Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.

BACKGROUND AND AIMS: Minimum EUS and ERCP volumes that should be offered per trainee in "high quality" advanced endoscopy training programs (AETPs) are not established. We aimed to define the number of procedures required by an "average" advanced endoscopy trainee (AET) to achieve competence in technical and cognitive EUS and ERCP tasks to help structure AETPs. METHODS: American Society for Gastrointestinal Endoscopy (ASGE)-recognized AETPs were invited to participate; AETs were graded on every fifth EUS and ERCP examination using a validated tool. Grading for each skill was done using a 4-point scoring system, and learning curves using cumulative sum analysis for overall, technical, and cognitive components of EUS and ERCP were shared with AETs and trainers quarterly. Generalized linear mixed-effects models with a random intercept for each AET were used to generate aggregate learning curves, allowing us to use data from all AETs to estimate the average learning experience for trainees. RESULTS: Among 62 invited AETPs, 37 AETs from 32 AETPs participated. Most AETs reported hands-on EUS (52%, median 20 cases) and ERCP (68%, median 50 cases) experience before starting an AETP. The median number of EUS and ERCPs performed per AET was 400 (range, 200-750) and 361 (range, 250-650), respectively. Overall, 2616 examinations were graded (EUS, 1277; ERCP-biliary, 1143; pancreatic, 196). Most graded EUS examinations were performed for pancreatobiliary indications (69.9%) and ERCP examinations for ASGE biliary grade of difficulty 1 (72.1%). The average AET achieved competence in core EUS and ERCP skills at approximately 225 and 250 cases, respectively. However, overall technical competence was achieved for grade 2 ERCP at about 300 cases. CONCLUSION: The thresholds provided for an average AET to achieve competence in EUS and ERCP may be used by the ASGE and AETPs in establishing the minimal standards for case volume exposure for AETs during their training. (Clinical trial registration number: NCT02509416.).

Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography, From Training Through Independent Practice.

BACKGROUND & AIMS: It is unclear whether participation in competency-based fellowship programs for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) results in high-quality care in independent practice. We measured quality indicator (QI) adherence during the first year of independent practice among physicians who completed endoscopic training with a systematic assessment of competence. METHODS: We performed a prospective multicenter cohort study of invited participants from 62 training programs. In phase 1, 24 advanced endoscopy trainees (AETs), from 20 programs, were assessed using a validated competence assessment tool. We used a comprehensive data collection and reporting system to create learning curves using cumulative sum analysis that were shared with AETs and trainers quarterly. In phase 2, participating AETs entered data into a database pertaining to every EUS and ERCP examination during their first year of independent practice, anchored by key QIs. RESULTS: By the end of training, most AETs had achieved overall technical competence (EUS 91.7%, ERCP 73.9%) and cognitive competence (EUS 91.7%, ERCP 94.1%). In phase 2 of the study, 22 AETs (91.6%) participated and completed a median of 136 EUS examinations per AET and 116 ERCP examinations per AET. Most AETs met the performance thresholds for QIs in EUS (including 94.4% diagnostic rate of adequate samples and 83.8% diagnostic yield of malignancy in pancreatic masses) and ERCP (94.9% overall cannulation rate). CONCLUSIONS: In this prospective multicenter study, we found that although competence cannot be confirmed for all AETs at the end of training, most meet QI thresholds for EUS and ERCP at the end of their first year of independent practice. This finding affirms the effectiveness of training programs. Clinicaltrials.gov ID NCT02509416.

Use of a lumen-apposing metal stent to treat GI strictures (with videos).

BACKGROUND AND AIMS: Benign GI strictures occur typically in the esophagus and pyloric channel but can occur anywhere in the GI tract and at anastomotic sites. Such strictures can be treated with dilation, incisional therapy, steroid injection, and stents. Our aim was to describe the use of a lumen-apposing metal stent (LAMS) to treat short, benign GI strictures. PATIENTS AND METHODS: Consecutive patients who underwent LAMS placement for various benign strictures at 2 tertiary care centers from August 2014 to November 2015 were reviewed retrospectively. The main outcome measures were technical success, clinical success, stent migration, and adverse events. RESULTS: Twenty-five patients (7 males, 18 females) with a median age of 54 years (33-85 years) underwent 28 LAMS placements to treat various benign strictures. The location of the strictures included esophagogastric anastomoses (n=4), gastrojejunal anastomoses (n=13), pylorus (n=6), vertical banded gastroplasty (n=1), and ileocolonic anastomosis (n=1). Twenty patients had been previously treated with dilation alone (9 patients with ≥3 dilations), 11 patients with dilation and steroid injection, 2 patients with additional needle-knife therapy, and 1 patient with placement of a traditional fully covered self-expandable metal stent. A 15-mm internal diameter LAMS was placed in all patients; 3 patients had been treated previously with a 10-mm LAMS. Technical success was achieved in all patients, whereas clinical success was achieved in 15 of 25 patients (60%) who completed a minimum of 6 months of follow-up after placement. Median stent dwell time was 92 days (range, 3-273 days). Stent migration was seen in 2 of 28 stent placements (7%). Four of 25 patients (16%) developed 5 moderate adverse events (pain requiring removal, 2; new stricture formation, 2; bleeding, 1). Median follow-up was 301 days after stent placement. Study limitations include the small, select group of patients, the retrospective study design, and short follow-up. CONCLUSIONS: LAMS placement for benign GI strictures is technically easy and safe with low migration rates and may be an option to treat selected patients with short-length strictures.

Impact of EUS-guided fine-needle biopsy sampling with a new core needle on the need for onsite cytopathologic assessment: a preliminary study.

BACKGROUND AND AIMS: FNA is the primary method of EUS tissue acquisition. In an attempt to improve our yield of EUS-guided tissue acquisition, we compared fine-needle biopsy (FNB) sampling without rapid onsite evaluation (ROSE) with FNA with ROSE and assessed the concordance of FNA and FNB sampling. METHODS: This was a retrospective review of prospectively collected data from consecutive patients. Patients underwent FNB sampling and FNA of the same single lesion, with the same needle gauge and number of passes. FNA with ROSE was performed with a standard FNA needle. FNB sampling was performed with a new dedicated core needle. FNA samples were assessed with ROSE, and a final interpretation was provided by cytopathology staff; FNB samples were analyzed by surgical pathologists, each not made aware of the other's opinion. RESULTS: Thirty-three patients underwent 312 passes in 42 different lesions. A diagnosis of malignancy was more likely with FNB sampling than with FNA (72.7% vs 66.7%, P = .727), although statistical significance was not reached. FNA and FNB sampling had similar sensitivities, specificities, and accuracies for cancer (81.5% vs 88.9%, 100% vs 100%, and 84.8% vs 90.9%, respectively). FNB sampling provided qualitative information not reported on FNA, such as degree of differentiation in malignancy, metastatic origin, and rate of proliferation in neuroendocrine tumors. CONCLUSIONS: FNB sampling without ROSE using a dedicated core needle performed as well as FNA with ROSE in this small cohort, suggesting that FNB sampling with this new core needle may eliminate the need for an onsite cytopathologic assessment, without loss of diagnostic accuracy.

Proton radiotherapy dose perturbations caused by esophageal stents of varying material composition are negligible in an experimental model.

BACKGROUND: Self-expanding metal and plastic esophageal stents (SEMS and SEPS, respectively) are used in conjunction with chemoradiation for palliation of malignant dysphagia. To date, the dosimetric effects of stents undergoing proton radiotherapy are not known. STUDY AIM: To investigate the proton radiotherapy dose perturbations caused by esophageal stents of varying designs and materials undergoing external beam treatment for esophageal cancer. PATIENTS AND METHODS: Simulated clinical protocol. Solid acrylic phantom was used to mimic the esophageal tissue environment. Stents made of nitinol, stainless steel and polyester were tested. Proton beam dose of 2 Gy-E was delivered to each stent in a single anterior to posterior field. Film and image based evidence of dose perturbation were main outcomes measured. RESULTS: Only the stainless steel and plastic stents demonstrated slight overall dose attenuations (- 0.5 % and - 0.4 %, respectively). All the nitinol-based stents demonstrated minimal overall dose perturbations ranging from 0.0 % to 1.2 %. Negligible dose perturbations were observed on each of the stent surfaces proximal to the radiation source, ranging from - 0.8 % (stainless steel stent) to 1.0 % (nitinol stent). Negligible dose effects were also observed on the distal surfaces of each stent ranging from - 0.5 % (plastic and stainless steel stents) to 1.0 % (nitinol stent). CONCLUSION: Proton radiotherapy dose perturbations caused by stents of varying designs and material composition are negligible. Negligible dose perturbation is in keeping with the inherent advantage of proton therapy over traditional radiotherapy composed of photons - given its relative large mass, protons have little side scatter.

Gastrointestinal manifestations, diagnosis, and management of hereditary angioedema.

Abdominal pain is one of the most common conditions in clinical practice and yet a challenging complaint to accurately diagnose due to the vast number of possible etiologies. When other health care providers cannot identify the cause of abdominal pain, gastroenterologists are often looked upon to help solve the diagnostic dilemma. Consequently, it is incumbent upon gastroenterologists to be well versed in the diagnosis and management of not only common but also rare causes of abdominal pain. One such uncommon but well-described cause of abdominal pain is angioedema of the intestinal tract due to hereditary angioedema. Acute onset, recurrent abdominal pain of varying severity is its most common presenting symptom, and misdiagnosis can not only lead to unnecessary surgical procedures but also death. The purpose of this review is to raise awareness among gastroenterologists about hereditary angioedema as a potential cause of recurrent, unexplained abdominal pain.