Rational colonoscopy, realistic simulation, and accelerated teaching

Efficacy of ScopeGuide-Assisted Training in Enhancing Colonoscopy Competence and Reducing Patient Discomfort

OBJECTIVE

In this study, we aimed to evaluate the efficacy of the Magnetic Scope Guide Assist (ScopeGuide) in enhancing the procedural competence of endoscopists and reducing patient discomfort during colonoscopy.

METHODS

This was a retrospective study with 88 trainee participants. The study participants were trained on patients who underwent colonoscopy without anesthesia. Both ScopeGuide-assisted training and conventional training (without ScopeGuide) were utilized for colonoscopy instruction. The outcomes of training were compared, with a particular emphasis on the competency of looping resolution.

RESULTS

ScopeGuide-assisted training was superior to conventional training in multiple aspects, including looping resolution ( Z =-3.681, P <0.001), pain scores ( Z =-4.211, P <0.001), time to reach the cecum ( Z =-4.06, P <0.001), willingness to undergo repeat colonoscopy ( Z =-4.748, P <0.001), competence of positional changes ( Z =-4.079, P <0.001), and the effectiveness of assisted compression ( Z =-3.001, P =0.003). Further stratified analysis revealed that the ScopeGuide-assisted training mode was more beneficial for junior endoscopists ( P <0.05 in all parameters) but not for intermediate endoscopists ( P >0.05) and partially beneficial for senior endoscopists ( P <0.05 for all parameters except looping resolution).

CONCLUSION

ScopeGuide-assisted training can significantly facilitate endoscopists in resolving loops and reducing patient pain, thereby enhancing their colonoscopy abilities.

Report of the First Training the Colonoscopy Trainers Courses Held in India

Background and Aim Training the colonoscopy trainers (TCT) courses have become widespread in the United Kingdom and elsewhere but have never taken place in India. This is an account of the first such course delivered in India with an attempt to demonstrate its impact on the training knowledge and abilities of the delegates.

Materials and Methods Twelve independent colonoscopists, all with a training remit, underwent a structured 2-day TCT course. They were asked retrospectively to self-assess their knowledge and training skills across a number of metrics using a 1–10 scale, before and after attending the course.

Statistical Analysis Scores were analyzed by the Wilcoxon’s two-tail test

Results Delegates training knowledge and skills improved significantly across all seven metrics (p < 0.01 for all).

Conclusion The TCT is highly suitable in the Indian endoscopic environment and very effective in improving the training knowledge and skills of even experienced colonoscopists.

The efficacy of training insertion skill on a physical model colonoscopy simulator

Background and study aims: Prior research supports the validity of performance measures derived from the use of a physical model colonoscopy simulator - the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd., Kyoto, Japan) - for assessing insertion skill. However, its use as a training tool has received little research attention. We assessed the efficacy of a brief structured program to develop basic colonoscope insertion skill through unsupervised practice on the model. Participants and methods: This was a training study with pretesting and post-testing. Thirty-two colonoscopy novices completed an 11-hour training regime in which they practiced cases on the model in a colonoscopy simulation research laboratory. They also attempted a series of test cases before and after training. For each outcome measure (completion rates, time to cecum and peak force applied to the model), we compared trainees' post-test performance with the untrained novices and experienced colonoscopists from a previously-reported validation study. Results: Compared with untrained novices, trained novices had higher completion rates and shorter times to cecum overall (Ps < .001), but were out-performed by the experienced colono-scopists on these metrics (Ps < .001). Nevertheless, their performance was generally closer to that of the experienced group. Overall, trained novices did not differ from either experience-level comparison group in the peak forces they applied (P > .05). We also present the results broken down by case. Conclusions: The program can be used to teach trainees basic insertion skill in a more or less self-directed way. Individuals who have completed the program (or similar training on the model) are better prepared to progress to supervised live cases.

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.

Virtual reality simulators for gastrointestinal endoscopy training

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees' learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.

Construct validation of a physical model colonoscopy simulator

BACKGROUND

Previous studies have demonstrated the construct validity of virtual reality colonoscopy simulators by showing that they can distinguish between users according to their level of endoscopic experience. Although physical model simulators are known to simulate looping more realistically than these devices, they lack published validation evidence.

OBJECTIVE

To assess the construct validity of a physical model simulator, the Kyoto Kagaku Colonoscope Training Model (Kyoto Kagaku Co. Ltd, Kyoto, Japan) and to determine its suitability for assessing the insertion skill of trainee colonoscopists.

DESIGN

Validation study; 21 experienced colonoscopists and 18 novices made 2 attempts at each of 4 standard cases on the Kyoto Kagaku physical model simulator, and we compared their performance on each case.

SETTING

A medical simulation center in a large tertiary hospital.

MAIN OUTCOME MEASUREMENTS

Completion rates, times to cecum, and peak forces applied to the colon model.

RESULTS

Compared with novices, experienced colonoscopists had significantly higher completion to cecum rates and shorter times to cecum for each of the 4 cases (all P < .005). For 2 cases, experienced colonoscopists also exerted significantly lower peak forces than did novices (both P = .01).

LIMITATIONS

Two of the model's 6 "standard cases" were not included in the study.

CONCLUSIONS

The 4 cases included in the study have construct validity in that they can distinguish between the performance of experienced colonoscopists and novices, reproducing experienced/novice differences found in real colonoscopy. These cases can be used to validly assess the insertion skill of colonoscopy trainees.

Assessing the realism of colonoscopy simulation: the development of an instrument and systematic comparison of 4 simulators

BACKGROUND

No useful comparative data exist on the relative realism of commercially available devices for simulating colonoscopy.

