Role of virtual reality simulation in endoscopy training

Table 1 Summary of analysed oesophagogastroduodenoscopy studies and their design

Ref.	No. of participants	Participants' level of training	Design	Task	Model	Primary outcome	Secondary outcomes
Bloom et al[6]	35	Novice and advanced	NRSIS	Visualisation	5 DT gastroscope training simulator	Time to complete procedure1	Wall visualisation1
				Questionnaire			Questionnaire responses
Clark et al[2]	13	Novice and advanced	NRSIS	Completion of monthly assignments over two years on simulator	GI Mentor I	Objective criteria measured by simulator1
Di Giulio et al[4]	22	Novice	MC RCT	Complete simulator or control training programme	GI Mentor I	Competency scores2	Instructor assessed2
Ferlitsch et al[7]	13	Mixed novice and advanced	RCT	Comparison of novice and expert performance in simulated endoscopy. Comparison of performance of simulation-trained and control group of novices	GI Mentor I	Competency scores from simulator1
Ferlitsch et al[3]	28	Novice	RCT	Training on simulator against traditional training	GI Mentor I	Competency scores from expert after 10 and 60 endoscopic examinations2	Pain experienced by patient
Sedlack[9]	8	Novice	RCT	6 h simulation training before 1 mo of traditional training	GI Mentor II	Mixed competency scores from expert2
Shirai et al[5]	20	Novice	RCT	5 h simulation training before 2 assessed endoscopies	GI Mentor II	Mixed competency scores from expert2
Van Sickle et al[8]	41	Mixed novice and advanced	MC NRSIS	Baseline assessment on simulator and after 8 wk of training	GI Mentor II	Competency scores from expert1

¹Simulator-related outcome;

²Patient-related outcome. MC: Multicentre; RCT: Randomised control trail; NRSIS: Non-randomised single-intervention study; GI: Gastro-intestinal; DT: Dimension technologies.

Table 2 Results of studies evaluating the role of simulation in oesophagogastroduodenoscopy training

Ref.	Primary outcome	Secondary outcome
Bloom et al[6]	Mean time to complete procedure was 224 ± 27.65 s for novice, 171.22 ± 25.43 s for intermediate and 106.40 ± 13.08 s for experienced candidates (P = 0.008)	Mean percentage of total surface visualised was 60.56 ± 2.56 for novice, 66.56 ± 2.80 for intermediate and 72.10 ± 0.23 for experienced candidates (P = 0.005)
	The study demonstrated the construct validity of the simulator	Questionnaire responses suggested that novice and intermediate candidates considered VR simulation an important training tool
Clark et al[2]	Efficiency scores (total time to complete procedure divided by percentage of mucosal surface examined) of senior residents were higher than those of junior residents (85% vs 59%) demonstrating improved efficiency with continued use of simulator
Di Giulio et al[4]	The simulator-trained group performed a higher number of complete procedures (87.8% vs 70%, P < 0.0001) and needed less assistance (41.3% vs 97.9%, P < 0.0001) compared to control group. Length of procedure was similar in the two groups	Instructor marked performance as positive more frequently in the simulator-trained group compared to the controls (86.8% vs 56.7%, < 0.0001)
Ferlitsch et al[7]	Performance of expert candidates (compared to novices) was better in performance of J-manoeuvre during oesophagogastroduodenoscopy (P < 0.005), complications at colonoscopy (P < 0.02), insertion time (P < 0.001), identification of abnormal findings in gastroscopy and colonoscopy (P < 0.02) and skill performance (P < 0.01). Amongst novices, the simulation-trained group had a better performance compared to the controls in relation to complication rates at virtual endoscopy (P < 0.04), the insertion time during colonoscopy (P < 0.03) and skill performance (P < 0.01)
Ferlitsch et al[3]	The simulation-trained group performed better than the control group in terms of time needed to reach the duodenum [239 s (range 50-620) vs 310 s (110-720), P < 0.0001] and technical ability (P < 0.02) in the first ten endoscopic examinations on patients. Diagnostic ability was similar in the two groups	There were no significant differences in pain scores between the groups after 10 and after 60 endoscopies
	After 60 endoscopic examinations, investigation time was still less in the simulation-trained group. Technical and diagnostic ability improved during on-patient training in both groups and differences between groups were no longer seen at that stage
Sedlack[9]	The control group performed better than the simulation-trained group in terms of patient discomfort (5; IQR, 4-6 vs 6; IQR, 5-6; P = 0.015), sedation, independence and competence scores
Shirai et al[5]	The simulator-trained group achieved significantly higher scores than the control group in the following skills: oesophageal intubation, passing from the EGJ to the antrum, pyloric intubation, and examination of the duodenum and the fundus
Van Sickle et al[8]	The study group showed an improvement in endoscopic skills (e.g., Global Assessment of Gastrointestinal Endoscopic Skills scores) after 8 wk of VR simulation training

