Download PDF
Endoscopy 2013; 45(10): 799-805
DOI: 10.1055/s-0033-1344224
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Coached practice using ERCP mechanical simulator improves trainees’ ERCP performance: a randomized controlled trial

Wei-Chih Liao
1   Gastroenterology, National Taiwan University Hospital, Taipei, Taiwan
2   Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
,
Joseph W. Leung
3   Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, CA and UC Davis Medical Center, Sacramento, California, USA
,
Hsiu-Po Wang
1   Gastroenterology, National Taiwan University Hospital, Taipei, Taiwan
,
Wen-Hsinug Chang
4   Gastroenterology, Mackay Memorial Hospital, Taipei, Taiwan
,
Cheng-Hsin Chu
4   Gastroenterology, Mackay Memorial Hospital, Taipei, Taiwan
,
Jaw-Town Lin
1   Gastroenterology, National Taiwan University Hospital, Taipei, Taiwan
,
Robert E. Wilson
3   Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, CA and UC Davis Medical Center, Sacramento, California, USA
,
Brian S. Lim
3   Gastroenterology, Sacramento VA Medical Center, VANCHCS, Mather, CA and UC Davis Medical Center, Sacramento, California, USA
5   Riverside Kaiser Permanente Medical Center, Riverside, California, USA
,
Felix W. Leung
6   Gastroenterology, Sepulveda ACC, VAGLAHS, David Geffen School of Medicine at UCLA, North Hills, California, USA
› Author Affiliations
Further Information

Publication History

submitted08 October 2012

accepted after revision 28 April 2013

Publication Date:
29 July 2013 (online)

Also available at
    Permissions and Reprints

Background and study aims: Preliminary data suggested that simulation practice using an endoscopic retrograde cholangiopancreatography (ERCP) mechanical simulator (EMS) improved trainees’ skill. The aims of the current study were to confirm the impact of coached EMS practice at the beginning of ERCP training and to investigate whether subsequent uncoached EMS practice provides additional benefit.

Methods: Trainees entering ERCP training in 2008 (n = 8) and 2009 (n = 8) at two referral medical centers were randomized to receive a coached EMS practice either with (2009) or without (2008) subsequent uncoached practices or only routine training (controls). The outcome measures were successful deep biliary cannulation by the trainee and overall performance score as rated by blinded trainers, during the subsequent 3 months of clinical practice.

Results: Trainees undergoing single and multiple EMS practices were more likely than controls to achieve successful biliary cannulation (single: adjusted odds ratio [aOR] 2.89, 95 % confidence interval [CI] 2.21 – 3.80 [P < 0.001]; multiple: 3.09, 95 %CI 1.13 – 8.46 [P = 0.028]) and to have superior overall performance scores (aOR 3.29, 95 %CI 1.37 – 7.91 [P = 0.008] and 6.92, 95 %CI 3.77 – 12.69 [P < 0.001], respectively). The benefit of single and multiple EMS practices on overall performance score remained significant after adjustment for success or failure of deep biliary cannulation (aOR 2.98, 95 %CI 1.38 – 6.43 [P = 0.005] and 6.09, 95 %CI 2.40 – 15.45 [P < 0.001], respectively). The benefits of single vs. multiple EMS practices were not statistically different.

Conclusions: Coached simulation using EMS improved novice trainees’ success of biliary cannulation and overall ERCP performance. Additional uncoached practices did not appear to provide further benefit. Trainees should undergo a coached EMS practice at the beginning of ERCP training.

 

