Successful Training in Gastrointestinal Endoscopy E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1269

Veröffentlichungsjahr: 2011

Beschreibung

Endoscopy is the primary diagnostic method for GI complaints and is replete with an ever expanding array of therapeutic capabilities. Successful Training in Gastrointestinal Endoscopy will provide all gastroenterologists with the exact set of skills required to perform endoscopy at the highest level. GI trainees will find it a crucial primer for learning endoscopy; teachers will find it a guide to understand how best to develop the expertise of their students; and experienced practicing gastroenterologists will find it a useful refresher tool to brush up on their existing endoscopic skills and to familiarise themselves with new procedures, including issues of safety and competence while performing them.

With contributions from internationally recognized leaders in endoscopy education and an endorsement by the World Organisation of Digestive Endoscopy, each chapter will examine the specific skill sets and procedure related tasks which must be mastered when learning a particular technique, including:

• Specific descriptions of accessories required
• Standard training methods for the procedure
• Optimal utilization of novel learning modalities such as simulators
• Quality measures and objective parameters for competency
• Available tools for assessing competency once training has been completed

In addition to the 400 high-quality, outstanding colour photos, the book will come with a DVD containing over 130 annotated teaching videos of both actual procedures and ex-vivo animal model simulations. These videos will illustrate, in a step by step fashion the proper techniques to be followed, highlighting clinical pearls from the experts and the most common mistakes to avoid.

Successful Training in Gastrointestinal Endoscopy will be a key purchase for all gastroenterologists, whether in training or experienced, to allow them to develop and perfect their endoscopic skills. It will be a particularly useful guide for those interested in mastering the latest new techniques and procedures and an essential reference for teachers of endoscopy and students alike.

Note: DVD and other supplementary materials are not included as part of eBook file. These materials are available for download upon purchase.

Leseprobe

Contents

Cover

Companion DVD-ROM

Title Page

Copyright

List of Contributors

Foreword

Preface

Acknowledgements

I: The Evolution of Basic Principles and Practice

1: Training in Endoscopy: A Historical Background

Introduction

Standard training in endoscopy: then and now

Standards and endpoints of current endoscopic training

Emergence of complementary teaching modalities

The future of simulators in endoscopy training

Conclusion

Videos

2: How Endoscopy is Learned: Deconstructing Skill Sets

Introduction

Identification of fundamental endoscopy skills

Introduction of the scope

Navigation

Overcoming obstacles

Inspection

Instrumentation

Summary

Video

3: Training to Become a High-Quality Endoscopist: Mastering the Nonprocedural Aspects

Preprocedure

Intra-procedure

Post-procedure

Conclusion

II: Training in the Major Endoscopic Procedures

4: Esophagogastroduodenoscopy (EGD)

Introduction to EGD training

Requirements for EGD training

EGD training

Alternatives for EGD training—Simulator-based training

Assessment of performance

Conclusions

Videos

5: Colonoscopy

Introduction

Early skills

Intermediate skills

How to teach and assess colonoscopy skills

Videos

6: Endoscopic Ultrasound

EUS requires different skill sets than standard endoscopy

Learning resources for EUS

The skill sets needed to learn EUS

Pathways for EUS training

Complementary training options

Assessing EUS quality performance

Conclusion

Video

7: ERCP

Introduction to ERCP training

Prerequisite for training

ERCP training

Alternatives for ERCP training

Assessment of performance

Training and clinical outcome correlation

How much volume is needed to maintain skill—retraining and new techniques

The role of the assistant

Conclusion

Videos

8: Capsule Endoscopy

Introduction

Description of the capsules

The capsule endoscopy unit

Preparing the patient

Administering the capsule

Capsule endoscopy reading in clinical settings

Reading capsule endoscopy study

Credentialing the capsule endoscopist: current guidelines

Training the capsule endoscopist: current literature

Conclusions

Videos

9: Deep Enteroscopy

Introduction

Prerequisites for training in deep enteroscopy

Cognitive component of deep enteroscopy

Technical aspects of enteroscopy training

Equipment for deep enteroscopy

Diagnostic enteroscopy

Other diagnostic considerations

Advancement technique(s)

