Successful Training in Gastrointestinal Endoscopy

Cover
Title Page
Copyright Page
Contents
List of Contributors
Foreword
Preface
Acknowledgments
About the Companion Website
Part I The Evolution of Basic Principles and Practice
	Chapter 1 Training in Endoscopy: A Historical Background
		Introduction
		Standard training in endoscopy: then and now
			What must be learned?
		Standards and end points of current endoscopic training
		Emergence of complementary teaching modalities
			Why use simulators?
			Evolution and types of endoscopy simulators
		The future of simulators in endoscopy training
			Ongoing evolution of endoscopic training
		A peek into the future of endoscopic training to 2030
		Conclusion
		References
	Chapter 2 How Endoscopy is Learned: Deconstructing Skill Sets
		Introduction
		Identification of fundamental endoscopy skills
		Introduction of the scope
		Navigation
		Overcoming obstacles
		Inspection
		Instrumentation
		Simulators and task deconstruction
		Summary
		References
	Chapter 3 Training to Become a High-Quality Endoscopist: Mastering the Nonprocedural Aspects
		Preprocedure
			Informed consent
			Preoperative clinical assessment: focused history and physical exam
		Intraprocedure
		Postprocedure
			Documentation of procedure
			Feedback to referring provider
			Recognition of complications
			Patient satisfaction
			Medicolegal issues
			Training in quality assurance and improvement
		Conclusion
		References
	Chapter 4 Training the Endoscopic Trainer
		Introduction
		Training environment
		Attributes of effective endoscopy trainers
		Framework for endoscopic training
			Preparation
			Training
			Wrap-up
			Summary
		Training aids
			Magnetic imagers
			Endoscopic simulators
		Train-the-trainer programs
		Conclusions
		References
Part II Training in the Major Endoscopic Procedures
	Chapter 5 Esophagogastroduodenoscopy (EGD)
		Introduction to EGD training
			Need for training
			Format of training
		Requirements for EGD training
			Trainee
			Trainer
			Setting
		EGD training
			Cognitive aspects
			Equipment
			Diagnostic endoscopy
			Therapeutic endoscopy
		Alternatives for EGD training: simulator-based training
			Computer simulators
			Animal models
		Assessment of performance
		Conclusions
		Videos
		References
	Chapter 6 Colonoscopy
		Introduction
			Specific skills
		Early skills
			Early cognitive skills
			Early motor skills
		Intermediate skills
			Intermediate cognitive skills
			Intermediate motor skills
		How to teach and assess colonoscopy skills
			Early cognitive skills
			Early motor skills
			Intermediate cognitive skills
			Intermediate motor skills
			Ongoing assessment
		Videos
		References
	Chapter 7 Endoscopic Ultrasound
		EUS requires different skill sets than standard endoscopy
		Learning resources for EUS
		The skill sets needed to learn EUS
			Anatomy
			Understand diseases and conditions assessed with EUS
			Ultrasound principles
			EUS image interpretation
			How to operate EUS equipment
			Use of EUS scope
			Diagnostic EUS imaging
			EUS-guided fine-needle aspiration (FNA)
			EUS FNA cytologic evaluation
			Interventional EUS
			Report generation and communication with referring physicians
		Pathways for EUS training
			EUS fellowship training
			EUS training for established practitioners
			Barriers to EUS training
		Complementary training options
			Simulators
			Assessing EUS quality performance
		Conclusion
		References
	Chapter 8 ERCP
		Introduction to ERCP training
			The need for training
			The format of training
			The types of training—from clinical to simulation
		Prerequisite for training
			Trainee—level of skill and expertise
			Setting—case load
			Trainer—a skilled endoscopist may not be a good teacher
			Advice for trainers
		ERCP training
			Cognitive and technical aspects
			Equipment—scope, accessories, and diathermy
			Accessories can be separated into diagnostic and therapeutic categories
		Performance—key steps to technique and trick of trade
			Scope handling
			Cannulation—selective
			Advanced techniques to overcome difficult biliary cannulation
			Precutting with the (regular) wire-guided papillotome along the biliary axis
