Main RecommendationsThe European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). This manuscript represents the outcome of a formal Delphi process resulting in an official Position Statement of the ESGE and provides a framework to develop and maintain skills in ERCP and EUS. This curriculum is set out in terms of the prerequisites prior to training; recommended steps of training to a defined syllabus; the quality of training; and how competence should be defined and evidenced before independent practice. 1 Trainees should be competent in gastroscopy prior to commencing training. Formal training courses and the use of simulation in training are recommended. 2 Trainees should keep a contemporaneous logbook of their procedures, including key performance indicators and the degree of independence. Structured formative assessment is encouraged to enhance feedback. There should be a summative assessment process prior to commencing independent practice to ensure there is robust evidence of competence. This evidence should include a review of a trainee’s procedure volume and current performance measures. A period of mentoring is strongly recommended in the early stages of independent practice. 3 Specifically for ERCP, all trainees should be competent up to Schutz level 2 complexity (management of distal biliary strictures and stones > 10 mm), with advanced ERCP requiring a further period of training. Prior to independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 300 cases, a native papilla cannulation rate of ≥ 80 % (90 % after a period of mentored independent practice), complete stones clearance of ≥ 85 %, and successful stenting of distal biliary strictures of ≥ 90 % (90 % and 95 % respectively after a mentored period of independent practice). 4 The progression of EUS training and competence attainment should start from diagnostic EUS and then proceed to basic therapeutic EUS, and finally to advanced therapeutic EUS. Before independent practice, ESGE recommends that a trainee can evidence a procedure volume of > 250 cases (75 fine-needle aspirations/biopsies [FNA/FNBs]), satisfactory visualization of key anatomical landmarks in ≥ 90 % of cases, and an FNA/FNB accuracy rate of ≥ 85 %. ESGE recognizes the often inadequate quality of the evidence and the need for further studies pertaining to training in advanced endoscopy, particularly in relation to therapeutic EUS.
ГБУЗ Московский клинический научно-практический центр им. А.С. Логинова ДЗМ, Москва, Россия Эволюция хирургического лечения дивертикула Ценкера имеет достаточно большую историю. Традиционные хирургические методики, заключающиеся в иссечении дивертикула или его фиксации к позвоночной фасции в сочетании с крикофарингомиотомией долгое время не получали широкого распространения из-за большого числа осложнений и высокой летальности. Реальный прогресс в лечении заболевания связан с внедрением трансоральных эндоскопических вмешательств, предусматривающих рассечение общей перегородки между полостью дивертикула и просветом пищевода. В течение короткого периода времени появилось несколько модификаций эндоскопического лечения с использованием жестких и гибких эндоскопов, а также различного инструментального обеспечения, используемого в лапароскопической хирургии и оперативной эндоскопии. Отличительной особенностью эндоскопических вмешательств является малая травматичность. Но вместе с этим отмечается достаточно большой процент рецидивов клинических проявлений заболевания и необходимости проведения лечения в несколько этапов. Закономерным витком эволюции является разработка и внедрение в клиническую практику новой эндоскопической технологии-тоннельного вмешательства, которое позволяет выполнить больший объем миотомии-эндоскопической крикофарингоэзофагомиотомии по тоннельной методике. Целью исследования являлось разработка технических аспектов нового оперативного вмешательства и оценка первых результатов клинического применения. Материал и методы: по описанной методике оперированы 26 пациентов. Результаты: Время оперативного вмешательства составило в среднем 55 мин. Ранний послеоперационный период протекал без осложнений. Все пациенты выписаны на 2 сутки после операции. Заключение: Первый опыт показывает, что тоннельная эндоскопическая операция по поводу дивертикула Ценкера технически выполнима, позволяет успешно расширить объем оперативного вмешательства за счет выполнения продленной миотомии и создать условия для профилактики рецидива заболевания, тем самым обеспечивая лучший результат лечения. Ключевые слова: дивертикул Ценкера, эндоскопическое лечение, тоннельная операция, эндоскопическая крикофарингомиотомия. Endoscopic treatment of Zenker´s diverticulum with the use of the novel tunnel technique. First experience
Introduction: Peutz-Jeghers syndrome (PEUTZ-JEGHERS SYNDROME; PJS; OMIM#175200) is hereditary tumor syndrome and is characterized by the occurrence of hamartomatous polyps of gastrointestinal tract, melanocytic pigmentation of the skin and mucous membranes, as well as a high predisposition to malignant tumors of various locations. Despite the fact that the clinical features of PJS are currently well understood, the nature of the variability in the phenotypic manifestations of the disease has not been fully described. Aims: to determine the phenotypic and clinical features in patients with PJS depending on the type of mutation in the STK11 gene. Patients and methods: the clinical and genetic data of 3 patients aged 21, 28 and 39 years with clinical signs of PJS are presented. All patients underwent medical genetic counseling and molecular genetic diagnostics of the STK11 gene using NGS and MLPA methods. Results: large deletions of ex2-8 and ex1 in the STK11 gene were revealed in two patients, and one patient showed a splice site variant c.921-1G > A. The identified variant ex2-8 has not previously been described in international databases. When evaluating the clinical and genetic features, the most severe picture of the disease was in a patient with an extended deletion of exons 2-8, large number of polyps and surgical procedures in history. However, in this case, melanocytic pigmentation became less with age, in contrast to patients with a splice site mutation and a single exon deletion. No cancers were detected in the patients. Conclusion: the molecular genetic test made it possible to confirm the clinical diagnosis of PJS, based on various phenotypic features, and to work out the personalized plan for follow-up. Evaluation of the genotype-phenotype correlations will be possible with the development of a unified register of mutation carriers.
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