IQR: Interquartile range; EGJ: Esophagogastric junction; VR: Virtual reality.

Table 3 Summary of analysed endoscopic retrograde cholangio-pancreatography study and its design

Ref.	No. of participants	Participants' level of training	Design	Task	Model	Primary outcome	Secondary outcomes
Bittner et al[10]	12	Mixed	NRSIS	2 simulator ERCP cases	GI Mentor II	Time to complete procedure1	Time to papilla1
							Questionnaire on views

¹Simulator-related outcome. NRSIS: Non-randomised single-intervention study; ERCP: Endoscopic retrograde cholangio-pancreatography; GI: Gastro-intestinal.

Table 4 Summary of analysed colonoscopy studies and their design

Ref.	No. of participants	Participants' level of training	Design	Task	Model	Primary outcome	Secondary outcomes
Aabakken et al[12]	33	Mixed	NRSIS	1 simulated colonoscopy and questionnaire	GI Mentor	User satisfaction1
Ahlberg et al[13]	12	Novice3	RCT	Completion of simulator or control training programme followed by assessment on 10 colonoscopic procedures	AccuTouch	Mixed competency scores2	Time to caecum2
Buzink et al[14]	35	Mixed	NRSIS	4 training sessions	GI Mentor II	Mixed competency scores1
Cohen et al[15]	45	Novice	MC RCT	Completion of simulator or control training programme followed by assessment of first 200 colonoscopies	GI Mentor I	Mixed competency scores2	Long term impact2
Eversbusch et al[22]	28	Novice3	RCT	10 consecutive assessments on VR simulator	GI Mentor II	Mixed competency scores1
Gerson et al[24]	16	Novice	RCT	Completion of simulator or control training programme followed by assessment on 5 endoscopic procedures	AccuTouch	Mixed competency scores2
Haycock et al[16]	36	Novice	RCT	Completion of simulator or control training programme followed by simulator and patient-based assessment	Olympus Endo TS-1	Mixed competency scores1,2
Kruglikova et al[21]	30	Mixed	NRSIS	10 repetitions of one VR simulator task	AccuTouch	Mixed competency scores1
Park et al[17]	24	Novice	RCT	Completion of simulator or control training programme followed by assessment on one patient-based colonoscopy	AccuTouch	Mixed competency scores2
Sedlack et al[18]	8	Novice3	RCT	Completion of simulator or control training programme followed by assessment of one endoscopic procedure	AccuTouch	Mixed competency scores2	Patient discomfort2
Sugden et al[23]	50	Mixed	NRSIS	Completion of modules on the VR simulator	Olympus Endo TS-1	Mixed competency scores1
Thomas-Gibson et al[19]	21	Novice	NRSIS	Completion of 5 d training programme including VR simulation, with pre- and post-training assessments followed by a 9-mo follow-up assessment	AccuTouch	Mixed competency scores1,2	Long term outcome (9 mo)1,2
Thomson et al[20]	13	Novice	NRSIS	Completion of respective training with or without simulator use with assessments during that period	GI Mentor	Mixed competency scores2

¹Simulator-related outcome;

²Patient-related outcome;

³Subjects had previous oesophagogastroduodenoscopy training and knowledge. MC: Multicentre; RCT: Randomised control trail; NRSIS: Non-randomised single-intervention study; VR: Virtual reality; GI: Gastro-intestinal.