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DOI: 10.1055/a-2683-9906
Minimum standards for training in colorectal endoscopic mucosal resection among advanced endoscopy trainees
Abstract
Background and study aims
Data on colorectal endoscopic mucosal resection (C-EMR) training during advanced endoscopy fellowship remain limited. We aimed to determine the number of procedures required by an “average” advanced endoscopy trainee (AET) to achieve competence in cognitive and technical C-EMR skills.
Methods
AETs from advanced endoscopy training programs (AETPs) were graded on every C-EMR using a standardized assessment tool. Cumulative sum (CUSUM) analysis was used to generate individual and aggregate learning curves to estimate the minimum number of cases required to achieve competence for overall, technical, and cognitive components of C-EMR. AETs completed a self-assessment questionnaire on C-EMR competence at the end of their training.
Results
A total of 22 AETs among 16 AETPs participated in this study. Nineteen AETs (86%) reported formal training in C-EMR with a mean number of 32 ± 22 cases prior to their AETP. In aggregate, 637 C-EMRs were performed (median of 32 per AET; interquartile range 17–45). Learning curve analyses revealed substantial variability in minimum volume of procedures needed to attain competence across different C-EMR skills (range: 19–39). A minimum of 19 cases were required to achieve overall competence using the global assessment score. All AETs reported feeling comfortable performing C-EMR independently at the end of AETP, yet only three (14%) achieved competence in their overall performance.
Conclusions
The relatively low number of C-EMRs performed by many AETs may be insufficient to achieve competence. The estimated thresholds for an average AET to achieve competence in C-EMR provide a framework for AETPs in determining the minimal standards for case volume exposure during training.
Keywords
Endoscopy Lower GI Tract - Polyps / adenomas / ... - Endoscopic resection (polypectomy, ESD, EMRc, ...) - Quality and logistical aspects - TrainingIntroduction
Advanced endoscopy training programs (AETPs) have evolved over the years to offer training in a myriad of procedures besides endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). Many AETPs provide additional training in colorectal endoscopic mucosal resection (C-EMR), which is widely regarded as the preferred treatment strategy for large non-pedunculated colorectal polyps (LNPCPs) [1] [2]. Although several studies have shown that C-EMR outcomes are invariably dependent on the training and experience of the endoscopist [3] [4], markers of training competency are lacking.
With the increasing focus on competency-based medical education, there has been an emphasis on establishing specific standardized milestones and metrics to guide the design, implementation, assessment, and evaluation of procedure training [5] [6]. In recent years, studies evaluating threshold to achieve competence in EUS and ERCP by advanced endoscopy trainees (AETs) based on standardized assessment tools have helped AETPs establish minimal standards for case volume exposure during training [7] [8]. There is currently no consensus on minimum standards for C-EMR training for AETs. Although establishing a minimum procedure volume threshold does not equate to competence for all trainees, understanding the number of procedures required to achieve competence for the “average” AET in all aspects of C-EMR helps create a working framework for those AETPs providing such training. The primary aim of this study was to evaluate learning curves and define the number of procedures required by an average AET to achieve competence in all technical and cognitive aspects of C-EMR during their fellowship.
Methods
Study setting and subjects
This was a prospective, multicenter, cohort study that included 16 AETPs in the United States. AETs were defined as trainees who had completed a standard gastroenterology fellowship in the United States or Canada. A total of 22 AETs from the participating centers were enrolled in the study from July 2022 to July 2023. All AETs provided informed consent. The study was approved by the Human and Research Protection Office or Institutional Review Board at each participating institution, with the Center for Interventional Endoscopy (CIE) at AdventHealth, Orlando, Florida, United States serving as the central coordinating center. All authors had access to the study data and reviewed and approved the final manuscript.
