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 19 November 2017

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Endoscopy Practice and Safety

Peter B. Cotton ed.

12. Towards excellence and accountability

Peter B . Cotton and Roland Valori

Top of page Synopsis  Next section

Documenting and improving quality has become a hot topic in the world of endoscopy. Key issues are what to measure, how to do it, and why.

Top of page Introduction  Previous section Next section

No one—practitioner, payer, or patient—can doubt the importance of ensuring that interventional procedures are performed well. Professional organizations representing endoscopy around the world have published numerous recommendations and guidelines on various aspects of this quality agenda [1,2]. These include methods for training, evaluation of competence, principles for the granting of privileges to perform procedures, and methods for recredentialing (revalidation). The mirror of excellence is accountability. There is increasing interest in defining the metrics and mechanisms for documenting levels of endoscopic performance, which will allow appropriate comparisons and benchmarking.

The proliferation of thoughtful publications on this subject has had relatively little effect so far in the complex and diffuse world of endoscopic practice. Guidelines are not mandatory, and peer pressure has limited influence. Training program directors have little objective data with which to judge the competence of their graduates, and credentialing bodies have even less. In addition, there is (as yet) no consensus on what level of performance is really acceptable. In the United States, many of the routine procedures are performed by doctors (general internists and surgeons) who have not undergone formal gastroenterology training. These endoscopists may see the recommendations of the gastroenterology and endoscopy societies as being too stringent and also self-serving. Finally, most routine procedures are performed in offices and free-standing endoscopy centers and are not subject to the (albeit flawed) credentialing process in hospitals.

Top of page Achieving competence—the goal of training  Previous section Next section

Endoscopists can be categorized broadly into four levels of performance—from beginner/learner through states of competence, proficiency, to excellence (Fig. 1). Competence defines the level of performance at which independent practice is justified, i.e. the completion of initial training. The key issues are:

  • What needs to be learned to become competent?
  • What level of performance is needed for 'competence'?
  • Who makes that determination?
  • How is competence assessed and documented?

The appropriate application of endoscopy requires cognitive knowledge, technical skills, and some humanity. Until recently, it was assumed that a standard period of gastroenterology training (e.g. GI Fellowship in the United States, or a Specialist Registrar position in the UK) would get trainee endoscopists to a reasonable level of competence. However, this is clearly not always the case, even for standard procedures such as colonoscopy. The situation for advanced procedures (e.g. ERCP and EUS) is even more unsatisfactory.

Top of page What experience is necessary in training? The fallacy of numbers  Previous section Next section

In the late 1980s, professional societies began to recommend minimum numbers of cases during training. Initially, the American Society for Gastrointestinal Endoscopy (ASGE) suggested that endoscopists might be competent after approximately 100 upper endoscopies, 100 colonoscopies, and 100 ERCPs (provided that these included the relevant common therapeutic applications) [1]. However, these numbers were not based on data, and there was never a clear definition of what should 'count' as a case; how much of the procedure must the trainee do? The reliance on numbers was softened somewhat by the inclusion of the word 'threshold' in later ASGE recommendations. This was intended to indicate that trainees could ask their Training Program Directors whether they were indeed competent only after they reached that threshold number of cases. However, this subtlety was widely ignored. More important, several studies showed clearly that these numbers were too low. This was brought into bright focus by the seminal study at Duke University which showed that ERCP trainees were only barely reaching 80% competence after participating in 180–200 procedures [3]. This study and others led to an escalation of the numbers recommended by the ASGE (EGD 130, colon 140, ERCP 200), and by other professional organizations [1]. The Australian Gastroenterology Society proposed the most rigorous test for ERCP, indicating that trainees need to have completed 200 ERCP procedures, unassisted. The fact that professional societies representing surgeons and internists initially recommended much lower numbers [1] was confusing and contentious.

Some of these issues of competence and numbers are amplified in the chapter on 'Training and credentialing in gastrointestinal endoscopy' by Jonathan Cohen (

It is now obvious that mere numbers are poor markers for expertise. Would we submit ourselves to a procedure by one of our graduates if the sole determinant of competence was the number of procedures that he/she had experienced (or just observed)? We need meaningful objective outcome data.

