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Qatomah A, Aihara H. Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives. DEN OPEN 2025; 5:e394. [PMID: 38915785 PMCID: PMC11194299 DOI: 10.1002/deo2.394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 06/26/2024]
Abstract
Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.
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Affiliation(s)
- Abdulrahman Qatomah
- Division of Gastroenterology and HepatologyMcGill University Health CenterMontrealCanada
- Division of Gastroenterology and HepatologyKing Faisal Specialist Hospital and Research CenterJeddahSaudi Arabia
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and EndoscopyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Toba T, Ishii T, Sato N, Nogami A, Hojo A, Shimizu R, Fujimoto A, Matsuda T. Effectiveness of a novel ex vivo training model for gastric endoscopic submucosal dissection training: a prospective observational study conducted at a single center in Japan. Clin Endosc 2025; 58:94-101. [PMID: 39489604 PMCID: PMC11837555 DOI: 10.5946/ce.2024.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/01/2024] [Accepted: 06/03/2024] [Indexed: 11/05/2024] Open
Abstract
BACKGROUND/AIMS The efficacy of endoscopic submucosal dissection (ESD) for early-stage gastric cancer is well established. However, its acquisition is challenging owing to its complexity. In Japan, G-Master is a novel ex vivo gastric ESD training model. The effectiveness of training using G-Master is unknown. This study evaluated the efficacy of gastric ESD training using the G-Master to evaluate trainees' learning curves and performance. METHODS Four trainees completed 30 ESD training sessions using the G-Master, and procedure time, resection area, resection completion, en-bloc resection requirement, and perforation occurrence were measured. Resection speed was the primary endpoint, and learning curves were evaluated using the Cumulative Sum (CUSUM) method. RESULTS All trainees completed the resection and en-bloc resection of the lesion without any intraoperative perforations. The learning curves covered three phases: initial growth, plateau, and late growth. The transition from phase 1 to phase 2 required a median of 10 sessions. Each trainee completed 30 training sessions in approximately 4 months. CONCLUSIONS Gastric ESD training using the G-Master is a simple, fast, and effective method for pre-ESD training in clinical practice. It is recommended that at least 10 training sessions be conducted.
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Affiliation(s)
- Takahito Toba
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Tsuyoshi Ishii
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Nobuyuki Sato
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Akira Nogami
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Aya Hojo
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ryo Shimizu
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ai Fujimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takahisa Matsuda
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
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Masunaga T, Sasaki M, Sato M, Minezaki D, Morioka K, Tojo A, Sakurai H, Iwata K, Miyazaki K, Kubosawa Y, Mizutani M, Akimoto T, Takatori Y, Kawasaki S, Matsuura N, Nakayama A, Sujino T, Takabayashi K, Yahagi N, Nakajima K, Kato M. Intraoperative bleeding model for swine gastric endoscopic submucosal dissection via heparinization. Endosc Int Open 2024; 12:E1360-E1365. [PMID: 39610944 PMCID: PMC11604307 DOI: 10.1055/a-2411-9979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 09/09/2024] [Indexed: 11/30/2024] Open
Abstract
Background and study aims: Live swine have a high degree of coagulation and aggregation and using them for training about how to manage intraoperative bleeding during endoscopic submucosal dissection (ESD) is unsatisfactory. This study aimed to identify the appropriate heparin dose in an intraoperative bleeding model and validate its applicability. Methods: First, we explored the dose of heparin required for a swine bleeding model in which the activated clotting time reached and maintained the upper limit of measurement (1500 s) after 10 minutes. Second, we compared intraoperative bleeding and hematoma frequency during ESD for 2-cm lesions between the heparinized bleeding model and control groups. Intraoperative bleeding was classified according to the Forrest classification. Results: The combination of a bolus (300 U/kg), continuous infusion (300 U/kg/h), and a bolus dose (150 U/kg) of heparin 10 minutes after the first infusion was identified as the dose for the bleeding model. Five ESDs were performed in each heparinized bleeding model and the control group. The median number of intraoperative bleeds was significantly higher in the heparinized model than in the control group (5 interquartile range [IQR] 4-7 vs. 3 [IQR 0-4, P = 0.028). All of the intraoperative bleeding events oozing (Forrest Ib) rather than spurting (Forrest Ia). The median number of hematomas was significantly higher in the heparinized model group than in the control group (3 [IQR 1-4] vs. 0 [IQR 0-1], P = 0.023). Conclusions: High doses of heparin significantly increased intraoperative bleeding and hematoma during swine ESD.
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Affiliation(s)
- Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Moe Sato
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Minezaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Morioka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Anna Tojo
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hinako Sakurai
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kurato Miyazaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tomohisa Sujino
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kiyokazu Nakajima
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
| | - Motohiko Kato
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
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Sundaram S, Mahajan A, Patil P. Advanced endoscopic resection for early gastrointestinal cancers in India: Challenges and opportunities await! Indian J Gastroenterol 2024; 43:866-868. [PMID: 39259448 DOI: 10.1007/s12664-024-01686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Affiliation(s)
- Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India.
| | - Akhil Mahajan
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India
| | - Prachi Patil
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. E Borges Road, Parel, Mumbai, 400 012, India
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Wlodarczyk J, Gupta A, Lee SW. Combined Endoscopy-Laparoscopy Surgery: When and How to Utilize This Tool. Clin Colon Rectal Surg 2024; 37:309-317. [PMID: 39132203 PMCID: PMC11309789 DOI: 10.1055/s-0043-1770945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Combined endoscopic and laparoscopic surgery (CELS) has been used to resect colon polyps since the 1990s. These colon-sparing techniques, however, have not yet been widely adopted. With the evolution of technology in both diagnosing and treating colon cancer, colorectal surgeons should strive for a diverse and complete armamentarium through which they can best serve their patients. In this article, we hope to provide clarity on CELS by discussing three topics: (1) the history and fruition of CELS; (2) the techniques involved in CELS; and (3) the utility of CELS within different clinical scenarios. Our goal is to educate readers and stimulate consideration of CELS in select patients who might benefit greatly from these techniques.
