Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop

Simulators and training models for diagnostic and therapeutic gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Technical and Technology Review

Gastrointestinal (GI) endoscopy comprises both diagnostic and therapeutic procedures involving the luminal GI tract as well as the biliary tree, liver, and pancreas. GI endoscopy is challenging to learn, requiring both cognitive (nontechnical) and technical skills, and requires extensive practice to attain proficiency. Simulation-based training has been shown to assist trainees and young endoscopists in acquiring new skills and accelerating the learning curve. Moreover, simulation-based training creates an ideal environment for trainees to initially learn and practice skills while making mistakes with no risk to patients.This review, divided in two parts, offers a comprehensive summary of the different classes of simulators available for GI endoscopic training.In Part I, only mechanical simulators are reported and described. In Part II, animal simulators (ex vivo/in vivo) and virtual reality models are detailed, together with prototypes that are currently not commercially available.

Endoscopic submucosal dissection training: evaluation of an ex vivo training model with continuous perfusion (ETM-CP) for hands-on teaching and training in China

BACKGROUND

The existing ex vivo models of endoscopic submucosal dissection (ESD) cannot simulate intraoperative hemorrhage well. We aimed to establish an ESD training method by applying an ex vivo training model with continuous perfusion (ETM-CP).

METHODS

Four training sessions were conducted for 25 novices under the guidance of 2 experts. Eventually, 10 novices completed ESD operations on a total of 89 patients after the training. The resection effectiveness, resection speed, complication rate, and novice performance before and after the training were compared. The data regarding the effects of the training and the model were gathered through a questionnaire survey.

RESULTS

In terms of the simulation effect of the model, ETM-CP was evaluated as similar to the live pig in all aspects (P > 0.05). The questionnaire analysis revealed that the ESD theoretical knowledge, skill operation, and self-confidence of novices were improved after the training (P < 0.05). The resection time per unit area had a correlation with the number of training periods (rs = - 0.232). For novice performance, the resection time per unit area was shortened (P < 0.05). There was no difference in patient performance between the novice group and the expert group after the training in terms of en bloc resection, R0 resection, complication rate, endoscopic resection bleeding (ERB) score, muscularis propria injury (MPI) score, and resection time per unit area (P > 0.05).

CONCLUSION

The ETM-CP is effective for ESD training.

Therapeutic Endoscopic Procedures on a Human Cadaver—A Pilot Feasibility Study

Introduction The traditional apprentice model of teaching therapeutic endoscopic skills is inadequate due to unpredictable frequency and high stakes for patient outcome. Simulation had gained widespread acceptance for training modules. But all the procedures cannot be trained on simulator. We designed a novel human cadaver hands-on training module for practicing percutaneous endoscopic gastrostomy (PEG), endoscopic variceal band ligation (EVL), endoscopic injection (EI), snare polypectomy (SP), thermal cautery (TC), and endoscopic clip (EC) placement.

Methods A single preserved pre-coronavirus disease 2019 human cadaver was used as a training model. Twelve trainees (6 teams) used the module to acquire and practice new skills of PEG, EVL, EI, SP, and EC using standard endoscope and regular endoscopic accessories. All the trainees completed the course evaluation using a 5-point Likert scale (5= strongly agree).

Results The training resulted in a self-reported increase in equipment familiarity and all the trainees felt uniformly that they are better prepared for performing the procedures on real patients. They strongly agreed that this exhaustive hands-on exercise has more educational value than attending lectures.

Conclusion Human cadaver can be used for trainees to hone therapeutic endoscopic skills by teaching modules with predefined learning objectives.

ASGE EndoVators Summit: simulators and the future of endoscopic training

Interest in the use of simulation for acquiring, maintaining, and assessing skills in GI endoscopy has grown over the past decade, as evidenced by recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines encouraging the use of endoscopy simulation training and its incorporation into training standards by a key accreditation organization. An EndoVators Summit, partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, (NIH) was held at the ASGE Institute for Training and Technology from November 19 to 20, 2017. The summit brought together over 70 thought leaders in simulation research and simulator development and key decision makers from industry. Proceedings opened with a historical review of the role of simulation in medicine and an outline of priority areas related to the emerging role of simulation training within medicine broadly. Subsequent sessions addressed the summit's purposes: to review the current state of endoscopy simulation and the role it could play in endoscopic training, to define the role and value of simulators in the future of endoscopic training and to reach consensus regarding priority areas for simulation-related education and research and simulator development. This white paper provides an overview of the central points raised by presenters, synthesizes the discussions on the key issues under consideration, and outlines actionable items and/or areas of consensus reached by summit participants and society leadership pertinent to each session. The goal was to provide a working roadmap for the developers of simulators, the investigators who strive to define the optimal use of endoscopy-related simulation and assess its impact on educational outcomes and health care quality, and the educators who seek to enhance integration of simulation into training and practice.

Polypectomy skills of gastroenterology fellows: can we improve them?

