How to establish endoscopic submucosal dissection in Western countries

Esophageal ESD Training; Perspective of West vs. East

PURPOSE OF REVIEW: Esophageal cancer is one of the most common cancers in the world and carries a poor prognosis. While esophagectomy poses considerable mortality and morbidity risks, endoscopic resection can provide a safer and less invasive alternative. RECENT FINDINGS: Endoscopic resection therapy has allowed a less invasive approach with comparable outcomes to esophagectomy. EMR is considered safe and requires less intensive training, yet it does not offer complete histopathological assessment due to the nature of piecemeal resection for larger lesions. Alternatively, ESD offers an R0 resection, therefore allowing precise histopathological evaluation. Training in ESD is essential; however, a uniform training model has not been agreed upon. The Japanese apprenticeship training model has proven effective, with promising training outcomes from the Eastern experience. In the West, a comprehensive training model through a combination of apprenticeship with progressive exposure, including ex-vivo and live animal hands-on training, could be the optimal approach. Different methods of ESD training are currently available, all of which aim to provide the experience needed to perform safe ESD. Despite the differences in training styles between the East and the West, a modified apprenticeship model could potentially result in more effective and better training outcomes. The currently available technologies provide the environment to enhance ESD training.

Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives

Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.

Learning curve for endoscopic submucosal dissection in early gastric neoplasm using a multibending endoscope

Background

Endoscopic submucosal dissection (ESD) is a representative treatment modality for early gastric neoplasms. However, the learning curve for beginners performing ESD using a multibending endoscope has not been introduced.

Objective

This study aimed to evaluate the learning curves of operators undergoing intensive training using a multibending endoscope.

Design

This was a retrospective single center study.

Methods

We retrospectively analyzed data of over 1500 consecutive gastric ESDs performed by two operators using a multibending endoscope. A change-point analysis with 50 cases of moving average speeds was used to determine the new target resection speed. Cumulative sum (CUSUM) analysis was used to identify the cases required for proficiency in ESD. Risk-adjusted CUSUM (RA-CUSUM) analysis was performed for each operator after adjusting for confounding factors influencing the resection speed.

Results

In total, 1491 cases were enrolled, with early gastric cancer accounting for 43.2% (n = 644). Overall, the en bloc resection, R0 resection, and curability rates were 97.7%, 96.0%, and 92.3%, respectively. The mean resection speed was 19.8 cm2/h. Because both operators surpassed the commonly used benchmark resection speed of 9 cm2/h in the first 50-case block, we established a new target benchmark of 17.9 cm2/h in the change-point analysis. CUSUM analysis indicated that performing 166 cases overall was required to achieve the benchmark, with the 2 operators needing 153 and 69 cases to meet this target speed after RA-CUSUM analysis.

Conclusion

Using a multibending endoscope for gastric ESD can help beginners achieve safe and excellent outcomes. These findings will serve as a useful guide for beginners attempting to use a multibending endoscope.

Prospective, randomized controlled study evaluating a double-balloon interventional endoscopic platform for colorectal endoscopic submucosal dissection (with video)

BACKGROUNDS AND AIMS

Endoscopic submucosal dissection (ESD) can be challenging and time-consuming. A double-balloon interventional platform (DBIP) was designed to assist with navigation, stabilization, traction, and device delivery during complex colorectal polypectomy. We compared traditional ESD (T-ESD) with DBIP-assisted ESD (DBIP-ESD) in a prospective, randomized trial.

METHODS

Patients with colorectal polyps ≥2 cm were randomly assigned (1:1) to DBIP-ESD or T-ESD. The primary study endpoint was the mean total procedure time difference between groups. Secondary endpoints were intraprocedural time points, en bloc resection rate, procedure cost, adverse events, and 3-month assessment. A sample size of 200 subjects for ≥80% power was calculated. Interim analysis for early study termination was planned at 70% enrollment if the primary endpoint was met (P ≤ .05).

RESULTS

One hundred forty-seven patients were enrolled between February 2019 and February 2020. Seven patients dropped out, and the interim analysis was performed on 140 patients (71 DBIP-ESD, 69 T-ESD). Demographics, comorbidities, and lesion size, location, and classification were similar between groups. The mean procedure time decreased with DBIP-ESD (88.6 ± 42.7 minutes) versus T-ESD (139.5 ± 83.2 minutes; difference of ∼51 minutes [36.5%]; P < .001], with procedural savings of $610.16 (11.4%) per patient after DBIP cost. The DBIP increased dissection speed by 49.0% (15.1 ± 8.0 vs 7.7 ± 6.6 cm2/h, P < .001). En bloc resection was superior with the addition of DBIP (97.2% vs 87.0%, P = .030). The mean navigation time with DBIP-ESD for sutured defect closure decreased by 7.7 minutes (P < .001). There were no adverse events in the DBIP-ESD group.

CONCLUSIONS

DBIP-ESD decreased the total procedure time, improved the en bloc resection rate, and facilitated sutured defect closure, making DBIP a promising and cost-effective tool to improve colorectal ESD adoption. (Clinical trial registration number: NCT03846609.).

Learning curve of colorectal endoscopic submucosal dissection of an endoscopist experienced hands-on training in Japan

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection is a technically demanding procedure with a steep learning curve. In Japan, the National Cancer Center Hospital allows overseas doctors to participate in hands-on training. We aimed to assess the colorectal endoscopic submucosal dissection performance and learning curve of an endoscopist who participated in hands-on training.

METHODS

In this retrospective analysis using a prospectively collected database, 100 consecutive superficial colorectal tumors from 100 patients treated with endoscopic submucosal dissection by a colorectal surgeon between January 2020 and May 2024 were included. The cases were grouped into three learning periods: phase I (the initial 30 cases under local expert supervision before training in Japan), phase II (the middle 30 cases), and phase III (the last 40 cases). The primary outcome was resection speed.

RESULTS

The median resection speed was 5, 11.7, and 13.2 cm2/h in phases I, II, and III, respectively. In matched data, the resection speeds in phases II and III were higher than that in phase I (P = 0.02 and P < 0.001, respectively). En bloc and R0 resection rates were 99% and 95%, respectively. The en bloc resection, R0 resection, and complication rates were not different between phases. Cumulative sum analysis of the resection speed revealed that proficiency was achieved after 36 cases.

CONCLUSIONS

An endoscopist who underwent a tutored approach and hands-on training in Japan achieved the proficiency benchmarks for colorectal endoscopic submucosal dissection after 36 cases. However, the endoscopist's extensive experience before training may contribute to excellent outcomes.

Effectiveness and safety of newly introduced endoscopic submucosal dissection in a Western center: a real-life study

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a minimally invasive technique for the resection of superficial gastrointestinal lesions, providing high rates of 'en bloc' and R0 resection. East-West differences in ESD quality indicators have been reported. This study aims to assess feasibility, effectiveness, and safety of ESD for the treatment of superficial gastrointestinal (GI) lesions in a Western cohort.

METHODS

Consecutive patients undergoing ESD at one Italian endoscopic referral center from September 2018 to March 2020 were included in this prospective study. Primary outcomes were technical success, R0 resection rate, curative resection rate, and adverse events (AEs).

RESULTS

In total 111 patients (111 lesions) undergoing ESD were included. Anatomic site of the lesions was rectum in 56.8%, colon in 13.5%, stomach in 24.3%, and esophagus in 5.4% of cases, respectively. For upper GI procedures, technical success was 100%, and R0 and curative resection rates were 84.8% and 78.8%, respectively. For colorectal procedures, technical success was 98.7%, R0 and curative resection rates were 88.5% and 84.6%, respectively. Major AEs were reported in 12 cases (10.8%).

CONCLUSION

The introduction of ESD in a Tertiary Center is feasible, effective, and safe, and should be taken into consideration for the treatment of superficial GI lesions requiring 'en bloc' resection.

Untutored training pathway to achieve competence in esophagogastric endoscopic submucosal dissection in a Western center

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) has a long learning curve. The aim of this study was to assess the efficacy of an ESD unsupervised training model for experienced endoscopists.

METHODS

Stepwise training included a visit to a high-volume center, unsupervised training on an ex vivo porcine model, and in vivo human upper GI cases with anatomic progression. Performance measures included en bloc resection, R0 resection, adverse event rates, and operating time.

RESULTS

After observation of 30 esophagogastric ESDs and 15 untutored ex vivo ESDs, 5 human cases of distal gastric ESDs were performed, followed by 55 unselected esophagogastric cases. En bloc and R0 resection rates were 93.0% and 80.7%, respectively. Operating time was 14.0 min/cm2 in the stomach and 25.1 min/cm2 in the esophagus, with evidence of a learning curve for esophageal ESDs (first block 30.26 min/cm2 vs second block 14.81 min/cm2, P = .01).

CONCLUSIONS

Untutored training for esophagogastric ESD is feasible and allows endoscopists, experienced in therapeutic endoscopy, to achieve the required standards toward competency.

Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study

BACKGROUND AND AIMS

Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center.

METHODS

From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes.

RESULTS

R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1).

CONCLUSION

eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.

Esophageal Endoscopic Submucosal Dissection in Older Patients Is Safe and Feasible: A Retrospective Single-Center Cohort Study in the United States

BACKGROUND

Endoscopic submucosal dissection (ESD) is a well-established method for treating early esophageal carcinomas. However, data on the safety and efficacy of esophageal ESD in older patients in the United States are limited.

METHODS

This retrospective study investigated the outcomes of esophageal ESD in patients aged ≥80 years and included those who underwent esophageal ESD between June 2018 and April 2023 at a single center in the United States. Patients were divided into two age groups for comparison: ≥80 and <80 years. Treatment outcomes and complications were evaluated and compared between these groups.

RESULTS

A total of 53 cases of esophageal ESD for malignant neoplasms were included, with 12 patients in the ≥80 years age group. No significant differences were observed in the patients' background and characteristics, except for a prior history of interventions (p = 0.04). The en bloc resection rate was 100% in both groups. The R0 resection rate was lower in the ≥80 years age group (75% vs. 88%). There were no complications requiring additional intervention in the ≥80 years age group, such as post-ESD bleeding, perforation, mediastinal emphysema, or pneumonia.

CONCLUSIONS

Esophageal ESD may be a safe and feasible procedure for treating esophageal carcinomas in older patients.

Decreasing rates of colectomy for benign neoplasms: A nationwide analysis

BACKGROUND

Despite advances in endoscopic techniques for management of benign colonic neoplasms, a rise in rates of surgical treatment has been reported. We used a nationally representative cohort to characterize temporal trends, patient characteristics, and outcomes associated with colectomy for colonic neoplasms.

METHODS

All patients undergoing elective partial colectomy for benign or malignant colonic neoplasms were identified using the 2012-2019 National Inpatient Sample. Those presenting with inflammatory bowel disease, or experiencing intestinal perforation were excluded. Patients with benign neoplasms were classified as the Benign cohort (others: Malignant). Trends, characteristics, and outcomes were assessed between groups.

RESULTS

Of 569,280 colectomy procedures included for analysis, 153,435 (27.0%) were performed for benign lesions. The proportion of Benign operations decreased from 28.6% in 2012 to 23.7% in 2019 (P for trend<0.001). While overall national incidence of colectomy for benign neoplasms decreased from 2012 to 2019 (IRD -1.19, 95%CI -1.20- -1.19), Black patients demonstrated an incremental increase (IRD +0.04, 95%CI +0.02-0.06). On average, Benign was younger (66 [57-72] vs 68 years [58-77], P<0.001), and demonstrated a lower Elixhauser comorbidity index (2 [1-3] vs 3 [2-4], P<0.001), relative to Malignancy. Following adjustment, Benign demonstrated lower odds of in-hospital mortality (AOR 0.61, 95%CI 0.50-0.74; P<0.001), stoma creation (AOR 0.46, 95%CI 0.43-0.50; P<0.001), and infectious complications (AOR 0.68, 95%CI 0.63-0.73; P<0.001).

CONCLUSIONS

The present national study identifies a decrease in colectomy for benign polyps from 2012-2019. Future investigations should identify patients who would most benefit from surgical resection and address persistent inequities in access to screening and treatment for colonic neoplasms.

Clinical outcomes of endoscopic submucosal dissection for giant rectal tumors larger than 8 cm: A European referral center experience

BACKGROUND AND AIMS

To date, western data on colorectal ESD are limited. This study aimed to assess the efficacy and safety of rectal ESD for superficial lesions ≥ 8 cm.

METHODS

A total of 138 superficial rectal neoplasms treated by ESD were allocated in two groups: 25 in the "giant" ESD group and 113 in the control group.

RESULTS

En bloc resection was achieved in 96% of cases in both groups. En bloc R0 resection rate was similar between the "giant" ESD group and the control group (84% vs 86%; p: 0.5) and curative resection was higher in the control group (81%) than in "giant" ESD group (68%) without reaching statistical significance (p: 0.2). Dissection time was significantly longer in the "giant" ESD group (251 vs 108 min; p <0.001), however, dissection speed was significantly higher (0.35 vs 0.17 cm2/min; p: 0.02).). Post-ESD stenosis was observed in 2 patients from the "giant" ESD group (8% vs 0% of control group, p: 0.03). No significant differences were found in delayed bleeding, perforation, local recurrences, and need for additional surgery.

CONCLUSIONS

ESD for superficial rectal tumors ≥ 8 cm is a feasible, safe, and effective therapeutic option.

