Virtual Reality Simulator: Unveiling the "Inner" Skills of Endoscopists

Virtual Reality Simulator: Unveiling the "Inner" Skills of Endoscopists | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Virtual Reality Simulator: Unveiling the "Inner" Skills of Endoscopists Bei Zhao, Wenqi Sun, Xinrong Wu, Yifan Li, Weiwei Wang, Xiaotan Dou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4223971/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study aimed to create a simulation-based assessment system for evaluating endoscopist proficiency due to the absence of evidence-based scoring systems. Methods After feasibility and clinical relevance assessments of simulator modules by gastroenterology experts, a colonoscopy module with relatively high operational difficulty was chosen for testing and underwent preliminary validation. Additionally, a questionnaire was designed to collect information about endoscopist experience, including the number of colonoscopy and gastroscope performed, insertion time, cecal intubation rate, early colorectal cancer detection rate. Subsequently, 38 physicians from our hospital's endoscopy center completed the questionnaire and underwent virtual reality simulator training. The endoscopist's proficiency was assessed in real-time based on scoring criteria, including total operation time, percentage of examined mucosa, time to reach the cecum, screening efficiency, proportion of time with clear vision, and total time spent on colonoscope looping. Results In our study, no statistically significant differences were found among endoscopy experts, specialist attending physicians, and resident physicians in terms of their experience and early cancer detection rates ( P > 0.05). However, the VR system scores, including operational completion time, time to reach the cecum, and the percentage of observed mucosa, were correlated with the number of colonoscopies completed by the endoscopists ( P < 0.05). Operational completion time and time to reach the cecum were strongly correlated with usual insertion times ( P < 0.001), and the percentage of observed mucosa score was related to early disease detection rates. Notably, screening efficiency and endoscopic clarity scores were not correlated with physicians' disease detection rates ( P > 0.05). Conclusion Virtual reality endoscopy can be utilized to assess endoscopist proficiency and provide targeted guidance to enhance their clinical practice. Based on these findings, further expansion and enrichment of simulator content, as well as optimization of training methods, can be pursued promisingly in the future. Virtual reality Digestive endoscopy Simulation training Endoscopists Endoscopic proficiency Figures Figure 1 Figure 2 Figure 3 Introduction Virtual Reality (VR) technology, originating in the United States in the 1960s, boasts a history of over 50 years of development [ 1 ] . With continuous advancements in science and technology, VR has made groundbreaking progress. Virtual endoscopy simulators are integrated systems composed of mechanical components and software. By running computer programs, they simulate the process of endoscopic examinations using images from the gastrointestinal endoscope. Trainees operate the endoscope connected to a processor, which transmits signals to a monitor. The movements of the endoscope interact with the monitor's images, providing operators with a virtual environment to practice theoretical and practical knowledge under various conditions [ 2 ] . Currently, VR technology is primarily employed for training novice endoscopists due to its safety features [ 3 – 4 ] . However, there is scarce research utilizing VR technology to assess the clinical endoscopic proficiency of physicians with a certain level of expertise and experience. In clinical practice, the ultimate goal of colonoscopy screening is to reduce the incidence and mortality of colorectal cancer. This places higher demands on endoscopists regarding adenoma detection rates, polyp detection rates, and other metrics. Hence, the assessment of an endoscopist's proficiency becomes particularly crucial. Since colonoscopy is an invasive procedure, approximately half of the patients experience new gastrointestinal symptoms following the examination [ 5 ] . It is thus unbefitting to perform colonoscopy on patients without a clear understanding of the physician's endoscopic proficiency. Therefore, this study aims to explore the feasibility of VR as a tool for assessing the operational proficiency of endoscopists. Materials and methods Simulator modules and simulator metrics The simulator model used in this study is the GI-Bronch Mentor, which includes pre-installed endoscopy examinations and surgical modules. The endoscopy examination module comprises gastrointestinal endoscopy operations, visualization of the digestive tract, biopsies, 3D navigation, while the surgical module primarily encompasses endoscopic hemostasis, EMR (Endoscopic Mucosal Resection), ESD (Endoscopic Submucosal Dissection) and others. The complexity of these modules is categorized into easy, moderate, difficult, and advanced levels. Each module's score is primarily calculated based on total operation time, the percentage of examined mucosal surface, time to reach the cecum, screening efficiency (as a ratio), proportion of time with a clear view, and the total time spent on colonoscope looping. Research method Between December 2022 and June 2023, both endoscopists from the Digestive Endoscopy Center of Nanjing University Medical School Affiliated Drum Tower Hospital and experts from our institution were selected. Initially, the endoscopists completed a questionnaire, including information on the number of colonoscopies performed, insertion times, cecal intubation rates, cases of early colorectal cancer detection, the number of magnifying endoscopies performed, and the frequency of using NBI mode. Subsequently, a brief introduction to VR endoscopy was provided, followed by individual "one-on-one" assessments. A moderately difficult colonoscopy examination module was uniformly selected for the VR assessment. The assessors were scored according to specific evaluation criteria, with the candidates unaware of the scoring details beforehand. The scoring primarily included total operation time, the percentage of examined mucosal surface, time taken to reach the cecum, screening efficiency, the proportion of time with a clear view, and the total time spent on colonoscope looping. An on-site VR senior engineer was responsible for invoking the operational module and supervising the entire scoring process. Statistics analysis The continuous data are presented as means ± standard deviations. Differences