EUS 2010 in Shanghai – Highlights and Scientific Abstracts^[1]

Education Around The World

EUS education in the Americas (A. Chak): Medical education in the United States begins after 12 years of high school and 4 years of college. Following four years of medical school, which results in the MD degree and three years of internal medicine residency physicians become eligible for specialty training, a fellowship in gastroenterology. Physicians who are board certified in internal medicine learn basic endoscopy during their three years of gastroenterology training and then become eligible to take board examinations in gastroenterology. To become an endosonographer most physicians who are board certified or eligible in gastroenterology obtain EUS training during an additional year of apprenticed training generally at an academic University hospital where such training is available.

To understand how graduate medical education is conducted and regulated in the United States you have to understand the multiple organizations that regulate education. The American Council for Graduate Medical Education or the ACGME accredits all training programs at different hospitals. Many of these hospitals are affiliated with universities and medical schools. The American Board of Internal Medicine or the ABIM tests individual physicians after they are trained and certifies that they have training in internal medicine or a specialty such as cardiology or gastroenterology. There is no separate board for EUS. The American Society for Gastrointestinal Endoscopy or the ASGE is a national society of gastrointestinal endoscopists who has the primary responsibility of educating post graduates and along with other sister GI societies developing guidelines and curricula for endoscopic training of fellows in training programs. The training of gastroenterologists is actually provided at individual independent academic hospitals. Most of these hospitals are either affiliated with a University or owned by a University.

The ACGME requires that GI training programs afford trainees the opportunity to attain competence in a core group of standard procedures, which include EGD, esophageal dilation, colonoscopy etc. Advanced procedures such as EUS are more complex and generally require an additional year of dedicated training. Not all trainees should pursue these procedures both due to variation in skill and manpower needs. Not all training programs should offer such training.

The components of education in EUS include an understanding of 3 dimensional anatomy, learning the principles of basic endoscopy, some understanding of the physics of ultrasonographic imaging, familiarity with other radiology techniques of abdominal imaging, learning the staging of GI cancers, and a rudimentary understanding of cytology. The ASGE has outlined the following endoscopic training objectives.

• Trainees need to learn when it is appropriate to recommend or not recommend EUS. 

• Trainees need to learn safe and complete performance of the procedure. This includes training in the principles and safe use of sedation.

• Trainees need to identify and correctly interpret EUS findings.

• Trainees need to identify and minimize risk factors for complications.

A training program in endoscopic procedures should include the following components: a) Core Curriculum, b) Training director, c) Endoscopic trainers, and d) Defined training process. The training process will be different for standard procedures, advanced procedures and new procedures. The ASGE has developed a series of Core Curricula for training directors that contain information on pre-procedural management, patient considerations, post-procedural management, basic techniques, therapeutic techniques, applications, and the goals of training. Curricula are available for EGD, colonoscopy, ERCP, and enteral nutrition through the ASGE website. The curriculum for EUS is currently being developed.

Training programs should designate a training director. This should generally be an expert in endoscopy who also has the aptitude of a teacher. The training director should regularly monitor each trainee in terms of their technical and cognitive skills in relation to their level of training and achievement of performance standards. He should incorporate endoscopic teaching resources such as textbooks, videos, CDs. The training methodology in the program should be periodically reviewed and updated and the training director should meet with the trainee periodically and review the evaluation forms from other trainers and give the trainee opportunity for feedback. In the past, the EUS training program director was also the one and only EUS trainer. But now many programs have more than one EUS trainer. Qualities that make someone a good trainer are: a) established endoscopic skills; b) ability to communicate, providing tactile as well as verbal instruction; c) academic programs must provide trainers protected time to participate in the training as well as regular evaluation processof trainees; and d) gastroenterologists doing research in endoscopy are especially valuable as trainers.

