- Email: [email protected]
Uniform standards for gastrointestinal endoscopic training in the U.S.—a need for evaluation and definition
are fairly slow and complex to perform. 6 Reflectance spectrophotometry is practical for endoscopic use but it is slow because each point of interest is analyzed individually. Sato et a1. 7 have reported the use of reflectance spectrophotometry during endoscopy, but note that it takes 20 min to study hemoglobin content at a total of 20 points of interest. The method described by Tsuji et a1. 3 uses technology that is part of the video system. The correlation of this technique with other measurements of blood flow are excellent and suggest that this method may give accurate estimates of mucosal hemoglobin content and, therefore, mucosal blood flow. Clinically, this information may help, for example, to assess mucosal injury or study the area surrounding a peptic ulcer. From a research point of view, it may increase our understanding of the physiology of blood flow as it relates to disease states and mechanisms. New applications of video technology are not limited to studies of mucosal color. There are other ways in which digital technology may provide data which are currently impossible to obtain. One example is digital subtraction endoscopic angiography. In this instance, low concentrations of a systemically injected dye may be detected in gastric blood vessels, perhaps by using a portion of the light spectrum which is invisible to the eye but not to a charged couple device. The vessel image may be enhanced by subtracting a control image of the mucosa obtained before the dye was injected to result in a high resolution image of gastric blood vessels. We could then study what happens to blood vessels in various disease states and under a variety of physiological conditions. For example, a benign ulcer might be surrounded by blood vessel patterns different from those surrounding a malignant ulcer. There are many questions that could be studied using the video technology suggested by Dr. Tsuji. It is the development of these techniques that may allow us to use endoscopy to improve our understanding of intestinal physiology and pathophysiology. This type of development will determine whether video endoscopy will significantly improve endoscopic diagnosis and treatment. Fred E. Silverstein, MD Department of Medicine University of Washington Seattle, Washington
REFERENCES 1. Schapiro M, Auslander MO, Schapiro MB. The electronic video
endoscope: clinical experience with 1200 diagnostic and therapeutic cases in the community hospital. Gastrointest Endosc 1987;33:63-8. 2. Satava RM. A comparison of direct and indirect video endoscopy. Gastrointest Endosc 1987;33:69-72. 3. Tsuji S, Sato N, Kawano S, Kamada T. Functional imaging for the analysis of the mucosal blood hemoglobin distribution using electronic endoscopy. Gastrointest Endosc 1988;34:332-6.
362
4. Kiel JW, Riedel GL, Shepherd AP. Autoregulation of canine gastric mucosal blood flow. Gastroenterology 1987;93:12-20. 5. Feld AD, Fondacaro JD, Holloway G, Jacobson ED. Laser Doppler velocimetry: a new technique for the measurement of intestinal mucosal blood flow. Gastrointest Endosc 1984;30:225-30. 6. Soybel Dr, Wan YL, Ashley SW, Yan ZY, Ordway FS, Cheung LY. Endoscopic measurements of canine colonic mucosal blood flow using hydrogen clearance. Gastroenterology 1987;92:104550. 7. Sato N, Kamada T, Schichiri M, Kawano S, Abe H, Hagihara B. Measurement of hemoperfusion and oxygen sufficiency in gastric mucosa in vivo. Gastroenterology 1979;76:814-9.
From the Rostrum
Uniform standards for gastrointestinal endoscopic training in the U.S.-a need for evaluation and definition Endoscopic training experience in the United States varies significantly among academic centers with gastrointestinal postgraduate programs. There are a number of explanations. A shortage of experienced endoscopic faculty compromises the quality of instruction and appropriate utilization of endoscopic procedures. Deficiencies in sophisticated equipment, trained endoscopy personnel, and physical facilities detract dramatically from an ideal training melieu. Only recently, for instance, have academic centers begun to recognize the need for developing adequate endoscopic space within the Gastrointestinal Unit. Finally, high tech endoscopic training requires a big time commitment on the part of the academic center in terms of faculty, time expenditure, and funding. These may be difficult to obtain. Ultimately, the trainee in gastrointestinal endoscopy may lack appropriate clinical experience and skills to qualify as "competent" in certain endoscopic procedures. These concerns about our endoscopic training programs are increasingly relevant to issues such as quality assurance, procedural accreditation, and staff credentialing which affect both the gastrointestinal academian and gastrointestinal practitioner. To better evaluate gastrointestinal endoscopic procedural training in academic centers, therefore, the American SociGASTROINTESTINAL ENDOSCOPY
ety for Gastrointestinal Endoscopy has decided to split the "Standards of Training and Practice" Committee into two separate committees. The charge of the "Standards of Training" Committee is to deal with specific issues concerning procedural education and training within our academic endoscopic training programs, e.g., curriculum content, teacher expertise, teaching methodologies, and criteria for determining procedural "competence." A/S/G/E members appointed to the Standards of Training Committee are well known directors of academic endoscopic training programs in the U.S. Dr. Jack Vennes, renowned for his endoscopic teaching ability and commitment to excellence in this endeavor, will chair the Training Committee. The task of this new committee is not easy. For instance, many directors of academic medical and surgical endoscopic programs are not listed as such in official gastrointestinal publications? They will have to be identified before their input can be solicited for this project. Development of a core curriculum and training manual of endoscopic training is needed. Definition of "level of experience" and "case exposure" should be incorporated into a better description of procedural competence. Methods of testing procedural skills and accumen need to be developed. Conceivably, procedural testing could become part of a standardized "competence" examination and could be incorporated into both Boards of Surgery and Gastroenterology.
