Training Facilities in Gastrointestinal Endoscopy

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Part 1
The Erlanger Endo-Trainer
M. Neumann 1, J. Hochberger 2, T. Felzmann 3, C. Ell 4, W. Hohenberger 1
1

Dept. of Surgery, University of Erlangen-Nrnberg, Germany

Dept. of Medicine, University of Erlangen-Nrnberg, Germany
3
Erlangen Surgery and Endoscopy Training Co. Ltd. (ECE), Erlangen, Germany
4
Dept. of Medicine, Dr. Horst-Schmidt Clinic, Wiesbaden, Germany

Introduction
Various issues in the field of endoscopy reinforce the need
for adequate training of sufficient quality. Pressure is exerted from various sides: trainees are faced with limited time
in which to gain experience in the various diagnostic and
therapeutic techniques; endoscopists are required to stay
in touch with the latest technological developments and
treatment modalities; there are increased demands and restrictions from health reform systems which further limit
time and investment possibilities. Furthermore, the risk of
complications needs to be kept to a minimum in the light
of the increasing legal pressure placed on endoscopists.
Last but not least, the growing awareness of patients about
the various treatment options and their associated risks is
leading towards specific questioning about the ability of
the individual endoscopist to carry out a particular procedure.
In existing training programs there are usually no qualitative criteria: requirements are commonly based on quantitative parameters, such as the number of procedures, and
the methods of assessing quality are generally less structured. In a recent article on the topic of quality assurance
in gastrointestinal endoscopy, OMahony et al. refer to the
threshold number of procedures specified by the American
Society of Gastrointestinal Endoscopy (ASGE) training
committee, the Union of European Medical Specialists
and the European Board of Gastroenterology [1]. In its
statement on credentialing and granting privileges for gastrointestinal endoscopy, ASGE also addresses the issue of
objective criteria of skill [2].
All these considerations, and the statements of gastrointestinal endoscopy societies, strongly emphasize the need for
suitable lifelike training models. We present here our Erlanger Endo-Trainer, a lifelike model constructed from

Endoscopy 2001; 33 (10): 887 890

 Georg Thieme Verlag Stuttgart New York
ISSN 0013-726X

synthetic materials and integrating biogenic organs taken

from slaughtered animals. The Erlanger Endo-Trainer has
been shown to be suitable for both basic courses and training in sophisticated therapeutic endoscopic techniques [3].
Development
Inspired initially by the demand for training facilities in the
field of minimally invasive surgery, in 1992 we developed
a lifelike training model which combined an anatomy
constructed from synthetic materials with biogenic specimens taken from slaughtered pigs. The model was then
perfected for endoscopic training requirements and the integrated perfusion system was used to recreate bleeding sequences in the pig stomach (Figure 1). Today the model is
produced and marketed accompanied by a structured training concept. Table 1 shows the spectrum of training possibilities offered by the Erlanger Endo-Trainer.
Anatomy
The lower half of the anatomy (Figure 2) is fitted with a
baseplate on which the biogenic specimens are fixed using
suture thread. The upper breastplate can be provided in
opaque or transparent form, the latter being especially suitable for beginners courses as it permits visual orientation
(Figure 3). The anatomy is of lifelike in size, and is fitted
with a head constructed from synthetic materials which allows realistic insertion of the endoscope through the mouth
and throat passages to the esophagus (Figure 4). The entire
model is fixed to an adjustable aluminum framework
which permits tilting of the model to recreate the various
body positions assumed during investigations.
For training in endoscopic hemostasis a tubing and perfusion system with adjustable container and stop-valve system is incorporated into the frame, and allows for recreation of bleeding sequences (Figures 5, 6). The perfusion
system is powered by an electric pump integrated into the
base of the frame. This can be controlled easily by assistants or technicians and simulates the heartbeat of the patient. Either real blood from slaughtered animals or col-

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888 Endoscopy 2001; 33

Neumann M et al
Figure 4 Endoscopic view of the
vocal chords as a
synthetic part of
the model

Figure 5

Perfusion system for bleeding simulation

Figure 2 Lower (open) anatomy with biogenic specimen fitted to

a base plate by suture thread, and specimen esophagus connected
to the plastic tube of the model

Figure 3
source

Model with transparent cover and endoscopic light

ored synthetic fluids are used. The model is adjustable to

other training needs; for endoscopic retrograde cholangiopancreatography (ERCP) training, the upper gastrointestinal tract is mounted with liver and bile ducts.

