Impact of ERCP simulator training on early ERCP learning curves of novice trainees: a cohort study

Abstract

Background and study aim Simulator-based training has been extensively studied in training gastroduodenoscopy and colonoscopy and shown to significantly improve learning curves of novices. Data on simulator-based training in endoscopic retrograde cholangiopancreatography (ERCP) are scarce. We aimed to determine the impact of 2-day intensive hands-on simulator training on the course of the learning curve of novice trainees.

Methods We conducted a prospective cohort study using a validated mechanical ERCP simulator (Boškoski-Costamagna ERCP Trainer). Six trainees were allocated to the simulation course program (SG). Each of these trainees were paired with an endoscopy trainee starting regular ERCP training at the same center who had no exposure to a simulation course program (control group; CG). The course included lectures, live ERCP demonstrations, and hands-on ERCP training to educate trainees in basic techniques related to cannulation, stent placement, stone extraction and stricture management. After the course, both the SG and CG started formal ERCP training in their respective centers. The Rotterdam Assessment Form for ERCP was used to register each performed ERCP. Simple moving average was applied to create learning curves based on successful common bile duct (CBD) cannulation. Outcomes were plotted against a historical cohort (HC).

Results Thirteen trainees were included, six trainees in the SG and seven trainees in the CG, with a total of 717 ERCPs. Mean successful ERCP cannulation rate was higher for the simulator group at baseline compared to both CG and HC, 64% versus 43% and 42%, respectively. Differences became less explicit after 40 ERCPs, but persisted until a median of 75 ERCPs.

Conclusions We demonstrate that 2-day hands-on simulator-based ERCP training course has a positive effect on the learning curves of ERCP trainees and should be considered an integral part of the training curricula for ERCP to develop skills prior to patient-based training.

Keywords

Pancreatobiliary (ERCP/PTCD) - Pancreatobiliary (ERCP/PTCD) - ERC topics - Quality and logistical aspects - Training

• References

• 1 Andriulli A, Loperfido S, Napolitano G. et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102: 1781-1788
• 2 Cotton PB. Endoscopic retrograde cholangiopancreatography: maximizing benefits and minimizing risks. Gastrointest Endosc Clin N Am 2012; 22: 587-599
• 3 Jowell PS, Baillie J, Branch MS. et al. Quantitative assessment of procedural competence. A prospective study of training in endoscopic retrograde cholangiopancreatography. Ann Intern Med 1996; 125: 983-989
• 4 Baron TH, Petersen BT, Mergener K. et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Am J Gastroenterol 2006; 101: 892-897
• 5 Jorgensen J, Kubiliun N. ASGE Training Committee. et al. Endoscopic retrograde cholangiopancreatography (ERCP): core curriculum. Gastrointest Endosc 2016; 83: 279-289
• 6 Verma D, Gostout CJ, Petersen BT. et al. Establishing a true assessment of endoscopic competence in ERCP during training and beyond: a single-operator learning curve for deep biliary cannulation in patients with native papillary anatomy. Gastrointest Endosc 2007; 65: 394-400
• 7 Wani S, Hall M, Wang AY. et al. Variation in learning curves and competence for ERCP among advanced endoscopy trainees by using cumulative sum analysis. Gastrointest Endosc 2016; 83: 711-719 e711
• 8 Ekkelenkamp VE, Koch AD, de Man RA. et al. Training and competence assessment in GI endoscopy: a systematic review. Gut 2016; 65: 607-615
• 9 Singh S, Sedlack RE, Cook DA. Effects of simulation-based training in gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2014; 12: 1611-1623 e1614
• 10 Koch AD, Ekkelenkamp VE, Haringsma J. et al. Simulated colonoscopy training leads to improved performance during patient-based assessment. Gastrointest Endosc 2015; 81: 630-636
• 11 van der Wiel SE, Koch AD, Bruno MJ. Face and construct validity of a novel mechanical ERCP simulator. Endosc Int Open 2018; 6: E758-E765
• 12 van der Wiel SE, Koch AD, Bruno MJ. Face validity of a synthetic papilla designed for biliary sphincterotomy training. Endosc Int Open 2019; 7: E757-E761
• 13 Ekkelenkamp VE, Koch AD, Haringsma J. et al. Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance. Frontline Gastroenterol 2014; 5: 10-16
• 14 Baron TH, Petersen BT, Mergener K. et al. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 2006; 63: S29-S34
• 15 Ekkelenkamp VE, Koch AD, Rauws EA. et al. Competence development in ERCP: the learning curve of novice trainees. Endoscopy 2014; 46: 949-955
• 16 Koch AD, Haringsma J, Schoon EJ. et al. Competence measurement during colonoscopy training: the use of self-assessment of performance measures. Am J Gastroenterol 2012; 107: 971-975
• 17 Siau K, Crossley J, Dunckley P. et al. Colonoscopy direct observation of procedural skills assessment tool for evaluating competency development during training. Am J Gastroenterol 2020; 115: 234-243
• 18 Wani S, Keswani R, Hall M. et al. A prospective multicenter study evaluating learning curves and competence in endoscopic ultrasound and endoscopic retrograde cholangiopancreatography among advanced endoscopy trainees: the Rapid Assessment of Trainee Endoscopy Skills Study. Clin Gastroenterol Hepatol 2017; 15: 1758-1767 e1711
• 19 Voiosu T, Balanescu P, Voiosu A. et al. Measuring trainee competence in performing endoscopic retrograde cholangiopancreatography: A systematic review of the literature. United European Gastroenterol J 2019; 7: 239-249
• 20 Lim BS, Leung JW, Lee J. et al. Effect of ERCP mechanical simulator (EMS) practice on trainees' ERCP performance in the early learning period: US multicenter randomized controlled trial. Am J Gastroenterol 2011; 106: 300-306
• 21 Leung JW, Liao W-C, Wang H-P. et al. A RCT of mechanical simulator practice and usual training vs. usual training on novice trainee clinical ERCP performance. Gastrointest Endosc 2009; 69
• 22 Meng W, Yue P, Leung JW. et al. Impact of mechanical simulator practice on clinical ERCP performance by novice surgical trainees: a randomized controlled trial. Endoscopy 2020; 52: 1004-1013