Safety and efficacy of three-dimensional versus two-dimensional endoscopy in otolaryngology surgery and training: A systematic review.

OBJECTIVE: Three-dimensional (3D) endoscopy has been developed to provide depth perception to allow for improved visualisation during otolaryngology surgery. We conducted a systematic review to determine the surgical safety and efficacy of 3D endoscopy in comparison to two-dimensional (2D) endoscopy in performing otolaryngology procedures, and the role of 3D endoscopy as a training tool for novice otolaryngology surgeons. METHODS: Primary studies were identified through MEDLINE, Embase and Web of Science databases, which were searched for articles published through June 2022 that compared the outcomes of 2D and 3D endoscopy in otolaryngology surgical procedures or otolaryngology-relevant simulations. Candidate articles were independently reviewed by two authors. RESULTS: A total of 18 full-text articles met inclusion criteria for this study. In clinical trials (n = 8 studies, 362 subjects), there were no significant differences in performance time, intraoperative or postoperative complications with 3D endoscopes when compared to 2D. In simulation studies (n = 10 studies, 336 participants), 3D endoscopes demonstrated a decreased error rate (n = 5 studies) and shorter performance time (n = 3 studies). Studies also reported improved depth perception (n = 14 studies) and visualisation preference (n = 5 studies) with 3D over 2D systems. The 3D systems were found to have a shorter learning curve and better manoeuvrability among novice surgeons. CONCLUSION: 3D endoscopy showed equivalent safety and efficacy compared to 2D endoscopy in otolaryngology surgery. The improved depth perception and performance for novices using 3D endoscopes suggests the technology may be superior to 2D endoscopes as a training tool for otolaryngology surgeons.

Endoscopic part-task training box scores correlate with endoscopic outcomes.

BACKGROUND: Competency in endoscopy has traditionally been based on number of procedures performed. With movement towards milestone-based accreditation, new standards of establishing competency are required. The Thompson Endoscopic Skills Trainer (TEST) is a training device previously shown to differentiate between novice and expert endoscopists. This study aims to correlate TEST scores to other markers of performance in endoscopy. METHODS: Trainees of a gastroenterology fellowship program were guided through the TEST. Their scores and sub-scores were correlated to their endoscopic metrics of performance, including adenoma detection rate, cecal intubation rate, cecal intubation time, withdrawal time, fentanyl usage, midazolam usage, pain score, overall procedure time, and performance on the ASGE Assessment of Competency in Endoscopy Tool (ACE Tool). RESULTS: The Overall Score positively correlated with the ACE Tool Total Score (r = 0.707, p = 0.010) and sub-scores (Cognitive Skills Score: r = 0.624, p = 0.030; Motor Skills Score: r = 0.756, p = 0.004), and negatively correlated with cecal intubation time (r = - 0.591, p = 0.043). The Gross Motor Score positively correlated with cecal intubation rate (r = 0.593, p = 0.042), ACE Tool Total Score (r = 0.594, p = 0.042) and Motor Skills Score (r = 0.623, p = 0.031), and negatively correlated with cecal intubation time (r = - 0.695, p = 0.012). The Fine Motor Score positively correlated with the ACE Tool Polypectomy Score (r = 0.601, p = 0.039), and negatively correlated with procedure time (r = - 0.640, p = 0.025), cecal intubation time (r = - 0.645, p = 0.024), and withdrawal time (r = - 0.629, p = 0.028). CONCLUSION: This study demonstrates that performance on the TEST correlate to endoscopic measures. Given these results, the TEST may be used in conjunction with existing assessment tools for demonstrating competency in endoscopy.

A new minimally invasive porcine model for the study of intrahepatic bile duct dilatation.

