Study on impact of flexible endoscopy training course for surgeons in India

Abstract

Context:

Competence in flexible endoscopy is essential for all surgeons during this era of minimal access surgery. However, fewer surgeons have expertise in endoscopy due to a lack of training and interest. The Indian Association of Gastrointestinal Endo Surgeons devised a short-structured training course in the art and science of endoscopy.

Aims:

This study aimed to find the impact of the endoscopy training course (Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons [EFIAGES]) in improving the endoscopic skill of surgeons.

Settings and Design:

Twenty-two-part electronic survey forms were sent to all 375 candidates who took the course between 2016 and 2019 for this retrospective observational study.

Subjects and Methods:

The following outcome measures were noted, namely technical competence in endoscopy before the course, delegate feedback about the course modules, volume of endoscopies before and after the course and quality indicators such as reaching up to duodenum (D2) and caecum before and after the course.

Statistical Analysis Used:

Statistical analysis of the impact of the course was done using Chi-square test.

Results:

Responses from 262 out of a total of 375 candidates were received. Seventy-seven per cent of trainees were pleased with content and mode of conduct of the course. The quality indicator of gastroscopy with the ability to reach D2 in 90% of the caseload was achieved by only 28% of trainees before the EFIAGES. This increased to 72% of candidates after the course and similar results were seen with colonoscopy also. Most of the candidates noted a distinct improvement in their endoscopic navigation skills subsequent to the course.

Conclusions:

Endoscopy skill transfer was possible with a short-structured endoscopy course. The surgical fraternity should realise the importance of endoscopy skills in the current era of surgical practice.

INTRODUCTION

Flexible endoscopic skills are essential for all general surgeons in this era of minimal access surgery. Ironically, many surgeons are not competent to perform even basic diagnostic endoscopic procedures due to a lack of structured endoscopic training programme. Although surgeons are exposed to endoscopic procedures during their post-graduate training, often it is poorly structured and hence inefficient in skill transfer. It is also noted that most of the medical universities in India do not have any organised teaching programme for endoscopy training of young surgeons. The Joint Advisory Group (JAG) in gastrointestinal (GI) endoscopy highlighted the inadequacy of endoscopy training for higher surgical trainees (HSTs) in the United Kingdom.[1-3] Similarly, the Society of American Gastrointestinal Endo Surgeons (SAGES) also realised the importance of endoscopy training for surgeons and hence initiated the Flexible Endoscopic Surgery programme (FES) for surgical residents.[4-6] The American Board of Surgery (ABS) now warrants every surgeon to complete FES programme before becoming board certified. The Endoscopy Board of the Indian Association of Gastrointestinal Endo Surgeons (IAGES) came out with a 3-day structured endoscopic training programme, Endoscopic Fellowship of IAGES (EFIAGES). It is a basic flexible endoscopic training programme, in which training is given in diagnostic upper GI endoscopies and colonoscopies and also basic therapeutic procedures such as Foreign Body (FB) removal and banding.

The aim of the study was to study the impact of endoscopic courses on the competence, quality and extent of endoscopy practice by the surgeons who have undergone this short onsite fellowship course (EFIAGES) organised by IAGES in various training centres in India. It will also help the IAGES Endoscopy Board to modify the course content and its duration accordingly to improve the quality of training. Incidentally, this was the first such study on the impact of short-structured flexible endoscopy training courses for surgeons in India.

SUBJECTS AND METHODS

An electronic survey was conducted using Google Forms with 22-part questions prepared by the IAGES Endoscopy Board [Table 1] to assess the feedback about the basic endoscopy training course (EFIAGES) and its impact on the quality and extent of endoscopy practice by the surgeons who have taken the onsite endoscopy fellowship courses (EFIAGES) conducted by a panel of endoscopy training faculty at various study centres in India since 2016.

Table 1.