EUS training occurs in stages. The first step is for the trainee to learn basic anatomy and how to manipulate the scope. The trainee then moves on to diagnostic procedures, learns how to intubate the esophagus and recognizes the difference between normal and abnormal anatomy. In the next stage, the trainee learns how to perform the basic procedure without supervision and becomes more active in interventional procedures. Finally the trainee is able to perform all aspects of the procedures independently and is deemed competent.

Competency in endoscopic procedures needs to be assessed. The measurement can be divided into technical competency, i. e., endoscopic manipulation, and cognitive competency, i. e., recognizing the ultrasound image and understanding disease. Each individual acquires technical and cognitive skills at different rates. Cognitive skills, which include knowledge of indications and contraindications, interpretation of endoscopic findings, integration of findings into clinical management, recognition and management of procedure related complications, safe administration of sedation and analgesia, informed consent and ethics are tested by the ABIM. Technical competence needs to be assessed by individual programs. Methods for assessing technical competence require the trainees to maintain logbooks of their procedures (examples are available on the ASGE website); periodic subjective evaluation by the training director and endoscopic trainers; and an assessment that the trainee has met objective performance standards of benchmark numbers and performance criteria. The minimum number of procedures threshold is a convenient and widely used practice for assessing competency. These numbers are based on consensus expert opinion only. Learners progress at different rates and number of procedures does not guarantee proficiency. These threshold numbers are meant to simply be a threshold before trainees can be expected to have achieved competency. Most trainees require far greater numbers to achieve competency.

Trainees should be asked to keep a log of procedures they participate in and this log should periodically be monitored. Trainees can be evaluated subjectively using comprehensive skill evaluation forms l available to training directors on the ASGE web site. The results of these periodic evaluations should be discussed with the trainees with opportunity for feedback. Performance criteria for EUS include the ability to visualize the desired anatomical structure, accurately stage cancers using the TNM system, and obtain adequate yield when performing FNA

In summary, training in EUS must occur in a comprehensive program that integrates teaching of cognitive and technical skills. Despite obvious problems, threshold numbers for individual procedures remain an objective criterion for assessing technical competence. Education in EUS and assessment of competence is by necessity largely subjective. Rigorous monitoring of trainees helps ensure that patients receive the best outcome.

Europe (C. de Angelis with information provided by C. Boustière, J.-M. Godchaux, L. Palazzo and the CFED, G. Caletti, G. Bonanno and the Italian Endosonography Club (IEC), A. Ginès, E. Vasquez-Sequeiros and the Spanish AEG-EUS Interest Group, P. Deprez, V. Gillard, S.  Seewald and A. Fritscher-Ravens, J. Meenan, N.Carroll, J. Penman and the UK EUS Users Group, E.D. Fedorov, Z.V. Galkova, S.Yu. Orlov, O. Malikova, T. Silina and the RASEUS, C. Kalayci, D. Oguz and the Turkish EUS Group of Interest, M. Polkowski, K. Markoglou, I. Scotiniotis and V. Nosek): One of the major problems in EUS diffusion in clinical practice has been a well structured and organized training of good quality endosonographers. Apart from some pioneer centers, EUS had difficulties to diffuse into the medical practice, with mostly use of only one instrument type, radial or linear; only recently of both scope types has become routine in major centers. This slow spread could be both a cause and a consequence of the relative lack of formal EUS education included in gastroenterology fellowship training in Europe. In the last 15 years however we witnessed an almost exponential growth in the number of EUS units and, to a lesser degree, in the number of centers performing FNA. This is in some contrast to the relative lack of formal EUS training and the low number of EUS training centers. Therefore, EUS clubs or groups have been formed in some European countries endosonographers grouped themselves in some sort of national associations or groups, named EUS Clubs or Groups of interest in EUS, in other countries there are some Groups of work or committees within the national endoscopic Societies, but in many other European countries. In 2002 France, Belgium and Italy started a new cooperation of their national EUS Clubs. In 2003 the Spanish EUS Group of interest joined in and an International EUS Working Group named European Group for Endoscopic Ultrasound (EGEUS) was founded. The EGEUS is an Association of National Clubs or Groups of Interest or Committees in the field of EUS and /or individual members dedicated to EUS. Main aims of the association are to develop and spread the knowledge of EUS and other associated endoscopic/ ultrasonographic or gastroenterological techniques and to promote education and training of doctors and nurses in endosonography. Very recently the Russian Association for Specialists of EUS (RASEUS) and the Turkish EUS Group of Interest joined or are going to join the EGEUS, which today has nearly 800 members. The Group has also relationships and is starting cooperation with EUS Groups of Interest or EUS Committees outside Europe, like the EUS Working Group of India (EWGI) that emanates from the Gastrointestinal Endoscopy Society of India (SGEI). Data, information and opinions contained in the following presentation were collected from many European experts (see the Acknowledgments section), from surveys and census conducted by some national EUS clubs and Groups of interest (French Digestive Endosonography Club, CFED, Italian Endosonography Club, IEC, Spanish AEG-EUS Interest Group, Belgian Group of digestive Endosonography, BDGES, Russian Association for Specialists of EUS, RASEUS and Turkish EUS Group of interest) and last but not least from meetings and Courses organized by the EGEUS.

