Impact of observational training on endoscopic mucosal resection outcomes and competency for large colorectal polyps: single endoscopist experience

Abstract

Background and study aims Endoscopic mucosal resection (EMR) is standard treatment for large colorectal polyps. However, it is a specialized technique with limited data on the effectiveness of training methods to acquire this skill. The aim of this study was to evaluate the impact of observational training on EMR outcomes and competency in an early-stage endoscopist. Patients and methods A single endoscopist completed comprehensive EMR training, which included knowledge acquisition and direct observation of EMR cases, and proctored supervision, during the third year of gastroenterology fellowship. After training, EMR was independently attempted on 142 consecutive, large (i. e., ≥ 20 mm), non-pedunculated colorectal polyps between July 2014 and December 2017 (mean age 61.7 years; mean polyp size 30.4 mm; en-bloc resection 55 %). Surveillance colonoscopy for evaluation of residual neoplasia was available for 86 % of the cases. Three primary outcomes were evaluated: endoscopic assessment of complete resection, rate of adverse events (AEs), and rate of residual neoplasia on surveillance colonoscopy. Results Complete endoscopic resection was achieved in 93 % of cases, the rates of AEs and residual neoplasia were 7.8 % and 7.3 %, respectively. The rate of complete resection remained stable (at 85 % or greater) with increasing experience while rates of AEs and residual neoplasia peaked and decreased after 60 cases. Conclusions An early-stage endoscopist can acquire the skills to perform effective EMR after completing observational training. At least 60 independent EMRs for large colorectal polyps were required to achieve a plateau for clinically meaningful outcomes.

Endoscopic Mucosal Resection of Non-pedunculated Colorectal Polyps ≥20mm: Outcome in a Self-taught Skills Environment

“…Interestingly, the results for the first 50 polyps did not differ from results for the following polyps, and even for the first 20 polyps outcome parameters were acceptable (one deep mural injury, 13% recurrence rate, one patient referred to surgery for non-resectable adenoma). In previous studies it was expected that between 60 and 100 EMRs were needed to achieve a plateau for relevant outcomes [6,7]. However, our data indicate that acceptable results can be achieved earlier, and learning curves, even for relatively complex procedures, may vary interindividual.…”

“…There is only one other report presenting outcomes in a newly established EMR service [5]. Specific training programs to gain experience in EMR of complex polyps will be easy to implement in specialized centres with a high caseload and the opportunity to attend a relevant number of procedures [7].…”

“…Since most data on EMR outcome come from specialized referral centres, little is known about the outcome of EMR for large polyps at institutions establishing this competency. In fact, data on the EMR learning curve are scarce [5][6][7][8]. Thus, we report on the first 100 consecutive large non-pedunculated polyps resected by a single endoscopist with self-taught acquisition of skills.…”

Validated training tools are needed for assessing competency in colorectal endoscopic mucosal resection

“…Putting aside the limitations mentioned in the study, including small sample size (only 6 AEFs) and the relatively low and highly variable number of C-EMRs performed (2 trainees with <20 C-EMRs in the study period), 1 methodologic concern is that the outcome measureddEMR-STATd is an unvalidated tool with no data to support an association with previously reported, [2][3][4][5][6][7][8][9][10] clinically meaningful outcomes such as rates of complete resection and rate of residual neoplasia on surveillance colonoscopy. Thus, although the parameters included in the EMR-STAT are important general principles of polypectomy and presumably of C-EMR, we are unaware of any data to support that "competence," as measured by the tool, leads to successful complete resections, thereby preventing colorectal cancer development and the need for surgery while minimizing morbidity to the patient.…”