Endoscopic Submucosal Dissection Training Research Articles

DESIRABLE TRAINING AND ROLES OF JAPANESE ENDOSCOPISTS TOWARDS THE FURTHER PENETRATION OF ENDOSCOPIC SUBMUCOSAL DISSECTION IN ASIA

Endoscopic submucosal dissection (ESD) was invented in Japan and is now permeating into the rest of the world. Therefore, it is necessary to elucidate the desirable ESD training by knowing the current status of ESD training in Japan. After this, we mainly discussed the following three topics: (i) requirements for preceptees to start ESD training; (ii) requirements for competent endoscopists in ESD; and (iii) requirements for preceptors in the first half of the upper gastrointestinal tract session at the Endoscopic Forum Japan 2011. Additionally, we discussed what Japanese endoscopists can do for further permeation of ESD outside Japan, especially in Asia in the second half. The session was wrapped up by the conclusions that it was absolutely necessary to establish official training courses authorized by the Japan Gastroenterological Endoscopy Society with certification for trainees and trainers and our Japanese endoscopists had a responsibility to spread ESD safely and reliably by collaborating with enthusiastic endoscopists in each country which have different backgrounds in terms of incidences and screening systems of target diseases, accessibility to endoscopy, medical economics, national characters, and so on.

CURRENT SITUATION OF ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUPERFICIAL NEOPLASMS IN THE UPPER DIGESTIVE TRACT IN EAST ASIAN COUNTRIES: A QUESTIONNAIRE SURVEY

This study was carried out to understand the current practice and learning of endoscopic submucosal dissection (ESD) for superficial esophageal and gastric cancers in East Asian countries. A questionnaire survey was used to investigate differences in upper gastrointestinal (GI) ESD among East Asian countries. ESD is used by many endoscopists in not only tertiary centers but also secondary care hospitals in China, Korea and Japan. By contrast, it is less used by doctors in tertiary centers in Hong Kong and Taiwan. However, the general trend appears to be the same; ESD, which is a highly advanced endoscopic technique, is being transmitted from preceptors to preceptees in tertiary centers, then from doctors in tertiary centers to experienced doctors in secondary hospitals. The speed of learning and uptake in the practice of this procedure will depend on the volume of cases. Upper GI ESD can be expected to spread at a similar rate across different districts or hospitals in East Asia because of similarities in disease prevalence. Also, endoscopists in this region can easily learn from each other by attending international conferences or visiting endoscopy units to learn the procedure. Efforts to establish a standardized protocol for ESD practice and training are important, and may help endoscopists around the world develop this technique further.

COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION IN JAPAN AND WESTERN COUNTRIES

Various studies by Japanese endoscopists have demonstrated that colorectal endoscopic submucosal dissection (ESD) can overcome technical limitations of the endoscopic mucosal resection (EMR) technique such as piecemeal resection for flat lesions larger than 20 mm, resection of lesions involving the dentate line or the ileocecal valve and lesions with the non-lifting sign, and achieve higher en bloc resection rate. However, it is infrequently performed in Western countries in comparison with Japan, despite the advantages explained above. There are some differences between Japan and Western countries in environments and clinical settings for performing ESD in the colorectum. Endoscopists who perform colorectal ESD around the world are considering that refinements in ESD techniques, devices and training will be necessary to further reduce a higher risk of complications and longer procedure times before adoption of ESD can be recommended on a widespread international scale.

CURRENT STATUS OF TRAINING FOR ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC EPITHELIAL NEOPLASM AT CANCER INSTITUTE HOSPITAL, JAPANESE FOUNDATION FOR CANCER RESEARCH, A FAMOUS JAPANESE HOSPITAL

