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Koch K, Duckworth-Mothes B, Schweizer U, Grund KE, Moreels TG, Königsrainer A, Wichmann D. Development and evaluation of artificial organ models for ERCP training in patients with surgically altered anatomies. Sci Rep 2023; 13:22920. [PMID: 38129520 PMCID: PMC10739860 DOI: 10.1038/s41598-023-49888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
Endoscopy training models (ETM) using artificial organs are practical, hygienic and comfortable for trainees. However, few models exist for training endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. This training is necessary as the number of bariatric surgeries performed worldwide increases. ETM with human-like anatomy were developed to represent the postoperative anatomy after Billroth II (BII) reconstruction for a standard duodenoscope and the situs of a long-limbed Roux-en-Y (RY) for device-assisted enteroscopy (DAE). In three independent workshops, the models were evaluated by international ERCP experts. In RY model, a simulation for small bowel behavior in endoscopy was created. Thirty-three experts rated the ETM in ERCP expert courses. The BII model was evaluated as suitable for training (school grades 1.36), with a haptic and visual impression rating of 1.73. The RY model was rated 1.50 for training suitability and 2.06 for overall impression. Animal tissue-free ETMs for ERCP in surgically altered anatomy were successfully created. Evaluation by experienced endoscopists indicated that the models are suitable for hands-on ERCP training, including device-assisted endoscopy. It is expected that patient care will improve with appropriate training in advanced procedures.
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Affiliation(s)
- Kai Koch
- Working Group of Experimental Endoscopy, Development, and Training, University Hospital Tübingen, Waldhörnlestrasse 22, 72072, Tübingen, Germany
- Department of Gastroenterology and Hepatology Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany
| | - Benedikt Duckworth-Mothes
- Working Group of Experimental Endoscopy, Development, and Training, University Hospital Tübingen, Waldhörnlestrasse 22, 72072, Tübingen, Germany
| | - Ulrich Schweizer
- Working Group of Experimental Endoscopy, Development, and Training, University Hospital Tübingen, Waldhörnlestrasse 22, 72072, Tübingen, Germany
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Karl-Ernst Grund
- Working Group of Experimental Endoscopy, Development, and Training, University Hospital Tübingen, Waldhörnlestrasse 22, 72072, Tübingen, Germany
| | - Tom G Moreels
- Department of Gastroenterology and Hepatology, Cliniques Universitaires Saint-Luc, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Dörte Wichmann
- Working Group of Experimental Endoscopy, Development, and Training, University Hospital Tübingen, Waldhörnlestrasse 22, 72072, Tübingen, Germany.
- Central Endoscopy, University Hospital of Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Germany.
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He XJ, Wang XL, Jiang CS, Hong DG, Lin HL, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Luo BX, Li DL, Li DZ, Wang W. Novel beagle model of gastric local fibrotic target lesions for the evaluation and training of endoscopic techniques. BMC Gastroenterol 2023; 23:412. [PMID: 38012582 PMCID: PMC10683295 DOI: 10.1186/s12876-023-03055-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 11/18/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Novel endoscopic techniques used in the treatment of gastric lesions with local submucosal fibrosis need preclinical evaluation and training due to safety limitations. Therefore, the purpose of our study was to establish an animal model of gastric local fibrotic target lesions and assess its feasibility in the evaluation and training of endoscopic techniques. METHODS In six experimental beagles, a 50% glucose solution was injected into three submucosal areas of the fundus, body, and antrum of the stomach to create gastric local fibrotic target lesions (experimental group). On post-injection day (PID) 7, the injection sites were assessed endoscopically to confirm the presence of submucosal fibrosis formation, and the dental floss clip traction assisted endoscopic submucosal dissection (DFC-ESD) procedure was performed on the gastric local fibrotic target lesions to confirm its feasibility after endoscopic observation. The normal gastric mucosa of six control beagles underwent the same procedure (control group). All the resected specimens were evaluated by histological examination. RESULTS All 12 beagles survived without postoperative adverse events. On PID 7, 16 ulcer changes were observed at the injection sites (16/18) under the endoscope, and endoscopic ultrasonography confirmed the local submucosal fibrosis formation in all ulcer lesions. The subsequent DFC-ESD was successfully performed on the 32 gastric target lesions, and the mean submucosal dissection time in the ulcer lesions was greater than that in the normal gastric mucosa (15.3 ± 5.6 vs. 6.8 ± 0.8 min; P < 0.001). There was no difference in rates of en bloc resection, severe hemorrhage, or perforation between the two groups. Histological analysis of the ulcer lesions showed the absence of epithelial or muscularis mucosae and extensive submucosal fibrous tissue proliferations compared with normal gastric mucosa. Overall, endoscopists had high satisfaction with the realism and feasibility of the animal model. CONCLUSION We developed a novel animal model of gastric local fibrotic target lesions to simulate difficult clinical situations, which strongly appeared to be suitable for the preclinical evaluation and learning of advanced endoscopic techniques.
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Affiliation(s)
- Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Hai-Lan Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Bao-Xiang Luo
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Liang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Hepatobiliary Disease, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
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Knoop RF, Amanzada A, Petzold G, Ellenrieder V, Engelhardt M, Neesse A, Bremer SCB, Kunsch S. Endoscopic mucosal resection and endoscopic submucosal dissection with an external additional working channel (EMR+ and ESD+) are equivalent to using a double-channel endoscope: a systematic evaluation in a porcine ex vivo model. Surg Endosc 2023; 37:7749-7758. [PMID: 37567979 PMCID: PMC10520185 DOI: 10.1007/s00464-023-10295-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 07/02/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND AND AIMS With an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed "EMR+" and "ESD+." These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC). METHODS Our trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm. RESULTS EMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72). ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions). Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*). CONCLUSIONS With the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.
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Affiliation(s)
- Richard F Knoop
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany.
| | - Ahmad Amanzada
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Golo Petzold
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Michael Engelhardt
- Department of Gastroenterology, Internal Medicine and Geriatrics, Rems-Murr-Hospital, Winnenden, Germany
| | - Albrecht Neesse
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Sebastian C B Bremer
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
| | - Steffen Kunsch
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Georg-August-University, Göttingen, Germany
- Department of Gastroenterology, Internal Medicine and Geriatrics, Rems-Murr-Hospital, Winnenden, Germany
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Wichmann D, Grether S, Fundel J, Schweizer U, Wedi E, Walter B, Königsrainer A, Duckworth-Mothes B. Evaluation of a New Animal Tissue-Free Bleeding Model for Training of Endoscopic Hemostasis. J Clin Med 2023; 12:jcm12093230. [PMID: 37176670 PMCID: PMC10179644 DOI: 10.3390/jcm12093230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND For endoscopists, knowledge of the available hemotherapeutic devices and materials as well as competence in using them is a life-saving expertise in the treatment of patients with acute gastrointestinal bleeding. These competences can be acquired in training on live animals, animal organs, or simulators. We present an animal tissue-free training model of the upper gastrointestinal tract for bleeding therapy. METHODS An artificial, animal tissue-free mucosa and submucosa with the opportunity of injection and clipping therapy were created first. Patches with this artificial mucosa and submucosa were placed into silicone and latex organs with human-like anatomy. Esophageal bleeding situations were imitated as variceal bleeding and bleeding of a reflux esophagitis in latex organs. Finally, a modular training model with human anatomy and replaceable bleeding sources was created. Evaluation of the novel model for gastroscopic training was performed in a multicentric setting with endoscopic beginners and experts. RESULTS Evaluation was carried out by 38 physicians with different levels of education in endoscopy. Evaluation of the model was made with grades from one (excellent) to six (bad): suitability for endoscopic training was 1.4, relevance of the endoscopic training was 1.6, and grading for haptic and optic impression of the model was 1.7. CONCLUSIONS The creation of a gastroscopic model for the training of hemostatic techniques without animal tissues was possible and multiple endoscopic bleeding skills could be trained in it. Evaluation showed good results for this new training option, which could be used in every endoscopic unit or other places without hygienic doubts.
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Affiliation(s)
- Dörte Wichmann
- Working Group for Experimental Endoscopy, Development and Training, University Hospital of Tübingen, Waldhörnlestrasse 22, 72072 Tübingen, Germany
- Interdisciplinary Endoscopic Unit, University Hospital of Tübingen, Otfried-Müller-Strasse 10, 72076 Tübingen, Germany
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Sarah Grether
- Working Group for Experimental Endoscopy, Development and Training, University Hospital of Tübingen, Waldhörnlestrasse 22, 72072 Tübingen, Germany
- General Psychiatry and Psychotherapy with Outpatient Clinic, University Hospital of Tübingen, Calwerstraße 14, 72076 Tübingen, Germany
| | - Jana Fundel
- Working Group for Experimental Endoscopy, Development and Training, University Hospital of Tübingen, Waldhörnlestrasse 22, 72072 Tübingen, Germany
- Department of Gynecology and Obstetrics, Diakonissen-Stiftungs-Krankenhaus Speyer, Paul-Egell-Straße 33, 67346 Speyer, Germany
| | - Ulrich Schweizer
- Working Group for Experimental Endoscopy, Development and Training, University Hospital of Tübingen, Waldhörnlestrasse 22, 72072 Tübingen, Germany
- Interdisciplinary Endoscopic Unit, University Hospital of Tübingen, Otfried-Müller-Strasse 10, 72076 Tübingen, Germany
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Edris Wedi
- Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Klinikum Offenbach GmbH, Starkenburgring 66, 63069 Offenbach, Germany
| | - Benjamin Walter
- Department of Interventional Endoscopy, Clinic of Internal Medicine I, University Hospital Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany
| | - Benedikt Duckworth-Mothes
- Working Group for Experimental Endoscopy, Development and Training, University Hospital of Tübingen, Waldhörnlestrasse 22, 72072 Tübingen, Germany
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Kim Y, Lee JH, Lee GH, Kim GH, Huh G, Hong SW, Jung HY. Simulator-based training method in gastrointestinal endoscopy training and currently available simulators. Clin Endosc 2023; 56:1-13. [PMID: 36604834 PMCID: PMC9902695 DOI: 10.5946/ce.2022.191] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/19/2022] [Indexed: 01/07/2023] Open
Abstract
The apprenticeship-based training method (ABTM) is highly effective for gastrointestinal (GI) endoscopic training. However, the conventional ABTM has significant issues. Although many supplementary training methods (TMs) have been developed and utilized, they cannot entirely replace the ABTM, which remains the major TM strategy. Currently, new TM construction is crucial and necessary due to financial constraints, difficulty of obtaining sufficient training time due to patient safety-related regulations, and catastrophic damage caused by disasters such as the coronavirus disease 2019 pandemic. The simulator-based TM (SBTM) is widely accepted as an alternative to the ABTM, owing to the SBTM's advantages. Since the 1960s, many GI endoscopy training simulators have been developed and numerous studies have been published on their effectiveness. While previous studies have focused on the simulator's validity, this review focused on the accessibility of simulators that were introduced by the end of 2021. Although the current SBTM is effective in GI endoscopic education, extensive improvements are needed to replace the ABTM. Incorporating simulator-incorporated TMs into an improved ABTM is an attempt to overcome the incompleteness of the current SBTM. Until a new simulator is developed to replace the ABTM, it is desirable to operate a simulator-integrated and well-coordinated TM that is suitable for each country and institution.