			Precutting with regular papillotome positioned in pancreatic axis/duct (septostomy)
			Precutting with needle knife alongside an indwelling pancreatic stent
			Fistulotomy with needle knife
			Papillotomy—standard
			Stone extraction—balloon and basket
			Stenting—plastic and metal
			Stent length measurement
			Guide wire negotiation of bile duct stricture
			Dilation of stricture
			Brush cytology
			Stent placement
			Short-wire system
			Multiple stents insertion
			Pancreatic stenting
			Special accessories—mechanical lithotripter
		Alternatives for ERCP training
			Setting and tools—traditional, caseload, simulator training (comparison)
			Comparison of the different simulators for ERCP practice
			Impact of supplemental simulator training
			Assessment of performance
			Training and clinical outcome correlation
			How much volume is needed to maintain skill—retraining and new techniques
			The role of the assistant
		Conclusion
		Videos
		References
	Chapter 9 Capsule Endoscopy
		Introduction
		Description of the capsules
		The capsule endoscopy unit
		Preparing the patient
		Administering the capsule
		Capsule endoscopy reading in clinical settings
		Reading capsule endoscopy study
		Credentialing the capsule endoscopist: current guidelines
		Training the capsule endoscopist: current literature
			Future directions
		Conclusions
		References
	Chapter 10 Deep Enteroscopy
		Introduction
		Prerequisites for training in deep enteroscopy
			Trainee
			Trainers
			Setting
		Cognitive component of deep enteroscopy
			Indications
			Bowel preparation
			Sedation
		Equipment for deep enteroscopy
			Endoscopes
			Overtubes and balloons
			Endoscopic accessories
		Technical aspects of enteroscopy training
		Advancement technique(s)
		Therapeutic enteroscopy maneuvers
			Hemostasis
			Polyp resection
			Stricture dilation
			ERCP and enteral stent placement in the setting of altered anatomy
			Recognition of complications
		Ex vivo training models
			Achieving competence
		Conclusion
		Videos
		References
	Chapter 11 Cholangioscopy and Pancreatoscopy
		Introduction
		Technique of cholangiopancreatoscopy
			Indications for cholangioscopy
			Cholangioscopy for the characterization of biliary lesions and strictures
			Biliary stricture
			Differentiating malignant from benign biliary stricture
			Cholangioscopy-guided stone therapy
			Cholangioscopy-guided selective cannulation
			Indications for cholangioscopy without fluoroscopy
			Cholangioscopy in therapy of malignant bile duct lesions
			Contraindications to cholangioscopy
			Complications of cholangioscopy
			Peroral direct cholangioscopy
			Methods for cannulation for PDCS
			Wire-guided method
			Balloon-anchoring method
			Utilities of the ultraslim upper endoscope
			Pancreatoscopy
			Pancreatoscopy for intraductal papillary mucinous neoplasm
			Pancreatoscopy in chronic pancreatitis
			Intraoperative pancreatoscopy
			Complications of pancreatoscopy
		Trainee prerequisites
		Trainer and facility prerequisites
		Steps to learn
		Competency
		Summary
		Videos
		References
	Chapter 12 Principles of Electrosurgery
		Introduction
		Basics of electricity as applied to electrosurgery
		Monopolar and bipolar circuits
		Safety measures in electrosurgery
			The return electrode
		Pacemakers
		Neuromuscular stimulation
		Explosion risk
		Current leaks
		Tissue effects of electrosurgery in endoscopy
		Cutting
		Coagulation
		Combination cutting and coagulation
		Clinical applications of electrosurgery in endoscopy
			Resection techniques
		Incision techniques
		Bipolar techniques
		Argon plasma coagulation (APC) (Figure 12.12)
		Incorporation of electrosurgical principles into endoscopy training
		References
	Chapter 13 Training in the Use of Fluoroscopy for Gastrointestinal Endoscopy
		Introduction
		Training in fluoroscopy
		Hardware basics
		Protective garments
		Scout films
		ERCP
		Fluoroscopy and enteral stents
			Esophageal stents
			Gastroduodenal stents
			Colon stents
		Enteroscopy
			Push enteroscopy
			Single- and double-balloon enteroscopy
		Lumen-apposing metal stents (LAMS)
		Conclusion
		References
	Chapter 14 Training in Pediatric Endoscopy
		Introduction
		Training program requirements
