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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 11
| Issue : 2 | Page : 122-132 |
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A core curriculum for basic EUS skills: An international consensus using the Delphi methodology
John Gásdal Karstensen1, Leizl Joy Nayahangan2, Lars Konge3, Peter Vilmann4, The EUS Delphi Panel5
1 Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
2 Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
3 Department of Clinical Medicine, University of Copenhagen; Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
4 Department of Clinical Medicine, University of Copenhagen, Copenhagen; Division of Endoscopy, Gastro Unit, Herlev and Gentofte Hospital, Denmark
5 The EUS Delphi Panel shares co-authorship of the article and the members are listed at the end of this article.
| Date of Submission | 11-May-2021 |
| Date of Acceptance | 30-Nov-2021 |
| Date of Web Publication | 23-Apr-2022 |
Correspondence Address:
John Gásdal Karstensen
Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital- Amager and Hvidovre, Hvidovre
Denmark
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/EUS-D-21-00125
Background and Objectives: During recent years, the demand for EUS has increased. However, standardized training programs and assessments of clinical quality measures are lacking. We therefore aimed to establish a basic curriculum for EUS fellows that includes a prioritized list of interpretational capabilities and technical skills. Materials and Methods: International key-opinion leaders were invited to participate in a Delphi process. An electronic three-round iterative survey was performed to attain consensus on skills that 70% of the participants found either very important or essential for a newly graduated endosonographer. Results: Of 125 invited experts, 77 participated in the survey. Initially, 1,088 skills were suggested, resulting in a core curriculum containing 29 interpretational skills and 12 technical skills. The top-five interpretation skills included abilities to discern between normal anatomy and pathology, to identify the entire pancreas and ampullary region, to identify solid versus fluid-filled structures, to detect bile duct and gallstones, and to identify a pancreatic mass of 5 mm or larger. For technical skills, ability to insert the endoscope from the mouth to the second part of duodenum, to obtain FNA adequately and safely, to navigate the scope tip to follow anatomical landmark structures, to achieve endoscopic position of each of the four stations, and to perform passage of the scope past a hiatal hernia were given the highest ranking. Conclusions: After a structured Delphi process involving 77 international experts, a consensus was reached for a basic curriculum for EUS fellows to be included during training.
Keywords: education, EUS, training
How to cite this article:
Karstensen JG, Nayahangan LJ, Konge L, Vilmann P, The EUS Delphi Panel. A core curriculum for basic EUS skills: An international consensus using the Delphi methodology. Endosc Ultrasound 2022;11:122-32 |
How to cite this URL:
Karstensen JG, Nayahangan LJ, Konge L, Vilmann P, The EUS Delphi Panel. A core curriculum for basic EUS skills: An international consensus using the Delphi methodology. Endosc Ultrasound [serial online] 2022 [cited 2022 May 22];11:122-32. Available from: http://www.eusjournal.com/text.asp?2022/11/2/122/343773 |
John Gásdal Karstensen and Leizl Joy Nayahangan contributed equally to this work.
| Introduction | |  |
EUS has become a fundamental part of endoscopic patient care for a variety of gastrointestinal and pulmonary indications.[1] The range of EUS procedures is expanding, leading to an increasing demand for skilled clinicians as well as the need to develop and implement extensive training programs to cater to this need and ensure competency.[2],[3],[4] Prior to supervised practice on patients, training in EUS has been recommended by recent guidelines.[5],[6] In past years, the development and implementation of training programs have mainly been unstandardized and based on local initiatives. It is imperative that the selection of interpretational and technical skills to include in a training curriculum should align to current needs.
Studies and guidelines have suggested a minimum number of cases during EUS fellowship to achieve suggested performance targets (e.g., diagnostic rate of adequate sampling of solid lesions >85% or incidence of acute pancreatitis <2% after EUS-FNA) during 1st year of independent practice, and in addition, competence measures have been proposed and validated.[7],[8],[9],[10] Furthermore, both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have suggested a set of performance measures established to monitor and assess the quality of EUS.[1],[11] However, the requirements for EUS operators during individual practice may differ between medical specialties and the quality indicators for the experienced endosonographer may not reflect mandatory skills needed by a newly qualified specialist in EUS. More importantly, while it is clinically important for instance to reach a sensitivity of 90% for EUS-FNA in solid lesions or document EUS landmarks in >90%, the road to reaching such performance targets is paved with several procedural skills. To reach the performance targets outlined in the guidelines, these specific skills need to be identified for training and assessment during EUS fellowships.
To establish an adequate and focused training curriculum for an EUS fellowship, we wanted to achieve expert consensus on what basic skills should be prioritized and warranted. While we believe that a systematically gathered curriculum for basic interpretational and technical skills is needed, communicative skills and knowledge about e.g., indications, as prioritized in many guidelines, were intentionally not included. With the identification of an interpretational and technical skillsets, focused learning programs may be developed, validated and compared optimizing the learning curve during EUS fellowships. The aim of this study was to create a prioritized list of interpretational capabilities and technical skills to establish a basic curriculum for EUS fellows.
| Materials and Methods | | |
The study was designed as a Delphi study aiming at a prioritized skill set for basic EUS operators to incorporate into an EUS training curriculum.[12] The Delphi method is a widely used structured process to gather information from a defined group of experts and arrive at a consensus regarding a certain topic.[13],[14] This method uses iterative survey rounds sent anonymously to an expert panel, where responses from previous rounds are re-evaluated until a group decision is made. In this study, we followed a three-round Delphi process [Figure 1] using electronic survey questionnaires (SurveyMonkey, San Mateo, CA, USA).
International panel of experts as Delphi participants
The panel consisted of international EUS experts, which the senior author (PV) knows and has collaborated with for up to 30 years. Moreover, most of these participants have contributed to numerous academic papers within the field of EUS. In order to arrive at a consensus document of EUS skills based on a collaborative effort of international experts, all participant who responded to initial rounds were invited to subsequent survey rounds. The participants complete each round blinded to one another's responses for that round.
Facilitation of the Delphi process
A steering group was formed to facilitate the Delphi process including identification and invitation of the participants [Supplementary Material 1], formulation and piloting of the questionnaires, data gathering and organization between rounds, and data analysis. The group consisted of LJN (nurse, senior researcher in medical education), JGK (MD, associate professor of endoscopy), LK (MD, professor of medical education), and PV (MD, professor of endoscopy).
Round 1
This was the brainstorm stage, where all participants were asked to list “EUS procedural skills that a newly qualified specialist in endosonography should be able to perform.” The participants individually constructed a list of skills considered mandatory for an EUS operator during individual practice. Specifically, procedural skills are defined as the psychomotor domains that are involved when performing an EUS procedure. To avoid any bias, the list was completed by free hand and there was no limitation to number of suggested skills. The participants were given 2 weeks to complete the survey with a 1-week extension. When all answers were received and registered, the steering group made a qualitative assessment of the data by removing duplicates or synonyms and excluded items such as communicative abilities and skills related to knowledge such as relation between basic anatomical structures and EUS indications. The included items were organized and grouped into two categories based on the responses: Interpretation skills and technical skills. The lists of selected items were sent as an electronic survey to the participants in the second Delphi round.
Round 2
The suggestions from Round 1, organized into interpretational and technical skills, were sent to the participants to review and re-evaluate. They were asked to rate the statements according to importance. Specifically, we aimed to explore the importance of each item to include in an EUS training curriculum for residents in endosonography. The rating scale was from 1 = not important, 2 = somewhat important, 3 = moderately important, 4 = very important, and 5 = essential. The participants were asked to use the complete scale. A comment box was provided to allow the participants to expand on their choice of rating, as well as provide further comments or suggestions. The participants were given 2 weeks to complete the survey with a 1-week extension. The steering group gathered the responses and analyzed the data for the third round. Statements or items with a mean score lower than two were eliminated.
Round 3
The statements selected during the second round were ranked according to mean score and subsequently included in the third round, where the participants were asked to re-rate the items a final time using the same scoring system as in round 2. The participants were given 2 weeks to complete the survey with a 5-day extension. Consensus was defined as percent agreement in which a statement is included when 70% of the expert panel rated it as 4 – very important or 5 – essential. The statements that failed to reach 70% were excluded.[14]
Statistics
In Round 1, content summative analysis was performed to organize the data gathered from the brainstorming phase. Duplicates were removed and similar items were combined and rephrased for clarity. Suggestions that did not fit the inclusion criteria were deleted. In Rounds 2 and 3, descriptive analysis was performed to calculate the mean scores, which were arranged in descending order to indicate high ranking. Statistical analyses were performed using IBM SPSS Statistics 25.0 (SPSS 2017, Chicago, IL, USA).
| Results | | |
Out of the 125 identified experts in endosonography, a total of 77 (62%) agreed to participate by responding to the questionnaire (first round), representing 25 countries across the world. The median age of the panel was 52 years (range 38–69) and the expert panelist had a median of 19 years (range 2–42) experience in endosonography. Two out of 77 participants were pulmonologists. The demographic characteristics are presented in [Table 1].
Round 1
The brainstorming phase produced a raw list of 1,088 EUS skills, many of which were duplicate items [Supplementary Material 2]. These were reduced and organized into two categories: Interpretation skills (n = 47 items) and technical skills (n = 37 items). These lists were sent to the expert panel in round 2 to rate each item according to importance.