Top of page Beyond numbers: tools to measure competence  Previous section Next section

In order to measure endoscopic performance, it is necessary to dissect out the essential elements of the procedures, and then to develop a list of the essential 'competencies', covering the domains of knowledge, technical skill, and attitude. Some competencies can be assessed by standard written tests, others by documenting the achievement of technical milestones. Computer simulation may well become an important part of the assessment process. Evaluating attitudes, appropriate application of knowledge (judgement), and technical skills require proctoring of real cases, so-called DOPS (direct observation of procedural skills). The Joint Advisory Group (JAG) in Britain, which represents all parties interested in endoscopy, has recently defined processes for assessing competence of trainees [4]. This group is also actively pursuing a competence test, at least for colonoscopy, for established endoscopists who have not been through a competency test as a trainee. This 'driving test' has been stimulated by the upcoming introduction of a national bowel cancer screening program.

Top of page What level of competence is good enough? How is it recognized?  Previous section Next section

When we have the tools to measure performance, we then will have to decide on the 'pass mark' for competence, and to agree who is in a position to make that determination. Should it be the professional organizations (who may be seen as self-serving, and often fail to find a consensus), the payers (who come in many guises), or the consumers? All have different agendas.

Another issue is how endoscopic competence should be certified. An endoscopy diploma (procedure specific) would seem to be the obvious answer, but there is no move towards that concept in the United States. The JAG issues certificates of competence in Britain that are recognized by physicians and nurses. To date the surgical colleges in Britain have not acknowledged the legitimacy of JAG certification.

Top of page Endoscopic performance beyond training  Previous section Next section

Once a trainee is deemed 'competent', a process is required to ensure that acceptable performance is maintained. Hopefully, skills will increase progressively in practice. Competent endoscopists should become proficient, and some will become true experts (Fig. 1). Performance is influenced by the extent and quality of prior training, by case volume, by the availability of mentoring by senior colleagues, and by continuing education activities. An important but unanswered question is how many procedures need to be done on an annual basis to ensure continuing adequate performance (let alone to enhance it). Numbers in this context are important not only to maintain expertise but also to provide sample sizes sufficient to detect areas of concern within a reasonable time frame. For example, adverse endoscopic event rates are so low that it could take many years for variance to be recognized and remedial action taken.

Making individual endoscopists aware of their skill levels compared to their colleagues is a strong stimulus to improve performance [5]. This 'benchmarking' can be done only if there is a continuous and reliable measurement process in place, and a central system for analysis and feedback.

Top of page Issues in measuring endoscopic performance  Previous section Next section

Most published data on the outcomes of endoscopy come from expert centers, or from motivated collaborative groups [1,2,6], and concentrate on technical 'success rates' and complications. For colonoscopy, attention has been focused mainly on cecal intubation rates. Studies from experts and major multicenter research studies suggest that completion rates often exceed 95% [7,8]. However, the non-experts rarely publish their data, so that it is difficult to know much about overall standards in the community. A database audit of almost 20 000 colonoscopies from seven hospitals in the United States showed that only 54% of 108 endoscopists reached the cecum in more than 90% of cases [9], and even lower rates have been reported [10]. However, it is obvious that the goal of colonoscopy is not merely to reach the cecum, but rather to examine the whole mucosa and to detect/manage all lesions with acceptable levels of comfort and safety. A good example of more meaningful quality data comes from a community study which correlated polyp detection rates with withdrawal durations [11]. Recent comparative studies with CT colonography have shown that colonoscopy is not 'as good as gold'[12]. There are very few data on the complications of colonoscopy in community practice, and even fewer of patient acceptability. Two British studies, one of unselected practice and the other of a screening pilot, showed wide variation in perforation rates of from 1 : 769 to 1 : 4000 [5,13]. Several more widespread audits are underway in Britain (

These general surveys are of interest, but we need to embrace a new paradigm—the collection of performance data for and by individual endoscopists.

Top of page The report card agenda  Previous section Next section

The American Society for Gastrointestinal Endoscopy (ASGE) recommended in 2000 that all endoscopists should keep track of their practice [14], but there is little evidence that many have done so. A key issue is what parameters to measure. The most comprehensive review of endoscopy performance metrics was produced by a joint working party of the ASGE and ACG [7]. An attempt to provide slightly simpler metrics was published recently [15], and other working parties are in progress. Some data points are obvious (e.g. annual procedure numbers, case mix, certain technical endpoints), and can be incorporated easily into a report card (Fig. 2). These should be available to any interested parties, whether payers, credentialing bodies, patients, and even lawyers [16].

