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Endoscopy education in underdeveloped countries: Vietnam
Techniques in Gastrointestinal Endoscopy (2011) 13, 199-202
Techniques in GASTROINTESTINAL ENDOSCOPY www.techgiendoscopy.com
Endoscopy education in underdeveloped countries: Vietnam Franklin Kasmin, MD Saint Vincent’s Hospital Manhattan, The Pancreas and Biliary Center, New York, New York. KEYWORDS: Vietnam; Endoscopic training; Developing countries
The example of Vietnam demonstrates the wide range of endoscopic capabilities in an underdeveloped country with emerging economic strength. Barriers to advancement in endoscopic techniques can be overcome through the donation of equipment and on-site, hands-on training. In a country where the endoscopists are experienced and skillful in basic techniques, significant advances in health care delivery can be achieved with relatively small investments in time and money. This process is naturally enormously gratifying for both the students and their mentors. © 2011 Published by Elsevier Inc.
Endoscopy education is a process in flux, even in the most established centers around the world. The process is not simple and not all trainees will necessarily become skillful endoscopists by simple observation and routine participation. Guidelines have been established based on not only numbers of procedures accomplished but also acquisition of defined skill sets and success rates that must be demonstrated. There is also a heightened awareness of the role of training simulators in assisting in endoscopic education. In considering how endoscopy is taught in developed nations, one might find interesting the contrast with the process in underdeveloped countries. The author has traveled repeatedly over a span of 4 years to Vietnam for the purpose of providing training in therapeutic endoscopy; the example of this country’s status regarding the state of endoscopy practice, the availability of training, and the potential for change may prove illuminating. The training of gastroenterologists in endoscopy presents a number of challenges. The gastroenterologist trainee must have access to an acceptable training facility with appropriate equipment and access to patients and must have mentors with skill and interest in sharing their expertise. In the United States a supervisory organization, the Accreditation
The authors report no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript. Address reprint requests to Franklin Kasmin, MD, Saint Vincent’s Hospital Manhattan, The Pancreas and Biliary Center, 170 West 12thStreet, New York, NY 10011. E-mail: [email protected] 1096-2883/11/$-see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.tgie.2011.06.004
Council for Graduate Medical Education, ensures that each gastrointestinal fellowship program meets minimum standards for training. The training sites are visited on a regular basis, and records are reviewed to ensure that trainees are obtaining an adequate number of supervised procedure experiences, are receiving appropriate didactic education, and have adequate breadth of exposure to experienced mentors. The Accreditation Council for Graduate Medical Education thus accredits each training program. Only with a completed fellowship from an accredited program can trainees become “Board Certified” by the Board of Medical Specialties and gain privileges to perform endoscopy in hospitals and other accredited endoscopy facilities. Other developed countries have similar bodies of accreditation. Less well-developed countries train endoscopists in a fashion similar to developed countries, but the emergence of training programs is a dynamic process, which started more recently and continues to evolve. In Vietnam there are approximately seven centers training endoscopists, mostly located in the major cities: Hanoi (3 sites), Ho Chi Minh City (formerly Saigon, 2 sites), and Hue City (1 site), as well as 1 site in the southern delta, Can Tho, and 1 site in the northern mountains in Thai Nguyen City. Prior to the year 2000, only three sites existed, with 1 each in Hanoi, Ho Chi Minh City, and Hue City. Thus, one can correctly guess that endoscopy is a relatively more recent development in Vietnam than elsewhere. In the 1980s, only a handful of doctors were performing endoscopy, with training obtained from France and Germany. The 1990s began to see a rapid
200
Techniques in Gastrointestinal Endoscopy, Vol 13, No 3, July 2011
increase in the number of gastroenterologists, and at present there are about 1000 endoscopists in Vietnam. The path to training in Vietnam is similar to that of other countries, wherein a young physician graduates from an internal medicine program and then chooses an extra year of gastroenterology training. The trainee works at the hospital in a full-time role, manages the patients in the medical wards, presents consultations in teaching rounds, and assists the attending gastroenterologist in endoscopic procedures, thereby learning procedural skills. Some research is also done in the more academic centers. However, there is not a great deal of competition for the gastrointestinal training positions, as there is in the United States where gastroenterology as a career is perceived to be financially lucrative. This may be because most doctors receive a fixed monthly stipend from the government, and thus high volumes of endoscopy procedures do not yield dramatic additions to the physician’s salary as they can elsewhere. In