Endoscopic Submucosal Dissection Training Research Articles

Gastric endoscopic submucosal dissection in Western countries: Indications, applications, efficacy and training perspective.

Endoscopic submucosal dissection was introduced in Japan for the mini-invasive treatment of early gastric cancer, as part of national screening program considering high prevalence of disease in these latitudes. This technique allows en-bloc curative oncological excision and to obtain in a single step R0-resection, characterization, histological staging and potential cure of the tumor with a very high cost-benefit balance. Over the years, Western endoscopists have adopted endoscopic submucosal dissection, achieving good rates of efficacy, long-term improved outcomes and safety, with low risk of local recurrence comparable to those obtained in Asian institutes. However, according to some authors, the excellent outcomes from East country could not be representative of the Western experience. Despite epidemiological differences of early gastric cancer, scant volume data and limitations in training opportunities between Western and Eastern countries, European Society of Gastrointestinal Endoscopy have adopted Japanese guidelines and developed a European core curriculum for endoscopic submucosal dissection training. Endoscopists should be able to estimate the probability of performing a curative resection by considering the benefit/risk relationship case-by-case in order to implement a correct decision-making process.

Training program using a traction device improves trainees' learning curve of colorectal endoscopic submucosal dissection.

Colorectal endoscopic submucosal dissection (ESD) requires advanced endoscopic skill. For safer and more reliable ESD implementation, various traction devices have been developed in recent years. The purpose of this research was to evaluate whether an ESD training program using a traction device (TD) would contribute to the improvement of trainees' skill acquisition. The differences in treatment outcomes and learning curves by the training program were compared before and after the introduction of TD (control group: January 2014 to March 2016; TD group: April 2016 to June 2018). A total of 316 patients were included in the analysis (TD group: 202 cases; control group: 114 cases). The number of cases required to achieve proficiency in ESD techniques was 10 in the TD group and 21 in the control group. Compared to the control group, the TD group had a significant advantage in ESD self-completion rate (73.8% vs. 58.8%), dissection speed (19.5 mm2/min vs. 15.9 mm2/min), en bloc resection rate (100% vs. 90%), and R0 resection rate (96% vs. 83%). The rate of colorectal ESD self-completion by trainees improved immediately after the start of the training program using a traction device compared to the conventional method, and the dissection speed tended to increase linearly with ESD experience. We believe that ESD training using a traction device will help ESD techniques to be performed safely and reliably among trainees.

Asurvey of physician training and credentialing in endoscopic submucosal dissection in the United States.

Endoscopic submucosal dissection (ESD) is technically challenging, has a longer learning curve and a greater complication rate than most new endoscopic procedures. Formal training and credentialing guidelines for ESD are currently lacking in the United States (US). To survey ESD experts across the US to determine their learning process and obtain their opinion on how training and credentialing for ESD should develop. Anonymous electronic survey. ASGE members who are practicing US endoscopists. The survey was developed by iterative revisions of questions administered to three investigators who have been performing ESD for > 5years. The final survey was distributed electronically to US endoscopists who had previously attended ESD expert conferences. Thirty-five (58.3%) of 60 practicing ESD experts responded to the survey. A majority (91%) were in university-based, community, or tertiary care hospitals. All practitioners practiced on porcine explants and observed live ESD procedures as part of the training. Out of the participants, 75.8% received formal supervised hands-on training on porcine explants and/or humans before performing ESD independently. Fifty percent indicated that their facility had written guidelines specifically for ESD credentialing. Four out of 5 felt that credentialing requirements should include attending weekend ESD courses, observing live procedures, practicing on explants, and advanced endoscopic training in interventional endoscopy such as an additional year of fellowship. Survey completion rate of 58.3%. ESD training should include practicing on explants, observation of live procedures, training in interventional endoscopy, and attending educational courses. Credentialing guidelines for ESD based on expert opinion need to be developed in the US.

Is Ex Vivo Training before In Vivo Training Effective in Learning Gastric Endoscopic Submucosal Dissection?