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Affiliation(s)
- Jordan Wlodarczyk
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
| | - Abhinav Gupta
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
| | - Sang W. Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
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Mitsui T, Sunakawa H, Yoda Y, Nishio M, Kondo S, Hamanaka J, Tokoro C, Nakajo K, Maeda S, Yano T, Hirasawa K. Novel gastric endoscopic submucosal dissection training model enhances the endoscopic submucosal dissection skills of trainees: a multicenter comparative study. Surg Endosc 2024; 38:3088-3095. [PMID: 38619558 DOI: 10.1007/s00464-024-10838-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) requires high endoscopic technical skills, and trainees should develop effective training methods. In collaboration with KOTOBUKI Medical, we developed the G-Master, which is a non-animal training model that can simulate various parts of gastric ESD. We aimed to clarify the usefulness of the G-Master for inexperienced ESD trainees. METHODS We collected data from the first 5 gastric ESD cases conducted by 15 inexperienced ESD trainees at 5 participating centers between 2018 and 2022. The participants were divided into two groups: the G-Master training and non-G-Master training groups. Outcome measurements, such as procedural speed, perforation rate, self-completion rate, and en bloc resection rate, were compared between the two groups retrospectively. RESULTS A total of 75 gastric ESD cases were included in this study. The G-Master training group included 25 cases performed by 5 trainees, whereas the non-G-Master training group included 50 cases performed by 10 trainees. The median procedural speed for all cases was significantly faster in the G-Master training group than in the non-G-Master training group. Moreover, the procedural speed was linearly improved from the initial to the last cases in the lower location in the G-Master training group compared with the non-G-Master training group. In addition, although there was no significant difference, the G-Master training group showed lower rates of perforation and a lesser need to transition to expert operators than the non-G-Master training group. CONCLUSION The G-Master could improve the ESD skills of inexperienced ESD trainees.
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Affiliation(s)
- Tomohiro Mitsui
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
- Division of Endoscopy, Saitama Cancer Center, Saitama, Japan
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Hironori Sunakawa
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
- NEXT Medical Device Innovation Center, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Yusuke Yoda
- Division of Endoscopy, Saitama Cancer Center, Saitama, Japan
| | - Masafumi Nishio
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
| | - Shinpei Kondo
- Department of Gastroenterology, Fujisawa City Hospital, Kanagawa, Japan
| | - Jun Hamanaka
- Department of Gastroenterology, Yokohama Minami Kyosai Hospital, Kanagawa, Japan
| | - Chikako Tokoro
- Department of Gastroenterology, Saiseikai Yokohamashi Nannbu Hospital, Kanagawa, Japan
| | - Keiichiro Nakajo
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Shin Maeda
- Department of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
- NEXT Medical Device Innovation Center, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Kingo Hirasawa
- Division of Endoscopy, Yokohama City University Medical Center, Kanagawa, Japan
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Masunaga T, Kato M, Sasaki M, Iwata K, Miyazaki K, Kubosawa Y, Mizutani M, Takatori Y, Matsuura N, Nakayama A, Takabayashi K, Yahagi N. Novel quantitative assessment indicators for efficiency and precision of endoscopic submucosal dissection in animal training models by analyzing an electrical surgical unit. Dig Endosc 2024; 36:19-27. [PMID: 37405690 DOI: 10.1111/den.14632] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/02/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES Although endoscopic submucosal dissection (ESD) training is important, quantitative assessments have not been established. This study aimed to explore a novel quantitative assessment system by analyzing an electrical surgical unit (ESU). METHODS This was an ex vivo study. Step one: to identify the novel efficiency indicators, 20 endoscopists performed one ESD each, and we analyzed correlations between their resection speed and electrical status. Step two: to identify the novel precision indicators, three experts and three novices performed one ESD each, and we compared the stability of the electrical status. Step three: three novices in step two performed 19 additional ESDs, and we analyzed the learning curve using novel indicators. RESULTS Step one: the percentage of total activation time (AT) of ESU in the procedure time (β coefficient, 0.80; P < 0.01) and AT required for submucosal dissection (β coefficient, -0.57; P < 0.01) were significantly correlated with the resection speed. Step two: coefficient of variation of the AT per one pulse (0.16 [range, 0.13-0.17] vs. 0.26 [range, 0.20-0.41], P = 0.049) and coefficient of variation of the peak electric power per pulse during mucosal incision (0.14 [range, 0.080-0.15] vs. 0.25 [range, 0.24-0.28], P = 0.049) were significantly lower in the experts than in the novices. Regarding the learning curve, the percentage of total AT of ESU in the procedure time and AT required for submucosal dissection had a trend of improvement. CONCLUSION Novel indicators identified by analyzing ESU enable quantitative assessment for endoscopist's skill.
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Affiliation(s)
- Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kurato Miyazaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Jeon SW. There is no royal road: a shortcut for endoscopic submucosal dissection training. Clin Endosc 2023; 56:590-591. [PMID: 37614149 PMCID: PMC10565439 DOI: 10.5946/ce.2023.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Seong Woo Jeon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Sun Y, Liu L, Shi D, Ma C, Xu X. Assessment of a Real-world Learning Curve for the Endoscopic Resection of Gastric Gastrointestinal Stromal Tumors. J Int Med Res 2023; 51:3000605231194448. [PMID: 37646636 PMCID: PMC10469254 DOI: 10.1177/03000605231194448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/27/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Endoscopic resection (ER) is a proven treatment for gastric gastrointestinal stromal tumors (gGISTs). We aimed to assess the learning curve (LC) associated with ER for gGISTs and identify determinants. METHODS We conducted an analysis of 289 patients who underwent the ER of gGISTs by an experienced endoscopist. To characterize the LC, we employed cumulative sum analysis of the duration of surgery. The participants were divided into an early phase (cases 1-50) and a later phase (case 51-289), which were compared. Furthermore, we identified risk factors for the conversion from endoscopic to laparoscopic resection (LR). RESULTS The durations of surgery and hospitalization were shorter, and there were fewer complications and fasting days in the later phase. The conversion rates to LR were 6.0% and 2.5% in the early and later phases, respectively. The tumor diameter (≥3.0 cm) and invasion beyond the muscularis propria were significant risk factors for conversion to LR (odds ratio 17.92, 95% confidence interval 2.66-120.87; and 58.03, 6.40-525.84; respectively). CONCLUSIONS The LC for ER of gGISTs lasts for approximately 50 cases. In addition, tumors ≥3.0 cm in diameter and those that invade beyond the muscularis propria are more likely to require conversion to LR.
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Affiliation(s)
- Ying Sun
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China
| | - Luojie Liu
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University. Suzhou, China
| | - Dongtao Shi
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University. Suzhou, China
| | - Chao Ma
- Department of Gastroenterology, the First Affiliated Hospital of Soochow University. Suzhou, China
| | - Xiaodan Xu
- Department of Gastroenterology, Changshu Hospital Affiliated to Soochow University, Suzhou, China
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Gonzalez JM, Meunier E, Debourdeau A, Basile P, Le-Mouel JP, Caillo L, Vitton V, Barthet M. Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy. Surg Endosc 2023; 37:2062-2069. [PMID: 36289086 DOI: 10.1007/s00464-022-09736-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/11/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients' cases under expert supervision. The objective was to establish a learning curve of POEM. MATERIALS AND METHODS Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP). RESULTS The operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM. CONCLUSION The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau.