Google form candidate questionnaire template

No	Questions Asked
1	How long since the course completion
	A. 1 year
	B. 2 years
	C. >3 years
2	Current surgical practice
	A. Own hospital
	B. Working with senior consultant
	C. Territory care multispecialty hospital
	D. Teaching institutions
3	Endoscopic Exposure before EFIAGES course
	A. None
	B. Very minimal
	C. Satisfactory
	D. Good
4	Attended any other endoscopic course
	A. Yes
	B. No
5	Opinion about gastroscopy modules
	A. Unsatisfactory
	B. Satisfactory
	C. Good
	D. Very good
6	Opinion about colonoscopy modules
	A. Unsatisfactory
	B. Satisfactory
	C. Good
	D. Very good
7	Opinion about overall modules
	A. Unsatisfactory
	B. Satisfactory
	C. Good
	D. Very good
8	Recommend this course to colleagues
	A. Won’t recommend
	B. Recommend
	C. Strongly
	D. Recommend
9	Suggestions to improve the course
	A. Better lecture modules
	B. More hands-on simulator models
	C. More live sessions
	D. Others (mention)
10	Interest in further endoscopic training
	A. Yes
	B. No
11	Focus of training at present
	A. Upper GI endoscopy
	B. Colonoscopy
	C. ERCP
	D. EUS
12	Facilities in their institution
	A. Basic scopes
	B. HD/NBI scope
	C. ERCP
	D. EUS
13	Number of diagnostic gastroscopy per month
	A. Before EFIAGES
	B. After EFIAGES
14	Number of basic therapeutic gastroscopy per month
	A. Before EFIAGES
	B. After EFIAGES
15	Number of diagnostic colonoscopies per month
	A. Before EFIAGES
	B. After EFIAGES
16	Before EFIAGES: Reaching up to D2
	A. <50%
	B. 50%-75%
	C. 75%-90%
	D. >90%
17	After EFIAGES: Reaching up to D2
	A. <50%
	B. 50%-75%
	C. 75%-90%
	D. >90%
18	Before EFIAGES: Reaching up to caecum
	A. <50%
	B. 50%-75%
	C. 75%-90%
	D. >90%
19	After EFIAGES reaching up to caecum
	A. <50%
	B. 50%-75%
	C. 75%-90%
	D. >90%
20	Major complications during endoscopy
	A. Yes
	B. No
	C. If yes, mention
21	Awareness of FAGIE (advanced endoscopy course)
	A. Yes
	B. No
22.	Willingness to join for FAGIE course
	A. Yes
	B. No

GI: Gastrointestinal, IAGES: Indian Association of GI Endo Surgeons, EFIAGES: Endoscopic Fellowship of IAGES, ERCP: Endoscopic retrograde cholangiopancreatography, EUS: Endoscopic ultrasound, FAGIE: Fellowship in Advanced GI Endoscopy, HD: High Definition, NBI: Narrow Band Imaging

EFIAGES is a 3-day short-structured training course in the art and science of flexible endoscopy with the aim of imparting key cognitive and technical skills of endoscopy to all qualified general surgeons (Master of Surgery) who have assisted or done at least 25 upper GI endoscopies already. An expert panel of faculty with more than 10 years of experience in endoscopy trained the candidates with the help of lecture modules, simulation modules, and live demonstrations during the 3 days of training [Table 2]. Assessment of endoscopy skills was done by 50 questions multiple-choice question paper followed by viva and a practical session to assess the cognitive and technical skills of the candidates. They would be declared successful only after obtaining a minimum of 50% marks in the assessment. The trainees would be expected to maintain endoscopy procedure logbook, and they should show that they have already performed a minimum of 25 endoscopies independently or under supervision before their assessment for fellowship certification.

Table 2.

Syllabus of basic flexible endoscopy training course (Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons)

Duration: 3 days/8 h each day Faculty: Expert endoscopists across India (one trainer for every five candidates) Training places: IAGES-accredited centres across India
Lecture modules
Endoscopy hardware/room set-up
Endoscopy: When to do and when not to do/consent
Endoscopic atlas of upper GI pathology
Steps of upper GI endoscopy
Role of endoscopy in FB upper GI tract
Role of endoscopy in GERD
Role of endoscopy in achalasia
Role of endoscopy in upper GI bleeding
Role of endoscopy in upper GI malignancy
Colonoscopy hardware/room set-up
Colonoscopy: Indication/preparation/consent
Steps of colonoscopy
Colonoscopic atlas of lower GI tract
Scope of therapeutic colonoscopy
Panel discussion on complications of flexible endoscopy
ABC of ERCP
Role of endoscopy in bariatric surgery
Advances in GI endoscopy
Endoscopy rescue in surgical complications
Intraoperative flexible endoscopy
Hands-on training in simulation models
Inanimate stomach and colon plastic models
EASIE animal model for upper GI endoscopy
Simbionix (GI Mentor) for gastroscopy, colonoscopy and ERCP
Costamagna ERCP models
Live demonstration of cases
Diagnostic and basic therapeutic endoscopy cases: 30
Diagnostic and basic therapeutic colonoscopy cases: 5
ERCP/EUS case demonstration: 3
Assessment of trainees on day 3
50 MCQ written assessment for 1 h
Viva on cognitive and technical skills and assessment of navigation skills on simulation models by 2 expert faculty

