Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves

Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: A systematic review

“…Moreover, lesions that would be very difficult to resect by conventional EMR from the technical viewpoint are also considered as an indication for ESD, including the lesions showing poor-or non-lifting after submucosal injection, local recurrent lesions following previous treatment, and relatively large protruded type lesions (Saito et al, 2010a;Toyonaga et al, 2010;Tajika et al, 2011;Lee et al, 2012;Kobayashi et al, 2012;Terasaki et al, 2012;Kim et al, 2013;Oka et al, 2015;Fujishiro et al, 2007;Saito et al, 2013;Matsuda et al, 2010;Yamamoto et al, 2002;Saito et al, 2001Saito et al, , 2007Tanaka et al, 2007;Tamegai et al, 2007;Hurlstone et al, 2007;Isomoto et al, 2009;Niimi et al, 2010;Saito et al, 2010b;Takeuchi et al, 2010;Uraoka et al, 2011;Probst et al, 2012;Iacopini et al, 2012;Lee et al, 2013;Xu et al, 2013;Repici et al, 2013;Rahmi et al, 2014;Białek et al, 2014;Agapov and Dvoinikova, 2014;Spychalski and Dziki, 2015).…”

Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

“…This is multifactorial with anatomical and vascular differences between the two sites. The rectum is the first place to start training endoscopists in ESD because it is easily accessible compared to other parts of the colon [30] . Furthermore, rectal insufflation creates a neat and stable workspace to perform ESD compared to a mobile, narrow colon with folds or flexures to consider.…”

Endoscopic submucosal dissection

“…98,99 Similarly, experts suggest that rectal ESD is anatomically favorable compared with colonic ESD and that smaller rectal lesions may be a reasonable early target for Western endoscopists. 100 Indeed, in some series of colorectal ESD performed by novice/trainee endoscopists, all perforations occurred in colonic (nonrectal) cases. 101,102 Learning curves There is no single "learning curve" for ESD, but rather multiple learning curves that vary based on lesion characteristics (eg, anatomic site, size) and outcome of interest (eg, total procedure time, R0 resection rate, adverse event rate).…”

“…103 With these caveats stated, many studies reflect a breakpoint that occurs between 20 and 50 human procedures, during which significant improvements across multiple outcomes can be demonstrated, irrespective of anatomic site. 100,[104][105][106][107][108] In centers with ESD expertise, this level of experience may also correspond to graduating to performing unsupervised ESD. However, most ESD training studies incorporate fewer than 50 procedures per endoscopist, and outcomes at the conclusion of these studies for the most critical endpoints (ie, R0 resection) still fall short of results achieved by providers at expert Japanese centers, indicating that further improvement in operator skill occurs far out on the learning curve.…”