Robert Sedlack

Utility of EUS in the evaluation of cystic pancreatic lesions.

BACKGROUND Preoperative differentiation of benign and malignant/potentially malignant pancreatic cystic lesions is problematic. Data to support the role of EUS and EUS-guided fine-needle aspiration (EUS-FNA) are limited. This study assessed the sensitivity, specificity, and accuracy of EUS, cytopathology, and analysis of cyst fluid for pancreatic cystic lesions. METHODS Retrospectively, 111 consecutive patients were identified (54 men, 57 women; mean age 59 years, range 18-79 years) who underwent EUS from July 1997 to September 2000 because of known or suspected pancreatic cystic lesions based on CT or transabdominal US. Thirty-four patients (16 men, 18 women; mean age 55 years, 25-79 years) who underwent surgery formed the basis for this analysis. EUS diagnosis was compared with surgical pathology. Selected patients underwent EUS-FNA to obtain specimens for cytopathologic analysis and for determination of carcinoembryonic antigen levels. Based on surgical pathology, cysts were classified as benign (simple cyst, pseudocyst, serous cystadenoma) or malignant/potentially malignant (mucinous cystadenoma, intraductal papillary mucinous tumor, cystic islet cell tumor, cystic adenocarcinoma). RESULTS EUS-FNA with cytopathologic assessment of cyst fluid was performed for 18 of the 34 patients; carcinoembryonic antigen level was determined in 11 cases. For EUS, cytopathology, and carcinoembryonic antigen, sensitivity was, respectively, 91%, (p = 0.01 vs. cytology), 27%, and 28%; specificity was, respectively, 60%, 100%, and 25%; and, accuracy was, respectively, 82%, 55%, and 27%. The sensitivity of EUS in all 13 patients with cystic islet cell tumor, intraductal papillary mucinous tumor, or cystic adenocarcinoma was 100%. Combining EUS, cytopathology, and carcinoembryonic antigen results did not improve accuracy. There were no complications related to the EUS or EUS-FNA. CONCLUSIONS EUS alone is sensitive and accurate in identifying malignant/potentially malignant pancreatic cystic lesions. EUS-FNA to obtain specimens for cytopathologic analysis and determination of carcinoembryonic antigen levels, although safe, does not enhance diagnostic yield.

The Mayo Colonoscopy Skills Assessment Tool: validation of a unique instrument to assess colonoscopy skills in trainees

BACKGROUND Defining competence in colonoscopy is elusive because there is no objective means by which to assess skills. OBJECTIVE We describe the development and validation of the Mayo Colonoscopy Skills Assessment Tool (MCSAT) designed for the assessment of cognitive and motor skills during colonoscopy training. DESIGN Prospective development and analysis of the validity evidence of a unique colonoscopy skills assessment tool. SETTING Outpatient endoscopy center, Mayo Clinic in Rochester, Minn, from July 2007 through May 2010. SUBJECTS All gastroenterology fellows in training at this institution during the study period. INTERVENTION The MCSAT was developed and used to assess fellow performance over a 3-year period. MAIN OUTCOME MEASUREMENTS A descriptive report of the forms development, correlation of each MCSAT assessment parameter with overall competency scores, and a comparison of MCSAT scores at various stages of training. RESULTS There is strong individual item correlation to overall skills assessment for many of the parameters as well as significant improvement in all parameter scoring at increasing stages of experience. LIMITATIONS Compliance with MCSAT completion was 62% of all colonoscopies performed. CONCLUSIONS The MCSAT provides a valid means to objectively assess individual cognitive and motor skills in a continuous manner throughout colonoscopy training. The resultant data can eventually be used to establish average learning curves in colonoscopic skills and define competency thresholds based on performance scores rather than basing assessment simply on numbers of procedures performed.

Principles of training in GI endoscopy

E This document, prepared by the American Society for Gastrointestinal Endoscopy Committee on Training, was undertaken to provide general guidelines for endoscopy training and written primarily for individuals involved in teaching endoscopic procedures to fellows/trainees. This updates the previous Principles of Training document.1 Research in objective evaluation of procedural skills makes revision of the guidelines at this time highly appropriate.

Colonoscopy core curriculum

n d S i t i v f t a b This is one of a series of documents prepared by the American Society for Gastrointestinal Endoscopy (ASGE) Training Committee. This curriculum document contains recommendations for training, intended for use by endoscopy training directors, endoscopists involved in teaching endoscopy, and for trainees in endoscopy. It was developed as an overview of techniques currently favored for the performance and training of colonoscopy 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 colonoscopy.

Validation of computer simulation training for esophagogastroduodenoscopy: Pilot study.

Background:  Little is known regarding the value of esophagogastroduodenoscopy (EGD) simulators in education. The purpose of the present paper was to validate the use of computer simulation in novice EGD training.

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.