EGEUS and EUS education: The European Group for Endoscopic Ultrasound (EGEUS) organizes an European meeting every two years (we had already Paris 2005, Turin 2007 and Barcelona 2009), the 4^th EGEUS meeting will be held in Brussels in 2011. Each meeting has been attended by 250 – 350 participants. In these meetings participants can attend state of the heart assessments on all possible topics in EUS, can follow more practical workshops, can discuss with the experts in the Speaker’s corner sessions or Breakfast with the experts. They have also the opportunity to present their scientific works and experiences as oral communication or video-communication in the Free papers sessions or as posters. During the congress all participants can see a lot of EUS images and videos in a rich Learning center and can test themselves against the EUS simulator. In 2008 (Castel San Pietro Terme, Imola) and 2010 (Villa Gualino, Turin) the EGEUS in collaboration with the Italian Endosonograghy Club (IEC) organized an International EUS live Course with more than 10 hours of live demonstrations and also theoretical lessons and video-sessions. On our website: www.egeus.org and the correlated www.eusclub.it you can find every kind of EUS images, videos, lectures of international experts, news about new and old EUS meetings and Courses and you can test yourself with the video- or the image-quiz of the month. Now we are working on the possibility of e-learning and CME on-line Courses or real-time live-demonstration via Internet. In the next future the EGEUS Board has the program to try to standardize a formal EUS educational program in Europe, will try to establish guidelines for education and some EGEUS certified EUS training centers to be proposed for a certified training.

EUS education in different European Countries: The issue of education in EUS is very differently dealt with in the various European countries. The most important topics are listed in the folllowing

France: EUS has a very good distribution on the territory, the national mean is of 1 EUS center × 250000 inhabitants, with obviously great geographical differences in distribution because of demographic conditions, with a case volume of about 65 600 EUS examinations/year in 2008. The French EUS Club is a well established association of endosonographers strictly linked to the major gastroenterological and endoscopic scientific Societies, like the SFED and SNFGE. It has more than 300 members and organizes an annual EUS meeting with live demonstrations every two years. The CFED has organized an academic diploma of digestive EUS on the behalf of M. Barthet and 2 co-Directors (M. Giovannini e C. Boustière). It accepts 35 students every year that have to attend 3 sessions of 1 week of theoretical and practical training. The inscriptions for the next 2 years are already closed! Even if this educational program in France is probably one of the best formal academic training program for EUS in the world, learning EUS is still a problem also in France: first of all this interuniversity diploma is not mandatory in order to perform EUS and secondly less than a third of people practicing EUS were trained via this interuniversity qualification.

Italy: the Italian Endosonography Club (IEC) was born in 2002, after the breakup of the Committee first and then the Group of work for EUS of the Italian Society of Digestive Endoscopy (SIED). It works in close relationship with the SIED and other Italian Gastroenterological Societies, like AIGO and SIGE. It groups together more than 180 doctors who are practicing or are simply interested in EUS and EUS education and training are between its major commitments. In this respect the Italian EUS Club organizes an annual Joint Meeting with other gastroenterological societies during their national congress. A national EUS Course every two years (only theoretical the first two editions, Bertinoro I e II), with live demonstrations the last three (Monte del Re, Castel San Pietro Terme and Turin). Some centers organize practical Courses of 1 – 4 weeks for 1 – 3 fellows, with daily frequency in the procedure room. In cooperation with the IEC the University of Bologna started in 2003 the first University Master of 2^nd level in Advanced Endoscopy. It lasts 1 year, at least 40 days of attendance in the endoscopic room are requested and a relevant part of the theoretical and practical activity deals with EUS. Since 2006 a yearly Master in Endosonography is held in Milan, Vita-Salute San Raffaele University. The IEC is planning to organize a new Master in EUS in cooperation with another Italian University. In 2008 the Italian Society of Digestive Endoscopy (SIED) and the Italian EUS Club (IEC) started an educational program in EUS, named National EUS training Course IEC/SIED, dedicated to doctors and nurses, with 2 – 5 different modules in distinct venues, with basic and advanced courses. There is an Italian website, that has also an English version: www.eusclub.it linked with the above-mentioned European website, www.egeus.org. On these websites you can find a lot of EUS images, videos, lectures of international experts, news about new and old EUS meetings and Courses and you can test yourself with the video or the image-quiz of the month. Again is ongoing the possibility of e-learning and CME on-line Courses or real-time live-demonstration via Internet.

Spain: also Spain witnessed an exponential increase in the number of EUS centers and EUS procedures performed in the last 15 years, from 2 centers in 1995 to 58 centers in 2008. Data from a survey in 50 % of centers give us a very good news: 91 % of endosonographers practicing EUS in Spanish centers had a specific training in EUS and only 9 % are self-taught. They have a Group of interest in EUS, the Spanish AEG-EUS Interest Group, linked with the Spanish Association of Gastroenterology; it groups together more than 70 doctors. They organize every year three specific EUS Courses, few hands-on courses and one annual meeting of the EUS Group of interest. Audience is constantly increasing in the Spanish national courses.

Belgium: in Belgium there was one of the oldest EUS Club in Europe, the Belgian Club of digestive EUS (BDGES), that today has joined the French Club in the new Club Francophone of EUS (CFED): they have about 50 members, the EUS centers in Belgium are about 40, performing nearly 7000 EUS cases a year in 2008. They don’t have a formal program of education in EUS, but they actively participate in the program of the CFED.

Germany: probably (data were supplied by manufacturers of EUS equipment and also by German experts, personal communications) there are more than 500 EUS centers in Germany, it means about 1 center/200 000 inhabitants and they perform almost 200 000 examinations a year. In Germany there was one of the first national EUS Club, but as far as we know it seems to be no more active today. There is probably a regional EUS Club in the area of Berlin, but only locally active. An EUS Working Group is in the DEGUM (Deutsche Gesellschaft fur Ultraschall in der Medizin) Society, that is the German Society for Ultrasound in Medicine. At least 10 EUS training Courses a year were organized by Companies like Olympus or Pentax.

