WEO Newsletter.

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Digestive EndoscopyVolume 35, Issue 3 p. 408-417 WEO NewsletterFree Access WEO Newsletter First published: 09 March 2023 https://doi.org/10.1111/den.14522AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat WEO Newsletter Editor: Nalini M Guda MD, FASGE, AGAF, FACG, FJGES Editorial Asadur Tchekmedyian, MD, FASGE, FSIED, Endoscopy Department, Asociacion Española, Montevideo, Uruguay At the beginning of 2022, I was proud to receive an invitation from Professor Nalini M. Guda (USA), Chair of WEO's News and Communication Ad hoc Committee, to contribute as guest editor to the WEO-DEN newsletter. The chance to contribute to this publication is highly appreciated and provides the opportunity to share relevant information and resources from the Americas and beyond. In the past DEN newsletter issue, we touched on the memories of an unforgettable event, ENDO2020. After this outstanding congress the pandemic emerged and modified almost all of our daily activities. One of these activities, key for all of us, is education and training in endoscopy as this requires on-site and patient driven interaction. Taking this into account and trying to shorten this gap, we have this newsletter to help reach the endoscopy community worldwide and help with resources and expertise. In the present (and past) issue of the WEO-DEN newsletter, we have been honored with the kind support of distinguished authors from all over the world, who have generously contributed their expertise, addressing a wide range of topics in endoscopy. We will continue with this series of basic and advanced topics in endoscopy. Dr Douglas K. Rex and Dr Rachel E. Lahr from the USA will share with us the assessment and management of endoscopic resection scars. Dr Rodrigo Mansilla-Vivar (Chile) and Dr James Tabibian (USA) provide an extensive description with tips and tricks for percutaneous endoscopic gastrostomy. The question of whether simulation-based training can help endoscopists acquire new skills and accelerate the learning curve is generally raised. Covering this topic, Dr David Zagalsky and Dr Andres Wonaga from Argentina tell us about their experience with virtual education and endoscopic simulation. I hope you find these resources helpful and that you can apply the information to deliver high quality procedures while protecting our patients, teammates, and ourselves. Please circulate this newsletter among your colleagues as this is the best way to spread the voice of endoscopy around the world. As the slogan for ENDO meetings says, we are very glad to “connect the world of endoscopy.” Assessment and management of endoscopic resection scars Douglas K. Rex, MD, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA Rachel E. Lahr, BS, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA Resections of large nonpedunculated colorectal lesions by either endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are usually accompanied by endoscopic follow-up examinations at shorter intervals, typically 6–12 months post resection, than recommended for small colorectal polyps. Endoscopists should be familiar with the appearance of endoscopic resection scars to guide accurate and effective management at this follow-up. Scar identification and diagnosis Careful photography of EMR defects at the time of resection, including photographs showing the relationship of the defect to fixed structures such as the appendiceal orifice, ileocecal valve, or anorectal junction when those structures are nearby, facilitates scar identification at follow-up. If tattoos have been used, detailed description of the location of the tattoo in relation to the defect should be included in the procedure report. At the follow-up examination, scar identification is facilitated by full gas distension of the colon lumen,1 which amplifies the color difference between the white scar and the salmon-colored normal mucosa and accentuates the disruption of normal fold structure by the EMR scar. Accurate diagnosis of scar status is enhanced by cleaning the mucosal surface, inspection in both white light and with electronic chromoendoscopy, and with optical magnification. Cold EMR scar, and management of recurrence Cold EMR (injection and snare resection without electrocautery) is not accompanied by clip placement following resection, so at follow-up cold EMR scars are flat and undistorted by clip artifacts. Recurrence rates after cold EMR of large laterally spreading adenomas are high,2 and recurrences are usually easily identified by their nodular appearance and pit structure, in combination with the absence of clip artifact distortion (Fig. 1a,b). Figure 1Open in figure viewerPowerPoint (a) Cold (without electrocautery) endoscopic mucosal resection (EMR) defect after EMR of a 90-mm proximal ascending colon lesion. Histology was tubulovillous adenoma with multifocal high-grade dysplasia. (b) EMR scar 4 months later from the lesion shown in Figure 1a, showing smooth flat