- Email: [email protected]
The influence of fellow involvement and level of fellowship training on adenoma detection rates
Letters to the Editor 4. Quan C, Ghen G, Lee-Henderson M, et al. Overtube-assisted placement of the wireless capsule endoscopy device. Gastrointest Endosc 2005;61: 914-6. 5. Tóth E, Fork FT, Almqvist P, Thorlacius H. Endoscopically-assisted capsule endoscopy in patients with swallowing disorders. Endoscopy 2004;36: 746. 6. Skogestad JE, Tholfsen JK. Capsule endoscopy: in difficult cases capsule can be ingested through an overtube. Endoscopy 2004;36:1038. 7. Hollerbach S, Kraus K, Willert J, Schulmann K, Schmiegel W. Endoscopically assisted video capsule endoscopy of the small bowel in patients with functional gastric outlet obstruction. Endoscopy 2003;35:226-9. doi:10.1016/j.gie.2010.02.018
It’s not the precut; it’s the why done and who by To the Editor: The title of a recent editorial, “Time to lower the threshold for the needle?,”1 might lead a casual reader to conclude that precutting is suddenly safe. The authors are careful to say that “it should be considered only in cases of difficult biliary cannulation,” and “should be performed only by experienced endoscopists.” Of course we agree, but they could have added that it should be considered only when there is a strong indication for bile duct cannulation, eg, a known stone, tumor, or leak. The reason why I have cautioned repeatedly against precutting,2 and will continue to do so, is that it is still being done by inexperienced endoscopists, and often when the indication is marginal. Perforation and severe pancreatitis in that context is disastrous. These are the cases that end up in court.3 The author’s traditional plea for more randomized studies will not help. Inexpert endoscopists with poor judgment do not report their data, and will certainly not participate in any randomized trial. Peter B. Cotton, MD Professor of Medicine Digestive Disease Center Medical University of South Carolina Charleston, South Carolina, USA REFERENCES 1. Tham TC, Vandervoort J. Needle-knife sphincterotomy and post-ERCP pancreatitis: time to lower the threshold for the needle? Gastrointest Endosc 2010;71:272-4. 2. Cotton PB. Precut papillotomy--a risky technique for experts only. Gastrointest Endosc 1989;35:578-9. 3. Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006:63:378-82; quiz 464. doi:10.1016/j.gie.2010.02.028
Response: We appreciate Dr Cotton’s interest in our editorial. We agree that precuts should be considered only when there 1114 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 5 : 2010
is a strong indication for biliary cannulation, such as when therapy is intended. We accept that this point could have been emphasized in our editorial, and we are grateful to Dr Cotton for highlighting it. We also concluded in our editorial that precutting should be performed only by experienced endoscopists. We hope the casual reader will be sufficiently intrigued by the title of the editorial to read the conclusion, in which it is clear that precutting is not suddenly safe nor is it for the inexperienced. Quality assurance measures, such as audit, should be encouraged in endoscopy units and perhaps made mandatory for revalidation of endoscopists. For example, an unacceptably high incidence of post-ERCP complications ought to trigger an investigation. Such measures should discourage inexperienced endoscopists with poor judgement from performing precuts. Tony C.K. Tham, MD, FRCP, FRCPI Division of Gastroenterology Ulster Hospital Dundonald, Belfast, Northern Ireland, United Kingdom Jo Vandervoort, MD Division of Gastroenterology Onze-Lieve-Vrouw Aalst, Belgium doi:10.1016/j.gie.2010.03.1074
The influence of fellow involvement and level of fellowship training on adenoma detection rates To the Editor: The adenoma detection rate (ADR) has become perhaps the most widely used surrogate to measure the quality of colonoscopy, and it is critical to the success of colonoscopy for colorectal cancer screening. The effects of involving gastroenterology fellows and the level of training in screening colonoscopies remain unclear. In a recent issue of Gastrointestinal Endoscopy, Spier et al1 assess the minimum number of required colonoscopies for gastroenterology fellows to attain competence. Although various procedure-related parameters, including total colonoscopy time, withdrawal time, and independent completion rates, all significantly improved when first and third years of training were compared, the ADR and polyp detection rate (PDR) did not change between years of training. The authors attributed this to the supervised nature of these procedures. In a retrospective study by Rogart et al,2 fellow involvement in colonoscopy was found to significantly increase not only the ADR (37% vs 23%; P ⬍ .01), but also the total number of adenomas detected. Second- and third-year fellows had an ADR of 38% compared with 31% for first-year fellows, suggesting no statistically significant differences in the ADR based on the level www.giejournal.org
Letters to the Editor
of the trainee involved. Similarly, Peters et al3 reported significantly higher ADR and PDR among colonoscopies that included a gastroenterology fellow. However, they found the ADR to differ greatly and increase with each year of training compared with colonoscopies performed by an attending gastroenterologist alone: odds ratio (OR) for first-year fellows, 0.89 (95% confidence interval [CI], 0.66-1.22); OR for second-year fellows, 1.31 (95% CI, 0.891.93); and OR for third-year fellows, 1.70 (95% CI, 1.332.17). Although the effects of fellow participation on ADR are unambiguous, the reasons for contradictory results regarding level of fellowship training are unclear. All of these studies were done at university-based training programs, with all procedures performed by a gastroenterology fellow supervised by an attending physician. Larger studies are needed to clarify these findings.
