hand position for ESD in which the index and middle finger wrap around to support the dials.
Alternatives for EGD training: simulator‐based training
Simulator‐based training in upper endoscopy includes computer simulators and animal models. Advantages associated with usage of computer simulation models include didactic videos, multiple cases with varying degrees of difficulty and wide range of pathologic findings, and the ability to receive feedback from a virtual patient. Advantages associated with ex vivo porcine models include the ability to perform endoscopic hemostasis and other therapeutic maneuvers.
Computer simulators
While older computer simulation models utilize mannequins, newer simulators are based on virtual reality (VR) [26]. Two major VR simulators available for training in upper endoscopy include GI Mentor™ (Figure 5.14) by 3D Systems (formerly Simbionix; 3D System Ltd., Airport City, Israel) and CAE EndoVR Simulator (CAE Healthcare, Montreal, Quebec, Canada). Both simulators provide a large library of simulated cases that train in basic endoscopic skills and escalate in procedural difficulty to more complicated scenarios such as emergent GI bleeding. These simulators also feature scope locators, pain indicators, and virtual patient feedback. The primary disadvantage for both systems is high cost.
Figure 5.14 Sample case from GI Mentor™.
In a randomized study, novice fellows were assigned to either 10 hours of preclinical training on the former Simbionix simulator or to no simulator training. Each trainee then performed EGDs in 20 subjects. The trainees who received simulator training demonstrated more complete procedure rates and required less instructor assistance [27]. Another study using the former Simbionix simulator randomized half of the medical residents to 5 hours of simulator‐based training in EGD and demonstrated that this group had higher skill level for performance parameters measured during subsequent live EGD cases [28]. A recent systematic review concluded that virtual endoscopy simulator training was more effective than bedside teaching or other interventions for novice endoscopists: the percentage of independently completed EGDs was 88% with simulator training compared to 70% in the non‐simulator training group [29].
Animal models
The primary animal model used has been the Erlangen Endo‐Trainer (ECE Ltd., Erlangen, Germany) or the compact Erlanger Active Simulator for Interventional Endoscopy (EASIE) simulator. Both models feature a rotatable plastic torso in which organ packages can be placed for training. In the compact EASIE model, a roller pump has been used to drive an artificial blood circulation through major organ arteries and simulate spurting arterial bleeding. Initial comparison of both models used during endoscopic courses showed no difference in trainee preferences between the two models [30]. Subsequent analyses of data generated from training courses showed that trainees all improved in endoscopic skills [31] and that the usage of the EASIE simulator improved skills over bedside training alone [32]. In a multicenter study enrolling novices in endoscopy, a 1‐week course with the Erlangen Endo‐Trainer was associated with significant improvements in the tested endoscopic parameters, but no control group was used [33]. In a subsequent study where fellows were randomized to education only versus simulator training in EGD with the Erlangen Endo‐Trainer, the learning curve for the simulator‐trained group after 9 months of fellowship was significantly higher compared to the group receiving education alone [34].
Assessment of performance
Evaluation of each trainee's endoscopic skill is commonly done by applying ACGME's core competencies and using their Next Accreditation System that focuses on milestone attainment [35]. However, it is also important that trainees receive timely and routine feedback on their endoscopy skills from their attendings throughout the training period. Assessment of performance in upper endoscopy should include the following cognitive and motor skills [3,35]:
Understand the appropriate indications and contraindications of upper endoscopy, and diagnostic and/or therapeutic alternatives.
Understand the risks of upper endoscopy and how to minimize them.
Safely administer sedation and monitor the patient during endoscopy.
Perform and document successful intubation to the second portion of the duodenum.
Conduct a thorough examination of the upper GI tract including retroflexion in the stomach.
Correctly identify landmarks and parts of the upper GI tract including esophagus, GEJ, cardia, fundus, gastric body, antrum, pylorus, duodenal bulb, and second portion of duodenum.
Recognize pathology including esophagitis, varices, gastropathy, peptic ulcer disease, and villous blunting in the duodenum.
Understand when to obtain tissue samples and perform endoscopic mucosal biopsy successfully.
Perform effective endoscopic therapy including hemostasis, variceal band ligation, foreign body removal, stricture dilation, and PEG tube placement.
Complete timely and thorough documentation of all endoscopic procedures.
Integrate endoscopic findings to formulate a plan of care.
The training program director should monitor procedure logs to ensure that the minimal threshold of 130 EGDs is achieved and surpassed [3,35]. Periodic evaluations of trainees should also be submitted to the program director and/or clinical competency committee for review to assess skill proficiency and appropriate clinical judgment as determined by faculty proctors.
Conclusions
Proper training in upper endoscopy is essential for residents or fellows in an endoscopic training program. Trainees should become proficient in both cognitive and procedural aspects of endoscopy. This includes understanding when a procedure is indicated, recognizing landmarks and pathology, performing the procedure safely and thoroughly, and translating endoscopic findings into a management plan for the patient. Skills in therapeutic endoscopy, particularly in the management of endoscopic hemostasis, are important, and thresholds exist for the determination of competence for each therapeutic modality. Simulation in EGD is available through computer and animal models; both models have shown that trainees improve endoscopic skill sets with simulation compared to no simulation, but further studies are needed to determine if simulation alone can reduce or even ultimately replace bedside training.
Videos
Video 5.1 Handling the endoscope
Video 5.2 Esophageal intubation
Video 5.3 Retroflexion in the stomach
Video 5.4 Advancing into the duodenum
Video 5.5 Endoscopic biopsy
References
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3 3 American Society for Gastrointestinal Endoscopy: Principles of training in GI endoscopy. Gastrointest Endosc 2012; 75:231–235.
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