Therapeutic maneuvers

Ex vivo training models

Recognition of complications

Quality/performance assessment

Conclusion

Videos

10: Choledochoscopy and Pancreatoscopy

Introduction

Technical and cognitive aspects

Training and development of competency

Summary

Videos

11: Principles of Electrosurgery

Introduction

Basics of electricity as applied to electrosurgery

Monopolar and bipolar circuits

Safety measures in electrosurgery

Tissue effects of electrosurgery in endoscopy

Clinical applications of electrosurgery in endoscopy

Incorporation of electrosurgical principles into endoscopy training

12: The Use of Fluoroscopy for Gastrointestinal Endoscopy

Introduction

Training in fluoroscopy

Hardware basics

Protective garments

Scout films

ERCP

Fluoroscopy and enteral stents

Enteroscopy

Conclusion

Videos

13: Pediatric Endoscopy

Introduction

Training program requirements

Esophagogastroduodenoscopy and colonoscopy

Patient assessment

Informed consent

Sedation

Cognitive aspects of training in sedation

Technical aspects of training in sedation

Upper endoscopy

Technical skills

Instruments

Colonoscopy

Cognitive skills

Technical skills

Instruments

Diagnostic techniques in upper endoscopy and colonoscopy

Identifying pathology

Therapeutics procedure in endoscopy

Percutaneous endoscopic gastrostomy (PEG)

Stricture dilation

Management of GI bleeding

The role of adult endoscopists in pediatrics

Defining and assessing procedural competency

Assessing competency

Simulation in pediatric endoscopy

Advanced procedures

Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic ultrasound

Wireless video capsule endoscopy

III: Training in Specific Techniques

14: Contrast-Enhanced Endoscopy—Chromo and Optical Contrast Techniques

Introduction

Overview of contrast (image)-enhancement techniques: chromoendoscopy and other optical techniques

Evidence for effect of training

Summary

Videos

15: GI Hemostasis

Introduction

Prerequisite cognitive knowledge required prior to learning endoscopic hemostatic techniques

Prerequisite technical knowledge and skills required to learn endoscopic hemostatic techniques

Required technical knowledge and skills to be proficient in endoscopic hemostasis

Common knowledge and skills for all hemostatic strategies

Specific hemostatic strategies

Thermal

Mechanical

Simulators to learn and practice endoscopic hemostasis

Available models of endoscopic hemostasis

Teaching in endoscopic hemostasis

Data supporting the role of hemostasis training on simulators

Learning progress in endoscopic hemostasis

Concept of integrating simulator work into standard endoscopy training

Maintaining skills in endoscopic hemostasis

Additional teaching aides for learning GI hemostasis

Limitations of GI endoscopy for diagnosis and hemostasis of GI bleeding: teaching pearls for troubleshooting and challenges for the future

Definition of minimal thresholds for determining competency in endoscopic hemostasis

Requirements to maintain endoscopic hemostasis skills

Summary

Videos

16: Luminal Dilation Techniques (Strictures, Achalasia, Anastomotic, IBD)

Introduction

Equipment

Ancillary devices

Endoscope key points to remember

Fluoroscopy

Mechanism of dilation

Technique of dilation

Goal

Ancillary techniques

Contraindications

Some key points

Achalasia

Endoscopy and performance of pneumatic balloon dilation in achalasia

Suggested skill set to master and potential outcome measures to assess proficiency in performing luminal dilation

Suggested skill level to perform dilation

Videos

17: Foreign Body Extraction

Introduction

Training in FB extraction

Pre-procedure assessment

Identify devices

Anticipate the endoscopy

Endoscopic removal

Further evaluation

Conclusions

Videos

18: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Introduction

Endoscopic mucosal resection

Endoscopic submucosal dissection

Post-EMR and post-ESD management

Management of complications

When to use EMR and when ESD?

