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Hadjinicolaou AV, Pappas A, Sujendran V, Kakhandki V, Abe S, di Pietro M. Untutored training pathway to achieve competence in esophagogastric endoscopic submucosal dissection in a Western center. Gastrointest Endosc 2024; 99:439-443.e6. [PMID: 37898221 DOI: 10.1016/j.gie.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/30/2023]
Abstract
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.
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Affiliation(s)
- Andreas V Hadjinicolaou
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom; Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Apostolos Pappas
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom; Department of Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Vijay Sujendran
- Cambridge Oesophago-Gastric Center, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Vibhay Kakhandki
- Department of Anaesthesia, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Massimiliano di Pietro
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom.
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Cao J, Yip HC, Chen Y, Scheppach M, Luo X, Yang H, Cheng MK, Long Y, Jin Y, Chiu PWY, Yam Y, Meng HML, Dou Q. Intelligent surgical workflow recognition for endoscopic submucosal dissection with real-time animal study. Nat Commun 2023; 14:6676. [PMID: 37865629 PMCID: PMC10590425 DOI: 10.1038/s41467-023-42451-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/11/2023] [Indexed: 10/23/2023] Open
Abstract
Recent advancements in artificial intelligence have witnessed human-level performance; however, AI-enabled cognitive assistance for therapeutic procedures has not been fully explored nor pre-clinically validated. Here we propose AI-Endo, an intelligent surgical workflow recognition suit, for endoscopic submucosal dissection (ESD). Our AI-Endo is trained on high-quality ESD cases from an expert endoscopist, covering a decade time expansion and consisting of 201,026 labeled frames. The learned model demonstrates outstanding performance on validation data, including cases from relatively junior endoscopists with various skill levels, procedures conducted with different endoscopy systems and therapeutic skills, and cohorts from international multi-centers. Furthermore, we integrate our AI-Endo with the Olympus endoscopic system and validate the AI-enabled cognitive assistance system with animal studies in live ESD training sessions. Dedicated data analysis from surgical phase recognition results is summarized in an automatically generated report for skill assessment.
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Affiliation(s)
- Jianfeng Cao
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong, China
| | - Hon-Chi Yip
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
| | - Yueyao Chen
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong, China
| | - Markus Scheppach
- Internal Medicine III-Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Xiaobei Luo
- Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hongzheng Yang
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong, China
| | - Ming Kit Cheng
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Hong Kong, China
| | - Yonghao Long
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong, China
| | - Yueming Jin
- Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - Philip Wai-Yan Chiu
- Multi-scale Medical Robotics Center and The Chinese University of Hong Kong, Hong Kong, China.
| | - Yeung Yam
- Department of Mechanical and Automation Engineering, The Chinese University of Hong Kong, Hong Kong, China.
- Multi-scale Medical Robotics Center and The Chinese University of Hong Kong, Hong Kong, China.
- Centre for Perceptual and Interactive Intelligence and The Chinese University of Hong Kong, Hong Kong, China.
| | - Helen Mei-Ling Meng
- Centre for Perceptual and Interactive Intelligence and The Chinese University of Hong Kong, Hong Kong, China.
| | - Qi Dou
- Department of Computer Science and Engineering, The Chinese University of Hong Kong, Hong Kong, China.
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Lee JG, Park CH, Chung H, Park JC, Kim DH, Lee BI, Byeon JS, Jung HY. Current status and trend in training for endoscopic submucosal dissection: A nationwide survey in Korea. PLoS One 2020; 15:e0232691. [PMID: 32384112 PMCID: PMC7209322 DOI: 10.1371/journal.pone.0232691] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/19/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Jae Gon Lee
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Bo-In Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
- * E-mail:
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Cetinsaya B, Gromski MA, Lee S, Xia Z, Demirel D, Halic T, Bayrak C, Jackson C, De S, Hegde S, Cohen J, Sawhney M, Stavropoulos SN, Jones DB. A task and performance analysis of endoscopic submucosal dissection (ESD) surgery. Surg Endosc 2019; 33:592-606. [PMID: 30128824 PMCID: PMC6344246 DOI: 10.1007/s00464-018-6379-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/10/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries. METHODS We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons. RESULTS The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores. CONCLUSIONS We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.
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Affiliation(s)
- Berk Cetinsaya
- Department of Computer Science, University of Arkansas at Little Rock, Little Rock, AR, United States
| | - Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sangrock Lee
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Zhaohui Xia
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Doga Demirel
- Department of Computer Science, University of Arkansas at Little Rock, Little Rock, AR, United States
| | - Tansel Halic
- Department of Computer Science, University of Central Arkansas, 201 Donaghey Ave, Conway, AR, 72035, USA.
| | - Coskun Bayrak
- Department of Computer Science & Information Systems, Youngstown State University, Youngstown, OH, USA
| | - Cullen Jackson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Suvranu De
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Sudeep Hegde
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonah Cohen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mandeep Sawhney
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Daniel B Jones
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Gromski MA, Cohen J, Saito K, Gonzalez JM, Sawhney M, Kang C, Moore A, Matthes K. Learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator. Surg Endosc 2017; 31:4231-4237. [PMID: 28281126 DOI: 10.1007/s00464-017-5484-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 02/16/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is increasingly being used in Asia as a minimally invasive therapy to eradicate large laterally spreading superficial tumors in the colon. To date, the learning curve and effectiveness of ex vivo simulators in colonic ESD training remain unclear. The aim of the study is to determine the learning curve of colonic ESD in an ex vivo simulator. METHODS We conducted a prospective study of colon ESD in ex vivo porcine colons in a prototype simulator. Three endoscopists with prior experience in gastric ESD but with no experience in colonic ESD each performed 30 ESD resections on standardized lesions in the rectosigmoid and left colon of the porcine simulator. Procedure time, en bloc resection status, and perforation were recorded. RESULTS All 90 lesions were resected using the ESD technique. The mean time of procedure was 49.6 min (standard deviation 29.6 min). The aggregate rate of perforation was 14.4% and the aggregate rate of non-en bloc resection was 5.6%. Using a composite quality score integrating complications and procedural time, it was found that there was a significant difference between two local polynomial regression lines when using a cut-point at the 9th procedure (p = 0.04), reflecting the point at which most of the learning curve is traversed. CONCLUSIONS In this study, there were significant improvements realized in colonic ESD performance after 9 colon ESD procedures in ex vivo specimens. Although training will depend on endoscopist skill and expertise, we suggest at least 9 ex vivo procedures prior to moving to live animal or proctored training in colonic ESD.
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Affiliation(s)
- Mark A Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN, 46202, USA.
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Jonah Cohen
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kayoko Saito
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Medical Topia Soka Hospital, Soka, Japan
| | - Jean-Michel Gonzalez
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Gastroenterology, Aix-Marseille University, APHM, Hôpital Nord, Marseille, France
| | - Mandeep Sawhney
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Changdon Kang
- Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Andrew Moore
- Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | - Kai Matthes
- Department of Anesthesia, Critical Care and Pain Medicine, Children's Hospital, Harvard Medical School, Boston, MA, USA
- T.A.M.G.I., Maui, HI, USA
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