Gastroenterological Endoscopy. Группа авторов

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СКАЧАТЬ Costamagna et al³⁴ allows to practice cannulation and different ERCP techniques except sphincterotomy via a plastic papilla with varying ampullary anatomy, orientation, and cannulation difficulty.

      Another promising simulator is the “T.E.S.T box simulator” (

Fig. 1.5).³⁵ The model, designed by Christopher Thompson has demonstrated an ability to distinguish skills levels with significant differences between all categories from beginner to expert interventional endoscopist. One limitation of this and all static simulators to date is the limited exposure to pathology for training in image recognition and application of findings into management decisions.

      Fig. 1.5 The Thompson Endoscopic Part Task Simulator Training (T.E.S.T.) box containing five different training modules.³³

      1.4.2. Computer Simulators

      Various computer simulation systems have been developed since the early 1980s.¹ Rapid progress in computer technology and electronics at the early 2000s allowed the development of commercially available systems. The first of these models was the Simbionix GI Mentor (3D Systems Healthcare, Littleton, CO, United States, formerly Simbionix Corporation), at the time in the shape of a human torso mannequin.³⁴ The system creates a relatively realistic virtual endoscopy environment and allowed the simulation of various diagnostic and interventional procedures at different levels. During training, teaching modules with anatomy and pathology (

Fig. 1.7) atlases are at the trainee’s disposition. Beginners can train their dexterity in a “GI Fundamental Skills” module including navigation, targeting, retroflection, loop reduction, or in “Cyberscopy,” a module to further enhance hand–eye coordination. Different modules such as upper and lower GI endoscopy, sigmoidoscopy, EUS, ERCP, and hemostasis training are available. EUS and ERCP modules allow parallel viewing of radiographic and endoscopic simulations. Virtual sphincterotomy, stone extraction, and other techniques have been implemented. In addition to the current GI Mentor model (3D Systems Healthcare), the EndoVR virtual reality endoscopy simulator (CAE Healthcare, Montreal, Canada, formerly “Accutouch” by Immersion Medical, Inc., Gaithersburg, MD, United States) has been used in multiple studies (see later). Recently, another system the so-called “Endo X” has been presented (Medical-X BV, EM Rotterdam, the Netherlands (Fig. 1.8). The system provides mainly upper and lower GI techniques, but also includes analyzing tools such as insufflation performance simulation and video recording of the procedure. All devices allow user-specific training curricula and reflect the user-specific learning curve. Modules are supervised by a virtual tutor and the whole system can be connected to a real supervisor via internet for additional personal feedback and to view learning curves of different trainees by the supervisor (Fig. 1.9). Various studies have demonstrated the benefits of additional computer simulator training in connection with colonoscopy.^1,28

      In a prospective simulation study, four fellows at the Mayo Clinic received 6 hours of simulator-based training, compared with four fellows without training. The simulator-trained fellows outperformed the traditionally trained fellows during their initial 15 to 30 colonoscopies in all performance aspects except for insertion time (p < 0.05). Beyond 30 procedures, there were no differences in performance between the two groups (evidence level B).

      Fig. 1.6 The Kyoto Kagaku colonoscopy training model with different possibilities to vary the difficulty of passage of the sigmoid (Level 1-6). (Images are provided courtesy of Kyoto Kagaku, Kyoto, Japan.)

      Fig. 1.7 Hands-on training using the compactEASIE simulator. (a) Groups of three or four fellows per simulator and teacher receiving instructions. (b) Individual practice, for example, for basic gastroscopy.¹

      Fig. 1.8 The EASIE-R model designed by Kai Matthes and based on the compactEASIE simulator.¹

      In a randomized controlled multicenter trial of 45 first-year GI fellows in New York comparing 10 independent hours of work on the Simbionix GI Mentor II versus no simulator training, trainees who worked on the simulator had significantly better objective technical and cognitive performance on their first 20 to 80 real supervised colonoscopy examinations but no difference in the time required to achieve competency nor in subjective proctor assessment of patient discomfort. These studies suggest that virtual reality simulator training prior to real cases accelerates early training, but improvement in final competency has not yet been established. Nor has there been any computer-based skills test that has been correlated with competent performance on actual endoscopic procedures.

      1.4.3 Training Courses with Live Animals

      Animal models offer a realistic learning environment; however, a substantial organizational, technical, and financial effort is required. Ethical considerations, animal welfare, and problems of hygiene, along with the need for dedicated endoscopes for animal use and substantial staff and financial expenditure, are major restrictions. Currently, training courses on live animals are performed for many different techniques including endoscopic submucosal dissection and peroral endoscopic myotomy.^36,37

      1.4.4 Ex Vivo Porcine Tissue Models (EASIE, Erlanger Endo-Trainer, EASIE-R)

      Clean pig stomachs with a dedicated mold have been used for training in diagnostic gastroscopy for many years.¹ As in the pulsatile organ perfusion simulator described by Szinicz et al,⁴⁰ a roller pump can be used to simulate spurting arterial bleeding in hollow GI viscera.

      The “compactEASIE” device is a simplified version of the original biosimulation model and was developed in 1998 (

Fig. 1.10a-c). For ERCP interventions such as sphincterotomy and stent placement the hepatobiliary system with the liver, extrahepatic bile ducts, and gallbladder is dissected and added to the upper GI tract. Bile duct stones can be simulated by inserting pieces of plastic stents into the bile duct. Matthes and Cohen have reported an interesting model called the “neopapilla.”⁴¹

      Fig. 1.9 A computer simulation model for gastroscopy and colonoscopy skills (Image is provided courtesy of Medical-X BV, EM Rotterdam, the Netherlands).

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