OBJECTIVES

To develop an instrument for quantifying realism and provide the first wide-ranging empiric comparison.

DESIGN

Repeated measures, observational study. Nineteen experienced colonoscopists completed cases on 4 colonoscopy simulators (AccuTouch, GI Mentor II, Koken, and Kyoto Kagaku) and evaluated each device.

SETTING

A medical simulation center in a large tertiary hospital.

MAIN OUTCOME MEASURES

For each device, colonoscopists completed the newly developed Colonoscopy Simulator Realism Questionnaire (CSRQ), which contains 58 items grouped into 10 subscales measuring the realism of different aspects of the simulation. Subscale scores are weighted and combined into an aggregated score, and there is also a single overall realism item.

RESULTS

Overall, current colonoscopy simulators were rated as only moderately realistic compared with real human colonoscopy (mean aggregated score, 56.28/100; range, 48.39-60.45, where 0 = "extremely unrealistic" and 100 = "extremely realistic"). On both overall realism measures, the GI Mentor II was rated significantly less realistic than the AccuTouch, Kyoto Kagaku, and Koken (P < .001). There were also significant differences between simulators on 9 subscales, and the pattern of results varied between subscales.

LIMITATIONS

The study was limited to commercially available simulators, excluding ex-vivo models. The CSRQ does not assess simulated therapeutic procedures.

CONCLUSIONS

The CSRQ is a useful instrument for quantifying simulator realism. There is no clear "first choice" simulator among those assessed. Each has unique strengths and weaknesses, reflected in the differing results observed across 9 subscales. These findings may facilitate the targeted selection of simulators for various aspects of colonoscopy training.

The box simulator is useful for training novice endoscopists in basic endoscopic techniques

PURPOSE

The present study was aimed at evaluating the usefulness of box simulators for training novice endoscopists.

MATERIALS AND METHODS

An explanation of the goals, contents, and features of the simulator was given to study participants. The participants then received "hands-on training" in gastrointestinal endoscopy techniques using a box simulator. Subsequently, they were asked to answer 19 structured questions about the simulator. Ratings were scored on a scale from 1 to 5 for questions concerning their first impression of the simulator. Questions on the usefulness of the simulator and the training course were answered as "agree", "disagree", or "no opinion".

RESULTS

A total of 32 participants filled out the questionnaire. The mean scores on the simulator's usefulness, features, and realistic movements before the training were between 1.5 and 2.0. There were no significant differences between the mean values of the scores given by novice users compared to non-novice users. However, after receiving training on the simulator, 90.6% of the participants considered the box simulator a generally useful tool for learning basic endoscopic techniques, and 90.6% agreed that the simulator was useful for improving hand-eye coordination.

CONCLUSION

Box simulators may be useful for training novice endoscopists in basic gastrointestinal endoscopic techniques.

Early use of magnetic endoscopic imaging by novice colonoscopists: improved performance without increase in workload

BACKGROUND

Magnetic endoscopic imaging represents a recent advance in colonoscopy training. This technique provides adjunct information to the endoscopist, specifically with regard to colonoscope loop formation.

OBJECTIVE

To examine the effect of a magnetic endoscopic imager on novice performance and workload in colonoscopy.

METHODS

Twenty complete novices received an introductory teaching session followed by the completion of two procedures on a colonoscopy model. One-half of the participants performed their first procedure with the imager, and the second procedure without, while the other one-half were trained with the inverse sequence. Two main outcome measures were recorded: distance achieved and total workload as measured by the National Aeronautics and Space Administration task load index tool.

RESULTS

A significant improvement was noted between the first and second colonoscopies, with the best performance recorded for participants who performed their first procedure with the imager, and their second without. The imager did not significantly change the total workload.&nbsp;

DISCUSSION

The study participants paid attention to the magnetic endoscopic imager; however, this did not translate into a measurable increase in novice workload. A delayed learning benefit was conferred to the group exposed to the imager on their first colonoscopy, suggesting that, even at an early training stage, the additional imager information entered working memory and was processed in a useful fashion. The introductory teaching strategy used in the present study was successful as judged by the overall distance achieved and performance improvement seen in all study participants.

Retention of Colonoscopy Skills after Virtual Reality Simulator Training by Independent and Proctored Methods

Virtual reality (VR) simulators may enhance surgical resident colonoscopy skills, but the duration of skill retention and the effects of different simulator training methods are unknown. Medical students participating in a randomized trial of independent (automated simulator feedback only) versus proctored (human expert feedback plus simulator feedback) simulator training performed a standardized VR colonoscopy scenario at baseline, at the end of training (posttraining), and after a median 4.5 months without practice (retention). Performances were scored on a 10-point scale based on expert proficiency criteria and compared for the independent and proctored groups. Thirteen trainees (8 proctored, 5 independent) were included. Performance at retention testing was significantly better than baseline (median score 10 vs 5, P < 0.0001), and no different from posttraining (median score 10 vs 10, P = 0.19). Score changes from baseline to retention and from posttraining to retention were no different for the proctored and independent groups. Over-insufflation and excessive force were the most common reasons for nonproficiency at retention. After proficiency-based VR simulator training, colonoscopy skills are retained for several months, regardless of whether an independent or proctored approach is used. Error avoidance skills may not be retained as well as speed and efficiency skills.

Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training

BACKGROUND

The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency.

OBJECTIVE

To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training.

DESIGN

Multinational, multicenter, single-blind, randomized, controlled trial.

SETTING

Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands.

PARTICIPANTS AND INTERVENTION

This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts.

MAIN OUTCOME MEASUREMENTS

Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets.

RESULTS

Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups.

LIMITATIONS

Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices.

CONCLUSION

Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice.