The field of pediatric gastroenterology has experienced dramatic growth over the past 20 years, fuelled by major technical developments in gastrointestinal endoscopy. Endoscopy of the gastrointestinal and hepatobiliary systems has led to remarkable advances in the diagnosis and treatment of diseases of these organ systems. Pediatric gastrointestinal endoscopy has evolved from solely a diagnostic technique to a potential therapeutic modality. Pediatric digestive endoscopy has clearly reached maturity, with widespread recognition of its value and future promise and increasing demand for more specifically trained pediatric gastrointestinal endoscopists. Concurrently, noninvasive techniques such as capsule endoscopy and helical abdominal computed tomography (CT) scanning have evolved into useful clinical tools. The Working Group emphasizes three major issues: the development of the wireless endoscopic capsule, the use of endoscopic surgical procedures, and training of new pediatric endoscopists.
WIRELESS ENDOSCOPIC CAPSULE
Because of the discomfort of small bowel endoscopy, it is not always possible to advance the enteroscope to the entire small bowel. The capsule endoscope (1), which is small enough to be swallowed (11 × 30 mm), has the advantage of being painless; it has no external wires, fiberoptic bundles, or cables and can be used to examine the entire small intestine. The capsule is propelled by peristalsis throughout the gastrointestinal tract. Images are obtained with a short focal length lens as the optical window of the capsule sweeps past the intestinal wall, and there is no need to inflate without requiring air inflation of the lumen. The video images are transmitted by radiotelemetry to an array of aerials attached to the abdomen, stored on a small portable recorder carried on a belt, and subsequently downloaded for analysis. Capsule endoscopy is superior to push enteroscopy and small bowel radiography in detecting bleeding of unknown origin (2,3).
The main indications for capsule endoscopy have been unexplained gastrointestinal bleeding, diagnosis of small bowel diseases such as Crohn disease, and assessment of small bowel involvement in children with polyp syndromes such as Peutz-Jeghers syndrome (4,5). In the near future, pediatric gastroenterologists will be able to routinely use capsule endoscopy to evaluate potential small bowel diseases in children.
Plans to Develop Capsule Endoscopy in Pediatrics
- Undertake a census (within the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition [FISPGHAN]) to determine the expertise in this field.
- Promote collaborative programs and share technical equipment with adult specialists to gain experience and reduce costs.
- Promote exchange of experience and information among different societies: imaging, radiology, surgery, oncology and so on.
- Promote research to find the appropriate age-related applications in children, such as undiagnosed bleeding, Crohn disease, polyp syndromes, celiac disease.
- Promote the publication of an overview on the potentials of capsule endoscopy in children to encourage the widespread use of this technique.
- Develop a web-based tutorial on the use and interpretation of capsule endoscopy to allow rapid dissemination of information among the various societies.
ENDOSCOPIC SURGICAL PROCEDURES
Percutaneous gastrostomy, jejunostomy, cecostomy, variceal ligation, polyp removal, and the endoscopic retrograde cholangiographic procedure are well-established surgical procedures in pediatric endoscopy. More recently, the role of endoscopy in surgery has expanded, and three main areas are beginning to emerge: (1) endoscopic antireflux procedures; (2) endosonographic guided surgical interventions; and (3) endoscopic mucosal resection.
These techniques have enormous potential in pediatric gastrointestinal endoscopy, but experience is minimal and, consequently, the efficacy of these techniques is as yet unproven.
Endoscopic Antireflux Procedures in Children
Although open or laparoscopic antireflux procedures are still the optimal surgical treatment, three potentially less invasive endoscopic antireflux procedures have become available. The first is endoscopic suturing. One such procedure makes use of a sewing machine attached to the endoscope and involves pairs of stitches placed below the gastroesophageal junction to create internal endoluminal plications of the fundus (6). There is some preliminary but promising experience in pediatrics with this technique (7), and 1-year follow-up findings in adults, and now in children, show a sustained antireflux effect. With the second technique, the Stretta procedure, application of radiofrequency energy to the LES decreases the frequency of LES relaxations in adults but was associated with a risk of perforations. The third technique entails the injection of an inert biopolymer into the submucosal/muscularis space at the gastroesophageal junction to bolster this area and has been shown to increase LES pressure in adults. Neither the Stretta procedure nor the biopolymer injection technique has been attempted in children, and because both techniques remain unproven in adult trials, their use in children should remain at the stage of clinical trials.