Round 2
Sixty-five out of 77 experts answered the survey (84%). All 47 interpretation skills had a mean score of >2. Thirty-four out of the 37 technical skills were rated >2 and were included. The three items that were eliminated included the ability to perform angiotherapy, perform EUS-guided gastrojejunostomy, and perform dilatation of duodenal stricture with linear EUS scope. The complete list and ratings scores are presented in [Table 2]. | Table 2: List of all EUS skills identified in Round 1, ranked by importance in Round 2
Click here to view |
Round 3
The response rate in the final round was 82% with 63 out of 77 experts. The final list included EUS skills that were ranked as very important or essential by more than 70% of the experts. There was a broad consensus to include 29 interpretational skills and 12 technical skills in the final list. Eighteen interpretational skills and 25 technical skills did not achieve consensus and were therefore eliminated. The top five interpretation skills include the ability to discern between normal anatomy and pathology (stones, tumors, lymph nodes, metastasis), ability to identify the entire pancreas and ampullary region, ability to identify solid lesions and discriminate them from fluid-filled structures, ability to detect bile duct stone and gallstone, and ability to identify a pancreatic mass of 5 mm or larger. For technical skills, the highest ranked items include the ability to insert the endoscope from the mouth to the second part of duodenum, ability to obtain FNA adequately and safely, ability to navigate the scope tip to follow anatomical landmark structures, ability to achieve endoscopic position of each of the 4 stations for imaging the pancreas and bile duct, and ability to perform passage of the scope past a hiatal hernia. The final list of interpretational and technical skills that are included in the EUS curriculum for residency training is presented in [Table 3] and [Table 4], respectively. | Table 3: Final list of interpretation to include in an EUS curriculum for specialist training
Click here to view |
 | Table 4: Final list of technical skills to include in an EUS curriculum for specialist training
Click here to view |
| Discussion | | |
Seventy-seven EUS experts participated in a three-round modified Delphi process, resulting in the core curriculum for EUS training including 29 interpretational and 12 technical skills, respectively.
The Delphi process that has been applied in this study secures an efficient and quick gathering of information, starting with brainstorming followed by a two round assessment and selection course to ensure consensus.[12] The process is constructed as electronic surveys with anonymous and confidential responding. This ensures independent answering and limits the risk of bias compared to for instance an expert meeting where one or a few dominating figures can have an unproportionate impact on the final result. The steering group had extensive experience with Delphi methodology and before initiation of the study, they defined the specific methodology that has been applied in this study.[12],[15],[16] The decision about the final threshold of 70% of the participants finding the specific skill very important or essential is a common approach which has been advised or applied in numerous papers.[14]
As several guidelines and papers already defined proper indications for EUS associated procedures, it was agreed to exclude skills related to knowledge and communication.[1],[9] That was also emphasized in the letter of invitation to the participants [Supplementary Material 1]. However, during the study, the steering group made the decision to separate the skillset into interpretational and technical categories for didactic reasons.
The background and opinion of the expert participants included in the Delphi progress are obviously reflected in the results. The participants are all internationally, well-known experts in endosonography, and academically active. They are also part of the network of the senior author of the steering group and have not been appointed by medical societies, official committees, etc., So, by definition the expert panel was selected by convenience sampling. However, we ended up with a broad, international panel and do not believe that the results are biased by the selection of the Delphi participants. The considerable number of participants contributing to the curriculum will most likely outweigh any distinct opinions within the group. In addition, to promote transparency of the participants, the demography is included in [Table 1].
The expert consensus includes 29 interpretational skills and 12 technical skills. Some of the excluded skills call for attention, in particular mediastinal staging, which is mandatory for pulmonologists.[17] The exclusion of this reflects that the vast majority of the participants were gastroenterologists thus, the curriculum is in our opinion only valid for gastrointestinal endosonography. Similarly, the skill in relation to anorectal EUS has all been excluded from the final list. Whether this may reflect a shift in staging of rectal cancers towards MRI or that radiologists or surgeons now perform these procedures with conventional rigid transluminal probes is unknown. Regional differences in the use also play a role for the priorities of the skill set. In general, many skills with radial EUS were suggested by the expert panel. Most of these skills were, however, eliminated during the Delphi process. Most of the skills that reached a consensus and were included, such as the ability to obtain FNA adequately and safely, involved the use of linear echoendoscopes. This change likely reflects a trend toward greater use due to its inherent biopsy, invasive capacity and greater comfort using linear EUS alone for recognizing the anatomy.
During recent years several papers have proposed sets of quality indicators for EUS.[1],[11],[18] A certain number of procedures during fellowships is often defined hoping that this will enable the endosonographer to fulfill quality indicators.[6] For instance, the British Society of Gastroenterology recommends a minimum of 250 supervised cases including 150 pancreaticobiliary indications (75 pancreatic cancers), 80 luminal indications (10 anorectal EUS), 10 subepithelial lesions, and 75 EUS-guided FNA (45 celiac pancreatic).[8] These minimum numbers are recommended even though learning curves alter significantly among trainees.[19] Recently, a push has been made by the ASGE to standardize the assessment of the procedures in order to individualize the number of procedures per fellow and furthermore, a recent prospective study by Wani et al. demonstrated how the majority of fellows enrolled in competency-based programs in EUS and ERCP met the quality targets during their index year of independent practice.[7],[10] The curriculum developed from this study does not answer the important shift from volume or time-based training to competency-based training.[20] As several EUS quality indicators have become widely accepted, we hope this curriculum will facilitate a more efficient training program with steeper learning curves during EUS fellowship, ultimately securing that newly graduated endosonographers fulfill these quality indicators.[1] Furthermore, the interpretational and technical skills ranked at the top of our lists [Table 3] and [Table 4] do not conflict with the quality indicators suggested by the ASGE and ESGE. The skill included in our curriculum are mandatory to reach the performance measures.[11],[18]
The advances of artificial intelligence (AI) have already impacted luminal endoscopy for both upper and lower gastrointestinal indications.[21],[22] In EUS, convolutional neural network models have proven beneficial for differentiating autoimmune pancreatitis from pancreatic carcinomas and other benign lesions.[23] AI may also become an inevitable part of endoscopic training.[24],[25] Recently, Zhang et al. published a study describing how a deep-learning system was able to recognize the standard positions for pancreas examinations with EUS – a technique that potentially may lead to enhanced real-time monitoring during EUS procedures and serve as an important training tool.[26]
There are several limitations in relation to this study. The results of the survey are solely dependent of the participants selected for the Delphi process – the importance of for instance mediastinal staging, anorectal EUS, and biliary interventions may differ between pulmonologists, and lower gastrointestinal and hepatobiliary endoscopists. Furthermore, the link to a clinically relevant outcome such as sensitivity of biliary stone detection or EUS-FNA has yet to be established. The next steps would be to develop and implement training programs on these procedural and interpretational skills including assessment of competence both in simulation and the clinical environment.
| Conclusions | | |
In conclusion, after a structured Delphi process including 77 international experts, a consensus was reached for a basic curriculum for EUS fellows that may be included during fellowship training in order to be defined as sufficiently competent. The important interpretational capabilities and technical skills included in the curriculum may be further evaluated during an implementation phase and finally integrated in future studies to assess the correlation with quality indicators after graduation.
Supplementary materials
Supplementary information is linked to the online version of the paper on the Endoscopic Ultrasound website.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
# Members of The EUS Delphi Panel are listed below
Adrian Saftoiu1,2: 1University of Medicine and Pharmacy, Craiova, Romania; 2Ponderas Academic Hospital Bucharest, Romania
Aleksei Epshtein: First City Hospital Named after Volosevich E. E, Arkhangelsk, Russia
Anand Sahai: University of Montréal Hospital Center, Montréal, Canada
Andrew Y. Wang: Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
Anthony Y. Teoh: Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, China
Eike Burmester: Medizinische Klinik I-Endoskopie Sana Kliniken Lübeck, Lübeck, Germany
Can Gonen: Department of Gastroenterology, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
Christoph F Dietrich: Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland
Christian Jenssen1,2: 1Krankenhaus Märkisch-Oderland, Department of Internal Medicine, Strausberg, Germany; 2Brandenburg Institute for Clinical Ultrasound at Medical University Brandenburg “Theodor Fontane,” Neuruppin, Germany
Enrique Vazquez-Sequeiros: University Hospital Ramon Y Cajal, Madrid, Spain
Erik H. F. M. van der Heijden: Interventional Pulmonology - Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
Erwan Loïc Bories: Clinique Axium, Hopital privé de Provence, Aix En Provence, France
Erwin Santo: Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
Evangelos Kalaitzakis: Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece
Everson L. A. Artifon: Department of Surgery University of Sao Paulo, Sao Paulo, Brazil
Fauze Maluf-Filho: Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo-ICESP, University of São Paulo, São Paulo, Brazil
Girish Mishra: Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
Harry R. Aslanian: Yale Gastrointestinal Cancers Program, Smilow Cancer Hospital Yale University, Connecticut, USA
James Scheiman1,2: 1Division of Gastroenterology and Hepatology, University of Virginia, Virginia, USA; 2Michigan Medicine, Ann Arbor MI, USA
Jan-Werner Poley: Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands
Jeanin van Hooft: Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
John M. DeWitt: Indiana University Health Medical Center, Indianapolis, USA
Julio Iglesias-Garcia: Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Spain
Khanh Do-Cong Pham: Department of Medicine, Haukeland University Hospital, Bergen, Norway
Lars Aabakken1,2: 1Oslo University Hospital, Rikshospitalet, Norway; 2Faculty of Medicine, University of Oslo, Norway
Lene Brink: Division of Endoscopy, Gastro Unit, Herlev and Gentofte Hospital, Denmark
Leonardo Sosa Valencia : Strasbourg Institute of Image-Guided Surgery (IHU), Strasbourg, France
Linda S. Lee: Brigham and Women's Hospital and Harvard Medical School, USA
Manoop S. Bhutani: Department of Gastroenterology, Hepatology and Nutrition, UT MD Anderson Cancer Center, Houston, TX, USA
Manuel Perez-Miranda: Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
Maor Lahav: Sheba Medical Center, Tel Aviv Medical School, Tel Aviv, Israel
Maria Chiara Petrone: Pancreato-Biliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
Mariana Jinga: University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
Mark Topazian1, 2, 3: 1Mayo Clinic, Rochester, MN, USA; 2Tikur Anbessa Hospital, Addis Ababa, Ethiopia 3St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia
Michael B. Kimmey: University of Washington, Washington, USA
Michael Bau Mortensen1,2: 1Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Denmark; 2Odense Pancreas Center, Odense PIPAC Center, Denmark
Michael Hareskov Larsen: Upper GI surgery, Odense University Hospital, Denmark
Michael Hocke: Helios Hospital Meiningen, Meiningen, Germany
Michael Levy: Mayo Clinic, Rochester, Minnesota, USA
Mohammad Al-Haddad: Indiana University School of Medicine, Indiana, USA
Laurent Palazzo: Endoscopy Dept Trocadéro Clinic Paris, France
Maxime Palazzo: European Hospital of Marseille, Digestive Disease Department
Paolo Giorgio Arcidiacono: Pancreatico/Biliary Endoscopy and Endosonography Division, Vita Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy
Paul Fockens1,2: 1Amsterdam University Medical Centers location University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands; 2Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands
Paul Frost Clementsen: Copenhagen Academy for Medical Education and Simulation (CAMES), Denmark
Pierre H. Deprez: Cliniques universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
Pietro Fusaroli: University of Bologna, Hospital of Imola, Italy
Pramod Garg: All India Institute of Medical Sciences, New Delhi, India
Rabindra Watson: Karsh Division of Gastroenterology Cedars-Sinai Medical Center, Santa Monica, USA
Rajesh N. Keswani: Northwestern Medicine, Chicago, IL, USA
Riadh Sadik: Sahlgrenska University Hospital, Gothenburg
Roald Flesland Havre1,2: 1Department of Medicine, Haukeland University Hospital, Bergen, Norway; 2Department of Clinical Medicine, University of Bergen, Norway
Serta Kilincalp: Department of Gastroenterology, University of Gothenburg, Sweden
Shou-jiang Tang: University of Mississippi Medical Center, Jackson, MS, USA
Siyu Sun: Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
Stephan Hollerbach: Department of Gastroenterology/Endoscopy, AKH Celle, Academic Teaching Hospital, Germany
Stephen P Pereira: Institute for Liver and Digestive Health, University College London, London, UK
Sundeep Lakhtakia: Asian Institute of Gastroenterology, Hyderabad, Telangana, India
Surinder Rana: Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Saad Haque: Medstar Medical Group, Maryland, USA
Takao Itoi: Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
Timothy Woodward: Mayo Clinic, Gastroenterology and Hepatology, Jacksonville, USA
Todd Baron: University of North Carolina at Chapel Hill, USA
Uzma D. Siddiqui: University of Chicago, Center for Endoscopic Research and Therapeutics, USA
Vanessa M Shami: University of Virginia, Virginia, USA
Vijay Sharma: Regional institute of health medicine and research, Jaipur, Rajasthan, India
Vikram Bhatia: Institute of Liver and Biliary Sciences, New Delhi, India
Vinay Dhir: Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, Maharashtra, India
Vitor Nunes Arantes: Endoscopy Unit, Federal University of Minas Gerais, Belo Horizonte, Brazil
| Supplementary Materials | | |
Supplementary Material 1: Expert consensus on training needs for different EUS procedures
Dear Colleague,
As an important key opinion leader in EUS, we would like to invite you to participate in a project to understand and identify the need for technical skills training in EUS across different countries. Training in EUS has been recommended by recent guidelines prior to supervised practice on patients.[1] The range of EUS procedures are growing, leading to an increasing demand for skilled clinicians as well as the need to develop and implement extensive training programs to cater to this need and ensure competency.[2] In past years, the development and implementation of training programs have mainly been based on local interests and decisions. It is imperative that the selection of technical skills to include in a training curriculum should align to current needs.
