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353: Self-Assessment in Colonoscopy, a Novel Tool for Assessment of Skills
Abstracts
Table 1. Adherence to surveillance colonoscopy guidelines Patients Patients with Time interval to Adequate SC (n) SC (n,(%)) SC (median (IQR)) (guideline ⴞ25%)(%) Group A (IC ⬍ 2002) Group B (IC in 2002) * p⫽0.03
2662
1351(51)
17(12-36)
35
404
292(72)
26(11-43)*
19
352 Quality of Colonoscopy Withdrawal Technique and Variability in Adenoma Detection Rates: Is Technique More Important Than Time? Raymond S. Tang, Thomas J. Savides, V. Raman Muthusamy, Ana Maria Crissien, Samuel B. Ho, Nimeesh K. Shah, Andrew J. Bain, Erin E. Mackintosh, Lida Jafari Saraf, Denise Kalmaz, Robert H. Lee Background/Aims: Studies suggest that factors related to the individual endoscopist are important in determining Adenoma Detection Rates (ADR) during screening colonoscopy. The aim of this study was to examine the impact of withdrawal technique in distinguishing between endoscopists with varying ADR.Methods: ADR’s from screening colonoscopies were calculated on 11 gastroenterologists from 5 academic medical centers for the preceding 12 months. Based upon the distribution, endoscopists were divided into 3 groups: 1) Low (ADR⬍20%) 2) Moderate (ADR 20-42%) 3) High (ADR⬎42%). A total of 20 video-recordings (10 real, 10 sham) of colonoscopy withdrawals were then performed on each endoscopist. The recordings were reviewed by 3 blinded expert gastroenterologists who assigned withdrawal technique scores (0-5) for Fold Examination, Cleansing and Distension for 5 areas of the colon. Mean withdrawal times were calculated based upon the recordings. Technique scores and withdrawal times were compared among the groups using ANOVA for repeated measures.Results: Mean withdrawal technique scores were higher in the Moderate and High ADR groups compared to the Low ADR group (p⫽0.006) (Figure 1). Scores for Fold Examination, Cleansing, and Distension were higher in the Moderate and High ADR groups. Withdrawal times were 6 minutes (Low ADR), 10 minutes (Moderate ADR) and 11 minutes (High ADR) (p⫽0.29). A comparison of the two individual endoscopists with the lowest and highest ADR’s did not find a significant difference in withdrawal time (6.7 minutes versus 5.8 minutes) but did find a nearly 2-fold difference in technique score (36.2 vs. 62.8)(p⬍0.05)Conclusions: 1) Withdrawal technique is an important indicator that differentiates endoscopists with Moderate and High ADR’s from those with Low ADR. 2) It is possible that withdrawal technique is a more important indicator than withdrawal time in determining ADR.
Figure 1: Mean withdrawal technique scores among Endoscopists with varying ADR
353 Self-Assessment in Colonoscopy, a Novel Tool for Assessment of Skills Arjun D. Koch, Jelle Haringsma, Erik J. Schoon, Robert A. De Man, Ernst J. Kuipers Introduction: Colonoscopy is a key diagnostic and therapeutic modality in gastroenterology. Proficiency in advancing a colonoscope is usually obtained by structured skills training and performing several hundred procedures. To date
AB116 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
there has been little attempt to comprehensively assess both generic and specific technical skills in flexible endoscopy. This study reports the results of a newly developed assessment tool for colonoscopy training. The purpose of this tool is to gain insight in individual learning curves and to create a self-awareness of individual strong and weak points.Methods: The Rotterdam Assessment Form (RAF) consists of a series of identical questionnaires that are filled out, each immediately following every colonoscopy. The questionnaire is divided in 3 parts. The first part covers objective data on depth of intubation and time taken. The second part invites trainees to subjectively judge their own performance on a visual analogue scale. The third part is repeated every 10 colonoscopies and encourages the trainee to extrapolate an improvement plan. Gastroenterology trainees performing colonoscopy in the Erasmus MC participated in this study. Filled out questionnaires are entered into a database and pooled in sets of 20 colonoscopies for each trainee.Results: A total of 1860 colonoscopies were selfassessed by 12 trainees. Seven trainees were evaluated from the start, 5 trainees were already in their last years of training. Initial adherence to self-assessment varied strongly among trainees ranging from 38 to 100% but increased after feedback to a median of 90%. The RAF took a median 36 seconds to complete. Cecal intubation rate was calculated and plotted in a learning curve as well as intubation time. The mean cecal intubation rate improved from 65% (range 4580%) to 78% (range 65-95%) and 85% (range 80-90%) after performing 100 and 200 colonoscopies respectively. Cecal intubation time improved from 13:10 minutes (range 9-19) to 9:30 (range 7-13) and 8:30 (range 7-10). Trainers picked up problems sooner by studying the individual learning curves.Conclusions: This novel self-assessment form provides insight in individual learning curves of colonoscopists in training. It provides data on the development of dexterity skills and stimulates trainees to develop steps for self-improvement.