scar (arrows) and single 8-mm focus of residual polyp (white line indicates margin of recurrence). We use electrocautery to manage all recurrences seen at follow-up, including those after cold EMR. Treatment of the recurrence usually includes hot snare resection without submucosal injection, with hot avulsion as needed to treat visible polyp that resists snaring, followed by thermal ablation of the margin of the resection site, and finally clip closure of the defect.3 In our experience, this sequence of initial cold EMR followed by thermal resection of any recurrences, which are usually very small, allows near-complete avoidance of complications through the resection process. Clip artifacts Clip closure is currently indicated after EMR using electrocautery for laterally spreading adenomas ≥20 mm in size located proximally to the splenic flexure.4-6 Clip closure of EMR defects is associated with mucosal distortions at follow-up scar inspection in about one-third of cases.7 These mucosal distortions of the EMR site at follow-up, called clip artifact, can be classified into three types.1 Type 1 are mounds of inflammatory tissue at the base of a still-adherent clip (Fig. 2a,b). Type 2 clip artifact consists of inflammatory nodules characterized by erythema and sometimes ulceration, representing a site of recent clip detachment (Fig. 3a,b). Type 3 is mature clip artifact, representing resolution of inflammatory change but persistent nodular mucosal distortion (Fig. 4). Figure 2Open in figure viewerPowerPoint (a) Type 1 clip artifact. The clip is the gold object in the upper right. Granulation tissue is seen (white arrow), and large open inflammatory pits on intact mucosa at the base of the nodule of the clip artifact (green arrows). (b) Adherent clip with small, inflamed nodule at the base of a clip (type 1 clip artifact; white arrow). A small nodule of mature noninflamed type 3 artifact can also be seen (black arrow). Figure 3Open in figure viewerPowerPoint (a) Type 2 clip artifact with large open inflammatory pits at the perimeter (green arrow). More centrally there is marked erythema and ulceration (white arrows). (b) Nodules of type 2 clip artifact with persistent inflammation but no visible exudate or granulation tissue (white arrows), and small distortions of noninflamed mucosa consistent with type 3 clip artifact (green arrows). Figure 4Open in figure viewerPowerPoint Mature noninflamed type 3 clip artifact (black arrows). The three types of clip artifact represent evolution of a process from an inflamed nodule at the base of a foreign body (the clip) to resolution of inflammation with persistent mucosal distortion (type 3 clip artifact). Accurate diagnosis is accomplished by pit inspection, which reveals enlarged round pits consistent with inflamed mucosa in types 1 and 2, to small round pits consistent with normal colonic mucosa in type 3. In the absence of clip placement on overt unresected polyp at the time of resection, it is extremely rare to encounter residual polyp at the base of an adherent clip at follow-up.7, 8 Clip artifact should be recognized as essentially normal tissue, and should not be resected by thermal means with their risk of complications. Clip artifact can be sampled by cold biopsy forceps to confirm the diagnosis.7, 8 If cold forceps are used to biopsy type 3 clip artifact, the artifact is typically less prominent at subsequent follow-up. Distortion after use of submucosal lifting gel Recently, we have described submucosal distortions after use of ORISE submucosal lifting gel (Boston Scientific, Marlborough, MA, USA) that were identified at endoscopic follow-up.9 These present as smooth submucosal lumps with normal overlying mucosa, with a distinctly different appearance from clip artifact (Fig. 5a–c). Biopsy of these sites may reveal submucosal eosinophilic material with associated multinucleated giant cell reaction.1 Figure 5Open in figure viewerPowerPoint (a) Granular tubulovillous adenoma adjacent to the appendiceal orifice. (b) Mucosal defect following endoscopic resection of the lesion in Figure 5a, using ORISE for submucosal injection and snare electrocautery, and prior to snare tip soft coagulation of the margin and clip closure. (c) EMR site at follow-up 6 months after EMR, showing a region of submucosal distortion related to previous ORISE use (yellow arrows), and a small nodule of type 3 clip artifact (red arrow). Conclusion Endoscopists should be familiar with the appearance of both clip artifact and submucosal distortion from ORISE, and recognize that both are benign processes not requiring additional endoscopic treatment, and not representing recurrent polyp in the mucosa or submucosa. A detailed understanding of these changes allows accurate endoscopic identification of recurrences and guides accurate and effective management. REFERENCES 1Rex DK. Diagnosis and management of clip artifact on endoscopic mucosal resection scars. Gastroenterol Hepatol 2021; 17: 464– 8. 