Best live endoscopy practices: an ASGE white paper

Events that demonstrate endoscopic techniques in real time, termed live endoscopy courses, provide invaluable lessons from real-life situations, advances in endoscopic techniques and practices, and the opportunity to demonstrate standards of care. Attendees learn the thought process involved in making decisions while a procedure is being performed. Live endoscopy courses also provide a unique insight into technologies and techniques that may benefit those in the community as well as in academic practice. Live endoscopy courses provide an opportunity to learn complex decision-making skills during endoscopic procedures in real time. Although training with prerecorded endoscopic videos can help simulate this experience, it cannot re-create some of the real-life factors that affect endoscopic care and decision making, including, but not limited to, the time-sensitive nature of certain techniques and decisions and unpredictable patient, healthcare provider, and/or endoscopic device issues. In addition, prerecorded endoscopic videos used for training are often edited, causing the learning experience to be an altered version of real life. The American Society for Gastrointestinal Endoscopy (ASGE), similarly to other GI endoscopy societies,1Webster G.J. El Menabawey T. Arvanitakis M. et al.Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement - Update 2021.Endoscopy. 2021; 53 (842-9.2)Crossref Scopus (2) Google Scholar plays a pivotal role in organizing, conducting, and endorsing live endoscopy courses. The ASGE emphasizes that live demonstrations must be conducted with the patient as the first priority. With the surge in live endoscopy courses conducted in person or virtually and across multiple centers, the ASGE Governing Board commissioned an expert panel to revise the previous guidelines published by the ASGE.2Carr-Locke D.L. Gostout C.J. Van Dam J. A guideline for live endoscopy courses: an ASGE white paper.Gastrointest Endosc. 2001; 53: 685-688Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar, 3Loren D.E. Azar R. Charles R.J. et al.Updated guidelines for live endoscopy demonstrations.Gastrointest Endosc. 2010; 71: 1105-1107Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Legemate J.D. Zanetti S.P. Baard J. et al.Outcome from 5-year live surgical demonstrations in urinary stone treatment: are outcomes compromised?.World J Urol. 2017; 35: 1745-1756Crossref PubMed Scopus (15) Google Scholar, 5Rocco B. Grasso A.A.C. De Lorenzis E. et al.Live surgery: highly educational or harmful?.World J Urol. 2018; 36: 171-175Crossref PubMed Scopus (21) Google Scholar The aim of this document is to offer recommendations addressing key issues related to live endoscopy courses. The following questions were considered: 1) endoscopist-, patient-, procedure-, and attendee-related concerns, 2) patient outcomes, 3) legal issues related to live endoscopy courses, 4) the value of a patient advocate, and 5) ethical issues and issues related to management of conflicts of interest and quality control. The topics were conceptualized by the authors of the document, the ASGE Education Council, and approved by the ASGE Governing Board. The panel composition consisted of content experts (expertise in conducting live endoscopy courses and endoscopy education), members of the ASGE Education Council, legal experts, and nursing staff. All members were asked to disclose conflicts of interest based on the ASGE policy: https://www.asge.org/forms/conflict-of-interest-disclosure and https://www.asge.org/docs/default-source/about-asge/mission-andgovernance/asge-conflict-of-interest-and-disclosure-policy.pdf. The recommendations were drafted by the panel during a virtual meeting on January 9, 2022. This document was approved by the ASGE Governing Board in July 2022. The strength of a recommendation reflects the extent to which the panel is confident that the desirable effects of an intervention outweigh the undesirable effects, or vice versa, across the range of patients for whom the recommendation is intended. This document was based on a systematic review of the available literature for the pertinent clinical questions. Given that no outcomes data addressing the impact of live endoscopy course participation were identified, the panel decided to provide 2 categories of recommendations: should or may. The main factor that drove this categorization was the impact of the intervention on patient benefits and harms, patient preferences, and patient outcomes. The final wording of the statements (direction, remarks, qualifications) was decided by consensus and was approved by all members of the panel, the ASGE Educational Council, and the ASGE governing board. Concerns with live endoscopy courses may be related to the endoscopist, patient, procedure, course setup, and attendee. Every effort to minimize risks to patients during a live endoscopy course must be considered, and evaluating these concerns can help mitigate overall risk.2Carr-Locke D.L. Gostout C.J. Van Dam J. A guideline for live endoscopy courses: an ASGE white paper.Gastrointest Endosc. 