INTRODUCTION

Since November 1995, the Korean Society of Gastrointestinal Endoscopy (KSGE) has launched a board of gastrointestinal (GI) endoscopy specialists, and many gastroenterologists have obtained the privilege of being GI endoscopists. The KSGE has established the goals and guidelines for educating trainees in 2011, and an updated version for both endoscopic faculties and trainees is now required to meet the need to catch up to the recent rapid changes in clinical practice [1]. GI endoscopy is the most valuable and final diagnostic tool used in gastroenterology. Education of endoscopic skills is an essential portion of the GI fellowship training program. The GI endoscopic field is now sub-classified as a part of the diagnostic and therapeutic procedures for the GI tract, including esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS). Small bowel endoscopies, including balloon-assisted and capsule endoscopies, are now standard procedures for small bowel diseases; however, these procedures require specialized techniques and skills [2,3]. Furthermore, small bowel endoscopy is generally performed on rare occasions only in the limited referral centers in Korea. For these reasons, small bowel endoscopy is not included as a learning item in this guideline; however, further discussion is needed in the near feature. Considering the relatively short training duration in Korea, there can be limitations for trainees in acquiring adequate skills during their training course. Endoscopic procedures by fellows are initially performed under constant supervision by faculties; however, the endoscopic skills of trainees are expected to progress without supervision. Thus, there is a need to revise the guidelines and training programs to provide the acknowledgement of individual skill levels for performing procedures without supervision. The KSGE Education of Practice Committees develop revised educational guidelines and provide training goals for both endoscopic faculties and trainees designed to estimate the individual level of endoscopic skill for performing endoscopic procedures without supervision. This document describes each endoscopic technique, method of measuring quality indicators, education goals and updated guidelines on conscious sedation, EGD, colonoscopy, ERCP, and EUS, and quality control of endoscopic procedures and disinfection methods. To complete the training on GI endoscopy, trainees should be prepared to (1) perform effective and safe procedures, including conscious sedation and pre-procedure evaluation and monitoring of each patient; (2) describe endoscopic findings adequately and provide proper treatment accordingly; (3) identify procedure-related risks and complications to minimize the adverse effects in patients and manage complications appropriately when they occur; (4) acknowledge the indications or contraindications of endoscopic procedures and respond to or guide patients appropriately when consultation is needed; (5) identify their personal degree of skill, limitation, and when to request for a senior’s help; (6) identify the concepts of quality control and maintain qualified endoscopic procedures; and (7) acknowledge and maintain the protocol of disinfection and educate it to nursing staff.

SEDATION IN GI ENDOSCOPY (ESSENTIAL)

Sedation is an essential procedure for endoscopic specialist training because it decreases patients’ pain and discomfort levels and improves endoscopists’ performance and satisfaction. Since February 2017, sedation in GI endoscopy for treatments has been covered by the national health insurance. The guidelines of sedation for GI endoscopy have been introduced in the USA and Japan in 1995 [4,5]. In Korea, such guidelines have already been established [1]. The educational objectives of sedation in GI endoscopy are essential to train the endoscopic subspecialty for a safe and efficient sedation during endoscopy. The education and training guidelines of sedation in GI endoscopy are summarized in Table 1.

Training aims

Understand the pharmacokinetics, pharmacodynamics, antagonists, side effects, and contraindications of sedatives and analgesics

Know safe sedation and patient monitoring

Have the ability to know and respond to emergencies related to sedation

Training details

Prior to endoscopic sedation, patients’ consent should be obtained, and patients’ up-to-date medical history and physical examination results should be assessed. Endoscopic sedation should be performed with knowledge on sedative drugs, degree of sedation, patient monitoring, complications of sedation, and post-sedation care. Appropriate management of the adverse events related to sedation should also be reminded.

Knowledge of sedative drugs

Pre-sedation assessment

1. Agreement

2. Understand the classification of the patients’ physical states as suggested by the American Society of Anesthesiologists before sedation [6].

3. Judge whether the patients’ condition is normal by measuring the vital signs, including the state of consciousness and blood pressure before sedation.