Baseline training in C-EMR
All AETs completed a questionnaire to assess their exposure to C-EMR before their fellowship (Appendix 1). The survey included questions regarding their participation in didactics and hands-on training in C-EMR through their gastroenterology fellowship, national conferences, and courses. The AETs were provided a second survey questionnaire following completion of their training to assess their perceptions and attitudes toward C-EMR training from their AETP (Appendix 2)
Grading of AETs using a C-EMR standardized assessment tool (STAT)
AETs were graded on every C-EMR during their fellowship to capture the total number of procedures performed through their academic year. C-EMR was defined as resection of colorectal polyps in which submucosal lifting (via needle injection or water-assisted) was performed to elevate the polyp followed by snare resection. Grading was standardized and performed by attending endoscopists at each institution. The study protocol required that grading be performed shortly after each procedure to reduce recall bias, halo, and recency effect.
We used the C-EMR standardized skills assessment tool (C-EMR STAT) previously validated in a pilot study [9] to grade C-EMR skills in a continuous fashion throughout training. This tool was created by consensus opinion and review of the literature by expert endoscopists in C-EMR with the aim of including key concepts and core skills necessary for high-quality C-EMR as per the American Society for Gastrointestinal Endoscopy (ASGE) Practice Guidelines [2] [9]. The C-EMR STAT contains various cognitive and technical procedure steps (Appendix 3). The four core cognitive and technical skills of C-EMR were defined as: 1) lesion assessment based on polyp morphology; 2) lesion assessment based on pit and vascular pattern; 3) submucosal injection; and 4) snare resection. A four-point scoring system was used to grade each cognitive and technical endpoint, based on the format of previously validated endoscopic assessment tools [8] [10]: 4 (superior), achieves task without instruction; 3 (advanced), achieves with minimal verbal cues; 2 (intermediate), achieves with multiple verbal cues or hands-on assistance; 1 (novice), unable to complete and requires trainer to take over. Independent grading of individual endpoints was performed. These anchors allowed for the supervising endoscopists to attach behaviors and skills to anchors and ensure reproducibility over the course of the study [8] [9] [10]. In addition to these grading parameters, the C-EMR STAT also included pertinent information regarding procedure time, polyp characteristics (i.e. size, morphology, location), procedure difficulty based on established criteria, adverse events (AEs), and degree of AET participation (observation only, hands-on participation with assistance, or completion of the C-EMR without hands-on assistance) (Appendix 3). Polyp complexity was then categorized according to the SMSA (Size, Morphology, Site, Access) classification system [11].
Prior to initiation of the study, the C-EMR STAT was shared with all the supervising endoscopists, who were interventional endoscopists at their respective centers with experience in C-EMR. The systematic evaluation process with this tool was explained, discussed, and clarified by the principal investigator and CIE research team. The AETs were unblinded and had access to their EMR STAT grading following each procedure.
Data collection
All participating sites entered data on a CIE AdventHealth instance of REDCap, a secure, online database system. Each site was provided with unique logins in order to access the centralized electronic database for entry. A combination of an application programming interface, REDCap and SAS (version 9.4; SAS Institute, Cary, North Carolina, United States) were used to generate a graphic representation of overall and individual endpoint cumulative sum (CUSUM) analysis learning curves.
Study outcomes
The primary study outcome was to identify the number of procedures required by an average AET to achieve competence in C-EMR (composite performance) and its various cognitive and technical constituents.
