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• W2001754731 abstract "EUS and EUS-guided FNA (EUS-FNA) finally have moved out of the “boutique” and into mainstream utilization and clinical practice. To date, EUS is still the single best modality for detection of pancreatic tumors. Four studies comparing helical CT with EUS confirmed the superiority of EUS for detection of pancreatic tumors,1.Legmann P. Vignaux O. Dousset B. Baraza A.J. Palazzo L. Dumortier I. et al.Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography.AJR Am J Roentgenol. 1998; 170: 1315-1322Crossref PubMed Scopus (384) Google Scholar, 2.Midwinter M.J. Beveridge C.J. Wilsdon J.B. Bennett M.K. Baudouin C.J. Charnley R.M. Correlation between spiral computed tomography, endoscopic ultrasonography and findings at operation in pancreatic and ampullary tumours.Br J Surg. 1999; 86: 189-193Crossref PubMed Scopus (218) Google Scholar, 3.Tierney W.M. Francis I.R. Eckhauser F. Elta G. Nostrant T.T. Scheiman J.M. The accuracy of EUS and helical CT in the assessment of vascular invasion by peripapillary malignancy.Gastrointest Endosc. 2001; 53: 182-188Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 4.Mertz H.R. Sechopoulos P. Delbeke D. Leach S.D. EUS, PET, and CT scanning for evaluation of pancreatic adenocarcinoma.Gastrointest Endosc. 2000; 52: 367-371Abstract Full Text Full Text PDF PubMed Scopus (292) Google Scholar with a pooled average sensitivity of 73% vs. 97%, respectively (p<0.001).5.Hunt G.C. Faigel D.O. Assessment of EUS for diagnosing, staging, and determining resectability of pancreatic cancer: a review.Gastrointest Endosc. 2002; 55: 232-237Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar Once detected, EUS-FNA affords the highest cytopathologic yield and diagnostic accuracy (85%-95%)6.Fritscher-Ravens A. Brand L. Knofel W.T. Bobrowski C. Topalidis T. Thonke F. et al.Comparison of endoscopic ultrasound-guided fine needle aspiration for focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis.Am J Gastroenterol. 2002; 97: 2768-2775Crossref PubMed Google Scholar, 7.Gress F. Gottlieb K. Sherman S. Lehman G. Endoscopic ultrasonography-guided fine-needle aspiration biopsy of suspected pancreatic cancer.Ann Intern Med. 2001; 134: 459-464Crossref PubMed Scopus (294) Google Scholar, 8.Voss M. Hammel P. Molas G. et al.Value of endoscopic ultrasound guided fine needle aspiration biopsy in the diagnosis of solid pancreatic masses.Gut. 2000; 46: 244-249Crossref PubMed Scopus (340) Google Scholar, 9.Suits J. Frazee R. Erickson R.A. Endoscopic ultrasound and fine needle aspiration for the evaluation of pancreatic masses.Arch Surg. 1999; 134 (discussion 642-3): 639-642Crossref PubMed Scopus (123) Google Scholar, 10.Chang K.J. Nguyen P. Erickson R.A. Durbin T.E. Katz K.D. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma.Gastrointest Endosc. 1997; 45: 387-393Abstract Full Text Full Text PDF PubMed Scopus (537) Google Scholar, 11.Faigel D.O. Ginsberg G.G. Bentz J.S. Gupta P.K. Smith D.B. Kochman M.L. Endoscopic ultrasound-guided real-time fine-needle aspiration biopsy of the pancreas in cancer patients with pancreatic lesions.J Clin Oncol. 1997; 15: 1439-1443PubMed Google Scholar and can be performed efficiently during the EUS procedure. However, until recently, despite numerous publications regarding its diagnostic and staging capabilities, EUS has been limited to a small number of academic centers. The inability of EUS to “mainstream” into community practices was multifactorial, including issues such as equipment cost, ease of use, reimbursement, and, most importantly, training.12.Chang K.J. Endoscopic ultrasound: moving toward permanence.Gastrointest Endosc. 1996; 44 ([editorial; comment]): 502-504Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar There is general agreement among endoscopists who perform EUS and ERCP that the learning curve for EUS is steeper than that for ERCP. There are still only a few dedicated EUS training centers in the country, and training in most of these is geared toward fellows in gastroenterology and advanced EUS trainees. The length of these intensive EUS apprenticeships typically ranges from 6 to 24 months, the most common duration being 1 year of dedicated training. For the practicing, experienced endoscopist, the prospect of learning to perform EUS in such “formal” settings has been impractical and, for the most part, impossible. Despite this, I have noted tremendous growth in the number of new EUS units throughout the country, predominantly in the community sector. Manufacturers of EUS equipment also have noted a steady rise in sales within the past few years, mostly to private practices. This, in part, may be driven by the increasing awareness and “demand” for EUS.13.Parada K.S. Peng R. Erickson R.A. Hawes R. Sahai A.V. Ziogas A. et al.A resource utilization projection study of EUS.Gastrointest Endosc. 