between groups using univariate ANOVA analysis. Pearson correlation coefficients were utilized in this study, and statistical significance was defined as P < 0.05. Data analysis was conducted using SPSS version 25.0 software (IBM Corp, Armonk, NY, USA). Results There were a total of 38 participants, comprising 9 endoscopy experts, 26 attending physicians, and 3 resident physicians. Relations to endoscopists Both endoscopy experts and specialist attending physicians, whether in colonoscopy or gastroscopy, have completed a relatively large number of procedures, whereas resident physicians have conducted fewer endoscopic examinations. However, a one-way ANOVA analysis indicated no statistically significant differences among endoscopy experts, specialist attending physicians, and resident physicians ( P > 0.05). Figure 1 and Fig. 2 illustrate the insertion time and caecal intubation rate among the three groups. Additionally, there were no statistically significant differences among the three groups in terms of the number of early cancer detections ( P > 0.05)(Table 1 ). Table 1 Comparison between endoscopists variable Expert (n = 9) Attending doctor (n = 26) Physician (n = 3) P-value Endoscopic operations 15333.33 ± 1927.34 7560.77 ± 7150.74 1033.33 ± 400 0.098 Colonoscopy 2611.11 ± 1409.30 2272.31 ± 2122.21 433.33 ± 665.83 0.101 Gastroscope 12722.22 ± 1861.73 5288.46 ± 5358.1 600.00 ± 458.25 0.239 Flat early lesions found 31.44 ± 35.54 28.81 ± 51.52 3.33 ± 5.00 0.646 Caecal intubation rate 70%-100%(44.4%) 100%(55.5%) <70%(15.3%) 70%-100%(30.7%) 100%(53.8%) <70%(33.3%) 70%-100%(33.3%) 100%(33.3%) 0.518 Insertion time <10min(77.7%) 10-20min(22.2%) 20min(11.5%) 20min(33.3%) 0.142 Table 2 Consequences of testing Score Number of colonoscopy done Total operation time Pearson's r 0.339 P-value 0.037 Time taken to reach the cecum Pearson's r 0.360 P-value 0.026 The percentage of examined mucosal surface Pearson's r 0.395 P-value 0.046 Screening efficiency Pearson's r 0.197 P-value 0.334 Insertion time Total operation time Pearson's r -0.500 P-value 0.001 Time taken to reach the cecum Pearson's r -0.628 P-value 0.001 Flat early lesions found The percentage of examined mucosal surface Pearson's r 0.410 P-value 0.038 The proportion of time with a clear view Pearson's r 0.116 P-value 0.572 Screening efficiency Pearson's r 0.078 P-value 0.705 Consequences of testing The scores provided by the VR system based on operational completion time, time to reach the cecum, and the percentage of observed mucosa were found to be correlated with the number of colonoscopies completed by endoscopists ( P < 0.05). Furthermore, scores related to operational completion time and time to reach the cecum exhibited a strong correlation with endoscopists' usual insertion times ( P < 0.001). The percentage of observed mucosa score was related to endoscopists' early disease detection rates. However, scores related to screening efficiency and endoscopic clarity were not correlated with physicians' disease detection rates ( P > 0.05). Discussion This study aims to investigate whether VR endoscopy can be used to evaluate endoscopists' endoscopic proficiency. Previous research has primarily focused on employing VR endoscopy as a training tool, creating virtual environments that closely resemble real clinical cases. Trainees practice extensively with VR systems to master endoscopic techniques, accumulate experience in disease recognition and treatment, and significantly alleviate patient discomfort [ 6 – 7 ] . However, there has been limited research on the utilization of VR endoscopy as a tool for evaluating endoscopic proficiency. A bovine colon model has been used to assess endoscopic manipulation, but this model can only test the endoscopist's ability to enter the microscope, and the rest of the ability cannot be adequately assessed [ 8 ] . This study revealed correlations between the operational time, time to reach the cecum, and the percentage of observed mucosa in a complete module of VR endoscopy with the number of colonoscopies completed by endoscopists. Notably, the first two factors exhibited significant associations with the usual insertion time of endoscopists. Therefore, it can be inferred that scores related to operational time and time to reach the cecum in VR endoscopy can serve as initial assessments of endoscopists' regular insertion speed. From Figs. 1 and 2 , it is visually evident that experts generally outperform other endoscopists in terms of insertion time and caecal intubation rates. No expert exceeded insertion time of 20 minutes, and the caecal intubation rate remained above 70% for all experts. Similar observations have been noted in our daily examination processes at the endoscopy center. Prior research has used cecal intubation rates and insertion time as measures of endoscopist capability. It has been suggested that experienced endoscopists typically achieve cecal intubation within an average time of less than 10 minutes [ 9 ] . In practical procedures, insertion time is influenced by factors such as patient age, gender, lower BMI, and poor bowel preparation quality, making it less accurate to assess endoscopic proficiency based solely on patient-related variables [ 10 – 11 ] . VR endoscopy can eliminate these influencing factors and provide a standardized scoring system for insertion time, ensuring a more precise evaluation of endoscopic capabilities. Moreover, as endoscopists gain mastery in endoscopic techniques with an increasing number of colonoscopies performed, leading to enhanced speed, there is also the potential for a further increase in the percentage of observed mucosa. We found a correlation between endoscopists' early cancer detection rates and the percentage of observed mucosa. This suggests that the mucosal percentage score provided by the simulator holds a certain level of reference value. Physicians with higher adenoma detection rates in colonoscopy demonstrated a significant reduction in the risk of post-colonoscopy colorectal cancer-related deaths [ 12 ] . While a higher percentage of mucosa observed during VR endoscopy seemly suggests that endoscopists detect early lesions more frequently in their routine practice, there is currently limited clinical research examining the relationship between the percentage of exposed mucosa during colonoscopy and endoscopists' adenoma detection rates. In a meta-analysis, Rishad Khan proposed that there is insufficient evidence to demonstrate the superiority of VR simulation training over traditional endoscopy training, and the performance of trainees using VR endoscopy for individualized training remains uncertain [ 13 ] . And several studies have shown that