BACKGROUND: Endoscopic ultrasound (EUS) procedures are becoming more frequent nowadays and novel techniques are on the rise. These procedures require high technical experience and complex endoscopic skills. The goal of this study was to develop a new minimally invasive animal model of bile duct dilatation in the pig, in order to offer a new tool for endoscopic and surgical therapy training and to test new therapeutic strategies. METHODS: Twenty-five female pigs underwent laparoscopic surgery in order to perform a common hepatic duct ligation. A pre- and postoperative biochemical analyses were performed: glucose, albumin, total bilirubin (TBil), gamma glutamyl transferase (GGT), alkaline phosphatase, and alanine aminotransferase were measured. Surgical time and intra- and postoperative complications were registered. Five to six days after surgery, an EUS was performed to measure intrahepatic duct size (mm). Distance from the bile duct to the EUS transductor was also recorded (mm). T-student for quantitative variables was applied. Statistical significance was defined as p value ≤ 0.05. RESULTS: The mean surgical time was 29.5 ± 14.9 min. In five pigs (20%), some mild intraoperative problems occurred. A severe postoperative complication occurred in one animal (4%). No postoperative mortality was registered. Postoperative serum analyses showed an increase in total bilirubin (p = 0.005) and gamma glutamyl transferase levels (p = 0.001). Postoperative EUS showed dilatation of the intrahepatic bile duct in 76% of pigs, with a mean diameter of 9.6 ± 3.6 mm (distance from the gastric wall of 17.0 ± 6.4 mm). CONCLUSION: The surgical procedure described here is a safe technique to induce dilatation of the intrahepatic bile ducts in the pig, with a minimally invasive approach and a high efficacy rate. This animal model might be useful for EUS techniques training and for evaluating new therapeutic approaches.

Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early united states experience.

BACKGROUND/AIMS: Adoption of endoscopic submucosal dissection (ESD) in the USA is challenging due to limited training opportunities. We describe the development of an ESD fellowship program in the USA and evaluate outcomes of ESD performed during this experience. METHODS: A 1-year ESD fellowship was implemented under close supervision from a recognized ESD expert. The curriculum was tailored to the trainee based on their background and prior endoscopic training. Under the expert's discretion, the trainee started by assisting cases and was gradually allowed to begin performing portions of ESD, with increasing difficulty as determined by technical progress, until complete procedures could be performed. Technical characteristics, outcomes, and adverse events were recorded. RESULTS: A total of 72 consecutive ESD cases were performed during the training period, in which the trainee assisted/observed 19 cases, partially performed 18 cases, and mainly performed 26 cases. Mean lesion diameter was 44.5 mm, with 79.2% colorectal cases. The trainee more frequently performed procedures with lower degree of fibrosis (p = 0.016). En bloc, complete, and curative resection was achieved in 84.7, 81.2, and 76.8% of cases, with no significant differences in resection outcomes or adverse events from trainee involvement. CONCLUSIONS: ESD can be safely and effectively taught within a 1-year advanced endoscopy fellowship. This was possible in the USA, even with limited gastric lesions, due to a progression focusing on easier portions of complex ESD procedures and advancing as technical progress allowed. Importantly, there was no increase in adverse event rate with trainee involvement in complex ESD cases.

Evaluation of a Human Virtual-Reality Endoscopy Trainer for Teaching Early Endoscopy Skills to Veterinarians.

Competency in flexible endoscopy is a major goal of small animal internal medicine residency training programs. Hands-on laboratories to teach entry-level skills have traditionally used anesthetized laboratory dogs (live dog laboratory [LDL]). Virtual-reality endoscopy trainers (VRET) are used for this purpose in human medicine with the clear benefits of avoiding live animal use, decreasing trainee stress, and allowing repeated, independent training sessions. However, there are currently no commercially available veterinary endoscopy simulators. The purpose of the study was to determine whether a human VRET can be a reasonable alternative to a LDL for teaching early veterinary endoscopy skills. Twelve veterinarians with limited or no endoscopy experience underwent training with a VRET (n = 6) or a LDL (n = 6), performed two recorded esophagogastroduodenoscopies (EGD) on anesthetized dogs for evaluation purposes (outcomes laboratory), and then underwent training with the alternative method. Participants completed questionnaires before any training and following each training session. No significant differences were found between training methods based on: measured parameters from the outcomes laboratory, including duration of time to perform EGD; evaluators' assessment of skills; and, assessment of skills through blinded review of the esophageal portion of EGD recordings. The VRET was less stressful for participants than the LDL (p = .02). All participants found that the VRET was a useful and acceptable alternative to the LDL for training of early endoscopy skills. Based on this limited study, VRET can serve as a reasonable alternative to LDL for teaching endoscopy skills to veterinarians.