patient care while teaching endoscopy highlights the supervisor’s critical role, which should not be overlooked. We agree with the conclusions of Peters et al recommending that further studies on the training and assessment of faculty who are acting as supervisory educators would help to standardize teaching while maintaining a high level of patient care. Bret J. Spier, MD Eric A. Gaumnitz, MD Section of Gastroenterology and Hepatology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison, Wisconsin, USA
REFERENCES
Tarun Rustagi, MD Department of Internal Medicine University of Connecticut Farmington, Connecticut, USA
REFERENCES 1. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71: 319-24. 2. Rogart JN, Siddiqui UD, Jamidar PA, et al. Fellow involvement may increase adenoma detection rates during colonoscopy. Am J Gastroenterol 2008;103:2841-6. 3. Peters SL, Hasan AG, Jacobson NB, et al. Level of fellowship training increases adenoma detection rates. Clin Gastroenterol Hepatol 2010;8: 439-42. doi:10.1016/j.gie.2010.03.1069
Response: Our recent article published in Gastrointestinal Endoscopy, “Colonoscopy Training in Gastroenterology Fellowships: Determining Competence,”1 revealed that colonoscopic competency requires at least 500 observed colonoscopies to ensure ⬎90% independence in all trainees. A second common measure of quality colonoscopy is that of a consistently high adenoma detection rate. Our findings1 and a study by Rogart et al2 demonstrated that the adenoma detection rate in colonoscopies performed by fellows in training was high and maintained throughout the 3 successive years of fellowship. In comparison, a study by Peters et al3 found a low adenoma detection rate in the first year of fellowship, with an increase in adenoma detection with each subsequent year of training. Our study suggests that a consistent adenoma detection rate across 3 years of training reflects the standardized nature of our trainee colonoscopy instruction program in which fellows are observed and evaluated for 100% of all cases from start to finish. We believe that maintaining a high level of www.giejournal.org
1. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71: 319-24. 2. Rogart JN, Siddiqui UD, Jamidar PA, et al. Fellow involvement may increase adenoma detection rates during colonoscopy. Am J Gastroenterol 2008;103:2841-6. 3. Peters SL, Hasan AG, Jacobson NB, et al. Level of fellowship training increases adenoma detection rates. Clin Gastroenterol Hepatol 2010 Feb 1 [Epub ahead of print]. doi:10.1016/j.gie.2010.03.1122
ERCP by laparoscopic transgastric access and cholecystectomy at the same time in a patient with gastric bypass who was seen with choledocholithiasis To the Editor: It was with great interest that we read the manuscript about laparoscopically assisted transgastric ERCP by Badaoui et al.1 The authors bring up the problem of limited handling of the endoscope because of the distance between trocar and stomach during pneumoperitoneum. They suggest the development of a flexible trocar. In our institution, we have adapted the technique to overcome this problem without the use of a flexible trocar.2,3 The issue is to mobilize the greater curve of the gastric remnant at the site of the antrum until this part of the stomach can reach the anterior abdominal wall. Next, a purse-string is fashioned on the gastric wall and a trocar is inserted through a gastrotomy created in the center of this purse-string. The purse-string is tightened and the gastric pouch is lifted to the anterior abdominal wall thereby providing controlled access (Fig. 1). In this technique, the endoscope is inserted almost directly from the skin into the stomach allowing optimal movement. This strategy also reduces the risks of escape of gastric content or room air during endoscopy. The escape of room air in a pneumoperitoneum may cause Volume 72, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY
1115
