The utility of intraoperative endoscopy in esophagogastric surgery

Flexible endoscopy (FE) plays a major role in the diagnosis and treatment of gastrointestinal disease. Although its intraoperative use has spread over the years, its use by surgeons is still limited in our setting. FE training opportunities are different among many institutions, specialties, and countries. Intraoperative endoscopy (IOE) presents peculiarities that increase its complexity compared to standard FE. IOE has a positive impact on surgical results, due to increased safety and quality, as well as a reduction in the complications. Due to its innumerable advantages, its intraoperative use by surgeons is currently a current project in many countries and is part of the near future in others because of the creation of better structured training projects. This manuscript reviews and updates the indications and uses of intraoperative upper gastrointestinal endoscopy in esophagogastric surgery.

EndoTrainer: a novel hybrid training platform for endoscopic surgery

PURPOSE

Endoscopy implies high demanding procedures, and their practice requires structured formation curricula supported by adequate training platforms. Physical platforms are the most standardised solution for surgical training, but over the last few years, virtual platforms have been progressively introduced. This research work presents a new hybrid, physic-virtual, endoscopic training platform that exploits the benefits of the two kind of platforms combining realistic tools and phantoms together with the capacity of measuring all relevant parameters along the execution of the exercises and of providing an objective assessment performance.

METHODS

The developed platform, EndoTrainer, has been designed to train and assess surgical skills in hysteroscopy and cystoscopy following a structured curricula. The initial development and validation is focused on hysteroscopic exercises proposed in the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) Certification Programme from The Academy and European Society for Gynaecological Endoscopy (ESGE) and analyses the obtained results of an extensive study with 80 gynaecologists executing 30 trials of the standard 30 degree endoscope navigation exercise.

RESULTS

The experiments demonstrate the benefits of the presented hybrid platform. Multi-variable statistical analysis points out that all subjects have obtained statistically significant improvement in all relevant parameters: shorter and safer trajectories, improved 30-degree endoscope navigation, accurate positioning over the targets and reduction of the execution time.

CONCLUSION

This paper presents a new hybrid approach for training, and evaluating whether it provides an objectivable improvement of camera navigation endoscopic basic skills. The obtained results demonstrate the initial hypothesis: all subjects have improved their camera handling and navigation skills.

A system for real-time multivariate feature combination of endoscopic mitral valve simulator training data

Purpose

For an in-depth analysis of the learning benefits that a stereoscopic view presents during endoscopic training, surgeons required a custom surgical evaluation system enabling simulator independent evaluation of endoscopic skills. Automated surgical skill assessment is in dire need since supervised training sessions and video analysis of recorded endoscope data are very time-consuming. This paper presents a first step towards a multimodal training evaluation system, which is not restricted to certain training setups and fixed evaluation metrics.

Methods

With our system we performed data fusion of motion and muscle-action measurements during multiple endoscopic exercises. The exercises were performed by medical experts with different surgical skill levels, using either two or three-dimensional endoscopic imaging. Based on the multi-modal measurements, training features were calculated and their significance assessed by distance and variance analysis. Finally, the features were used automatic classification of the used endoscope modes.

Results

During the study, 324 datasets from 12 participating volunteers were recorded, consisting of spatial information from the participants’ joint and right forearm electromyographic information. Feature significance analysis showed distinctive significance differences, with amplitude-related muscle information and velocity information from hand and wrist being among the most significant ones. The analyzed and generated classification models exceeded a correct prediction rate of used endoscope type accuracy rate of 90%.

Conclusion

The results support the validity of our setup and feature calculation, while their analysis shows significant distinctions and can be used to identify the used endoscopic view mode, something not apparent when analyzing time tables of each exercise attempt. The presented work is therefore a first step toward future developments, with which multivariate feature vectors can be classified automatically in real-time to evaluate endoscopic training and track learning progress.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11548-022-02588-1.

Endoscopic training during fellowship: A nationwide French study: Impact of theoretical courses and simulation-based training during fellowship

BACKGROUND

In France, it is mandatory that gastroenterology fellows have mastered the basic level of endoscopy by the end of training. The aim of this study was to assess improvement in the quality of fellows' endoscopy training in France during the last four years.

METHODS

All fellows in France in training were eligible for participation. A 21-item questionnaire was sent out. The primary outcome was the completion by fourth year fellows of all the number of procedures recommended. Results were compared with those of a 2016 survey.

