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5 Esophagogastroduodenoscopy (EGD)

      Susan Y. Quan^1,2, Lauren B. Gerson^†, Thomas E. Kowalski³, and Shai Friedland^1,2

      ¹ Stanford University School of Medicine, Stanford, CA, USA

      ² Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA

      ³ Thomas Jefferson University, Philadelphia, PA, USA

Introduction to EGD training

      Need for training

      An esophagogastroduodenoscopy (EGD) is often the first procedure performed by gastroenterology fellows during the training period. Compared to other procedures performed by gastroenterologists, diagnostic upper endoscopy has the most straightforward learning curve and lowest complication rates. Esophageal intubation can be mastered earlier compared to intubation of the cecum during a colonoscopy [1]. Indications for upper endoscopy include evaluation of symptoms such as heartburn, dyspepsia, dysphagia, chest or abdominal pain, nausea and/or vomiting, and chronic diarrhea [2]. Diagnostic EGD is also indicated in patients with iron‐deficiency anemia, acute or chronic gastrointestinal (GI) bleeding, and weight loss. Training in therapeutic endoscopy can include acquisition of skills in endoscopic hemostasis, variceal ligation, foreign body extraction, stricture dilation, percutaneous endoscopic gastrostomy (PEG), endoscopic resection, and stent placement.

      Format of training

      Training in upper endoscopy typically starts on the first day of an Accreditation Council for Graduate Medical Education (ACGME) certified fellowship in gastroenterology. Most gastroenterology fellows initially learn endoscopy during inpatient service and on‐call rotations during the first year of training. While this format gives fellows exposure to more challenging endoscopic therapies such as hemostasis for GI bleeding and foreign body extraction, these cases often require intervention by the attending physician as the first year fellow is still learning basic endoscopic skills. During the second and third years of training, most of the EGDs performed are elective outpatient cases, while exposure to inpatient EGDs continues when the trainee is on call.

      Bedside teaching, involving a trainer and a trainee, remains the cornerstone of endoscopic education. An alternative method to training using simulators will be discussed below.

Requirements for EGD training

      Trainee

      There are no formal trainee prerequisites other than being enrolled in an ACGME‐approved training program in gastroenterology or general surgery. ACGME has mandated that programs in gastroenterology and general surgery provide training to each fellow or resident in upper endoscopy and colonoscopy.

      Trainer

      The trainer should be an experienced endoscopist who possesses the ability to teach endoscopic skills. This includes the ability to verbalize endoscopic maneuvers, demonstrate the use of scope components, and participate in the evaluation process. It is important that the trainer enjoy teaching and possess patience so that he/she can allow the trainee adequate time to learn maneuvers and perform a thorough examination while receiving verbal coaching. A trainer who takes away the endoscope from the trainee consistently during the procedure or who is unable to teach with a hands‐off approach will be less effective.

      Setting

EGDs should be performed in both the inpatient and outpatient setting. The 2012 American Society for Gastrointestinal Endoscopy (ASGE) guidelines recommend 130 EGDs as the threshold for assessment of competence [3]. This recommendation is consistent with findings from a study by Cass and colleagues that demonstrated that the esophageal intubation rate was about 75% after 100 cases, suggesting that more than 100 EGDs were needed for the acquisition of technical skills [1]. The trainee should be encouraged to keep a procedural log so that both the trainee and the fellowship program can easily track the cases performed. The procedural log should contain the number of diagnostic and therapeutic procedures performed as well as various types of intervention including endoscopic hemostasis of ulcer disease or other vascular lesions, ligation or sclerotherapy of varices, stricture dilation, foreign body removal, and PEG tube placements.

EGD training

      Cognitive aspects

      Indication for the EGD

      For each upper endoscopy that is performed, it is important that there is an appropriate indication for the procedure. In a series assessing indications for EGD, approximately 15–20% of cases have been determined to be non‐indicated examinations [4]. Published data have shown that many patients undergo repeat EGDs for dyspepsia where the yield of a second EGD is very low, particularly in patients without alarm symptoms. Similarly, in patients with chronic GERD who have an initial normal EGD, the yield of repeated endoscopic examinations remains low; performance of an esophageal pH or motility study may yield more diagnostic information in patients who fail to respond to PPI therapy [5]. However, in patients with repeated hematemesis or ongoing melena, studies have demonstrated a miss rate of 15–20% for lesions in the upper GI tract, highlighting the importance of second‐look endoscopy in patients with ongoing acute or chronic GI bleeding [6].

      Administration of moderate sedation

      In addition to understanding the appropriate indications for upper endoscopy, another important cognitive aspect of EGD training is the administration of moderate sedation. Studies have demonstrated that the administration of moderate sedation increases the probability of a successful examination, patient satisfaction, and willingness

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