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GI Mentor Clinical Validations


Surg Endosc. 2014 May;28(5):1494-9. doi: 10.1007/s00464-013-3339-z. Epub 2013 Dec 12.

Endoscopic simulator curriculum improves colonoscopy performance in novice surgical interns as demonstrated in a swine model.

Telem DA1, Rattner DW, Gee DW.

1Division of Laparoscopic, Bariatric and Advanced GI Surgery, Stony Brook University Medical Center, Stony Brook, NY, USA, 

INTRODUCTION: The purpose of this study was to determine whether independent virtual endoscopic training accelerates the acquisition of endoscopic skill by novice surgical interns.

METHODS: Nine novice surgical interns participated in a prospective study comparing colonoscopy performance in a swine model before and after an independent simulator curriculum. An independent observer evaluated each intern for the ability to reach the cecum within 20 min and technical ability as determined by Global Assessment of Gastrointestinal Endoscopic Skills-Colonoscopy (GAGES-C) score and performance compared. In addition, at the conclusion of training, a post test of two basic simulated colonoscopy modules was completed and metrics evaluated. As a control, three attending physicians who routinely perform colonoscopy also completed colonoscopy in the swine model.

RESULTS: Prior to endoscopic training, one (11 %) intern successfully intubated the cecum in 19.56 min. Following training, six (67 %) interns reached the cecum with mean time of 9.2 min (p < 0.05). Statistically significant improvement was demonstrated in four out of five GAGES-C criteria. All three experts reached the cecum, with a mean time of 4.40 min. Comparison of expert and post-curriculum intern times demonstrated the experts to be significantly faster (p < 0.05). Comparison of interns who were and were not able to reach the cecum following the simulator curriculum demonstrated significantly improved GI Mentor™ performance in the efficiency (79 vs. 67.1 %, p = 0.05) and time to cecum (3.37 vs. 5.59 min, p = 0.01) metrics. No other significant difference was demonstrated in GAGES-C categories or other simulator parameter.

CONCLUSION: Simulator training on the GI Mentor™ alone significantly improved endoscopic skills in novice surgical interns as demonstrated in a swine model. This study also identified parameters on the GI Mentor™ that could indicate ‘clinical readiness’. This study supports the role for endoscopic simulator training in surgical resident education as an adjunct to clinical experience.


Why fundamentals of endoscopic surgery (FES)?

Hazey JW, Marks JM, Mellinger JD, Trus TL, Chand B, Delaney CP, Dunkin BJ, Fanelli RD, Fried GM, Martinez JM, Pearl JP, Poulose BK,Sillin LF, Vassiliou MC, Melvin WS.

Section of Minimally Invasive Surgery, Department of Surgery, The Wexner Medical Center, The Ohio State University, N708 Doan Hall, 410 West Tenth Avenue, Columbus, OH, 43210, USA,

Surg Endosc. 2013 Dec 7.

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Fundamentals of endoscopic surgery: creation and validation of the hands-on test.

Vassiliou MC, Dunkin BJ, Fried GM, Mellinger JD, Trus T, Kaneva P, Lyons C, Korndorffer JR Jr, Ujiki M, Velanovich V, Kochman ML, Tsuda S, Martinez J, Scott DJ, Korus G, Park A, Marks JM.

Surg Endosc. 2013 Nov 20.

BACKGROUND: The Fundamentals of Endoscopic Surgery™ (FES) program consists of online materials and didactic and skills-based tests. All components were designed to measure the skills and knowledge required to perform safe flexible endoscopy. The purpose of this multicenter study was to evaluate the reliability and validity of the hands-on component of the FES examination, and to establish the pass score.

METHODS: Expert endoscopists identified the critical skill set required for flexible endoscopy. They were then modeled in a virtual reality simulator (GI Mentor™ II, Simbionix™ Ltd., Airport City, Israel) to create five tasks and metrics. Scores were designed to measure both speed and precision. Validity evidence was assessed by correlating performance with self-reported endoscopic experience (surgeons and gastroenterologists [GIs]). Internal consistency of each test task was assessed using Cronbach’s alpha. Test-retest reliability was determined by having the same participant perform the test a second time and comparing their scores. Passing scores were determined by a contrasting groups methodology and use of receiver operating characteristic curves.

RESULTS: A total of 160 participants (17 % GIs) performed the simulator test. Scores on the five tasks showed good internal consistency reliability and all had significant correlations with endoscopic experience. Total FES scores correlated 0.73, with participants’ level of endoscopic experience providing evidence of their validity, and their internal consistency reliability (Cronbach’s alpha) was 0.82. Test-retest reliability was assessed in 11 participants, and the intraclass correlation was 0.85. The passing score was determined and is estimated to have a sensitivity (true positive rate) of 0.81 and a 1-specificity (false positive rate) of 0.21.

CONCLUSIONS: The FES hands-on skills test examines the basic procedural components required to perform safe flexible endoscopy. It meets rigorous standards of reliability and validity required for high-stakes examinations, and, together with the knowledge component, may help contribute to the definition and determination of competence in endoscopy.
 


The following abstract was presented at Annual Digestive Disease Week (DDW), May 18-21, 2013, Orlando, Florida

Sequential Analysis of the Ergonomics of First Year Gastroenterology Fellows With Simulated Endoscopy to Assess Effect of Practice on Range of Motion: an Attempt to Reduce Musuloskeletal Injury During Endoscopy

Kevin C. Ruff1, Deepika Mohankumar2, Mary A. Atia1, Shiva K. Ratuapli1, Darren Andrade1, Michael Foley1, Bobby R. Kakati1, Marco Santello2, David E. Fleischer1, Francisco C. Ramirez1

Mayo Clinic, Scottsdale, Arizona,  Arizona State University, Phoenix, Arizona

Background: The relationship between musculo-skeletal injuries and endoscopy performance is not well understood. Studying the ergonomics and kinematics of the procedure may provide information about the cause of these injuries.

Aim: The aim of the study was to determine the effect of practice on the range of motion of the wrist joints during performance of simulated colonoscopy in first year Gastroenterology fellows prior to and after a period of formal endoscopic training.

Materials & Methods: Five first year Gastroenterology fellows (4 men, 1 woman; all right-handed, one ambidextrous fellow) participated in the study. Simulations of colonoscopy were performed (Simbionix GI Mentor Endoscopy), one practice and 2 experimental trials for each subject. The trials were up to 10 minutes in length with 1 easy and 1 difficult procedure as described by the simulator manual. Procedures were completed in counterbalanced order across subjects. Wrist kinematics were recorded in two sessions, one at the start of fellowship training (“baseline) and one three months later (“follow-up”).

Right forearm kinematics were measured using a magnetic position/orientation tracker (Fastrak, Polhemus; 120 Hz sampling rate). We measured three degrees of freedom (DoF) of wrist motion: pronation/supination, flexion/extension, and abduction/adduction. We defined four different zones based on the wrist angle relative to the extreme and the center ranges of motion: center, mid, extreme, and out of range. (see Figure 1 for data of single procedure) The time spent in each of these zones was calculated and statistical analysis was performed to determine whether three months of endoscopy practice had any affect.

Results: Fellows performed an average of 150 endoscopic procedures in between the two measurement periods. Mixed model analysis of the time spent in each wrist movement zone revealed that three months of endoscopy practice did not significantly change the time spent in each zone for any degree of freedom. Fellows spent most time in the mid range followed by the extreme range at both baseline and follow-up sessions (p <0.0001). (see Figure 2)

Conclusions: Although our pilot study was conducted on a small number of subjects, our data indicate that tracking wrist motion and time spent at extreme ranges of motions during endoscopy training is a promising approach that may lead to improving training procedures and potentially minimize the risk of musculoskeletal injuries. The fact that the time spent in each movement zone did not change after three months suggests that training (practice) led subjects to use the same movement patterns used in the baseline session while executing the endoscopic maneuvers. This continuous, ongoing sequential analysis will allow us to observe patterns in a cohort of Gastroenterology fellows beginning at the start of their endoscopic training.

GI_Image

Disclosure: Kevin C. Ruff – Consulting: ProVation

David E. Fleischer – Grant/Research Support: BARRX Medical, Fujinon, Olympus America
The following people have nothing to disclose: Deepika Mohankumar, Mary A. Atia, Shiva K. Ratuapli, Darren Andrade, Michael Foley, Bobby R. Kakati, Marco Santello, Francisco C. Ramirez


The following abstract was presented at Annual Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), April 17-20, 2013, Baltimore, Maryland

Can Surgery Residents Be Trained to Perform Diagnostic and Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) During Their Training?

Matthew Johnson, MD, Cory Richardson, MD, Maris Jones, MD, Shawn Tsuda, MD, Adnan Mohsin, Charles St. Hill, MD, Noel Devera, RN, Louise Shadwick, RN, Nathan Ozobia, MD

University of Nevada School of Medicine, Nevada, USA

Introduction: In 1983, Nathan Ozobia(NIO) attended an advanced ERCP course in London, UK under Peter Cotton, MD where he subsequently became one of the earliest surgeons to be credentialed in ERCP. That course changed NIOs management of choledocholithiasis which prior to that time was treated exclusively by an open surgical method. From the training he received at this course NIO believed that ERCP was feasible in the supine position so an institutional review board(IRB) study was carried out successfully. That study was titled, “Is ERCP Feasible in the Management of Blunt and Penetrating Pancreatico-Biliary Injuries?” The answer was clear and the paper was presented by Dr. Marchella at a Regional Residents conference in California. The experience gathered by NIO led to an additional presentation, titled: “ONE STEP MANAGEMENT OF OBSTRUCTING BILIARY DISEASES OF THE BILE DUCT”, presented at the 6th World Congress of Endoscopic Surgery, Rome 1998. In 2000, two surgery residents, Matthew Johnson(MJ) and Randy St.Hill(RSH), approached NIO and expressed a desire to learn ERCP. This was the beginning of surgical resident ERCP training at the University of Nevada School of Medicine at University Medical Center, Las Vegas, NV and five surgical endoscopy related papers from our institution. This paper illustrates our experience to date with surgical residents performing ERCP and being successful.

Methods and Procedures: Initially, residents in training underwent ERCP simulation using an endoscopic simulation lab. This was followed by specific didactic training involving selected readings, equipment familiarity, and subsequently surgical endoscopic case proctorship under NIO. An IRB study was then developed and titled: “ONE-STEP AND TWO-STEP LAPAROSCOPIC CHOLECYSTECTOMIES”. Patients were accrued and admitted under the service of NIO. Presentations were made to emergency room physicians, internal medicine physicians, and surgical colleagues regarding collaboration. Apart from the cases from the IRB approved study, other ERCP cases included the following: complex liver injuries; diagnostic and for placement of biliary stents for bilio-peritoneal and bilio-cutaneous fistulas, acute acalculous cholecysttitis with hyperbilirubinemia, post laparoscopic cholecystectomy complications to exclude cystic and bile duct leaks, and cases of biliary pancreatitis that needed a pre-operative ERCP. The procedures were exclusively performed by the residents in over 90% of the cases.

