Magdalena Stefanova

Training on an ex vivo animal model improves endoscopic skills: a randomized, single-blind study

BACKGROUND Animal models are used for training of different endoscopic procedures. Whether this really improves endoscopic skills remains controversial. OBJECTIVE To assess the effectiveness of training by using an ex vivo animal gastric model on the performance of two therapeutic procedures-hemostasis and treatment of perforation. DESIGN A randomized, single-blind study. SETTING An experimental endoscopy center in a university hospital. PARTICIPANTS Thirty-one gastroenterology fellows with comparable endoscopic experience. METHODS Participants were randomized into two groups: with (T, n = 16) and without (S, n = 15) training. All fellows continued with standard endoscopic practice. Baseline skills were assessed at enrollment. All physicians in group T underwent 2 full days of a hands-on course over a 3-month period, in addition to their standard endoscopic practice. Both groups then underwent a blinded, final evaluation. Endoscopic skills were scored from 1 (best) to 5 (poorest) by two expert, blinded tutors. Outcomes of clinical hemostatic procedures also were analyzed. MAIN OUTCOME MEASUREMENTS Successful hemostasis and successful perforation closure. RESULTS Thirty physicians completed the study. Hemostasis results (n = 15): The number of physicians who carried out a successful hemostasis procedure increased significantly in the group with training (27% vs 73%; P = .009) but did not change in the group without training (20% vs 20%). The mean scores of injection and clipping technique improved significantly only after training. The number of clips used decreased significantly only in the group with training; the time of clipping did not change significantly in either group. Perforation results (n = 15): The number of physicians with a successful and complete perforation closure increased nearly significantly in the group with training (40% vs 73%, P = .06) as opposed to the group without training (27% vs 47%; P = .27). The procedure time decreased significantly in the group with training only. In clinical practice, fellows in group T had a significantly higher success rate with respect to hemostatic procedures (83.2%, range 67-100 vs 63.6%, range 25-100; P = .0447). The majority of participants (93%) agreed that such courses should be compulsory in gastroenterological credentials. LIMITATIONS A retrospective analysis of clinical outcomes. Clinical outcome data were based on self-reporting of the participants. CONCLUSION Hands-on training by using an animal ex vivo model improves endoscopic skills in both hemostasis and perforation closure. In clinical practice, the training improves the outcome of hemostatic procedures.

Improved specimen adequacy using jumbo biopsy forceps in patients with Barrett's esophagus.

AIM To assess the sampling quality of four different forceps (three large capacity and one jumbo) in patients with Barretts esophagus. METHODS This was a prospective, single-blind study. A total of 37 patients with Barretts esophagus were enrolled. Targeted or random biopsies with all four forceps were obtained from each patient using a diagnostic endoscope during a single endoscopy. The following forceps were tested: A: FB-220K disposable large capacity; B: BI01-D3-23 reusable large capacity; C: GBF-02-23-180 disposable large capacity; and jumbo: disposable Radial Jaw 4 jumbo. The primary outcome measurement was specimen adequacy, defined as a well-oriented biopsy sample 2 mm or greater with the presence of muscularis mucosa. RESULTS A total of 436 biopsy samples were analyzed. We found a significantly higher proportion of adequate biopsy samples with jumbo forceps (71%) (P < 0.001 vs forceps A: 26%, forceps B: 17%, and forceps C: 18%). Biopsies with jumbo forceps had the largest diameter (median 2.4 mm) (P < 0.001 vs forceps A: 2 mm, forceps B: 1.6 mm, and forceps C: 2mm). There was a trend for higher diagnostic yield per biopsy with jumbo forceps (forceps A: 0.20, forceps B: 0.22, forceps C: 0.27, and jumbo: 0.28). No complications related to specimen sampling were observed with any of the four tested forceps. CONCLUSION Jumbo biopsy forceps, when used with a diagnostic endoscope, provide more adequate specimens as compared to large-capacity forceps in patients with Barretts esophagus.

Training of Different Endoscopic Skills on Ex-vivo Animal Model

Introduction Virtual reality simulator and ex vivo animal models are used for training of both basic and advanced endoscopic techniques. The aim of this study was to assess whether hands-on training on ex vivo animal model improves endoscopic skills. Four different endoscopic techniques were practiced: endoscopic resection, endoscopic stenting, application of the over-the-scope (OVESCO) clip, and endoscopic submucosal dissection (ESD). Methods Except for 2 participants, all trainees participated in a 1-day course. Two remaining participants took part in 7 ESD courses. All training courses consisted of theoretical introduction and a 6-hour training on Erlangen Active Training Simulator. The endoscopic skills were assessed before and after the training session by 2 independent assessors. Each assessor evaluated the skills by using a score on a scale of 1 to 5, where 1 stands for excellent and 5 for insufficient. Each assessor also assessed whether the procedure was successfully completed. The main outcome measurement was the percentage of participants who successfully completed the procedure during the test. Results For endoscopic resection, endoscopists (n = 15) improved their skills (median [10th and 90th percentiles] score before training, 3.5 [2.7–4.2]; after training 1.5 [1–2.3], P < 0.001). Seven procedures were assessed as successful before the course (47%); after the training, 13 procedures were assessed as successful (87%) (P = 0.02). For stenting, participants (n = 15) significantly improved their abilities to place both self-expandible metallic and plastic stents. For OVESCO clip (n = 10), participants (n = 10) improved their skills to prepare and apply the clip (given the score of 4.5 [3.9–5] before and 2.0 [1.2–2.8] after, P < 0.01). Before the training, only 1 clip application had been successful (10%), whereas the number rose to 9 after the course (90%). For endoscopic submucosal dissection (n = 10), eight participants of the 1-day course did not improve their competences (with scores of 4.2 [3.8–5] before and 4.0 [3.1–4.8] after, nonsignificant). Two participants who had undertaken 7 ESD courses improved their skills (with scores of 4 before and 1.6 after); given the small number of participants, this finding is statistically insignificant. Limitation The effect of training on clinical outcome was not investigated. There was a lack of pretraining versus posttraining tests blinding. Conclusions A 1-day training course on ex vivo animal model improves general endoscopic competence on simulator in endoscopic resection, insertion of stents, and application of OVESCO clips. In contrast, 1-day course does not improve skills for ESD that requires a higher number of training courses.