Simulation training may boost polypectomy technique

"Colonoscopy with polypectomy is a core procedure performed by practicing gastroenterologists," noted Srinadh Komanduri, MD, and colleagues in a research letter. "Yet, there is no universal method for performing polypectomy, despite the high volume of procedures performed annually."

 

Incomplete resection of adenomatous tissue has been linked to colorectal cancers diagnosed after a previously negative colonoscopy, highlighting the importance of consistent procedural technique, reported Dr. Komanduri — of the Department of Medicine at Feinberg School of Medicine, Northwestern University, Chicago —and colleagues.

 

SBML is a competency-based training model in which participants must meet a defined minimum passing standard (MPS) to complete the curriculum. In this study, the program included a simulated skills pretest, an instructional video and lecture, expert-guided deliberate practice using an ex vivo bovine colon simulator with sessile and stalked polyps, and a simulated post-test in which participants were required to meet or exceed the MPS.

 

Investigators conducted a pre–post study at an academic medical center in Chicago. Nineteen practicing gastroenterologists participated, nearly two-thirds of whom had more than 10 years of clinical experience. Researchers analyzed videos of patient polypectomies performed  12 months before and after completion of the SBML curriculum.

 

The analysis included procedures involving sessile or stalked polyps measuring at least 8 mm. A total of 168 polypectomies were reviewed from the pretraining period and 178 from the post-training period. Each procedure was evaluated using the 17-item modified Direct Observation of Polypectomy Skills (m-DOPyS) checklist, which assesses technical aspects of lesion evaluation, resection technique, and postresection management.

 

The primary outcome was the proportion of procedures meeting the checklist’s minimum passing standard. Before the training intervention, the median participant pass rate was 33.3%. After SBML training, the median pass rate increased to 80%.

 

Overall checklist scores also improved. The median mean score for each gastroenterologist increased from 78.8% of checklist items correct before training to 91.5% after training. When all procedures were analyzed together, median checklist scores increased from 86.7% to 100%.

 

The proportion of individual procedures meeting the minimum passing standard increased from 36.9% before training to 73.6% afterward. Improvements were seen across most technical domains of the checklist, including lesion visualization, snare placement, selection of resection technique, and post-polypectomy assessment.

For example, the proportion of procedures in which endoscopists identified and treated residual polyp tissue increased from 49% before training to 80% after training. Photo documentation and retrieval of resected polyps also improved following the training intervention.

 

Patient and procedural characteristics were similar before and after the intervention. Mean polyp size was approximately 12.5 mm before training and 13.2 mm afterward, and average polypectomy time did not differ significantly between the two periods. Inter-rater reliability among blinded reviewers scoring the videos was substantial, with κ values ranging from 0.75 to 0.84.

 

"Our study results highlight the urgent need for continuing procedural education for practicing gastroenterologists. The traditional model of skill acquisition during fellowship with limited ongoing assessment is insufficient. SBML is a promising component of continuing education for polypectomy and warrants further study for potential inclusion as a component of continuing education for core endoscopic procedures," wrote reseachers.

 

Several limitations should be considered. The study used a pre–post design, which may introduce confounding factors. Video clips evaluated in the analysis included only the polypectomy segment of procedures, so some steps may not have been captured. In addition, the study was conducted at a single academic center, which may limit generalizability to other practice settings. Even after training, approximately one-quarter of procedures did not meet the minimum passing standard, suggesting that ongoing training or additional practice may be needed to achieve consistent proficiency.