2002; 55: 328-334Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar If this emerging phenomenon is true, it begs the following questions: How are these endosonographers being trained? What is the outcome in terms of quality of “informal” compared with “formal” training? What is the “optimal” training solution for future community endosonographers—balancing the highest quality EUS skills attainable with a feasible, practical, and efficient training curriculum? The “informal” training model is extremely variable but, in general, consists of piecemeal exposure (observation of actual procedures, use of videotapes), with intermittent “hands-on” experience (using ex vivo models/simulators and animal models with proctoring), combined with shear determination to persevere through learning the anatomy and interpretation of images (books, publications, computer disks [CD], videotapes, digital video disks [DVD]). At our institution, we have been involved in both formal and informal models of EUS training for over a decade. Within the informal model of our 2-day intensive EUS workshops, we have noted an interesting trend. Initially, physicians taking the course only wanted to “see what EUS could do,” were curious about the procedure, and/or wanted to understand the indications for EUS. Over the past few years, many of the trainees have actually started to perform EUS in practice after attending an initial workshop and have been returning regularly to further enhance their skills. I always have wondered how effective this kind of training is and how it compares with the formal training model with respect to clinical outcomes. In this issue of Gastrointestinal Endoscopy, Mertz and Gautman14.Mertz H.R. Gautam S. The learning curve for EUS-guided fine needle aspiration of pancreatic cancer.Gastrointest Endosc. 2004; 59: 33-37Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar describe Dr. Mertz's personal “informal” EUS learning curve for EUS-FNA of pancreatic cancer and correlate this with incremental outcomes.14.Mertz H.R. Gautam S. The learning curve for EUS-guided fine needle aspiration of pancreatic cancer.Gastrointest Endosc. 2004; 59: 33-37Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar This is the first study, to my knowledge, that describes an informal non-traditional EUS training program that also includes measures of success and clinical outcomes. The first 50 EUS-FNA procedures in patients with confirmed pancreatic cancer performed by the single examiner, Dr. Mertz, were analyzed retrospectively. During the same period of time, EUS-FNA of the pancreas was performed in 7 patients who ultimately proved to have a benign diagnosis. The results show that the sensitivity for EUS-FNA in the diagnosis of adenocarcinoma of the pancreas increased with operator experience, i.e., number of cases (sensitivity from first to last quintile: respectively, 50%, 40%, 70%, and 80%). A sensitivity for adenocarcinoma of 80% to 90% was achieved after 30 cases, and this remained stable at 87% for cases 51 through 80. Mertz and Gautman14.Mertz H.R. Gautam S. The learning curve for EUS-guided fine needle aspiration of pancreatic cancer.Gastrointest Endosc. 2004; 59: 33-37Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar list a number of technical changes implemented during the first 30 procedures that may have contributed to the increasing diagnostic yield. They conclude that it took 30 procedures to achieve a sensitivity of 80%, “a yield reached by most high-volume EUS centers” and that their experience indicates that self-education is effective. Although I essentially agree with the conclusion of Mertz and Gautman14.Mertz H.R. Gautam S. The learning curve for EUS-guided fine needle aspiration of pancreatic cancer.Gastrointest Endosc. 2004; 59: 33-37Abstract Full Text Full Text PDF PubMed Scopus (149) Google Scholar that “the current ASGE (American Society for Gastrointestinal Endoscopy) guideline15.Eisen G.M. Dominitz J.A. Faigel D.O. Goldstein J.A. Petersen B.T. Raddawi H.M. et al.Guidelines for credentialing and granting privileges for endoscopic ultrasound.Gastrointest Endosc. 2001; 54: 811-814Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar of 25 supervised EUS-FNA cases for diagnosis of pancreatic adenocarcinoma is reasonable,” there are a number of qualifiers to this statement. The specific training of Dr. Mertz and the reported outcomes must be considered carefully before generalizing this “N of 1” experience. He performed 15 EUS procedures during GI fellowship training and observed an additional 80 cases, including 5 EUS-FNAs of pancreatic cancer. He subsequently was proctored for 117 EUS procedures by a radiologist experienced in radial and linear EUS before beginning EUS-FNA. The first 10 pancreatic EUS-FNA procedures were proctored, presumably by the same radiologist. The remaining procedures were unsupervised. Additional training included an EUS didactic workshop at a Digestive Diseases Week meeting, telephone consultation, review of published information, and review of personal cases. Thus, Dr. Mertz had what I would consider a “modified” self-education. In addition, the training required for EUS-FNA cannot be discussed without first addressing training in EUS, which is fundamental. It may be informative at this point to examine and interpret each component of Dr. Mertz'a EUS training with the goal of developing principles of training for future endosonographers. Dr. Mertz had a fairly intensive “exposure” to EUS between his fellowship and observing procedures at two high-volume EUS centers. One of the main benefits of observational learning is acclimation to the appearance of normal structures as demonstrated by EUS. Once you have seen different shapes, contours, and textures of the normal pancreas or other GI organs and structures, you are more likely to be able to identify them on your own. Especially for navigational purposes, one must become highly familiar