Other Surgical Procedures with Endosonographic Guidance
Other surgical procedures with endosonographic guidance involve innovative work, usually with ultrasonographic guidance, in such areas as pancreatic cyst drainage, gastrojejunal anastomosis, and choledochogastric or choledochoduodenal drainage. These procedures promise to expand the role of the interventional pediatric endoscopist in coming years.
Endoscopic Mucosal Resection
The technique of endoscopic mucosal resection is mainly applicable to mucosal and submucosal gastrointestinal tumors and therefore usually is applied to adult patients. However, endoscopic mucosal resection of large sessile polyps is feasible and hence may have application in pediatric endoscopic practice. Its efficacy may be further enhanced by simultaneous endosonographic guidance (8).
Plans to Develop Endoscopic Surgical Procedures in Pediatrics
- Undertake a census (within FISPGHAN) to determine the experience in these areas.
- Promote collaborative programs and share technical equipment with adult specialists to gain expertise and reduce costs.
- Promote exchange of experience and information with different specialities, such as radiology and pediatric surgery.
- Promote research to find potential applications of these techniques in children, especially in relation to antireflux procedures.
- Publish an overview of the potential of these techniques for pediatric endoscopy and pediatric gastrohepatologic diseases to encourage the widespread use of these techniques.
UPDATING TRAINING OF PEDIATRIC ENDOSCOPISTS
During the past decades, the use of endoscopy of the gastrointestinal and hepatobiliary systems in children has advanced considerably thanks to the emergence of very specific techniques for diagnostic purposes and for interventional procedures. Training in pediatric endoscopy must keep pace with these developments. It is the responsibility of national and international pediatric gastroenterology organizations to guide its membership in the initial acquisition of skills during fellowship training and in the maintenance and enhancement of those skills over time. It should be a recommended, or even made a mandatory part of trainees preparation for a pediatric endoscopy training program, that they attend a basic hands-on course in endoscopy/colonoscopy and other theoretical and practical endoscopy courses. Increasingly, virtual training devices should be made available to the trainee before training in actual clinical situations.
Level 1 (Basic Training)
Training programs should provide a comprehensive and balanced view of the relationship between diagnostic and therapeutic procedures. Trainees should perform endoscopic procedures under the direct observation and guidance of an experienced pediatric gastroenterologist. Trainees should learn
- To recommend endoscopic procedures based on the findings of personal consultation and to recognize indications, contraindications, and diagnostic or therapeutic alternatives.
- To perform procedures safely, completely, and expeditiously and to understand the use of sedation and its indications.
- To interpret correctly most endoscopic findings and to perform endoscopic intervention as needed.
- To integrate endoscopic findings into a management plan.
- To understand risk factors and recognize and manage complications associated with the various procedures.
- To learn and apply proper cleaning and maintenance of endoscopic equipment.
- To identify age- and problem-appropriate endoscopic equipment.
- To recognize personal and procedural limits and learn when to request help.
Gastrointestinal endoscopy has become a fundamental tool for the diagnosis and management of children with digestive disease. As with any tool, endoscopy in children requires appropriate cognitive and technical skills to diagnose and treat disorders of the gastrointestinal tract, liver, and pancreas. Diagnostic competence is the ability to promptly recognize and understand abnormalities as they are found. Technical competence is the ability to recognize the need for a therapeutic procedure and the ability to safely and successfully perform the indicated task.
In 1999, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) established guidelines for training in pediatric gastroenterology (9). In these guidelines, two levels of training were recommended. Level 1 trainees are expected to achieve competence in the procedural skills necessary to provide comprehensive care to pediatric patients with gastrointestinal disorders. Level 2 trainees are those who plan to perform specialized endoscopic procedures required for children with complex gastrointestinal problems. This Working Group endorses the overall NASPGHAN view but calls for a more detailed core curriculum for pediatric endoscopy.
