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CC BY-NC-ND 4.0 · Endosc Int Open 2024; 12(05): E697-E703
DOI: 10.1055/a-2308-1613
Original article

More than 20 procedures are necessary to learn small bowel capsule endoscopy: Learning curve pilot study of 535 trainee cases

Anders Bo Nielsen 
1   Research Unit of Medical Education, Department of Clinical Research, University of Southern Denmark, Odense, Denmark (Ringgold ID: RIN6174)
2   Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark (Ringgold ID: RIN11286)
3   Research Unit of OPEN - Open Patient data Explorative Network, University of Southern Denmark Department of Clinical Research, Odense, Denmark (Ringgold ID: RIN528291)
4   Department of Anesthesiology and Intensive Care, Svendborg, Odense University Hospital, Odense, Denmark (Ringgold ID: RIN11286)
,
Michael Dam Jensen
5   Department of Regional Health Research, University of Southern Denmark, Odense, Denmark (Ringgold ID: RIN6174)
6   Internal Medicine, Section of Gastroenterology, Hospital South West Jutland, Esbjerg, Denmark (Ringgold ID: RIN532010)
,
Jacob Broder Brodersen
5   Department of Regional Health Research, University of Southern Denmark, Odense, Denmark (Ringgold ID: RIN6174)
6   Internal Medicine, Section of Gastroenterology, Hospital South West Jutland, Esbjerg, Denmark (Ringgold ID: RIN532010)
,
Jens Kjeldsen
2   Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark (Ringgold ID: RIN11286)
7   University of Southern Denmark Department of Clinical Research, Odense, Denmark (Ringgold ID: RIN528291)
,
Christian B. Laursen
8   Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark (Ringgold ID: RIN11286)
9   Odense Respiratory Research Unit (ODIN), University of Southern Denmark Department of Clinical Research, Odense, Denmark (Ringgold ID: RIN528291)
,
Lars Konge
10   Copenhagen Academy for Medical Education and Simulation, Capital Region of Denmark, Copenhagen, Denmark (Ringgold ID: RIN72735)
1   Research Unit of Medical Education, Department of Clinical Research, University of Southern Denmark, Odense, Denmark (Ringgold ID: RIN6174)
,
Stig Borbjerg Laursen 
2   Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark (Ringgold ID: RIN11286)
11   University of Southern Denmark Department of Clinical Research, Odense, Denmark (Ringgold ID: RIN528291)
› Author Affiliations Clinical Trial: Registration number (trial ID): NCT04186390, Trial registry: ClinicalTrials.gov (http://www.clinicaltrials.gov/), Type of Study: Prospective
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Abstract

Background and study aims The number of procedures needed to acquire a sufficient level of skills to perform an unassisted evaluation of small bowel capsule endoscopy (SBCE) is unknown. We aimed to establish learning curves, diagnostic accuracy, and the number of procedures needed for reviewing small bowel capsule endoscopies unassisted.

Methods An expert panel developed a 1-day course including lessons (examination, anatomy, and pathology) and hands-on training. After completing the course, participants received 50 cases in a randomized sequence. An interactive questionnaire about landmarks, findings, and diagnosis followed each case. After submitting the questionnaire, participants received feedback. Data are presented using CUSUM (cumulative sum control chart) learning curves and sensitivity/specificity analyses compared with expert opinions.

Results We included 22 gastroenterologists from 11 different Danish hospitals. A total of 535 cases were reviewed (mean: 28; range: 11–50). CUSUM plots demonstrated learning progression for diagnosis and findings during the course, but none of the participants reached a learning plateau with sufficient competencies. The sensitivity for all findings was 65% (95% confidence interval [CI] 0.51–0.82) for the first 20 procedures and 67% (95% CI 0.58–0.73) from case 21 until completion or dropout. The specificity was 63% (95% CI 0.52–0.74) for the first 20 procedures and 57% (95% CI 0.37–0.77) for the rest.

Conclusions Our data indicate that learning SBCE may be more difficult than previously recognized due to low discriminative abilities after 20 cases except for the identification of CD. This indicates that 20 SBCE cases may not be sufficient to achieve competency for reviewing SBCE without supervision.

Keywords

Endoscopy Small Bowel - Capsule endoscopy - Quality and logistical aspects - Training - Quality management


Publication History

Received: 27 October 2023

Accepted after revision: 13 March 2024

Article published online:
29 May 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

