The compact Erlangen Active Simulator for Interventional Endoscopy: a prospective comparison in structured team‐training courses on ‘endoscopic hemostasis’ for doctors and nurses to the ‘Endo‐Trainer’ model

Background: In 1997 Hochberger and Neumann presented the ‘Erlangen Biosimulation Model’ (commercialized as the ‘Erlangen Endo‐Trainer’) at various national and international meetings. The new compactEASIE® is a simplified version of the original ‘Biosimulation Model’ (Endo‐Trainer) and is specially designed for easy handling. CompactEASIE is reduced in its features, focusing exclusively on fexible endoscopy training. The acceptance of training in endoscopic hemostasis is accepted by workshop participants, as evaluated by a questionnaire on both models. Methods: Eleven structured courses on endoscopic hemostasis for doctors and nurses organized by the same endoscopists from 3/1998 to 5/1999 were evaluated using one of both models. The questionnaires were filled in by 207/291 trainees (71%). The Endo‐Trainer was used in 4 (n?=?103) and the compactEASIE in 7 courses (n?=?104). Both simulators were equipped with identical types of specially prepared pig‐organ packages consisting of esophagus, stomach and duodenum, including artificial sewn‐in vessels, polyps and varices. Blood perfusion was done with a roller pump connected to the sewn‐in vessels and blood surrogate. All workshops were identical concerning the course structure: a 30‐min theoretical introduction on ulcer bleeding was followed by 2?h of practical training in injection techniques and hemoclip application. The second part of variceal therapy consisted of a 30‐min theoretical introduction prior to 2?h of practical training on sclerotherapy, band ligation and cyanoacrylate application. Finally, a questionnaire on the trainees' pre‐experience and their rating of the different workshop sections was handed out to each participant. Results: Previous endoscopic experience was comparable in both groups. The training in both simulators was highly accepted by the trainees (compactEASIE 95% excellent and good versus EASIE (Endo‐Trainer) 97%) and did not show any significant difference (P?=?0.493). Even in the assessment of the single techniques, no statistical difference was observed. Furthermore, the assessments of the closeness to reality and the endoscopic environment in both simulators were identical. Conclusions: Both simulators (Endo‐Trainer, compactEASIE) are excellent educational tools for interventional endoscopy with a high level of acceptance. The easy‐to‐handle, ‘lightweight’ compactEASIE is a significant, progress tool for the future.     

Efficacy and costs of a one-day hands-on EASIE endoscopy simulator train-the-trainer workshop

BACKGROUND: The efficacy of an intensive hands-on training in endoscopic hemostasis on the compactEASIE simulator has been previously demonstrated in a randomized prospective trial. In the current study, we evaluated how quickly and effectively new tutors, without simulator training experience, are able to acquire teaching skills in endoscopic hemostasis. METHODS: Five tutors with prior Erlangen Active Simulator for Interventional Endoscopy (EASIE) teaching experience instructed 7 endoscopists without prior EASIE experience on how to teach when using the model. These new tutors then independently conducted a workshop for 8 fellows in 4 hemostasis techniques. Results were compared with a historical control trained similarly by experienced tutors. Two one-day workshops in endoscopic hemostasis on the compactEASIE ex vivo endoscopy simulator were conducted in a category A hospital in New York City, New York. Skill scores at the end of training were compared with baseline skills assessments, and qualitative ratings of the new tutors were obtained from both the trainees and the experienced tutors. RESULTS: Significant improvement was achieved by the fellows in all 4 skills areas. Both the expert tutors and the trainees consistently rated the teaching skill of the new tutors highly. Fellows' skill acquisition using new tutors was of similar magnitude to that achieved in the prior EASIE trial using experienced trainers teaching the fellows. CONCLUSIONS: It is feasible to conduct an effective EASIE train-the-trainer course in one day. Tutors trained in this manner are able to provide a similar educational experience with objective improvement in trainee skill to experts who have conducted many hands-on workshops.     

