Key messages
1. Virtual reality simulation training may provide trainee endoscopists (specialists who look inside the stomach and bowel to check for problems) an advantage in completing upper and lower gastrointestinal ("gut") endoscopy procedures independently compared to no training.
2. We did not find conclusive evidence that virtual reality simulation training offers a benefit compared to patient-based training in novice endoscopists.
What is virtual reality simulation training, and how can it be used in gastrointestinal endoscopy?
Gastrointestinal endoscopy involves using an endoscope, a flexible tube with a camera, to examine the stomach or bowel. Traditionally, this is taught in clinical settings under the supervision of a trained endoscopist. Virtual reality computer simulators use computer technology to create a three-dimensional environment where learners can practice skills safely, without risk to patients. These simulations mimic real-life situations or healthcare procedures. They use physical tools, like an endoscope, to make the experience more interactive. However, simulation-based training can be expensive. It is therefore important to ensure that the skills novices (i.e. trainees) gain through simulation-based training translate to real-life procedures.
What did we want to find out?
We wanted to determine if virtual reality simulation training can supplement or replace traditional, patient-based gastrointestinal endoscopy training. Our primary outcome of interest was to discover whether virtual reality simulation training made a difference to the 'composite score of competency' that trainees received – that is, a combined score showing how skilled someone is.
What did we do?
We searched for studies looking at the benefit of virtual reality simulation training compared to no training, patient-based training, or another form of virtual reality training. We summarised and compared the results of the different studies and rated our confidence in the evidence, based on factors such as study methods and size.
What did we find?
We included 20 studies with 500 participants and 3975 endoscopy procedures. Ten trials compared virtual reality training with no training; five compared virtual reality training with patient-based endoscopy training; one compared virtual reality training with another form of endoscopy simulation training; and four compared two different methods of virtual reality training. Twelve trials studied colonoscopy, which examines the entire colon; three studied sigmoidoscopy, which examines only the lower part of the colon; and five studied upper gastrointestinal endoscopy, which examines the oesophagus, stomach, and small bowel. Participants were medical trainees and nurses with limited or no endoscopy training.
Main results
Virtual reality endoscopy simulation training versus no training
Amongst novices, virtual reality training may result in little to no difference in the composite score of competency compared to no training. However, novices who train using virtual reality simulation are probably better able to complete procedures independently. We do not know if virtual reality simulation training helps novices complete procedures faster, see more of the inner lining of the bowel, cause less patient discomfort, or achieve a higher overall performance rating than no training, because the evidence is very uncertain. No adverse (i.e. harmful, unwanted) events were reported in either group.
Virtual reality endoscopy simulation training versus conventional patient-based training
Of the studies that compared virtual reality simulation to conventional training, only one study reported a composite score of competency for the participants, but it did not provide enough data to permit us to analyse the results. We do not know about the effects of virtual reality simulation training, compared to conventional patient-based training, on novices’ ability to complete procedures independently, complete procedures faster, see more of the inner lining of the bowel, cause less patient discomfort, or achieve a higher overall performance rating, because the evidence is very uncertain. No adverse events were reported in either group.
What are the limitations of the evidence?
We are not confident in the evidence for many of our outcomes. Some studies provided little or no information about how trainees were assigned to the different groups, or whether the people measuring the outcomes knew which trainees were in which group, which could influence how they assessed the trainees. Additionally, there were too few participants and endoscopic procedures to be certain about the results of some outcomes. Future studies should consider which learning theories underpinning simulation training programmes work best.
How current is this evidence?
The evidence is current to 18 October 2023.
Read the full abstract
Training in endoscopy has traditionally been based upon an apprenticeship model, where novices develop their skills on real patients under the supervision of experienced endoscopists. In an effort to prioritise patient safety, simulation training has emerged as a means to allow novices to practice in a risk-free environment. This is the second update of the review, which was first published in 2012 and updated in 2018. It evaluates the effectiveness of virtual reality (VR) simulation training in gastrointestinal endoscopy.
Objectives
To determine whether VR 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.
Search strategy
We searched CENTRAL, MEDLINE, Embase, and 13 other databases, together with reference checking and handsearching of review articles, conference abstracts and proceedings, to identify the studies included in the review. We conducted database searches to 18 October 2023, and grey literature searches to December 2023.