2Suresh S, Zhang J, Ahmed A et al. Risk factors associated with adenoma recurrence following cold snare endoscopic mucosal resection of polyps ≥ 20 mm: A retrospective chart review. Endosc Int Open 2021; 9: E867– 73. 3El Rahyel A, Abdullah N, Love E et al. Recurrence after endoscopic mucosal resection: Early and late incidence, treatment outcomes, and outcomes in non-overt (histologic-only) recurrence. Gastroenterology 2021; 160: 949– 51.e2. 4Pohl H, Grimm IS, Moyer MT et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157: 977– 84.e3. 5Albeniz E, Alvarez MA, Espinos JC et al. Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 2019; 157: 1213– 21.e4. 6Spadaccini M, Albeniz E, Pohl H et al. Prophylactic clipping after colorectal endoscopic resection prevents bleeding of large, proximal polyps: Meta-analysis of randomized trials. Gastroenterology 2020; 159: 148– 58.e11. 7Sreepati G, Vemulapalli KC, Rex DK. Clip artifact after closure of large colorectal EMR sites: Incidence and recognition. Gastrointest Endosc 2015; 82: 344– 9. 8Ponugoti PL, Rex DK. Clip retention rates and rates of residual polyp at the base of retained clips on colorectal EMR sites. Gastrointest Endosc 2017; 85: 530– 4. 9Lahr RE, DeWitt JM, Zhang D et al. Assessment of submucosal distortion and mass effect seen at follow-up after colorectal EMR with ORISE (with video). Gastrointest Endosc 2022; 96: 679– 82. Tips and tricks for percutaneous endoscopic gastrostomy Rodrigo Mansilla-Vivar, Digestive Endoscopy Unit, Hospital Puerto Montt, Puerto Montt, Chile James Tabibian, Department of Medicine, Olive View-UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA Percutaneous endoscopic gastrostomy (PEG) is a method of inserting a tube transabdominally into the stomach to provide nutrition, decompress, and/or administer medication. Enterostomy feeding is the most common indication for gastrostomy tube placement and is critical to preserve nutritional status and improve prognosis for a wide spectrum of medical conditions. PEG is the most developed procedure for this purpose. As this invasive procedure is associated with a number of potential adverse events (AEs), it is essential to be familiar with appropriate selection of patients and techniques. PEG indications PEG is most often indicated for provision of nutrition and to bypass obstruction. Placement of a gastrostomy tube is appropriate in patients with underlying conditions that require more than 4 weeks of artificial enteral nutrition, for example many neurological conditions, severe burns, facial trauma, esophageal disease, malnutrition, and treatment for head and neck tumors. Permanent PEG placement may also be appropriate in certain conditions with poor prognosis. These include neurological diseases such as multiple sclerosis and amyotrophic lateral sclerosis, advanced head and neck tumors, oropharyngeal malformations, advanced esophageal or gastric malignancy, rheumatologic disorders with associated esophageal dysfunction, cystic fibrosis, and amyloidosis. Contraindications to PEG Relative contraindications include recent gastrointestinal (GI) bleeding, hemodynamic instability, ascites, respiratory failure, peritoneal carcinomatosis, and anatomical alterations. Absolute contraindications include mechanical obstruction of the GI tract unless the procedure is indicated for decompression, active peritonitis, uncorrectable coagulopathy, and bowel ischemia. Preprocedural physical examination and imaging considerations Physical examination may help to identify certain contraindications to gastrostomy tube placement and prevent occurrence of AEs. The oropharynx and head should be inspected for features that preclude an endoscopic approach, such as facial fractures or complete obstruction. An anesthesia or sedation team should additionally look for features that may impact sedation, such as stridor, large neck circumference, or presence of obstructive sleep apnea, to reduce procedure-related cardiopulmonary adverse events. The abdomen should be examined for ascites and obesity, which can increase the risk of tube dislodgement, failed transillumination, or failed gastropexy. To avoid puncture of the liver, the caudal and lower edge of the liver should be identified with percussion before gastrostomy placement. Any devices such as ventriculoperitoneal shunts should also be noted so that the endoscopist can be aware of any infection risk. The patient's mental status should be investigated to determine ability to consent. Abdominal imaging with computed tomography (CT) or radiography can be obtained prior to the procedure if abnormal anatomy is suspected, or is known because of previous surgery. Antibiotic prophylaxis Patients undergoing PEG tube placement are more prone to infection, because of poor nutrition, advanced age, immunocompromise, and comorbidities (diabetes, obesity, malnutrition). Infection may occur more frequently with the transoral technique because of exposure to oral flora, and is one of the most common AEs of external bolster traction. Management of antiplatelet