Background/Aims: The learning curve is essential in endoscopic submucosal dissection (ESD) training to improve outcomes and reduce the risk of procedure-related complications. We compared the outcomes of gastric ESD in live pigs performed by inexperienced endoscopists with or without ex vivo training.Materials and Methods: At the Olympus Medical Training and Education Center, nine endoscopists inexperienced in ESD were randomly divided into two groups (group A: ex vivo training followed by in vivo training; group B: in vivo training only), and they performed gastric ESDs.Results: A total of 18 ESDs were performed. The en bloc resection rate was 88.9% (16/18), and the complete resection rate was 94.4% (17/18). The median specimen size was 2.5 cm in group A and 2.1 cm in group B (P=0.227). There was no significant difference in the procedure time between the two groups, except for the marking time (0′58″ vs. 2′58″, P=0.027). However, group A took a shorter time in dissecting the same area than group B (109 vs. 246 sec/cm2, P=0.083). Complication rates were not significantly different between both groups.Conclusions: The procedure time during in vivo ESD training in pigs may be shortened by prior ex vivo training. However, the ex vivo model presented poor air inflation, unstable fixation, and excessive mucosal hardness for cutting. An advanced simulator or sufficient ex vivo training may be effective in training for the ESD procedure.

Endoscopic submucosal dissection (ESD): how do Western endoscopists value animal models?

Introduction Endoscopic Submucosal Dissection (ESD)was introduced in the West later than in the East. Our aim was to assess how Western endoscopists performing ESD have been trained and how they value animal models for training. Material and methods An online survey regarding training in ESD was sent to Western endoscopists who published articles on advanced resection techniques. Results From 279 endoscopists, 58 (21%) completed the questionnaire, of which 50 confirmed performance of clinical ESD. Endoscopists had a median of 15 years of endoscopic experience (IQR 9.75–20.25) and all of them were performing conventional EMR, before starting ESD. Prior to clinical ESD, 74% (n = 37) underwent training with ex vivo models, 84% (n = 42) with live animal models and 92% (n = 46) with at least, one of the two models. After starting clinical ESD, as trainers, 52% (n = 26) were involved with ex vivo and 60% (n = 30) with live animal models. Personal usefulness of ex vivo and live animal models was rated with a median of 9 (IQR 8–10) and 10 (IQR 8–10), out of 10, respectively. Courses with ex vivo and live animal models were considered a prerequisite before clinical practice by 84% (n = 42) and 78% (n = 39), respectively. Conclusions Western endoscopists have extensive endoscopic experience before starting ESD. The majority had pre-clinical training with ex vivo and live animal models and more than half are acting as trainers of other endoscopists with these models. Animal models are considered very useful and deemed a prerequisite before clinical practice by the majority of the endoscopists.

Endoscopic submucosal dissection for colorectal lesions: outcomes from a United States experience.

Endoscopic submucosal dissection (ESD) is commonly used in Asia for resection of large non-pedunculated colorectal polyps (LNPCPs) and early (T1) colorectal cancers. It allows for en bloc removal and is often curative. We describe outcomes of colorectal ESD from a United States (US) academic medical center and compare this to international experiences. Retrospective review was performed of colonic lesions referred to the University of Chicago Medical Center for ESD from 2012 to 2020. Clinical and procedural data were collected. The study included 78 lesions with mean size of 29.7mm (range 10-100mm). The overall en bloc resection rate was 73.1% (n = 57). Between the first and second half of the study, it improved from 61.5 to 84.6% (p = 0.02). Histology showed adenocarcinoma in fifteen lesions (19.2%). Of all neoplastic lesions (n = 68), resection with negative margins (R0) was achieved in 54 cases (79.4%). Adverse events occurred in 9 cases (11.5%), but most (n = 6, 66.7%) were successfully treated endoscopically. Follow-up endoscopy was performed in 46 patients (59.0%) at a mean interval of 6.8months (SD ± 5.0months) with two case of recurrent lesion (4.3%). This study shows successful colorectal ESD outcomes at a US tertiary center. The en bloc resection rate was lower than other cohorts, but a learning curve was demonstrated. The R0 resection, lesion recurrence, and adverse event rates were similar to other non-Asian experiences, but not as favorable as in Asia [Fuccio et al. in Gastrointest Endosc 86:74-86.e17, 2017]. Increased ESD training in the US can help optimize utilization and outcomes.

Which Kind of Gastrointestinal Endoscopic Doctors Should Receive Endoscopic Submucosal Dissection (ESD) Training—ESD Training in The Affiliated Drum Tower Hospital from Single Center’s Experience

Which Kind of Gastrointestinal Endoscopic Doctors Should Receive Endoscopic Submucosal Dissection (ESD) Training—ESD Training in The Affiliated Drum Tower Hospital from Single Center’s Experience

Development of an animal model that reproduces pulsations for training in esophageal endoscopic submucosal dissection.

Development of an animal model that reproduces pulsations for training in esophageal endoscopic submucosal dissection.

A novel endoscopic submucosal dissection training model using skinned chicken meat with gel.

A novel endoscopic submucosal dissection training model using skinned chicken meat with gel.

