ORIGINAL ARTICLE

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The Compact Erlangen Active Simulator for Interventional Endoscopy:

A Prospective Comparison in Structured Team-Training Courses on
Endoscopic Hemostasis for Doctors and Nurses to the Endo-Trainer
Model
J. Hochberger, K. Euler, A. Naegel, E. G. Hahn & J. Maiss
Dept. of Medicine IIIGastroenterology, Acad. Teaching Hospital St. Bernward, Hildesheim,
Germany; Dept. of Medicine I, University of Erlangen-Nuremberg, Erlangen, Germany

Hochberger J, Euler K, Naegel A, Hahn EG, Maiss J. The compact Erlangen Active Simulator for
Interventional Endoscopy: a prospective comparison in structured team-training courses on endoscopic
hemostasis for doctors and nurses to the Endo-Trainer model. Scand J Gastroenterol 2004;39:895902.
Background: In 1997 Hochberger and Neumann presented the Erlangen Biosimulation Model
(commercialized as the Erlangen Endo-Trainer) at various national and international meetings. The new
compactEASIE1 is a simplified version of the original Biosimulation Model (Endo-Trainer) and is
specially designed for easy handling. CompactEASIE is reduced in its features, focusing exclusively on
fexible endoscopy training. The acceptance of training in endoscopic hemostasis is accepted by workshop
participants, as evaluated by a questionnaire on both models. Methods: Eleven structured courses on
endoscopic hemostasis for doctors and nurses organized by the same endoscopists from 3/1998 to 5/1999
were evaluated using one of both models. The questionnaires were filled in by 207/291 trainees (71%).
The Endo-Trainer was used in 4 (n = 103) and the compactEASIE in 7 courses (n = 104). Both simulators
were equipped with identical types of specially prepared pig-organ packages consisting of esophagus,
stomach and duodenum, including artificial sewn-in vessels, polyps and varices. Blood perfusion was
done with a roller pump connected to the sewn-in vessels and blood surrogate. All workshops were
identical concerning the course structure: a 30-min theoretical introduction on ulcer bleeding was
followed by 2 h of practical training in injection techniques and hemoclip application. The second part of
variceal therapy consisted of a 30-min theoretical introduction prior to 2 h of practical training on
sclerotherapy, band ligation and cyanoacrylate application. Finally, a questionnaire on the trainees preexperience and their rating of the different workshop sections was handed out to each participant.
Results: Previous endoscopic experience was comparable in both groups. The training in both simulators
was highly accepted by the trainees (compactEASIE 95% excellent and good versus EASIE (EndoTrainer) 97%) and did not show any significant difference (P = 0.493). Even in the assessment of the
single techniques, no statistical difference was observed. Furthermore, the assessments of the closeness to
reality and the endoscopic environment in both simulators were identical. Conclusions: Both simulators
(Endo-Trainer, compactEASIE) are excellent educational tools for interventional endoscopy with a high
level of acceptance. The easy-to-handle, lightweight compactEASIE is a significant, progress tool for
the future.
Key words: Endoscopic hemostasis; endoscopy; training
Juergen Maiss, M.D., Dept. of Medicine I, University of Erlangen-Nuremberg, Ulmenweg 18, DE-91054
Erlangen, Germany (fax. 49 9133 602618, e-mail. juergen.maiss@med1.imed.uni-erlangen.de)

iagnostic and interventional endoscopy is undergoing

continuous technological advancement and has
replaced numerous surgical techniques in the past
few decades, e.g. laser lithotripsy for difficult bile-duct stones
(1). However, the endoscopist needs several years of practical
training in addition to a continuous refinement of his
theoretical knowledge to develop the background and manual
proficiency required for therapeutic interventions (27). A
standardized teaching program in gastrointestinal (GI) endoscopy has not been established on a general basis so far. Until