RESULTS

Two-hundred-and-sixty-five fellows responded to the survey. The participation rate was 47.0%. The mean age was 27.3 ± 1.0 years and 56.4% were female. Access to theoretical courses (63.7% vs. 30.6%, p < 0.001) and simulation-based training (virtual reality simulator: 58.4% vs. 28.2%, p < 0.001, animal models: 29.4% vs. 17.2%, p < 0.001) was significantly higher in 2020. Although the number of procedures did not increase, significantly higher perception of skill acquisition in colonoscopy as well as diminished pressure to advance procedures were noted.

CONCLUSION

Access to theoretical courses and simulation-based training and perceived acquisition of numerous skills has gotten better. However, the quality of training in endoscopy still needs improvement.

Endoscopic part-task training box scores correlate with endoscopic outcomes

BACKGROUND

Competency in endoscopy has traditionally been based on number of procedures performed. With movement towards milestone-based accreditation, new standards of establishing competency are required. The Thompson Endoscopic Skills Trainer (TEST) is a training device previously shown to differentiate between novice and expert endoscopists. This study aims to correlate TEST scores to other markers of performance in endoscopy.

METHODS

Trainees of a gastroenterology fellowship program were guided through the TEST. Their scores and sub-scores were correlated to their endoscopic metrics of performance, including adenoma detection rate, cecal intubation rate, cecal intubation time, withdrawal time, fentanyl usage, midazolam usage, pain score, overall procedure time, and performance on the ASGE Assessment of Competency in Endoscopy Tool (ACE Tool).

RESULTS

The Overall Score positively correlated with the ACE Tool Total Score (r = 0.707, p = 0.010) and sub-scores (Cognitive Skills Score: r = 0.624, p = 0.030; Motor Skills Score: r = 0.756, p = 0.004), and negatively correlated with cecal intubation time (r = - 0.591, p = 0.043). The Gross Motor Score positively correlated with cecal intubation rate (r = 0.593, p = 0.042), ACE Tool Total Score (r = 0.594, p = 0.042) and Motor Skills Score (r = 0.623, p = 0.031), and negatively correlated with cecal intubation time (r = - 0.695, p = 0.012). The Fine Motor Score positively correlated with the ACE Tool Polypectomy Score (r = 0.601, p = 0.039), and negatively correlated with procedure time (r = - 0.640, p = 0.025), cecal intubation time (r = - 0.645, p = 0.024), and withdrawal time (r = - 0.629, p = 0.028).

CONCLUSION

This study demonstrates that performance on the TEST correlate to endoscopic measures. Given these results, the TEST may be used in conjunction with existing assessment tools for demonstrating competency in endoscopy.

Development of a Technical Skills Test to Improve Assessment and Evaluation in Neuroendoscopic Education

BACKGROUND

Endoscopy requires a unique set of skills that are difficult to acquire in most training programs. A method to test technical skills, in a validated manner, has rarely been attempted. The purpose of this study was to develop a technical skills examination for objective assessment in neuroendoscopic education.

METHODS

Twenty-nine participants were included for analysis and divided by seniority level into 2 groups defined as before or upon postgraduation year (PGY) 5 (n = 18, junior surgeons) or after PGY5 (n = 11, senior surgeons). Study participants were assessed for baseline performance and then again following a 4-hour neuroendoscopy course. Wilcoxon test was used to evaluate for performance differences between cohorts. Correlation analyses were performed using the Pearson or Spearman coefficient.

RESULTS

Increasing PGY level was correlated with a decreased average time to complete all 3 tasks (r = -0.44, P = 0.03) at baseline. Overall performance improved in both cohorts following the course (P < 0.001). When comparing junior surgeons after endoscopy training (posttest) to senior surgeons at their baseline (pretest), the junior surgeons were faster after endoscopic training than the senior surgeons were before training (P < 0.001).

CONCLUSIONS

A neuroendoscopic skills test can distinguish between more or less experienced surgeons. Significant overall performance improvement, regardless of seniority level, following neuroendoscopic training demonstrates the accuracy of the test at detecting operating improvement in all stages of learning.

How We Do It: Creation of a Low-Cost Endoscopic Skills Model for Fundamentals of Endoscopic Surgery Training

OBJECTIVE

To design a low cost, high fidelity endoscopic skills model to help surgical trainees pass the Fundamentals of Endoscopic Surgery (FES) testing.