354 Randomized Trial Comparing EUS and Surgery for Pancreatic Pseudocyst Drainage Shyam Varadarajulu, Jessica Trevino, C. Mel Wilcox, Bryce Sutton, John D. Christein BACKGROUND: Although EUS-guided cystogastrostomy is increasingly performed, surgery is still considered the gold standard technique for management of pancreatic pseudocysts (PC). AIM: Compare treatment outcomes, quality of life (QOL) and costs between EUS and surgery for pancreatic cystogastrostomy. METHODS: Symptomatic patients with PC measuring ⬎ 6cm in size were randomized to undergo EUS-guided or surgical cystogastrostomy. Pancreatic abscess or necrosis, multiple PC and those PC located distant from the stomach were excluded. The primary endpoint was PC recurrence at 18 months. The secondary endpoints were pain pattern (measured by brief pain inventory), quality of life (assessed by SF-36), total costs, length of post-procedure hospital stay (LOS), complications and reinterventions at end of follow-up. Treatment success was defined as symptom relief without need for repeat intervention during follow-up. RESULTS: Of 90 screened patients, 36 met inclusion criteria and underwent randomization, 19 to EUS and 17 to surgery. There was no difference in patient demographics, clinical presentation, pseudocyst size, rates of technical (both cohorts, 100%) or treatment success (94.4% vs. 100%, p⫽1) and procedural complications (none in both cohorts) between EUS and surgery, respectively. At a median follow-up of 18 months, there was no difference in rates of PC recurrence (0% vs. 5.8%, p⫽0.48) or reinterventions (5.2% vs. 0%, p⫽1) between EUS and surgery, respectively. Although there were no long-term differences, when compared to surgery, the average scores for pain (3.3 vs. 1.6, p⫽0.009) and interference of general activity (4.9 vs. 2.2, p⫽0.007) and mood (4.1 vs. 1.8, p⫽0.005) were significantly better at 1 week for the EUS cohort. Compared to surgery, the mean QOL scores for general health (50.4 [SD⫽19.7] vs. 71.4 [19.7], p ⫽ 0.007), general vitality (47.1 [14.5] vs. 63.8 [12.5], p ⫽ 0.004) and physical function (57.2 [27.9] vs. 80 [23.9], p ⫽ 0.008) were significantly better for EUS from post-procedure and up to 3 months. After 3 months, the improvement in QOL was similar between both groups. Compared to surgery, the median LOS (6 vs. 2 days, p ⬍0.0001) and average costs ($22,475 vs. $8195, p⬍0.0001) were significantly less for EUS-guided cystogastrostomy. CONCLUSIONS: EUS-guided cystogastrostomy should be the preferred treatment approach for patients with uncomplicated symptomatic pancreatic pseudocysts as the procedure is less costly, yields quick pain relief, is associated with shorter length of hospital stay and has long-term clinical outcomes and quality of life comparable to that of surgery.