2004 Taylor & Francis

now, the training of endoscopic newcomers has primarily

pursued a policy of learning by doing under the supervision
of an experienced colleague, mostly from the same endoscopy
department.
A number of initiatives aiming to improve this situation
had already been launched in the past. Courses using plastic
dummies for gastroscopy and colonoscopy should be mentioned in this context. However, these models have the
disadvantage of not allowing virtually any interventions to be
carried out. Apart from these efforts, computer simulations
DOI 10.1080/00365520410006765

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J. Hochberger et al.

demanding a highly sophisticated technology have been

developed (811). The complexity of therapeutic simulations
as in hemostasis and the hardware platforms required for a
near-to-reality representation have thus far limited the
proliferation of these systems. By far the most developed
system is the Simbionix Simulator (Simbionix Corporation,
Israel), allowing the simulation of interventional procedures
such as hemostasis and ERCP (12). Nevertheless, computer
simulators have some disadvantages regarding the illustration
of the findings and the performance of interventions. Only
training courses using animal models offer a realistic,
animate, working environment for endoscopy so far. However, a substantial organizational, technical and financial
effort is involved (13, 14). No experimental animal model has
so far been able adequately to train endoscopic hemostasis in
acute bleeding situations. This led to the realization that
endoscopic hemostasis techniques could only be sufficiently
learned by gaining experience in human patients.
In 1997 Hochberger and Neumann presented the first
generation of training models using specially prepared pig
specimens (Biosimulation models) for the training of
interventional upper GI endoscopy (15, 16). Starting from a
purely surgical model with a focus on laparoscopic training
(Neumann Biosimulation model), they integrated endoscopic
pathologies as the ideal way to create a close-to-reality
spurting arterial bleedings as described below (Hochberger
1996) as well as varices, strictures or polyps. Initially, the
modified surgical model had been named EASIE, but was
then commercialized by Neumann and Felzmann as the
Erlanger Endo-Trainer (17).
In 1998, as a further development of the above-mentioned
simulator, Hochberger and Maiss presented the so-called
miniEASIE or compactEASIE (18, 19). In the compact
EASIE simulator all hardware simulation parts were reduced
in the interests of flexible endoscopy. Therefore, compactEASIE was lighter and easier to clean than the original dummy
model. Both models (Endo-Trainer and compactEASIE)
allowed, for the first time, nearly the entire spectrum of
interventional procedures in the upper gastrointestinal tract
including hemostasis of acute arterial pulsatile bleedingsto
be simulated under close-to-reality conditions (Fig. 2).
In this study we prospectively compared the acceptance of
both the EASIE1 (Endo-Trainer) and compactEASIE1
simulator in structured training courses for endoscopic hemostasis. We investigated whether the reduction of the hardware
in the compactEASIE model led to a lower acceptance by the
trainees.
Materials and Methods
The EASIE and compactEASIE simulator (Fig. 1)
The Erlangen Active Training Simulator for Interventional
Endoscopy (EASIE; Hochberger 1997) was first established
by integrating an endoscopic environment into the surgical
biosimulation model shell of Neumann (17, 20), which was
Scand J Gastroenterol 2004 (9)

