Internet based e-learning systems: a tool for the future in endoscopy

In many parts of the world, gastric cancer continues to be a leading cause of mortality [1]. Early detection and treatment are needed to address this problem and to reduce mortality from this cancer. Nevertheless, the most powerful tool, upper endoscopy, may have a miss rate as high as 10 % [2]. Suboptimal performance likely reflects inexperience and inadequate training in the recognition of early gastric cancer (EGC) by endoscopists, particularly in the Western world.

“E-learning platforms may become an important tool for training, improving quality, and future developments in the endoscopy field.”

E-learning systems are a promising way to address these challenges. They have the advantage of allowing many gastroenterologists to be trained simultaneously in different parts of the world. The value of e-learning systems has been demonstrated in radiology and surgery [3] [4]. Unfortunately, only a few small series have been reported in the endoscopy literature, though they do suggest that that e-learning and other web-based hybrid approaches are a favorable way to teach and standardize endoscopy classification systems [5] [6]. Nevertheless, to our knowledge, e-learning systems have yet to be shown to conclusively increase the diagnostic capability of participating endoscopists.

With that in mind, we applaud the efforts of Nakanishi et al. The authors previously developed an e-learning system for the endoscopic diagnosis of EGC, based on three basic principles for improving detection: technique, knowledge, and experience [7]. Through a randomized controlled trial, they conclusively showed the usefulness of this kind of e-learning system for the diagnosis of EGC with white-light endoscopy [7]. They have now tested the ability of this e-learning system to teach the technique of magnification narrow-band imaging (M-NBI), a more challenging but powerful technique to diagnose EGC [8].

The study by Nakanishi et al. in this issue of Endoscopy has a number of important strengths [9]. Randomization to the e-learning program allowed for a true assessment of the intervention’s impact throughout Japan. Stratification by site and provider volume helped to ensure that the results were not compromised by differences in baseline M-NBI experience. The authors’ report a significantly improved accuracy among those who completed the e-learning system program, and they performed a multivariate analysis to define the groups who benefit most from the intervention. Interestingly, they showed that older age is a factor for poorer results (odds ratio [OR] 0.43), and that taking the self-exercise twice or more may increase the effectiveness of the program (OR 2.99). Their analysis suggests that motivation is an important factor and that younger, less-experienced endoscopists may benefit most from this kind of training.

Nevertheless, there are several limitations. The authors did not have a predefined sample size; thus, whether a 7 % difference is clinically important may be debated. Additionally, the inclusion of only Japanese centers may limit generalizability. Magnification endoscopes (GIF-240Z, GIF-H260Z) are not readily available in Europe or the United States. Moreover, the detailed gastric examinations performed by Japanese endoscopists may be less likely in Western centers, where more focused examinations are motivated by work flow demands, historically low yield, and financial incentives. Examination time is a primary determinant of the yield of endoscopy for gastric neoplasia and it may be difficult to change endoscopy cultures using web-based teaching [10]. To address limited technology, our group (“Porto group”) developed a “simplified” classification using available technology [11] [12]. Although a prospective study and our collaborative experience indicate that the simplified NBI system may be taught through a web-based system, this remains to be tested conclusively [5] [13]. Thus, it is not clear whether the benefit of this e-learning system may also be applicable to Western society.

Nevertheless, we believe that these findings are of great practical importance. Japan has a high rate of gastric cancer, which has catalyzed the development of cutting-edge diagnostic and treatment strategies, including M-NBI and stomach-preserving resection techniques. However, as a result of migration (i. e. Latin America or East Asia to the United States), an increased frequency of gastric cancer is being detected in the West [14]. Between 2010 and 2014, we encountered 160 new cases of gastric cancer in an immigrant population at the Los Angeles County Hospital, which necessitated the initiation of an early detection program [15]. Only through a fortuitous research collaboration was our team of American endoscopists able to train in gastric NBI using the internet-based learning system developed by the Porto group. Following e-training, we demonstrated, in a blinded controlled study, that NBI increased detection of gastric cancer precursors by more than 200 % compared with white-light endoscopy [13]. In the current paper, Nakanishi et al. demonstrated that electronic, web-based programs represent an expeditious mechanism of transmitting the tools needed to manage gastric cancer, including M-NBI, throughout Japan and perhaps other parts of the world [9].

Technology has transformed many other facets of modern life and even greater problems have been solved by creative electronic solutions. In fact, it looks as though e-learning platforms may become an important tool for training, improving quality, and future developments in the endoscopy field. Taken altogether, we believe that this kind of learning has great potential and should be disseminated widely. In the battle against gastrointestinal cancer, we have a new and compelling weapon – we should use it!

• References

• 1 Torre LA, Bray F, Siegel RL. et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65: 87-108
• 2 Pimenta-Melo AR, Monteiro-Soares M, Libanio D. et al. Missing rate for gastric cancer during upper gastrointestinal endoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2016; 28: 1041-1049
• 3 Maertens H, Madani A, Landry T. et al. Systematic review of e-learning for surgical training. Br J Surg 2016; 103: 1428-1437
• 4 den Harder AM, Frijlingh M, Ravesloot CJ. et al. The importance of human-computer interaction in radiology E-learning. J Digit Imaging 2016; 29: 195-205
• 5 Dias-Silva D, Pimentel-Nunes P, Magalhaes J. et al. The learning curve for narrow-band imaging in the diagnosis of precancerous gastric lesions by using Web-based video. Gastrointest Endosc 2014; 79: 910-920
• 6 Dinis-Ribeiro M, Correia R, Santos C. et al. Web-based system for training and dissemination of a magnification chromoendoscopy classification. World J Gastroenterol 2008; 14: 7086-7092
• 7 Yao K, Uedo N, Muto M. et al. Development of an E-learning system for the endoscopic diagnosis of early gastric cancer: an international multicenter randomized controlled trial. EBioMedicine 2016; 9: 140-147
• 8 Ezoe Y, Muto M, Uedo N. et al. Magnifying narrowband imaging is more accurate than conventional white-light imaging in diagnosis of gastric mucosal cancer. Gastroenterology 2011; 141: 2017-2025 e2013
• 9 Nakanishi H, Doyama H, Ishikawa H. Evaluation of an e-learning system for diagnosis of gastric lesions using magnifying narrow-band imaging: a multicenter randomized controlled study. Endoscopy 2017; 49: 957-967
• 10 Teh JL, Tan JR, Lau LJ. et al. Longer examination time improves detection of gastric cancer during diagnostic upper gastrointestinal endoscopy. Clin Gastroenterol Hepatol 2015; 13: 480-487 , e482
• 11 Pimentel-Nunes P, Dinis-Ribeiro M, Soares JB. et al. A multicenter validation of an endoscopic classification with narrow band imaging for gastric precancerous and cancerous lesions. Endoscopy 2012; 44: 236-246
• 12 Pimentel-Nunes P, Libanio D, Lage J. et al. A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions. Endoscopy 2016; 48: 723-730
• 13 Buxbaum JL, Hormozdi D, Dinis-Ribeiro M. et al. Narrow-band imaging versus white light versus mapping biopsy for gastric intestinal metaplasia: a prospective blinded trial. Gastrointest Endosc 2017; DOI: 10.1016/j.gie.2017.03.1528.
• 14 Dong E, Duan L, Wu B. Racial and ethnic minorities at increased risk for gastric cancer in a regional US population study. Clin Gastroenterol Hepatol 2017; 15: 511-517
• 15 Jani N, Kankotia R, Buxbaum J. Detection of gastric cancer and metaplasia in a high risk population in the USA. Gastroenterology 2015; 148: S566