To achieve this aim, we will perform a systematic needs assessment process using the Delphi method consisting of a three-round iterative online survey, where the results from each round are fed back to the key opinion leaders to review and further explore in the succeeding round.[3] These will be sent individually through email and answers will be handled confidentially.
The result of this needs assessment will be a consensus document that includes a prioritized list of EUS skills and procedures for residency training. This informs and guides decision making on what training programs to develop and implement in the future.
Your key role and participation in this project is very important and will be acknowledged in a publication as a collaborative author.
Should you wish to participate, please start the first round below by clicking on the link.
Round 1: Brainstorming Phase.
For this first round, we kindly ask you to identify EUS procedural skills that a newly qualified specialist in endosonography should be able to perform. Procedural skills are defined as the psychomotor domains that are involved when performing an EUS procedure.
Please click on the survey link below to start answering the survey which will take approximately 15 min.
https://www.surveymonkey.com/r/EUS_Skills
Please complete the Round 1 survey by the August 28, 2020.
The other two rounds will include:
Round 2: After gathering and synthesizing all your answers from Round 1, we will ask you to rate the identified procedures from the first round according to:
- Perceived difficulty of the procedure
- Importance.
This will be in the form of a survey to be sent in September 2020. This round will result in a pre-prioritized list of procedures that will be sent and reviewed in Round 3.
Round 3: In this final round, we will ask you to review and prioritize the list of identified procedures. This will again be in the form of a survey to be sent in October 2020.
We are grateful for your commitment and enthusiasm in ensuring educational excellence and patient safety in our countries.
Should you opt to not participate in this project, please inform us so we can remove you from the mailing list.
For further questions, please do not hesitate to contact us directly using the following project E-mail: [email protected]
With kind regards
Peter Vilmann, MD., DSci, HC
Professor of Endoscopy, Herlev-Gentofte Hospital, Copenhagen University, Denmark
John Gásdal Karstensen, MD., Ph.D.
Associate Professor, Hvidovre Hospital, Copenhagen University, Denmark
Leizl Joy Nayahangan, RN., MHCM
Researcher in Medical Education (Simulation-based education), Copenhagen Academy for Medical Education and Simulation, Denmark
Lars Konge, MD., Ph.D.
Professor in Medical Education, Copenhagen Academy for Medical Education and Simulation, Denmark
| References | | |
- Vilmann P, Frost Clementsen P, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2015;48:1-15.
- Cho CM. Training in endoscopy: Endoscopic ultrasound. Clin Endosc 2017;50:340-4.
- Dalkey NC, Brown BB, Cochran S. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica, CA: Rand Corporation; 1969.
Supplementary Material 2: Raw list of EUS skills from Delphi Round 1
1 Ability to determine vascular flow by Doppler
2 Ability to identify solid versus fluid-filled structures
3 Anatomical interpretation of the linear anatomy
4 Anatomical interpretation of the radial anatomy
5 Ascertaining the wall layers of luminal organs
6 Identifying and interpreting in the sonographic anatomy of all three stations by both radial and linear scopes
7 Identifying endoscopic side view anatomy (e.g., ampulla)
8 Proficiency in EUS block/neurolysis
9 Proficiency in being able to make an FNA slide
10 Proficiency in being able to read the FNA slide sufficiently enough to determine adequacy of aspirate
11 Proficiency in EUS assisted bleed management (e.g., gastric varices)
12 Proficiency in EUS guided drainage
13 Proficiency in FNA
14 180° rotation of linear scope
15 Three-dimensional understanding of intraabdominal anatomy
16 (3a) Having good skills the basic normal anatomy, (3b) Good skills of the variations in the location and looking of the normal anatomy
17 3d image reconstruction in the brain
18 Three-dimensional understanding of relevant anatomy
19 A sensitive haptic feedback feeling
20 Ability to accurately pass biopsy or aspiration needle into desired target
21 Ability to accurately place FNA/fine needle biopsy needles into target structures
22 Ability to ascertain wall/vascular involvement with regards to tumor
23 Ability to blend findings at different imaging stations into a unified, three-dimensional understanding of the patient's anatomical findings
24 Ability to create an ideal image and how to problem solve when the image is suboptimal
25 Ability to decide frequency for area of interest
26 Ability to deploy LAMS stent through gastric or duodenal wall into pancreatic fluid collection
27 Ability to discern between normal anatomy and pathology (stones, tumors, lymph nodes, metastasis)
28 Ability to discern subepithelial lesions based on wall layer of origin
29 Ability to identify and to visit the typical EUS positions using the radial and the curvi-linear scope
30 Ability to navigate the scope tip to follow anatomical landmark structures (radial and curvi-linear scope)
31 Ability to operate a modern ultrasound processor used with EUS
32 Ability to optimize B-Mode imaging according to different organs/anatomical structures and to different examination conditions (“knobology”)
33 Ability to pass guidewires and stents into otherwise inaccessible bile ducts and pancreatic ducts
34 Ability to perform celiac plexus block/neurolysis
35 Ability to perform EUS guided FNA and fine needle biopsy (involve use of Doppler US to identify vessels)
36 Ability to perform EUS-FNA and fine needle biopsy
37 Ability to perform neurolysis
38 Ability to problem solve in instances where it is difficult to advance the FNA or fine needle biopsy needle
39 Ability to puncture solid and cystic lesions at any station in mediastinum or from stomach/duodenum
40 Ability to recognize and successfully drain pseudocysts, fluid collections and abscesses
41 Ability to shorten the EUS scopes in D2
42 Ability to stage luminal lesions/cancers (may include miniprobe competency for endoscopic resectors)
43 Ability to understand anatomy in short and long position in D1/D2
44 Ability to use colour Doppler ultrasound
45 Able to assess FNA specimens for adequacy
46 Able to differentiate ultrasound artifacts from normal and abnormal strucutures
47 Able to diffrentiate layers of origin and echo features of subepithelial masses
48 Able to do mediastinal staging
49 Able to drain peripancreatic collection; able to place a plastic stent
50 Able to identify a pancreatic mass of 5 mm or larger
51 Able to identify and avoid structures that should not be routinely entered during FNA/fine needle biopsy (for instance lung parenchyma and bone)