Results: Over 200 cases have been successfully performed by the residents MJ and RSH. Two additional residents, Cory Richardson(CR) and Maris Jones(MJ) have recently started the training program. There has been been one major complication; transection of the right hepatic duct(unrelated to ERCP), treated with a Roux-en-Y and 2 cases of post-ERCP pancreatitis.

Conclusions: By utilizing a specific training paradigm under the guise of an experienced surgical endoscopist, general surgery residents can be taught to perform diagnostic and therapeutic ERCP during their training.

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Endoscopy simulator for training in digestive endoscopy.

Bures J, Rejchrt S, Tachecí I, Cyrany J, Fejfar T, Douda T, Kopácová M.

Subkatedra gastroenterologie, Lékarská fakulta UK, Hradec Králové.

Cas Lek Cesk. 2012;151(1):9-12.

This paper reports on a computer-based simulator (GI Mentor II) used for initial training in digestive endoscopy. The highly sophisticated apparatus employs real endoscopes and virtual accessories. The training program starts with a group of exercises, specially designed to enhance eye-hand coordination. Interactive computerized simulator contains modules for training in gastroscopy, colonoscopy, endoscopic retrograde cholangio-pancreatography and endoscopic control of gastrointestinal bleeding. Virtual library contains 88 authentic cases of diagnostic and therapeutic procedures. Computer-based endoscopy simulators enable trainees to learn and gain technical endoscopic skills before operating on patients. It has the potential to shorten the learning process to competency in digestive endoscopy.


A multicenter, simulation-based skills training collaborative using shared GI Mentor II systems: results from the Texas Association of Surgical Skills Laboratories (TASSL) flexible endoscopy curriculum.

Van Sickle KR, Buck L, Willis R, Mangram A, Truitt MS, Shabahang M, Thomas S, Trombetta L, Dunkin B, Scott D.

Department of Surgery, University of Texas Health Science Center-San Antonio (UTHSCSA), 7703 Floyd Curl, Mail Code 7840, San Antonio, TX 78229-3900, USA.

Surg Endosc. 2011 Sep;25(9):2980-6. Epub 2011 Apr 13.

Background: The Texas Association of Surgical Skills Laboratories (TASSL) is a nonprofit consortium of surgical skills training centers for the accredited surgery residency programs in Texas. A training and research collaborative was forged between TASSL members and Simbionix (Cleveland, OH, USA) to assess the feasibility and efficacy of a multicenter, simulation- and Web-based flexible endoscopy training curriculum using shared GI Mentor II systems.

Methods: Two GI Mentor II flexible endoscopy simulators were provided for the study, and four institutions, namely, the University of Texas Health Science Center-San Antonio (UTHSCSA), Texas A & M University (TAMU), Methodist Hospital (MHD), and Brooke Army Medical Center (BAMC), agreed to share them. One additional site, University of Texas Southwestern (UTSW), already owned a device and participated during the study period. Postgraduate years (PGYs) 1 to 4 subjects completed pre- and posttraining questionnaires and one pre- and posttraining trial of Colonoscopy Case Module 1. EndoBubble 1 and 2 tasks with predefined, expert-derived levels were used for training. Pre- and posttesting performance data were recorded on the simulator and by the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES). All study materials were available through the TASSL Web site. Pre- and posttest comparisons were made by paired t-test.

Results: The curriculum was completed successfully by 41 participants from four institutions. The mean number of trials to proficiency was 13 ± 10 for EndoBubble 1 and 23 ± 16 for EndoBubble 2. Significant improvements from pre- to post training were seen in cecal intubation time (229 ± 97 vs. 150 ± 57 s; p < 0.001), total time (454 ± 147 vs. 320 ± 115 s; p < 0.001), screening efficiency (85% ± 12% vs. 91% ± 5%; p < 0.002), GAGES scores (15 vs. 19; p < 0.001), subjects’ endoscopy self-rating scores (1.5 ± 1.0 vs. 2.7 ± 0.6; range, 0-4; p < 0.001), and comfort level with flexible endoscopy skills (3.4 ± 3.0 vs. 7.2 ± 1.2; range, 0-8; p < 0.001).

Conclusions: The feasibility of sharing educational and training resources among institutions was demonstrated. Likewise, the concept of “mobile simulation” appears to be useful and effective, with three of the four institutions involved successfully in implementing the training curriculum during a fixed period. Additionally, subjects who completed the training demonstrated both subjective and objective improvements in flexible endoscopy skills.

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Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial.

Ende A, Zopf Y, Konturek P, Naegel A, Hahn EG, Matthes K, Maiss J.

Department of Medicine, University of Erlangen-Nuremberg, Erlangen, Germany.

Gastrointest Endosc. 2011 Dec 6.

Background: Training simulators have been used for decades with success; however, a standardized educational strategy for diagnostic EGD is still lacking.

Objective: Development of a training strategy for diagnostic upper endoscopy.

Study Design: Prospective, randomized trial.

Settings: A total of 28 medical and surgical residents without endoscopic experience were enrolled. Basic skills evaluations were performed after a structured program involving theoretical lectures and a hands-on course in diagnostic EGD. Subsequently, stratified randomization to clinical plus simulator training (group 1, n = 10), clinical training only (group 2, n = 9), or simulator training only (group 3, n = 9) was performed. Ten sessions of simulator training (Simbionix, compactEASIE, plastic phantom) were conducted for groups 1 and 3 during the 4-month program. Group 2 underwent standard training in endoscopy without supplemental simulator training. The final evaluation was performed on the simulator and by observation of 3 clinical cases. Skills and procedural times were recorded by blinded and unblinded evaluators.

Main Outcome Measurements: Time to reach the duodenum, pylorus, or esophagus.

Results: All trainees demonstrated a significant reduction in procedure time during a simple manual skills test (P < .05) and significantly better skills scores (P = .006, P = .042 and P = .017) in the simulator independent of the training strategy. Group 1 showed shorter times to intubate the esophagus (61 ± 26 seconds vs 85 ± 30 seconds and 95 ± 36 seconds) and the pylorus (183 ± 65 seconds vs 207 ± 61 seconds and 247 ± 66 seconds) during the clinical evaluation. Blinded assessment of EGD skills showed significantly better results for group 1 compared with group 3. Blinded and unblinded evaluations were not statistically different.

Limitations: Small sample size.

Conclusions: Structured simulator training supplementing clinical training in upper endoscopy appears to be superior to clinical training alone. Simulator training alone does not seem to be sufficient to improve endoscopic skills.


Fundamentals of Endoscopy (FES)

Brian J. Dunkin, MD; Jeffrey M. Marks, MD

Textbook of Simulation: Skills and Team Training Chapter 17: page 193- 204


Effect of virtual endoscopy simulator training on performance of upper gastrointestinal endoscopy in patients: a randomized controlled trial.

Ferlitsch A, Schoefl R, Puespoek A, Miehsler W, Schoeniger-Hekele M, Hofer H, Gangl A, Homoncik M.

Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.

Endoscopy. 2010 Dec;42(12):1049-56. Epub 2010 Oct 22.

Background: Skills in gastrointestinal endoscopy mainly depend on experience and practice.Patients upon whom trainees perform their first endoscopic examinations are likely to suffer more discomfort and prolonged procedures. Training on endoscopy simulators may reduce the time required to reach competency in patient endoscopy. 

Patients and Methods: Residents in internal medicine without experience of endoscopy wererandomized to a group who trained on a simulator before conventional training (group S) or one that received conventional training only (group C) before starting upper gastrointestinal endoscopy inpatients. After endoscopy, discomfort and pain were evaluated by patients, who were blind to the beginners’ training status. Results in terms of time, technique (intubation, pyloric passage, J-maneuver), and diagnosis of pathological entities were evaluated by experts.

Results: From 2003 to 2007, 28 residents were enrolled. Comparing group S with group C in their first ten endoscopic examinations in patients, time taken to reach the duodenum (239 seconds (range 50 - 620) vs. 310 seconds (110 - 720; P < 0.0001) and technical accuracy ( P < 0.02) were significantly better in group S. Diagnostic accuracy did not differ between the groups. Fourteen residents (7simulator-trained, 7 not simulator-trained) continued endoscopy training. After 60 endoscopic examinations, investigation time was still shorter in group S. Technical and diagnostic accuracy improved during on-patient training in both groups; here differences between groups were no longer observable. There were no significant differences in discomfort and pain scores between the groups after 10 and after 60 endoscopies. Discomfort and pain were higher than for endoscopy performed by experts. 

Conclusion: This randomized controlled trial shows that virtual simulator training significantly affects technical accuracy in the early and mid-term stages of endoscopic training. It helps reduce the time needed to reach technical competency, but clinically the effect is limited. Simulator training could be useful in an endoscopy training curriculum but cannot replace on-patient training.

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World J Surg. 2010 May;34(5):933-40.

Do basic psychomotor skills transfer between different image-based procedures?

Buzink SN, Goossens RH, Schoon EJ, de Ridder H, Jakimowicz JJ.

Faculty of Industrial Design Engineering, Delft University of Technology, Landbergstraat 15, 2628 CE, Delft, The Netherlands. s.n.buzink@tudelft.nl

Abstract

Background: Surgical techniques that draw from multiple types of image-based procedures (IBP) are increasing, such as Natural Orifice Transluminal Endoscopic Surgery, fusing laparoscopy and flexible endoscopy. However, little is known about the relation between psychomotor skills for performing different types of IBP. For example, do basic psychomotor colonoscopy and laparoscopy skills interact?

Methods: Following a cross-over study design, 29 naïve endoscopists were trained on the Simbionix GI Mentor and the SimSurgery SEP simulators. Group C (n = 15) commenced with a laparoscopy session, followed by four colonoscopy sessions and a second laparoscopy session. Group L (n = 14) started with a colonoscopy session, followed by four laparoscopy sessions and a second colonoscopy session.

Results: No significant differences were found between the performances of group L and group C in their first training sessions on either technique. With additional colonoscopy training, group C outperformed group L in the second laparoscopy training session on the camera navigation task.

Conclusions: Overall, training in the basic colonoscopy tasks does not affect performance of basic laparoscopy tasks (and vice versa). However, to limited extent, training of basic psychomotor skills for colonoscopy do appear to contribute to the performance of angled laparoscope navigation tasks. Thus, training and assessment of IBP type-specific skills should focus on each type of tasks independently. Future research should further investigate the influence of psychometric abilities on the performance of IBP and the transfer of skills for physicians who are experienced in one IBP type and would like to become proficient in another type of IBP.