		Esophagogastroduodenoscopy and colonoscopy
		Patient assessment
		Informed consent
		Sedation
			Sedation for pediatric endoscopy procedures: when not to use it
		Cognitive aspects of training in sedation
		Technical aspects of training in sedation
			Topical agents
			Benzodiazepines
			Narcotics
			Ketamine
			Propofol
			Reversal agents for pediatric sedation
		Upper endoscopy
		Technical skills
		Instruments
		Colonoscopy
		Cognitive skills
		Technical skills
		Instruments
		Diagnostic techniques in upper endoscopy and colonoscopy
		Identifying pathology
		Therapeutic procedures in pediatric endoscopy
			Foreign body removal
		Percutaneous endoscopic gastrostomy (PEG)
			Contraindications
			Complications
		Stricture dilation
		Management of GI bleeding
			Injection therapy
			Thermal coagulation
			Mechanical therapy
			Band ligation
		The role of adult endoscopists in pediatrics
		Defining and assessing procedural competency
		Assessing competency
		Simulation in pediatric endoscopy
		Advanced procedures
		Endoscopic retrograde cholangiopancreatography (ERCP)
		Endoscopic ultrasound
		Wireless video capsule endoscopy
		References
Part III Training in Specific Techniques
	Chapter 15 Contrast-Enhanced Endoscopy: Chromo and Optical Contrast Techniques
		Introduction
		Overview of contrast (image)-enhancement techniques: chromoendoscopy and other optical techniques
		Chromoendoscopy
			Chromoendoscopy in inflammatory bowel disease
			Chromoendoscopy in esophageal neoplasia
			Chromoendoscopy for colorectal polyps and nonpolypoid neoplasia
			Narrowband imaging
		FICE, BLI, BLI-Bright, LCI, and iScan
			Fluorescence imaging
			Confocal laser endomicroscopy
			Molecular imaging
			Methods for training in contrast-enhanced endoscopy techniques
		Evidence for effect of training
		Summary
		Videos
		References
	Chapter 16 Training in GI Hemostasis
		Introduction
		Prerequisite cognitive knowledge required prior to learning GI endoscopic hemostatic techniques
		Prerequisite technical knowledge and skills required to learn endoscopic hemostasis
		Required technical knowledge and skills to be proficient in endoscopic hemostasis
		Common knowledge and skills for all hemostatic strategies
			Knowledge
			Skill
		Specific hemostatic strategies
			Injection
		Thermal
			Knowledge
			Skill
		Mechanical
			Knowledge
			Skill
		Simulators to learn and practice endoscopic hemostasis
		Available models of endoscopic hemostasis
			Virtual reality simulators
			In vivo large animal models of upper GI hemorrhage
		Teaching in endoscopic hemostasis
			Key components of hemostasis to teach
		Data supporting the role of hemostasis training on simulators
		Learning progress in endoscopic hemostasis
		Concept of integrating simulator work into standard endoscopy training
		Maintaining skills in endoscopic hemostasis
		Additional teaching aides for learning GI hemostasis
		Limitations of GI endoscopy for diagnosis and hemostasis of GI bleeding: teaching pearls for troubleshooting and challenges for the future
		Definition of minimal thresholds for determining competency in endoscopic hemostasis
		Requirements to maintain endoscopic hemostasis skills
		Ongoing challenges in learning new GI hemostasis techniques or improving skills
		Summary
		Acknowledgment
		Videos
		References
	Chapter 17 Luminal Dilation Techniques (Strictures, Achalasia, Anastomotic, IBD)
		Introduction
		Equipment
			Fixed-diameter push-type or “bougie” dilators
			Balloon dilators
			Differences between fixed-diameter push-type and balloon dilators
		Ancillary devices
		Endoscope key points to remember
		Fluoroscopy
		Mechanism of dilation
			Terminology
		Technique of dilation
			Fixed-diameter push-type or “bougie” dilation
			TTS balloon dilation
			Continuous access technique
			Maloney dilators
			Dilator selection
		Goal
		Ancillary techniques
		Contraindications
			Complications
		Some key points
		Achalasia
		Endoscopy and performance of pneumatic balloon dilation in achalasia
		Suggested skill set to master and potential outcome measures to assess proficiency in performing luminal dilation
			Skills to master
			Measurable outcomes for instructor to assess while working with trainee