addition, the medical schools and major hospitals are all government run, and so the number of training positions varies according to the government’s perceived need for gastroenterologists in the provincial hospitals. There is ample opportunity for the trainee to practice endoscopy at the large centers because it is common for these hospitals to perform between 40 and 200 procedures per day. This is possible because perhaps 95% of the 800,000 endoscopy procedures per year in Vietnam are straightforward diagnostic procedures, with the vast majority of those being upper endoscopies performed without sedation. That said, there is much less in the way of opportunity for training in therapeutic interventions. These limitations exist because of a small number of faculty members in gastroenterology who themselves are adequately trained in therapeutic procedures, as well as because most sites do not have the equipment or supplies needed to perform interventions. As an example, the placement of metal selfexpandable esophageal stents in the main teaching hospital of Ho Chi Minh City (Saigon) is limited by cost. The government does not purchase these items for the hospital or for the patient, regardless of any insurance they might have. The access to these stents is via the patient’s own ability to pay the approximately US$1500 required to buy the stent. In a country as poor as Vietnam (2009 per capita income $1000),1 the number of patients able to afford expensive endoscopic accessories required for advanced therapeutics is small indeed. In the smaller hospital facilities located in the country’s smaller cities and towns there is much less opportunity to foster the growth of new endoscopic techniques. It is common that the provincial hospitals will have only 1 or 2 endoscopists, and it is not unusual for the endoscopic equipment to be antiquated or of limited use. A 2007 visit to the very poor, agrarian Dak Nong province along the central mountainous border of Vietnam and Cambodia found the 1 young gastroenterologist using an almost new video gastroscopy system in the performance of about 15 gastroscopies daily. However, the single reusable forceps owned by
the hospital hung from a hook, broken. A 2010 visit to the provincial hospital in Quang Tri, along the coast near the 17th Parallel, found a hospital with 2 physicians trained in gastroenterology but no longer able to do endoscopy because their nonvideo fiberscope hung nonworking in a room. Additional training is available to gastroenterologists at the major medical centers on a postgraduate basis. At University Hospital in Ho Chi Minh City, endoscopists with at least 500 upper endoscopies can begin training in colonoscopy through a 3-month course, and other opportunities for advanced endoscopy training are possible.2 For those interested in seeing important endoscopic advances like endoscopic ultrasound or endoscopic mucosal resection, a visit to a neighboring Asian country such as Japan, Singapore, or China is feasible. Organized academics exist in Vietnam through the Vietnam Association of Gastroenterology (VNAGE). Currently based in Hanoi, the VNAGE sponsors national symposia, with the 16th iteration of the National Meeting on Gastroenterology held over 2 days in October 2010. The association also produces a primarily English language publication, the Vietnamese Journal of Gastroenterology. A recent issue focused on Helicobacter pylori and gastric cancer and emerging therapies for hepatitis, as opposed to endoscopic techniques.3 What is interesting about the state of endoscopic skills across Vietnam is that in a relatively small country, with both a sizeable number of able endoscopists and several medical university sites with extensive experience in advanced endoscopic techniques, there still remains a limitation in the dissemination of therapeutic endoscopic techniques and practice. In part this is simply caused by the lack of funds and available equipment. Even in the medical school at Hue, endoscopic retrograde cholangiopancreatography (ERCP) was not possible until 2010, when a C-arm fluoroscope was finally purchased by the hospital. In smaller hospitals, we have seen that often there are no endoscopic accessories or cautery units and nonworking endoscopy equipment. Most hospitals do not own a colonoscope. So, although the physicians are skillful with their hands and have performed many endoscopic procedures, the training in advanced techniques is necessarily hampered foremost by the lack of equipment to perform the procedures. The availability of endoscopic equipment and accessories is likely to increase significantly in the coming few years; the Vietnamese economy has grown strongly in recent years as international corporations find a cost-effective location for their manufacturing plants.4 This growth in tools will certainly have an impact on the dissemination of endoscopic technique, although uptraining in these techniques is also required. The current situation also presents a unique opportunity for international endoscopists to enable more rapid growth in these capabilities. The author, along with others, has had the opportunity to participate in the dissemination of endoscopy technology to various sites in Vietnam over the past 6 years. The visits
Kasmin
Endoscopy Education in Vietnam
Figure 1 Physician and staff creating variceal ligation bands in Dak Nong, Vietnam. (Color version of figure is available online at www.techgiendoscopy.com.)
were coordinated by an American urologist who had served in the U.S. army as a physician in the central highlands region of Vietnam during 1969-1970. Contacts to hospital administration were made in person during early on-site visits to hospitals with which the urologist had been familiar, and as the program became more successful, additional sites sought visits from the American team. The program is composed of physicians who bring donated equipment and the skill set to teach the use of these tools and devices in performing new procedures. Donated devices have included urological resectoscopes and lithotripters, endoscopic light and video processors, gastroscopes and colonoscopes, and an extensive inventory of tissue sampling and therapeutic devices such as snares, sphincterotomes, stents, and guidewires. Endoscopy training was tailored to the site: in cases where the general diagnostic and therapeutic possibilities were limited in a general sense (ie, limited access to CT scanning or no fluoroscopy), training was tailored to endoscopic polypectomy, foreign body extraction, and band ligation. In more sophisticated sites, ERCP was introduced. Naturally, it is the responsibility of the trainer to assess the general abilities of the trainee prior to undertaking the introduction of advanced skills like ERCP and sphincterotomy. Fortunately, in the sites where this was undertaken, candidate trainees were experienced in endoscopy and laparoscopy and appeared able to begin to learn these new techniques. The visiting endoscopists generally spent a week at each site, performing procedures with the trainee and supervising hands-on learning. Rounds were made in the hospital each day to discuss potential patients, and
201 techniques, complications, and alternatives to endoscopy were considered in an informal teaching conference. It was understood that the trainees would consider performing these procedures dependent on their comfort level and that the possibility of a visit to an academic teaching center in Saigon or Hanoi was possible. The success of this informal program became evident at follow-up visits. Photographs of the many foreign bodies extracted awaited us at one site. An endoscopist demonstrated the use of the multiband ligator—and how he made and loaded his own rubber bands back on the device to have enough material to last a whole year (Figure 1). We were presented with stented biliary patients—palliated for mass or giant stones—who needed a stent change or lithotripsy. Clearly progress was being made, and patients who would not have had access to this type of care were now being appropriately managed by endoscopists whose skills and experience grew by the month. In preparation for our fifth visit, hospital leaders at one of the larger sites prepared a 2-day conference focused on ERCP (Figure 2). Physicians were invited from outlying hospitals in the region, and a guest speaker was also invited from Saigon, who demonstrated the first purcutaneous endoscopic gastrostomy (PEG) placement done in that city. Amazingly, few PEGs had ever been placed in the country because the tubes are generally not available and few endoscopists had ever had the opportunity to learn the technique. That fact led to the plans for our sixth trip, where PEG placement would be taught to a wide cross-section of endoscopists from throughout Vietnam. The most recent visit was a cooperative effort with the American Society of Gastrointestinal Endoscopy (ASGE) and its Ambassador Program. A 3-day program was devised, which covered PEG placement, ERCP, and an overview of endoscopic ultrasound. Five gastroenterologists traveled from the United States, joined by a Vietnamese program codirector. The instruction in PEG began with a
Figure 2 Workshop on ERCP held in Nha Trang, Vietnam, 2009. (Color version of figure is available online at www. techgiendoscopy.com.)
202
Techniques in Gastrointestinal Endoscopy, Vol 13, No 3, July 2011
didactic lecture on proper technique, indications, and potential complications. Next, an introduction was given to the ex vivo pig stomach model (Erlangen Active Simulator for Interventional Endoscopy: EASIE-R, Endosim LLC, Berlin, MA), which would be used to give hands-on experience in the training efforts. The hands-on training in PEG placement proved to be a very successful effort. The model is very realistic and allows transillumination, palpation (of a rubber sheet stretched over the tray that holds the stomach), and all other maneuvers of PEG such as puncture, incision, capture of the wire, and placement of the tube (Figure 3). The students worked in pairs and spent about 20 minutes per group. The models needed adjustments regularly, especially at the incision site, because an air leak would occur after each tube placement. The students became adept at repairing the models (many were surgeons by initial training and were naturally very quick at suturing the stomach) and after 2 or 3 groups finished, the prior students began training the subsequent groups! On day 2, Vietnamese patients underwent PEG placement, and several of the students successfully performed the procedure with supervision but no intervention from the trainers (Figure 4). Subsequently, the entire group underwent skill evaluation on the models, as pairs of students demonstrated first the endoscopist’s role and then the assistant’s role. As the trainers stepped back and watched the students undergo their evaluations, it became clear that these 50 physicians were prepared not only to perform PEG placement at their various sites within Vietnam, but also to teach others the skill. One wonders whether perhaps the
Figure 4 Vietnamese endoscopists performing a PEG under supervision. (Color version of figure is available online at www. techgiendoscopy.com.)
entire country’s endoscopists will be able to ultimately perform PEG because of this effort. The ASGE Ambassador program provides resources for follow-up evaluations, and self-evaluation forms will be submitted so assessment of the outcomes after training can be made. Future efforts in Vietnam by the author’s group will focus on ongoing one-on-one training in ERCP at larger sites that have already begun to perform this procedure and the use of the pig stomach model to teach therapeutic mucosal techniques such as mucosal resection, polypectomy, and bleeding control. The plastic trays that form the basis of the simulator were donated by the ASGE and remain in Vietnam for use by educators on-site. The VNAGE was extremely pleased with the outcome of the latest training program and has requested assistance with additional seminars.
Acknowledgments The author thanks Ho Dang Quy Dung, MD, MS, Head of the Endoscopy Department, Cho Ray Hospital, Vietnam, for his assistance in reviewing the manuscript.
References
Figure 3 Vietnamese endoscopists learning PEG placement using the Erlangen pig stomach simulator. (Color version of figure is available online at www.techgiendoscopy.com.)
1. U.S. Department of State. http://www.state.gov/r/pa/ei/bgn/4130.htm. 2. University Medical Center, Ho Chi Min City. http://www.bvdaihoc. com.vn/eng/news_detail.asp?catid⫽152&msgid⫽587. 3. Vietnamese Journal of Gastroenterology. Volume 5, No. 20, 2010. 4. “Economy looks ship-shape, say experts.” Vietnam Business News, August 11, 2010. Available at: http://vietnambusiness.asia/economylooks-ship-shape-say-experts/.
Techniques in GASTROINTESTINAL ENDOSCOPY www.techgiendoscopy.com
Endoscopy education in underdeveloped countries: Vietnam Franklin Kasmin, MD Saint Vincent’s Hospital Manhattan, The Pancreas and Biliary Center, New York, New York. KEYWORDS: Vietnam; Endoscopic training; Developing countries
The example of Vietnam demonstrates the wide range of endoscopic capabilities in an underdeveloped country with emerging economic strength. Barriers to advancement in endoscopic techniques can be overcome through the donation of equipment and on-site, hands-on training. In a country where the endoscopists are experienced and skillful in basic techniques, significant advances in health care delivery can be achieved with relatively small investments in time and money. This process is naturally enormously gratifying for both the students and their mentors. © 2011 Published by Elsevier Inc.
Endoscopy education is a process in flux, even in the most established centers around the world. The process is not simple and not all trainees will necessarily become skillful endoscopists by simple observation and routine participation. Guidelines have been established based on not only numbers of procedures accomplished but also acquisition of defined skill sets and success rates that must be demonstrated. There is also a heightened awareness of the role of training simulators in assisting in endoscopic education. In considering how endoscopy is taught in developed nations, one might find interesting the contrast with the process in underdeveloped countries. The author has traveled repeatedly over a span of 4 years to Vietnam for the purpose of providing training in therapeutic endoscopy; the example of this country’s status regarding the state of endoscopy practice, the availability of training, and the potential for change may prove illuminating. The training of gastroenterologists in endoscopy presents a number of challenges. The gastroenterologist trainee must have access to an acceptable training facility with appropriate equipment and access to patients and must have mentors with skill and interest in sharing their expertise. In the United States a supervisory organization, the Accreditation
The authors report no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript. Address reprint requests to Franklin Kasmin, MD, Saint Vincent’s Hospital Manhattan, The Pancreas and Biliary Center, 170 West 12thStreet, New York, NY 10011. E-mail: [email protected] 1096-2883/11/$-see front matter © 2011 Published by Elsevier Inc. doi:10.1016/j.tgie.2011.06.004
Council for Graduate Medical Education, ensures that each gastrointestinal fellowship program meets minimum standards for training. The training sites are visited on a regular basis, and records are reviewed to ensure that trainees are obtaining an adequate number of supervised procedure experiences, are receiving appropriate didactic education, and have adequate breadth of exposure to experienced mentors. The Accreditation Council for Graduate Medical Education thus accredits each training program. Only with a completed fellowship from an accredited program can trainees become “Board Certified” by the Board of Medical Specialties and gain privileges to perform endoscopy in hospitals and other accredited endoscopy facilities. Other developed countries have similar bodies of accreditation. Less well-developed countries train endoscopists in a fashion similar to developed countries, but the emergence of training programs is a dynamic process, which started more recently and continues to evolve. In Vietnam there are approximately seven centers training endoscopists, mostly located in the major cities: Hanoi (3 sites), Ho Chi Minh City (formerly Saigon, 2 sites), and Hue City (1 site), as well as 1 site in the southern delta, Can Tho, and 1 site in the northern mountains in Thai Nguyen City. Prior to the year 2000, only three sites existed, with 1 each in Hanoi, Ho Chi Minh City, and Hue City. Thus, one can correctly guess that endoscopy is a relatively more recent development in Vietnam than elsewhere. In the 1980s, only a handful of doctors were performing endoscopy, with training obtained from France and Germany. The 1990s began to see a rapid