Training and first steps in ESD

Conclusions and perspectives

Nonstandard Abbreviations

Videos

19: Mucosal Ablation Techniques

Introduction

Procedures and equipment involved in mucosal ablation

Prerequisite cognitive and technical skills for trainees prior to learning mucosal ablation

Setting of training

Specific knowledge trainees must acquire during training to perform esophageal mucosal ablation

Equipment and technical steps

Opportunities and methods for training in mucosal ablation

Defining competency

Maintaining skill level

Videos

20: Complicated Polypectomy

The electrosurgical unit

Snares for polypectomy

The snare handle as an information center

Safety in snare handling

Techniques for successful removal of sessile polyps

Pedunculated polyps

Fluid injection for polypectomy

The nonlifting sign

Retroversion

EMRC

Endoscopic submucosal dissection (Videos 20.4 and 20.5)

The argon plasma coagulator

Hemostasis

Endoscopic closure using hemoclips

Precolonoscopic laboratory testing

Intraoperative colonoscopy

Follow-up after polypectomy

Summary

Videos

21: Natural Orifice Translumenal Endoscopic Surgery (NOTES®)

Introduction

Clinical Interest in NOTES®

Words of Caution

Knowledge and Skills Sets of NOTES® Training

Guidelines

Assessment of Competency

Team Development

Simulation

Animal Lab Experience

Preceptorship/Training Centers

Privileging and Credentialing

Postgraduate and Residency Training

Continuing Education

Videos

22: Bariatric Endoscopy

The procedure(s) to be considered

Prerequisite level of expertise and technical ability

Special considerations/setting

Essential cognitive and technical skill sets

Essential equipment

Key steps of proper technique

Setting and tools for training

Defining competency for this particular skill

Maintaining skill level

Conclusion

Videos

23: Repair of Mucosal Defects: A Primer on Endoscopic Closure of Gastrointestinal Perforations

Introduction

Learning to close perforations

Conclusion

Videos

24: Esophageal, Gastroduodenal and Colorectal Stenting

Procedure(s) to be considered

Prerequisite level of expertise and skill for learning this

Special considerations

Specific technical and cognitive skill sets

Equipment

Key steps of proper technique

Setting and tools for training

Defining competency

Maintaining skill level

Videos

25: ERCP Management of Complicated Stone Disease of the Bile Duct and Pancreas

Mechanical lithotripsy

Large diameter balloon sphincteroplasty

Cholangiopancreatoscopy

Electrohydraulic lithotripsy

Laser lithotripsy

Extracorporeal shock wave lithotripsy and pancreatic duct stones

Difficult anatomy

Training modalities

Competency

Videos

26: ERCP Management of Malignancy: Tissue Sampling, Metal Stent Placement and Ampullectomy

Introduction

Tissue sampling at ERCP

Metal stent placement

Management of ampullary neoplasms

Thoughts on advanced endoscopy training

Videos

27: Sphincter of Oddi Manometry

Method of SOM

Technical performance of SOM (see accompanying Video 27.1)

Interpretation criteria

Reproducibility of SOM

Complications of SOM

Video

28: Pseudocyst Management

Procedure(s) to be considered

Prerequisite level of expertise and skill for learning this

Special considerations

Specific technical and cognitive skill sets

Acute fluid collections

Acute pancreatic pseudocyst

Chronic pancreatic pseudocyst

Pancreatic Abscess

Organized or walled-off pancreatic necrosis

Equipment

Key steps of proper technique

Setting and tools for training

Defining competency

Maintaining skill level

Video

29: Enteral Access Techniques: Percutaneous Endoscopic Gastrostomy and Jejunostomy

Introduction

Prerequisite expertise and skill

Setting

Equipment

Key steps for proper technique

Setting and tools for training

Defining competency

Maintenance of skills

Videos

30: The Endoscopic Management of Immediate Complications of Therapeutic Endoscopy

Introduction

Assessing risk prior to procedure

Intraprocedure recognition of complications

Videos

IV: Challenges for the Future

31: Assessing Manpower Needs in Gastroenterology and Digestive Endoscopy: Lessons from the Past and Implications for the Future of Endoscopic Training

Modeling manpower

Physician workforce estimates

Gastroenterology workforce modeling

Future projections in gastroenterology: lessons from the past

Endoscopic demands for screening colonoscopy

Conclusions

Acknowledgements

32: Providing Resources and Opportunities for Retraining for Practicing Endoscopists

33: Evolving Role of GI Societies and Industry in Training Endoscopists to Perform New Techniques: Supporting the Process and Setting the Standards

Background

Evolving role of industry

Evolving role of GI societies

Future directions and challenges

Video

34: The Importance of Skills Assessment and Recording Personal Outcomes in the Future of Training