As shown in Table 1, procedures considered “basic” for all trainees include upper endoscopy, with the ability to perform foreign body removal and lower endoscopy, including polypectomy (9,10). The number of procedures necessary to achieve competence varies greatly between trainees. The number of needed procedures listed in Table 1 serves only as a guideline for achievement of individual competence. Objective criteria that verify procedural competence do not exist (11). Thus, an experienced training director best determines certification of the procedural competence of an individual trainee. It is not possible for all training programs to teach every trainee all endoscopic procedures. Acquisition of advanced endoscopic skills will require additional training, usually post-fellowship.
Level 2 (Advanced Training)
This level of training assumes successful completion of, or relative seniority in training in, a fellowship in Pediatric Gastroenterology. Trainees may learn diagnostic and therapeutic endoscopic retrograde cholangiographic procedure, endoscopic sonography, endoscopic laser therapy, intestinal stent placement, pneumatic dilation of achalasia, endoscopic tumor ablation, and endoscopic surgery. This training is usually obtained gradually in collaboration with an experienced endoscopist, often an adult gastroenterologist. Such advanced training necessitates that certain basic requirements are fulfilled, as follows:
- A program director to ensure:
- a structured curriculum that ensures appropriate exposure to children with digestive diseases;
- competent mentors to teach technical and cognitive skills;
- appropriate teaching materials, such as books, atlases, videotapes;
- ongoing review of the trainee's progress to determine competence;
- ongoing review and update of the training program, mentors, training materials, and facilities.
- Appropriate, up-to-date facilities for training in the comprehensive care of children (i.e., inpatient and outpatient facilities, laboratory, pathology and radiology facilities).
- Recognition of age- and size-appropriate equipment and training in endoscopic procedures (i.e., recognition of the different needs of an infant vs. an adolescent).
- Access to certified specialists in pediatric critical care, surgery, anesthesia, radiology, and pathology.
Assessment of competence in advanced training requires direct observation of the trainee, ongoing evaluation to correct and improve skills, and formal documentation of procedural skills. The number of procedures needed to be considered competent in more advanced endoscopy remains controversial. Only the North American Society for Pediatric Gastroenterology and Nutrition has published minimum numbers of procedures required to achieve competency (Table 1) (9). It must be stated that these numbers are based on limited data, and hence there is no substitute for trainer assessment of every trainee in as many training endoscopic procedures as possible, with documentation of competence for each procedure. These numbers represent only a general guideline, and the training director must assess each trainee on an individual basis. Obviously, assessment and requirement for trainees can change, such as in developing countries.
MAINTENANCE AND DEVELOPMENT OF NEW SKILLS BEYOND FELLOWSHIP TRAINING
The acquisition of skills in pediatric endoscopy is achieved during fellowship training in pediatric gastroenterology. Board certification in pediatric gastroenterology verifies the individual's knowledge and skills. However, there is no formal mechanism to ensure the maintenance of acquired skills and development of new skills in pediatric endoscopy. The setting of the Second World Congress of Pediatric Gastroenterology, Hepatology and Nutrition should serve as an impetus for the establishment of a program or programs for the maintenance and enhancement of skills in pediatric endoscopy.
It is proposed that the following be developed:
- Annual courses in pediatric endoscopy
- Training videos in pediatric endoscopy
- Centers of excellence in pediatric endoscopy
Annual Courses on Pediatric Endoscopy
Using the successful “Masterclass in Pediatric Endoscopy” by Dr. Michael Thomson as an outstanding example, it is proposed that the World Congress formally develop similar courses. These would cover all aspects of diagnostic and therapeutic pediatric endoscopy. A template of the London-based course can be found at the website www.royalfreepaedgastro.com
Training Videos in Pediatric Endoscopy
Training videos have been successfully developed and used by the American Society for Gastrointestinal Endoscopy for many years. These videos give the physician expert demonstration of endoscopic techniques. They are often used in the training of pediatric endoscopists but provide no instruction in the unique aspects of endoscopy in infants and children with complex digestive diseases.
When more comprehensive pediatric endoscopy videos are developed within FISPGHAN, they could be placed into digital format and made available on the Internet at specific websites similar to the NASPGHAN website. Such an arrangement would allow online continuing medical education in pediatric endoscopy. This program would be a means of circulating endoscopy information to FISPGHAN member societies.
