Elevating standards: Training and quality metrics in interventional endoscopic ultrasound

Abstract

In this issue of Digestive Endoscopy, Miutescu and Dhir present an in-depth review of the training and quality indicators essential for proficiency in interventional endoscopic ultrasound (iEUS).¹ The transformation of EUS from a diagnostic tool to a therapeutic one necessitates specialized training to ensure efficacy and safety in various interventional procedures.

Performing iEUS procedures requires high technical skill and expertise. Therefore, selecting candidates with the appropriate background and qualities is crucial for advancing the field of iEUS. The selection of candidates should be based on a solid foundation in gastroenterology, demonstrated interest, and prior experience in endoscopic procedures.² This foundational expertise is pivotal, as it allows candidates to transition more effectively into the complexities of iEUS.

Acquiring theoretical knowledge is a foundational step in training for iEUS. This phase encompasses a deep understanding of gastrointestinal and adjacent organ anatomy, pathology, and specific EUS techniques.³ Trainees should be well-versed in using various echoendoscopes and EUS devices, which is critical for the practical interpretation and execution of procedures. A structured syllabus that includes simulation models and virtual reality enhances this theoretical foundation, enabling trainees to develop the competence needed for advanced EUS procedures. Prior experience in diagnostic EUS and other imaging techniques, like transabdominal ultrasonography, can significantly shorten the learning curve and enhance procedural proficiency.

One of the critical challenges of training iEUS is the lack of standardization in training programs and quality metrics. The variability in training approaches across institutions can lead to inconsistencies in skill levels among practitioners, potentially impacting patient care. To address this, the authors advocate establishing universally accepted training standards and quality indicators. Such standardization would ensure that all practitioners meet the same high standards, leading to consistent and high-quality care globally. The average advanced endoscopy trainee needs a minimum of 225 EUS procedures to achieve core competence, with an ~50% greater number of procedures required in some cases.⁴ European Society of Gastrointestinal Endoscopy Guidelines recommend a minimum of 250 supervised EUS procedures, including specific numbers for different lesion types, to evaluate competence and key performance measures that should be recorded and evaluated.⁵ There are several proposed programs to accumulate practical knowledge in iEUS, including conferences, case studies with detailed procedural walkthroughs on various platforms, specialized online courses, World Endoscopy Organization's International School of EUS, and the Educational Program of Kindai.^{6, 7} Dhir et al.⁸ suggested a structured virtual EUS training program focusing on learning the EUS anatomy. Based on virtual live training, this program provides trainees with the initial theoretical and technical information needed to understand from the basics of EUS procedures to the advanced iEUS procedures in multiple countries simultaneously.

In addition to mastering the procedural aspects of iEUS, understanding the specific devices used for procedures is crucial for both technical success and safety. Fistula dilation, for example, depends significantly on the device chosen, such as cystotomes or balloon dilators. Balloon dilators allow for gradual, controlled expansion, reducing the risk of perforation, while cystotomes enable precise initial incisions. Proper training in the selection and use of these tools is essential for achieving optimal outcomes.

International variations in device availability and medical practices are important factors in EUS education. Different countries may have access to distinct sets of devices, which can influence procedural techniques and outcomes. As a result, country-specific educational programs are necessary to address these variations, ensuring that training is tailored to the local context. This approach helps ensure that practitioners are proficient with the tools and techniques available in their region, while maintaining high standards of care across diverse health-care systems.

Continuous training in iEUS is imperative for maintaining and enhancing practitioners' skills. Due to the rapid advancements in iEUS techniques and technology, ongoing education is vital to ensure that practitioners remain proficient and up-to-date. Regular engagement in workshops, refresher courses, advanced training sessions, peer reviews, and performance evaluations is vital for sustaining high standards of care and improving patient outcomes.^{9, 10} This dedication to lifelong learning is essential for adapting to new iEUS methodologies and incorporating innovative practices into clinical iEUS practice.

The education system for EUS trainers is distinct from that of trainees, as it focuses on advanced skills, teaching methodologies, and mentoring abilities. Trainers are required to master complex EUS techniques, ensuring they stay up-to-date with the latest advancements. Programs such as those offered by the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy also emphasize the importance of simulation-based training, peer networking, and continuous medical education to maintain the highest standards in EUS education. Trainers are certified through formal programs that validate their teaching skills, ensuring that they can successfully guide and evaluate future EUS practitioners.

This review provides a comprehensive framework for understanding the current state of iEUS training and the necessary quality indicators for proficiency. By establishing clear benchmarks and advocating standardized training programs, significant improvements will be achieved in the field of iEUS.

Authors declare no conflict of interest for this article.

None.