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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 122-132

A core curriculum for basic EUS skills: An international consensus using the Delphi methodology


1 Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
2 Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
3 Department of Clinical Medicine, University of Copenhagen; Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
4 Department of Clinical Medicine, University of Copenhagen, Copenhagen; Division of Endoscopy, Gastro Unit, Herlev and Gentofte Hospital, Denmark
5 The EUS Delphi Panel shares co-authorship of the article and the members are listed at the end of this article.

Date of Submission11-May-2021
Date of Acceptance30-Nov-2021
Date of Web Publication23-Apr-2022

Correspondence Address:
John Gásdal Karstensen
Pancreatitis Centre East, Gastro Unit, Copenhagen University Hospital- Amager and Hvidovre, Hvidovre
Denmark
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EUS-D-21-00125

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  Abstract 


Background and Objectives: During recent years, the demand for EUS has increased. However, standardized training programs and assessments of clinical quality measures are lacking. We therefore aimed to establish a basic curriculum for EUS fellows that includes a prioritized list of interpretational capabilities and technical skills. Materials and Methods: International key-opinion leaders were invited to participate in a Delphi process. An electronic three-round iterative survey was performed to attain consensus on skills that 70% of the participants found either very important or essential for a newly graduated endosonographer. Results: Of 125 invited experts, 77 participated in the survey. Initially, 1,088 skills were suggested, resulting in a core curriculum containing 29 interpretational skills and 12 technical skills. The top-five interpretation skills included abilities to discern between normal anatomy and pathology, to identify the entire pancreas and ampullary region, to identify solid versus fluid-filled structures, to detect bile duct and gallstones, and to identify a pancreatic mass of 5 mm or larger. For technical skills, ability to insert the endoscope from the mouth to the second part of duodenum, to obtain FNA adequately and safely, to navigate the scope tip to follow anatomical landmark structures, to achieve endoscopic position of each of the four stations, and to perform passage of the scope past a hiatal hernia were given the highest ranking. Conclusions: After a structured Delphi process involving 77 international experts, a consensus was reached for a basic curriculum for EUS fellows to be included during training.

Keywords: education, EUS, training


How to cite this article:
Karstensen JG, Nayahangan LJ, Konge L, Vilmann P, The EUS Delphi Panel. A core curriculum for basic EUS skills: An international consensus using the Delphi methodology. Endosc Ultrasound 2022;11:122-32

How to cite this URL:
Karstensen JG, Nayahangan LJ, Konge L, Vilmann P, The EUS Delphi Panel. A core curriculum for basic EUS skills: An international consensus using the Delphi methodology. Endosc Ultrasound [serial online] 2022 [cited 2022 Jul 2];11:122-32. Available from: http://www.eusjournal.com/text.asp?2022/11/2/122/343773

John Gásdal Karstensen and Leizl Joy Nayahangan contributed equally to this work.





  Introduction Top


EUS has become a fundamental part of endoscopic patient care for a variety of gastrointestinal and pulmonary indications.[1] The range of EUS procedures is expanding, leading to an increasing demand for skilled clinicians as well as the need to develop and implement extensive training programs to cater to this need and ensure competency.[2],[3],[4] Prior to supervised practice on patients, training in EUS has been recommended by recent guidelines.[5],[6] In past years, the development and implementation of training programs have mainly been unstandardized and based on local initiatives. It is imperative that the selection of interpretational and technical skills to include in a training curriculum should align to current needs.

Studies and guidelines have suggested a minimum number of cases during EUS fellowship to achieve suggested performance targets (e.g., diagnostic rate of adequate sampling of solid lesions >85% or incidence of acute pancreatitis <2% after EUS-FNA) during 1st year of independent practice, and in addition, competence measures have been proposed and validated.[7],[8],[9],[10] Furthermore, both the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have suggested a set of performance measures established to monitor and assess the quality of EUS.[1],[11] However, the requirements for EUS operators during individual practice may differ between medical specialties and the quality indicators for the experienced endosonographer may not reflect mandatory skills needed by a newly qualified specialist in EUS. More importantly, while it is clinically important for instance to reach a sensitivity of 90% for EUS-FNA in solid lesions or document EUS landmarks in >90%, the road to reaching such performance targets is paved with several procedural skills. To reach the performance targets outlined in the guidelines, these specific skills need to be identified for training and assessment during EUS fellowships.

To establish an adequate and focused training curriculum for an EUS fellowship, we wanted to achieve expert consensus on what basic skills should be prioritized and warranted. While we believe that a systematically gathered curriculum for basic interpretational and technical skills is needed, communicative skills and knowledge about e.g., indications, as prioritized in many guidelines, were intentionally not included. With the identification of an interpretational and technical skillsets, focused learning programs may be developed, validated and compared optimizing the learning curve during EUS fellowships. The aim of this study was to create a prioritized list of interpretational capabilities and technical skills to establish a basic curriculum for EUS fellows.


  Materials and Methods Top


The study was designed as a Delphi study aiming at a prioritized skill set for basic EUS operators to incorporate into an EUS training curriculum.[12] The Delphi method is a widely used structured process to gather information from a defined group of experts and arrive at a consensus regarding a certain topic.[13],[14] This method uses iterative survey rounds sent anonymously to an expert panel, where responses from previous rounds are re-evaluated until a group decision is made. In this study, we followed a three-round Delphi process [Figure 1] using electronic survey questionnaires (SurveyMonkey, San Mateo, CA, USA).
Figure 1: Flowchart of the Delphi process

Click here to view


International panel of experts as Delphi participants

The panel consisted of international EUS experts, which the senior author (PV) knows and has collaborated with for up to 30 years. Moreover, most of these participants have contributed to numerous academic papers within the field of EUS. In order to arrive at a consensus document of EUS skills based on a collaborative effort of international experts, all participant who responded to initial rounds were invited to subsequent survey rounds. The participants complete each round blinded to one another's responses for that round.

Facilitation of the Delphi process

A steering group was formed to facilitate the Delphi process including identification and invitation of the participants [Supplementary Material 1], formulation and piloting of the questionnaires, data gathering and organization between rounds, and data analysis. The group consisted of LJN (nurse, senior researcher in medical education), JGK (MD, associate professor of endoscopy), LK (MD, professor of medical education), and PV (MD, professor of endoscopy).

Round 1

This was the brainstorm stage, where all participants were asked to list “EUS procedural skills that a newly qualified specialist in endosonography should be able to perform.” The participants individually constructed a list of skills considered mandatory for an EUS operator during individual practice. Specifically, procedural skills are defined as the psychomotor domains that are involved when performing an EUS procedure. To avoid any bias, the list was completed by free hand and there was no limitation to number of suggested skills. The participants were given 2 weeks to complete the survey with a 1-week extension. When all answers were received and registered, the steering group made a qualitative assessment of the data by removing duplicates or synonyms and excluded items such as communicative abilities and skills related to knowledge such as relation between basic anatomical structures and EUS indications. The included items were organized and grouped into two categories based on the responses: Interpretation skills and technical skills. The lists of selected items were sent as an electronic survey to the participants in the second Delphi round.

Round 2

The suggestions from Round 1, organized into interpretational and technical skills, were sent to the participants to review and re-evaluate. They were asked to rate the statements according to importance. Specifically, we aimed to explore the importance of each item to include in an EUS training curriculum for residents in endosonography. The rating scale was from 1 = not important, 2 = somewhat important, 3 = moderately important, 4 = very important, and 5 = essential. The participants were asked to use the complete scale. A comment box was provided to allow the participants to expand on their choice of rating, as well as provide further comments or suggestions. The participants were given 2 weeks to complete the survey with a 1-week extension. The steering group gathered the responses and analyzed the data for the third round. Statements or items with a mean score lower than two were eliminated.

Round 3

The statements selected during the second round were ranked according to mean score and subsequently included in the third round, where the participants were asked to re-rate the items a final time using the same scoring system as in round 2. The participants were given 2 weeks to complete the survey with a 5-day extension. Consensus was defined as percent agreement in which a statement is included when 70% of the expert panel rated it as 4 – very important or 5 – essential. The statements that failed to reach 70% were excluded.[14]

Statistics

In Round 1, content summative analysis was performed to organize the data gathered from the brainstorming phase. Duplicates were removed and similar items were combined and rephrased for clarity. Suggestions that did not fit the inclusion criteria were deleted. In Rounds 2 and 3, descriptive analysis was performed to calculate the mean scores, which were arranged in descending order to indicate high ranking. Statistical analyses were performed using IBM SPSS Statistics 25.0 (SPSS 2017, Chicago, IL, USA).


  Results Top


Out of the 125 identified experts in endosonography, a total of 77 (62%) agreed to participate by responding to the questionnaire (first round), representing 25 countries across the world. The median age of the panel was 52 years (range 38–69) and the expert panelist had a median of 19 years (range 2–42) experience in endosonography. Two out of 77 participants were pulmonologists. The demographic characteristics are presented in [Table 1].
Table 1: Participants characteristics

Click here to view


Round 1

The brainstorming phase produced a raw list of 1,088 EUS skills, many of which were duplicate items [Supplementary Material 2]. These were reduced and organized into two categories: Interpretation skills (n = 47 items) and technical skills (n = 37 items). These lists were sent to the expert panel in round 2 to rate each item according to importance.

Round 2

Sixty-five out of 77 experts answered the survey (84%). All 47 interpretation skills had a mean score of >2. Thirty-four out of the 37 technical skills were rated >2 and were included. The three items that were eliminated included the ability to perform angiotherapy, perform EUS-guided gastrojejunostomy, and perform dilatation of duodenal stricture with linear EUS scope. The complete list and ratings scores are presented in [Table 2].
Table 2: List of all EUS skills identified in Round 1, ranked by importance in Round 2

Click here to view


Round 3

The response rate in the final round was 82% with 63 out of 77 experts. The final list included EUS skills that were ranked as very important or essential by more than 70% of the experts. There was a broad consensus to include 29 interpretational skills and 12 technical skills in the final list. Eighteen interpretational skills and 25 technical skills did not achieve consensus and were therefore eliminated. The top five interpretation skills include the ability to discern between normal anatomy and pathology (stones, tumors, lymph nodes, metastasis), ability to identify the entire pancreas and ampullary region, ability to identify solid lesions and discriminate them from fluid-filled structures, ability to detect bile duct stone and gallstone, and ability to identify a pancreatic mass of 5 mm or larger. For technical skills, the highest ranked items include the ability to insert the endoscope from the mouth to the second part of duodenum, ability to obtain FNA adequately and safely, ability to navigate the scope tip to follow anatomical landmark structures, ability to achieve endoscopic position of each of the 4 stations for imaging the pancreas and bile duct, and ability to perform passage of the scope past a hiatal hernia. The final list of interpretational and technical skills that are included in the EUS curriculum for residency training is presented in [Table 3] and [Table 4], respectively.
Table 3: Final list of interpretation to include in an EUS curriculum for specialist training

Click here to view
Table 4: Final list of technical skills to include in an EUS curriculum for specialist training

Click here to view



  Discussion Top


Seventy-seven EUS experts participated in a three-round modified Delphi process, resulting in the core curriculum for EUS training including 29 interpretational and 12 technical skills, respectively.

