Lower gastrointestinal (LGI) endoscopy has evolved from being a diagnostic procedure to include therapeutic procedures such as polypectomy and EMR. For training purposes, there is a need to define the learning curve (LC) and competency markers for these procedures.Methods
A systematic review of the literature from 1946 to August 2016 was conducted by searching Pubmed, Embase and Web of Science. The search strategy used key MeSH terms and text words related to LC in LGI polypectomy and EMR. Full-text review of eligible studies and a quality appraisal (modified Down’s and Black scale2) was performed for each identified study. Outcome measures were analysed to try to identify LC and competency markers.Results
Initial database search identified 754 articles and after applying exclusion criteria, 3 articles for polypectomy and 3 articles for EMR were identified for review. A variable range of predefined outcome measures were used to calculate LC and technical competence in the included studies.Results
Table 1 summarises the LC studies on polypectomy. Choung et al.3 noted a <1.2% DPPB* rate for endoscopists who had performed >400 polypectomies, which was below the 2% predefined cut-off. In Boo et al.4, the enbloc resection rate for trainees increased steadily & average CP time decreased significantly with experience (p<0.001). The success rate of >80% was achieved by trainees after 250 snare polypectomies. Patwardhan et al.5 noted that rates of independent snare polypectomy were consistently >90% after 300 colonoscopies & >95% after 700 colonoscopies.Results
Table 2 summarises the LC studies in EMR. Bhurwal et al6 observed that after 100 EMR procedures, the proportion of residual neoplasia (recurrence) at <2 years follow up was <20% & the frequency of incomplete EMR was between 20%-25%. Lamb et al7 showed that the recurrence rates at 3 months & adverse events (bleeding & perforation) were comparable after 50 EMR procedures. Choi et al8 demonstrated that complete resection rates increased significantly from 37.4% within the first 100 EMRs to 57.6% after 300 EMRs (on par with the expert group).Conclusions
There are very few studies examining the LC of polypectomy and EMR with wide variation in LC. Several outcome measures were identified that could be used to assess competency in polypectomy (DPPB, recurrence, and polypectomy completion rate) and EMR (recurrence and bleeding). There is a need for more robust studies to further understand the LC of polypectomy and EMR. Current training guidelines for polypectomy and EMR require further evaluation.