Difficulties and outcomes in starting endoscopic submucosal dissection

Abstract

Endoscopic submucosal dissection (ESD) is a technically demanding procedure associated with a higher risk of complications. This study aimed to assess the difficulties and outcomes experienced by endoscopists beginning to perform ESD. This prospective study investigated course participants in an ESD training workshop. The participants were asked at the end of the workshop about the ease of using various ESD knives, the occurrence of complications and their management, the procedural time, and the outcomes for the swine used for the procedure. For this study, 24 endoscopists were trained in performing gastric and esophageal ESD techniques using a porcine model. The mean size of the specimen retrieved was 2.66 +/- 1.18 cm. The mean procedural times were 52.09 +/- 24.67 min for gastric ESD and 32.50 +/- 8.45 min for esophageal ESD. During gastric ESD, 15 participants (65.22%) encountered perforations, whereas bleeding occurred during 13 ESDs (56.52%). There were two procedure-related mortalities. Significantly, a higher proportion of perforations were encountered with the use of noninsulated knives. The perforated and nonperforated groups did not show a difference in prior endoscopic experience (P = 0.335). The majority of the participants agreed that the swine model is appropriate for simulating both human gastric (96%) and esophageal (96%) ESD. The ESD procedure is technically challenging and associated with a high rate of complications for beginners. The use of noninsulated knives may increase the risk of perforations during the learning curve for gastric ESD, and future prospective trials must evaluate their use. The development of training models may augment the acquisition of skills in low-volume centers but will not replace a standardized patient-based training program.