Training in GI endoscopy: can we objectively predict the performance of trainees? A prospective correlation study

BACKGROUND: No objective criteria have hitherto been available for assessing the individual talents and skills of trainees involved in GI endoscopy. The aim of our study was to compare the correlation of various psychological, psychomotor and cognitive tests (psy-tests) and of the subjective assessment of the trainer (expert assessment) at the beginning of the training with the objective performance of the trainees at the end of a one-week training period in upper GI endoscopy. METHODS: In a prospective study including 12 endoscopic centers, a total of 58 participants without any prior endoscopic experience were analyzed. During a practical training week in each center with the "Erlangen Endo-Trainer," an assessment using a "score card" protocol was used as reference method. Prior to the start of the training, various psy-tests (personality test, vigilance endurance test, test of spatial thinking and two tests of sensorimotor coordination) as well as assessment of the trainer were obtained. These parameters were compared with a blinded analysis of the performance at the end of the training. RESULTS: There was significant overall improvement during the training course. Multiple logistic regression analysis revealed that testing sensorimotoric coordination was significantly associated with defined improvement margins (odds ratio 11.46, p = 0.035). An expert's judgment on the prognosis correlated also significantly with the trainee's improvement (OR = 41.46; p = 0.018). Self-assessments were not significantly associated with performance or progress. CONCLUSIONS: Sensorimotoric tests may provide a reliable prediction of the trainee's learning progress. In contrast to self-assessment, the judgement of an experienced endoscopist provides the best guidance for the young candidate endoscopists prior to the start of his/her endoscopic training program.     

Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS: Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS: Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS: compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.     

The compactEASIE is a feasible training model for endoscopic novices: A prospective randomised trial

BACKGROUND: The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects. METHODS: Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n=14) and control group (n=13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1=worst, 10=optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003. RESULTS: We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p<0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques). CONCLUSION: Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE.     

Combined simulation training: a new concept and workshop is useful for crisis management in gastrointestinal endoscopy

INTRODUCTION: Crisis management as well as realistic emergency situations can be trained in the new developed simulation workshop "Gastrointestinal Endoscopy and Crisis Resource Management" by combining a full-scale simulator and the Erlanger Endoscopy Trainer. The aim of the current study was to evaluate the efficiency of the newly developed simulation workshop. METHODS: Endoscopists with more than 12 months experience can train their endoscopic skills and crisis resource management with the help of different simulators. In addition, two different scenarios (GI bleeding with significant blood loss and sedation overdoses) embedded in a realistic surrounding (emergency room) have to be managed by the participants. Vital parameters, endoscopic skills, as well as personal interactions were recorded and graded. RESULTS: 100 participants took part in the newly developed workshop (between June and December 2003). The participants showed a significantly better endoscopic performance and a significantly better crisis management after the standardized training program. CONCLUSIONS: Simulation training plays an essential role in aviation and minimizes the risk for human errors. In the current study it is clearly shown that simulation training is also useful in gastrointestinal endoscopy. The newly developed workshop may thus be of crucial importance to improve personal crisis management. Simulation also leads to an improvement of endoscopic and emergency skills. Accordingly, simulation training should be recommended or offered as an education option in gastrointestinal endoscopy.     

Training with a computer-based simulator achieves basic manual skills required for upper endoscopy: a randomized controlled trial

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Prospective randomized study on the use of a computer-based endoscopic simulator for training in esophagogastroduodenoscopy

Background and Aim:  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.
Methods:  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.
Results:  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.
Conclusions:  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.     

Current status of core and advanced adult gastrointestinal endoscopy training in Canada: Survey of existing accredited programs

OBJECTIVE:

To determine the current status of core and advanced adult gastroenterology training in Canada.

METHODS:

A survey consisting of 20 questions pertaining to core and advanced endoscopy training was circulated to 14 accredited adult gastroenterology residency program directors. For continuous variables, median and range were analyzed; for categorical variables, percentage and associated 95% CIs were analyzed.

RESULTS:

All 14 programs responded to the survey. The median number of core trainees was six (range four to 16). The median (range) procedural volumes for gastroscopy, colonoscopy, percutaneous endoscopic gastrostomy and sigmoidoscopy, respectively, were 400 (150 to 1000), 325 (200 to 1500), 15 (zero to 250) and 60 (25 to 300). Eleven of 13 (84.6%) programs used endoscopy simulators in their curriculum. Eight of 14 programs (57%) provided a structured advanced endoscopy training fellowship. The majority (88%) offered training of combined endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The median number of positions offered yearly for advanced endoscopy fellowship was one (range one to three). The median (range) procedural volumes for ERCP, endoscopic ultrasonography and endoscopic mucosal resection, respectively, were 325 (200 to 750), 250 (80 to 400) and 20 (10 to 63). None of the current programs offered training in endoscopic submucosal dissection or natural orifice transluminal endoscopic surgery.