GI: Gastrointestinal, IAGES: Indian Association of GI Endo Surgeons, ERCP: Endoscopic retrograde cholangiopancreatography, EUS: Endoscopic ultrasound, FB: Foreign Body, GERD: Gastro Esophageal Reflux Disease, MCQ: Multiple-Choice Questions, EASIE: Erlangen Active Simulator for Interventional Endoscopy

The survey was endorsed by the IAGES Endoscopy Board and the Google Forms was mailed to all those endoscopy course candidates who have successfully completed the 3-day on-site training course and assessment between May 2016 and December 2019. Surgeons who were unsuccessful or failed to satisfactorily complete the course or those who have not completed at least 1-year period after the course were excluded from the study.

Data analysis was done especially to look into the following points, namely:

• Technical competence in endoscopy before the course

• Feedback about the course modules

• Volume of endoscopies before and after the course

• Quality indicators such as reaching up to D2 and caecum before and after the course.

Chi-square test for independence of attributes was used for statistical analysis for both quality indicators, namely reaching up to duodenum and caecum.

RESULTS

All the endoscopy training course candidates (EFIAGES) who had been successful with their assessment till December 2019 were included in the study.

Of the 375 eligible candidates who received the Google form questionnaire through E-mail to respond within 4 weeks, we received the responses from 262 candidates with a response rate of 70%. Two hundred and forty-four candidates were male and 18 were female surgeons. The mean age of the surgeons was 38 (standard deviation: 7.02). Nearly 70% of the candidates were from southern India [Figure 1].

Figure 1.

IAGES zonal demography of EFIAGES course candidates. IAGES: Indian Association of Gastrointestinal Endo Surgeons, EFIAGES: Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons

One hundred and forty-four (54%) candidates were working as consultants in tertiary care hospital or government teaching institution, 106 (40%) candidates had their own private hospital and the rest were working as senior residents. Nearly two-third (65%) of the candidates admitted that they had minimal or no prior endoscopy experience [Figure 2]. With regard to lecture modules and simulation modules and live sessions, 77% of all candidates were pleased with the content and conduct of the training course as a whole. The quality indicator of gastroscopy with the ability to reach D2 in 90% of the caseload was achieved by only 28% of trainees before the EFIAGES. This increased to 72% of candidates after the course [Figure 3a and b]. Similarly, quality indicator for colonoscopy, namely reaching caecum in 90% of their cases, was noted to improve from 25% before the course to 75% of trainees after the course.

Figure 2.

Endoscopy experience of surgeons before EFIAGES course (numbers, percentage). EFIAGES: Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons

Figure 3.

(a) Quality indicator for gastroscopy: Reaching D2 before and after EFIAGES course, (b) Quality indicator for colonoscopy: Reaching caecum before and after EFIAGES course. EFIAGES: Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons

When we applied Chi-square test for both the quality indicators, it was observed that there was a significant improvement in the attainment of both quality indicators (reaching up to D2 during gastroscopy/reaching up to caecum during colonoscopy) after the training course of the candidates [Table 3a and b].

Table 3a.

Quality indicator of reaching duodenum (Chi-square test)

Category	A. <50%	B. 50%-75%	C. 75%-90%	D. >90%	Row total
Before EFIAGES
Reaching up to D2	94	75	31	57	257
Column total × Row total/Grand total	50	51	45	111
After EFIAGES
Reaching up to D2	5	26	59	165	255
Column total × Row total/Grand total	49	50	45	111
Column total	99	101	90	222	512
Before EFIAGES: (O−E)^2/E	39.50	11.65	4.45	26.59	82.19
After EFIAGES: (O−E)^2/E	39.81	11.74	4.48	26.80	82.84
Total					165.03

Calculated value of Chi-square q3=165.03. Table value of Chi-square at 0.05 significance level for 3 d.o.f=7.815. Calculated value is greater than the table value. Hence, we tend to reject the null hypothesis H0. GI: Gastrointestinal, IAGES: Indian Association of GI Endo Surgeons, EFIAGES: Endoscopic Fellowship of IAGES

Table 3b.