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Affiliation(s)
- Yuri Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence: Gin Hyug Lee Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea E-mail:
| | - Ga Hee Kim
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Gunn Huh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Wook Hong
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kanno T, Arata Y, Hatayama Y, Koike T, Masamune A. Novel simulator of endoscopic hemostasis with actual endoscope and devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2022; 8:56-59. [PMID: 36820256 PMCID: PMC9938294 DOI: 10.1016/j.vgie.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Video 1Demonstration of novel simulator of endoscopic hemostasis.
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Affiliation(s)
- Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan,Department of Education and Support for Regional Medicine, Tohoku University Hospital, Sendai, Japan
| | - Yutaro Arata
- Graduate Medical Education center, Tohoku University Hospital, Sendai, Japan
| | - Yutaka Hatayama
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Balekuduru AB, Appaji AC. Therapeutic Endoscopic Procedures on a Human Cadaver—A Pilot Feasibility Study. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1728223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
| | - Ashwini C. Appaji
- Department of Anatomy, M. S. Ramaiah Hospitals, Bangalore, Karnataka, India
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DE Angelis CG, Rizza S, Rizzi F, Debernardi-Venon W, Caronna S, Gaia S, Bruno M. Training in advanced bilio-pancreatic endoscopy. Minerva Gastroenterol (Torino) 2021; 68:121-132. [PMID: 33793163 DOI: 10.23736/s2724-5985.21.02869-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As the clinical applications of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) take more and more root in everyday practice and these endoscopic procedures become increasingly more complex and interventional with a higher chance for complications, the demand for expert bilio-pancreatic endoscopists continues to increase. In response to this growing need, specific postgraduate fellowships have been developed, however the standardization of training programs and the assessment of the achieved competence still remains an open debate. ERCP and EUS competency often requires training beyond the scope of a standard GI fellowship program, which lasts at least 1-2 years, and there are some differences in the way to face the issues of advanced bilio-pancreatic endoscopy training between Europe, America and the Asian regions. Today there is no role for the self-teaching of ERCP and EUS through trial and error without supervision and, in the near future, it is necessary to critically revise current training guidelines, to establish a standardized curriculum for advanced bilio-pancreatic endoscopists and to implement universally validated skill assessment tools, able to ensure constant and targeted feedback to trainees.
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Affiliation(s)
- Claudio G DE Angelis
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy -
| | - Stefano Rizza
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy.,Gastroenterology and Digestive Endoscopy Unit, FPO-IRCCS Candiolo Cancer Institute, Candiolo, Turin, Italy
| | - Felice Rizzi
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Wilma Debernardi-Venon
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Stefania Caronna
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Silvia Gaia
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Mauro Bruno
- Gastroenterology and Digestive Endoscopy Unit, AOU Città della Salute e della Scienza, University of Turin, Turin, Italy
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Finocchiaro M, Cortegoso Valdivia P, Hernansanz A, Marino N, Amram D, Casals A, Menciassi A, Marlicz W, Ciuti G, Koulaouzidis A. Training Simulators for Gastrointestinal Endoscopy: Current and Future Perspectives. Cancers (Basel) 2021; 13:cancers13061427. [PMID: 33804773 PMCID: PMC8004017 DOI: 10.3390/cancers13061427] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/11/2021] [Accepted: 03/16/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary Over the last decades, visual endoscopy has become a gold standard for the detection and treatment of gastrointestinal cancers. However, mastering endoscopic procedures is complex and requires long hours of practice. In this context, simulation-based training represents a valuable opportunity for acquiring technical and cognitive skills, suiting the different trainees’ learning pace and limiting the risks for the patients. In this regard, the present contribution aims to present a critical and comprehensive review of the current technology for gastrointestinal (GI) endoscopy training, including both commercial products and platforms at a research stage. Not limited to it, the recent revolution played by the technological advancements in the fields of robotics, artificial intelligence, virtual/augmented reality, and computational tools on simulation-based learning is documented and discussed. Finally, considerations on the future trend of this application field are drawn, highlighting the impact of the most recent pandemic and the current demographic trends. Abstract Gastrointestinal (GI) endoscopy is the gold standard in the detection and treatment of early and advanced GI cancers. However, conventional endoscopic techniques are technically demanding and require visual-spatial skills and significant hands-on experience. GI endoscopy simulators represent a valid solution to allow doctors to practice in a pre-clinical scenario. From the first endoscopy mannequin, developed in 1969, several simulation platforms have been developed, ranging from purely mechanical systems to more complex mechatronic devices and animal-based models. Considering the recent advancement of technologies (e.g., artificial intelligence, augmented reality, robotics), simulation platforms can now reach high levels of realism, representing a valid and smart alternative to standard trainee/mentor learning programs. This is particularly true nowadays, when the current demographic trend and the most recent pandemic demand, more than ever, the ability to cope with many patients. This review offers a broad view of the technology available for GI endoscopy training, including platforms currently in the market and the relevant advancements in this research and application field. Additionally, new training needs and new emerging technologies are discussed to understand where medical education is heading.
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Affiliation(s)
- Martina Finocchiaro
- The BioRobotics Institute, Scuola Superiore Sant’Anna, 56025 Pisa, Italy; (A.M.); (G.C.)
- Center of Research in Biomedical Engineering, Universitat Politècnica de Catalunya, 08034 Barcelona, Spain; (A.H.); (A.C.)
- Department of Excellence in Robotics & AI, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Correspondence:
| | - Pablo Cortegoso Valdivia
- Gastroenterology and Endoscopy Unit, University Hospital of Parma, University of Parma, 43126 Parma, Italy;
| | - Albert Hernansanz
- Center of Research in Biomedical Engineering, Universitat Politècnica de Catalunya, 08034 Barcelona, Spain; (A.H.); (A.C.)
| | - Nicola Marino
- Department of Medical and Surgical Sciences University of Foggia, 71121 Foggia, Italy;
| | - Denise Amram
- LIDER-Lab, DIRPOLIS Institute, Scuola Superiore Sant’Anna, 56025 Pisa, Italy;
| | - Alicia Casals
- Center of Research in Biomedical Engineering, Universitat Politècnica de Catalunya, 08034 Barcelona, Spain; (A.H.); (A.C.)
| | - Arianna Menciassi
- The BioRobotics Institute, Scuola Superiore Sant’Anna, 56025 Pisa, Italy; (A.M.); (G.C.)
- Department of Excellence in Robotics & AI, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Wojciech Marlicz
- Department of Gastroenterology, Pomeranian Medical University, 71-252 Szczecin, Poland;
- The Centre for Digestive Diseases Endoklinika, 70-535 Szczecin, Poland
| | - Gastone Ciuti
- The BioRobotics Institute, Scuola Superiore Sant’Anna, 56025 Pisa, Italy; (A.M.); (G.C.)
- Department of Excellence in Robotics & AI, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Anastasios Koulaouzidis
- Department of Social Medicine & Public Health, Pomeranian Medical University, 71-252 Szczecin, Poland;
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Lee SY, Pakela JM, Na K, Shi J, McKenna BJ, Simeone DM, Yoon E, Scheiman JM, Mycek MA. Needle-compatible miniaturized optoelectronic sensor for pancreatic cancer detection. SCIENCE ADVANCES 2020; 6:eabc1746. [PMID: 33219025 PMCID: PMC7679167 DOI: 10.1126/sciadv.abc1746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 10/07/2020] [Indexed: 06/11/2023]
Abstract
Pancreatic cancer is one of the deadliest cancers, with a 5-year survival rate of <10%. The current approach to confirming a tissue diagnosis, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), requires a time-consuming, qualitative cytology analysis and may be limited because of sampling error. We designed and engineered a miniaturized optoelectronic sensor to assist in situ, real-time, and objective evaluation of human pancreatic tissues during EUS-FNA. A proof-of-concept prototype sensor, compatible with a 19-gauge hollow-needle commercially available for EUS-FNA, was constructed using microsized optoelectronic chips and microfabrication techniques to perform multisite tissue optical sensing. In our bench-top verification and pilot validation during surgery on freshly excised human pancreatic tissues (four patients), the fabricated sensors showed a comparable performance to our previous fiber-based system. The flexibility in source-detector configuration using microsized chips potentially allows for various light-based sensing techniques inside a confined channel such as a hollow needle or endoscopy.
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Affiliation(s)
- Seung Yup Lee
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - Julia M Pakela
- Applied Physics Program, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kyounghwan Na
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jiaqi Shi
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Barbara J McKenna
- Department of Pathology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Diane M Simeone
- Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Euisik Yoon
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI 48109, USA
| | - James M Scheiman
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mary-Ann Mycek
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA.