2001; 53: 685-688Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar,6Cotton P.B. Live endoscopy demonstrations are great, but.Gastrointest Endosc. 2000; 51: 627-629Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Live endoscopy courses present an exciting forum for experts to demonstrate endoscopic best practices and innovation. It is essential that the endoscopist performing the procedure is comfortable, is experienced, and has the necessary expertise in the procedure being demonstrated. The procedure should be the standard of care and should be in the patient’s best interest rather than an avenue for demonstrating a new technique or device. On occasion, visiting endoscopists may bring different points of view and skills from various areas of the world. However, visiting faculty may not be familiar with local room setup, available devices, and experience level of the supporting staff. It is crucial to ensure that the endoscopist is familiar with the patient and procedure details and is accustomed to or has been introduced to the staff in the room. There are additional auditory, visual, and physical distractions during a live course: the presence of lights, cameras, and extra personnel in a warmer-than-usual procedure room in addition to time/production pressure can cause heightened stress on the endoscopist and procedure room staff. The need for constant communication with the in-room staff, the moderator, and the expert panel while simultaneously answering questions from the audience can lead to added stress on the endoscopist; this may be mitigated by having a second expert in the room to help interface with the moderator and audience. The plan for endoscopy, sedation, and the procedure to be demonstrated should be discussed with the patient. The patient’s understanding of the risks and benefits of participation in a live endoscopy course may be limited. These should be explicitly discussed with the patient in advance of the procedure, to provide the patient enough time to weigh the pros and cons and to make an informed decision about participation. The patient’s introduction to the expert endoscopist performing the procedure (if not done before the course) can help establish a physician-patient relationship. A separate consent for participating in a live endoscopy course should be obtained in addition to the standard institutional procedure consent (addressed in detail under Legal Issues Pertaining to Live Endoscopy). A plan must be in place to ensure that patient healthcare information is removed from all video feeds. Live course procedures could be longer than usual owing to teaching elements and room switching involved with multiple procedures being performed and transmitted simultaneously. The course director/organizing committee should ensure that patients selected for live procedures are appropriate and that the possibility of prolonged sedation will not cause any detrimental outcome. Postprocedure follow-up/aftercare may not be ideal if the organizers are busy with the course or are not familiar with the techniques performed and do not have experience in appropriate aftercare, especially if the visiting endoscopist has departed at the completion of the course. Assuring that there is a local team to follow up the patient with a proper sign-out is important. A theoretical concern exists that live courses could be associated with higher adverse event rates; however, there are insufficient data to support this. In a study comparing ERCP outcomes in 168 live endoscopy workshop patients with 168 control patients, it was reported that ERCP was delayed in 18 patients to allow treatment during the live endoscopy courses.6Cotton P.B. Live endoscopy demonstrations are great, but.Gastrointest Endosc. 2000; 51: 627-629Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar General anesthesia was used in 87.5% of the workshop patients, in comparison with 44% of the control patients (P < .001). There was no difference in the duration of the endoscopies or radiation exposure. No significant difference was found in the endoscopic treatments with the exception of cholangiopancreatoscopy, which was performed in 7% in the workshop group versus 0% in the control group (P < .01). The success and adverse event rates were similar in the workshop and control patients, as was the duration of hospitalization. Forty-five percent of the patients from the workshop group benefited financially because they were not charged for stents or other devices. Nonetheless, it seems that the rate of use of general anesthesia and the length of procedural times may be higher during live endoscopic procedures. The live endoscopy course should foster audience engagement and participation; this can be challenging