Competency in esophagogastroduodenoscopy: a validated tool for assessment and generalizable benchmarks for gastroenterology fellows.

BACKGROUND AND AIMS: The Assessment of Competency in Endoscopy (ACE) tools for colonoscopy and EGD were both put forth by the Training Committee of the American Society for Gastrointestinal Endoscopy (ASGE), with the intent of providing teachers and programs a means to continuously assess fellow skills in these procedures throughout their years of training. Despite the availability of the tools, there are no data that define when competency in EGD has been reached. The goal of this study is to validate the EGD ACE tool (ACE-E) and for the first time describe learning curves and competency benchmarks for EGD by examining a large national cohort of trainees. METHODS: In a prospective, multicenter trial, gastroenterology fellows at all stages of training had their core cognitive and motor skills in EGDs assessed by staff using the ACE-E tool. Evaluations occurred at set intervals of every 50 procedures over an academic year. Like the previously reported and validated ACE tool for colonoscopy, the ACE-E tool uses a 4-point grading scale to define a skills continuum from novice to competent. At each assessment interval, average scores for each skill were computed and overall competency benchmarks for each skill were established using the contrasting groups method. RESULTS: Ninety-six GI fellows at 10 U.S. academic institutions had 1002 EGDs assessed using the ACE-E tool. Average ACE-E scores of 3.5 were found to be inclusive of all minimal competency thresholds identified for each core skill. In addition, independent intubation of the second part of the duodenum (D2) at rates of ≥95% as well as D2 intubation times of ≤4.75 minutes and average total procedure times of ≤12.5 minutes were identified as the points separating competent from non-competent groups. Although the average fellow achieves the D2 intubation rates and time criteria by 100 and 150 procedures, respectively, achieving ACE-E threshold scores on the remaining metrics was typically not achieved until 200 to 250 procedures. CONCLUSIONS: Nationally generalizable learning curves for EGD skills in GI fellows are described. Average ACE-E scores of 3.5, independent D2 intubation rates of 95%, and D2 intubation times of ≤4.75 minutes are recommended as minimum competency criteria. On average, it takes GI fellows only 150 procedures to simply drive the scope adequately but 250 procedures to achieve minimum competence in the remaining cognitive and motor skills. The D2 intubation rate threshold and learning curve found in this multicenter cohort using the ACE-E tool are similar to those recently described by researchers in the United Kingdom; however, development of cognitive and overall competence requires a higher procedure threshold than previously described.

[Simulation of the interaction of gastroenterologists, endoscopists and surgeons, as the present and the future of high-tech gastroenterology of Chuvashia].

The analysis of the joint work of gastroenterologists, surgeons and endoscopists Republican gastroenterological center of the Chuvash Republic. The importance of creating a model of interaction of gastroenterologists, surgeons and endoscopists for the development of high-tech gastroenterology in the Chuvash Republic.

Development of simulator guidelines for resident assessment in flexible endoscopy.

Virtual reality (VR) simulators may hold a role in the assessment of trainee abilities independent of their role as instructional instruments. Thus, we piloted a course in flexible endoscopy to surgical trainees who had met Accreditation Council for Graduate Medical Education endoscopy requirements to establish the relationship between metrics produced by a VR endoscopic simulator and trainee ability. After a didactic session, we provided faculty instruction to senior residents for Case 1 upper endoscopy and colonoscopy modules on the CAE EndoscopyVR. Course conclusion was defined as a trainee meeting all proficiency standards in basic endoscopic procedures on the simulator. Simulator metrics and course evaluation comprised data. Eleven and eight residents participated in the colonoscopy and upper endoscopy courses, respectively. Average time to reach proficiency standards for esophagogastroduodenoscopy was 6 and 13 minutes for colonoscopy after a median of one (range, one to two) and one (range, one to four) task repetitions, respectively. Faculty instruction averaged 7.5 minutes of instruction per repetition. A subjective course evaluation demonstrated that the course improved learners' knowledge of the subject and comfort with endoscopic equipment. Within a VR-based curriculum, experienced residents rapidly achieved task proficiency. The resultant scores may be used as simulator guidelines for resident assessment and readiness to perform flexible endoscopy.

The Global Rating Scale in clinical practice: a comprehensive quality assurance programme for endoscopy departments.

