ESD Hands-on Course Using Ex Vivo and In Vivo Models in South Korea

Risk Factors Indicating Difficulty During Gastric Endoscopic Submucosal Dissection for Inexperienced Endoscopists: A Retrospective Study

AIM

Factors that may make endoscopic submucosal dissection (ESD) difficult for operators have been evaluated according to results based on the performance of experienced endoscopists. This study aimed to verify the predictors of difficult gastric ESD for ESD beginners.

METHODS

From January 2015 to December 2021, 466 superficial gastric neoplasms were treated with ESD at Showa University Hospital. Excluding 103 lesions that performed ESD by experts who experienced more than 80 ESDs, a total of 363 lesions were included. The lesions were divided into two groups according to the ESD performance experience of the operator: ESD beginner (EB; ESD experience≤30 cases) and ESD intermediate (EI; ESD experience 31-80 cases) groups. Relationships between difficult ESD (having at least one of the following: procedure time>60 min, incomplete resection, change of operator, and occurrence of severe complications) and clinicopathological findings of the lesion were analyzed.

RESULTS

The complete resection rates and the difficult ESD rates in the EB and EI groups were 99.3%, 94.8%, and 61.2%, 50.7%, respectively. In the EB group, univariate analysis showed that difficult ESD rate was significantly higher in the non-lower third lesions, the lesser curvature lesions, and cancerous lesions. In the EI group, univariate analysis showed that difficult ESD rate was significantly higher in lesion with ≥20 mm size, lesser curvature lesions, lesions with ulcers, and submucosal cancers. Multivariate analysis showed that the lesser curvature location and cancerous histology in the EB group and ≥20 mm lesion size, the lesser curvature location and submucosal invasion in the EI group were independent predictors of difficult ESD.

CONCLUSIONS

The lesser curvature location is recognized as independent ESD difficulty factor for both beginners and intermediates. Cases with lesions located in the lesser curvature should not be selected for gastric ESD training by beginners.

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.

[Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer]

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

A Template for Curriculum Development to Teach Complex Surgical or Endoscopic Techniques With Logistical Challenges

OBJECTIVE

The current, unprecedented pace of change in medicine challenges healthcare professionals to stay up-to-date. To more effectively disseminate new surgical or endoscopic techniques a modern paradigm of training is required. Our aim was to develop a curricular framework for complex techniques that provide logistical challenges to training in order to increase safe, effective use. We use colonic endoscopic submucosal dissection (cESD) as an example.

DESIGN

Curriculum development followed a multistep process representing best practice in training and education. First, a Clinical Needs Assessment established the demand for/sustainability of training. A Training Needs Analysis then identified the knowledge, skills, and attitudes required to perform cESD. A modified Delphi process defined desired learner characteristics, identified indications/contraindications to cESD, and developed a procedural task list. A pilot simulation program gathered feedback from cESD faculty experts and learners. Finally, a Behavioral Observation Scale was developed as a clinical assessment tool to assess procedural performance.

SETTING

The Houston Methodist Institute for Technology, Innovation and Education.

PARTICIPANTS

The first Curriculum Design Summit engaged 11 clinical SMEs, 4 education and training SMEs, 3 market development SMEs, and 1 medical device research and design engineer. The second Curriculum Design Summit engaged 10 clinical SMEs, 4 education and training SMEs, and 4 market development SMEs. We also engaged 12 Learner SMEs at both hands-on pilot courses who currently are training to perform cESD.

RESULTS

Desired learner criteria were defined (e.g., in practice >2 years, available case volume ≥25/year) to ensure ability and motivation of learners. Lesions were classified by (1) suitability for cESD (Clinical T1N0M0, Paris 0-IIa +1s  > 2 cm, 0-IIc + IIa, 0-IIc), and (2) suitability for trainee experience level. A comprehensive cESD task list was constructed and an assessment tool created based on SME review of key characteristics (e.g., comprehensiveness and usability).