There will be close liaison and coordination of activities at the outset between the new Standards of Training Committee and its previous alter ego, the Standards of Practice Committee. This latter A/S/G/E Committee has become so busy with the task of developing and promulgating the important "Endoscopic Guidelines" that a schism into separate committees was considered necessary. These two committees working in concert will be better able to formulate guidelines for quality endoscopic training and its clinical application, which will be more meaningfully based on comparable teaching and experience within the framework of academic postgraduate gastrointestinal education.
Letters to the Editor Necrosis of the soft palate secondary to upper gastrointestinal tract intubation To the Editor: Necrosis ofthe uvula is a very rare complication of upper gastrointestinal tract endoscopy and intubation. 1 We recently observed and report here necrosis and sloughing of the soft palate following a series of upper gastrointestinal procedures including multiple esophagogastroduodenoscopies, endotracheal intubation, Sengstaken-Blakemore and nasogastric intubation, and endoscopic sclerotherapy in a patient with massive variceal hemorrhage. A 47-year-old women with a long history of alcohol abuse and numerous admissions for gastrointestinal bleeding, alcoholic hepatitis, and ascites presented to North Central VOLUME 34, NO.4, 1988
Bronx Hospital with worsening ascites, fever, and jaundice. Physical examination on admission revealed a jaundiced woman with numerous ecchymoses and spider telangiectasias on the upper torso, hepatosplenomegaly, and ascites. Admission laboratory data included the following pertinent values: hematocrit, 37.8%; white blood count, 8000 cells/ cm 3 ; platelets, 99,000; PT 15/11 sec; BUN, 4 mg/dl; potassium, 2.8 mEq/liter; bilirubin, 10.0 mg/dl (direct 6.3 mg/dl); total protein, 7.1 g/dl; albumin, 2.5 g/dl; alkaline phosphatase, 302 IV/liter; SGOT, 215 IV/liter; and SGPT, 41 IV/ liter. Soon after admission, the patient began to vomit copious amounts of bright red blood. Her blood pressure dropped to a systolic level of 80 mm Hg and she became confused and agitated. With volume expansion her blood pressure returned to 130/80 but she remained combative. Endoscopy was performed without sedation. The distal esophagus revealed prominent varices which were eroded and oozing. An attempt at sclerotherapy was unsuccessful because of the patient's agitated state. Hematemesis persisted with resultant hypotension and tachycardia despite use of intravenous pitressin and administration of packed red blood cells, albumin, and saline. Endotracheal intubation was performed, after which a triple lumen Sengstaken-Blakemore tube and nasogastric tube were inserted albeit with great difficulty. Her condition stabilized over the next 24 hours, although her course was complicated by encephalopathy and aspiration pneumonia. The Sengstaken-Blakemore tube remained in place for several days, after which it was removed and she was extubated; her mental status improved and she resumed oral feedings without any difficulty. Elective endoscopic sclerotherapy was performed 1 week after the initial sclerotherapy using only local pontocaine anesthesia. She remained calm and cooperative during the procedure and was again eating several hours afterwards. Twenty-four hours after sclerotherapy, she began to complain of a sore throat, odynophagia, dysphonia, and nasopharyngeal regurgitation of solids and liquids during meals. Examination revealed hypernasal speech with diminished volume and a 4- by 4-cm perforation of the midportion and right side of the soft palate with loss of the uvula (Fig. 1). The remaining rim of soft palate was covered with green exudate. White blood cell count was 16,000 cells/cm3 and her temperature was 100.4OF. Primary closure of the soft palate perforation was not possible, and it was suggested that either a pharyngeal obturator be fashioned or a pharyngeal flap be performed surgically if her medical condition improved. Over the next 2 weeks, the patient noted slightly less throat pain and an increased ability to eat; low grade fever, leukocytosis, hypernasal speech, and oral cavity findings remained unchanged. On the 25th hospital day and 10 days after sclerotherapy, the patient had a massive variceal hemorrhage followed by cardiopulmonary arrest and death. Oropharyngeal complications of upper gastrointestinal tract endoscopy include submandibular and parotid gland swelling, perforation of the pyriform sinus, and necrosis of the uvula. 1• 2 Soft palate perforation, while known to result from various forms of oral trauma, has not to our knowledge been previously associated with either endoscopy or Sengstaken-Blakemore tube placement. 363