at that time not suitable for therapeutic endoscopic interventions but primarily designed for surgical procedures. The
original 30 kg Neumann simulator consists of a rotatable
plastic torso (a thorax-abdomen dummy) to allow different
open and laparoscopic surgical interventions. Organ packages
fresh from the slaughterhouse are placed into the simulator
shell for training. Similar to the POP simulator devised by
Scinicz et al. (21), a roller pump drives an artificial blood
circulation with citrated and diluted blood through major
organ arteries like the cystic artery in laparoscopic cholecystectomy, or in the Scinicz set-up even through the capillary
bed of previously heparinized organs for parenchymal
resections.
According to Hochbergers proposal, this perfusion system
was used for the first time to simulate arterial spurting
bleedings (Fig. 2) in hollow organs (15). This was established
initially by perforating the organ wall externally with a
venous cannula (Abbocath type 1618 G) and connecting it to
the blood circuit. Because of the better tactile feeling and
natural behavior of tissue, we replaced the plastic cannula
with pig artery segments sewn into the wall after previous
scalpel perforation. A special suturing technique is applied to
fix the vessels in the wall such that a 12 mm vessel stump is
visible from inside. The outer end of the 2-cm mesentery or
splenic artery segment is brought over a large-bore ball-tip
cannula and fixed by a surgical knot. The cannula is then
connected to the perfusion system so that a pulsatile arterial
spurting bleeding can be obtained inside the hollow organ.
Several of these vessels are, e.g., sewn into the stomach for
hemostasis training. Diluted or citrated blood from the pig
served as human blood substitute initially. In the meantime,
we used a cherry-red food colorant with the addition of about
0.1% methylene blue for hygenic reasons.
Polyps, preferably in the stomach, can be formed artificially by lifting the mucosa with surgical forceps from inside
and ligating it with a surgical thread. In addition, submucosal
injection and consecutive rubber-band ligation is possible for
the band and snare EMR technique for small lesions. Submucosal tumors can be implanted by carefully opening the
mucularis propria from outside and filling in material such as
little pieces of beef tongue plus/or gelatine.
Artificial varices are created best during training by longitudinal submucosal injections of stained saline externally as
described before in an experimental set-up to test and
compare different variceal ligation devices (22). This is
possible in the esophagus as well as in the gastric fundus and
best accomplished by injection with a 23 G needle externally.
Strictures in the gut can be created externally by surrounding the tubular structure in the esophagus or duodenum with
plasticine (play gum; clay, etc.) or foam plastic which can
be balloon dilated or used for esophageal or enteral stenting.
The retraction force of strictures can be reinforced with a
latex tube on the outside.
For ERCP interventions, e.g. sphincterotomy or stent
implantation, additionally the hepatobiliary system with liver,

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extrahepatic bile ducts and the gallbladder are dissected.

However, in the pig, the pancreatic duct and the biliary system
are drained via two separate papillae into the duodenum (23).
The larger papilla is the biliary one, which is usually located
at the roof of the duodenal bulb with consecutively a very flat
position for cannulation with a duodenoscope. The pancreatic papilla is located deep in the descending duodenum or
even horizontal part and is small and difficult to cannulate.
Thus, it is generally not used for training. Additional artificial
papillae can be implanted in the duodenum or stomach.
Endoscopists, especially beginners in ERCP, have first to
adapt to the pig anatomy, as is the case in live pig training
courses. It is possible to perform conventional endoscopic
sphincterotomy (EST) as well as needle-knife techniques
(Fig. 3). In addition to the handling and the coordination of
doctor and nurse in standard wire exchange procedures,
advanced techniques like selective left, right and subsegment
cannulation in the hilus are also possible. Furthermore, the
cystic duct can be used for cannulation to demonstrate special
tricks to facilitate steering of the wire and catheter. Stent
implantation can be performed in a uni- or bihilar way using
plastic as well as metal stents. Bihilar metal stenting is the
subject of expert training as well as retrieval of lost plastic
endoprostheses in the common bile duct. Stone extraction is
simulated by the implantation of 35 mm pieces of 8.4 F
plastic endoprostheses which are introduced into the bile duct
via a guide wire and pusher and which can be retrieved by
means of a balloon or basket after EPT.
The organs used are subject to veterinary inspection and
comply with the pertinent food hygiene regulations. The
organ packages have to be specifically prepared and adapted
to the topic and the objectives of the course. The freshly
slaughtered and prepared organs can be stored deep frozen at
about 18 C. The organs were taken out of the deep freezer
the evening before the training.
Training courses
For this study we evaluated prospectively 11 structured

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team-training courses (3/98, 3/98, 4/98, 4/98, 7/98, 9/98, 11/

