Tu1079 UN-TUTORED TRAINING PATHWAY TO ACHIEVE COMPETENCE IN ESOPHAGO-GASTRIC ENDOSCOPIC SUBMUCOSAL DISSECTION IN A WESTERN CENTRE

Abstract

Endoscopic submucosal dissection (ESD) is a complex endoscopic procedure, which requires high level of skills and has a long learning curve. Training typically involves performance of procedures under expert supervision, which limits widespread dissemination of the technique. There is little data on un-tutored training pathway. This study aimed to assess the efficacy of an ESD unsupervised training model for experienced endoscopists. Following a visit to a high-volume centre, an endoscopist experienced in upper GI endoscopic resections underwent unsupervised training on an ex-vivo pig model until acquisition of adequate technical skills. The endoscopist advanced then to in-vivo human cases of upper GI ESD in the distal stomach, followed by progression to proximal gastric and esophageal cases. Indications for ESD were: i. gastric neoplastic lesion larger than 10mm or ii. Early esophageal or junctional adenocarcinoma with sessile morphology or suspicion of submucosal invasion; iii. Residual or recurrent esophageal neoplasia post EMR, unsuitable for repeat EMR; iv. Esophageal squamous cell carcinoma larger than 10mm; glandular neoplastic lesions. All human cases were performed in a surgical theatre under general anaesthesia . Performance measures were en-bloc resection, R0 resection and complication rates, as well as operative time (min/cm2). During a two-week visiting fellowship to the Tokyo National Cancer Centre 30 upper GI ESDs were observed. The endoscopists performed 15 unsupervised ESD procedures in the ex-vivo model, until 100% en-bloc resection and 0% perforation rates were achieved in the last 10 procedures. Five human cases of distal gastric ESDs were performed followed by 21 unselected esophago-gastric neoplastic lesions, which were referred for endoscopic treatment. Histopathological analysis showed invasive neoplasia in 80.7%, with submucosal involvement in 46.1% of cases. En-bloc and R0 resection were achieved in 91.6% and 78.3% of cases, respectively. Adverse events were recorded in 7.7%, including 1 perforation leading to surgery and 1 delayed bleeding. An additional case was converted to surgery as deemed to be technically unsafe. The operative time was 13.8 min/cm2 in stomach and 33.8 min/cm2 in the esophagus, with no definite evidence of learning curve when comparing the first and the second blocks of gastric and esophageal ESDs (p=0.24 and p=0.32, respectively). Un-tutored training for upper GI ESD is feasible and can allow endoscopists, who are experienced in therapeutic endoscopy, to achieve the required standards towards competency.