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Affiliation(s)
- Jean-Michel Gonzalez
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France.
| | - Elise Meunier
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
| | | | | | | | | | - Véronique Vitton
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
| | - Marc Barthet
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France
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11
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Simsek C, Aihara H. Training in Endoscopic Submucosal Dissection in the United States: The Current Paradigm. Gastrointest Endosc Clin N Am 2023; 33:41-53. [PMID: 36375885 DOI: 10.1016/j.giec.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Endoscopic submucosal dissection (ESD) training in Japan is pursued through a designated master-apprentice, organ-based stepwise training model. However, applying a similar program to the United States is not a practical strategy due to the significant differences in the training system and disease prevalence. To incorporate the ESD training into the current advanced endoscopy fellowship program, the use of recently developed techniques and technologies to improve the efficiency of ESD is ideal. The ESD training program in the United States should be prevalence-based, with increased involvement of trainees depending on their objectively assessed competency levels.
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Affiliation(s)
- Cem Simsek
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Cecinato P, Lucarini M, Azzolini F, Campanale M, Bassi F, Cippitelli A, Sassatelli R. Endoscopic submucosal dissection in colorectal neoplasia performed with a waterjet system-assisted knife: higher en-bloc resection rate than conventional technique. Clin Endosc 2022; 55:775-783. [PMID: 36464827 PMCID: PMC9726436 DOI: 10.5946/ce.2022.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND/AIMS Colorectal endoscopic submucosal dissection (ESD) is burdened by its associated high risk of adverse events and long procedure time. Recently, a waterjet-assisted knife was introduced to simplify and speed up the procedure. The aim of this study was to evaluate the efficacy and safety of waterjet-assisted ESD (WESD) compared to that of the conventional ESD (CESD) technique. METHODS The charts of 254 consecutive patients who underwent colorectal ESD between January 2014 and February 2021 for colorectal neoplasms were analyzed. The primary outcome was the en-bloc resection rate. Secondary outcomes were complete and curative resection rates, the need to switch to a hybrid ESD, procedure speed, the adverse event rates, and the recurrence rates. RESULTS Approximately 174 neoplasias were considered, of which, 123 were removed by WESD and 51 by CESD. The en-bloc resection rate was higher in the WESD group (94.3% vs. 84.3%). Complete resection rates and curative resection rates were similar. The need to switch to a hybrid ESD was greater during CESD (39.2% vs. 13.8%). Procedure speed and adverse event rates were similar. During follow-up, one recurrence occurred after a WESD. CONCLUSION WESD allows a high rate of en-bloc resections and less frequently requires a rescue switch to the hybrid ESD compared to CESD.
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Affiliation(s)
- Paolo Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy,Correspondence: Paolo Cecinato Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Via Giovanni Amendola 2, 42122 Reggio Emilia, Italy E-mail:
| | - Matteo Lucarini
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Azzolini
- Unit of Digestive Endoscopy, Vita Salute San Raffaele University, Milan, Italy
| | - Mariachiara Campanale
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Fabio Bassi
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Annalisa Cippitelli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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13
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John S. Waterjet-assisted endoscopic submucosal dissection in the colorectum: safe and effective? Clin Endosc 2022; 55:755-756. [PMID: 36464823 PMCID: PMC9726437 DOI: 10.5946/ce.2022.271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/14/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sneha John
- Endoscopy, Gold Coast University Hospital, Southport, Australia,Correspondence: Sneha John Endoscopy, Gold Coast University Hospital, Southport, Australia E-mail:
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14
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Küttner-Magalhães R, Dinis-Ribeiro M, Bruno MJ, Marcos-Pinto R, Rolanda C, Koch AD. A Steep Early Learning Curve for Endoscopic Submucosal Dissection in the Live Porcine Model. Dig Dis 2022; 40:816-825. [PMID: 34915487 PMCID: PMC9808771 DOI: 10.1159/000521429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 12/08/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Ricardo Küttner-Magalhães
- Department of Gastroenterology, Santo António Hospital, Porto University Hospital Center, Porto, Portugal,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine of Porto, Porto, Portugal
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Ricardo Marcos-Pinto
- Department of Gastroenterology, Santo António Hospital, Porto University Hospital Center, Porto, Portugal,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal,Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine of Porto, Porto, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Arjun D. Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands,*Arjun D. Koch,
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Visrodia K, Sawas T, Zakko L, Genere JR, Leggett C, Lutzke L, Wang KK. Scissor-type knife improves the safety of endoscopic submucosal dissection (ESD) among endoscopists without experience in ESD: a randomized ex vivo study. Endosc Int Open 2021; 9:E1207-E1213. [PMID: 34447866 PMCID: PMC8383092 DOI: 10.1055/a-1487-5469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/19/2020] [Indexed: 10/28/2022] Open
Abstract
Background and study aims Endoscopic submucosal dissection (ESD) is technically challenging, difficult to learn, and carries a substantial risk of perforation, all of which remain significant barriers to its adoptability. We aimed to determine whether use of a novel scissor-type knife improved efficacy and safety among novice performers of ESD. Materials and methods Following a brief didactic session on ESD, participants performed ESD of two lesions (2 cm diameter) in an ex vivo porcine gastric model. One resection was performed with a conventional knife and the other with the scissor knife (order of knife randomized). We recorded procedure time, successful en bloc resection, and adverse events (including full-thickness perforation and muscle injury) for each dissection. Participants completed a post-study survey. Results 10 endoscopists (8 trainees, 2 staff) considered novices in ESD participated. Compared with the conventional knife, use of the scissor knife was associated with a significantly shorter time to completion of submucosal dissection (mean 6.2 [SD 5.6] vs. 15.6 [SD 15.6] minutes; P = 0.04) and total procedure time was not significantly different (22.1 [SD 13.3] vs. 24.9 [SD 26.5] minutes; P = 0.65). Scissor knife use was also associated with a significantly lower proportion of perforation and/or muscle injury (10.0 % vs. 70.0 %; P < 0.01) and proportion of muscle injury alone (10.0 % vs. 60.0 %; P = 0.02). Conclusions Among novices performing ESD on an ex vivo animal model, use of a scissor knife was associated with a significantly lower proportion of adverse events without prolonging procedure time. Scissor-type knives may improve ESD safety, at least among novices.
