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

Background and aims: 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.

Methods: 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.

Results: 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.

Conclusion: 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.