Endoscopic Rotations

The Case Western Reserve University/University Hospitals Cleveland Medical Center Gastroenterology Fellowship Program offers an excellent endoscopic training schedule during the three-year track where fellows learn everything about basic and therapeutic esophagogastroduodenoscopy (EGD), flexible sigmoidoscopy, colonoscopy, percutaneous endoscopic gastrostomy (PEG), capsule endoscopy and non-endoscopicn procedures such as esophageal manometry, breath testing and ambulatory pH monitoring.

First Year Endoscopic Training Schedule

At the beginning of the Gastroenterology Fellowship, new trainees will receive an orientation to the endoscopy units at UH Cleveland Medical Center and the Louis Stokes Cleveland VA Medical Center and will be instructed in the following:

• Antibiotic prophylaxis (if required)
• Basic equipment care
• Cleaning and disinfection of instruments
• Patient preparation (including informed consent, sedation, documentation and follow-up)

First-year fellows will start by performing diagnostic upper endoscopies and flexible sigmoidoscopies under supervision. They will also be allowed to spend 10 minutes performing the initial segment of routine, uncomplicated diagnostic colonoscopies. By the end of first six months fellows are expected to be competent in performing uncomplicated diagnostic flexible sigmoidoscopies, including taking biopsies and capturing pictures.

Fellows should also have gained skills in intubating the esophagus under direct vision and be able to perform a complete examination of the upper gastrointestinal tract in patients with normal anatomy. Around the middle of the first year fellows will begin doing routine colonoscopies under supervision.

At the end of the first year fellows will be expected to know the general principles involved in the performance of diagnostic colonoscopies. They will be expected to perform an efficient diagnostic upper endoscopy (average time under 15 minutes), which includes the ability to do directed biopsies of all lesions and adequate biopsies of the esophagus.

Second Year Endoscopic Training Schedule

During the second year fellows will learn therapeutic upper endoscopy. This includes the following:

• Band ligation for esophageal varices
• Coagulation
• Contact therapy (heat probe and bipolar electrocoagulation)
• Endoclipping
• Gastrointestinal bleeding therapy
• Injection therapy (epinephrine)
• Thermal non-contact therapy (argon plasma)

This training also includes the removal of foreign bodies. They will begin performing through-the-scope balloon dilatations and wire-guided dilations of the esophagus under supervision.

Second-year fellows (and some first year) will also learn the placement of PEG. Fellows will perform colonoscopies on all patients. They will learn the principles of electrosurgery and acquire skills essential for removing uncomplicated polyps.

Fellows will learn how to endoscopically treat Ogilvie's syndrome (colonic pseudo-obstruction) and colonic volvulus. By the end of the second year fellows are expected to be competent in the performance of diagnostic and therapeutic upper endoscopy (including esophageal dilatation, except for pneumatic dilatation). They are also expected to be competent in the performance of diagnostic colonoscopies (cecal intubation rate <85 percent and average time to cecum <15 min) and be able to safely remove uncomplicated colorectal polyps.

Third Year Endoscopic Training Schedule

In the final year fellows are expected to continually sharpen and improve their skills in basic and therapeutic EGD, flexible sigmoidoscopy, colonoscopy and PEG. At the end of the fellowship all fellows will be expected to be competent (both technical and cognitive skills) in performing the following:

• Diagnostic and therapeutic colonoscopies
• Diagnostic and therapeutic upper endoscopies
• Esophageal dilatations
• Flexible sigmoidoscopies
• PEG

Although fellows may gain some preliminary/introductory experience in endoscopic ultrasound (EUS) and diagnostic endoscopic retrograde cholangiopancreatography (ERCP), third-year fellows will not be trained in EUS or ERCP, unless they have been selected as the advanced endoscopy fellow (dedicated fourth year).

Endoscopic Rotations Evaluation

The definition of competence in the Gastroenterology Fellowship Program has several aspects, including:

• Communication with referring physicians
• Documentation
• Formulation of a reasonable plan of management based on endoscopic findings
• Knowledge of one's limitations; knowing when to stop
• Knowledge of the indications, contraindications, risks, benefits and alternatives of procedures
• Minimization of risks with appropriate and timely management of complications when they arise
• Obtaining informed medical consent for the procedure
• Recognition of pathology
• Safe use of conscious sedation and monitoring
• Technical skills in the performance of an efficient and thorough procedure