Over the past decade, advances in therapeutic EUS have expanded the interface between hepatology and endoscopy, giving rise to the emerging field of endohepatology. Despite increasing clinical adoption and evidence supporting these procedures, no standardized training framework currently exists. This project seeks to inform the development of consensus-driven standards for an Endohepatology Fellowship by identifying the essential hepatology and endoscopic competencies required for safe and effective practice.

We conducted a cross-sectional electronic survey of international experts in hepatology, advanced endoscopy, and endohepatology to assess essential standards for endohepatology fellowship development. A steering committee of recognized leaders designed the survey, drawing on published literature, existing training curricula, and expert experience to generate statements across key training domains. Participants were asked to rate a total of 74 statements on the following topics: 1) basic framework for a proposed endohepatology fellowship program; 2) candidate selection; 3) training environment; 4) supervisor qualification; 5) clinical exposure; 6) endoscopic exposure; 7) interventional radiology exposure; 8) evaluation of training; 9) support from learned societies; and 10) maintenance of competence after training. Statements were rated on a 9-point Likert scale (1 = strongly disagree, 9 = strongly agree) with the possibility to add free-text comments. Consensus was defined using a modified RAND/UCLA approach. Agreement or disagreement was determined based on median panel scores (7-9 = agreement; 1-3 = disagreement), and statistical disagreement was assessed using the IPRAS method. 

Forty-four (83%) out of 53 invited experts completed the survey (21 (48%) advanced endoscopists; 18 (41%) hepatologists; 5 (11%) endohepatologists). Duration of independent practice was < 5 years in 9 (20%), 5-10 years in 13 (30), and > 15 years in 22 (50%). Location of practice was USA in 22 (50%), Canada in 11 (25%), Europe in 7 (16%; Belgium, Italy, Spain, UK), KSA in 1 (2%), and 3 did not say. In total, all panelists reached a consensus on 55 (74%) statements. An additional 8 (11%) statements reached consensus in only a subgroup of participants. All statements reaching consensus are highlighted in Figure 1 and 2. These statements belong to all topics covered. More than half of survey responders thought that the minimum number of cases needed to evaluate competency were at least 25 cases for EUS-liver palpation, 50 cases for EUS-guided non-liver biopsy, 25 cases for EUS-guided liver biopsy, 25 cases for EUS-portal pressure gradient measurement, 25 cases for EUS-shear wave elastography, 25 cases for variceal gluing, and 10 cases for variceal gluing and coiling.

Figure1. Statements on which consensus was reached (* represents consensus in a subgroup of participants only).

Figure2. Procedural aspects which reached consensus agreement 

Figure3. Complete list of authors who participated in this Endohepatology Training Framework Group

Our survey identifies multiple statements and establishes key standards that should be used to develop an endohepatology fellowship training program. Further work is needed to refine these standards.