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.

In-class didactic versus self-directed teaching of the probe-based confocal laser endomicroscopy (pCLE) criteria for Barrett's esophagus.

BACKGROUND AND AIMS: Optimal teaching methods for disease recognition using probe-based confocal laser endomicroscopy (pCLE) have not been developed. Our aim was to compare in-class didactic teaching vs. self-directed teaching of Barrett's neoplasia diagnosis using pCLE. METHODS: This randomized controlled trial was conducted at a tertiary academic center. Study participants with no prior pCLE experience were randomized to in-class didactic (group 1) or self-directed teaching groups (group 2). For group 1, an expert conducted a classroom teaching session using standardized educational material. Participants in group 2 were provided with the same material on an audio PowerPoint. After initial training, all participants graded an initial set of 20 pCLE videos and reviewed correct responses with the expert (group 1) or on audio PowerPoint (group 2). Finally, all participants completed interpretations of a further 40 videos. RESULTS: Eighteen trainees (8 medical students, 10 gastroenterology trainees) participated in the study. Overall diagnostic accuracy for neoplasia prediction by pCLE was 77 % (95 % confidence interval [CI] 74.0 % - 79.2 %); of predictions made with high confidence (53 %), the accuracy was 85 % (95 %CI 81.8 % - 87.8 %). The overall accuracy and interobserver agreement was significantly higher in group 1 than in group 2 for all predictions (80.4 % vs. 73 %; P = 0.005) and for high confidence predictions (90 % vs. 80 %; P < 0.001). Following feedback (after the initial 20 videos), the overall accuracy improved from 73 % to 79 % (P = 0.04), mainly driven by a significant improvement in group 1 (74 % to 84 %; P < 0.01). Accuracy of prediction significantly improved with time in endoscopy training (72 % students, 77 % FY1, 82 % FY2, and 85 % FY3; P = 0.003). CONCLUSION: For novice trainees, in-class didactic teaching enables significantly better recognition of the pCLE features of Barrett's esophagus than self-directed teaching. The in-class didactic group had a shorter learning curve and were able to achieve 90 % accuracy for their high confidence predictions.

Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center.

Pancreatic fistula is a known complication of distal pancreatectomy. Endotherapy with pancreatic duct stent placement and pancreatic sphincterotomy has been shown to be effective in its management; however, experience of endotherapy in the management of this complication has not been extensively reported from the United States. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement has also been proposed to prevent this complication after distal pancreatectomy. In our cohort of 59 patients who underwent distal pancreatectomy, 13 (22%) developed a pancreatic fistula in the immediate postoperative period, of whom 8 (14%) patients (5 female, mean age 52 years) were referred for an ERCP because of ongoing symptoms related to the pancreatic fistula. The pancreatic fistula resolved in all patients after a median duration of 62 days from the index ERCP. The median number of ERCPs required to document resolution of the pancreatic fistula was 2. Although a sizeable percentage of patients develop a pancreatic fistula after distal pancreatectomy, only a small percentage of patients require ERCP for management of this complication. Given the high success rate of endotherapy in resolving pancreatic fistula and the fact that the majority of patients who undergo distal pancreatectomy never require an ERCP, performing ERCP for prophylactic pancreatic duct stent prior to distal pancreatectomy might not be necessary.

Are endoscopic ultrasonography imaging characteristics reliable for the diagnosis of small upper gastrointestinal subepithelial lesions?

PURPOSE OF THE STUDY: To compare the accuracy of endoscopic ultrasonography (EUS) imaging with histopathology in the diagnosis of upper gastrointestinal subepithelial lesions. METHODS: Thirty-seven patients (21 female; mean age: 55 y) underwent endoscopic submucosal resection (ESMR) of upper gastro intestinal subepithelial lesions at a tertiary care facility. All patients underwent EUS before ESMR of the lesion. Information regarding location, size, echogenecity, layer of origin, presumptive diagnosis based on EUS imaging, and histopathology diagnosis after ESMR of the subepithelial lesion was recorded. RESULTS: Twenty-seven subepithelial lesions were resected from the stomach, 5 from the esophagus, and 5 from the duodenum. The mean size of the lesions was 9 mm (range, 6-18 mm). Thirty-six lesions originated from the submucosa, and 1 from the muscularis propria. Using histopathology as the gold standard, the overall diagnostic accuracy of EUS imaging was 49% (18 out of 37). The accuracy of EUS imaging for the diagnosis of esophageal, gastric, and duodenal subepithelial lesions was 20%, 56%, and 40%, respectively. One patient developed a microperforation, and 1 developed bleeding during the ESMR procedure. No complications were reported with the EUS procedure. CONCLUSIONS: The diagnostic accuracy of EUS imaging is inferior to histopathology in the diagnosis of small upper gastrointestinal subepithelial lesions. Endoluminal resection is a relatively safe and noninvasive modality that not only provides tissue sample for accurate diagnostic interpretation, but also aids in the complete removal of small subepithelial lesions of the upper gastrointestinal tract.

Mediastinal schwannoma diagnosed by endoscopic ultrasonography-guided fine needle aspiration cytology.

Schwannoma is the most common neurogenic tumor that is derived from the peripheral nerve sheath. There are no specific serologic markers or characteristic imaging abnormalities associated with schwannoma. Tissue diagnosis and immunohistochemistry are required to diagnose this lesion. We describe a 65-year-old male with a finding of three mass lesions in the superior and middle mediastinum on computed tomography of the chest. The largest lesion measured 4.6 × 5 cm. The patient subsequently underwent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) of the lesion and cytology was consistent with spindle cell neoplasm. Immunohistochemical staining of the cytologic specimen was positive for S-100 and negative for pan-cytokeratin, CD34, CD117, calcitonin, smooth muscle actin and desmin. These findings were consistent with schwannoma. This is the second reported case of a mediastinal schwannoma diagnosed by EUS-FNA.