The effect of clinical ERCP experience using a virtual reality simulator and salivary biochemical stress markers

Whereas the value of endoscopic retrograde cholangiopancreatography (ERCP) training in clinical practice is well known, the impact on stress markers and performance in a virtual reality (VR) simulator is not. The primary aim of the study was to see how the number of clinical ERCPs performed during a 1-year period influenced VR-ERCP performance. A secondary aim was to compare differences in salivary stress marker levels, between the first and final simulator attempts.

Thirty-one endoscopists completed three VR-ERCP procedures of increasing difficulty. The times taken to complete the different steps of the procedures were recorded. Saliva chromogranin A, cortisol, and α-amylase were measured before and after each phase of the cystic leakage procedure. Participants then did 1 year of clinical ERCP training at their respective centers. The remaining cohort (26/31) was divided into two subgroups according to their level of clinical training. They then completed the same VR-ERCP procedures. Differences in time before and after each phase as well as stress marker levels during the cystic leakage procedure were assessed.

Those with >100 ERCPs of clinical training improved times to completion of all 15 phases in the VR-ERCP procedures (p < 0.05) in contrast to the group with 20-50 ERCPs who only improved in 11/15. Differences in increases in salivary stress marker levels of chromogranin A before and after each phase of the cystic leakage procedure, adjusted for number of ERCPs, showed significant reductions in four of the five phases measured.

Clinical ERCP training enhances subsequent performance in terms of time to completion in a VR-ERCP simulator. Additional intended use of simulators could be used as a benchmark for clinical progress. Saliva markers may be feasible to use in measuring stress reactions in a training setting.