CONCLUSION:

Most accredited adult Canadian gastroenterology programs met the minimal procedural requirements recommended by the Canadian Association of Gastroenterology during core training. However, a more heterogeneous experience has been observed for advanced training. Additional studies would be required to validate and standardize evaluation tools used during gastroenterology curricula.     

Role of virtual reality simulation in endoscopy training

Recent advancements in virtual reality graphics and models have allowed virtual reality simulators to be incorporated into a variety of endoscopic training programmes. Use of virtual reality simulators in training programmes is thought to improve skill acquisition amongst trainees which is reflected in improved patient comfort and safety. Several studies have already been carried out to ascertain the impact that usage of virtual reality simulators may have upon trainee learning curves and how this may translate to patient comfort. This article reviews the available literature in this area of medical education which is particularly relevant to all parties involved in endoscopy training and curriculum development. Assessment of the available evidence for an optimal exposure time with virtual reality simula-tors and the long-term benefits of their use are also discussed.     

The complementary Erlangen active simulator for interventional endoscopy training is superior to solely clinical education in endoscopic hemostasis--the French training project: a prospective trial

BACKGROUND: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) using ex-vivo porcine organs was introduced in 1997. The present study should analyze whether repeated EASIE simulator training in endoscopic hemostasis led to superior performance compared with a traditionally educated group. The results were compared with a similar project in New York. METHODS: Thirty-five French GI fellows were enrolled. Baseline skills evaluation was performed in four disciplines (manual skills, injection/coagulation, clip application and variceal ligation) using the compactEASIE-simulator equipped with an upper gastrointestinal organ package for bleeding simulation. The same, translated evaluation forms (from the prior New York project) were used. Subsequently, fellows were randomized into group A (n=17, only clinical education) and group B (n=18, additional three simulator trainings). Group B was trained the next day and after 4 and 7 months by experts of the French Society of Gastrointestinal Endoscopy. Both groups performed routine and emergency endoscopies at their home hospitals during the study period. Both groups were re-evaluated blindly after 9 months. RESULTS: The learning curve for group B showed a significant improvement in all disciplines (P<0.004) whereas group A improved significantly in only two of four disciplines at blinded final evaluation (manual skills P=0.02, injection/coagulation P=0.013). The direct comparison of groups B and A at blinded final evaluation showed significantly superior ratings for group B in all disciplines (P<0.006) and significantly shorter performance times in two disciplines (P=0.016 each). The comparison with the similar 'New York project' revealed that preexisting differences in skills were adjusted by the training. CONCLUSION: Complementary trainings (three workshops in 7 months) in endoscopic hemostasis using the compactEASIE improved skills compared with a solely clinical education. The results of the 'New York project' were confirmed and benefits were independent from the medical educational system.     

Virtual reality simulators for gastrointestinal endoscopy training简

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees’ learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-the-art simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.     

Virtual reality simulators for gastrointestinal endoscopy training

The use of simulators as educational tools for medical procedures is spreading rapidly and many efforts have been made for their implementation in gastrointestinal endoscopy training. Endoscopy simulation training has been suggested for ascertaining patient safety while positively influencing the trainees' learning curve. Virtual simulators are the most promising tool among all available types of simulators. These integrated modalities offer a human-like endoscopy experience by combining virtual images of the gastrointestinal tract and haptic realism with using a customized endoscope. From their first steps in the 1980s until today, research involving virtual endoscopic simulators can be divided in two categories: investigation of the impact of virtual simulator training in acquiring endoscopy skills and measuring competence. Emphasis should also be given to the financial impact of their implementation in endoscopy, including the cost of these state-of-theart simulators and the potential economic benefits from their usage. Advances in technology will contribute to the upgrade of existing models and the development of new ones; while further research should be carried out to discover new fields of application.     