BACKGROUND: The Global Rating Scale is an endoscopy quality assurance programme, successfully implemented in England. It remains uncertain whether it is applicable in another health care setting. AIM: To assess the applicability of the Global Rating Scale as benchmark tool in an international context. METHODS: Eleven Dutch endoscopy departments were included for a Global Rating Scale-census, performed as a cross-sectional evaluation, July 2010. Two Global Rating Scale-dimensions - 'clinical quality' and 'patient experience' - were assessed across six items using a range of levels: from level-D (basic) to level-A (excellent). Construct validity was assessed by comparing department-specific colonoscopy audit data to GRS-levels. RESULTS: For 'clinical quality', variable scores were achieved in items 'safety' (9%=B, 27%=C, 64%=D) and 'communication' (46%=A, 18%=C, 36%=D). All departments achieved a basic score in 'quality' (100%=D). For 'patient experience', variable scores were achieved in 'timeliness' (18%=A, 9%=B, 73%=D) and 'booking-choice' (36%=B, 46%=C, 18%=D). All departments achieved basic scores in 'equality' (100%=D). Departments obtaining level-C or above in 'information', 'comfort', 'communication', 'timeliness' and 'aftercare', achieved significantly better audit outcomes compared to those obtaining level-D (p<0.05). CONCLUSION: The Global Rating Scale is appropriate to use outside England. There was significant variance across departments in dimensions. Most Global Rating Scale-levels were in line with departments' audit outcomes, indicating construct validity.

Gastrointestinal endoscopy in a low budget context: delegating EGD to non-physician clinicians in Malawi can be feasible and safe.

Gastrointestinal endoscopy is rarely performed in low-income countries in sub-Saharan Africa. One reason is the lack of available medical doctors and specialists in these countries. At Zomba Central Hospital in Malawi, clinical officers (non-physician clinicians with 4 years of formal training) were trained in upper gastrointestinal endoscopy. Prospectively recorded details of 1732 consecutive esophagogastroduodenoscopies (EGDs) performed between September 2001 and August 2010 were analyzed to evaluate whether upper gastrointestinal endoscopy can be performed safely and accurately by clinical officers. A total of 1059 (61.1%) EGDs were performed by clinical officers alone and 673 (38.9%) were carried out with a medical doctor present who performed or assisted in the procedure. Failure and complication rates were similar in both groups (P=0.105). Endoscopic diagnoses for frequent indications were generally evenly distributed across the two groups. The main difference was a higher proportion of normal findings and a lower proportion of esophagitis in the group with a doctor present, although this was significant only in patients who had presented with epigastric/abdominal pain (P<0.001). In conclusion, delegating upper gastrointestinal endoscopy to clinical officers can be feasible and safe in a setting with a shortage of medical doctors when adequate training and supervision are provided.

A laparoscopic surgical skills assessment tool for veterinarians.

Our aim in this study was to validate a test of laparoscopic surgical performance by determining the relation of scores from an objective structured assessment of technical skills performed in a canine abdominal model to experience and basic laparoscopic skills. The number of years the participants had performed rigid video-endoscopic procedures (VEP), using triangulation skills, correlated positively with both evaluators' total surgical performance scores for all three evaluation methods: global rating scale, visual analog scale (VAS) rating of overall performance, and operative component rating scale (OCRS). Experience of VEP without triangulation skills (i.e., flexible endoscopy, otoscopy) or video game experience did not correlate with surgical performance. A highly validated basic laparoscopic skills assessment (McGill University inanimate system for training and evaluation of laparoscopic skills, or MISTELS) score was strongly correlated with the VAS score for surgical performance and OCRS scores. Inter-rater reliability was high for the VAS and OCRS evaluation methods, and scores from the detailed OCRS method did not differ between evaluators. In conclusion, the surgical performance test correlated with VEP triangulation experience and basic laparoscopic skills. This type of test needs to be evaluated in a larger sample population including higher numbers of veterinary laparoscopic surgeons for further validation.

Transnasal esogastroduodenoscopy (EGD): comparison with conventional EGD and new applications.

Technical improvements have allowed to significantly reduce the diameter of endoscopes used to examine the upper gastrointestinal tract. Hence, transnasal introduction of endoscopes used to perform a standard esogastroduodenoscopy (EGD) has become possible. Transnasal EGD (T-EGD) is better tolerated by patients than conventional EGD (C-EGD), and it presents the advantage of requiring no sedation in most patients (and, consequently, to reduce associated costs). However, the reduction in endoscope diameter has been obtained at the expense of a somewhat inferior image quality and a smaller biopsy channel diameter. Specific diagnostic and therapeutic applications taking advantage of the transnasal approach have also recently emerged (e.g., cholangioscopy placement of feeding tubes or of nasobiliary drains). The technique, feasibility, patient tolerance to unsedated procedure, diagnostic accuracy, costs, and novel therapeutic applications of T-EGD are reviewed.

Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement.

Endoscopy is the driving force in gastroenterology today, and recent exciting advances in technology have extended its frontiers at an unprecedented rate. We have a wider range of diagnostic and therapeutic possibilities at our disposal with more detailed methods available to analyse what we see on our video screens. We can access the small bowel lumen with consistency and intra-abdominal operations have been performed through the mouth and anus so where are the current limitations of the procedure? In spite of these remarkable advances many challenges remain for both the endoscopist and for industry, they are mainly ones associated with human weakness. Endoscopy is an art, performed by individuals who require training and continued education and it is done to patients who are vulnerable, afraid and often seriously unwell. It is human aspects of endoscopy that require improvement. This chapter addresses the areas where endoscopy is falling short and suggests what can be done to improve practice. Changes are needed in management, information technology, education, team working, quality, patient comfort and safety. There also remain a number of areas where improved technology may be able to reduce human error.

Hospital and health plan liability in granting privileges for endoscopy.

In December 1992, the American College of Gastroenterology (ACG) published a legal opinion which had been developed by the nationally renowned litigation law firm, Williams & Connolly, which has long served as ACG's litigation counsel. The opinion set forth potential litigation liabilities/risks that hospitals incur if they are negligent in their credentialing practices and enable undertrained physicians to perform endoscopy in their inpatient and outpatient facilities. The opinion was published as part of a broader joint effort by ACG and the American Society for Gastrointestinal Endoscopy (ASGE) that resulted in ASGE's Guidelines on Appropriate Training for GI Endoscopy together with the legal opinion on undertrained endoscopists being circulated to all of America's hospitals. Much has changed in both the practice of medicine and the law, since 1992. The two societies decided to join forces again to update these materials. The ACG legal opinion was expanded to also provide guidance about liability of insurance plans when they indicate preferences as to where and by whom procedures should be performed. Some of the key findings from the liability update section of this joint effort follow.

Resident self-assessment of operative performance.

BACKGROUND: In medicine, the development of expertise requires the recognition of one's capabilities and limitations. This study aimed to verify the accuracy of self-assessment for the performance of a surgical task, and to determine whether self-assessment may be improved through self-observation or exposure to relevant standards of performance. METHODS: Twenty-six senior surgical residents were videotaped performing a laparoscopic Nissen fundoplication in a pig. Experts rated the videos using two scoring systems. Subjects evaluated their performances after performance of the Nissen, after self-observation of their videotaped performance, and after review of four videotaped "benchmark" performances. RESULTS: Expert interrater reliability was 0.66 (intraclass correlation coefficient). The correlation between experts' and residents' self-evaluations was initially moderate (r = 0.50, P <0.01), increasing significantly after the residents reviewed their own videotaped performance to r = 0.63 (Deltar = 0.13, P <0.01), yet did not change after review of the benchmarks. CONCLUSIONS: Self-observation of videotaped performance improved the residents' ability to self-evaluate.

Preparation, premedication and surveillance.

The main end points for sedation during endoscopy are patients' satisfaction, short duration of the procedure, and safety. During the last year, attention has focused on attempting to identify the "ideal" candidate for moderate sedation/analgesia and on the importance of providing the patient with appropriate information before the procedure. The increasing pressure to perform more procedures, reduce costs, and achieve shorter patient turnaround times has affected recent approaches to sedation during endoscopy, focusing attention on alternatives to pharmacological sedation such as providing relaxing music, using small-caliber endoscopes for unsedated peroral gastroscopy, and using magnetic endoscopic imaging to increase tolerance and reduce discomfort during colonoscopy. The results, however, have not been convincing. The role of benzodiazepines was discussed in some studies, highlighting the well-known effect of midazolam on postprocedural amnesia, its pharmacological profile and tolerability after intranasal spraying in healthy volunteers, and the efficacy and safety of this route of administration as an alternative to intravenous administration in diagnostic upper gastrointestinal endoscopy. The form of sedation for gastrointestinal endoscopy that has attracted great interest over the last year is the use of intravenous propofol, either alone or with concomitant benzodiazepines or opioids. As expected in view of the drug's known pharmacological properties, the quality of sedation was better and recovery time was shorter in patients treated with propofol. However, important questions involving the narrow therapeutic range and the mode of administration of propofol (by endoscopists or nurses, or by anesthesiologists) remain open. One important aspect of sedation procedures is prevention of cardiopulmonary complications. The use of electronic monitoring techniques, with a pulse oximeter, has been recommended as a standard procedure during digestive endoscopy; however, pulse oximetry no longer reflects the normal ventilatory functions and does not detect episodes of severe CO2 retention. CO2 monitoring by transcutaneous measurement - or better, by capnography - appears to be useful, as an alternative to pulse oximetry, as a measure of hypoventilation, and for detecting potentially important abnormalities in respiratory activity in patients undergoing sedation for gastrointestinal endoscopy. With regard to preparation for endoscopic procedures, several "ideal" formulas for bowel preparation have been presented. These include the use of sodium phosphate compounds as an alternative to polyethylene glycol electrolyte lavage solutions (PEG-ELS); however, the results so far have been conflicting. The best and most cost-effective bowel cleansing procedure for colonoscopy and sigmoidoscopy has yet to be established.