200
Techniques in Gastrointestinal Endoscopy, Vol 13, No 3, July 2011
increase in the number of gastroenterologists, and at present there are about 1000 endoscopists in Vietnam. The path to training in Vietnam is similar to that of other countries, wherein a young physician graduates from an internal medicine program and then chooses an extra year of gastroenterology training. The trainee works at the hospital in a full-time role, manages the patients in the medical wards, presents consultations in teaching rounds, and assists the attending gastroenterologist in endoscopic procedures, thereby learning procedural skills. Some research is also done in the more academic centers. However, there is not a great deal of competition for the gastrointestinal training positions, as there is in the United States where gastroenterology as a career is perceived to be financially lucrative. This may be because most doctors receive a fixed monthly stipend from the government, and thus high volumes of endoscopy procedures do not yield dramatic additions to the physician’s salary as they can elsewhere. In addition, the medical schools and major hospitals are all government run, and so the number of training positions varies according to the government’s perceived need for gastroenterologists in the provincial hospitals. There is ample opportunity for the trainee to practice endoscopy at the large centers because it is common for these hospitals to perform between 40 and 200 procedures per day. This is possible because perhaps 95% of the 800,000 endoscopy procedures per year in Vietnam are straightforward diagnostic procedures, with the vast majority of those being upper endoscopies performed without sedation. That said, there is much less in the way of opportunity for training in therapeutic interventions. These limitations exist because of a small number of faculty members in gastroenterology who themselves are adequately trained in therapeutic procedures, as well as because most sites do not have the equipment or supplies needed to perform interventions. As an example, the placement of metal selfexpandable esophageal stents in the main teaching hospital of Ho Chi Minh City (Saigon) is limited by cost. The government does not purchase these items for the hospital or for the patient, regardless of any insurance they might have. The access to these stents is via the patient’s own ability to pay the approximately US$1500 required to buy the stent. In a country as poor as Vietnam (2009 per capita income $1000),1 the number of patients able to afford expensive endoscopic accessories required for advanced therapeutics is small indeed. In the smaller hospital facilities located in the country’s smaller cities and towns there is much less opportunity to foster the growth of new endoscopic techniques. It is common that the provincial hospitals will have only 1 or 2 endoscopists, and it is not unusual for the endoscopic equipment to be antiquated or of limited use. A 2007 visit to the very poor, agrarian Dak Nong province along the central mountainous border of Vietnam and Cambodia found the 1 young gastroenterologist using an almost new video gastroscopy system in the performance of about 15 gastroscopies daily. However, the single reusable forceps owned by
the hospital hung from a hook, broken. A 2010 visit to the provincial hospital in Quang Tri, along the coast near the 17th Parallel, found a hospital with 2 physicians trained in gastroenterology but no longer able to do endoscopy because their nonvideo fiberscope hung nonworking in a room. Additional training is available to gastroenterologists at the major medical centers on a postgraduate basis. At University Hospital in Ho Chi Minh City, endoscopists with at least 500 upper endoscopies can begin training in colonoscopy through a 3-month course, and other opportunities for advanced endoscopy training are possible.2 For those interested in seeing important endoscopic advances like endoscopic ultrasound or endoscopic mucosal resection, a visit to a neighboring Asian country such as Japan, Singapore, or China is feasible. Organized academics exist in Vietnam through the Vietnam Association of Gastroenterology (VNAGE). Currently based in Hanoi, the VNAGE sponsors national symposia, with the 16th iteration of the National Meeting on Gastroenterology held over 2 days in October 2010. The association also produces a primarily English language publication, the Vietnamese Journal of Gastroenterology. A recent issue focused on Helicobacter pylori and gastric cancer and emerging therapies for hepatitis, as opposed to endoscopic techniques.3 What is interesting about the state of endoscopic skills across Vietnam is that in a relatively small country, with both a sizeable number of able endoscopists and several medical university sites with extensive experience in advanced endoscopic techniques, there still remains a limitation in the dissemination of therapeutic endoscopic techniques and practice. In part this is simply caused by the lack of