			For push-type dilation
			For balloon dilation
			For achalasia
		Suggested skill level to perform dilation
			Basic
			Advanced
		Videos
		References
	Chapter 18 Management of Foreign Body Ingestion and Esophageal FoodBolus Obstruction
		Introduction
		Training in FB extraction
		Pre-procedure assessment
		Identify devices
			Protective instruments
			Retrieval instruments
		Anticipate the endoscopy
		Endoscopic removal
		Further evaluation
		Conclusions
		Videos
		References
	Chapter 19 Endoscopic Mucosal Resection, Submucosal Dissection, and Full Thickness Resection Techniques
		Introduction
		Endoscopic mucosal resection
			EMR techniques to be considered
			Procedures to be considered
			Prerequisite level of expertise for endoscopic mucosal resection (EMR)
			Special considerations
			Specific technical and cognitive skills for endoscopic resection techniques
			Equipment for EMR
			Patient preparation
			Key steps for proper technique in EMR (see Video 19.1)
			Resection techniques for EMR
		Endoscopic submucosal dissection
			Lesions to be considered for ESD
			Skills for ESD and who should do it
			Equipment for ESD
			Equipment independent of the procedure
			Antibiotics and proton pump inhibitor (PPI)
			Pre-interventional endosonography (EUS)
			Transparent distal endoscope cap for ESD
			Resection knifes
			Resection knifes with integrated fluid injection capability
			Electrosurgical settings
			Procedural steps of endoscopic submucosal dissection (Figures 19.9; 19.12–19.15)
			Preparation of the specimen for histopathologic evaluation
		Post-EMR and post-ESD management
			Control endoscopy
			Risk of secondary bleeding
			Peri-interventional antibiotics
		Management of complications
			Acute procedure-related complications
			Late and secondary complications
		When to use EMR and when ESD?
		Training and first steps in ESD
		Endoscostrapic Full Thickness Resection using the Ovesco eFTRD® system
			Characteristics of the eFTRD® system
			Clinical application of the system
			Anatomical basics and clinical implications
			e FTRD® in the colon
			Material and accessories
			Handling of the resection specimen
			Special follow-up care
			The eFTR procedure with the gastroduodenal FTRD® system
			Instruction for implementation
			Further fields of FTRD® application
		Conclusions and perspectives
		Videos
		References
	Chapter 20 Mucosal Ablation Techniques
		Introduction
		Procedures and equipment involved in mucosal ablation
		Prerequisite cognitive and technical skills for trainees prior to learning mucosal ablation
		Setting of training
		Specific knowledge trainees must acquire during training to perform esophageal mucosal ablation
			Patient selection
			Selection of particular ablation method
			Anticoagulation considerations
			Acid suppression
			Post-ablation analgesia
			Pacemakers and implantable cardiac defibrillators (ICDs)
			Post-ablation surveillance
		Equipment and technical steps
			Argon plasma coagulation
			Radiofrequency ablation (RFA)
			Focal ablation with through-the-scope ablation catheter
			Liquid nitrogen spray cryotherapy (LNSCT)
		Opportunities and methods for training in mucosal ablation
		Defining competency
		Maintaining skill level
		Videos
		References
	Chapter 21 Complicated Polypectomy
		Patient assessment and consent
		Timing
		Endoscopy Team
		General principles
		The electrosurgical unit
		Carbon dioxide
		Snares for polypectomy
		The snare handle as an information center
		Safety in snare handling
		Techniques for successful removal of sessile polyps
		Special techniques for sessile polyps
		Pedunculated polyps
		Fluid injection
		The non-lifting lesion
		Retroflexion
		EMRC
		Lesions involving the ileocecal valve
		Lesions at the appendiceal orifice
		Lesions at the anorectal junction (Video 21.8)
		Circumferential lesions
		Endoscopic submucosal dissection (Videos 21.9 and 21.10)
		Endoscopic full thickness resection
		Adjuvant thermal ablation of the resection margin
		Defect closure with mechanical clips
		Deep mural injury
		Surveillance
		Two-stage EMR
		Adverse events associated with complex polypectomy
		Training and achieving competency in endoscopic tissue resection