52 Able to identify and avoid vascular and neural structures during advancement of FNA/fine needle biopsy needles
53 Able to identify findings that were not identified on the patient's prior imaging procedures
54 Able to identify sonographic artifacts
55 Able to insert the EUS scope in sedation without cause too much trauma
56 Able to insert the scope into the duodenum
57 Able to interpret significance of sonographic artifacts
58 Able to interpret the different image optimization functions available on the ultrasound processors
59 Able to obtain FNA adequately and safely
60 Able to optimise color Doppler function/overlay for different vessels.
61 able to perform EUS FNA
62 able to perform EUS guided celiac neurolysis
63 able to perform EUS guided core biopsies
64 Able to perform safety FNA/fine needle biopsy
65 Able to perform simple interventions e.g., CPN or aspiration therapy
66 Able to recognize problematic cases and seek for help
67 Able to recognize which anatomic features have not been confidently visualized or examined
68 Able to remove unwanted sonographic artifacts to optimise imaging
69 Able to safely deploy EUS-FNA/B needles in common target lesions
70 Able to stage esophageal, gastric, periampullary, bile duct, and pancreatic cancers
71 Able to trace the CBD, cystic duct and gallbladder
72 Able to trace the whole PD and the pancreas
73 Able to troubleshoot basic scope functions, including valves and balloon inflation.
74 Able to use Doppler and CEUS
75 Able to withdraw and maintain position in 1st and 2nd parts of duodenum for visualising different organs
76 Access to second part of duodenum
77 Accurate interpretion of the echogenicity of a structure
78 Achieving echoendoscope insertion into the 2nd/3rd part of the duodenum
79 Achieving endoscopic position of each of the 4 stations for imaging the pancreas and bile duct
80 Achieving positioning in EUS imaging stations
81 Achieving short scope position to view uncinate
82 Acieving the endoscopic stations for the mediastinum
83 Actuation of biopsy needle
84 Adjusting tip pressure on GI wall to obtain proper acoustic coupling
85 Administering proper sedation before and during the procedure
86 Advanced knowledge of color and power Doppler
87 Advanced knowledge of elastography
88 Advanced knowledge of Pulsed Doppler (flow alterations depending on disease and/or vessel involvement)
89 Advanced skills in biliary endoscopy
90 Advancing endoscope to desired station
91 Advancing the scope in the duodenal bulb to maintain visualization of the distal cbd
92 Again, depending on the clinical setting, ability to place fiducials
93 Alcohol ablation (tumor)
94 All of the above are for both linear and radial EUS
95 Ampullary mass study
96 Ampullary region
97 Anal endosonography and identification of anal anatomy
98 Anatomic interpretation of the linear anatomy
99 Anatomic interpretation of the radial anatomy
100 Anatomical identification of ampulla
101 Anatomical identification of bile duct
102 Anatomical identification of both kidneys
103 Anatomical identification of celiac axis and ganglia
104 Anatomical identification of crus of diaphragm
105 Anatomical identification of cystic duct and gallbladder
106 Anatomical identification of left adrenal
107 Anatomical identification of left lobe liver and major vasculatue
108 Anatomical identification of pancreatic duct in all positions from uncinate to tail
109 Anatomical identification of portal vein confluence from duodenum
110 Anatomical identification of portal vein confluence from stomach
111 Anatomical identification of spleen
112 Anatomical identification of splenic vein
113 Anatomical identification of uncinate
114 Anatomical interpretation of mediastinum with linear scope
115 Anatomical interpretation of Abdominal US
116 Anatomical interpretation of anal canal with linear scope
117 Anatomical interpretation of anal canal with radial scope
118 Anatomical interpretation of computed tomography
119 Anatomical interpretation of digestive wall with linear scope
120 Anatomical interpretation of digestive wall with radial scope
121 Anatomical interpretation of linear anatomy
122 Anatomical interpretation of linear anatomy
123 Anatomical interpretation of linear anatomy from duodenum - head pancreas, biliary tree, GB, major vessels, liver
124 anatomical interpretation of linear anatomy from every location
125 Anatomical interpretation of linear anatomy from stomach e.g., liver, body pancreas, coeliac axis, left adrenal
126 Anatomical interpretation of linear anatomy in mediastinum
127 Anatomical interpretation of linear anatomy - includes normal and abnormal
128 Anatomical interpretation of mediastinum with radial scope
129 Anatomical interpretation of normal linear anatomy and variants
130 Anatomical interpretation of perigastric and periduodenal area with linear scope
131 Anatomical interpretation of perigastric and periduodenal area with radial scope
132 Anatomical interpretation of perirectal area with linear scope
133 Anatomical interpretation of perirectal area with radial scope
134 Anatomical interpretation of radial anatomy
135 Anatomical interpretation of radial anatomy
136 Anatomical interpretation of radial anatomy - includes normal and abnormal (tumor, subepithelial lesions, etc)
137 Anatomical interpretation of radial and linear, or only linear scanning scanning
138 Anatomical interpretation of radial EUS anatomy
139 Anatomical interpretation of the linear anatomy
140 Anatomical interpretation of the linear anatomy
141 Anatomical interpretation of the linear anatomy
142 Anatomical interpretation of the linear anatomy
143 Anatomical interpretation of the linear anatomy
144 Anatomical interpretation of the linear anatomy from SMA to upper esophageal sphincter
145 Anatomical interpretation of the linear anatomy, with ability to interpret with radial EUS if needed, as it pertains to the area of practice
146 Anatomical interpretation of the linear anatomy
147 Anatomical interpretation of the linear anatomy
148 Anatomical interpretation of the linear anatomy
149 Anatomical interpretation of the linear and radial anatomy
150 Anatomical interpretation of the radial anatomy
151 Anatomical interpretation of the radial anatomy
152 Anatomical interpretation of the radial anatomy
153 Anatomical intrepretation of linear anatomy
154 Anatomical problem solving (ability to confidently and correctly interpret anatomic findings that are variants, poorly visible in individual patients, or distorted by disease processes, with reference to cross-sectional imaging studies and adjacent normal anatomic structures)
