Clinical Practice of Endoscopic Submucosal Dissection for Early Colorectal Neoplasms by a Colonoscopist with Limited Gastric Experience

Abstract

Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.

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

“…The study of Chong et al was the only one to describe the learning curve in a trainee with no prior ESD experience [28]. Thirteen studies described trainees who started colorectal ESD with previous upper gastrointestinal (UGI) ESD experience [29][30][31][32][33][34][35][36][37][38][39][40][41]. Twelve studies described trainees with previous experience on animal models [22,23,[25][26][27][42][43][44][45][46][47][48].…”

“…The most common outcome measures used were en bloc resection rates and procedural speed, which were reported in 18 studies [25][26][27][28][29][30][31][33][34][35][36]38,40,[42][43][44][45]49]. The other common outcome measure used was R0 resection, defined as an en bloc resection where lateral and basal margins were free of tumour cells.…”

A task and performance analysis of endoscopic submucosal dissection (ESD) surgery

“…Six major phases for the ESD procedure were identified: (1) procedural preparation, (2) coagulative marking circumferentially outside of the borders of the lesion, in order to improve visualization of the boundaries of the tumor during the procedure, (3) injection of a solution into the submucosal space to lift the lesion and create a protective cushion [34] for cutting, (4) circumferential cutting around the lesion using endoscopic electrocautery knives which have been described elsewhere (Matsui et al [35]), (5) submucosal dissection by using an electrosurgical knife, and (6) evaluation of the colon for bleeding and perforations throughout the procedure and at the conclusion of the procedure. Furthermore, we described all the tasks performed for each of six ESD phases.…”

Endoscopic submucosal dissection

“…100 Indeed, in some series of colorectal ESD performed by novice/trainee endoscopists, all perforations occurred in colonic (nonrectal) cases. 101,102 Learning curves There is no single "learning curve" for ESD, but rather multiple learning curves that vary based on lesion characteristics (eg, anatomic site, size) and outcome of interest (eg, total procedure time, R0 resection rate, adverse event rate). Further, learners with abundant experience assisting in human procedures and/or performing resections in animal models will enter at a higher point on most learning curves and thus experience measurable improvements at a less rapid pace than more novice operators.…”