The emerging role of screen based simulators in the training and assessment of colonoscopists

Morven Cunningham1, Bimbi Fernando2, Pasquale Berlingieri3

1Centre for Gastroenterology, Royal Free Hospital, London, UK 2Centre for Surgery, Royal Free Hospital, London, UK 3Centre for Screen-Based Medical Simulation, Royal Free Hospital, London, UK

Frontline Gastroenterol 2010;1:76-81

Incorporation of screen based simulators into medical training has recently gained momentum, as advances in technology have coincided with a government led drive to increase the use of medical simulation training to improve patient safety with progressive reductions in working hours available for junior doctors to train. High fidelity screen based simulators hold great appeal for endoscopy training. Potentially, their incorporation into endoscopy training curricula could enhance speed of acquisition of skills and improve patient comfort and safety during the initial phase of learning. They could also be used to demonstrate competence as part of the future relicensing and revalidation of trained endoscopists. Two screen based simulators are widely available for lower gastrointestinal endoscopy training, with a third recently produced in prototype. The utility of these simulators in lower gastrointestinal endoscopy training has been investigated, and construct and expert validity has been shown. Novices demonstrate a learning curve with simulator training that appears to represent real learning of colonoscopy skills. This learning transfers well to the real patient environment, with improvements in performance and patient discomfort scores in subsequent initial live colonoscopy. The significant limitations of currently available screen based simulators include cost implications, and restrictions on a role in certification and revalidation. Many questions remain to be answered by future research, including how best to incorporate screen based simulators into a colonoscopy training programme, their role in training in therapeutic endoscopy and the impact of simulator training on patient safety.


Visuo-spatial ability in colonoscopy simulator training.

Luursema JM, Buzink SN, Verwey WB, Jakimowicz JJ.

Department of Technical Medicine, University of Twente, P.O. box 217, 7500 AE, Enschede, The Netherlands.

Adv Health Sci Educ Theory Pract. 2010 Dec;15(5):685-94. Epub 2010 May 9.

Visuo-spatial ability is associated with a quality of performance in a variety of surgical and medical skills. However, visuo-spatial ability is typically assessed using Visualization tests only, which led to an incomplete understanding of the involvement of visuo-spatial ability in these skills. To remedy this situation, the current study investigated the role of a broad range of visuo-spatial factors in colonoscopy simulator training. Fifteen medical trainees (no clinical experience in colonoscopy) participated in two psycho-metric test sessions to assess four visuo-spatial ability factors. Next, participants trained flexible endoscope manipulation, and navigation to the cecum on the GI Mentor II simulator, for four sessions within 1 week. Visualization, and to a lesser degree Spatial relations were the only visuo-spatial ability factors to correlate with colonoscopy simulator performance. Visualization additionally covaried with learning rate for time on task on both simulator tasks. High Visualization ability indicated faster exercise completion. Similar to other endoscopic procedures, performance in colonoscopy is positively associated with Visualization, a visuo-spatial ability factor characterized by the ability to mentally manipulate complex visuo-spatial stimuli. The complexity of the visuo-spatial mental transformations required to successfully perform colonoscopy is likely responsible for the challenging nature of this technique, and should inform training- and assessment design. Long term training studies, as well as studies investigating the nature of visuo-spatial complexity in this domain are needed to better understand the role of visuo-spatial ability in colonoscopy, and other endoscopic techniques.

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The following abstract was presented at Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) April 14- 17, 2010, Gaylord National Resort and Convention Center Landover, Maryland USA

A Multi-Center, Simulation-Based Skills Training Collaborative Using Shared GI Mentor II™ Systems: Results from the Texas Association of Surgical Skills Laboratories (TASSL) Flexible Endoscopy Curriculum

Kent R. Van Sickle MD1, Lauren Buck MD1, Ross Willis PhD1, Alicia Mangram MD2, Michael S. Truitt MD2, Mohsen Shabahang MD, PhD3, Scott Thomas MD3, Lee Trombetta MD4, Brian Dunkin MD5, and Daniel Scott MD6 1University of Texas Health Science Center San Antonio, San Antonio, TX (UTHSCSA) 2Methodist Hospital, Dallas, TX (MHD) 3Texas A & M University, Temple, TX (TAMU) 4Brooke Army Medical Center, San Antonio, TX (BAMC) 5Methodist Hospital, Houston TX 6University of Texas Southwestern, Dallas, TX (UTSW)

Background: The Texas Association of Surgical Skills Laboratories (TASSL) is a state-wide, non-profit consortium of surgical skills training centers for all of the accredited surgery residency programs in Texas. A training and research collaborative was forged between TASSL members and Simbionix (Cleveland, OH, USA) to assess the feasibility and efficacy of a multicenter, simulation- and web-based flexible endoscopy training curriculum using shared GI Mentor II™ systems.

Methods: Two GI Mentor II™ flexible endoscopy simulators were provided for the study and 4 institutions (UTHSCSA, TAMU, MHD, and BAMC) agreed to share them. Two devices were delivered to UTHSCSA and TAMU for 7 weeks and then shipped to BAMC and MHD for another 7 weeks. One additional site (UTSW) already owned a device and participated in the curriculum during the study period. PGY 1 – 4 residents participated and all subjects completed pre- and post-training questionnaires and 1 pre- and post-training trial of Colonoscopy Case Module #1. EndoBubble (EB) I and II tasks with predefined, expert-derived levels were used for training. Pre- and post-testing performance data was recorded on the simulator and by global skills assessment (GAGES) by site coordinators and all study materials were available through the TASSL website. Pre- and post-test comparisons were made using a paired t-test.

Results: Forty-one (41) subjects from four (4) institutions successfully completed the curriculum. One (1) institution had no data to report. Breakdown by training year: PGY1=17, PGY2=5, PGY3=13, PGY4=6; with mean prior endoscopy experience of 21 cases (range 0-100). The mean number of trials to proficiency was 13±10 and 23±16 for EBI and EBII respectively. Significant improvements from pre- to post-training were seen in cecal intubation time (229±97 sec vs. 150±57 sec; p<0.001), total time (454±147 sec vs. 320±115 sec; p<0.001), screening efficiency (85±12% vs. 91±5%; p<0.002), GAGES scores (15 vs. 19; p<0.001), subjects’ endoscopy self-rating score (1.5±1.0 vs. 2.7±0.6 (range 0-4); p<0.001) and comfort level with flexible endoscopy skills (3.4±3.0 vs. 7.2±1.2 (range 0-8); p<0.001).

Conclusions: The feasibility of sharing educational and training resources amongst different institutions was demonstrated. Likewise, the concept of “mobile simulation” appears useful and effective, with three of the four institutions involved successfully implemented the training curriculum in a fixed time period. Additionally, subjects who completed training demonstrated both subjective and objective improvements in flexible endoscopy skills. This type of collaborative effort shows promise for future training paradigms.


Face and Construct Validity of a Computer-Based Virtual Reality Simulator for ERCP

Bittner JG 4th, Mellinger JD, Imam T, Schade RR, Macfadyen BV Jr.

Current affiliations: Department of Surgery (J.G.B., J.D.M., B.V.M.), the Virtual Education and Surgical Simulation Laboratory (J.G.B., J.D.M., T.I., B.V.M.), and the Department of Medicine, Section of Gastroenterology and Hepatology (R.R.S.), Medical College of Georgia School of Medicine, Augusta, Georgia, Department of Surgery (T.I.), Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.

Gastrointest Endosc. 2010 Feb Volume 71, Issue 2, Pages 357-364 on-line 2009 Nov 16.

Background: Currently, little evidence supports computer-based simulation for ERCP training.

Objectives: To determine face and construct validity of a computer-based simulator for ERCP and assess its perceived utility as a training tool. DESIGN: Novice and expert endoscopists completed 2 simulated ERCP cases by using the GI Mentor II. SETTING: Virtual Education and Surgical Simulation Laboratory, Medical College of Georgia.

Main outcomes measurmnts: Outcomes included times to complete the procedure, reach the papilla, and use fluoroscopy; attempts to cannulate the papilla, pancreatic duct, and common bile duct; and number of contrast injections and complications. Subjects assessed simulator graphics, procedural accuracy, difficulty, haptics, overall realism, and training potential.

Results: Only when performance data from cases A and B were combined did the GI Mentor II differentiate novices and experts based on times to complete the procedure, reach the papilla, and use fluoroscopy. Across skill levels, overall opinions were similar regarding graphics (moderately realistic), accuracy (similar to clinical ERCP), difficulty (similar to clinical ERCP), overall realism (moderately realistic), and haptics. Most participants (92%) claimed that the simulator has definite training potential or should be required for training.

Limitations: Small sample size, single institution.

Conclusions: The GI Mentor II demonstrated construct validity for ERCP based on select metrics. Most subjects thought that the simulated graphics, procedural accuracy, and overall realism exhibit face validity. Subjects deemed it a useful training tool. Study repetition involving more participants and cases may help confirm results and establish the simulator’s ability to differentiate skill levels based on ERCP-specific metrics.


Testing the Construct Validity of the Simbionix GI Mentor II Virtual Reality Colonoscopy Simulator Metrics: Module Matters

Fayez R, Feldman LS, Kaneva P, Fried GM.

Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, McGill University, Montreal, Quebec, Canada.

Surg Endosc. 2010 May;24(5):1060-5. Epub 2009 Nov 13.

Background: The use of simulation for competency assessment requires validation of the simulator’s performance metrics. This study evaluated whether the Simbionix GI Mentor II virtual reality simulator metrics differentiate gastrointestinal endoscopists with varying clinical experience (known-groups construct validity).
Methods: For this study, 20 subjects (medical and surgical) were classified into two groups based on self-reported clinical experience with colonoscopy: a novice group (<5 scope experiences, n = 12) and an experienced group (>50 scope experiences, n = 8). Three virtual colonoscopy simulation modules of increasing difficulty were used (modules I-1, II-2, and I-7). The data reported by the simulator after each module were compared using the Wilcoxon-Mann-Whitney test. Data are expressed as median and interquartile range (IQR). A p value less than 0.05 was considered statistically significant.
Results: With module 1, only the time taken to reach the cecum was different between the groups: experienced group (1.6 min; IQR, 1.2-1.9 min) versus novice group (3.2 min; IQR, 2.4-4 min) (p < 0.01). With module 2, the two groups differed only in the time needed to reach the cecum (experienced group: 2.3 min; IQR, 1.6-2.3 min vs novice group: 3.3 min; IQR, 2.3-4.2 min; p = 0.03) and overall efficiency (experienced group: 94%; IQR, 94-96% vs novice group: 88%, IQR, 69-92%) (p < 0.01). In contrast, with the module 3 (the most difficult), performance differed between the groups for most of the parameters. The experienced group reached the cecum faster (5.7 min; IQR, 3.6-6.6 min vs. 14 min; IQR, 9-16 min; p < 0.01) and had fewer occasions of lost view (0.5; IQR, 0-1 vs. 2; IQR, 2-3; p < 0.01), fewer episodes of excessive pressure (2; IQR, 1-2 vs. 4.5; IQR, 2.5-6; p < 0.01), and greater overall efficiency (87%; IQR, 82-89% vs. 29%; IQR, 23-55%; p < 0.01). There were no differences in the percentage of time the patient was in pain or in the total time the colon was looped. The experienced group saw slightly less of the mucosa (91%; IQR, 89-92% vs 94%; IQR, 93-95%; p = 0.01).
Conclusions: The GI Mentor II metrics differentiated novice colonoscopists from those with more clinical experience, but primarily when used to evaluate the more complex scenarios. In setting performance benchmarks, the case scenario must be taken into account.