A critical appraisal of laparoscopic staging in hepatobiliary and pancreatic malignancy.

Prognosis for patients with hepatobiliary and pancreatic cancers is dismal. Surgery is the best therapeutic option for those with tumors which have not yet metastasized. Standard radiologic tests such as computed tomography (CT) scan and trans-abdominal ultrasound are useful in identifying patients for whom an attempt at resection would be futile. Staging laparoscopy with laparoscopic ultrasound allows greater precision in identifying those for whom resection would be helpful with less morbidity than an open exploration. Metastatic disease can be identified more precisely than with radiologic tests and can be characterized by biopsy techniques. Palliative procedures are now being performed laparoscopically with low morbidity and short hospital stays. The use of laparoscopy prior to open exploration for patients with hepatobiliary and pancreatic tumors is advantageous.

Procedure-specific outcomes assessment for esophagogastroduodenoscopy.

For many, if not most, of our new technology applications, it is time for a broadening of study goals to include clinical endpoints such as health-related quality of life. Similarly, effectiveness studies to evaluate the application of known and new technology in every day practice, are needed. Establishing uniform definitions and terminology for important constructs such as comorbidity, disease severity, endoscopic findings, and complications must be undertaken in order to ensure accuracy of conclusions. Critical evaluation of how we deliver care to patients with upper GI diseases requiring endoscopy, must proceed with the knowledge that medical care is a process, and within that process, is the means to deliver care of ever increasing quality and efficiency. In this context, this article provides a brief overview of our current knowledge and potential of outcomes research in upper GI endoscopy.

Disease-specific outcomes assessment for gastroesophageal reflux disease.

Endoscopy is commonly performed to evaluate patients with symptoms of gastroesophageal reflux disease (GERD). This review focuses on outcomes related to endoscopy in GERD. There is clear evidence that patients with GERD who have dysphagia are likely to benefit from endoscopy. In the vast majority of patients without dysphagia, the benefits of endoscopy are less certain and require further study.

Disease-specific outcomes assessment for common bile duct stones.

Clinicians often manage patients with suspected bile duct stones. Research has focused on assessing the accuracy of diagnostic alternatives to endoscopic retrograde cholangiography or on establishing predictors for stones. Studies using costs and quality of life as primary outcomes are rare. This may be caused in part by specific challenges inherent to outcomes research in the field of gastrointestinal endoscopy. It is unlikely that one strategy will be suitable for all; however, once a primary outcome is chosen, knowing what variables most affect this outcome should help clinicians objectively tailor the optimal strategy for their needs. The most important variable may be the risk of symptoms caused by untreated stones. There may be a substantial group of patients who are best managed expectantly (with no bile duct imaging). It may therefore, be useful to obtain better prospective data on the natural history of choledocholithiasis.

Disease-specific outcomes assessment for chronic pancreatitis.

Outcomes assessment for individuals with chronic pancreatitis is a relatively new area of research. It is particularly important because of the lack of validated clinical assessment tools for those with this disease process. This article critically evaluates the current medical, endoscopic, and surgical interventions available for patient management.

Value of fibreoptic oesophago-gastro-duodenoscopy: experience with 4000 procedures at Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

The paper presents the results of a retrospective study and the experiences with 4000 fibreoptic oesophago-gastro-duodenoscopies (EGD), which were performed at Kilimanjaro Christian Medical Centre (KCMC) between 1985 and 1989 in an open access service. Seventy per cent of all patients examined had abnormal findings with duodenal ulcer as the most frequent diagnosis (22%). Pyloric stenosis was seen in 6%, gastric ulcer in 5% and esophageal varices in 4% of all patients. High figures were found for carcinoma of the esophagus (4%) and malignancy of the stomach (5%). Gastritis was diagnosed in 11%. We consider fibreoptic EGD a cost effective and appropriate technology. Because of its high diagnostic yield, we advocate its use in certain centres in developing countries.