- Applied Physics Program, University of Michigan, Ann Arbor, MI 48109, USA
- Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI 48109, USA
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11
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Knoop RF, Wedi E, Petzold G, Bremer SCB, Amanzada A, Ellenrieder V, Neesse A, Kunsch S. Endoscopic submucosal dissection with an additional working channel (ESD+): a novel technique to improve procedure time and safety of ESD. Surg Endosc 2020; 35:3506-3512. [PMID: 32676726 PMCID: PMC8195965 DOI: 10.1007/s00464-020-07808-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/10/2020] [Indexed: 02/07/2023]
Abstract
Background and aims A new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed “ESD+ ”. We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD. Methods The study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions. Results Overall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*). Conclusions By its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions. Electronic supplementary material The online version of this article (10.1007/s00464-020-07808-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard F Knoop
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Golo Petzold
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Sebastian C B Bremer
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Ahmad Amanzada
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Albrecht Neesse
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany
| | - Steffen Kunsch
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center Goettingen, Georg-August-University, 37075, Göttingen, Germany.
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12
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Purnell SM, Vargo DJ, Sarap M, Nguyen-Lee JJ, Allen C, Dunkin BJ. Simulation training for the endoscopic management of upper gastrointestinal bleeding: a nationwide survey of rural surgeons' needs and preferences analysis. Surg Endosc 2020; 35:333-339. [PMID: 32030550 DOI: 10.1007/s00464-020-07405-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/30/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Published needs analyses of rural surgeons have identified a need for training in the endoscopic management of non-variceal upper gastrointestinal bleeding (NVUGIB). The study aim was to survey rural surgeons regarding their requirements and preferences for a simulation model on which they could rehearse the endoscopic management of NVUGIB. METHODS Rural surgeons were contacted via the American College of Surgery Advisory Council listserv and invited to complete an online survey. RESULTS A total of 66 responses were received, representing all 4 US regional divisions. Seventy-seven percent of respondents perform > 100 endoscopy cases per year. A majority have no experience with simulation models (77%), citing cost, time, and access to training courses as the three most limiting factors. Thirty-three percent lacked confidence in managing UGIBs, and 73% were interested in receiving additional training. Preference analysis revealed that respondents preferred a portable simulation model (81%) that costs between $500 and $1000 (46%), and requires 1-2 weeks of training (34%). Verbal feedback from an expert was viewed as the most helpful type of feedback (61%). CONCLUSION Rural surgeons frequently perform flexible endoscopy in their practice and are interested in further training for the endoscopic management of NVUGIB. These results will be used to develop a simulation platform for training in the endoscopic management of NVUGIB that meets rural surgeons' needs.
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Affiliation(s)
- Shawn M Purnell
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower 1661, Houston, TX, 77030, USA. .,Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, USA.
| | - Daniel J Vargo
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, USA
| | - Michael Sarap
- Southeastern Ohio Regional Medical Center, Cambridge, USA
| | - John J Nguyen-Lee
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower 1661, Houston, TX, 77030, USA
| | - Chelsea Allen
- Center for Clinical and Translational Science, University of Utah, Salt Lake City, USA
| | - Brian J Dunkin
- Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Smith Tower 1661, Houston, TX, 77030, USA.,Methodist Institute of Technology, Innovation, and Education, Houston, USA
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13
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Knoop RF, Wedi E, Petzold G, Bremer SC, Amanzada A, Ellenrieder V, Neesse A, Kunsch S. Endoscopic mucosal resection with an additional working channel (EMR+) in a porcine ex vivo model: a novel technique to improve en bloc resection rate of snare polypectomy. Endosc Int Open 2020; 8:E99-E104. [PMID: 32010740 PMCID: PMC6976338 DOI: 10.1055/a-0996-8050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/14/2019] [Indexed: 02/08/2023] Open
Abstract
Background and study aims Recently, a new external additional working channel (AWC) was introduced by which conventional endoscopic mucosal resection (EMR) can be improved to a technique termed "EMR+". We first evaluated this novel technique in comparison to classical EMR in flat lesions. Methods The trial was prospectively conducted in an ex vivo animal model with porcine stomachs placed into the EASIE-R simulator. Prior to intervention, standardized lesions were set by coagulation dots, measuring 1, 2, 3 or 4 cm. Results Overall, 152 procedures were performed. EMR and EMR+ were both very reliable in 1-cm lesions, each showing en bloc resection rates of 100 %. EMR+ en bloc resection rate was significantly higher in 2-cm lesions (95.44 % vs. 54.55 %, P = 0.02), in 3-cm lesions (86.36 % vs. 18.18 %, P < 0.01) and also in 4-cm lesions (60.00 % vs. 0 %, P < 0.01). Perforations occurred only in EMR+ procedures in 4-cm lesions (3 of 20; 15 %). Conclusions With its grasp-and-snare technique, EMR+ facilitates en bloc resection of larger lesions compared to conventional EMR. In lesions 2 cm and larger, EMR+ has demonstrated advantages, especially concerning en bloc resection rate. At 3 cm, EMR+ reaches its best discriminatory power whereas EMR+ has inherent limits at 4 cm and in lesions of that size, other techniques such as ESD or surgery should be considered.
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Affiliation(s)
- Richard F. Knoop
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Golo Petzold
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Sebastian C.B. Bremer
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Ahmad Amanzada
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Albrecht Neesse
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany
| | - Steffen Kunsch
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, Goettingen, Germany,Corresponding author Steffen Kunsch Department of Gastroenterology and GI OncologyUniversity Medical Center GoettingenGeorg-August-UniversityD-37075 GoettingenGermany+0495513966327
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European Society for Paediatric Gastroenterology, Hepatology and Nutrition Position Paper on Training in Paediatric Endoscopy. J Pediatr Gastroenterol Nutr 2020; 70:127-140. [PMID: 31799965 DOI: 10.1097/mpg.0000000000002496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Wedi E, Knoop R, Jung C, Gromski M, Ho CN, Conrad G, Maiss J, Milenovic S, Klemme D, Baulain U, Seif Amir Hosseini A, Ellenrieder V, Koehler P. EMR + with the AWC improves endoscopic resection speed compared to ESD: a porcine ex-vivo pilot study. MINIM INVASIV THER 2019; 30:47-54. [PMID: 31597491 DOI: 10.1080/13645706.2019.1673778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION To improve resection speed and to reach higher en bloc resection rates in lesions ≥ 2 cm, a novel grasp and snare EMR technique termed "EMR+", accomplished by an additional working channel (AWC), was developed. Its use compared to endoscopic submucosal dissection (ESD) is evaluated for the first time. MATERIAL AND METHODS We prospectively conducted a randomized pre-clinical ex-vivo pilot study in explanted porcine stomachs for the comparison of EMR + with classical ESD of mucosal-based lesions. Prior to intervention, we set flat lesions with a standardized size of 3 × 3 cm. RESULTS The median time of procedure was significantly shorter in the EMR + group (median 10.5 min, range 4.4-24 min) than in the ESD group (median 32 min, range 14-61.6 min, p < .0001). The rate of en bloc resection was significantly lower in the EMR + group (38 % vs. 95 %) (p < .0001). Nevertheless, an improvement in the learning curve for EMR + was achieved after the first 12 procedures, with a subsequent en bloc resection rate of 100 %. CONCLUSIONS EMR + could improve the efficiency of mucosal resection procedures. Initial experience demonstrates a higher and satisfactory en bloc resection rate after going through the learning curve of EMR+.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Richard Knoop
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Carlo Jung
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Juergen Maiss
- Department of Gastroenterology, Associate Prof. Maiss, Forchheim, Germany
| | - Sinisa Milenovic
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - David Klemme
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Ulrich Baulain
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Peter Koehler
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
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Goodman AJ, Melson J, Aslanian HR, Bhutani MS, Krishnan K, Lichtenstein DR, Navaneethan U, Pannala R, Parsi MA, Schulman AR, Sethi A, Sullivan SA, Thosani N, Trikudanathan G, Trindade AJ, Watson RR, Maple JT. Endoscopic simulators. Gastrointest Endosc 2019; 90:1-12. [PMID: 31122746 DOI: 10.1016/j.gie.2018.10.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Simulation refers to educational tools that allow for repetitive instruction in a nonpatient care environment that is risk-free. In GI endoscopy, simulators include ex vivo animal tissue models, live animal models, mechanical models, and virtual reality (VR) computer simulators. METHODS After a structured search of the peer-reviewed medical literature, this document reviews commercially available GI endoscopy simulation systems and clinical outcomes of simulation in endoscopy. RESULTS Mechanical simulators and VR simulators are frequently used early in training, whereas ex vivo and in vivo animal models are more commonly used for advanced endoscopy training. Multiple studies and systematic reviews show that simulation-based training appears to provide novice endoscopists with some advantage over untrained peers with regard to endpoints such as independent procedure completion and performance time, among others. Data also suggest that simulation training may accelerate the acquisition of specific technical skills in colonoscopy and upper endoscopy early in training. However, the available literature suggests that the benefits of simulator training appear to attenuate and cease after a finite period. Further studies are needed to determine if meeting competency metrics using simulation will predict actual clinical competency. CONCLUSIONS Simulation training is a promising modality that may aid in endoscopic education. However, for widespread incorporation of simulators into gastroenterology training programs to occur, simulators must show a sustained advantage over traditional mentored teaching in a cost-effective manner. Because most studies evaluating simulation have focused on novice learners, the role of simulation training in helping practicing endoscopists gain proficiency using new techniques and devices should be further explored.