A task and performance analysis of endoscopic submucosal dissection (ESD) surgery.

BACKGROUND: ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries. METHODS: We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons. RESULTS: The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores. CONCLUSIONS: We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.

Volume, specialty background, practice pattern, and outcomes in endoscopic retrograde cholangiopancreatography: an analysis of the national inpatient sample.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a complex endoscopic procedure performed by both gastroenterologists and surgeons. There has been recent controversy regarding training paradigms for gastrointestinal endoscopy. No prior studies have evaluated comparative outcomes for ERCP in relation to specialty training background. This study utilized the National Inpatient Sample (NIS) to assess ERCP outcomes as a function of training background, practice pattern, and individual provider volume. METHODS: NIS data was queried from 2007 to 2009. Gastroenterologists and surgeons were identified by procedural profiles and unique physician identifiers. Comorbidity was assessed via Charlson Score. Outcomes including cost, length of stay (LOS), and mortality were analyzed, with and without propensity score matching (PSM). Analysis of outcomes as a function of provider procedural volume was also performed. Comparison for statistical significance was accomplished via t test. RESULTS: A total of 110,811 ERCP's were identified, of which 42,025 (37.9%) were performed by surgeons. Surgeons exhibited longer LOS (8.7 vs. 7.2 days), overall cost ($24,739 vs. $16,960), and mortality (3.9 vs. 1.2%, odds ratio 3.3), with p < 0.001 for all measures. 71.6% of surgical patients, versus 19.6% of gastroenterologic, underwent subsequent inpatient laparoscopic cholecystectomy or laparotomy. Outcome differences persisted when PSM included performance of subsequent laparoscopic cholecystectomy. Evaluation of minimum performance standards revealed up to a fivefold increased mortality for providers who performed less than 5 ERCP's/year, irrespective of specialty background. CONCLUSIONS: Gastroenterologists demonstrate favorable gross outcomes compared to surgeons performing ERCP. Differences may correlate in part with more frequent subsequent surgical management of comorbid conditions by surgical providers. Lower volume providers achieve inferior outcomes regardless of specialty background. Analyses of this type may help inform discussions on optimal training and proficiency paradigms, including maintenance of proficiency, for therapeutic endoscopic procedures.

Esophageal bougination: a novel ex vivo endoscopic training model correlated with clinical data.

BACKGROUND: Esophageal bougination is a worldwide standard endoscopic procedure. Clinical methods and recommendations are based on clinical experiences only. Mechanical properties have never been described. Aim of the study was to establish a realistic ex vivo training model. Therefore, detailed assessment of relevant mechanical features of esophageal bougination should be evaluated ex vivo and in patient setting and correlated against. PATIENTS AND METHODS: A three-step concept was used to evaluate mechanical properties at stenosis level. First, insertion forces were evaluated in an ex vivo linear single stenosis model during steady mechanical insertion. Second, adding friction and properties of the pharynx and upper esophagus, the model was integrated in an artificial endoscopic training model (ELITE training model). Third, in vivo measurements were taken to correlate ex vivo data with parameters of a realistic patient setting. RESULTS: With the presented setup, we were able to assess insertion force and pressure levels in an artificial stricture using different sizes of commercially available standard bougies. In all models, there was a relevant increase in insertion force with higher stricture pressure levels. Insertion force levels in the ELITE model show higher levels compared to the linear stenosis model. Having regard to the maximum forces in patients, there is also a constant increase in mean insertion force according to higher bougie sizes, but lower forces were measured as in the ELITE model. DISCUSSION: The applied models are suitable to appraise mechanical properties of esophageal bougination in an ex vivo model and patient setting. Forces could be constituted reliable, significant increase was documented according to stenosis level and results were comparable to patient data. This was comparable to patient data. Further clinical evaluation in different kinds of stenosis is necessary.