Figure 6 Endoscopic view of simulated arterial

bleeding

Once assembled, the model weighs a total of 18 kg and

measures 120 by 50 cm. Each workspace, including endoscopic equipment, and space for tutor, endoscopic nurse,
technicians, and participants, measures 300 by 300 cm in
total.
Specimens and Set-Up
The specimens used in the Erlanger Endo-Trainer are
usually harvested from the municipal Erlangen abattoir
where pigs are slaughtered on a daily basis for consumer
purposes, and therefore no special slaughtering is required
to supply specimens for the Endo-Trainer. The specimens

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Figure 1 Complete model with head fitted on the frame plate,

with the tilting device and perfusion system

Endoscopy 2001; 33 889

The Erlanger Endo-Trainer

Table 1

Spectrum of training possibilities

Technique
Basic techniques and handling
Injection therapy
Variceal bleeding techniques: clipping, fibrin glue,
argon plasma coagulation
Endoscopic retrograde cholangiopancreatography (ERCP)
and cutting techniques for the papilla
Guide wire placement techniques
Stent placement
Stone (foreign body) extraction
Mucosectomy, polypectomy
Coloscopy polyp removal
Percutaneous endoscopic gastrostomy (PEG),
percutaneous endoscopic jejunostomy (PEJ)
Bronchoscopy

Porcine organs are very suitable for use in such training

models as their anatomical structure and size are comparable to those of humans [4].
In contrast to human anatomy, the papilla of a pig specimen with an isolated bile duct the pancreatic duct is located about 10 cm distally can be visualized approximately 3 4 cm postpylorically as a small prominence with
a central porus, but lacking, however, the plica longitudinalis and transversalis typical in humans. The pigs bile duct
branches off upwards at an acute angle from the ampulla
and is therefore difficult to intubate. This inconvenient
anatomical configuration can be improved if the papillabearing duodenal segment is strapped to the stomach depression of the plate and placed under tension with sutures.
This increases the angle of the branching bile duct and
simplifies endoluminal access.
The freezing of specimens to minus 80 8C has facilitated
their transport to workshops throughout the world. Specimens are available on order for those centers which either

have an Erlanger Endo-Trainer permanently available, or

where the model is being used in a series of workshops.
Infrastructure support is provided by a team of medical students and engineers, responsible for the collection and preparation of specimens, the maintenance of equipment and
the servicing of workshops. Thus, course directors are offered assistance throughout the workshops, during which
the supporting course material is offered, and endoscopic
equipment can also be provided on demand. The model
can be used in various configurations as outlined above.
The workstations are transported by means of a specially
constructed trailer to the meeting/course venue.
Advantages of the Erlanger Endo-Trainer
Unlike the effect achieved with computer simulators, trainees on the Erlanger Endo-Trainer are presented with real
tissue substance and thus they are able to acquire a better
feel for handling tissue during endoscopic procedures
than is presently provided by computer systems [5, 6]. As
specimens are collected from slaughterhouses, animals are
not being sacrificed specifically for training as is the case
in live-animal courses in experimental laboratories. All
specimens are certified as noninfectious by the local
authorities. The model is easy to transport and can be assembled wherever required: in the endoscopy unit, lecture
hall, or industry exhibition booth for demonstration purposes.
Results/Workshops
In the period from April 1997 to May 2001, 230 courses
took place using the Erlanger Endo-Trainer in centers
throughout Europe, in particular in Germany. A total of
2500 participants (2000 from the field of gastroenterology,
500 from the field of surgery) had the opportunity to participate in intensive training workshops, usually lasting 4
5 hours. We recommend that, to achieve optimal results
from a course, a maximum of 4 6 trainees be allocated
per model. This ensures that each trainee has the opportunity for hands-on experience as the specimens can also be
replenished throughout the course.
With regard to endoscopic experience, participants ranged
from those who had never undertaken an endoscopic procedure to those who practiced endoscopy on a regular basis
and wished to refine or extend their techniques. Questioning of the trainees with previous endoscopic experience has
shown that the majority undertook their first endoscopic
procedure directly on a patient. Exact data are currently
being recorded to verify this. The most popular courses
proved to be those concentrating on bleeding techniques
and ERCP (Figures 5 8).
Experience and feedback gained from courses is collected
and used to further improve services. Where requested,
educational accreditation points can be applied for, from
the relevant state medical authorities.