REFERENCES 1. Schapiro M, Auslander MO, Schapiro MB. The electronic video
endoscope: clinical experience with 1200 diagnostic and therapeutic cases in the community hospital. Gastrointest Endosc 1987;33:63-8. 2. Satava RM. A comparison of direct and indirect video endoscopy. Gastrointest Endosc 1987;33:69-72. 3. Tsuji S, Sato N, Kawano S, Kamada T. Functional imaging for the analysis of the mucosal blood hemoglobin distribution using electronic endoscopy. Gastrointest Endosc 1988;34:332-6.
362
4. Kiel JW, Riedel GL, Shepherd AP. Autoregulation of canine gastric mucosal blood flow. Gastroenterology 1987;93:12-20. 5. Feld AD, Fondacaro JD, Holloway G, Jacobson ED. Laser Doppler velocimetry: a new technique for the measurement of intestinal mucosal blood flow. Gastrointest Endosc 1984;30:225-30. 6. Soybel Dr, Wan YL, Ashley SW, Yan ZY, Ordway FS, Cheung LY. Endoscopic measurements of canine colonic mucosal blood flow using hydrogen clearance. Gastroenterology 1987;92:104550. 7. Sato N, Kamada T, Schichiri M, Kawano S, Abe H, Hagihara B. Measurement of hemoperfusion and oxygen sufficiency in gastric mucosa in vivo. Gastroenterology 1979;76:814-9.
From the Rostrum
Uniform standards for gastrointestinal endoscopic training in the U.S.-a need for evaluation and definition Endoscopic training experience in the United States varies significantly among academic centers with gastrointestinal postgraduate programs. There are a number of explanations. A shortage of experienced endoscopic faculty compromises the quality of instruction and appropriate utilization of endoscopic procedures. Deficiencies in sophisticated equipment, trained endoscopy personnel, and physical facilities detract dramatically from an ideal training melieu. Only recently, for instance, have academic centers begun to recognize the need for developing adequate endoscopic space within the Gastrointestinal Unit. Finally, high tech endoscopic training requires a big time commitment on the part of the academic center in terms of faculty, time expenditure, and funding. These may be difficult to obtain. Ultimately, the trainee in gastrointestinal endoscopy may lack appropriate clinical experience and skills to qualify as "competent" in certain endoscopic procedures. These concerns about our endoscopic training programs are increasingly relevant to issues such as quality assurance, procedural accreditation, and staff credentialing which affect both the gastrointestinal academian and gastrointestinal practitioner. To better evaluate gastrointestinal endoscopic procedural training in academic centers, therefore, the American SociGASTROINTESTINAL ENDOSCOPY
ety for Gastrointestinal Endoscopy has decided to split the "Standards of Training and Practice" Committee into two separate committees. The charge of the "Standards of Training" Committee is to deal with specific issues concerning procedural education and training within our academic endoscopic training programs, e.g., curriculum content, teacher expertise, teaching methodologies, and criteria for determining procedural "competence." A/S/G/E members appointed to the Standards of Training Committee are well known directors of academic endoscopic training programs in the U.S. Dr. Jack Vennes, renowned for his endoscopic teaching ability and commitment to excellence in this endeavor, will chair the Training Committee. The task of this new committee is not easy. For instance, many directors of academic medical and surgical endoscopic programs are not listed as such in official gastrointestinal publications? They will have to be identified before their input can be solicited for this project. Development of a core curriculum and training manual of endoscopic training is needed. Definition of "level of experience" and "case exposure" should be incorporated into a better description of procedural competence. Methods of testing procedural skills and accumen need to be developed. Conceivably, procedural testing could become part of a standardized "competence" examination and could be incorporated into both Boards of Surgery and Gastroenterology.