The initial training period

Credentialing

Competence in practice

Impact of practice measurements on the training process

Conclusion

Index

Download CD/DVD content

Companion DVD-ROM

This book is accompanied by a companion DVD with:

Over 130 annotated teaching videos of both actual procedures and ex-vivo animal model simulations.A search featureAll videos are referenced in the text where you see this logo

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Library of Congress Cataloging-in-Publication Data

Successful training in gastrointestinal endoscopy / edited by Jonathan Cohen. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-9663-5 (hardcover : alk. paper) 1. Gastroscopy--Study and teaching. 2. Gastrointestinal system--Endoscopic surgery--Study and teaching. I. Cohen, Jonathan, 1964-- [DNLM: 1. Endoscopy, Gastrointestinal. 2. Endoscopy--education. WI 141] RC804.G3S83 2011 617.4′30597–dc22 2010047391

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444397758; Wiley Online Library 9781444397772; ePub 9781444397765

List of Contributors

Douglas G. Adler, MD, FACG, FASGE Associate Professor of Medicine Director of Therapeutic Endoscopy Division of Gastroenterology and Hepatology University of Utah School of Medicine Huntsman Cancer Center Salt Lake City, UT, USA

Alan Barkun, MD,CM, FRCP(C), FACP, MSc Chairholder The Douglas G. Kinnear Chair in Gastrology Professor of Medicine Division of Gastroenterology McGill University McGill University Health Centre Montreal, QC, Canada

Todd H. Baron, MD, FASGE Professor of Medicine Director Pancreaticobiliary Endoscopy Division of Gastroenterology & Hepatology Mayo Clinic Rochester, MN, USA

Anna M. Buchner, MD, PhD Instructor of Medicine Division of Gastroenterology Department of Medicine University of Pennsylvania School of Medicine Philadelphia, PA, USA

Karl-Friedrich Buerrig, MD, PhD Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

Jonathan M. Buscaglia, MD Director, Center for Advanced Endoscopy Assistant Professor of Medicine Division of Gastroenterology and Hepatology State University of New York Stony Brook, NY, USA

David L. Carr-Locke, MB, FRCP, FASGE Chief, Division of Digestive Diseases; Co-Director, Center for Digestive Health; Director, GI Services Continuum Cancer Centers of NY Beth Israel Medical Center New York, NY, USA

Jonathan Cohen, MD Clinical Professor of Medicine New York University School of Medicine New York, NY, USA

Gregory A. Coté, MD, MS Assistant Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, IN, USA

Peter B. Cotton, MD, FRCP, FRCS Professor of Medicine Digestive Disease Center Medical University of South Carolina Charleston, SC, USA

SongSa Dammer, CN Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

John Day, BBA Vice-President, Marketing ERBE USA Inc. Marietta, GA, USA

James A. DiSario, MD, FASGE Monterey Bay Gastroenterology Consultants Monterey, CA, USA; Adjunct Professor of Medicine University of Utah Health Sciences Center Salt Lake City, UT, USA

John A. Dumot, DO Digestive Health Institute University Hospitals Cleveland, OH, USA

Brian J. Dunkin, MD, FACS Professor of Clinical Surgery Weill Cornell Medical College; Head, Section of Endoscopic Surgery; Medical Director, The Methodist Institute for Technology, Innovation, and Education The Methodist Hospital Houston, TX, USA

Steven A. Edmundowicz, MD Professor of Medicine Director of Endoscopy Washington University School of Medicine St. Louis, MO, USA

Douglas O. Faigel, MD Professor of Medicine Mayo Clinic Scottsdale, AZ, USA

Syed M. Abbas Fehmi, MD, MSc Assistant Professor Division of Gastroenterology Department of Medicine University of California San Diego San Diego, CA, USA

David E. Fleischer, MD Professor of Medicine Mayo School of Medicine Mayo Clinic Scottsdale, AZ, USA

Evan L. Fogel, MD, FRCP(C) Professor of Clinical Medicine Indiana University School of Medicine Indianapolis, IN, USA

Martin L. Freeman, MD Professor of Medicine Interim Director, Division of Gastroenterology, Hepatology, and Nutrition Director of Pancreaticobiliary Endoscopy Fellowship University of Minnesota Minneapolis, MN, USA