It’s not the precut; it’s the why done and who by To the Editor: The title of a recent editorial, “Time to lower the threshold for the needle?,”1 might lead a casual reader to conclude that precutting is suddenly safe. The authors are careful to say that “it should be considered only in cases of difficult biliary cannulation,” and “should be performed only by experienced endoscopists.” Of course we agree, but they could have added that it should be considered only when there is a strong indication for bile duct cannulation, eg, a known stone, tumor, or leak. The reason why I have cautioned repeatedly against precutting,2 and will continue to do so, is that it is still being done by inexperienced endoscopists, and often when the indication is marginal. Perforation and severe pancreatitis in that context is disastrous. These are the cases that end up in court.3 The author’s traditional plea for more randomized studies will not help. Inexpert endoscopists with poor judgment do not report their data, and will certainly not participate in any randomized trial. Peter B. Cotton, MD Professor of Medicine Digestive Disease Center Medical University of South Carolina Charleston, South Carolina, USA REFERENCES 1. Tham TC, Vandervoort J. Needle-knife sphincterotomy and post-ERCP pancreatitis: time to lower the threshold for the needle? Gastrointest Endosc 2010;71:272-4. 2. Cotton PB. Precut papillotomy--a risky technique for experts only. Gastrointest Endosc 1989;35:578-9. 3. Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006:63:378-82; quiz 464. doi:10.1016/j.gie.2010.02.028
Response: We appreciate Dr Cotton’s interest in our editorial. We agree that precuts should be considered only when there 1114 GASTROINTESTINAL ENDOSCOPY
Volume 72, No. 5 : 2010
is a strong indication for biliary cannulation, such as when therapy is intended. We accept that this point could have been emphasized in our editorial, and we are grateful to Dr Cotton for highlighting it. We also concluded in our editorial that precutting should be performed only by experienced endoscopists. We hope the casual reader will be sufficiently intrigued by the title of the editorial to read the conclusion, in which it is clear that precutting is not suddenly safe nor is it for the inexperienced. Quality assurance measures, such as audit, should be encouraged in endoscopy units and perhaps made mandatory for revalidation of endoscopists. For example, an unacceptably high incidence of post-ERCP complications ought to trigger an investigation. Such measures should discourage inexperienced endoscopists with poor judgement from performing precuts. Tony C.K. Tham, MD, FRCP, FRCPI Division of Gastroenterology Ulster Hospital Dundonald, Belfast, Northern Ireland, United Kingdom Jo Vandervoort, MD Division of Gastroenterology Onze-Lieve-Vrouw Aalst, Belgium doi:10.1016/j.gie.2010.03.1074
The influence of fellow involvement and level of fellowship training on adenoma detection rates To the Editor: The adenoma detection rate (ADR) has become perhaps the most widely used surrogate to measure the quality of colonoscopy, and it is critical to the success of colonoscopy for colorectal cancer screening. The effects of involving gastroenterology fellows and the level of training in screening colonoscopies remain unclear. In a recent issue of Gastrointestinal Endoscopy, Spier et al1 assess the minimum number of required colonoscopies for gastroenterology fellows to attain competence. Although various procedure-related parameters, including total colonoscopy time, withdrawal time, and independent completion rates, all significantly improved when first and third years of training were compared, the ADR and polyp detection rate (PDR) did not change between years of training. The authors attributed this to the supervised nature of these procedures. In a retrospective study by Rogart et al,2 fellow involvement in colonoscopy was found to significantly increase not only the ADR (37% vs 23%; P ⬍ .01), but also the total number of adenomas detected. Second- and third-year fellows had an ADR of 38% compared with 31% for first-year fellows, suggesting no statistically significant differences in the ADR based on the level www.giejournal.org
Letters to the Editor
of the trainee involved. Similarly, Peters et al3 reported significantly higher ADR and PDR among colonoscopies that included a gastroenterology fellow. However, they found the ADR to differ greatly and increase with each year of training compared with colonoscopies performed by an attending gastroenterologist alone: odds ratio (OR) for first-year fellows, 0.89 (95% confidence interval [CI], 0.66-1.22); OR for second-year fellows, 1.31 (95% CI, 0.891.93); and OR for third-year fellows, 1.70 (95% CI, 1.332.17). Although the effects of fellow participation on ADR are unambiguous, the reasons for contradictory results regarding level of fellowship training are unclear. All of these studies were done at university-based training programs, with all procedures performed by a gastroenterology fellow supervised by an attending physician. Larger studies are needed to clarify these findings.
