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Training in Gastrointestinal Bleeding Therapeutic Endoscopy: Rethinking Knowledge and Skill Acquisition

Sauer, Cary G.*,†; Fishman, Douglas S.

Journal of Pediatric Gastroenterology and Nutrition: April 2017 - Volume 64 - Issue 4 - p 497–498
doi: 10.1097/MPG.0000000000001456
Invited Commentaries

*Department of Pediatrics, Emory University School of Medicine

Children's Healthcare of Atlanta, Atlanta, GA

Section of Pediatric Gastroenterology, Hepatology and Nutrition, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.

Address correspondence and reprint requests to Cary G. Sauer, MD, MSc, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Emory Children's Center Suite 250, 2015 Uppergate Dr NE, Atlanta, GA 30322 (e-mail:

Received 5 August, 2016

Accepted 26 October, 2016

C.G.S. is a consultant for Abbvie. D.S.F. is a consultant for Cook Medical, unpaid consultant for Due North, and contributor; UpToDate.

See “Therapeutic Endoscopy for the Control of Nonvariceal Upper Gastrointestinal Bleeding in Children: A Case Series” by Banc-Husu et al on page e88.

Therapeutic endoscopy is relatively rare in children; thus, training in pediatric therapeutic endoscopy is challenging. In this issue of Journal of Pediatric Gastroenterology and Nutrition, Banc-Husu et al (1) report a 6-year experience of nonvariceal bleeding therapeutic endoscopy, and conclude that there are insufficient numbers of therapeutic procedures to adequately train fellows. The present study adds to a recent study that included 12 centers and reported similar findings of inadequate procedural numbers in pediatric therapeutic endoscopy, with control of bleeding the least common procedure (2).

Knowledge and skills are required for competency in bleeding control therapeutic endoscopy. Because skills can be difficult to assess, experience as defined by a number of procedures is often used extrapolating that this experience will result in the necessary knowledge and skills. For bleeding control procedures, NASPGHAN training guidelines recommend at least 15 procedures. The study by Banc-Husu et al in this issue of Journal of Pediatric Gastroenterology and Nutrition, and the previous study by Lerner et al suggest that this number of procedures or experience for therapeutic endoscopy is unlikely to be obtained. Thus, training programs must be creative in finding a solution to this discrepancy.

Knowledge of therapeutic endoscopy including bleeding control can be addressed by a variety of approaches. Training programs should ensure that there is a therapeutic endoscopy curriculum that includes approach to nonvariceal bleeding, in addition to other therapeutic procedures including variceal bleeding, polypectomy, and dilation. This curriculum should include teaching conferences but may also include attendance at NASPGHAN or ASGE postgraduate courses, ASGE videos, and other available content including articles and videos available on the NASPGHAN Curriculum Resources page for procedures found in the “Training and Career Development” section of the Web site.

Skills required for therapeutic endoscopy may be more difficult to obtain, but these skills are an essential aspect of training that fellowship training programs must address. Although standard technical skills for scope manipulation are necessary, these skills are obtained most often during standard endoscopy. Skills specific to the control of bleeding include injection, clipping, and the use of electrocautery and argon plasma coagulation. Skills with all of these modalities are necessary to have a repertoire of therapies to control bleeding. Banc-Husu et al also mention >70 cases of variceal bleeding managed during this timeframe. Although variceal band ligation is the most frequent method in managing these patients, smaller patients (typically <10 kg) need to be managed with sclerotherapy. Sclerotherapy is a similar technique to the use of injection and matches the relative acuity of a nonvariceal upper gastrointestinal (GI) bleed. Injection skills and technique may also be obtained during injection of other substances (eg, botulinum toxin). Likewise, skills and technique using argon plasma coagulation may be obtained during a variety of procedures such as for fulguration of duodenal polyps in familial adenomatous polyposis or treating a variety of other lesions. Hemostatic clips can be used during polypectomy and gastrostomy closure, and while they may not exactly replicate the dynamics of an actively bleeding vessel, the skills and technique of using clips are still acquired. Ultimately, whether skills typically used in a bleeding case are obtained during a bleeding case, or another case may be irrelevant, given that the skills are obtained.

The use of hands-on advanced endoscopy courses and skills workshops should also be considered to specifically develop clipping, injection, and electrocautery skills. NASPGHAN and ESPGHAN continue to offer hands-on endoscopy courses during the annual meeting, with spaces reserved for trainees. Institutions should also consider their own skills workshops, for example, a 1-hour workshop using argon plasma coagulation and electrocautery on a piece of raw meat set up in the endoscopy suite. Other opportunities to obtain the necessary skills may also be available locally including the use of simulators, animal models, and adult endoscopy rotations if available.

Experience in nonvariceal upper GI bleeding therapeutic endoscopy is limited in most if not all fellowships. Thus, the knowledge and skills necessary for these procedures must be addressed by other means. We suggest training programs consider a structured curriculum that includes institutional conferences and national postgraduate courses in addition to educational videos and articles specific to therapeutic endoscopy designed to obtain the knowledge necessary for therapeutic endoscopy. In addition, skill acquisition is essential and should be accomplished through national hands-on endoscopy courses, institutional skill workshops, and experience in the limited number of cases that are available at the institution. In addition, proctoring and assistance should be available to new graduates for ongoing support especially in therapeutic GI bleeding and other therapeutic endoscopy.

With a concerted effort by training programs, and support by NASPGHAN, trainees can obtain the necessary knowledge, and develop the necessary skills to achieve competence in upper GI bleeding and other therapeutic endoscopy procedures, an important aspect of training and a necessary skill for practice.

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1. Banc-Husu AM, Ahmad NA, Chandrasekhara V, et al. Therapeutic endoscopy for the control of nonvariceal upper gastrointestinal bleeding in children: a case series. J Pediatr Gastroenterol Nutr 2017; 64:e88–e91.
2. Lerner DG, Li BU, Mamula P, et al. Challenges in meeting fellowship procedural guidelines in pediatric therapeutic endoscopy and liver biopsy. J Pediatr Gastroenterol Nutr 2014; 58:27–33.
© 2017 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,