Assessment of the degree of sedation and monitoring

1. Assessment of the degree of sedation

2. Monitoring

Post-sedation care

1. Ensure proper monitoring until the patients recover from the sedation.

2. If necessary, determine whether antagonists of the sedative drugs should be administered.

3. To determine discharge status from the endoscopic unit, the patients’ condition should be evaluated according to the Aldrete’s score [9].

4. Explain the precautions after discharge.

Special conditions

1. Determine safe sedation according to the cases of a child, elderly, pregnant woman, and lactating woman.

2. Be aware of the risks and sedation-related adverse events in patients with liver cirrhosis and other chronic illnesses.

Emergent management (respond to emergent conditions accurately and quickly)

1. Know the situations that require you to stop the sedation in endoscopy.

2. Be aware of the use of emergency medications and equipment for emergency resuscitation.

EGD (ESSENTIAL)

EGD is the most important tool for the diagnosis and treatment of upper GI tract diseases and is one of the most frequently performed tests in Korea where the prevalence of gastric cancer is high. As the national cancer screening project started in 1999, and the number of affected patients increased gradually, the national cancer screening rate reached 67.3% in 2014. As the demand for endoscopy increases, the demand for doctors to perform endoscopy surges, and a large number of endoscopic specialists are released every year. Therefore, the KSGE was established in 2011 to provide detailed guidelines for upper GI endoscopic subspecialty training and appropriate endoscopic education during the entire period of GI fellowship training. At present, training regulations of subspecialty in the KSGE are prescribed as recommendations of at least 1,000 times of upper GI endoscopy (more than 100 times in case of trainees who majored in pediatrics) and more than 30 times of endoscopic treatment procedures. The purpose of this upper GI endoscopic training is to provide a new guideline that summarizes the items to be acquired during the endoscopic training period by referring to the recently revised endoscopic training guidelines of other countries. Based on this guideline, we would like to create a fruitful education on upper GI endoscopy. The education and training guidelines of EGD are summarized in Table 2.

Training aims

Understand the anatomy of the upper GI tract and normal endoscopic findings

Learn the indications, limitations, and contraindications of EGD Understand the method of preparation for EGD, adverse events associated with the procedure, and countermeasures to use in such situations

Understand upper GI tract diseases, differentiation of endoscopic findings, and differentiation between benign and malignant neoplasms

Understand the indications, limitations, and contraindications for EGD treatment and procedures, and consider alternatives to treatments

Understand the prior consent of the EGD and related ethical issues

Learn newer skills and knowledge pertaining to EGD

Understand the indications for the use of prophylactic antibiotics for EGD

Understand and be aware of the risk of cerebrovascular complications in patients who receive anti-thrombotic agents and management of bleeding risk according to endoscopic procedures

Training details

Gain basic knowledge on EGD

1. Learn the endoscopic features and causes of malfunctions and how to solve them.

2. Learn common diseases depending on the sites.

3. Learn the principles of lesion observation and image recording.

Diagnostic EGD

1. Esophageal disease

2. Stomach disease

3. Duodenal disease

4. Target biopsy

Therapeutic EGD

1. Upper GI bleeding

2. Foreign body removal

3. Esophageal dilation: pneumatic dilatation, balloon dilatation, and bougie dilation

4. Percutaneous endoscopic gastrostomy

5. Polypectomy

6. Endoscopic mucosal resection and endoscopic submucosal dissection

7. Stent insertion: esophagus and pylorus

COLONOSCOPY (ESSENTIAL)

During the training period of GI endoscopic fellowship, colonoscopy is an interesting and rewarding process to learn the most accurate and useful diagnostic method for colonic diseases, as well as establish a basis for endoscopic therapy. It is also important to understand the indications and contraindications for accurate diagnosis and treatment, understand the patients’ condition before the procedure, learn to monitor the patients properly during the procedure, learn to select a procedure that would minimize inconvenience to the patients, learn proper evaluation of endoscopic findings, understand how to identify and minimize risk factors associated with the procedure, prevent complications, and take appropriate remedial measures [10]. The KSGE has mandated that at least 150 colonoscopic procedures be performed by trainees (recommendation of more than 30 colonoscopic procedures for trainees specializing in pediatrics). The number of colorectal endoscopy procedures that can be performed safely, accurately, and comfortably is incumbent on the individual abilities of trainees, interest of the educator, ability to use educational equipment, and work milieu [11-15]. There are no systematic training goals or guidelines available for colonoscopies. The KSGE intends to prescribe specific knowledge qualifications related to colonoscopy for trainees during the training period for them to acquire and use the desired skills. The education and training guidelines of colonoscopy are summarized in Table 3.