Endoscopic Eradication Therapy in Barrett's Esophagus.

Endoscopic eradication therapy (EET), the standard of care for treatment of Barrett's esophagus with dysplasia and early neoplasia, consists of a combination of endoscopic resection and ablative modalities. Resection techniques primarily include endoscopic mucosal resection or endoscopic submucosal dissection. Resection of nodular disease is generally followed by one of multiple ablative therapies among which radiofrequency ablation has the best evidence supporting safety and efficacy. These advanced endoscopic procedures require both experience and expertise in the cognitive and procedural aspects of EET. However, very few formal programs exist that teach endoscopists the necessary skills to perform EET in a safe, standardized, and efficacious manner. Case volume at both the endoscopist and center level has been shown to impact clinical outcomes based on limited data. As a result, some recent guidelines endorse case volume as a measure of competency. Quality indicators, which can be used as benchmarks for training and as part of pay for quality initiatives, have recently been derived for EET. However, quality metrics in EET have not been widely accepted, nor are they broadly used currently. While the efficacy of EET for BE is established, there is a need for application of quality metrics to both assure adequate training in these procedures, as well as to assess treatment outcomes. A standardized EET training curriculum during endoscopic training, with competency assessment of both new clinicians and endoscopists in practice has potential to improve care in EET.

Validation of a realistic simulator for veterinary gastrointestinal endoscopy training.

This article reports on the face, content, and construct validity of a new realistic composite simulator (Simuldog) used to provide training in canine gastrointestinal flexible endoscopy. The basic endoscopic procedures performed on the simulator were esophagogastroduodenoscopy (EGD), gastric biopsy (GB), and gastric foreign body removal (FBR). Construct validity was assessed by comparing the performance of novices (final-year veterinary students and recent graduates without endoscopic experience, n=30) versus experienced subjects (doctors in veterinary medicine who had performed more than 50 clinical upper gastrointestinal endoscopic procedures as a surgeon, n=15). Tasks were scored based on completion time, and specific rating scales were developed to assess performance. Internal consistency and inter-rater agreement were assessed. Face and content validity were determined using a 5-point Likert-type scale questionnaire. The novices needed considerably more time than the experts to perform EGD, GB, and FBR, and their performance scores were significantly lower (p<.010). Inter-rater agreement and the internal validity of the rating scales were good. Face validity was excellent, and both groups agreed that the endoscopy scenarios were very realistic. The experts highly valued the usefulness of Simuldog for veterinary training and as a tool for assessing endoscopic skills. Simuldog is the first validated model specifically developed to be used as a training tool for endoscopy techniques in small animals.

Navigating the learning landscape: Comprehensive training in third space endoscopy - training, techniques, and practical recommendations.

Third space endoscopy (TSE), including ESD, POEM, or STER are advanced procedures requiring precise endoscopic control and tissue recognition. Despite its increasing adoption, evidence-based curricula, and standardized training protocols for TSE are lacking. This review explores training methods, cognitive skills, and technical proficiency requirements for endoscopists performing TSE, with a primary emphasis on POEM. Generally, it seems wise to recommend a step-up approach to TSE training, starting with ex-vivo models or POEM simulators; mechanical and virtual reality (VR) simulators are commonly used during early training. Preclinical training involving ex-vivo and live animal models is suggested to prepare trainees for safe and effective procedures. Studies suggest varying numbers of procedures for training, with approximately 20-40 cases needed before a first plateau is achieved in terms of complications and speed. The duration of on-patient clinical training varies depending on prior experience. Mentorship programs, workshops, and case discussions may facilitate dynamic knowledge transfer. In addition, adverse event management is a crucial aspect of any TSE training program. Existing evidence supports the use of preclinical models and emphasizes the importance of specialized training programs for TSE in alignment with our proposed step-up training approach. This review outlines practical recommendations for the theoretical knowledge and technical skills required before commencing TSE training, covering clinical understanding, diagnostic and outcome assessment, procedural requirements, and the role of mentorship programs.

