How to establish endoscopic submucosal dissection in Western countries

Abstract

Endoscopic submucosal dissection (ESD) has been invented in Japan to provide resection for cure of early cancer in the gastrointestinal tract. Professional level of ESD requires excellent staging of early neoplasias with image enhanced endoscopy (IEE) to make correct indications for ESD, and high skills in endoscopic electrosurgical dissection. In Japan, endodiagnostic and endosurgical excellence spread through personal tutoring of skilled endoscopists by the inventors and experts in IEE and ESD. To translocate this expertise to other continents must overcome two fundamental obstacles: (1) inadequate expectations as to the complexity of IEE and ESD; and (2) lack of suitable lesions and master-mentors for ESD trainees. Leading endoscopic mucosal resection-proficient endoscopists must pioneer themselves through the long learning curve to proficient ESD experts. Major referral centers for ESD must arise in Western countries on comparable professional level as in Japan. In the second stage, the upcoming Western experts must commit themselves to teach skilled endoscopists from other referral centers, in order to spread ESD in Western countries. Respect for patients with early gastrointestinal cancer asks for best efforts to learn endoscopic categorization of early neoplasias and skills for ESD based on sustained cooperation with the masters in Japan. The strategy is discussed here.

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

“…Nevertheless, this ESD-ITT approach is consistent with clinical practice in the management of colorectal lesions with indication criteria for ESD 11 and supports the strategy of "How to implement ESD technique", 3,6 provided the data are: (i) not skewed by additional technical training; (ii) unbiased with regard to patients, indications and strategy for ESD; and (iii) the outcome well compares with benchmarks set for ESD. 2 Each of the three operators had participated in the same experimental ESD training for preparation, including approximately 30 porcine ex vivo ESD procedures, 3 and one annual expert training course on experimental ESD. 7 After endoscopic treatment of recurrent/residual adenomas (by biopsy forceps, argon plasma coagulation or EMR).…”

“…Each of the three operators had participated in the same experimental ESD training for preparation, including approximately 30 porcine ex vivo ESD procedures, and one annual expert training course on experimental ESD . Independent self‐learning of ESD was based on principles .…”

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

“…2,[11][12][13] Currently, existing training programmes have consistently included: acquiring basic knowledge, practicing on animal models (ex vivo animal organs and live porcine models), visiting centres with a high ESD volume, attendance of hands-on training ESD workshops and only then proceeding to clinical practice, ideally under supervision by an expert when available during the first cases. 2,[11][12][13] Workshops using animal models are being organised in many specialised training centres with the potential to aid in speeding up the learning process and achieving initial competence in ESD in a safe learning environment with direct one-on-one expert supervision. [14][15][16] It seems logical to practise skills in advanced endoscopic resections in a live porcine model, which is considered to have the closest resemblance to the human anatomy.…”

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

“…A learning curve in performing successful ESD procedures has been demonstrated, and more experienced endoscopists have higher rate of en bloc resection, reduced procedure duration and fewer adverse events, mostly related to perforations [64,65]. Therefore, a pre-patient training program is recommended before ESD is performed in the clinical setting [64,66,67]. The differences between the East and West support the use of simulators for ESD training in the West, whereas in the East, where expert supervision and suitable learning cases are easily available, a simulator phase may not be necessary [68].…”

“…Performing ESD in the oesophagus is more demanding than gastric ESD. This is in part due to the thinner muscle layer and the tubular shape of the oesophagus which provides a limited space to work in [67]. It has been demonstrated that by training in ex vivo models for oesophageal ESD, endoscopists with experienced in gastric ESD, were able to reduce the operation time and the number of deep injuries to the muscularis propria after 10 procedures, when the five initial ESDs were compared to the final five [76].…”