simulator training is only useful for novices, while experienced doctors are seemingly useless, and the improvement of ability only occurs in the early stages of training [ 14 ] . However, based on our observations and the VR simulator assessment, endoscopists will consciously address their deficiencies once they are aware of them; however, we did not reevaluate their performance after a certain amount of time. Further research is required to investigate whether improvements in mucosal observation percentage and screening efficiency, achieved by endoscopists through VR simulation training, would result in an enhanced adenoma detection rate. The historical information collected through the questionnaire we designed can reflect the long-term training outcomes of endoscopists, and the scores provided by the VR system objectively reflect the proficiency of endoscopists. In our study, all physicians had accumulated endoscopic experience through traditional teaching methods. Comparing physicians who extensively used simulators during their training phase with those who did not, further research is needed to explore potential differences in factors such as total operation time, the percentage of examined mucosal surface, time taken to reach the cecum. According to the scores derived from questionnaire responses and VR assessments, as depicted in Figs. 3 , it is observed that, overall, a higher number of colonoscopy procedures correspond to relatively higher scores. However, for beginners, regardless of whether they are new to colonoscopy or have conducted a limited number of procedures, the scores exhibit uncertainty. During the procedure, some novice practitioners demonstrate faster insertion times, yet their scores for factors such as mucosal exposure ratio, time spent on clear mucosal observation, and screening efficiency are relatively lower. Furthermore, less proficient endoscopists with prolonged insertion times tend to achieve higher scores due to increased mucosal exposure. However, it is noted that in actual practice, mucosal observation typically occurs during the withdrawal phase, and the increase in scores for mucosal exposure ratio and time spent on clear mucosal observation, resulting from prolonged insertion times, may not accurately reflect the true proficiency of endoscopists. Therefore, for beginners, VR may be more suitable for practicing endoscopic procedures rather than being used as an assessment tool for endoscopic skills. In addition, we also observed that the scores for insertion time are relatively low only among novice endoscopists, while those with some experience in endoscopy consistently achieve near-perfect scores. Endoscopists who have completed around 200 procedures seem to have mastered the technical aspects of endoscopic operations, as reflected by their nearly perfect scores in insertion time. However, their performance in other aspects does not stand out. If assessed according to traditional evaluation systems, the true proficiency of these endoscopists may be somewhat overestimated. Possibly due to variations in the learning curve and individual comprehension abilities among endoscopists, or other confounding factors, we observed through scatter plots that there is no direct linear relationship between the number of colonoscopies performed by endoscopists and their respective scores. Perhaps, in future studies, we can use VR systems to observe how the scores of a specific physician change with an increasing number of colonoscopies performed. In Suck-Ho Lee's research on colonoscopy training, it was manifested that under the supervision of on-site mentors, trainees might take more detailed actions to alleviate patient discomfort, such as carefully undoing loops formed by the colonoscope or adjusting insufflation [ 15 ] . Similarly, in our study, the presence of mentors and engineers might induce greater anxiety in trainees during the operation. Therefore, in this experiment, we aimed to select experienced and psychologically resilient physicians to minimize this influence as much as possible. However, it remains unclear whether this influence still exists, and in the future, we may consider reducing observations during endoscopic assessments and relying solely on the VR system for evaluation. A primary limitation of this study was that the chosen colonoscopy module was not highly complex. In future research, experiments can be designed to select more suitable modules for evaluation. Furthermore, the participants were not randomly selected, which might affect the representativeness of the study's findings. Considering safety, patient variability and differences in the learning curve, we did not verify the consistency between VR scores and assessments based on real-life proficiency levels. Conclusion In summary, VR endoscopy was considered as a safe and efficient tool for evaluating an operator's existing endoscopic proficiency. It facilitates the identification of potential areas for improvement in the current endoscopic procedure based on the operator's score, ultimately leading to enhanced effectiveness in digestive endoscopy. Declarations Author Contribution Prof. Min Chen and Prof. Lei Wang contributed to the manuscript by designing experiments; approving the final version of the manuscript.Dr. Bei Zhao made the contributions to the work in collecting the data, analyzing and interpreting the data and writing the manuscript. Dr. Wenqi Sun, Dr. Xinrong Wu and Dr. Yifan Li contributed to the work of data analysis and statistics as well as collecting references. Dr. Weiwei Wang, Dr. Wen Li and Dr. Xiaotan Dou mainly provided critical revisions that were important for the intellectual content. Ethics approval and consent to participate This study has received ethical approval from the Institutional Review Board of the Affiliated Drum Tower Hospital of Nanjing University (HA9830202101). Informed consent has been obtained from all subjects for this study. Consent for publication Not applicable. Statement No funding was obtained for this study. Competing interests All the authors declared that they had no conflicts of interest or financial ties to disclose. Data availability statement The data that support the study findings are available upon reasonable request from the corresponding authors (Min Chen). Contributors Prof. Min Chen and Prof. Lei Wang contributed to the manuscript by designing experiments; approving the final version of the manuscript. Dr. Bei Zhao made the contributions to the work in collecting the data, analyzing and interpreting the data and writing the manuscript. Dr. Wenqi Sun, Dr. Xinrong Wu and Dr. Yifan Li contributed to the work of data analysis and statistics as well as collecting references. Dr. Weiwei Wang, Dr. Wen Li and Dr. Xiaotan Dou mainly provided critical revisions that were important for the intellectual content. References Wang Q, Li C, Xie Z, Bu Z, Shi L, Wang C, Jiang F. The Development and Application of Virtual Reality Animation Simulation Technology: Take Gastroscopy Simulation System as an Example. Pathol Oncol Res. 2020;26(2):765–9. 