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are then thoroughly cleaned and prepared for the various

techniques listed in Table 1. This includes the sewing in
of pseudopolyps, marking of bullets with methylene blue
dye for biopsy purposes, submucous injection of saline solution for mucosectomy, submucous injection of blood for
training in variceal ligation, and the careful incision and
placement of vessels into the stomach wall through which
blood or artificially colored water can be pumped, recreating bleeding. Once completed, the specimens are then vacuum-packed, labeled and deep-frozen. They are then removed 5 6 hours prior to a workshop, during which time
they thaw out naturally. During the assembly of the model,
the specimens are sewn onto the baseplate which is fitted
with holes for this purpose. The perfusion system is then
attached using blunted needles, and is ready for bleeding
simulation.

890 Endoscopy 2001; 33

Neumann M et al
Figure 7 Endoscopic view of
stone extraction
from the bile duct
after performance
of papillotomy

four complete workstations including the model and endoscopic equipment. This laboratory can be leased for varying lengths of time and use can be made of additional services. Students assist with the collection of data, media facilities are available for filming and recording and collaboration with other departments can be established if required.

In their recent article on quality assurance in gastrointestinal endoscopy, OMahoney et al. warn against the tendency
to overemphasize technical competence [1], stating that the
endoscopic procedure must be viewed in the context of the
overall management of the patient. There exists an apparent and urgent need to establish an all-inclusive training
concept for endoscopy. We believe that the acquisition of
technical skills will remain one important aspect of such a
program, and that the Erlanger Endo-Trainer provides an
efficient tool with which to achieve this.
References
1

Figure 8 Course participants at an ERCP workshop supervised by

an experienced tutor and endoscopic nurse

In centers in Germany (Erlangen and Munich), the USA

(Charleston (South Carolina), San Diego, Rochester, Irvine, Baltimore, and Galveston), and Hong Kong the model has been installed for training and research purposes. In
particular, training can be given in new endoscopic accessories (e. g. endoscopic sewing machines, mucosectomy devices), in special courses. The fact that the model is permanently set up in the abovementioned centers enables
trainees to work on their techniques at times suited to their
duty rosters.
Multicenter Studies
Studies have commenced at the University of Erlangen,
and in cooperation with the Munich Working Group of
Gastroenterology, the aim of which is to evaluate the rates
of improvement and establish learning curves with trainees
using the Erlanger Endo-Trainer. A special protocol has
been developed with which these learning curves can be
measured; the first tests and studies have already been performed [7, 8]. The long-term goal is to include other major
centers in Europe and the USA in a multicenter study
using a standardized protocol.
Research and Development Simulator Labs
A further interesting development is the use of the model
by biomedical companies for testing prototypes and conducting studies. In collaboration with the University of Erlangen, ECE GmbH has equipped a 40 m2 laboratory with

OMahony S, Naylor G, Axon A. Quality assurance in gastrointestinal endoscopy. Endoscopy 2000; 32: 483 488
2
American Society for Gastrointestinal Endoscopy. Guidelines
for credentialing and granting privileges for gastrointestinal endoscopy. ASGE Publication No. 1012. Revised December 1997
3
Neumann M, Mayer G, Ell C, et al. The Erlangen Endo-Trainer: life-like simulation for diagnostic and interventional endoscopic retrograde cholangiography. Endoscopy 2000; 32 (11):
906 910
4
Freys SM, Heimbucher J, Fuchs KH. Teaching upper gastrointestinal endoscopy. The pig stomach. Endoscopy 1995; 27: 73
76
5
Soehendra N, Binmoeller KF. Overview of interactive endoscopy simulators. Endoscopy 1992; 24: 549 550
6
Bar-Meir S. A new endoscopic simulator. Endoscopy 2000; 32:
898 900
7
Neumann M, Friedl S, Egger K, et al. Prospektive Evaluierung
einer Score-Card fr die Beurteilung der diagnostischen GD:
Inter-Observer-Varianz (abstract). Z Gastroenterol 2001 (in
press)
8
Neumann M, Friedl S, Egger K, et al. Prospektive Evaluierung
einer Score-Card fr die Beurteilung der diagnostischen GD:
Welche Parameter unterscheiden zwischen Untersuchern unterschiedlicher Erfahrung (abstract)? Z Gastroenterol 2001 (in press)

Corresponding Author
M. Neumann, M.D.
Chirurgische Klinik mit Poliklinik
der Universitt Erlangen-Nrnberg
Krankenhausstrasse 12
91054 Erlangen
Germany
Fax:
+ 49-9131-8536328
E-mail: Martin.Neumann@chir.imed.uni-erlangen.de

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Summary