Endoscopic submucosal dissection (ESD) is relatively difficult compared with endoscopic mucosal resection (EMR), thus, proper training is essential for the safe performance of the procedure. The aim of this study is to clarify the current status of training for ESD for gastric epithelial neoplasm by following the performance of 13 preceptees. We performed ESD for 1520 lesions between March 2005 and April 2011 and conducted ESD training of 13 preceptees who were supervised by experts. We classified the samples into four groups according to the number of ESD performed by the preceptees to chart their progress by comparing the procedural outcomes. Group A included cases 1-40 performed by all 13 preceptees, group B consisted of cases 41-80 performed by 10 of the preceptees and group C included cases 81 onwards executed by five of the preceptees. Group D comprised the cases that were performed by experts during the same period as group C. The procedural outcomes of group A were similar to those of group B with regard to operation time, complete en bloc resection and complications. However, the results of group B included significantly more lesions of the middle or upper third of the stomach, resected specimen and lesions were larger in diameter, lesions with positive ulcer finding were more frequent and a higher frequency of lesions were of expanded, non-indication type. Group B outcomes were similar to those of group C but differed in location of lesions and specimen size. Group C outcomes were similar to group D's in all parameters. Preceptees were able to safely perform ESD for gastric epithelium neoplasms under appropriate supervision by expert endoscopists. The number of cases in which preceptees successfully extracted guideline-indication lesions and expanded-indication lesions by ESD were approximately 40 and 80 cases, respectively. The procedural outcomes of ESD performed by preceptees who had experience in over 80 cases were similar to those by expert endoscopists. Thus, these findings show that the minimal amount of training for achieving preceptorship of ESD is performance of at least 80 of the procedures.

TERMINOLOGY FOR TRAINING OF ENDOSCOPIC SUBMUCOSAL DISSECTION

Like many other advanced endoscopic skills, to master the skill of endoscopic submucosal dissection (ESD) requires training for a novice. The general medical terminology should be used similarly even in case of ESD training. However, it is not common for everyone to recall the same meaning from one medical term. Therefore, it is necessary to unify the meaning of medical terms and review their usage in a meeting to achieve a consensus. For this purpose, terms used in the upper gastrointestinal session, Endoscopic Forum Japan 2011, entitled 'Towards further penetration of ESD techniques - what is the role of Japanese ESD experts?', were determined beforehand as shown. Additionally, the present educational approach of ESD in Japan is simply outlined in this article.

HOW TO TEACH AND LEARN ENDOSCOPIC SUBMUCOSAL DISSECTION FOR UPPER GASTROINTESTINAL NEOPLASM IN JAPAN

Endoscopic submucosal dissection (ESD) is an innovative and promising procedure. However, ESD experience is mostly limited to Japan and a few countries in Asia. An appropriate training system should be proposed from Japan to promote a permeation of ESD technique. We conducted questionnaire survey to representative Japanese experts to reveal their training method of ESD for upper gastrointestinal neoplasm. We sent the questionnaire on gastric and esophageal ESD to 9 Japanese experts in ESD. The questionnaire results were discussed in a session of Endoscopic Forum Japan 2011 held in Tokyo. The inception criteria consisted of two main elements, diagnostic ability and primary endoscopy technique of preceptees. Preceptees should observe and attend as many ESD cases as possible. Most of the experts recommend training with isolated or live animal stomach or esophagus. Lesion in the distal stomach is the most suitable for the first real ESD by a preceptee. Being proficient in a gastric ESD is needed before starting esophageal ESD. Preceptor should have significantly high level of diagnostic ability and proficient ESD techniques in the colorectum as well as the stomach and esophagus. The present questionnaire survey seems to reveal basic elements required for ESD training program. We believe that this is also helpful in other countries where ESD would be initiated and penetrated safely and properly.

Endoscopic Submucosal Dissection (ESD) Training and Performing ESD with Accurate and Safe Techniques

Introduction of endoscopic submucosal dissection (ESD) has brought about a renaissance in therapeutic endoscopy. For the globalization and universalization of ESD, the number of physicians who can perform ESD has rapidly increased with general ex vivo and in vivo training using animal models and hand-on courses. In this focused review series, world-renowned ESD experts described the published studies or their own precious experiences about ESD training and performing ESD with accurate and safe techniques. First, Dr. Adolfo Parra-Blanco reviewed on ex vivo and in vivo models for ESD training. Next, Dr. Joo Young Cho described detailed practical settings and current status of hands-on courses using ex vivo and in vivo models in Korea. Dr. Takashi Toyonaga described quality controlled ESD and basic techniques to prevent complications. Dr. Tsuneo Oyama reviewed recently published methods to facilitate ESD. Dr. Jae-Young Jang reviewed the usefulness of magnifying and narrow band imaging to measure the depth of invasion before ESD.