10.1007/s12253-019-00590-8 . Epub 2019 Feb 26. PMID: 30809768. Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ. A systematic review of skills transfer after surgical simulation training. 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Kneebone R, ApSimon D. Surgical skills training: simulation and multimedia combined. Med Educ. 2001;35(9):909 – 15. 10.1046/j.1365-2923.2001.00997.x . PMID: 11555230. Krummel TM. Surgical simulation and virtual reality: the coming revolution. Ann Surg. 1998;228(5):635–7. 10.1097/00000658-199811000-00002 . PMID: 9833801; PMCID: PMC1191568. Sedlack RE, Baron TH, Downing SM, Schwartz AJ. Validation of a colonoscopy simulation model for skills assessment. Am J Gastroenterol. 2007;102(1):64–74. 10.1111/j.1572-0241.2006.00942.x . Epub 2006 Nov 13. PMID: 17100968. Rex DK. Effect of variable stiffness colonoscopes on cecal intubation times for routine colonoscopy by an experienced examiner in sedated patients. Endoscopy. 2001;33(1):60 – 4. 10.1055/s-2001-11179 . PMID: 11204989. Bernstein C, Thorn M, Monsees K, Spell R, O'Connor JB. A prospective study of factors that determine cecal intubation time at colonoscopy. Gastrointest Endosc. 2005;61(1):72 – 5. 10.1016/s0016-5107(04)02461-7 . PMID: 15672059. Cirocco WC, Rusin LC. Factors that predict incomplete colonoscopy. Dis Colon Rectum. 1995;38(9):964-8. 10.1007/BF02049733 . PMID: 7656745. Rex DK. Adenoma Detection Rate and Colorectal Cancer Prevention by Colonoscopy. JAMA. 2022;327(21):2088–2089. 10.1001/jama.2022.3822 . PMID: 35670806. Khan R, Plahouras J, Johnston BC, Scaffidi MA, Grover SC, Walsh CM. Virtual reality simulation training in endoscopy: a Cochrane review and meta-analysis. Endoscopy. 2019;51(7):653–64. 10.1055/a-0894-4400 . Epub 2019 May 9. PMID: 31071757. Courneya KS, Segal RJ, Gelmon K, Reid RD, Mackey JR, Friedenreich CM, Proulx C, Lane K, Ladha AB, Vallance JK, Liu Q, Yasui Y, McKenzie DC. Six-month follow-up of patient-rated outcomes in a randomized controlled trial of exercise training during breast cancer chemotherapy. Cancer Epidemiol Biomarkers Prev. 2007;16(12):2572-8. 10.1158/1055-9965.EPI-07-0413 . PMID: 18086760. Lee SH, Chung IK, Kim SJ, Kim JO, Ko BM, Hwangbo Y, Kim WH, Park DH, Lee SK, Park CH, Baek IH, Park DI, Park SJ, Ji JS, Jang BI, Jeen YT, Shin JE, Byeon JS, Eun CS, Han DS. An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve. Gastrointest Endosc. 2008;67(4):683–9. 10.1016/j.gie.2007.10.018 . Epub 2008 Feb 14. PMID: 18279862. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4223971","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":291009097,"identity":"f7bb87dc-49b6-4bb1-95bf-01275ecbaac0","order_by":0,"name":"Bei Zhao","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bei","middleName":"","lastName":"Zhao","suffix":""},{"id":291009098,"identity":"bbb82d8d-9e28-48d7-9c60-5f9b0a19f16c","order_by":1,"name":"Wenqi Sun","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wenqi","middleName":"","lastName":"Sun","suffix":""},{"id":291009099,"identity":"ae634298-5d7b-4b84-889d-6f1df9754b9e","order_by":2,"name":"Xinrong Wu","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xinrong","middleName":"","lastName":"Wu","suffix":""},{"id":291009100,"identity":"ad5f5734-1ae6-4855-b617-7310e6215381","order_by":3,"name":"Yifan Li","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yifan","middleName":"","lastName":"Li","suffix":""},{"id":291009101,"identity":"d40497d1-21e9-4d07-a51c-2c932e4311e0","order_by":4,"name":"Weiwei Wang","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weiwei","middleName":"","lastName":"Wang","suffix":""},{"id":291009102,"identity":"f72ccfdd-a7a1-4018-8ebd-76a4d8bd7d73","order_by":5,"name":"Xiaotan Dou","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaotan","middleName":"","lastName":"Dou","suffix":""},{"id":291009103,"identity":"314f4227-cad7-4a6f-bbb6-59bdad1301a5","order_by":6,"name":"Wen Li","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Li","suffix":""},{"id":291009104,"identity":"d846a60c-3176-4d6a-a1a2-e7f9cb2e6376","order_by":7,"name":"Lei Wang","email":"","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Wang","suffix":""},{"id":291009105,"identity":"4a722ce8-3022-4cab-a5b6-915e60d05643","order_by":8,"name":"Min Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYPACCTBi+MDABuIZEK+FcQYJWiC6mHkgTPxa+GcfPibxMccij39287PHtjv4EhvYm7dJMNTcwW32ubQ0yZnbJIol7hwzN849w5bYwHOsTILh2DOcWgx4eMxu826TSNwgkWAmndsG1CKRYybB2HAYv5a/YC3p36QtQVrk3xChhRGsJcdMmhFsCw9+LRJn2NJ/9gK1zLiRUybZ28Zm3MaTVmyRcAy3Fv4e5sMGP7fVJfbPSN8m8bPtmGw/++GNNz7U4NaCDo5BIjOBaA0MDDUkqB0Fo2AUjIKRAgDYBk2RW9u3/wAAAABJRU5ErkJggg==","orcid":"","institution":"Nanjing Drum Tower Hospital","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-04-05 15:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4223971/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4223971/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54789300,"identity":"5704434e-5729-4e4b-b80e-f85b0c983be0","added_by":"auto","created_at":"2024-04-16 20:19:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142093,"visible":true,"origin":"","legend":"\u003cp\u003eHistograms of different endoscopist insertion times and caecal intubation rate.\u003c/p\u003e\n\u003cp\u003eA. Figure A illustrates the endoscopy insertion time for physician, attending doctors, and experts. More than seventy-seven percent of the experts finish the process in less than ten minutes, and all within twenty minutes. Only 11.5% of attending doctors surpass the 20-minute mark, with 42.3% falling between 10 and 20 minutes, and 46.1% finishing in under 10 minutes. It seems like a fairly balanced distribution of physicians.\u003c/p\u003e\n\u003cp\u003eB. Figure B illustrates the various groups' rates of caecal intubation. The expert group consistently surpasses 70%, with over half achieving near-perfect cecal intubation rates approaching 100%. Similarly, attending doctors exhibit a cecal intubation success rate of nearly 100% in over half of the cases, reaching 53.8%, while 15.3% fall short of the 70% success threshold. Beginners are evenly distributed across the three stages, each contributing one-third.