155 Anatomy; aorta, liver, kidney, spleen, adrenal gland, pancreas, lymph nodes, CBD, PD, free fluid
156 Angiotherapy
157 Anticipation of the next step of the examination
158 Aorta and cava
159 AP window
160 Apply Mannheim criteria
161 Apply TNM staging
162 Aspirate ascitic fluid
163 Aspiration nodes
164 Aspiration of tumors
165 Assess submucosal processes
166 At least know something about interventional EUS
167 Avoids placing EUS-guided stents across vascular structures, intervening bowel, and diaphragm
168 Awareness of 3D spatial positioning of the probe inside the patient
169 Awareness of the use of a side viewing scope
170 Basi drainage techniques (PFC such as WON, pseudocyts)
171 Basic and advanced skills in set up of Doppler software (pulsed, color and power)
172 Basic experience of endoscopy
173 Basic FNA-fine needle biopsy
174 Basic injection therapy techniques (e.g., neurolysis)
175 Basic interpretation of arterial and venous spectral Doppler waveforms
176 Basic knowledge of advanced techniques
177 Basic knowledge of cleaning/disinfection criteria - needs - regulations
178 Basic knowledge of color and power Doppler
179 Basic knowledge of Elastography
180 Basic knowledge of interventional techniques
181 Basic knowledge of Pulsed Doppler (flow differentiation)
182 Basic trans-abdominal ultrasound skills
183 Basic ultrasonography skills using a US-processor
184 Be able to all the above mentioned using the EBUS endoscope (perform EUS-B-FNA) and not the EUS endoscope
185 Be able to characterize a subepithelial lesion in the esophagus/stomach/duodenum/rectum
186 Be able to charaterize a lesion in the GI tract and layer of origin
187 Be able to deploy FNA/B needle into lesion of interest
188 Be able to describe a pancreatic cyst commenting on the presence/abscence of any feature considered worrisome
189 Be able to dicriminate a cyst from a solid lesion
190 Be able to handle complications
191 BE able to identify all wall layers and how this relates to primary staging of GI cancers
192 Be able to identify and name thoracic lymph nodes
193 Be able to identify lung tumors
194 Be able to identify retroperitoneal lymph nodes
195 Be able to identify suspicious lesions in the left liver lobe
196 Be able to identify the intended lesion (linear echoendoscope)
197 Be able to identify the left adrenal gland
198 Be able to know if an organ is completely or incompletely visualized
199 Be able to make measurements of structures in frozen images
200 Be able to perform an FNA/fine needle biopsy for diagnostic purpose
201 Be able to perform celiac plexus neurolysis
202 Be able to perform diagnostic cyst fluid dranage
203 Be able to perform FNA/fine needle biopsy of the target lesion
204 Be able to perform plastic/metal stetning of an uncomplicated pseudocyst
205 Be able to perform TN staging of esophageal cancer
206 Be able to perform TN staging of gastric cancer
207 Be able to propose appropriate differential diagnoses
208 Be able to recognize lymph nodes and the normal presentation of LN
209 Be able to suggest appropriate course of action (i.e., refer to MDT, etc.)
210 Be able to use and adjust color Doppler for identification of blood vessels
211 Be able to visualize the head, body and tail of the pancreas
212 Be confident at performing EUS-guided FNA: know all steps and be fluent at using them
213 Be familiar with every step of sampling process of FNA
214 Being able to identify wall layers
215 Being able to more or less do a complete gastroscopy with linear EUS scope (as surrogate for scope handling)
216 Best understanding of maneuvring the linear echoendoscope forward
217 Bile duct stone and gallstone detection
218 Biliary anatomy study
219 Biliary device knowledge and technical use
220 BILIARY DRAINAGE UNDER SUPERVISION
221 Biliary rendezvous
222 Biopsy in the correct order in the lung cancer patient: M1->N3->N2->N1->lung tumor
223 Biopsy the structures mentioned
224 Body movements recognition
225 Can demonstrate how to process specimens when onsite cytopathology is not available
226 Can do cancer staging (esophagus, stomach, pancreas, rectum etc.)
227 Can identify features associated with chronic pancreatitis and understands how to interpret them
228 Can image the whole bile duct
229 Can perform contrast enhanced EUS (outside of USA)
230 Can safely and effectively (i.e., hits metrics for detecting PDAC) perform EUS-FNA/fine needle biopsy
231 Cancer detection and staging
232 Cancer staging
233 Cancer staging (luminal and solid organ)
234 Capability in recognition of pattern in ultrasound
235 Capability to communicate the next step of the EUS examination to others before it happens
236 Capability to perform endoscopic treatment of complications (clips, OVESCO, injection etc.)
237 Capability to recognize complications
238 Cardiac anatomy
239 Causes for a bad image quality
240 Celiac and sup mesenteric node identification and FNAC
241 Celiac ganglion neurolysis
242 Celiac axis
243 Celiac bloc injection
244 Celiac block
245 Celiac plexus neurolysis
246 Celiac plexus and ganglia block/neurolysis
247 Celiac plexus block
248 Celiac plexus neurolysis or block
249 Celiac take-off, the entire pancreas, pancreatic duct, vasculature including splenic vein, artery, SMA, celiac
250 CEUS imaging by avoiding artefacts
251 Characterise submucosal lesions
252 Characterization of submucosal lesion
253 Characterize and perform FNA for pancreatic diseases
254 Characterize and perform FNA on submucosal tumors
255 Check 4R nodes
256 Clinical knowledge of indications for FNA/fine needle biopsy, not only listing up diseases, but when and why, when to stop
257 Coeliac plexus block
258 Commitment to routinely examining relevant organs to detect incidental or novel findings during EUS exams (for instance, routinely examining all of pancreas and left lobe liver during upper EUS)
259 Communicate with ROSE technologist
260 Competence in contrast enhanced ultrasound examination
261 Competence in Doppler use (angle correction, preventing aliasing…)
262 Competence in elastographic analysis
263 Complete imaging of the pancreas from uncinate to tail
264 Coordinating tip up deflection with elevator activation for EUS-FNA/B
265 Correct biopsy technique
266 Correct identification of mediastinal lymph node stations and mediastinal staging
267 Correct identification of vascular structures (portal vein, SMV, celiac)
268 Correct interpretation of GI wall layers
269 Correct positioning of the transducer
270 Correct use of baloon
271 Correct use of needle
272 Correct use of sheet
273 Correlate EUS anatomy with cross section anatomy seen on a CT scan
274 CPN
275 Create a good ultrasound image
276 Create a good ultrasound window
277 CRM competency
278 Cytology slide preparation
279 Demonstrate basic uses of the EUS processor
280 Describe depth of invasion of oesophageal tumor
281 Describe location of esophageal tumor
282 Describe location of lesion visualized
283 Describe tissue layer
284 Describe type of lesion
285 Describe were lesion originates from e.g., mucosa, submucosa
286 Detection of ascites and pleural effusions
287 Detection of common bile dust stones
288 Detection of luminal lesions (cancer/smt)
289 Detection of lymph nodes
290 Detection of metastatic lymph nodes
291 Develop an understanding of different anatomical landmarks (stations) to visualise the regions of interest
292 Diagnosis and Staging of biliary cancer
293 Diagnosis and staging of GI cancer
294 Diagnosis and staging of pancreatic cancer
295 Diagnosis of GI submucosal lesion
296 Diagnostic yield of FNA of solid lesion should be > 90%
297 Differential diagnosis of lesion
298 Differentiate between normal anatomy and (potential) diseased structures/organs
299 Differentiate Malignant from benign LN
300 Differentiate microcystic serous cyst from other pancreatic cysts
301 Differentiate normal appearing pancreas from autoimmune pancreatitis and pancreatic mass
302 Differentiation of splenule from pancreatic endocrine tumor
303 Dilation of duodenal stricture with linear EUS scope
304 Direct gallbladder drainage
305 Discriminating between waypoints (left vs right) in the mediastinum
306 Discrimination of the GI layers
307 Dissociate endoscopy image from ultrasound image
308 Distinguish 9L from 9L
309 Distinguish vessels from other structures with doppler
310 Distinguishing normal from abnormal EUS findings
311 Do EUS guided pseudocyst drainage (optional, is an advanced skill that every endosonographer may not need to know based on their practice nature and volume)
312 Document lesion
313 Document specific stations
314 Doing manuvers
315 Doppler imaging by avoiding artefacts
316 Drainage of cysts if necessary
317 Drainage of fluid collection via needle
318 Duodenal intubation
319 Ecographic appearance and diagnosis of different diseases
320 Elastographic imaging by avoiding artefacts
321 Elastography
322 Elastography knowledge of data interpretation and analysis
323 Elastography technical set up of the system
324 Endoscopy with oblique viewing scope
325 Endosonographic tumor staging (T and N)
326 Esophageal cancer staging
327 Esophageal intubation
328 Esophageal wall radial scope study
329 EUS - FNA???
330 EUS core biopsy (solid and cystic)
331 EUS FNA (solid and cystic)
332 EUS FNA in tumors, lymphadenopathies
333 EUS FNA liver metastases
334 EUS FNA lymph nodes
335 EUS FNA of cysts, if is necessary
336 EUS FNA pancreatic cysts
337 EUS FNA solid lesions
338 EUS guided biliary drainage (advanced skill, optional, is an advanced skill that every endosonographer may not need to know based on their practice nature and volume)
339 EUS guided biopsy
340 EUS guided drainage biliary and cavities
341 EUS-FNA
342 EUS guided fine needle biopsy (EUS-fine needle biopsy)
343 EUS guided fluid aspiration
344 EUS-biliary drainage
345 EUS-fine needle injection, including CPN, ablation, etc
346 EUS - Pancreatic fluid collection drainage and necrosectomy
347 Evaluation of pancreatic cysts
348 Examination of the common bile duct
349 Examination of the pancreatic duct
350 Excellent knowledge in anatomy
351 Expanded screening from every station
352 Experience in duodenoscopy
353 Experience with endoscopic handling of complications like bleeding, perforation: Use of clips, SEMS
354 Experience with pathological anatomy like diverticula, strictures, varices, volvulus etc.
355 Explaining why “39” is a correct statement
356 Find 8L/8R nodes
357 Find an identify the left adrenal gland (in all cases)
358 Find and identify the different parts of the pancreas
359 Find and identify the intrathoracic organs including the heart valves, the azygos vein, and the aorta-pulmonary window
360 Find celiac nodes
361 Find left adrenal gland
362 Find left and find right side
363 Find left kidney
364 Find stones and sludge
365 Find VCI - judge width/collaps
366 Finding target organs/lesions
367 Fine motor movements
368 FNA
369 FNA of pancreas cyst
370 FNA of solid pancreas mass
371 Fine needle biopsy of solid pancreas mass
372 Fine scope rotation
373 Finger strength to rapidly advance EUS needle across gut wall and into target structure
374 First, I do not think everyone needs to be trained in all parts of EUS. For example a pancreatobiliary specialist may need pancreatobiliary diagnostic and interventional EUS to assist ERCP and care for patients, but may not need expertise in mediastinal EUS if he she doesn't get patients with esophageal cancers. Not all health systems operate where one person just does EUS of the whole body, but rather one might specialize in an area. General knowledge in the other EUS areas may be enough without high level expertise
375 Fluid collection drainage (plastic and/or metal)
376 FNA
377 FNA/fine needle biopsy
378 FNA and fine needle biopsy biopsies
379 FNA LAG
380 FNA needle insertion and tissue acquisition techniques
381 FNA of cystic lesion
382 FNA of solid lesion
383 FNA/fine needle biopsy lesions
384 FNA/fine needle biopsy performance
385 Fine needle biopsy
386 Follow ductal or vascular structures with linear scope from the duodenum to the stomach
387 Follow the bile duct with linear scope from the papilla to the hilum
388 Follow up the whole bile duct into the liver
389 Following anatomical structures, e.g., pancreas from the head to the tail
390 Following anatomical structures, e.g., vessels over a longer distance
391 For those practicing in a pancreatobiliary referral center: EUS-necrosectomy, EUS-biliary access (possibly EUS-pancreatic duct access and GB drainage)
392 For those who do pancreatobiliary endoscopy (ERCP) and care for patients with severe pancreatitis, the ability to perform EUS-cystgastrostomy
393 For those who work with thoracic surgery/oncology, ability to stage esophageal cancer, and possibly help stage lung cancers
394 For those working in an oncology center, possibly EUS-guided gastrojejunostomy
395 Gallbladder
396 Gastric cancer staging
397 Gastrointestinal Cancer staging with accuracy
398 Gastrojejunostomy
399 General knowledge in ERCP
400 General knowledge in US
401 General knowledge in US into transcutaneous US (TUS) images
402 Get a feel for the importance of the up/down handle
403 Get detailed images from the GB
404 GI perforations
405 GIST study and sampling
406 Good skills in a safe puncturing of these findings
407 Good skills in approaching and stabilizing the instrument close to these findings
408 Good skills in approaching different and interesting parts of a lesion with the needle
409 Good skills in characterizing abnormal findings
410 Good skills in detecting abnormal findings
411 Good skills in handling different needles
412 Good skills in optimizing the images
413 Gradual endoscope movement permitting progressive, confident and correct interrogation of the patient's anatomy, without skipping over regions
414 Handle your microscoop and slides without breaking it
415 Handling (including loading) of FNA/fine needle biopsy needle
416 Handling biopsy needle with one hand
417 Handling biopsy speciments
418 handling 'gastroscope' (two wheel steering, suction and flushing) are new for pulmonologists
419 Handling of the Albaran-device
420 Handling of the suck- and inflate-knobs (balloon and gi lumen)
421 Handling wheels and elevator with one hand
422 Handling when needle will not advance out of scope
423 Have a detailed knowledge on how to handle the endoscope
424 Have a detailed knowledge on the anatomy in the mediastinum
425 Have an excellent knowledge of EUS anatomy with both the radial and linear echoendoscope
426 Having good skills in handling changing related to surgery
427 Having good skills of the changing related to age for example in the pancreas
428 Head of the pancreas
429 High experience iin transabdominal ultrasound
430 High experience in diagnostic and therapeutic endoscopy
431 How often do you need to aspirate
432 How to get control over the orientation
433 I am not sure about radial EUS: depends on practice settings
434 I am not sure about rectal EUS: pertains more to the colo-proctologist than to the endosonographer. Also depends on practice setting
435 I am sure that advance therapeutic hybrid procedures (involving fluoroscopy) do not pertain to the EUS area primarily, but to the interventional (ERCP) arena
436 I identify from the duodenum the great vessels, uncinate process, the paipilla, PD, CBD
437 ID of Metatastic liver lesions
438 Ideally knowledge in CT scan
439 Identification (linear) of AP window
440 Identification (linear) of bifurcation of the trachea
441 Identification (linear) of body/tail/head of pancreas and uncinate process
442 Identification (linear) of celiac trunk/portosplenic confluence
443 Identification (linear) of gallbladder
444 Identification (linear) of the CBD/H from ampulla to the liver hilum
445 identification and interpretation of abnormal findings in the mediatinum, liver and bilipancreatic region
446 Identification of all segments of pancreas including pancreatic duct
447 Identification of ampulla (endoscopically and on linear EUS)
448 Identification of autoimmune pancreatitis
449 Identification of biliary pathology
450 Identification of biliary system from papilla to intrahepatic ducts
451 Identification of fix points - etc. Liverhilum
452 Identification of landmarks upper abdomen ultrasound
453 Identification of left adrenal gland
454 Identification of lesion of interest or rule out
455 Identification of lesions in the ultrasound anatomy
456 Identification of liver lesions
457 Identification of liver pathology
458 Identification of major papilla
459 Identification of mural sonolayers
460 Identification of optimum safe site for biopsy or puncture
461 Identification of pancreatic pathology
462 Identification of subepithelial lesions
463 Identification of the aorta
464 Identification of the biliopancreatic confluence
465 Identification of the celiac artery
466 Identification of the different wall layers of the luminal GI tract
467 Identification of the left adrenal gland
468 Identification of the lymphonod in the chest during esophageal passage
469 Identification of the mass invasion of the vessels
470 Identification of usual abnormal anatomy (peri GI masses, lymph nodes & stations, intramural abormalities, pancreatobiliary disease such as CBD stones and chronic pancreatitis)