The Delphi process that has been applied in this study secures an efficient and quick gathering of information, starting with brainstorming followed by a two round assessment and selection course to ensure consensus.[12] The process is constructed as electronic surveys with anonymous and confidential responding. This ensures independent answering and limits the risk of bias compared to for instance an expert meeting where one or a few dominating figures can have an unproportionate impact on the final result. The steering group had extensive experience with Delphi methodology and before initiation of the study, they defined the specific methodology that has been applied in this study.[12],[15],[16] The decision about the final threshold of 70% of the participants finding the specific skill very important or essential is a common approach which has been advised or applied in numerous papers.[14]

As several guidelines and papers already defined proper indications for EUS associated procedures, it was agreed to exclude skills related to knowledge and communication.[1],[9] That was also emphasized in the letter of invitation to the participants [Supplementary Material 1]. However, during the study, the steering group made the decision to separate the skillset into interpretational and technical categories for didactic reasons.

The background and opinion of the expert participants included in the Delphi progress are obviously reflected in the results. The participants are all internationally, well-known experts in endosonography, and academically active. They are also part of the network of the senior author of the steering group and have not been appointed by medical societies, official committees, etc., So, by definition the expert panel was selected by convenience sampling. However, we ended up with a broad, international panel and do not believe that the results are biased by the selection of the Delphi participants. The considerable number of participants contributing to the curriculum will most likely outweigh any distinct opinions within the group. In addition, to promote transparency of the participants, the demography is included in [Table 1].

The expert consensus includes 29 interpretational skills and 12 technical skills. Some of the excluded skills call for attention, in particular mediastinal staging, which is mandatory for pulmonologists.[17] The exclusion of this reflects that the vast majority of the participants were gastroenterologists thus, the curriculum is in our opinion only valid for gastrointestinal endosonography. Similarly, the skill in relation to anorectal EUS has all been excluded from the final list. Whether this may reflect a shift in staging of rectal cancers towards MRI or that radiologists or surgeons now perform these procedures with conventional rigid transluminal probes is unknown. Regional differences in the use also play a role for the priorities of the skill set. In general, many skills with radial EUS were suggested by the expert panel. Most of these skills were, however, eliminated during the Delphi process. Most of the skills that reached a consensus and were included, such as the ability to obtain FNA adequately and safely, involved the use of linear echoendoscopes. This change likely reflects a trend toward greater use due to its inherent biopsy, invasive capacity and greater comfort using linear EUS alone for recognizing the anatomy.

During recent years several papers have proposed sets of quality indicators for EUS.[1],[11],[18] A certain number of procedures during fellowships is often defined hoping that this will enable the endosonographer to fulfill quality indicators.[6] For instance, the British Society of Gastroenterology recommends a minimum of 250 supervised cases including 150 pancreaticobiliary indications (75 pancreatic cancers), 80 luminal indications (10 anorectal EUS), 10 subepithelial lesions, and 75 EUS-guided FNA (45 celiac pancreatic).[8] These minimum numbers are recommended even though learning curves alter significantly among trainees.[19] Recently, a push has been made by the ASGE to standardize the assessment of the procedures in order to individualize the number of procedures per fellow and furthermore, a recent prospective study by Wani et al. demonstrated how the majority of fellows enrolled in competency-based programs in EUS and ERCP met the quality targets during their index year of independent practice.[7],[10] The curriculum developed from this study does not answer the important shift from volume or time-based training to competency-based training.[20] As several EUS quality indicators have become widely accepted, we hope this curriculum will facilitate a more efficient training program with steeper learning curves during EUS fellowship, ultimately securing that newly graduated endosonographers fulfill these quality indicators.[1] Furthermore, the interpretational and technical skills ranked at the top of our lists [Table 3] and [Table 4] do not conflict with the quality indicators suggested by the ASGE and ESGE. The skill included in our curriculum are mandatory to reach the performance measures.[11],[18]

The advances of artificial intelligence (AI) have already impacted luminal endoscopy for both upper and lower gastrointestinal indications.[21],[22] In EUS, convolutional neural network models have proven beneficial for differentiating autoimmune pancreatitis from pancreatic carcinomas and other benign lesions.[23] AI may also become an inevitable part of endoscopic training.[24],[25] Recently, Zhang et al. published a study describing how a deep-learning system was able to recognize the standard positions for pancreas examinations with EUS – a technique that potentially may lead to enhanced real-time monitoring during EUS procedures and serve as an important training tool.[26]

There are several limitations in relation to this study. The results of the survey are solely dependent of the participants selected for the Delphi process – the importance of for instance mediastinal staging, anorectal EUS, and biliary interventions may differ between pulmonologists, and lower gastrointestinal and hepatobiliary endoscopists. Furthermore, the link to a clinically relevant outcome such as sensitivity of biliary stone detection or EUS-FNA has yet to be established. The next steps would be to develop and implement training programs on these procedural and interpretational skills including assessment of competence both in simulation and the clinical environment.


  Conclusions Top


In conclusion, after a structured Delphi process including 77 international experts, a consensus was reached for a basic curriculum for EUS fellows that may be included during fellowship training in order to be defined as sufficiently competent. The important interpretational capabilities and technical skills included in the curriculum may be further evaluated during an implementation phase and finally integrated in future studies to assess the correlation with quality indicators after graduation.

Supplementary materials

Supplementary information is linked to the online version of the paper on the Endoscopic Ultrasound website.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

# Members of The EUS Delphi Panel are listed below

Adrian Saftoiu1,2: 1University of Medicine and Pharmacy, Craiova, Romania; 2Ponderas Academic Hospital Bucharest, Romania

Aleksei Epshtein: First City Hospital Named after Volosevich E. E, Arkhangelsk, Russia

Anand Sahai: University of Montréal Hospital Center, Montréal, Canada

Andrew Y. Wang: Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA

Anthony Y. Teoh: Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, China

Eike Burmester: Medizinische Klinik I-Endoskopie Sana Kliniken Lübeck, Lübeck, Germany

Can Gonen: Department of Gastroenterology, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey

Christoph F Dietrich: Department Allgemeine Innere Medizin, Kliniken Hirslanden, Beau Site, Salem und Permanence, Bern, Switzerland

Christian Jenssen1,2: 1Krankenhaus Märkisch-Oderland, Department of Internal Medicine, Strausberg, Germany; 2Brandenburg Institute for Clinical Ultrasound at Medical University Brandenburg “Theodor Fontane,” Neuruppin, Germany

Enrique Vazquez-Sequeiros: University Hospital Ramon Y Cajal, Madrid, Spain

Erik H. F. M. van der Heijden: Interventional Pulmonology - Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands

Erwan Loïc Bories: Clinique Axium, Hopital privé de Provence, Aix En Provence, France

Erwin Santo: Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

Evangelos Kalaitzakis: Department of Gastroenterology, University Hospital of Heraklion, University of Crete, Heraklion, Greece

Everson L. A. Artifon: Department of Surgery University of Sao Paulo, Sao Paulo, Brazil

Fauze Maluf-Filho: Department of Gastroenterology, Instituto do Câncer do Estado de São Paulo-ICESP, University of São Paulo, São Paulo, Brazil

Girish Mishra: Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA

Harry R. Aslanian: Yale Gastrointestinal Cancers Program, Smilow Cancer Hospital Yale University, Connecticut, USA

James Scheiman1,2: 1Division of Gastroenterology and Hepatology, University of Virginia, Virginia, USA; 2Michigan Medicine, Ann Arbor MI, USA

Jan-Werner Poley: Department of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, The Netherlands

Jeanin van Hooft: Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands

John M. DeWitt: Indiana University Health Medical Center, Indianapolis, USA

Julio Iglesias-Garcia: Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Spain

Khanh Do-Cong Pham: Department of Medicine, Haukeland University Hospital, Bergen, Norway

Lars Aabakken1,2: 1Oslo University Hospital, Rikshospitalet, Norway; 2Faculty of Medicine, University of Oslo, Norway

Lene Brink: Division of Endoscopy, Gastro Unit, Herlev and Gentofte Hospital, Denmark

Leonardo Sosa Valencia : Strasbourg Institute of Image-Guided Surgery (IHU), Strasbourg, France

Linda S. Lee: Brigham and Women's Hospital and Harvard Medical School, USA

Manoop S. Bhutani: Department of Gastroenterology, Hepatology and Nutrition, UT MD Anderson Cancer Center, Houston, TX, USA

Manuel Perez-Miranda: Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain

Maor Lahav: Sheba Medical Center, Tel Aviv Medical School, Tel Aviv, Israel

Maria Chiara Petrone: Pancreato-Biliary Endoscopy and Endosonography Division, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy

Mariana Jinga: University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

Mark Topazian1, 2, 3: 1Mayo Clinic, Rochester, MN, USA; 2Tikur Anbessa Hospital, Addis Ababa, Ethiopia 3St. Paul's Hospital Millennium Medical Center, Addis Ababa, Ethiopia

Michael B. Kimmey: University of Washington, Washington, USA

Michael Bau Mortensen1,2: 1Department of Surgery, Upper GI and HPB Section, Odense University Hospital, Denmark; 2Odense Pancreas Center, Odense PIPAC Center, Denmark

Michael Hareskov Larsen: Upper GI surgery, Odense University Hospital, Denmark

Michael Hocke: Helios Hospital Meiningen, Meiningen, Germany

Michael Levy: Mayo Clinic, Rochester, Minnesota, USA

Mohammad Al-Haddad: Indiana University School of Medicine, Indiana, USA

Laurent Palazzo: Endoscopy Dept Trocadéro Clinic Paris, France

Maxime Palazzo: European Hospital of Marseille, Digestive Disease Department

Paolo Giorgio Arcidiacono: Pancreatico/Biliary Endoscopy and Endosonography Division, Vita Salute San Raffaele University, San Raffaele Scientific Institute, Milan, Italy