Skeptics of this approach put forward several arguments. They are concerned about the quality of the data, which may not be verifiable independently, and that the need to report outcomes may stimulate interventionists to avoid the most difficult and risky cases. Perhaps the most powerful point is that there is little evidence that their use in other fields (for example in cardiac surgery) has yet influenced the choices of patients or indeed payers. The final problem is that this exercise will be time consuming and expensive. Some of these concerns will fade as all endoscopy reporting becomes electronic. The performance data can be generated automatically at the time of the procedure, and easily uploaded into systems for benchmarking. Furthermore, such systems allow adjustment for case mix.

The argument for collecting and sharing data remains strong. If we do not collect the data, others will do it for us, and we will have little control over its relevance or quality. Secondly, documentation of our experience will provide some legal protection to individual endoscopists, and indeed, to those who credential them. Perhaps the most persuasive argument is that endoscopists with report cards will have a practice advantage in the future. Patients (and payers) will increasingly ask their providers for objective data on their expertise, and may well go elsewhere if it is not forthcoming or reassuring. Furthermore, there is a strong tide running in the United States for 'pay for performance', in other words tying reimbursement to outcomes. It really is time for action to supersede discussion. Professionals proud of their practice should set an example and start documenting their practice and outcomes. We should wear our data as badges of quality.

Top of page Benchmarking  Previous section Next section

If enough endoscopists collect their data, and agree to share them (albeit anonymously) in a voluntary 'quality network', it will be possible to compare practice and outcomes, and to develop benchmarks of performance. When such data are fed back to participants, they act as a powerful incentive for self-improvement [5]. Benchmarks can help to define and to raise standards. An important question is who will pay for the necessary infrastructure.

Top of page The quality of endoscopy units  Previous section Next section

The quality of an endoscopy experience depends on the environment in which it is performed, as well as on the individual practitioner, in the same way that the experience in a restaurant depends on more than the individual chef (or server). Thus it is logical to extend the concept of report cards to document the structure and function of endoscopy units. This concept has been embraced in the United Kingdom with the development of a 'global rating scale (GRS)' for endoscopy units ( Initially this was simply a self-administered questionnaire on aspects of practice and process. It is now a web-based reporting tool backed up with specific measures of processes, data, and performance. The GRS has been accepted as the service standard for accreditation of endoscopy units participating in the national bowel cancer screening programme ( Furthermore, it has been underpinned with a knowledge management system to support quality improvement.

Top of page Conclusion  Previous section Next section

Everyone is (or should be) interested in improving the performance of endoscopy, and its documentation. We are convinced that this agenda can be advanced effectively and easily by the widespread acceptance of ongoing collection and sharing of quality data, for example, the use of report cards for endoscopists, and for endoscopy units. In most environments this will be a voluntary exercise initially, but there will be increasing peer pressure to participate. Aggregation of the data in a voluntary 'quality network' will allow benchmarking, and stimulate improvement. It is the right thing to do.

Top of page Outstanding issues and future trends  Previous section Next section

Numerous professional bodies and groups in several countries are now addressing the key issues of endoscopy performance measurement and enhancement. Soon there will be a consensus on the basic metrics, and methods for collecting and sharing the data, a process which will be greatly facilitated by electronic reporting. The resistance to 'report cards' will be overcome as their practice advantages are better appreciated, and as our patients learn to ask for the data. It remains to be seen who will provide the infrastructure needed to support this agenda, and how exactly the data will impact the quality of endoscopy in different practice environments.