471 Identification of vascular anatomy of upper abdomen
472 Identification of vasculature and appropriate use of Doppler
473 identifications the uncinate process
474 Identify anatomy with rectal ultrasound
475 Identify and delinate anatomy of liver and biliary system
476 Identify and delinate anatomy of pancreas and surroundings
477 Identify and delineate anatomy in mediastinum
478 Identify bile duct and portal vein
479 Identify B-mode characteristics of nodes
480 Identify celiac axis
481 Identify defined anatomic EUS landmarks for orientation and interpretation of findings
482 Identify ductus choledochus
483 Identify features of chronic pancreatitis
484 Identify galblatter
485 Identify gallbladder and bile duct stones
486 Identify in this order: liver, abdominal aorta, left adrenal gland, station 7, 4L, 4R
487 Identify key anatomical structures: PV, SV, SMV, Aorta, Celiac A, Pancreas, Hepatic veins, IVC
488 Identify level 7 nodes
489 Identify mediastinum
490 Identify mural nodules and epithelial nodules in pancreatic cyst
491 Identify organs and vessels on EUS
492 Identify pancreas and pancreas duct
493 Identify pancreatic duct
494 Identify pancreatic mass and describe EUS characters- hypo-/hyperechoic, calicfication, PD
495 Identify papila echographic image
496 Identify papila endoscopic image
497 Identify physiologic narrowings and steer safely around these structures
498 Identify relevant lymfnodes for staging of oesophageal tumor
499 Identify standard stations: subcarinal space, AP window, LN stations in mediastinum
500 Identify structures from each station
501 Identify the bile duct
502 Identify the celiac artery takeoff from the aorta
503 Identify the gallbladder
504 Identify the intestinal layers
505 Identify the lesion
506 Identify the liver
507 Identify the portal confluence vasculature
508 Identify the relationship of organs, vessels, ducts
509 Identify the various parts of the pancreas
510 Identifying bile duct/gall bladder
511 Identifying head of pancreas and uncinate
512 Identifying left love of liver
513 Identifying pancreatic body and tail/neck
514 Identifying relevant (numbered) LN stations in the medisatinum and peritoneum/retroperitoneum
515 IDENTIFYING STRUCTURES AND PROBLEMS
516 Identifying the 5 layers of gut wall
517 Identifying the celiac axis
518 Identifying the papilla region
519 Immortalization through pictures and films
520 In most cases people should also be trained in EUS guided interventions (i.e., pseudosycst/biliary drainage etc.)
521 Indentification of the body of the pancreas
522 Indentification of the CBD and PD from ampulla (2nd portion)
523 Indentification of the head of the pancreas
524 Indentification of the head of the pancreas
525 Indentification of the hepatic hilum (portal vein and bile duct) from stomach
526 Indentification of the liver
527 Indentification of the spleen
528 Indentification of the tail of the pancreas
529 Indentification of the uncinate process
530 Insert a miniprobe and obtain adequately clear images for interpretation
531 insert a needle in different scope positions (in the stomach and duodenum)
532 Insert echoendoscope across the cricopharynx safely
533 insert linear endoscope in esophagus
534 insert the endoscope in the patient
535 Insert the endoscope into the 2nd part of the duodenum
536 Inserting a radial and linear EUS scopes to the sigmoid colon
537 Inserting a side-viewing duodenoscope or Echoendoscope from mouth to second part of duodenum
538 Inserting both linear (and radial if possible) into the second part of the duodenum
539 Inserting endoscope through the Killian
540 Inserting scope into the duodenum under EUS guidance
541 Inserting scope till rectosigmoid junction under EUS guidance
542 Inserting the echoendoscope into the 2nd duodenum
543 Inserting the echoendoscope into the duodenal bulb
544 Inserting the echoendoscope into the esophagus
545 Inserting the echoendoscope into the esophagus
546 Inserting the echoendoscope into the rectum
547 Inserting the echoendoscope into the second part of the duodenum
548 Inserting the echoendoscope into the second part of the duodenum
549 Inserting the echoendoscope into the second portion of the duodenum
550 Inserting the echoendoscope into the third part of the duodenum
551 Inserting the echoendoscope to the second part of the duodenum
552 Inserting the endoscope into the 2nd part of the duodenum
553 Inserting the endoscope into the esophagus
554 Inserting the endoscope into the esophagus
555 Inserting the endoscope into the esophagus
556 Inserting the endoscope into the second part of the duodenum
557 Inserting the endoscope into the second part of the duodenum
558 Inserting the endoscope into the second part of the duodenum
559 Inserting the endoscope into the second part of the duodenum
560 Inserting the endoscope into the second part of the duodenum
561 Inserting the endoscope into the second part of the duodenum
562 Inserting the endoscope into the stomach
563 Inserting the endoscopio into 2nd duodenum
564 Inserting the EUS scope into 2nd portion duodenum
565 Inserting the EUS scope to the descending colon
566 Inserting the linear and radial echoendoscope into the second part of the duodenum
567 Inserting the linear endoscope in the second part of the duodenum
568 Inserting the linear endoscope into sigmoid colon
569 Inserting the linear endoscope into the anorectum
570 Inserting the linear EUS endoscope into the second part of the duodenum
571 Inserting the radial endoscope in the second part of the duodenum
572 Insertion accessories into working channel of echoendoscopy e.g., biopsy needle
573 Insertion in esophagus
574 Insertion of bulb
575 Insertion of D2
576 Insertion of endoscope through to the duodenum and from rectum to illiac vessels
577 Insertion of EUS in thé oesophagus
578 Insertion of lumen apposing metal stent into pancreatic fluid collection
579 Insertion of the linear scope to D3
580 insertion of the scope in the esophagus
581 Insertion through the upper esophageal sphincter
582 Inspect 2L
583 Insufflation of balloon with water without air-bubbles
584 Integrating and co-ordinating endoscopic and sonographic anatomy
585 Interpret elastography strain histogram
586 Interpret elastopgrahy strain graph
587 Interpret Linear EUS anatomy in D1
588 Interpret Linear EUS anatomy in D2
589 Interpret Linear EUS anatomy in D3
590 Interpret Linear EUS anatomy in mediastinum
591 Interpret Linear EUS anatomy in stomach- proximal, mid and distal
592 Interpret microscopic view of slides
593 Interpret pancreas head from distal stomach across PV
594 Interpret radial EUS anatomy in D1
595 Interpret radial EUS anatomy in D2
596 Interpret radial EUS anatomy in mediastinum
597 Interpret radial EUS anatomy in stomach - proximal, mid and distal
598 Interpret the linear anatomy form the 2nd part of duodenum and the duodenal bulb
599 Interpret the linear anatomy from mediastinum
600 Interpret the linear anatomy from the ventricle
601 Interpret the sonographic appearance and offer a differential diagnosis of sub-epithelial lesions
602 Interpret ultrasound illusional images
603 Interpretation and characterization of cystic lesions of pancreas
604 interpretation of abnormal/suspect LAG
605 Interpretation of abnormal anatomy
606 Interpretation of all functions and dysfunctions of an EUS scope
607 Interpretation of anatomical guiding structures
608 Interpretation of digestive wall layers in EUS
609 Interpretation of layer of origin of subepithelial lesions
610 Interpretation of normal anatomy/radial and linear
611 Interpretation of oblique view endoscopic image
612 Interpretation of pancreatico-biliary anatomy
613 Interpretation of sonomorphology: conventional abdominal ultrasound including doppler/duplex and CEUS
614 Interpretation of the pathology
615 Interpretation of tumor invasion into mediastinal structures (T4 criteria)
616 Interpreting the images and tracing the structures at each of the 4 pancreatobiliary stations for both radial and linear echoendosdcopes
617 Interpreting the images and tracing the structures for the mediastinal stations for both the radial and linear echoendoscopes
618 Interventional endoscopists may require facility with forward-viewing EUS scope
619 Introducing the scope, also/especially in difficult anatomy
620 Introduction of EUS scope into the 2nd part of duodenum with minimal air insufflation
621 Introduction scope into esophagus
622 Intubation
623 Intubation
624 Intubation of esophagus
625 Intubation of oesophagus and down to second part duodenum
626 Intubation of the esophagus
627 Intubation of the esophagus
628 Intubation of the esophagus with a linear therapeutic echoendoscope
629 Is cytology fine or histology needed
630 Judicious use of water instillation in GI lumen
631 Keeping insufflation to the minimum
632 Keeping the echoendoscope straight at all times to maximize tip control
633 Knobology, at least 20 features
634 Know all the basic physics principles (range, gain, contrast, depth, etc.)
635 Know all the different techniques for FNA (fanning, suction, no suction)
636 Know all the differing FNA and fine needle biopsy needles on the market
637 Know EUS stations for radial and linear echoendoscope
638 Know how to best display ultrasound image with the echoendoscope (adequate frequency, focus, gain, contrast, harmonics, etc.)
