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The UK National Endoscopy Training Programme Has Improved Colonoscopy Training Over a Five-Year Period: Closing the Audit Loop
W1491 Training Session Using a Magnetic Imaging Probe in An Ex-Vivo Colon Model Leads to Improved Trainee Colonoscopy Performance Tonya R. Kaltenbach, Cynthia W. Leung, Kuan K. Wu, Shai Friedland, Roy M. Soetikno Background: Gastrointestinal endoscopy skills require significant time and effort to teach, learn and maintain. Historically, procedural skills are learned in a patientbased setting - a teaching paradigm that poses an increasing challenge. As such, realistic endoscopic simulators are needed to teach and learn endoscopic skills more efficiently and safely. Understanding the colon loops has been among the most difficult concepts to teach at the bedside. We hypothesized that simulation training using a colon model in combination with the non-radiologic magnetic imaging system (Scope Guide, Olympus) may improve the training and performance of colonoscopy, particularly in understanding looping and proper insertion technique. Methods: Three gastroenterology fellows, who were not proficient in colonoscopy, performed patient based colonoscopy per their routine fellowship training schedule with a supervising instructor. Following each examination, the instructor completed a modified ASGE standardized procedure assessment form. Data from a two week period was collected. Subsequently, each fellow participated in an individualized half-day colonoscopy insertion technique training session using an ex-vivo colon model with the aid of a magnetic imaging probe, during which they completed six standardized colon cases. Performance data was collected within 2 weeks after training. The instructors were blinded to the intervention. We compared the trainees’ performance before and after the training session, and additional study measurements of cecal intubation and withdrawal times, medication doses, application of abdominal pressure, patient repositioning and endoscope insertion length. Results: A total of 86 colonoscopy procedures were evaluated. Following the colon model simulator session, trainees’ overall colonoscopy performance score significantly improved (4.4 2.3 vs 5.9 2.4; p Z 0.005) - scale 0 to 9. Furthermore, they showed improvement in cecal intubation rate from 47% to 76%; p Z 0.0039, and took less time to reach the cecum from 18 11 minutes to 14 7 minutes; p Z 0.05. The average dose of administered sedation medications did not change. Conclusion: Simulation colonoscopy using the magnetic imaging system in an ex-vivo colon model immediately improved trainee colonoscopy performance and efficiency. In the limited number of trainees and time, the improvement was immediate and significant- suggesting a large effect. The training system described appears to be a readily available tool that can be deployed to further improve the quality of colonoscopy and could be part of formal training. A confirmatory study is currently underway.
W1492 Tap Water Lavage At Sigmoid Colon: A Simple and Effective Method to Decrease Cecal Inubation Time Deepthi Bollineni, Vijaypal Arya, Niket Sonpal Introduction: Colonoscopy has been proved as most effective procedure to screen patients for colorectal cancer. Screening at appropriate time helps early detection of cancer and decreases mortality. Various techniques have developed to ease the passage of the flexible scope through the sigmoid colon bent and ease the spasm associated with the procedure. A simple means to achieve this is with warm water instead of antispasmodic agents as in previous studies. This study has evaluated cecal intubation time with 120 cc room temperature tap water lavage at sigmoid colon and its effect on colon spasm. Methods: A prospective randomized trial using 115 patients undergoing colonoscopies was done. Exclusion criteria were sigmoid colon stricture, sigmoidectomy, irritable bowel syndrome, diabetic gastroparesis and thyroid dysfunction. 13 patients were excluded. 102 patients (51 males: 51 females-mean age 56.3[range 23-81 years]) undergoing screening or therapeutic colonoscopies were split into 2 groups- Group A- receiving lavage and group Bthose not receiving lavage undergoing standard colonoscopy. The degree of spasm during procedure and the cecal intubation time with total colonoscopy time was noted. Results: Patients receiving lavage (Group A) reached the cecum earlier than those not receiving the lavage (Group B) [P ! 0.05, Mean in lavage-242.4 sec vs. mean in no lavage 261.3 sec]. Further interesting findings were patients who underwent previous abdominal or pelvic surgeries had longer cecal intubation times than those who did not, [P ! 0.05, mean of non surgical 229.6 sec vs. mean surgical 262.3 sec) irrespective of the lavage. Mean time for cecal intubation in moderate colon spasm was 323 sec with no lavage and 277 sec with lavage (a difference of 16%), however this was not statistically significant pertaining to the sample size (18 patients with moderate spasm). Conclusion: Water helps decrease the shearing force between the flexible scope and the colon wall helping the scope pass through the whole colon giving a glistening effect especially to a spastic colon . Our data suggests that sigmoid colon lavage does decrease the time to cecal intubation regardless of the indication. In addition we recommend water lavage for patients with history of any kind of abdominal surgeries. Spasm of the colon is rare, we hypothesize that enrolling more number of patients in the study will prove an affect in overcoming spasm with sigmoid colon lavage. Water is a simple and effective means of lubrication and helps the endoscopist and the patient a faster and easier colonoscopy thereby reducing patient discomfort and increasing the patient compliance.