Gastroenterology trainees can easily learn histologic characterization of diminutive colorectal polyps with narrow band imaging.

BACKGROUND & AIMS: Little is known about how teaching gastroenterology trainees polyp patterns by using narrow band imaging (NBI) affects their ability to characterize the histology of diminutive colorectal polyps. We developed and tested a tool to teach trainees to characterize the histology of diminutive polyps by using NBI. METHODS: Twelve gastroenterology trainees with varying levels of colonoscopy experience watched a teaching tool that described the NBI criteria to distinguish polyp histology. The trainees then watched 80 videos of NBI examination of diminutive polyps, recording their predictions of polyp histology and their degree of confidence. After each video, an expert provided feedback about actual polyp histology and the NBI criteria that supported each diagnosis. Twelve weeks later, without training or feedback during the interval, the trainees watched the same videos and predicted histologies of the polyps. Performance was evaluated by comparing predicted classification with actual histologic findings. Cumulative sum analysis was used to determine the learning curve for each trainee. RESULTS: Trainees made significant improvements in accuracy and the proportion of high-confidence predictions as they progressed through video blocks during the first session (P < .001). With active feedback, all trainees predicted polyp histologies with >90% accuracy, with a negative predictive value >90% for adenomatous histology. A median of 49 videos was required to achieve competency. For diagnoses made with high confidence, trainee performance exceeded 90% during the first and second sessions. Interobserver agreement was substantial (session 1, κ = 0.71; session 2, κ = 0.70). CONCLUSIONS: We developed a computer-based tool, combined with short videos and active feedback, to train gastroenterologists to identify polyp histology by using NBI. After training, gastroenterology trainees characterized the histology of diminutive polyps with ≥ 90% accuracy.

EndoTrainer: a novel hybrid training platform for endoscopic surgery.

PURPOSE: Endoscopy implies high demanding procedures, and their practice requires structured formation curricula supported by adequate training platforms. Physical platforms are the most standardised solution for surgical training, but over the last few years, virtual platforms have been progressively introduced. This research work presents a new hybrid, physic-virtual, endoscopic training platform that exploits the benefits of the two kind of platforms combining realistic tools and phantoms together with the capacity of measuring all relevant parameters along the execution of the exercises and of providing an objective assessment performance. METHODS: The developed platform, EndoTrainer, has been designed to train and assess surgical skills in hysteroscopy and cystoscopy following a structured curricula. The initial development and validation is focused on hysteroscopic exercises proposed in the Gynaecological Endoscopic Surgical Education and Assessment (GESEA) Certification Programme from The Academy and European Society for Gynaecological Endoscopy (ESGE) and analyses the obtained results of an extensive study with 80 gynaecologists executing 30 trials of the standard 30 degree endoscope navigation exercise. RESULTS: The experiments demonstrate the benefits of the presented hybrid platform. Multi-variable statistical analysis points out that all subjects have obtained statistically significant improvement in all relevant parameters: shorter and safer trajectories, improved 30-degree endoscope navigation, accurate positioning over the targets and reduction of the execution time. CONCLUSION: This paper presents a new hybrid approach for training, and evaluating whether it provides an objectivable improvement of camera navigation endoscopic basic skills. The obtained results demonstrate the initial hypothesis: all subjects have improved their camera handling and navigation skills.

The utility of intraoperative endoscopy in esophagogastric surgery.

Flexible endoscopy (FE) plays a major role in the diagnosis and treatment of gastrointestinal disease. Although its intraoperative use has spread over the years, its use by surgeons is still limited in our setting. FE training opportunities are different among many institutions, specialties, and countries. Intraoperative endoscopy (IOE) presents peculiarities that increase its complexity compared to standard FE. IOE has a positive impact on surgical results, due to increased safety and quality, as well as a reduction in the complications. Due to its innumerable advantages, its intraoperative use by surgeons is currently a current project in many countries and is part of the near future in others because of the creation of better structured training projects. This manuscript reviews and updates the indications and uses of intraoperative upper gastrointestinal endoscopy in esophagogastric surgery.