Quality indicator of reaching caecum (Chi-square test)

Category	A. <50%	B. 50%-75%	C. 75%-90%	D. >90%	Row total
Before EFIAGES
Reaching up to caecum	168	44	33	13	258
Column total × Row total/Grand total	105	62	51	41	258
After EFIAGES
Reaching up to caecum	43	80	69	70	262
Column total × Row total/Grand total	106	62	51	42	262
Column total	211	124	102	83	520
Before EFIAGES: (O−E)^2/E	38.29	4.99	6.13	19.28	68.69
After EFIAGES: (O−E)^2/E	37.70	4.91	6.03	18.99	67.64
Total					136.33

Calculated value of Chi-square q3=136.33. Table value of Chi-square at 0.05 significance level for 3 d.o.f=7.815. Calculated value is greater than the table value. Hence, we tend to reject the null hypothesis H0. GI: Gastrointestinal, IAGES: Indian Association of GI Endo Surgeons, EFIAGES: Endoscopic Fellowship of IAGES

One hundred and twelve of 262 candidates expressed their wish to see more live sessions and 65 candidates wanted more hands-on simulator sessions in the future courses. Subsequent to the course, most of the surgeons found more endoscopy caseload in their clinical practice and also noted a significant improvement in their navigation skills. Some of the surgeons were even able to perform basic endotherapeutic procedures such as banding of varices, removal of foreign bodies’ GI tract and injection of bleeding peptic ulcers.

DISCUSSION

Flexible endoscopic training is essential for general surgeons in this era of laparoscopy. With its immense diagnostic and therapeutic potentials, endoscopy has become an important tool for the practicing surgeons. Pre-operative endoscopy in cases of hiatus hernia before fundoplication in cases of achalasia cardia before Heller’s myotomy and diagnostic endoscopy in obese patients before bariatric surgery should all be preferably done by the operating surgeons. There is also now an increasing role for intraoperative endoscopy. On-table endoscopy during difficult laparoscopic Heller’s myotomy and colonoscopic localisation of tumour before laparoscopic colectomy are classic examples. One should not underestimate the potential of endoscopic rescue in the event of any post-operative surgical complication such as anastomotic leaks or bleeding at the anastomosis. Hence, one can clearly understand that endoscopy skills are really essential in the era of minimal access surgery.

JAG in the UK has highlighted the inadequacy of endoscopy training of the HSTs when compared to gastroenterologists in the UK. Furthermore, the American Board of Surgeons (ABS) also noted similar endoscopic training difficulties amidst surgical residents. Hence, ABS has made the residents to mandatorily take short flexible endoscopic surgery training course (FES) run by SAGES before board certification.[6,7]

The importance of endoscopy training is now clearly understood by the surgical fraternity. However, the real challenge has been the availability of proper training platforms or trainers to impart the cognitive and technical skills to the interested surgeons.[8-10] Apprenticeship model of 6 months to 2-year endoscopy fellowship training is neither practicable nor preferred by the already qualified surgeons. Performing close to 150 gastroscopy or colonoscopy procedures before certification as recommended by ASGE is difficult to achieve by practicing surgeons. Furthermore, competency in endoscopy cannot always be assured by just the number of cases performed by every surgeon. A number of endoscopic procedures are no longer considered a measure of competence in endoscopy. Due importance should be given for both the cognitive and technical skills. Surgeons should acquire cognitive skills such as when to perform endoscopy, when not to do endoscopy, how to get consent for endoscopy, how to monitor the patients during the procedure and how to recognise and manage any complication during endoscopy. With their good knowledge in anatomy and pathology and better hand–eye coordination, surgeons are better placed to learn the art of endoscopy with short learning curve. Some of the cognitive skills are already acquired from prior general surgical experience. The Residency Review Committee of the American Board of Surgeons (ABS) has also brought down the minimum required endoscopy procedures to 35 from 140 procedures and colonoscopy to 50 procedures for all surgical residents in the USA. However, completing a short flexible endoscopic surgery course by SAGES (FES) is essential before getting board certified. Hence, basic diagnostic endoscopy and colonoscopy skills could very well be taught by short well-structured training course.

