Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early united states experience

Abstract

Adoption of endoscopic submucosal dissection (ESD) in the USA is challenging due to limited training opportunities. We describe the development of an ESD fellowship program in the USA and evaluate outcomes of ESD performed during this experience. A 1-year ESD fellowship was implemented under close supervision from a recognized ESD expert. The curriculum was tailored to the trainee based on their background and prior endoscopic training. Under the expert's discretion, the trainee started by assisting cases and was gradually allowed to begin performing portions of ESD, with increasing difficulty as determined by technical progress, until complete procedures could be performed. Technical characteristics, outcomes, and adverse events were recorded. A total of 72 consecutive ESD cases were performed during the training period, in which the trainee assisted/observed 19 cases, partially performed 18 cases, and mainly performed 26 cases. Mean lesion diameter was 44.5mm, with 79.2% colorectal cases. The trainee more frequently performed procedures with lower degree of fibrosis (p = 0.016). En bloc, complete, and curative resection was achieved in 84.7, 81.2, and 76.8% of cases, with no significant differences in resection outcomes or adverse events from trainee involvement. ESD can be safely and effectively taught within a 1-year advanced endoscopy fellowship. This was possible in the USA, even with limited gastric lesions, due to a progression focusing on easier portions of complex ESD procedures and advancing as technical progress allowed. Importantly, there was no increase in adverse event rate with trainee involvement in complex ESD cases.