98, 3/99, 3/99, 3/99, 5/99) in endoscopic hemostasis for
doctors and nurses by using questionnaires. The EASIE
simulator (Surgical Neumann biosimulation model equipped
with an upper GI-organ package) was used for 4 training
courses (3/98, 3/98, 4/98, 4/98) with 134 participants. The
questionaires were filled in by 103/134 participants (77%).
We compared this group with 157 participants of 7 training
courses (7/98, 9/98, 11/98, 3/99, 3/99, 3/99, 5/99) in which the
lightweight compactEASIE simulator was used (Fig. 1). In
the compactEASIE courses, 104/157 trainees (66%) completed the questionnaires.
The structure of the training courses was the same in both
simulators. All training courses were designed as a teamtraining session for doctors and GI assistants. Teams of 3
physicians and 3 nurses were trained per simulator per day.
The training included hemostasis techniques for ulcer and
variceal bleedings. The courses started with a theoretical
introduction and a review of the current data published on
endoscopic ulcer hemostasis and variceal treatment (30 min
each). Afterwards, practical training was performed in four
blocks of 1 h each regarding injection techniques (adrenalin,
fibrin glue, sclerotherapy, cyanoacrylate), hemoclip-application and banding techniques (multiband ligation, mini-loop).
Each technique was demonstrated by skilled endoscopists and
GI-assistants and was subsequently performed by the trainees
under supervision of the tutors. The time schedule of such a
team-training course is shown in Fig. 4.
Team-training courses using the EASIE models
In total, 4 training courses including 134 participants were
performed using the EASIE-simulator. The questionnaire was
answered by 77% of the trainees (103/134). The group trained
on the EASIE simulator comprised 69 physicians (21 interns,
30 senior physicians, 9 senior consultants, 9 practitioners) and
28 nurses (2 senior nursing officers, 22 endoscopy nurses, 4
nurses). Six of the trainees did not make any statement about
their profession.

Fig. 1. EASIE and compactEASIE model. The picture shows the EASIE model on the left (modified surgical Neumann biosimulation model)
and the lightweight compactEASIE simulator on the right.
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J. Hochberger et al.

Fig. 2. Close-to-reality simulation of a spurting arterial bleeding in the EASIE simulator during the EndoClub Nord meeting, 1998. Because of the reality of the simulation, it was not obvious to the participants
that it was simulated bleeding and not a real patient.

To compare the EASIE-simulator and the compactEASIE

simulator, we evaluated 7 training courses including 157
participants. Overall 104/157 trainees (66%) filled in the
questionnaire. The compactEASIE group included 64 physicians (26 interns, 33 senior physicians, 3 senior consultants, 2

practitioners) and 37 nurses (2 senior nursing officers, 26

endoscopy nurses, 9 nurses). Three of the trainees did not
make a statement about their profession.
Statistical analysis
For statistical analysis we used the SPSS 10.0 software.
The statistical analysis of comparison of the assessment of
EASIE and compactEASIE courses was done with the Fisher
exact test. P values <0.05 were judged as statistically
different.
Results

Fig. 3. Needle-knife sphincterotomy in the compactEASIE simulator

during an ERCP training course.
Scand J Gastroenterol 2004 (9)

Previous endoscopic experience of the trainees

EASIE group. Most of the trainees rated themselves as
advanced (35 trainees, 34%) or experienced (45 trainees,
44%) endoscopists or GI assistants. Twenty participants
(19%) characterized themselves as beginners. Previous
experience in endoscopic hemostasis was: No experience
21% (n = 22); less than 1 year 11% (n = 11); 13 years 18%
(n = 18); 36 years 22% (n = 23); more than 6 years 21%
(n = 22); 7% of the participants (n = 7) made no statement
(median: 13 years experience in hemostasis).
CompactEASIE group. Like the EASIE group most of the
trainees ranked themselves as advanced (n = 47, 45%) or
experienced endoscopists (n = 27, 26%) and GI assistants.
Nineteen participants (19%) were beginners and 11 trainees
made no statement (11%). The experience in endoscopic
hemostasis showed a similar distribution: no experience 16%

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The CompactEASIE1 Simulator

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Fig. 4. Time schedule of a structured one-day EASIE team-training course on endoscopic hemostasis.