355 PillCam Colon 2, Second Generation Colon Capsule Endoscopy Versus Colonoscopy - The First Prospective, Multi-Center Trial Rami Eliakim, Samuel N. Adler Background and study aims: A second generation PillCam Colon 2 capsule endoscopy was developed to primarily increase capsule sensitivity for the detection of patients with colorectal polyps versus the first generation system. The present study provides the first report of the performance of the second generation capsule endoscopy compared with optical colonoscopy. Patients and
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Table 1. Adherence to surveillance colonoscopy guidelines Patients Patients with Time interval to Adequate SC (n) SC (n,(%)) SC (median (IQR)) (guideline ⴞ25%)(%) Group A (IC ⬍ 2002) Group B (IC in 2002) * p⫽0.03
2662
1351(51)
17(12-36)
35
404
292(72)
26(11-43)*
19
352 Quality of Colonoscopy Withdrawal Technique and Variability in Adenoma Detection Rates: Is Technique More Important Than Time? Raymond S. Tang, Thomas J. Savides, V. Raman Muthusamy, Ana Maria Crissien, Samuel B. Ho, Nimeesh K. Shah, Andrew J. Bain, Erin E. Mackintosh, Lida Jafari Saraf, Denise Kalmaz, Robert H. Lee Background/Aims: Studies suggest that factors related to the individual endoscopist are important in determining Adenoma Detection Rates (ADR) during screening colonoscopy. The aim of this study was to examine the impact of withdrawal technique in distinguishing between endoscopists with varying ADR.Methods: ADR’s from screening colonoscopies were calculated on 11 gastroenterologists from 5 academic medical centers for the preceding 12 months. Based upon the distribution, endoscopists were divided into 3 groups: 1) Low (ADR⬍20%) 2) Moderate (ADR 20-42%) 3) High (ADR⬎42%). A total of 20 video-recordings (10 real, 10 sham) of colonoscopy withdrawals were then performed on each endoscopist. The recordings were reviewed by 3 blinded expert gastroenterologists who assigned withdrawal technique scores (0-5) for Fold Examination, Cleansing and Distension for 5 areas of the colon. Mean withdrawal times were calculated based upon the recordings. Technique scores and withdrawal times were compared among the groups using ANOVA for repeated measures.Results: Mean withdrawal technique scores were higher in the Moderate and High ADR groups compared to the Low ADR group (p⫽0.006) (Figure 1). Scores for Fold Examination, Cleansing, and Distension were higher in the Moderate and High ADR groups. Withdrawal times were 6 minutes (Low ADR), 10 minutes (Moderate ADR) and 11 minutes (High ADR) (p⫽0.29). A comparison of the two individual endoscopists with the lowest and highest ADR’s did not find a significant difference in withdrawal time (6.7 minutes versus 5.8 minutes) but did find a nearly 2-fold difference in technique score (36.2 vs. 62.8)(p⬍0.05)Conclusions: 1) Withdrawal technique is an important indicator that differentiates endoscopists with Moderate and High ADR’s from those with Low ADR. 2) It is possible that withdrawal technique is a more important indicator than withdrawal time in determining ADR.
Figure 1: Mean withdrawal technique scores among Endoscopists with varying ADR
353 Self-Assessment in Colonoscopy, a Novel Tool for Assessment of Skills Arjun D. Koch, Jelle Haringsma, Erik J. Schoon, Robert A. De Man, Ernst J. Kuipers Introduction: Colonoscopy is a key diagnostic and therapeutic modality in gastroenterology. Proficiency in advancing a colonoscope is usually obtained by structured skills training and performing several hundred procedures. To date
AB116 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
there has been little attempt to comprehensively assess both generic and specific technical skills in flexible endoscopy. This study reports the results of a newly developed assessment tool for colonoscopy training. The purpose of this tool is to gain insight in individual learning curves and to create a self-awareness of individual strong and weak points.Methods: The Rotterdam Assessment Form (RAF) consists of a series of identical questionnaires that are filled out, each immediately following every colonoscopy. The questionnaire is divided in 3 parts. The first part covers objective data on depth of intubation and time taken. The second part invites trainees to subjectively judge their own performance on a visual analogue scale. The third part is repeated every 10 colonoscopies and encourages the trainee to extrapolate an improvement plan. Gastroenterology trainees performing colonoscopy in the Erasmus MC participated in this study. Filled out questionnaires are entered into a database and pooled in sets of 20 colonoscopies for each trainee.Results: A total of 1860 colonoscopies were selfassessed by 12 trainees. Seven trainees were evaluated from the start, 5 trainees were already in their last years of training. Initial adherence to self-assessment varied strongly among trainees ranging from 38 to 100% but increased after feedback to a median of 90%. The RAF took a median 36 seconds to complete. Cecal intubation rate was calculated and plotted in a learning curve as well as intubation time. The mean cecal intubation rate improved from 65% (range 4580%) to 78% (range 65-95%) and 85% (range 80-90%) after performing 100 and 200 colonoscopies respectively. Cecal intubation time improved from 13:10 minutes (range 9-19) to 9:30 (range 7-13) and 8:30 (range 7-10). Trainers picked up problems sooner by studying the individual learning curves.Conclusions: This novel self-assessment form provides insight in individual learning curves of colonoscopists in training. It provides data on the development of dexterity skills and stimulates trainees to develop steps for self-improvement.