Paul Fockens1,2: 1Amsterdam University Medical Centers location University of Amsterdam, Department of Gastroenterology and Hepatology, Meibergdreef 9, Amsterdam, the Netherlands; 2Amsterdam Gastroenterology, Endocrinology & Metabolism, Amsterdam, the Netherlands

Paul Frost Clementsen: Copenhagen Academy for Medical Education and Simulation (CAMES), Denmark

Pierre H. Deprez: Cliniques universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium

Pietro Fusaroli: University of Bologna, Hospital of Imola, Italy

Pramod Garg: All India Institute of Medical Sciences, New Delhi, India

Rabindra Watson: Karsh Division of Gastroenterology Cedars-Sinai Medical Center, Santa Monica, USA

Rajesh N. Keswani: Northwestern Medicine, Chicago, IL, USA

Riadh Sadik: Sahlgrenska University Hospital, Gothenburg

Roald Flesland Havre1,2: 1Department of Medicine, Haukeland University Hospital, Bergen, Norway; 2Department of Clinical Medicine, University of Bergen, Norway

Serta Kilincalp: Department of Gastroenterology, University of Gothenburg, Sweden

Shou-jiang Tang: University of Mississippi Medical Center, Jackson, MS, USA

Siyu Sun: Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China

Stephan Hollerbach: Department of Gastroenterology/Endoscopy, AKH Celle, Academic Teaching Hospital, Germany

Stephen P Pereira: Institute for Liver and Digestive Health, University College London, London, UK

Sundeep Lakhtakia: Asian Institute of Gastroenterology, Hyderabad, Telangana, India

Surinder Rana: Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Saad Haque: Medstar Medical Group, Maryland, USA

Takao Itoi: Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan

Timothy Woodward: Mayo Clinic, Gastroenterology and Hepatology, Jacksonville, USA

Todd Baron: University of North Carolina at Chapel Hill, USA

Uzma D. Siddiqui: University of Chicago, Center for Endoscopic Research and Therapeutics, USA

Vanessa M Shami: University of Virginia, Virginia, USA

Vijay Sharma: Regional institute of health medicine and research, Jaipur, Rajasthan, India

Vikram Bhatia: Institute of Liver and Biliary Sciences, New Delhi, India

Vinay Dhir: Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, Maharashtra, India

Vitor Nunes Arantes: Endoscopy Unit, Federal University of Minas Gerais, Belo Horizonte, Brazil


  Supplementary Materials Top


Supplementary Material 1: Expert consensus on training needs for different EUS procedures

Dear Colleague,

As an important key opinion leader in EUS, we would like to invite you to participate in a project to understand and identify the need for technical skills training in EUS across different countries. Training in EUS has been recommended by recent guidelines prior to supervised practice on patients.[1] The range of EUS procedures are growing, leading to an increasing demand for skilled clinicians as well as the need to develop and implement extensive training programs to cater to this need and ensure competency.[2] In past years, the development and implementation of training programs have mainly been based on local interests and decisions. It is imperative that the selection of technical skills to include in a training curriculum should align to current needs.

To achieve this aim, we will perform a systematic needs assessment process using the Delphi method consisting of a three-round iterative online survey, where the results from each round are fed back to the key opinion leaders to review and further explore in the succeeding round.[3] These will be sent individually through email and answers will be handled confidentially.

The result of this needs assessment will be a consensus document that includes a prioritized list of EUS skills and procedures for residency training. This informs and guides decision making on what training programs to develop and implement in the future.

Your key role and participation in this project is very important and will be acknowledged in a publication as a collaborative author.

Should you wish to participate, please start the first round below by clicking on the link.

Round 1: Brainstorming Phase.

For this first round, we kindly ask you to identify EUS procedural skills that a newly qualified specialist in endosonography should be able to perform. Procedural skills are defined as the psychomotor domains that are involved when performing an EUS procedure.

Please click on the survey link below to start answering the survey which will take approximately 15 min.

https://www.surveymonkey.com/r/EUS_Skills

Please complete the Round 1 survey by the August 28, 2020.

The other two rounds will include:

Round 2: After gathering and synthesizing all your answers from Round 1, we will ask you to rate the identified procedures from the first round according to:

  1. Perceived difficulty of the procedure
  2. Importance.


This will be in the form of a survey to be sent in September 2020. This round will result in a pre-prioritized list of procedures that will be sent and reviewed in Round 3.

Round 3: In this final round, we will ask you to review and prioritize the list of identified procedures. This will again be in the form of a survey to be sent in October 2020.

We are grateful for your commitment and enthusiasm in ensuring educational excellence and patient safety in our countries.

Should you opt to not participate in this project, please inform us so we can remove you from the mailing list.

For further questions, please do not hesitate to contact us directly using the following project E-mail: [email protected]

With kind regards

Peter Vilmann, MD., DSci, HC

Professor of Endoscopy, Herlev-Gentofte Hospital, Copenhagen University, Denmark

John Gásdal Karstensen, MD., Ph.D.

Associate Professor, Hvidovre Hospital, Copenhagen University, Denmark

Leizl Joy Nayahangan, RN., MHCM

Researcher in Medical Education (Simulation-based education), Copenhagen Academy for Medical Education and Simulation, Denmark

Lars Konge, MD., Ph.D.

Professor in Medical Education, Copenhagen Academy for Medical Education and Simulation, Denmark


  References Top


  1. Vilmann P, Frost Clementsen P, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2015;48:1-15.
  2. Cho CM. Training in endoscopy: Endoscopic ultrasound. Clin Endosc 2017;50:340-4.
  3. Dalkey NC, Brown BB, Cochran S. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica, CA: Rand Corporation; 1969.


Supplementary Material 2: Raw list of EUS skills from Delphi Round 1

1 Ability to determine vascular flow by Doppler

2 Ability to identify solid versus fluid-filled structures

3 Anatomical interpretation of the linear anatomy

4 Anatomical interpretation of the radial anatomy

5 Ascertaining the wall layers of luminal organs

6 Identifying and interpreting in the sonographic anatomy of all three stations by both radial and linear scopes

7 Identifying endoscopic side view anatomy (e.g., ampulla)

8 Proficiency in EUS block/neurolysis

9 Proficiency in being able to make an FNA slide

10 Proficiency in being able to read the FNA slide sufficiently enough to determine adequacy of aspirate

11 Proficiency in EUS assisted bleed management (e.g., gastric varices)

12 Proficiency in EUS guided drainage

13 Proficiency in FNA

14 180° rotation of linear scope

15 Three-dimensional understanding of intraabdominal anatomy

16 (3a) Having good skills the basic normal anatomy, (3b) Good skills of the variations in the location and looking of the normal anatomy

17 3d image reconstruction in the brain

18 Three-dimensional understanding of relevant anatomy

19 A sensitive haptic feedback feeling

20 Ability to accurately pass biopsy or aspiration needle into desired target

21 Ability to accurately place FNA/fine needle biopsy needles into target structures

22 Ability to ascertain wall/vascular involvement with regards to tumor

23 Ability to blend findings at different imaging stations into a unified, three-dimensional understanding of the patient's anatomical findings

24 Ability to create an ideal image and how to problem solve when the image is suboptimal

25 Ability to decide frequency for area of interest

26 Ability to deploy LAMS stent through gastric or duodenal wall into pancreatic fluid collection

27 Ability to discern between normal anatomy and pathology (stones, tumors, lymph nodes, metastasis)

28 Ability to discern subepithelial lesions based on wall layer of origin

29 Ability to identify and to visit the typical EUS positions using the radial and the curvi-linear scope

30 Ability to navigate the scope tip to follow anatomical landmark structures (radial and curvi-linear scope)

31 Ability to operate a modern ultrasound processor used with EUS

32 Ability to optimize B-Mode imaging according to different organs/anatomical structures and to different examination conditions (“knobology”)

33 Ability to pass guidewires and stents into otherwise inaccessible bile ducts and pancreatic ducts

34 Ability to perform celiac plexus block/neurolysis

35 Ability to perform EUS guided FNA and fine needle biopsy (involve use of Doppler US to identify vessels)

36 Ability to perform EUS-FNA and fine needle biopsy

37 Ability to perform neurolysis

38 Ability to problem solve in instances where it is difficult to advance the FNA or fine needle biopsy needle

39 Ability to puncture solid and cystic lesions at any station in mediastinum or from stomach/duodenum

40 Ability to recognize and successfully drain pseudocysts, fluid collections and abscesses

41 Ability to shorten the EUS scopes in D2

42 Ability to stage luminal lesions/cancers (may include miniprobe competency for endoscopic resectors)

43 Ability to understand anatomy in short and long position in D1/D2

44 Ability to use colour Doppler ultrasound

45 Able to assess FNA specimens for adequacy

46 Able to differentiate ultrasound artifacts from normal and abnormal strucutures

47 Able to diffrentiate layers of origin and echo features of subepithelial masses

48 Able to do mediastinal staging

49 Able to drain peripancreatic collection; able to place a plastic stent

50 Able to identify a pancreatic mass of 5 mm or larger

51 Able to identify and avoid structures that should not be routinely entered during FNA/fine needle biopsy (for instance lung parenchyma and bone)