		Summary
		Videos
		References
	Chapter 22 Training and Credentialing in Natural Orifice Transluminal Endoscopic Surgery (NOTES)
		Training
		Credentialing
		Conclusion
		References
	Chapter 23 Training in Bariatric Endoscopy
		Bariatric endoscopy procedures
		Training goals
		Infrastructure and personnel
			Facilities
			Mentors
			Simulators and hands-on for training
			Trainees
			Settings
		Pre-procedural assessment
		Equipment
		Procedural considerations and techniques
		Bariatric endoscopy procedures
		Endoscopic management of post-bariatric surgery complications
			Leaks/fistulas
			Stenosis
			Foreign body reaction/pain syndromes
			Band erosion/ring slippage
			Ulceration
		Revisional procedures for weight regain
			Sclerotherapy
			Argon plasma coagulation
			Suturing (Apollo Endosurgery)
			Incisionless Operating Platform and ROSE procedure
		Primary bariatric and metabolic procedures
			Endoluminal gastric volume reduction
			Endoluminal metabolic devices
			Others
		Defining competency for particular skill
		Conclusion
		References
	Chapter 24 Repair of Mucosal Defects: A Primer on Endoscopic Closure of Gastrointestinal Perforations
		Introduction
		Learning to close perforations
			Endoscopic closure devices
			Key steps in endoscopic management of gastrointestinal perforations
			Prevent perforation
			Diagnosis of perforation
			Immediate endoscopic management
			Postendoscopic perforation closure management
			Setting and tools for training
		Conclusion
		Videos
		References
	Chapter 25 Esophageal, Gastroduodenal, and Colorectal Stenting
		Procedure(s) to be considered
		Prerequisite level of expertise and skill for learning this
		Special considerations
		Specific technical and cognitive skill sets
		Equipment
		Key steps of proper technique
			Esophagus
			Distal stomach/duodenum
			Colon/rectum
			Setting and tools for training
		Defining competency
		References
	Chapter 26 ERCP Management of Complicated Stone Disease of the Bile Duct and Pancreas
		Mechanical lithotripsy
		Large-diameter balloon sphincteroplasty
		Cholangiopancreatoscopy
		Electrohydraulic lithotripsy
		Laser lithotripsy
		Extracorporeal shock wave lithotripsy and pancreatic duct stones
		Endoscopic ultrasound as an adjunct
		Difficult anatomy
		Training modalities
		Competency
		References
	Chapter 27 ERCP Management of Malignancy: Tissue Sampling, Metal Stent Placement, and Ampullectomy
		Introduction
		Tissue sampling at ERCP
			Fluid aspiration
			Brush cytology
			Fine needle aspiration
			Forceps biopsy and cytology
			Triple sampling
			Intraprocedural ERCP tissue diagnosis
		Metal stent placement
			Tissue-proven cancer, not resectable
			Tissue-proven cancer, resectable or borderline resectable
			No tissue diagnosis, resectable, or nonresectable
			Extrahepatic SEMS placement
			Bifurcation SEMS placement
		Management of ampullary neoplasms
		Thoughts on advanced endoscopy training
		Videos
		References
	Chapter 28 Sphincter of Oddi Manometry
		Patient selection
		Method of SOM
			Sedation
			Equipment
		Technical performance of SOM (see accompanying Video 28.1)
		Interpretation criteria
		Reproducibility of SOM
		Complications of SOM
		Training in SOM
		Video
		References
	Chapter 29 Training for Pseudocyst Management
		Procedure(s) to be considered
		Prerequisite level of expertise and skill for learning this
		Special considerations
		Specific technical and cognitive skill sets
			Acute peripancreatic fluid collections
			Acute pancreatic pseudocyst
			Chronic pancreatic pseudocyst
			Acute necrotic collection (ANC)
			Walled-off Pancreatic Necrosis (WOPN)
		Equipment
			Essential equipment
		0.018”–0.035” guidewires (depending on needle used)
			Salvage accessories:
		Key steps of proper technique
			Pre-drainage evaluation
			Anesthesia support
			Types of endoscopic drainage
			Transmural drainage
			Transpapillary drainage
		Setting and tools for training
		Defining competency
		Maintaining skill level
		References
	Chapter 30 Enteral Access Techniques: Percutaneous Endoscopic Gastrostomy and Jejunostomy
		Introduction
		Prerequisite expertise and skill
		Setting
		Equipment
		Key steps for proper technique
