Gastrointestinal bleeding is an acute medical emergency with a potentially lethal outcome. Flexible endoscopy plays a central role in diagnosis and therapy of gastrointestinal hemorrhage, as it allows direct minimally invasive therapy using a variety of endoscopic hemostatic methods. In principle, mechanical (including injection therapy) and thermal methods are available. These therapy strategies are very effective, but require not only in-depth knowledge of the procedures used but also intensive training to ensure sufficient procedural safety in the acute situation. The success depends crucially on the expertise of the endoscopist and the assistant. This can only be achieved by adequate training, including the use of the necessary instruments.
A realistic training for emergency situations during bleeding in flexible endoscopy is currently hardly possible. The only corresponding training situation is the therapy on patients, which must be judged a priori to be unethical, even though it is practiced worldwide on a daily basis in response to need. Training on a patient has to be refused due to reduced patient-safety and impaired logistics in an emergency situation. A training alternative is training in a live animal. In addition to ethical problems, high costs and very high expenditure (separate rooms and endoscopes are necessary), this training shows low efficiency. The anatomical conditions of animals (especially those of the most commonly used pig) differ considerably from those of humans, so that the training effect is limited. In principle, the use of so-called biosimulators, prepared animal organs for training of flexible endoscopy, is not suitable for simulating emergency situations due to many serious limitations with regard to diverging anatomy, lack of pathologies and hygienic concerns (e.g. zoonoses). All other alternatives that are currently available for the training of endoscopic bleeding therapy - including plastic models or virtual reality simulators - are also unsuitable for effective training due to serious disadvantages (lack of haptics, lack of micromanipulation, lack of tissue resistance, often unrealistic optics and haptics).
In summary, the development of alternative training models for the emergency situation of gastrointestinal bleeding are urgently needed to avoid training on patients or animals that is inadequate and inappropriate for many reasons and reduce animal consumption for educational purposes. In addition, a realistic training system, which can be used in a clinical environment, helps to increase patient safety.
With the development of the "Tübingen training system for interventional flexible endoscopy", a realistic research, learning and exercise environment has already been created, consistently avoiding the use of animals. So far, however, no module for adequate bleeding simulation is available.
Within the framework of the present research project, the existing training system will be modularly extended in order to realistically simulate the entire spectrum of gastrointestinal bleeding (ulcer, tumor bleeding, bleeding after polypectomy, variceal hemorrhage etc.). Such further development has been made possible by novel materials (e.g. special textiles, some of which can be integrated biologically) and new methods and materials in model construction (especially 3D printing), which are currently revolutionizing phantom construction. The result should be the development of organs and organ parts with corresponding pathological structures that are free of animal material, and the establishment of a didactically sound training curriculum as part of a training SYSTEM. An integration of the newly developed bleeding simulation module in existing Tübingen phantoms is planned.
Experimental Surgical Endoscopy Waldhörnlestraße 22 D-72072 Tübingen, Germany
01/2019 - 03/2020