Top of page References  Previous section

 1 Cohen, J. (2004). Endoscopic training and credentialing. In: Advanced endoscopy, e-book/annual (ed. Cotton PB),

 2 Freeman, ML. Training and competence in gastrointestinal endoscopy. Rev Gastroenterol Disord 2001; 1: 73–86. PubMed

 3 Jowell, PS, Baillie, J, Branch, MS, Affronti, MD, Browning, CL & Bute, BP. Quantitative assessment of procedural competence: a prospective study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med 1996; 125: 983–8. PubMed


 5 Ball, JE, Osbourne, J, Jowett, S, Pellen, M & Welfare, MR. Quality improvement program to achieve acceptable colonoscopy completion rates: prospective before and after study. BMJ 2004; 329: 665–7. PubMed

 6 Cotton, PB & Leung, JWC (2005). Advanced digestive endoscopy: ERCP. Blackwell Publishing, Oxford.

 7 Rex, DK, Bond, JH, Winawer, S, Levin, TR, Burt, RW & Johnson, DA et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296–305. PubMed CrossRef

 8 Cotton, PB, Durkalski, VL, Pineau, BC, Palesch, Y, Mauldin, PD & Hoffman, B et al. Computer tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia lesions. JAMA 2004; 291: 1713–19. PubMed

 9 Cotton, PB, Connor, P, McGee, D, Jowell, P, Nickl, N & Schutz, S et al. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest Endosc 2003; 57: 352–7. PubMed

10 Bowles, CJ, Leicester, R, Romaya, C, Swarbrick, E, Williams, CB & Epstein, O. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004; 53: 277–83. PubMed

11 Barclay, RI, Vicari, JJ, Johanson, JF & Greenlaw, RI. Variation in adenoma detection rates and colonoscopic withdrawal times during screening colonoscopy. Gastrointest Endosc 2005; 6: AB107.

12 Lieberman, D. Colonoscopy: as good as gold? Ann Int Med 2004; 141: 401–3. PubMed

13 UK Colorectal Cancer Screening Pilot Group. Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom. BMJ 2004; 329: 133.

14 ASGE. Quality and outcomes assessment in gastrointestinal endoscopy. Gastrointest Endosc 2000; 52: 827–30.

15 Cotton, PB, Hawes, RH, Barkun, A, Ginsberg, GG, Amman, S & Cohen, J et al. Excellence in endoscopy: toward practical metrics. Gastrointest Endosc 2006; 63: 286–91. PubMed