52 Able to identify and avoid vascular and neural structures during advancement of FNA/fine needle biopsy needles

53 Able to identify findings that were not identified on the patient's prior imaging procedures

54 Able to identify sonographic artifacts

55 Able to insert the EUS scope in sedation without cause too much trauma

56 Able to insert the scope into the duodenum

57 Able to interpret significance of sonographic artifacts

58 Able to interpret the different image optimization functions available on the ultrasound processors

59 Able to obtain FNA adequately and safely

60 Able to optimise color Doppler function/overlay for different vessels.

61 able to perform EUS FNA

62 able to perform EUS guided celiac neurolysis

63 able to perform EUS guided core biopsies

64 Able to perform safety FNA/fine needle biopsy

65 Able to perform simple interventions e.g., CPN or aspiration therapy

66 Able to recognize problematic cases and seek for help

67 Able to recognize which anatomic features have not been confidently visualized or examined

68 Able to remove unwanted sonographic artifacts to optimise imaging

69 Able to safely deploy EUS-FNA/B needles in common target lesions

70 Able to stage esophageal, gastric, periampullary, bile duct, and pancreatic cancers

71 Able to trace the CBD, cystic duct and gallbladder

72 Able to trace the whole PD and the pancreas

73 Able to troubleshoot basic scope functions, including valves and balloon inflation.

74 Able to use Doppler and CEUS

75 Able to withdraw and maintain position in 1st and 2nd parts of duodenum for visualising different organs

76 Access to second part of duodenum

77 Accurate interpretion of the echogenicity of a structure

78 Achieving echoendoscope insertion into the 2nd/3rd part of the duodenum

79 Achieving endoscopic position of each of the 4 stations for imaging the pancreas and bile duct

80 Achieving positioning in EUS imaging stations

81 Achieving short scope position to view uncinate

82 Acieving the endoscopic stations for the mediastinum

83 Actuation of biopsy needle

84 Adjusting tip pressure on GI wall to obtain proper acoustic coupling

85 Administering proper sedation before and during the procedure

86 Advanced knowledge of color and power Doppler

87 Advanced knowledge of elastography

88 Advanced knowledge of Pulsed Doppler (flow alterations depending on disease and/or vessel involvement)

89 Advanced skills in biliary endoscopy

90 Advancing endoscope to desired station

91 Advancing the scope in the duodenal bulb to maintain visualization of the distal cbd

92 Again, depending on the clinical setting, ability to place fiducials

93 Alcohol ablation (tumor)

94 All of the above are for both linear and radial EUS

95 Ampullary mass study

96 Ampullary region

97 Anal endosonography and identification of anal anatomy

98 Anatomic interpretation of the linear anatomy

99 Anatomic interpretation of the radial anatomy

100 Anatomical identification of ampulla

101 Anatomical identification of bile duct

102 Anatomical identification of both kidneys

103 Anatomical identification of celiac axis and ganglia

104 Anatomical identification of crus of diaphragm

105 Anatomical identification of cystic duct and gallbladder

106 Anatomical identification of left adrenal

107 Anatomical identification of left lobe liver and major vasculatue

108 Anatomical identification of pancreatic duct in all positions from uncinate to tail

109 Anatomical identification of portal vein confluence from duodenum

110 Anatomical identification of portal vein confluence from stomach

111 Anatomical identification of spleen

112 Anatomical identification of splenic vein

113 Anatomical identification of uncinate

114 Anatomical interpretation of mediastinum with linear scope

115 Anatomical interpretation of Abdominal US

116 Anatomical interpretation of anal canal with linear scope

117 Anatomical interpretation of anal canal with radial scope

118 Anatomical interpretation of computed tomography

119 Anatomical interpretation of digestive wall with linear scope

120 Anatomical interpretation of digestive wall with radial scope

121 Anatomical interpretation of linear anatomy

122 Anatomical interpretation of linear anatomy

123 Anatomical interpretation of linear anatomy from duodenum - head pancreas, biliary tree, GB, major vessels, liver

124 anatomical interpretation of linear anatomy from every location

125 Anatomical interpretation of linear anatomy from stomach e.g., liver, body pancreas, coeliac axis, left adrenal

126 Anatomical interpretation of linear anatomy in mediastinum

127 Anatomical interpretation of linear anatomy - includes normal and abnormal

128 Anatomical interpretation of mediastinum with radial scope

129 Anatomical interpretation of normal linear anatomy and variants

130 Anatomical interpretation of perigastric and periduodenal area with linear scope

131 Anatomical interpretation of perigastric and periduodenal area with radial scope

132 Anatomical interpretation of perirectal area with linear scope

133 Anatomical interpretation of perirectal area with radial scope

134 Anatomical interpretation of radial anatomy

135 Anatomical interpretation of radial anatomy

136 Anatomical interpretation of radial anatomy - includes normal and abnormal (tumor, subepithelial lesions, etc)

137 Anatomical interpretation of radial and linear, or only linear scanning scanning

138 Anatomical interpretation of radial EUS anatomy

139 Anatomical interpretation of the linear anatomy

140 Anatomical interpretation of the linear anatomy

141 Anatomical interpretation of the linear anatomy

142 Anatomical interpretation of the linear anatomy

143 Anatomical interpretation of the linear anatomy

144 Anatomical interpretation of the linear anatomy from SMA to upper esophageal sphincter

145 Anatomical interpretation of the linear anatomy, with ability to interpret with radial EUS if needed, as it pertains to the area of practice

146 Anatomical interpretation of the linear anatomy

147 Anatomical interpretation of the linear anatomy

148 Anatomical interpretation of the linear anatomy

149 Anatomical interpretation of the linear and radial anatomy

150 Anatomical interpretation of the radial anatomy

151 Anatomical interpretation of the radial anatomy

152 Anatomical interpretation of the radial anatomy

153 Anatomical intrepretation of linear anatomy

154 Anatomical problem solving (ability to confidently and correctly interpret anatomic findings that are variants, poorly visible in individual patients, or distorted by disease processes, with reference to cross-sectional imaging studies and adjacent normal anatomic structures)

155 Anatomy; aorta, liver, kidney, spleen, adrenal gland, pancreas, lymph nodes, CBD, PD, free fluid

156 Angiotherapy

157 Anticipation of the next step of the examination

158 Aorta and cava

159 AP window

160 Apply Mannheim criteria

161 Apply TNM staging

162 Aspirate ascitic fluid

163 Aspiration nodes

164 Aspiration of tumors

165 Assess submucosal processes

166 At least know something about interventional EUS

167 Avoids placing EUS-guided stents across vascular structures, intervening bowel, and diaphragm

168 Awareness of 3D spatial positioning of the probe inside the patient

169 Awareness of the use of a side viewing scope

170 Basi drainage techniques (PFC such as WON, pseudocyts)

171 Basic and advanced skills in set up of Doppler software (pulsed, color and power)

172 Basic experience of endoscopy

173 Basic FNA-fine needle biopsy

174 Basic injection therapy techniques (e.g., neurolysis)

175 Basic interpretation of arterial and venous spectral Doppler waveforms

176 Basic knowledge of advanced techniques

177 Basic knowledge of cleaning/disinfection criteria - needs - regulations

178 Basic knowledge of color and power Doppler

179 Basic knowledge of Elastography

180 Basic knowledge of interventional techniques

181 Basic knowledge of Pulsed Doppler (flow differentiation)

182 Basic trans-abdominal ultrasound skills

183 Basic ultrasonography skills using a US-processor

184 Be able to all the above mentioned using the EBUS endoscope (perform EUS-B-FNA) and not the EUS endoscope

185 Be able to characterize a subepithelial lesion in the esophagus/stomach/duodenum/rectum

186 Be able to charaterize a lesion in the GI tract and layer of origin

187 Be able to deploy FNA/B needle into lesion of interest

188 Be able to describe a pancreatic cyst commenting on the presence/abscence of any feature considered worrisome

189 Be able to dicriminate a cyst from a solid lesion

190 Be able to handle complications

191 BE able to identify all wall layers and how this relates to primary staging of GI cancers

192 Be able to identify and name thoracic lymph nodes

193 Be able to identify lung tumors

194 Be able to identify retroperitoneal lymph nodes

195 Be able to identify suspicious lesions in the left liver lobe

196 Be able to identify the intended lesion (linear echoendoscope)

197 Be able to identify the left adrenal gland

198 Be able to know if an organ is completely or incompletely visualized

199 Be able to make measurements of structures in frozen images

200 Be able to perform an FNA/fine needle biopsy for diagnostic purpose

201 Be able to perform celiac plexus neurolysis

202 Be able to perform diagnostic cyst fluid dranage

203 Be able to perform FNA/fine needle biopsy of the target lesion

204 Be able to perform plastic/metal stetning of an uncomplicated pseudocyst

205 Be able to perform TN staging of esophageal cancer

206 Be able to perform TN staging of gastric cancer

207 Be able to propose appropriate differential diagnoses

208 Be able to recognize lymph nodes and the normal presentation of LN

209 Be able to suggest appropriate course of action (i.e., refer to MDT, etc.)

210 Be able to use and adjust color Doppler for identification of blood vessels

211 Be able to visualize the head, body and tail of the pancreas

212 Be confident at performing EUS-guided FNA: know all steps and be fluent at using them

213 Be familiar with every step of sampling process of FNA

214 Being able to identify wall layers

215 Being able to more or less do a complete gastroscopy with linear EUS scope (as surrogate for scope handling)

216 Best understanding of maneuvring the linear echoendoscope forward

217 Bile duct stone and gallstone detection

218 Biliary anatomy study

219 Biliary device knowledge and technical use

220 BILIARY DRAINAGE UNDER SUPERVISION

221 Biliary rendezvous

222 Biopsy in the correct order in the lung cancer patient: M1->N3->N2->N1->lung tumor

223 Biopsy the structures mentioned

224 Body movements recognition

225 Can demonstrate how to process specimens when onsite cytopathology is not available

226 Can do cancer staging (esophagus, stomach, pancreas, rectum etc.)

227 Can identify features associated with chronic pancreatitis and understands how to interpret them

228 Can image the whole bile duct

229 Can perform contrast enhanced EUS (outside of USA)

230 Can safely and effectively (i.e., hits metrics for detecting PDAC) perform EUS-FNA/fine needle biopsy

231 Cancer detection and staging

232 Cancer staging

233 Cancer staging (luminal and solid organ)

234 Capability in recognition of pattern in ultrasound

235 Capability to communicate the next step of the EUS examination to others before it happens

236 Capability to perform endoscopic treatment of complications (clips, OVESCO, injection etc.)

237 Capability to recognize complications

238 Cardiac anatomy

239 Causes for a bad image quality

240 Celiac and sup mesenteric node identification and FNAC

241 Celiac ganglion neurolysis

242 Celiac axis

243 Celiac bloc injection

244 Celiac block

245 Celiac plexus neurolysis

246 Celiac plexus and ganglia block/neurolysis

247 Celiac plexus block

248 Celiac plexus neurolysis or block

249 Celiac take-off, the entire pancreas, pancreatic duct, vasculature including splenic vein, artery, SMA, celiac

250 CEUS imaging by avoiding artefacts

251 Characterise submucosal lesions

252 Characterization of submucosal lesion

253 Characterize and perform FNA for pancreatic diseases

254 Characterize and perform FNA on submucosal tumors

255 Check 4R nodes

256 Clinical knowledge of indications for FNA/fine needle biopsy, not only listing up diseases, but when and why, when to stop