(n = 17); less than 1 year 7% (n = 7); 13 years 29% (n = 30);

36 years 19% (n = 20), more than 6 years 18% (n = 19); 11%
(n = 11) made no statement (median: 13 years experience in
hemostasis).
There was no significant difference between the groups
regarding previous endoscopic experience (P = 0.052) and
experience in endoscopic hemostasis (P = 0.301).
Previous experience with training models
In both simulators most of the trainees had no previous
experience with endoscopy training models. In the EASIE
group, 16/103 trainees (16%) versus 23/104 participants
(22%) in the compactEASIE group had used training
simulators before. Despite the slightly higher rate of training
experience in the compactEASIE group, there was no
significant difference between the groups (P = 0.283)
Assessment of the workshops in general
The overall assessment in workshops with the lightweight
compactEASIE was as good as the assessment of training
courses with the EASIE simulator: The assessment in the

compactEASIE group was as follows: 83% excellent (n = 86);

12% good (n = 13), 0% insufficient (n = 0) and 5% no
statement (n = 5). The EASIE group assessment was 81%
excellent (n = 83); 16% good (n = 17); 1% insufficient (n = 0)
and 2% no statement (n = 2). These results were not
statistically different (P = 0.493).
Assessment of single techniques
The trainees were also asked to give their opinion of each
training technique. The evaluation covered the following
techniques: injection of diluted epinephrine solution, injection of fibrin glue, clip application, sclerotherapy, multiband
ligation, mini-loop application and injection of cyanoacrylate.
The training was judged as excellent or good by most of the
trainees in both simulators. Detailed results are presented in
Table I. No significant difference was observed in any
technique in the EASIE and compactEASIE.
Closeness to reality
We also asked the participants for their opinion on
endoscopic environment, visual impression and tactile

Table I. Evaluation of each endoscopic technique in both simulators

Injection of
diluted
epinephrine
EASIE

CompactEASIE

Comparison
EASIE
versus
compactEASIE

Excellent
Good
Insufficient
No statement
Excellent
Good
Insufficient
No statement

69.9% n = 72
13.6% n = 14
1.0% n = 1
15.5% n = 16
75.0% n = 78
22.1% n = 23
0.0% n = 0
2.9% n = 3
P = 0.235

Fibrin glue
injection

Clip
application

52.4% n = 54 79.6% n = 82
20.4% n = 21 10.7% n = 11
1.0% n = 1
1.9% n = 2
26.2% n = 27 7.8% n = 8
63.5% n = 66 86.5% n = 90
19.2% n = 20 6.7% n = 7
1.0% n = 1
0.0% n = 1
16.3% n = 17 6.7% n = 7
P = 0.793
P = 0.175

Sclerotherapy

Multiband
ligation

Mini-loop
application

Injection of
cyanoacrylate

57.3% n = 59
17.5% n = 18
1.0% n = 1
24.3% n = 25
61.5% n = 64
19.2% n = 20
1.0% n = 1
18.3% n = 19
P = 1.00

71.8% n = 74
16.5% n = 17
1.0% n = 1
10.7% n = 11
80.8% n = 84
17.3 n = 18
0.0 n = 0
1.9% n = 2
P = 0.778

46.6% n = 48
16.5% n = 17
8.7% n = 9
28.2% n = 29
36.5% n = 38
27.9% n = 29
10.6% n = 11
25.0% n = 26
P = 0.105

55.3% n = 57
21.4% n = 22
2.9% n = 3
20.4% n = 21
58.7% n = 61
24.0% n = 25
1.9% n = 2
15.4% n = 16
P = 0.912

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Table II. Evaluation of the different criteria regarding the endoscopic environment in the EASIE1 and compactEASIE1 simulator

EASIE

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CompactEASIE

Excellent
Good
Insufficient
No statement
Excellent
Good
Insufficient
No statement

Comparison EASIE
versus compactEASIE

Endoscopic
environment

Visual
impression

Tactile
perception

Mean of the
3 categories

78% n = 80
17% n = 18
0% n = 0
5% n = 5
67% n = 70
26% n = 27
0% n = 0
7% n = 7
P = 0.129

