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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References
- Cancer statistics, 2016.CA Cancer J Clin. 2016; 66: 7-30
- American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected].Am J Gastroenterol. 2009; 104: 739-750
- Colonoscopy reduces colorectal cancer incidence and mortality in patients with non-malignant findings: a meta-analysis.Am J Gastroenterol. 2016; 111: 355-365
- Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study.Gastrointest Endosc. 2012; 76: 110-117
- Prevention of colorectal cancer by flexible endoscopy and polypectomy: a case-control study of 32,702 veterans.Ann Intern Med. 1995; 123: 904-910
- Quality indicators for colonoscopy and the risk of interval cancer.N Engl J Med. 2010; 362: 1795-1803
- Adenoma detection rate and risk of colorectal cancer and death.N Engl J Med. 2014; 370: 1298-1306
- Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.N Engl J Med. 2006; 355: 2533-2541
- Wide variation in adenoma detection rates at screening flexible sigmoidoscopy.Gastroenterology. 2004; 126: 1247-1256
- The time and financial impact of training fellows in endoscopy. CORI Research Project. Clinical Outcomes Research Initiative.Am J Gastroenterol. 2000; 95: 3129-3132
- Colonoscopy training in gastroenterology fellowships: determining competence.Gastrointest Endosc. 2010; 71: 319-324
- Fellow involvement may increase adenoma detection rates during colonoscopy.Am J Gastroenterol. 2008; 103: 2841-2846
- Level of fellowship training increases adenoma detection rates.Clin Gastroenterol Hepatol. 2010; 8: 439-442
- Does trainee participation during colonoscopy affect adenoma detection rates?.Dis Colon Rectum. 2009; 52: 1337-1344
- Trainee participation is associated with increased small adenoma detection.Gastrointest Endosc. 2011; 73: 1223-1231
- A longitudinal study of adenoma detection rate in gastroenterology fellowship training.Dig Dis Sci. 2016; 61: 2831-2837
- Colonoscopy core curriculum.Gastrointest Endosc. 2012; 76: 482-490
- Sedation in gastrointestinal endoscopy: current issues.World J Gastroenterol. 2013; 19: 463-481
- Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study.Gastrointest Endosc. 2006; 63: 87-94
- Glucagon facilitates colonoscopy and reduces patient discomfort: a randomized double-blind controlled trial with salivary amylase stress analysis.Eur J Gastroenterol Hepatol. 2013; 25: 575-579
- Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy.Am J Gastroenterol. 2007; 102: 856-861
- Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme.Gut. 2015;
- Latest generation, wide-angle, high-definition colonoscopes increase adenoma detection rate.Clin Gastroenterol Hepatol. 2012; 10: 155-159
- New-generation high-definition colonoscopes increase adenoma detection when screening a moderate-risk population for colorectal cancer.Clin Colorectal Cancer. 2016; 16: 44-50
- Gastrointestinal endoscopy nurse experience and polyp detection during screening colonoscopy.Clin Gastroenterol Hepatol. 2008; 6: 1342-1347
- A tandem colonoscopy study of adenoma miss rates during endoscopic training: a venture into uncharted territory.Gastrointest Endosc. 2012; 75: 561-567
ACGME program requirements for graduate medical education in gastroenterology. 2017. Available at: http://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/2/Internal%20Medicine. Accessed November 19, 2017.
- Serrated lesions of the colorectum: review and recommendations from an expert panel.Am J Gastroenterol. 2012; 107 (quiz 4, 30): 1315-1329
- Sessile serrated polyp prevalence determined by a colonoscopist with a high lesion detection rate and an experienced pathologist.Gastrointest Endosc. 2015; 81: 517-524
- Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy.Clin Gastroenterol Hepatol. 2011; 9: 42-46
- Miss rate of right-sided colon examination during colonoscopy defined by retroflexion: an observational study.Gastrointest Endosc. 2011; 74: 246-252
- Impact of retroflexion vs. second forward view examination of the right colon on adenoma detection: a comparison study.Am J Gastroenterol. 2015; 110: 415-422
- Right-sided adenoma detection with retroflexion versus forward-view colonoscopy.Gastrointest Endosc. 2015; 81: 608-613
- Endoscopic sedation in the United States: results from a nationwide survey.Am J Gastroenterol. 2006; 101: 967-974
- Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015.Gastrointest Endosc. 2010; 72: 580-586
Vargo JJ, DeLegge MH, Feld AD, et al; American Association for Study of Liver Disease, American College of Gastroenterology, American Gastroenterological Association I, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc 2012;76:e1-25.
- Virtual reality simulators for gastrointestinal endoscopy training.World J Gastrointest Endosc. 2014; 6: 6-12
- Human patient simulation and its role in endoscopic sedation training.Gastrointest Endosc Clin North Am. 2008; 18: 801-813
- Achieving competence in colonoscopy: milestones and the need for a new endoscopic curriculum in gastroenterology training.World J Gastrointest Endosc. 2015; 7: 1279-1286
- Quality indicators for colonoscopy.Am J Gastroenterol. 2006; 101: 873-885
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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