Gerald M. Fried, MD Professor of Surgery and Adair Family Chair of Surgical Education McGill University; Steinberg—Bernstein Chair of Minimally Invasive Surgery and Innovation McGill University Health Centre; Montreal General Hospital Montreal, QC, Canada

Shai Friedland, MD Assistant Professor of Medicine Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford, CA, USA

Lauren B. Gerson, MD, MSc Associate Professor of Medicine Division of Gastroenterology and Hepatology Stanford University School of Medicine Stanford, CA, USA

Sahar Ghassemi, MD Director of EUS Santa Rosa Community Hospital Santa Rosa, OR, USA

Christopher J. Gostout, MD, FASGE Professor of Medicine Mayo Clinic Rochester, MN, USA

Bruce D. Greenwald, MD Professor of Medicine University of Maryland School of Medicine and Greenebaum Cancer Center Baltimore, MD, USA

David A. Greenwald, MD Gastroenterology Fellowship Process Director Associate Division Director Montefiore Medical Center; Associate Professor of Clinical Medicine Albert Einstein College of Medicine New York, NY, USA

Frank G. Gress, MD, FACP, FACG Professor of Medicine Chief, Division of Gastroenterology and Hepatology State University of New York (SUNY) Downstate Medical Center New York, NY, USA

Mark A. Gromski, BA Research Fellow in Developmental Endoscopy Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA

Gregory B. Haber, MD, FRCP(C) Director, Division of Gastroenterology Director, Center for Advanced Therapeutic Endoscopy Lenox Hill Hospital New York, NY, USA

Robert Hawes, MD Professor of Medicine Peter Cotton Chair for Endoscopic Innovation Division of Gastroenterology and Hepatology Medical University of South Carolina Charleston, SC, USA

Juergen Hochberger, MD, PhD Professor of Medicine and Chairman Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

Douglas A. Howell, MD, FASGE Associate Clinical Professor of Medicine University of Vermont College of Medicine Burlington, VT, USA; Director, Advanced Training Fellowship Director, Pancreaticobiliary Center Maine Medical Center Portland, ME, USA

Dennis M. Jensen, MD Professor of Medicine David Geffen School of Medicine at UCLA Los Angeles, CA, USA

Sreenivasa S. Jonnalagadda, MD, FASGE Professor of Medicine Director of Biliary and Pancreatic Endoscopy Division of Gastroenterology Washington University School of Medicine St. Louis, MO, USA

Nithin Karanth, MD Center for Advanced Therapeutic Endoscopy Lenox Hill Hospital New York, NY, USA

Peter Kelsey, MD Associate Director of Endoscopic Services Massachusetts General Hospital; Assistant Professor of Medicine Harvard Medical School Boston, MA, USA

Michael L. Kochman, MD, FACP Willmott Family Professor of MedicineVice-Chair of Medicine for Clinical Services Center for Endoscopic Innovation, Research, and Training Gastroenterology Division University of Pennsylvania Health System Philadelphia, PA, USA

Peter Koehler, PhD Federal Research Institute for Animal Health (FLI)Mariensee, Neustadt, Germany

Elena Kruse, MD Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

Jeffrey H. Lee, MD, FACG, FASGE Professor Director of Advanced Endoscopy Fellowship and Training Department of Gastroenterology, Hepatology, and Nutrition MD Anderson Cancer Center Houston, TX, USA

Glen A. Lehman, MD Professor of Medicine and Radiology Indiana University School of Medicine Indianapolis, IN, USA

Joseph Leung, MD, FRCP, FACP, FACG, FASGE Mr. & Mrs. C.W. Law Professor of Medicine University of California, Davis School of Medicine Sacramento, CA, USA; Chief of Gastroenterology VA Northern California Health Care System Mather, CA, USA

Michael J. Levy, MD Division of Gastroenterology and Hepatology Mayo Clinic Rochester, MN, USA

Jenifer R. Lightdale, MD, MPH Assistant Professor of Pediatrics Harvard Medical School; Associate in Medicine, Gastroenterology and Nutrition Children's Hospital Boston Boston, MA, USA