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Expert Benchmark for the GI Mentor II

Phitayakorn R, Marks JM, Reynolds HL, Delaney CP.
Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH 44106-5047, USA.
Surg Endosc. 2009 Mar;23(3):611-4. Epub 2008 Sep 24.
Background: There is increasing interest in the use of virtual-reality simulators in general surgery residency training. Many simulators lack a benchmark against which trainees can measure competence and skill.

Methods:Surgeons who had performed over 1,000 colonoscopies were evaluated on module 1, case 5 of the GI Mentor I or II virtual-reality endoscopy simulator (Simbionix, Cleveland). Participants were given 5 min to familiarize themselves with the simulator, and then performed the study case with standardized instructions. Metrics were recorded by using the previously calibrated simulator.

Results: Twenty-three surgeons (21 male, 2 female) participated. Mean height was 69.6 /- 2.6 inches, mean age 51 /- 9 years, median surgical glove size 7.5, and surgeons had 18.8 /- 10.1 years of practice, and did 8 /- 6 colonoscopies weekly. Ten participants had advanced training in endoscopy, laparoscopy or colorectal surgery; eight had used the simulator before, of whom six had used it once. Mean time to complete the study case was 13.6 /- 5.3 min and time to reach the cecum was 6.5 /- 4.3 min. Participants examined 92.3 /- 3.6% of the simulated colonic mucosa with a clear view of the lumen 89.5 /- 4.2% of the time. Total time the colon was looped was 22 /- 35 s (range 0-133 s). The overall efficiency of screening was 70.33 /- 23.45% (range 20-94%). Participants tended to mistake normal simulated colonic structures as pathology.

Conclusions: Performance on a virtual-reality endoscopic simulator has a wide amount of variability even among a group of experienced endoscopists. Expert benchmark tests should be performed on simulators that will be used for resident assessment prior to any attempts at certification of competence.


Prospective Randomized Study on the Use of a Computer-Based Endoscopic Simulator for Training in Esophagogastroduodenoscopy

Shirai Y, Yoshida T, Shiraishi R, Okamoto T, Nakamura H, Harada T, Nishikawa J, Sakaida I.

Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
J Gastroenterol Hepatol. 2008 Jul;23(7 Pt 1):1046-50. Epub 2008 Jun 28.
Background & Aim: Computer-based endoscopic simulators have been developed in recent years, and their usefulness has been reported. However, there is no blinded prospective randomized controlled study on esophagogastroduodenoscopy (EGD) training using virtual reality simulators. The present study aimed to assess the effectiveness of a computer-based simulator for basic training in EGD.

Methods: The GI-Mentor II simulator was used. The subjects were 20 hospital medical residents. After receiving an explanation regarding the fundamentals of endoscopy, 10 trainees were each randomized into a simulator group and a non-simulator group. The simulator group received 5 h of training with the GI-Mentor II plus bedside training, while the non-simulator group received bedside training. Subsequently, each subject performed endoscopy twice for assessment. Performance was evaluated according to a five-grade scale for a total of 11 items.

Results: The score was significantly higher in the skills required for insertion into the esophagus, passing from the esophagogastric junction (EGJ) to the antrum, passing through the pylorus, and examination of the duodenal bulb and the fornix.

Conclusions: The performance of endoscopy was improved by 5 h of simulator training. The simulator was more effective with regard to the items related to manipulation skills. Computer-based simulator training in EGD is useful for beginners.


The following abstract was presented at the Annual Meeting of the Digestive Disease Week (DDW) May 17 – 22, 2008. San Diego Convention Center, San Diego, CA, USA

Face and Construct Validity of a Computer-Based Virtual Reality Simulator for Endoscopic Retrograde Cholangiopancreatography

James G. Bittner, Obinna Ezeamuzie, Toufic Imam, Bruce V Macfadyen, Robert R. Schade, John D. Mellinger
Medical College of Georgia Augusta, Georgia, USA

Introduction: The American Society For Gastrointestinal Endoscopy encourages curriculum-based simulator use for endoscopir retrograde cholangiopancreatography (ERCP) training, though little data currently exist related to this recommendation. The study aim was to determine face and construct validity of a high-fidelity ERCP simulator and to assess its perceived utility as a training tool.

Methods: Twelve subjects were grouped into novice (n = 4 < 25 ERCPs), intermediate (n = 4; 100-200 ERCPs), and expert (n = 4; >200 ERCPs) skill levels. After 30 minutes of monitored practice to ensure simulator familiarity, subjects completed two cases. Case 1 requires stent placement with optional sphincterotomy for cystic duct leak. Case 2 involves common bile duct brushing and balloon dilation for stricture plus sphincterotomy and stent placement for duct decompression. Performance measures include times to complete procedure, reach papilla, and apply flouroscopy; number of attempts to cannulate the papilla, pancreatic duct, and common bile duct; number of contrast injections; use of endoscopic tools, and complications. By online survey, subjects assessed the graphics, procedural accuracy, difficulty, and haptics, plus overall realism and training potential of the simulator using Likert-type scales. Data are given as medians and analyzed using proper nonparametric tests.

Results: Age, postgraduate year, and prior endoscopy and ERCP experience positively correlate with skill level (all p < 0.001). There was no difference between groups with regard to gender, handedness, or interest in ERCP. For all cases combined, total procedure time differed across novices (607 sec), intermediates, and experts (332 sec; P = 0.009). For the same measure, Case I differentiated all skill levels (p = 0.024) while Case 2 distinguished only novice from expert (487 sec. 273 sec; p = 0.043). Across all skill levels and regardless of interest in ERCP opinions were similar regarding graphics (moderately realistic), accuracy (similar to real procedure), difficulty (somewhat less difficult), overall realism (moderately realistic), and haptics. As skill level decreased, subjects felt the haptics were comparable to real ERCP (p < 0.001). Subjects (67%) believe the simulator has definite training potential.

Conclusions: The two simulated cases on the Gl Mentor II differentiate novice, intermediate, and expert skill levels (construct validity) for FRCP based on total procedure time. The majority of subjects felt the simulated graphics, procedural accuracy and overall realism exhibit face validity, though haptics seemed most appreciated by novices. In addition, subjects believe it is- useful training tool.


The following abstract was presented at the Annual Meeting of the Digestive Disease Week (DDW) May 17 – 22, 2008. San Diego Convention Center, San Diego, CA, USA

Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for GI Fellow Trainees in Colonoscopy

JR Lightdale, ME Fredette, PA Rufo, VL Fox, JR Saltzman, JM Poneros

Division of Gastroenterology, Children’s Hospital Boston, Boston, Massachusetts, USA.

The Simbionix GI Mentor II Endoscopy Simulator is designed to provide detailed feedback, including time to anatomic landmarks, intraprocedural patient discomfort, and visualization of the mucosa. While construct validation studies have shown that the GI Mentor II can distinguish beginners from experts, its capacity to discriminate between
fellows in a 3-year training program is unknown.
Aim: To determine whether feedback measures provided by the GI Mentor II differ between 1st and 3rd year fellows.

Methods: Fellows in their 1st and 3rd years of training at Children’s Hospital Boston and the Brigham and Women’s Hospital were invited to record colonoscopies (6/06 – ll/07) on a GI Mentor II. Fellows were instructed to reach the cecum as quickly as possible, while visualizing the entire mucosa and avoiding colonoscopic looping. Patient discomfort was defined as the # and % duration of procedure time excessive loops were
formed causing local pressure. Other simulator parameters included % time spent with clear view of the lumen, and # of times view of the lumen was lost.

Results: 16 GI Trainees (10 1st Yrs, 6 3rd Yrs; 9 male; median age 32 yrs (IQR 29, 35)) recorded a total of 63 simulated colonoscopies. No differences were found between groups in # pediatric fellows (80% vs. 50%, p= .225), nor median # of simulations (1st Yr: 3 (IQR (2,7) 3rd Yr: 3 (3, 5). P=0.865). 1st year fellows did not spend more total time per simulated procedure than 3rd year fellows (13 min (9, l9) vs. 9 (8, l5). P=0.084), but did take longer to reach the cecum (7 min (4, 11) vs. 3 (2, 6), p=0.002). Few fellows formed excessive loops (1st Yrs: 0 (0, l); 3rd Yrs: 0 (0, l), p=0.383), and there was no difference in “virtual” patient discomfort (1st Yr: 1% procedural time in pain (0, 5); 3rd Yr: 0% (0,2), P= .108). 1st and 3rd year fellows did not differ in terms of their propensity to lose view of the lumen (1 time (0,2) vs. 0 (0,1), p=0.102), but 1st Yrs spent less time visualizing the entire mucosa (1st Yr: 84% (77,88) vs. 3rd Yr: 89% (8I,91), p= .011) and were less efficient in screening as calculated by the simulator (64% (39, 81) vs. 84o/o (64,89), p= .006).

Conclusions: Test parameters concerning time to anatomic landmarks and visualization of the mucosa generated by the GI Mentor II Endoscopy Simulator can discriminate between 1st and 3rd year GI fellows. Although the simulator did not detect differences in patient comfort, our findings suggests progression in endoscopy skills over a 3 year fellowship training period. Further study is needed to understand how performance enhancement on simulator measures translates into improved endoscopy in live patients.


The following abstract was presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) April 9- 12, 2008, Pennsylvania Convention Center, Philadelphia, PA, US

The Influence of Simulator Feedback on the Colonoscopy Performance Curve

S.N. Buzink H.G. Baan1, J.D. Degenaar1, K.A.Y. van Mourik1, J.J. Jakimowicz
Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands.
Catharina Hospital, Eindhoven, The Netherlands.