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Affiliation(s)
| | - Adam J Goodman
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Joshua Melson
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, The University of Texas, Houston, Texas, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Mansour A Parsi
- Department of Gastroenterology & Hepatology, Tulane University, New Orleans, Louisiana, USA
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Amrita Sethi
- Division of Digestive and Liver Diseases, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Shelby A Sullivan
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Nirav Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, New York, USA
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - John T Maple
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
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Walsh CM, Cohen J, Woods KL, Wang KK, Andersen DK, Anderson MA, Dunkin BJ, Edmundowicz SA, Faigel DO, Law JK, Marks JM, Sedlack RE, Thompson CC, Vargo JJ. ASGE EndoVators Summit: simulators and the future of endoscopic training. Gastrointest Endosc 2019; 90:13-26. [PMID: 31122744 DOI: 10.1016/j.gie.2018.10.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/24/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, the Research and Learning Institutes, Hospital for Sick Children and the Wilson Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Jonathan Cohen
- School of Medicine, New York University Langone Health, New York, New York
| | - Karen L Woods
- Houston Methodist Gastroenterology Associates, Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, Texas
| | - Kenneth K Wang
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Michelle A Anderson
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Brian J Dunkin
- Institute for Technology, Innovation, and Education, Houston Methodist Hospital, Houston, Texas
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Joanna K Law
- Digestive Disease Institute, Virginia Mason Hospital and Medical Center, Seattle, Washington
| | - Jeffrey M Marks
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Robert E Sedlack
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - John J Vargo
- Department of Gastroenterology, Hepatology, and Nutrition, Cleveland Clinic, Cleveland, Ohio
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Jacques J, Legros R, Sautereau D. Mechanical model of sphincterotomy: a step forward for trainees. Endosc Int Open 2019; 7:E762-E763. [PMID: 31157799 PMCID: PMC6524996 DOI: 10.1055/a-0830-4712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Jérémie Jacques
- Gastroenterology and Endoscopy Unit, Dupuytren University Hospital, Limoges, France
- Bio-Em, Xlim, Limoges, France
| | - Romain Legros
- Gastroenterology and Endoscopy Unit, Dupuytren University Hospital, Limoges, France
| | - Denis Sautereau
- Gastroenterology and Endoscopy Unit, Dupuytren University Hospital, Limoges, France
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Wedi E, Koehler P, Hochberger J, Maiss J, Milenovic S, Gromski M, Ho N, Gabor C, Baulain U, Ellenrieder V, Jung C. Endoscopic submucosal dissection with a novel high viscosity injection solution (LiftUp) in an ex vivo model: a prospective randomized study. Endosc Int Open 2019; 7:E641-E646. [PMID: 31058206 PMCID: PMC6497499 DOI: 10.1055/a-0874-1844] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/02/2018] [Indexed: 02/08/2023] Open
Abstract
Introduction Endoscopic submucosal dissection (ESD) is increasingly being used in the western world. Submucosal injectates are an essential tool for the ESD procedure. In this study, we evaluated a novel copolymer injectate (LiftUp, Ovesco, Tübingen Germany) in an established ESD model (EASIE-R) in comparison to existing submucosal injectables. Materials and methods We conducted a prospective, randomized ex vivo study performing ESD with three injectates: LiftUp, hydroxyethyl starch (HAES 6 %) and normal saline solution (NaCl 0.9 %). A total of 60 artificial lesions, each 3 × 3 cm in size, were resected in an ex vivo porcine model, utilizing one of the three studied injectates (n = 20 ESDs per injectate). Study parameters were: en bloc resection rate, perforation rate, lifting property, time of injection, injectate volume, general ESD procedure time, and overall procedure time. Results All 60 lesions were successfully resected using the standard ESD technique. LiftUp had no procedure related perforations, one perforation occurred in the HAES group, and two perforations in the NaCl group ( P > 0.05). Furthermore, adequate lifting was achieved in 16/20 (80 %) using LiftUp, 6/20 (30 %) in the HAES group and 6/20 (30 %) in the NaCl group ( P < 0.0002). En bloc resection was achieved in 19 (95 %) with LiftUp, in 20 (100 %) with HAES, and in 16 (80 %) with NaCl. General ESD procedure time and overall procedure time were not different among the three groups. Conclusion LiftUp appears to be a safe alternative to established fluids for ESD. It had a significantly improved lifting effect and required significantly less injected volume compared to well-established lifting solutions.
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Affiliation(s)
- E. Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, Center of Interdisciplinary Endoscopy, University Medical Centre Göttingen, Göttingen, Germany
| | - P. Koehler
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
| | - J. Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, Berlin, Germany
| | - J. Maiss
- Department of Gastroenterology, Associates Dr. Kerzel and Prof. Maiss, Forchheim, Germany
| | - S. Milenovic
- Department of Gastroenterology and Gastrointestinal Oncology, Center of Interdisciplinary Endoscopy, University Medical Centre Göttingen, Göttingen, Germany
| | - M. Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - N. Ho
- Ovesco Endoscopy AG, Tübingen, Germany
| | - C. Gabor
- Ovesco Endoscopy AG, Tübingen, Germany
| | - U. Baulain
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
| | - V. Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, Center of Interdisciplinary Endoscopy, University Medical Centre Göttingen, Göttingen, Germany
| | - C. Jung
- Department of Gastroenterology and Gastrointestinal Oncology, Center of Interdisciplinary Endoscopy, University Medical Centre Göttingen, Göttingen, Germany
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Chandrasekhara V, Rhoades D, Kaimakliotis PZ, Dai SC, Kochman ML. An endoscopic training and assessment model for argon plasma coagulation. Adv Med Sci 2019; 64:152-156. [PMID: 30669115 DOI: 10.1016/j.advms.2018.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 06/08/2018] [Accepted: 08/31/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Argon plasma coagulation (APC) is a standard modality for the treatment of gastrointestinal bleeding. However, there are no metrics to assess technical proficiency. We aimed to determine if a Quick APC Training Test (QAPCTT) can improve performance and assess proficiency with this modality. MATERIALS AND METHODS Endoscopy trainees at various levels of training were asked to perform the QAPCTT with an in vivo model before and after an APC curriculum with didactic lectures and additional hands-on experience. As trainees performed the test, endoscopic supervisors recorded the time required to complete each task as well as the number of inadvertent mucosal touchdowns. Each partipant was assigned a technical proficiency score by supervising endoscopists. RESULTS Fourteen adult gastroenterology fellows participated in the course. 100% of fellows were comfortable with generator settings and APC equipment after the course compared to only 21% (p < 0.001) on the pre-test questionnaire. Those deemed technically proficient on the post-course QAPCTT required significantly less time for the task of making a square (100 s vs. 215 s; p = 0.006) and had significantly fewer inadvertent mucosal touchdowns (5 vs. 19; p = 0.0017). CONCLUSIONS Dedicated APC training is required to achieve competence with this modality. A structured curriculum improves knowledge about the technique and hands-on training is important for achieving technical proficiency. The QAPCTT appears improve APC technique and may readily identify trainees in need of additional APC experience to gain proficiency.
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Affiliation(s)
- Vinay Chandrasekhara
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Daniel Rhoades
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Pavlos Z Kaimakliotis
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA; Gastroenterology Division, Department of Internal Medicine, Lahey Medical Center, Burlington, MA, USA
| | - Sun-Chuan Dai
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA; Gastroenterology Division, Department of Internal Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Michael L Kochman
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
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Placek SB, Franklin BR, Ritter EM. Simulation in Surgical Endoscopy. COMPREHENSIVE HEALTHCARE SIMULATION: SURGERY AND SURGICAL SUBSPECIALTIES 2019. [DOI: 10.1007/978-3-319-98276-2_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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22
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Tan RY, Lee KG, Gan SWS, Li H, Yeon W, Pang SC, Teh SP, Htay H, Teo SH, Kwek JL, Tok PL, Poh CB, Ng CY, Liu P, Tay HB, Koniman R, Foo MWY, Choong LHL, Tan CS. Impact of simulation‐based learning on immediate outcomes of temporary haemodialysis catheter placements by nephrology fellows. Nephrology (Carlton) 2018; 23:933-939. [DOI: 10.1111/nep.13156] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/21/2017] [Accepted: 08/13/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Ru Yu Tan
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Kian Guan Lee
- Department of Renal MedicineSingapore General Hospital Singapore
| | | | - Huihua Li
- Health Services Research UnitSingapore General Hospital Singapore
| | - Wenxiang Yeon
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Suh Chien Pang
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Swee Ping Teh
- Health Services Research UnitSingapore General Hospital Singapore
| | - Htay Htay
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Su Hooi Teo
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Jia Liang Kwek
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Pei Loo Tok
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Cheng Boon Poh
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Chee Yong Ng
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Peiyun Liu
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Hui Boon Tay
- Department of Renal MedicineSingapore General Hospital Singapore
| | - Riece Koniman
- Department of Renal MedicineSingapore General Hospital Singapore
| | | | | | - Chieh Suai Tan
- Department of Renal MedicineSingapore General Hospital Singapore
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Biswas S, Alrubaiy L, China L, Lockett M, Ellis A, Hawkes N. Trends in UK endoscopy training in the BSG trainees' national survey and strategic planning for the future. Frontline Gastroenterol 2018; 9:200-207. [PMID: 30046424 PMCID: PMC6056087 DOI: 10.1136/flgastro-2017-100848] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/26/2017] [Accepted: 08/19/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Improvements in the structure of endoscopy training programmes resulting in certification from the Joint Advisory Group in Gastrointestinal Endoscopy have been acknowledged to improve training experience and contribute to enhanced colonoscopy performance. OBJECTIVES The 2016 British Society of Gastroenterology trainees' survey of endoscopy training explored the delivery of endoscopy training - access to lists; level of supervision and trainee's progression through diagnostic, core therapy and subspecialty training. In addition, the barriers to endoscopy training progress and utility of training tools were examined. METHODS A web-based survey (Survey Monkey) was sent to all higher specialty gastroenterology trainees. RESULTS There were some improvements in relation to earlier surveys; 85% of trainees were satisfied with the level of supervision of their training. But there were ongoing problems; 12.5% of trainees had no access to a regular training list, and 53% of final year trainees had yet to achieve full certification in colonoscopy. 9% of final year trainees did not feel confident in endoscopic management of upper GI bleeds. CONCLUSIONS The survey findings provide a challenge to those agencies tasked with supporting endoscopy training in the UK. Acknowledging the findings of the survey, the paper provides a strategic response with reference to increased service pressures, reduced overall training time in specialty training programmes and the requirement to support general medical and surgical on-call commitments. It describes the steps required to improve training on the ground: delivering additional training tools and learning resources, and introducing certification standards for therapeutic modalities in parallel with goals for improving the quality of endoscopy in the UK.
