A Prospective Multicenter Study Evaluating Learning Curves and Competence in Endoscopic Ultrasound and Endoscopic Retrograde Cholangiopancreatography Among Advanced Endoscopy Trainees: The Rapid Assessment of Trainee Endoscopy Skills (RATES) Study

Background and aims Based on the Next Accreditation System, trainee assessment should occur on a continuous basis with individualized feedback. We aimed to validate endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) learning curves among advanced endoscopy trainees (AETs) using a large national sample of training programs and to develop a centralized database that allows assessment of performance in relation to peers. Methods ASGE recognized training programs were invited to participate and AETs were graded on ERCP and EUS exams using a validated competency assessment tool that assesses technical and cognitive competence in a continuous fashion. Grading for each skill was done using a 4-point scoring system and a comprehensive data collection and reporting system was built to create learning curves using cumulative sum analysis. Individual results and benchmarking to peers were shared with AETs and trainers quarterly. Results Of the 62 programs invited, 20 programs and 22 AETs participated in this study. At the end of training, median number of EUS and ERCP performed/AET was 300 (range 155-650) and 350 (125-500). Overall, 3786 exams were graded (EUS:1137; ERCP–biliary 2280, pancreatic 369). Learning curves for individual endpoints, and overall technical/cognitive aspects in EUS and ERCP demonstrated substantial variability and were successfully shared with all programs. The majority of trainees achieved overall technical (EUS: 82%; ERCP: 60%) and cognitive (EUS: 76%; ERCP: 100%) competence at conclusion of training. Conclusions These results demonstrate the feasibility of establishing a centralized database to report individualized learning curves and confirm the substantial variability in time to achieve competence among AETs in EUS and ERCP

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

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

Gastric Peroral Endoscopic Myotomy for Management of Refractory Gastroparesis in Patients with Gastric Neurostimulator Devices: A Multicenter Retrospective Case Control Study

BACKGROUND AND AIMS: Gastric neurostimulation (GNS) and gastric peroral myotomy (G-POEM), therapies for refractory gastroparesis, are associated with suboptimal outcomes. We studied the role of G-POEM as a salvage therapy in patients with refractory symptoms after GNS implantation. METHODS: This was a multicenter, retrospective, matched-case control study. Consecutive patients with GNS device and underwent G-POEM as a salvage therapy for clinical failure (cases) and patients without GNS implantation and underwent G-POEM for refractory gastroparesis (control) between 10-2018 and 08-2021 were included. The primary outcome was clinical success after G-POEM. RESULTS: A total of 123 patients (mean age 45.7 ± 14.7 years; 88 females [72%]) underwent G-POEM therapy during the duration of the study: 41 cases and 82 controls. Clinical success was achieved in 66% in the case group and 65% in the control, (P=0.311), during a median total clinical follow-up time of 11.8 (IQR: 2.4-6.3) months. In the case group, the mean Gastroparesis Cardinal Symptom Index (GCSI) decreased from 2.8 ± 1.8 to 1.5 ± 1.9, (P=0.024), and gastric retention at 4 hours improved from 45% ± 25.8 to 16.6% ± 13.1, (P=0.06). The mean delta improvement in the subscales of nausea/vomiting (1.3 ± 0.6 vs. 0.9 ± 1.1; P=0.044) and bloating (1.6 ± 1.3 vs. 1.2 ± 1.4; P=0.041) were significantly higher in cases than in controls. CONCLUSIONS: Among patients with refractory symptoms after GNS, G-POEM can be a reasonable salvage therapy to provide further symptomatic relief with evidence of a potential additive effect of both G-POEM and GNS

Long-Term Quality of Life Following Endoscopic Therapy Compared to Esophagectomy for Neoplastic Barrett\u27s Esophagus