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Affiliation(s)
- Kavel Visrodia
- Digestive and Liver Diseases, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, United States
| | - Tarek Sawas
- Division of Digestive and Liver Diseases, University of Texas Southwestern, Dallas, Texas, United States
| | - Liam Zakko
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Juan Reyes Genere
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Cadman Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Lori Lutzke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Jung Y, Baik GH, Ko WJ, Ko BM, Kim SH, Jang JS, Jang JY, Lee WS, Cho YK, Lim SG, Moon HS, Yoo IK, Cho JY. Diode Laser-Can It Replace the Electrical Current Used in Endoscopic Submucosal Dissection? Clin Endosc 2021; 54:555-562. [PMID: 33435658 PMCID: PMC8357600 DOI: 10.5946/ce.2020.229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS A new medical fiber-guided diode laser system (FDLS) is expected to offer high-precision cutting with simultaneous hemostasis. Thus, this study aimed to evaluate the feasibility of using the 1,940-nm FDLS to perform endoscopic submucosal dissection (ESD) in the gastrointestinal tract of an animal model. METHODS In this prospective animal pilot study, gastric and colorectal ESD using the FDLS was performed in ex vivo and in vivo porcine models. The completeness of en bloc resection, the procedure time, intraprocedural bleeding, histological injuries to the muscularis propria (MP) layer, and perforation were assessed. RESULTS The en bloc resection and perforation rates in the ex vivo study were 100% (10/10) and 10% (1/10), respectively; those in the in vivo study were 100% (4/4) and 0% for gastric ESD and 100% (4/4) and 25% (1/4) for rectal ESD, respectively. Deep MP layer injuries tended to occur more frequently in the rectal than in the gastric ESD cases, and no intraprocedural bleeding occurred in either group. CONCLUSION The 1,940-nm FDLS was capable of yielding high en bloc resection rates without intraprocedural bleeding during gastric and colorectal ESD in animal models.
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Affiliation(s)
- Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Gwang Ho Baik
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Weon Jin Ko
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Bong Min Ko
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seong Hwan Kim
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Jin Seok Jang
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Young Jang
- Department of Gastroenterology and Hepatology, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Wan-Sik Lee
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Gwangju, Korea
| | - Young Kwan Cho
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Hee Seok Moon
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - In Kyung Yoo
- Division of Gastroenterology, Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, CHA Bundang Medical Center, Seongnam, Korea
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17
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Endoscopic submucosal dissection using a detachable assistant robot: a comparative in vivo feasibility study (with video). Surg Endosc 2021; 35:5836-5841. [PMID: 34143290 DOI: 10.1007/s00464-021-08510-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/17/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Appropriate tissue tension and clear visibility of the dissection area using traction are essential for effective and safe endoscopic submucosal dissection (ESD). We developed a robotic assistive traction device for flexible endoscopy and compared its safety and efficiency in ESD between experienced and novice endoscopists. METHODS Robotic ESD was performed by experienced and novice endoscopist groups (n = 2, each). The outcomes included time to complete each ESD step, total procedure time, size of the dissected mucosa, rate of en bloc resection, and major adverse events. Furthermore, incision and dissection speeds were compared between groups. RESULTS Sixteen gastric lesions were resected from nine live pigs. The submucosal incision speed was significantly faster in the expert group than in the novice group (P = 0.002). There was no significant difference in the submucosal dissection speed between the groups (P = 0.365). No complications were reported in either group. CONCLUSIONS When the robot was assisting in the ESD procedure, the dissection speed improved significantly, especially in the novice surgeons. Our robotic device can provide simple, effective, and safe multidirectional traction during ESD.
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Aihara H, Dacha S, Anand GS, Byrne KR, Chahal P, James T, Kowalski TE, Repaka A, Saadi M, Sheth SG, Taylor JR, Williams RL, Wagh MS. Core curriculum for endoscopic submucosal dissection (ESD). Gastrointest Endosc 2021; 93:1215-1221. [PMID: 33820649 DOI: 10.1016/j.gie.2021.01.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Dacha
- Division of Gastroenterology, Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, Texas, USA
| | - Gobind S Anand
- Division of Gastroenterology, University of California San Diego, San Diego, California, USA
| | - Kathryn R Byrne
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Prabhleen Chahal
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aparna Repaka
- Division of Gastroenterology, VA Boston Healthcare System, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Mohammed Saadi
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jason R Taylor
- Division of Gastroenterology and Hepatology, St Louis University, St Louis, Missouri, USA
| | - Renee L Williams
- Division of Gastroenterology and Hepatology, NYU Langone Health, New York, New York, USA
| | - Mihir S Wagh
- University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
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19
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Prinz F, Ebigbo A, Probst A, Messmann H. Gastric cancer- endoscopic treatment of early lesions, the West learns from the East. Best Pract Res Clin Gastroenterol 2021; 50-51:101739. [PMID: 33975685 DOI: 10.1016/j.bpg.2021.101739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 01/31/2023]
Abstract
Gastric cancer still has one of the highest incidence rates worldwide. Screening programs have been established in high incidence regions, especially in Asia, but in the West, screening for gastric cancer is not generally recommended. Gastroscopy is the gold standard for diagnosing gastric cancer. For the treatment of early gastric cancer, endoscopic resection is the method of choice. With the ESD technique, larger lesions can be resected en-bloc. Guideline and extended guideline criteria for the choice of lesions for ESD have been evaluated extensively, initially in Asia and later in the West as well. For lesions which are out of indication, a surgical approach must be recommended. To detect early recurrence or metachronous lesions, follow-up should be performed after ER.
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Affiliation(s)
- Friederike Prinz
- University Hospital Augsburg, Department of Gastroenterology, Germany.
| | - Alanna Ebigbo
- University Hospital Augsburg, Department of Gastroenterology, Germany
| | - Andreas Probst
- University Hospital Augsburg, Department of Gastroenterology, Germany
| | - Helmut Messmann
- University Hospital Augsburg, Department of Gastroenterology, Germany
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20
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McCarty TR, Aihara H. Current state of education and training for endoscopic submucosal dissection: Translating strategy and success to the USA. Dig Endosc 2020; 32:851-860. [PMID: 31797470 DOI: 10.1111/den.13591] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/02/2019] [Indexed: 02/08/2023]
Abstract
Endoscopic submucosal dissection (ESD) is a rigorous and technically sophisticated method for removal of lesions within the gastrointestinal tract. Despite having advantages of en-bloc resection of lesions, regardless of size, and widespread use in Japan and Asia, ESD has not become widely adopted in the USA for a variety of reasons. Based upon Japanese education and the master-apprentice model, modification to the education system and additional techniques designed to facilitate broader adoption are required for trainees in the USA. This article will review the current state of education and training for ESD in the USA.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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21
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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22
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Kim BG, Choi HS, Park SH, Hong JH, Lee JM, Kim SH, Chun HJ, Hong D, Keum B. A Pilot Study of Endoscopic Submucosal Dissection Using an Endoscopic Assistive Robot in a Porcine Stomach Model. Gut Liver 2020; 13:402-408. [PMID: 30600676 PMCID: PMC6622573 DOI: 10.5009/gnl18370] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/01/2018] [Accepted: 10/15/2018] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Endoscopic assistive devices have been developed to reduce the complexity and improve the safety of surgeries involving the use of endoscopes. We developed an assistive robotic arm for endoscopic submucosal dissection (ESD) and evaluated its efficiency and safety in this in vitro pilot study. Methods ESD was performed using an auxiliary transluminal endoscopic robot. An in vitro test bed replicating the intra-abdominal environment and pig stomachs were used for the experiment. Participants were divided into skilled operators and unskilled operators. Each group performed ESD 10 times by using both conventional and robot-assisted methods. The perforation incidence, operation time, and resected mucous membrane size were measured. Results For the conventional method, significant differences were noted between skilled and unskilled operators regarding operation time (11.3 minutes vs 26.7 minutes) and perforation incidence (0/10 vs 6/10). Unskilled operators showed a large decrease in the perforation incidence with the robot-assisted method (conventional method vs robot-assisted method, 6/10 vs 1/10). However, the operation time did not differ between the conventional and robot-assisted methods. On the other hand, skilled operators did not show differences in the operation time and perforation incidence between the conventional and robot-assisted methods. Among both skilled and unskilled operators, the operation time decreased with the robot-assisted method as the experiment proceeded. Conclusions The surgical safety of unskilled operators greatly improved with robotic assistance. Thus, our assistive robotic arm was beneficial for ESD. Our findings suggest that endoscopic assistive robots have positive effects on surgical safety.