  • References

  • 1 Adler DG, Baron TH, Davila RE et al. ASGE guideline: the role of ERCP in diseases of the biliary tract and the pancreas. Gastrointest Endosc 2005; 62: 1-8
    CrossrefPubMedGoogle Scholar
  • 2 Leung JW. Fundamentals of ERCP. In: Cotton P, Leung JW, eds. Advanced digestive endoscopy: ERCP. Malden: Blackwell Publishing; 2005: 17-80
    CrossrefGoogle Scholar
  • 3 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
    CrossrefPubMedGoogle Scholar
  • 4 Cotton PB, Lehman G, Vennes J et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-383
    CrossrefPubMedGoogle Scholar
  • 5 Freeman ML, Nelson DB, Sherman S et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
    CrossrefPubMedGoogle Scholar
  • 6 Chutkan RK, Ahmad AS, Cohen J et al. ERCP core curriculum. Gastrointest Endosc 2006; 63: 361-376
    CrossrefPubMedGoogle Scholar
  • 7 Cotton PB. Outcome, documentation, quality and training. In: Cotton PB, Wiliams CB, eds. Practical gastrointestinal endoscopy. 4th. edn. Malden: Blackwell Publishing; 1996: 313
    Google Scholar
  • 8 Kowalski T, Kanchana T, Pungpapong S. Perceptions of gastroenterology fellows regarding ERCP competency and training. Gastrointest Endosc 2003; 58: 345-349
    CrossrefPubMedGoogle Scholar
  • 9 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
    CrossrefPubMedGoogle Scholar
  • 10 Singh H, Thomas EJ, Petersen LA et al. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med 2007; 167: 2030-2036
    CrossrefPubMedGoogle Scholar
  • 11 Cheng CL, Sherman S, Watkins JL et al. Risk factors for post–ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101: 139-147
    CrossrefPubMedGoogle Scholar
  • 12 Williams EJ, Taylor S, Fairclough P et al. Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice. Gut 2007; 56: 821-829
    CrossrefPubMedGoogle Scholar
  • 13 Cotton PB. Quality endoscopists and quality endoscopy units. J Interv Gastroenterol 2011; 1: 83-87
    CrossrefPubMedGoogle Scholar
  • 14 Fried GM, Feldman LS, Vassiliou MC et al. Proving the value of simulation in laparoscopic surgery. Ann Surg 2004; 240: 518-525
    Google Scholar
  • 15 Mayo PH, Hackney JE, Mueck JT et al. Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator. Crit Care Med 2004; 32: 2422-2427
    CrossrefPubMedGoogle Scholar
  • 16 Patel AD, Gallagher AG, Nicholson WJ et al. Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography. J Am Coll Cardiol 2006; 47: 1796-1802
    CrossrefPubMedGoogle Scholar
  • 17 Wayne DB, Didwania A, Feinglass J et al. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case–control study. Chest 2008; 133: 56-61
    CrossrefPubMedGoogle Scholar
  • 18 Haycock AV, Youd P, Bassett P et al. Simulator training improves practical skills in therapeutic GI endoscopy: results from a randomized, blinded, controlled study. Gastrointest Endosc 2009; 70: 835-845
    CrossrefPubMedGoogle Scholar
  • 19 Leung JW, Lee JG, Rojany M et al. Development of a novel ERCP mechanical simulator. Gastrointest Endosc 2007; 65: 1056-1062
    CrossrefPubMedGoogle Scholar
  • 20 Frimberger E, von Delius S, Rösch T et al. A novel and practicable ERCP training system with simulated fluoroscopy. Endoscopy 2008; 40: 517-520
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Leung JW, Lee W, Wilson R et al. Comparison of accessory performance using a novel ERCP mechanical simulator. Endoscopy 2008; 40: 983-988
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 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
    CrossrefPubMedGoogle Scholar
  • 23 Wicks AC, Robertson GS, Veitch PS. Structured training and assessment in ERCP has become essential for the Calman era. Gut 1999; 45: 154-156
    CrossrefPubMedGoogle Scholar
  • 24 Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics 1986; 42: 121-130
    CrossrefPubMedGoogle Scholar
  • 25 Rochon J. Application of GEE procedures for sample size calculations in repeated measures experiments. Stat Med 1998; 17: 1643-1658
    CrossrefPubMedGoogle Scholar
  • 26 Vandervoort J, Soetikno RM, Tham TC et al. Risk factors for complications after performance of ERCP. Gastrointest Endosc 2002; 56: 652-656
    CrossrefPubMedGoogle Scholar
  • 27 Aggarwal R, Mytton OT, Derbrew M et al. Training and simulation for patient safety. Qual Saf Health Care 2010; 19: i34-43
    CrossrefPubMedGoogle Scholar
  • 28 Maiss J, Dumser C, Zopf Y et al. “Hemodynamic efficacy” of two endoscopic clip devices used in the treatment of bleeding vessels, tested in an experimental setting using the compact Erlangen Active Simulator for Interventional Endoscopy (compactEASIE) training model. Endoscopy 2006; 38: 575-580
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Maiss J, Prat F, Wiesnet J et al. The complementary Erlangen active simulator for interventional endoscopy training is superior to solely clinical education in endoscopic hemostasis – the French training project: a prospective trial. Eur J Gastroenterol Hepatol 2006; 18: 1217-1225
    PubMedGoogle Scholar
  • 30 Kruglikova I, Grantcharov TP, Drewes AM et al. The impact of constructive feedback on training in gastrointestinal endoscopy using high-fidelity Virtual-Reality simulation: a randomised controlled trial. Gut 2010; 59: 181-185
    CrossrefPubMedGoogle Scholar
  • 31 Ende A, Zopf Y, Konturek P et al. Strategies for training in diagnostic upper endoscopy: a prospective, randomized trial. Gastrointest Endosc 2012; 75: 254-260
    CrossrefPubMedGoogle Scholar
  • 32 Mahmood T, Darzi A. The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc 2004; 18: 1224-1230
    CrossrefPubMedGoogle Scholar
  • 33 Desilets DJ, Banerjee S, Barth BA et al. Endoscopic simulators. Gastrointest Endosc 2011; 73: 861-867
    CrossrefPubMedGoogle Scholar
  • 34 Leung JW, Yen D. ERCP training – the potential role of simulation practice. J Interv Gastroenterol 2011; 1: 14-18
    CrossrefPubMedGoogle Scholar
  • 35 Leung J, Lim B, Ngo C et al. Head-to-head comparison of practice with endoscopic retrograde cholangiopancreatography computer and mechanical simulators by experienced endoscopists and trainees. Dig Endosc 2012; 24: 175-181
    CrossrefPubMedGoogle Scholar
  • 36 Leung JW, Wang D, Hu B et al. A head-to-head hands-on comparison of ERCP mechanical simulator (EMS) and ex-vivo porcine stomach model (PSM). J Interv Gastroenterol 2011; 1: 108-113
    PubMedGoogle Scholar