Mo1261 THE EFFECT OF FIBROSIS ON EFFICACY OF ENDOSCOPIC SUBMUCOSAL RESECTION IN BARRETT’S ESOPHAGUS

Endoscopic submucosal dissection (ESD) is an established endoscopic resection technique used to treat superficial esophageal cancer. ESD is predominantly used in Asia where en bloc resection is often successful for esophageal squamous cell cancer or gastric adenocarcinoma due to good tissue plane delineation. It is in these lesions that early training in ESD is recommended. In comparison, most Western ESD procedures occur in the setting of Barrett’s esophagus (BE), a known inflammatory condition often treated with ablation therapy or endoscopic mucosal resection prior to ESD, making fibrosis more common. To determine the effect of submucosal fibrosis on ESD in BE. A prospectively maintained database of esophageal ESD performed in the BE unit for neoplasia was reviewed for cases of fibrosis. All procedures were performed by a single endoscopist using an Olympus H190 (Center Valley, PA) gastroscope and a Fujifilm Clutch Cutter DP2618DT device (Tokyo, Japan) at Mayo Clinic (Rochester, MN) from 2017-2018. ESD was performed after injection of epinephrine, hydroxymethylcellulose, and methylene blue to elevate the mucosa. Primary outcomes were intraprocedural or post-procedural complications up to 7 days following ESD, and R0 curative and en bloc resection. A total of 142 ESDs were performed among 97 patients (74.2% male, mean age 69.1±10.4 y). Refer to Table 1 for lesion characteristics. En bloc resection was achieved in 124 (87.3%) cases. Mean resection size was 24.0±10.8 mm, with the defect measuring a mean 27.8±14.9% (range 10-80%) of the luminal circumference. For adenocarcinoma or squamous cell carcinoma-related resections, R0 was achieved in 16 of 50 resections (32%). Fibrosis was encountered in 24 (16.9%), and of these, 2 were noted as F1, 13 as F2 per standard classification. Notably, patients with fibrosis were more likely to have had prior endoscopic resection (p 0.01) and were more likely to go on to failed en bloc ESD (p <0.0001). Mean procedure time did not differ (p 0.44). Complications were identified in 2 cases without fibrosis; 1 involved intraprocedural bleeding from a 3 mm arterial branch that was cauterized with the Clutch Cutter device and also resulted in use of topical hemostatic spray, while 1 involved need for blood transfusion within 24 hours of the procedure, followed by topical hemostatic spray and epinephrine to address bleeding along the resection margin at 5 days post-procedure. Patients were on antiplatelet/anticoagulants for 52.8% of procedures, including 30.3% on aspirin, 2.1% clopidogrel, 9.9% warfarin, 9.2% direct oral anticoagulants. ESD in BE with fibrosis is more likely to result in failed en bloc resection though complications were not increased. Fibrosis is common in patients with BE and may make lesions less ideal for training for Western endoscopists.

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

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.

Current status and trend in training for endoscopic submucosal dissection: A nationwide survey in Korea.

BackgroundAlthough endoscopic submucosal dissection (ESD) is widely used, the current status and trend in its training have yet to be fully evaluated. We aimed to investigate how ESD endoscopists have been trained in actual clinical practice.MethodsEndoscopists aged <45 years who have completed a gastroenterology fellowship or were currently in a fellowship for ≥2 years were included. We conducted a nationwide survey on the ESD training experiences of these endoscopists.ResultsAmong 79 young Korean endoscopists invited to participate in the survey, 68 (86.1%) trained in 24 major hospitals responded to the questionnaire. Twenty, 25, and 23 participants belonged to the second-year fellow, <5 years after training, and ≥5 years after training groups, respectively. Sixty-nine percent of the participants observed ≥50 ESD cases before starting ESD under supervision by an expert endoscopist. Additionally, 22% experienced ≥20 supervised ESDs during the training period. The proportion of the participants who underwent a hands-on course differed among the groups (≥5 years after training, 13.0%; <5 years after training, 40.0%; and second-year fellow, 50.0%; P = 0.027). ESD under supervision, observation, and hands-on course were the preferred methods for learning ESD (91.1%, 80.9%, and 35.3%, respectively). Overall, 42.6% of the participants were satisfied with their training program. More experience in supervised ESD (≥20 cases) was associated with an increased satisfaction (odds ratio, 6.65; 95% confidence interval, 1.62–36.31).ConclusionsObservation and performance of ESD under the supervision of an expert endoscopist are the primary methods for learning ESD. Hands-on course program has been used more frequently in recent years.

Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA.

Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.