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Affiliation(s)
- Byung Gon Kim
- Department of Mechanical Engineering, Korea University, Seoul, Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Gastrointestinal Medical Instrument Research, Korea University College of Medicine, Seoul, Korea
| | - Sei Hoon Park
- Department of Mechanical Engineering, Korea University, Seoul, Korea
| | - Jun Ho Hong
- Department of Mechanical Engineering, Korea University, Seoul, Korea
| | - Jung Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Gastrointestinal Medical Instrument Research, Korea University College of Medicine, Seoul, Korea
| | - Seung Han Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Gastrointestinal Medical Instrument Research, Korea University College of Medicine, Seoul, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Gastrointestinal Medical Instrument Research, Korea University College of Medicine, Seoul, Korea
| | - Daehie Hong
- Department of Mechanical Engineering, Korea University, Seoul, Korea
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Institute of Gastrointestinal Medical Instrument Research, Korea University College of Medicine, Seoul, Korea
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23
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Wedi E, Knoop R, Jung C, Gromski M, Ho CN, Conrad G, Maiss J, Milenovic S, Klemme D, Baulain U, Seif Amir Hosseini A, Ellenrieder V, Koehler P. EMR + with the AWC improves endoscopic resection speed compared to ESD: a porcine ex-vivo pilot study. MINIM INVASIV THER 2019; 30:47-54. [PMID: 31597491 DOI: 10.1080/13645706.2019.1673778] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION To improve resection speed and to reach higher en bloc resection rates in lesions ≥ 2 cm, a novel grasp and snare EMR technique termed "EMR+", accomplished by an additional working channel (AWC), was developed. Its use compared to endoscopic submucosal dissection (ESD) is evaluated for the first time. MATERIAL AND METHODS We prospectively conducted a randomized pre-clinical ex-vivo pilot study in explanted porcine stomachs for the comparison of EMR + with classical ESD of mucosal-based lesions. Prior to intervention, we set flat lesions with a standardized size of 3 × 3 cm. RESULTS The median time of procedure was significantly shorter in the EMR + group (median 10.5 min, range 4.4-24 min) than in the ESD group (median 32 min, range 14-61.6 min, p < .0001). The rate of en bloc resection was significantly lower in the EMR + group (38 % vs. 95 %) (p < .0001). Nevertheless, an improvement in the learning curve for EMR + was achieved after the first 12 procedures, with a subsequent en bloc resection rate of 100 %. CONCLUSIONS EMR + could improve the efficiency of mucosal resection procedures. Initial experience demonstrates a higher and satisfactory en bloc resection rate after going through the learning curve of EMR+.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Richard Knoop
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Carlo Jung
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Mark Gromski
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Juergen Maiss
- Department of Gastroenterology, Associate Prof. Maiss, Forchheim, Germany
| | - Sinisa Milenovic
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - David Klemme
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Ulrich Baulain
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
| | - Ali Seif Amir Hosseini
- Department of Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, Interdisciplinary Endoscopy, University Medical Center, Goettingen, Germany
| | - Peter Koehler
- Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Federal Research Institute for Animal Health, Mariensee, Germany
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Na HK, Ahn JY, Lee GH, Lee JH, Kim DH, Jung KW, Choi KD, Song HJ, Jung HY. The efficacy of a novel percutaneous endoscopic gastrostomy simulator using three-dimensional printing technologies. J Gastroenterol Hepatol 2019; 34:561-566. [PMID: 30371943 DOI: 10.1111/jgh.14527] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/17/2018] [Accepted: 10/18/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM We developed a novel training simulator for percutaneous endoscopic gastrostomy (PEG) and determined its efficacy and realism in PEG insertion training. METHODS The gastrostomy simulator was made using three-dimensional printing and silicone molding technology. The simulator is of two types: pull type and introducer type. We enrolled 20 participants, comprising 10 beginners with no experience of PEG insertion and 10 PEG-experienced endoscopists. Each participant underwent two training sessions for the two simulator types. We recorded the simulation time, self-evaluation, and difficulty score based on a 5-score scale for PEG insertion among the participants. Subsequently, simulator performance was assessed via a questionnaire based on a 7-point Likert scale. RESULTS The mean time to completion of PEG simulation decreased from 11.9 (5.2) to 9.0 (4.0) min for the pull type and from 13.8 (7.0) to 12.0 (5.8) min for the introducer type in the beginner group. The mean self-evaluation scores of beginners increased from 2.2 (1.1) to 3.1 (0.7) (pull type) and from 2.2 (1.2) to 3.3 (0.8) (introducer type). The mean procedure difficulty scores of beginners decreased from 3.4 (1.1) to 2.7 (0.9) (pull type) and from 4.4 (0.5) to 3.0 (0.8) (introducer type). The improvement of skill score was 6.3 (1.2) for the beginner group. The general realism score of the simulator for handling was judged to be 6.0 (0.9) by the experienced group. CONCLUSIONS The three-dimensional-printed simulator for PEG insertion can be useful for training of beginner endoscopists and shows good efficacy and realism.
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Affiliation(s)
- Hee Kyong Na
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho June Song
- 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
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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: 1.0] [Reference Citation Analysis] [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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Yamazaki K, Moura EGHD, Veras MM, Mestieri LH, Sakai P. USEFULNESS OF GASTRIC SUBMUCOSAL DISSECTION DEPTH TO EVALUATE SKILL ACQUIREMENT IN SHORT TERM TRAINING COURSES IN ESD: AN EXPERIMENTAL STUDY. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:221-229. [PMID: 30540082 DOI: 10.1590/s0004-2803.201800000-58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a complex endoscopic procedure, with high rates of adverse events and technical difficulties. To overcome that problem, many training centers published the importance of animal models for skill acquirement in ESD. However, no study has used the submucosal dissection depth (DSUB) as a parameter to evaluate the learning curve in ESD, which might be a relevant factor since an optimal resection plane is important to achieve a curative resection and avoid intraoperative complications. OBJECTIVE This study aimed to assess ESD skill acquirement after short-term training sessions by evaluating the submucosal dissection depth (DSUB) and the association with adverse events. METHODS This experimental study included 25 experienced endoscopists in therapeuthic procedures (>5years) and 75 specimens resected by ESD (three resections / endoscopist). Learning parameters (resection time, size, en bloc resection rate, bleeding, perforation and submucosal dissection depth) were prospectively evaluated. The percentages of DSUB of all specimens resected were calculated. RESULTS All specimens were resected from the gastric body (n=75). The mean size of the resected specimens was 23.97±7.2 mm. The number of adverse events, including bleeding, perforation, and death, were 17 (22.67%), 3 (4%), and 0 cases, respectively. The average mean time by the third dissection decreased from 28.44±9.73 to 18.72±8.81 min (P<0.001). The proportion of DSUB in the bleeding and non-bleeding group were respectively 37.97%±21.13% and 68.66%±23.99%, indicating a significant association between DSUB and bleeding incidence (P<0.001). The ROC curve analysis indicated a cut-off point of 61% (sensitivity, 64%; specificity, 94%) of submucosal dissection depth associated with bleeding. Therefore, when ESD was performed at a depth of >61% of the submucosal layer, the risk for bleeding during the procedure decreased (PPV, 0.97; 95% CI, 0.85-0.99). CONCLUSION Improvement in the learning curve in ESD and a better cognitive ability were seen by the third dissection in these short term training courses. And a significant association between DSUB and the risk of bleeding.
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Affiliation(s)
- Kendi Yamazaki
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Endoscopia Gastrointestinal, SP, Brasil
| | | | - Mariana Matera Veras
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Patologia, SP, Brasil
| | - Luiz Henrique Mestieri
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Endoscopia Gastrointestinal, SP, Brasil
| | - Paulo Sakai
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Endoscopia Gastrointestinal, SP, Brasil
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Rodríguez Sánchez J, Úbeda Muñoz M, de la Santa Belda E, Olivencia Palomar P, Olmedo Camacho J. Underwater hybrid endoscopic submucosal dissection in a rectal polyp: a case report of a new application of "underwater endoscopy". REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:62-64. [PMID: 29168640 DOI: 10.17235/reed.2017.5181/2017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hybrid endoscopic submucosal dissection (ESD) has been described as an alternative to traditional ESD. This technique is less time consuming, but the en bloc resection rate is lower than in ESD. Similar to endoscopic mucosal resection, the underwater technique could improve preliminary disadvantages of hybrid ESD. CASE REPORT We attempted a mixture resection technique of Hybrid ESD with underwater endoscopic mucosal resection (EMR). Using this approach, an underwater hybrid ESD was successfully performed without adverse events on a 71 year old woman with a 20 mm adenoma. The histologic analysis identified a tubulovillious adenoma with high grade dysplasia and tumor free margins. DISCUSSION Underwater hybrid ESD could be an alternative to ESD. Moreover the modification of the "underwater method" provides a suitable way to overcome the technical drawbacks of the hybrid ESD.
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Ma MX, Bourke MJ. Endoscopic submucosal dissection in the West: Current status and future directions. Dig Endosc 2018; 30:310-320. [PMID: 28884493 DOI: 10.1111/den.12960] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/31/2017] [Indexed: 02/08/2023]
Abstract
Endoscopic submucosal dissection (ESD) was first conceptually described almost 30 years ago in Japan and is now widely practiced throughout East Asia. ESD expands the boundaries of endoscopic resection (ER) by allowing en bloc resection of large early neoplastic lesions within the gastrointestinal tract (GIT). This offers advantages over other ER techniques by facilitating definitive histological staging and curative treatment of early cancer in selected cases. Indeed, the experience of ESD in Eastern countries is significant, and excellent outcomes from high-volume centers are reported. The potential benefits of ESD are recognized by Western endoscopists, but its adoption has been limited. A number of factors contribute to this, including epidemiological differences in GIT neoplasia between Western and Eastern populations and limitations in training opportunities. In this review, we discuss the role of ESD, its current status and the future in Western endoscopic practice.
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Affiliation(s)
- Michael X Ma
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, Australia.,University of Sydney, Sydney, Australia
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Rodríguez Sánchez J, Rodríguez Sánchez E, de la Santa Belda E, Olivencia PP, Salmoral Luque R, Sánchez Alonso M, Olmedo Camacho J, Redondo Calvo FJ. Electromagnetic assisted endoscopic submucosal dissection is more efficient than water-jet assisted and conventional ESD in experimental model. Endosc Int Open 2018; 6:E498-E504. [PMID: 29607403 PMCID: PMC5876038 DOI: 10.1055/s-0043-125364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/18/2017] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The adequate visualization of the dissection line, inside the submucosal layer, supposes the main challenging issue in ESD. For this reason, several counter traction methods have been developed focused on overcoming this handicap. One of which, Magnetic anchor guided - ESD (MG-ESD) is an attractive alternative. However, the usefulness of this approach has been scarcely assessed and compared with other ESD strategies. Therefore, the aim of this study is to compare three different ESD alternatives in experimental faction. METHODS This was a prospective non-randomized study, in which three different ESD techniques were performed in an ex-vivo gastric porcine model by an endoscopist slight expertise in ESD: conventional ESD, waterjet assisted ESD and MG-ESD. MG-ESD was performed using two different magnets: inner Neodymiun ringed shape magnet attached to the simulated lesions by an endoclip and external electromagnet connected to a Single Output Adjustable 24V/0.3A Power Supply Unit. RESULTS Forty-six ESD procedures were performed: 24 conventional ESD, 12 waterjet-assisted ESD and 10 MG-ESD. Average size of the simulated lesions was 33.86 mm. No differences in terms of safety and efficacy were registered between the three approaches. Nevertheless, MG-ESD proved to be faster and more efficient than conventional ESD and water-jet assisted ESD (min per cm 2 10.85 vs. 7.43 vs. 3,41; P = 0.001). CONCLUSIONS MG-ESD could be a feasible alternative to conventional ESD even at the beginning of the learning curve. Therefore, researches focused on developing appropriate ESD magnetic devices and further comparative studies must be promoted, in order to assess the reliable usefulness of the magnet-assistance in ESD.