78% n = 80
17% n = 18
0% n = 0
5% n = 5
72% n = 75
20% n = 21
1% n = 1
7% n = 7
P = 0.533

59% n = 60
28% n = 29
1% n = 1
12% n = 12
43% n = 45
42% n = 44
1% n = 1
14% n = 14
P = 0.035

71.6%
20.6%
0.3%
7.3%
60.6%
29.3%
0.6%
9.3%

perception paraphrasing three different aspects of a close-toreality anatomical situation. The results of the assessment in
both simulators are presented in Table II. There was an
excellent estimation of all categories in both simulators. No
significant difference was demonstrated in the categories
endoscopic environment (P = 0.129) and visual impression (P = 0.533) between the simulators. Only tactile
perception was judged significantly more favorably in the
EASIE simulator (P = 0.035).
Transferability of the training/relevance for clinical practice
The overall assessment for the transferability of the training
into clinical practice was excellent in both simulators. None
of the trainees showed insufficient judgement. In the EASIE
simulator 84/103 (82%) made a statement about the transferability of the training, in the compactEASIE group the figure
was 69/104 trainees (66%). In the EASIE group 77% (n = 65)
rated the relevance for the practice as excellent, 23% (n = 19)
as good and 0% as insufficient. The assessment in the
compactEASIE group showed similar results: 70% (n = 48)
as excellent, 30% (n = 21) as good and 0% as insufficient.
There was no signifcant difference between the two simulators (P = 0.355).
Theoretical introduction
The assessment of the theoretical introduction in all
categories (overall, ulcer hemostasis, variceal treatment)
was rated significantly differently between the two simula-

tors. The assessment of the theoretical education in all

subareas was inferior in the EASIE courses compared with
the compactEASIE courses (Data are shown in Table III).

Discussion
Throughout the world, there is growing interest in and
awareness of the importance of training in gastrointestinal
endoscopy (3, 4). New, sophisticated, minimally invasive
techniques and legal aspects have led to a high level of inquiry
and acceptance of training programs and simulators. Different
national and international medical associations have started
initiatives for training guidelines (2, 3). For interventional
endoscopic techniques in particular, there has been a lack of
training possibilities outside the patient in the past decades.
For the first time, the EASIE simulator has allowed the
simulation of a spurting arterial bleeding outside a living
individual (15, 16). This has offered new great options for
training in emergency situations.
In 1997, Hochberger, Maiss and Euler established the
EASIE training concept (24). The crucial aspect of this
concept is the corporate training of doctors and nurses. During
our courses, both occupational groups were taught by
experienced tutors of each profession. In this way, both
groups were able to develop a better understanding of the
problems and difficulties of the opposite side leading to better
cooperation in the acute situation. At the beginning of a
training workshop, we start with a theoretical introduction to

Table III. Assessment of the theoretical instruction of the workshops using the different simulators

EASIE

CompactEASIE

Comparison EASIE
versus compactEASIE
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Excellent
Good
Insufficient
No statement
Excellent
Good
Insufficient
No statement