ESD Hands-on Course UsingEx VivoandIn VivoModels in South Korea

Endoscopic submucosal dissection (ESD) is an established treatment for gastric neoplasias especially in regions with a high volume of gastric cancer. Although ESD has many advantages over endoscopic mucosal resection, ESD is technically more difficult and can result in severe complications. Therefore establishment of an effective training system is required to help endoscopists climb the ESD learning curve. Although a standard training system for ESD remains to be established, some centers are incorporating ex vivo and/or in vivo animal models to provide a safe and effective means of ESD training. However, it is unknown if these animal models are more effective than other programs. Moreover the efficacy of the animal model may vary according to socio-economic status and the volume of gastric cancer. In this article we introduce the basic and advanced ESD training model using the ex vivo and in vivo animal model from South Korea and review the associated literature from other regions.

Simulating a target lesion for endoscopic submucosal dissection training in an ex vivo pig model

Currently, there is no training model that simulates the target lesion encountered during endoscopic submucosal dissection. To develop a novel method simulating a target lesion for endoscopic submucosal dissection. Training program with the use of an ex vivo porcine stomach model. Clinical skills training center. A pseudopolyp was created by using an esophageal variceal ligation device to simulate a protruding (0-Ip) lesion, and the pseudopolyp was transected with a snare cautery to simulate a depressed (0-IIc) lesion. Evaluate the histological depth of the target lesions and resected specimens. Histological findings of the simulated targets showed artificial ulcerative or polypoid lesions involving the muscularis mucosa or superficial submucosa. The resected specimen was limited to the submucosal layer, and no perforation was noted. Pilot study in an ex vivo porcine stomach model. The most important advantage of the model is to simulate realistic target lesions like those encountered in clinical practice in endoscopic submucosal dissection training. It allows trainees to practice how to make proper markings, delineate adequate safety margins, and properly manage different subtypes of early gastric cancer.

EXPERIMENTAL ENDOSCOPIC SUBMUCOSAL DISSECTION TRAINING IN A PORCINE MODEL: LEARNING EXPERIENCE OF SKILLED WESTERN ENDOSCOPISTS

Endoscopic submucosal dissection (ESD) demands a new level of endoscopic skill in Europe. A 2-day workshop was set up for trainees to carry out five ESD each in order to obtain the skill level required to perform ESD in the stomach or rectum. This study describes: (i) the workshop setup; (ii) the participant's performance; and (iii) the training effect on post-workshop clinical ESD performance. Eighteen very experienced European endoscopists participated in four half-day (4.5 h) training sessions, with everybody rotating daily through six separate training stations (two each with dual, hook, or hybrid knives) with expert tutors. One anesthetized piglet was used per station and session. After 1 year, the clinical ESD performance was surveyed to estimate the training effect of the workshop. Overall, 74 ESD were performed, that is, 4.1 ESD per participant. On average ESD lasted 57 min for 6 cm(2) specimens. We detected a 22% rate of perforation (16 of 74 ESD with perforations), mostly attributable to participants with less experience in ESD. Those who started clinical ESD within 1 year after the workshop performed 144 clinical ESD (median 8 [0-20] per trainee) mostly in the stomach (40%) and large bowel (46%) with an acceptable rate of perforation (9.7%) and surgical repair (3.5%) without mortality or persistent morbidity. Intense skill training for ESD is needed to reduce the risk of perforation, as demonstrated by the results of this workshop. We show that experimental ESD training, however, enables skilled European endoscopists to perform ESD in standard locations with moderate risk of perforation during the clinical learning curve.