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Affiliation(s)
- Joaquín Rodríguez Sánchez
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain),Translational Research Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain),Corresponding author Joaquín Rodríguez Sánchez, MD, PhD Gastrointestinal Endoscopy UnitHospital General Universitario de Ciudad RealC/Obispo Rafael Torija s/n. 13005Ciudad Real, Spain+0034 926278000
| | | | - Eva de la Santa Belda
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain)
| | - Pilar Palomar Olivencia
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain)
| | - Rosario Salmoral Luque
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain)
| | - Mónica Sánchez Alonso
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain)
| | - José Olmedo Camacho
- Gastrointestinal Endoscopy Unit. Hospital General Universitario de Ciudad Real, Ciudad Real (Spain)
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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: 2.6] [Reference Citation Analysis] [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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31
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Wang AY, Draganov PV. Training in endoscopic submucosal dissection from a Western perspective. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Yoshida M, Kakushima N, Mori K, Igarashi K, Kawata N, Tanaka M, Takizawa K, Ito S, Imai K, Hotta K, Ishiwatari H, Matsubayashi H, Ono H. Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators. Surg Endosc 2016; 31:3614-3622. [PMID: 28039646 DOI: 10.1007/s00464-016-5393-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 12/15/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists. METHODS Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42-50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed. RESULTS The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm2 in Phase I, 4.7 ± 2.7 min/cm2 in Phase II, and 4.3 ± 2.2 min/cm2 in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months. CONCLUSIONS For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes.
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Affiliation(s)
- Masao Yoshida
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Naomi Kakushima
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Keita Mori
- Clinical Trial Coordination Office, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, Japan
| | - Kimihiro Igarashi
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Noboru Kawata
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masaki Tanaka
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hirotoshi Ishiwatari
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan
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Gonzalez JM, Cohen J, Gromski MA, Saito K, Loundou A, Matthes K. Learning curve for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic lesions in a novel ex-vivo simulation model. Endosc Int Open 2016; 4:E1286-E1291. [PMID: 27995190 PMCID: PMC5161137 DOI: 10.1055/s-0042-118176] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is essential in the management of digestive cancers. However, teaching and learning this technique remain challenging due to the lack of cost-effective models. Material and methods: This was a prospective experimental study using a complete porcine upper gastrointestinal ex-vivo organ package, placed in an Erlangen Active Simulator for Interventional Endoscopy (EASIE-R), and prepared with one cyst and two solid masses (2 cm). Five fellows inexperienced in EUS-FNA were enrolled, performing 10 procedures on each lesion, alternatively. The total time, number of attempts for success, of needle view losses, and of scope handling were recorded, associated with an independent skills rating by procedure. We compared the first 15 procedures with the last 15 for each fellow. Results: The fellows successfully performed all procedures in 2 to 40 minutes, requiring 1 to 6 attempts. All (5/5) improved their total time taken (P < 0.001), number of times when the EUS view of the needle was lost (P < 0.05), scope handling (P < 0.005), and skills rating (P < 0.001), whereas 4/5 (80 %) improved their number of attempts. The overall evaluation showed a significant decrease (P < 0.001) in the total time taken (11.2 ± 7.8 vs 4.3 ± 2.2 minutes), number of attempts (2.6 ± 1.2 vs 1.2 ± 0.7), number of times when the EUS view of the needle was lost (2.3 ± 2 vs 0.5 ± 0.7), and need for scope handling (1.1 ± 1.7 vs 0.1 ± 0.2). We also observed an improvement in skills rating (5 ± 1.9 vs. 7.7 ± 1.1). Conclusion: This newly designed ex-vivo model seems to be an effective way to improve the initial learning of EUS-FNA, by performing 30 procedures.
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Affiliation(s)
- J. M. Gonzalez
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA,Department of Gastroenterology, North
Hospital, Aix-Marseille University, AP-HM, Marseille, France,Corresponding author Jean-Michel
Gonzalez, MD North
HospitalDepartment of
GastroenterologyChemin des
Bourrelys13915MarseilleFrance+33-4-91968737
| | - J. Cohen
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA
| | - M. A. Gromski
- Division of Gastroenterology, Indiana
University School of Medicine, Indianapolis, IN, USA
| | - K. Saito
- Division of Gastroenterology, Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA,
USA
| | - A. Loundou
- Department of Public Health, Medical
Evaluation, Aix-Marseille University, AP-HM, Marseille,
France
| | - K. Matthes
- Department of Anesthesiology, Kaiser
Permanente Maui Memorial Medical Center, Wailuku, HI, USA
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Tsou YK, Chuang WY, Liu CY, Ohata K, Lin CH, Lee MS, Cheng HT, Chiu CT. Learning curve for endoscopic submucosal dissection of esophageal neoplasms. Dis Esophagus 2016; 29:544-550. [PMID: 26123695 DOI: 10.1111/dote.12380] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There is a significant learning curve for endoscopic submucosal dissection of esophageal neoplasms that has not been fully characterized. This retrospective study included 33 consecutive superficial esophageal neoplasms for analysis of the learning curve for esophageal endoscopic submucosal dissection based on a single, novice endoscopist's experience. The study was divided into three periods (T1, T2, and T3) of 10 endoscopic submucosal dissection procedures in chronological order, with 13 procedures in the last period. Patient factors (age, sex, coexistent esophageal varices, or submucosal fibrosis) and tumor factors (location at upper esophagus, involving >3/4 esophageal circumference) for endoscopic submucosal dissection were not statistically different between the periods. The mean procedure time was 74.6 min/cm(2) , 23.4 min/cm(2) , and 10.5 min/cm(2) for T1, T2, and T3, respectively. The procedure time decreased over time (P = 0.02) and post hoc test revealed significant difference was only between T3 and T1 (P = 0.019). The en bloc resection rate was 50%, 100%, and 92.3% for T1, T2, and T3, respectively (P for trend = 0.015). R0 resection rate was 40%, 100%, and 84.6% for T1, T2, and T3, respectively (P for trend = 0.023). Two patients had complications: each one patient in T1 and T3 period experienced major bleeding during the procedure (P for trend = 0.875). None of the patients had esophageal perforation. The results of the study concluded that at least 30 cases of endoscopic submucosal dissection of esophageal neoplasms are needed for a novice endoscopist to gain early proficiency in this technique.
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Affiliation(s)
- Y-K Tsou
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - W-Y Chuang
- Deparment of Pathology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - C-Y Liu
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital and Department of Medicine, Mackay Medical College, Tokyo, Japan
| | - K Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo, Japan
| | - C-H Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - M-S Lee
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - H-T Cheng
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - C-T Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
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van der Wiel SE, Küttner Magalhães R, Rocha Gonçalves CR, Dinis-Ribeiro M, Bruno MJ, Koch AD. Simulator training in gastrointestinal endoscopy - From basic training to advanced endoscopic procedures. Best Pract Res Clin Gastroenterol 2016; 30:375-87. [PMID: 27345646 DOI: 10.1016/j.bpg.2016.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/14/2016] [Accepted: 04/28/2016] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- S E van der Wiel
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, 's Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - R Küttner Magalhães
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Center, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal.
| | - Carla Rolanda Rocha Gonçalves
- Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal; Life and Health Sciences Research Institute/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Department of Gastroenterology, Hospital Braga, Portugal.