AB298 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
W1493 Strategies for Training in Diagnostic Upper GI-Endoscopy Juergen Maiss, Anke Ende, Peter Konturek, Yurdaguel Zopf, Andreas Naegel, Eckhart G. Hahn Background: Since the 1990ies training simulators (plastic phantoms, computer and animal part simulators) have been introduced increasingly in the education of endoscopic novices. Nevertheless, the best educational strategy in diagnostic upper-GI endoscopy is not clear up to now. Methods: Study design: prospective randomized trial. Study period: 9/05 - 4/06. Participants: 28 interns of internal medicine of 15 hospitals of Northern Bavaria without endoscopic experience. Initial evaluation of basic endoscopic skills was done after an intensive practical (4h) and theoretical course (6h) in upper GI-endoscopy. Subsequently stratified randomisation due to the results of a simple skills test in the compactEASIEsimulator was done into clincical plus simulator training (group 1, n Z 10), only clinical (group 2, n Z 9) or only simulator training (group 3, n Z 9). Over 4 month 10 sessions (2 hours, 3 trainees per simulator) of simulator training (Simbionix, compactEASIE, plastic phantom) were performed for group 1 and 3. Group 2 was trained only clinical. Final skills evaluation for all trainees was first done in the compactEASIE-simulator and subsequently in three clinical cases between 2/06 and 4/06. In clinical cases, skills and procedural times were recorded by blinded and unblinded evaluators. Results: All trainees showed a significant time reduction for a simple skills test (p ! 0.001) in the simulator evaluation as well as a significantly better skills scoring (p ! 0.05) for this test indepedent to the training strategy. Trainees of group 1 had shorter times to reach the esophagus (61 26 sec vs. 85 30 and 95 36 sec) and the pylorus (183 65 sec vs. 207 61 and 247 66 sec) in the clinical evaluation cases, but this reached not significance (p Z 0.07). The group trained only in the simulator had the slowest times. Blinded and unblinded evaluation was not significantly different. Conclusions: In summary, clinical education accompanied by structured simulator training is the best way to teach diagnostic gastroscopy. Simulator training alone seems not sufficient enough to improve skills in clinical diagnostic upper GI-Endoscopy.
W1494 First Experiences with the Olympus Single Balloon Enteroscopy System Lars Helmstaedter, Dirk Hartmann, Axel Eickhoff, Juergen F. Riemann Background: Since introduction of double balloon enteroscopy in 2001, endoscopic diagnostics and therapy in the entire small bowel has become feasible. In 2007 Olympus Medical Systems introduced a simplified system with only one balloon at the tip of the overtube. We report our experience with the newly developed system in a clinical use. Patients and Methods: Since January 2007 we examined - in the beginning with a prototype - 28 patients with a mean age of 66.0 years (30-83). All patients had an enteroscopy from the oral approach, 4 patients in addition from the anal way. Indication for diagnostics was suspected small bowel bleeding. Before enteroscopy all patients had upper and lower GI endoscopy, in 18 patients capsule endoscopy was performed before enteroscopy during the actual diagnostic workup. All examinations were performed with a sedation with propofol and if needed with midazolam additionally. Results: 2 of 32 examinations had to be aborted, both in one patient: enteroscopy from the oral approach due to nonresolvable looping after progression of 100 cm behind duodenojejunal flexure, examination from the anal way because of circulation instability after progression of 60 cm behind ileocecal valve. Mean examination time was 57 minutes (30-94), from the oral way 57 minutes (30-94) and from anal 62 minutes (55-73). For sedation on average 3.9 mg midazolam (0-5) and 458.1 mg propofol (200-920) were necessary. The mean insertion depth behind the duodenojejunal flexure or the ileocecal valve were 239 cm (100-300) and 165 cm (60-250), respectively. Pathologic lesions were found in 20 of 32 examinations (62.5%), in 10 of these (50%) endoscopic therapy was performed. Intervention-related complications were not observed. Conclusions: Single balloon enteroscopy seems to be a comparable system to double balloon enteroscopy, but with a significantly simplified and therefore shortened examination procedure. Diagnostic yield, therapeutic capabilities and mean insertion depth seem to be comparable to double balloon enteroscopy.