The training course is expected to provide focused endoscopy training with hands-on simulation modules and live endoscopy modules to teach all key technical skills such as navigation, targeting and retroflexion. Hands-on simulators such as GI Mentor (Simbionix) and AccuTouch were found to have good validity.[11] Such simulation-based training could certainly complement the patient-based learning. They would be immensely useful in the early training period to shorten the learning curve. It was noted that hours of hands-on training in such simulators certainly improve the navigation skill of the trainees and could reduce the number of endoscopy procedures needed to reach the level of competence in endoscopy.

IAGES instituted the Endoscopy Board during the year 2016 to formulate the curriculum for endoscopy training of surgeons. It consists of 20 lecture modules, hands-on simulation modules and hands-on live endoscopic sessions.

We have used plastic simulators such as St Mark’s colonoscopy models and wet models such as EASIE animal models to facilitate endoscopy skill transfer during the EFIAGES course. Once trained in this programme, he/she can not only be fully aware of the basics of endoscopy and colonoscopy but also able to learn key technical skills under the supervision of experts in the field. This would be followed by 1-h multiple-choice question paper and viva assessment.

Till December 2019, nearly 375 of its members have successfully taken up the course. In spite of the short duration of the course, key cognitive and technical skill transfers were possible and the fellowship candidates were able to improve their endoscopy skills in the subsequent period of their clinical practice. Although two-third of the course candidates had very minimal endoscopic training before EFIAGES course, majority of them were able to place themselves in the trajectory of excellence in endoscopy. All lecture modules and simulation modules had clear learning objectives to ensure that the candidates received key practical tips and tricks in endoscopic navigation and diagnosis. Hands-on live endoscopy session showed many important technical skills needed for day-to-day endoscopy practice. Hence, we were able to note in our study that quality indicators such as reaching second part of the duodenum during endoscopy and caecum during colonoscopy were much better 1 year after undergoing the EFIAGES course.

It was gratifying to note that many surgeons in our study had access to or already owned high-definition endoscopy in their clinical setting. Several candidates were also keen to pursue advanced endoscopy training such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. Nearly 70% of the candidates expressed their interest to join the Fellowship in Advanced Gastrointestinal Endoscopy by IAGES in the coming years.

Endoscopy training can be categorised into three levels as per the guidelines from the Society of Gastrointestinal Endoscopy of India. Level 1 is suitable for general surgeons with training in diagnostic endoscopy, colonoscopy and basic therapeutic procedures. EFIAGES course is expected to provide level 1 training.

Although this type of short endoscopy training course cannot be an alternative to long duration (6 months or more) fellowship courses, certainly such short-structured courses are now preferred by the practicing general surgeons to fine-tune his/her skills in the art and science of endoscopy. By providing the trainees with necessary endoscopy-related textbooks or study materials, guidance to maintain endoscopy practice logbook and continued teaching through virtual platform and periodic weekend live workshops, we could, over the period of time, improve the quality of endoscopy training of surgeons. We should make the trainee surgeons to fully understand the fact that endoscopic training, such as learning of any new surgical skill, is not one-stop training but a life-long journey.

CONCLUSIONS

Our study has clearly shown the need for endoscopy training of surgeons. It was gratifying to find that the endoscopy skill transfer was possible with such short-structured endoscopy courses and most of the candidates were able to perform endoscopy independently subsequent to successfully completing the course. The surgical fraternity should realise the importance of endoscopy skills in the current era of surgical practice. We understand the limitations of our survey regarding the short endoscopy course and one cannot make any concrete recommendation with regard to the duration and method of the upcoming endoscopic training programme based merely on our observations. We are proposing a large multi-centre study comprising multiple-choice question assessment and hands-on simulation assessment before and after the course to more accurately assess the impact of such novel short-structured endoscopy courses. Hence, a prospective multi-centre study on the impact of such short endoscopy training course is recommended for further validation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.