Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve

Yamamoto, Shunsuke; Uedo, Noriya; Ishihara, Ryu; Kajimoto, Noriko; Ogiyama, Hideharu; Fukushima, Yasumasa; Yamamoto, Sachiko; Takeuchi, Yoji; Higashino, Koji; Iishi, Hiroyasu; Tatsuta, Masaharu

doi:10.1055/s-0029-1215129

Cited by 158 publications

(135 citation statements)

References 14 publications

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“…Japanese endoscopists receive board certification from the Japan Gastroenterological Endoscopy Society (JGES) after 5 years of training in a JGES-approved educational institution of endoscopy, and must also pass an examination administered by JGES. In the present study, the doctors who were defined as experienced endoscopists had board certification from the JGES and had each performed more than 30 ESD procedures for early gastric cancers [5,19,20] .…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study

Watari

Tomita²,

Toyoshima³

et al. 2013

WJGE

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AIM:To evaluate clinical outcomes and risk factors for endoscopic perforation during endoscopic submucosal dissection (ESD) in a prospective study. METHODS:We investigated the clinical outcomes and risk factors for the development of perforation in 98 consecutive gastric neoplasms undergoing ESD regarding. Demographic and clinical parameters including patient-, tumor-, and treatment-related factors, clinical parameters, and duration of hospital stay were analyzed for risk factors for perforation. In subgroup analysis, we also compared the clinical outcomes between perforation and "silent" free air without endoscopically visible perforation detected only by computed tomography. RESULTS:Perforation was identified in 8.2% of patients. All patients were managed conservatively by the administration of antibiotics. The mean procedure time was significantly longer in patients with endoscopic perforation than in those without. According to the receiver-operating characteristic analysis, the resulting cutoff value of the procedure time for perforation was 115 min (87.5% sensitivity, 56.7% specificity). Prolonged procedure time (≥ 115 min) was associated with an increased risk of perforation (odds ratio 9.15; 95%CI: 1.08-77.54; P = 0.04). Following ESD, body temperature and C-reactive protein level were significantly higher in patients with perforation than in those without (P = 0.02), whereas there was no difference between these patient groups on the starting day of oral intake or of hospitalization. In subgroup analysis, the post-ESD clinical course was not different between endoscopic perforation and silent free air. CONCLUSION:Only prolonged procedure time (≥ 115 min) was significantly associated with perforation. The clinical outcomes of perforation are favorable and are comparable to those of patients with or without silent free air. Key words: Gastric cancer; Endoscopic submucosal dissection; Perforation; Risk factors; Treatment outcome Core tip: There has been little prospective study on the clinical outcomes of endoscopic perforation in endoscopic submucosal dissection for gastric neoplasia. In the current study, we investigated clinical outcomes of perforation during gastric endoscopic submucosal dissection, and analyzed various demographic and clinical parameters for risk factors. The results clearly demonstrated that prolonged procedure time (≥ 115 min),

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Section: Discussionmentioning

confidence: 99%

Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study

Watari

Tomita²,

Toyoshima³

et al. 2013

WJGE

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“…From their data, which included 383 ESD procedures for gastric epithelial neoplasms performed over a 5-year period, Kakushima et al [11] estimated that a trainee could begin to treat lesions in the lower part of the stomach independently after performing about 30 supervised ESD procedures. In a more recent study, two of the three operators could not achieve a sufficient selfcompletion rate for submucosal dissection after 30 cases, which suggests that more extensive experience is required before the trainees can be considered proficient [35] . However, in this study, the trainees performed the ESD under the supervision of an experienced endoscopist and their training did not include hands-on training on exvivo animal models or living animals, which might have improved the learning curve.…”

Section: Learning Curve For Gastric Esdmentioning

confidence: 97%

“…As expected, most well-implemented training programs/algorithms are in Japan. These algorithms typically include two major stages of training: pre-procedural, theoretic preparation and hands-on training [32,[35][36][37][38] . The first stage has two phases: phase 1-accumulation of basic knowledge and phase 2-observe experts in action.…”

Section: Esd Training Systemsmentioning

confidence: 99%

“…One of the earliest proposed training algorithms by Yamamoto et al [35] in 2009 puts emphasis on the initial pre-procedural phase of the training. Thus, the endoscopists who intend to learn ESD must attend pre-and post-treatment conferences, and take part in actual ESD procedures as an assistant for at least 1 year before beginning doing the procedure themselves.…”

Section: Esd Training Systemsmentioning

confidence: 99%

“…By assisting experienced endoscopists, trainees acquire the skills needed to troubleshoot various situations. Moreover, obtaining expertise in hemostasis before starting ESD is highly recommended since most of the difficulties surrounding the procedure were related to uncontrollable hemorrhage [35] . The same group expanded the requirements of the pre-procedural training to master detailed preoperative examination by magnifying endoscopy with narrowband imaging, preoperative marking using ink and endo-clips, hemostasis of second-look endoscopy after ESD [36] .…”

Section: Esd Training Systemsmentioning

confidence: 99%

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Training in endoscopic submucosal dissection

Coman

Gotoda²,

Draganov³

2013

WJGE

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Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient' s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee's background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide. Key words: Endoscopic submucosal dissection; Training; Learning curve; Early gastrointestinal cancer; Endoscopic mucosal resection Core tip: Endoscopic submucosal dissection (ESD) is a complex procedure associated with high complication rate. In Japan, training in ESD follows the traditional mentor/apprentice approach but significant variability in training approaches exists. We review the learning curves for ESD and describe the training algorithm proposed in Japan aiming to standardize training, and its applicability in the West. We highlight the challenges for ESD dissemination in the West, describing both the consensus and the diverging opinions between Asian and Western training models. Finally, we emphasize the need for structured training system to enhance trainee experience and, most importantly, to reduce the risks of complications and inadequate treatment.Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013; 5(8): 369-378 Available from:

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Management of gastrointestinal subepithelial tumors with endoscopic resection

Chou

Liao

Chen

et al. 2020

Adv in Digestive Medicine

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The diagnosis and management of gastrointestinal subepithelial tumors (GI SETs) have been under debate because of the low biopsy yield rate and risk of surgery. Owing to the advancement in endoscopic submucosal dissection (ESD) and submucosal tunneling endoscopic resection (STER), GI SETs may be resected under acceptable risk, and the nature of GI SETs can be studied. However, the efficacy of endoscopic resection in the diagnosis and management of GI SETs remains unclear. We present our single-hospital experience of resecting GI SETs with ESD and STER to explore the efficacy of this technique and the nature of GI SETs. Thirty-nine patients with GI SETs who underwent ESD and STER were analyzed retrospectively. Patients' clinical data, procedure parameters, pathologic diagnosis, and outcomes were collected and analyzed. Thirty-nine GI SETs were resected, 36 by ESD, and 3 by STER. Thirty-eight (97.4%) tumors were from the submucosal layer and one from the muscular layer. Fifteen, 13, and 11 tumors were located in the esophagus, stomach, and colon, respectively. The mean tumor size was 16.8 ± 1.3 mm. In the esophagus, leiomyomas were the most common diagnosis, followed by the lymphoepithelial cyst, epithelial hyperplasia, focal lymphoid hyperplasia, and dilated submucosal gland. The esophageal tumor from the muscularis propria was GI stromal tumor (GIST). In the stomach, 53.8% of the submucosal tumors were ectopic pancreas, followed by lipoma, calcifying fibrous tumor, GIST, submucosal inflammation, and angiodysplasia with focal ulcers. The submucosal tumors in the colon were diagnosed as neuroendocrine tumors (NETs, n = 5), lipomas (n = 4), leiomyoma (n = 1), and foreign body-related granuloma (n = 1). Seven (17.9%) of all tumors were NETs and GISTs with malignant potential. All cases were resected completely. The overall procedural time was 37.9 ± 4.6 minutes. Severe fibrosis was more likely encountered in the stomach with a rate of 46.1%, with the gastric ectopic pancreas having a 71.4% severe fibrosis rate. Only 13 patients completed follow-up endoscopic ultrasound or endoscopy within 1 year after ESD and STER, and no recurrence was noted. There were no major complications, and none of the patients required admission to the intensive care unit or surgery. Three perforations were encountered during STER, which were smoothly

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Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve

Cited by 158 publications

References 14 publications

Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study

Clinical outcomes and risk factors for perforation in gastric endoscopic submucosal dissection: A prospective pilot study

Training in endoscopic submucosal dissection

Management of gastrointestinal subepithelial tumors with endoscopic resection

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