Statistical analysis
The criterion standard for each endpoint analysis was based on the impression by the supervising endoscopist. CUSUM analysis was applied to evaluate and plot learning curves for each trainee. This statistical method permits continuous assessment of performance against a predetermined standard and has been widely applied and validated for learning in endoscopic procedures [8] [9] [10] [12] [13]. For the individual skills, we used a four-point rating system: a rating of ≥ 3 was considered a success (minimally required numeric score for competence) and a rating < 3 was considered a failure. In addition, a 10-point overall assessment score (1–3, below average; 4–6, intermediate; 7–9, advanced; 10, superior) was provided on each case. For overall performance, we used a 10-point scoring system, with success defined as above average (score of 7 to 9) or attending level (score of 10). CUSUM graphs were constructed as previously described by Bolsin and Colson [14]. A successful procedure was labeled as s and failure as 1-s. In calculating the CUSUM score, the score of s was derived from the prespecified acceptable failure rates (p0, level of inherent error if procedure is performed correctly) and unacceptable failure rates (p1, where p1-p0 represents the maximum acceptable level of human error). The CUSUM scores of both individual skills and overall performance were calculated for each AET. Learning curves were created by plotting the CUSUM scores against the index number of EMR cases by each trainee. Decision limits were calculated based on the type I (0.1) and type II (0.1) errors, p0 (10%) and p1 (20%). [Fig. 1] is a graphical representation of how CUSUM analysis is applied to evaluate learning curves. If the CUSUM curve crosses the upper decision limit from below (unacceptable threshold), failure rates have reached preset unacceptable rates, indicating need for further training and the CUSUM score is reset to 0 [9] [14]. Conversely, competence is defined when the curve crosses the lower decision limit (competence threshold) from above. If the CUSUM curve remains between the two decision limits, then ongoing observation is indicated.
Results
Seventy-two AETPs were invited to participate. These AETPs were identified based on their profile on the ASGE website indicating “Lower GI EMR” as a procedure offered during training. Of these programs, 41 AETPs responded to the invitation, of whom 25 declined participation because the programs did not expect their trainees to perform > 10 C-EMRs throughout the academic year. Twenty-two AETs from 16 centers agreed to participate in the study.
Baseline C-EMR training experience
All AETs responded to the baseline survey questionnaire. Of the 22 AETs, 20 (91%) reported having undergone formal training in colorectal polypectomy and 19 (86%) in colorectal EMR. Mean numbers of polypectomies and C-EMRs reported by the AETs prior to their advance endoscopy fellowship were 358 ± 157 and 32 ± 22, respectively.
Polyp and procedure characteristics
Colorectal polyp and C-EMR characteristics are summarized in Table 1. In aggregate, 22 AETs from 16 AETPs performed a total of 637 C-EMRs (median per AET of 32; interquartile range 17–45) during their training. Mean lesion size was 27.8 ± 12.9 mm. The three most common polyp morphologies encountered based on the Paris classification system [15] were IIa (n = 251; 39.4%), followed by Is (n = 195; 30.6%) and IIb (n = 40; 6.3%). Nearly half of the lesions were classified as lateral spreading granular lesions (n = 308; 48.4%). Most of the polyps were in the colon proximal to the splenic flexure (n = 450; 72.5%).
Mean procedure time was 27.6 ± 19.7 minutes. There were five cases (0.8%) of post-procedure bleeding within 24 hours from C-EMR. Bleeding had ceased upon repeat colonoscopy with none of these patients requiring endoscopic intervention. A single case of perforation (0.16%) occurred, which was identified during C-EMR and successfully closed endoscopically. Post-procedure imaging with enteral contrast did not show evidence of extravasation. Nearly all cases were performed in the outpatient setting, with only six patients (0.9%) admitted postoperatively. Hospital length of stay in these patients ranged between 1 and 2 days and all were discharged without AEs.
AET participation and procedure complexity/difficulty
Of the 637 C-EMR procedures, the AETs did not have hands-on participation in 46 (7.2%) of cases. The main reasons for lack of hands-on participation were time constraints (n = 21; 3.3%) and a procedure deemed to be of high complexity/difficulty (n = 22; 3.5%) not suitable for AET participation based on supervising endoscopist discretion. The factors associated with increased procedure complexity/difficulty are shown in [Table 1].