Background: Pre-clinical training of fundamental colonoscopy skills is important to safeguard patient safety. The objective was to investigate the influence of simulator feedback on the colonoscopy performance curve on the Simbionix GI Mentor II VR simulator.

Methods: Thirty medical trainees (no flexible endoscopy experience) performed four preset training sessions within one week. Each session comprised one EndoBubble L1 task and multiple VR colonoscopies (two in first session, three in subsequent sessions), with the assignment to accomplish the task as quick as possible, while causing as little patient discomfort as possible. VR colonoscopy I-3 was repeatedly performed as last VR colonoscopy in each session. Group F (N=15) performed the VR colonoscopies in ‘Full Screen Mode’ and group T (N=15) in ‘Training Mode’, which provides additional visual information on the level of patient discomfort and on-screen tips and warnings.

Results: Both groups improved their performances significantly, particularly for the time to accomplish the tasks (Friedman’s ANOVA, p=.001). Between the groups, the performances differed considerably on several aspects, particularly in the first session (Mann-Whitney U, p=.05). And overall, Group F performed the tasks with considerable better scores on the parameters ‘percentage of time the patient was in pain’ and the ‘percentage of time with clear view’.

Conclusions: In Training Mode, trainees appear to be inclined to take slightly more risks and operate closer to the verge of patient discomfort than in Full Screen Mode. The added value of the supplementary feedback could be superseded by the dispersion of attention.


Expert and Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for Colonoscopy

Koch AD, Buzink SN, Heemskerk J, Botden SM, Veenendaal R, Jakimowicz JJ, Schoon EJ.

Department of Gastroenterology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
Surg Endosc. 2008 Jan;22(1):158-62.

Objectives: The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.

Methods: Four groups were selected to perform one hand-eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200-1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.

Results: Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).

Conclusions: In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.


Acquiring Basic Endoscopy Skills by Training on the GI Mentor II

Buzink SN, Koch AD, Heemskerk J, Botden SM, Goossens RH, de Ridder H, Schoon EJ, Jakimowicz JJ.
Faculty of Industrial Design Engineering, Delft University of Technology,
Landbergstraat 15, 2628 CE, Delft, The Netherlands.
Surg Endosc. 2007 Nov;21(11):1996-2003.

Background: Achieving proficiency in flexible endoscopy requires a great amount of practice. Virtual reality (VR) simulators could provide an effective alternative for clinical training. This study aimed to gain insight into the proficiency curve for basic endoscope navigation skills with training on the GI Mentor II.

Methods: For this study, 30 novice endoscopists performed four preset training sessions. In each session, they performed one EndoBubble task and managed multiple VR colonoscopy cases (two in first session and three in subsequent sessions). Virtual reality colonoscopy I-3 was repeatedly performed as the last VR colonoscopy in each session. The assignment for the VR colonoscopies was to visualize the cecum as quickly as possible without causing patient discomfort. Five expert endoscopists also performed the training sessions. Additionally, the performance of the novices was compared with the performance of 20 experienced and 40 expert endoscopists.

Results: The novices progressed significantly, particularly in the time required to accomplish the tasks (p < 0.05, Friedman’s analysis of variance [ANOVA], p < 0.05, Wilcoxon signed ranks). The experts did not improve significantly, except in the percentage of time the patient was in excessive pain. For all the runs, the performance of the novices differed significantly from that of both the experienced and the expert endoscopists (p < 0.05, Mann-Whitney U). The performance of the novices in the latter runs differed less from those of both the experienced and the expert endoscopists.

Conclusions: The study findings demonstrate that training in both VR colonoscopy and EndoBubble tasks on the GI Mentor II improves the basic endoscope navigation skills of novice endoscopists significantly.


Endoscopic Ultrasound Teaching and Learning

Barthet M.
Department of Gastroenterology, Hôpital Nord, Marseille, France.
Minerva Med. 2007 Aug;98(4):247-51.

Scientific publications in the field of endoscopic ultrasound (EUS) are raising up since the last twenty years. The value of EUS is directly proportional to the training, skill and experience of the endosonographer. In a recent series, the lowest annual number of examinations requested per year might be around 200-250 procedures. For achieving competence in all the fields of EUS, they recommended a minimum of 150 supervised cases, 75 of them being devoted to pancreaticobiliary diseases and 50 to fine needle aspiration (FNA). Many studies have yet confirmed the importance of the learning curve to improve the EUS accuracy. The accuracy of EUS staging of esophageal cancer was significantly improved over an 8-year period for T staging from 64% to 90% but not for N staging. Considering pancreaticobiliary diseases, some series reported the influence of training on accuracy of EUS-guided FNA of pancreatic masses. Even if the exact type and modalities for EUS training remained to be determined, the usefulness of a period of training in a center performing more than 200 procedures per year is confirmed. Improving cognitive EUS learning and technique required theoretical teaching and practical teaching with observation during live demonstration and echoendoscope hands-on in humans with an expert supervision or with different simulator models. In France, formal EUS training has been underway since 1991, with a two-year intensive program including 4 weeks of theoretical training and 20 one-day practical sessions per year. This program was updated in 2004 to include 3 weeks of theoretical course work including numerous video sessions and 1 week of practical sessions. Theoretical courses are given primarily by gastroenterologists and EUS experts, but also by pathologists, surgeons, anatomists and radiologists. Practical sessions include 4 days of live demonstrations and computed-based simulator (EUS mentor; Simbionix, Tel Hashomer, Israel) and one day with a swine model. Simulators, either computed-based simulator, Erlangen model, or live pigs are believed to shorten the learning phase of EUS. The live pig model was chosen for EUS credentialing because it appears to be similar in many respects to the human anatomy, especially for the pancreas, portal and mesenteric vessels, celiac axis, left kidney and spleen. In addition, for trainees, it often appears more exciting and stimulating than virtual model. However, EUS training on a swine model is recognized to be the more expansive way for EUS teaching. Between the pre and post-test, EUS fellows significantly improved their competence for the visualization of anatomical structures i.e. vena cava, mesenteric/splenic vein, celiac axis, pancreas and bile duct. At the end of the day-session, trainees were mostly able to recognize and follow these anatomical structures with both endoscopes. Interventional EUS learning was also assessed. A significant decrease in procedural duration and a significant increase in FNA precision were demonstrated for the puncture of a hilar liver lymph node.


Expert and Construct Validity of the Simbionix GI Mentor II Endoscopy Simulator for Colonoscopy

Koch AD, Buzink SN, Heemskerk J, Botden SM, Veenendaal R, Jakimowicz JJ, Schoon EJ.
Department of Gastroenterology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
Surg Endosc. 2007 May 22;

Objectives: The main objectives of this study were to establish expert validity (a convincing realistic representation of colonoscopy according to experts) and construct validity (the ability to discriminate between different levels of expertise) of the Simbionix GI Mentor II virtual reality (VR) simulator for colonoscopy tasks, and to assess the didactic value of the simulator, as judged by experts.

Methods: Four groups were selected to perform one hand-eye coordination task (EndoBubble level 1) and two virtual colonoscopy simulations on the simulator; the levels were: novices (no endoscopy experience), intermediate experienced (<200 colonoscopies performed before), experienced (200-1,000 colonoscopies performed before), and experts (>1,000 colonoscopies performed before). All participants filled out a questionnaire about previous experience in flexible endoscopy and appreciation of the realism of the colonoscopy simulations. The average time to reach the cecum was defined as one of the main test parameters as well as the number of times view of the lumen was lost.

Results: Novices (N = 35) reached the cecum in an average time of 29:57 (min:sec), intermediate experienced (N = 15) in 5:45, experienced (N = 20) in 4:19 and experts (N = 35) in 4:56. Novices lost view of the lumen significantly more often compared to the other groups, and the EndoBubble task was also completed significantly faster with increasing experience (Kruskal Wallis Test, p < 0.001). The group of expert endoscopists rated the colonoscopy simulation as 2.95 on a four-point scale for overall realism. Expert opinion was that the GI Mentor II simulator should be included in the training of novice endoscopists (3.51).

Conclusions: In this study we have demonstrated that the GI Mentor II simulator offers a convincing realistic representation of colonoscopy according to experts (expert validity) and that the simulator can discriminate between different levels of expertise (construct validity) in colonoscopy. According to experts the simulator should be implemented in the training programme of novice endoscopists.



Multicenter, Randomized, Controlled Trial of Virtual-Reality Simulator Training in Acquisition of Competency in Colonoscopy

Cohen J, Cohen SA, Vora KC, Xue X, Burdick JS, Bank S, Bini EJ, Bodenheimer H, Cerulli M, Gerdes H, Greenwald D, Gress F, Grosman I, Hawes R, Mullen G, Schnoll-Sussman F, Starpoli A, Stevens P, Tenner S, Villanueva G.
Gastrointest Endosc. 2006 Sep;64(3):361-368

Current affiliations: NYU School of Medicine, New York, NY (Drs J Cohen and Vora); Beth Israel Medical Center, New York, NY (Drs SA Cohen and Bodenheimer); Albert Einstein College of Medicine, Bronx, NY (Dr Xue); University of Texas Southwestern, Dallas, Tex (Dr Burdick); Long Island Jewish Hospital, New Hyde Park, NY (Dr Bank); NYU Medical Center, New York, NY (Drs Bini and Villanueva); Brooklyn Hospital, Brooklyn, NY (Dr Cerulli); Memorial Sloan Kettering, New York, NY (Dr Gerdes); Montefiore Hospital, Bronx, NY (Dr Greenwald); Winthrop Hospital, Mineola, NY (Dr Gress); Long Island City Hospital, Long Island City, NY (Dr Grosman); Medical University of South Carolina, Charleston, SC (Dr Hawes), North Shore Hospital, Manhasset, NY (Dr Mullen); Cornell University Hospital, New York, NY (Dr Schnoll-Sussman); St. Vincent’s Hospital, New York, NY (Dr Starpoli); Columbia University, New York, NY (Dr Stevens); and Maimonides Hospital, Brooklyn, NY (Dr Tenner).

Background: The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience.

Objectives: 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.

Intervention: 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 Measurments: 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.


Perceptual, Visuospatial, and Psychomotor Abilities Correlate with Duration of Training Required on a Virtual-Reality Flexible Endoscopy Simulator

Ritter EM, McClusky DA 3rd, Gallagher AG, Enochsson L, Smith CD.

E*STAR Laboratory, Emory Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA, and Center for Advanced Medical Simulation, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.
Am J Surg. 2006 Sep;192(3):379-84
Background: Trainees acquire endoscopic skills at different rates. Fundamental abilities testing could predict the amount of training required to reach a performance goal on a virtual-reality simulator.