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Affiliation(s)
- Sujata Biswas
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Laith Alrubaiy
- Department of Gastroenterology, Swansea University Medical School, Swansea, UK
| | - Louise China
- Division of Medicine, University College London, London, UK
| | | | - Melanie Lockett
- Department of Gastroenterology, North Bristol NHS Trust, Bristol, UK
| | - Antony Ellis
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Neil Hawkes
- Department of Gastroenterology, Royal Glamorgan Hospital, Llantrisant, UK
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Grover SC, Scaffidi MA, Khan R, Garg A, Al-Mazroui A, Alomani T, Yu JJ, Plener IS, Al-Awamy M, Yong EL, Cino M, Ravindran NC, Zasowski M, Grantcharov TP, Walsh CM. Progressive learning in endoscopy simulation training improves clinical performance: a blinded randomized trial. Gastrointest Endosc 2017; 86:881-889. [PMID: 28366440 DOI: 10.1016/j.gie.2017.03.1529] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 03/17/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS A structured comprehensive curriculum (SCC) that uses simulation-based training (SBT) can improve clinical colonoscopy performance. This curriculum may be enhanced through the application of progressive learning, a training strategy centered on incrementally challenging learners. We aimed to determine whether a progressive learning-based curriculum (PLC) would lead to superior clinical performance compared with an SCC. METHODS This was a single-blinded randomized controlled trial conducted at a single academic center. Thirty-seven novice endoscopists were recruited and randomized to either a PLC (n = 18) or to an SCC (n = 19). The PLC comprised 6 hours of SBT, which progressed in complexity and difficulty. The SCC included 6 hours of SBT, with cases of random order of difficulty. Both groups received expert feedback and 4 hours of didactic teaching. Participants were assessed at baseline, immediately after training, and 4 to 6 weeks after training. The primary outcome was participants' performance during their first 2 clinical colonoscopies, as assessed by using the Joint Advisory Group Direct Observation of Procedural Skills assessment tool (JAG DOPS). Secondary outcomes were differences in endoscopic knowledge, technical and communication skills, and global performance in the simulated setting. RESULTS The PLC group outperformed the SCC group during first and second clinical colonoscopies, measured by JAG DOPS (P < .001). Additionally, the PLC group had superior technical and communication skills and global performance in the simulated setting (P < .05). There were no differences between groups in endoscopic knowledge (P > .05). CONCLUSIONS Our findings demonstrate the superiority of a PLC for endoscopic simulation, compared with an SCC. Challenging trainees progressively is a simple, theory-based approach to simulation whereby the performance of clinical colonoscopies can be improved. (Clinical trial registration number: NCT02000180.).
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Affiliation(s)
- Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ankit Garg
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Al-Mazroui
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tareq Alomani
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey J Yu
- Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute, and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian S Plener
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Al-Awamy
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elaine L Yong
- Division of Gastroenterology, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cino
- Division of Gastroenterology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nikila C Ravindran
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark Zasowski
- Division of Gastroenterology, St. Michael's Hospital Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute, and Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; The Wilson Centre, University of Toronto, Toronto, Ontario, Canada
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Gromski MA, Cohen J, Saito K, Gonzalez JM, Sawhney M, Kang C, Moore A, Matthes K. Learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator. Surg Endosc 2017; 31:4231-4237. [PMID: 28281126 DOI: 10.1007/s00464-017-5484-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 02/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is increasingly being used in Asia as a minimally invasive therapy to eradicate large laterally spreading superficial tumors in the colon. To date, the learning curve and effectiveness of ex vivo simulators in colonic ESD training remain unclear. The aim of the study is to determine the learning curve of colonic ESD in an ex vivo simulator. METHODS We conducted a prospective study of colon ESD in ex vivo porcine colons in a prototype simulator. Three endoscopists with prior experience in gastric ESD but with no experience in colonic ESD each performed 30 ESD resections on standardized lesions in the rectosigmoid and left colon of the porcine simulator. Procedure time, en bloc resection status, and perforation were recorded. RESULTS All 90 lesions were resected using the ESD technique. The mean time of procedure was 49.6 min (standard deviation 29.6 min). The aggregate rate of perforation was 14.4% and the aggregate rate of non-en bloc resection was 5.6%. Using a composite quality score integrating complications and procedural time, it was found that there was a significant difference between two local polynomial regression lines when using a cut-point at the 9th procedure (p = 0.04), reflecting the point at which most of the learning curve is traversed. CONCLUSIONS In this study, there were significant improvements realized in colonic ESD performance after 9 colon ESD procedures in ex vivo specimens. Although training will depend on endoscopist skill and expertise, we suggest at least 9 ex vivo procedures prior to moving to live animal or proctored training in colonic ESD.
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Affiliation(s)
- Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA.
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Jonah Cohen
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kayoko Saito
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Medical Topia Soka Hospital, Soka, Japan
| | - Jean-Michel Gonzalez
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Aix-Marseille University, APHM, Hôpital Nord, Marseille, France
| | - Mandeep Sawhney
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Changdon Kang
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Andrew Moore
- Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Kai Matthes
- Department of Anesthesia, Critical Care and Pain Medicine, Children's Hospital, Harvard Medical School, Boston, MA, USA
- T.A.M.G.I., Maui, HI, USA
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Kim JS, Kim BW. Training in Endoscopy: Esophagogastroduodenoscopy. Clin Endosc 2017; 50:318-321. [PMID: 28783922 PMCID: PMC5565047 DOI: 10.5946/ce.2017.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal endoscopy is important in diagnosis, treatment, and prevention of many diseases of the digestive tract. The ability to perform esophagogastroduodenoscopy (EGD) safely, effectively, and efficiently has become the mainstay of gastroenterology practice. In Korea, EGD education is usually imparted as a component of gastroenterology training programs during fellowship. In this review, we discuss the general principles of EGD training. Formal curriculum development with devising clear goals and effective training methods should be developed in the future.
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Affiliation(s)
- Joon Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
| | - Byung-Wook Kim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Korea
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Ahn JY, Lee JS, Lee GH, Lee JW, Na HK, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Jung HY, Kim JH. The Efficacy of a Newly Designed, Easy-to-Manufacture Training Simulator for Endoscopic Biopsy of the Stomach. Gut Liver 2017; 10:764-72. [PMID: 27563021 PMCID: PMC5003200 DOI: 10.5009/gnl16044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 04/01/2016] [Accepted: 04/15/2016] [Indexed: 12/25/2022] Open
Abstract
Background/Aims We developed a new endoscopic biopsy training simulator and determined its efficacy for improving the endoscopic biopsy skills of beginners. Methods This biopsy simulator, which presents seven biopsy sites, was constructed using readily available materials. We enrolled 40 participants: 14 residents, 11 first-year clinical fellows, 10 second-year clinical fellows, and five staff members. We recorded the simulation completion time for all participants, and then simulator performance was assessed via a questionnaire using the 7-point Likert scale. Results The mean times for completing the five trials were 417.7±138.8, 145.2±31.5, 112.7±21.9, and 90.5±20.0 seconds for the residents, first-year clinical fellows, second-year clinical fellows, and staff members, respectively. Endoscopists with less experience reported that they found this simulator more useful for improving their biopsy technique (6.8±0.4 in the resident group and 5.7±1.0 in the first-year clinical fellow group). The realism score of the simulator for endoscopic handling was 6.4±0.5 in the staff group. Conclusions This new, easy-to-manufacture endoscopic biopsy simulator is useful for biopsy training for beginner endoscopists and shows good efficacy and realism.
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Affiliation(s)
- Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Seo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Wan Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Gonzalez JM, Cohen J, Gromski MA, Saito K, Loundou A, Matthes K. Learning curve for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic lesions in a novel ex-vivo simulation model. Endosc Int Open 2016; 4:E1286-E1291. [PMID: 27995190 PMCID: PMC5161137 DOI: 10.1055/s-0042-118176] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is essential in the management of digestive cancers. However, teaching and learning this technique remain challenging due to the lack of cost-effective models. Material and methods: This was a prospective experimental study using a complete porcine upper gastrointestinal ex-vivo organ package, placed in an Erlangen Active Simulator for Interventional Endoscopy (EASIE-R), and prepared with one cyst and two solid masses (2 cm). Five fellows inexperienced in EUS-FNA were enrolled, performing 10 procedures on each lesion, alternatively. The total time, number of attempts for success, of needle view losses, and of scope handling were recorded, associated with an independent skills rating by procedure. We compared the first 15 procedures with the last 15 for each fellow. Results: The fellows successfully performed all procedures in 2 to 40 minutes, requiring 1 to 6 attempts. All (5/5) improved their total time taken (P < 0.001), number of times when the EUS view of the needle was lost (P < 0.05), scope handling (P < 0.005), and skills rating (P < 0.001), whereas 4/5 (80 %) improved their number of attempts. The overall evaluation showed a significant decrease (P < 0.001) in the total time taken (11.2 ± 7.8 vs 4.3 ± 2.2 minutes), number of attempts (2.6 ± 1.2 vs 1.2 ± 0.7), number of times when the EUS view of the needle was lost (2.3 ± 2 vs 0.5 ± 0.7), and need for scope handling (1.1 ± 1.7 vs 0.1 ± 0.2). We also observed an improvement in skills rating (5 ± 1.9 vs. 7.7 ± 1.1). Conclusion: This newly designed ex-vivo model seems to be an effective way to improve the initial learning of EUS-FNA, by performing 30 procedures.