C-EMR learning curve and competence
Data from all AETs were used to generate the CUSUM learning curves to estimate the competence threshold for the various individual cognitive and technical C-EMR endpoints. There was substantial variability in the minimum threshold of procedures needed to attain competence across different cognitive and technical C-EMR skills ([Table 2]). The CUSUM curves for the core cognitive and technical skills for C-EMR are shown in Fig. 1. By the end of training, competence in cognitive skills was achieved by nine (40.9%) for assessment of polyp morphology and by eight (36.4%) for assessment of pit/vascular pattern. Only six (27.3%) and three (13.6%) of the AETs crossed the competence threshold for submucosal injection and endoscopic resection, respectively. Overall competence, based on the global score, was attained by three of the 22 trainees (14%) by the end of the study ([Fig. 1]).
AET self-assessment on completion of C-EMR training
Nineteen AETs completed the self-assessment questionnaire at the end of their training ([Table 3]). From a cognitive skills standpoint, all AETs strongly agreed or tended to agree with the statement that they were comfortable recognizing the indication and contraindications for C-EMR and classifying polyps based on their morphology; although three trainees (14%) disagreed with the statement that they could routinely classify a lesion based on its vascular and pit pattern. Nearly all AETs agreed (18/19; 94.7%) about feeling comfortable performing all technical C-EMR skills and independently performing C-EMR at the end of their training.
Discussion
C-EMR is the most widely accepted first-line treatment of large non-malignant colorectal polyps in clinical practice. Although most AETPs offer training in C-EMR according to the information provided to the ASGE advanced endoscopy fellowship match website, there is a lack of formal data on C-EMR training and there is no fixed mandatory curriculum and no set minimum standards. In this study of 22 AETs from 16 AETPs, we identified the minimum threshold for an average AET to achieve overall competence in C-EMR as approximately 19 cases, with significant variability in the number of C-EMRs performed by AETs among the different participating AETPs. Overall, these data may provide a framework for AETPs in determining minimum standards for case volume exposure in C-EMR during training.
The main training focus of most AETPs still revolves around ERCP and EUS. However, in recent years, many AETPs have expanded their curricula to include training in procedures across various subspecialties of interventional endoscopy, such as submucosal endoscopy, endoscopic resection, and bariatric endoscopy [16]. With this expanding portfolio, it is important for AETPs to understand how many C-EMR procedures the average AET will require during their fixed training period to achieve competency. Understanding this threshold volume has important implications. For instance, on the ASGE website, 72 AETPs indicated that “lower GI EMR” is a procedure that is being offered during training. However, it remains unclear how many of these programs actually expose and train their AETs in a substantial number of C-EMRs. Indeed, more than half of the programs indicating that they train their AETs in C-EMRs on the ASGE website ended up declining participation (25/41; 61%) in this study citing their concern that most of their trainees do not perform > 10 C-EMRs during the fixed training period. Hence, identifying the minimum threshold required to achieve competency in C-EMR by the average AET provides a benchmark for programs to determine whether this will be a procedure for which they can realistically offer training. We hope that this knowledge will be useful to AETPs committed to training AETs in C-EMR and that it will inform prospective AETs interested in learning C-EMR so that they can identify programs that offer sufficient volume in this procedure to attain competency.
Overall, our study suggests that comprehensive C-EMR training within the constraints of a standard 12-month AETP can be challenging. There was significant variability in the number of C-EMR cases by AETs (range 5 to 120), with 11 of the AETs (50%) performing < 19 procedures during training. None of the AETs with less than 19 C-EMR procedures completed were able to attain competence in any of the cognitive and technical skills components or on their global assessment. Notably, the number of C-EMR procedures required to cross the competency threshold for management of procedure-related AEs (i.e. bleeding, perforation) was even higher. Patient safety should be a key factor when determining competency. Hence, we strongly believe that formal assessment of a trainee’s ability to manage procedure-related complications should be an important component when establishing their readiness for independent practice. Although it is clear that trainees acquire endoscopic skills at variable rates and volume thresholds do not necessarily ensure competence, our findings further emphasize the value of establishing minimum standards with regard to procedure volume. It should be emphasized that irrespective of the number of C-EMRs the trainees performed during the study period, all AETs had already completed a general gastroenterology fellowship, which included exposure and/or hands-on training on C-EMR. This in turn raises the important question about whether further emphasis and structured assessment of C-EMR training should be initiated at earlier stages during general gastroenterology fellowship. Our study demonstrated a discrepancy between AET self-assessment and their performance based on their evaluations. These findings are consistent with those from our pilot study [9]. At completion of their training, nearly all AETs indicated feeling comfortable with cognitive and technical aspects of C-EMR; nearly all also reported feeling comfortable with performing C-EMR in independent practice. Yet, data based on CUSUM analysis demonstrated that most trainees did not meet competence thresholds. Our results have important implications. For one, they suggest that trainee self-assessment should not replace formal assessment by trainers and underscore the importance of using standardized procedure-specific structured assessment tools. Despite being evaluated by trainers on each C-EMR using the C-EMR STAT as part of this study, it remains unclear whether the AETs received regular input on their performance, which may have accounted for the discrepancy. Providing structured feedback to trainees at regular intervals may potentially unmask unrecognized areas for improvement and permit corrective measures throughout their fellowship [17] [18]. Whether periodic feedback using C-EMR STAT scores may translate into improved training outcomes based on objective measures needs to be addressed in future studies.
This study is not without limitations. First, this study did not include all AETPs in the United States, thereby limiting generalizability of our results. Second, there is a potential for selection bias among AETs and their programs who opted to participate in the study. We recognize that the subjective assessment of the trainer was regarded as the criterion standard. This is a common limitation of any study evaluating learning curves and competency. Similarly, interobserver and intraobserver variability among trainers, differences in experience and training styles, and variations in C-EMR techniques were also not accounted for in this study. We attempted to address these issues by using a previously established standardized assessment tool with well-defined anchors for all specific endpoints that was reviewed by all trainers prior to study enrollment. However, variance across different trainers and institutions may have impacted our results. Lastly, the relatively low and highly variable number of C-EMRs performed by AETs limited meaningful individual learning curve analyses and competence assessment among those with very few procedures and when evaluating certain C-EMR-related endpoints. Nonetheless, rather than a limitation of study design, the low volume numbers may simply be a reflection of the current status of C-EMR training among AETPs.
Conclusions
In conclusion, this prospective multicenter study provided data on minimum thresholds for an average AET to achieve competence in various cognitive and technical aspects of C-EMR. The relatively low number of C-EMRs performed by many AETs may be insufficient to achieve competence, despite their prior exposure to this procedure during general gastroenterology fellowship and reporting feeling comfortable performing C-EMR independently in clinical practice. Our data provide a framework for AETPs to adjust their educational curricula in response to the increasing number and complexity of advanced endoscopic techniques to which trainees are exposed during their training.
Contributorsʼ Statement
D Yang was responsible for the conception and design of the study. D Yang, E Robalino Gonzaga, A Mohammed, J Zhu, T Hong, and J Pepe were involved in data collection and analysis. D Yang was involved in the drafting of the manuscript. All authors were involved in the critical appraisal and final approval of the manuscript.