Methods: Eleven medical students were tested for fundamental abilities. Baseline endoscopic proficiency was evaluated with the GI Mentor II VR simulator (Simbionix, USA, Cleveland, OH). Subjects trained on the simulator with a defined performance goal. Subjects who achieved the goal were then reassessed.
Results: All subjects completed at least 10 trials or reached the performance goal. The <10 trial group (n=6) tested better for all fundamental abilities and baseline endoscopic performance than the >10 trial group (n=5). The number of trials required to reach the performance goal correlated significantly with both perceptual (r=.92, P=0.001) and visuospatial ability (r=.76, P=.03). Multiple regression showed strong correlation of all three abilities with duration of training (r=.95, P=.015).

Conclusions: Most of the variability in acquisition of endoscopic skills can be accounted for by differences in fundamental abilities of trainees. Testing of fundamental abilities could help identify trainees who will require additional training to achieve desired performance objectives.


Simbionix Simulator

Bar-Meir S.
Department of Gastroenterology, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
Gastrointest Endosc Clin N Am. 2006 Jul;16(3):471-8

The GI Mentor (Simbionix, Lod, Israel) is a computer-based simulator used for training in endoscopy. It contains modules for training in hand-eye coordination, upper and lower gastrointestinal endoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography. It provides experience in the steering and torque of the endoscope, suction, and inflation, a realistic view through the monitor, and a realistic force feedback when performing the procedure. Its advantages include its availability for training with no need for previous preparation and the constant interaction with the trainee. It is costly, however, and presently is suitable only for the initial steps of training.


Objective Assessment of Visuospatial and Psychomotor Ability and Flow of Residents and Senior Endoscopists in Simulated Gastroscopy

Enochsson L, Westman B, Ritter EM, Hedman L, Kjellin A, Wredmark T, Fellander-Tsai L.
Surg Endosc: 2006 May 12
Department of Clinical Science Intervention and Technology (CLINTEC), Division of Surgery, Karolinska Institutet and Center for Advanced Medical Simulation at Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden, Lars.Enochsson@karolinska.se.

Background: Advanced medical simulators have predominantly been used to shorten the learning curve of endoscopy for medical students and young residents. Rarely have the effects of visuospatial ability and attitudes of intermediately experienced and experienced specialists been studied with regard to simulator training. The aim of this study was to assess the effects of visuospatial ability and attitude on performance in simulator training.

Methods: Eighteen surgical residents were included in the study. Prior to the simulated gastroscopy task, they performed a visuospatial test (the card rotation test). After the simulated gastroscopy task, they completed a questionnaire regarding flow experiences. Their results were compared with those of 11 expert endoscopists who performed the same tests.

Results: Total gastroscopy time was significantly shorter for the expert endoscopists compared to residents (2 min 11 sec, p = 0.003). There was also a trend of more mucosa inspected (p = 0.088) and higher efficiency of screening (p = 0.069) by the experts. The residents made fewer errors in the card rotation test than the expert endoscopists (2.5 /- 0.8 vs 5.5 /- 1.2, respectively; p = 0.034), and their visuospatial card rotation test results correlated better with their performance in the simulated gastroscopy.

Conclusions: A virtual gastroscopy task presents more of an emotional as well as a psychomotoric challenge to intermediately experienced endoscopists than to senior experts. Our study demonstrates that these differences can be objectively assessed by the use of visuospatial ability tests, flowsheets, and an endoscopic simulator.


Visuospatial Abilities Correlate with Performance of Senior Endoscopy Specialist in Simulated Colonoscopy

Westman B, Ritter EM, Kjellin A, Torkvist L, Wredmark T, Fellander-Tsai L, Enochsson L.
Center for Advanced Medical Simulation, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
J Gastrointest Surg. 2006 Apr;10(4):593-9

Visuospatial abilities have been demonstrated to predict the performance of medical students in simulated endoscopy. However, little has been reported whether differences in visuospatial abilities influence the performance of senior endoscopists or whether their vast endoscopy experience reduces the importance of these abilities. Eleven senior endoscopists were included in our study. Before the simulated endoscopies in GI Mentor II (gastroscopy: case 3, module 1 and colonoscopy: case 3, module 1), the endoscopists performed three visuospatial tests: (1) pictorial surface orientation (PicSOr), (2) card rotation, and (3) cube comparison tests that monitor the ability of the tested person to re-create a three-dimensional image from a two-dimensional presentation as well as mentally manipulate that re-created image. The results of the visuospatial tests were correlated to the performance parameters of the virtual-reality endoscopy simulator. The percent of time spent with clear view in the simulated colonoscopy correlated well with the performance in the visuospatial PicSOr (r = -0.75, P = 0.01), card rotation (r = 0.75, P = 0.01), and cube comparison (r = 0.79, P = 0.004) tests. The endoscopists who performed better in the visuospatial tests also were better at maintaining visualization of the colon lumen. Those who performed better in the PicSOr test formed fewer loops during colonoscopy (r = 0.60, P = 0.05). In the technically less demanding simulated gastroscopy, there were no such correlations. The visuospatial tests performed better in endoscopists not playing computer games. Good visuospatial ability correlates significantly with the performance of experienced endoscopists in a technically demanding simulated colonoscopy, but not in the less demanding simulated gastroscopy.


Objective Assessment of Gastrointestinal Endoscopy Skills Using a Virtual Reality Simulator

Grantcharov TP, Carstensen L, Schulze S.
Department of Surgical Gastroenterology D, Copenhagen University, Glostrup Hospital, Glostrup, Denmark.
JSLS. 2005 Apr-Jun;9(2):130-3.

Background: This study was carried out to validate the role of virtual reality computer simulation as a method of assessment of psychomotor skills in gastrointestinal endoscopy. We aimed to investigate whether the GI Mentor II computer system (Simbionix Ltd.) was able to differentiate between subjects with different experience with GI endoscopy.

Methods: Twenty-eight subjects were included in the study. They were divided into 3 groups according to their experience with GI endoscopy: experienced [group 1, performed > 200 endoscopic procedures, (n = 8)] residents [group 2, performed < 50 endoscopic procedures, (n = 10)] and medical students [group 3, never performed GI endoscopy, (n = 10)]. All participants received identical pretest instruction on the simulator. Assessment of endoscopic skills was performed during a simulated colonoscopy and was based on parameters measured by the computer system: time, percentage of mucosa surface examined, efficiency of screening, time with a clear view, excessive local pressure, pain, time with pain, loop formation, and total time with a loop.

Results: Significant differences in performance existed between surgeons in the 3 groups. Experienced surgeons demonstrated best performance parameters, followed by the residents and the medical students. Significant differences in time (Kruskal-Wallis test, P < 0.001), percentage of mucosa surface examined (P = 0.001), efficiency of screening (P = 0.001), time with a clear view (P = 0.001), pain experienced (P = 0.004), time with pain (P = 0.012), loop formation (P < 0.001), time with a loop (P < 0.001), and excessive local pressure (P = 0.001) were demonstrated. Significant differences existed between group 1 and 2 and 1 and 3 (Mann-Whitney test, P < 0.05). Differences between groups 2 and 3 did not reach statistical significance (P > 0.05).

Conclusions: The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates that the GI Mentor measures skills relevant for gastrointestinal endoscopy and can be used in training programs as an assessment tool.


Validation of a Flexible Endoscopy Simulator

Felsher JJ, Olesevich M, Farres H, Rosen M, Fanning A, Dunkin BJ, Marks JM.
Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, OH, USA.
Am J Surg. 2005 Apr;189(4):497-500.

Background: Virtual reality (VR) simulation is a rapidly proliferating adjunct of surgical training. Numerous devices have evolved as educational tools in a variety of fields. Whether these tools can be used for validation of physicians’ skills has yet to be determined. The objective of this study was to determine whether the GI Mentor (Simbionix, Lod, Israel) flexible endoscopy simulator construct could distinguish experienced endoscopists from beginners.

Methods: Seventy-five surgical attendings, fellows, and residents were recruited for participation in the study. Two cohorts were used and these groups were selected from 2 separate scientific sessions. Participants completed a standardized questionnaire documenting their endoscopic training and experience. Physicians subsequently were designated as experienced or beginner after their endoscopic training and experience were evaluated. All participants completed 1 of 2 colonoscopic simulations. The GI Mentor objectively evaluated performance on the basis of programmed data points, including the time to reach the cecum, the percentage of mucosa visualized, the completed polypectomy rate, the percentage of time spent in clear view through the lumen, the percentage of time that the patient was in pain, and overall efficiency.

Results: In both simulations, experienced endoscopists were more efficient than beginners (.32%/s vs. .26%/s, P=.02; and .53%/s vs. .37%/s, P=.03) and achieved a greater polypectomy rate (78% vs. 43%, P=.03; and 87% vs. 48%, P=.01). Furthermore, experienced endoscopists visualized more of the colonic surface (86% vs. 82%, P=.02) and spent a greater proportion of the time in clear view of the lumen (55% vs. 47%, P=.05) than beginners completing the first simulation. In the second simulation, experienced participants reached the cecum more rapidly than beginners (175 vs. 262 s, P=.01).

Conclusions: The G1 Mentor VR colonoscopy construct appears valid. Significant performance differences were shown between the experienced and beginner cohorts. The beginner participants in this study were all physicians with some degree of endoscopic experience. Therefore, the G1 Mentor distinguished endoscopists of varying experience and exposure. Further validation studies are needed to evaluate the breadth of programs inherent to this simulator and to determine whether it may be used in the future for qualification and certification purposes.


Initial Experience Using an Endoscopic Simulator to Train Surgical Residents in Flexible Endoscopy in a Community Medical Center Residency Program

Clark JA, Volchok JA, Hazey JW, Sadighi PJ, Fanelli RD.
Department of Surgery, Berkshire Medical Center, Pittsfield, Massachusetts, USA.
Curr Surg. 2005 Jan-Feb;62(1):59-63

Introduction: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins.

Methods: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed.

Results: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%.

Conclusions: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.


Teaching and Testing Surgical Skills on a VR Endoscopy Simulator- Learning Curves and Impact of Psychomotor Training on Performance in Simulated Colonoscopy

Teodor P Grantcharov MD, Andreas Eversbusch MD, Peter Funch-JensenMD Department of Surgical Gastroenterology, Copenhagen University, Glostrup Hospital & Department of Surgery L, Aarhus University Hospital

The abstract was published and presented as part of the poster session at the 2004 SAGES meeting, March 31 – April 3 2004 in Denver , Colorado. Education/Outcomes, Poster P179
This study demonstrates that different learning curves exist for surgeons with different endoscopic background. The familiarization rate on the simulator was proportional to the endoscopic experience of the surgeons. It also demonstrates that a significant effect of psychomotor training on performance in simulated colonoscopy.


