European Association for Endoscopic Surgery and other Interventional Techniques

Position statement of EAES on training and practice of flexible endoscopy among surgeons

The European Association for Endoscopic Surgery (EAES) continues to play a leading role in Endoscopic Surgery and Allied Interventional Techniques. The EAES is dedicated to education, training, research, development, and publication in this field and to this purpose also organizes annual Top Level European Congresses in different European countries as well as sharing the journal Surgical Endoscopy with our sister society SAGES (The Society of Gastrointestinal and Endoscopic Surgery). The EAES has always been a society that advocates and supports good practice through the development of training programmes, curricula, and evidence-based guidelines.
EAES promotes and supports the use of flexible endoscopy in surgical practice which must be delivered by trained and competent surgeons. This is focused on optimizing patient care, with the aim to enhance the quality and safety of surgical interventions. This is also aimed to increase access to high-quality endoscopic alternatives and increase the pool of endoscopists who are able to deliver innovative therapies to complement or replace traditional surgical procedures with the goal of providing the least invasive treatments to patients. This is achieved in the spirit of advancing innovation and promoting collaborative interactions and cross-pollination between gastroenterologists and practicing surgeons, fostering best practices for maximum patient benefit.
While gastroenterologists clearly added tremendously to advancing techniques for examination of the esophagus and stomach, it was the surgeon who first dealt with therapeutic interventions in the gastrointestinal tract. Since the introduction of flexible endoscopy by surgeons and its eventual adoption by gastroenterologists, there have been episodic calls among some Gastroenterology societies, advocating the restriction of flexible endoscopy practice only to gastroenterologists, arguing that training among other specialists in this field is insufficient, specifically based on procedure numbers established for medical gastroenterologists. This is likely however, to disadvantage both specialties and may ultimately negatively impact the quality of patient care. Of course, sufficient endoscopic training and demonstrated skills are required from any specialist performing endoscopic surgery. In this context EAES considers the following:

  • Training in Digestive Flexible Endoscopy for general surgeons does not compromise the quality of surgical training but is likely to support it in terms of advancing the knowledge and skills of surgeons to encompass intraoperative approaches to pathologies that best enable them to offer the highest quality of care in the treatment of patients.
  • Performing perioperative endoscopy enhances surgeons’ decision-making and may reduce the rate of complications and reinterventions in the immediate postoperative period (particularly during rigid endoscopic surgery, during which tactile sensation is compromised). Hence, having endoscopic skills for surgeons is an essential tool at critical moments in the patient care pathway that can enhance surgical decision making and improve patient outcomes.
  • Additionally, intraoperative diagnostic endoscopy is important to not only decide the best treatment strategy to follow (location of the lesion, resection margins, complication detection, etc), but also to immediately assess the quality of reconstructions (integrity of the anastomosis, haemostasis) or to correct any technical defects or complications of surgery. Not infrequently, this needs to be repeated a number of times during the same operation. Relying solely on gastroenterologists to perform these procedures is often impractical and may negatively impact the efficiency of both services; surgical and gastroenterology as well as patient outcomes.
  • The endoscope is a tool. The approach to cavities with optical systems such as a flexible endoscope is common among many other specialties, such as Urology, Gynaecology and Otorhinolaryngology, so the practice of digestive endoscopy can be considered a transversal and basic competence. In fact, in many countries digestive endoscopy practice is performed by both general surgeons and gastroenterologists, with well documented quality assurance of acceptable outcomes by both specialties and with an improvement in access for patients.
  • Such close collaboration between general surgeon and gastroenterologist regarding the performance of the intraoperative diagnostic endoscopy can be very beneficial to the workflow of patient care, since gastroenterologists have their own heavy work schedule and may have difficulties to attend the operating room either at urgent or scheduled bases, especially when they are required to attend the operating room for prolonged periods.
  • It is clear from the examination of the history and practice of gastrointestinal endoscopy that surgeons have played an ongoing and integral role in its development and practice. It is therefore, imperative that surgeons remain involved in the practice of flexible endoscopy. Numerous international scientific societies, such as the EAES; European Union of Medical Specialties (UEMS), the American Society for Gastrointestinal Surgery (SAGES), the American Board of Surgery, the Association for Gastrointestinal Surgery (AUGIS) and Coloproctology of Great Britain and Ireland (ACPGBI), among many others, today have mandated digestive endoscopy to be a necessary skill to be certified as a specialist in Digestive Surgery. The same logic that led to these mandates can be extended to other countries who have not yet made such training mandatory. Denying surgeons in these countries from those skills would go against the international general practice and may impact patient care.
  • EAES certainly encourages surgeons and medical endoscopists to collaborate and work together whenever possible and when it is in the patient’s best interest. EAES recognizes that basic training in endoscopy does not in any way replace the role of gastroenterologists (specialists in the Digestive System), nor the rest of the auxiliary personnel necessary to perform these procedures but to support the workforce in order to cope with the increasing workload demand in flexible endoscopy.
  • EAES is aware that flexible endoscopy is technical challenging especially in advanced therapeutic procedures. For this reason, EAES recognizes the need for structured and supervised competency-based training in flexible endoscopy to ensure patient safety by that surgeons have acquired the required competency to undertake complex procedures. The use of non-validated minimum numbers of cases does not guaranty competency in flexible endoscopy. In addition, such numbers may not translate equally between surgical and medical specialties considering the unique training surgeons receive. It is clear that additional collaborative efforts for objective measures of competency should be made in both specialties.
  • EAES supports all efforts to train surgeons to competency in flexible endoscopy. We encourage collaborative efforts within hospitals among involved specialities that will allow all Digestive System specialists to be trained to ensure their ability to practice quality endoscopy. We commend collaborative programs that work together to train general surgeons in basic and advanced endoscopy and to ensure that surgeons have acquired sufficient skills to safely perform flexible endoscopy independently. EAES recognizes that there are several models of such training and supports collaborations to develop and monitor successful programs in basic and advanced Digestive Endoscopy. The EAES continues to advocate for competency-based accreditations that ensure patient safety for all endoscopic practitioners.
  • To this aim, the EAES has created a flexible endoscopy subcommittee. This task force will operate in collaboration with national and international surgical societies to promote high quality surgical endoscopy practice. This will also guarantee surgeons’ rights to practice flexible endoscopy throughout the EU, create uniform standards of training and practice for flexible endoscopy for surgeons, facilitate the credentialing of surgeons in flexible endoscopy. Additionally, it will promote innovation in the field of flexible surgical endoscopy and support the introduction and implementation of new endoscopic techniques and technology into the surgical clinical practice.

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