257 Coeliac plexus block

258 Commitment to routinely examining relevant organs to detect incidental or novel findings during EUS exams (for instance, routinely examining all of pancreas and left lobe liver during upper EUS)

259 Communicate with ROSE technologist

260 Competence in contrast enhanced ultrasound examination

261 Competence in Doppler use (angle correction, preventing aliasing…)

262 Competence in elastographic analysis

263 Complete imaging of the pancreas from uncinate to tail

264 Coordinating tip up deflection with elevator activation for EUS-FNA/B

265 Correct biopsy technique

266 Correct identification of mediastinal lymph node stations and mediastinal staging

267 Correct identification of vascular structures (portal vein, SMV, celiac)

268 Correct interpretation of GI wall layers

269 Correct positioning of the transducer

270 Correct use of baloon

271 Correct use of needle

272 Correct use of sheet

273 Correlate EUS anatomy with cross section anatomy seen on a CT scan

274 CPN

275 Create a good ultrasound image

276 Create a good ultrasound window

277 CRM competency

278 Cytology slide preparation

279 Demonstrate basic uses of the EUS processor

280 Describe depth of invasion of oesophageal tumor

281 Describe location of esophageal tumor

282 Describe location of lesion visualized

283 Describe tissue layer

284 Describe type of lesion

285 Describe were lesion originates from e.g., mucosa, submucosa

286 Detection of ascites and pleural effusions

287 Detection of common bile dust stones

288 Detection of luminal lesions (cancer/smt)

289 Detection of lymph nodes

290 Detection of metastatic lymph nodes

291 Develop an understanding of different anatomical landmarks (stations) to visualise the regions of interest

292 Diagnosis and Staging of biliary cancer

293 Diagnosis and staging of GI cancer

294 Diagnosis and staging of pancreatic cancer

295 Diagnosis of GI submucosal lesion

296 Diagnostic yield of FNA of solid lesion should be > 90%

297 Differential diagnosis of lesion

298 Differentiate between normal anatomy and (potential) diseased structures/organs

299 Differentiate Malignant from benign LN

300 Differentiate microcystic serous cyst from other pancreatic cysts

301 Differentiate normal appearing pancreas from autoimmune pancreatitis and pancreatic mass

302 Differentiation of splenule from pancreatic endocrine tumor

303 Dilation of duodenal stricture with linear EUS scope

304 Direct gallbladder drainage

305 Discriminating between waypoints (left vs right) in the mediastinum

306 Discrimination of the GI layers

307 Dissociate endoscopy image from ultrasound image

308 Distinguish 9L from 9L

309 Distinguish vessels from other structures with doppler

310 Distinguishing normal from abnormal EUS findings

311 Do EUS guided pseudocyst drainage (optional, is an advanced skill that every endosonographer may not need to know based on their practice nature and volume)

312 Document lesion

313 Document specific stations

314 Doing manuvers

315 Doppler imaging by avoiding artefacts

316 Drainage of cysts if necessary

317 Drainage of fluid collection via needle

318 Duodenal intubation

319 Ecographic appearance and diagnosis of different diseases

320 Elastographic imaging by avoiding artefacts

321 Elastography

322 Elastography knowledge of data interpretation and analysis

323 Elastography technical set up of the system

324 Endoscopy with oblique viewing scope

325 Endosonographic tumor staging (T and N)

326 Esophageal cancer staging

327 Esophageal intubation

328 Esophageal wall radial scope study

329 EUS - FNA???

330 EUS core biopsy (solid and cystic)

331 EUS FNA (solid and cystic)

332 EUS FNA in tumors, lymphadenopathies

333 EUS FNA liver metastases

334 EUS FNA lymph nodes

335 EUS FNA of cysts, if is necessary

336 EUS FNA pancreatic cysts

337 EUS FNA solid lesions

338 EUS guided biliary drainage (advanced skill, optional, is an advanced skill that every endosonographer may not need to know based on their practice nature and volume)

339 EUS guided biopsy

340 EUS guided drainage biliary and cavities

341 EUS-FNA

342 EUS guided fine needle biopsy (EUS-fine needle biopsy)

343 EUS guided fluid aspiration

344 EUS-biliary drainage

345 EUS-fine needle injection, including CPN, ablation, etc

346 EUS - Pancreatic fluid collection drainage and necrosectomy

347 Evaluation of pancreatic cysts

348 Examination of the common bile duct

349 Examination of the pancreatic duct

350 Excellent knowledge in anatomy

351 Expanded screening from every station

352 Experience in duodenoscopy

353 Experience with endoscopic handling of complications like bleeding, perforation: Use of clips, SEMS

354 Experience with pathological anatomy like diverticula, strictures, varices, volvulus etc.

355 Explaining why “39” is a correct statement

356 Find 8L/8R nodes

357 Find an identify the left adrenal gland (in all cases)

358 Find and identify the different parts of the pancreas

359 Find and identify the intrathoracic organs including the heart valves, the azygos vein, and the aorta-pulmonary window

360 Find celiac nodes

361 Find left adrenal gland

362 Find left and find right side

363 Find left kidney

364 Find stones and sludge

365 Find VCI - judge width/collaps

366 Finding target organs/lesions

367 Fine motor movements

368 FNA

369 FNA of pancreas cyst

370 FNA of solid pancreas mass

371 Fine needle biopsy of solid pancreas mass

372 Fine scope rotation

373 Finger strength to rapidly advance EUS needle across gut wall and into target structure

374 First, I do not think everyone needs to be trained in all parts of EUS. For example a pancreatobiliary specialist may need pancreatobiliary diagnostic and interventional EUS to assist ERCP and care for patients, but may not need expertise in mediastinal EUS if he she doesn't get patients with esophageal cancers. Not all health systems operate where one person just does EUS of the whole body, but rather one might specialize in an area. General knowledge in the other EUS areas may be enough without high level expertise

375 Fluid collection drainage (plastic and/or metal)

376 FNA

377 FNA/fine needle biopsy

378 FNA and fine needle biopsy biopsies

379 FNA LAG

380 FNA needle insertion and tissue acquisition techniques

381 FNA of cystic lesion

382 FNA of solid lesion

383 FNA/fine needle biopsy lesions

384 FNA/fine needle biopsy performance

385 Fine needle biopsy

386 Follow ductal or vascular structures with linear scope from the duodenum to the stomach

387 Follow the bile duct with linear scope from the papilla to the hilum

388 Follow up the whole bile duct into the liver

389 Following anatomical structures, e.g., pancreas from the head to the tail

390 Following anatomical structures, e.g., vessels over a longer distance

391 For those practicing in a pancreatobiliary referral center: EUS-necrosectomy, EUS-biliary access (possibly EUS-pancreatic duct access and GB drainage)

392 For those who do pancreatobiliary endoscopy (ERCP) and care for patients with severe pancreatitis, the ability to perform EUS-cystgastrostomy

393 For those who work with thoracic surgery/oncology, ability to stage esophageal cancer, and possibly help stage lung cancers

394 For those working in an oncology center, possibly EUS-guided gastrojejunostomy

395 Gallbladder

396 Gastric cancer staging

397 Gastrointestinal Cancer staging with accuracy

398 Gastrojejunostomy

399 General knowledge in ERCP

400 General knowledge in US

401 General knowledge in US into transcutaneous US (TUS) images

402 Get a feel for the importance of the up/down handle

403 Get detailed images from the GB

404 GI perforations

405 GIST study and sampling

406 Good skills in a safe puncturing of these findings

407 Good skills in approaching and stabilizing the instrument close to these findings

408 Good skills in approaching different and interesting parts of a lesion with the needle

409 Good skills in characterizing abnormal findings

410 Good skills in detecting abnormal findings

411 Good skills in handling different needles

412 Good skills in optimizing the images

413 Gradual endoscope movement permitting progressive, confident and correct interrogation of the patient's anatomy, without skipping over regions

414 Handle your microscoop and slides without breaking it

415 Handling (including loading) of FNA/fine needle biopsy needle

416 Handling biopsy needle with one hand

417 Handling biopsy speciments

418 handling 'gastroscope' (two wheel steering, suction and flushing) are new for pulmonologists

419 Handling of the Albaran-device

420 Handling of the suck- and inflate-knobs (balloon and gi lumen)

421 Handling wheels and elevator with one hand

422 Handling when needle will not advance out of scope

423 Have a detailed knowledge on how to handle the endoscope

424 Have a detailed knowledge on the anatomy in the mediastinum

425 Have an excellent knowledge of EUS anatomy with both the radial and linear echoendoscope

426 Having good skills in handling changing related to surgery

427 Having good skills of the changing related to age for example in the pancreas

428 Head of the pancreas

429 High experience iin transabdominal ultrasound

430 High experience in diagnostic and therapeutic endoscopy

431 How often do you need to aspirate

432 How to get control over the orientation

433 I am not sure about radial EUS: depends on practice settings

434 I am not sure about rectal EUS: pertains more to the colo-proctologist than to the endosonographer. Also depends on practice setting

435 I am sure that advance therapeutic hybrid procedures (involving fluoroscopy) do not pertain to the EUS area primarily, but to the interventional (ERCP) arena

436 I identify from the duodenum the great vessels, uncinate process, the paipilla, PD, CBD

437 ID of Metatastic liver lesions

438 Ideally knowledge in CT scan

439 Identification (linear) of AP window

440 Identification (linear) of bifurcation of the trachea

441 Identification (linear) of body/tail/head of pancreas and uncinate process

442 Identification (linear) of celiac trunk/portosplenic confluence

443 Identification (linear) of gallbladder

444 Identification (linear) of the CBD/H from ampulla to the liver hilum

445 identification and interpretation of abnormal findings in the mediatinum, liver and bilipancreatic region

