Canadian credentialing guidelines for colonoscopy

Abstract

Technical competence for routine colonoscopy can be assessed after 150 procedures; however, Sompletion of a specified number of colonoscopies does not imply competence. It is recommended that documentation of competence be based on the completion of at least 100 unassisted procedures. Competent colonoscopists should be able to intubate the cecum in at least 85% to 90% of all cases (3,13,22) land in at least 95% of screening cases in healthy adults (3). The mean completion time for colonoscopy should be approximately 30 min, with an emphasis on methodical, careful withdrawal to optimize lesion detection. However, it should be recognized that some procedures may take more than 30 min, particularly if multiple or complex polypectomies are required. The proposal that withdrawal times should generally be in excess of 7 min (16-18) emphasizes the importance of careful inspection on withdrawal of the colonoscope, although the optimal time has not been determined, Success rates improve with experience and higher annual procedure volume (31) particularly in the early years after completion of training (32). Better results have been associated with a volume of at least 100 to 200 procedures per year (31,32). Photodocumentation of cecal intubation is encouraged for quality assurance purposes, to prompt appropriate ancillary investigations in the event of incomplete colonoscopy and to minimize the risk that right-sided lesions are missed. When colonoscopy is performed for cancer screening, adenomata should be detected in at least 25% of men and 15% of women older than 50 years of age; lower detection rates raise the concern that polyps are being missed or that the procedure has been performed for an inappropriate indication (3). Competence in colonoscopy requires the ability to perform appropriate diagnostic and therapeutic interventions during the same procedure. At least 30 supervised, unassisted snare polypectomies should be completed as a threshold for competency (8,13). Complication rates should be comparable with those reported in the literature, that is, a perforation rate of less than one in 500 for all patients and less than one in 1000 for patients undergoing screening (48-50), with a postpolypectomy bleeding rate of less than 1% (51-55). Nontechnical components of competence (knowledge of expected pathology, judgment regarding biopsy and therapy, indications, contraindications, informed consent and immediate postprocedural management) require a training program that generally involves a minimum of six to 12 months of training. Although endoscopic simulators may shorten the early phase of technical training, it is not clear how the rapid acquisition of apparent competence using a simulator translates into competence at colonoscopy in clinical practice. Institutions that grant privileges for colonoscopy should be encouraged to develop endoscopic reporting mechanisms and databases so that colonoscopists may monitor the quality of their practice and effect improvements if they identify deficiencies, thus maintaining colonoscopic procedural competece and optimizing clinical care over the long term.