A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy. Virtual reality colonoscopy simulation: a compulsory practice for the future colonoscopist? Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality (MIST VR). Effect of virtual endoscopy simulator training on performance of upper gastrointestinal endoscopy in patients: a randomized controlled trial. Randomized controlled trial of virtual reality simulator training: transfer to live patients. Prospective randomized study on the use of a computer-based endoscopic simulator for training in esophagogastroduodenoscopy. Virtual reality flexible sigmoidoscopy simulator training: impact on resident performance. Training and transfer of colonoscopy skills: a multinational, randomized, blinded, controlled trial of simulator versus bedside training. Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy. Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial. Validation of computer simulation training for esophagogastroduodenoscopy: Pilot study. Computer simulation training enhances patient comfort during endoscopy.
Clinical investigation using endoscopy simulators is now possible due to recent advances in virtual reality technology. A prospective randomized trial was conducted to compare the exclusive use of a virtual reality endoscopy simulator with bedside teaching for training in sigmoidoscopy.
                Internal medicine residents were randomly assigned to training exclusively using a virtual reality simulator (group 1) or via bedside teaching (group 2). Residents were then observed performing five sigmoidoscopic procedures in asymptomatic patients referred for colorectal cancer screening. Endoscopic examinations were evaluated for procedure duration, completion, ability to perform retroflexion, and level of patient comfort/discomfort. Each examination was scored from 1 (inability to insert the endoscope beyond the rectum) to 5 (able to complete the entire examination independently in less than 20 min).
                Sixty-six sigmoidoscopic examinations were completed by nine residents in group 1 (simulator-trained group) and seven residents in group 2 (traditional teaching group). Participants in group 1 had more difficulty with initial endoscope insertion and negotiation of the rectosigmoid junction (mean score +/- SEM 2.9 +/- 0.2) than those in group 2 (3.8 +/- 0.2) ( P < 0.001). The splenic flexure was reached independently in 10 of 34 examinations (29 %) in group 1, compared with 23 of 32 examinations (72 %) in group 2 ( P = 0.001). Retroflexion was successfully performed by 19 of 34 (56 %) in group 1 compared to 27 of 32 (84 %) in group 2 ( P = 0.02). The average procedure time, patient satisfaction, and discomfort associated with the procedure did not differ statistically between the two groups.
                The use of a state-of-the-art virtual reality-based endoscopy simulator is inferior to traditional bedside teaching techniques when used exclusively for training medical residents to perform sigmoidoscopy. As for any manual procedure, the learning curves for medical interventions can have undesirable phases, occurring mostly in the early experience of applying a technique. There have been impressive advances in endoscopic procedures during recent years, and there is an emerging trend that the number of procedures is increasing in parallel with these. In addition, the introduction of screening programs for colorectal cancer will also increase the numbers of procedures needed. Recent developments in medical simulation seem promising with regard to the possibility of "training out" undesirable parts of the learning curve outside the operating room. The aim of this study was to investigate whether the use of the AccuTouch flexible endoscopy simulator improves the early part of the learning curve in colonoscopy training.
                12 endoscopy trainees, 10 surgeons and two medical gastroenterologists, all with experience in gastroscopy but with no specific colonoscopy experience, were randomly assigned to either simulator training or to a control group. They all received the same theoretical study package and the training group practiced with the AccuTouch colonoscopy simulator until a predefined expert level of performance was reached. All trainees performed their first ten individual colonoscopies described in detail in a separate protocol.
                Trainees in the simulator-trained group performed significantly better (P=0.0011) and managed to reach the cecum in 52% of their cases (vs. 19% in the control group), and were 4.53 times more likely to succeed compared with the controls. Additionally, there was a significantly shorter procedure time and less patient discomfort in the hands of the simulator-trained group.
                Skills acquired using the AccuTouch simulator transfer well into the clinical colonoscopy environment. The results of this trial clearly support the plan to integrate simulator training into endoscopic education curricula. The "fulcrum effect" of the body wall on surgical instrument manipulation is a major hurdle for novice endoscopic surgeons. Virtual reality training has not previously been evaluated as a means to overcome this problem.
