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Background: Dysplasia surveillance is recognized as an integral component in the management of inflammatory bowel diseases (IBDs). The adherence to surveillance guidelines is variable, and understanding of quality indicators and predictors of behavior is currently limited., Objective: To perform a nationwide evaluation of the quality of IBD surveillance practiced by Australian endoscopists and to determine the predictors of quality practice., Design: Cross-sectional nationwide survey., Setting: Survey distributed through the gastroenterology and colorectal surgery societies covering knowledge and practice of IBD surveillance., Main Outcome Measurements: Adherence to indicators of high-quality surveillance and median score of IBD surveillance guideline knowledge., Results: A total of 264 responses were received, comprising 240 respondents who perform surveillance screening (218 gastroenterologists, 46 colorectal surgeons). Gastroenterologists were significantly more likely to undertake surveillance (P < .001), adhere to guidelines (P = .02), use advanced imaging modalities (P = .04), and have greater surveillance knowledge than colorectal surgeons (P < .001). Knowledge score and gastroenterologists were independent predictors of dysplasia screening (odds ratio [OR] 1.66; 95% confidence interval [CI], 1.41-1.96 and OR 11.2; 95% CI, 4.53-27.87), guideline adherence (OR 1.15; 95% CI, 1.01-1.31 and OR 2.42; 95% CI, 1.11-5.30), and advanced endoscopic imaging technique use (OR 1.19; 95% CI, 1.05-1.35 and OR 2.2; 95% CI, 1.02-4.74)., Limitations: Potential responder bias results appear, however, aligned with those of previous studies., Conclusions: IBD dysplasia surveillance in Australia is being performed at a high standard. Gastroenterology specialization and knowledge score have been demonstrated to be strong predictors of high-quality surveillance practice. This is the first study to determine predictors of screening behavior and quantify surveillance quality. These results further emphasize that gastroenterologists should play a key role in IBD surveillance., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Background: Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States., Objective: To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States., Design: Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010., Setting: Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI)., Patients: Patients undergoing upper endoscopy., Interventions: PEG tube placement., Main Outcome Measurements: Number of PEG tubes placed., Results: Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists., Limitations: Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers., Conclusion: Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: Despite having one of the highest rates per capita for colonoscopy worldwide, colorectal cancer remains the second most commonly diagnosed malignancy in Australia., Objective: Our aim was to document colonoscopy/polypectomy practice nationwide and assess whether significant differences exist., Design: Observational study., Setting: Online survey conducted nationally in 2012., Participants: Medical practitioners registered with the Gastroenterological Society of Australia practicing colonoscopy., Main Outcome Measurements: Rates of polypectomy techniques for varying polyp sizes, postpolypectomy bleeding prophylaxis techniques, and adenoma detection practices. To assess whether variations exist according to practice location, specialty, and experience and comparison of practice with a previous American cohort., Results: Of the 846 members contacted, 244 (28.8%) responded. The cohort consisted primarily of consultant gastroenterologists (182/244, 74.6%). The cold-snare technique was preferred (165/244, 67.6%) for polyps 3 mm in size; however, this decreased rapidly with increasing polyp size (5 mm [120/244, 49.2%] and 7-9 mm [18/244, 7.4%]). EMR was the preferred method of resection for polyps 7 to 9 mm in size (148/244, 60.7%). The withdrawal technique predominantly consisted of double-passing high-risk areas and rectal retroflexion (134/244, 54.9%). Significant differences across specialty, location, and experience included polypectomy method for diminutive polyps, the use of EMR, and retroflexion., Limitations: Survey-based study and response rate., Conclusion: Although variations in colonoscopy and polypectomy practice exist, the majority of our cohort performs cold-snare polypectomy for diminutive polyps and pass high-risk, poorly visualized areas twice on withdrawal. This is a significant shift in practice from that of the U.S. cohort studied 10 years earlier., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: American Society for Gastrointestinal Endoscopy (ASGE) EUS training and credentialing guidelines exist, but the capability of U.S. GI fellowships to meet these guidelines has not been assessed., Objective: To ascertain the capability of U.S. GI fellowship programs to meet ASGE guidelines for EUS training in the context of 3-year and advanced GI fellowships., Methods: U.S. GI fellowship programs were surveyed for the presence or the absence, type, and extent of EUS training. Demographics regarding the programs and the program directors were obtained., Main Outcome Measurements: Data on the annual total EUS volume and data on EUS performed by 3-year and/or advanced-year fellows were collected and analyzed., Results: Ninety-one of 142 contactable GI programs responded (64%); 72% of programs performed >200 EUS/y and thus could train >or=1 EUS trainee/y. For 3-year GI fellows, 55% received less than 3 months of training, with 43% not receiving actual "hands-on" EUS experience, and 61% not learning EUS-guided FNA. The median EUS performed by 3-year fellows was 50 (0-350). Programs that offer advanced endoscopy fellowship had a median advanced-trainee EUS volume of 200 procedures (range, 50-1100 procedures). Of advanced fellows, 20% failed to receive "hands-on" training and 52% performed <200 procedures. We observed a significant difference in the median EUS volume performed by 3-year versus advanced-year fellows (P<.001). Program director variables did not correlate with training EUS volumes., Conclusions: The majority of U.S. GI fellowship programs have established the EUS volume to train at least 1 EUS fellow, per ASGE guidelines; however, most 3-year and many advanced fellows are currently receiving insufficient EUS training.

