Simulation-based mastery learning in gastrointestinal endoscopy training

Table 1 Development of endoscopy simulators

Ref.	Developer	Yr	Characteristics
Telleman et al[19], 2009	Erlangen-Nuremberg University Clinic	1974	An anatomical model of the esophagus, stomach, and duodenum used to train for endoscopic maneuvers
Williams et al[20], 2000	Imperial College/St Mark’s Hospital	1980	An anatomical model of the colon to train for angling maneuver in the organ
			Constant supervision is needed because trainees could damage the endoscope by excessive maneuvering
			The appearance of the colon surface is not realistic in the model
Classen and Ruppin[21], 1974	Imperial College/St Mark’s Hospital	1980	More realistic control compared to previous models as the endoscope can be rotated, and endoscope insertion and withdrawal can be detected
			Integrated with a monitor showing live simulation
			The length of the endoscope that can be inserted is limited
Williams et al[22], 1990	Imperial College/St Mark’s Hospital	1985	The endoscope can be fully inserted
			A sensation of resistance and an audio simulation that mimics patient’s complaints are included
			Still unrealistic
Long and Kalloo[15], 2006	Immersion Medical	2001	Provides an opportunity to practice various procedures, including biopsy
			Provides immediate feedback
			Realistic simulation as a sensation of resistance and contraction is included
Koch et al[23], 2008	Simbionix	2008	Provides realistic simulation
			Can be used to practice endoscopic maneuvers
			Can distinguish between the ability level of endoscopy experts and intermediate level
Triantafyllou[24], 2014	CAE Healthcare	2013	Can be accompanied by the patient’s history and various clinical parameters that can change during the endoscopy by the participant
			Combines endoscopic procedures with virtual backgrounds

Table 2 Minimum number of trainings needed to achieve competence in different procedures according to gastroenterology associations

Source	EGD	Colonoscopy	ERCP
European Diploma of Gastroenterology[32]	300	100	150
ASGE[33]	130	140	200
SAGES[34]	35	50	-
Korean Society of Gastrointestinal Endoscopy[35]	1000	150	30
British Society of Gastroenterology[36]	300	100	150

ASGE: American Society for Gastrointestinal Endoscopy; EGD: Esophagogastroduodenoscopy; ERCP: Endoscopic retrograde cholangiopancreatography; SAGES: Society of American Gastrointestinal and Endoscopic Surgeons.

Table 3 Studies on simulation-based endoscopy training

Ref.	Study design	Methods	Conclusion
Ferlitsch et al[39], 2002	Prospective randomized trial	13 endoscopy trainees were divided into two groups: simulator training and no simulator training	Simulator-trained group had better skills, shorter scope insertion time, and fewer adverse events
Giulio et al[44], 2004	Prospective randomized trial	22 fellows with no experience in endoscopy were divided into two groups: preclinical training with computer-based simulator and no preclinical training	The first group performed a more complete procedure, required less assistance, and was assessed as better by the instructor
Cohen et al[43], 2006	Prospective randomized trial	45 1st-yr GI fellows were divided into two groups: unsupervised simulator training using GI mentor and no simulator	Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. Fellows who underwent GI mentor training performed significantly better during the early phase of real colonoscopy training
Shirai et al[45], 2008	Prospective randomized trial	10 trainees were divided into two groups: simulator and non-simulator	5 h of simulator training improved EGD performance
Ferlitsch et al[46], 2010	Prospective randomized trial	28 internal medicine residents were divided into two groups: simulator-trained before conventional training and conventional training only	Virtual simulator training improved technical accuracy during the early and mid-term phase of training, thus reducing the time needed to reach technical competency. However, the clinical effect is limited
Haycock et al[47], 2010	Prospective randomized trial	36 novice colonoscopists were divided into two groups: simulator training and patient-based training	Simulator-trained group performance matched the patient-based group performance, and showed superior technical skills on simulated cases
Ende et al[30], 2012	Prospective randomized trial	Residents with no previous experience in endoscopy were divided into three groups: clinical and simulator training, clinical training only, and simulator training only	First group showed better results than the other groups. Third group showed a shorter procedure duration
Qiao et al[48], 2014	Systematic review	Fifteen studies comparing virtual colonoscopy or gastroscopy training with other intervention were analyzed	Virtual endoscopy simulator training might be effective for gastroscopy, but no data are available for colonoscopy
Singh et al[49], 2014	Systematic review and meta-analysis	Thirty-nine articles, including twenty-one randomized trials on simulation-based training in gastrointestinal endoscopy were analyzed	Simulation-based training significantly enhanced the skills of trainees, reduced the time needed to finish a procedure, and improved patient outcomes
Ekkelenkamp et al[50], 2016	Systematic review	Twenty-three studies on simulator training and learning curves, including seventeen randomized controlled trials, were analyzed	Validated VR simulator training in the early phase accelerated the learning of practical skills. Assessment of performance level on GI endoscopy procedures should be done continuously with validated assessment tool, rather than threshold number
Mahmood et al[5], 2018	Systematic review	Twenty-one randomized controlled trials on VR simulation in endoscopy training were analyzed	VR simulation showed improved skills in all areas at the beginning of learning; nonetheless it was not effective as a replacement for conventional training
Khan et al[51], 2018	Systematic review	Eighteen trials on endoscopic procedures were analyzed	VR-based training in combination with conventional training showed superior result over VR training alone. Evidence was inconclusive regarding whether VR-based training can replace conventional training
Smith et al[52], 2021	Systematic review and meta-analysis	Twenty-four studies on simulation of EGD, colonoscopy, ERCP, flexible sigmoidoscopy, or hemostasis procedures were analyzed	Likely positive impact of simulation training on patient comfort, cecal and biliary intubation. However, studies on the effect of simulation training are small and have a short follow-up time
Zhang et al[53], 2021	Systematic review	Twenty-two studies on endoscopy VR simulation training were analyzed	VR simulation training resulted in comparable or significantly better performance than clinical training, no training, other types of simulation, and another form of VR

GI: Gastrointestinal; ERCP: Endoscopic retrograde cholangiopancreatography; EGD, Esophagogastroduodenoscopy; VR: Virtual reality.