Predictive Factors for the Outcome of Unsupervised Endoscopic Submucosal Dissection During the Initial Learning Curve with Prevalence-Based Indication

BACKGROUND

For an adequate educational strategy of ESD in non-Asian settings with prevalence-based indication it is essential to define adequate lesions, suitable for the beginner without on-site expert-supervision.

AIMS

We analyzed possible predictors for outcome parameters of effectiveness and safety during the initial learning curve.

METHODS

The first 120 ESDs of four operators (n = 480), performed between 2007 and 2020 in four tertiary hospitals, were enrolled. Uni-/multivariable regression analysis was done with sex, age, pretreated lesion, lesion size, organ, and organ-based localization as possible independent predictors for en bloc resection (EBR), complication, and resection speed.

RESULTS

Rates of EBR, complication, and resection speed were 84.5%, 14.2%, and 6.20 (± 4.45) cm2/h. Independent predictors for EBR were pretreated lesion (OR 0.27 [0.13-0.57], p < 0.001) and non-colonic ESD (OR 2.29 [1.26-4.17] (rectum)/5.72 [2.36-13.89] (stomach)/7.80 [2.60-23.42] (esophagus), p < 0.001), for complication pretreated lesion (OR 3.04 [1.46-6.34], p < 0.001) and lesion size (OR 1.02 [1.004-1.04], p = 0.012) and for resection speed pretreated lesion (RC - 3.10 [- 4.39 to - 1.81], p < 0.001), lesion size (RC 0.13 [0.11-0.16], p < 0.001) and male patient (RC - 1.11 [- 1.85 to - 0.37], p < 0.001). We found no significant difference in the incidence of technically unsuccessful resections in esophageal (1/84), gastric (3/113), rectal (7/181), and colonic (3/101) ESDs (p = 0.76). Technical failure was mainly caused by complication and fibrosis/pretreatment.

CONCLUSION

During the initial learning curve of an unsupervised ESD program with prevalence-based indication, pretreated lesions and colonic ESDs should be avoided. In contrast, lesion size and organ-based localizations have less predictive value for the outcome.

Pilot study on a new endoscopic platform for colorectal endoscopic submucosal dissection

Background

The endoscopic submucosal dissection (ESD) is a technically demanding and time-consuming procedure, with an increased risk of adverse events compared to standard endoscopic resection techniques. The main difficulties are related to the instability of the operating field and to the loss of traction. We aimed to evaluate in a pilot trial a new endoscopic platform [tissue retractor system (TRS); ORISE, Boston scientific Co., Marlborough, MA, USA], designed to stabilize the intraluminal space, and to provide tissue retraction and counter traction.

Method

We prospectively enrolled all consecutive patients who underwent an ESD for sigmoid/rectal lesions. The primary outcome was the rate of technical feasibility. Further technical aspects such as en-bloc and R0 resection rate, number of graspers used, circumferential incision time, TRS assemblage time, submucosal dissection time, and submucosal dissection speed were provided. Clinical outcomes (recurrence rate and adverse events) were recorded as well.

Results

In all, 10 patients (M/F 4/6, age: 70.4 ± 11.0 years old) were enrolled. Eight out of 10 lesions were located in the rectum. Average lesion size was 31.2 ± 2.7 mm, and mean lesion area was 1628.88 ± 205.3 mm². The two sigmoid lesions were removed through standard ESD, because the platform assemblage failed after several attempts. All rectal lesions were removed in an en-bloc fashion. R0 resection was achieved in 7/8 (87.5%) patients in an average procedure time of 60.5 ± 23.3 min. None of the patients developed neither intraprocedural nor postprocedural adverse events.

Conclusion

TRS-assisted ESD is a feasible option when used in the rectum, with promising result in terms of efficacy and safety outcomes. Nevertheless, our pilot study underlines few technical limitations of the present platform that need to be overcome before the system could be widely and routinely used.

Training in Endoscopic Submucosal Dissection in the United States: The Current Paradigm

Endoscopic submucosal dissection (ESD) training in Japan is pursued through a designated master-apprentice, organ-based stepwise training model. However, applying a similar program to the United States is not a practical strategy due to the significant differences in the training system and disease prevalence. To incorporate the ESD training into the current advanced endoscopy fellowship program, the use of recently developed techniques and technologies to improve the efficiency of ESD is ideal. The ESD training program in the United States should be prevalence-based, with increased involvement of trainees depending on their objectively assessed competency levels.

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

BACKGROUND

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.

METHODS

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 > 9.0 cm²/hour. The CUSUM method was used to assess the number of ESDs required for achieving proficiency and mastery.

RESULTS

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.

CONCLUSION

The time required to achieve relevant competency in gastric ESD depends on the tumor location.

Learning curve of endoscopic submucosal dissection (ESD) with prevalence-based indication in unsupervised Western settings: a retrospective multicenter analysis

BACKGROUND AND AIMS

As there is still no consensus about the adequate training strategy for ESD in Western countries, we evaluated unsupervised prevalence-based learning curves including detailed organ-specific subgroup analysis.

METHODS

The first 120 ESDs of four operators (n = 480) were divided into three groups (1: ESD 1-40, 2: ESD 41-80, 3: ESD 81-120). Outcome parameters were rates of technical success, en bloc and R0 resection, the resection speed, rates of conversion to EMR, curative resection, adverse events, surgery due to adverse events, and recurrence. In addition, we analyzed the achievement of quality benchmarks indicating levels of expertise.

RESULTS

After exclusion of pretreated lesions, 438 procedures were enrolled in the final analysis. Technical success rates were > 96% with significant improvements regarding rate of en bloc resection (from 82.6 to 91.2%), resection speed (from 4.54 to 7.63 cm²/h), and rate of conversion to EMR (from 22.0 to 8.1%). No significant differences could be observed for rates of R0 resection (65.9 vs. 69.6%), curative resection (55.8 vs. 55.7%), adverse events (16.3 vs. 11.7%), surgery due to adverse events (1.5 vs. 1.3%), and recurrence (12.5 vs. 4.5%). Subgroup and benchmark analysis revealed an improvement in esophageal, gastric, and rectal ESD with achievement of competence levels for the esophagus and stomach within 80 and most of the benchmarks for proficiency level within 120 procedures. Some of the benchmarks could also be achieved in rectal ESD.

CONCLUSIONS

This trial confirms safety and feasibility of unsupervised ESD along the initial learning curve with prevalence-based indication and exclusion of colonic cases.

A Steep Early Learning Curve for Endoscopic Submucosal Dissection in the Live Porcine Model

BACKGROUND

Endoscopic submucosal dissection (ESD) is a demanding procedure requiring high level of expertise. ESD training programs incorporate procedures with live animal models. This study aimed to assess the early learning curve for performing ESD on live porcine models by endoscopists without any or with limited previous ESD experience.

