Endoscopy simulators offer a promising tool for teaching basic dexterity prior to training in patient-based endoscopy. Training can be given in a learning environment, without putting patients at unnecessary discomfort or risk. This allows for trainees to train their skills and repeat exercises until specific endoscopy skills are mastered. Furthermore it enables trainees to test the boundaries of certain maneuvers like insufflation or endoscope pushing with regards to the effect on discomfort of the virtual patient.
Numerous studies have been performed on the validation and early learning curves of both virtual reality (VR) and mechanical endoscopy simulators. Most studies focus on colonoscopy training. Only a few studies focus on competence measurement using simulators as an assessment tool.
Several studies, again mostly on colonoscopy, provide high quality evidence for the positive effect of simulator training in novices in flexible endoscopy, measured in terms of both VR as well as live endoscopy. Based on this evidence, one can conclude that simulator training is complementary to patient-based learning and is useful in the early training phase in speeding up the early learning curve and reducing patient burden. To reach procedural competency in patient-based endoscopy, the same numbers of patient-based procedures seem to be necessary.
Currently, it seems that simulators and models for training skills in endoscopy are mostly used in the early phase of learning. There is no evidence to support the use of simulators during the remainder of the learning curve to reach competency although many experts share the feeling that the full potential of these simulators has not yet been investigated.
Interestingly, when it comes to training the most advanced procedures like endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and complication management, animal models are being used, both ex vivo and live animal models. Especially live animal models like the porcine model, offer realistic training scenarios when it comes to tissue resection and dissection, bleeding situations and perforations. The first validation study of this model is currently ongoing.
What is currently lacking is the availability of simulators and model to train endoscopists from novice to realistic competent levels that transfer to the same competency in patient-based endoscopy. There is an even greater scarcity of evidence on training models for ERCP and endosonography. ERCP procedures are among the most challenging procedures withy high complication rates in GI endoscopy and EUS is widely practiced with an increasing number of therapeutic possibilities. Yet, there is little evidence to assess high quality outcome parameters and competency based certification. A few validated simulation models are available for ERCP but no recommendation can be given regarding the use of simulators in order to speed up the learning curve.
Future research, based on the available evidence, should include a complete training program. I would propose a pre-patient curriculum using simulator training. The transfer of simulation skills to patient-based procedures needs to be further explored. Simulation training needs to be followed by the continuous assessment of patient-based endoscopies to provide individual and group learning curves and after a period of time, (repeated) overall assessments of performance by an expert. Therefore, the development of validated assessment tools is necessary and the effect of expert assessments on daily practice needs to be measured.
