What Sort of Endoscopist for the Endoscopy of the Future?

Dear Sir,

Endoscopy, for both diagnostic and therapeutic purposes, is a progressively more complex and demanding procedure. The increasing competition offered by other modalities for diagnosis and treatment emphasizes the need to maintain optimal outcome levels and to compare the costs of endoscopic procedures and these approaches. Furthermore, endoscopic procedures are often required in selected and unusually difficult circumstances, such as ERCP in Billroth II patients. This represents a handicap to the maintenance of quality levels and to training [1] [2]. It is obviously extremely important that, to ensure an acceptable outcome, clinicians need to perform an adequate number of procedures [3].

Whereas in the past endoscopy consisted almost entirely of easy diagnostic or simple therapeutic procedures, thus permitting widespread practice because there were few demanding techniques, by contrast the endoscopy of the future will be characterized by increasingly difficult procedures. The dilemma, then, is whether the practice of endoscopy should be as widespread in the future as it has been in the past, or whether we need to reconsider how endoscopy is carried out, and also the characteristics of the endoscopist [4] [5].

Thus there are current issues about the future of endoscopy, concerning what type of endoscopist will be called upon to use these difficult and complex procedures, where they will be performed, and how we can prepare ourselves for the future. Few papers similar to that of Lee et al., which examined whether complicated endoscopies should be performed only by specialist endoscopists [6], have been published concerning these issues. I have read this paper with great attention and I wish to make some comments.

I agree with Lee et al. that patients who need complicated endoscopies should be referred to a tertiary center if a competent endoscopist is not available, in order to achieve a higher standard of care. The problem then is the definition of competency, and the relationship between endoscopic talent, training in endoscopy, and endoscopic workload. Lee et al. report the outcomes of 341 ERCPs performed over 20 months by two groups of endoscopists, a “nonspecialist” and a “specialist” group. Clearly the outcomes for the specialist group were better. It is known that workload is an important factor in determining the outcome of endoscopic procedures; thus if the minimum for one group is two endoscopists, the resulting workload of 4.2 ERCPs each per months is very low for maintaining or acquiring an acceptable endoscopic technique. In endoscopic centers with a low work flow, where several endoscopists work, complicated endoscopies should be performed only by endoscopists whose experience and, predictably, success rates are the greatest [7].

The second question is: Why are nonspecialist endoscopists performing specialized endoscopic techniques? The time of the “nonspecialist” endoscopist has passed. In the paper of Lee et al., a “specialist endoscopist” is defined as one who has already done more than 300 ERCPs in a gastrointestinal qualification training program. But this is the definition of only a first-level trainee in ERCP! During the 20 months of the study the specialist group performed 160 ERCP procedures; thus if they comprised two endoscopists, they had carried out four ERCPs per month each, with a mean of 2.6 therapeutic ERCPs per month each, a very low number for gaining or maintaining solid experience. The nonspecialist group showed a very high mortality rate (1.7 %) among their 181 ERCPs, with 50 failed procedures, but there was also a death among the 160 procedures of the specialist group.

Thus the main messages from the paper by Lee et al. are the questions: Who should perform endoscopic procedures, and how do we manage low work flow centers as endoscopy becomes much more demanding?

The simpler the procedure, the more important is training relative to endoscopic talent; the more demanding the procedure, the more relevant is the combination of endoscopic talent, training, and workload. The more demanding the procedure, the more difficult its implementation and delivery in current practice. Thus the more demanding endoscopy of the future must be delivered in a different way from in the past: practiced less widely, but with more specialist referral centers. The competency and workload of the small low-flow endoscopic unit thus needs to be reconsidered [8] [9].

References

• 1 Mosca S. Which scope and which technique will enhance the success rate in ERCP for the Billroth 11 patient?.  Am J Gastroenterol. 2000;  95 553-555
• 2 Mosca S. How can we reduce complicatioon rates and enhance the success rate in Billroth 11 patients during endoscopic retrograde cholangiography?.  Endoscopy. 2000;  32 589-590
• 3 Siegel J, Cohen S A, Kasmin F E. Experience and volume: The ingredients for successful therapeutic endoscopic outcomes: Especially ERCP and postgastrectomy patients.  Am J Gastroenterol. 2000;  95 2133-2134
• 4 Mosca S. Is ERCP a procedure for all, the majority or just a few endoscopists? A dilemma.  Gastrointest Endosc. 2001;  54 140-142
• 5 Baillie J. ERCP for all?.  Gastrointest Endosc. 1995;  42 373-376
• 6 Lee D WH, Poon C M, Chan K H, Chan A CW. Should specialist endoscopists perform all complicated endoscopies?.  Endoscopy. 2002;  34 174-175
• 7 Mosca S, Galasso G, Bottino V. et al .Endoscopic retrograde cholangiopancreatography in patients with previous Billroth II gastrectomy: Analysis of a single endoscopist series. submitted to: Am J Gastroenterol
• 8 Schlup M MT, Williams S M, Barbezat G O. ERCP: A review of technical competency and workload in a small unit.  Gastrointest Endosc. 1997;  46 48-49
• 9 Yarze J C, Herlihy K J, Chase M P, Fritz H P. ERCP experience in a community-based private practice setting.  Am J Gastroenterol. 2000;  95 3006-3007