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4223971/v1/88772d010d5c7c3b842b5666.png"},{"id":54789301,"identity":"8f8c6c96-1957-401c-bdd4-b4764120e36a","added_by":"auto","created_at":"2024-04-16 20:19:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":207731,"visible":true,"origin":"","legend":"\u003cp\u003eScatter plots depicting the relationship between the quantity of colonoscopy operations and various factors, including operation time, time taken to reach the cecum, examined mucosal surface , screening efficiency and the proportion time with a clear view.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4223971/v1/b9de466e673fd5fcc7bd2ee9.png"},{"id":54789302,"identity":"ccd17d3c-9f99-4513-b254-eec9be140acd","added_by":"auto","created_at":"2024-04-16 20:19:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":313942,"visible":true,"origin":"","legend":"\u003cp\u003eThe figure clearly illustrates the flow relationship between the number of colonoscopies performed by different endoscopists and the scores provided through the VR system. Endoscopists who have conducted a higher number of colonoscopies predominantly exhibit a flow towards higher scores in the respective segments. Conversely, less experienced endoscopists tend to receive relatively lower scores.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4223971/v1/c7d1b38d3b3f8ac287a3c181.png"},{"id":91146002,"identity":"9d64145d-8af9-4573-b52e-eee10ad98561","added_by":"auto","created_at":"2025-09-12 06:13:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1203810,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4223971/v1/74d60aeb-30a7-448e-b4f1-3389c7146868.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Virtual Reality Simulator: Unveiling the \"Inner\" Skills of Endoscopists","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVirtual Reality (VR) technology, originating in the United States in the 1960s, boasts a history of over 50 years of development\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. With continuous advancements in science and technology, VR has made groundbreaking progress. Virtual endoscopy simulators are integrated systems composed of mechanical components and software. By running computer programs, they simulate the process of endoscopic examinations using images from the gastrointestinal endoscope. Trainees operate the endoscope connected to a processor, which transmits signals to a monitor. The movements of the endoscope interact with the monitor's images, providing operators with a virtual environment to practice theoretical and practical knowledge under various conditions\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCurrently, VR technology is primarily employed for training novice endoscopists due to its safety features\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. However, there is scarce research utilizing VR technology to assess the clinical endoscopic proficiency of physicians with a certain level of expertise and experience. In clinical practice, the ultimate goal of colonoscopy screening is to reduce the incidence and mortality of colorectal cancer. This places higher demands on endoscopists regarding adenoma detection rates, polyp detection rates, and other metrics. Hence, the assessment of an endoscopist's proficiency becomes particularly crucial. Since colonoscopy is an invasive procedure, approximately half of the patients experience new gastrointestinal symptoms following the examination\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. It is thus unbefitting to perform colonoscopy on patients without a clear understanding of the physician's endoscopic proficiency. Therefore, this study aims to explore the feasibility of VR as a tool for assessing the operational proficiency of endoscopists.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSimulator modules and simulator metrics\u003c/h2\u003e \u003cp\u003eThe simulator model used in this study is the GI-Bronch Mentor, which includes pre-installed endoscopy examinations and surgical modules. The endoscopy examination module comprises gastrointestinal endoscopy operations, visualization of the digestive tract, biopsies, 3D navigation, while the surgical module primarily encompasses endoscopic hemostasis, EMR (Endoscopic Mucosal Resection), ESD (Endoscopic Submucosal Dissection) and others. The complexity of these modules is categorized into easy, moderate, difficult, and advanced levels. Each module's score is primarily calculated based on total operation time, the percentage of examined mucosal surface, time to reach the cecum, screening efficiency (as a ratio), proportion of time with a clear view, and the total time spent on colonoscope looping.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResearch method\u003c/h2\u003e \u003cp\u003eBetween December 2022 and June 2023, both endoscopists from the Digestive Endoscopy Center of Nanjing University Medical School Affiliated Drum Tower Hospital and experts from our institution were selected. Initially, the endoscopists completed a questionnaire, including information on the number of colonoscopies performed, insertion times, cecal intubation rates, cases of early colorectal cancer detection, the number of magnifying endoscopies performed, and the frequency of using NBI mode. Subsequently, a brief introduction to VR endoscopy was provided, followed by individual \"one-on-one\" assessments. A moderately difficult colonoscopy examination module was uniformly selected for the VR assessment. The assessors were scored according to specific evaluation criteria, with the candidates unaware of the scoring details beforehand. The scoring primarily included total operation time, the percentage of examined mucosal surface, time taken to reach the cecum, screening efficiency, the proportion of time with a clear view, and the total time spent on colonoscope looping. An on-site VR senior engineer was responsible for invoking the operational module and supervising the entire scoring process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistics analysis\u003c/h2\u003e \u003cp\u003eThe continuous data are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations. Differences between groups using univariate ANOVA analysis. Pearson correlation coefficients were utilized in this study, and statistical significance was defined as \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Data analysis was conducted using SPSS version 25.0 software (IBM Corp, Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were a total of 38 participants, comprising 9 endoscopy experts, 26 attending physicians, and 3 resident physicians.