Introduction

Endoscopic sphincterotomy (EST) is a critical procedure in cholangiopancreatic endoscopic practice. However, learning opportunities outside of actual patients are limited, and effective learning methods are needed to understand complications and ensure the correct flow of procedures. To address this, we developed EST simulator with a duodenal papilla composed of soft material and pseudo-vessel that mimics the bleeding complication under abnormal incision: other than the 11-12 o'clock direction or over cutting with the appropriate direction.

Aims & Methods

The aim of this study was to evaluate the effectiveness of the EST learning program which included hands-on training using this simulator.
First, trainees filled out pre-program questionnaire including the self-confidence and understanding of EST, and expectation for simulator learning. Before hands-on training with the simulator, trainees watched the instruction video. The video contained basic flow of EST procedure, how to control the duodenoscope, overview of EST devices such as guidewire/ cannula/ sphincterotomy knife/ a basket catheter, and introducing the simulator model. Then trainees freely attempted EST with the simulator once. After 1st trial, expert endoscopists gave the trainees feedback and 6 tips based on Bethesda ERCP Skill Assessment Tool (BESAT). Afterwards, trainees tried second EST procedure. Finally, participants filled out post-program questionnaire. A successful EST was defined as a medium incision made in the 11-12 o'clock direction. Too small incision or causing bleeding complication was defined as fault. Primary outcomes were subjective score using the Visual Analogue Scale (VAS) between before and after the training program. The evaluation of simulator training with feedback was compared the success rates of EST between 1st and 2nd trials. Statistical differences between the two groups were analyzed by the McNemar’s Chi-square test for categorical variables. Wilcoxon signed-rank test for comparing VAS scores. A p value <0.05 was considered statistically significant. This study is registered as UMIN000044823 in UMIN Clinical Trials Registry.

Results

Thirty gastroenterology-related physicians completed the program, with a median age of 32 years, a median year of graduation of 6.5 years, and a median duration of endoscopic training of 57.5 months. Self-confidence in performing EST without the assistance of a senior physician also increased significantly from a median score of 24 before training to a median score of 53 after training. Furthermore, understanding of the procedures and devices increased significantly from a median score of 42.5 before training to a median score of 65 after training. The level of expectation for simulator learning using this model also increased significantly from a median score of 69.5 before training to a median score of 85.5 after training. The success rate of EST improved significantly from 43% on 1^st trial to 77% on 2^nd trial.

Conclusion

Education program with a novel EST simulator reproducing bleeding complication that combined with video learning of knowledge and the procedural flow, possibly contributes to improvement of skills and self-confidence.

References

Elmunzer BJ, Walsh CM, Guiton G, et al. Development and initial validation of an instrument for video-based assessment of technical skill in ERCP. Gastrointest Endosc. 2021;93(4):914-923.

Disclosure

One of the authors (T.K.) is supported by research funding from DENKA company.