446 Identification of all segments of pancreas including pancreatic duct

447 Identification of ampulla (endoscopically and on linear EUS)

448 Identification of autoimmune pancreatitis

449 Identification of biliary pathology

450 Identification of biliary system from papilla to intrahepatic ducts

451 Identification of fix points - etc. Liverhilum

452 Identification of landmarks upper abdomen ultrasound

453 Identification of left adrenal gland

454 Identification of lesion of interest or rule out

455 Identification of lesions in the ultrasound anatomy

456 Identification of liver lesions

457 Identification of liver pathology

458 Identification of major papilla

459 Identification of mural sonolayers

460 Identification of optimum safe site for biopsy or puncture

461 Identification of pancreatic pathology

462 Identification of subepithelial lesions

463 Identification of the aorta

464 Identification of the biliopancreatic confluence

465 Identification of the celiac artery

466 Identification of the different wall layers of the luminal GI tract

467 Identification of the left adrenal gland

468 Identification of the lymphonod in the chest during esophageal passage

469 Identification of the mass invasion of the vessels

470 Identification of usual abnormal anatomy (peri GI masses, lymph nodes & stations, intramural abormalities, pancreatobiliary disease such as CBD stones and chronic pancreatitis)

471 Identification of vascular anatomy of upper abdomen

472 Identification of vasculature and appropriate use of Doppler

473 identifications the uncinate process

474 Identify anatomy with rectal ultrasound

475 Identify and delinate anatomy of liver and biliary system

476 Identify and delinate anatomy of pancreas and surroundings

477 Identify and delineate anatomy in mediastinum

478 Identify bile duct and portal vein

479 Identify B-mode characteristics of nodes

480 Identify celiac axis

481 Identify defined anatomic EUS landmarks for orientation and interpretation of findings

482 Identify ductus choledochus

483 Identify features of chronic pancreatitis

484 Identify galblatter

485 Identify gallbladder and bile duct stones

486 Identify in this order: liver, abdominal aorta, left adrenal gland, station 7, 4L, 4R

487 Identify key anatomical structures: PV, SV, SMV, Aorta, Celiac A, Pancreas, Hepatic veins, IVC

488 Identify level 7 nodes

489 Identify mediastinum

490 Identify mural nodules and epithelial nodules in pancreatic cyst

491 Identify organs and vessels on EUS

492 Identify pancreas and pancreas duct

493 Identify pancreatic duct

494 Identify pancreatic mass and describe EUS characters- hypo-/hyperechoic, calicfication, PD

495 Identify papila echographic image

496 Identify papila endoscopic image

497 Identify physiologic narrowings and steer safely around these structures

498 Identify relevant lymfnodes for staging of oesophageal tumor

499 Identify standard stations: subcarinal space, AP window, LN stations in mediastinum

500 Identify structures from each station

501 Identify the bile duct

502 Identify the celiac artery takeoff from the aorta

503 Identify the gallbladder

504 Identify the intestinal layers

505 Identify the lesion

506 Identify the liver

507 Identify the portal confluence vasculature

508 Identify the relationship of organs, vessels, ducts

509 Identify the various parts of the pancreas

510 Identifying bile duct/gall bladder

511 Identifying head of pancreas and uncinate

512 Identifying left love of liver

513 Identifying pancreatic body and tail/neck

514 Identifying relevant (numbered) LN stations in the medisatinum and peritoneum/retroperitoneum

515 IDENTIFYING STRUCTURES AND PROBLEMS

516 Identifying the 5 layers of gut wall

517 Identifying the celiac axis

518 Identifying the papilla region

519 Immortalization through pictures and films

520 In most cases people should also be trained in EUS guided interventions (i.e., pseudosycst/biliary drainage etc.)

521 Indentification of the body of the pancreas

522 Indentification of the CBD and PD from ampulla (2nd portion)

523 Indentification of the head of the pancreas

524 Indentification of the head of the pancreas

525 Indentification of the hepatic hilum (portal vein and bile duct) from stomach

526 Indentification of the liver

527 Indentification of the spleen

528 Indentification of the tail of the pancreas

529 Indentification of the uncinate process

530 Insert a miniprobe and obtain adequately clear images for interpretation

531 insert a needle in different scope positions (in the stomach and duodenum)

532 Insert echoendoscope across the cricopharynx safely

533 insert linear endoscope in esophagus

534 insert the endoscope in the patient

535 Insert the endoscope into the 2nd part of the duodenum

536 Inserting a radial and linear EUS scopes to the sigmoid colon

537 Inserting a side-viewing duodenoscope or Echoendoscope from mouth to second part of duodenum

538 Inserting both linear (and radial if possible) into the second part of the duodenum

539 Inserting endoscope through the Killian

540 Inserting scope into the duodenum under EUS guidance

541 Inserting scope till rectosigmoid junction under EUS guidance

542 Inserting the echoendoscope into the 2nd duodenum

543 Inserting the echoendoscope into the duodenal bulb

544 Inserting the echoendoscope into the esophagus

545 Inserting the echoendoscope into the esophagus

546 Inserting the echoendoscope into the rectum

547 Inserting the echoendoscope into the second part of the duodenum

548 Inserting the echoendoscope into the second part of the duodenum

549 Inserting the echoendoscope into the second portion of the duodenum

550 Inserting the echoendoscope into the third part of the duodenum

551 Inserting the echoendoscope to the second part of the duodenum

552 Inserting the endoscope into the 2nd part of the duodenum

553 Inserting the endoscope into the esophagus

554 Inserting the endoscope into the esophagus

555 Inserting the endoscope into the esophagus

556 Inserting the endoscope into the second part of the duodenum

557 Inserting the endoscope into the second part of the duodenum

558 Inserting the endoscope into the second part of the duodenum

559 Inserting the endoscope into the second part of the duodenum

560 Inserting the endoscope into the second part of the duodenum

561 Inserting the endoscope into the second part of the duodenum

562 Inserting the endoscope into the stomach

563 Inserting the endoscopio into 2nd duodenum

564 Inserting the EUS scope into 2nd portion duodenum

565 Inserting the EUS scope to the descending colon

566 Inserting the linear and radial echoendoscope into the second part of the duodenum

567 Inserting the linear endoscope in the second part of the duodenum

568 Inserting the linear endoscope into sigmoid colon

569 Inserting the linear endoscope into the anorectum

570 Inserting the linear EUS endoscope into the second part of the duodenum

571 Inserting the radial endoscope in the second part of the duodenum

572 Insertion accessories into working channel of echoendoscopy e.g., biopsy needle

573 Insertion in esophagus

574 Insertion of bulb

575 Insertion of D2

576 Insertion of endoscope through to the duodenum and from rectum to illiac vessels

577 Insertion of EUS in thé oesophagus

578 Insertion of lumen apposing metal stent into pancreatic fluid collection

579 Insertion of the linear scope to D3

580 insertion of the scope in the esophagus

581 Insertion through the upper esophageal sphincter

582 Inspect 2L

583 Insufflation of balloon with water without air-bubbles

584 Integrating and co-ordinating endoscopic and sonographic anatomy

585 Interpret elastography strain histogram

586 Interpret elastopgrahy strain graph

587 Interpret Linear EUS anatomy in D1

588 Interpret Linear EUS anatomy in D2

589 Interpret Linear EUS anatomy in D3

590 Interpret Linear EUS anatomy in mediastinum

591 Interpret Linear EUS anatomy in stomach- proximal, mid and distal

592 Interpret microscopic view of slides

593 Interpret pancreas head from distal stomach across PV

594 Interpret radial EUS anatomy in D1

595 Interpret radial EUS anatomy in D2

596 Interpret radial EUS anatomy in mediastinum

597 Interpret radial EUS anatomy in stomach - proximal, mid and distal

598 Interpret the linear anatomy form the 2nd part of duodenum and the duodenal bulb

599 Interpret the linear anatomy from mediastinum

600 Interpret the linear anatomy from the ventricle

601 Interpret the sonographic appearance and offer a differential diagnosis of sub-epithelial lesions

602 Interpret ultrasound illusional images

603 Interpretation and characterization of cystic lesions of pancreas

604 interpretation of abnormal/suspect LAG

605 Interpretation of abnormal anatomy

606 Interpretation of all functions and dysfunctions of an EUS scope

607 Interpretation of anatomical guiding structures

608 Interpretation of digestive wall layers in EUS

609 Interpretation of layer of origin of subepithelial lesions

610 Interpretation of normal anatomy/radial and linear

611 Interpretation of oblique view endoscopic image

612 Interpretation of pancreatico-biliary anatomy

613 Interpretation of sonomorphology: conventional abdominal ultrasound including doppler/duplex and CEUS

614 Interpretation of the pathology

615 Interpretation of tumor invasion into mediastinal structures (T4 criteria)

616 Interpreting the images and tracing the structures at each of the 4 pancreatobiliary stations for both radial and linear echoendosdcopes

617 Interpreting the images and tracing the structures for the mediastinal stations for both the radial and linear echoendoscopes

618 Interventional endoscopists may require facility with forward-viewing EUS scope

619 Introducing the scope, also/especially in difficult anatomy

620 Introduction of EUS scope into the 2nd part of duodenum with minimal air insufflation

621 Introduction scope into esophagus

622 Intubation

623 Intubation

624 Intubation of esophagus

625 Intubation of oesophagus and down to second part duodenum

626 Intubation of the esophagus

627 Intubation of the esophagus

628 Intubation of the esophagus with a linear therapeutic echoendoscope

629 Is cytology fine or histology needed

630 Judicious use of water instillation in GI lumen

631 Keeping insufflation to the minimum

632 Keeping the echoendoscope straight at all times to maximize tip control

633 Knobology, at least 20 features

634 Know all the basic physics principles (range, gain, contrast, depth, etc.)

635 Know all the different techniques for FNA (fanning, suction, no suction)

636 Know all the differing FNA and fine needle biopsy needles on the market

637 Know EUS stations for radial and linear echoendoscope

638 Know how to best display ultrasound image with the echoendoscope (adequate frequency, focus, gain, contrast, harmonics, etc.)