Tu1469 Recommendations About Training for Colorectal Endoscopic Submucosal Dissection in the Western World. Results of a Survey to Experts

Endoscopic Submucosal Dissection (ESD) is the treatment of choice for gastric intramucosal neoplasia in Japan. Colorectal ESD (CR-ESD) is slowly becoming increasingly applied, and there are clear advantages over conventional endoscopic resection techniques; however it is technically very challenging. Whereas in Japan there are already a number of experts to teach and make this technique more widespread, in the Western countries there are very few real experts in this technique. No prospective studies have determined how training for CR-ESD should be done.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective

Endoscopic mucosal resection (EMR) has become the standard of care for removal of large flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) was introduced in Japan as an alternative technique, which allows en bloc resection of large lesions. The applications of EMR and ESD are expanding and many Western endoscopists are adopting these techniques. Paris classification and Kudo pit pattern classification allows prediction of the depth of invasion of early neoplastic lesions and thus, avoids resection of lesions invading the deep submucosa which have higher rates of lymphatic spread. ESD of early stomach cancer is the standard of care in Japan. Recent published reports from Western countries showed comparable results for ESD of early gastric cancers to those done in Japan. Recently, EMR combined with ablation has been used frequently in Western countries for treatment of high-grade dysplasia in early adenocarcinoma of the esophagus. Although ESD of early neoplastic lesions of the esophagus is technically difficult, few promising reports were published proving the feasibility of this technique in the West. ESD has been shown to achieve higher en bloc resection and lower rates of tumour recurrence in removal of lateral spreading colonic polyps. A hybrid technique of circumferential submucosal incision followed by en bloc EMR has been used for removal of large colonic lesions in some Western endoscopy centres. In Western countries, training for ESD is challenging given the lack of training in the relatively easier early gastric cancer lesions. Animal model training combined with observing experts in ESD could be an alternative for Western endoscopists. Inspite of obstacles, ESD applications are continuing to grow in Western countries.

Endoscopic submucosal dissection training with pig models in a Western country

To test a strategy for endoscopic submucosal dissection (ESD) training in animal models designed to overcome the initial learning curve. ESD was attempted in ex vivo and in vivo pig models. Thirty ESD procedures were attempted in the esophagus (n = 9) or the stomach (n = 21). The ex vivo model was used until initial competence was achieved. In the in vivo model, several ESD procedures were performed in up to 3 sessions. The following variables were analyzed: specimen size, complete and en bloc resection rate, time for circumferential incision, time for submucosal dissection, total ESD duration, and complications. Complete resection was achieved in 28 cases (en bloc 27); 2 could not be completed (one perforation, one technical difficulty). The mean +/- SD time for circumferential incision was 36.2 +/- 16.8 min (range: 8-87 min), and the mean +/- SD time for submucosal dissection was 45.1 +/- 35.7 min (range: 9-196 min). The mean +/- SD size of the resected specimens was 45.2 +/- 17.8 mm. The mean +/- SD total resection time was significantly increased for the gastric cases performed in the first half of the study (n = 13) than in the second half (n = 8) (98.9 +/- 62.4 min vs 61.7 +/- 17.6 min, P = 0.04), although the specimen size did not differ. Training in animal models could help endoscopists overcome the learning curve before starting ESD in humans.

Difficulties and outcomes in starting endoscopic submucosal dissection

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.

Training model for teaching endoscopic submucosal dissection of gastric tumors

The elevated risk of complications and technical complexity of endoscopic submucosal dissection (ESD) has limited its implementation in our medical system. To design and evaluate a training program for learning the ESD technique. Four endoscopists with no experience with ESD underwent a 4-step training program: 1) review of the existing literature, didactic material, and theoretical aspects of ESD; 2) ESD training in an ex-vivo animal model; 3) ESD training in an in-vivo animal model (supervised by ESD expert); and 4) ESD performance in a patient. A standard gastroscope and an ESD knife (IT, Flex or Hook-knife Olympus) were employed. The classical ESD technique was performed: rising of the lesion, circumferential incision, and submucosal dissection. Ex-vivo animal model: 6 x swine stomach/esophagus -cost < 100 euro; 6 x ESD: antrum (n = 2), body (n = 3) and fundus/cardia (n = 1)-; size of resected specimen: 4-10 cm; ESD duration: 105-240 minutes; therapeutic success: 100%; complications: perforation (1/6: 16%) sealed with clips. In-vivo animal model: 6 ESD (antrum/body of stomach: 4; esophagus: 2); size: 2-5 cm; duration: 40-165 minutes; success: 100%; complications: 0%. ESD of a gastric lesion located in the antrum/body; size: 3 cm; duration 210 minutes; a complete resection was achieved; no complications. The results of the present study support the usefulness of this model for learning ESD in our system.