How feasible is sub-specialisation for diagnostic EUS?

Background: Training opportunities to meet the wide demands EUS are few, hindering the expansion of services. Conventional approaches have not resolved this problem. The natural division between diagnostic and therapeutic EUS raises the question of whether sub-specialisation is feasible and whether there might be a role for the non-physician endoscopist (NE).

Methods: One hundred patients underwent radial EUS staging of esophageal cancer by a NE who had received prior hands-on-training in EUS (125 cases) observed by an experienced endosonographer. Both independently reported in writing a TNM stage. Impact of a nurse-lead staging on the wider EUS service was measured.

Results: The NE completed the EUS in 98 cases. The accuracy of T-staging over 98 cases showed very good agreement (k=0.834) between both observers. When the first and second fifty cases were compared, agreement rose from Good (k=0.79) to Very Good (k=0.89). Agreement for N-staging for this study was Very Good (k=0.858). The subsequent introduction of a NE-performed service accounted for 22% procedures performed with a parallel rise in the number of complex cases performed by physicians.

Conclusion: Extending the role of the NE to include radial EUS for esophageal cancer staging is feasible. Such an approach would allow medically trained endoscopists to focus on more complex EUS. These results are challenging and suggest that the role of non-physician endoscopists in advanced endoscopy should be re-assessed.