Validity and Reliability of a Virtual Reality Upper Gastrointestinal Simulator and Cross Validation Using Structured Assessment of Individual Performance with Video Playback

Moorthy K, Munz Y, Jiwanji M, Bann S, Chang A, Darzi A.
Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed Street, London, W2 1NY, United Kingdom.
Surg Endosc. 2004 Feb;18(2):328-33.

Background: This study aims to evaluate the ability of an upper gastrointestinal virtual reality simulator to assess skills in endoscopy, and to validate its metrics using a video-endoscopic (VES) technique.

Methods: The 32 participants in this study were requested to undertake two cases on the simulator ( Simbionix , Israel ). Each module was repeated twice. The simulator’s metrics of performance were used for analysis. two blinded observers rated performance watching the simulator’s playback feature.

Results: There were 11 novices (group 1), 11 trainees with intermediate experience (10-50 procedures, group 2), and 10 experienced endoscopists (>200 procedures, group 3). There was a significant difference in the total time required to perform the procedure (p < 0.001), percentage of mucosa visualized (p < 0.001), percentage of pathologies visualized (p < 0.001), and number of inappropriate retroflexions (p = 0.015) across the three groups. The reliability of assessment on the simulator was greater than 0.80 for all parameters. The VES assessment also was able to discriminate performance across the groups (p < 0.001). There was a significant correlation between the VES score and the percentage of mucosa visualized (rho = 0.60; p < 0.001).

Conclusions: The upper gastrointestinal simulator may be a useful tool for determining whether a trainee has achieved a desired level of competence in endoscopy. The next step will be to validate the VES score in real procedures.


Objective Psychomotor Skills Assessment of Experienced and Novice Flexible Endoscopists with a Virtual Reality Simulator

Ritter EM, McClusky DA 3rd, Lederman AB, Gallagher AG, Smith CD.
Emory Endosurgery Unit, Emory University School of Medicine, Atlanta, Georgia 30322, USA .
J Gastrointest Surg. 2003 Nov;7(7):871-7; discussion 877-8.

The objective of this study was to determine whether the GI Mentor II virtual reality simulator can distinguish the psychomotor skills of intermediately experienced endoscopists from those of novices, and do so with a high level of consistency and reliability. A total of five intermediate and nine novice endoscopists were evaluated using the EndoBubble abstract psychomotor task. Each subject performed three repetitions of the task. Performance and error data were recorded for each trial. The intermediate group performed better than the novice group in each trial. The differences were significant in trial 1 for balloons popped (P=.001), completion time (P=.04), and errors (P=.03). Trial 2 showed significance only for balloons popped (P=.002). Trial 3 showed significance for balloons popped (P=.004) and errors (P=.008). The novice group showed significant improvement between trials 1 and 3 (P<0.05). No improvement was noted in the intermediate group. Measures of consistency and reliability were greater than 0.8 in both groups with the exception of novice completion time where test-retest reliability was 0.74. The GI Mentor II simulator can distinguish between novice and intermediate endoscopists. The simulator assesses skills with levels of consistency and reliability required for high-stakes assessment.


Flexible Endoscopy Simulator

Dunkin BJ.
Department of Surgery, University of Miami School of Medicine, Miami , Florida 33136, USA.
Semin Laparosc Surg. 2003 Mar;10(1):29-35

Training in flexible endoscopy is becoming increasingly complex. In an effort to improve the efficiency of endoscopic education, physicians are turning to simulation technology to provide a platform for training away from the endoscopy suite. The concept of medical simulation is not new, but the recent addition of powerful computer-generated virtual reality simulation has revolutionized the field. These compact computers are now able to generate a simulated environment that not only mimics the movement of the endoscope, but also recreates the sounds of the endoscopy suite, the feel of the movement of the scope, the reaction of intestinal tissue, and the response of a patient experiencing discomfort. Within this life-like simulated environment, a wide variety of diagnostic and therapeutic endoscopic procedures can be performed. This article reviews the history of flexible endoscopy simulators and details the most advanced models currently available. The literature supporting the use of these simulators is also presented, and issues involving the incorporation of simulation technology into endoscopic education and credentialing are discussed.


Evaluation of a Virtual Endoscopy Simulator for Training in Gastrointestinal Endoscopy

Ferlitsch A, Glauninger P, Gupper A, Schillinger M, Haefner M, Gangl A Schoefl R
Endoscopy 2002; 34: 698–702

This virtual endoscopy simulator is capable of identifying differences between beginners and experts in gastrointestinal endoscopy.

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Poster of Distinction–P014

Establishing the Reliability and Validity of a Virtual Reality Upper Gastrointestinal Simulator Using a Novel Video-Endoscopic Assessment Technique

Krishna Moorthy MBBS, Yaron Munz MD, Avril Chang MBBS, Mustafa Jiwanji, Ara Darzi MD, Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, St. Mary’s Hospital, London, UK

Background: This study aims to establish the construct validity of an Upper GI simulator (Simbionix, Israel) and to cross validate its parameters using a novel video-endoscopic assessment technique developed by us.

Methods: Study participants were requested to undertake 2 modules on the simulator, twice each. The simulator’s assessment of percentage of mucosa visualized fails to give details regarding the part of the upper gastro-intestinal tract which was missed or inadequately visualized. Using a video-endoscopic assessment method developed by us, two independent blinded observers rated the performance by scoring different components of the procedure on a 5 point Likart scale. Statistical analysis was done using the Kruskal Wallis test, Mann-Whitney U test and Spearman’s correlation.

Results: There were 11 novices (Group 1), 11 residents (20-80 procedures, Group 2) and 10 experienced endoscopists (> 200, Group 3). There was a significant difference in the total time taken to perform the procedure (p<0.001), percentage of mucosa visualized (p<0.001), percentage of pathologies visualized (p=0.002) and the number of inappropriate retroflexions (p=0.016) across the groups. Inter-group analyses were significant between 1 and 3 for all parameters and in between 2 and 3 for three of the parameters.

There was also a significant difference in the video-endoscopic score across the groups (p<0.001). This was significant between 1 and 3 (p<0.001) and 1 and 2 (p=0.001) but not between 2 and 3 (p=0.50). There was a significant correlation between the video-endoscopic score and percentage of mucosa visualized (rho= .64, p< 0.001) and number of inappropriate retroflexions (rho= 0.67, p<0.001).

Conclusion: This study has established the construct validity of the simulator which can strongly discriminate between groups with different levels of experience.
The video-endoscopic method developed by us validates the simulator’s assessment parameters.

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Education/Outcomes–P155

Assessment of GI Endoscopic Skills on a VR Simulator – Validation of GI Mentor

Teodor Grantcharov, M.D., Sven Adamsen, M.D., Jacob Rosenberg, M.D., Peter Funch-Jensen, M.D., Departments of Surgical gastroenterology: 1) Aarhus University, Kommunehospitalet 2) University of Copenhagen, Glostrup Hospital 3) University of Copenhagen, Gentofte Hospital 4) University of Copenhagen, Herlev Hospital. Denmark

Methods and Procedures: Twenty-four surgeons and medical gastroenterologists were included in the study. They were divided into two groups according to their experience with GI endoscopy: experienced (performed> 200 endoscopic procedures) and unexperienced (performed <100 endoscopic procedures). All participants performed level 1 of the Cyberscopy task on an endoscopy simulator GI Mentor II). Assessment of endoscopic skills was based on three parameters – time, error score (sum of number of punctured objects and number of wall collisions), and economy score (sum of economy of movement- and confidence of manipulations scores). Time- and error scores were measured by the computer system, while economy score was assessed by a observer with big experience in GI endoscopy.

 Results:Significant differences in performance existed between the 2 groups. Experienced endoscopists performed faster (Mann-Whitney’s test, p<0.001), made less errors (Mann-Whitney’s test, p=0.006) and demonstrated better economy score (Mann-Whitney’s test, p=0.005) than unexperienced.

Conclusion:The VR simulator was able to differentiate between subjects with different endoscopic experience. This indicates GI Mentor measures skills relevant for GI endoscopy and can be used in training programs as an assessment tool.


Education/Outcomes–P156

Are Technical Skills in Minimally Invasive Surgery and GI Endoscopy Identical?

Teodor P. Grantcharov, M.D., Sven Adamsen, M.D., Peter Funch-Jensen, M.D., Jacob Rosenberg, M.D., Departments of surgical gastroenterology: 1) Aarhus University, Kommunehospitalet 2) University of Copenhagen, Glostrup Hospital 3) University of Copenhagen, Gentofte Hospital 4) University of Copenhagen, Herlev Hospital. Denmark

Objectives: It has been considered that “good” laparoscopists are also “good” GI endoscopists and vice versa. However, no scientific data exist on this matter. The study was carried out to evaluate quantitatively the correlation between laparoscopic and endoscopic performance using virtual reality computer simulators, and thus to investigate whether the psychomotor skills required for the performance of these procedures are identical.

Methods and Procedures: Twenty-four surgeons and medical gastroenterologists were included in the study. All participants performed task 6 on a laparoscopy simulator (MIST-VR, Core Skills II) and level 1 of the Cyberscopy task on an endoscopy simulator (GI Mentor II). Assessment of laparoscopic manual skills was based on three parameters measured by the computer simulator – time, errors and economy of hand movement. Assessment of endoscopic skills was based on corresponding parameters – time, error score (sum of number of punctured objects and number of wall collisions), and economy score (sum of economy of movement- and confidence of manipulations scores).

Results: Data was analysed by use of Spearman’s correlation test. Significant correlations existed between performance on MIST-VR and GI Mentor regarding all three performance parameters: time (Spearman’s r=0.669, p<0.001), error score (Spearman’s r=0.720, p<0.001) and economy of motion score (Spearman’s r=0.5, p=0.024).

Conclusion: The study provides objective and quantitative evidence of strong correlation between performance scores demonstrated during simulated laparoscopy and GI endoscopy. This indicates that psychomotor skills necessary for the performance of these procedures are identical.


Flexible Diagnostic & Therapeutic Endoscopy–P233

Initial Experience Using an Endoscopic Simulator to Train Residdents in Felxible Endoscopy in a Community Medical Center Based Residency Program

Robert D. Fanelli, MD, FACS; Mark T. Mainella, DO; Justin R. Clark, DO; Keith S. Gersin, MD, FACS, Surgical Specialists of Western New England, PC, Pittsfield, MA; Berkshire Medical Center, Department of Surgery, Pittsfield, MA; University of Cincinatti, Department of Surgery, Cincinatti, OH.

Introduction: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite mandates from the RRC, few programs have managed to incorporate effective endoscopic training into their curricula, making it difficult for their graduates to be credentialled in GI endoscopy. We report our initial success using a virtual reality endoscopic simulator to improve education in flexible endoscopy.