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Affiliation(s)
- J. M. Gonzalez
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA,Department of Gastroenterology, North
Hospital, Aix-Marseille University, AP-HM, Marseille, France,Corresponding author Jean-Michel
Gonzalez, MD North
HospitalDepartment of
GastroenterologyChemin des
Bourrelys13915MarseilleFrance+33-4-91968737
| | - J. Cohen
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA
| | - M. A. Gromski
- Division of Gastroenterology, Indiana
University School of Medicine, Indianapolis, IN, USA
| | - K. Saito
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA
| | - A. Loundou
- Department of Public Health, Medical
Evaluation, Aix-Marseille University, AP-HM, Marseille,
France
| | - K. Matthes
- Department of Anesthesiology, Kaiser
Permanente Maui Memorial Medical Center, Wailuku, HI, USA
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Dorozhkin D, Nemani A, Roberts K, Ahn W, Halic T, Dargar S, Wang J, Cao CGL, Sankaranarayanan G, De S. Face and content validation of a Virtual Translumenal Endoscopic Surgery Trainer (VTEST™). Surg Endosc 2016; 30:5529-5536. [PMID: 27129546 DOI: 10.1007/s00464-016-4917-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 04/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES) is an emerging surgical paradigm, where peritoneal access is achieved through one of the natural orifices of the body. It is being reported as a safe and feasible surgical technique with significantly reduced external scarring. Virtual Translumenal Endoscopic Surgical Trainer (VTEST™) is the first virtual reality simulator for the NOTES. The VTEST™ simulator was developed to train surgeons in the hybrid transvaginal NOTES cholecystectomy procedure. The initial version of the VTEST™ simulator underwent face validation at the 2013 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) summit. Several areas of improvement were identified as a result, and the corresponding modifications were implemented in the simulator. This manuscript outlines the results of the subsequent evaluation study, performed in order to assess the face and content validity of the latest VTEST™ simulator. METHODS Twelve subjects participated in an institutional review board-approved study that took place at the 2014 NOSCAR summit. Six of the 12 subjects, who are experts with NOTES experience, were used for face and content validation. The subjects performed the hybrid transvaginal NOTES cholecystectomy procedure on VTEST™ that included identifying the Calot's triangle, clipping and cutting the cystic duct/artery, and detaching the gallbladder. The subjects then answered five-point Likert scale feedback questionnaires for face and content validity. RESULTS Overall, subjects rated 12/15 questions as 3.0 or greater (60 %), for face validity questions regarding the realism of the anatomical features, interface, and the tasks. Subjects also highly rated the usefulness of the simulator in learning the fundamental NOTES technical skills (3.50 ± 0.84). Content validity results indicate a high level of usefulness of the VTEST™ for training prior to operating room experience (4.17 ± 0.75).
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Affiliation(s)
- Denis Dorozhkin
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Arun Nemani
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Kurt Roberts
- Gastrointestinal Surgery, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Woojin Ahn
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Tansel Halic
- Computer Science Department, University of Central Arkansas, Conway, AR, USA
| | - Saurabh Dargar
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Jinling Wang
- Biomedical, Industrial and Human Factors Engineering, College of Engineering and Computer Science, Wright State University, Dayton, OH, USA
| | - Caroline G L Cao
- Biomedical, Industrial and Human Factors Engineering, College of Engineering and Computer Science, Wright State University, Dayton, OH, USA
| | - Ganesh Sankaranarayanan
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA
| | - Suvranu De
- Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, 110, 8th Street, Troy, NY, 12180, USA.
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van Doorn SC, Bastiaansen BAJ, Thomas-Gibson S, Fockens P, Dekker E. Polypectomy skills of gastroenterology fellows: can we improve them? Endosc Int Open 2016; 4:E182-9. [PMID: 26878046 PMCID: PMC4751015 DOI: 10.1055/s-0041-109086] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 10/27/2015] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Sascha C. van Doorn
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands ,Corresponding author Sascha van Doorn, MD Department of Gastroenterology and HepatologyAcademic Medical CentreMeibergdreef 91105 AZ AmsterdamThe Netherlands+31-20-691-7033
| | - Barbara A. J. Bastiaansen
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Siwan Thomas-Gibson
- Wolfson Unit for Endoscopy, St. Mark's Hospital and Imperial College London, London, United Kingdom
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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King N, Kunac A, Merchant AM. A Review of Endoscopic Simulation: Current Evidence on Simulators and Curricula. JOURNAL OF SURGICAL EDUCATION 2016; 73:12-23. [PMID: 26699281 DOI: 10.1016/j.jsurg.2015.09.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 08/27/2015] [Accepted: 09/01/2015] [Indexed: 06/05/2023]
Abstract
Upper and lower endoscopy is an important tool that is being utilized more frequently by general surgeons. Training in therapeutic endoscopic techniques has become a mandatory requirement for general surgery residency programs in the United States. The Fundamentals of Endoscopic Surgery has been developed to train and assess competency in these advanced techniques. Simulation has been shown to increase the skill and learning curve of trainees in other surgical disciplines. Several types of endoscopy simulators are commercially available; mechanical trainers, animal based, and virtual reality or computer-based simulators all have their benefits and limitations. However they have all been shown to improve trainee's endoscopic skills. Endoscopic simulators will play a critical role as part of a comprehensive curriculum designed to train the next generation of surgeons. We reviewed recent literature related to the various types of endoscopic simulators and their use in an educational curriculum, and discuss the relevant findings.
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Affiliation(s)
- Neil King
- Division of General Surgery, Department of General Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey
| | - Anastasia Kunac
- Division of Trauma, Department of General Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey
| | - Aziz M Merchant
- Division of General Surgery, Department of General Surgery, New Jersey Medical School, Rutgers Biomedical and Health Sciences, Newark, New Jersey.
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Natural orifice translumenal endoscopic surgery (NOTES): emerging trends and specifications for a virtual simulator. Surg Endosc 2015; 30:190-8. [PMID: 25840893 DOI: 10.1007/s00464-015-4182-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 03/20/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND STUDY AIM A virtual translumenal endoscopic surgical trainer (VTEST) is being developed to accelerate the development of natural orifice translumenal endoscopic surgery (NOTES) procedures and devices in a safe and risk-free environment. For a rapidly developing field such as NOTES, a needs analysis must be conducted regularly to discover emerging research trends and areas of potential high impact for a virtual simulator. This paper presents a survey-based study which follows a similar study conducted by this group in 2011 (Sankaranarayanan et al. in Surg Endosc 27:1607-1616, 2013). METHODS A 32-point questionnaire was distributed at the 2012 Natural Orifice Surgery Consortium for Assessment and Research annual meeting. These data were subsequently augmented by an identical online survey, targeted at the members of the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons, and analyzed. RESULTS Twenty-eight NOTES experts participated in the 2012 study. Cholecystectomy (CE) procedure remained the most commonly performed NOTES technique, with 18 positive responses (64%). In contrast to 2011, the popularity of the NOTES appendectomy (AE) was significantly lower, with only 2 (7%) instances (CE vs. AE, p < 0.001), while the number of peroral endoscopic myotomy (POEM, PE) cases had increased significantly, with 11 (39%) positive responses, respectively (PE vs. AE, p = 0.013). Strong preference toward hybrid rather than pure NOTES techniques (82 vs. 11%, p < 0.001) was also expressed. Other responses were similar to those in the 2011 study, with the VTEST™ utility in developing and testing new techniques and instruments ranked particularly high. CONCLUSION Based on the results of this study, a decision was made to focus exclusively on the transvaginal hybrid NOTES cholecystectomy procedure, including both rigid and flexible scope techniques. The importance of developing a virtual NOTES simulator was reaffirmed, with POEM identified as a promising candidate for future simulator development.
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Abstract
INTRODUCTION Virtual reality simulator and ex vivo animal models are used for training of both basic and advanced endoscopic techniques. The aim of this study was to assess whether hands-on training on ex vivo animal model improves endoscopic skills. Four different endoscopic techniques were practiced: endoscopic resection, endoscopic stenting, application of the over-the-scope (OVESCO) clip, and endoscopic submucosal dissection (ESD). METHODS Except for 2 participants, all trainees participated in a 1-day course. Two remaining participants took part in 7 ESD courses. All training courses consisted of theoretical introduction and a 6-hour training on Erlangen Active Training Simulator. The endoscopic skills were assessed before and after the training session by 2 independent assessors. Each assessor evaluated the skills by using a score on a scale of 1 to 5, where 1 stands for excellent and 5 for insufficient. Each assessor also assessed whether the procedure was successfully completed. The main outcome measurement was the percentage of participants who successfully completed the procedure during the test. RESULTS For endoscopic resection, endoscopists (n = 15) improved their skills (median [10th and 90th percentiles] score before training, 3.5 [2.7-4.2]; after training 1.5 [1-2.3], P < 0.001). Seven procedures were assessed as successful before the course (47%); after the training, 13 procedures were assessed as successful (87%) (P = 0.02). For stenting, participants (n = 15) significantly improved their abilities to place both self-expandible metallic and plastic stents. For OVESCO clip (n = 10), participants (n = 10) improved their skills to prepare and apply the clip (given the score of 4.5 [3.9-5] before and 2.0 [1.2-2.8] after, P < 0.01). Before the training, only 1 clip application had been successful (10%), whereas the number rose to 9 after the course (90%). For endoscopic submucosal dissection (n = 10), eight participants of the 1-day course did not improve their competences (with scores of 4.2 [3.8-5] before and 4.0 [3.1-4.8] after, nonsignificant). Two participants who had undertaken 7 ESD courses improved their skills (with scores of 4 before and 1.6 after); given the small number of participants, this finding is statistically insignificant. LIMITATION The effect of training on clinical outcome was not investigated. There was a lack of pretraining versus posttraining tests blinding. CONCLUSIONS A 1-day training course on ex vivo animal model improves general endoscopic competence on simulator in endoscopic resection, insertion of stents, and application of OVESCO clips. In contrast, 1-day course does not improve skills for ESD that requires a higher number of training courses.