W1495 The UK National Endoscopy Training Programme Has Improved Colonoscopy Training Over a Five-Year Period: Closing the Audit Loop Adam Haycock, Jaymin H. Patel, Siwan Thomas-Gibson A multi-center UK audit in 2002) showed that colonoscopy training was poorly structured, with low levels of supervision and high complication rates. Subsequently, the UK National Endoscopy Training Programme introduced centrally funded, accredited courses and new assessment tools to standardize training and raise the quality of practitioners. The aim of this study was to determine if this has had an impact on the standard of colonoscopy within the same region. Method: This was a cross-sectional survey. Questionnaires used in the previous study were updated and emailed to all gastroenterology and GI surgery trainees in the region. Trainees could complete the forms electronically and return them using an anonymous web-based secure upload portal. Results: 37 out of 113 trainees responded (33%). 92% were aware of the national guidelines for training.
www.giejournal.org
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
W1492 Tap Water Lavage At Sigmoid Colon: A Simple and Effective Method to Decrease Cecal Inubation Time Deepthi Bollineni, Vijaypal Arya, Niket Sonpal Introduction: Colonoscopy has been proved as most effective procedure to screen patients for colorectal cancer. Screening at appropriate time helps early detection of cancer and decreases mortality. Various techniques have developed to ease the passage of the flexible scope through the sigmoid colon bent and ease the spasm associated with the procedure. A simple means to achieve this is with warm water instead of antispasmodic agents as in previous studies. This study has evaluated cecal intubation time with 120 cc room temperature tap water lavage at sigmoid colon and its effect on colon spasm. Methods: A prospective randomized trial using 115 patients undergoing colonoscopies was done. Exclusion criteria were sigmoid colon stricture, sigmoidectomy, irritable bowel syndrome, diabetic gastroparesis and thyroid dysfunction. 13 patients were excluded. 102 patients (51 males: 51 females-mean age 56.3[range 23-81 years]) undergoing screening or therapeutic colonoscopies were split into 2 groups- Group A- receiving lavage and group Bthose not receiving lavage undergoing standard colonoscopy. The degree of spasm during procedure and the cecal intubation time with total colonoscopy time was noted. Results: Patients receiving lavage (Group A) reached the cecum earlier than those not receiving the lavage (Group B) [P ! 0.05, Mean in lavage-242.4 sec vs. mean in no lavage 261.3 sec]. Further interesting findings were patients who underwent previous abdominal or pelvic surgeries had longer cecal intubation times than those who did not, [P ! 0.05, mean of non surgical 229.6 sec vs. mean surgical 262.3 sec) irrespective of the lavage. Mean time for cecal intubation in moderate colon spasm was 323 sec with no lavage and 277 sec with lavage (a difference of 16%), however this was not statistically significant pertaining to the sample size (18 patients with moderate spasm). Conclusion: Water helps decrease the shearing force between the flexible scope and the colon wall helping the scope pass through the whole colon giving a glistening effect especially to a spastic colon . Our data suggests that sigmoid colon lavage does decrease the time to cecal intubation regardless of the indication. In addition we recommend water lavage for patients with history of any kind of abdominal surgeries. Spasm of the colon is rare, we hypothesize that enrolling more number of patients in the study will prove an affect in overcoming spasm with sigmoid colon lavage. Water is a simple and effective means of lubrication and helps the endoscopist and the patient a faster and easier colonoscopy thereby reducing patient discomfort and increasing the patient compliance.