patient care while teaching endoscopy highlights the supervisor’s critical role, which should not be overlooked. We agree with the conclusions of Peters et al recommending that further studies on the training and assessment of faculty who are acting as supervisory educators would help to standardize teaching while maintaining a high level of patient care. Bret J. Spier, MD Eric A. Gaumnitz, MD Section of Gastroenterology and Hepatology Department of Medicine University of Wisconsin School of Medicine and Public Health Madison, Wisconsin, USA
REFERENCES
Tarun Rustagi, MD Department of Internal Medicine University of Connecticut Farmington, Connecticut, USA
REFERENCES 1. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71: 319-24. 2. Rogart JN, Siddiqui UD, Jamidar PA, et al. Fellow involvement may increase adenoma detection rates during colonoscopy. Am J Gastroenterol 2008;103:2841-6. 3. Peters SL, Hasan AG, Jacobson NB, et al. Level of fellowship training increases adenoma detection rates. Clin Gastroenterol Hepatol 2010;8: 439-42. doi:10.1016/j.gie.2010.03.1069
Response: Our recent article published in Gastrointestinal Endoscopy, “Colonoscopy Training in Gastroenterology Fellowships: Determining Competence,”1 revealed that colonoscopic competency requires at least 500 observed colonoscopies to ensure ⬎90% independence in all trainees. A second common measure of quality colonoscopy is that of a consistently high adenoma detection rate. Our findings1 and a study by Rogart et al2 demonstrated that the adenoma detection rate in colonoscopies performed by fellows in training was high and maintained throughout the 3 successive years of fellowship. In comparison, a study by Peters et al3 found a low adenoma detection rate in the first year of fellowship, with an increase in adenoma detection with each subsequent year of training. Our study suggests that a consistent adenoma detection rate across 3 years of training reflects the standardized nature of our trainee colonoscopy instruction program in which fellows are observed and evaluated for 100% of all cases from start to finish. We believe that maintaining a high level of www.giejournal.org
1. Spier BJ, Benson M, Pfau PR, et al. Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71: 319-24. 2. Rogart JN, Siddiqui UD, Jamidar PA, et al. Fellow involvement may increase adenoma detection rates during colonoscopy. Am J Gastroenterol 2008;103:2841-6. 3. Peters SL, Hasan AG, Jacobson NB, et al. Level of fellowship training increases adenoma detection rates. Clin Gastroenterol Hepatol 2010 Feb 1 [Epub ahead of print]. doi:10.1016/j.gie.2010.03.1122
ERCP by laparoscopic transgastric access and cholecystectomy at the same time in a patient with gastric bypass who was seen with choledocholithiasis To the Editor: It was with great interest that we read the manuscript about laparoscopically assisted transgastric ERCP by Badaoui et al.1 The authors bring up the problem of limited handling of the endoscope because of the distance between trocar and stomach during pneumoperitoneum. They suggest the development of a flexible trocar. In our institution, we have adapted the technique to overcome this problem without the use of a flexible trocar.2,3 The issue is to mobilize the greater curve of the gastric remnant at the site of the antrum until this part of the stomach can reach the anterior abdominal wall. Next, a purse-string is fashioned on the gastric wall and a trocar is inserted through a gastrotomy created in the center of this purse-string. The purse-string is tightened and the gastric pouch is lifted to the anterior abdominal wall thereby providing controlled access (Fig. 1). In this technique, the endoscope is inserted almost directly from the skin into the stomach allowing optimal movement. This strategy also reduces the risks of escape of gastric content or room air during endoscopy. The escape of room air in a pneumoperitoneum may cause Volume 72, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY
1115