Overall
assessment

Ulcer
hemostasis

Variceal
treatment

45%
36%
4%
15%
55%
20%
0%
25%
P = 0.007

38%
29%
2%
31%
65%
25%
0%
10%
P = 0.021

38%
29%
3%
30%
68%
22%
0%
10%
P = 0.003

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The CompactEASIE1 Simulator

the topic. Subsequently, each technique (e.g. injection

therapy, clip application, variceal banding) is first demonstrated and trained consecutively under the supervision of our
skilled tutors. The good evaluation given to our training
courses from the day we started is perhaps due to the
deliberate training concept, the long tradition of endoscopy
courses and the high level of competence of endoscopists and
GI assistants in our department. At the beginning of our
training activities we used the EASIE simulator, which is a
large dummy simulator. After one year of regular and structured training courses, we developed the compactEASIE
simulator, in which the simulator hardware is reduced to a
minimum. In this study we were able to show that this reduction of the simulation hardware did not lead to deterioration of
the training as assessed by the trainees. In nearly all evaluated
categories of our workshops, there was no significant difference between the EASIE (Endo-Trainer) and the compact
EASIE simulator. This shows impressively that the reduction
in the simulation hardware of the new compactEASIE
simulator has not led to any impairment of the training
courses.
A close-to-life environment is important for realistic
training of interventional endoscopy. One of the most relevant
questions put to the trainees was how realistic they felt the use
of the two simulators had been. The question of major interest
was whether the reduction of the hardware in the compact
EASIE simulator led to deterioration in the assessment of the
endoscopic environment. Even the closeness-to-reality, as
well as the anatomical environment, was not negatively
influenced by hardware reduction and showed no statistical
differences in both simulators. Only the category tactile
perception showed a slightly better assessment for the
EASIE simulator, which led to a significant difference (Table
II). Nevertheless, this small difference in one of three
categories seems to be negligible in view of the considerable
reduction in the hardware in the compactEASIE simulator.
On comparing the theoretical part of our courses, we found
a slightly better overall assessment in the compactEASIE
group (55% versus 45% excellent) as well as in the parts
ulcer hemostasis and variceal treatment. This difference
was statistically significant in all theoretical parts (Table III).
This trend could be explained by the greater experience of the
tutors in presenting and teaching each topic. At that time
when we changed our simulators, all tutors had at least one
years experience in teaching endoscopic hemostasis in
structured training courses. This also includes the understanding of the tutors for the problems and questions of the
participants.
Nevertheless, our data represent only subjective data and
reflect the impressions and feelings of the participants. There
was no objective proof of the value of simulator training.
Thus, in September 2000, together with the New York Society
of Gastrointestinal Endoscopy, we started a prospective
randomized trial to investigate the value of regular simulator
training compared to the traditional endoscopic education.

901

Two groups of 14 fellows each from 9 great New York

hospitals were enrolled in this study. The project ran for a
period of 7 months and included three intensive simulator
training courses in endoscopic hemostasis. The study finished
in April 2001. The results of this project showed a significant
improvement in intensive training groups in nearly all
sections (original paper sent for publication) (25). This
project is the first objective proof that training in the
compactEASIE simulator is leading to a significantly higher
performance in endoscopic hemostasis.

Conclusions
Both simulators (EASIE and compactEASIE) are excellent
educational tools for the training of endoscopic hemostasis.
The reduction of the simulator hardware in the interests of
endoscopy in the compactEASIE simulator has not brought
about any impairment in the acceptance of the training. The
EASIE team-training concept endoscopic hemostasis is
highly accepted by the participants. The content of the
courses is highly relevant for clinical practice and could be
transferred to daily practice.

References
1. Hochberger J, Bayer J, May A, Muhldorfer S, Maiss J, Hahn EG,
et al. Laser lithotripsy of difficult bile duct stones: results in 60
patients using a rhodamine-6G dye laser with optical stone tissue
detection system. Gut 1998;43:8239.
2. American Society for Gastrointestinal Endoscopy. Position
statement. Maintaining competency in endoscopic skills. Gastrointest Endosc 1995;42:6201.
3. American Society for Gastrointestinal Endoscopy. Principles of
training in gastrointestinal endoscopy. Gastrointest Endosc 1999;
49:84550.
4. Waye J, Leicester RJ. Teaching endoscopy in the new
millennium. Gastrointest Endosc 2001;54:6713.
5. Friedman LS. How long does it take to learn endoscopy?
Gastrointest Endosc 1995;42:3713.
6. Carr-Locke DL. Videoendoscopy in clinical application: impact
on teaching. Endoscopy 1990;22 Suppl 1:1922.
7. Hart A, Mayberry M, Mayberry J. Video education and evidence
in endoscopy. Gut 1997;40:554.
8. Soehendra N, Binmoeller KF. Overview over interactive endoscopy simulators. Endoscopy 1992;24 Suppl 2:54950.
9. Gillies D, Haritsis A, Williams C. Computer simulation for
teaching endoscopic procedures. Endoscopy 1992; 24 Suppl 2:
5448.
10. Noar MD. Robotics interactive endoscopy simulation of ERCP/
sphincterotomy and EGD. Endoscopy 1992;24 Suppl 2:53941.
11. Williams CB, Saunders BP, Bladen JS. Development of
colonoscopy teaching simulation. Endoscopy 2000;32:9015.
12. Bar-Meir S. A new endoscopic simulator. Endoscopy 2000;32:
898900.
13. Noar MD. An established porcine model for animate training in
diagnostic and therapeutic ERCP. Endoscopy 1995;27:7780.
14. Gholson CF, Provenza JM, Silver RC, Bacon BR. Endoscopic
retrograde cholangiography in the swine: a new model for
endoscopic training and hepatobiliary research. Gastrointest
Endosc 1990;36:6003.
15. Hochberger J, Neumann M, Maiss J, Bayer A, Nagel A, Hahn
EG. Erlanger Ausbildungssimulator fur die interventionelle
Endoskopie (EASIE)Eine neue Perspektive fur die qualitatsScand J Gastroenterol 2004 (9)

