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Face and Construct Validity of a Computer-Based Virtual Reality Simulator for Endoscopic Retrograde Cholangiopancreatography
Abstracts
Significantly more trainees said that they had been formally taught the principles of colonoscopy (89% vs 65%;p Z 0.02), polypectomy (76% vs 53%;p Z 0.04) and extubation (82% vs 55%;p Z 0.02) than in 2002. Trainers are significantly more likely to be present in the room for a trainee’s first 100 colonoscopies (77% vs 49%;p Z 0.04) and attempt explaining a solution to a problem before taking over (55% vs 23%;p Z 0.03). Course attendance significantly increased (76% vs 45%;p Z 0.006), and although most had to wait between 4-6 months to attend, all trainees were ‘quite’ or ‘very’ satisfied with the course. There was an increase in trainees who record their complication rate (51% vs 32%) although this was not significant (p Z 0.11). Reported complication rates were lower, with 3 of 18 (16%) having had a perforation compared to 8 of 13 (61%) in 2002. 78% of trainees think that their training has been adequate or better than adequate, compared to 25% in 2002. The average caecal intubation rate, a surrogate marker of competence, did not change (90% vs 93%;p Z 0.09). Conclusion: There has been a significant improvement in colonoscopy training both at base hospitals and in access to specialist courses compared to 2002, although 83% of trainees believe that training can still be improved further. New technologies such as simulators and the 3-D imager were considered by the majority to have contributed towards the improvement, but most trainees still feel they need greater regular access to dedicated training lists and courses. The central training programme and funding has made a significantly positive impact, and the loss of such investment may have a detrimental effect on future colonoscopy training.)Thomas-Gibson S, Saunders, BP. CME Journal Gastroenterology, Hepatology and Nutrition 2004;6:44-7.
W1496 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 Introduction: The American Society for Gastrointestinal Endoscopy encourages curriculum-based simulator use for endoscopic 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 Z 4; %25 ERCPs), intermediate (n Z 4; 100-200 ERCPs), and expert (n Z 4; O200 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 Z 0.009). For the same measure, Case 1 differentiated all skill levels (p Z 0.024) while Case 2 distinguished only novice from expert (487 sec, 273 sec; p Z 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 GI Mentor IIÔ differentiate novice, intermediate, and expert skill levels (construct validity) for ERCP 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 a useful training tool.
W1497 Approach to Develop a Competent Training Program for Upper Gastrointestinal Endoscopy Hyoung-Chul Oh, Hwoon-Yong Jung, Kwi-Sook Choi, Jun-Won Chung, Kee Wook Jung, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim Background: High competency in gastrointestinal endoscopy is based on experience and practice. Increasing expectation for high quality care demands systematic training program for the beginners. This study aims to develop a stepwise training program for the upper gastrointestinal endoscopy (UGIE) by evaluating the competency of training system designed by our endoscopy unit. Methods: Seven 4th year residents (R) and twelve 1st year fellows (F) participated
www.giejournal.org
in this study. R had never performed UGIE, whereas F had performed O 500 procedures. As a 1st step, R had a 10-hour text-based lecture which consisted of basic knowledge about endoscopic evaluation and manipulation of endoscope. As a 2nd step, R underwent simulator-based training (Simbionix GI mentor) under supervision of an expert and were requested to perform 2 cases on simulator when the accumulated number of cases performed reached 20, 50, 80 and 110. The efficiency and time taken to perform were compared according to the accumulated number and with those results of F to validate the efficacy of simulator. As a 3rd step, R had an education on ethics and voluntarily underwent UGIE to experience the real situation. As a 4th step, R had learning session on real performance; after an attending endoscopist had finished his endoscopic procedures and just before retrieving the scope, R performed basic skills in stomach (20 cases) and stomach and duodenum (15 cases) under supervision of attending endoscopist. Then, R performed esophageal intubation (20 cases). R and F were requested to record the moving pictures of 5 cases. Two blinded expert endoscopists rated the performance using a rating scale which consisted of 7 items, 1-5 points for each, and the difference were analyzed by using linear mixed-effects model. Results: The mean efficiency of GI mentor was or tended to be lower by 80 cases in R than F, but there was no difference at 110 cases (97.8 vs 97.3, p Z 0.48). The mean time taken to perform also showed a pattern similar to the efficiency. The efficiency and time among R significantly improved as the number of cases performed on simulator accumulated (p ! 0.01 by repeated measure ANOVA). The mean rating scales and time (R vs F) on real performance were 29.9 vs 31.9 (p ! 0.01) and 413.0 vs 315.4 (p ! 0.01), and the difference of rating scales between 2 expert endoscopists was 1.03 (p ! 0.01). Conclusion: The stepwise training system might be rather competent, and significantly lower rating scores by residents than fellows can be interpreted by wide difference in number of real performances between the two. This training system needs to be enforced to develop a more competent training program.