funds and available equipment. Even in the medical school at Hue, endoscopic retrograde cholangiopancreatography (ERCP) was not possible until 2010, when a C-arm fluoroscope was finally purchased by the hospital. In smaller hospitals, we have seen that often there are no endoscopic accessories or cautery units and nonworking endoscopy equipment. Most hospitals do not own a colonoscope. So, although the physicians are skillful with their hands and have performed many endoscopic procedures, the training in advanced techniques is necessarily hampered foremost by the lack of equipment to perform the procedures. The availability of endoscopic equipment and accessories is likely to increase significantly in the coming few years; the Vietnamese economy has grown strongly in recent years as international corporations find a cost-effective location for their manufacturing plants.4 This growth in tools will certainly have an impact on the dissemination of endoscopic technique, although uptraining in these techniques is also required. The current situation also presents a unique opportunity for international endoscopists to enable more rapid growth in these capabilities. The author, along with others, has had the opportunity to participate in the dissemination of endoscopy technology to various sites in Vietnam over the past 6 years. The visits
Kasmin
Endoscopy Education in Vietnam
Figure 1 Physician and staff creating variceal ligation bands in Dak Nong, Vietnam. (Color version of figure is available online at www.techgiendoscopy.com.)
were coordinated by an American urologist who had served in the U.S. army as a physician in the central highlands region of Vietnam during 1969-1970. Contacts to hospital administration were made in person during early on-site visits to hospitals with which the urologist had been familiar, and as the program became more successful, additional sites sought visits from the American team. The program is composed of physicians who bring donated equipment and the skill set to teach the use of these tools and devices in performing new procedures. Donated devices have included urological resectoscopes and lithotripters, endoscopic light and video processors, gastroscopes and colonoscopes, and an extensive inventory of tissue sampling and therapeutic devices such as snares, sphincterotomes, stents, and guidewires. Endoscopy training was tailored to the site: in cases where the general diagnostic and therapeutic possibilities were limited in a general sense (ie, limited access to CT scanning or no fluoroscopy), training was tailored to endoscopic polypectomy, foreign body extraction, and band ligation. In more sophisticated sites, ERCP was introduced. Naturally, it is the responsibility of the trainer to assess the general abilities of the trainee prior to undertaking the introduction of advanced skills like ERCP and sphincterotomy. Fortunately, in the sites where this was undertaken, candidate trainees were experienced in endoscopy and laparoscopy and appeared able to begin to learn these new techniques. The visiting endoscopists generally spent a week at each site, performing procedures with the trainee and supervising hands-on learning. Rounds were made in the hospital each day to discuss potential patients, and
201 techniques, complications, and alternatives to endoscopy were considered in an informal teaching conference. It was understood that the trainees would consider performing these procedures dependent on their comfort level and that the possibility of a visit to an academic teaching center in Saigon or Hanoi was possible. The success of this informal program became evident at follow-up visits. Photographs of the many foreign bodies extracted awaited us at one site. An endoscopist demonstrated the use of the multiband ligator—and how he made and loaded his own rubber bands back on the device to have enough material to last a whole year (Figure 1). We were presented with stented biliary patients—palliated for mass or giant stones—who needed a stent change or lithotripsy. Clearly progress was being made, and patients who would not have had access to this type of care were now being appropriately managed by endoscopists whose skills and experience grew by the month. In preparation for our fifth visit, hospital leaders at one of the larger sites prepared a 2-day conference focused on ERCP (Figure 2). Physicians were invited from outlying hospitals in the region, and a guest speaker was also invited from Saigon, who demonstrated the first purcutaneous endoscopic gastrostomy (PEG) placement done in that city. Amazingly, few PEGs had ever been placed in the country because the tubes are generally not available and few endoscopists had ever had the opportunity to learn the technique. That fact led to the plans for our sixth trip, where PEG placement would be taught to a wide cross-section of endoscopists from throughout Vietnam. The most recent visit was a cooperative effort with the American Society of Gastrointestinal Endoscopy (ASGE) and its Ambassador Program. A 3-day program was devised, which covered PEG placement, ERCP, and an overview of endoscopic ultrasound. Five gastroenterologists traveled from the United States, joined by a Vietnamese program codirector. The instruction in PEG began with a
Figure 2 Workshop on ERCP held in Nha Trang, Vietnam, 2009. (Color version of figure is available online at www. techgiendoscopy.com.)
