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

doi:10.1016/j.gie.2012.08.024

Gastrointestinal Endoscopy

Volume 76, Issue 6, December 2012, Pages 1188-1196

https://doi.org/10.1016/j.gie.2012.08.024 Get rights and content

Background

Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed.

Objective

To evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol.

Design

Prospective study in the Western setting.

Setting

This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD.

Patients

Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis.

Intervention

Training consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved.

Main Outcome Measurements

Competence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures.

Results

From February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .031); perforations occurred in 2 patients.

Limitations

Single-center design.

Conclusions

A minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon.

Section snippets

Study population

Patients with superficial neoplastic colorectal lesions referred to a nonacademic hospital were prospectively included to undergo an attempt of resection by ESD. Inclusion criteria were (1) lesions 20 mm or larger classified as sessile polyps, granular and nongranular LSTs, with or without a depressed area, in which en bloc EMR is difficult and ESD is recommended⁵; and (2) absent or superficial sm invasion estimated by white-light endoscopy and chromoscopy with 0.4% indigo carmine according to

Results

The operative training started in March 2009, and removal of 30 rectal and 30 colonic superficial lesions was attempted by ESD in an equal number of patients up to February 2012. Among lesions evaluated for inclusion in the study, 6 were referred to surgery because of endoscopic features of deep invasion and a positive no-lifting sign.

The patients' median age was 68 years (range 50-85 years), there were 19 (32%) female patients, antiplatelets and/or anticoagulants were withdrawn in 7 patients,

Discussion

The learning curve from the novice level to competent, proficient, and expert levels should be as steep as possible and supported by training protocols. Japanese expert opinion is that competence in ESD should be achieved in the distal stomach before moving to more difficult lesions and locations, with the colon as the final stage of this stepwise training.15, 16 The setting in Western countries is very unfavorable: early gastric cancer is less prevalent, and it is very difficult to accumulate

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Endoscopic submucosal dissection (ESD) has a long learning curve. The aim of this study was to assess the efficacy of an ESD unsupervised training model for experienced endoscopists.
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After observation of 30 esophagogastric ESDs and 15 untutored ex vivo ESDs, 5 human cases of distal gastric ESDs were performed, followed by 55 unselected esophagogastric cases. En bloc and R0 resection rates were 93.0% and 80.7%, respectively. Operating time was 14.0 min/cm² in the stomach and 25.1 min/cm² in the esophagus, with evidence of a learning curve for esophageal ESDs (first block 30.26 min/cm² vs second block 14.81 min/cm², P = .01).
Untutored training for esophagogastric ESD is feasible and allows endoscopists, experienced in therapeutic endoscopy, to achieve the required standards toward competency.
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Colorectal endoscopic submucosal dissection (ESD) is widely used in several countries. However, it is associated with technical difficulties. Rectal ESD is considered an intermediate step in colorectal ESD training. Nevertheless, some rectal lesions require a longer procedure time than usual, and the reason for the prolonged time taken for these specific lesions remains unclear. Therefore, this study aimed to clarify the factors associated with prolonged rectal ESD.
In total, 483 rectal lesions resected using ESD from February 1998 to June 2021 were investigated. Prolonged ESD procedure time was defined as the time from the first submucosal injection to lesion removal exceeding 120 minutes, whereas other procedures were defined as average ESD procedure time. Clinicopathologic and endoscopic findings were compared between the 2 groups using univariate and multivariate analyses.
One hundred forty-four lesions were resected using a prolonged ESD procedure time of 202.9 ± 92.3 minutes, whereas 339 lesions were resected using an average ESD procedure time of 77.8 ± 29.4 minutes. Multivariate analysis revealed that tumors involving the dentate line (P = .026), resection size ≥50 mm (P < .001), invasion depth ≥T1b (P = .006), and circumferential range ≥2/3 (P = .001) were independent risk factors for prolonged-duration ESDs, regardless of whether the procedure was performed by an expert or not.
The results of the present study suggest that the location of a lesion involving the dentate line, resection size ≥50 mm, circumferential range ≥2/3, and invasion depth ≥T1b are the independent risk factors for prolonged ESD procedure time.
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Surgeons with different working experiences or exposure to different training programs at Sir Run Run Shaw Hospital were divided into four groups. Each was required to perform laparoscopic pancreaticojejunostomy using a designed three-dimensional dry lab model. All surgeons' baseline characteristics and surgical performance, including operation time and score, were recorded and analysed. The authenticity of the model was evaluated by four senior surgeons.
The surgeon group with higher seniority had an older average age, longer working time, and had completed more laparoscopic cholecystectomy and laparoscopic common bile duct exploration procedures. Meanwhile, the surgeon group with higher seniority presented better operation performance, including shorter operation time and higher operation score in their initial simulation training. Resident surgeons who underwent stepwise training with the laparoscopic biliary-enteric anastomosis training program showed better initial performance than resident surgeons who underwent stepwise training with the laparoscopic basic suture training program. After repeated training, the surgeons showed improved surgical performance.
Our pancreaticojejunostomy model showed a good degree of discernibility, as surgeons with more experience performed better with the model for their initial simulation training in laparoscopic pancreaticojejunostomy. Stepwise training of the laparoscopic biliary-enteric anastomosis training program helped surgeons obtain a better initial performance, and repeated simulation training on this model improved the surgeon's operative performance.
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Citation Excerpt :
Training programs may need to modify their program structure and/or duration to meet the specific needs and expectations of the trainee21 to incorporate ESD training. The reported number of cases required to achieve proficiency in ESD is also highly variable (ranging from 20 to 250 cases depending on the anatomic locations, definitions of proficiency, experience of trainees, and presence of proctors22-23), with most reports based on the personal learning curves of experienced endoscopists rather than training data. The core technical, nontechnical, and cognitive skills for training in ESD are listed in Table 1 and further discussed below.
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: DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Iacopini at [email protected].

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Original articleClinical endoscopyStepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Study population

Results

Discussion

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002

Gastrointest Endosc

Local recurrence after endoscopic resection of colorectal tumors

Int J Colorectal Dis

Endoscopic resection of gastrointestinal lesions: advancement in the application of endoscopic submucosal dissection

J Gastroenterol Hepatol

The concurrence of histologically positive resection margins and sessile morphology is an important risk factor for lymph node metastasis after complete endoscopic removal of malignant colorectal polyps

Int J Colorectal Dis

Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection

Surg Endosc

Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm

J Gastroenterol Hepatol

Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors

Eur J Gastroenterol Hepatol

Therapeutic strategy for colorectal laterally spreading tumor

Dig Endosc

Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum

Gut

Endoscopic submucosal dissection for laterally spreading tumours of the colorectum in 200 consecutive cases

Surg Endosc

Detection of early gastric cancer: misunderstanding the role of mass screening

Gastric Cancer

Endoscopic submucosal dissection for colorectal tumors: technical difficulties and rate of perforation

Endoscopy

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

Endoscopy

How to justify endoscopic submucosal dissection in the Western world

Endoscopy

Original article
Clinical endoscopy
Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves