How to establish endoscopic submucosal dissection in Western countries

Table 4 Principles for establishing endoscopic submucosal dissection by an untutored learning curve (modified from[38])

Evaluate the lesion during prior endoscopy for ESD indication and resection strategy

Avoid risk of any R2 resection of cancer (no signs for deep submucosal invasion!)

Avoid high risk lesions (> 5 cm diameter, or in fornix and cardia, duodenum, colonic flexures)

Safety comes first, procedure time of ESD is of minor importance in the beginning

Only cut tissue or fibers in submucosa that you clearly see and have identified

Keep the vision field clear, prevent and immediately stop bleeding

Close any perforation immediately by endoscopic clipping on expert level

Complete any started ESD procedure with intention for safe, curative resection

Guide personally the patient pre-ESD (informed consent) and post-ESD (for any complication)

Only a single endoscopist per unit should do untutored ESD until he is on competence level1

Document all entire ESD procedures on DVD recordings (for evidence and error analysis)

Follow-up short-term and long-term (center Registry), trend in dozens

¹Performance of 20 consecutive ESD procedures with < 10% complications. ESD: Endoscopic submucosal dissection.