknown. The primary aim of this study was to determine the impact of GI fellow gender on endoscopic procedural volume during training. Secondary aims were to determine if fellow career choice or other training program-related factors, such as program size, location, or setting, affect procedure volume during fellowship.