and anticoagulant agents and coagulopathy Gastrostomy placement is a high-risk procedure according to GI society consensus guidelines. It is a moderate risk procedure according to guidelines regarding patients receiving anticoagulant or antiplatelet therapy. The risk of bleeding should be weighed against that of a thromboembolic event after stopping medication. Additionally, resumption of medication is dependent on achieving proper hemostasis. Patients on antiplatelet agents do not necessarily need to have low dose aspirin withheld. Thienopyridines such as clopidogrel, prasugrel, ticagrelor, and ticlopidine should be withheld 5–7 days before gastrostomy placement. Endoscopic placement: Brief overview of technique With endoscopic guidance for percutaneous gastrostomy, the “pull” (Ponsky–Gauderer), “push-over-wire” (Sachs–Vine), or “introducer” (Russell) technique can be used, depending on training or operator preference. We perform and recommend the pull technique because this method may have lower rates of AEs in non-oropharyngeal cancer patients, especially for palliative decompression. The introducer method is the only truly transabdominal method that can be used to avoid transoral passage of the PEG tube. The transoral approach is usually performed in both the push-over-wire and pull techniques. Upper endoscopy is done to insufflate and transilluminate the stomach. A placement site is chosen by means of endoscopic visualization combined with manual palpation of the stomach (Fig. 1). Figure 1Open in figure viewerPowerPoint Site for tube placement selected by transillumination and manual palpation. (Written patient consent was obtained for publication). After local anesthesia has been administered through the chosen site, a small cutaneous incision is made through the fascia. A catheter is passed percutaneously over the needle into the stomach. A snare is passed through the endoscope. Then, with the “pull” method, the needle is removed while the catheter remains in situ. A silk suture loop (“string”) is passed through the catheter into the stomach where it is grasped by the snare that had been passed through the endoscope. The string is pulled out via the endoscope through the mouth. The wire loop at the oral end of the string is then tied to the wire loop at the tapered end of the PEG tube. The string is then pulled back to draw the tube through the mouth to the stomach and then out through the abdominal wall (Fig. 2). Figure 2Open in figure viewerPowerPoint The string is pulled back to draw the tube through the mouth to the stomach and then out through the abdominal wall. (Written patient consent was obtained for publication). The endoscope is then reinserted to confirm placement (Fig. 3). Figure 3Open in figure viewerPowerPoint (a) Endoscopic view of adequate transgastric position. (b) Distance measure from gastric mucosa to skin. (Written patient consent was obtained for publication). Adverse events and approach to prevention and management Placement and use of gastrostomy tubes are associated with potential AEs. A variety of measures can be taken to prevent and mitigate these. Aspiration Aspiration related to the gastrostomy tube procedure is rare; it is associated with supine position, deeper sedation, advanced age, and neurologic impairment. The endoscopist should avoid excessive sedation, ensure prior evaluation by a sedation team, aspirate all gastric contents before gastrostomy tube placement, suction all insufflated air after the gastrostomy tube has been placed, and minimize procedural time. Bleeding Acute bleeding is also rare. The endoscopist should consider blood transfusion and temporarily withholding anticoagulation according to guidelines. Additionally, if the patient is particularly prone to bleeding, the pull technique should be considered rather than the introducer technique. Cutaneous puncture should be performed laterally to the rectus muscle. Puncture of the anterior gastric wall should be performed at the mid to distal body of the stomach and equidistant from the lesser and greater curvatures to avoid arterial injury. Perforation and pneumoperitoneum Inadvertent perforation of the intestines is a rare but potentially fatal AE. The endoscopist can minimize this risk by, among other methods, performing a “safe track” maneuver to ensure that there are no intervening bowel loops. With high intragastric insufflation pressure during endoscopy, air may escape during gastrostomy tube insertion or needle puncture, leading to pneumoperitoneum. Transient subclinical pneumoperitoneum is a common benign finding that is usually asymptomatic, but a minority of patients can have signs and symptoms of peritonitis. Use of carbon dioxide rather than ambient air for insufflation can significantly reduce the severity of pneumoperitoneum. Placement of the internal bolster below the upper body of the stomach may also be done to prevent pneumoperitoneum. Peristomal infection Infection of the peristomal site can be prevented with appropriate preprocedural