16 Cotton, PB. How many times have you done this procedure, doctor? Am J Gastrenterol 2002; 97: 522–3.

Copyright © Blackwell Publishing, 2006

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  A (very) brief history of endoscopy
  Professionalism and quality
Unit design
  Space planning
   Daily room volumes
   Procedure room size
   Preparation and recovery ratios
   Separate entrances
   Common space problems
  Physical infrastructure
  Intake and recovery areas
   Intake areas
   Managing clothes and valuables
   Recovery facilities
  Procedure room reprocessing and storage
   Standard procedure rooms
   Scope reprocessing and storage
   Patient flow issues
   Complex procedure rooms
   Storage of supplies and medications
   Travel carts for emergencies
Unit management
  Major areas of responsibility
  Staffing design
   Staffing emergencies
  Procedure schedules
   Relative time requirements
   Barriers to efficiency
   How many endoscopes?
   Endoscope repair costs
  Endoscope reprocessing
  Coding and billing
Outstanding issues and future trends
  Capsule endoscopy
  Colon screening technologies
  Endoscopy by non-specialists
  Growth of advanced endoscopy
  Moderate sedation
  Deep sedation/analgesia
Advances in monitoring during sedation
  Standard pulse oximetry
  CO2 monitoring
   Transcutaneous CO2 monitoring
  BIS monitoring
Topical anesthetics: are they worth the effort?
Titration vs. bolus administration of sedation and analgesia
  Problems with propofol
  Specific training for use of propofol
  Contraindications of propofol
  Clinical trials of propofol
   Propofol or midazolam?
   Upper endoscopy
   Upper endoscopy and colonoscopy
   Propofol with or without midazolam
   Patient-controlled administration of propofol
   Nurse-administered propofol
   Gastroenterologist-administered propofol
Outstanding issues and future trends
Gastrointestinal endoscopes
  Endoscope design
   Control section
   Insertion tube
   Connector section
   Light source/processors
  Endoscope equipment compatibility
  Endoscope categories
   Esophagogastroduodenoscope (gastroscope)
   Wireless capsule endoscopy
Gastrointestinal endoscopic accessories
  Tissue sampling
   Biopsy forceps
   Single-bite cold-biopsy forceps
   Biopsy cup jaws
   Multi-bite forceps
   Other specialty forceps
   Monopolar hot biopsy forceps
   Reusable vs. disposable biopsy
   Cytology brushes
   Needle aspiration
  Polypectomy snares
  Retrieval devices
  Injection devices
   Injection needles
   Spray catheters
   ERCP catheters
  Hemostatic and ablation devices
   Contact and non-contact thermal devices
   Heater probe
   Laser fibers
   Argon plasma beam coagulator
   Mechanical hemostatic devices
   Band ligation
   Metallic clip application via flexible endoscopes
   Marking with clips
   Detachable loops
  Transparent cap
  Dilation devices
   Push-type fixed-diameter dilators
   Hurst and Maloney dilators
   Savary-type dilators
   American Dilation System dilators
   TTS fixed diameter dilators
   Threaded-tip stent retrievers
   Radial expanding balloon dilators
   TTS dilators
  Achalasia balloon dilators
Outstanding issues and future trends
  Fiberoptic imaging
   Teaching attachments and photography
   Image capture
   Standardized image terminology
   Structured reporting
   The opportunities and challenges of the digital revolution
Digital imaging
  Imaging the gastrointestinal tract using a videoendoscope requires several steps
  Color models
Digitization of color
Color depth
Pixel density
File size
  What detail is needed?
  File compression
  Compression techniques
   Lossless compression
   Lossy compression
  Image file formats
  Color and black and white compression
  JPEG 2000 and beyond
DICOM standard
  Information Objects
   Patient name attributes
  DICOM conformance
  DICOM in endoscopy
  Expanding the scope of DICOM
How much compression is clinically acceptable?
  Studies of compression acceptability
   Vakil and Bourgeois
   Kim (personal communication)
  Developments in compression
Still pictures or live video?
  Video storage developments
What images should be recorded in practice?
  Lesion documentation
  Recording negative examinations
  Structured image documentation
  Costs of image documentation
Image enhancement
  Color manipulation
  Narrow band imaging and spectroscopy
Terminology standardization
  OMED standardized terminology
  Minimal standard terminology—MST
   Problems with MST
Outstanding issues and future trends
Editor's note
Relevant thermal effects in biological tissues
  Thermal devitalization
  Thermal coagulation
  Thermal desiccation
  Thermal carbonization
  Thermal vaporization
Generation of temperature in thermal tissue
  Heater probe
  High-frequency surgery
   General principles of high-frequency electric devices
   Electric arcs
Principles of high-frequency surgical coagulation
  Monopolar coagulation instruments
  Electro-hydro-thermo probes
  Bipolar coagulation instruments
Principles of high-frequency surgical cutting with particular regard to polypectomy
Technical aspects of polypectomy
  Polypectomy snares
  The polypectomy snare handle
  Polypectomy snare catheters
Safety aspects of high-frequency surgery