CONCLUSION

We describe a comprehensive framework to develop educational curricula for complex surgical/endoscopic techniques with logistical challenges. To illustrate the sustainability of this training model and impact on patient outcomes, we plan to further develop and implement this program nationally.

Clinical practice guideline for endoscopic resection of early gastrointestinal cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by en bloc fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

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

BACKGROUND

Although endoscopic submucosal dissection (ESD) is widely used, the current status and trend in its training have yet to be fully evaluated. We aimed to investigate how ESD endoscopists have been trained in actual clinical practice.

METHODS

Endoscopists aged <45 years who have completed a gastroenterology fellowship or were currently in a fellowship for ≥2 years were included. We conducted a nationwide survey on the ESD training experiences of these endoscopists.

RESULTS

Among 79 young Korean endoscopists invited to participate in the survey, 68 (86.1%) trained in 24 major hospitals responded to the questionnaire. Twenty, 25, and 23 participants belonged to the second-year fellow, <5 years after training, and ≥5 years after training groups, respectively. Sixty-nine percent of the participants observed ≥50 ESD cases before starting ESD under supervision by an expert endoscopist. Additionally, 22% experienced ≥20 supervised ESDs during the training period. The proportion of the participants who underwent a hands-on course differed among the groups (≥5 years after training, 13.0%; <5 years after training, 40.0%; and second-year fellow, 50.0%; P = 0.027). ESD under supervision, observation, and hands-on course were the preferred methods for learning ESD (91.1%, 80.9%, and 35.3%, respectively). Overall, 42.6% of the participants were satisfied with their training program. More experience in supervised ESD (≥20 cases) was associated with an increased satisfaction (odds ratio, 6.65; 95% confidence interval, 1.62-36.31).

CONCLUSIONS

Observation and performance of ESD under the supervision of an expert endoscopist are the primary methods for learning ESD. Hands-on course program has been used more frequently in recent years.

Clinical Practice Guideline for Endoscopic Resection of Early Gastrointestinal Cancer

Although surgery was the standard treatment for early gastrointestinal cancers, endoscopic resection is now a standard treatment for early gastrointestinal cancers without regional lymph node metastasis. High-definition white light endoscopy, chromoendoscopy, and image-enhanced endoscopy such as narrow band imaging are performed to assess the edge and depth of early gastrointestinal cancers for delineation of resection boundaries and prediction of the possibility of lymph node metastasis before the decision of endoscopic resection. Endoscopic mucosal resection and/or endoscopic submucosal dissection can be performed to remove early gastrointestinal cancers completely by <i>en bloc</i> fashion. Histopathological evaluation should be carefully made to investigate the presence of risk factors for lymph node metastasis such as depth of cancer invasion and lymphovascular invasion. Additional treatment such as radical surgery with regional lymphadenectomy should be considered if the endoscopically resected specimen shows risk factors for lymph node metastasis. This is the first Korean clinical practice guideline for endoscopic resection of early gastrointestinal cancer. This guideline was developed by using mainly de novo methods and encompasses endoscopic management of superficial esophageal squamous cell carcinoma, early gastric cancer, and early colorectal cancer. This guideline will be revised as new data on early gastrointestinal cancer are collected.

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.

Short-Term Outcomes of Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer: A Prospective Multicenter Cohort Study

BACKGROUND/AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment for early gastric cancer (EGC) that has demonstrated a minimal risk of lymph node metastasis in retrospective studies. We sought to prospectively evaluate the short-term outcomes of ESD treatment in EGCs.

METHODS

A prospective multicenter cohort study of neoplasms 3 cm or less in diameter at endoscopic size evaluation was performed in 12 Korean ESD study grouprelated university hospitals and the National Cancer Center. Resected specimens were evaluated by the central pathologic review board.

RESULTS

A patient cohort (n=712) with a total of 737 EGCs was analyzed. The margin-free en bloc resection rate was 97.3%, and curative resection of 640 lesions (86.8%) was achieved. Lower curative resection rates were associated with lesions 2 to 3 cm in size prior to ESD compared with lesions 2 cm or less in size (78.6% vs 88.1%, respectively, p=0.009). Significant factors associated with noncurative resection were moderately or poorly differentiated histological type, posterior wall tumor location, tumor size larger than 3 cm, ulceration, and submucosal invasion. Delayed bleeding occurred in 49 patients (6.9%), and 12 patients (1.7%) exhibited perforations.

