Training in endoscopic submucosal dissection

Abstract

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:

Training in endoscopic mucosal resection and endoscopic submucosal dissection: Face, content and expert validity of the live porcine model

“…The same properties make it possible to deal with adverse events, such as bleeding and perforation. 11,15,25,27 When teaching ESD, the process of submucosal dissection has been considered the most challenging one and its difficulty is related mainly to controlling haemorrhage. 28 We found that ratings addressing the porcine model on complication detection and management, namely controlling haemorrhage, were very high, emphasising the value of the model in training all the steps involved in ESD.…”

“…16,27,29 Nonetheless, issues pertaining ethics, dedicated facilities, equipment, veterinarian support, availability of general anaesthesia and preparation of the animal, including intensive bowel cleansing (in the case of colorectal ESD), euthanasia or follow-up care (when performing survival studies), as well as financial considerations may limit its use. 11,15,25,27,30 Animal models have been incorporated in ESD training programmes by different groups. Although previous papers have focused on feasibility of ESD, validation of the model itself has not been formally demonstrated.…”

“…2,[11][12][13] Currently, existing training programmes have consistently included: acquiring basic knowledge, practicing on animal models (ex vivo animal organs and live porcine models), visiting centres with a high ESD volume, attendance of hands-on training ESD workshops and only then proceeding to clinical practice, ideally under supervision by an expert when available during the first cases. 2,[11][12][13] Workshops using animal models are being organised in many specialised training centres with the potential to aid in speeding up the learning process and achieving initial competence in ESD in a safe learning environment with direct one-on-one expert supervision. [14][15][16] It seems logical to practise skills in advanced endoscopic resections in a live porcine model, which is considered to have the closest resemblance to the human anatomy.…”

Hospital Authority audit of the outcome of endoscopic resection of superficial upper gastro-intestinal lesions in Hong Kong

“…The introduction of endoscopic resection techniques in Hong Kong is in its infancy with many challenges similar to those described in western literature. [20][21][22] The emphasis in our region, however, was not just on the technical performance of ESD but also the ability to detect and diagnose these lesions. In 2011, a total of 1101 new cases of gastric cancer were diagnosed in Hong Kong but the percentage of cases that were amenable to endoscopic resection is unknown.…”

Implementation of Endoscopic Submucosal Dissection for Gastric Lesions in Norway

“…Moreover, he participated in several ESD training courses on anesthetized pigs at The Intervention Center, Rikshospitalet, Oslo, Norway, in addition to attending theoretical courses and live demonstrations at congresses. Structured training programs for ESD have been proposed both in Japan (27) and in Western countries (28). After obtaining extensive basic endoscopic skills, key elements in such programs are attending courses, congresses, and live demonstrations; watching and assisting experts at work; training on isolated pig stomachs and live pigs; and finally, performing easy human cases under supervision.…”