Training aims

Understand the anatomy of the large intestines and normal endoscopic findings

Learn the indications, limitations, and contraindications of colonoscopy

Understand the method of preparation for colonoscopy, adverse events associated with the procedure, and countermeasures to use in such situations

Gain knowledge pertaining to types of anesthetics with respect to pharmacokinetics, antagonists, complications, and contraindications to their use

Understand the techniques for safe insertion of a colonoscope

Gain knowledge regarding colonic diseases, effective interpretation of endoscopic findings, and differentiation between benign and malignant neoplasms detected endoscopically

Learn the indications, limitations, and contraindications of therapeutic colonoscopy

Understand the complications associated with therapeutic colonoscopic procedures and how to deal with them

Understand the issues pertaining to consent and ethical concerns related to colonoscopy

Learn newer skills and knowledge pertaining to colonoscopy

Understand and be aware of the quality indicators of colonoscopy [16]

Training details

Gain basic knowledge on colonoscopy

1. Learn a particular colonoscopic specification, and learn to cope with malfunctions of the instrument.

2. Understand the types, principles, methods, evaluation, advantages, and disadvantages, as well as contraindications of colonic preparation.

3. Understand the methods and principles of insertion of a colonoscope and how to eliminate/reduce looping.

4. Understand the principles of observation of lesions and recording of images.

5. Learn the indications and use of prophylactic antibiotics.

6. The adenoma detection rates should be maintained at 20% for women and 30% for men in the at-risk group, with the mean age being above 50 years [16].

7. In patients who have not undergone colonic resection or intestinal surgery, the colonoscope withdrawal time should be at least 6 minutes.

8. The success rate of cecal intubation should be maintained above 90% with no stenosis and good preparation.

9. Understand and be mindful of the screening interval and follow-up colonoscopy required for each patient.

Diagnostic colonoscopy

1. Colon cancer

2. Colonic polyps

3. Chronic inflammatory bowel disease

4. Vascular diseases of the colon

5. Miscellaneous

Therapeutic colonoscopy

1. Colonoscopic hemostasis

2. Polypectomy

3. Mucosal resection and submucosal dissection

4. Colonic stent insertion

ERCP (OPTIONAL)

ERCP is an advanced endoscopic procedure that is used for the management of various biliary and pancreatic diseases. This procedure is one of the most technically demanding and highest-risk procedures performed by endoscopists. Therefore, training in ERCP requires technical and cognitive skills over and above routine endoscopy and significant time and effort to attain competency [19]. In the American Society of Gastrointestinal Endoscopy (ASGE) guideline, trainees who opt to pursue additional training in ERCP to attain procedural competence should have completed at least 18 months of a standard gastroenterology training program [20]. Similarly, many other countries also require competency in general endoscopy before ERCP training [21,22]. Our previous guideline also suggested that ERCP training should begin after completion of the 1-year fellowship training of GI endoscopy [1]. According to this aspect, our guideline suggests that ERCP training is not essential for the fellowship training of general GI endoscopy; however, all trainees require some exposure to ERCP to develop an understanding of the diagnostic and therapeutic role of ERCP during the first year of training. The education and training guidelines of ERCP are summarized in Table 4.

