Resection speed of endoscopic submucosal dissection according to the location of gastric neoplasia: a learning curve using cumulative sum analysis.

Abstract

There is few study evaluating the relationship between endoscopic submucosal dissection (ESD) resection speed and the lesion characteristics of gastric neoplasia. We investigated the learning curve of consecutive ESDs using cumulative sum (CUSUM) analysis. A total of 356 ESDs performed by a single endoscopist were grouped chronologically into three learning periods. The ESD procedure was defined to be fast when resection speed was > 9.0cm2/hour. The CUSUM method was used to assess the number of ESDs required for achieving proficiency and mastery. Mean resection speed was significantly faster in Phase III (15.1 cm2/hour) compared to those in Phase I (9.3 cm2/hour) and II (11.4 cm2/hour) (p < 0.001). Tumors in the stomach's upper and middle third location were significantly associated with difficulty in attaining the fast resection speed (odds ratios, 0.05 and 0.36) compared to the lower third location. The number of ESDs required to achieve a competency for fast resection was 15 for tumors in the lower third of the stomach and 98 for those in the upper/middle third location, respectively. In the lower third location of the tumor, the CUSUM curve revealed that 75 cases were needed to achieve proficiency and 174 cases to achieve mastery. However, mastery was not achieved in ESD for the upper/middle third tumor during the study period. The time required to achieve relevant competency in gastric ESD depends on the tumor location.