CONCLUSIONS

ESD is an effective treatment with a high curative resection rate for EGCs that meets relatively conservative pre-ESD indications. Long-term survival outcomes should be evaluated in followup studies.

Experimental gastric endoscopic submucosal dissection: training in a porcine model

Background

Endoscopic submucosal dissection (ESD) requires special skills and a long procedure time for a quality-controlled procedure. A universal training system remains to be established. Hands-on courses in animal models before advancing to the human colon appear to be essential, especially in Europe. The learning curve is a prerequisite in ESD, in order to improve technical outcomes and decrease the rate of procedural adverse events.

Methods

In the experimental research center of ELPEN Pharmaceuticals, 18 European endoscopists, inexperienced at ESD, performed gastric ESDs in porcine models. The course lasted two days and was conducted under the supervision of experts.

Results

A total of 72 of 76 ESDs were completed en bloc (94.7%). The procedural time and cutting speed differed significantly between the first and second day: 48±4.4 vs. 43±4.8 min (P=0.0045), and 1.38±0.20 vs. 1.63±0.23 cm²/min (P=0.0033), respectively. The complications were not significantly different between the two groups: five (13.88%) vs. four (11%) episodes of bleeding (P>0.05). The perforation rate was similar, at two episodes per day (5.55%). We documented an acceptable rate of en bloc resections and complications.

Conclusion

ESD demands a new level of endoscopic skills in Europe. A formal sequential training program, using porcine models, may benefit countries with a low volume of cases.

ENDOSCOPIC GASTRIC SUBMUCOSAL DISSECTION: experimental comparative protocol between standard technique and Hybrid-Knife(r)

BACKGROUND

Endoscopic treatment of superficial gastrointestinal tumors is routinely performed, however the advantages and shortcomings of submucosal pressure-jet dissection is still debated.

OBJECTIVE

- Aiming to compare this technique with conventional submucosal dissection, a study was designed in pigs.

METHODS

- Areas of the antral mucosa of the stomach with a diameter of 2 cm2 (6 per animal) were marked, and resected by means of the hybrid-knife (experimental technique), and Flush-knife or IT-knife (controls). An ERBE ICC 300 electrosurgical unit was adopted. End-points were procedural time, complications, and quality of the resected specimen.

RESULTS

- A total of 27 interventions were conducted in five animals. Time spent with the two options was quite short, and similar: 9.5±3.1 vs 8.0±3.0 minutes (P=0.21). Complications didn't differ (three per group, not significant), and removed specimen looked adequate in both circumstances.

CONCLUSION

- The hybrid-knife technique is an acceptable alternative to submucosal dissection, showing no difference compared to the standard technique taking into consideration the procedure, the presence of complications and the quality of the resected specimen.

Simulator training in gastrointestinal endoscopy - From basic training to advanced endoscopic procedures

Simulator-based gastrointestinal endoscopy training has gained acceptance over the last decades and has been extensively studied. Several types of simulators have been validated and it has been demonstrated that the use of simulators in the early training setting accelerates the learning curve in acquiring basic skills. Current GI endoscopy simulators lack the degree of realism that would be necessary to provide training to achieve full competency or to be applicable in certification. Virtual Reality and mechanical simulators are commonly used in basic flexible endoscopy training, whereas ex vivo and in vivo models are used in training the most advanced endoscopic procedures. Validated models for the training of more routine therapeutic interventions like polypectomy, EMR, stenting and haemostasis are lacking or scarce and developments in these areas should be encouraged.