United Kingdom: in Great Britain nearly all healthcare is provided by the State and it is free. Training isssues and Endoscopy units are strictly controlled by national standards, all endoscopists must be assessed to complete training and must demonstrate ongoing “quality indicators” every six months. There are 66 EUS centers, in which 95 endosonographers are working, with an estimate number of about 15 000 cases a year. British EUS users grouped themselves in the UK EUS User Group, that is a multidisciplinary society which aims to promote “education, best practice and innovation in endosonography and to forge links between clinicians with an interest in EUS both in the UK and overseas” (see www.eususers.com). They held an annual meeting in October/November each year. The UK EUS users Group prepared a document named Recommendations for training in Endosonography (EUS)” (N. Carroll and J. Penman). In this document they stated that “in the UK intake to EUS training may be from trainees in gastrointestinal medicine, gastrointestinal surgery, pancreatico-biliary surgery or radiology. All trainees should be competent in diagnostic and appropriate aspects of therapeutic upper gastrointestinal endoscopy before attempting to learn EUS and should have attended a JAG (Joint Advisory Group) approved or JAG compliant basic endoscopy course at a minimum. Gastroenterology trainees seeking to acquire skills in EUS must have completed at least 24 months of a standard gastrointestinal training scheme and have documented competence in routine endoscopic procedure. The UK EUS Users Group considers it desirable if not essential for trainees from other backgrounds to gain some preliminary experience in transabdominal ultrasound prior to EUS training. JAG guidelines were used as basis for EUS training in the UK. Trainees are expected to attend at least one session per week for a minimum of 6 months. With increasing use of linear EUS particularly linear EUS/FNA this period should ideally be for 1 year. A period of intensive training at a recognised centre of excellence in the UK or overseas should be considered to enhance the learning process. A log-book should be kept of all procedures undertaken and audit of performance against recognised standards from peer review literature is essential.

Trainees should attend the UK EUS Users Group meeting. International meetings are also recommended. Interventional techniques should only be commenced following adequate training in diagnostic EUS”. In the same documents they give other statements about numbers of procedures required to achieve competency, citing also the ASGE Guidelines for credentialing and granting privileges for Endoscopic Ultrasound, GIE 2001, but also declaring that the numbers themselves are less relevant than the context, quality and outcome of each procedure. They give suggestions about training in EUS-FNA: “Interventional techniques should only be commenced following adequate training in diagnostic EUS. Trainees may commence EUS-FNA after 50 or so examinations” … “Animal and mechanical models and short courses may help in the development of initial EUS-FNA skills; however, these cannot replace supervised experience under the guidance of a recognised specialist in EUS-FNA”. The aims of the UK EUS Users Group are to achieve standardisation of UK training and to promote methods of assessment of “best practice “. In this respect the Group will establish centers to be recognized by JAG for training, establish guidelines for training, set objectives and standardise across centers indications, performance, reporting and terminology and monitoring of trainees. Very ambitious goals, as you can see, but we don’t know if till now they were partially or totally achieved.

Russia: Russian people had at the very beginning an EUS Committee in the Russian Endoscopy Society (RES) and training of the first nine endosonographers was obtained at leading EUS clinic in Japan, TKH, Sapporo and other 4 ones were trained in Europe. The issue of EUS training was then faced by opening educational Centers in Russia, in which Russian-Japanese EUS Hands-on trainings and EUS live-courses were held. Today there are five Centers: Moscow University Hospital №31, Irkutsk Regional Diagnostic Center, Leningrad Central Regional Hospital, Russian Oncological Center, Moscow, Yaroslavl Regional Clinical Oncological Hospital. In recent times the Russian Association for Specialists of EUS (RASEUS) was founded and it has a governing Board and about 60 members, it manages an EUS School and an EUS website, of which they are building also an english version. The idea, in such an immense country like Russia, is to develop mainly Internet education. They are dealing today with big problems: lack of certification of EUS by the Ministry of Health, no formal EUS training program at Endoscopy study courses and their aim is to include EUS into the state university program and postgraduate courses of Gastroenterology and Surgery. They are convinced that only training will promote the spread of EUS all over Russia. In the month of October 2010, the RASEUS entered the EGEUS as national Club member and will have its own representative in the EGEUS governing Board.

Turkey: EUS started in 2000, but became more available in the country after 2004, more than 90 % of the centers are located in three major cities (Istanbul, Ankara and Izmir). The situation of training is disappointing, there are no formal training programs, most of Turkish endosonographers were trained by means of short visits (1 – 8 weeks) to North American and European sites, the educational program consists mainly in observation, rarely in hands-on courses and is mostly sponsored by companies manufacturing endoscopes. The need for a more formal training program recently brought Turkish endosonographers to set up an EUS Interest Group that emanates from the Turkish Society of GI Endoscopy and they now are going to apply to EGEUS national Clubs or Groups of Interest or EUS Committees membership in order to become member of the European Group for Endoscopic Ultrasound.

