Historical perspective

Over the course of the past decade, there has been an enthusiasm and resultant evolution in endoscopic training not witnessed in the antecedent three decades since the inception of formal endoscopic training. The traditional “see one, do one, teach one” method long espoused in medical and surgical training had been adopted by and adapted to training in the new field of endoscopy at its nascence [1, 2]. However, since the mid‐ to late‐1990s, endoscopic training has undergone a renaissance at all levels, from the fundamental to the cutting edge. Multiple coincident trends not only in endoscopy but also in medical education and in health care delivery at large have helped drive this. These include the burgeoning appearance of new technologies and techniques; increased emphasis on relevance and accountability in medical education and training; pressures from within and outside of the medical community to deliver higher quality; cost‐effective care [3, 4]; and the advent of awareness, concern, and interest in the application of new paradigms in procedural training [5–7].

An unprecedented number of new technologies are being introduced by the endoscopic industry, from completely novel imaging and tissue‐acquisition technologies such as endoscopic ultrasound (EUS), to image enhancement technologies such as high‐definition video endoscopy, to extended anatomical capabilities represented by deep enteroscopy and capsule endoscopy technologies, to a seemingly limitlessly expanding array of interventional devices involving endoluminal stenting, closure, hemostasis, excision, and ablation. This technological abundance has not only created an increasing need for greater time and effort directed toward endoscopy training during fellowship but has also driven a demand for courses and other venues designed to impart new skills to update already fully trained, busy, practicing endoscopists in time‐efficient formats. At the same time, in medical education and training at large, pedagogical initiatives are being directed toward improving the entire learning experience by increasing clinical relevance from the first day of medical school forward, through earlier and better correlation of science to clinical medicine, through the introduction of clinical material earlier in medical education, and by applying novel teaching methods, procedures, and technologies. Such methods were often adapted from other disciplines, professions, and occupations, such as case studies, procedural simulations on live animals and animal parts, and enhanced computer haptics.

The advent of using ex vivo animal organs as models created a high‐fidelity, economical format for demonstration and training of gastrointestinal flexible endoscopic therapies on a large scale. These explant animal models offer a hands‐on experience comparable to the live animal model to vastly more trainees as a result of their low cost, easy availability, and overwhelmingly simplified logistical deployment [8, 9].

Making it all possible: novel simulator platforms in endoscopic training

Simulators have been applied to training in gastrointestinal endoscopy for over three decades. All types of simulators provide the trainee with hands‐on experience in endoscopic techniques in settings that replicate intraluminal gastrointestinal conditions with varying fidelity without exposing patients to trainee operators. As therapeutic intervention has expanded, the role of simulators in all phases of training has gained in importance and garnered intense interest. Endoscopic simulators can be grouped simply into five basic types: completely synthetic models (plastic mannequins and rubber or latex models of the upper GI tract and colon), three‐dimensional models, computer or video simulators, live sedated or anesthetized animals, and explanted animal organs attached to and supported by synthetic frames configured to mimic human gastrointestinal anatomy [10, 11]. Progress in computer technology and increased experience with ex vivo animal models has created realistic characteristics that more closely reproduce the visual appearance and tactile sensation of actual clinical settings and circumstances. Gastroenterology and surgical training programs increasingly are integrating these models into their curricula [12–14].

Live, anesthetized animals represented the initial iteration of hands‐on simulator training in gastrointestinal endoscopy and were good models because of their high fidelity in terms of appearance, tactile sensation, and tissue response to endoscopic manipulation [7], but share protean and substantial limitations. Prominent among these is that the investment required in terms of facilities for appropriate procurement, care, sedation, analgesia, perioperative, and postoperative management is cost‐prohibitive in many endoscopic training settings, particularly those whereby a single simulation or demonstration renders the model unusable for repetitive use. For example, once a sphincterotomy has been performed on the porcine papilla, the animal is no longer usable for another sphincterotomy. Live animal training can expose the sponsoring institution to criticism from animal‐rights activists and organizations [15].

Computer‐based simulators have evolved over their nearly three decades of development. While haptics, visual fidelities, and clinical scenario reproduction have improved markedly over the past decade, substantial limitations still exist with respect to the overall ability to faithfully reproduce tactile feedback response on tissue manipulation and recreation of the overall clinical experience. While most systems are compact and require little active maintenance, initial entry investment remains high, with each individual unit costing upward of $100,000 if a number of simulation modules are included [16].