639 Know how to identify subepithelial tumors, by the layer of origin
640 Know how to prepare an echoendendoscope (connexions, balloon,…)
641 Know how to store images and/or video loops
642 Know how to use air and water during EUS exam for a better outcome
643 Know how to use and adjust Doppler signal
644 Know how to use Doppler in EUS exam and obtain maximum benefit from it
645 know the advantages and disadvantages of different needles
646 Know the basics and physics beyond ultrasound
647 Know the classification and nomenclature of various lymph node stations in the chest and abdomen
648 Know the difference between cytology, immunohistochemestry and histology
649 Know the features of chronic pancreatitis
650 Know the technique for a complete radial and linear exam
651 Know to use external aids like gallbladder pressure, to improve detection of stones
652 Know what structures are mandatory not to biopsy
653 Know what structures are mandatory to biopsy
654 Know when aspiration is a risk for complications
655 Know when not to aspirate (cysts)
656 Know which drugs may help improve EUS image and therefore outcomes (e.g., buscapine)
657 Know which order to aspirate different regions
658 Knowing stations
659 Knowledge (we call it pancreas mobile) why the tail of the pancreas is so close to the head in a left lateral position
660 Knowledge and interpretation of computed tomography scan and magnetic resonance images
661 Knowledge fo the different tools and techniques for histological sampling with EUS
662 Knowledge how to handle the biopsy specimen in case of MOSE
663 Knowledge how to handle the specimen in case of no ROSE
664 Knowledge how to perform contrast injection and result interpretation
665 Knowledge in US guided punctures and interventions
666 Knowledge of anatomical variations
667 Knowledge of both radial and linear EUS endoscopes
668 Knowledge of both, TUS and EUS
669 Knowledge of different biopsy techniques (FNA/fine needle biopsy)
670 Knowledge of EUS-BD drainage
671 Knowledge of EUS-FNA (accuracy, etc.)
672 Knowledge of EUS-GBD drainage
673 Knowledge of EUS-PD drainage
674 Knowledge of EUS-PFC drainage
675 Knowledge of FNA needles
676 Knowledge of imaging EUS (elastography, contrast EUS)
677 Knowledge of linear anatomy in different sites
678 Knowledge of local clinical management algorithms determining appropriateness of FNA/fine needle biopsy
679 Knowledge of lymph node stations
680 Knowledge of principles of general US-investigation - brightness, focus, depth, recording, Doppler
681 Knowledge of technical set up of echo graphic machine
682 Knowledge of the Limitations of US imaging compared to anatomy
683 Knowledge of the UL technique
684 Knowledge of troubleshooting of diagnostic EUS and EUS-FNA
685 Knowledge of troubleshooting of EUS-BD
686 Knowledge of troubleshooting of EUS-GBD
687 KNOWLEDGE of troubleshooting of EUS-PD
688 Knowledge of troubleshooting of EUS-PFC drainage
689 Knowledge of ultrasound artifacts
690 Knowledge of various knobs on the utlrasound console: knobology
691 Knowledge on how to handle a rigid endorectal probe
692 Knowledge on how to identify arcuatum ligament
693 Knowledge on how to identify normal sized lymph nodes in the liver hilum
694 Knowledge on how to identify normal sized lymph nodes subcarinal
695 Knowledge on how to identify supraadrenal gland vessels
696 Knowledge on how to identify the aortopulmonary window
697 Knowledge on how to identify the mesorectum
698 Knowledge on how to identify the prostate (at which position)
699 Learn B-mode identifiers for risk of malignancy
700 Learn elastography technical background
701 Left hand movements recognition
702 Limits of EUS
703 Linear anatomy
704 Linear anr radial orientation
705 Linear EUS scope insertion up to D2
706 Locate cystic structures from within the pancreas and relationship to the duct
707 Locate the gastroduodenal artery and hepatic artery
708 Locate the GB from the antrum and duodenal bulb
709 Locate the left adrenal, left kidney and trace the renal vein to the kidney
710 Locate the PV and SMV confluence
711 Locating scope in D1 and D2
712 Location of aorta and celiac trunk
713 Location of left kidney and left adrenal
714 Location of pancreatic body and tail
715 Location of pancreatic head
716 Location of portal vein and superior mesenteric vein
717 Location of superior mesenteric artery and vein
718 Location of the aorto-pulmonary window
719 Location of the left liver lobe
720 Location of the subcarinal space
721 Luminal tumor staging
722 Lymph node biopsy
723 Lymph node stations in the chest
724 Maintaing EUS image for performance of FNA
725 Make “ERCP”-maneuver (shortening duodenum while withdrawing a scope)
726 Make slides
727 Make your own slides for ROSE
728 Making sure that the relevant persons are ready/prepared
729 Manage long and short position EUS évaluation of the duodenum with linear scope
730 Manage long and short position EUS évaluation of the duodenum with linear scope
731 Manage long and short position EUS évaluation of the duodenum with radial scope
732 Manage short position EUS evaluation of the neck of the pancreas with radial scope
733 Management of anticoagulants
734 Maneuver both radial and linear scope in upper GI tract
735 Maneuvering safely the rigid non-steerable tract of the echoendoscopes
736 Manipulate with linear scope in the stomach
737 Manipulation if big wheel and elevator during FNA to change needle trajectory
738 Manipulation of sonoscope
739 Mastering upper endoscopy including duodenoscopy
740 Mediastinal anatomy
741 Medical doctor is better
742 Mesenteric vessels
743 Mesurement of structures
744 Minimizing complications when doing FNA/fine needle biopsy
745 Mounting of scope
746 Move scope to level 9 nodes
747 Move to 4L
748 Mucosal trauma in GI tract
749 Multiple plan imaging
750 Navigate an oblique viewing endoscope
751 Navigate the EUS scope from mouth to the 3rd portion of the duodenum
752 Navigating the scope by US imaging
753 Necrosectomy
754 Need for EBUS combination
755 Needle handling
756 Needles knowledge and different use
757 Negotiate GE Junction carefully with dexterity
758 New EUS devices for therapeutic procedures (LAMS, RFA etc.) knowledge and technic
759 Number 1 and 2 agree
760 Obtain a stack sign
761 Obtain endoscopic view of papilla
762 Obtain rotation with shoulder and shaft movement and not applying torquing
763 Obtaining images with landmarks to identfiy structures
764 Obtaining the ampullary view from D2
765 Optimizing cellularity of samples from various lesions (e.g., fan, use of different needles, number of passes, ROSE, MOSE, etc.)
766 Optimizing visualization of target organ or lesion by using controls on the processor (e.g., change frequency, gain, etc.)
767 Optimizing visualization of target organ or lesion endoscopically
768 Other structures which may be of relevance: Adrenal, thoracic duct, Azygos vein
769 Pancreatic body
770 Pancreatic cancer staging
771 Pancreatic cancer staging
772 Pancreatic cyst drainage
773 Pancreatic imaging station from duodenum
774 Pancreatic lesion biopsy
775 Pancreatic mass FNAC or biopsy
776 Pancreatic pathology study
777 Pancreatic rendezous
778 Pancreatic tail
779 Papilla identification
780 Passage of echoendoscope across the pylorus into the duodenal bulb
781 Passage of echoendoscope into esophagus
782 Passage of echoendoscope into the second duodenum
783 Passage of FNA needle
784 Passage of scope into second portion of duodenum
785 Passage of the scope past a hiatal hernia
786 Passing bot the radial and linear echoendoscope with ease beyond the EUS and through the pylorus
787 Passing echoendoscope around the duodenal apex
788 Passing scope through pylorus
789 Passing scope to D2
790 Passing scope to esophagus
791 Passing scope to proximal stomach
792 Passing the scope into the esophagus past the EUS
793 Passing the scope past pylorus into 2nd portion duodenum
794 Passing the scope to D2
795 Patient monitoring
796 Patient position with intubation
797 Patient position without intubation
798 Perfect anatomy recognition in magnetic resonance
799 Perfect anatomy recognition in scanner
800 Perfect echographic pattern of normal organs recognition
801 Perfect endoscopic correlation with outside organs and vessels
802 Perfect endoscopic localisation
803 Perfect knowledge of mediastinal and abdominal anatomy
804 Perform celiac plexus neurolysis
805 Perform EUS assessment for biliopancreatic benign and malignant diseases
806 Perform EUS staging for malignacies
807 Perform EUS-FNA and EUS-fine needle biopsy
808 Perform EUS-guided biliary drainage
809 Perform EUS-guided fiducial placement
810 Perform FNA from all EUS stations
811 Perform FNA of a 1 cm lesion of the pancreas
812 Perform needle based sampling
813 Perform sedation for diagnostic EUS
814 Perform stent insertion in mediastinal and abdominal fluid collections
815 Performing cyst aspiration supervised
816 Performing EUS guided biopsy of LN/solid tumor
817 Performing EUS procedures including FNA, pseudocyst drainage, transgastric access to the biliary tree,
818 Performing EUS-BD drainage
819 Performing EUS-FNA (B)
820 Performing EUS-GBD drainage
821 Performing EUS-PD drainage
822 Performing EUS-PFC drainage
823 Performing FNA/fine needle biopsy supervised
824 Performing linear EUS as the best tool much better than radial EUS except in the anorectum
825 Performing screening diagnostic EUS (GI, pancreatobiliary)
826 Place a needle into a target
827 Place fiducials (optional-all programs don't do that)
828 Placement of fiducials
829 Placement of the ultrasound transducer on a target
830 Portal confluence
831 Positioning for FNA
832 Preparation of the scope (filling of the balloon)
833 Procedural sedation
834 Proficiency in Axios stent use
835 Proficiency in EUS pseudocyst management
836 Proper room setup for EUS exam
837 Pseudocyst drainage
838 Puncture and drainage of a pancreatic collection
839 Puncture of lesions > 1 cm (pancreas)
840 Puncture of lymph nodes
841 Radial EUS scope insertion up to D2
842 Radiofrequency ablation
843 Reaching all locations
844 Reaching all stations
845 Reaching the papilla
846 Reaching the papilla of Vater and identify the biliary and pancreatic duct
847 Reading standard textbook to depiction each organs
848 Recognise key landmarks - OG, M, PB, anorectal
849 Recognise liver and focal lesions/abnormal texture
850 Recognise major vessels
851 Recognition of benign and malignant adenopathy
852 Recognition of bleeding after FNA
853 Recognition of major venous and arterial blood vessels
854 Recognize anatomical landmarks in mediastinum and abdomen for both linear and radial EUS
855 Recognize and reproduce the vascular anatomy
856 Recognize liver from spleen
857 Recognize sarcoid characteristics ultrasound
858 Recognize the need for antibiotic prophilaxis for FNA
859 Recognizing all anatomical landmarks with the radial and linear to include the following structures and to locate on own the following:
860 Recognizing mediastinal structures with both radial and linear scopes
861 recognizing needle pathway in case of FNA/fine needle biopsy
862 Rectal cancer staging
863 Relatively Younger is better
864 Reliably complete imaging of the bile duct from ampulla to hilum
865 Reliably recognize lymph node stations and staging
866 Reliably stage pancreatic malignancy or at least recognize areas of weakness in staging
867 Reposition the echoendoscope in the esophagus into a standardized position (“33 cm subcarinal region)
868 Reposition the echoendoscope in the esophagus into a standardized position (“44 cm Aorta, celica trunc)
869 Reposition the echoendoscope in the esophagus into a standardized position (“55 cm part I/II of duodenum, distal part of the bulb
870 Requirements for a good image qualitiy (contact, pressure on the transducer, water filling, balloon …)
871 Right hand movements recognition
872 Riskfree insertion of an duodenoscope into the second part of the duodenum
873 Role of suction in EUS
874 Safe and comfortable intubation of the EUS instrument
875 Safe and comfortable manovering of the EUS instrument in different parts of the gut
876 Safe handling of a forward-viewing endoscope
877 Safe handling of a side-viewing endoscope
878 Safe introduction in esophagus
879 Safe intubation
880 Safe passage into the second portion of the duodenum
881 Safely insert the echoendoscope into the duodenum
882 Scope insertion across cricopharynx
883 Scope maneuvering to complete anatomical evaluation – e.g., witndrawing scope from D2
884 Scope manoeuvring across D1
885 Scope motion to identify subcarinal space
886 Securely pass linear scope to the second part of duodenum
887 Self-critical interpretation of the own knowledge
888 Setting adjustments in keyboard - Gain and contrast
889 Shorten echoendoscope in the duodenum
890 Should be able to interpret abnormal anatomy and recognise lesions
891 Should have an understanding of the movements of the scope to visualise anatomy
892 Should have theoretical knowledge of features and classification of pathologies e.g., tumour TNM classification, chronic pancreatitis etc.