Brian S. Lim, MD, MCR Staff Gastroenterologist Department of Gastroenterology Kaiser Permanente Riverside Medical Center Riverside, CA, USA

Michael A. Manfredi, MD Instructor in Pediatrics Harvard Medical School Boston, MA, USA; Associate Director of Endoscopy Children's Hospital Boston Boston, MA, USA

John A. Martin, MD Associate Professor of Medicine and Surgery Director of Endoscopy Division of Gastroenterology Northwestern University Feinberg School of Medicine Chicago, IL, USA

Kai Matthes, MD, PhD Director Developmental Endoscopy Department of Gastroenterology Beth Israel Deaconess Medical Center Harvard Medical School Boston, MA, USA

Detlev Menke, MD Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

Girish Mishra, MD, MSc, FACG, FACP Vice-Chief & Associate Professor Director, Endoscopy & GI Fellowship Program Section on Gastroenterology Wake Forest University School of Medicine Winston-Salem, NC, USA

Patrick I. Okolo, MD, MPH Chief of Endoscopy Division of Gastroenterology Johns Hopkins University School of Medicine Baltimore, MD, USA

John L. Petrini, MD, FASGE Chairman Department of Gastroenterology Sansum Clinic Santa Barbara, CA, USA

Gottumukkla S. Raju, MD, FRCP, FACG, FASGE Professor of Medicine Department of Gastroenterology, Hepatology, and Nutrition University of Texas, MD Anderson Cancer Center Houston, TX, USA

Marvin Ryou, MD Advanced Endoscopy Fellow Brigham and Women's Hospital Massachusetts General Hospital Boston, MA, USA

Yasushi Sano, MD, PhD Director Gastrointestinal Center Sano Hospital Tarumi-ku, Kobe, Hyogo, Japan

Thomas J. Savides, MD Professor of Clinical Medicine Division of Gastroenterology University of California San Diego, CA, USA

Felice Schnoll-Sussman, MD, FACG Weill Medical College Cornell University New York, NY, USA

Robert E. Sedlack, MD, MHPE Division of Gastroenterology and Hepatology Mayo Clinic Rochester, MN, USA

Sohail N. Shaikh, MD Developmental and Bariatric Endoscopy Research Fellow Division of Gastroenterology Brigham and Women's Hospital; Post-Doctoral Fellow Harvard Medical School Boston, MA, USA

Prateek Sharma, MD Professor of Medicine Division of Gastroenterology and Hepatology Veterans Affairs Medical Center University of Kansas School of Medicine Kansas City, KS, USA

Virender K. Sharma, MD, FASGE, FACG, AGAF Director Arizona Center for Digestive Health Gilbert, AZ, USA

Stuart Sherman, MD Professor of Medicine Indiana University School of Medicine Indianapolis, IN, USA

Peter D. Siersema, MD, PhD Professor of Gastroenterology Director, Department of Gastroenterology and Hepatology University Medical Center Utrecht Utrecht, The Netherlands

Christopher C. Thompson, MD, MHES, FACG, FACGE Director of Developmental and Bariatric Endoscopy Brigham and Women's Hospital; Assistant Professor of Medicine Harvard Medical School Boston, MA, USA

Roland M. Valori, MD, FRCP, MSc Gloucestershire Hospitals NHS Foundation Trust Gloucestershire, UK

Michael B. Wallace, MD, MPH Professor and Vice-Chairman of Medicine Department of Gastroenterology and Hepatology Mayo Clinic Jacksonville, FL, USA

Kevin A. Waschke, MD, CM, FRCPC, CPSQ Director of Therapeutic Endoscopy and Endosonography McGill University Health Centre McGill University Montreal, QC, Canada

Jerome D. Waye, MD Director of Endoscopic Education Mt. Sinai Hospital New York, NY, USA

Edris Wedi, MD Department of Medicine III—Gastroenterology, Interventional Endoscopy St. Bernward Academic Teaching Hospital Hildesheim, Germany