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRelations to endoscopists\u003c/h2\u003e \u003cp\u003eBoth endoscopy experts and specialist attending physicians, whether in colonoscopy or gastroscopy, have completed a relatively large number of procedures, whereas resident physicians have conducted fewer endoscopic examinations. However, a one-way ANOVA analysis indicated no statistically significant differences among endoscopy experts, specialist attending physicians, and resident physicians (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrate the insertion time and caecal intubation rate among the three groups. Additionally, there were no statistically significant differences among the three groups in terms of the number of early cancer detections (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between endoscopists\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpert\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttending doctor\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic operations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15333.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1927.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7560.77\u0026thinsp;\u0026plusmn;\u0026thinsp;7150.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1033.33\u0026thinsp;\u0026plusmn;\u0026thinsp;400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColonoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2611.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1409.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2272.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2122.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e433.33\u0026thinsp;\u0026plusmn;\u0026thinsp;665.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastroscope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12722.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1861.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5288.46\u0026thinsp;\u0026plusmn;\u0026thinsp;5358.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e600.00\u0026thinsp;\u0026plusmn;\u0026thinsp;458.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.239\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlat early lesions found\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.44\u0026thinsp;\u0026plusmn;\u0026thinsp;35.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.81\u0026thinsp;\u0026plusmn;\u0026thinsp;51.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaecal intubation rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70%-100%(44.4%)\u003c/p\u003e \u003cp\u003e100%(55.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;70%(15.3%)\u003c/p\u003e \u003cp\u003e70%-100%(30.7%)\u003c/p\u003e \u003cp\u003e100%(53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;70%(33.3%)\u003c/p\u003e \u003cp\u003e70%-100%(33.3%)\u003c/p\u003e \u003cp\u003e100%(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInsertion time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;10min(77.7%)\u003c/p\u003e \u003cp\u003e10-20min(22.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;10min(46.1%)\u003c/p\u003e \u003cp\u003e10-20min(42.3%)\u003c/p\u003e \u003cp\u003e\u0026gt;20min(11.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;10min(33.3%)\u003c/p\u003e \u003cp\u003e10-20min(33.3%)\u003c/p\u003e \u003cp\u003e\u0026gt;20min(33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.142\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConsequences of testing\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNumber of colonoscopy done\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime taken to reach the cecum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.360\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe percentage of examined mucosal surface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.395\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening efficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.334\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsertion time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal operation time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime taken to reach the cecum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFlat early lesions found\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe percentage of examined mucosal surface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe proportion of time with a clear view\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.116\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreening efficiency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePearson's r\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.705\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConsequences of testing\u003c/h2\u003e \u003cp\u003eThe scores provided by the VR system based on operational completion time, time to reach the cecum, and the percentage of observed mucosa were found to be correlated with the number of colonoscopies completed by endoscopists (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, scores related to operational completion time and time to reach the cecum exhibited a strong correlation with endoscopists' usual insertion times (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The percentage of observed mucosa score was related to endoscopists' early disease detection rates. However, scores related to screening efficiency and endoscopic clarity were not correlated with physicians' disease detection rates (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to investigate whether VR endoscopy can be used to evaluate endoscopists' endoscopic proficiency. Previous research has primarily focused on employing VR endoscopy as a training tool, creating virtual environments that closely resemble real clinical cases. Trainees practice extensively with VR systems to master endoscopic techniques, accumulate experience in disease recognition and treatment, and significantly alleviate patient discomfort\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, there has been limited research on the utilization of VR endoscopy as a tool for evaluating endoscopic proficiency. A bovine colon model has been used to assess endoscopic manipulation, but this model can only test the endoscopist's ability to enter the microscope, and the rest of the ability cannot be adequately assessed\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study revealed correlations between the operational time, time to reach the cecum, and the percentage of observed mucosa in a complete module of VR endoscopy with the number of colonoscopies completed by endoscopists. Notably, the first two factors exhibited significant associations with the usual insertion time of endoscopists. Therefore, it can be inferred that scores related to operational