Faculty Bibliography

This article focuses on potential complications of standard upper and lower endoscopic procedures. Adverse events associated with endoscopic retrograde cholangiopancreatography, EUS, and certain advanced therapeutic techniques such as mucosal resection are not covered. Rather, the article focuses on the recognition of preprocedure risk factors for various complications and the diagnosis and management for procedure-related adverse events.

Training in colonoscopy occurs in the traditional mentoring method, wherein trainees are exposed to procedures under the guidance of an experienced teacher. This teaching experience is unstructured and dictated by the random admission of patients rather than a consistent exposure to fundamental medical problems in an organized programmatic fashion. Evidence shows that a higher incidence of complications is observed in procedures performed by trainees in comparison to experienced endoscopists. Colonoscopy simulator training is without the involvement of patient risk and might lead to improved quality of patient care without any additional risk. Virtual reality simulators provide the ability of feedback of patient discomfort and could increase the awareness of trainees causing discomfort. This increased vigilance could potentially lead to a decreased rate of colon perforation. Training on ex-vivo simulators may lead to better performance of interventional procedures, such as polypectomy and endoscopic mucosal resection, with the possibility of decreasing the incidence of intraoperative and postoperative bleeding. Data shows that with the use of structured simulator training with ample feedback from tutors, fellows advance faster to more proficient skill levels. Reaching a more advanced level of expertise by simulator training in the early phase of training could potentially lead to increased patient comfort and thus less requirement of sedation, which has been shown to decrease the rate of unexpected cardiopulmonary events. However, clinical evidence of simulator training in colonoscopy in reducing procedure-related complications is currently not available and subject to further investigation. Given the low rate of complications associated with colonoscopy, studies to provide this evidence may be difficult to conduct

BACKGROUND: Computer simulators, live pigs, and ex vivo porcine simulators are used for training in ERCP. The location of the porcine biliary orifice in the proximal duodenum is dissimilar to human anatomy, making the endoscopy experience less realistic. In addition, in native porcine anatomy, the pancreatic duct enters the duodenum distal to the biliary orifice, limiting the teaching of pancreatic techniques and selective duct cannulation. OBJECTIVE: To overcome these limitations, we aimed to construct a Neo-Papilla that could be incorporated into an ex vivo model. DESIGN: We attached chicken heart tissue to the porcine duodenum, with integrated porcine arteries that resembled an artificial common bile duct and a pancreatic duct. SETTING: The simulator was presented and evaluated at 2 major GI endoscopy conferences. MAIN OUTCOME MEASUREMENTS: The feasibility and the realism of this prototype was tested by 9 recognized ERCP experts who rated this model in comparison to other teaching models for ERCP by recollection of prior experience. RESULTS: The Neo-Papilla was more prominent and more distally located than the native porcine papilla. The experts rated this modification superior to existing models in its usefulness as an educational tool. LIMITATIONS: Pilot study. CONCLUSIONS: We demonstrated the technical feasibility of a real-tissue Neo-Papilla modification of porcine ex vivo simulators, more closely approximating the natural anatomy. This new model should facilitate ERCP training. Formal validation studies are warranted.

BACKGROUND: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience. OBJECTIVE: To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy. DESIGN: Randomized, controlled, blinded, multicenter trial. SETTING: Academic medical centers with accredited gastroenterology training programs. PATIENTS: First-year GI fellows. INTERVENTIONS: Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure. MAIN OUTCOME MEASUREMENTS: A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time. RESULTS: Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar. CONCLUSIONS: Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training.

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

BACKGROUND: The efficacy of an intensive hands-on training in endoscopic hemostasis on the compactEASIE simulator has been previously demonstrated in a randomized prospective trial. In the current study, we evaluated how quickly and effectively new tutors, without simulator training experience, are able to acquire teaching skills in endoscopic hemostasis. METHODS: Five tutors with prior Erlangen Active Simulator for Interventional Endoscopy (EASIE) teaching experience instructed 7 endoscopists without prior EASIE experience on how to teach when using the model. These new tutors then independently conducted a workshop for 8 fellows in 4 hemostasis techniques. Results were compared with a historical control trained similarly by experienced tutors. Two one-day workshops in endoscopic hemostasis on the compactEASIE ex vivo endoscopy simulator were conducted in a category A hospital in New York City, New York. Skill scores at the end of training were compared with baseline skills assessments, and qualitative ratings of the new tutors were obtained from both the trainees and the experienced tutors. RESULTS: Significant improvement was achieved by the fellows in all 4 skills areas. Both the expert tutors and the trainees consistently rated the teaching skill of the new tutors highly. Fellows' skill acquisition using new tutors was of similar magnitude to that achieved in the prior EASIE trial using experienced trainers teaching the fellows. CONCLUSIONS: It is feasible to conduct an effective EASIE train-the-trainer course in one day. Tutors trained in this manner are able to provide a similar educational experience with objective improvement in trainee skill to experts who have conducted many hands-on workshops.

BACKGROUND AND STUDY AIMS: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 as a training model for interventional endoscopy. Objective evidence of the benefits of training with this model has not previously been published. As part of two long-term projects, the benefits of a 1-day training course with the "compactEASIE" simulator were evaluated. MATERIALS AND METHODS: Fourteen American and 18 French gastroenterology fellows were enrolled. These fellows were participants in the intensive groups performing training in endoscopic hemostasis, with a total number of 28 fellows in New York and 36 in France. Gastrointestinal endoscopy faculty members in New York and France evaluated and timed the fellows in four disciplines to establish baseline skills (manual skills; injection and coagulation; Hemoclip application; and variceal ligation) with the compactEASIE simulator. The trainees were reevaluated after an intensive 1-day course (with two or three fellows and one instructor per station), also including preparation and assistance for each procedure. The assessment (overall and parts) was done by expert tutors using an ordinal scale ranging from 1 to 10 (1 = poorest, 10 = best), recording also mistakes and performance time. The compactEASIE simulator, equipped with an upper gastrointestinal organ package and an artificial blood perfusion system, was used as the training tool. RESULTS: A highly significant improvement ( P < or = 0.001) was observed in the performance of all endoscopic techniques. A significant reduction in performance time was also observed with three of the four endoscopic techniques. Successful hemostasis was significantly improved in two out of three techniques. CONCLUSIONS: A 1-day training course on endoscopic hemostasis using the compactEASIE simulator is capable of improving the performance of hemostasis procedures. Long-term effects of repeated training sessions are currently subject of collaborative studies in New York and France.