Background and Aims
Previous studies have described variable effects of fellow involvement on the adenoma
detection rate (ADR), but few have stratified this effect by level of training. We
aimed to evaluate the “fellow effect” on multiple procedural metrics including a newly
defined adenoma management efficiency index, which may have a role in documenting
colonoscopy proficiency for trainees. We also describe the impact of level of training
on moderate sedation use.
Methods
We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94%
men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our
Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first
2 groups were first-year fellows in the first 6 months and last 6 months of the training
year. Second- and third-year fellows and attending-only procedures accounted for 1
group each. We collected data on doses of sedatives used, frequency of adjunctive
agent use, procedural times, and location, size, and histology of polyps. We defined
the adenoma management efficiency index as average time required per adenoma resected
during withdrawal.
Results
Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the
attending alone. There was no difference in ADR between fellows according to level
of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further
for attending-only procedures. This translated into improvement in the adenoma management
efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3
minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used
among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement
was associated with higher doses of fentanyl and midazolam and more frequent use of
diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively).
Conclusions
ADR was similar at different stages of fellowship training and comparable with the
attending group. Efficiency of detecting and resecting polyps improved throughout
training without reaching the attending level. Fellow involvement led to a greater
use of moderate sedation, which may relate to a longer procedure duration and an evolving
experience in endoscopic technique.
Abbreviations:
ADR (adenoma detection rate), CRC (colorectal cancer), IQR (interquartile range)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: April 18, 2018
Accepted:
April 10,
2018
Received:
October 1,
2017
Footnotes
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
If you would like to chat with an author of this article, you may contact Dr Bitar at [email protected]
Identification
Copyright
© 2018 by the American Society for Gastrointestinal Endoscopy
ScienceDirect
Access this article on ScienceDirectLinked Article
- Oldie but goodie? Do attending endoscopists really need their fellows?Gastrointestinal EndoscopyVol. 89Issue 2
- PreviewIn their retrospective study of more than 2000 colonoscopies, Bitar et al1 showed that adenoma detection rate (ADR) was not increased by the participation of fellows during colonoscopy. This finding prompted us to review our past 2 consecutive years of colonoscopy data of 2241 screening, surveillance, and diagnostic examinations (1580; 70.5% fellow-involved), inflammatory bowel disease evaluation and obstruction cases excluded. ADR, mean adenoma per colonoscopy, and examination completion rate were not different between the fellow-involved and the attending endoscopist-only groups (27.8% vs 26.1%, 0.45 ± 0.93 vs 0.44 ± 0.98 and 95.3% vs 94.6% [P = .51], respectively).
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- Impact of fellowship training level on colonoscopy quality and efficiency metrics: a United Kingdom perspectiveGastrointestinal EndoscopyVol. 89Issue 2
- PreviewPerformance metrics during colonoscopy training can be used to indicate readiness for independent practice. The study by Bitar et al1 is therefore a welcome addition to the colonoscopy training literature. The distinguishing feature of fellow seniority (and presumably competence) was the “efficiency” or speed with which the colon was intubated and adenomas detected and removed. However, speed does not necessarily imply proficiency.
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