time and time to reach the cecum in VR endoscopy can serve as initial assessments of endoscopists' regular insertion speed. From Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, it is visually evident that experts generally outperform other endoscopists in terms of insertion time and caecal intubation rates. No expert exceeded insertion time of 20 minutes, and the caecal intubation rate remained above 70% for all experts. Similar observations have been noted in our daily examination processes at the endoscopy center. Prior research has used cecal intubation rates and insertion time as measures of endoscopist capability. It has been suggested that experienced endoscopists typically achieve cecal intubation within an average time of less than 10 minutes\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. In practical procedures, insertion time is influenced by factors such as patient age, gender, lower BMI, and poor bowel preparation quality, making it less accurate to assess endoscopic proficiency based solely on patient-related variables\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. VR endoscopy can eliminate these influencing factors and provide a standardized scoring system for insertion time, ensuring a more precise evaluation of endoscopic capabilities. Moreover, as endoscopists gain mastery in endoscopic techniques with an increasing number of colonoscopies performed, leading to enhanced speed, there is also the potential for a further increase in the percentage of observed mucosa. We found a correlation between endoscopists' early cancer detection rates and the percentage of observed mucosa. This suggests that the mucosal percentage score provided by the simulator holds a certain level of reference value. Physicians with higher adenoma detection rates in colonoscopy demonstrated a significant reduction in the risk of post-colonoscopy colorectal cancer-related deaths\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. While a higher percentage of mucosa observed during VR endoscopy seemly suggests that endoscopists detect early lesions more frequently in their routine practice, there is currently limited clinical research examining the relationship between the percentage of exposed mucosa during colonoscopy and endoscopists' adenoma detection rates. In a meta-analysis, Rishad Khan proposed that there is insufficient evidence to demonstrate the superiority of VR simulation training over traditional endoscopy training, and the performance of trainees using VR endoscopy for individualized training remains uncertain\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. And several studies have shown that simulator training is only useful for novices, while experienced doctors are seemingly useless, and the improvement of ability only occurs in the early stages of training\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. However, based on our observations and the VR simulator assessment, endoscopists will consciously address their deficiencies once they are aware of them; however, we did not reevaluate their performance after a certain amount of time. Further research is required to investigate whether improvements in mucosal observation percentage and screening efficiency, achieved by endoscopists through VR simulation training, would result in an enhanced adenoma detection rate.\u003c/p\u003e \u003cp\u003eThe historical information collected through the questionnaire we designed can reflect the long-term training outcomes of endoscopists, and the scores provided by the VR system objectively reflect the proficiency of endoscopists. In our study, all physicians had accumulated endoscopic experience through traditional teaching methods. Comparing physicians who extensively used simulators during their training phase with those who did not, further research is needed to explore potential differences in factors such as total operation time, the percentage of examined mucosal surface, time taken to reach the cecum.\u003c/p\u003e \u003cp\u003eAccording to the scores derived from questionnaire responses and VR assessments, as depicted in Figs.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, it is observed that, overall, a higher number of colonoscopy procedures correspond to relatively higher scores. However, for beginners, regardless of whether they are new to colonoscopy or have conducted a limited number of procedures, the scores exhibit uncertainty. During the procedure, some novice practitioners demonstrate faster insertion times, yet their scores for factors such as mucosal exposure ratio, time spent on clear mucosal observation, and screening efficiency are relatively lower. Furthermore, less proficient endoscopists with prolonged insertion times tend to achieve higher scores due to increased mucosal exposure. However, it is noted that in actual practice, mucosal observation typically occurs during the withdrawal phase, and the increase in scores for mucosal exposure ratio and time spent on clear mucosal observation, resulting from prolonged insertion times, may not accurately reflect the true proficiency of endoscopists. Therefore, for beginners, VR may be more suitable for practicing endoscopic procedures rather than being used as an assessment tool for endoscopic skills. In addition, we also observed that the scores for insertion time are relatively low only among novice endoscopists, while those with some experience in endoscopy consistently achieve near-perfect scores. Endoscopists who have completed around 200 procedures seem to have mastered the technical aspects of endoscopic operations, as reflected by their nearly perfect scores in insertion time. However, their performance in other aspects does not stand out. If assessed according to traditional evaluation systems, the true proficiency of these endoscopists may be somewhat overestimated.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePossibly due to variations in the learning curve and individual comprehension abilities among endoscopists, or other confounding factors, we observed through scatter plots that there is no direct linear relationship between the number of colonoscopies performed by endoscopists and their respective scores. Perhaps, in future studies, we can use VR systems to observe how the scores of a specific physician change with an increasing number of colonoscopies performed.