Perspective and practice patterns of mediastinal staging among thoracic surgeons.

Background: Accurate mediastinal staging of lung cancer patients is critical for determining appropriate treatment. Mediastinoscopy and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration are the most commonly utilized techniques. Limited data exist on training and practice trends among thoracic surgeons. We aimed to determine training and practice patterns and find whether there is a paradigm shift in mediastinal staging after the introduction of EBUS into practice among thoracic surgeons in the United States. Methods: 28-question survey was constructed querying demographic, training, and practice patterns with mediastinoscopy and EBUS and was sent to practicing thoracic surgeons in the United States. Descriptive statistics were used to summarize quantitative data. Results: Ninety-eight responded with a 93% completion rate. Eighty-seven percent of respondents received training in EBUS and 70% perform EBUS routinely. All respondents believe EBUS should be incorporated into thoracic surgery training curriculums. Majority of those who prefer EBUS feel EBUS is safer than mediastinoscopy, allows access to lymph nodes stations or lesions inaccessible by mediastinoscopy and prefer EBUS to avoid re-do mediastinoscopy and in irradiated mediastinum. Majority of those who prefer mediastinoscopy reported they perform more accurate staging compared to EBUS, that mediastinoscopy is more accurate in diagnosing lymphoma or sarcoidosis and that frozen section can be done at the same interval as resection. Among surgeons who prefer EBUS, 94% biopsy 3 or more lymph node stations, 86% routinely biopsy hilar (N1) nodes while 8% never biopsy N1 nodes. Of surgeons who prefer mediastinoscopy. Ninety-seven percent biopsy 3 or more lymph node stations, only 27% routinely biopsy N1 nodes and 70% never biopsy N1 nodes. Conclusions: EBUS is used frequently by thoracic surgeons in their practice for mediastinal staging. Methods of obtaining proficiency in EBUS widely varied among surgeons. In addition to mediastinoscopy, dedicated EBUS training should be incorporated into thoracic surgery training curriculums.

A system for real-time multivariate feature combination of endoscopic mitral valve simulator training data.

PURPOSE: For an in-depth analysis of the learning benefits that a stereoscopic view presents during endoscopic training, surgeons required a custom surgical evaluation system enabling simulator independent evaluation of endoscopic skills. Automated surgical skill assessment is in dire need since supervised training sessions and video analysis of recorded endoscope data are very time-consuming. This paper presents a first step towards a multimodal training evaluation system, which is not restricted to certain training setups and fixed evaluation metrics. METHODS: With our system we performed data fusion of motion and muscle-action measurements during multiple endoscopic exercises. The exercises were performed by medical experts with different surgical skill levels, using either two or three-dimensional endoscopic imaging. Based on the multi-modal measurements, training features were calculated and their significance assessed by distance and variance analysis. Finally, the features were used automatic classification of the used endoscope modes. RESULTS: During the study, 324 datasets from 12 participating volunteers were recorded, consisting of spatial information from the participants' joint and right forearm electromyographic information. Feature significance analysis showed distinctive significance differences, with amplitude-related muscle information and velocity information from hand and wrist being among the most significant ones. The analyzed and generated classification models exceeded a correct prediction rate of used endoscope type accuracy rate of 90%. CONCLUSION: The results support the validity of our setup and feature calculation, while their analysis shows significant distinctions and can be used to identify the used endoscopic view mode, something not apparent when analyzing time tables of each exercise attempt. The presented work is therefore a first step toward future developments, with which multivariate feature vectors can be classified automatically in real-time to evaluate endoscopic training and track learning progress.

Advancing endoscopic traction techniques in endoscopic submucosal dissection.

Traction techniques have emerged as a desirable "second-hand" while performing endoscopic submucosal dissection (ESD), enabling adequate visualization of submucosal tissue and vasculature, which allows for safe and efficient dissection. Multiple traction techniques have been developed over the years, and these can be broadly divided into internal and external traction techniques. This arsenal of techniques allows for traction that is personalized to the location of the lesion undergoing ESD. Mastering traction techniques requires structured training, and understanding of the benefits and pitfalls of each technique. Future research and development efforts need to focus on pathways and curriculums for trainees to master the currently available endoscopic traction techniques and provide avenues for the development of newer traction modalities.