with the appearance of major blood vessels. The other benefit of observation is that the myriad of pathologic changes seen on EUS are registered in the memory of the trainee. For example, a neuroendocrine tumor may be readily recognized as markedly distinct from an adenocarcinoma of the pancreas. Ideally, the novice endosonographer should observe procedures intermittently throughout the different points on the learning curve. Initially, attention should be focused on recognition of normal organs and vessels. Once this is mastered, the trainee can progress to the recognition of pathology. Access to observation of actual procedures performed by an expert endosonographer may not be readily available. Alternatives would be to attend “live demonstration” courses; to observe local experts as they perform EUS on your patients; and to study EUS atlases, videotapes, Web sites, CDs, and DVDs, including still images and videotapes of EUS procedures. The 15 procedures performed by Dr. Mertz as a fellow probably served as an orientation to insertion of the echoendoscope and allowed him to get the “feel of the scope.” Then, after an intensive observational exposure to EUS, he was proctored for 117 EUS procedures by a radiologist ultrasonographer. There are two unique features to this component of his training that may not be generalizable for most trainees. First, it is an extremely unusual to have an experienced endosonographer, much less a radiologist, present and available to proctor a trainee at his/her institution through entire procedures and over a sustained period of time. Second, there are few radiologists who have a working knowledge of EUS. Although interpretation of normal and pathologic US images of extra-intestinal structures are certainly within their expertise, recognition of intramural abnormalities (e.g., appearance of submucosal lesions, T staging of esophageal cancer), and advice regarding maneuvering of the echoendoscope to optimize imaging usually are not within the scope of a radiologist's practice. Of major importance in hands-on training is acquisition of the dexterity needed to maneuver the echoendoscope systematically through established anatomic landmarks/stations to successfully complete a comprehensive examination. Alternatives to hands-on training include attendance at courses that use animal models, use of simulators (emerging technology, but expensive), a colleague or partner with EUS experience who is willing to provide proctoring, and privileges at a nearby center of excellence that permits you to perform EUS procedures on your patients under the supervision of an expert. Some physicians have obtained consent from their patients who are undergoing an endoscopy or ERCP to perform a “non-billable” EUS for the purposes of possibly acquiring additional clinical information as well as physician learning. Others have even gone outside the country (where privileges to perform procedures and malpractice issues are not as insurmountable) to acquire intensive hands-on EUS experience. Such opportunities also are extremely limited. Access to supervised, hands-on experience on a continuing basis throughout the initial phase of the learning curve is perhaps the most difficult hurdle to overcome and requires “outside of the box” solutions. These include such concepts as “distance mentoring” via bidirectional, real-time videoconferencing. Telephone consultation with experts is insufficient for meeting this goal. As pointed out above, training in EUS-FNA cannot be considered in isolation. The actual technical aspects of EUS-FNA, such as maintaining good echoendoscope position, advancing the needle, and obtaining a specimen for cytopathologic analysis, are, by themselves, not tremendously difficult (with the recognition that pancreatic lesions are the most challenging and time-consuming), and certainly can be learned within 25 to 30 procedures. However, it is all the acquired skills and services that come before and after the actual EUS-FNA that make for a much steeper learning curve; hence, the ASGE recommendations for 150 total EUS procedures, including 75 pancreaticobiliary cases.15.Eisen G.M. Dominitz J.A. Faigel D.O. Goldstein J.A. Petersen B.T. Raddawi H.M. et al.Guidelines for credentialing and granting privileges for endoscopic ultrasound.Gastrointest Endosc. 2001; 54: 811-814Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar The skills and services that precede EUS-FNA include patient evaluation, assessment of the pretest probability of disease, review of pertinent imaging studies (e.g., CT, magnetic resonance images), and a thorough knowledge of the indications, risks, benefits, and expected outcome of the procedure. For the EUS examination before EUS-FNA, it is necessary to have mastered the skills of proper echoendoscope intubation, thorough disciplined imaging at pertinent anatomic stations, detection of any and all pathologic lesions, and accurate staging. The EUS staging of vascular invasion of pancreatic cancer is probably the most difficult and challenging task facing the endosonographer. However, proper staging often is a prerequisite for appropriate EUS-FNA. For example, if it is determined that the celiac artery is encased by tumor, the thought of performing EUS-FNA on a small lymph node or scant ascitic fluid may no longer be reasonable. In this case, the endosonographer should opt to aspirate the large pancreatic tumor to