Training aims

For the acceptable level of competence to perform independent ERCP after training, the ASGE guidelines emphasize objective measures over case volume itself, that is, achievement of selective cannulation in at least 90% of procedures [23]. In addition, trainees should be expected to perform at least 80 independent sphincterotomies and 60 biliary stent placements [23]. This level of success may not be achievable within 1 year of ERCP training or even after 200 supervised independent ERCP procedures, which is the threshold number of cases before competency can be evaluated [23]. In the UK, trainees should perform at least 180 ERCPs under supervision, and they cannot be considered competent in ERCP until they can cannulate the desired duct in over 90% of cases [24,25]. In Canada, the competence for ERCP can be assessed after 200 procedures and include 85% success rate of selective cannulation and 85% success rate of biliary stone removal or biliary drainage [22]. Because each trainee has different abilities and learning curves, this minimum number does not guarantee competence. In 2017, the Korean Pancreatobiliary Association (KPBA) published ERCP educational guidelines for fellows. In these guidelines, the goal of training is to achieve success rates of 80% of selective cannulation and 85% of biliary stone removal [26]. Although the KPBA did not define the minimum number of supervised procedures needed for credentialing, this needs to be discussed in the near future.

Training details

The cognitive aspects of ERCP are important and include an understanding of the indications and contraindications of the procedure and appropriateness of different diagnostic and therapeutic modalities in the management of pancreatobiliary diseases. Further, trainees should know about informed consent, sedation, and reporting. Understanding the risks and benefits of ERCP in certain patient groups, as well as alternative investigations, such as computed tomography, magnetic resonance cholangiopancreatography, and EUS, is paramount for an adequate management of patients with biliary and pancreatic disorders.

Basic knowledge and skills of ERCP

1. Be competent in diagnostic and therapeutic upper and lower endoscopies before ERCP training.

2. Have thorough knowledge on the anatomy and physiology of the pancreas and the biliary tree, including common variants in anatomy.

3. Be knowledgeable on side-viewing endoscopes, and be competent in passing the side-viewing endoscope into the duodenal papilla.

4. Be knowledgeable on the indications and contraindications for ERCP, procedure-related complications, risk stratification, and management of complications.

5. Be competent in proper positioning of the duodenoscope and the maneuvers that facilitate successful cannulation of the bile duct and pancreatic duct.

6. Understand low-pressure injection of contrasts.

7. Understand the various maneuvers to optimize fluoroscopic images.

8. Interpret and record the endoscopic and radiological findings.

Knowledge of the common features of cholangiography in biliary disorders

1. Normal anatomy and common anatomic variations

2. Diagnosis of biliary stones

3. Features of benign and malignant strictures

4. Features and classification of choledochal cysts

5. Classification of Klatskin tumor

6. Features of primary sclerosing cholangitis and primary biliary cirrhosis

Knowledge of the common features of pancreatography in pancreatic disorders

1. Diagnosis of chronic pancreatitis

2. Features of pancreatic ductal adenocarcinoma

3. Features of various pancreatic cystic lesions

4. Features of pancreas divisum

5. Features of anomalous union of the pancreatobiliary duct

Knowledge of therapeutic ERCP

1. Biliary and pancreatic sphincterotomies

2. Bile duct stone management

3. Dilation

4. Stent placement

EUS (OPTIONAL)

With the introduction of EUS and the technical progress over the past decade, the role of EUS in the diagnosis and treatment of GI tract lesions and lesions in its vicinity is constantly increasing. However, since there are a limited number of facilities that can perform EUS and much effort and time are required to become proficient in EUS, EUS is not a prerequisite during the 1-year GI fellowship program in Korea. The ASGE recommends that training on EUS should be provided to those who have completed at least 18 to 24 months of basic GI endoscopy training [27,28]. Although acquiring sufficient skills on advanced endoscopy, such as EUS, is not realistic considering the relatively short GI fellowship program currently employed in Korea, basic knowledge and understanding on EUS are fundamental in taking care of the patients as a GI specialist. Therefore, the KSGE recommends the following requirements to be met during the trainees’ endoscopy training program as a tool to facilitate understanding on the diagnostic and therapeutic role of endoscopy. The education and training guidelines of EUS are summarized in Table 5.

