Entrenamiento en enteroscopia asistida. Revisión rápida / No disponible

La enteroscopia asistida no dispone actualmente de un modelo validado de entrenamiento, a diferencia de lo que ocurre con la otra técnica principal de estudio del intestino delgado como es la cápsula endoscópica. La formación debería basarse en definir y alcanzar una serie de competencias para la adquisición de los conocimientos y habilidades necesarios para desarrollar la enteroscopia de forma segura y efectiva. La necesidad de formación es clara, ya que esta técnica se considera como endoscopia avanzada, y además de equipación específica, requiere de unas maniobras diferentes a las habituales que necesitan de entrenamiento. Por lo que los candidatos ideales para recibir formación son profesionales con una acreditada experiencia en endoscopia digestiva terapéutica. Dentro de las recomendaciones para el entrenamiento en enteroscopia asistida destaca principalmente el aprendizaje de la estimación de la profundidad de exploración del intestino delgado y la elección de la ruta de exploración, bien oral o anal. La descripción de las curvas de aprendizaje presentan la limitación de que son explorador-dependiente y de que no existe consenso sobre que parámetro debe escogerse para determinar una correcta curva de aprendizaje en enteroscopia. El parámetro más frecuentemente empleado es la profundidad de exploración alcanzada. Los escasos modelos de entrenamiento descritos recomiendan el empleo de una herramienta de gran utilidad como es el uso de simuladores y el inicio de la práctica bajo la tutela de expertos. Sobre la base de la variabilidad de datos publicados, un endoscopista experimentado podría realizar una técnica de enteroscopia de forma segura y eficaz después de un entrenamiento de entre 5 y 35 exploraciones, aunque alcanzar el nivel de experto requiere de una larga práctica clínica con la exposición a diferentes patologías del intestino delgado

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Device-assisted enteroscopy training. A rapid review.

Device-assisted enteroscopy is currently lacking a validated training model, in contrast to the other major technique used for the study of the small bowel, namely capsule endoscopy. Training should be based on defining and achieving competency for the acquisition of the knowledge and skills required to perform enteroscopy in a safe and effective manner. The need for training is clear, since the technique is considered an advanced endoscopy form that requires maneuvers that differ from the usual ones that must be learned, in addition to specific equipment. Therefore, the ideal candidates for this training include professionals with accredited experience in therapeutic digestive endoscopy. Amongst the recommendations issued regarding device-assisted enteroscopy training, the estimation of small-bowel insertion depth and the choice of the examination route, whether oral or anal, should be highlighted. Learning curve descriptions have the limitation of being explorer-dependent with no consensus on the parameter that should be selected to establish a correct learning curve in enteroscopy. The most commonly used parameter is insertion depth. The few training models that have been proposed recommend using a highly useful tool, namely simulators and to start practicing under expert guidance. Based on the variability of published data, an experienced endoscopist may perform enteroscopy in a safe and effective manner after 5 to 35 training procedures. Although reaching the expert level requires prolonged clinical practice with exposure to the various disorders of the small bowel.

Los imposibles de hoy serán posibles mañana. K. Tsiolkovski / No disponible

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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.

Comparison of the effect of laparoscopic and conventional pyloric surgery on gastric emptying in dogs.

The effect of a laparoscopic approach and pyloric surgery on canine gastrointestinal activity, particularly gastric emptying time, is not well understood. The purpose of this study was to compare the effect of laparoscopic and conventional pyloric surgery, in Ramstedt pyloromyotomy and Heineke-Mikulicz pyloroplasty, on complete gastric emptying time in 20 clinically normal dogs. Dogs were divided into four groups of five animals: dogs with laparoscopic Ramstedt pyloromyotomy, conventional Ramstedt pyloromyotomy, or laparoscopic Heineke-Mikulicz pyloroplasty, and the conventional Heineke-Mikulicz pyloroplasty group. Gastric emptying time using barium sulfate mixed with dry kibble dog food was measured fluoroscopically before and 1 month after surgery. Gastric emptying of solids was significantly enhanced in the pyloroplasty groups in the postoperative period compared with preoperative emptying. Just as after conventional pyloromyotomy, gastric emptying time after laparoscopic pyloromyotomy was not statistically different as compared with preoperative values. This study indicates that the fluoroscopic test meal is a valuable tool for defining complete gastric emptying time in normal dogs. We conclude that pyloromyotomy was less effective in decreasing complete gastric emptying time than Heineke-Mikulicz pyloroplasty in normal dogs. The possibility of decreasing complete gastric emptying time by laparoscopic surgery suggests a potential clinical application for this technique in small animals.

Comparison of ultrasonographic characteristics of the gastroduodenal junction during pyloroplasty performed laparoscopically or via conventional abdominal surgery in dogs.

OBJECTIVE: To evaluate the use of ultrasonography to detect morphologic changes in the pylorus during pyloroplasty performed laparoscopically or via conventional abdominal surgery in dogs. ANIMALS: 10 healthy mixed-breed dogs. PROCEDURE: Laparoscopic ultrasonography of the pylorus was performed in 5 dogs during laparoscopic pyloroplasty (LP), and ultrasonography of the pylorus was performed in 5 dogs during pyloroplasty via conventional abdominal surgery (CAP group). Appearance and dimensions of the pyloric sphincter were evaluated by use of a 7.5-MHz flexible laparoscopic linear-transducer probe. RESULTS: Mean +/- SD duration of the ultrasonographic procedure was 11 +/- 3.04 minutes (range, 6 to 18 minutes). In the CAP group, cross-sectional views of the pylorus revealed significant differences between the overall transverse external diameter, overall craniocaudal external diameter, and transverse diameter of the pyloric lumen. After surgery, the pyloric area was significantly increased. Longitudinal views of the pylorus revealed that width of the pyloric ring was significantly less after surgery. Transverse views of the pylorus for the LP group revealed a significant increase in the transverse diameter and craniocaudal diameter of the pyloric lumen after LP. The pyloric area was also significantly increased after surgery. Longitudinal views of the pylorus revealed that width of the pyloric ring was significantly less after surgery. Transverse diameter of the pyloric lumen was significantly increased after LP. CONCLUSIONS AND CLINICAL RELEVANCE: Analysis of results of this study suggests that ultrasonography is useful for detecting relevant morphologic changes in the pyloric sphincter after pyloroplasty.

Laparoscopic sonography in the urinary system.

This work reports the use of laparoscopic-transducer sonography for the examination of the urinary system in a swine model. Animals underwent a two-phase study. In the first phase, the urinary system was examined using laparoscopic sonography. In the second a partial ureteral obstruction was induced, and sonographic changes were recorded and evaluated. Sonography was used to evaluate kidneys, ureters, and bladder. Anatomic structures were evaluated and the following pathological findings were identified: renal cysts, one polycystic kidney, dilation of the renal pelvis, hydronephrosis, and one perirenal pseudocyst. Where necessary, contrast digital fluoroscopy (excretory urography and retrograde ureteropyelography) was also performed. Laparoscopic sonography mainly is used for evaluation prior to laparoscopic surgery to guide decisions relating to surgery. The quality of the images obtained laparoscopically is superior to that of percutaneous or transabdominal images, because artifacts are reduced and the contact surface of the transducer is placed directly over the study area. Laparoscopic sonography proved highly effective for studying renal and ureteral disorders prior to minimally invasive surgery.