\u003c/p\u003e \u003cp\u003eIn Suck-Ho Lee's research on colonoscopy training, it was manifested that under the supervision of on-site mentors, trainees might take more detailed actions to alleviate patient discomfort, such as carefully undoing loops formed by the colonoscope or adjusting insufflation\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Similarly, in our study, the presence of mentors and engineers might induce greater anxiety in trainees during the operation. Therefore, in this experiment, we aimed to select experienced and psychologically resilient physicians to minimize this influence as much as possible. However, it remains unclear whether this influence still exists, and in the future, we may consider reducing observations during endoscopic assessments and relying solely on the VR system for evaluation.\u003c/p\u003e \u003cp\u003eA primary limitation of this study was that the chosen colonoscopy module was not highly complex. In future research, experiments can be designed to select more suitable modules for evaluation. Furthermore, the participants were not randomly selected, which might affect the representativeness of the study's findings. Considering safety, patient variability and differences in the learning curve, we did not verify the consistency between VR scores and assessments based on real-life proficiency levels.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, VR endoscopy was considered as a safe and efficient tool for evaluating an operator's existing endoscopic proficiency. It facilitates the identification of potential areas for improvement in the current endoscopic procedure based on the operator's score, ultimately leading to enhanced effectiveness in digestive endoscopy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eProf. Min Chen and Prof. Lei Wang contributed to the manuscript by designing experiments; approving the final version of the manuscript.Dr. Bei Zhao made the contributions to the work in collecting the data, analyzing and interpreting the data and writing the manuscript. Dr. Wenqi Sun, Dr. Xinrong Wu and Dr. Yifan Li contributed to the work of data analysis and statistics as well as collecting references. Dr. Weiwei Wang, Dr. Wen Li and Dr. Xiaotan Dou mainly provided critical revisions that were important for the intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has received ethical approval from the Institutional Review Board of the Affiliated Drum Tower Hospital of Nanjing University (HA9830202101). Informed consent has been obtained from all subjects for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors declared that they had no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the study findings are available upon reasonable request from the corresponding authors (Min Chen).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProf. Min Chen and Prof. Lei Wang contributed to the manuscript by designing experiments; approving the final version of the manuscript. Dr.\u0026nbsp;Bei Zhao\u0026nbsp;made the contributions to the work in collecting the data, analyzing and interpreting the data and writing the manuscript. Dr. Wenqi Sun, Dr. Xinrong Wu and Dr. Yifan Li contributed to the work of data analysis and statistics as well as collecting references. Dr. Weiwei Wang, Dr. Wen Li and Dr. Xiaotan Dou mainly provided critical revisions that were important for the intellectual content.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang Q, Li C, Xie Z, Bu Z, Shi L, Wang C, Jiang F. The Development and Application of Virtual Reality Animation Simulation Technology: Take Gastroscopy Simulation System as an Example. 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PMID: 18279862.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Virtual reality, Digestive endoscopy, Simulation training, Endoscopists, Endoscopic proficiency","lastPublishedDoi":"10.21203/rs.3.rs-4223971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4223971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study aimed to create a simulation-based assessment system for evaluating endoscopist proficiency due to the absence of evidence-based scoring systems.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAfter feasibility and clinical relevance assessments of simulator modules by gastroenterology experts, a colonoscopy module with relatively high operational difficulty was chosen for testing and underwent preliminary validation. Additionally, a questionnaire was designed to collect information about endoscopist experience, including the number of colonoscopy and gastroscope performed, insertion time, cecal intubation rate, early colorectal cancer detection rate. Subsequently, 38 physicians from our hospital's endoscopy center completed the questionnaire and underwent virtual reality simulator training. The endoscopist's proficiency was assessed in real-time based on scoring criteria, including total operation time, percentage of examined mucosa, time to reach the cecum, screening efficiency, proportion of time with clear vision, and total time spent on colonoscope looping.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn our study, no statistically significant differences were found among endoscopy experts, specialist attending physicians, and resident physicians in terms of their experience and early cancer detection rates (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, the VR system scores, including operational completion time, time to reach the cecum, and the percentage of observed mucosa, were correlated with the number of colonoscopies completed by the endoscopists (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Operational completion time and time to reach the cecum were strongly correlated with usual insertion times (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the percentage of observed mucosa score was related to early disease detection rates. Notably, screening efficiency and endoscopic clarity scores were not correlated with physicians' disease detection rates (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVirtual reality endoscopy can be utilized to assess endoscopist proficiency and provide targeted guidance to enhance their clinical practice. Based on these findings, further expansion and enrichment of simulator content, as well as optimization of training methods, can be pursued promisingly in the future.\u003c/p\u003e","manuscriptTitle":"Virtual Reality Simulator: Unveiling the \"Inner\" Skills of Endoscopists","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 20:19:03","doi":"10.21203/rs.3.rs-4223971/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0e434105-9200-4d8c-bf69-e861fa832f4f","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T05:56:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-16 20:19:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4223971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4223971","identity":"rs-4223971","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}