Reply to Lee et al.

Dear Sir,
We are grateful to Lee et al. for their comments on our article [1] and for highlighting the importance of endoscopists' experience and competence in order to achieve a higher success rate with a low rate of complications. Whatever procedure is discussed in modern medicine, and specifically in surgery, it has been obvious that the results differ depending upon the individual surgeon. Therefore population-based data are of utmost importance and will confirm whether or not new technology will be implemented in a proper way. Previous studies have emanated from specialized referral centers and it has not been well understood until now to what extent the success rates and rate of complications reported were valid in other clinical settings. The only way to explore this very important issue is of course the exploration and validation of the different end points. Without defining the end points and analysing the results of an endoscopic or surgical procedure, preferably in a population-based setting, it is not possible to detect whether a procedure is being adequately performed. A comparison can be made with rectal cancer surgery. It has been claimed the surgical technique is difficult, demanding, and has to be performed in a specific way, but without monitoring of the results, the outcome of rectal cancer surgery can never be evaluated. End points such as postoperative mortality and morbidity, as well as cancer-related end points such as local recurrence and cancer-specific survival, are knowledge which is essential for evaluation of the final outcome [2] [3]. When proper monitoring is undertaken, the surgical community becomes aware of the results and can act to improve upon them.

We agree with the conclusion of Lee et al. that it is crucial that specialist endoscopists should perform colonoscopy as well as ERCP. Different learning curves for individual endoscopists have been reported [4] [5] [6]. Important tasks are to evaluate whether or not each endoscopist is suitable for carrying out colonoscopy, and how learning takes place. Again, meticulous monitoring is important for finding out as soon as possible whether a ”new” colonoscopist has the required aptitude for not only performing easy procedures, but also for learning new, more demanding techniques. The finding in our study of a large interendoscopist variation, and also among experienced practitioners, in the ability to perform a complete colonoscopy supports the monitoring of endoscopists to maintain and improve performance [7]. The main question, of course, is whether it is possible to educate everyone to become a “good” endoscopist if endoscopic skill is more a matter of talent than training. Unfortunately this issue cannot be addressed without prospective studies carried out to answer this specific question.

References

• 1 Dafnis G, Granath F, Påhlman L. et al . The impact of endoscopists' experience and learning curves and interendoscopist variation on colonoscopy completion rates.  Endoscopy. 2001;  33 511-517
• 2 Martling A L, Holm T, Rutqvist L E. et al . Effect of a surgical training programme on outcome of rectal cancer in the county of Stockholm. Stockholm Colorectal Cancer Study Group, Basingstoke Bowel Cancer Research Project.  Lancet. 2000;  356 93-96
• 3 Dahlberg M, Påhlman L, Bergström R. et al . Improved survival in patients with rectal cancer: a population-based register study.  Br J Surg. 1998;  85 515-520
• 4 Parry B R, Williams S M. Competency and the colonoscopist: a learning curve.  Aust N Z J Surg. 1991;  61 419-422
• 5 Marshall J B. Technical proficiency of trainees performing colonoscopy: a learning curve.  Gastrointest Endosc. 1995;  42 287-291
• 6 Tassios P S, Ladas S D, Grammenos I. et al . Acquisition of competence in colonoscopy: the learning curve of trainees.  Endoscopy. 1999;  31 702-706
• 7 Cass O W. Training to competence in gastrointestinal endoscopy: a plea for continuous measuring of objective end points.  Endoscopy. 1999;  31 751-754