METHODS

In a live porcine model ESD workshop, number of resections, completeness of the resections, en bloc resections, adverse events, tutor intervention, type of knife, ESD time and size of resected specimens were recorded. ESD speed was calculated.

RESULTS

A total of 70 procedures were carried out by 17 trainees. The percentage of complete resections, en bloc resections and ESD speed increased from the first to the latest procedures (88.2%-100%, 76.5%-100%, 8.6-31.4 mm2/min, respectively). The number of procedures in which a trainee needed tutor intervention and the number of adverse events also decreased throughout the procedures (4 to 0 and 6 to 0, respectively). During the workshop, when participants changed to a different type of knife, ESD speed slightly decreased (18.5 mm2/min to 17.0 mm2/min) and adverse events increased again (0-2).

CONCLUSIONS

Through successive procedures, complete resections, en bloc resections, and ESD speed improve whereas adverse events decrease, supporting the role of the live porcine model in the preclinical learning phase. Changing ESD knives has a momentarily negative impact on the learning curve.

Robotic-assisted vs non-robotic traction techniques in endoscopic submucosal dissection for malignant gastrointestinal lesions

Endoscopic submucosal dissection is an effective approach with higher en bloc resection and complete resection rate for superficial gastrointestinal (GI) lesions. However, endoscopic submucosal dissection is technically challenging and associated with several adverse events, such as bleeding or perforations. The single channel flexible endoscope’s intrinsic limitations in preserving visualization of the submucosal dissection plane as compared to laparoscopic surgery are the most common cause of complications during the endoscopic submucosal dissection technique. As a result, traction techniques were created as the endoscope’s second helping hand in order to improve the effectiveness of the endoscopic submucosal dissection method. Trainees can master endoscopic submucosal dissection methods more quickly by using traction techniques. The anatomical location of the lesion plays a major role in determining which traction technique should be employed. An appealing way of traction is robot-assisted endoscopic submucosal dissection, and various types of endoscopic robots that allow bimanual operation are currently being developed. The advent of robot-assisted endoscopic technology ushers in a new era of endoscopic submucosal dissection, and with it come its own unique challenges that remain to be elucidated. Future research and development efforts are needed to focus on pathways and curriculums for trainees to master the currently available traction techniques and provide avenues for the development of newer traction modalities. In this article, we discuss evolution, characteristics, technological improvements and clinical comparisons of both robotic and non-robotic endoscopic traction techniques used in endoscopic submucosal dissection.

From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s

Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.

Efficacy and safety of a thermosensitive hydrogel for endoscopic submucosal dissection: An in vivo swine study

Injectable thermo-sensitive chitosan hydrogels have recently been developed for the use of submucosal fluids in endoscopic submucosal dissections (ESD). This study aimed to investigate the efficacy and safety of chitosan hydrogels during ESD. Submucosal fluids were administered as follows: 0.9% normal saline (NS), 0.4% hyaluronic acid (HA) and chitosan/β-glycerophosphate (CS/GP) hydrogel. Each solution was administered twice into the stomach and colon of a pig, with a total of 72 ESD procedures performed on 12 pigs. The injected volume and procedure-related parameters were recorded and analyzed. ESDs that created ulcers after 7 days were histologically compared. All ESD specimens were resected en bloc. The total injected volumes during ESD of the stomach (NS, 16.09±3.27 vs. HA, 11.17±2.32 vs. CS/GP, 9.44±2.33; p<0.001) and colon (NS, 9.17±1.80 vs. HA, 6.67±1.50 vs. CS/GP, 6.75±1.57; p = 0.001) were significantly different. Hydrogel showed significant differences from normal saline in terms of fluid power (mm²/vol; NS, 35.70±9.00 vs. CS/GP 57.48±20.77; p = 0.001) and consumption rate (vol/min; NS, 2.59±0.86 vs. CS/GP, 1.62±0.65; p = 0.013) in the stomach. Histological examination revealed preserved muscularis propria, although the chitosan hydrogel resulted in a partial inflammatory response, with a hypertrophied submucosal layer. Chitosan hydrogel was found to be superior to normal saline, with an efficacy similar to that of hyaluronic acid. Nonetheless, long-term histological changes should be evaluated before clinical implementation.

Gastric Eosinophilic Granuloma Related to Anisakiasis Resected by Laparoscopic and Endoscopic Cooperative Surgery

BACKGROUND

Anisakiasis-related gastric eosinophilic granuloma is rare.

CASE REPORT

Herein, we report a patient with anisakiasis-related gastric eosinophilic granuloma who was treated with laparoscopic and endoscopic cooperative surgery (LECS). A 59-year-old woman was presented to our hospital for further examination of a gastric lesion that was initially diagnosed by a local medical doctor. Esophagogastroduodenoscopy showed a submucosal tumor-like lesion in the lower body of the stomach. Endoscopic ultrasonography showed a heterogeneous hypoechoic submucosal mass lesion in the submucosal layer measuring 10 mm, without evidence of deep involvement. Under a clinical diagnosis of gastrointestinal stromal tumor, the patient underwent LECS. Gross appearance of the resected specimen revealed a 1.5×1.0 cm submucosal tumor-like lesion. Microscopic examination revealed necrosed insects consistent with the characteristics of gastric anisakiasis, around which prominent eosinophilic infiltration and granulomas were observed. This prompted a diagnosis of gastric eosinophilic granuloma related to anisakiasis.

CONCLUSION

To the best of our knowledge, this is the second case of gastric eosinophilic granuloma related to anisakiasis resected by LECS in the English medical literature. LECS might be a useful procedure for minimally invasive therapeutic diagnosis.

Evaluation of improved bi-manual endoscopic resection using a customizable 3D-printed manipulator system designed for use with standard endoscopes: a feasibility study using a porcine ex-vivo model

Background and study aims  A major drawback of endoscopic en-bloc resection technique is its inability to perform bimanual tasks. Although endoscopic platforms that enable bimanual tasks are commercially available, they are neither approved for various locations nor adaptable to specific patients and indications. Methods  Based on evolution of an adaptive 3D-printable platform concept, system variants with different characteristic properties were evaluated for ESD scenarios, ex-vivo in two locations in the stomach and colorectum. Results  In total 28 ESDs were performed (7 antrum, 7 corpus in inversion, 7 cecum, 7 rectum) in a porcine ex-vivo setup. ESD was feasible in 21 cases. Investigated manipulator variants are differently well suited for performing ESD within the varying interventions scenarios. Dual-arm manipulators allowed autonomous ESD, while single-arm flexible manipulators could be used more universally due to their compact design, especially for lesions difficult to access. Pediatric scopes were too frail to guide the overtube-manipulators in extremely angled positions. Working in the rectum was impaired using long-sized manipulator arms. Conclusions  The presented endoscopic platform based on 3D-printable and customizable manipulator structures might be a promising approach for future improvement of ESD procedure. With regard to localization, especially flexible manipulators attached to standard endoscopes appear to be most promising for further application of specific and individualised manipulator systems.