establish the cancer type and leave it at that. This underscores the point that before performing an EUS-FNA, it is necessary to understand how the results will change management and what alternative imaging or diagnostic approaches are available or, perhaps, more appropriate. If multiple lesions are encountered, the endosonographer must prioritize the sequence to get maximum clinical information with the least number of passes with the fine needle. In addition, knowing how to perform EUS-FNA goes beyond advancement of the needle into the tumor: it includes varying the speed and throw of the needle, depending on the characteristics of the GI wall and targeted lesion; variations in negative suction pressure; cytologic processing of the specimens in special circumstances (e.g., special stains, flow cytometry); and indications for prophylactic administration of antibiotics.16.Chang K.J. Maximizing the yield of EUS-guided fine-needle aspiration.Gastrointest Endosc. 2002; 56: S28-S34Abstract Full Text Full Text PDF PubMed Google Scholar Once the echoendoscope is removed from the patient, the procedure is not yet “completed.” Successful completion of EUS-FNA (quality indicators) includes patient satisfaction. This often means spending time with the patient and family to go over the results of the EUS-FNA, including answering questions regarding the ramifications of a cancer diagnosis, prognosis, and the next step(s) in management. Thus, the successful completion of an EUS-FNA procedure encompasses far more than the technique of acquiring tissue for diagnosis. For example, one may be proficient at acquiring a cytologic specimen, yet lesions that may have gone undetected (and hence not aspirated), would not be reflected in an outcome analysis based on cytologic yield alone. A more comprehensive and revealing analysis of outcomes would necessarily include long-term follow-up of all patients in whom EUS with or without EUS-FNA of the pancreas was performed to determine the true sensitivity for the diagnosis of pancreatic cancer. I support the ASGE guidelines: “for comprehensive competence in all aspects of EUS, at least 150 supervised cases should be performed, with 50 EUS-guided FNA, and at least 75 pancreaticobiliary cases.” I would consider this a minimum and underscore the point that numbers do not necessarily equate with competence. With regard to EUS-FNA, I have found that teaching the technique for advancement of the needle under EUS guidance is relatively straightforward, and our EUS trainees (one or two per year) begin performing EUS-FNA fairly early in the 1-year course of their training, roughly after 2 months or 50 cases. However, it takes a good part of the remainder of the year (total per fellow of 250-300 cases, including 125 pancreaticobiliary, 150 total EUS-FNAs) to become “comprehensively competent” in all aspects of EUS, including EUS-FNA. Most of our EUS fellows already are proficient in ERCP. Therefore, the 25 recommended supervised EUS-FNA pancreatic procedures are probably sufficient to become proficient at this technique in isolation. However, this assumes basic EUS skills are already in place. There may be practice situations, however, where an endosonographer may not necessarily need to be comprehensively competent in all aspects of EUS. This might include practices that are limited to rectal cancer staging alone, or esophageal cancer staging or evaluation of gastric submucosal lesions with catheter probes. In the same way, EUS-FNA may be performed in a limited practice setting. There are situations where EUS-FNA is needed for tissue diagnosis when CT already shows an obvious lesion in the pancreas. The referring physician may not require additional staging information, merely a tissue diagnosis. In this scenario, the number of procedures required for proficiency would be substantially lower, because the main goal is tissue acquisition. Especially because only one type of echoendoscope is required (i.e., linear array) for EUS-FNA, the endosonographer merely has to become familiar with one anatomic orientation as compared with two (radial and linear). To maintain the high quality of EUS and EUS-FNA currently available and yet accommodate the increasing demand for EUS, the availability of and resources for EUS training must continue to increase. Some informal or non-traditional methods of training have been described in this editorial. In the same way that technology has greatly improved the operability and functionality of EUS, I believe that technology (e.g., simulators, telementoring) also will offer solutions to the problems of training. I am confident that with the continued collective efforts of professional societies in collaboration with industry partners, this challenge will be met." @default.
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• W2001754731 title "EUS-guided FNA: the training is moving" @default.
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• W2001754731 cites W1996924966 @default.
• W2001754731 cites W1998493903 @default.
• W2001754731 cites W2002355914 @default.
• W2001754731 cites W2005311575 @default.
• W2001754731 cites W2009890097 @default.
• W2001754731 cites W2076256098 @default.
• W2001754731 cites W2088491379 @default.
• W2001754731 cites W2108630285 @default.
• W2001754731 cites W2133963544 @default.
• W2001754731 cites W2141566787 @default.
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