Walsh Catharine M, Sherlock Mary E, Ling Simon C, Carnahan Heather
Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Canada.
Cochrane Database Syst Rev. 2012 Jun 13(6):CD008237. doi: 10.1002/14651858.CD008237.pub2.
Traditionally, training in gastrointestinal endoscopy has been based upon an apprenticeship model, with novice endoscopists learning basic skills under the supervision of experienced preceptors in the clinical setting. Over the last two decades, however, the growing awareness of the need for patient safety has brought the issue of simulation-based training to the forefront. While the use of simulation-based training may have important educational and societal advantages, the effectiveness of virtual reality gastrointestinal endoscopy simulators has yet to be clearly demonstrated.
To determine whether virtual reality simulation training can supplement and/or replace early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience.
Health professions, educational and computer databases were searched until November 2011 including The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Scopus, Web of Science, Biosis Previews, CINAHL, Allied and Complementary Medicine Database, ERIC, Education Full Text, CBCA Education, Career and Technical Education @ Scholars Portal, Education Abstracts @ Scholars Portal, Expanded Academic ASAP @ Scholars Portal, ACM Digital Library, IEEE Xplore, Abstracts in New Technologies and Engineering and Computer & Information Systems Abstracts. The grey literature until November 2011 was also searched.
Randomised and quasi-randomised clinical trials comparing virtual reality endoscopy (oesophagogastroduodenoscopy, colonoscopy and sigmoidoscopy) simulation training versus any other method of endoscopy training including conventional patient-based training, in-job training, training using another form of endoscopy simulation (e.g. low-fidelity simulator), or no training (however defined by authors) were included. Trials comparing one method of virtual reality training versus another method of virtual reality training (e.g. comparison of two different virtual reality simulators) were also included. Only trials measuring outcomes on humans in the clinical setting (as opposed to animals or simulators) were included.
Two authors (CMS, MES) independently assessed the eligibility and methodological quality of trials, and extracted data on the trial characteristics and outcomes. Due to significant clinical and methodological heterogeneity it was not possible to pool study data in order to perform a meta-analysis. Where data were available for each continuous outcome we calculated standardized mean difference with 95% confidence intervals based on intention-to-treat analysis. Where data were available for dichotomous outcomes we calculated relative risk with 95% confidence intervals based on intention-to-treat-analysis.
Thirteen trials, with 278 participants, met the inclusion criteria. Four trials compared simulation-based training with conventional patient-based endoscopy training (apprenticeship model) whereas nine trials compared simulation-based training with no training. Only three trials were at low risk of bias. Simulation-based training, as compared with no training, generally appears to provide participants with some advantage over their untrained peers as measured by composite score of competency, independent procedure completion, performance time, independent insertion depth, overall rating of performance or competency error rate and mucosal visualization. Alternatively, there was no conclusive evidence that simulation-based training was superior to conventional patient-based training, although data were limited.
AUTHORS' CONCLUSIONS: The results of this systematic review indicate that virtual reality endoscopy training can be used to effectively supplement early conventional endoscopy training (apprenticeship model) in diagnostic oesophagogastroduodenoscopy, colonoscopy and/or sigmoidoscopy for health professions trainees with limited or no prior endoscopic experience. However, there remains insufficient evidence to advise for or against the use of virtual reality simulation-based training as a replacement for early conventional endoscopy training (apprenticeship model) for health professions trainees with limited or no prior endoscopic experience. There is a great need for the development of a reliable and valid measure of endoscopic performance prior to the completion of further randomised clinical trials with high methodological quality.
传统上，胃肠内镜检查培训基于学徒模式，新手内镜医师在临床环境中在经验丰富的带教老师监督下学习基本技能。然而，在过去二十年中，对患者安全需求的日益认识使基于模拟的培训问题成为前沿。虽然基于模拟的培训可能具有重要的教育和社会优势，但虚拟现实胃肠内镜模拟器的有效性尚未得到明确证明。
确定虚拟现实模拟培训是否可以补充和/或替代早期传统内镜培训（学徒模式），用于诊断食管胃十二指肠镜检查、结肠镜检查和/或乙状结肠镜检查，针对先前内镜经验有限或没有内镜经验的卫生专业学员。
检索卫生专业、教育和计算机数据库直至2011年11月，包括Cochrane对照试验中央注册库、MEDLINE、EMBASE、Scopus、科学引文索引、生物学文摘数据库、护理学与健康照护领域数据库、联合与补充医学数据库、教育资源信息中心、教育全文数据库、加拿大广播公司教育数据库、学者门户职业与技术教育数据库、学者门户教育文摘数据库、学者门户扩展学术 ASAP 数据库、美国计算机协会数字图书馆、电气和电子工程师协会数据库、新技术与工程摘要数据库以及计算机与信息系统摘要数据库。还检索了直至2011年11月的灰色文献。
纳入比较虚拟现实内镜检查（食管胃十二指肠镜检查、结肠镜检查和乙状结肠镜检查）模拟培训与任何其他内镜检查培训方法的随机和半随机临床试验，包括传统的基于患者的培训、在职培训、使用另一种形式的内镜模拟（如低保真模拟器）的培训或无培训（作者定义的任何方式）。还纳入比较一种虚拟现实培训方法与另一种虚拟现实培训方法（如比较两种不同的虚拟现实模拟器）的试验。仅纳入在临床环境中对人类测量结果的试验（与动物或模拟器相对）。
两位作者（CMS、MES）独立评估试验的合格性和方法学质量，并提取关于试验特征和结果的数据。由于显著的临床和方法学异质性，无法汇总研究数据以进行荟萃分析。对于每个连续结果有数据时，我们基于意向性分析计算标准化均数差及95%置信区间。对于二分结果有数据时，我们基于意向性分析计算相对危险度及95%置信区间。
13项试验，共278名参与者，符合纳入标准。4项试验比较基于模拟的培训与传统的基于患者的内镜检查培训（学徒模式），而9项试验比较基于模拟的培训与无培训。仅3项试验偏倚风险低。与无培训相比，基于模拟的培训一般似乎能使参与者在能力综合评分、独立完成操作、操作时间、独立插入深度、操作或能力总体评分或黏膜可视化方面比未培训的同行具有一定优势。另外，没有确凿证据表明基于模拟的培训优于传统的基于患者的培训，尽管数据有限。
本系统评价结果表明，虚拟现实内镜培训可有效补充早期传统内镜培训（学徒模式），用于诊断食管胃十二指肠镜检查、结肠镜检查和/或乙状结肠镜检查，针对先前内镜经验有限或没有内镜经验的卫生专业学员。然而，仍然没有足够证据建议支持或反对使用基于虚拟现实模拟的培训替代早期传统内镜培训（学徒模式），用于先前内镜经验有限或没有内镜经验的卫生专业学员。在完成更多方法学质量高的随机临床试验之前，非常需要开发一种可靠且有效的内镜操作测量方法。