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Singh S, Sedlack RE, Cook DA. Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014; 12:1611-23.e4. [PMID: 24509241 DOI: 10.1016/j.cgh.2014.01.037] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/18/2014] [Accepted: 01/25/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Siddharth Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Robert E Sedlack
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Cook
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; Office of Education Research, Mayo Medical School, Rochester, Minnesota.
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Ansell J, Hurley JJ, Horwood J, Rizan C, Arnaoutakis K, Goddard S, Warren N, Torkington J. The Welsh Institute for Minimal Access Therapy colonoscopy suitcase has construct and concurrent validity for colonoscopic polypectomy skills training: a prospective, cross-sectional study. Gastrointest Endosc 2014; 79:490-7. [PMID: 24210655 DOI: 10.1016/j.gie.2013.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 08/04/2013] [Indexed: 01/06/2023]
Abstract
BACKGROUND The Welsh Institute for Minimal Access Therapy (WIMAT) colonoscopy suitcase is an ex vivo porcine simulator for polypectomy training. OBJECTIVE To establish whether this model has construct and concurrent validity. DESIGN Prospective, cross-sectional study. SETTING Endoscopic training center. PARTICIPANTS Twenty novice (N), 20 intermediate (I), 20 advanced (Ad), and 20 expert (E) colonoscopists. INTERVENTION A simulated polypectomy task aimed at removing 2 polyps; A (simple), B (complex). MAIN OUTCOME MEASUREMENTS Two accredited colonoscopists, blinded to group allocation, scored performances according to Direct Observation of Polypectomy Skills (DOPyS) assessment parameters. Group performances were compared. Real-life DOPyS scores were correlated to simulator DOPyS results. RESULTS Median overall DOPyS scores for novices were 1.00 (1.00-1.87) for A and 0.50 (0.00-1.00) for B (A vs B; P < .01). Intermediates scored 2.50 (2.00-2.88) for A and 2.00 (1.13-2.50) for B (A vs B; P = .03). The advanced group scored 3.00 (2.50-3.50) for A and 2.50 (2.00-3.00) for B (A vs B; P = .01). Experts scored 3.00 (3.00-3.88) for A and 3.00 (2.50-3.50) for B (A vs B; P = .47). Intergroup comparisons for A were, N vs I; P < .01, N vs Ad; P < .01, N vs E; P < .01, I vs Ad; P < .01, I vs E; P < .01, and Ad vs E; P = .46. Intergroup comparisons for B were, N vs I; P < .01, N vs Ad; P < .01, N vs E; P < .01, I vs Ad; P = .03, I vs E; P <.01, and Ad vs E; P = .06. There was no difference between real-life DOPyS scores and simulator scores (0.07). LIMITATIONS The model does not have inbuilt assessment parameters. CONCLUSION This simulator demonstrates construct and concurrent validity for colon polypectomy training.
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Affiliation(s)
- James Ansell
- Welsh Institute for Minimal Access Therapy, Cardiff, Wales, United Kingdom
| | - Joanna J Hurley
- University Hospital Llandough, Cardiff, Wales, United Kingdom
| | | | - Chantelle Rizan
- Cardiff University School of Medicine, Cardiff, Wales, United Kingdom
| | | | - Stuart Goddard
- Welsh Institute for Minimal Access Therapy, Cardiff, Wales, United Kingdom
| | - Neil Warren
- Welsh Institute for Minimal Access Therapy, Cardiff, Wales, United Kingdom
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The effect of virtual endoscopy simulator training on novices: a systematic review. PLoS One 2014; 9:e89224. [PMID: 24586609 PMCID: PMC3931711 DOI: 10.1371/journal.pone.0089224] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 01/17/2014] [Indexed: 12/12/2022] Open
Abstract
Background Advances in virtual endoscopy simulators have paralleled an interest in medical simulation for gastrointestinal endoscopy training. Objective The primary objective was to determine whether the virtual endoscopy simulator training could improve the performance of novices. Design A systematic review. Setting Randomized controlled trials (RCTs) that compared virtual endoscopy simulator training with bedside teaching or any other intervention for novices were collected. Patients Novice endoscopists. Interventions The PRISMA statement was followed during the course of the research. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ScienceDirect were searched (up to July 2013). Data extraction and assessment were independently performed. Main outcome measurements Independent procedure completion, total procedure time and required assistance. Results Fifteen studies (n = 354) were eligible for inclusion: 9 studies designed for colonoscopy training, 6 for gastroscopy training. For gastroscopy training, procedure completed independently was reported in 87.7% of participants in simulator training group compared to 70.0% of participants in control group (1 study; 22 participants; RR 1.25; 95% CI 1.13–1.39; P<0.0001). For colonoscopy training, procedure completed independently was reported in 89.3% of participants in simulator training group compared to 88.9% of participants in control group (7 study; 163 participants; RR 1.10; 95% CI 0.88–1.37; P = 0.41; I2 = 85%). Limitations The included studies are quite in-homogeneous with respect to training schedule and procedure. Conclusions Virtual endoscopy simulator training might be effective for gastroscopy, but so far no data is available to support this for colonoscopy.
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Challenges in meeting fellowship procedural guidelines in pediatric therapeutic endoscopy and liver biopsy. J Pediatr Gastroenterol Nutr 2014; 58:27-33. [PMID: 24051484 DOI: 10.1097/mpg.0000000000000184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aims of this study were to assess the opportunities for therapeutic endoscopy, liver biopsies, and percutaneous endoscopic gastrostomy (PEG) placements available to fellows during a 3-year pediatric gastroenterology fellowship, and to evaluate access to ancillary procedural-training opportunities. METHODS Data were collected from 12 pediatric gastroenterology fellowship programs in the United States. Procedures completed in the years 2009-2011 were queried using CPT codes and endoscopy databases. The maximal opportunity for procedures was based on the total procedures performed by the institution in 3 years divided by the total number of fellows in the program. The centers completed a questionnaire regarding ancillary opportunities for endoscopic training. RESULTS There is significant variability in pediatric endoscopic training opportunities in specialized gastrointestinal (GI) procedures. Under the 1999 guidelines, no centers were able to meet the thresholds for polypectomy and control of nonvariceal bleeding. The 2013 guidelines allowed the number of programs reaching polypectomy thresholds to increase by 67% but made no difference for control of bleeding despite a decrease in the threshold. Training in PEG placement was not available in 42% of the surveyed centers. Elective ancillary procedural training is offered by 92% of the surveyed centers. CONCLUSIONS Most training programs do not have the volume of therapeutic endoscopy procedures for all of the fellows to meet the training guidelines. Training in therapeutic endoscopy, PEG placement, and liver biopsy in pediatric GI fellowships should be supplemented using all of the possible options including rotations with adult GI providers and hands-on endoscopy courses. A shift toward evaluating competency via quality measures may be more appropriate.
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Abstract
OBJECTIVES Evaluating the patient impact of health professions education is a societal priority with many challenges. Researchers would benefit from a summary of topics studied and potential methodological problems. We sought to summarize key information on patient outcomes identified in a comprehensive systematic review of simulation-based instruction. DATA SOURCES Systematic search of MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, key journals, and bibliographies of previous reviews through May 2011. STUDY ELIGIBILITY Original research in any language measuring the direct effects on patients of simulation-based instruction for health professionals, in comparison with no intervention or other instruction. APPRAISAL AND SYNTHESIS Two reviewers independently abstracted information on learners, topics, study quality including unit of analysis, and validity evidence. We pooled outcomes using random effects. RESULTS From 10,903 articles screened, we identified 50 studies reporting patient outcomes for at least 3,221 trainees and 16,742 patients. Clinical topics included airway management (14 studies), gastrointestinal endoscopy (12), and central venous catheter insertion (8). There were 31 studies involving postgraduate physicians and seven studies each involving practicing physicians, nurses, and emergency medicine technicians. Fourteen studies (28 %) used an appropriate unit of analysis. Measurement validity was supported in seven studies reporting content evidence, three reporting internal structure, and three reporting relations with other variables. The pooled Hedges' g effect size for 33 comparisons with no intervention was 0.47 (95 % confidence interval [CI], 0.31-0.63); and for nine comparisons with non-simulation instruction, it was 0.36 (95 % CI, -0.06 to 0.78). LIMITATIONS Focused field in education; high inconsistency (I(2) > 50 % in most analyses). CONCLUSIONS Simulation-based education was associated with small-moderate patient benefits in comparison with no intervention and non-simulation instruction, although the latter did not reach statistical significance. Unit of analysis errors were common, and validity evidence was infrequently reported.
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Abstract
Over the past decade, the capabilities and use of endoscopic simulators have steadily expanded. Nevertheless, simulator use has yet to become fully integrated into standard endoscopic training programs. There are two obstacles. First, we lack adequate knowledge about how competency should be defined and how people become proficient in various specific techniques. Second, there has not been an affordable and convenient model to effectively assist in training and assessment. This paper explores the barriers to incorporation of simulators in training programs, and discusses currently available mechanical, computer, and ex vivo tissue models for assessment.