893 Should understand the movements of the endoscopist to visualise anatomy and pathology
894 Simultaneous handling of endoscope and improving ultrasound image quality
895 Sonographic hallmarks of various normal variants, and benign and malignant diseases
896 Staging of esophageal cancer
897 Staging of gastric cancer
898 Staging of luminal cancer
899 Staging of pancreas cancer
900 Staging of rectal cancer
901 Standardized examination
902 Standardized procedure to examine the adrenal glands
903 Standardized procedure to examine the anorectum
904 Standardized procedure to examine the bile ducts
905 Standardized procedure to examine the duodenum
906 Standardized procedure to examine the esophagus
907 Standardized procedure to examine the gallbaldder
908 Standardized procedure to examine the liver hilum
909 Standardized procedure to examine the lung and mediastinum according to the lymph node localisation
910 Standardized procedure to examine the pancreas
911 Standardized procedure to examine the rectum
912 Standardized procedure to examine the spleen
913 Standardized procedure to examine the stomach
914 Starting with radial or linear EUS anatomy
915 Subepithelial lesion characterisation
916 Submucosal tumor study and sampling
917 Successful FNA
918 Sufficient knowledge of normal and pathological findings in abdominal ultrasound
919 Supra renal gland identification
920 Systematic examination of the entire pancreas
921 Systematic examination of the extrahepatic bile duct
922 Systematic examination of the mediastinal anatomy
923 Taking FNAC from different stations organs
924 Technique of core biopsy of intramural masses
925 Technique of FNA sampling of lymph nodes
926 Techniques of FNA sampling of extraluminal organs
927 The above applies to gut wall lesions and extraluminal conditinons such as pancrea
928 The pancreatic head is larger than often assumed
929 The relevant instrument - FNA/fine needle biopsy etc., in the room
930 Therapeutic EUS
931 Theroetical (at least) knowledge of all indications for EUS-guided interventions
932 Thinking about differential diagnosis
933 TNM stage
934 TNM staging
935 To be able to indentify liver segments and vessels through the stomach and the duodenum
936 To be able to find and follow celiac axis and his branches using linear scope
937 To be able to follow the cystic duct from the neck of the gallbladder to the CBD using linear and radial scope
938 To be able to identify all vascular structures and heart cavities in thin young patients where all these structures are well visible
939 To be able to identify body and entire tail of the pancreas using radial scope and to be able to recognize the 20% of the patients where the top of the tail is not visible using radial scope justifying the linear scope if these is an indication to examine the entire pancreas (Aciute pancréatites of unknown origin, looping for insulinoma or MEN 1 syndrom, or staging of IPMN
940 To be able to indentify lesser curve greater curve anterior and posterior wall of the stomach under EUS guidance without air intillation
941 To be able to indentify neck of the pancreas through the stomach using radial scope in ladies and neck using radial and linear scope in male and female
942 To be able to perform dis-guided drainage of pseudo-cysts using double pigtail stents and metallic stents for abscesses.
943 To be able to perform EUS-guided celiac block and neurolysis
944 To be able to perform EUS-guided FNA with fanning method in pancreatic mass through the duodenum and the stomach
945 To be able to perform FNA in submucosal mass and in mediastinal lymph node
946 To be able to perform staging of oesophageal gastric and rectal cancer
947 To be able to visualize CBD stones in more than 80% of the cases when present.
948 To be able to visualize the 3 parts of the gallbladder through the antrum and the duodénal bulb in more than 95% of the cases
949 To be able to visualize the entire bile duct from the hilum to the ampulla when it is dilated
950 To be able to visualize using radial and linear scopes the 3 parts of the head (uncinate process, posterior and anterior part of the head using radial and linear scopes
951 To introduce the scope carefully without damage in any case
952 To move into the descending duodenum Using EUS guidance following the CBD or the PD to the ampullary region
953 To move into the duodenal bulb using a radial scope with EUS guidance avoiding to introduce air within the gastric cavity
954 To study the mediastinum with knowledge of all visible lymph node stations
955 Torque of scope to identify periampullary cbd and pd
956 Torque of scope to maintain visualization of the EUS needle tip during FNA
957 Torque of the scope to visualize the pancreas tail
958 Trace common bile duct from papilla to hepatic ilum
959 Trace pancreatic cysts to pancreatic duct
960 Trace pancreatic duct from the papilla to the tail
961 Trace the bile duct from hilum to ampulla
962 Trace the CBD from the GB to the ampulla and identify CBD stones
963 Trace the entire PD from tail to the ampulla
964 Trace the pancreas duct from neck of pancreas to major or minor papilla
965 Trace the PV
966 Trace the SMA
967 Trace the splenic vein and artery
968 Transformation of anatomical interpretation of the linear anatomy in radial imaging
969 Transformation of anatomical interpretation of the linear anatomy into MRI and CT imaging
970 Transrectal imaging
971 Troubleshooting when equipment not working
972 Uncinate process
973 Understand anatomy as continuous and not fragmented
974 Understand anatomy as seen on EUS
975 Understand and perform miniprobe EUS
976 Understand and performs the different methods of tissue acquisition (slow pull vs. capillary vs. etc.)
977 Understand the different Doppler functions, including color, power, and spectral Doppler (pulsed Doppler)
978 Understand the normal radial and linear anatomy in the thorax
979 Understand the structure and components of different EUS FNA and fine needle biopsy needles
980 Understand what is abnormal findings, specially tumors
981 Understand when it is helpful to use fine needle biopsy (vs. FNA)
982 Understandig of the movements of a radial and linear transducer within the body
983 Understanding 3 dimensional normal and altered anatomy based on 2D imaging
984 Understanding anatomy
985 Understanding and handling properly the oblique endoscopic viewing
986 Understanding and use of fanning technique for biopsy
987 Understanding and use of slow pull technique for biopsy
988 Understanding and use of suction technique for biopsy
989 Understanding new techniques and innovations
990 Understanding of and using power Doppler mode
991 Understanding of and using contrast enhanced EUS
992 Understanding of and using Elastografi
993 Understanding of and using of color Doppler mode
994 Understanding of basics of FNA needle
995 Understanding of the relationship between endoscope position and anatomical perspective at common EUS imaging stations
996 Understanding of the role of endoscope torque in accurately accessing and sampling target structures
997 Understanding radial and linear imaging
998 Understanding relationship in history and finding
999 Understanding voxelman imaing
1000 Understanding why radial scanning is unphysiological (“stupid”)
1001 Understands how EUS works
1002 Understands how to identify and classify submucosal lesions
1003 Understands how to interpret EUS tests (i.e., cyst fluid results)
1004 Understands how to manage patients with diseases evaluated by EUS
1005 Understands limitation of EUS
1006 Understands options for performing EUS-FNA/fine needle biopsy, different needles, different techniques, when and how to use them
1007 Understands the basic physics principles and different imaging modalities of EUS
1008 Understands the cancer staging and is able to accurately stage both luminal and pancreaticobiliary cancers
1009 Understands the indications for EUS
1010 Understands where lesions can be missed
1011 Upper abdominal anatomy from proximal stomach
1012 Upper GI endoscopy advanced skills
1013 Use and indication of contrast
1014 Use of balloon
1015 Use of balloon
1016 Use of basic US function
1017 Use of contrast media technical set up of the system
1018 Use of Doppler
1019 Use of Doppler, sonoelastography
1020 Use of elevator during FNA
1021 Use of linear echoendoscope without transducer balloon
1022 Use of processor including Doppler, calipers, pulse wave, gain, frequency change, etc.
1023 Use of prophylactic antibiotics
1024 Use of US processor
1025 Use of water
1026 Use relevant force in handling the scope
1027 Using left hand and straight scope and not right hand for torquing
1028 Using linear and radial EUS for diagnostic and therapeutic indications
1029 Using long/short echoendoscope position as needed to improve stability
1030 Utilization of the big wheel to keep scope against the intestinal lumen to maintain image quality
1031 Varices study and guided therapy
1032 Velocity of movement
1033 Visualisation of the whole pancreas
1034 Visualise and demonstrate normal anatomy of mediastinum and pancreatobiliary regions
1035 Visualize landmarks of specific stations
1036 Visualize the ampulla
1037 Visualize the entire pancreas (uncinate, head, body, tail)
1038 Visualize the PV and the splenoportal confluence
1039 Visualizing the body
1040 Visualizing the head
1041 Visualizing the key vessels (PV, SMV/SMA, SV/SA, aorta, coeliac etc.)
1042 Visualizing the neck
1043 Visualizing the tail
1044 Visualizing the uncinate
1045 What caliber needle is optimal
1046 What is the role of the big and small wheel at the EUS scope
1047 When do you need to use a new needle
1048 When to ask for help!
1049 When to use suction
1050 Which scope or probe to use.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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