AB298 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
W1493 Strategies for Training in Diagnostic Upper GI-Endoscopy Juergen Maiss, Anke Ende, Peter Konturek, Yurdaguel Zopf, Andreas Naegel, Eckhart G. Hahn Background: Since the 1990ies training simulators (plastic phantoms, computer and animal part simulators) have been introduced increasingly in the education of endoscopic novices. Nevertheless, the best educational strategy in diagnostic upper-GI endoscopy is not clear up to now. Methods: Study design: prospective randomized trial. Study period: 9/05 - 4/06. Participants: 28 interns of internal medicine of 15 hospitals of Northern Bavaria without endoscopic experience. Initial evaluation of basic endoscopic skills was done after an intensive practical (4h) and theoretical course (6h) in upper GI-endoscopy. Subsequently stratified randomisation due to the results of a simple skills test in the compactEASIEsimulator was done into clincical plus simulator training (group 1, n Z 10), only clinical (group 2, n Z 9) or only simulator training (group 3, n Z 9). Over 4 month 10 sessions (2 hours, 3 trainees per simulator) of simulator training (Simbionix, compactEASIE, plastic phantom) were performed for group 1 and 3. Group 2 was trained only clinical. Final skills evaluation for all trainees was first done in the compactEASIE-simulator and subsequently in three clinical cases between 2/06 and 4/06. In clinical cases, skills and procedural times were recorded by blinded and unblinded evaluators. Results: All trainees showed a significant time reduction for a simple skills test (p ! 0.001) in the simulator evaluation as well as a significantly better skills scoring (p ! 0.05) for this test indepedent to the training strategy. Trainees of group 1 had shorter times to reach the esophagus (61 26 sec vs. 85 30 and 95 36 sec) and the pylorus (183 65 sec vs. 207 61 and 247 66 sec) in the clinical evaluation cases, but this reached not significance (p Z 0.07). The group trained only in the simulator had the slowest times. Blinded and unblinded evaluation was not significantly different. Conclusions: In summary, clinical education accompanied by structured simulator training is the best way to teach diagnostic gastroscopy. Simulator training alone seems not sufficient enough to improve skills in clinical diagnostic upper GI-Endoscopy.
W1494 First Experiences with the Olympus Single Balloon Enteroscopy System Lars Helmstaedter, Dirk Hartmann, Axel Eickhoff, Juergen F. Riemann Background: Since introduction of double balloon enteroscopy in 2001, endoscopic diagnostics and therapy in the entire small bowel has become feasible. In 2007 Olympus Medical Systems introduced a simplified system with only one balloon at the tip of the overtube. We report our experience with the newly developed system in a clinical use. Patients and Methods: Since January 2007 we examined - in the beginning with a prototype - 28 patients with a mean age of 66.0 years (30-83). All patients had an enteroscopy from the oral approach, 4 patients in addition from the anal way. Indication for diagnostics was suspected small bowel bleeding. Before enteroscopy all patients had upper and lower GI endoscopy, in 18 patients capsule endoscopy was performed before enteroscopy during the actual diagnostic workup. All examinations were performed with a sedation with propofol and if needed with midazolam additionally. Results: 2 of 32 examinations had to be aborted, both in one patient: enteroscopy from the oral approach due to nonresolvable looping after progression of 100 cm behind duodenojejunal flexure, examination from the anal way because of circulation instability after progression of 60 cm behind ileocecal valve. Mean examination time was 57 minutes (30-94), from the oral way 57 minutes (30-94) and from anal 62 minutes (55-73). For sedation on average 3.9 mg midazolam (0-5) and 458.1 mg propofol (200-920) were necessary. The mean insertion depth behind the duodenojejunal flexure or the ileocecal valve were 239 cm (100-300) and 165 cm (60-250), respectively. Pathologic lesions were found in 20 of 32 examinations (62.5%), in 10 of these (50%) endoscopic therapy was performed. Intervention-related complications were not observed. Conclusions: Single balloon enteroscopy seems to be a comparable system to double balloon enteroscopy, but with a significantly simplified and therefore shortened examination procedure. Diagnostic yield, therapeutic capabilities and mean insertion depth seem to be comparable to double balloon enteroscopy.
W1495 The UK National Endoscopy Training Programme Has Improved Colonoscopy Training Over a Five-Year Period: Closing the Audit Loop Adam Haycock, Jaymin H. Patel, Siwan Thomas-Gibson A multi-center UK audit in 2002) showed that colonoscopy training was poorly structured, with low levels of supervision and high complication rates. Subsequently, the UK National Endoscopy Training Programme introduced centrally funded, accredited courses and new assessment tools to standardize training and raise the quality of practitioners. The aim of this study was to determine if this has had an impact on the standard of colonoscopy within the same region. Method: This was a cross-sectional survey. Questionnaires used in the previous study were updated and emailed to all gastroenterology and GI surgery trainees in the region. Trainees could complete the forms electronically and return them using an anonymous web-based secure upload portal. Results: 37 out of 113 trainees responded (33%). 92% were aware of the national guidelines for training.
www.giejournal.org
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
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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