Melina C. Vassiliou, MD, M.Ed, FRCSC

1. How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy? Melina C. Vassiliou, MD, M.Ed, FRCSC Benjamin K Poulose MD, Pepa A Kaneva MSc, Brian J Dunkin MD, Jeffrey M Marks MD, Riadh Sadik MD, Gideon Sroka MD, Stephen D Pooler MD, Klaus Thaler MD, Gina L Adrales MD, Jeffrey W Hazey MD, Jenifer R Lightdale MD, Vic Velanovich MD ,Lee L. Swanstrom MD, John D Mellinger MD, Gerald M Fried MD

2. Flexible endoscopy is a necessary part of the general surgery curriculum • Flexible endoscopy: important skill for GI & community surgeons • Retrospective review of 5 surgeons: 54% of procedures were flex endo • Survey of PD in 2000: 60% of programs have formal endoscopy rotations, only 33.3% by fellowship trained instructors • Increased requirements for surgical trainees (35 EGDs and 50 colos) 1- Nimeri AA, Hussein SA, Panzeter E, et al. The economic impact of incorporating flexible endoscopy into a community general surgery practice. Surg Endosc 2005; 19(5):702-4. 2- Marks JM, Nussbaum MS, Pritts TA, et al. Evaluation of endoscopic and laparoscopic training practices in surgical residency programs. Surg Endosc 2001; 15(9):1011-5

3. How many cases are needed to achieve proficiency? • Case #’s as a surrogate for proficiency • ASGE - 130 EGDs & 140 colos (90% esophageal & pyloric/splenic flex &cecum) • Surgical study: no correlation between #’s and completion/complications • Another study – only 50 colonoscopies needed for 90% completion rate Cass OW, Freeman ML, Cohen J, et al. Acquisition of competency in endoscopic skills (ACES) during training: a multicenter study [abstract]. Gastrointest Endosc 1995;41:317 Reed WP, Kilkenny JW, Dias CE, Wexner SD. A prospective analysis of 3525 esophagogastroduodenoscopies performed by surgeons. Surg Endosc 2004;18:11-21. Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc 2001;15:251-61.

4. GAGESGlobal Assessment of Gastrointestinal Endoscopic Skills • Created by expert endoscopists • Multicenter study demonstrated interrater reliability, internal consistency and construct validity

5. GAGES- Upper endoscopy consists of 5 items scored on a Likert scale 1- Intubation of the esophagus 2- Scope Navigation 3- Ability to keep a clear endoscopic field 4-Instrumentation 5- Quality of the Examination Interrater Reliability: 0.96 (0.90-0.99) Internal Consistency: 0.89 (n=82)

6. GAGES- Colonoscopy consists of 5 items scored on Likert scale 1- Scope Navigation 2- Use of Strategies 3- Ability to keep a clear endoscopic field 4-Instrumentation 5- Quality of the Examination Interrater Reliability: 0.97 (0.92-0.99) Internal Consistency: 0.95 (n=57)

7. The purpose of this study was to: • Challenge the current case number recommendations and methods by which proficiency in flexible endoscopy is determined • Use GAGES to help define proficiency in flexible endoscopy

8. Methods • IRB approved 11 institutions in Europe and NA • Demographic information • Participants from surgery and gastroenterology • Scored by attending during routine upper endoscopy and/or colonoscopy

9. Data Analysis • For Upper endoscopy: 3 groups compared using ANOVA (Tukey post-hoc analysis) <35, >35<130, >130 • GAGES –C scores compared for different case cut-offs (T-test): >50 versus >140 • Scores plotted against case numbers to identify plateau

10. Results: The participants 139 evaluations, 11 centers

11. GAGES upper endoscopy 1 2 3 There is no difference between groups 2 and 3 Both groups 2 and 3 are significantly different compared to group 1

12. Both groupings show statistically significant differences between novice and experienced colonoscopists

13. Scores plateau at ~ 50 cases for upper endoscopy Total GAGES-Upper Score Upper Endoscopy Case numbers

14. Scores seem to plateau at ~ 100 cases for colonoscopy Total GAGES Colonoscopy Score Colonoscopy Case numbers

15. Summary- Upper endoscopy • For upper endoscopy, participants with 35-130 previous cases perform similarly to those with >130 cases • Both of these groups perform better than those with less than 35 cases • Performance as measured by GAGES seems to plateau at the 50 case level for upper endoscopy

16. Summary- Colonoscopy • There was no difference in performance when the cut-off was set a 50 cases or at 140 cases • We do not have enough data for the “intermediate” group • Performance measured by GAGES plateaus at ~ 100 cases

17. Discussion & Limitations • Still not enough data in the intermediate group • We have not yet determined what the “passing score” for GAGES should be • ROC – sensitivity and specificity • Ceiling effect

18. In Conclusion • Current case recommendations may not represent what is needed for proficiency • GAGES scores may help to define proficiency in basic flexible endoscopy • Clinical numbers needed to achieve proficiency may vary from one learner to another • GAGES may be a valuable tool to measure outcomes of training strategies and to provide feedback to learners

19. Acknowledgements: Members of the FES committee Lisa Jukelevics, Carla Bryant & Sarah Colon Participants and contributors from all of the institutions