Background: The computer-based colonoscopy simulator is intended to provide a realistic colonoscopic experience and feedback to operators regarding procedure skills. Advocates hope that computer-based colonoscopy simulators will enhance the mastery of colonoscopy by trainees. Before this hypothesis can be tested, the claims made for a simulator must be validated. The aims of this study were to answer the following: Does a computer-based colonoscopy simulator provide a "realistic" experience? Do computer-based colonoscopy simulators' performance parameters differentiate varying levels of experience?, Methods: Ten staff gastroenterologists, 6 gastroenterology fellows, and 6 residents each performed 2 computer-based colonoscopy simulator colonoscopies and performance parameters were recorded. Staff colonoscopists then completed a 6-item survey grading the "realism" of the simulation and procedure difficulty. Survey responses and performance scores were compared with the Wilcoxon rank-sum test., Results: Faculty found the computer-based colonoscopy simulator experience to be realistic despite the "cases" being markedly easier than actual colonoscopy. The computer-based colonoscopy simulator distinguishes subjects according to endoscopic experience with 3 of its measured parameters (total procedure time, insertion time, time in "red-out"). No significant difference in the ability to distinguish among user types was found for the other 10 computer-based colonoscopy simulator measurements for which data were analyzable., Conclusion: The computer-based colonoscopy simulator provides a favorable degree of virtual realism with regard to visual simulation and colonoscope mechanics, although the "cases" were regarded as considerably easier than actual colonoscopy. The computer-based colonoscopy simulator has only limited capability for distinguishing varying levels of competence at actual colonoscopy. These findings suggest that a study to determine the role of computer-based colonoscopy simulators in the curriculum of trainees is warranted.

Background: Traditional methods of sedation and analgesia for advanced endoscopic procedures can be inadequate and frequently prolong recovery room observation. Propofol is a rapidly acting agent that produces an excellent hypnotic state, but its use is typically limited to anesthesiologist-assisted cases because of the inadequacy of current monitoring standards to reliably detect early stages of respiratory depression., Methods: Ten patients undergoing advanced upper endoscopic procedures (endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, esophageal stent placement) received a propofol infusion under the control of a second qualified gastroenterologist with advanced cardiac life support skills. Graphic assessment of respiratory activity was made by using a sidestream carbon dioxide detecting cannula. Patient satisfaction was measured with a 100 mm visual analog scale. Recovery scores were measured by standardized scoring of discharge criteria., Results: Monitoring with graphic assessment of respiratory activity detected early phases of respiratory depression, resulting in a timely decrease in the propofol infusion without significant hypoxemia, hypercapnia, hypotension, or arrhythmias. Satisfaction scores were extremely high (median score 92 of 100) and 9 of 10 patients met discharge criteria at 15 minutes after discontinuation of the propofol infusion., Conclusions: With the use of monitoring by graphic assessment of respiratory activity, propofol infusion by a second qualified gastroenterologist for prolonged upper endoscopic procedures is safe and results in high levels of patient satisfaction with rapid recovery times.

Background: Our aim was to compare the effectiveness and patient satisfaction with flexible sigmoidoscopy performed by a registered nurse, general surgeons, and gastroenterology fellows., Methods: Consecutive outpatients referred for sigmoidoscopy were assigned to have the procedure performed by the first available provider. Depth of insertion of the sigmoidoscope, complications, duration of the procedure, and percentage of patients with adenomas were recorded. After the procedure, patients completed a validated patient satisfaction questionnaire., Results: Mean depth of insertion was less for general surgeons compared with the nurse and gastroenterology fellows (50 vs 53 vs 54 cm, respectively; p = 0.01). Mean duration of procedure was longer for the nurse compared with general surgeons and gastroenterology fellows (8.3 vs 7.6 vs 6.8 min, respectively; p = 0.0001). Percentage of patients with adenomas was similar among patients who underwent sigmoidoscopy by the endoscopists (7% vs 8% vs 9%; p = 0.81). No differences were detected between endoscopists for overall satisfaction (p = 0.60), technical skills of the endoscopist (p = 0.58), communication skills of the endoscopist (p = 0.61), or interpersonal skills of the endoscopist (p = 0.59)., Conclusion: No clinically significant differences in effectiveness or patient satisfaction were detected with flexible sigmoidoscopy performed by a registered nurse, general surgeons, or gastroenterology fellows.

Background: In an effort to maintain procedure volumes and control consultation costs, many gastrointestinal endoscopists and primary care providers have implemented systems of open access endoscopy. In these systems, specialists in digestive diseases perform endoscopy without prior consultation. The purpose of this study is to determine if indications for upper endoscopic procedures requested in an open access system conform to national practice guidelines and to establish the yield of diagnostic information relevant for patient care in this system., Methods: Procedural indications and results for 3715 upper endoscopic procedures performed in an open access system were recorded in a computer database. The practice guideline "Appropriate Use of Gastrointestinal Endoscopy" (AUGE) of the American Society for Gastrointestinal Endoscopy was used to determine appropriateness of procedural indications., Results: Eighty-four percent of procedures were performed for indications listed in the AUGE, and 59% resulted in findings relevant to patient care. Specialists requested endoscopy more frequently for "approved" indications than did nonspecialists (p = .004) and more frequently had findings relevant to patient care (p < .001). Findings relevant to patient care are significantly more frequent for some indications listed in the AUGE compared to others (p < .001)., Conclusions: Adherence to practice guidelines can and does occur in an open access system. Specialists request endoscopy more frequently for appropriate indications compared to nonspecialists and have a higher yield of information relevant to patient care. Further refinement and better definition of some indications within the AUGE are needed to increase the clinical utility of this document.