A more practicable application for using real tissue in endoscopic training involves acquiring selected sections of the gut of animals slaughtered for food (chiefly pigs), and using these organs ex vivo in a configuration mimicking the human gastrointestinal tract. The overall cost of explant organ simulation is minuscule compared to live animal simulations. The porcine upper gastrointestinal tract was the first of such simulators to appear. Originally, specially trained butchers selectively dissected these specimens, but this can readily be performed in any abattoir under specific direction [17]. The liver, gallbladder, and bile ducts can also be included if pertinent to the simulation, and may be modified by the addition of other animal tissue to enhance reproduction of biliary anatomy specifically pertinent to endoscopic retrograde cholangiopancreatography (ERCP) [18]. Luminal contents are removed by lavage, and then the organs are inspected for compliance with food hygiene regulations before being approved for use, and may be preserved at −18°C before use [19]. The fresh or thawed specimen then is attached to a supporting frame structure, commonly a tray‐like plastic mold that conforms the organ(s) to a normal configuration. This type of model was first described in 1995, employing needles to pin the tissue to a cork plate for upper gastrointestinal endoscopy [20]. The Erlanger Active Simulator for Interventional Endoscopy (EASIE) or Erlanger Endo‐Trainer was originally designed for surgical applications, and refined and downsized specifically for endoscopic application as the compact EASIE; both were designed for use with porcine specimens [19, 21].

The characteristics of the porcine gastrointestinal tract prepared and oriented in the anatomic mold permit further manipulation and modification of the tissues to simulate pathology applicable to endoscopic therapy [10]. Initial outlays for the equipment used for mounting the organ components are comparatively low (approximately $3,000 for a molded anatomic tray); costs for purchasing organs and technician time for harvesting, preparation, and disposal are approximately $150–200 per simulation [16]. Compared to computer simulation, however, this simulator platform, much as with the live animal platform, requires high faculty‐to‐trainee ratios and staff support. Nonetheless, the advantages of the explant model are many, and the smaller, more portable tray models allow mobility with options for training at more than a fixed location. Of course, dedicated endoscopy simulator training centers with permanently installed fixtures, complete amenities, and fully stocked resources allow for tightly controlled conditions, predictability, and flexibility to accommodate special needs as they might arise in real time.

The pioneering work of Juergen Hochberger marked a major advance in endoscopic training; his innovation in developing this essential ex vivo training tool, by expanding its applicability and integrating its use into rigorous and validated training programs had unprecedented impact on simulation in hands‐on endoscopic training. The details of the development of various simulators and their validation for various techniques are covered in detail in Chapter 1 and other chapters in this text. After initial use primarily in the research setting with sporadic demonstrations at endoscopic meetings, intensive hands‐on workshops based on the ex vivo tabletop animal tissue models gained popularity in the late 1990s, primarily at regional GI meetings such as the New York Society for Gastrointestinal Endoscopy (NYSGE). This explant model, with its efficiency, economy, fidelity, and flexibility, acted as the catalyst making possible the archetypal dedicated hands‐on endoscopy training facility of the American Society for Gastrointestinal Endoscopy (ASGE), the original Interactive Training & Technology Center (IT&T Center) located in Westmont, IL, a suburb of Chicago [22]. This initial IT&T facility, which has since been eclipsed by a completely new and much more sophisticated multiuse facility, was designed specifically to provide hands‐on training in endoscopy using models similar to the Erlangen compactEASIE endoscopy simulator, with 10 endoscopic simulator stations in a large room with an open configuration. This original center was operated from 2003 through 2013, and, then as now, managed by full‐time nursing and technical staff, and overseen by both ASGE executive leadership and educational management. The ASGE ITT Committee is charged by the ASGE Governing Board with formulating and executing all programming including hands‐on courses and associated didactic sessions, as well as continuous technological and technical innovation of the IT&T Center itself, including simulators and models utilized in endoscopic training activities. Many such models have been developed in‐house at IT&T, and deployed both at IT&T and throughout the world at hands‐on endoluminal training venues. Such simulation innovation is a core part of the asset portfolio of the IT&T Center. Expert faculty are chosen by education and training committees on a course‐by‐course basis largely from ASGE membership. Active faculty and staff supervision and instruction are provided for the entire duration of every course held at the center, with each faculty member supervising and instructing a small group of trainees at each station. In 2009, 15 interactive and hands‐on CME courses were held on‐site at the ASGE IT&T Center, in addition to six fellows’ courses and two nursing courses (Table 38.1). Both the number of courses offered and overall course attendance have increased dramatically year to year, with new courses and novel formats added each year and recurring courses continuously refined. The attendance at the IT&T Center doubled over the 3 years spanning 2006 through 2009, to over 1,100 in 2009.