                16 participants with no experience of endoscopy were required to make multiple defined incisions under laparoscopic laboratory conditions within 2-minute periods. Half of the subjects were randomized to receive initial training on the Minimally Invasive Surgical Trainer, Virtual Reality (MIST VR) computer programme.
                Participants with MIST VR training made significantly more correct incisions (P = 0.0001) than the control group on test trial 1, and even after extended practice by both groups (P = 0.0001). They were also significantly more likely to actively use both hands to perform the endoscopic evaluation task (P = 0.01).
                Virtual reality training represents a potential, viable solution for junior endoscopists, for overcoming the "fulcrum effect", in a replicable, safe learning environment which allows objective and reliable quantification of skill levels by trainers. Skills in gastrointestinal endoscopy mainly depend on experience and practice. Patients upon whom trainees perform their first endoscopic examinations are likely to suffer more discomfort and prolonged procedures. Training on endoscopy simulators may reduce the time required to reach competency in patient endoscopy.
                Residents in internal medicine without experience of endoscopy were randomized to a group who trained on a simulator before conventional training (group S) or one that received conventional training only (group C) before starting upper gastrointestinal endoscopy in patients. After endoscopy, discomfort and pain were evaluated by patients, who were blind to the beginners' training status. Results in terms of time, technique (intubation, pyloric passage, J-maneuver), and diagnosis of pathological entities were evaluated by experts.
                From 2003 to 2007, 28 residents were enrolled. Comparing group S with group C in their first ten endoscopic examinations in patients, time taken to reach the duodenum (239 seconds (range 50 - 620) vs. 310 seconds (110 - 720; P < 0.0001) and technical accuracy ( P < 0.02) were significantly better in group S. Diagnostic accuracy did not differ between the groups. Fourteen residents (7 simulator-trained, 7 not simulator-trained) continued endoscopy training. After 60 endoscopic examinations, investigation time was still shorter in group S. Technical and diagnostic accuracy improved during on-patient training in both groups; here differences between groups were no longer observable. There were no significant differences in discomfort and pain scores between the groups after 10 and after 60 endoscopies. Discomfort and pain were higher than for endoscopy performed by experts.
                This randomized controlled trial shows that virtual simulator training significantly affects technical accuracy in the early and mid-term stages of endoscopic training. It helps reduce the time needed to reach technical competency, but clinically the effect is limited. Simulator training could be useful in an endoscopy training curriculum but cannot replace on-patient training.
                © Georg Thieme Verlag KG Stuttgart · New York. New Residency Review Committee requirements in general surgery require 50 colonoscopies. Simulators have been widely suggested to help prepare residents for live clinical experience. We assessed a computer-based colonoscopy simulator for effective transfer of skills to live patients.
                A randomized controlled trial included general surgery and internal medicine residents with limited endoscopic experience. Following a pretest, the treatment group (n = 12) practiced on the simulator, while controls (n = 12) received no additional training. Both groups then performed a colonoscopy on a live patient. Technical ability was evaluated by expert endoscopists using previously validated assessment instruments.
                In the live patient setting, the treatment group scored significantly higher global ratings than controls (t(22) = 1.84, P = .04). Only 2 of the 8 computer-based performance metrics correlated significantly with previously validated global ratings of performance.
                Residents trained on a colonoscopy simulator prior to their first patient-based colonoscopy performed significantly better in the clinical setting than controls, demonstrating skill transfer to live patients. The simulator's performance metrics showed limited concurrent validity, suggesting the need for further refinement. Computer-based endoscopic simulators have been developed in recent years, and their usefulness has been reported. However, there is no blinded prospective randomized controlled study on esophagogastroduodenoscopy (EGD) training using virtual reality simulators. The present study aimed to assess the effectiveness of a computer-based simulator for basic training in EGD.
                The GI-Mentor II simulator was used. The subjects were 20 hospital medical residents. After receiving an explanation regarding the fundamentals of endoscopy, 10 trainees were each randomized into a simulator group and a non-simulator group. The simulator group received 5 h of training with the GI-Mentor II plus bedside training, while the non-simulator group received bedside training. Subsequently, each subject performed endoscopy twice for assessment. Performance was evaluated according to a five-grade scale for a total of 11 items.
