Gastroenterological Endoscopy. Группа авторов

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      Fig. 1.10 (a) The compactEASIE model for hands-on training using specially prepared pig organs. (b) A roller pump drives artificial blood into vessels that have been sutured into a pig stomach, to provide training in hemostasis procedures in realistic conditions. (c) Practicing hemoclipping with the compactEASIE simulator.

      Training in more than 30 interventional endoscopic techniques can be provided (

Table 1.2). It is generally recommended to use special animal endoscopes for the training with isolated (“ex vivo”) pig organs. Sedlack et al⁴² compared computer simulator, harvested porcine organ, and live anesthetized pigs for ERCP training. The authors concluded the harvested porcine organ model to be the most realistic model for instruction in both basic and advanced ERCPs.

      1.4.5 Training Courses

      Ways of Integrating Educational Material, Demonstration, Practice, Feedback, and Evaluation into a Comprehensive Workshop

      Regular training workshops on endoscopic hemostasis using the compactEASIE simulator have been available since 1997. EASIE team training comprises the simultaneous training of doctors and nurses in different interventional endoscopic techniques using this type of simulator and was first described in detail in 2001.¹

      Basic skills. To assess an individual’s capacity for brain–hand coordination, a practical simulator test for manual skills was developed. For this hand–eye dexterity test performed before the training course, four 2- to 3-mm dots are created on the anterior wall of the ex vivo porcine simulator using a thermal device. The dots are arranged in the form of a square standing on one corner, with a diagonal length of 2 cm. Precision in the brain–hand coordination test can be evaluated by asking the trainee to touch each mark with the probe in a clockwise fashion. The time needed to complete the task is also measured. In this exercise, precision is weighted more heavily than speed.

      Studies on training using ex vivo simulators (e.g., compactEASIE) for fellows and the EASIE team-training method

      Since the introduction of the EASIE simulator, considerable efforts have been made to assess the value of additional simulator training using the EASIE model in endoscopic hemostasis. Several prospective trials have been conducted in recent years to provide objective evidence that participants benefit from simulator training. A prospective randomized study conducted in collaboration with the New York Society for Gastrointestinal Endoscopy (NSYGE) was undertaken.⁶ The results provided the first evidence of benefit from simulator training in the treatment of upper GI bleeding. In this prospective training project, 37 gastroenterology fellows from nine hospitals in New York were first evaluated in five endoscopic techniques using the compactEASIE simulator. These included manual skills, ulcer hemostasis using injection, a coagulation probe and hemoclipping, as well as variceal band ligation. Twenty-eight fellows with comparable skills were then randomly assigned either to an intensive training group attending three 1-day simulator hands-on workshops over a period of 7 months or to a control group only receiving traditional clinical training in endoscopy in their home hospitals (

Fig. 1.11). During the 7-month study period, it was demonstrated that the additional simulator training in four endoscopic hemostasis techniques significantly enhanced the participants’ skills in comparison with the fellows who only received a clinical training. In particular, the evaluation of clinical cases following the training period showed a higher initial hemostasis rate and a lower complication rate among simulator-trained fellows, although the difference in the complication rate was not significant. These results were confirmed in a national training project conducted in France on training in endoscopic hemostasis that started 1 year later, with a similar study design.⁴³ The efficacy of the EASIE simulator was also confirmed in another project including novice endoscopists, in which remarkable levels of skill in hemostatic techniques were achieved using intensified simulator training every second week.⁷

Table 1.2 Selection of endoscopic interventions for which training can be carried out using the compactEASIE simulator

Training goal	Technique
Ulcer hemostasis	Injection techniques
	Thermal probes
	Clip application
	Over-the-scope-clip (OTSC)
	others
Variceal treatment	Multiple band ligationCyanoacrylate glue injection
	Sclerotherapy
Tissue resection techniques	Snare polypectomy, loop applicationSaline-assisted polypectomy/endoscopic mucosal resection (EMR) including piecemeal EMR, capEMR, “band and snare” techniqueEndoscopic submucosal dissection (ESD)Full-thickness resection (FTRD)Rotablation of tissue
Tissue coagulation and cryoablation	Argon plasma coagulation (APC)Radiofrequency ablation (RFA)Cryoablation, etc.
Stricture management and stenting	Balloon dilation, bougienageStenting: esophageal, gastro-duodenal, enteral, colonic
ERCP	Cannulation techniques, sphincterotomy and precut techniques, (Over)Guidewire exchange techniques (long and short wire/Rx)Stone extraction (balloon, basket), mechanical lithotripsy,Dilatation and bougienageStents, plastic, self-expanding metalstents (SEMS)Complex stenting techniques (multiple, bi-hilar stents)Fine caliber cholangioscopy
Complication management	Bleeding, perforation closure

      1.4.6 Incorporating Simulator Training into Educational Programs and Maintaining Skills in Complex Procedures

      Simulator training in interventional endoscopy provides an effective opportunity for endoscopy trainees to gain considerable experience in ERCP techniques without time limitations and patient risk. In the New York study on EASIE simulator training in hemostasis, the trainees achieved significant improvement in the performance of multiple skills on the simulator after only three workshops.⁴⁴ It appears that a structured educational program with access to simulator training, in addition to supervised real cases in the hospital plus DOPS evaluation, would increase the effectiveness of education in any interventional technique. The results of the real hemostasis cases performed in the New York study highlight this potential.⁴⁰ The analogous French training project confirmed that more complex techniques like clipping or injection/gold-probe application need repeat training courses to acquire and to maintain competence compared to easier techniques like band ligation.³⁹

      Fig. 1.11 Outline of a prospective and randomized study of training conducted in New York City, comparing conventional clinical education in endoscopic hemostasis provided for 14 gastroenterology fellows with 14 fellows who received additional hands-on training in simulators in three 1-day workshops. After a period of 7 months, the intensive training group had significantly improved in all disciplines, while the conventional clinical group had only improved in variceal band ligation. (Adapted from Hochberger et al 2005.⁶)

      The role of simulators in training the proper application of new devices and new techniques is not really known. However, many manufacturers have already now made specific certified training and supervision of the first clinical cases obligatory for new suturing, closure, or resective devices.

      There is little doubt that the knowledge and skills gained once may decline over time. Apart from sphincterotomy volume, little is known about deterioration of skill or outcome with infrequently practiced techniques. British experience СКАЧАТЬ