Image-Guided Surgical Training in Percutaneous Hepatobiliary Procedures: Development of a Realistic and Meaningful Bile Duct Dilatation Porcine Model

Cholangioscopy under direct visualization: skill progress during a dedicated Image-Guided Surgery Course

AIMS

Training programs are essential to introduce new methods for bile duct clearance. Visual examination via cholangioscopy is ideal to diagnose and treat biliary tract diseases such as cancer and choledocholithiasis. However, surgeons rarely use cholangioscopes. Specific training is required to master laparoscopic and percutaneous cholangioscopy. This study aims to assess skill acquisition and retention during cholangioscopy training in the Image-Guided Therapies Masterclass.

METHODS

This prospective study enrolled 17 physicians undergoing training in interventional treatments of biliary diseases. A novel disposable cholangioscope and access kit were used with a biliary tract model including two simulated common bile duct (CBD) stones. The curriculum required visualization of all critical structures before removal of one stone with a Dormia basket. After informed consent, demographic data and time to exercise completion were recorded on each of two subsequent training days. Task-specific questions were measured at the completion of training using a Likert scale (strongly disagree to strongly agree, 1-5 points).

RESULTS

All participants successfully completed the task (6F/11 M, age 36 ± 5 years; 13 surgeons, 4 interventional radiologists; median experience with percutaneous procedures 2 years, range 0-20). Significant improvement in mean task completion time was observed (day 1: 172 ± 59 s, day 2: 89 ± 45 s; P < 0.0001). All task-specific questions were answered with a median rating of 5/5: "The platform facilitates cholangioscopy" and "This training method accelerates gain in proficiency and is useful for residents/fellows" (IQR 5-5), "This platform is useful to measure the proficiency level" and "There is an application for simulation in percutaneous surgery training" (IQR 4.5-5), "The platform is user-friendly" and "The model quality recreates realistic scenarios" (IQR 4-5).

CONCLUSION

Cholangioscopic bile duct exploration and stone retrieval were achieved by all participants using a dedicated training program and physical simulator. Significant skill progress was observed during 2 days of dedicated training.

Development and validation of a novel porcine bile duct dilation model for EUS training

Background and study aims  Image-guided minimally invasive techniques have transformed the management of malignant and benign bile duct obstructions. These evolving techniques are being widely adopted and applied and hands-on training using high quality models is required to improve the proficiency of practitioners. This experimental study aimed to validate an in vivo porcine model created to simulate bile duct dilation for interventional endoscopic ultrasound (EUS) hands-on training curriculums. Materials and methods  Thirty-six porcine models were involved and the procedures were performed in an experimental hybrid operating room under general anesthesia. Animals underwent endoscopic duodenal papilla clipping with several hemostatic metallic clips. After a survival period of 24 to 48 hours, the models with effective intrahepatic and extrahepatic bile duct dilatation were included in the hands-on training. Trainees and faculty were given structured evaluations of the model realism and usefulness. Results  Extrahepatic bile duct and gallbladder dilation was achieved in all 36 of the models, and in 11 of the 36 models, a treatable intrahepatic duct dilatation was achieved. During the hands-on training, EUS-guided biliary drainage, EUS-guided transgastric gallbladder drainage, and EUS through-the-needle microbiopsy forceps procedures were feasible. Overall, 75 % of the experts and trainees evaluated the training as excellent. Conclusions  We present a minimally invasive, reliable and time- effective model of extrahepatic dilation suitable for interventions. The model was less effective for intrahepatic ducts, which should be considered if intrahepatic biliary dilation is required for training.

Complications in Bariatric Surgery

Bariatric surgery represents the most valid option to treat the chronic disease of morbid obesity and all its related comorbid conditions with the purpose to increase life expectancy. Despite multiple recommendations of the different scientific societies, bariatric surgery remains worldwide largely underused. Considering only a 16% rate of obesity disease, with the largest number of bariatric surgeries performed in Europe of 50k procedures a year, France should need more than 200 years to surgically approach all morbid obese patients. Similarly, in the United States, obesity is a chronic condition that affects more than 1 in 3 adults, with a mean number of 250k bariatric procedures a year, hence they would need 437 years to manage this population. Definitely, the bariatric surgery is very poorly used and there are several factors to explain it. Inadequate access to medical care and insufficient information provided by the general practitioner are frequently encountered in our practice. But the main limitation for the bariatric treatment remains the patients' "fear" of a surgical complication.