W1498 A New Module of the X-Vision ERCP-Training System for Peroral Cholangioscopy Eckart Frimberger, Stefan Von Delius, Roland M. Schmid, Christian Prinz Introduction: Recently, we presented the X-Vision ERCP-Training System, a new fluoroscopy-free mechanical simulator for ERCP with several model subtypes according to various training steps of diagnostic and therapeutic ERCP. Herein, we describe the development of a new module for peroral cholangioscopy. Methods: A custom-made mechanical model was built with the use of universally obtainable materials and tools. The trainees control ERCP and cholangioscopy activities on three screens: the aspects of the papilla/duodenum and the bile ducts are shown on two conventional endoscopy monitors, and the trainees‘ actions in the equivalents of thebiliary ducts are shown on the viewing screen of the model. Thereby, the latter screen serves as a substitute for fluoroscopy (Figure 1). Strictures can be simulated by introduction of organic material into the bile ducts, which allows taking biopsies. Laser lithotripsy, electrohydraulic lithothripsy and stone removal with a Dormia basket can be performed via the cholangioscope within the bile ducts. The new model was first evaluated during an ERCP expert meeting. The training system was evaluated by the participants using a specific questionnaire. Results: Mean endoscopic experience of ERCP experts (n Z 6) was 16.5 years. Cholangioscopy could easily be performed within the artificial bile ducts. Overall, the new model achieved favourable results in all categories assessed (Table 1). Conclusion: The new module for cholangioscopy is simple and effective. A first evaluation in the context of an ERCP expert meeting showed impressive results.
Figure 1. Table 1. Benefit Operator for Question convenience patients Score 6.0 6.3
Integration within training program 5.7
Direct, successful Realism learning process 5.2 6.5
6 analysed questionnaires, rate of return: 100%. Mean scores on a 7-point Likert scale (1, complete refusal; 7, complete agreement) assigned by experts.
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB299
Significantly more trainees said that they had been formally taught the principles of colonoscopy (89% vs 65%;p Z 0.02), polypectomy (76% vs 53%;p Z 0.04) and extubation (82% vs 55%;p Z 0.02) than in 2002. Trainers are significantly more likely to be present in the room for a trainee’s first 100 colonoscopies (77% vs 49%;p Z 0.04) and attempt explaining a solution to a problem before taking over (55% vs 23%;p Z 0.03). Course attendance significantly increased (76% vs 45%;p Z 0.006), and although most had to wait between 4-6 months to attend, all trainees were ‘quite’ or ‘very’ satisfied with the course. There was an increase in trainees who record their complication rate (51% vs 32%) although this was not significant (p Z 0.11). Reported complication rates were lower, with 3 of 18 (16%) having had a perforation compared to 8 of 13 (61%) in 2002. 78% of trainees think that their training has been adequate or better than adequate, compared to 25% in 2002. The average caecal intubation rate, a surrogate marker of competence, did not change (90% vs 93%;p Z 0.09). Conclusion: There has been a significant improvement in colonoscopy training both at base hospitals and in access to specialist courses compared to 2002, although 83% of trainees believe that training can still be improved further. New technologies such as simulators and the 3-D imager were considered by the majority to have contributed towards the improvement, but most trainees still feel they need greater regular access to dedicated training lists and courses. The central training programme and funding has made a significantly positive impact, and the loss of such investment may have a detrimental effect on future colonoscopy training.)Thomas-Gibson S, Saunders, BP. CME Journal Gastroenterology, Hepatology and Nutrition 2004;6:44-7.
W1496 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 Introduction: The American Society for Gastrointestinal Endoscopy encourages curriculum-based simulator use for endoscopic 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 Z 4; %25 ERCPs), intermediate (n Z 4; 100-200 ERCPs), and expert (n Z 4; O200 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 Z 0.009). For the same measure, Case 1 differentiated all skill levels (p Z 0.024) while Case 2 distinguished only novice from expert (487 sec, 273 sec; p Z 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 GI Mentor IIÔ differentiate novice, intermediate, and expert skill levels (construct validity) for ERCP 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 a useful training tool.