Methods: Prior to October 2001, residents were taught flexible endoscopy by staff surgical endoscopists. Because flexible endoscopy requires different skills than surgery, even senior residents spent considerable time observing endoscopic procedures rather than performing them. Although residents met RRC minimums, rarely did they log enough actual experience to qualify for clinical privileges. Since October 2001, we have used an endoscopic simulator to train residents in GI endoscopy. Residents are given monthly assignments of simulated cases. Junior residents master diagnostic procedures, and therapeutic procedures are emphasized in senior years. PGY-2 and PGY-4 residents participate in a 3-month surgical endoscopy rotation, where they gain significant clinical experience.

Results: The simulator allows residents to master the learning curve quickly, so that they may perform the majority of procedures independently when they rotate through the surgical endoscopy service.
Residents learn endoscopy quickly since they develop basic skills using the simulator, and build advanced skills during clinical exposure. Chief residents planning careers in general surgery have successfully logged enough cases to perform GI endoscopy with facility and qualify for privileges.

Conclusions: Endoscopic simulators provide surgical residents with valuable training that allows them to master basic skills quickly, and prepares them to perform GI endoscopy in less time than exposure based learning.


Flexible Sigmoidoscopy: Assessing Endoscopic Skills Using Computer- Based Simulator

Abstract (P736) published at ACG meeting, October 2002 (Seattle, Washington). Mahmoud M.Yousfi, M.D.,Darius Sorbi, M.D. Todd Baron, M.D., David E. Fleischer, M.D., Mayo Clinic, Scottsdale, AZ

The study shows that compared to expert gastroenterologists, GI nurses with no prior hands-on endoscopy experience required more time to reach the transverse colon, caused more excessive pressure, and received more help from the virtual instructor and the 3-D map. The authors claim that such variables could be used to assess the skills of endoscopy trainees.


Evaluation of a Virtual Endoscopy Simulator for Training in Gastrointestinal Endoscopy

Published in Endoscopy 2002; 34(9): 698-702. A. Ferlitsch, P. Glauninger, A. Gupper, M. S. Schillinger, M. Haefner, A. Gangl, R. schoefl.

The article shows that the GI MENTOR™ is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. In addition, 3 week training improves the performance of beginners significantly.


Basic Endoscopy Training: Usefulness of A Computer-Based Simulator

DIEGO FREGONESE, TINO CASETTI, RENZO CESTARI, FAUSTO CHILOVI, GIANCARLO D’AMBRA, GIANFRANCO DELLE FAVE, EMILIO DI GIULIO, GIOVANNI DI MATTEO, LEONARDO FICANO
Cooperative Group for Training in Endoscopy (Endo Teaching Group) – Rome, Italy
Presented as a Poster at the DDW exhibition on May 22, 2001, Atlanta, U.S.A

This study is supported by an unrestricted education grant by Bracco Italia.

Aim of The Study: Education in medical practice is time consuming and very expensive. An endoscopic fellowship is particularly difficult due to the invasive endoscopic procedures. To learn endoscopy adds a potential risk for the patients. Endoscopic training on simulators could theoretically reduce both the learning curvature than critical mistakes, dangerous for the patients. Endoscopic training is generally long and expensive. The introduction of sophisticated simulators as GI Mentor has made possible to evaluate a training program based on a simulator device. Our prospective study has the aim to validate the use of a computer-based simulator in the endoscopic fellowship.
Generally it starts with the simpler procedure: the upper gastrointestinal endoscopy (UGE).
Our study has evaluated the differences between two groups of fellows, one of them pre-trained on the simulator.

The GI-Mentor: a computer-based simulator
The Simbionix simulators are based on the production of a three-dimensional geometric model. The texture of the GI tract is videotaped during a real endoscopic procedure and manipulated by a computer. The computer also stores information related to the endoscope movement during the procedure. Information about the location of the endoscope is transmitted form sensors located in the endoscope. The force feedback is based on both the motion model and the characteristics of GI tract. All these effects are finally manipulated by the computer and give a realistic effect: in real-time. The endoscopy is performed in a mannequin using a Pentax endoscope. Steering and torque of the endoscope is therefore possible and there are suction and inflation buttons as well. All these effects made the simulator endoscopic procedure similar to the reality.

Plan of The Study:
Two groups of fellows has been considered:

  1. NoSIM GROUP: Gastroenterology fellows without any previous experience on endoscopy. They were request to perform UGE after the simply observation of UGE procedures performed by an experienced endoscopist, as usually happen during the fellowship.
  2. SIM GROUP: Gastroenterology fellows without any previous experience on endoscopy. They were pre-trained for 10 hours on GI Mentor, before start the normal UGE learning procedure, as described before.

Each fellow has been requested to perform up to 20 UGEs inclusive of intubation, in a pre-definite time, with a complete exploration of the UGI tract. An experienced tutor has been always present to the procedures, recording definite steps of during the UGEs, and giving help if request and/or necessary.
Patients has been normal scheduled cases, relate to the tutor list. All the procedures have been performed in an Endoscopy Unit of a teaching hospital. Patients under 18 years were excluded, as patients with previous gastric operations. Patients need to give their agreement as routine.

Final considerations:
GI-Mentor looks to be very helpful in the endoscopic training program. SIM Group requires less assistance and in this group fellows quickly learn to manage a complete UGE without assistance. Intubation does not improve after simulator training, as the length of the procedure. In both the groups the skipped lesions number is not surprisingly high: this data has been expected. Endoscopic movements capture all the fellows attention, and they easily miss little lesions.

Finally the difference in trainer judgement is significatively high. More data are necessary to confirm our study, but the practical use of a simulator on a training endoscopic program looks to be validated.


Virtual Endoscopy Simulation for Training of Gastrointestinal Endoscopy

Presented as a Poster at the DDW exhibition on May 22, 2001, Atlanta, U.S.A

Arnulf Ferlitsch, Peter Glauninger, Astrid Gupper, Martin Schillinger, Michael Haefner, Alfred Gangl, Rainer Schoefl
Dept. of Internal Medicine IV, Div. of Gastroenterology and Hepatology, Univ. of Vienna

Background: Skills in gastrointestinal endoscopy mainly depend on experience and exercise. Patients, in whom a trainee does the first endoscopies, are likely to suffer more pain and prolonged procedures. Training on endoscopy simulators, their latest generation being electronic virtual reality devices, is said to decrease time to reach competency in endoscopy. The purpose of the study was to determine whether the GI-Mentor® simulator (Simbionix, Israel) (Figure 1) can distinguish between beginners and experts in endoscopy, and to evaluate, if training for a limited time period can improve the performance of beginners.


Figure 1: Outside view of the GI-Mentor including torso, endoscope and computer unit

Methods: Testing and training took place on the GI-Mentor® (Simbionix, Israel), a virtual endoscopy simulation. Thirteen beginners and 11 experts (1000 procedures, both EGD and colonoscopy) in GI-endoscopy were included. The assessment of basic abilities included both two virtual gastroscopies and colonoscopies as well as two virtual skill tests. (Figure 2-4) The beginners were then randomised to a training (n=7) and a non training (n=6) group. The training group was allowed to work with the simulator two hours a day. After three weeks all participants were re-examined with two new endoscopy cases and the same virtual skill test. Insertion time, correctly identified pathologies, adverse events (inappropriate or unsuccessful retroflection, excessive wall pressure, impaired lumen view), and number of bubble hits in the virtual skill test were recorded. Chi-square test and Mann-Whitney tests were used for comparison.


Figure 2: Study design as described in the methods section


Figure 3 4: Endoscopic view of the virtual skill tests. Task in figure 3 is to move a ball placed in the biopsy forceps into the basket, task in figure 4 is to stitch the bubble with the needle

Results I: Basic assessment revealed significant differences in favour of experts in the virtual skill tests for the time used (p<0,05) (Figure 5) and for the number of bubble hits (p<0,01). Differences in the endoscopic tests differences could be seen for the number of adverse events in colonoscopy (p=0,02), for successful retroflection during EGD (p<0,005), for insertion time of gastroscopy and colonoscopy (p<0,001), and for the percentage of correctly identified pathologies (p<0,02) At the basic assessment, training and non training group did not differ in any tested parameter.

Results II: Final evaluation after three weeks showed significant differences between the two beginner groups in favour of the exercising group for number of adverse events during gastroscopy (p=0,02) and colonoscopy (p=0,04), for insertion time (p<0,03) and time of unrestrained lumen view during colonoscopy (p<0,02) and for the number of bubble hits (p<0,01). Significant differences were no longer seen between experts and exercising group at the final evaluation for any tested parameter
(Figure 6).


Figure5: Virtual skill test results demonstrating differences between beginners and experts before training.


Figure 6: Virtual skill test revealing similar performance between experts and exercising beginners after training

Discussion: Testing with the GI-Mentor® virtual endoscopy simulator is capable to disclose differences between beginners and experts of GI endoscopy. A training period of three weeks and two hours per day improves the performance of beginners, verified by significant differences in several tested parameters. The value of virtual reality simulator training for accelerating the development of hand-eye skills in endoscopy is obvious. Experts and beginners appreciated the realistic three-dimensional movements. Complex manipulative techniques- e.g. loop formations- are not simulated, which would make the simulator more attractive for the experienced endoscopist.


Figure 7-10: Virtual image of reflux esophagitis IV, angio-dysplasia (corpus), pseudo-polyposis (caecum), colon cancer

Figure 7-10: Virtual image of reflux esophagitis IV, angio-dysplasia (corpus), pseudo-polyposis (caecum), colon cancer


A multi-institutional international study evaluating the use of simulation technology to train fellows in colonoscopy is in the process of being conducted by Brian J. Dunkin, M.D. from University of Miami School of Medicine, Jeffrey M. Marks, M.D. from Case Western Reserve School of Medicine and Jeffrey Ponsky, M.D. from CCF. The study which began on July 1, 2002 is planned to last for one year, and includes participation by a number of major medical centers from around the world. The study seeks to show that colonoscopy training of endoscopy fellows on the GI MENTOR simulator measurably improves their performance on real patients, increases patient safety and comfort and shortens the trainee learning curve.


The Future of Simulators in GI Endoscopy

An article published in the April issue of Gastrointestinal Endoscopy, poses the question of the future of simulators in GI endoscopy. The article contains a review of current literature reporting studies conducted on at least 2 medical training simulators. Though the article poses a number of yet to be answered questions on how best to employ simulators, it concludes that the initial goals of medical simulation have been achieved, and their future is promising.
Gerson, Lauren B. MD, MSC and Van Dam, Jacques, Ph.D. The future of simulators in GI endoscopy: An unlikely possibility or a virtual reality?

Gastrointestinal Endoscopy 4/2002;55: 608-611


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