			Percutaneous endoscopic gastrostomy (PEG) insertion, replacement and removal
		Starting enteral nutrition
		Setting and tools for training
		Defining competency
		Maintenance of skills
		Videos
		References
	Chapter 31 Training in GI Upper Motility Techniques
		Esophageal manometry testing
			Esophageal Anatomy
			Esophageal motility studies
			Procedure and patient protocols
			Analysis of HRM
			Diagnosis of esophageal motor disorders using Chicago Classification
		Conclusion
			Endoflip™ testing
			Reflux testing
			pH testing
			pH and impedance testing
		Wireless motility capsule (WMC) testing
		WMC procedure
		WMC interpretation
		Assessment of gastric emptying
		Specific applications of WMC testing
		Possible complications
		References
	Chapter 32 Training in the Endoscopic Management of Anorectal Disorders
		Introduction
			Procedures and equipment in diagnosis and management
		Prerequisite cognitive and technical skills for trainees prior to learning DRE anoscopy and hemorrhoid treatment
			Visual examination
			The digital rectal exam
			Anoscopy
		Specific knowledge trainees must acquire during training to perform office hemorrhoid banding
		Selection of particular treatment method
		Anticoagulation considerations
		Post banding analgesia
		Incision and drainage of acutely thrombosed external hemorrhoids
		Anal fissures
		Anal pruritus
		Treatment
		Anorectal manometry
		References
	Chapter 33 The Endoscopic Management of Immediate Complications of Therapeutic Endoscopy
		Introduction
		Assessing risk prior to procedure
		Intraprocedure recognition of complications
			Risks of therapeutic endoscopy
			Risks of therapeutic colonoscopy
			Risks of therapeutic ERCP/EUS
			Avoiding complications
			Training to manage complications
			Post-procedure follow-up
		Videos
		References
Part IV Challenges for the Future
	Chapter 34 Assessing Manpower Needs in Gastroenterology and Digestive Endoscopy: Lessons from the Past and Implications for the Future of Endoscopic Training
		Modeling manpower
		Physician workforce estimates
		Gastroenterology workforce modeling
		Future projections in gastroenterology: lessons from the past
		Endoscopic demands for screening colonoscopy
			Endoscopic training for the surgeon
			Future demands for endoscopy
			Demand for training in gastroenterology
		Conclusions
		Acknowledgments
		References
	Chapter 35 International Opportunities for Obtaining Endoscopy Training
		Introduction
		Available opportunities
		Benefits
			Immersion
			Perspective
			Visibility
			Culture
		Drawbacks
		Training in Japan
		A successful training model
			Creating a ‘flying’ training center
			Overcoming the lack of resources
			Portable simulators
			Combining simulator training and patient’s observation
		Conclusion
		References
	Chapter 36 Virtual Tools for Training: The Spectrum of Apps and Virtual Aids for Learning Gastrointestinal Endoscopy
		Introduction
		GI procedure videos
			Online resources with GI procedural videos
			GI society educational platforms
			Smartphone/Smartpad applications
			On-demand videos from conferences and virtual courses
			Podcasts
			Virtual learning and the future
	Chapter 37 Providing Resources and Opportunities for Retraining for Practicing Endoscopists
		References
	Chapter 38 Evolving Role of GI Societies and Industry in Training Endoscopists to Perform New Techniques: Supporting the Process and Setting the Standards
		Background
			Historical perspective
			Making it all possible: novel simulator platforms in endoscopic training
		Evolving role of industry
		Evolving role of GI societies
			IT&T Center initiative
			Expanding course offerings and brand extension
		Future directions and challenges
			GI society role in navigation and standardization of new technology evaluation and adoption
		Video
		References
	Chapter 39 The Importance of Skills Assessment and Recording Personal Outcomes in the Future of Training
		The initial training period
			Tools for direct observation and assessment of endoscopy skills
		Credentialing
		Competence in practice
		Impact of practice measurements on the training process and future directions
		Conclusion
		References
Index
EULA