1、共聚焦显微内镜的学习与培训Learning and Training of Confocal Endomicroscopy 提 纲 学习与培训的实施要点 共聚焦内镜学习曲线 The Learning Pyramid The Training Ethos Tell me and I forget Show me and I remember Involve me and I learn -Benjamin Franklin 怎样学习效果最好Adults learn best when:lThey are motivatedlThe learning is relevantlThe aims an
2、d objectives are clearlThey are actively involvedlA variety of learning methods is usedlThey get feedbacklIt is FUN!“The ability to establish an immediate endoscopic diagnosis that is virtually consistent with the histologic diagnosis has been the ultimate objective of endoscopists since the very ea
3、rliest phases of the development of endoscopy.”Kudo,Gastrointest Endosc 1996 共聚焦激光显微内镜是一种革命 共聚焦激光显微内镜是一种趋势 两种共聚焦内镜比较eCLEpCLE优势优势获得的图片可以在不同组获得的图片可以在不同组织层面织层面图片扫描速度更快图片扫描速度更快在临床操作中更灵活在临床操作中更灵活可以获得动态图像，观察血流可以获得动态图像，观察血流缺点缺点花费较高花费较高需要利用对比剂需要利用对比剂 两种主要的造影剂荧光素钠荧光素钠(静脉使用，显示组织静脉使用，显示组织结构结构)用于视网膜血管造用于视网膜血管造影
4、的静脉注射影的静脉注射吖啶黄吖啶黄 (通过钳道使用喷管进通过钳道使用喷管进行，显示细胞核）行，显示细胞核）荧光素钠染色 吖啶黄染色 怎样学习共聚焦内镜？图片识别操作过程 识图面临的困惑?l是否需要掌握足够多的病理知识呢?l是否很难掌握呢？l请跟随以下的几篇共聚焦内镜学习曲线研究一起来认识共聚焦图片以及了解共聚焦学习的难易程度。食管胃结肠BE食管 食管上皮内瘤变胃上皮内瘤变胃息肉IBD结肠上皮内瘤变食管病变食管病变 食 管 Barrett食管正常食管粘膜正常食管粘膜:鳞鳞状上皮状上皮Z-线线:食管食管鳞鳞柱状上柱状上皮交界皮交界处处 荧光造影剂：荧光素钠荧光造影剂：荧光素钠(5ml；10%)Ba
5、rrett食管食管鳞状上皮柱状上皮Gaddam S,Mathur SC,Singh M et al.Novel probe-based confocal laser endomicroscopy criteria and interobserver agreement for the detection of dysplasia in Barretts esophagus.Am J Gastroenterol 2011;106:1961-1969Gaddam S,Mathur SC,Singh M et al.Novel probe-based confocal laser endomicro
6、scopy criteria and interobserver agreement for the detection of dysplasia in Barretts esophagus.Am J Gastroenterol 2011;106:1961-1969Gaddam S,Mathur SC,Singh M et al.Novel probe-based confocal laser endomicroscopy criteria and interobserver agreement for the detection of dysplasia in Barretts esopha
7、gus.Am J Gastroenterol 2011;106:1961-1969 结 果1.有经验组与无经验组诊断准确率无统计学差异2.前30组录像与后45 组录像的诊断准确率无统计学差异共聚焦内镜图片诊断Barrett 食管学习曲线较短操作过程Kerry B.Dunbar,Elizabeth A.Montgomery,Marcia I,Canto et al.The learning curve of in vivo Confocal Laser Endomicroscopy for prediction of Barretts Esophagus Abstract19 GERD with
8、out known BE 58 BE surveillance 41 Possible BE-associated neoplasiaWith prior hands on experience of 30 supervised cases 操作过程Kerry B.Dunbar,Elizabeth A.Montgomery,Marcia I,Canto et al.The learning curve of in vivo Confocal Laser Endomicroscopy for prediction of Barretts Esophagus Abstract一个无经验内镜医师大约
9、经过100例的共聚焦内镜操作学习过程就可以掌握共聚焦内镜对BE食管的实时诊断 食管上皮内瘤变及食管癌SMS 评分法Li M,Zuo XL,Yu T,et al.Surface maturation scoring for oesophageal squamous intraepithelial neoplasia:a novel diagnostic approach inspired by first endomicroscopic 3-dimensional reconstruction.Gut.2012 早期食管癌Study in our center 食管炎症Study in our
