Virtual reality simulation in endoscopy training: Current evidence and future directions

Table 1 Summary of randomized controlled trials

Ref.	Sample size	Intervention	Outcomes
Flexible Sigmoidoscopy
Tuggy et al[19]	10	Group 1: VR simulation	Group 1 performed better: Faster mean completion time (323 s vs 654 s), lower directional errors (1.6% vs 8.6%), higher % of colon visualized (79% vs 45%)
		Group 2: No simulation
Gerson et al[20]	16	Group 1: VR simulation	Group 1 performed worse: Lower mean score (2.9 vs 3.8 out of 5), lower cases completed independently (29% vs 72%), lower retroflexion completed (56% vs 84%); average time, patient satisfaction did not differ
		Group 2: Conventional teaching
Sedlack et al[21]	38	Group 1: VR simulation	Group 1 performed better: Higher patient comfort; procedural skills (independence, identifying pathology, landmarks, performing biopsies, adequate visualization) did not differ
		Group 2: Conventional teaching
Colonoscopy
Sedlack et al[22]	8	Group 1: VR simulation	Group 1 performed better in first 30 procedures: High depth of unassisted insertion, higher % of procedures completed independently (64.1% vs 56.3%), high scores on other measures such as ability to insert in a safe manner, adequality visualize mucosa, identify landmarks; mean time to reach maximum insertion did not differ
		Group 2: No simulation
Ahlberg et al[23]	12	Group 1: VR simulation	Group 1 performed better: Higher rates of insertion to cecum (52% vs 19%), shorter procedure time (30 min vs 40 min), less patient discomfort
		Group 2: No simulation
Cohen et al[24]	45	Group 1: VR simulation	Group 1 performed better: Higher competence scores as judged by ability to reach the transverse colon and cecum without assistance (92.7% vs 90.9% by Session 10); patient comfort did not differ
		Group 2: No simulation
Park et al[25]	24	Group 1: VR simulation	Group 1 performed better: Higher global ratings (17.9 vs 14.8 out of 35) based on technique, use of controls, flow of procedures, advancement.
		Group 2: No simulation
Yi et al[26]	11	Group 1: VR simulation	Group 1 performed better: Higher scores during colonoscopy. Higher number of procedures completed independently (76% vs 43%), higher patient comfort; no difference in time or visualization of mucosa
		Group 2: No simulation
Haycock et al[27]	36	Group 1: VR simulation	Group 1 performed better: Higher completion rates (95% vs 70%) and shorter times (407 s vs 743 s), higher patient comfort, higher use of correction abdominal pressure (79% vs 52%), lower insertion force; other variables such as number of transverse loops, correct use of variable stiffness did not differ
		Group 2: Conventional teaching
McIntosh et al[28]	18	Group 1: VR simulation	Group 1 performed better: Less instances of requiring assistance (1.94 vs 3.43), greater unassisted insertion depth (43 cm vs 24 cm), greater rate of cecal intubation (26% vs 10%), high overall competence scores; patient comfort did not differ
		Group 2: No simulation
Gomez et al[29]	27	Group 1: VR simulation + benchtop simulation	Group 1 and 2 improved: Performed better on post-test compared to pre-test through Global Assessment of Gastrointestinal Endoscopic Skills tool (navigation, strategies, clear lumen and quality of examination)
		Group 2: VR simulation
		Group 3: Benchtop simulation
Grover et al[30]	33	Group 1: Self-regulated learning with VR simulation	Group 1 and 2 improved; Group 2 performed better: Both groups improved on colonoscopy-specific performance; Group 2 performed better based on Joint Advisory Group on GI Endoscopy’s Direct Observation of Procedural Skills Tool (JAG DOPS), had better communication rating, and better integrated global rating
		Group 2: Structured curriculum with VR simulation
Grover et al[31]	37	Group 1: Progressive learning with VR simulation	Group 1 performed better: Higher JAG DOPS score, communication and integrated global rating
		Group 2: Non-progressive learning with benchtop simulator
Esophagogastroduodenoscopy
Di Giulio et al[32]	22	Group 1: VR simulation	Group 1 performed better: Higher number of completed procedures (87.8% vs 70%), required less assistance (41.3% vs 97.9%), overall performance was better; length of time was not significantly different
		Group 2: No simulation
Sedlack et al[33]	8	Group 1: VR simulation	Group 1 performed worse: Lower patient comfort (5 vs 6), independence and competence scores
		Group 2: No simulation
Shirai et al[34]	20	Group 1: VR simulation + Conventional teaching	Group 1 performed better: Required less direct assistance (8.6% vs 25.9%), higher score on 11 items scored during the procedure; no significant difference in completion time
		Group 2: Conventional teaching
Ferlitsch et al[35]	28	Group 1: VR simulation	Group 1 performed better: Decreased total time to reach duodenum (239 s vs 310 s); higher technical accuracy; diagnostic accuracy did not differ
		Group 2: No simulation
Ende et al[36]	29	Group 1: VR simulation + Conventional teaching	Group 1 and 2 improved: Improvement in time within group (195 s vs 119 s; 261 s vs 150 s); no significant difference in between groups
		Group 2: Conventional teaching	All groups showed improvement in post-intervention manual skills test score.
		Group 3: VR simulation alone	None of the other outcomes reached statistical significance, such as time to intubate esophagus
Endoscopic retrograde cholangiopancreatography (ERCP)
Lim et al[37]	16	Group 1: Mechanical simulator	Group 1 performed better: Improved cannulation rates (47.1% vs 69.6%), decreased total time (4.7 vs 10.3 mins); overall performance score not significantly different.
		Group 2: No simulator
Liao et al[38]	16	Group 1: Mechanical simulator	Group 1 performed better: Improved cannulation rates (73.25% vs 47.35%) and improve overall performance; benefit of single vs multiple simulator practices was not statistically significant.
		Group 2: No simulator
Meng et al[39]	5	Group 1: Mechanical simulator	Group 1 performed better: Improved cannulation rates (79.4% vs 61.5%), lower total time (19.38 min vs 26.31 min), and improved overall performance score.
		Group 2: No simulator

Summary of 21 randomized controlled trials investigating endoscopic techniques, including flexible sigmoidoscopy, colonoscopy, organic gastrointestinal disease and endoscopic retrograde cholangiopancreatography, including sample size, groups in the study and summary of results. Conventional training refers to the apprenticeship model.