W1497 Approach to Develop a Competent Training Program for Upper Gastrointestinal Endoscopy Hyoung-Chul Oh, Hwoon-Yong Jung, Kwi-Sook Choi, Jun-Won Chung, Kee Wook Jung, Kee Don Choi, Ho June Song, Gin Hyug Lee, Jin-Ho Kim Background: High competency in gastrointestinal endoscopy is based on experience and practice. Increasing expectation for high quality care demands systematic training program for the beginners. This study aims to develop a stepwise training program for the upper gastrointestinal endoscopy (UGIE) by evaluating the competency of training system designed by our endoscopy unit. Methods: Seven 4th year residents (R) and twelve 1st year fellows (F) participated
www.giejournal.org
in this study. R had never performed UGIE, whereas F had performed O 500 procedures. As a 1st step, R had a 10-hour text-based lecture which consisted of basic knowledge about endoscopic evaluation and manipulation of endoscope. As a 2nd step, R underwent simulator-based training (Simbionix GI mentor) under supervision of an expert and were requested to perform 2 cases on simulator when the accumulated number of cases performed reached 20, 50, 80 and 110. The efficiency and time taken to perform were compared according to the accumulated number and with those results of F to validate the efficacy of simulator. As a 3rd step, R had an education on ethics and voluntarily underwent UGIE to experience the real situation. As a 4th step, R had learning session on real performance; after an attending endoscopist had finished his endoscopic procedures and just before retrieving the scope, R performed basic skills in stomach (20 cases) and stomach and duodenum (15 cases) under supervision of attending endoscopist. Then, R performed esophageal intubation (20 cases). R and F were requested to record the moving pictures of 5 cases. Two blinded expert endoscopists rated the performance using a rating scale which consisted of 7 items, 1-5 points for each, and the difference were analyzed by using linear mixed-effects model. Results: The mean efficiency of GI mentor was or tended to be lower by 80 cases in R than F, but there was no difference at 110 cases (97.8 vs 97.3, p Z 0.48). The mean time taken to perform also showed a pattern similar to the efficiency. The efficiency and time among R significantly improved as the number of cases performed on simulator accumulated (p ! 0.01 by repeated measure ANOVA). The mean rating scales and time (R vs F) on real performance were 29.9 vs 31.9 (p ! 0.01) and 413.0 vs 315.4 (p ! 0.01), and the difference of rating scales between 2 expert endoscopists was 1.03 (p ! 0.01). Conclusion: The stepwise training system might be rather competent, and significantly lower rating scores by residents than fellows can be interpreted by wide difference in number of real performances between the two. This training system needs to be enforced to develop a more competent training program.
W1498 A New Module of the X-Vision ERCP-Training System for Peroral Cholangioscopy Eckart Frimberger, Stefan Von Delius, Roland M. Schmid, Christian Prinz Introduction: Recently, we presented the X-Vision ERCP-Training System, a new fluoroscopy-free mechanical simulator for ERCP with several model subtypes according to various training steps of diagnostic and therapeutic ERCP. Herein, we describe the development of a new module for peroral cholangioscopy. Methods: A custom-made mechanical model was built with the use of universally obtainable materials and tools. The trainees control ERCP and cholangioscopy activities on three screens: the aspects of the papilla/duodenum and the bile ducts are shown on two conventional endoscopy monitors, and the trainees‘ actions in the equivalents of thebiliary ducts are shown on the viewing screen of the model. Thereby, the latter screen serves as a substitute for fluoroscopy (Figure 1). Strictures can be simulated by introduction of organic material into the bile ducts, which allows taking biopsies. Laser lithotripsy, electrohydraulic lithothripsy and stone removal with a Dormia basket can be performed via the cholangioscope within the bile ducts. The new model was first evaluated during an ERCP expert meeting. The training system was evaluated by the participants using a specific questionnaire. Results: Mean endoscopic experience of ERCP experts (n Z 6) was 16.5 years. Cholangioscopy could easily be performed within the artificial bile ducts. Overall, the new model achieved favourable results in all categories assessed (Table 1). Conclusion: The new module for cholangioscopy is simple and effective. A first evaluation in the context of an ERCP expert meeting showed impressive results.
Figure 1. Table 1. Benefit Operator for Question convenience patients Score 6.0 6.3
Integration within training program 5.7
Direct, successful Realism learning process 5.2 6.5
6 analysed questionnaires, rate of return: 100%. Mean scores on a 7-point Likert scale (1, complete refusal; 7, complete agreement) assigned by experts.
Volume 67, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY AB299