Use of capsule endoscopy in inflammatory bowel disease in clinical practice in Spain. Results from a national survey. / Uso de la cápsula endoscópica en enfermedad inflamatoria intestinal en práctica clínica en España. Resultados de una encuesta nacional.

INTRODUCTION: Small bowel capsule endoscopy (SBCE) is a non-invasive diagnostic technique whose use in inflammatory bowel disease (IBD) has spread. A panenteric capsule, PillCam Crohn's (PCC), has recently been developed. We lack information on the availability and use of the CEID and PCC in our environment. METHODS: We conducted an electronic and anonymous survey among the members of the Grupo Español de Trabajo en Enfermedad de Crohn y Colitis Ulcerosa (GETECCU) [Spanish Working Group on Crohn's Disease and Ulcerative Colitis] and the Asociación Española de Gastroenterología (AEG) [Spanish Association of Gastroenterology], consisting of 37 multiple-choice questions. RESULTS: One hundred and fifty members participated, the majority dedicated to IBD (69.3%). 72.8% worked at centres with an IBD unit. 79% had SBCE available at their hospital, 14% referred patients to another centre; 22% had a PCC available, 9% referred patients to another centre. 79.3% of respondents with available SBCE used it in a small percentage of patients with IBD and 15.6% in the majority. The most frequent scenarios were suspicion of Crohn's disease (76.3%), assessment of inflammatory activity (54.7%) and assessment of the extent of the disease (54.7%). More than half (59.7%) preferentially used the Patency capsule to assess intestinal patency. Almost all respondents (99.3%) considered that training resources should be implemented in this technique. CONCLUSIONS: SBCE is widely available in Spanish hospitals for the management of IBD, although its use is still limited. There is an opportunity to increase training in this technique, and consequently its use.

A Deeper Look at the Small Bowel: Training Pathways in Video Capsule Endoscopy and Device-Assisted Enteroscopy.

BACKGROUND: Although there are guidelines for video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), little is known about fellowship training in these technologies. AIMS: The aims were to better characterize current small bowel endoscopy training in 3-year GI fellowship programs and 4th-year advanced endoscopy programs in the U.S. METHODS: We developed an online multiple-choice survey to assess current GI fellowship program training in small bowel endoscopy. The survey was distributed via email to GI fellowship program directors in the U.S. RESULTS: Of the 168 program directors contacted, 59 responded (response rate = 35.1%). There was no statistically significant difference in the availability of VCE or DAE between respondents and non-respondents. VCE training was universally available in 3-year training programs, with 84.8% (50/59) requiring it for fellows. The majority of 3-year GI fellows graduated with independence in VCE: 83.1% (49/59) of programs reported "most" or "all" graduates were able to read independently. DAE techniques were available in 86.4% of training programs (51/59). Training in DAE was more limited and shared between 3-year and 4th-year programs: 12.1% (7/58) of 3-year programs required training in DAE and 22.9% (8/35) of 4th-year programs required training in DAE . CONCLUSIONS: Training in VCE is widely available in U.S. GI fellowship programs, although programs have different ways of incorporating this training into the curriculum and of measuring competency. While DAE technology was available in the majority of programs, training was less frequently available, and training is shared between 3-year fellowship programs and 4th-year advanced endoscopy programs .

Influencia de la experiencia acumulada del explorador en el valor predictivo negativo de la cápsula endoscópica / Impact of the endoscopist's experience on the negative predictive value of capsule endoscopy