Effects of Simulation-Based Training in Gastrointestinal Endoscopy: A Systematic Review and Meta-analysis

BACKGROUND & AIMS Simulation-based training (SBT) in gastrointestinal endoscopy has been increasingly adopted by gastroenterology fellowship programs. However, the effectiveness of SBT in enhancing trainee skills remains unclear. We performed a systematic review with a meta-analysis of published literature on SBT in gastrointestinal endoscopy. METHODS We performed a systematic search of multiple electronic databases for all original studies that evaluated SBT in gastrointestinal endoscopy in comparison with no intervention or alternative instructional approaches. Outcomes included skills (in a test setting), behaviors (in clinical practice), and effects on patients. We pooled effect size (ES) using random-effects meta-analysis. RESULTS From 10,903 articles, we identified 39 articles, including 21 randomized trials of SBT, enrolling 1181 participants. Compared with no intervention (n = 32 studies), SBT significantly improved endoscopic process skills in a test setting (ES, 0.79; n = 22), process behaviors in clinical practice (ES, 0.49; n = 8), time to procedure completion in both a test setting (ES, 0.79; n = 16) and clinical practice (ES, 0.75; n = 5), and patient outcomes (procedural completion and risk of major complications; ES, 0.45; n = 10). Only 5 studies evaluated the comparative effectiveness of different SBT approaches; which provided inconclusive evidence regarding feedback and simulation modalities. CONCLUSIONS Simulation-based education in gastrointestinal endoscopy is associated with improved performance in a test setting and in clinical practice, and improved patient outcomes compared with no intervention. Comparative effectiveness studies of different simulation modalities are limited.

The impact of a hands-on ERCP workshop on clinical practice

BACKGROUND Hands-on endoscopy workshops are increasingly common venues for procedure training. However, the effect of this type of training on the practices of participants is unknown. The goal of this study was to examine the changes in individual clinical practices subsequent to participation in an ERCP hands-on course. METHODS Forty-eight practicing pancreatobiliary endoscopists participating in a 2-day hands-on advanced ERCP course were asked to complete a 24-item survey evaluating their endoscopic practices both before and 3 months after workshop participation. The surveys evaluated monthly volume and self-confidence in performing the following procedures: diagnostic ERCP, standard sphincterotomy, needle-knife pre-cut sphincterotomy, biliary stone extraction, mechanical lithotripsy, plastic stent placement, metal stent placement, and biliary brushing for cytologic specimens. RESULTS Thirty-one of the 48 participants (65%) who completed both pre- and postcourse surveys form the study cohort. After the workshop, there was a significant increase in use of needle-knife pre-cut sphincterotomy in clinical practices. In addition, the post-workshop survey indicated a significant increase in confidence for procedures such standard sphincterotomy, needle-knife pre-cut sphincterotomy, stone extraction, mechanical lithotripsy, placement of metal stents, and cytology brushing. Confidence in basic diagnostic ERCP and plastic stent placement did not increase because of high initial confidence levels. CONCLUSIONS Participation in a hands-on course appears to increase the confidence of endoscopists in the performance of more complex interventions. However, this was only associated with increased clinical application for one technique.

Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill

t n m t s d d t The PIVI (Preservation and Incorporation of Valuable endoscopic Innovations) initiative is an American Society for Gastrointestinal Endoscopy (ASGE) program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Additionally, PIVIs may also outline the data and/or the research study design required for proving that an established threshold is met. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice, presuming the appropriate training in that endoscopic technology has been achieved. The ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds. The PIVI initiative was developed primarily to direct endoscopic technology development toward resolving important clinical issues in endoscopy. The PIVI initiative is also designed to minimize the possibility that potentially valuable innovations are prematurely abandoned due to lack of use and to avoid widespread use of an endoscopic technology before clinical studies documenting their effectiveness have been performed. The following document, or PIVI, is one of a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice. It is also meant to serve as a guide for researchers or those seeking to develop technologies that are designed to improve digestive health outcomes. An ad hoc committee under the auspices of the existing ASGE Technology and Standards of Practice Committees Chairs develops PIVIs. An expert in the subject area hairs the PIVI, with additional committee members hosen for their individual expertise. In preparing this ocument, evidence-based methodology was used, with MEDLINE and PubMed literature search to identify ertinent clinical studies on the topic. PIVIs are ulti-

Entrustable professional activities for gastroenterology fellowship training

*Office of Academic Affairs and Education and Department of Medicine, Division of Gastroenterology, University of Connecticut School of Medicine, Farmington, CT, USA †Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA ‡Henry D. Janowitz Division of Gastroenterology, New York, NY, USA §The Brookdale Department of Geriatrics and Palliative Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA ¶American Gastroenterological Association, Bethesda, MD, USA **Division of Gastroenterology, Department of Medicine, State University of New York (SUNY), Upstate Medical University, Syracuse, NY, USA