Democratizing Flexible Endoscopy Training. Noninferiority Randomized Trial Comparing a Box-Trainer vs a Virtual Reality Simulator to Prepare for the Fundamental of Endoscopic Surgery Exam

Background: A considerable number of surgical residents fail the mandated endoscopy exam despite having completed the required clinical cases. Low-cost endoscopy box trainers (BTs) could democratize training; however, their effectiveness was never compared with higher-cost virtual reality simulators (VRSs). Study design: In this randomized noninferiority trial, endoscopy novices trained either on the VRS used in the Fundamental of Endoscopic Surgery manual skills (FESms) exam, or a validated BT, the Basic Endoscopic Skills Training (BEST) box. Trainees were tested at fixed timepoints on the FESms and on standardized ex-vivo models. Primary endpoint was FESms improvement at 1 week. Secondary endpoints were: FESms improvement at 2 weeks, FESms pass rates, ex-vivo tests performance and trainees' feedback. Results: 77 trainees completed the study. VRS and BT trainees showed comparable FESms improvements (25.16±14.29 vs 25.58±11.75 FESms points, respectively; p=0.89), FESms pass rates (76.32% vs 61.54%, respectively; p=0.16) and total ex-vivo tasks completion times (365.76±237.56 vs 322.68±186.04 seconds, respectively; p=0.55) after one week. Performance were comparable also after 2 weeks of training, but FESms pass rates increased significantly only in the first week. Trainees were significantly more satisfied with the BT platform (3.97±1.20 vs 4.81±0.40 points on a 5-point Likert scale for the VRS and the BT, respectively; p<0.001). Conclusions: Simulation-based training is an effective mean to develop competency in endoscopy, especially at beginning of the learning curve. Low-cost BTs like the BEST box compare well with high-tech VRSs and could help democratize endoscopy training.