Analysis of endoscopic submucosal dissection training system construction

Objective To investigate the prerequisites for endoscopists, who were chosen to receive endoscopic submucosal dissection (ESD) training. Methods A total of 41 trainees, who attended ESD training in the endoscopic center of Nanjing Drum Tower Hospital from January 2017 to June 2018 were enrolled in the study. The general information of the subjects were collected, including name, age, gender, the number of gastroscopy and colonoscopy independently performed before training, the independent usage of narrow band image (NBI), magnifying endoscopy (ME), endoscopic mucosal resection (EMR), ESD, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) before training. And then every trainee independently finished four in vitro experiments of pig esophagus ESD. The specimen area and operating time were recorded, and the operating speed was calculated. Linear regression analysis was used to analyze the affecting factors of operating speed of ESD. Results Among the 41 trainees, 26 were male and 15 were female, with age of 36.07±4.44 years. The specimen area, operating time and operating speed of pig esophagus ESD was 4.67±1.61 cm2, 24.54±5.97 min, and 0.19±0.05 cm2/min, respectively. Univariate linear regression analysis showed that the number of gastroscopy (n>5 000, P=0.001 8) and colonoscopy (n>3 000, P=0.000 1), the detect number of early cancer in upper digestive tract (n>30, P=0.000 3) and lower digestive tract (n>10, P=0.019 7), and the usage of ME (P=0.047 8), EMR (P=0.019 6) and ESD (P=0.000 3) before training were statistically correlated with the operating speed of ESD. Carrying out NBI (P=0.532 9), ERCP (P=0.500 7) and EUS (P=0.766 8) before training were not statistically correlated with the operating speed of ESD. The operating speed of ESD was negatively correlated with the perforation rate of ESD (P<0.000 1). According to multivariable linear regression model, the usage of EMR (P=0.029) and ESD (P=0.034) were statistically correlated with the operating speed of ESD. Conclusion ESD trainees, who have the number of gastroscopy more than 5 000, the number of colonoscopy more than 3 000, the detect number of early cancer more than 30 in upper digestive tract and 10 in lower digestive tract, and the usage of ME, EMR and ESD before training, can get a better training effect. The study provides a theoretical basis for selecting appropriate ESD trainees. Key words: Animal models; In vitro; Endoscopic submucosal dissection; Operating training; Dissection time

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8–88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4–81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19–76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.

Endoscopic submucosal dissection: Italian national survey on current practices, training and outcomes

Background and AimsMost of the evidence supporting endoscopic submucosal dissection (ESD) comes from Asia. European data are primarily reported by specialized referral centers and thus may not be representative of common European ESD practice. The aim of this study is to understand the current state of ESD practice across Italian endoscopy centers. MethodsAll Italian endoscopists who were known to perform ESD were invited to complete a structured questionnaire including: operator features and competencies, ESD training details and clinical outcomes over a 2-year period. ResultsTwenty-nine operators from 23 centers (69% response rate) completed the questionnaire: 18 (62%) were <50 years old; 7 (24%) were female; 16 (70%) were located in Northern Italy. Overall ESD volume was <40 cases in 9 (31%) operators, 40–80 in 8 (27.5%), 80–150 in 4 (13.8%) and >150 in 8 (27.5%). Colorectal ESD was predominant for operators with an experience >80 cases. En-bloc resection rates ranged from 77.2 to 97.2% depending on the anatomic location with an R0 resection rate range of 75.3–93.6%. ESD perforation rates in the colon and rectum were significantly lower when experience was >150 compared to 80–150 cases (p < 0.0001 and p = 0.006 for colon and rectum, respectively). ConclusionESD in Italy is performed by a significant number of operators. Overall, Italian endoscopists performing ESD have achieved a good competence level. However, there is much variability in training protocols, initial supervision of procedures, practice settings, case mix and procedural volume/year that are likely responsible for some of the suboptimal resectional outcomes and increased perforation risk, mainly in the colon. Standardized training programs, practice parameters and auditing of outcomes are required.