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.

Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy

AIM

The performance of therapeutic procedures in lower gastrointestinal endoscopy (LGI) can be challenging and carries an increased risk of adverse events. There is increasing demand for the training of endoscopists in these procedures, but limited guidelines exist concerning procedural competency. The aim of this study was to assess the learning curves for LGI polypectomy, colorectal endoscopic mucosal resection (EMR) and colorectal endoscopic submucosal dissection (ESD).

METHOD

A systematic review of electronic databases between 1946 and September 2019 was performed. Citations were included if they reported learning curve data. Outcome measures that defined the success of procedural competency were also recorded.

RESULTS

A total of 34 out of 598 studies met the inclusion criteria of which 28 were related to ESD, three to polypectomy and three to EMR. Outcome measures for polypectomy competency (en bloc resection, delayed bleeding and independent polypectomy rate) were achieved after completion of between 250 and 400 polypectomies and after 300 colonoscopies. EMR outcome measures, including complete resection and recurrence, were achieved variably between 50 and 300 procedures. Outcome measures for ESD included efficiency (resection rates and procedural speed) and safety (adverse events). En bloc resection rates of over 80% and R0 resection rates of over 70% were achieved at 20-40 cases and procedural speed increased after 30 ESD cases. Competency in safety metrics was variably achieved at 20-200 cases.

CONCLUSION

There is a paucity of data on learning curves in LGI polypectomy, EMR and ESD. Despite limited evidence, we have identified relevant outcome measures and threshold numbers for the most common LGI polyp resection techniques for potential inclusion in training programmes/credentialing guidelines.

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.

A Single-Center Early Experience of Endoscopic Submucosal Dissection for Gastric Lesions in Thailand

Endoscopic submucosal dissection (ESD) was also considered a “high risk” at the starting point with skillful endoscopic techniques and terrible complications. Still, it remains challenging yet has become widespread among institutes in many parts of the world. This study is aimed at further investigating the feasibility, efficacy, and safety of ESD of gastric lesions and at evaluating clinical outcomes in early experience. The patient characteristics, postoperative outcomes, and results of histopathological examinations were reviewed retrospectively between January 2017 and May 2019. Thirteen patients' gastric ESD were included with all of en bloc resections without recurrence. The long duration was related to the large lesion, the upper part of the stomach, and previous treatment. In this study, the ESD procedure of the stomach is a feasible and safe minimally invasive treatment option with organ preservation. It requires training and experience with a learning approach where skill may be improved to prevent unwanted complications.

Review on colorectal endoscopic submucosal dissection focusing on the technical aspect

BACKGROUND

Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD.

METHODS

We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques.

RESULTS

A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed.

CONCLUSIONS

Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.

Learning Curve for Endoscopic Submucosal Dissection With an Untutored, Prevalence-Based Approach in the United States

BACKGROUND & AIMS

Endoscopic submucosal dissection (ESD) is widely used in Asia to resect early-stage gastrointestinal neoplasms, but use of ESD in Western countries is limited. We collected data on the learning curve for ESD at a high-volume referral center in the United States to guide development of training programs in the Americas and Europe.

METHODS

We performed a retrospective analysis of consecutive ESDs performed by a single operator at a high-volume referral center in the United States from 2009 through 2017. ESD was performed in 540 lesions: 449 mucosal (10% esophageal, 13% gastric, 5% duodenal, 62% colonic, and 10% rectal) and 91 submucosal. We estimated case volumes required to achieve accepted proficiency benchmarks (>90% for en bloc resection and >80% for histologic margin-negative (R0) resection) and resection speeds >9cm²/hr.

RESULTS

Pathology analysis of mucosal lesions identified 95 carcinomas, 346 premalignant lesions, and 8 others; the rate of en bloc resection increased from 76% in block 1 (50 cases) to a plateau of 98% after block 5 (250 cases). The rate of R0 resection improved from 45% in block 1 to >80% after block 5 (250 cases) and ∼95% after block 8 (400 cases). Based on cumulative sum analysis, approximately 170, 150, and 280 ESDs are required to consistently achieve a resection speed >9cm²/hr in esophagus, stomach, and colon, respectively.

CONCLUSIONS

In an analysis of ESDs performed at a large referral center in the United States, we found that an untutored, prevalence-based approach allowed operators to achieve all proficiency benchmarks after ∼250 cases. Compared with Asia, ESD requires more time to learn in the West, where the untutored, prevalence-based approach requires resection of challenging lesions, such as colon lesions and previously manipulated lesions, in early stages of training.

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

BACKGROUND AND AIMS

Most 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.

METHODS

All 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.

RESULTS

Twenty-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).

CONCLUSION

ESD 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.

Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms

Endoscopic submucosal dissection (ESD) for superficial gastrointestinal neoplasms has become widespread. However, certain aspects of the procedure remain difficult to manage, such as intraoperative bleeding and perforation. There are two kinds of scissor-type knife: the Clutch Cutter (Fujifilm Co., Tokyo, Japan) and the SB knife (Sumitomo Bakelite Co., Tokyo, Japan). These knives have different features from other types of ESD knives and enable the performance of all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis. The standard approach with scissor-type knives involves first grabbing the tissue and then incising or dissecting it. Theoretically, perforation as a result of unintentional movement should never happen with scissor-type knives compared to needle- or blade-type knives, which may induce perforation through unintentional movement. Moreover, the rates of severe bleeding and self-completion of ESD with scissor-type knives by non-experts were reported to be significantly better than for other knives. Thus, scissor-type knives can resolve these problems and help to further standardize ESD globally. In this review, we summarize reports on the efficacy of such scissor-type knives for ESD of gastrointestinal tumors. We also present the pocket-creation method and the application of traction devices, such as dental floss and S-O clips (Zeon Medical Co., Tokyo, Japan) for improving the performance of ESD with a Clutch Cutter.

How to Learn and Perform Endoscopic Submucosal Dissection and Full-Thickness Resection in the Colorectum in the United States

Pioneered in Japan to address the limitations of endoscopic mucosal resection in the stomach, endoscopic submucosal dissection (ESD) has been applied throughout the gastrointestinal tract, including the colorectum. ESD is technically challenging and has been slowly gaining traction in the West. However, for the committed and resourceful endoscopist, proficiency in ESD can still be achieved. Moreover, improvement in techniques and devices are likely to ease the learning curve while improving procedural duration, safety, and efficacy of colorectal ESD. This article reviews challenges and methods in learning ESD in the United States and provides a primer on performing ESD and full-thickness resection in the colorectum.

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

BACKGROUND

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 of similar systems for ESD.