Is formal training necessary for capsule endoscopy?: The largest gastroenterology trainee study with controls

BACKGROUND: Little is known about the infrastructure to train gastroenterologists in capsule endoscopy. The level of capsule endoscopy exposure among trainees in the United Kingdom or Europe has also not been quantified. AIMS AND METHODS: To assess the ability of 10 gastroenterology trainees with endoscopy experience to interpret 10 capsule endoscopy videos against five medical students, with an expert in capsule endoscopy as the gold standard. Parameters assessed included gastric emptying time, small bowel transit and the diagnosis made. A questionnaire survey assessed the level of capsule endoscopy exposure among United Kingdom trainees. RESULTS: Trainees were better at determining the gastric emptying time (p=0.013) and more likely to record true positives compared to the students (p=0.037). They were also less likely to record false positives (p=0.005) and more likely to reach the correct diagnosis (p=0.001, OR 3.6, CI 1.8-7.4). Our survey found that, 65% of trainees had prior exposure to capsule endoscopy but only 13% had done capsule endoscopy reporting. Sixty seven percent felt capsule endoscopy should be incorporated into their training. CONCLUSION: This study has shown that prior endoscopic experience enables trainees to interpret capsule endoscopy more accurately than medical students. However, there is a demand for focussed training which would enable trainees to reliably interpret pathology on capsule endoscopy.     

Curriculum for surgical training

Since introduction, flexible endoscopy has been a mainstay of surgical practice for the management of gastrointestinal disorders. In rural settings, many surgeons are the primary providers of flexible endoscopy. However, in larger institutions gastroenterologists perform the majority of endoscopic procedures. Surgical training primarily occurs in large cities and academic institutions leaving many surgical trainees with inadequate exposure and training in flexible endoscopy during their residencies. Additionally, as the technology has developed, the utility of flexible endoscopy is being recognized and surgeons are taking advantage of the value added by being able to provide endoscopic therapy for their patients. This has led to an initiative by the American Board of Surgery and the Society of American Gastrointestinal and Endoscopic Surgeons to formalize a flexible endoscopy curriculum to promote endoscopic training in US surgical residencies. The comprehensive curriculum includes progressive cognitive and skills-based learning objectives to enhance training efficacy and ensure proficiency when completed. As of 2018, surgical trainees must successfully complete all components of the curriculum in order to be eligible for graduation. This paper reviews the development and components of a flexible endoscopy curriculum for US surgical residents.     

非静脉曲张性上消化道出血行急诊内镜止血患者病情严重且预后较差

目的：比较分析非静脉曲张性上消化道出血(NVUGIB)床边急诊内镜与择期内镜治疗的临床特点和疗效。方法：回顾性收集304例NVUGIB并接受内镜止血治疗患者的病例资料，其中接受床边急诊内镜的152例患者纳入急诊内镜组，接受择期内镜止血的152例患者纳入择期内镜组，比较分析2组患者的一般情况、病情严重程度、疗效等。结果：2组患者的一般情况、病因构成、止血方式无明显差异(P均>0.05)，与择期内镜组比较，急诊内镜组患者血红蛋白量和血小板计数低，凝血时间延长，AIMS65评分及内镜前Rockall(pRS)评分较高(P均<0.01)，输血率高(60.4% vs 47.4%，P<0.01)，输血量多(P<0.01)，再出血率高(12.2% vs 3.9%，P<0.01)，住院时间更长(P<0.01)。2组患者止血成功率都在80%以上，并发症发生率和死亡率无明显统计学差异(P>0.05)。结论：对于NVUGIB患者，需行床边急诊内镜止血者失血情况严重，凝血功能差，其输血量、再出血率、住院时间均较高或较长，但死亡率与择期内镜止血治疗者相近。     

Simulator training in gastrointestinal endoscopy – From basic training to advanced endoscopic procedures

Simulator-based gastrointestinal endoscopy training has gained acceptance over the last decades and has been extensively studied. Several types of simulators have been validated and it has been demonstrated that the use of simulators in the early training setting accelerates the learning curve in acquiring basic skills. Current GI endoscopy simulators lack the degree of realism that would be necessary to provide training to achieve full competency or to be applicable in certification. Virtual Reality and mechanical simulators are commonly used in basic flexible endoscopy training, whereas ex vivo and in vivo models are used in training the most advanced endoscopic procedures. Validated models for the training of more routine therapeutic interventions like polypectomy, EMR, stenting and haemostasis are lacking or scarce and developments in these areas should be encouraged.     

