Gastroenterological Endoscopy. Группа авторов

      In a randomized controlled multicenter trial of 45 first-year GI fellows in New York comparing 10 independent hours of work on the Simbionix GI Mentor II versus no simulator training, trainees who worked on the simulator had significantly better objective technical and cognitive performance on their first 20 to 80 real supervised colonoscopy examinations but no difference in the time required to achieve competency nor in subjective proctor assessment of patient discomfort. These studies suggest that virtual reality simulator training prior to real cases accelerates early training, but improvement in final competency has not yet been established. Nor has there been any computer-based skills test that has been correlated with competent performance on actual endoscopic procedures.

      1.4.3 Training Courses with Live Animals

      Animal models offer a realistic learning environment; however, a substantial organizational, technical, and financial effort is required. Ethical considerations, animal welfare, and problems of hygiene, along with the need for dedicated endoscopes for animal use and substantial staff and financial expenditure, are major restrictions. Currently, training courses on live animals are performed for many different techniques including endoscopic submucosal dissection and peroral endoscopic myotomy.^36,37

      1.4.4 Ex Vivo Porcine Tissue Models (EASIE, Erlanger Endo-Trainer, EASIE-R)

      Clean pig stomachs with a dedicated mold have been used for training in diagnostic gastroscopy for many years.¹ As in the pulsatile organ perfusion simulator described by Szinicz et al,⁴⁰ a roller pump can be used to simulate spurting arterial bleeding in hollow GI viscera.

      The “compactEASIE” device is a simplified version of the original biosimulation model and was developed in 1998 (

Fig. 1.10a-c). For ERCP interventions such as sphincterotomy and stent placement the hepatobiliary system with the liver, extrahepatic bile ducts, and gallbladder is dissected and added to the upper GI tract. Bile duct stones can be simulated by inserting pieces of plastic stents into the bile duct. Matthes and Cohen have reported an interesting model called the “neopapilla.”⁴¹

      Fig. 1.9 A computer simulation model for gastroscopy and colonoscopy skills (Image is provided courtesy of Medical-X BV, EM Rotterdam, the Netherlands).

      Fig. 1.10 (a) The compactEASIE model for hands-on training using specially prepared pig organs. (b) A roller pump drives artificial blood into vessels that have been sutured into a pig stomach, to provide training in hemostasis procedures in realistic conditions. (c) Practicing hemoclipping with the compactEASIE simulator.

      Training in more than 30 interventional endoscopic techniques can be provided (

Table 1.2). It is generally recommended to use special animal endoscopes for the training with isolated (“ex vivo”) pig organs. Sedlack et al⁴² compared computer simulator, harvested porcine organ, and live anesthetized pigs for ERCP training. The authors concluded the harvested porcine organ model to be the most realistic model for instruction in both basic and advanced ERCPs.

      1.4.5 Training Courses

      Ways of Integrating Educational Material, Demonstration, Practice, Feedback, and Evaluation into a Comprehensive Workshop

      Regular training workshops on endoscopic hemostasis using the compactEASIE simulator have been available since 1997. EASIE team training comprises the simultaneous training of doctors and nurses in different interventional endoscopic techniques using this type of simulator and was first described in detail in 2001.¹

      Basic skills. To assess an individual’s capacity for brain–hand coordination, a practical simulator test for manual skills was developed. For this hand–eye dexterity test performed before the training course, four 2- to 3-mm dots are created on the anterior wall of the ex vivo porcine simulator using a thermal device. The dots are arranged in the form of a square standing on one corner, with a diagonal length of 2 cm. Precision in the brain–hand coordination test can be evaluated by asking the trainee to touch each mark with the probe in a clockwise fashion. The time needed to complete the task is also measured. In this exercise, precision is weighted more heavily than speed.

      Studies on training using ex vivo simulators (e.g., compactEASIE) for fellows and the EASIE team-training method

      Since the introduction of the EASIE simulator, considerable efforts have been made to assess the value of additional simulator training using the EASIE model in endoscopic hemostasis. Several prospective trials have been conducted in recent years to provide objective evidence that participants benefit from simulator training. A prospective randomized study conducted in collaboration with the New York Society for Gastrointestinal Endoscopy (NSYGE) was undertaken.⁶ The results provided the first evidence of benefit from simulator training in the treatment of upper GI bleeding. In this prospective training project, 37 gastroenterology fellows from nine hospitals in New York were first evaluated in five endoscopic techniques using the compactEASIE simulator. These included manual skills, ulcer hemostasis using injection, a coagulation probe and hemoclipping, as well as variceal band ligation. Twenty-eight fellows with comparable skills were then randomly assigned either to an intensive training group attending three 1-day simulator hands-on workshops over a period of 7 months or to a control group only receiving traditional clinical training in endoscopy in their home hospitals (

Fig. 1.11). During the 7-month study period, it was demonstrated that the additional simulator training in four endoscopic hemostasis techniques significantly enhanced the participants’ skills in comparison with the fellows who only received a clinical training. In particular, the evaluation of clinical cases following the training period showed a higher initial hemostasis rate and a lower complication rate among simulator-trained fellows, although the difference in the complication rate was not significant. These results were confirmed in a national training project conducted in France on training in endoscopic hemostasis that started 1 year later, with a similar study design.⁴³ The efficacy of the EASIE simulator was also confirmed in another project including novice endoscopists, in which remarkable levels of skill in hemostatic techniques were achieved using intensified simulator training every second week.⁷

Table 1.2 Selection of endoscopic interventions for which training can be carried out using the compactEASIE simulator

Training goal	Technique
Ulcer hemostasis	Injection techniques
	Thermal probes
	Clip application
	Over-the-scope-clip (OTSC)
	others
Variceal treatment	Multiple band ligationCyanoacrylate glue injection
	Sclerotherapy
Tissue resection techniques	Snare polypectomy, loop applicationSaline-assisted polypectomy/endoscopic mucosal resection (EMR) including piecemeal EMR, capEMR, “band and snare” techniqueEndoscopic submucosal dissection (ESD)Full-thickness resection (FTRD)Rotablation of tissue
Tissue coagulation and cryoablation	Argon plasma coagulation (APC)Radiofrequency ablation (RFA)Cryoablation, etc.
Stricture management and stenting	Balloon dilation, bougienageStenting: esophageal, gastro-duodenal, enteral, colonic
ERCP	Cannulation techniques, sphincterotomy and precut techniques, (Over)Guidewire