Selection criteria
We included randomised and quasi-randomised clinical trials comparing VR endoscopy simulation training to any other method of endoscopy training (e.g. conventional patient-based training, another form of endoscopy simulation), or no training. We also included trials comparing two different methods of VR training. We included only trials evaluating outcomes on humans in the clinical setting. Participants were health professions trainees: physicians (medical students, residents, fellows, and practitioners), nurses, and physician assistants with limited or no prior endoscopy experience.
Data collection and analysis
Two authors independently assessed the eligibility and methodological quality of trials, and extracted trial characteristics and outcome data. The primary outcome was the composite score of competency, as defined by authors. Secondary outcomes were independent procedure completion, performance time, adverse event or critical flaw occurrence, patient discomfort, global rating of performance, and visualisation of mucosa.
We pooled data for meta-analysis where participant groups were similar, studies assessed the same intervention and comparator, and had similar definitions of outcome measures. We calculated risk ratios (RRs) for dichotomous outcomes with 95% confidence intervals (CIs). We calculated mean differences (MDs) and standardised mean differences (SMDs) with 95% CIs for continuous outcomes when studies reported the same or different outcome measures, respectively. We used GRADE to rate the certainty of evidence. We assessed the risk of bias using the original Cochrane domain-based tool.
Main results
We included 20 trials (500 participants; 3975 endoscopic procedures). We judged four trials (20%) as at low risk of bias. Ten trials compared VR training with no training, five trials with conventional endoscopy training, one trial with another form of endoscopy simulation training, and four trials compared different methods of VR training. Due to substantial clinical and methodological heterogeneity across our four comparisons, we did not perform a meta-analysis for several outcomes. We rated the certainty of evidence as moderate, low, or very low due to risk of bias, imprecision, and heterogeneity.
VR endoscopy simulation training versus no training. The composite score of competency was based on 5-point Likert scales assessing seven domains: atraumatic technique, colonoscope advancement, use of instrument controls, flow of procedure, use of assistants, knowledge of specific procedure, and overall performance. The scoring range was from 7 to 35; higher scores mean greater competence. Compared to no training, VR training may result in little to no difference in composite score of competency (MD 3.10, 95% CI -0.16 to 6.36; 1 trial, 24 procedures; low-certainty evidence). VR training likely provides participants with a benefit, as measured by independent procedure completion (RR 1.62, 95% CI 1.15 to 2.26; 6 trials, 815 procedures; moderate-certainty evidence). The evidence is very uncertain about the effects of VR simulation on overall rating of performance (MD 0.45, 95% CI 0.15 to 0.75; 1 trial, 18 procedures), visualisation of mucosa (MD 0.60, 95% CI 0.20 to 1.00; 1 trial, 55 procedures), performance time (MD -0.20 minutes, 95% CI -0.71 to 0.30; 2 trials, 29 procedures), and patient discomfort (SMD -0.16, 95% CI -0.68 to 0.35; 2 trials, 145 procedures). The three trials which reported on procedure-related adverse events or critical flaws reported no incidences in either group (550 procedures; moderate-certainty evidence).
VR endoscopy simulation training versus conventional patient-based training. One trial reported a composite score of competency but did not provide sufficient data for quantitative analysis. VR training compared to conventional patient-based training may result in fewer independent procedure completions (RR 0.45, 95% CI 0.27 to 0.74; 2 trials, 174 procedures; low-certainty evidence). The evidence is very uncertain about the effects of VR simulation on performance time (SMD 0.12, 95% CI -0.55 to 0.80; 2 trials, 34 procedures), overall rating of performance (MD -0.90, 95% CI -4.40 to 2.60; 1 trial, 16 procedures), and visualisation of mucosa (MD 0.0, 95% CI -6.02 to 6.02; 1 trial, 18 procedures). VR training in combination with conventional training appears to be advantageous over VR training alone. The three trials which reported on procedure-related adverse events or critical flaws reported no incidences in either group (72 procedures; very low-certainty evidence).
Authors' conclusions
Despite moderate- to very low-certainty evidence, we can conclude that VR training, as compared with no training, generally appears to provide participants with some advantage over their untrained peers, as measured by independent procedure completion, overall rating of performance or competency, and mucosal visualisation. We found insufficient evidence to advise for or against the use of VR simulation-based training as a replacement for early conventional endoscopy training. Further research is needed to help establish the potential use of VR simulation-based training to supplement and/or replace conventional endoscopy training.