Centers of Excellence in Pediatric Endoscopy
It is recognized that not all medical centers need advanced pediatric endoscopy. It is also recognized that only a small number of medical centers have the appropriate pediatric and adult gastroenterology training programs that offer state-of-the-art endoscopy services for children. It is proposed that several of these centers be designated “Centers of Excellence in Pediatric Endoscopy. Such a designation would include specific funding for the development of the first two proposals outlined above. It is hoped that this funding will lead to a national and international cooperative effort to create ongoing continuing medical education for pediatric endoscopy.
Endoscopic ultrasonography is a relatively new discipline that emerged in the 1980s and has evolved rapidly during the past decade. It allows visualization and measurement of the individual layers of the gut (mucosa, submucosa, and muscle) and extraluminal structures such as lymph nodes, blood vessels, pancreas, liver, and major bile ducts through the use of an ultrasonography transducer attached to an endoscope. There is little and mostly anecdotal experience published with its use in children, although smaller endoscopic probes are now suitable for use with pediatric-size scopes (12,13). Endoscopic ultrasonography continues to be a rarely used and expensive procedure that is not widely available, however. Moreover, there are not many diseases for which endoscopic ultrasonography might provide a benefit in pediatrics, and this situation is exacerbated by the lack of knowledge about this technique among pediatric specialists.
To evaluate the usefulness of endoscopic ultrasonography in the management of gastrointestinal, hepatic, and pancreatic disease in children and to explore possible future applications in new fields (e.g., oncology).
To better define the applications of endoscopic ultrasonography in the field of pediatrics.
Plans to achieve goals.
Promote a review of the published data and encourage collaborative works among experts in this discipline (especially adult gastroenterologists) with an evidence-based approach. This could take the form of a workshop within a major meeting (e.g., Digestive Disease Week), or it could be web-based at first.
(1) To improve the knowledge of our colleagues about the use of endoscopic ultrasonography in pediatrics. (2) To promote the worldwide development of centers that have mastered the technique.
(1) To achieve better utilization of endoscopic ultrasonography. (2) To achieve better results from the use of endoscopic ultrasonography in pediatrics.
Plans to achieve the goals.
(1) Promote the publication of a state-of-the-art overview of endoscopic ultrasonography for the pediatric community to enhance knowledge of this technique. (2) Promote collaborative programs with adult specialists to gain experience. (3) Promote an exchange of experience and information among different societies, such as imaging, surgery, and oncology.
To expand the use and reduce the cost of endoscopic ultrasonography in children.
Optimization in the utilization of available resources.
Plans to achieve the goal.
Take a census and share equipment with adult specialists. This would also be an opportunity to accelerate the “learning curve” in the acquisition of technical skills.
Digital Imaging for Endoscopy
Numerical formats are common in radiology, isotopes, and cardiology but not yet in endoscopy. Numerical formats have several advantages over analogical ones: (1) high fidelity of transmission (noise does not degrade the signals over transmission); (2) unlimited duplication without loss in quality, superior resolution, or quantitative analysis; (3) storage on hard drive or disk (more convenient than tapes); and (4) transfer into computer without conversion. Once loaded onto a computer or network, the video can be edited, stored in a structured archive, or placed in electronic medical records, imported into Internet web pages, and incorporated into slide presentations. Finally, still images can be extracted for printed endoscopy reports.
Structured archive of video sequences and/or images.
With the software now available, endoscopy reports can be illustrated with pictures taken during the procedures.
Illustrating endoscopy reports.
In the last 10 years, video-endoscopes have improved the learning curves of endoscopic procedures. Imaging tools such as video sequences or images are a convenient and effective medium for conveying medical information, training physicians, and controlling the quality of procedures, especially during supervision of fellows and during interventional endoscopies. Illustrating endoscopy reports with images or sequences should improve communication between physicians and facilitate, during the performance of control endoscopy, assessment of the evolution of mucosal lesions.
Physicians are faced with rapidly growing technical information related to computers, databases, video formats, and so on. We believe there is a need for a better understanding of these technologies as regards daily practice and the selection of new medical products.