Head-to-head comparison of practice with endoscopic retrograde cholangiopancreatography computer and mechanical simulators by experienced endoscopists and trainees

Background and Aim: The endoscopic retrograde cholangiopancreatography (ERCP) mechanical simulator (EMS) and computer simulator (ECS) are described herein. No direct hands‐on comparison has been reported to reflect the perception of trainers and trainees regarding the efficacy of each model for trainee ERCP education. We compared the trainers' and trainees' assessments of the EMS and ECS for trainee education. Methods: Eighteen gastrointestinal trainees and 16 trainers with varying ERCP experience completed a questionnaire survey before and after practice with each simulator at hands‐on ERCP practice workshops. They carried out scope insertion, selective bile duct cannulation, guidewire negotiation of a bile duct stricture, biliary papillotomy and insertion of a single biliary stent using both simulators. Main outcome measurement was respondents' assessments of comparative efficacy of EMS and ECS practice for trainee education. Results: Compared to pre‐practice evaluation, both EMS and ECS received higher scores after hands‐on practice. Both trainers and trainees showed significantly greater increases in scores for EMS when compared with ECS in facilitating understanding of ERCP procedure, enhancing confidence in carrying out ERCP and the simulator as a credible option for supplementing clinical ERCP training (P < 0.05). Participants also scored EMS significantly higher in realism and usefulness as an instructional tool. Conclusions: Both computer and mechanical simulators are accepted modalities for ERCP training. The current data (based on a head‐to‐head comparison of hands‐on practice experience) indicate EMS practice is rated higher than ECS practice in supplementing clinical ERCP training. EMS offers the additional advantage of coordinated practice with real equipment and accessories.     

Long-term Follow-up of Endoscopic Treatment for Bleeding Gastric and Duodenal Ulcers

Objective: To examine the long-term consequences of endoscopic therapy for bleeding peptic ulcers. Methods: Eighty-seven consecutive patients who underwent endoscopic treatment for bleeding gastric ulcer (GU) and/or duodenal ulcer (DU) over a 42-month period were identified. Long-term follow-up was available for 76 (mean, 495 days; SEM, 45 days). Therapy consisted of epinephrine injection, heater probe use, or both. Recurrent hemorrhage only at the primary treatment site was considered. Results: The sites of hemorrhage were GU (40 patients), DU (34 patients), and both (2 patients). Emergent surgery was required in two GU patients for whom endoscopic treatment was ineffective. Recurrent hemorrhage ultimately occurred in 33% of patients—40% of GU and 25% of DU patients. Surgical therapy was eventually required in 26% of patients after endoscopic he-mostasis and was more frequent in patients with recurrent hemorrhage from DU than GU (78% vs 56%). For those patients who re-bled within 8 days of the index endoscopy, 82% required surgery, compared with 33% of patients who re-bled more than 8 days after the index endoscopy ( p = 0.03). Conclusions: The rate of recurrent hemorrhage after endoscopic hemostasis for bleeding GU and DU was 33% in our long-term follow-up. After endoscopic hemostasis, surgery was eventually required in 24% of all patients and in 64% of patients who had recurrent hemorrhage. Patients who had recurrent hemorrhage more than 1 wk after initial endoscopic hemostasis were effectively treated by repeated endoscopic therapy and were significantly less likely to require surgery than patients who re-bled within 1 wk.     

Simulation-based mastery learning in gastrointestinal endoscopy training

Simulation-based mastery learning (SBML) is an emerging form of competency-based training that has been proposed as the next standard method for procedural task training, including that in gastrointestinal endoscopy. Current basic gastrointestinal endoscopy training relies on the number of procedures performed, and it has been criticized for its lack of objective standards that result in variable skills among trainees and its association with patient safety risk. Thus, incorporating simulators into a competency-based curriculum seems ideal for gastrointestinal endoscopy training. The curriculum for SBML in gastrointestinal endoscopy is currently being developed and has promising potential to translate into the clinical performance. Unlike the present apprenticeship model of “see one, do one, teach one,” SBML integrates a competency-based curriculum with specific learning objectives alongside simulation-based training. This allows trainees to practice essential skills repeatedly, receive feedback from experts, and gradually develop their abilities to achieve mastery. Moreover, trainees and trainers need to understand the learning targets of the program so that trainees can focus their learning on the necessary skills and trainers can provide structured feedback based on the expected outcomes. In addition to learning targets, an assessment plan is essential to provide trainees with future directions for their improvement and ensure patient safety by issuing a passing standard. Finally, the SBML program should be planned and managed by a specific team and conducted within a developed and tested curriculum. This review discusses the current state of gastrointestinal endoscopy training and the role of SBML in that field.