Adult Gastroenterology Training Program

Endoscopy Training

OVERVIEW

Endoscopy training in the Adult Gastroenterology Training Program takes place at four sites: the McMaster, the Juravinski and the General Sites of Hamilton Health Sciences, and St. Joseph’s Hospital. Experience on-call is acquired at all three acute care sites in Hamilton. Training in endoscopy occurs continuously throughout the two years of the fellowship, at whatever site the trainee is based for his/her rotation. All residents receive orientation to the Endoscopy Unit in the first month of residency. This includes instruction on patient preparation, safety, antibiotic prophylaxis, equipment maintenance, and disinfection of instruments. In addition to the endoscopic procedure, appropriate patient care is expected to include thorough explanation of the procedure, review of appropriateness of the indication, assessment of contraindications, explanation of risks, informed consent, appropriate conscious sedation, recovery, discharge planning and communication of findings and management plans to patients, families and referring health professionals. Endoscopy is provided as part of a comprehensive Gastroenterology service in cooperation with physicians, surgeons, radiologists, pathologists and allied health personnel.

FACILITIES

Endoscopy units at the four teaching hospitals in Hamilton perform approximately 20,000 gastrointestinal endoscopic procedures each year. A full range of endoscopic procedures is provided to assess and manage a broad spectrum of medical and surgical disorders. Each endoscopy unit is furnished with modern PentaxTM endoscopy equipment and access to fluoroscopy for ERCP (all sites), argon plasma coagulation (Juravinski, McMaster and St. Joseph’s Sites), laser (St. Joseph’s Site) and endoscopic ultrasound (McMaster Site).

The endoscopy suite at the McMaster Site offers four video-equipped endoscopy rooms with state-of-the art Pentax equipment for both adult and pediatric endoscopy. A fluoroscopy suite with radiologist supervision is available. The unit is staffed by endoscopy nurses well-trained in adult and pediatric endoscopy. Endoscopic ultrasound is provided at this site. Additionally, the unit is equipped for enteroscopy. Endoscopy reports are generated immediately post-procedure using EndoPro software with digital image capture. Capsule endoscopy is available on-site. In addition, the site offers computerized video simulations with the SymbionixTM endoscopy simulator.

The endoscopy suite at the Juravinski Site offers two video equipped rooms with full access to fluoroscopy suites and EndoPro software.

The endoscopy suite at the St. Joseph’s site has 5 fully equipped rooms with Pentax video endoscopic instruments. It also boasts interventional laser facilities. In addition, the site offers full endoscopic training facilities using computerized video simulations in collaboration with the Centre for Minimal Access Surgery.

Trainees’ initial exposure to endoscopy after joining the training program is with the SymbionixTM endoscopy simulator, housed at the McMaster Site. Trainees are expected complete a defined curriculum of simulator scenarios successfully before beginning to perform endoscopy under supervision on patients.

TRAINING EXPECTATIONS

Trainees attend a minimum of one endoscopy session each week over their two years of training. Generally, at least 500 procedures are completed under direct supervision. Because therapeutic endoscopy is considered more hazardous, it is taught only after satisfactory basic training in diagnostic endoscopy is complete. During all endoscopic training, the complementary roles of histology, radiology and surgery are emphasized.

Competence at diagnostic upper gastrointestinal endoscopy is achieved well before the end of the first year. During the first year, residents also become competent at flexible sigmoidoscopy and are introduced to colonoscopy. During the second year of training, the resident focuses on therapeutic aspects of upper endoscopy and becomes competent at colonoscopy, including polypectomy. Training in urgent endoscopy, including interventions for acute gastrointestinal bleeding, is acquired largely through participation in regional call rota. All emergency endoscopies are performed under direct supervision of the on-call consultant.

Competence at upper gastrointestinal endoscopy is expected to include diagnostic assessment, biopsy, brushing, injection therapies, thermal coaptive therapies (e.g. heater probe, BiCAP), mechanical hemostatic techniques (eg. hemo-clip), injection sclerotherapy, variceal band ligation, argon plasma coagulation, foreign body removal, polypectomy, bougie and balloon dilatation, and percutaneous endoscopic gastrostomy. Competence at lower gastrointestinal endoscopy is expected to include diagnostic assessment including terminal ileal intubation, biopsy, polypectomy, injection therapy, thermal coaptive therapies, mechanical hemostatic techniques, and balloon dilation. Endoscopy unit personnel provide training in equipment set-up, maintenance, cleaning and disinfection. This is also reviewed in detail at the introductory endoscopy course.

Trainees in the core two-year program are offered exposure to ERCP and EUS, but competence in diagnostic / therapeutic ERCP and EUS is not an objective of the program. Core trainees are expected to gain a thorough understanding of the technique, indications, contraindications, complications and interpretation of related radiography, and to gain early experience with intubation of a side-viewing endoscope.

Trainees interested in therapeutic biliary endoscopy (including endoscopic sphincterotomy and biliary stent placement) or endoscopic ultrasound are encouraged to consider a third year of advanced endoscopic training. Trainees in the core program may undertake electives in biliary endoscopy upon identifying an appropriate supervisor. However, priority to assist at ERCP is given to fellows in their third year. Third-year training in advanced endoscopy could also include experience in laser endoscopy, pediatric endoscopy, enteroscopy, endoscopic mucosal resection and intra-operative endoscopy.

Summary of Endoscopy Objectives

Competence at Upper Endoscopy
Diagnostic (including biopsy and brushing)
Injection (including sclerotherapy)
Coaptive therapy (including heater probe, BiCAP)
Hemoclip application
Dilation (bougie and balloon)
Argon plasma coagulation
Variceal ligation
Foreign body removal
Polypectomy
Percutaneous endoscopic gastrostomy

Competence in Colonoscopy
Diagnostic (including terminal ileal intubation, biopsy)
Polypectomy
Argon plasma coagulation
Balloon dilation
Injection
Coaptive therapy (including heater probe, BiCAP)
Hemoclip application