10、centerl由学前培训 约0.5h 共聚焦及食管病理知识表面成熟评分法5张良性，5张瘤变Learning curve and inter-observer agreement of confocal laser endomicroscopy for the detection of precancerous or early stage esophageal squamous cancers Study in our center 观察者诊断的准确性Study in our center 无经验组学习曲线评估Study in our centerStudy in our center胃（上皮
11、内瘤变及息肉）胃（上皮内瘤变及息肉）正常胃粘膜组织正常胃粘膜组织胃体胃体胃窦胃窦荧光造影剂：荧光素钠荧光造影剂：荧光素钠(5ml;10%)陷凹开口陷凹开口柱状上皮柱状上皮郭玉婷、李延青等，中华消化内镜杂志，2007Lim LG,Yeoh KG,Salto-Tellez M et al.Experienced versus inexperienced confocal endoscopists in the diagnosis of gastric adenocarcinoma and intestinal metaplasia on confocal images.Gastrointest E
12、ndosc 2011;73:1141-1147Lim LG,Yeoh KG,Salto-Tellez M et al.Experienced versus inexperienced confocal endoscopists in the diagnosis of gastric adenocarcinoma and intestinal metaplasia on confocal images.Gastrointest Endosc 2011;73:1141-1147Lim LG,Yeoh KG,Salto-Tellez M et al.Experienced versus inexpe
13、rienced confocal endoscopists in the diagnosis of gastric adenocarcinoma and intestinal metaplasia on confocal images.Gastrointest Endosc 2011;73:1141-1147Lim LG,Yeoh KG,Salto-Tellez M et al.Experienced versus inexperienced confocal endoscopists in the diagnosis of gastric adenocarcinoma and intesti
14、nal metaplasia on confocal images.Gastrointest Endosc 2011;73:1141-1147 胃（上皮内瘤变及腺癌）Pittayanon R,Rerknimitr R,Wisedopas N et al.The learning curve of gastric intestinal metaplasia interpretation on the images obtained by probe-based confocal laser endomicroscopy.Diagn Ther Endosc 2012;2012:278045 胃上皮
15、内瘤变及腺癌Pittayanon R,Rerknimitr R,Wisedopas N et al.The learning curve of gastric intestinal metaplasia interpretation on the images obtained by probe-based confocal laser endomicroscopy.Diagn Ther Endosc 2012;2012:2780451h 培训，5段GIM pcle录像,5段非GIM pcle录像20 videos20 videos20 videos20 videosPittayanon R,
16、Rerknimitr R,Wisedopas N et al.The learning curve of gastric intestinal metaplasia interpretation on the images obtained by probe-based confocal laser endomicroscopy.Diagn Ther Endosc 2012;2012:278045 胃上皮内瘤变及腺癌 共聚焦显微内镜下胃息肉诊断学习曲线研究u共聚焦显微内镜诊断胃息肉和腺瘤QILU标准l 增生性息肉 胃腺瘤l 增生上皮细胞围绕 异常的腺细胞较细长，荧光较暗，间质l细胞特点 隐窝排
17、列，细胞核的 荧光较亮（荧光素钠），异形腺上皮排列l 大小形态正常，不规则，呈嵴状或绒毛状，细胞核大小形态l 位于细胞基底部。不规则（吖啶黄）l l l 隐窝上皮显著增生 隐窝细胞呈现嵴状或绒毛或脑回状排列l隐窝结构 可见规则伸长扩张 形状不一致，在不同层面可见扩张、弯曲l 隐窝，间质荧光素 大小不一的腺体开口l 钠渗出及炎细胞浸润 Study in our center 增生性息肉（荧光素增生性息肉（荧光素钠）钠）增生性胃息肉（吖啶黄）增生性胃息肉（吖啶黄）Study in our center 胃腺瘤（荧光素钠）胃腺瘤（吖啶黄）Study in our center学前训练讲明研究目的及共
18、聚焦常识胃息肉齐鲁标准学习典型15处病变学习123Study in our centerl l 病变性质l 读取时间l l l 公布结果 公布结果 公布结果l 间隔1周 间隔1周 间隔1周第1阶段第2阶段第3阶段第4阶段8080个独立文件夹个独立文件夹（随机分为（随机分为4 4个部分，个部分，每个阶段包含每个阶段包含2020个个)学习过程Study in our center共聚焦显微内镜下初学者及有经验者各个学习阶段对胃息肉诊断的准确率Study in our centerIBD IBDNeumann H,Vieth M,Atreya R et al.Prospective evaluati
