Gastroenterological Endoscopy. Группа авторов

Чтение книги онлайн.

СКАЧАТЬ various studies, a minimum of 40 to 50 endoscopic sphincterotomies (ESTs) per endoscopist per year was found to be associated with a lower complication rate in comparison to endoscopists with a lower EST frequency.^8,21 Rabenstein et al²² showed that both prior experience and ongoing volume of ERCPs influence the success and complication rate.

      Fig. 1.1 Procedure time by experience. (Reproduced with permission from Sedlack et al 2016.¹¹)

      Fig. 1.2 Polyp detection and miss rates by experience. (Reproduced with permission from Sedlack et al 2016.¹¹)

      Fig. 1.3 The “learning pyramid” as an example of stepwise clinical training in interventional endoscopy. (Adapted from Hochberger et al 2010.¹)

      Fig. 1.4 The probability (with 95% confidence intervals) of achieving an acceptable score for cholangiography (a), pancreatography (b), deep pancreatic cannulation (c), and deep biliary cannulation (d) during training of fellows in endoscopic retrograde cholangiopancreatography (ERCP), as reported by Jowell et al¹⁹ for 17 gastroenterology fellows during 1,450 ERCP procedures.

      Now that most ERCPs are performed for therapeutic purposes, it is a matter of controversy whether cannulation is the next technique for the trainee to learn after he or she is able to maneuver the duodenoscope competently to the papilla. For example, it is well known that for routine stent exchanges in the setting of a prior sphincterotomy, fewer procedures (n = 60) are needed to obtain competence than is the case with cannulation of a native papilla (n = 180–200), and it is also known that stent exchanges are associated with a lower risk profile compared to cannulation. Patients with benign biliary strictures, chronic obstructive pancreatitis, and recurrent bile duct stones in the setting of prior sphincterotomy are also associated with lower risk during training.

      The ASGE published their latest core curriculum for training in ERCP in 2016.^8,23 Trainees who elect to perform ERCP should have completed at least 18 months of standard gastroenterology training, followed by at least 12 months of ERCP training.

      Schutz and Abbott²⁴ developed an ERCP grading scale based on procedural difficulty using benchmarks such as cannulation rates to gauge competency. A modification of this score was adopted by the ASGE as part of their quality-assessment document. Absolute numbers of procedures partially performed by a fellow may not realistically reflect competence.²⁵ Where possible, trainee logbook records should specify particular skills completed by the fellow (cannulation, sphincterotomy, stent placement, tissue sampling), and should also indicate cases that the trainee completed without assistance. The ASGE guidelines state that most fellows require at least 180 ERCP cases before competency can be assessed, with at least half being therapeutic.⁸ Although not all of the trainees may ultimately perform ERCP after the completion of their training, all fellows should at least develop an understanding of the diagnostic and therapeutic role of the procedure, including indications, contraindications, and possible complications.²⁶

      The decision by a program director as to whether to train one or more fellows each year to achieve sufficient competence will depend in some measure on the volume of ERCPs performed at the institution and the availability of experts in ERCP (

Fig. 1.4).¹⁹ For example, with an annual volume of 400 cases and three fellows, it would be reasonable to have one fellow perform 300 or more cases and provide the other two with an exposure to ERCP, rather than have all three individuals equally share cases, with a low likelihood that any of the three would reach competence by the end of the fellowship.

      1.2.3 Complementary E-learning and Video Courses

      Live endoscopy courses, interactive teaching programs, and video materials can help trainees to recognize pathology better and to understand the appropriate application of therapeutic techniques.²⁷ However, such passive activities cannot replace the performance of the actual procedures.

      1.3 Incorporation of Simulators in Training

      The Gastroenterology Core Curriculum, Third Edition in May 2007 states in section IV.A.6.(b): “Fellows must participate in training using simulation.”²³ To date, no simulator experience alone has been validated as sufficient to replace actual patient experience. To guide adoption of simulators for specific roles in training and assessing skill, the ASGE initiated a PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) task force in 2011.²⁸ This group set the following two thresholds for justifying adoption of a particular simulator:

      • Threshold for incorporation into training. For an endoscopy simulator to be integrated into the standard instruction for a procedure, it must demonstrate a 25% or greater reduction in the median number of clinical cases required for the trainees to achieve the minimal competence parameters for that procedure.

      • Threshold for assessing skill. Simulator-based assessment tools must be procedure-specific and predictive of independently defined minimal competence parameters from real procedures with a kappa value of at least 0.70 for high-stakes assessment.²⁸

      The logistic and cost issues for a particular simulator would need to be weighed. For example, a high-cost computer simulator that had a 25% reduction in a learning curve might not make any sense for a program in which trainees typically had sufficient actual case experience to develop competency. In contrast, a lower cost simulator in which a program typically had insufficient cases would be well worth the investment.

      1.4 Endoscopy Simulators and Training Models

      1.4.1 Plastic Phantoms and Other Static Models

      The initial experimental models for endoscopy training were made of plastic and textile tissues.¹ In 1974, Classen and Ruppin²⁹ in Erlangen presented an anatomically shaped plastic phantom that allowed examination of the upper GI tract. Christopher Williams and his group in London have been working on the first semi-rigid colonoscopy phantoms. A robust further development represents the Kyoto Kagaku Colonoscope Training Model, which presents greater technical difficulty to reach the cecum and allows a more realistic loop reduction

Fig. 1.6.²⁹ Grund and co-workers in Tübingen, Germany, developed a series of advanced static models for different training purposes.^32,33 They include artificial tissues for electrosurgical interventions and recently specific ERCP techniques. Unfortunately, those models are not commercially available so far and there are no published data validating their use in training.

      In addition, a number of device manufacturers have produced their own models to facilitate training in the procedures in which their accessories are used. The Cook Medical СКАЧАТЬ