Training model for teaching endoscopic submucosal dissection of gastric tumors

Abstract

Introduction: the elevated risk of complications and technical complexity of endoscopic submucosal dissection (ESD) has limited its implementation in our medical system.Objective: to design and evaluate a training program for learning the ESD technique.Methods: four endoscopists with no experience with ESD underwent a 4-step training program: 1) review of the existing literature, didactic material, and theoretical aspects of ESD; 2) ESD training in an ex-vivo animal model; 3) ESD training in an in-vivo animal model (supervised by ESD expert); and 4) ESD performance in a patient. A standard gastroscope and an ESD knife (IT, Flex or Hook-knife Olympus ® ) were employed. The classical ESD technique was performed: rising of the lesion, circumferential incision, and submucosal dissection.Results: ex-vivo animal model: 6 x swine stomach/esophagus -cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) and fundus/cardia (n = 1)-; size of resected specimen: 4-10 cm; ESD duration: 105-240 minutes; therapeutic success: 100%; complications: perforation (1/6: 16%) sealed with clips. In-vivo animal model: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size: 2-5 cm; duration: 40-165 minutes; success: 100%; complications: 0%. Patient: ESD of a gastric lesion located in the antrum/body; size: 3 cm; duration 210 minutes; a complete resection was achieved; no complications.Conclusions: the results of the present study support the usefulness of this model for learning ESD in our system. Key words: Endoscopic submucosal dissection. ESD. Submucosal resection. Large endoscopic resection. INTRODUCTIONEndoscopic mucosal resection (EMR) consists of resecting a superficial tumor of the gastrointestinal tract (esophagus, stomach, colon or rectum) by endoscopic means with curative intention (R0 resection) (1-5). An EMR-resected lesion may be submitted for pathological examination. One of the advantages of EMR compared with surgical resection is its lower morbidity/mortality and cost. At present EMR has become widely available in clinical practice in both Asian and Western countries (1-5). However, EMR presents a number of limitations: a) technical difficulty; b) risk for complications: bleeding (2-29%), perforation (0.36%) and stenosis (mainly in the esophagus); and c) restricted to superficial lesions with no lymphatic spread and size < 1-1.5 cm (1-8). Lesions with a diameter > 1.5 cm cannot be completely resected with a single EMR procedure, and repeated mucosectomies (several fragments) or endoscopic submucosal dissection (ESD) (allowing to resect the entire lesion in a single piece) will be required (2). It is generally assumed that it is better to resect tumoral lesions in single pieces, as we can be sure the tumor has been completely resected, and it also facilitates sample orientation at the time of the pathology study (8)(9)(10)(11)(12)(13)(14)(15). Furthermore, ESD allows to perfom wider and deeper resections versus EMR (2). However, the learning curve for ESD (high technical difficulty) is longer (compared with EMR), and compli...

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

“…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.…”

Therapeutic and Diagnostic Approaches in Colonoscopy

“…Generally, the clinical practice training proceeds according to the difficulty of the procedure, beginning with gastric ESD, then rectal ESD, and finally colonic ESD [93]. Regarding animal training in ESD, there are many reports on ex vivo animal models for gastric ESD [91,94,95]. There are also several reports on an ex vivo animal model for colorectal ESD [92,93].…”

Innovations in surgery simulation: a review of past, current and future techniques

“…Because of the numerous benefits to working with live animals, in vivo porcine and canine models have been used extensively in endoscopic, laparoscopic and other forms of training, including endoscopic submucosal dissection, cholecystectomy and coronary bypass (17,22). Many studies have been conducted on the efficacy of these forms of training, and most have validated their use in improving technical skills and selfconfidence (22)(23)(24). Ex vivo animal tissue is also sometimes used in surgical training, but offers lower-fidelity simulation than live animals.…”