19、on of the learning curve of confocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872 IBDNeumann H,Vieth M,Atreya R et al.Prospective evaluation of the learning curve of confocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872 IBDNeumann H,Vie
20、th M,Atreya R et al.Prospective evaluation of the learning curve of confocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872He attended a workshop on CLE before the studyCellvizio14 UC12 CDNeumann H,Vieth M,Atreya R et al.Prospective evaluation of the learning curve of c
21、onfocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872Neumann H,Vieth M,Atreya R et al.Prospective evaluation of the learning curve of confocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872Neumann H,Vieth M,Atreya R et al.Prospective evalu
22、ation of the learning curve of confocal laser endomicroscopy in patients with IBD.Histol Histopathol 2011;26:867-872结肠上皮内瘤变结肠上皮内瘤变Kuiper T,Kiesslich R,Ponsioen C et al.The learning curve,accuracy,and interobserver agreement of endoscope-based confocal laser endomicroscopy for the differentiation of
23、colorectal lesions.Gastrointest Endosc 2012;75:1211-1217正常粘膜Kuiper T,Kiesslich R,Ponsioen C et al.The learning curve,accuracy,and interobserver agreement of endoscope-based confocal laser endomicroscopy for the differentiation of colorectal lesions.Gastrointest Endosc 2012;75:1211-1217增生性息肉Kuiper T,
24、Kiesslich R,Ponsioen C et al.The learning curve,accuracy,and interobserver agreement of endoscope-based confocal laser endomicroscopy for the differentiation of colorectal lesions.Gastrointest Endosc 2012;75:1211-1217管状腺瘤对Mains标准的详细讲解，以及10张共聚焦图片示例30张图片30张图片30张图片6 个月后将图片重新排列，进行相同的过程 结 果三位内镜医师对3组共聚焦图片
25、均具有较高的诊断准确率Buchner AM,Gomez V,Heckman MG et al.The learning curve of in vivo probe-based confocal laser endomicroscopy for prediction of colorectal neoplasia.Gastrointest Endosc 2011;73:556-560Comparing the learning curve of different studies of CLE in the GI tract.Gaddam et al.AmJ Gastroenterol2011
26、Pittayanon R et al.Diagn Ther Endosc 2012Kuiper et al.GastrointestEndosc 2012 Buchner et al.GastrointestEndosc 2011 Neumann et al.Histol Histopathol2011Type of confocallaserpCLEpCLEiCLEpCLEpCLETissueEsophagus(Barrett)Stomach(GIM)Colonic polypColonic polypColon(IBD)Number of reader353112Number of cen
27、ter11131Type of studyOffline studyOffline studyOffline studyOffline studyOffline studyTraining duration1 hr1 hrN/A2 hrN/AIntraobserveragreement()N/AN/AYes(0.680.84)N/AN/AInterobserveragreement()Yes(0.480.68)Yes(0.520.86)Yes(0.670.73)N/AN/AConclusionShort learningcurveEasy to learnEasy to learnEasy to learnEasy to learnpCLE:probe-based confocal laser endomicroscope,iCLE:integrated confocal laser endomicroscope,GIM:gastric intestinal metaplasia,IBD:inflammatory bowel disease,and N/A:no data.共聚焦内镜图片学习方法一定的病理知识大约10张典型图片的识别诊断标准把握本次培训班的目的和期望 It is about lighting fires not filling buckets.