DESIGN

A homemade synthetic colon model was designed using liquid silicon and other commercially available products. The construction and design of the model is described here. The model was then successfully integrated into our simulation curriculum and endoscopic skills training modules.

SETTING

Cleveland Clinic Foundation, Cleveland, Ohio; large academic quaternary referral institution.

PARTICIPANTS

PGY 1-5 general surgery residents preparing for Fundamentals of Endoscopic Surgery testing.

RESULTS

A versatile, high fidelity model was designed for a total cost of approximately 25 dollars per unit. The model can be used with clinical endoscopic towers and easily integrated into an institution's simulation and endoscopic training curriculum. The flexibility of design allows trainees to practice all of the key motor skills necessary for FES examination success.

CONCLUSIONS

A homemade endoscopic colon model can be constructed at an affordable price point using commercially available materials. These models have significant versatility, low cost, and flexibility of design allowing for easy incorporation into a surgical residency simulation training program.

A task and performance analysis of endoscopic submucosal dissection (ESD) surgery

BACKGROUND

ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries.

METHODS

We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons.

RESULTS

The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores.

CONCLUSIONS

We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.

Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: An analysis of the national inpatient sample. Surg Endosc. 2017;31:2953-2958. [PMID: 27815746 DOI: 10.1007/s00464-016-5312-0]

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic procedure performed by both gastroenterologists and surgeons. There has been recent controversy regarding training paradigms for gastrointestinal endoscopy. No prior studies have evaluated comparative outcomes for ERCP in relation to specialty training background. This study utilized the National Inpatient Sample (NIS) to assess ERCP outcomes as a function of training background, practice pattern, and individual provider volume.

METHODS

NIS data was queried from 2007 to 2009. Gastroenterologists and surgeons were identified by procedural profiles and unique physician identifiers. Comorbidity was assessed via Charlson Score. Outcomes including cost, length of stay (LOS), and mortality were analyzed, with and without propensity score matching (PSM). Analysis of outcomes as a function of provider procedural volume was also performed. Comparison for statistical significance was accomplished via t test.

RESULTS

A total of 110,811 ERCP's were identified, of which 42,025 (37.9%) were performed by surgeons. Surgeons exhibited longer LOS (8.7 vs. 7.2 days), overall cost ($24,739 vs. $16,960), and mortality (3.9 vs. 1.2%, odds ratio 3.3), with p < 0.001 for all measures. 71.6% of surgical patients, versus 19.6% of gastroenterologic, underwent subsequent inpatient laparoscopic cholecystectomy or laparotomy. Outcome differences persisted when PSM included performance of subsequent laparoscopic cholecystectomy. Evaluation of minimum performance standards revealed up to a fivefold increased mortality for providers who performed less than 5 ERCP's/year, irrespective of specialty background.

CONCLUSIONS

Gastroenterologists demonstrate favorable gross outcomes compared to surgeons performing ERCP. Differences may correlate in part with more frequent subsequent surgical management of comorbid conditions by surgical providers. Lower volume providers achieve inferior outcomes regardless of specialty background. Analyses of this type may help inform discussions on optimal training and proficiency paradigms, including maintenance of proficiency, for therapeutic endoscopic procedures.

ESD around the world: United States

Endoscopic submucosal dissection (ESD) is a well-established advanced mucosal resection technique used in Japan, where it originated, and some other Asian countries. The technical difficulty and potentially higher rates of significant complications have been obstacles for its dissemination across the United States, on top of the lack of available equipment, candidate lesions in the gastrointestinal tract, and adequate training programs. Yet American physicians are becoming increasingly aware of the benefits of ESD. Simplification of technique, modification of tools and materials, and improved availability of training opportunities are essential in order to accelerate the adoption of ESD in the United States.

Training and teaching innovations in colonoscopy

Optimization of training and teaching methods in colonoscopy at all levels of experience is critical to ensure consistent high-quality procedures in practice. Competency in colonoscopy may not be achieved until more than 250 colonoscopies are performed by trainees. Such tools as computer-based endoscopic simulators can aid in accelerating the early phases of training in colonoscopy, and magnetic endoscopic imaging technology can guide the position of the colonoscope and aid with loop reduction. Periodic feedback and retraining experienced endoscopists can improve the detection of colonic lesions.