BACKGROUND AND AIMS

Currently, most training programs for gastroenterology (GI) fellows lack systematic training in polypectomy. Systematic education and direct feedback with the direct observational polypectomy skills (DOPyS) method is a simple and inexpensive way to train GI fellows in practical endoscopy. Our primary aim was to evaluate whether a lecture-based training course could improve the polypectomy skills of GI fellows. As a secondary aim, the interobserver agreement among the three assessors was evaluated.

PARTICIPANTS AND METHODS

We invited GI fellows to record five polypectomies, after which they attended a training course consisting of three lectures on polyps and polypectomy methods given by expert endoscopists. After training, the fellows recorded five polypectomies again. All videos were blindly assessed by three expert endoscopists, who used the DOPyS method.

RESULTS

Eight GI fellows participated in this study. There was no significant difference in the median overall competency scores before and after training; before training, 25 % (10/40) of the polypectomies were scored as "pass," compared with 37.5 % (15/40) after training (P = 0.56). The interobserver agreement among the experts was fair (intraclass correlation coefficient [ICC] 0.34, 95 % confidence interval [CI] 0.14 - 0.52).

CONCLUSIONS

Our lecture-based training course did not result in an improvement in overall competency scores for the polypectomy skills of GI fellows. Besides, the overall quality of the polypectomy techniques of the fellows was considered low. To optimize polypectomy training and competency, we believe that direct feedback in the endoscopy suite and hands-on training by dedicated teachers are essential.

Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis

BACKGROUND & AIMS

Simulation-based training (SBT) in gastrointestinal endoscopy has been increasingly adopted by gastroenterology fellowship programs. However, the effectiveness of SBT in enhancing trainee skills remains unclear. We performed a systematic review with a meta-analysis of published literature on SBT in gastrointestinal endoscopy.

METHODS

We performed a systematic search of multiple electronic databases for all original studies that evaluated SBT in gastrointestinal endoscopy in comparison with no intervention or alternative instructional approaches. Outcomes included skills (in a test setting), behaviors (in clinical practice), and effects on patients. We pooled effect size (ES) using random-effects meta-analysis.

RESULTS

From 10,903 articles, we identified 39 articles, including 21 randomized trials of SBT, enrolling 1181 participants. Compared with no intervention (n = 32 studies), SBT significantly improved endoscopic process skills in a test setting (ES, 0.79; n = 22), process behaviors in clinical practice (ES, 0.49; n = 8), time to procedure completion in both a test setting (ES, 0.79; n = 16) and clinical practice (ES, 0.75; n = 5), and patient outcomes (procedural completion and risk of major complications; ES, 0.45; n = 10). Only 5 studies evaluated the comparative effectiveness of different SBT approaches; which provided inconclusive evidence regarding feedback and simulation modalities.

CONCLUSIONS

Simulation-based education in gastrointestinal endoscopy is associated with improved performance in a test setting and in clinical practice, and improved patient outcomes compared with no intervention. Comparative effectiveness studies of different simulation modalities are limited.

Training gastroenterology fellows to perform gastric polypectomy using a novel ex vivo model

AIM

To evaluate the effect of hands-on training of gastroenterology fellows in gastric polypectomy using an ex vivo simulator.

METHODS

Eight gastroenterology fellows at Mackay Memorial Hospital, Taipei were evaluated in gastric polypectomy techniques using a pig stomach with artificial polyps created by a rubber band ligation device. The performance of four second year (year-2) fellows who had undergone one year of clinical training was compared with that of four first year (year-1) fellows both before and after a 4-h workshop using the ex vivo simulator. The workshop allowed for hands-on training in the removal of multiple artificial polyps and the placement of hemoclips at the excision site. Evaluation included observation of technical skills, procedure time, and the fellows' confidence scale.

RESULTS

One week after the workshop, the year-1 fellows were re-evaluated and had significantly improved mean performance scores (from 17.9 ± 1.8 to 22.5 ± 0.7), confidence scale (from 4.5 ± 1.0 to 7.8 ± 0.5) and procedure time (from 615.0 ± 57.4 s to 357.5 ± 85.0 s) compared with their baseline performance. After 4 h of training using the ex vivo simulator, the skills of the year-1 fellows were statistically similar to those of the year-2 fellows.

CONCLUSION

Use of this ex vivo simulator significantly improved the endoscopic gastric polypectomy skills of gastroenterology fellows who had not had previous clinical training in gastric polypectomy.

Training on an ex vivo animal model improves endoscopic skills: a randomized, single-blind study

BACKGROUND

Animal models are used for training of different endoscopic procedures. Whether this really improves endoscopic skills remains controversial.

OBJECTIVE

To assess the effectiveness of training by using an ex vivo animal gastric model on the performance of two therapeutic procedures-hemostasis and treatment of perforation.

DESIGN

A randomized, single-blind study.

SETTING

An experimental endoscopy center in a university hospital.

PARTICIPANTS

Thirty-one gastroenterology fellows with comparable endoscopic experience.

METHODS

Participants were randomized into two groups: with (T, n = 16) and without (S, n = 15) training. All fellows continued with standard endoscopic practice. Baseline skills were assessed at enrollment. All physicians in group T underwent 2 full days of a hands-on course over a 3-month period, in addition to their standard endoscopic practice. Both groups then underwent a blinded, final evaluation. Endoscopic skills were scored from 1 (best) to 5 (poorest) by two expert, blinded tutors. Outcomes of clinical hemostatic procedures also were analyzed.