                The score was significantly higher in the skills required for insertion into the esophagus, passing from the esophagogastric junction (EGJ) to the antrum, passing through the pylorus, and examination of the duodenal bulb and the fornix.
                The performance of endoscopy was improved by 5 h of simulator training. The simulator was more effective with regard to the items related to manipulation skills. Computer-based simulator training in EGD is useful for beginners. Flexible sigmoidoscopy, a core skill for the primary care physician, requires learned hand-eye skills that can be difficult to master during residency training. With recent advances in virtual reality simulation technology, simulated flexible sigmoidoscopes are available to family medicine residents for training before their initial and subsequent live patient examinations. The purpose of the study was to determine whether a virtual reality flexible sigmoidoscope simulator would improve the hand-eye skills and various performance parameters in a live patient.
                Residents were assigned to a control (n = 5) or experimental group (n = 5) in which the experimental group trained on a virtual reality sigmoidoscopy simulator before their first sigmoidoscopies on live patient volunteers. After the initial live patient sigmoidoscopies, both control and experimental groups trained on the simulator so that it was possible to evaluate presimulator and postsimulator training effects on live patient performance and to compare speed and skill between the groups at different levels of training.
                Training on the virtual reality simulator produced substantial improvements in examination times and hand-eye skill measures. After 6 to 10 hours of training on the simulator, the experimental group achieved significantly faster insertion times to 30 cm (119 versus 357 sec, P = 0.03), 40 cm (211 versus 518 sec, P = 0.03), and a shorter mean length of examination (323 versus 654 sec, P = 0.01). There was also significant improvement of hand-eye skill measures of the experimental group in directional errors (1.6 versus. 8.6, P < 0.01), percentage of colon visualized (79 versus 45 percent, P = 0.02), and viewing quality of examination when compared with the control group's initial performance on live patients. Resident survey findings after the study confirmed the trainee's perception of the benefit of the simulator training.
                This study shows the value of virtual reality simulator training for accelerating the development of the hand-eye skills to perform adequate sigmoidoscopy. The Olympus colonoscopy simulator provides a high-fidelity training platform designed to develop knowledge and skills in colonoscopy. It has the potential to shorten the learning process to competency.
                To investigate the efficacy of the simulator in training novices in colonoscopy by comparing training outcomes from simulator training with those of standard patient-based training.
                Multinational, multicenter, single-blind, randomized, controlled trial.
                Four academic endoscopy centers in the United Kingdom, Italy, and The Netherlands.
                This study included 36 novice colonoscopists who were randomized to 16 hours of simulator training (subjects) or patient-based training (controls). Participants completed 3 simulator cases before and after training. Three live cases were assessed after training by blinded experts.
                Automatically recorded performance metrics for the simulator cases and blinded expert assessment of live cases using Direct Observation of Procedural Skills and Global Score sheets.
                Simulator training significantly improved performance on simulated cases compared with patient-based training. Subjects had higher completion rates (P=.001) and shorter completion times (P < .001) and demonstrated superior technical skill (reduced simulated pain scores, correct use of abdominal pressure, and loop management). On live colonoscopy, there were no significant differences between the 2 groups.
                Assessment tools for live colonoscopies may lack sensitivity to discriminate between the skills of relative novices.
                Performance of novices trained on the colonoscopy simulator matched the performance of those with standard patient-based colonoscopy training, and novices in the simulator group demonstrated superior technical skills on simulated cases. The simulator should be considered as a tool for developing knowledge and skills prior to clinical practice. Computer-based colonoscopy simulation (CBCS) is being utilized in endoscopy training without supporting evidence that it improves patient-based colonoscopy performance. The goal of this pilot study was to determine if CBCS training improves gastroenterology (GI) fellows' patient-based colonoscopy skills.