Curriculum for endoscopic submucosal dissection training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

There is a need for well-organized comprehensive strategies to achieve good training in ESD. In this context, the European Society of Gastrointestinal Endoscopy (ESGE) have developed a European core curriculum for ESD practice across Europe with the aim of high quality ESD training.Advanced endoscopy diagnostic practice is advised before initiating ESD training. Proficiency in endoscopic mucosal resection (EMR) and adverse event management is recommended before starting ESD trainingESGE discourages the starting of initial ESD training in humans. Practice on animal and/or ex vivo models is useful to gain the basic ESD skills. ESGE recommends performing at least 20 ESD procedures in these models before human practice, with the goal of at least eight en bloc complete resections in the last 10 training cases, with no perforation. ESGE recommends observation of experts performing ESD in tertiary referral centers. Performance of ESD in humans should start on carefully selected lesions, ideally small ( < 30 mm), located in the antrum or in the rectum for the first 20 procedures. Beginning human practice in the colon is not recommended. ESGE recommends that at least the first 10 human ESD procedures should be done under the supervision of an ESD-proficient endoscopist.Endoscopists performing ESD should be able to correctly estimate the probability of performing a curative resection based on the characteristics of the lesion and should know the benefit/risk relationship of ESD when compared with other therapeutic alternatives. Endoscopists performing ESD should know how to interpret the histopathology findings of the ESD specimen, namely the criteria for low risk resection ("curative"), local risk resection, and high risk resection ("non-curative"), as well as their implications. ESD should be performed only in a setting where early and delayed complications can be managed adequately, namely with the possibility of admitting patients to a ward, and access to appropriate emergency surgical teams for the organ being treated with ESD.

The animal models using live pigs in the application and development of endoscopic submucosal dissection training

Endoscopic submucosal dissection (ESD) is the gold standard technique for performing en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. It has not started in China until early 2006, when it was introduced at Endoscopy Center of Zhongshan Hospital. However, ESD is technically more difficult and can result in more complications, limiting its development in China. At present, reports about ESD training system in China are still not available. Therefore, our center continuously explored and gradually established structured training courses relied on the live pig model. Between 2009 and 2013, we held 23 hands-on ESD training workshops with 550 endoscopists. Questionnaires were distributed via e-mail, and there were 460 participants performing ESD in a step-up approach on the live pigs. More than one half of trainees could perform ESD with en bloc resection in the imaginary "lesion" of colon and stomach, and there were higher rates of hemorrhage and perforation occurring in colorectal ESD as compared to gastric ESD. After graduating from our hands-on workshop, up to over 90% of participants started ESD practice in their home hospitals. It was mostly provided by high-grade hospitals (IIIA) which played a major role as tertiary referral centers, covering almost all provinces and major cities in China. The training on live pig model revealed to be safe and effective as a prior step to its application in humans. It may enable novice endoscopists to acquire ESD skills and start performing ESD as soon as possible. The role of adequate training is of course to influence the spread of this technique and promote ESD development around China.

Mo1698 RESIDENCY TRAINING IN COLORECTAL ESD IN WESTERN PRACTICE: OUTCOMES OF INDEPENDENT RESIDENT PERFORMED ESD IN A TERTIARY UNIT

There are no published reports on resident training in colorectal Endoscopic Submucosal Dissection (ESD) or resident performed ESD in western practice. It is unclear if any such training takes place in western centres where uptake of colorectal ESD has been slow and training, where it exists, is confined to experienced endoscopists who have already completed specialist training. The challenges of ESD training in the west compared to Japan are well known, but if safe and effective colorectal ESD is to take place on a larger scale in western centres it is important to establish the feasibility and efficacy of resident training in ESD. We evaluated resident training in colorectal ESD in our centre and report outcomes from the first 10 cases completed by a resident unassisted by a trainer.

Endoscopic submucosal dissection: a cognitive task analysis framework toward training design.

One of the major impediments to the proliferation of endoscopic submucosal dissection (ESD) training in Western countries is the lack of sufficient experts as instructors. One way to address this gap is to develop didactic systems, such as surgical simulators, to support the role of trainers. Cognitive task analysis (CTA) has been used in healthcare for the design and improvement of surgical training programs, and therefore can potentially be used for design ofsimilar systems for ESD. The aim of the study was to apply a CTA-based approach to identify the cognitive aspects of performing ESD, and to generate qualitative insights for training. Semi-structured interviews were designed based on the CTA framework to elicit knowledge of ESD practitioners relating to the various tasks involved in the procedure. Three observations were conducted of expert ESD trainers either while they performed actual ESD procedures or at a training workshop. Interviews were either conducted over the phone or in person. Interview participants included four experts and four novices. The observation notes and interviews were analyzed for emergent qualitative themes and relationships. The qualitative analysis yielded thematic insights related to four main cognition-related categories: learning goals/principles, challenges/concerns, strategies, and decision-making. The specific insights under each of these categories were systematically mapped to the various tasks inherent to the ESD procedure. The CTA approach was applied to identify cognitive themes related to ESD procedural tasks. Insights developed based on the qualitative analysis of interviews and observations of ESD practitioners can be used to inform the design of ESD training systems, such as virtual reality-based simulators.