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Itoi T, Gotoda T, Baron TH, Sofuni A, Itokawa F, Tsuji S, Tsuchiya T, Tanaka R, Tonozuka R, Honjo M, Ryozawa S, Kawai T, Moriyasu F, Isayama H. Creation of simulated papillae for endoscopic sphincterotomy and papillectomy training by using in vivo and ex vivo pig model (with videos). Gastrointest Endosc 2013; 77:793-800. [PMID: 23453186 DOI: 10.1016/j.gie.2012.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are few in vivo and ex vivo models for training in endoscopic sphincterotomy (ES) and endoscopic papillectomy (EP). OBJECTIVE We describe in vivo and ex vivo training pig models that use a simulated papilla for hands-on teaching of ES and EP. DESIGN Animal experiment. SETTING A referral center. MATERIALS AND INTERVENTIONS Hyaluronate solution (0.4%) was injected submucosally using a 25-gauge sclerotherapy needle to create a submucosal bleb by using porcine in vivo stomach, ex vivo stomach, and ex vivo rectum. ES and EP were then performed by using a pull-type sphincterotome and snare, respectively. MAIN OUTCOME MEASUREMENT The feasibility of creating a simulated papilla for ES and EP procedures was tested by experienced and nonexperienced ERCP endoscopists. RESULTS Creation of a hemispheroidal bulge was successful in 13 of 17 (76%) areas within an in vivo stomach, 13 of 16 (81%) areas of an ex vivo stomach, and 16 of 16 (100%) areas in an ex vivo rectum. In the in vivo stomach model, ES was successfully and realistically performed on the anterior wall of the stomach rather than in other walls. In the ex vivo stomach model, endoscopists experienced in ERCP and trainees performed ES without difficulty, whereas it was difficult or impossible for nonexperienced trainees to perform ES. In the ex vivo rectum model, all 3 endoscopists were able to complete not only ES but also EP. LIMITATIONS Pilot study. CONCLUSIONS Although further studies are necessary to evaluate the reproducibility and cost-effectiveness, this novel pig model appears useful for ES and EP training.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Sedlack RE. The state of simulation in endoscopy education: continuing to advance toward our goals. Gastroenterology 2013; 144:9-12. [PMID: 23149221 DOI: 10.1053/j.gastro.2012.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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McConnell RA, Kim S, Ahmad NA, Falk GW, Forde KA, Ginsberg GG, Jaffe DL, Makar GA, Long WB, Panganamamula KV, Kochman ML. Poor discriminatory function for endoscopic skills on a computer-based simulator. Gastrointest Endosc 2012; 76:993-1002. [PMID: 22968094 DOI: 10.1016/j.gie.2012.07.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 07/12/2012] [Indexed: 01/06/2023]
Abstract
BACKGROUND Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes. OBJECTIVE To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills. DESIGN Prospective, observational, non-randomized, parallel cohort study. SETTING Single academic center with accredited gastroenterology training program. PARTICIPANTS Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians. INTERVENTION Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys. MAIN OUTCOME MEASUREMENTS The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed. RESULTS Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy. LIMITATIONS Small sample size. CONCLUSION The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.
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Affiliation(s)
- Ryan A McConnell
- Department of Medicine, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Incorporating simulation into the GI curriculum: the time is now. Gastrointest Endosc 2012; 76:622-4. [PMID: 22898419 DOI: 10.1016/j.gie.2012.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 05/17/2012] [Indexed: 01/06/2023]
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Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) on the use of endoscopy simulators for training and assessing skill. Gastrointest Endosc 2012; 76:471-5. [PMID: 22809879 DOI: 10.1016/j.gie.2012.03.248] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/15/2012] [Indexed: 02/08/2023]
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Walsh CM, Sherlock ME, Ling SC, Carnahan H. Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev 2012:CD008237. [PMID: 22696375 DOI: 10.1002/14651858.cd008237.pub2] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Traditionally, training in gastrointestinal endoscopy has been based upon an apprenticeship model, with novice endoscopists learning basic skills under the supervision of experienced preceptors in the clinical setting. Over the last two decades, however, the growing awareness of the need for patient safety has brought the issue of simulation-based training to the forefront. While the use of simulation-based training may have important educational and societal advantages, the effectiveness of virtual reality gastrointestinal endoscopy simulators has yet to be clearly demonstrated. OBJECTIVES To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. SEARCH METHODS Health professions, educational and computer databases were searched until November 2011 including The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Scopus, Web of Science, Biosis Previews, CINAHL, Allied and Complementary Medicine Database, ERIC, Education Full Text, CBCA Education, Career and Technical Education @ Scholars Portal, Education Abstracts @ Scholars Portal, Expanded Academic ASAP @ Scholars Portal, ACM Digital Library, IEEE Xplore, Abstracts in New Technologies and Engineering and Computer & Information Systems Abstracts. The grey literature until November 2011 was also searched. SELECTION CRITERIA Randomised and quasi-randomised clinical trials comparing virtual reality endoscopy (oesophagogastroduodenoscopy, colonoscopy and sigmoidoscopy) simulation training versus any other method of endoscopy training including conventional patient-based training, in-job training, training using another form of endoscopy simulation (e.g. low-fidelity simulator), or no training (however defined by authors) were included. Trials comparing one method of virtual reality training versus another method of virtual reality training (e.g. comparison of two different virtual reality simulators) were also included. Only trials measuring outcomes on humans in the clinical setting (as opposed to animals or simulators) were included. DATA COLLECTION AND ANALYSIS Two authors (CMS, MES) independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. Due to significant clinical and methodological heterogeneity it was not possible to pool study data in order to perform a meta-analysis. Where data were available for each continuous outcome we calculated standardized mean difference with 95% confidence intervals based on intention-to-treat analysis. Where data were available for dichotomous outcomes we calculated relative risk with 95% confidence intervals based on intention-to-treat-analysis. MAIN RESULTS Thirteen trials, with 278 participants, met the inclusion criteria. Four trials compared simulation-based training with conventional patient-based endoscopy training (apprenticeship model) whereas nine trials compared simulation-based training with no training. Only three trials were at low risk of bias. Simulation-based training, as compared with no training, generally appears to provide participants with some advantage over their untrained peers as measured by composite score of competency, independent procedure completion, performance time, independent insertion depth, overall rating of performance or competency error rate and mucosal visualization. Alternatively, there was no conclusive evidence that simulation-based training was superior to conventional patient-based training, although data were limited. AUTHORS' CONCLUSIONS The results of this systematic review indicate that virtual reality endoscopy training can be used to effectively supplement early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. However, there remains insufficient evidence to advise for or against the use of virtual reality simulation-based training as a replacement for early conventional endoscopy training (apprenticeship model) for health professions trainees with limited or no prior endoscopic experience. There is a great need for the development of a reliable and valid measure of endoscopic performance prior to the completion of further randomised clinical trials with high methodological quality.
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Affiliation(s)
- Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada.
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Nicolás-Pérez D. [Endoscopic submucosal dissection: only for expert endoscopists?]. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:344-67. [PMID: 22341600 DOI: 10.1016/j.gastrohep.2011.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Accepted: 12/29/2011] [Indexed: 12/16/2022]
Abstract
Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.
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Affiliation(s)
- David Nicolás-Pérez
- Servicio de Aparato Digestivo, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain.
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Ende A, Zopf Y, Konturek P, Naegel A, Hahn EG, Matthes K, Maiss J. Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial. Gastrointest Endosc 2012; 75:254-60. [PMID: 22153875 DOI: 10.1016/j.gie.2011.07.063] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 07/29/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking. OBJECTIVE Development of a training strategy for diagnostic upper endoscopy. STUDY DESIGN Prospective, randomized trial. SETTINGS A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed following a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators. MAIN OUTCOME MEASUREMENTS Time to reach the duodenum, pylorus, or esophagus. RESULTS All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different. LIMITATIONS Small sample size. CONCLUSIONS Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.
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Affiliation(s)
- Anke Ende
- Department of Medicine, University of Erlangen-Nuremberg, Erlangen, Germany
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Aslanian HR. Ain't nothing like the real thing? Simulators in endoscopy training. Gastrointest Endosc 2012; 75:261-2. [PMID: 22248596 DOI: 10.1016/j.gie.2011.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 09/14/2011] [Indexed: 02/08/2023]
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Kato M, Jung Y, Gromski MA, Chuttani R, Matthes K. Prospective, randomized comparison of 3 different hemoclips for the treatment of acute upper GI hemorrhage in an established experimental setting. Gastrointest Endosc 2012; 75:3-10. [PMID: 22196807 DOI: 10.1016/j.gie.2011.11.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 11/03/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recently, endoscopic clip application devices have undergone redesign and improvements to optimize their clinical use and effectiveness. Initially designed for the treatment of bleeding nonvariceal lesions, these devices are also increasingly used for the closure of perforations, fistulas, and anastomotic leaks. Several clinical studies, both randomized and nonrandomized, have used endoscopic hemoclips for hemostasis. However, no comparative studies have yet been reported in the literature comparing the latest endoscopic clip devices for usability and effectiveness for hemostasis of acute upper GI hemorrhage. OBJECTIVE We aimed to compare the usability and efficacy of 3 different types of endoscopic clip application devices in an established experimental setting by using a porcine ex-vivo simulator of upper GI hemorrhage. DESIGN Randomized, controlled, ex-vivo study. SETTING Academic medical center. METHODS Spurting vessels were created within ex-vivo porcine stomachs as published in prior studies. The vessels were attached to a pressure transducer to record the pressure of the circulating blood replacement. Before the initiation of bleeding, each vessel was randomized to 1 of 3 endoscopic clipping devices: 2 different commonly used hemoclips deployed through the working channel and 1 novel clip deployed via an over-the-scope applications device. Two investigators treated 45 bleeding sites (15 bleeding sites for each device at various randomized locations in the stomach: fundus, body, and antrum). MAIN OUTCOME MEASUREMENTS Usability was measured via the endpoints of procedure time and quantity of clips required to achieve hemostasis. Efficacy was measured via the endpoint of pressure increase (Δp) from baseline to after treatment. RESULTS All of the 45 hemostasis treatments were carried out successfully. The mean procedure times were significantly different among the hemoclips, with the clip deployed in an over-the-scope fashion requiring significantly less time to attain hemostasis compared with the other 2 clips. For number of clips needed to attain hemostasis, the clip deployed in an over-the-scope fashion was significantly superior to the others. There were also significant differences among the changes in pressure (Δp ± SD) among the different hemoclips tested. LIMITATIONS Ex-vivo study. CONCLUSIONS In this prospective, randomized ex-vivo study, we observed significant differences in the usability (time to achieve hemostasis and number of clips required) and the efficacy (change in pressure achieved by the hemoclips) among the 3 clips. The clip applied in the over-the-scope fashion was superior to the other 2 tested clips with regard to time to achieve hemostasis and number of clips required.
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Affiliation(s)
- Masayuki Kato
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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