Impact of gastroenterology fellow involvement on screening colonoscopy outcomes in patients with longstanding inflammatory bowel disease
Rosenwald, Nathan J.
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Inflammatory bowel disease (IBD) affects millions of people in the United States, with the number of diagnoses steadily rising. It has been associated with poor quality of life and a host of comorbidities. Most notably, IBD patients are at an increased risk of developing colorectal cancer (CRC). The American Gastroenterological Association (AGA) recommends that IBD patients with involvement of 1/3 or more of the colon undergo colonoscopy regularly to screen for CRC starting 8 years after initial IBD diagnosis. Colonoscopy techniques for IBD-related CRC screening are highly variable and differ widely between clinical practices. Currently, high-definition white-light colonoscopy (HD-WLC) and dye spraying chromoendoscopy (DCE) are both standard of care. The use of these technologies requires a high level of skill that is typically attained during clinicians’ 3-year gastroenterology (GI) fellowship. This study intends to compare outcomes of screening colonoscopies performed by GI fellows and attending physicians in patients with longstanding IBD (>8 years) and to assess the impact of GI fellow involvement on these procedures. Additionally, the current research intends to draw distinctions between HD-WLC and DCE procedures. The research was performed in the Division of Gastroenterology at Beth Israel Deaconess Medical Center (BIDMC) as part of a large randomized controlled trial (RCT) that aims to evaluate the comparative efficacy of HD-WLC and DCE. Patients were screened for study eligibility using relevant criteria and then randomized to undergo colonoscopy using HD-WLC technique or DCE technique. Data from 128 procedures were included in the study. Of these procedures, 59 (46.1%) were attending-performed procedures while 69 (53.9%) were fellow-performed, attending-supervised procedures. Of the attending-performed procedures, 30 (50.8%) were performed using the DCE technique and 29 (49.2%) were performed using the HD-WLC technique. Of the fellow-performed, attending-supervised procedures, 32 (46.4%) were performed using the DCE technique while 37 (53.6%) were performed using the HD-WLC technique. Fellow-performed, attending-supervised procedures were associated with longer total procedure time (TPT) and increased intra-procedure administration of sedation medications without superior lesion detection. Thus, fellows appear to be on par with attendings in terms of lesion detection but this level of proficiency comes at the cost of increased TPT. Assessing the short-term and long-term impacts of this could be a valuable area of future investigation. Also, DCE procedures took longer for all clinicians to perform, especially fellows, and are not associated with enhanced lesion detection. Further research is needed to understand the usefulness of DCE.