Professor El-Omar has selected Dr Manu Nayar and Dr Tareq El Menabawey to do the next #GUTBlog. Dr Nayar is a Consultant Hepatopancreatobililary (HPB) Endoscopist at the Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK and Dr El Menabawey is a Consultant HPB trainee Endoscopist at the Pancreatobiliary Medicine Unit, University College London Hospitals NHS Foundation Trust, London, UK and at the Department of Gastroenterology, Homerton University Hospital, London, UK.
The #GUTBlog focusses on the paper “UK and Ireland Joint Advisory Group (JAG) consensus statements for training and certification in diagnostic endoscopic ultrasound (EUS)” which was published in paper copy in GUT in January 2024.
“Endoscopic ultrasound (EUS) is an advanced endoscopy procedure combining ultrasound for the diagnosis of various gastrointestinal disorders. Over the last couple of decades, EUS has evolved as an interventional treatment modality for conditions that were in the past exclusively the preserve of surgeons or radiologists including drainage of pancreatic fluid collections, the biliary tree or gallbladder and performing gastrojejunostomy,
Faced with an expanding requirement for EUS nationally, it is imperative to have quality standards to deliver the best possible care for the patient. The UK has been at the forefront of driving up the quality of diagnostic endoscopy through the early adoption of national key performance indicators (KPIs) and a National Endoscopy Training logbook (JETS). These have allowed robust, quality controlled, centralised accreditation of new practitioners of esophagogastroduodenoscopy (OGD), flexible sigmoidoscopy and colonoscopy [1–3]. Until recently, no such pathway existed for the more complex and higher risk modalities of EUS and ERCP[4]. In our article, “UK & Ireland Joint Advisory Group (JAG) Consensus Statements for Training and Certification in diagnostic EUS“[5], we set out the National training standards for diagnostic EUS along with a comprehensive curriculum of study for training endosonographers.
Setting the Standards
Between 2019 and 2023 we completed a Delphi process comprising a broad and representative population of UK endosonographers. Consultant and trainee representatives from teaching hospitals, district general hospitals, radiology, surgery and gastroenterology were invited. Four subgroups completed a literature review and collated statements for voting on the “definition,” “acquisition” and “assessment” of competence, and post certification mentorship.
In defining competence, we set out the key skills any endosonographer needs for independent practise. These include describing the gastrointestinal wall layers, T-staging tumours, identifying mediastinal and retroperitoneal landmarks, competent utilisation of the ultrasound console, constructing a structured report and demonstration of endoscopic non-technical skills. The focus of these competencies is to align the approach and knowledge base of the specialties practicing EUS, which may include radiologists, gastroenterologists and surgeons.
Assessment and Accreditation
- Complete at least 250 procedures prior to summative assessment
- Perform at least 75 fine needle aspiration/biopsy (including 50 pancreatic lesions)
- Demonstrate a 30-day complication rate of <5% (aspirational <3%)
- Achieve a tissue adequacy rate of 85% for solid pancreatic masses.
- Photodocument >90% of EUS landmarks relevant to the examination remit.
We have also incorporated these KPIs within the national JAG Endoscopy Training System (JETS) ePortfolio. This central database allows trainees to upload their procedures, trainers to complete formative assessments Direct Observation of Procedural Skills(DOPS) every 10 procedures and to monitor trainee progress. For the first time, we will be able to view trainees’ progress on a national scale. This presents exciting opportunities for research, including a better understanding of the learning curve toward competency and interventions that might accelerate trainee progression.
One of the challenges in creating a training pathway for EUS lies in the variability of the remit of our referrals, e.g., the skillset and knowledge base for assessing a subepithelial lesion of the stomach varies from that required to assess a pancreatic cyst. Indeed, there are some practitioners who may exclusively only perform oesophagogastric EUS reflective of their training and subspeciality interest. However, through this publication we advocate the need to standardise training and quality control future endosonographers to respond to the growing workforce requirement to be competent in all areas of upper GI EUS.
Supporting the new practitioner
EUS is niche sport in the world of gastroenterology and therefore the pool of colleagues one can call on for advice and support when setting out is much smaller. In line with the JAG ERCP pathway[4], we advocate establishing a formal mentorship with an established consultant colleague, particularly in centres where one might be a solo practitioner. To support this aim we are compiling a national list of mentors and assessors to assist in both accrediting trainees and supporting new consultants.
It is natural that many new endosonographers will want to immerse themselves in the rapidly developing and exciting world of therapeutic EUS. We assert that this requires specific training and a new, dedicated accreditation pathway. The core competencies required of a good therapeutic endosonographer develop from a thorough understanding of diagnostic EUS and we believe our article delivers a robust framework to deliver that.”
References
1 Siau K, Beales ILP, Haycock A, et al. JAG consensus statements for training and certification in esophagogastroduodenoscopy. Frontline Gastroenterol. 2022;13:193–205.
2 Siau K, Pelitari S, Green S, et al. JAG consensus statements for training and certification in colonoscopy. Frontline Gastroenterol. 2023;14:201–21.
3 Siau K, Pelitari S, Green S, et al. JAG consensus statements for training and certification in flexible sigmoidoscopy. Frontline Gastroenterol. 2023;14:181–200.
4 Siau K, Keane MG, Steed H, et al. UK Joint Advisory Group consensus statements for training and certification in endoscopic retrograde cholangiopancreatography. Endosc Int Open. 2022;10:E37–49.
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