                Competency at colonoscopy among 4 novice GI fellows who completed a 6-h CBCS curriculum was compared with 4 novice fellows who were not CBCS-trained. Measurements of competency were rendered by supervising faculty by recording "insertion time,"depth of unassisted insertion,"independent procedure completion,"ability to identify endoscopic landmarks,"inserts in a safe manner,"adequately visualizes mucosa on withdrawal," and "responds appropriately to patient discomfort" with each colonoscopy.
                Simulator-trained fellows outperformed traditionally trained fellows during their initial 15 colonoscopies in all performance aspects except "insertion time" (pp < 0.05). Simulator-trained fellows inserted the endoscope significantly further and reached the cecum independently nearly twice as often during this early training period. Three parameters ("depth of insertion,"independent completion," and "ability to identify landmarks") demonstrated a continued advantage out to 30 colonoscopies. Beyond 30 procedures, there was no difference in the performance of the two groups.
                In this pilot study, a 6-h CBCS curriculum provides an early training advantage by enhancing competency at the early stages of patient-based colonoscopy. These advantages are negligible after approximately 30 patient-based procedures. CBCS-enhanced training may allow faculty to be more efficient with their colonoscopy practice. The GI Mentor is a virtual reality simulator that uses force feedback technology to create a realistic training experience.
                To define the benefit of training on the GI Mentor on competency acquisition in colonoscopy.
                Randomized, controlled, blinded, multicenter trial.
                Academic medical centers with accredited gastroenterology training programs.
                First-year GI fellows.
                Subjects were randomized to receive 10 hours of unsupervised training on the GI Mentor or no simulator experience during the first 8 weeks of fellowship. After this period, both groups began performing real colonoscopies. The first 200 colonoscopies performed by each fellow were graded by proctors to measure technical and cognitive success, and patient comfort level during the procedure.
                A mixed-effects model comparison between the 2 groups of objective and subjective competency scores and patient discomfort in the performance of real colonoscopies over time.
                Forty-five fellows were randomized from 16 hospitals over 2 years. Fellows in the simulator group had significantly higher objective competency rates during the first 100 cases. A mixed-effects model demonstrated a higher objective competence overall in the simulator group (P < .0001), with the difference between groups being significantly greater during the first 80 cases performed. The median number of cases needed to reach 90% competency was 160 in both groups. The patient comfort level was similar.
                Fellows who underwent GI Mentor training performed significantly better during the early phase of real colonoscopy training. Changes in medical practice have constrained the time available for education and the availability of patients for training. Computer-based simulators have been devised that can be used to achieve manual skills without patient contact. This study prospectively compared, in a clinical setting, the efficacy of a computer-based simulator for training in upper endoscopy.
                Twenty-two fellows with no experience in endoscopy were randomly assigned to two groups: one group underwent 10 hours of preclinical training with a computer-based simulator, and the other did not. Each trainee performed upper endoscopy in 19 or 20 patients. Performance parameters evaluated included the following: esophageal intubation, procedure duration and completeness, and request for assistance. The performance of the trainees also was evaluated by the endoscopy instructor.
                A total of 420 upper endoscopies were performed; the computer pretrained group performed 212 and the non-pretrained group, 208. The pretrained group performed more complete procedures (87.8% vs. 70.0%; p < 0.0001), required less assistance (41.3% vs. 97.9%; p < 0.0001), and the instructor assessed performance as "positive" more often for this group (86.8% vs. 56.7%; p < 0.0001). The length of procedures was comparable for the two groups.
                The computer-based simulator is effective in providing novice trainees with the skills needed for identification of anatomical landmarks and basic endoscopic maneuvers, and in reducing the need for assistance by instructors. Little is known regarding the value of esophagogastroduodenoscopy (EGD) simulators in education. The purpose of the present paper was to validate the use of computer simulation in novice EGD training.