Foreword

Throughout the years, it is evident that the best practitioners of endoscopy are not necessarily the best teachers and, parenthetically, the best teachers may not be the best practitioners of this discipline. Teaching is a skill that can be learned, but in the field of gastrointestinal endoscopy, most teachers acquire their ability to impart their knowledge to others by watching their teachers over years of schooling and incorporating the best parts of several educators into their personal style of educational communication. In the field of endoscopy, all who become teachers have an enormous responsibility, not only to share their knowledge completely and selflessly with the student, but to watch over the patient at all times to ensure their safety and that the teaching aspect of the procedure does not infringe upon the ability to provide the best endoscopic examination possible. The information that is given must become a part of the student's approach to the entire endoscopic experience including such aspects as informed consent, the preparation of the patient, the discussion of the procedure both before and after the instrumentation takes place and, of course, the careful and repetitive steps needed for the effortless and practiced performance of the examination itself. The endoscopic approach, learned by the side of the instructor, will be used for the rest of the professional lives of the students and are skills that will be further enhanced as the student becomes more familiar with the myriad procedures that are possible and seemingly impossible but that can be built upon by a solid foundation to cope with emerging technology. It is not possible in this book to present all the facets of learning all aspects of endoscopy, but Dr. Cohen has made it a priority to present all facets of teaching the procedural aspect of gastrointestinal endoscopy, and has done it well.

Prior to assigning chapters to write, Dr. Cohen identified three attributes that had to be realized in each of the authors whom he invited to participate in this unique teaching endeavor. Each author had to be a superb endoscopic technician who also is currently engaged in formally teaching endoscopy to students as well as other endoscopists, and has demonstrated skill in writing and putting their thoughts on paper in an organized fashion. Having written a multiauthored book on narrow band imaging (Comprehensive Atlas of High Resolution Endoscopy and Narrowband Imaging), Dr. Cohen used his networking ability to find the right endoscopy colleagues for each chapter of the present book. In spite of its title “Successful Gastrointestinal Endoscopy”, this book is not just a teaching manual, but is actually a “how I do it” textbook developed from the standpoint of an endoscopic expert who also teaches. The accumulated mass of knowledge from these teachers of endoscopy are spread evenly throughout each chapter, which showcases their techniques developed over years of teaching fellows while standing by their side, giving verbal instructions, sharing tips, discussing the approach to problems, and being mentors in their training.

In addition to the wisdom imparted through the transfer of knowledge via the written page, there is an extensive video section contained on the enclosed DVD, which demonstrates the techniques that are written about. The videos complement the book and walk the student through the process to increase the understanding of the training set.

The World Endoscopy Organization (WEO) is pleased to endorse this book since its goals are clear and well defined: that to perform endoscopy one needs to have proper training. This training is best accomplished under the watchful tutelage of a person who is dedicated, expert, and facile not only in the performance of the procedure but also in the ability to transfer skills to the next generation of endoscopists. The WEO promotes excellence in endoscopy throughout all parts of the world and focuses on bringing endoscopy to underserved areas where endoscopy is underutilized.

This book will serve as a valuable resource for those who are in training, those accomplished endoscopists who want to increase their knowledge of techniques, and all the endoscopists who train others in this rapidly growing and exciting field.

Jerome D. Waye, MD President, World Endoscopy Organization

Preface

The field of gastrointestinal endoscopy today faces a frenetic intersection of change. Many new technologies are emerging to expand the diagnostic and therapeutic capabilities of endoscopists. Innovative investigators are also devising new therapeutic applications of existing equipment. A heightened focus on optimizing quality performance in our procedures necessarily has required a renewed attention on how to ensure that the individuals asked to practice endoscopy are fully trained to achieve the highest possible outcomes. Competing diagnostic and therapeutic modalities threaten to make some of the standard procedures obsolete and challenge the individuals who spend most of their time performing them to adapt. For many individuals caught in this crossroads mid-career, finding the time and opportunities to retool can be very challenging, irrespective of the personal economic concerns involved in making the commitment to upgrade skills in response to the changing conditions.

At the same time, practitioners from specialties previously not involved with endoscopy have been drawn by various forces to learn endoscopy. Resources for training in major GI endoscopy procedures and in specific advanced techniques are limited. For many procedures, the trainers and trainees are hindered by the lack of sufficient case volume in the given technique to be taught. The availability of expert mentors to teach required skills can be another major impediment to training opportunities.

The increased demand for high-quality training and the supply limitations due to the costs and time required for this labor intensive process have driven the development of novel teaching tools which aim to increase the efficiency of training, and where possible increase the potential for independent learning.