antibiotic prophylaxis. Patients who have comorbid diabetes, obesity, poor nutritional status, or long-term corticosteroid use have not only a higher incidence of mortality but also a greater infection risk. The introducer technique has been associated with intraperitoneal abscess in some reports. Standard infection control measures such as aseptic surgical field preparation and preprocedural hand disinfection should be applied. Nasopharyngeal decolonization of methicillin-resistant Staphylococcus aureus (MRSA) and mouthwash with oral chlorhexidine solution can be considered in order to reduce peristomal infection. Fungal degradation of tube Degradation of PEG tube by fungal colonization has been shown to cause PEG tube failure 6 months to 1 year after placement. Fungal growth leads to brittleness, cracking, and obstruction of the tube. Although there is no definitive management, the endoscopist should consider the use of polyurethane rather than silicone tubing to increase resistance to degradation. Buried bumper syndrome Buried bumper syndrome is a partial or complete growth of gastric mucosa over the internal bumper in the stomach. This could lead to migration of the bumper through the gastric wall and gastrostomy tract, which can cause abscess formation, leakage around the gastrostomy site, immobility of the gastrostomy tube, abdominal pain, and possible resistance to formula infusion. Risk factors include poor wound healing, malnutrition, significant weight gain due to successful nutrition, placement of the internal bumper in the upper gastric body, and excess tension between the internal and external bumpers. To reduce the risk of buried bumper, the endoscopist should place the outer bumper tightly enough to ensure proper gastropexy but loosely enough to allow room for post-procedural tissue swelling. The external bumper should be subjected to a very low traction without tension. The day after placement, the outer bumper should be loosened and rotated to allow back and forth movement of at least 1 cm with minimum resistance. The tube should also be covered to prevent inadvertent tugging. The tube needs to be rotated daily and moved inward from 2 to 10 cm once the gastrostomy tract has healed; this is after about 7–10 days. Ulceration Ulceration or erosion from the PEG tube is usually caused by friction on the gastric wall opposite to or underneath the internal bumper. Similarly, to prevention of buried bumper syndrome, the endoscopist should avoid excess tension between the internal and external bumpers. The mucosa under the internal bumper should be visualized after placement, and excess lateral traction on the tube should be avoided. The tube should be rotated daily and moved inward after the gastrostomy tract has healed. Colonic injury and fistulas Excessive gastric and small-bowel insufflation can lead to bowel transposition and gastric rotation. If the colon is accidentally punctured or cannulated, fistulous tracts can later form between stomach, colon, and skin. Many patients are asymptomatic but can develop severe diarrhea after feeding, fecal discharge around the tube, and even peritonitis and sepsis. If the gastrostomy tube is malpositioned into a gastrocolocutaneous fistula, the tube could miss the gastrostomy and enter the colon creating a new colocutaneous fistula. If misplaced gastrostomy tube is suspected, radiographic imaging (CT) should be performed with subsequent removal of the misplaced tube. Tube dislodgement and removal Maturation of the gastrostomy tract usually occurs within the first 7–10 days after placement but can take weeks longer if there is concurrent malnutrition, ascites, or steroid treatment. If the gastrostomy tube is removed during this period, it should be replaced endoscopically or radiographically as an immature tract can result in free perforation. Altered mental status including delirium and dementia increase the risk for accidental tube removal. Measures should be taken to reduce such events, such as using an abdominal binder or elastic bandage to restrict access, gastropexy devices at the time of tube placement, correct choice of gastrostomy site, and use of a low-profile gastrostomy button with detachable extension tubing. Tube occlusion Tube occlusion when feeding can be caused by obstruction of the internal lumen or by mechanical failure of the tube. Smaller-bore feeding tubes (narrower than 10–12 Fr) are more prone to occlusion associated with repeated aspiration to check gastric residuals. The endoscopist should consider placing larger-bore tubes if possible. Conclusion PEG has gained increasing acceptance as a safe and effective technique to provide enteral nutrition for a wide variety of indications. However, the preprocedural evaluation and selection of patients remains paramount for obtaining optimal benefit while reducing risk of AEs. The endoscopist should consider indications, contraindications, ethical considerations, and comorbidities regarding patients referred for gastrostomy