OBJECTIVE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Implementation of endoscopic submucosal dissection for early upper gastrointestinal tract cancer after primary experience in colorectal endoscopic submucosal dissection

Background  Current guidelines recommend endoscopic submucosal dissection (ESD) as a treatment option for early cancers of the upper gastrointestinal tract with absent or minimal risk of lymph node metastasis. However, due to the low prevalence of these entities, it is difficult to achieve a competence level for ESD of upper gastrointestinal tract cancers in the Western World. Here, we present single-center data on the implementation of upper gastrointestinal ESD after previous experience with 89 colorectal ESD cases. Methods  Retrospective case series of 39 consecutive patients with early cancers of the esophagus (n = 13) or cardia and stomach (n = 26) treated with ESD over a 4-year period. Results  ESD was technically feasible in all cases with en bloc, R0, and curative resection rates of 100 %, 76.9 %, and 71.8 %, respectively, and a mean procedure time of 100 minutes (30 - 360 minutes). After an initial 20 procedures, the R0 and curative resection rates increased from 65.0 % to 89.5 %, and from 60.0 % to 84.2 %, respectively. Complications were observed in four patients (10.3 %): three perforations, one case of delayed bleeding, and one esophageal stricture. No case required emergency surgery; the 30-day mortality rate was 0 %. Conclusion  In this modest case series from Europe, we observed an effectiveness and complication rate for ESD for early esophageal and gastric cancer that are comparable to other series from Europe but also to more abundant data from Asia. The results indicate that even small numbers of upper gastrointestinal cancers can be managed adequately in centers with expertise in colorectal ESD.

Improved endoscopic resection of large flat lesions and early cancers using an external additional working channel (AWC): a case series

Background  En-bloc resection of large, flat lesions or early stages of cancer is challenging. No bimanual tasks are possible using standard endoscopes. Dual-channel endoscopes are not available everywhere and have a small distance between the channels. Patients and methods  A new external additional working channel (AWC) (Ovesco, Tuebingen, Germany) was designed and developed potentially enabling bimanual tasks. Fixed to the tip of a standard gastroscope or pediatric colonoscope, a second endoscopic tool can be inserted through the AWC and used for tissue retraction during endoscopic resection. Results  In the upper and lower gastrointestinal tract, endoscopic mucosal resection (EMR) with a modified grasp-and-snare technique and endoscopic submucosal dissection (ESD) were performed successfully using the AWC in eight patients. Complications were acute arterial bleeding post-EMR in two cases treated by endoscopic clipping. Conclusions  We conclude that a newly developed external additional working channel (AWC) enables endoscopic resection of large lesions in the upper and lower gastrointestinal tract. Potential benefits are its suitability for EMR and ESD, no need for a dual-channel endoscope and an adjustable distance of working channels.

AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States

Endoscopic submucosal dissection (ESD) is an established endoscopic resection method in Asian countries, which is increasingly practiced in Europe and by early adopters in the United States for removal of early cancers and large lesions from the luminal gastrointestinal tract. The intent of this expert review is to provide an update regarding the clinical practice of ESD with a particular focus on its use in the United States. This review is framed around the 16 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects our experience as advanced endoscopists with extensive experience in performing and teaching others to perform ESD in the United States. Best Practice Advice 1: Endoscopic submucosal dissection should be recognized as a mature endoscopic technique that enables complete removal of lesions that are too large for en bloc endoscopic mucosal resection or are at increased risk of containing cancer. Best Practice Advice 2: The safety and feasibility of endoscopic submucosal dissection for early gastric cancer is well established. The absolute indications for curative endoscopic resection include moderately and well-differentiated, nonulcerated, mucosal lesions that are ≤2 cm in size. Best Practice Advice 3: Other relative (expanded) indications for gastric endoscopic submucosal dissection include moderately and well-differentiated superficial cancers that are >2 cm, lesions ≤3 cm with ulceration or that contain early submucosal invasion, and poorly differentiated superficial cancers ≤2 cm in size. The risk of lymph node metastasis when endoscopic submucosal dissection is performed for these indications is higher than when it is performed for absolute indications but remains acceptably low. Best Practice Advice 4: Endoscopic submucosal dissection may be considered in selected patients with Barrett's esophagus with the following features: large or bulky area of nodularity, lesions with a high likelihood of superficial submucosal invasion, recurrent dysplasia, endoscopic mucosal resection specimen showing invasive carcinoma with positive margins, equivocal preprocedural histology, and intramucosal carcinoma. Best Practice Advice 5: Endoscopic submucosal dissection is the primary modality for treatment of squamous cell dysplasia and cancer confined to the superficial esophageal mucosa. Any degree of submucosal invasion caries an increased risk of lymph node metastasis and alternative/additional therapy should be considered. Best Practice Advice 6: Duodenal endoscopic submucosal dissection is associated with an increased risk of intraprocedural perforation and delayed adverse events. Duodenal endoscopic submucosal dissection should be limited to endoscopists with extensive experience in performing endoscopic submucosal dissection in other locations. It is strongly suggested that endoscopists in the United States refrain from performing duodenal endoscopic submucosal dissection during the early phase of their endoscopic submucosal dissection practice. Best Practice Advice 7: All colorectal lesions should be evaluated for suitability for endoscopic resection. Accumulating evidence has shown that the majority of colorectal neoplasms without signs of deep submucosal invasion or advanced cancer can be treated by advanced endoscopic resection techniques. Best Practice Advice 8: Colorectal neoplasms containing dysplasia confined to the mucosa have no risk for lymph node metastasis and endoscopic resection should be considered as the criterion standard. Best Practice Advice 9: Large (>2 cm) colorectal lesions frequently (>43%) require piecemeal removal when endoscopic mucosal resection is used, which is associated with increased (up to 20%) rates of recurrent neoplasia. Endoscopic submucosal dissection enables higher rates of en bloc resection and lower recurrence rates for these lesions. Patients with large complex colorectal polyps should be referred to a high-volume, specialized center for endoscopic removal by endoscopic mucosal resection or endoscopic submucosal dissection. Best Practice Advice 10: Endoscopic resection for colorectal lesions offers significant cost benefit compared with surgery, and case-based endoscopic submucosal dissection selection for high-risk lesions could offer cost savings. Best Practice Advice 11: Endoscopists in the United States embarking on performing endoscopic submucosal dissection should be familiar with currently available endoscopic tissue closure devices. Both clip closure and endoscopic suturing techniques have been shown to be effective in managing intraprocedural perforation. Complete closure of a post-endoscopic submucosal dissection site may be considered in certain circumstances based on patient factors, procedural factors, and the location of the lesion. Best Practice Advice 12: Careful coagulation of exposed blood vessels in the resection site may reduce the risk of delayed bleeding after endoscopic submucosal dissection. The use of low-voltage coagulation current is recommended for this technique. Best Practice Advice 13: Endoscopists should affix the endoscopic submucosal dissection specimen to a flat surface (eg, pin the specimen to cork board) and immerse it in formalin. An expert gastrointestinal pathologist should evaluate the specimen for margin involvement, degree of differentiation, presence or absence of lymphovascular invasion, depth of submucosal invasion (if present), and tumor budding. Best Practice Advice 14: Acquiring high-level competency in endoscopic submucosal dissection is achievable in the United States. Alternative educational models should be used in the United States because of the limited number of experts and the differing prevalence of gastrointestinal luminal diseases as compared with Asia. Best Practice Advice 15: The endoscopic submucosal dissection educational model most suited for the current environment in the United States is a stepwise approach consisting of didactic self-study, attending training courses with increasing levels of complexity, self-practice on animal models, and observation of live cases performed by experts. Endoscopists should perform their initial endoscopic submucosal dissections on patients with lesions that have well-established indications for endoscopic submucosal dissection and are of the lowest technical complexity. Best Practice Advice 16: Endoscopists in the United States who perform endoluminal resection should educate referring physicians to avoid practices that may induce submucosal fibrosis hampering future endoscopic mucosal resection or endoscopic submucosal dissection. These practices include tattooing in close proximity to or beneath a lesion for marking and partial snare resection of a portion of a lesion for histopathology.