                In phase 1, expert endoscopists evaluated various aspects of simulation fidelity as compared to live endoscopy. Additionally, computer-recorded performance metrics were assessed by comparing the recorded scores from users of three different experience levels. In phase 2, the transfer of simulation-acquired skills to the clinical setting was assessed in a two-group, randomized pilot study. The setting was a large gastroenterology (GI) Fellowship training program; in phase 1, 21 subjects (seven expert, intermediate and novice endoscopist), made up the three experience groups. In phase 2, eight novice GI fellows were involved in the two-group, randomized portion of the study examining the transfer of simulation skills to the clinical setting. During the initial validation phase, each of the 21 subjects completed two standardized EDG scenarios on a computer simulator and their performance scores were recorded for seven parameters. Following this, staff participants completed a questionnaire evaluating various aspects of the simulator's fidelity. Finally, four novice GI fellows were randomly assigned to receive 6 h of simulator-augmented training (SAT group) in EGD prior to beginning 1 month of patient-based EGD training. The remaining fellows experienced 1 month of patient-based training alone (PBT group). Results of the seven measured performance parameters were compared between three groups of varying experience using a Wilcoxon ranked sum test. The staffs' simulator fidelity survey used a 7-point Likert scale (1, very unrealistic; 4, neutral; 7, very realistic) for each of the parameters examined. During the second phase of this study, supervising staff rated both SAT and PBT fellows' patient-based performance daily. Scoring in each skill was completed using a 7-point Likert scale (1, strongly disagree; 4, neutral; 7, strongly agree). Median scores were compared between groups using the Wilcoxon ranked sum test.
                Staff evaluations of fidelity found that only two of the parameters examined (anatomy and scope maneuverability) had a significant degree of realism. The remaining areas were felt to be limited in their fidelity. Of the computer-recorded performance scores, only the novice group could be reliably identified from the other two experience groups. In the clinical application phase, the median Patient Discomfort ratings were superior in the PBT group (6; interquartile range [IQR], 5-6) as compared to the SAT group (5; IQR, 4-6; P = 0.015). PBT fellows' ratings were also superior in Sedation, Patient Discomfort, Independence and Competence during various phases of the evaluation. At no point were SAT fellows rated higher than the PBT group in any of the parameters examined.
                This EGD simulator has limitations to the degree of fidelity and can differentiate only novice endoscopists from other levels of experience. Finally, skills learned during EGD simulation training do not appear to translate well into patient-based endoscopy skills. These findings suggest against a key element of validity for the use of this computer simulator in novice EGD training. Computer-based endoscopy simulator (CBES) training's impact on patient-based outcomes has never been examined. This study examines whether the endoscopy skills of trainees are improved and patient discomfort is reduced as a result of CBES training.
                From July 2001-June 2002, 38 residents received either 1 week of patient-based training (PBT) alone in flexible sigmoidoscopy (FS) or 3 hours of simulator-based training (SBT) before a week of training in FS. Patients completed questionnaires grading the discomfort experienced during endoscopy (1, no pain; 10, worst pain of life). In addition, residents' performance was graded by the supervising staff and themselves with 8 performance parameters by using a 1-10 Likert scale (1, strongly agree; 5, neutral; 10, strongly disagree).
                Nineteen SBT and 19 PBT residents performed 150 and 175 FS, respectively. During this same period, staff completed 585 FS. The median patient discomfort score for SBT residents was significantly less than for PBT residents, 3 (25%-75% interquartile range [IQR], 2-5) vs. 4 (IQR, 2-6) (P < 0.01). Discomfort scores for both resident groups were significantly greater than those recorded by staff endoscopists, 2 (IQR, 1-4) (P < 0.01). No difference was seen in the residents' procedural skill scores. Resident self-evaluation scores were significantly greater than those received from the supervising staff.
                Increased patient comfort resulted from simulation training, demonstrating that CBES training has a direct benefit to the patient. Although no measurable impact on residents' performance skills was observed, we do demonstrate that residents perceive themselves as having acquired greater endoscopic skills in contrast to staff evaluations.
The results of this systematic review indicate that virtual reality endoscopy training can be used to effectively supplement early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. However, there remains insufficient evidence to advise for or against the use of virtual reality simulation-based training as a replacement for early conventional endoscopy training (apprenticeship model) for health professions trainees with limited or no prior endoscopic experience. There is a great need for the development of a reliable and valid measure of endoscopic performance prior to the completion of further randomised clinical trials with high methodological quality.