902

16.

17.
18.

Scand J Gastroenterol Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/29/14
For personal use only.

19.
20.

21.

J. Hochberger et al.
orientierte praktische Ausbildung in der Endoskopie. Endoskopie
heute 1998;11:235.
Hochberger J, Neumann M, Hohenberger W, Hahn EG. EASIE
(Erlangen active simulator for interventional endoscopy)a new
biosimulation model: first experiences gained in training workshops [abstract]. Gastrointest Endosc 1998;47 Suppl 4:AB116.
Neumann M, Hochberger J, Felzmann T, Ell C, Hohenberger W.
Part 1. The Erlanger endo-trainer. Endoscopy 2001;33:88790.
Hochberger J, Maiss J, Hildebrand V, Bayer J, Hahn EG.
MiniEASIEa new easy to handle and widely available training
model for interventional endoscopy [abstract]. Gastrointest
Endosc 1999;49 Suppl 4:AB143.
Maiss J, Hahn EG, Hochberger J. A prospective evaluation of 14
EASIE team-trainings-workshops on endoscopic hemostasis.
Endoscopy 2000;32 Suppl 1:E23.
Neumann M, Gall FP. Neuentwicklung eines chirurgischen
Simulationsmodells fur die Weiterbildung und Forschung. 112.
Kongre der Deutschen Gesellschaft fur Chirurgie, Wissenschaftliche Ausstellung 1995.
Scinicz G, Beller S, Bodner W, Zerz A, Glaser K. Simulated

Received 26 September 2003

Accepted 26 March 2004

Scand J Gastroenterol 2004 (9)

22.

23.
24.

25.

operations by pulsatile organ perfusion in minimally invasive

surgery. Surg Laparosc Endosc 1993;3:3157.
Reh H, Hochberger J, Brather A, Martus P, Hahn EG. Comparison of different variceal single and multiple-band ligators for
ring elasticity and ligation volume using a multicylindrical
stretching apparatus and porcine esophagi in vitro [abstract].
Gastrointest Endosc 1996;43:344.
Sissons S. Porcine digestive system. In: Getty R, editor. The
anatomy of the domestic animals. 5th ed, Philadelphia: WB
Saunders; 1980. p. 126882.
Hochberger J, Maiss J, Magdeburg B, Cohen J, Hahn EG.
Training simulators and education in gastrointestinal endoscopy:
current status in 2001 and perspectives. Endoscopy 2001; 33:
5419.
Hochberger J, Cohen J, Matthes K, Maiss J, Koebnick C, Hahn
EG. New York Society for Gastrointestinal Endoscopy
(NYSGE): randomized, prospective comparison of compactEASIE-simulator hemostasis training with standard endoscopy
education (DDW 2002). Gastrointest Endosc 2002;55:AB78.