INTRODUCCIÓN: La influencia de la experiencia acumulada del médico que interpreta cápsulas endoscópicas sobre su capacidad diagnóstica es discutida. OBJETIVO: Determinar si existen diferencias en el valor predictivo negativo de las cápsulas endoscópicas informadas por los mismos endoscopistas a lo largo del tiempo. MÉTODOS: Revisamos las 900 primeras cápsulas endoscópicas realizadas por tres gastroenterólogos expertos en endoscopia durante 8 años. Se dividieron en 3 grupos de 300 cápsulas cada uno. El grupo 1 fue la suma de las tres primeras centenas informadas por cada uno, el grupo 2 la suma de las tres segundas centenas y el grupo 3 la suma de las tres terceras centenas. Se hizo un seguimiento mínimo de 28 meses a los casos con exploración normal. RESULTADOS: Aunque se consideraron normales el 18% de las cápsulas del grupo 1, el 19,3% de las del grupo 2 y el 15,6% de las del grupo 3, solo fue posible seguir y finalmente analizar a 34 enfermos en el grupo 1, a 38 en el 2 y a 36 en el 3. Sobre estos casos, el valor predictivo negativo fue del 88,2% en el grupo 1, del 89,5% en el grupo 2 y del 97% en el grupo 3 (p > 0,05). CONCLUSIÓN: El valor predictivo negativo de la cápsula endoscópica, aunque con tendencia a aumentar, se mantiene alto y sin diferencias significativas desde las 100 primeras exploraciones si los médicos que la interpretan son expertos en endoscopia convencional y tienen formación específica previa

INTRODUCTION: The impact of the accumulated experience of the capsule endoscopy (CE) reader on the accuracy of this test is discussed. AIM: To determine whether the negative predictive value of CE findings changes along the learning curve. METHODS: We reviewed the first 900 CE read by 3 gastroenterologists experienced in endoscopy over 8 years. These 900 CE were divided into 3 groups (300 CE each): group 1 consisted of the sum of the first 100 CE read by each of the 3 endoscopists; group 2, the sum of the second 100 and groups 3, the sum of the third 100. Patients with normal CE were monitored for at least 28 months to estimate the negative predictive value. RESULTS: A total of 54 (18%) CE in group 1, 58 (19.3%) in group 2 and 47 (15.6%) in group 3 were normal, although only 34 patients in group 1, 38 in group 2 and 36 in group 3 with normal CE completed follow up and were eventually studied. The negative predictive value was 88.2% in group 1, 89.5% in group 2 and 97% in group 3 (P > .05). CONCLUSION: The negative predictive value tended to increase, but remained high and did not change significantly after the first 100 when readers are experienced in conventional endoscopy and have preliminary specific training

NASPGHAN Capsule Endoscopy Clinical Report.

Wireless capsule endoscopy (CE) was introduced in 2000 as a less invasive method to visualize the distal small bowel in adults. Because this technology has advanced it has been adapted for use in pediatric gastroenterology. Several studies have described its clinical use, utility, and various training methods but pediatric literature regarding CE is limited. This clinical report developed by the Endoscopic and Procedures Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition outlines the current literature, and describes the recommended current role, use, training, and future areas of research for CE in pediatrics.

Assessment of an electronic learning system for colon capsule endoscopy: a pilot study.

BACKGROUND: Training for colon capsule endoscopy (CCE) procedures is currently performed as a lecture and hands-on seminar. The aims of this pilot study were to assess the utility of an electronic learning system for CCE (ELCCE) designed for the Japanese Association for Capsule Endoscopy using an objective scoring engine, and to evaluate the efficacy of ELCCE on the acquisition of CCE reading competence. METHODS: ELCCE is an Internet-based learning system with the following steps: step 1, introduction; step 2, CCE reading competence assessment test (CCAT), which evaluates the competence of CCE reading prior to training; step 3, learning reading theory; step 4, training with guidance; step 5, training without guidance; step 6, final assessment; and step 7, the same as step 2. The CCAT, step 5 and step 6 were scored automatically according to: lesion detection, diagnosis (location, size, shape of lesion), management recommendations, and quality of view. Ten trainee endoscopists were initially recruited (cohort 1), followed by a validating cohort of 11 trainee endoscopists (cohort 2). RESULTS: All but one participant finished ELCCE training within 7 weeks. In step 6, accuracy ranged from 53 to 98 % and was not impacted by step 2 pretest scores. The average CCAT scores significantly increased between step 2 pretest and step 7 in both cohorts, from 42 ± 18 % to 79 ± 15 % in cohort 1 (p = 0.0004), and from 52 ± 15 % to 79 ± 14 % in cohort 2 (p = 0.0003). CONCLUSIONS: ELCCE is useful and effective for improving CCE reading competence.

A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study.

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

Present Standard in Pediatric Gastroenterology Fellowship Training in the Interpretation of Capsule Endoscopy.

Consensuses on fellowship training in wireless capsule endoscopy (WCE) interpretation have been published for adult gastroenterology (GI) but not in pediatric GI training. A questionnaire has been sent to 64 pediatric and 45 adult GI fellowship programs to compare their present training approach. Adult GI programs reported having a formal GI capsule endoscopy module in 38% and required to attend hands-on course in 27% as compared with 4% and 8% in pediatric programs, respectively. A more formalized approach to WCE training may be required for credentialing pediatric trainees to be aligned with expectations in adult GI programs.

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.

Emergency physicians accurately interpret video capsule endoscopy findings in suspected upper gastrointestinal hemorrhage: a video survey.

BACKGROUND: Acute upper gastrointestinal (GI) hemorrhage is a common emergency department (ED) presentation whose severity ranges from benign to life-threatening and the best tool to risk stratify the disease is an upper endoscopy, either by scope or by capsule, a procedure performed almost exclusively by gastroenterologists. Unfortunately, on-call gastroenterology specialists are often unavailable, and emergency physicians (EPs) currently lack an alternative method to endoscopically visualize a suspected acute upper GI hemorrhage. Recent reports have shown that video capsule endoscopy is well tolerated by ED patients and has similar sensitivity and specificity to endoscopy for upper GI hemorrhage. OBJECTIVES: The study objective was to determine if EPs can detect upper GI bleeding on capsule endoscopy after a brief training session. METHODS: A survey study was designed to demonstrate video examples of capsule endoscopy to EPs and determine if they could detect upper GI bleeding after a brief training session. All videos were generated from a prior ED-based study on patients with suspected acute upper GI hemorrhage. The training session consisted of less than 10 minutes of background information and capsule endoscopy video examples. EPs were recruited at the American College of Emergency Physicians Scientific Assembly in Denver, Colorado, from October 8, 2012, to October 10, 2012. Inclusion criteria included being an ED resident or attending physician and the exclusion criteria included any formal endoscopy training. The authors analyzed the agreement between the EPs and expert adjudicated capsule endoscopy readings for each capsule endoscopy video. For the outcome categories of blood (fresh or coffee grounds type) or no blood detected, the sensitivity and specificity were calculated. RESULTS: A total of 126 EPs were enrolled. Compared to expert gastroenterology-adjudicated interpretation, the sensitivity to detect blood was 0.94 (95% confidence interval [CI] = 0.91 to 0.96) and specificity was 0.87 (95% CI = 0.80 to 0.92). CONCLUSIONS: After brief training, EPs can accurately interpret video capsule endoscopy findings of presence of gross blood or no blood with high sensitivity and specificity.

Small-bowel endoscopy core curriculum.

This is one of a series of documents prepared by the ASGE Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of small-bowel endoscopy and to serve as a guide to published references, videotapes, and other resources available to the trainer. By providing information to endoscopy trainers about the common practices used by experts in performing the technical aspects of the procedure, the ASGE hopes to improve the teaching and performance of small-bowel endoscopy.

A resource-efficient tool for training novices in wireless capsule endoscopy.

Nurses often function as capsule endoscopy "pre-readers" to save physicians' time and potentially increase diagnostic yield. Training pre-readers is time consuming, not standardized, and may not be feasible during regular business hours. A way to evaluate the progress and accuracy of pre-readers is needed to ensure competency. The aim of this study was to introduce a feedback and progress assessment tool for training novice capsule endoscopy pre-readers. We created a 1-page form with listings of potential findings for each segment of the examination. Findings could be circled or written in. The trainee reviewed capsule studies and filled out the form on each of 220 patients. The physician reviewers subsequently critiqued the data forms, providing feedback regarding missed lesions, overcalls, and overall agreement. Our trainee achieved consistent agreement with the physician reviewers, after reading 80 studies. In conclusion, a simple, 1-page standardized data sheet can be used to facilitate training of novice capsule pre-readers without significant time commitment from the supervising physician. Future studies may validate this resource-efficient instrument as a training and assessment tool for nurses, physicians, and other practitioners learning capsule endoscopy.

Can we improve the detection rate and interobserver agreement in capsule endoscopy?

BACKGROUND: Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking. AIM: (1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters. METHODS: 17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard). RESULTS: The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience. CONCLUSIONS: Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.