placement. Additionally, the endoscopist should consider whether radiologic or surgical tube placement may be more appropriate, and whether a transoral or transabdominal technique is best. If gastrostomy placement appears indicated, physical examination, imaging, and other interventions should be performed to reduce procedure-related AE. Virtual education and endoscopy simulation David Zagalsky, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina Andres Wonaga, Hospital de Clínicas José de San Martín, Universidad de Buenos Aires, Buenos Aires, Argentina The American Society of Gastrointestinal Endoscopy (ASGE) defines competency as the minimum level of skill, knowledge, and experience developed by training, which will allow performance of a procedure with dexterity. In the twentieth century, most endoscopists taught and learned endoscopy techniques while performing the procedures with real people. As patients were involved, this demanded close supervision, tutoring, or mentoring. The more difficult the endoscopic technique, the closer the supervision required, and the more likely a need to take over when the teacher realizesd that the trainee was not performing adequately – or needed more experience. Which was a classic catch-22: you needed more experience to perform procedures adequately, but you needed to do more procedures in order to gain the experience and improve. So, trainees were not able to complete procedures because of their inexperience, repeating a seemingly inescapable loop we'd call it main paradox: This means that you need experience to improve your techniques, but as you do not have experience enough you cannot gain that experience. From our own past teaching ERCP with the fiberoptic endoscope entailed a very slow learning curve: the trainee arrived to a stop and the mentor had to take over. The learning curve undoubtedly improved with the advent of video endoscopy, but “live teaching” demands close supervision, more time required to carry out a procedure, more need for scope repairs, longer clinics or fewer endoscopies per shift, all of which lead to a greater economic burden. Video endoscopy teaching is far more effective as the mentor can make precise observations and guide the trainee allowing him or her to do the job; nevertheless, the possible need to “take over” persists. The moment of stopping the trainee from handling the scope, to be replaced by the tutor, is pedagogically awful to put it mildly. However, aviation training has shown us that you do not need to crash a plane to learn how to fly. In fact, with simulation one can use worse weather flying conditions than are actually encountered. Today in endoscopy training, mechanical and virtual simulators widely extend the scope and variety provided by the older methods of ex vivo preparations and live animal interventions. Simulation in the world of endoscopy is here to stay, possibly helped by the advent of laparoscopic surgery and the need to train surgeons. Trainees can learn endoscopic skills, speed up learning times (in other words, shorten the learning curve), and endlessly repeat procedures until learning is accomplished. This can be done in a pleasant environment that is friendly and tailored to the trainees' needs. And yet more importantly: without putting patients at risk. Getting something wrong, instead of being a problem, offers the opportunity to correct and improve, while avoiding the famous “take over.” The simulation experience can be widened by preparation of a clinical case in which the endoscopy is just one step of the scenario. Feedback and debriefing are valuable components of the method. Many papers and systematic reviews have proved evidence of how simulation methods have improved the endoscopy learning curve. Key points on simulation in endoscopy training: Teaches basic, new, or advanced skills. Accelerates the learning curve. Can be repeated as needed. Avoids risks to patients. Avoids damage to endoscopes. Debriefing provides valuable feedback. No sterilization needed. Can be done anywhere, even in nonmedical facilities. Keep in touch! The WEO events calendar WEO upcoming events CRC SC Plenary meeting – SAVE THE DATE! May 5, 2023 – Chicago, USA WEO Course: Improving the Outcomes of Pancreatobiliary Endoscopy May 28, 2023 – Abu Dhabi, United Arab Emirates WEO webinars Save the date for the following webinar: Video Capsule Endoscopy in Children (Virtual) June 10, 2023 – Virtual WEO partner events ESGE Days 2023 April 20–22, 2023 – Dublin, Ireland Capsule Endoscopy Global Summit (CEGS) 2022 – POSTPONED UNTIL MAY 2023 May 20, 2023 – Chongqing, China International Digestive Endoscopy Network 2023 (IDEN 2023) June 8–10, 2023 – Seoul, South Korea WEO endorsed events 40th Gastroenterology and Endotherapy European Workshop (GEEW) June 25–27, 2023 – Brussels, Belgium (Hybrid) For a full list of upcoming events and WEO Centers of Excellence live courses, please see www.worldendo.org/events. Volume35, Issue3March 2023Pages 408-417 FiguresReferencesRelatedInformation