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Meta-Analysis
. 2025 Sep 8;9(9):CD008237.
doi: 10.1002/14651858.CD008237.pub4.

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

Nasruddin Sabrie  1 , Rishad Khan  2 , Joanne Plahouras  3 , Bradley C Johnston  4 , Michael A Scaffidi  5 , Samir C Grover  6 , Catharine M Walsh  7   8
Affiliations
Meta-Analysis

Virtual reality simulation training for health professions trainees in gastrointestinal endoscopy

Nasruddin Sabrie et al. Cochrane Database Syst Rev. .

Abstract

Background: 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 methods: 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.

Trial registration: ClinicalTrials.gov NCT01405443.

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Conflict of interest statement

Rishad Khan was an author of three studies included in this review (Grover 2017a; Satchwell 2019; Walsh 2020). He has received research funding from AbbVie and Ferring Pharmaceuticals outside the submitted work.

Nasruddin Sabrie has no conflicts of interest to declare.

Joanne Plahouras has no conflicts of interest to declare.

Bradley C Johnston has no conflicts of interest to declare.

Michael A Scaffidi was an author of four studies included in this review (Grover 2015; Grover 2017a; Satchwell 2019; Walsh 2020).

Samir C Grover was an author of four studies included in this review (Grover 2015; Grover 2017a; Satchwell 2019; Walsh 2020)). Additional conflicts of interest are as follows: Takeda California, Inc. (Grant / Contract), Volo Healthcare (Stock), Pendopharm (Grant / Contract), AbbVie (Grant / Contract), Lupin Pharmaceuticals, Inc (Independent Contractor ‐ Other), Sanofi Pasteur Biologics LLC (Grant / Contract), Ferring International Pharmascience Center US (Grant / Contract), Janssen Global Services, LLC (Grant / Contract).

Catharine M Walsh was an author of four studies included in this review (Grover 2015; Grover 2017a; Satchwell 2019; Walsh 2020).

Update of

References

References to studies included in this review

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References to studies excluded from this review

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Ahn 2016 {published data only}
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Gimpaya 2020 {published data only}
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Grover 2016 {published data only}
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Grover 2017b {published data only}
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Jirapinyo 2014 {published data only}
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Jirapinyo 2015 {published data only}
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Jun 2013 {published data only}
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Kaltenbach 2011 {published data only}
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Khan 2020 {published data only}
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Koch 2015 {published data only}
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Li 2012 {published data only}
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Li 2020 {published data only}
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Liao 2013 {published data only}
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Lim 2011 {published data only}
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Mascagni 2022 {published data only}
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Meng 2016 {published data only}
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Morato 2022 {published data only}
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NCT01405443 {unpublished data only}
    1. NCT01405443. Simulator training for gastrointestinal endoscopy [Simulator training for gastrointestinal endoscopy - how much simulator training is required to acquire proficiency in gastrointestinal endoscopy]. https://clinicaltrials.gov/ct2/show/NCT01405443 (first received 29 July 2011).
Nehme 2013 {published data only}
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Nielsen 2023 {published data only}
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Ou 2018 {published data only}
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Piskorz 2020a {published data only}
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Plooy 2016 {published data only}
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Qiao 2014 {published data only}
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Santos 2017 {published data only}
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Scaffidi 2018a {published data only}
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Scaffidi 2018b {published data only}
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Seshadri 2014 {published data only}
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Singh 2014 {published data only}
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Snyder 2011 {published data only}
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Soetikno 2020 {published data only}
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Strosberg 2017 {published data only}
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Van Sickle 2011 {published data only}
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Vilmann 2018 {published data only}
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Williams 2015 {published data only}
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