Other European Countries: EUS status and EUS education in other European countries is also disappointing, there are no Societies, Clubs, organizations or networks devoted to EUS and no structured training programs nor certification systems in Bulgaria, Czech Republic, Greece, Hungary, Poland, Switzerland, Serbia, Slovenia, Slovakia and so on.

In conclusion, EUS practice is expanding in Europe in many countries, but in some countries and in some proportion also in the best organized nations EUS is still self-taught. No condition or diploma or certification is required in order to perform EUS even where there is a formal university Diploma or Master in EUS. During fellowship, EUS learning and teaching is not efficient. Anyway EUS is today considered as a major tool by gastroenterologists, surgeons and oncologists in most European countries and is now a widely accepted method for pre-therapeutic staging of GI malignancies and for diagnosis of benign and malignant bilio-pancreatic diseases. EUS-guided FNA and therapy is rapidly evolving and expanding, even if mainly in specialized centers. There is a strong need for organized training. Improvement of the training issue is mandatory in order to guarantee the future of EUS. One of the first priority for the EGEUS is to organize training and education in EUS by creating a teaching network, put together endosonographers, experiences, ideas from different people in order to support EUS development and training programs, favour communication and exchanges between different countries and realities.

Asian-Pacific Countries (K. Yasuda): According to the widespread of imaging diagnosis of EUS and EUS-FNA, education and training become important subjects. Nowadays, everybody knows the clinical significance of EUS imaging and interventional EUS. However, there are some difficulties for endoscopists and gastroenterologist to perform EUS study and EUS-FNA. Some are not familiar with the ultrasound imaging and some are not familiar to manipulate ultrasound endoscopes which have bigger diameter and two functions of endoscope and ultrasound.

In Asian-Pacific countries including Japan, the diffusion of EUS system and system models, such as the ratio of radial and linear models, mechanical radial and electronic radial, and ultrasound endoscopes and probes, are various. And the spreading of the systems is also various. Some countries have long history of EUS and some countries show the quick development of EUS studies, and some just start the use of EUS.

At first, when we started EUS in 1980 by limited institutes and clinicians, “learning by doing” in clinical cases was a general agreement to perform EUS. Since then, our circumstances were changed. We have to perform EUS after having the education, training and clinical experience under supervisor, as EUS is a new technique to the doctors who start the EUS study for the first time to perform safe and complete EUS examinations. Training centers for new techniques not only for EUS but also for new therapeutic endoscopy procedures are becoming common. Recently education and training courses are established in most countries in this area, though the number of training center and supervisors, who had learned EUS in Japan, US and Europe in the late 1990 s, is different in each country. They prepare many kinds of training systems not only in imaging EUS but also in EUS-FNA in limited centers.

At present, EUS training modalities are many such as 1, Monograph, Textbook, Printed paper, 2, Lecture by expert, 3, DVD, Video forum, 4, Hands-on training using animal models, phantoms and simulators, 5, Live case demonstration, 6, Hands-on training through live case, 7, Web based education, Internet conference.

Although the contents depend on the conference, each country has their own EUS workshop and endoscopy workshop including EUS for the education and training of EUS in Asian-Pacific region. Regular workshops are held in most countries as follow, Korea, China, Hong Kong, Taiwan, Malaysia, Singapore, Thailand, India, Australia, New Zealand and Japan with selected contents. They are so useful for spreading and learning basic techniques of EUS and EUS-FNA procedures to achieve the successful clinical results.

¹ The largest EUS international symposium sponsored by Olympus was held in November 2010 in Shanghai, China with over 1000 attendents. This congress reports briefly reviews the main topics and conclusions of most of the invited oral presentations; at the end the scientific abstracts are listed.