202
Techniques in Gastrointestinal Endoscopy, Vol 13, No 3, July 2011
didactic lecture on proper technique, indications, and potential complications. Next, an introduction was given to the ex vivo pig stomach model (Erlangen Active Simulator for Interventional Endoscopy: EASIE-R, Endosim LLC, Berlin, MA), which would be used to give hands-on experience in the training efforts. The hands-on training in PEG placement proved to be a very successful effort. The model is very realistic and allows transillumination, palpation (of a rubber sheet stretched over the tray that holds the stomach), and all other maneuvers of PEG such as puncture, incision, capture of the wire, and placement of the tube (Figure 3). The students worked in pairs and spent about 20 minutes per group. The models needed adjustments regularly, especially at the incision site, because an air leak would occur after each tube placement. The students became adept at repairing the models (many were surgeons by initial training and were naturally very quick at suturing the stomach) and after 2 or 3 groups finished, the prior students began training the subsequent groups! On day 2, Vietnamese patients underwent PEG placement, and several of the students successfully performed the procedure with supervision but no intervention from the trainers (Figure 4). Subsequently, the entire group underwent skill evaluation on the models, as pairs of students demonstrated first the endoscopist’s role and then the assistant’s role. As the trainers stepped back and watched the students undergo their evaluations, it became clear that these 50 physicians were prepared not only to perform PEG placement at their various sites within Vietnam, but also to teach others the skill. One wonders whether perhaps the
Figure 4 Vietnamese endoscopists performing a PEG under supervision. (Color version of figure is available online at www. techgiendoscopy.com.)
entire country’s endoscopists will be able to ultimately perform PEG because of this effort. The ASGE Ambassador program provides resources for follow-up evaluations, and self-evaluation forms will be submitted so assessment of the outcomes after training can be made. Future efforts in Vietnam by the author’s group will focus on ongoing one-on-one training in ERCP at larger sites that have already begun to perform this procedure and the use of the pig stomach model to teach therapeutic mucosal techniques such as mucosal resection, polypectomy, and bleeding control. The plastic trays that form the basis of the simulator were donated by the ASGE and remain in Vietnam for use by educators on-site. The VNAGE was extremely pleased with the outcome of the latest training program and has requested assistance with additional seminars.
Acknowledgments The author thanks Ho Dang Quy Dung, MD, MS, Head of the Endoscopy Department, Cho Ray Hospital, Vietnam, for his assistance in reviewing the manuscript.
References
Figure 3 Vietnamese endoscopists learning PEG placement using the Erlangen pig stomach simulator. (Color version of figure is available online at www.techgiendoscopy.com.)
1. U.S. Department of State. http://www.state.gov/r/pa/ei/bgn/4130.htm. 2. University Medical Center, Ho Chi Min City. http://www.bvdaihoc. com.vn/eng/news_detail.asp?catid⫽152&msgid⫽587. 3. Vietnamese Journal of Gastroenterology. Volume 5, No. 20, 2010. 4. “Economy looks ship-shape, say experts.” Vietnam Business News, August 11, 2010. Available at: http://vietnambusiness.asia/economylooks-ship-shape-say-experts/.