Conflict of Interest
D Yang is a consultant for Boston Scientific, Olympus, Fujifilm, Medtronic, Microtech, 3D-Matrix, and Neptune. D Yang receives royalties from Slack, Inc. MK Hasan is a consultant for Boston Scientific, Olympus, Microtech, and Neptune Medical. MA Arain is a consultant for Boston Scientific, Olympus, Cook Medical. S Jawaid is a consultant for Boston Scientific, and Microtech. S Jawaid receives research funding by Creo Medical. M Othman is a consultant for Olympus, Boston Scientific, Creo Medical, Lumendi, AbbVie, and Nestle. M Othman receives research support from Boston Scientific, AbbVie, Nestle, ConMed, and Lucid Diagnostic. A Sethi is a consultant for Boston Scientific, Cook Medical, Medtronic, Pentax and Olympus.A Sethi receives research support from Fujifilm, Boston Scientific, ERBE and is on the advisory board for Endosound. AY Wang owns publicly-traded stocks in GE Healthcare Technologies and Pfizer. JD Mosko is a speaker and consultant for Boston Scientific, ERBE, Fujifilm, Medtronic, Janssen, Pendopharm, Pfizer, SCOPE, and Steris. D Diehl is a consultant for Boston Scientific, Cook Medical, Pentax, Olympus, GI Supply, Steris Endoscopy, Lumendi, Castle BioSciences, Merit Medical, Actuated Medical, Microtech, OnePass Medical, Kite Endoscopic Innovations, and Tricol Biomedical. S Gaddam is a consultant for Boston Scientific and receives research funding from Cook Medical. N Cosgrove is a consultant for Boston Scientific and Cook Medical. H Khara is a consultant for Boston Scientific, Olympus, Pentax Medical, Cook Medical, ConMed, Neptune Medical and Medtronic. M Gabr is a consultant for Boston Scientific, ConMed, Olympus, Fujifilm and Adaptiv Endo. C Shailendra is a consultant for Boston Scientific and Olympus. H Aslanian is a consultant for Boston Scientific and Olympus. U Siddiqui is a consultant, research and speaker for Olympus and Boston Scientific. U Siddiqui is a consultant and speaker for Cook Medical, Medtronic, and ConMed. J Salmaan is a consultant for Boston Scientific and Microtech. J Salmaan receives research support through Creo Medical. P Taunk is a consultant for Boston Scientific and Neptune Medical. J Poneros is a consultant for Boston Scientific. A Trindade is a consultant for Exact Science, Lucid Diagnostic and Pentax Medical. He receives research support from Exact Science and Lucid Diagnostic. J Samarasena is a consultant for Olympus, Neptune Medical, Boston Scientific, Applied Medical, Cook Medical and Mauna Kea. He has stock in SatisfAI Health. He receives education and research grant from Cook Medical. None of the other authors have anything to disclose.
Acknowledgement
C-EMR STAT Working Group: Artur Viana, Sanmeet Singh, Abdul Sattar Shariq Mohammed, Jianbin Zhu, Antonio Costantino, Daniel Hogan, Elizabeth Brindise, Samir Seleq, Danial Shaikh, Fares Ayoub, Mai Khalaf, Mohammad Alshelleh, Graham Appelbe, Rashmi Advani, Muhammad Mubarak, Sam Burton, Shreyans Doshi, Jaehoon Cho, Andrew Joelson, Kavel Visrodia, John Poneros, Usman Rahim, Isaac Perry, Shifa Umar, Samuel Igbinedion, Sultan Mahmood, Erik Holzwanger, Maham Hayat, Mustafa A. Arain, Deepanshu Jain, Kambiz Kadkhodayan, Natalie Cosgrove, Tao Hong, Julie Pepe
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Correspondence
Publication History
Received: 08 April 2025
Accepted after revision: 05 August 2025
Article published online:
09 September 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany
Dennis Yang, Ernesto Robalino Gonzaga, Muhammad Khalid Hasan, Arvind Julius Trindade, Mark Radlinski, Rebecca A Burbridge, Jeffrey Mosko, Pushpak Taunk, Salmaan Jawaid, Mohamed O. Othman, David L Diehl, Harshit S. Khara, Quin Liu, Srinivas Gaddam, Harry Aslanian, Shailendra S Chauhan, Amrita Sethi, John Poneros, Jason Samarasena, Ali M Ahmed, Uzma D. Siddiqui, Dennis Chen, Moamen Gabr, Andrew Y. Wang. Minimum standards for training in colorectal endoscopic mucosal resection among advanced endoscopy trainees. Endosc Int Open 2025; 13: a26839906.
DOI: 10.1055/a-2683-9906
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