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  • References

  • 1 Eliakim R, Fireman Z, Gralnek IM. et al. Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study. Endoscopy 2006; 38: 963-970
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Eliakim R, Yassin K, Niv Y. et al. Prospective multicenter performance evaluation of the second-generation colon capsule compared with colonoscopy. Endoscopy 2009; 41: 1026-1031
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Kakugawa Y, Saito Y, Saito S. et al. New reduced volume preparation regimen in colon capsule endoscopy. World J Gastroenterol 2012; 18: 2092-2098
    CrossrefPubMedSearch in Google Scholar
  • 4 Gerson LB, Fidler JL, Cave DR. et al. ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding. Am J Gastroenterol 2015; 110: 1265-1287
    CrossrefPubMedSearch in Google Scholar
  • 5 Goddard AF, James MW, McIntyre AS. et al. Guidelines for the management of iron deficiency anaemia. Gut 2011; 60: 1309-1316
    CrossrefPubMedSearch in Google Scholar
  • 6 Raju GS, Gerson L, Das A. et al. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology 2007; 133: 1697-1717
    CrossrefPubMedSearch in Google Scholar
  • 7 Lai LH, Wong GL, Chow DK. et al. Inter-observer variations on interpretation of capsule endoscopies. Eur J Gastroenterol Hepatol 2006; 18: 283-286
    CrossrefPubMedSearch in Google Scholar
  • 8 Lim YJ, Joo YS, Jung DY. et al. Learning curve of capsule endoscopy. Clin Endosc 2013; 46: 633-636
    CrossrefPubMedSearch in Google Scholar
  • 9 Koffas A, Laskaratos FM, Epstein O. Training in video capsule endoscopy: Current status and unmet needs. World J Gastrointest Endosc 2019; 11: 395-402
    CrossrefPubMedSearch in Google Scholar
  • 10 Tai FWD, Parker C, Sidhu R. et al. Training pathway for small bowel capsule endoscopy in the UK. Frontline Gastroenterol 2021; 13: 206-210
    CrossrefPubMedSearch in Google Scholar
  • 11 Rajan EA, Pais SA, Degregorio BT. et al. Small-bowel endoscopy core curriculum. Gastrointest Endosc 2013; 77: 1-6
    CrossrefPubMedSearch in Google Scholar
  • 12 Sidhu R, Chetcuti Zammit S, Baltes P. et al. Curriculum for small-bowel capsule endoscopy and device-assisted enteroscopy training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2020; 52: 669-686
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Postgate A, Haycock A, Fitzpatrick A. et al. How should we train capsule endoscopy? A pilot study of performance changes during a structured capsule endoscopy training program. Dig Dis Sci 2009; 54: 1672-1679
    CrossrefPubMedSearch in Google Scholar
  • 14 Sidhu R, Sakellariou P, McAlindon ME. et al. Is formal training necessary for capsule endoscopy? The largest gastroenterology trainee study with controls. Dig Liver Dis 2008; 40: 298-302
    CrossrefPubMedSearch in Google Scholar
  • 15 Ogrinc G, Armstrong GE, Dolansky MA. et al. SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education): Publication Guidelines for Educational Improvement. Acad Med 2019; 94: 1461-1470
    CrossrefPubMedSearch in Google Scholar
  • 16 Kharazmi AA, Aslani S, Kristiansen MF. et al. Indications and diagnostic yield of small-bowel capsule endoscopy in a real-world setting. BMC Gastroenterol 2020; 20: 177
    CrossrefPubMedSearch in Google Scholar
  • 17 Harris PA, Taylor R, Thielke R. et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377-381
    CrossrefPubMedSearch in Google Scholar
  • 18 Harris PA, Taylor R, Minor BL. et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform 2019; 95: 103208
    CrossrefPubMedSearch in Google Scholar
  • 19 Bolsin S, Colson M. The use of the Cusum technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 2000; 12: 433-438
    CrossrefPubMedSearch in Google Scholar
  • 20 Yap CH, Colson ME, Watters DA. Cumulative sum techniques for surgeons: a brief review. ANZ J Surg 2007; 77: 583-586
    CrossrefPubMedSearch in Google Scholar
  • 21 Albert JG, Humbla O, McAlindon ME. et al. A simple evaluation tool (ET-CET) indicates increase of diagnostic skills from small bowel capsule endoscopy training courses: A prospective observational european multicenter study. Medicine 2015; 94: e1941
    CrossrefPubMedSearch in Google Scholar
  • 22 Rondonotti E, Soncini M, Girelli CM. et al. Can we improve the detection rate and interobserver agreement in capsule endoscopy?. Dig Liver Dis 2012; 44: 1006-1011
    CrossrefPubMedSearch in Google Scholar
  • 23 Girelli CM, Porta P, Malacrida V. et al. Clinical outcome of patients examined by capsule endoscopy for suspected small bowel Crohn's disease. Dig Liver Dis 2007; 39: 148-154
    CrossrefPubMedSearch in Google Scholar
  • 24 Spada C, McNamara D, Despott EJ. et al. Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. United European Gastroenterol J 2019; 7: 614-641
    CrossrefPubMedSearch in Google Scholar
  • 25 Mascarenhas M, Mendes F, Ribeiro T. et al. Deep learning and minimally invasive endoscopy: automatic classification of pleomorphic gastric lesions in capsule endoscopy. Clin Transl Gastroenterol 2023; 14: e00609
    CrossrefPubMedSearch in Google Scholar
  • 26 Downing SM YR, Haladyne TM, Axelson RD. et al. Assessment in Health Professions Education. 2009
    PubMedSearch in Google Scholar
  • 27 Kilminster S, Cottrell D, Grant J. et al. AMEE Guide No. 27: Effective educational and clinical supervision. Med Teach 2007; 29: 2-19
    CrossrefPubMedSearch in Google Scholar