Endoscopic training during fellowship: A nationwide French study: Impact of theoretical courses and simulation-based training during fellowship.

BACKGROUND: In France, it is mandatory that gastroenterology fellows have mastered the basic level of endoscopy by the end of training. The aim of this study was to assess improvement in the quality of fellows' endoscopy training in France during the last four years. METHODS: All fellows in France in training were eligible for participation. A 21-item questionnaire was sent out. The primary outcome was the completion by fourth year fellows of all the number of procedures recommended. Results were compared with those of a 2016 survey. RESULTS: Two-hundred-and-sixty-five fellows responded to the survey. The participation rate was 47.0%. The mean age was 27.3 ± 1.0 years and 56.4% were female. Access to theoretical courses (63.7% vs. 30.6%, p < 0.001) and simulation-based training (virtual reality simulator: 58.4% vs. 28.2%, p < 0.001, animal models: 29.4% vs. 17.2%, p < 0.001) was significantly higher in 2020. Although the number of procedures did not increase, significantly higher perception of skill acquisition in colonoscopy as well as diminished pressure to advance procedures were noted. CONCLUSION: Access to theoretical courses and simulation-based training and perceived acquisition of numerous skills has gotten better. However, the quality of training in endoscopy still needs improvement.

Development of a Technical Skills Test to Improve Assessment and Evaluation in Neuroendoscopic Education.

BACKGROUND: Endoscopy requires a unique set of skills that are difficult to acquire in most training programs. A method to test technical skills, in a validated manner, has rarely been attempted. The purpose of this study was to develop a technical skills examination for objective assessment in neuroendoscopic education. METHODS: Twenty-nine participants were included for analysis and divided by seniority level into 2 groups defined as before or upon postgraduation year (PGY) 5 (n = 18, junior surgeons) or after PGY5 (n = 11, senior surgeons). Study participants were assessed for baseline performance and then again following a 4-hour neuroendoscopy course. Wilcoxon test was used to evaluate for performance differences between cohorts. Correlation analyses were performed using the Pearson or Spearman coefficient. RESULTS: Increasing PGY level was correlated with a decreased average time to complete all 3 tasks (r = -0.44, P = 0.03) at baseline. Overall performance improved in both cohorts following the course (P < 0.001). When comparing junior surgeons after endoscopy training (posttest) to senior surgeons at their baseline (pretest), the junior surgeons were faster after endoscopic training than the senior surgeons were before training (P < 0.001). CONCLUSIONS: A neuroendoscopic skills test can distinguish between more or less experienced surgeons. Significant overall performance improvement, regardless of seniority level, following neuroendoscopic training demonstrates the accuracy of the test at detecting operating improvement in all stages of learning.

Three-dimensional endoscopy: The future of nasoendoscopic training.

OBJECTIVES/HYPOTHESIS: Three-dimensional (3D) endoscopy is an emerging tool in surgery that provides real-time depth perception. Its benefits have been investigated in surgical training, but the current literature lacks significant objective outcome data. We aimed to objectively compare the efficacy of two-dimensional (2D) versus 3D high-definition endoscopes in novice users. STUDY DESIGN: Prospective, randomized crossover study. METHODS: Ninety-two novice medical students who used both 2D and 3D endoscopes to complete two validated tasks in a box trainer participated in the study. Time taken and error rates were measured, and subjective data were collected. RESULTS: Wilcoxon tests showed 3D technology was significantly faster than 2D (78 vs. 95 seconds, P = .004), and errors per task were significantly lower (3 vs. 5, P < .001). Sixty-nine percent of participants preferred the 3D endoscope. CONCLUSIONS: 3D high-definition endoscopy could be instrumental in training the next generation of endoscopic surgeons. Further research is required in a clinical setting. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:1280-1285, 2019.