The purpose of this book is to provide a comprehensive examination of the principles and specific components of training in endoscopy. The first section explores the important concepts of training and describes the range of tools that have been utilized in this regard. The next two sections provide in-depth discussion of the major current endoscopic procedure categories as well as most specialized diagnostic and therapeutic techniques. For each of these chapters, the authors have considered prerequisite skills for training, skill sets to be mastered, step-by-step components that must be taught and assessed by trainers, typical learning curve for trainees, and objective measures of competency which trainees must strive to attain. For some of these topics, there has been scant literature to define these parameters. Accordingly, the authors have drawn from their extensive experience in training and performing these procedures to provide their recommendations where data is lacking. The material presented will identify important questions about training that warrant future investigation. The accompanying edited and annotated video clips on the DVD highlight key teaching points for instructors to emphasize. The final section looks to the future of training and retraining in gastrointestinal endoscopy. Key logistical hurdles to this process are examined and the importance of keeping track of outcomes, the ultimate indicator of successful training, is emphasized.

This combined textbook with DVD provides a comprehensive guide for trainees and trainers in gastrointestinal endoscopy of all aspects of the process of acquiring expertise in the techniques that are currently performed. For each procedure, the focus is to cover what needs to be learned, how best to learn it, and how to ensure that sufficient training has taken place to ensure competency.

The chapters examine the specific skills sets and procedure-related tasks that must be mastered in learning a particular technique. They contain specific descriptions of accessories required, standard training methods for the particular procedure, and optimal utilization of novel learning modalities such as simulators. Quality measures and objective parameters for competency for each procedure are considered when available, along with available tools for assessing competency once training has been completed.

The accompanying DVD included with the text contains over 130 annotated video clips of both actual procedures and ex vivo animal model simulations to illustrate proper techniques in a step-by-step fashion and demonstrates common mistakes and improper technique.

The purpose of this volume is to help endoscopists realize optimal levels of skill as they perform the procedures they aspire to learn.

Though the focus of this textbook/DVD remains on how to learn and how to teach each technique, because doing so requires delineation and illustration of all skill sets to master, the textbook chapters and particularly the video unavoidably serve as learning tools for the proper performance of endoscopic techniques in addition to an authoritative primer on training.

Jonathan Cohen, MD

Acknowledgements

I wish to thank the many authors who contributed text and video for this volume for their great efforts and willingness in many cases to take on topics that have not been fully explored before. Beyond that, I want to extend my gratitude to the individuals who have been my teachers in endoscopy. Despite all advances in tools and methods of training detailed in this book, the importance of having wonderful mentors remains paramount to successful training in endoscopy. I have been particularly fortunate in this regard. Besides imparting their wisdom and expertise, they have given me a strong appreciation for the importance of training and of ongoing learning in this ever changing and exciting field.

Thanks also to Cori, Juliette, and Ben for their tremendous understanding, encouragement, and support.

This book is dedicated to JJC for his lifelong inspiration and for giving me the idea for this project. AELCFIS!

I

The Evolution of Basic Principles and Practice

1

Training in Endoscopy: A Historical Background

Jonathan Cohen1 & David A. Greenwald2,3

1New York University School of Medicine, New York, NY, USA

2Montefiore Medical Center, New York, NY, USA

3Albert Einstein College of Medicine, New York, NY, USA

Introduction

Gastrointestinal endoscopy has grown increasingly more complex as the field has evolved over the past several decades, now requiring the practitioner to become proficient at many techniques. To perform high-quality care, endoscopists often have had to devote time to learn new techniques as well as take care to continually maintain existing skills. As the technology and applications have progressed, so too have the methods by which individuals have learned to perform these procedures. In this chapter, we will trace the evolution in training from the self-taught pioneers of the early days to the advent of formal proctored tutelage that remains the mainstay of training in this field. The chapter will also relate the emergence of numerous innovative learning tools that have already served to further transform training in gastrointestinal endoscopy. In particular, we will describe the development of simulator-based instruction from the creation of realistic models to their validation and growing importance in endoscopic training. Lastly, we will address a number of novel principles of education in endoscopy that have paralleled the growing availability of these new teaching tools.