Endoscopic submucosal dissection of 301 large colorectal neoplasias: outcome and learning curve from a specialized center in Europe

Background and study aims  Endoscopic submucosal dissection (ESD) allows en bloc resection of large colorectal lesions but ESD experience is limited outside Asia. This study evaluated implementation of ESD in the treatment of colorectal neoplasia in a Western center. Patients and methods  Three hundred and one cases of colorectal ESD (173 rectal and 128 colonic lesions) were retrospectively evaluated in terms of outcome, learning curve and complications. Results  Median size was 4 cm (range 1 - 12.5). En bloc resection was achieved in 241 cases amounting to an en bloc resection rate of 80 %. R0 resection was accomplished in 207 cases (69 %), RX and R1 were attained in 83 (27 %) and 11 (4 %) cases, respectively. Median time was 98 min (range 10 - 588) and median proficiency was 7.2 cm ² /h. Complications occurred in 24 patients (8 %) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2 %), all with proximal lesions, had emergency surgery. Two hundred and four patients were followed up endoscopically and median follow-up time was 13 months (range 3 - 53) revealing seven recurrences (3 %). En bloc rate improved gradually from 60 % during the first period to 98 % during the last period. ESD proficiency significantly improved between the first study period (3.6 cm ² /h) and the last study period (10.8 cm ² /h). Conclusions  This study represents the largest material on colorectal ESD in the west and shows that colorectal ESD can be implemented in clinical routine in western countries after appropriate training and achieve a high rate of en bloc and R0 resection with a concomitant low incidence of complications. ESD of proximal colonic lesions should be attempted with caution during the learning curve because of higher risk of complications.

Transanal endoscopic microsurgical submucosa dissection in the treatment of rectal adenomas and T1 rectal cancer

Background

The treatment of flat rectal adenomas is challenging. The technical difficulty and the potential of malignancy in suspected benign lesions are the factors in question. Surgical and interventional endoscopic techniques are implemented in Europe without a clear strategy. To minimize recurrent adenoma and unclear histopathological work up en bloc excision is desirable.

Methods and results

We demonstrate in this article the transanal endoscopic microsurgical submucosa dissection (TEM-ESD) procedure as a feasible method for en bloc excision of rectal adenomas and early rectal cancer. The surgical technique is demonstrated in detail with the help of a video of the operation that is available online. The results of a consecutive series of 78 patients are presented.

Conclusion

TEM-ESD is a safe procedure for resection of rectal adenomas and low risk carcinomas. It offers the possibility of organ preservation and minimizes functional disturbances. In case of a necessary salvage operation, the preserved integrity of the rectal muscle tube grants maximal oncological safety.

Electronic supplementary material

The online version of this article (10.1007/s00053-018-0291-3) includes a video on the surgical technique: TEM ESD. The article and supplemental material are available at http://www.springermedizin.de/der-chirurg. The supplemental material can be found at the end of the article under “Supplementary material”.

Introduction of endoscopic submucosal dissection in the West

Endoscopic submucosal dissection (ESD) is well established in Asia as a modality for selected advanced lesions of both the upper and lower gastrointestinal tract, but ESD has not attained the same niche in the West due to a variety of reasons. These include competition from traditional surgery, minimally invasive surgery and endoscopic mucosal resection. Other obstacles to ESD introduction in the West include time commitment for learning and doing procedures, a steep learning curve, special equipment, lack of mentors, cost issues, interdisciplinary conflicts, concern regarding complications and lack of support from institutions and interfacing departments. There are intrinsic differences in pathology prevalence (e.g., early gastric cancer) between the two regions that are less conducive for ESD implementation in the West. We will elaborate on these issues and suggest measures as well as a protocol to overcome these obstacles and hopefully allow introduction of ESD as a tenable option for appropriate patients.

Efficacy of a three-day training course in endoscopic submucosal dissection using a live porcine model: a prospective evaluation

Background

Endoscopic submucosal dissection is currently regarded as the method of choice for the resection of superficial tumours. The objective of our study was to evaluate prospectively the efficiency of an endoscopic submucosal dissection training course using live anaesthetised pigs.

Methods

Fourteen novice endoscopists participated in three gastric endoscopic submucosal dissection training courses on anaesthetised pigs. Each trainee resected five 'fake' antral lesions. Resected specimen sizes, endoscopic submucosal dissection speeds and the complication rate were evaluated prospectively.

Results

Among the 70 procedures performed, 58 could be analysed. There was a strong increase in endoscopic submucosal dissection speed (from 9.7 mm²/minute to 30.4 mm²/minute) during the sessions, marked between the first two endoscopic submucosal dissections compared with the fourth and fifth. There was a significant relation between the surface area of the resected lesion and procedure speed (P < 0.0001). The complication rate was 8.6%.

Conclusion

There is a clear benefit from endoscopic submucosal dissection training courses on animal models. Improved endoscopist capability is evident from the third endoscopic submucosal dissection. These data validate the indispensable nature of dedicated training courses and echo the European Society of Gastrointestinal Endoscopy proposition for multistep learning, beginning on animal models.

Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm

Background:

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign.

Methods:

Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters.

Results:

En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups.

Conclusions:

Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.

Single-center implementation of endoscopic submucosal dissection (ESD) in the colorectum: Low recurrence rate after intention-to-treat ESD

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) shows higher R0 resection and lower local recurrence rates than endoscopic mucosal resection (EMR) in Japan. In Europe, independent learning of ESD in the colorectum is feasible, but yet to be analyzed for curative resection and recurrence rates.

METHODS

After experimental training under supervision by Japanese experts (T.O., N.Y.), three endoscopists independently carried out 83 ESD procedures intention-to-treat for lesions in the entire colorectum of 67 patients in a prospective registry (November 2009 to June 2016).

RESULTS

ESD was feasible in 80 (96%) colorectal neoplasias (mean diameter 33.6 [± 1.8] mm), and three more required conversion to piecemeal EMR. The lesions were adenomas in 66% with low-grade intraepithelial neoplasia (LGIN), 29% with high-grade intraepithelial neoplasia, and 5% with carcinomas (G2, pT1). ESD had to be facilitated by the final use of snaring (hybrid-ESD, n = 45), especially in the initial learning period. En-bloc resection rate was 85%. Complications were microperforations (7%, conducive to one hemicolectomy), and delayed bleeding (1%) without mortality or long-term morbidity. Residual adenomas with LGIN (5%) after hybrid-ESD did not recur after endoscopic ablation. All malignant neoplasias (34%) were curatively resected without recurrence after a mean follow up of 19.5 (± 3.2) months.

CONCLUSIONS

During independent ESD learning in the colorectum, ESD intention-to-treat showed a low recurrence rate after appropriate training, and hybrid-ESD showed acceptable complication and recurrence rates, justifying hybrid-ESD as a strategy for self-completion and rescue.

Step-up training for colorectal and gastric ESD and the challenge of ESD training in the proximal colon: results from a German Center

BACKGROUND AND STUDY AIMS

The endoscopic submucosal dissection (ESD) of cancerous and precancerous lesions in the gastrointestinal (GI) tract is an effective but difficult-to-learn procedure, especially for Western endoscopists. We developed a step-up training protocol and evaluated its outcome on a single endoscopist using specific performance measures.

PATIENTS AND METHODS

The training protocol included a 12-month period of 50 observational and supervised ESD cases as well as 24 animal procedures. After completion of the protocol, ESD competency was evaluated in the first 30 independent ESD cases. Majority of lesions were located in the stomach and rectum. Performance measures included R0-resection rate, complication rate and resection speed.

RESULTS

R0 resection rate was 93 %, complication rate was 7 % and median resection speed was 6,77 cm ² /h. 1 case of delayed perforation with subsequent hemicolectomy occurred in the descending colon.

CONCLUSION

The ESD step-up training protocol used in this study on a single endoscopist showed excellent outcomes for lesions in the rectum and stomach. However, ESD training in the upper colon remains a challenge.

Real-life evaluation of the safety, efficacy and therapeutic outcomes of endoscopic submucosal dissection in a Western tertiary centre

Background

Endoscopic submucosal dissection (ESD) enables accurate pathological evaluation and low recurrence rates. Large series describing ESD outcomes in Western countries are scarce.

Objective

To evaluate the real-life experience of ESD in a single Western centre.

Methods

Data of all the patients submitted to ESD in our centre were prospectively recorded in a database, from the first procedure in 2011 until May 2017. Feasibility, en bloc and R0 resection rates and safety were assessed.

Results

Three hundred and one ESDs were performed (37 in submucosal lesions) on 283 patients (54% male). Lesions were located in the oesophagus (n = 13), stomach (n = 169), duodenum (n = 4), colon (n = 35) and rectum (n = 80). ESD was technically successful in 292 lesions (97%); among malignant or premalignant epithelial lesions (n = 232), the en bloc resection rate was 91% and, of those, the R0 resection rate was 87% (between 69% in the colon and 93% in the stomach). Two patients needed surgery due to adverse events. Surgery for non-curative ESD was performed in 12 cases (58% without residual lesion). There were 10 perforations, 9 of them closed endoscopically. Mortality was 0%.

Conclusion

Our real-life experience shows that ESD is feasible, safe and effective in Western settings.

Colorectal endoscopic submucosal dissection (ESD) in the West - when can satisfactory results be obtained? A single-operator learning curve analysis

OBJECTIVES

Up to date we lack a detailed description of the colorectal endoscopic submucosal dissection (ESD) learning curve, that would represent the experience of the Western center. The aim of this study was to define the critical points of the learning curve and to draw up lesions qualification guidelines tailored to the endoscopists experience.

MATERIALS AND METHODS

We have carried out a single center prospective study. Between June 2013 and December 2016, 228 primary colorectal lesions were managed by ESD procedure. In order to create a learning curve model and to carry out the analysis the cases were divided into six periods, each consisting of 38 cases.

RESULTS

The overall en bloc resection rate was 79.39%. The lowest en bloc resection rate (52.36%) was observed in the first period. After completing 76 procedures, the resection rate surged to 86% and it was accompanied by the significant increase in the mean procedure speed of ≥9 cm²/h. Lesions localization and diameter had a signification impact on the outcomes. After 76 procedures, en bloc resection rate of 90.9 and 90.67% were achieved for the left side of colon and rectum, respectively. In the right side of colon statistically significant lower resection rate of 67.57% was observed.

CONCLUSION

We have proved that in the setting of the Western center, colorectal ESD can yield excellent results. It seems that the key to the success during the learning period is 'tailoring' lesions qualification guidelines to the experience of the endoscopist, as lesions diameter and localization highly influence the outcomes.

Training in endoscopic mucosal resection and endoscopic submucosal dissection: Face, content and expert validity of the live porcine model

Introduction

Endoscopic mucosal resection and endoscopic submucosal dissection are demanding procedures. This study aims to establish face, content and expert validity of the live porcine model in performing endoscopic mucosal resection, endoscopic submucosal dissection, complication management and to assess it as a training tool.

Material and methods

Tutors and trainees participating in live porcine model endoscopic mucosal resection and endoscopic submucosal dissection workshops filled out a questionnaire regarding the realism of the model compared to human setting and its role as a learning tool. A 10-point Likert scale was used.

Results

Ninety-one endoscopists (13 tutors; 78 trainees) were involved in four workshops. Median global classifications for the realism of the life porcine model ranged between 7.0-8.0 (interquartile range 5.0-9.0). Procedures resembled human cases with a median of 9.0 (8.0-9.0) for oesophageal multiband endoscopic mucosal resection; 8.5 (8.0-9.0) for oesophageal endoscopic submucosal dissection; 9.0 (8.0-10.0) for gastric endoscopic submucosal dissection; and 9.0 (8.5-9.75 and 8.0-9.69) for complication detection and management. The animal model as a learning tool had median scores of 9.0 (7.0-10.0) considering how procedures are performed; 9.0-9.5 (8.0-10.0) for usefulness for beginners; and 9.0-10.0 (5.0-10.0) regarding it a prerequisite.

Conclusions

Training in a live porcine model was considered very realistic compared to the human setting and was highly appreciated as a learning tool. This is the first study to establish face, content and expert validity of the live porcine model in performing multiband endoscopic mucosal resection, oesophageal and gastric endoscopic submucosal dissection. The validation of this model provides the rationale to incorporate it into formal teaching programmes.