Endoscopy training in upper GI bleeding for UK trainees in Khartoum, Sudan: South Yorkshire experience

The South Yorkshire Endoscopy Group was established in 2012 by a group of both Sudanese-trained and UK-based gastroenterologists. Our group has established links over 7 years with the Sudanese Society of Gastroenterology (SSG) and has provided training for consultant trainers, trainee endoscopists and endoscopy nurses, as well as supporting the annual SSG conference in Sudan.

Our host hospital, Ibn Sina (IS), is the national centre for upper gastrointestinal (GI) bleeding. IS also hosts the World Gastroenterology Organisation (WGO) Khartoum Training Center. This centre manages up to 60 cases of bleeding oesophageal varices/week.¹ This is accounted for by the endemic nature of schistosomiasis and a high prevalence of viral hepatitis.^{2 3}

In 2018, two UK gastroenterology registrars were invited to travel to Khartoum, after a competitive selection process, to gain experience in the endoscopic management of upper GI variceal bleeding plus understanding the challenges of working in a resource-limited environment. They performed gastroscopies from 8 to 11 January 2018 at IS under the direct supervision of experienced Sudanese endoscopists. The trainees were Joint Advisory Group accredited for diagnostic gastroscopy. The prior experience of each registrar was: 370 gastroscopies with four variceal band ligations (VBL) (16 months); and 242 gastroscopies, one VBL (24 months).

The two UK registrars performed 29 gastroscopies over 4 days. These were both acute (14) and elective therapeutic (15) cases with an age range of 17–85 (mean of 51). Sixteen patients were treated with VBL; five patients had sclerotherapy because of the shortage of VBL; one patient had histoacryl glue injection of gastric varices; one patient had an oesophageal balloon dilatation. Six patients did not require interventions. The use of sclerotherapy was one of the new skills acquired by trainees as it is now rarely used in the UK. Sclerotherapy may still have a place, particularly when VBL is not possible.⁴

WGO Khartoum Training Center is the only centre in Sudan which provides 24/7 upper GI endoscopy service for suspected upper GI bleeding. This is despite significant financial constraints and a lack of official support. The facilities and expertise available can deliver the whole range of endoscopic interventions. The centre has one emergency endoscopy room that is equipped with Fujifilm system. There are only two gastroscopes for use with band ligation and one paediatric gastroscope which is usually used for diagnostic purposes or injection therapy. The limited number of scopes presents one of the main challenges that restrict service provision and subsequent development.

We believe this is the first report of UK-based gastroenterology trainees receiving supervised, concentrated, hands-on training in therapeutic gastroscopies in a resource-challenged healthcare setting. In 4 days of hands-on endoscopy training, the two trainees gained experience that could require years to obtain inside the UK. This is mainly because of the number of cases encountered at IS compared with a typical UK hospital.⁵

The final and most important message of this experience is a simple one. More UK gastroenterologists and other healthcare professionals (as well as those from other well-resourced nations) are visiting less well-resourced countries to offer support with training and delivery of healthcare. While working there, they will often gain valuable life experiences and be exposed to whole new cultures. What we have shown is that, in an appropriate setting, UK-based healthcare workers can gain valuable clinical learning from these interactions. Medical education and training is truly a two-way street.