Endoscopic Submucosal Dissection (ESD) and Related Techniques as Precursors of "New Notes" Resection Methods for Gastric Neoplasms

Endoscopic full-thickness resection for subepithelial tumors is one of the more attractive proposed methods for less-invasive transluminal surgery but remains challenging in terms of safety and feasibility. Currently, laparoscopic endoscopic cooperative surgery is thought to be a more clinically acceptable approach. In targeting cancers, however, more advanced nonexposure techniques are required to avoid the risk of iatrogenic tumor seeding. By combining these techniques with possible regional lymphadenectomy using sentinel node navigation surgery, an ideal minimally invasive, function-preserving gastric resection can be achieved even in possible node-positive cancers. Further development for this type of advanced endoscopic surgery is expected.

Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis

AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer.

METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding).

RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively.

CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the “several years” of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.

International digestive endoscopy network 2014: turnpike to the future

Social networks are useful in the study of relationships between individuals or entire populations, and the ties through which any given social unit connects. Those represent the convergence of the various social contacts of that unit. Consequently, the term "social networking service" (SNS) became extremely familiar. Similar to familiar SNSs, International Digestive Endoscopy Network (IDEN) 2014 was based on an international network composed of an impressive 2-day scientific program dealing with a variety of topics for gastrointestinal (GI) diseases, which connects physicians and researchers from all over the world. The scientific programs included live endoscopic demonstrations and provided cutting-edge information and practice tips as well as the latest advances concerning upper GI, lower GI, and pancreatobiliary endoscopy. IDEN 2014 featured American Society for Gastrointestinal Endoscopy-Korean Society of Gastrointestinal Endoscopy (ASGE-KSGE)-joint sessions prepared through cooperation between ASGE and KSGE. Furthermore, IDEN 2014 provided a special program for young scientists called the 'Asian Young Endoscopist Award Forum' to foster networks, with many young endoscopists from Asian countries taking an active interest and participation.

Endoscopic submucosal dissection in the colorectum: Feasibility in the Canadian setting

Endoscopic submucosal dissection is a minimally invasive endoscopic technique for the removal of gastrointestinal tumours that is increasingly being used for colonic neoplasms to spare resection of colon in selected patients. Colonic endoscopic submucosal dissection is technically challenging and was initially pioneered in Japan but increasingly used in selected western centres. Its use in Canada is currently limited, and the authors review the challenges and opportunities, in addition to the unique training infrastructure required to practice the procedure under supervision. Specific tools are required to perform endoscopic submucosal dissection and meticulous attention to detail is essential. The authors provide a combined Japanese and Canadian perspective to this technique, and discuss training and performance of endoscopic submucosal dissection as well as potential indications.

Endoscopic submucosal dissection training with ex vivo human gastric remnants

BACKGROUND

Endoscopic submucosal dissection (ESD) offers en bloc resection of early cancer or precancerous lesions, potentially saving patients from major organ resection, such as gastrectomy, colectomy, and esophagectomy. Japan now leads the world in ESD due to its high rate of gastric cancer. Western countries, with their lower gastric cancer rates, do not get as much experience with the technique. Training in ESD utilizing both in vivo and ex vivo porcine stomach has been shown to decrease rates of perforation and operative time. Both models can be prohibitively expensive or not generally available to the majority of endoscopists on a regular basis. This study describes the framework for using human gastric remnants from sleeve gastrectomy patients for ESD training.

METHODS

Patients undergoing sleeve gastrectomy for morbid obesity were consented for use of their gastric specimen before surgery. The specimen was weighed and measured by the pathologist and then used for ESD training. The specimen was mounted to a 15-mm laparoscopic port and secured using a pursestring suture. ESD was then performed through this port.

RESULTS

We were able to successfully use this model to resect multiple marked out lesions in an en bloc fashion. Training using this model has improved our dissection times from approximately 2 h to 30 min for a 2-cm simulated lesion.

CONCLUSIONS

ESD requires the endoscopist to perform a surgical dissection. Until now, development of these skills required intensive training on porcine models that are not widely available. We were able to create a method using the excised portion from sleeve gastrectomy patients, providing a more accessible and cost-effective model for ESD training and potentially other endoscopic therapeutic modalities.