Argon plasma coagulation
  The principle of argon plasma coagulation
  Equipment for argon plasma coagulation
  Safety aspects of argon plasma coagulation
  Principle of Nd:YAG laser
  Specific characteristics of Nd:YAG lasers in flexible endoscopy
Safety aspects of Nd:YAG laser in flexible endoscopy
Sterilization and disinfection
  High-level disinfection
  What level of disinfection is required?
   Critical items
   Semi-critical items
  The practical problem
  The organisms
  The critical points in reprocessing
Risks of infections associated with endoscopic procedures
  Mechanisms of infection
  Clinical infections
   Infecting organisms
   Vegetative bacteria
   Clostridium difficile
   Mycobacterium tuberculosis
   Atypical mycobacteria
   Serratia marcescens
   Helicobacter pylori
   Human immunodeficiency virus (HIV)
   Hepatitis B
   Hepatitis C (HCV)
   What to do in practice about CJD?
   New variant CJD (vCJD)
   Other infections
  The endoscopic procedures
   Upper gastrointestinal endoscopy
   Lower gastrointestinal endoscopy
   Endoscopic retrograde cholangiopancreatography
   Percutaneous endoscopic gastrostomy
   Endoscopic ultrasound
  Host factors
   Immune competence
   The degree of tissue damage
   Intrinsic sources of infection
   Damaged valves and implants
Antibiotic prophylaxis for endoscopic procedures
  Principles of prevention of bacterial endocarditis
  High risk cardiovascular conditions [43]
  Moderate risk cardiovascular conditions [43]
  Recommendations for antibiotic prophylaxis
   Who should receive antibiotics?
   Clinical problems where opinions diverge
   What antibiotic regimen?
Antibiotic prophylaxis for ERCP
  Prophylactic antibiotic regimens for ERCP
Principles of effective decontamination protocols
  Cleaning is essential
  Effectiveness of recommended protocols
  Endoscope structure
   Common features
   External features
   Common internal features
   Special internal features
   Cleaning equipment
   Cleaning fluids
   Soaking time
   General maintenance
   Work areas
Reprocessing regimens
  Disinfect before and after procedures
  Manual cleaning
  Manual disinfection
  At the end of the list
  Endoscopic accessory equipment
   Cleaning accessories
   Special accessory items
   Sclerotherapy needles
   Water bottles and connectors
Problem areas in endoscope reprocessing
  Rinsing water
   Poor quality water
   Infections from rinsing water
   Bacteria free water
   Water testing
   Recommendations for rinsing water
Variation in cleaning and disinfection regimens depending upon the supposed infective status of the patient
Compliance with cleaning and disinfection protocols
The investigation of possible endoscopy infection transmission incidents
  Common causes
  Golden rules for investigating potential infection incidents
  The investigation process
  Transmission of viral disease
Automatic flexible endoscope reprocessors (AFERs)
  Machine design and principles
   Water supply
   Alarm function
   Fume containment
   Disinfectant supply
   Reprocessing time
   AFERs cannot guarantee to sterilize endoscopes
   Plumbing pathway
   Rinse and dry cycle
   Regular bacteriological surveillance
Quality control in endoscope reprocessing
  Quality control measures
Microbiological surveillance in endoscopy
  Testing procedures
  Interpretation of cultures
  Microbiological surveillance of AFERs
Outstanding issues and future trends
The contract with the patient; informed consent
  Educational materials
What are 'risks' and 'complications'?
  Threshold for 'a complication'
  Timing of unplanned events
  Direct and indirect events
  Data set for unplanned events
General issues of causation and management
  Technical and cognitive performance
  Fitness for procedures
   ASA score
   Other risk indices
  Prompt recognition and management
   Act promptly
  Specific unplanned events
   Failure to diagnose
   Risk factors
   Risk factors
   Cardiopulmonary and sedation complications
   Allergic reactions
   IV site issues
   Miscellaneous and rare events
Preventing unplanned events
Outstanding issues and future trends
Gastroenterologist–pathologist communication
  Endoscopist communication responsibility
  Pathologist communication responsibility
  Question-orientated approach
  Common terminology
Endoscopic biopsy specimens
  Specimen handling and interpretation issues
   Number of biopsies per container
   Tissue processing
   Prep-induced artifact
   Endoscopy-induced artifacts
   Biopsy-induced artifacts
   Crush artifact
   Burn/cautery artifact
   Endoscopic mucosal resection
   Core biopsy
  Regular stains
Exfoliative and fine-needle cytology
  Specimen handling; staining and fixation
   Cytological diagnosis
  Fine-needle aspiration
Organ system overview
   Where and when to biopsy
   Gastroesophageal reflux disease
   Barrett's esophagus
   Infective esophagitis
   Herpes simplex virus
   Adenocarcinoma and squamous cell carcinoma
   Where and when to biopsy
   Inflammatory conditions; gastritis
   H.pylori gastritis
   Hypertrophic folds
   Mass lesions
  Small bowel
   Celiac sprue
   Infective enteropathies
   Whipple's disease
   Mycobacterium avium–intracellulare
   Giardia lamblia
   Mass lesions
   Defining 'normal'