639 Know how to identify subepithelial tumors, by the layer of origin

640 Know how to prepare an echoendendoscope (connexions, balloon,…)

641 Know how to store images and/or video loops

642 Know how to use air and water during EUS exam for a better outcome

643 Know how to use and adjust Doppler signal

644 Know how to use Doppler in EUS exam and obtain maximum benefit from it

645 know the advantages and disadvantages of different needles

646 Know the basics and physics beyond ultrasound

647 Know the classification and nomenclature of various lymph node stations in the chest and abdomen

648 Know the difference between cytology, immunohistochemestry and histology

649 Know the features of chronic pancreatitis

650 Know the technique for a complete radial and linear exam

651 Know to use external aids like gallbladder pressure, to improve detection of stones

652 Know what structures are mandatory not to biopsy

653 Know what structures are mandatory to biopsy

654 Know when aspiration is a risk for complications

655 Know when not to aspirate (cysts)

656 Know which drugs may help improve EUS image and therefore outcomes (e.g., buscapine)

657 Know which order to aspirate different regions

658 Knowing stations

659 Knowledge (we call it pancreas mobile) why the tail of the pancreas is so close to the head in a left lateral position

660 Knowledge and interpretation of computed tomography scan and magnetic resonance images

661 Knowledge fo the different tools and techniques for histological sampling with EUS

662 Knowledge how to handle the biopsy specimen in case of MOSE

663 Knowledge how to handle the specimen in case of no ROSE

664 Knowledge how to perform contrast injection and result interpretation

665 Knowledge in US guided punctures and interventions

666 Knowledge of anatomical variations

667 Knowledge of both radial and linear EUS endoscopes

668 Knowledge of both, TUS and EUS

669 Knowledge of different biopsy techniques (FNA/fine needle biopsy)

670 Knowledge of EUS-BD drainage

671 Knowledge of EUS-FNA (accuracy, etc.)

672 Knowledge of EUS-GBD drainage

673 Knowledge of EUS-PD drainage

674 Knowledge of EUS-PFC drainage

675 Knowledge of FNA needles

676 Knowledge of imaging EUS (elastography, contrast EUS)

677 Knowledge of linear anatomy in different sites

678 Knowledge of local clinical management algorithms determining appropriateness of FNA/fine needle biopsy

679 Knowledge of lymph node stations

680 Knowledge of principles of general US-investigation - brightness, focus, depth, recording, Doppler

681 Knowledge of technical set up of echo graphic machine

682 Knowledge of the Limitations of US imaging compared to anatomy

683 Knowledge of the UL technique

684 Knowledge of troubleshooting of diagnostic EUS and EUS-FNA

685 Knowledge of troubleshooting of EUS-BD

686 Knowledge of troubleshooting of EUS-GBD

687 KNOWLEDGE of troubleshooting of EUS-PD

688 Knowledge of troubleshooting of EUS-PFC drainage

689 Knowledge of ultrasound artifacts

690 Knowledge of various knobs on the utlrasound console: knobology

691 Knowledge on how to handle a rigid endorectal probe

692 Knowledge on how to identify arcuatum ligament

693 Knowledge on how to identify normal sized lymph nodes in the liver hilum

694 Knowledge on how to identify normal sized lymph nodes subcarinal

695 Knowledge on how to identify supraadrenal gland vessels

696 Knowledge on how to identify the aortopulmonary window

697 Knowledge on how to identify the mesorectum

698 Knowledge on how to identify the prostate (at which position)

699 Learn B-mode identifiers for risk of malignancy

700 Learn elastography technical background

701 Left hand movements recognition

702 Limits of EUS

703 Linear anatomy

704 Linear anr radial orientation

705 Linear EUS scope insertion up to D2

706 Locate cystic structures from within the pancreas and relationship to the duct

707 Locate the gastroduodenal artery and hepatic artery

708 Locate the GB from the antrum and duodenal bulb

709 Locate the left adrenal, left kidney and trace the renal vein to the kidney

710 Locate the PV and SMV confluence

711 Locating scope in D1 and D2

712 Location of aorta and celiac trunk

713 Location of left kidney and left adrenal

714 Location of pancreatic body and tail

715 Location of pancreatic head

716 Location of portal vein and superior mesenteric vein

717 Location of superior mesenteric artery and vein

718 Location of the aorto-pulmonary window

719 Location of the left liver lobe

720 Location of the subcarinal space

721 Luminal tumor staging

722 Lymph node biopsy

723 Lymph node stations in the chest

724 Maintaing EUS image for performance of FNA

725 Make “ERCP”-maneuver (shortening duodenum while withdrawing a scope)

726 Make slides

727 Make your own slides for ROSE

728 Making sure that the relevant persons are ready/prepared

729 Manage long and short position EUS évaluation of the duodenum with linear scope

730 Manage long and short position EUS évaluation of the duodenum with linear scope

731 Manage long and short position EUS évaluation of the duodenum with radial scope

732 Manage short position EUS evaluation of the neck of the pancreas with radial scope

733 Management of anticoagulants

734 Maneuver both radial and linear scope in upper GI tract

735 Maneuvering safely the rigid non-steerable tract of the echoendoscopes

736 Manipulate with linear scope in the stomach

737 Manipulation if big wheel and elevator during FNA to change needle trajectory

738 Manipulation of sonoscope

739 Mastering upper endoscopy including duodenoscopy

740 Mediastinal anatomy

741 Medical doctor is better

742 Mesenteric vessels

743 Mesurement of structures

744 Minimizing complications when doing FNA/fine needle biopsy

745 Mounting of scope

746 Move scope to level 9 nodes

747 Move to 4L

748 Mucosal trauma in GI tract

749 Multiple plan imaging

750 Navigate an oblique viewing endoscope

751 Navigate the EUS scope from mouth to the 3rd portion of the duodenum

752 Navigating the scope by US imaging

753 Necrosectomy

754 Need for EBUS combination

755 Needle handling

756 Needles knowledge and different use

757 Negotiate GE Junction carefully with dexterity

758 New EUS devices for therapeutic procedures (LAMS, RFA etc.) knowledge and technic

759 Number 1 and 2 agree

760 Obtain a stack sign

761 Obtain endoscopic view of papilla

762 Obtain rotation with shoulder and shaft movement and not applying torquing

763 Obtaining images with landmarks to identfiy structures

764 Obtaining the ampullary view from D2

765 Optimizing cellularity of samples from various lesions (e.g., fan, use of different needles, number of passes, ROSE, MOSE, etc.)

766 Optimizing visualization of target organ or lesion by using controls on the processor (e.g., change frequency, gain, etc.)

767 Optimizing visualization of target organ or lesion endoscopically

768 Other structures which may be of relevance: Adrenal, thoracic duct, Azygos vein

769 Pancreatic body

770 Pancreatic cancer staging

771 Pancreatic cancer staging

772 Pancreatic cyst drainage

773 Pancreatic imaging station from duodenum

774 Pancreatic lesion biopsy

775 Pancreatic mass FNAC or biopsy

776 Pancreatic pathology study

777 Pancreatic rendezous

778 Pancreatic tail

779 Papilla identification

780 Passage of echoendoscope across the pylorus into the duodenal bulb

781 Passage of echoendoscope into esophagus

782 Passage of echoendoscope into the second duodenum

783 Passage of FNA needle

784 Passage of scope into second portion of duodenum

785 Passage of the scope past a hiatal hernia

786 Passing bot the radial and linear echoendoscope with ease beyond the EUS and through the pylorus

787 Passing echoendoscope around the duodenal apex

788 Passing scope through pylorus

789 Passing scope to D2

790 Passing scope to esophagus

791 Passing scope to proximal stomach

792 Passing the scope into the esophagus past the EUS

793 Passing the scope past pylorus into 2nd portion duodenum

794 Passing the scope to D2

795 Patient monitoring

796 Patient position with intubation

797 Patient position without intubation

798 Perfect anatomy recognition in magnetic resonance

799 Perfect anatomy recognition in scanner

800 Perfect echographic pattern of normal organs recognition

801 Perfect endoscopic correlation with outside organs and vessels

802 Perfect endoscopic localisation

803 Perfect knowledge of mediastinal and abdominal anatomy

804 Perform celiac plexus neurolysis

805 Perform EUS assessment for biliopancreatic benign and malignant diseases

806 Perform EUS staging for malignacies

807 Perform EUS-FNA and EUS-fine needle biopsy

808 Perform EUS-guided biliary drainage

809 Perform EUS-guided fiducial placement

810 Perform FNA from all EUS stations

811 Perform FNA of a 1 cm lesion of the pancreas

812 Perform needle based sampling

813 Perform sedation for diagnostic EUS

814 Perform stent insertion in mediastinal and abdominal fluid collections

815 Performing cyst aspiration supervised

816 Performing EUS guided biopsy of LN/solid tumor

817 Performing EUS procedures including FNA, pseudocyst drainage, transgastric access to the biliary tree,

818 Performing EUS-BD drainage

819 Performing EUS-FNA (B)

820 Performing EUS-GBD drainage

821 Performing EUS-PD drainage

822 Performing EUS-PFC drainage

823 Performing FNA/fine needle biopsy supervised

824 Performing linear EUS as the best tool much better than radial EUS except in the anorectum

825 Performing screening diagnostic EUS (GI, pancreatobiliary)

826 Place a needle into a target

827 Place fiducials (optional-all programs don't do that)

828 Placement of fiducials

829 Placement of the ultrasound transducer on a target

830 Portal confluence

831 Positioning for FNA

832 Preparation of the scope (filling of the balloon)

833 Procedural sedation

834 Proficiency in Axios stent use

835 Proficiency in EUS pseudocyst management

836 Proper room setup for EUS exam

837 Pseudocyst drainage

838 Puncture and drainage of a pancreatic collection

839 Puncture of lesions > 1 cm (pancreas)

840 Puncture of lymph nodes

841 Radial EUS scope insertion up to D2

842 Radiofrequency ablation

843 Reaching all locations

844 Reaching all stations

845 Reaching the papilla

846 Reaching the papilla of Vater and identify the biliary and pancreatic duct

847 Reading standard textbook to depiction each organs

848 Recognise key landmarks - OG, M, PB, anorectal

849 Recognise liver and focal lesions/abnormal texture

850 Recognise major vessels

851 Recognition of benign and malignant adenopathy

852 Recognition of bleeding after FNA

853 Recognition of major venous and arterial blood vessels

854 Recognize anatomical landmarks in mediastinum and abdomen for both linear and radial EUS

855 Recognize and reproduce the vascular anatomy

856 Recognize liver from spleen

857 Recognize sarcoid characteristics ultrasound

858 Recognize the need for antibiotic prophilaxis for FNA

859 Recognizing all anatomical landmarks with the radial and linear to include the following structures and to locate on own the following:

860 Recognizing mediastinal structures with both radial and linear scopes

861 recognizing needle pathway in case of FNA/fine needle biopsy

862 Rectal cancer staging

863 Relatively Younger is better

864 Reliably complete imaging of the bile duct from ampulla to hilum

865 Reliably recognize lymph node stations and staging

866 Reliably stage pancreatic malignancy or at least recognize areas of weakness in staging

867 Reposition the echoendoscope in the esophagus into a standardized position (“33 cm subcarinal region)

868 Reposition the echoendoscope in the esophagus into a standardized position (“44 cm Aorta, celica trunc)

869 Reposition the echoendoscope in the esophagus into a standardized position (“55 cm part I/II of duodenum, distal part of the bulb

870 Requirements for a good image qualitiy (contact, pressure on the transducer, water filling, balloon …)

871 Right hand movements recognition

872 Riskfree insertion of an duodenoscope into the second part of the duodenum

873 Role of suction in EUS

874 Safe and comfortable intubation of the EUS instrument

875 Safe and comfortable manovering of the EUS instrument in different parts of the gut

876 Safe handling of a forward-viewing endoscope

877 Safe handling of a side-viewing endoscope

878 Safe introduction in esophagus

879 Safe intubation

880 Safe passage into the second portion of the duodenum

881 Safely insert the echoendoscope into the duodenum

882 Scope insertion across cricopharynx

883 Scope maneuvering to complete anatomical evaluation – e.g., witndrawing scope from D2

884 Scope manoeuvring across D1

885 Scope motion to identify subcarinal space

886 Securely pass linear scope to the second part of duodenum

887 Self-critical interpretation of the own knowledge

888 Setting adjustments in keyboard - Gain and contrast

889 Shorten echoendoscope in the duodenum

890 Should be able to interpret abnormal anatomy and recognise lesions

891 Should have an understanding of the movements of the scope to visualise anatomy

892 Should have theoretical knowledge of features and classification of pathologies e.g., tumour TNM classification, chronic pancreatitis etc.

893 Should understand the movements of the endoscopist to visualise anatomy and pathology

894 Simultaneous handling of endoscope and improving ultrasound image quality

895 Sonographic hallmarks of various normal variants, and benign and malignant diseases

896 Staging of esophageal cancer

897 Staging of gastric cancer

898 Staging of luminal cancer

899 Staging of pancreas cancer

900 Staging of rectal cancer

901 Standardized examination

902 Standardized procedure to examine the adrenal glands

903 Standardized procedure to examine the anorectum

904 Standardized procedure to examine the bile ducts

905 Standardized procedure to examine the duodenum

906 Standardized procedure to examine the esophagus

907 Standardized procedure to examine the gallbaldder

908 Standardized procedure to examine the liver hilum

909 Standardized procedure to examine the lung and mediastinum according to the lymph node localisation

910 Standardized procedure to examine the pancreas

911 Standardized procedure to examine the rectum

912 Standardized procedure to examine the spleen

913 Standardized procedure to examine the stomach

914 Starting with radial or linear EUS anatomy

915 Subepithelial lesion characterisation

916 Submucosal tumor study and sampling

917 Successful FNA

918 Sufficient knowledge of normal and pathological findings in abdominal ultrasound

919 Supra renal gland identification

920 Systematic examination of the entire pancreas

921 Systematic examination of the extrahepatic bile duct

922 Systematic examination of the mediastinal anatomy

923 Taking FNAC from different stations organs

924 Technique of core biopsy of intramural masses

925 Technique of FNA sampling of lymph nodes

926 Techniques of FNA sampling of extraluminal organs

927 The above applies to gut wall lesions and extraluminal conditinons such as pancrea

928 The pancreatic head is larger than often assumed

929 The relevant instrument - FNA/fine needle biopsy etc., in the room

930 Therapeutic EUS

931 Theroetical (at least) knowledge of all indications for EUS-guided interventions

932 Thinking about differential diagnosis

933 TNM stage

934 TNM staging

935 To be able to indentify liver segments and vessels through the stomach and the duodenum

936 To be able to find and follow celiac axis and his branches using linear scope

937 To be able to follow the cystic duct from the neck of the gallbladder to the CBD using linear and radial scope

938 To be able to identify all vascular structures and heart cavities in thin young patients where all these structures are well visible

939 To be able to identify body and entire tail of the pancreas using radial scope and to be able to recognize the 20% of the patients where the top of the tail is not visible using radial scope justifying the linear scope if these is an indication to examine the entire pancreas (Aciute pancréatites of unknown origin, looping for insulinoma or MEN 1 syndrom, or staging of IPMN

940 To be able to indentify lesser curve greater curve anterior and posterior wall of the stomach under EUS guidance without air intillation

941 To be able to indentify neck of the pancreas through the stomach using radial scope in ladies and neck using radial and linear scope in male and female

942 To be able to perform dis-guided drainage of pseudo-cysts using double pigtail stents and metallic stents for abscesses.

943 To be able to perform EUS-guided celiac block and neurolysis

944 To be able to perform EUS-guided FNA with fanning method in pancreatic mass through the duodenum and the stomach

945 To be able to perform FNA in submucosal mass and in mediastinal lymph node

946 To be able to perform staging of oesophageal gastric and rectal cancer

947 To be able to visualize CBD stones in more than 80% of the cases when present.

948 To be able to visualize the 3 parts of the gallbladder through the antrum and the duodénal bulb in more than 95% of the cases

949 To be able to visualize the entire bile duct from the hilum to the ampulla when it is dilated

950 To be able to visualize using radial and linear scopes the 3 parts of the head (uncinate process, posterior and anterior part of the head using radial and linear scopes

951 To introduce the scope carefully without damage in any case

952 To move into the descending duodenum Using EUS guidance following the CBD or the PD to the ampullary region

953 To move into the duodenal bulb using a radial scope with EUS guidance avoiding to introduce air within the gastric cavity

954 To study the mediastinum with knowledge of all visible lymph node stations

955 Torque of scope to identify periampullary cbd and pd

956 Torque of scope to maintain visualization of the EUS needle tip during FNA

957 Torque of the scope to visualize the pancreas tail

958 Trace common bile duct from papilla to hepatic ilum

959 Trace pancreatic cysts to pancreatic duct

960 Trace pancreatic duct from the papilla to the tail

961 Trace the bile duct from hilum to ampulla

962 Trace the CBD from the GB to the ampulla and identify CBD stones

963 Trace the entire PD from tail to the ampulla

964 Trace the pancreas duct from neck of pancreas to major or minor papilla

965 Trace the PV

966 Trace the SMA

967 Trace the splenic vein and artery

968 Transformation of anatomical interpretation of the linear anatomy in radial imaging

969 Transformation of anatomical interpretation of the linear anatomy into MRI and CT imaging

970 Transrectal imaging

971 Troubleshooting when equipment not working

972 Uncinate process

973 Understand anatomy as continuous and not fragmented

974 Understand anatomy as seen on EUS

975 Understand and perform miniprobe EUS

976 Understand and performs the different methods of tissue acquisition (slow pull vs. capillary vs. etc.)

977 Understand the different Doppler functions, including color, power, and spectral Doppler (pulsed Doppler)

978 Understand the normal radial and linear anatomy in the thorax

979 Understand the structure and components of different EUS FNA and fine needle biopsy needles

980 Understand what is abnormal findings, specially tumors

981 Understand when it is helpful to use fine needle biopsy (vs. FNA)

982 Understandig of the movements of a radial and linear transducer within the body

983 Understanding 3 dimensional normal and altered anatomy based on 2D imaging

984 Understanding anatomy

985 Understanding and handling properly the oblique endoscopic viewing

986 Understanding and use of fanning technique for biopsy

987 Understanding and use of slow pull technique for biopsy

988 Understanding and use of suction technique for biopsy

989 Understanding new techniques and innovations

990 Understanding of and using power Doppler mode

991 Understanding of and using contrast enhanced EUS

992 Understanding of and using Elastografi

993 Understanding of and using of color Doppler mode

994 Understanding of basics of FNA needle

995 Understanding of the relationship between endoscope position and anatomical perspective at common EUS imaging stations

996 Understanding of the role of endoscope torque in accurately accessing and sampling target structures

997 Understanding radial and linear imaging

998 Understanding relationship in history and finding

999 Understanding voxelman imaing

1000 Understanding why radial scanning is unphysiological (“stupid”)

1001 Understands how EUS works

1002 Understands how to identify and classify submucosal lesions

1003 Understands how to interpret EUS tests (i.e., cyst fluid results)

1004 Understands how to manage patients with diseases evaluated by EUS

1005 Understands limitation of EUS

1006 Understands options for performing EUS-FNA/fine needle biopsy, different needles, different techniques, when and how to use them

1007 Understands the basic physics principles and different imaging modalities of EUS

1008 Understands the cancer staging and is able to accurately stage both luminal and pancreaticobiliary cancers

1009 Understands the indications for EUS

1010 Understands where lesions can be missed

1011 Upper abdominal anatomy from proximal stomach

1012 Upper GI endoscopy advanced skills

1013 Use and indication of contrast

1014 Use of balloon

1015 Use of balloon

1016 Use of basic US function

1017 Use of contrast media technical set up of the system

1018 Use of Doppler

1019 Use of Doppler, sonoelastography

1020 Use of elevator during FNA

1021 Use of linear echoendoscope without transducer balloon

1022 Use of processor including Doppler, calipers, pulse wave, gain, frequency change, etc.

1023 Use of prophylactic antibiotics

1024 Use of US processor

1025 Use of water

1026 Use relevant force in handling the scope

1027 Using left hand and straight scope and not right hand for torquing

1028 Using linear and radial EUS for diagnostic and therapeutic indications

1029 Using long/short echoendoscope position as needed to improve stability

1030 Utilization of the big wheel to keep scope against the intestinal lumen to maintain image quality

1031 Varices study and guided therapy

1032 Velocity of movement

1033 Visualisation of the whole pancreas

1034 Visualise and demonstrate normal anatomy of mediastinum and pancreatobiliary regions

1035 Visualize landmarks of specific stations

1036 Visualize the ampulla

1037 Visualize the entire pancreas (uncinate, head, body, tail)

1038 Visualize the PV and the splenoportal confluence

1039 Visualizing the body

1040 Visualizing the head

1041 Visualizing the key vessels (PV, SMV/SMA, SV/SA, aorta, coeliac etc.)

1042 Visualizing the neck

1043 Visualizing the tail

1044 Visualizing the uncinate

1045 What caliber needle is optimal

1046 What is the role of the big and small wheel at the EUS scope

1047 When do you need to use a new needle

1048 When to ask for help!

1049 When to use suction

1050 Which scope or probe to use.



 
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