to ensure when simultaneous rooms are being transmitted. Audience members may experience fatigue and disengagement. Moderators should present the case, patient history, the rationale for the demonstrated procedure, factors leading up to the procedure/device being showcased, the potential adverse events, and after-care as part of the course discussions. Without these aspects, the audience may not feel invested in the case. Adverse events and risks should be highlighted so that the audience members watching complex procedures do not have a false sense of ease while watching experts perform difficult maneuvers. Case selection may not entirely reflect the participants’ practice; however, having a balanced mix of not only esoteric cases or those featuring cutting-edge, infrequently performed techniques but also those that the audience members may encounter in practice should be the goal. Time should be allocated after live broadcast segments for panel commentary on key take-home lessons from the observed cases. Early data regarding ERCP outcomes during live endoscopy reveal variable results regarding differences in outcomes, with a European study demonstrating no differences in success rates or adverse event rates,7Schmit A. Lazaraki G. Hittelet A. et al.Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations.Endoscopy. 2005; 37: 695-699Crossref PubMed Scopus (47) Google Scholar whereas a large Asian study suggested that there was lower success when ERCPs were performed during live demonstrations compared with routine procedures.7Schmit A. Lazaraki G. Hittelet A. et al.Complications of endoscopic retrograde cholangiopancreatography during live endoscopy workshop demonstrations.Endoscopy. 2005; 37: 695-699Crossref PubMed Scopus (47) Google Scholar,8Liao Z. Li Z.S. Leung J.W. et al.How safe and successful are live demonstrations of therapeutic ERCP? A large multicenter study.Am J Gastroenterol. 2009; 104: 47-52Crossref PubMed Scopus (39) Google Scholar A later study demonstrated that when stratified into procedural complexity, there were lower success rates with higher-complexity ERCPs than with controls.9Ridtitid W. Rerknimitr R. Treeprasertsuk S. et al.Outcome of endoscopic retrograde cholangiopancreatography during live endoscopy demonstrations.Surg Endosc. 2012; 26: 1931-1938Crossref PubMed Scopus (17) Google Scholar This study also demonstrated increased use of general anesthesia associated with live demonstrations. One recent study looked at outcomes of endoscopic submucosal dissection (ESD) procedures performed during a live endoscopy event in Germany as compared with routine standard ESD procedures performed at the same institution.10Ebigbo A. Freund S. Probst A. et al.Outcomes of endoscopic submucosal dissection (ESD) during live endoscopy events (LEE): a 13-year follow-up.Endosc Int Open. 2019; 7: E1723-E1728Crossref PubMed Google Scholar Thirty-eight live ESD procedures were compared with 38 matched routine ESDs. En bloc and curative resection rates in the live group and in the control group were 100% versus 87% and 84% versus 71%, respectively, whereas procedure times were 135 and 125 minutes, respectively. Noninferiority was demonstrated for resection rates and procedure times. The adverse event rate was lower in the live group than in the control group (5% vs 13%), and propofol sedation was similar in both groups (863 mg vs 872 mg). Recurrence and 5-year survival rates for both groups were 4% versus 0% and 70% versus 65%, respectively. This study demonstrated that the resection rate and procedure time of ESD during live endoscopy courses were noninferior to those of routine ESD procedures. More recent data are described in the surgical literature with respect to live urologic surgery demonstrations. In a study that included 224 cases over 12 years, the adverse event rate was 11.6%, which was deemed to be not higher than rates of similar procedural results in the published literature.5Rocco B. Grasso A.A.C. De Lorenzis E. et al.Live surgery: highly educational or harmful?.World J Urol. 2018; 36: 171-175Crossref PubMed Scopus (21) Google Scholar Similar case-control comparison studies of live demonstrations in urology showed that the adverse event rates were similar to, or lower than, those in controls.4Legemate J.D. Zanetti S.P. Baard J. et al.Outcome from 5-year live surgical demonstrations in urinary stone treatment: are outcomes compromised?.World J Urol. 2017; 35: 1745-1756Crossref PubMed Scopus (15) Google Scholar,11Ogaya-Pinies G. Abdul-Muhsin H. Palayapalayam-Ganapathi H. et al.Safety of live robotic surgery: results from a single institution.Eur Urol Focus. 2019; 5: 693-697Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Given limitations such as the lack of standardized definitions for success, prospective studies are needed to truly demonstrate whether live endoscopy courses may carry any particular or additional risk or benefit to the patient. The primary objective of a live endoscopy event is to demonstrate the best endoscopic practices that can improve patient outcomes. Planning and infrastructure development often begins at least 1 year before the event. A comprehensive approach to identify the course objectives, intended audience, faculty, curriculum, format, and output is essential for a successful live event. The success of a live endoscopy event goes well beyond the performance of a case, having the most desirable faculty, or the final attendance numbers. The measure of a successful course is best identified by the impact the event makes on the attendees. As such, it is critical to tailor the course format and content to match the audience you have chosen to reach. As one plans an endoscopy event it is important to take the time and identify the objectives for the course and the intended audience, and ensure these both align.2Carr-Locke D.L. Gostout C.J. Van Dam J. A guideline for live endoscopy courses: an ASGE white paper.Gastrointest Endosc. 2001; 53: 685-688Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Once the desired audience and objectives for a course are identified, the next step is assembling a planning team early on. The team should include these members:1Webster G.J. El Menabawey T. Arvanitakis M. et al.Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement - Update 2021.Endoscopy. 2021; 53 (842-9.2)Crossref Scopus (2) Google Scholar1.Course directors: These should generally be 2 or 3 individuals who will be integrally involved with the course and have a vested interest in its success. Thought should be invested to ensure equity and bandwidth of the individuals selected. It is important to note that course directors are not limited to physicians, inasmuch as nurses and advanced practice providers can sometimes add significant value in this role depending on the course objectives and audience.a.Course details: The course directors will work with the planning committee to identify the date(s) of the event, the format (lectures, panel discussions, and live endoscopy cases), and the venue.b.Course date: It is important to identify a date(s) that will facilitate the greatest attendance. Care should be taken to avoid other key societal courses (eg, Digestive Disease Week), holidays, and times of slow attendance (eg, spring break).c.Venue: Identification of a venue that can accommodate a live endoscopy event is critical. The team should ensure that the event is comfortable, is accommodating, and has the resources to handle all of the audiovisual needs.2.Planning committee: This committee includes those individuals who will ultimately be the “boots on the ground.” This group generally consists of 3 to 5 people who will be tasked with many of the operational aspects of a live event that make it flow smoothly and ensure an outstanding event for attendees and faculty. This group may range from department/hospital administrators, divisional administrators, program coordinators, continuing medical education (CME) planners, and interns to volunteers. This committee will be tasked with the following responsibilities:a.Identifying and confirming all venue-related factors (eg, rooms, audiovisual [AV] supplies, catering) and the liaisons between the venue and the course directors.b.Inviting faculty, moderators, and coordinating with the marketing team to ensure alignment between distributed content and confirmed course faculty.c.Serving as a liaison between the course directors and the AV team. The planning committee will handle basic issues but would escalate any significant concerns to the course directors.d.Vendor coordination. The planning committee will be the team working with course sponsors/vendors. They will assist in applying, procuring, and handling all unrestricted educational grants. They will also serve to engage with the industry to direct them to booths and provide instruction about their roles in the event.e.Continuing medical education (CME)/maintenance of certification (MOC) accreditation. The CME planners will take on this task and work with the course directors to ensure that all CME/MOC regulations and requirements are satisfied. They will also work with registrants to claim appropriate credits.f.Week-of-event coordination. This team will be physically present to ensure that all faculty-related travel, hotel, and needs at the course are addressed. In addition, they will provide day-of direction to registrants, handle on-site registration, and distribute any materials that are needed.g.Day of the event. The planning committee will be the one-stop shop for all questions that may arise from faculty, vendors, and registrants. They are the ultimate concierge for a live endoscopy event and should be equipped for arising problems and questions. In addition, they will help escort faculty or registrants who may need to be in different locations as part of the course.h.Postevent feedback. The planning committee will also be tasked to solicit feedback, generally via surveys, from the registrants and faculty. These data will help improve future courses.3.AV team: Perhaps the most important aspect of a live endoscopy event is the AV team. The AV team is generally a third-party group hired by the planning committee or the venue itself. Before the selection of the AV team, the course directors should meet with the potential group and ensure that all of their goals are within the skill set of this team. An effective AV team should be able toa.Provide transmission of live endoscopy to the venues, including seamless transitions between endoscopy rooms, presentations, and other course activities.b.Ensure that there is precision 2-way audio between the conference room and the endoscopy suite. All members of the endoscopy team, AV team, and conference room support team should be able to hear the live audio feed at all times.c.Manage all essential in–conference room needs. including cameras, microphones (speakers, audience, and panels), and podium-related computer needs (eg, switching between laptops).d.Manage all essential in–endoscopy suite needs, including coordination of in-room cameras; transitions between cases, lectures, and presentations; and working with moderators as they transition to ensure no interruption in audio communication.e.Troubleshoot any AV needs that occur in the conference room or the endoscopy suite. Often this requires the inclusion of 1 additional runner for the AV team who can keep abreast of issues as they arise to allow the AV team to address them efficiently and effectively.4.Event coordinators: The planning committee should identify the following leaders for the course who will be in constant communication and be tasked to make the final decisions around course flow. They include the following:a.Endoscopy suite coordinator: This is usually a nurse or trainee whose only job is to ensure that case transition is smooth and patients and anesthesia support are ready, and to communicate with the endoscopists, staff, and in-room moderators.b.Conference room coordinator: This again is usually a trainee or administrative coordinator whose job is to identify any issues that occur in the conference room and address them or communicate them to the resource person who can fix them. These issues include audio and video concerns, faculty presentations, and course flow.c.AV coordinator: There should be 1 lead AV person who will be in the communication loop to ensure that all av transitions are smooth and to be the point person for any audio or video needs that arise.d.The runner: This is a supplementary individual who will be mobile between the conference room and endoscopy laboratory and will be able to facilitate any needs or concerns between the venue and the endoscopy suite. The course agenda should be geared toward the intended audience and be created to that all course objectives are addressed. The agenda is created by the course directors with input from the planning committee to optimize session lengths, networking breaks, and other logistic aspects that will ensure an excellent overall experience for all registrants. If the course is part of a series, care should be taken to develop a full curriculum that will be covered once the series is completed. This concept will ensure that you retain registrants and optimize events over the live endoscopy series. Planning for adequate breaks (number and length) is essential to allow registrants and faculty to stay fresh, network with each other, and engage with your supporting vendors. Adequate break time also ensures that a proper amount of time is reserved for room turnover between cases. The formats for a live endoscopy course can vary significantly. First, it is important to determine whether the course will be entirely in person or virtual. In the era of the COVID-19 pandemic, many courses have continued to be successful in a virtual format with live cases or even recorded live cases, which are then reviewed by a live panel. A virtual endoscopy course will require substantially less planning than an in-person live event but not allow for the networking and vendor engagement that may be desired. In addition, the format of the agenda should be considered carefully to match the objectives and audience. As a part of this, it is important to identify whether the course is strictly for practicing endoscopists or might benefit from separate breakout sessions for trainees, nurses, or even industry representatives. A thoughtful split of live endoscopy time, didactics, panel discussions, debates, or other formats is essential to the success of the event. With that said, most attendees at a live endoscopy course are there for just that. Ensuring the mix of cases matches the audience and provides as much of a realworld experience as possible will increase the registrants’ satisfaction and engagement with the event.1Webster G.J. El Menabawey T. Arvanitakis M. et al.Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement - Update 2021.Endoscopy. 2021; 53 (842-9.2)Crossref Scopus (2) Google Scholar The course faculty may consist of local and visiting experts, some of whom will actually perform live endoscopy. The directors should balance the notoriety of having a “big name” visiting faculty versus using a rising internal star who would benefit most from such a spotlight. In addition, although most endoscopy events have shifted away from allowing visiting faculty to perform live endoscopy, some courses continue to showcase cases performed by outside physicians. This pathway requires significantly greater effort and more legal implications, and it carries a host of ethical concerns that should be discussed early with the planning committee and leadership. The selection of faculty who are not only good endoscopists but good speakers and thoughtful moderators is important for the course’s success. It is advisable to have 2 or 3 faculty who have a strong experience with live courses who can serve as advocates when and if any problems do arise. Identification of faculty who can serve as in-room moderators is critical. In-room moderators serve as an extension of the endoscopist by taking the lead in the room, diversifying the case discussion with the audience, and allowing the endoscopist to focus on the performance of the case. Finally, it is important to clearly delineate roles for all faculty: when they will speak, moderate, and perform endoscopy (if applicable) to ensure that the event flows smoothly and efficiently. A successful course not only satisfies its objectives but does so while maintaining a keen eye for diversity and equity. These tenets should be considered not only for course faculty and moderators but also for all of the live endoscopy team. Diversity in gender, race, background, roles, and experience all adds to the flavor of a live endoscopy event and ensures that the team can put forth the best experience for registrants. Furthermore, course directors should avoid the implicit habit of selecting the same faculty each year as opposed to providing an opportunity to new and junior faculty who can also provide the expertise with a fresh outlook. Selected cases should directly correlate with the course learning objectives and should be limited to those for which available equipment and endoscopist and staff experience are present. Should local expertise or necessary equipment not be present, consideration of live transmission from another site or using a recorded case from a center with endoscopist/staff experience should be considered. The selected case types and number should reflect the composition and experience of the audience and the intended aims of the course as defined in the aforementioned learning objectives. Prerecorded cases, often done with minimal to no editing to better mimic live cases, can also be used and discussed “live” by the course faculty. Using such an approach and integrating it with live cases provides an excellent option to provide similar educational benefits while also ensuring that the demonstration fits within the required time limits. Industry partners play a major role in providing financial support and advertising live endoscopy courses. In addition, they typically supply technical equipment and professional support for novel technologies and techniques demonstrated during the event. The course organizers should meet with the industry partners before the course to discuss the planned cases and uses of technology so that the appropriate training occurs before the course and the necessary equipment and support are present during the course. The use of technology is a decision that should be made by the course organizers and not influenced by industry. When a technology/technique is to be demonstrated, it is essential that the endoscopist and the local endoscopy team be familiar with the use of the device. Prior use of and familiarity with the equipment are strongly preferred, but in cases where a device is new, appropriate preprocedure training for both the endoscopist and the local team is essential. The equipment should have a direct benefit to the patient and should not be used simply to showcase the technology. The course patient advocate should be consulted if there is uncertainty regarding the clinical benefit of a device/technique. During the procedure, the endoscopist and moderators should explain the rationale for use of the equipment while discussing potential alternatives when the device is unavailable. Although highlighted equipment may predominantly be obtained from course sponsors, there should be no hesitancy to use any device, regardless of manufacturer, that would maximize clinical efficacy or patient safety. 1.High-quality video feed: A high-quality video feed is essential for the success of a live endoscopy course. Detailed