Study: VA Surgeons Who Do Colonoscopies May Need More Training

CHICAGO -- Surgeons in the Veterans Affairs (VA) medical system did a poorer job at detecting adenomas during routine colonoscopies compared with gastroenterologists, a review of VA data suggested.

With results analyzed from nearly 670,000 colonoscopies performed in the VA system, adenoma detection rates were 53% for gastroenterologists versus 41% for surgeons, according to Andrew Gawron, MD, PhD, of the University of Utah and the VA Salt Lake City Health Care System.

This gap was apparent irrespective of patient sex or age, and whether the procedures were for routine screening or for follow-up of positive fecal tests results, Gawron told attendees at the annual Digestive Disease Week conference here.

He pointed out that colonoscopy training protocols vary dramatically between board-certified gastroenterologists and surgeons.

Standards for the latter include completion of a specific Flexible Endoscopy Curriculum, and the Society of American Gastrointestinal and Endoscopic Surgeons recommends that residents perform at least 50 colonoscopies and 35 upper gastrointestinal tract endoscopies.

Gastroenterologists, on the other hand, are expected to have done at least 275 colonoscopies in training, according to the American Society for Gastrointestinal Endoscopy, and a survey of fellowship programs published in 2021 indicated that their trainees had completed an average of about 1,000 prior to starting regular practice. As well, the American Board of Internal Medicine calls for 36 months of endoscopy training for gastroenterologists, including at least 18 months of clinical experience.

Gawron did emphasize that most of the clinicians in both specialties "are meeting benchmarks" for quality. He was careful not to seem harshly critical because surgeons are often the only physicians available to perform colonoscopies in rural locations.

Nevertheless, he said, the findings have implications for possibly missed colorectal cancer diagnoses -- "the impact on cancer outcomes requires further evaluation," he said. Gawron also suggested that training and credentialing requirements for surgeons performing colonoscopies may need reevaluation.

Data for the study came from the VA's internal records. Gawron and colleagues focused on patients ages 45-75 undergoing colonoscopies from October 2018 to September 2022, for all indications, for those with positive fecal immunochemical tests in the 12 months prior to the procedures, and for those performed as routine screening. Adenomas were diagnosed histologically from biopsied specimens.

A total of 594,000 procedures were performed by gastroenterologists, with about 74,000 by surgeons.

One of the most notable findings in the study was that 20% of the surgeons had adenoma detection rates below 30%, which is far lower than normally expected (more than 80% of patients were 55 or older), versus just 2% of gastroenterologists. That was for colonoscopies performed for all indications. For screening procedures, fully 28% of surgeons had adenoma detection rates below 30%, compared with 6% of gastroenterologists.

Such low rates were much less common when colonoscopies were performed after positive fecal tests. But the overall detection rate was still lower for surgeons than for gastroenterologists. One prospect on the horizon for improving performance in the short term is that the VA agreed last October to deploy 115 of Medtronic's GI Genius computer-aided polyp detection modules. However, all systems like this still require clinicians to judge for themselves whether a feature is indeed a polyp and whether it should be removed and sent for analysis.

Limitations to the study, the researchers said, included its retrospective design, lack of data on bowel preparation adequacy, and its overwhelmingly male VA patient population.

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