Training aims

Be able to insert the EUS after being fully aware of its structural differences from regular upper and lower endoscopes

Obtain adequate knowledge and fundamental concepts on basic EUS imaging, i.e., Doppler imaging and relationship between sound wave frequency and penetration depth

Know the characteristics of the different types of EUS and their applications

Understand the indications and contraindications of EUS

Understand the anatomy of the GI tract and its surrounding structures using images obtained from the different types of EUS, and differentiate the normal anatomy, anatomical variation, and abnormal findings

Training details

Staging of malignant tumors of the upper and lower GI tract

1. Describe the invasion depth of the tumor.

2. Discern the presence of lymph node metastasis.

3. Differentiate the lesion from surrounding structures, and determine the presence of invasion to the surrounding structures.

Evaluation of subepithelial lesions (SELs) in the GI tract

1. Distinguish the layer from which the SELs originate.

2. Differentiate SELs according their EUS characteristics, i.e., echogenicity, size, margin, and heterogenicity.

Evaluation of pancreaticobiliary lesions

1. Differentiate various types of pancreatic cysts.

2. Assess the involvement of surrounding structures based on the mass lesion and its associated findings.

3. Evaluate the presence of stones or polyps/masses in the bile duct and gallbladder.

4. Know the different types of diagnostic and therapeutic procedures that can be performed by EUS, i.e., EUS- fine needle aspiration (FNA), celiac plexus neurolysis, pseudocyst drainage, necrosectomy, and tumor ablation.

5. Understand the indications, contraindications, and complications related to EUS intervention.

ENDOSCOPIC QUALITY CONTROL AND REPROCESSING (ESSENTIAL)

GI endoscopic procedures are not only dependent on the performance of individual endoscopists, but can also be influenced by the quality control of endoscopic equipment and facilities. Therefore, it is important to abide by the guidelines on endoscopic quality control and endoscope reprocessing for efficient endoscopic procedures [29,30]. It is well known that the result of endoscopic procedures is likely to be suboptimal when the procedure is performed by an individual who is not fully trained.

In Korea, an endoscopic quality assessment program was established in 2009, which was demonstrated to improve the efficiency of endoscopic procedures by raising recognition of continuous quality control among endoscopists [31]. All trainees should fully recognize the purpose of training and importance of quality control, apply the concept into their daily practice, determine the drawbacks of the current system, and improve the quality of endoscopic procedures [32-34].

Reprocessing of endoscopic devices should be performed completely. In addition, all endoscopists should be able to educate the endoscope cleansing and disinfection guidelines by the KSGE and perform the process themselves [30]. All endoscopists should be able to perform all steps of endoscope reprocessing, which is composed of cleaning, disinfection, rinsing, and drying stages [35-37]. Reprocessing of endoscopic accessory equipment is also mandatory. It is recommended that all endoscopists should not only understand and comply with the endoscope cleaning and disinfection guidelines, but also actively participate in the endoscopic quality improvement program [38].

ASSESSMENT OF COMPETENCE

A GI endoscopic subspecialty trainee should satisfy a minimum number of procedures, as recommended by the KSGE, conducted under the supervision of a GI endoscopic education supervisor, meet the requirements of basic knowledge and clinical techniques of endoscopy, as defined in the self-evaluation form, and have a specialty to pass the qualification examination for the GI endoscopic subspecialty conducted by the KSGE. In each training hospital, competence is assessed via a direct observation of the clinical techniques of the trainee by an education supervisor, overall training evaluation by education officials, and case-based discussions.

CONCLUSIONS

Recently, all the GI endoscopic procedures have been widely performed as the public interest in early screening is growing with the advanced endoscopic diagnostic tools and therapeutic techniques. The KSGE has made a great effort to improve the quality of endoscopies and has rearranged the fundamental educational goals and guidelines for accurate and safe endoscopic procedures during fellowship training. The educational goals and guidelines for sedative endoscopies, EGD, and colonoscopy are mandatory, and those for ERCP and EUS are optional. A GI endoscopic subspecialty should obey the guidelines for quality management and disinfection and be able to educate that process. In the future, these educational goals for GI endoscopies should be modified and supplemented on the basis of the technological advancements of endoscopic instruments and techniques.

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Figure & Data

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