INTRODUCTION: Endoscopic therapy (ET) and esophagectomy result in similar survival for Barrett\u27s esophagus (BE) with high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC), but the long-term quality of life (QOL) has not been compared. AIMS: We aimed to compare long-term QOL between patients who had undergone ET versus esophagectomy. METHODS: Patients were included if they underwent ET or esophagectomy at the University of Michigan since 2000 for the treatment of HGD or T1a EAC. Two validated survey QOL questionnaires were mailed to the patients. We compared QOL between and within groups (ET = 91, esophagectomy = 62), adjusting for covariates. RESULTS: The median time since initial intervention was 6.8 years. Compared to esophagectomy, ET patients tended to be older, had a lower prevalence of EAC, and had a shorter duration since therapy. ET patients had worse adjusted physical and role functioning than esophagectomy patients. However, the adjusted odds ratio (OR) of having symptoms was significantly less with ET for diarrhea (0.287; 95% confidence interval [CI] = 0.114, 0.724), trouble eating (0.207; 0.0766, 0.562), choking (0.325; 0.119, 0.888), coughing (0.291; 0.114, 0.746), and speech difficulty (0.306; 0.0959, 0.978). Amongst the ET patients, we found that the number of therapy sessions and need for dilation were associated with worse outcomes. DISCUSSION: Multiple measures of symptom status were better with ET compared to esophagectomy following treatment of BE with HGD or T1a EAC. We observed worse long-term physical and role functioning in ET patients which could reflect unmeasured baseline functional status rather than a causal effect of ET

International multicenter study on digital single operator pancreatoscopy for the management of pancreatic stones.

Background: The role of the digital single-operator cholangioscopy (D-SOC) system for the treatment of pancreatic ductal (PD) stones in patients with chronic pancreatitis (CP), using electrohydraulic (EHL) and laser lithotripsy (LL), is not well known. Aims: (1)To study the technical success (complete ductal clearance) and safety (rate/ severity of adverse events (AE) per ASGE lexicon) of D-SOC system with EHL/LL in the treatment of pancreatic stones;(2)To compare the performance of EHL vs. LL. Methods: International, multicenter, retrospective study at 17 tertiary centers between 02/2015 and 09/2017. All patients who underwent D-SOC with EHL/LL for the treatment of PD stones were included. Logistic regression analysis was performed to identify factors associated with technical failure and the need for more than one D-SOC EHL/LL session. Results: 103 (30% F, mean age 54 yr.) patients were included. Most frequent cause of CP was alcohol (60%), 96% had abdominal pain, 49% diabetes, 77% were on narcotics and 45% on pancreatic enzymes. Overall, 12% of patients had previous extracorporeal shock wave lithotripsy (ESWL), 87% previous failed ERCP attempts to clear the PD, and 67% prior indwelling stents. Location of stones was: head 51%, neck 22%, body 15%, tail 4%, and multifocal 8%. The mean main PD diameter was 9.19±3.17 mm. A total of 59 patients were treated with EHL and 44 with LL. The mean procedure time was 64.2±23.2 min. Technical success was achieved in 92 (89%) patients, in a single session in 69 (75%) of patients, whereas 20 (21.7%) required 2-3 sessions and only 3 (3.3%) required more than 3 sessions. A total of 11 (11%) patients failed EHL/LL and were treated with ESWL (n=6), surgery (n=1), combined treatment (n=1) or other (n=3). Nine (8.7%) AEs occurred, 3 pancreatitis, 3 abdominal pain, 1 pancreatic duct perforation, 1 fever and 1 bleeding (mild 6 and moderate 3). Incomplete pancreatic stone removal/stone recurrence occurred in 7 (8%) patients during a median follow-up time of 214 days (IQR 66-403). Technical success was significantly higher in the LL group (81% vs 100%,p=0.002) and procedure time was shorter (55min vs. 74min, p\u3c0.001). AEs (8% vs 9%,pZ1) were similar between the two groups. On univariable analysis, the only factor associated with technical failure was the presence of a PD stricture (OR 3.68 (1.00-13.47),p=0.05). There were no significant predictors of the need for more than one D-SOC EHL/LL on logistic regression analysis Conclusion: D-SOC using EHL or LL is highly effective and safe in treating PD stones, although LL appears to be more effective and efficient when compared to EHL. Only a minority of patients will require additional treatment with ESWL or surgery to achieve ductal clearance. This is the first large multicenter study on D-SOC for PD stones and suggests its major role in the treatment of PD stones