Minimum standards for training in colorectal endoscopic mucosal resection among advanced endoscopy trainees

Abstract

Background and study aims

Data on colorectal endoscopic mucosal resection (C-EMR) training during advanced endoscopy fellowship remain limited. We aimed to determine the number of procedures required by an “average” advanced endoscopy trainee (AET) to achieve competence in cognitive and technical C-EMR skills.

Methods

AETs from advanced endoscopy training programs (AETPs) were graded on every C-EMR using a standardized assessment tool. Cumulative sum (CUSUM) analysis was used to generate individual and aggregate learning curves to estimate the minimum number of cases required to achieve competence for overall, technical, and cognitive components of C-EMR. AETs completed a self-assessment questionnaire on C-EMR competence at the end of their training.

Results

A total of 22 AETs among 16 AETPs participated in this study. Nineteen AETs (86%) reported formal training in C-EMR with a mean number of 32 ± 22 cases prior to their AETP. In aggregate, 637 C-EMRs were performed (median of 32 per AET; interquartile range 17–45). Learning curve analyses revealed substantial variability in minimum volume of procedures needed to attain competence across different C-EMR skills (range: 19–39). A minimum of 19 cases were required to achieve overall competence using the global assessment score. All AETs reported feeling comfortable performing C-EMR independently at the end of AETP, yet only three (14%) achieved competence in their overall performance.

Conclusions

The relatively low number of C-EMRs performed by many AETs may be insufficient to achieve competence. The estimated thresholds for an average AET to achieve competence in C-EMR provide a framework for AETPs in determining the minimal standards for case volume exposure during training.

Keywords

Endoscopy Lower GI Tract - Polyps / adenomas / ... - Endoscopic resection (polypectomy, ESD, EMRc, ...) - Quality and logistical aspects - Training

Publikationsverlauf

Eingereicht: 08. April 2025

Angenommen nach Revision: 05. August 2025

Artikel online veröffentlicht:
09. September 2025

• References

• 1 Meulen LWT, van der Zander QEW, Bogie RMM. et al. Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort. Gastrointest Endosc 2021; 94: 1085-1095
• 2 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions – Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91: 486-519
• 3 Bhurwal A, Bartel MJ, Heckman MG. et al. Endoscopic mucosal resection: learning curve for large nonpolypoid colorectal neoplasia. Gastrointest Endosc 2016; 84: 959-968
• 4 Rajendaran A, Pannick S, Thomas-Gibson S. et al. Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy. Colorectal Dis 2020; 22: 1085-1100
• 5 Wani S, Keswani RN, Petersen B. et al. Training in EUS and ERCP: standardizing methods to assess competence. Gastrointest Endosc 2018; 87: 1371-1382
• 6 Wani S, Keswani RN, Han S. et al. Competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography, from training through independent practice. Gastroenterology 2018; 155: 1483-1494
• 7 Wani S, Han S, Simon V. et al. Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees. Gastrointest Endosc 2019; 89: 1160-1168 e9
• 8 Wani S, Keswani R, Hall M. et al. A prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: The Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15: 1758-1767
• 9 Yang D, Perbtani YB, Wang Y. et al. Evaluating learning curves and competence in colorectal EMR among advanced endoscopy fellows: a pilot multicenter prospective trial using cumulative sum analysis. Gastrointest Endosc 2021; 93: 682-690 e4
• 10 Wani S, Hall M, Wang AY. et al. Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis. Gastrointest Endosc 2016; 83: 711-719
• 11 Gupta S, Miskovic D, Bhandari P. et al. A novel method for determining the difficulty of colonoscopic polypectomy. Frontline Gastroenterol 2013; 4: 244-248
• 12 Han S, Obuch JC, Keswani RN. et al. Effect of individualized feedback on learning curves in EGD and colonoscopy: a cluster randomized controlled trial. Gastrointest Endosc 2020; 91: 882-893
• 13 Lipman G, Markar S, Gupta A. et al. Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett’s. Gastrointest Endosc 2020; 92: 543-550 e1
• 14 Bolsin S, Colson M. The use of the cusum technique in the assessment of trainee competence in new procedures. Int J Qual Health Care 2000; 12: 433-438
• 15 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-S43.
• 16 Yang D, Wagh MS, Draganov PV. The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging. Gastrointest Endosc 2020; 92: 1016-1025
• 17 Dilly CK, Sewell JL. How to give feedback during endoscopy training. Gastroenterology 2017; 153: 632-636
• 18 Thurasingam AI, MacDonald J, Shaw IS. Insights into endoscopy training: a qualitative study of learning experience. Med Teach 2006; 27: 453-459