354 Randomized Trial Comparing EUS and Surgery for Pancreatic Pseudocyst Drainage Shyam Varadarajulu, Jessica Trevino, C. Mel Wilcox, Bryce Sutton, John D. Christein BACKGROUND: Although EUS-guided cystogastrostomy is increasingly performed, surgery is still considered the gold standard technique for management of pancreatic pseudocysts (PC). AIM: Compare treatment outcomes, quality of life (QOL) and costs between EUS and surgery for pancreatic cystogastrostomy. METHODS: Symptomatic patients with PC measuring ⬎ 6cm in size were randomized to undergo EUS-guided or surgical cystogastrostomy. Pancreatic abscess or necrosis, multiple PC and those PC located distant from the stomach were excluded. The primary endpoint was PC recurrence at 18 months. The secondary endpoints were pain pattern (measured by brief pain inventory), quality of life (assessed by SF-36), total costs, length of post-procedure hospital stay (LOS), complications and reinterventions at end of follow-up. Treatment success was defined as symptom relief without need for repeat intervention during follow-up. RESULTS: Of 90 screened patients, 36 met inclusion criteria and underwent randomization, 19 to EUS and 17 to surgery. There was no difference in patient demographics, clinical presentation, pseudocyst size, rates of technical (both cohorts, 100%) or treatment success (94.4% vs. 100%, p⫽1) and procedural complications (none in both cohorts) between EUS and surgery, respectively. At a median follow-up of 18 months, there was no difference in rates of PC recurrence (0% vs. 5.8%, p⫽0.48) or reinterventions (5.2% vs. 0%, p⫽1) between EUS and surgery, respectively. Although there were no long-term differences, when compared to surgery, the average scores for pain (3.3 vs. 1.6, p⫽0.009) and interference of general activity (4.9 vs. 2.2, p⫽0.007) and mood (4.1 vs. 1.8, p⫽0.005) were significantly better at 1 week for the EUS cohort. Compared to surgery, the mean QOL scores for general health (50.4 [SD⫽19.7] vs. 71.4 [19.7], p ⫽ 0.007), general vitality (47.1 [14.5] vs. 63.8 [12.5], p ⫽ 0.004) and physical function (57.2 [27.9] vs. 80 [23.9], p ⫽ 0.008) were significantly better for EUS from post-procedure and up to 3 months. After 3 months, the improvement in QOL was similar between both groups. Compared to surgery, the median LOS (6 vs. 2 days, p ⬍0.0001) and average costs ($22,475 vs. $8195, p⬍0.0001) were significantly less for EUS-guided cystogastrostomy. CONCLUSIONS: EUS-guided cystogastrostomy should be the preferred treatment approach for patients with uncomplicated symptomatic pancreatic pseudocysts as the procedure is less costly, yields quick pain relief, is associated with shorter length of hospital stay and has long-term clinical outcomes and quality of life comparable to that of surgery.
355 PillCam Colon 2, Second Generation Colon Capsule Endoscopy Versus Colonoscopy - The First Prospective, Multi-Center Trial Rami Eliakim, Samuel N. Adler Background and study aims: A second generation PillCam Colon 2 capsule endoscopy was developed to primarily increase capsule sensitivity for the detection of patients with colorectal polyps versus the first generation system. The present study provides the first report of the performance of the second generation capsule endoscopy compared with optical colonoscopy. Patients and
www.giejournal.org