   Inflammatory colitides
   Normal colonoscopy
   Abnormal colonoscopy
   Inflammatory bowel disease
   Pseudomembranous colitis
   Ischemic colitis
   Mass lesions
Special stains
  Histochemical stains
  Immunohistochemical stains
  In situ hybridization
  Flow cytometry
  Electron microscopy
  Molecular pathology
Outstanding issues and future trends
The endoscopy facility and personnel
  Endoscopy facility
   Endoscopy instruments
   Ancillary equipment
   The endoscopist
   Nursing and ancillary personnel
The pediatric patient and procedural preparation
  Patient preparation
   Psychological preparation
   Medical preparation
   Recommendations for fasting
   Bowel preparation
   Antibiotic prophylaxis
  Informed consent
Endoscopic procedures currently performed in pediatric patients
  Indications and limitations
  Patient sedation
  Endoscopic technique
   Therapeutic endoscopy
   Other endoscopic modalities
   Small bowel enteroscopy
   Wireless capsule endoscopy
   Endoscopic ultrasonography
   Endoscopic retrograde cholangiopancreatography (ERCP)
Selected gastrointestinal pathologies in pediatric patients
  Eosinophilic esophagitis
  Food allergic enteropathy and colitis
  Foreign body ingestion
  Helicobacter pylori gastritis
  Polyps in the pediatric patient
  Lymphonodular hyperplasia
Outstanding issues and future directions
General principles of endoscopy training
  Traditional standard means of instruction
   Is self-teaching still acceptable?
  What to teach and how to teach it
  Defining competency and how to access it
   Linking diagnosis and therapy
   How competent?
   Varying rates of learning
   Learning beyond the training period
Training and competency in specific endoscopic procedures
  Esophagogastroduodenoscopy (EGD)
   Published guidelines for training in EGD
   Defining competence for EGD
   Data on acquisition of competency in diagnostic EGD
   Competency and EGD outcome
  Therapeutic EGD techniques
   Standard upper GI endoscopy techniques
   Hemostasis techniques
   Bleeding team
   Retaining competence
   Other specialized therapeutic upper GI endoscopy techniques
  Flexible sigmoidoscopy
   Published guidelines for training in flexible sigmoidoscopy
   Published guidelines for training in colonoscopy
   Defining competence for colonoscopy
   Technical components
   Cognitive objectives
   Minimum training requirements to achieve competency for colonoscopy
   The Cass study
   Competency and colonoscopy outcome
   Acceptable outcomes
   Rate of skills acquisition for colonoscopy
   Cases per week
   Too many cases?
  Therapeutic colonoscopy (biopsy, polypectomy, hemostasis techniques, stricture dilation, stent deployment)
   Standard therapeutic techniques (integral to performance of diagnostic colonoscopy)
   Advanced therapeutic colonoscopy techniques
  Diagnostic and therapeutic ERCP
   Published guidelines for training in ERCP
   Non-technical training
   Defining competence for ERCP
   Technical success
   Varying case difficulty
   Minimum training requirements to achieve competency for ERCP
   Case numbers
   What is a case?
   Competency and ERCP outcome
   Improving after training
   Annual volume
   Competence affects complication rates
   Rate of acquisition of ERCP skills
   Therapeutic ERCP
   Rate of acquisition of therapeutic skills
  Diagnostic and therapeutic EUS
   Defining competency in EUS
   Learning curve for EUS
   Therapeutic EUS
   EUS training opportunities
Complementary methods for instructions in GI endoscopy
  Advances in didactic methods
   Group instruction
   Laboratory demonstrations
  Endoscopy simulators
   Static models
   Courses with static models
   Ex vivo artificial tissue models: the 'phantom' Tübingen models
   Ex vivo animal tissue simulators: EASIE and Erlangen models
   Live animals
   Computer simulation
   GI Mentor™
   Current status of simulators
   Costs of simulators
   EUS models and simulators
  Use of training resources: summary
Endoscopy training 2010—a glimpse into the future
Credentialing and granting of privileges
   ASGE guidelines
Renewal of privileges and privileging in new procedures
  New procedures
Privileging for non-gastroenterologists and non-physician providers
The future of credentialing and privileging
  The use of new technology for credentialing
The role of endoscopic societies in training and credentialing
  Society courses
  Hands-on courses
  Research in training
  Influencing credentialing
Outstanding issues and future trends
Achieving competence—the goal of training
What experience is necessary in training? The fallacy of numbers
Beyond numbers: tools to measure competence
What level of competence is good enough? How is it recognized?
Endoscopic performance beyond training
Issues in measuring endoscopic performance
The report card agenda
The quality of endoscopy units
Outstanding issues and future trends
Most endoscopists are not interested
Is the problem declining?
Newly recognized infections
Compliance with guidelines
What can be done to remedy this sorry state of affairs?
  Infection control staff
  Microbiological surveillance
   British practice
The role of industry
Manual cleaning is key

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