There will be close liaison and coordination of activities at the outset between the new Standards of Training Committee and its previous alter ego, the Standards of Practice Committee. This latter A/S/G/E Committee has become so busy with the task of developing and promulgating the important "Endoscopic Guidelines" that a schism into separate committees was considered necessary. These two committees working in concert will be better able to formulate guidelines for quality endoscopic training and its clinical application, which will be more meaningfully based on comparable teaching and experience within the framework of academic postgraduate gastrointestinal education.
Letters to the Editor Necrosis of the soft palate secondary to upper gastrointestinal tract intubation To the Editor: Necrosis ofthe uvula is a very rare complication of upper gastrointestinal tract endoscopy and intubation. 1 We recently observed and report here necrosis and sloughing of the soft palate following a series of upper gastrointestinal procedures including multiple esophagogastroduodenoscopies, endotracheal intubation, Sengstaken-Blakemore and nasogastric intubation, and endoscopic sclerotherapy in a patient with massive variceal hemorrhage. A 47-year-old women with a long history of alcohol abuse and numerous admissions for gastrointestinal bleeding, alcoholic hepatitis, and ascites presented to North Central VOLUME 34, NO.4, 1988
Bronx Hospital with worsening ascites, fever, and jaundice. Physical examination on admission revealed a jaundiced woman with numerous ecchymoses and spider telangiectasias on the upper torso, hepatosplenomegaly, and ascites. Admission laboratory data included the following pertinent values: hematocrit, 37.8%; white blood count, 8000 cells/ cm 3 ; platelets, 99,000; PT 15/11 sec; BUN, 4 mg/dl; potassium, 2.8 mEq/liter; bilirubin, 10.0 mg/dl (direct 6.3 mg/dl); total protein, 7.1 g/dl; albumin, 2.5 g/dl; alkaline phosphatase, 302 IV/liter; SGOT, 215 IV/liter; and SGPT, 41 IV/ liter. Soon after admission, the patient began to vomit copious amounts of bright red blood. Her blood pressure dropped to a systolic level of 80 mm Hg and she became confused and agitated. With volume expansion her blood pressure returned to 130/80 but she remained combative. Endoscopy was performed without sedation. The distal esophagus revealed prominent varices which were eroded and oozing. An attempt at sclerotherapy was unsuccessful because of the patient's agitated state. Hematemesis persisted with resultant hypotension and tachycardia despite use of intravenous pitressin and administration of packed red blood cells, albumin, and saline. Endotracheal intubation was performed, after which a triple lumen Sengstaken-Blakemore tube and nasogastric tube were inserted albeit with great difficulty. Her condition stabilized over the next 24 hours, although her course was complicated by encephalopathy and aspiration pneumonia. The Sengstaken-Blakemore tube remained in place for several days, after which it was removed and she was extubated; her mental status improved and she resumed oral feedings without any difficulty. Elective endoscopic sclerotherapy was performed 1 week after the initial sclerotherapy using only local pontocaine anesthesia. She remained calm and cooperative during the procedure and was again eating several hours afterwards. Twenty-four hours after sclerotherapy, she began to complain of a sore throat, odynophagia, dysphonia, and nasopharyngeal regurgitation of solids and liquids during meals. Examination revealed hypernasal speech with diminished volume and a 4- by 4-cm perforation of the midportion and right side of the soft palate with loss of the uvula (Fig. 1). The remaining rim of soft palate was covered with green exudate. White blood cell count was 16,000 cells/cm3 and her temperature was 100.4OF. Primary closure of the soft palate perforation was not possible, and it was suggested that either a pharyngeal obturator be fashioned or a pharyngeal flap be performed surgically if her medical condition improved. Over the next 2 weeks, the patient noted slightly less throat pain and an increased ability to eat; low grade fever, leukocytosis, hypernasal speech, and oral cavity findings remained unchanged. On the 25th hospital day and 10 days after sclerotherapy, the patient had a massive variceal hemorrhage followed by cardiopulmonary arrest and death. Oropharyngeal complications of upper gastrointestinal tract endoscopy include submandibular and parotid gland swelling, perforation of the pyriform sinus, and necrosis of the uvula. 1• 2 Soft palate perforation, while known to result from various forms of oral trauma, has not to our knowledge been previously associated with either endoscopy or Sengstaken-Blakemore tube placement. 363