Plans to Achieve Goals
The Digital Imaging and Communications in Medicine (DICOM) standard was created to aid the distribution and viewing of medical images. A single DICOM file contains a header as well as the image data. A video sequence is just a succession of 25 to 30 images per second. Thus, a structured archive of video sequences and images is composed of single files. DICOM server applications can be found free of charge. Another valuable evolution concerns CCD definition: since the usual resolution in video formats is 720 horizontal and 486 vertical pixels, there is a need for pediatric endoscopes with a CCD resolution of about 400,000 pixels.
As regards illustrating endoscopy reports, the commercially available medical software with the required capabilities are expensive and not flawless. Furthermore, they are still devised on a client/server basis (information displayed/entered into a “client” software), whereas Internet development favors web application (information displayed/entered into a web browser). Open-source web application that meets consensual medical requirements will offer a greater perspective of evolution for the future.
Articles should be provided to explain video format (definition of frame rate and resolution, color definition, and so on) and relational databases, web applications, and other factors and applications. This information should be incorporated into annual courses.
We are close to a major evolution in the way endoscopy signals are processed, displayed, and stored. Migration from an analog to a digital format in endoscopy is inevitable and will provide a simple way to illustrate endoscopy reports, to review details of a procedure, and to create a structured archive of video sequences and images. The cost of this procedure should be such that it can be made available worldwide.
Virtual Endoscopy in Children
Computed tomographic colonography (CTC) is a new technique with which to examine the colon and rectum using low-dose helical abdominal CT scanning of the colon in both the supine and the prone position. Combined with advanced imaging software, this technique allows forward and backward virtual imaging of the colon and rectum. The effective radiation dose in virtual colonoscopy is between 3 and 12 mSv (14). The primary focus has been on screening or follow-up of endoscopically detected lesions of the colon (primarily colon cancer) in adults. There is little or no information on the use of this technique in children.
Mucosal disease being the major indication for colonoscopy in infants and children, CTC will not replace endoscopy for most indications in pediatrics. However, this technology may be useful in the rare circumstances of cancer screening, such as in the case of juvenile polyposis coli. At present, there is good correlation with abnormal findings at colonoscopy and a mass lesion, detected by CT, of greater than 1 cm in the colon, and a lesser sensitivity for lesions smaller than 5 mm (15). To date, there are no published studies of CTC in children. The future use of CTC in children needs to await further data from adults and careful consideration of the specific indications. It cannot be recommended as a clinical application at this time.
(1) To determine the usefulness of CTC in the detection of lesions of the gastrointestinal tract in pediatric cases. (2) To develop CTC protocols for pediatric patients, if the technique proves to be effective in detecting gastrointestinal lesions in these patients.
(1) To know the role of CTC in the field of pediatrics. (2) To devise an optimal protocol for CTC use in pediatric patients.
Plans to achieve goals.
(1) Promote a review of the current status and encourage a collaborative evaluation of the technique, involving experts in the discipline (e.g., adult radiologists, and adult and pediatric gastroenterologists). This could involve workshops at Digestive Disease Week or radiology meetings and the development of centers of interest in pediatrics with expertise in the technology. (2) Develop CTC centers with an interest in pediatric gastrointestinal disorders. (3) Determine whether CTC has functional application in pediatrics.
(1) To improve the knowledge of our colleagues about the possible uses and limitations of CTC in pediatrics. (2) To promote the worldwide development of centers that have mastered the technique as reference facilities.
(1) To achieve a better use of this resource. (2) To achieve better results in the performance of studies.
Plans to achieve the goals.
(1) Promote the publication of a state-of-the-art overview on CTC for the pediatric community to enhance the knowledge of this technique. (2) Promote collaborative programs with CTC specialists to gain experience. Exchange of experience and information among different societies, such as imaging, adult gastroenterology, and oncology.
The proposals outlined here are intended to establish an evidence base for the development of new endoscopic techniques in the management of infants and children. Currently, there are no available data on the medical effectiveness and cost-effectiveness of pediatric endoscopic activities at an international level. The Working Group calls for (1) standardization of endoscopic interventions in children and assessment of trainees; and (2) multicenter collaborative research programs between FISPGHAN member societies.