MAIN OUTCOME MEASUREMENTS

Successful hemostasis and successful perforation closure.

RESULTS

Thirty physicians completed the study. Hemostasis results (n = 15): The number of physicians who carried out a successful hemostasis procedure increased significantly in the group with training (27% vs 73%; P = .009) but did not change in the group without training (20% vs 20%). The mean scores of injection and clipping technique improved significantly only after training. The number of clips used decreased significantly only in the group with training; the time of clipping did not change significantly in either group. Perforation results (n = 15): The number of physicians with a successful and complete perforation closure increased nearly significantly in the group with training (40% vs 73%, P = .06) as opposed to the group without training (27% vs 47%; P = .27). The procedure time decreased significantly in the group with training only. In clinical practice, fellows in group T had a significantly higher success rate with respect to hemostatic procedures (83.2%, range 67-100 vs 63.6%, range 25-100; P = .0447). The majority of participants (93%) agreed that such courses should be compulsory in gastroenterological credentials.

LIMITATIONS

A retrospective analysis of clinical outcomes. Clinical outcome data were based on self-reporting of the participants.

CONCLUSION

Hands-on training by using an animal ex vivo model improves endoscopic skills in both hemostasis and perforation closure. In clinical practice, the training improves the outcome of hemostatic procedures.

Development of a novel ERCP mechanical simulator

BACKGROUND

There is a paucity of objective methods for evaluating trainee performance and comparing ERCP accessories.

OBJECTIVE

Use of a mechanical ERCP simulator to evaluate trainee performance and to compare ERCP accessories via procedure time.

DESIGN

Pilot study using a mechanical simulator.

SETTING

Hands-on ERCP practice workshops.

SUBJECTS

Endoscopists at various levels of ERCP experience.

METHOD

Validation studies are described to show that the simulator permits participants with varying ERCP experience to demonstrate their skill levels and offers novel training applications in ERCP courses. The time required for completing a simulated stent placement procedure, simulated fluoroscopy time, and participant expectations were recorded in different settings. Participants' expectations were compared before and after training to determine whether the simulator was a credible adjunct to ERCP training.

RESULTS

Significantly shorter procedure times were recorded for the same accessories used by participants with more ERCP experience than those with less experience and for the same group of participants when using accessories with 1 design compared with another. The mean total credibility score showed a significant increase after simulator practice.

LIMITATIONS

In vitro practice by using a mechanical simulator; results may not translate directly to the clinical setting. How the objective procedure times measured during practice can complement assessment of trainee competence or define usefulness of different accessories is unknown but deserves to be explored in future studies.

CONCLUSIONS

The procedure times can categorize participants according to their ERCP experience and separate accessories according to their ease of use. An increase in credibility score validates participants' endorsement of such practice as a credible adjunct to ERCP training.

Simulator training in endoscopic hemostasis

Simulation of upper gastrointestinal (GI) hemorrhage provides the opportunity to practice endoscopic hemostasis without the risk of patient harm and time limitations. Various models have been developed to simulate an acute bleeding source in the upper GI tract to evaluate the feasibility of new endoscopic devices or to practice interventional techniques in a calm and controlled environment. Increasingly available ex vivo models provide this opportunity without the ethical concerns involved with live-animal courses. Validation studies have proven acceptance of ex vivo models and improved clinical performance by repetitive training using these models.

Currently available simulators: ex vivo models

The introduction of the ex vivo tissue endoscopy simulators represents a major advance in endoscopic training, particularly in therapeutic endoscopy. The simulators have been popular teaching tools from the start, and the data supporting their benefit are accruing, especially in hemostasis training. Simulators like the compact EASIE may prove most beneficial as training tools for interventional skills that require repetitive practice and a larger volume of procedures than may occur naturally during the course of standard endoscopy practice. More data are needed to confirm that hands-on simulator training improves outcomes in clinical endoscopic performance and to characterize better the influence of such simulator work on subsequent endoscopic practice. As ex vivo simulators become more available, it is likely that these models will enhance initial training and also allow practicing gastroenterologists to acquire new techniques, maintain their skills, and demonstrate proficiency for credentialing purposes.

Evolution of endoscopy simulators and their application

Significant advances already have been made in the use of simulators for teaching and training in GI endoscopy. Indeed, during the past decade the evolution and improvement of these devices is readily apparent with each passing year. Doubtless, these advances have led to the increased availability and popularity of simulator-based hands-on workshops. Simulator-based skills assessment remains a relatively undeveloped field, awaiting increased realism and the development and validation of proper tests. Still, static models, ex vivo artificial models, ex vivo animal models, and computer simulators collectively represent a substantial and powerful tool for education and training in GI endoscopy. It is easy to foresee a day when hands-on training using simulators will be readily available outside the gastroenterology fellowship setting. With the progression of technology and the continuous introduction of new devices and procedures will come a parallel, compelling need for hands-on, simulator-based experience with all such new tools and techniques.