| | - M Dinis-Ribeiro
- Department of Gastroenterology, Portugese Oncology Institute of Porto, Rua Dr. Bernardino de Almeida, 4200-072 Porto, Portugal; CIDES/CINTESIS, Porto Faculty of Medicine, Portugal.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, 's Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
| | - A D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC - University Medical Center Rotterdam, 's Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
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Gromski MA, Ahn W, Matthes K, De S. Pre-clinical Training for New Notes Procedures: From Ex-vivo Models to Virtual Reality Simulators. Gastrointest Endosc Clin N Am 2016; 26:401-412. [PMID: 27036905 PMCID: PMC4990456 DOI: 10.1016/j.giec.2015.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) is a newer field of endoscopic surgery that allows for scarless treatment of pathologic entities, using novel transluminal approaches. There has been a shift of focus from a clinical and research standpoint from the development and dissemination of "first-generation" NOTES procedures to "new NOTES" procedures that traverse the mucosa of luminal structures, yet do not stray far into the peritoneal cavity. It has been a challenge to find appropriate and effective ways to train gastroenterologists and surgeons in these novel approaches. We review the importance of simulation in training and discuss available simulation options.
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Affiliation(s)
- Mark A. Gromski
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Woojin Ahn
- Center for Modeling, Simulation and Imaging in Medicine, Rennselaer Polytechnic Institute, Troy, NY, USA
| | - Kai Matthes
- Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital Boston, Harvard Medical School, Boston, MA
| | - Suvranu De
- Center for Modeling, Simulation and Imaging in Medicine, Rennselaer Polytechnic Institute, Troy, NY, USA
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Abstract
ESD is an established effective treatment modality for premalignant and early-stage malignant lesions of the stomach, esophagus, and colorectum. Compared with EMR, ESD is generally associated with higher rates of en bloc, R0, and curative resections and a lower rate of local recurrence. Oncologic outcomes with ESD compare favorably with competing surgical interventions, and ESD also serves as an excellent T-staging tool to identify noncurative resections that will require further treatment. ESD is technically demanding and has a higher rate of adverse events than most endoscopic procedures including EMR. As such,sufficient training is critical to ensure safe conduct and high-quality resections. A standardized training model for Western endoscopists has not been clearly established,but will be self-directed and include courses, animal model training, and optimally an observership at an expert center.Numerous dedicated ESD devices are now available in the United States from different manufacturers. Although the use of ESD in the United States is increasing, issues related to technical difficulty, limited training opportunities and mentors, risk of adverse events, long procedure duration,and suboptimal reimbursement may limit ESD adoption in the United States to a modest number of academic referral centers for the foreseeable future.
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Oyama T, Yahagi N, Ponchon T, Kiesslich T, Berr F. How to establish endoscopic submucosal dissection in Western countries. World J Gastroenterol 2015; 21:11209-11220. [PMID: 26523097 PMCID: PMC4616199 DOI: 10.3748/wjg.v21.i40.11209] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/06/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023] Open
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.
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Tanimoto MA, Guerrero ML, Morita Y, Aguirre-Valadez J, Gomez E, Moctezuma-Velazquez C, Estradas-Trujillo JA, Valdovinos MA, Uscanga LF, Fujita R. Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis. World J Gastrointest Endosc 2015; 7:417-428. [PMID: 25901222 PMCID: PMC4400632 DOI: 10.4253/wjge.v7.i4.417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
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.
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Patel N, Seneci CA, Shang J, Leibrandt K, Yang GZ, Darzi A, Teare J. Evaluation of a novel flexible snake robot for endoluminal surgery. Surg Endosc 2015; 29:3349-55. [DOI: 10.1007/s00464-015-4088-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 01/15/2015] [Indexed: 12/13/2022]
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Weigt J, Kandulski A, Malfertheiner P. Technical improvement using ultra-slim gastroscopes for direct peroral cholangioscopy: analysis of the initial learning phase. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:74-8. [DOI: 10.1002/jhbp.169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Jochen Weigt
- Department of Gastroenterology, Hepatology and Infectious Diseases; Otto-von-Guericke University; Leipziger Str. 44 39120 Magdeburg Germany
| | - Arne Kandulski
- Department of Gastroenterology, Hepatology and Infectious Diseases; Otto-von-Guericke University; Leipziger Str. 44 39120 Magdeburg Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases; Otto-von-Guericke University; Leipziger Str. 44 39120 Magdeburg Germany
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Khashab MA, Saxena P, Sharaiha R, Messallam A, Akshintala VS, Singh VK, Lennon AM, Canto MI, Kalloo AN, Pasricha PJ. Pilot study of 'Scissorhands' technique for gastric endoscopic submucosal dissection using novel gel and endoscopic scissors in a porcine model (with video). Dig Endosc 2014; 26:365-8. [PMID: 24877237 DOI: 10.1111/den.12186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Endoscopic submucosal dissection (ESD) is a complex procedure and is associated with significant risks. The aims of this pilot study were to study feasibility and procedural times of gastric ESD using a novel gel and endoscopic scissors in a porcine model. METHODS Simulated 3-cm gastric submucosal lesions were created in a porcine model. Subsequently, viscous gel was injected into the created bleb. A needle knife was used to create an initial incision when needed. Endoscopic scissors were then used for circumferential incision around the simulated submucosal lesions. The inserted coil (i.e. submucosal lesion) was then removed. The submucosal surface was carefully examined for signs of injury. Procedural times were recorded. RESULTS ESD was carried out in four consecutive pigs using the 'Scissorhands' technique. A small submucosal incision was created a using needle knife in the first pig and electrocautery was not used in the remaining three pigs. Circumferential incision using the scissors was done successfully in all pigs. Submucosal dissection was not required in any case. 'Auto-dissection' of created lesions by the gel was noted to be complete in all cases. Inserted coils were noted in the submucosal space during all experiments and were removed. All lesions were successfully resected en bloc. The mean procedure time was 19 min (range 13-22 min). CONCLUSION The combined technique of endoscopic scissors for circumferential incision and viscous gel for submucosal dissection permitted easy, safe and efficient gastric ESD. Electrocautery may be avoided and its consequent adverse events (e.g. perforation).
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Affiliation(s)
- Mouen A. Khashab
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Payal Saxena
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Reem Sharaiha
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Ahmed Messallam
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Venkata S. Akshintala
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Vikesh K. Singh
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Anne Marie Lennon
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Marcia I. Canto
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Anthony N. Kalloo
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
| | - Pankaj J. Pasricha
- Division of Gastroenterology and HepatologyDepartment of MedicineThe Johns Hopkins Medical Institutions Baltimore USA
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Murata A, Okamoto K, Muramatsu K, Matsuda S. Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay. Surg Endosc 2014; 28:1298-1306. [PMID: 24337914 DOI: 10.1007/s00464-013-3326-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 11/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database. METHODS A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)]. RESULTS Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31-0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001). CONCLUSIONS The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan,
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Abstract
Endoscopic submucosal dissection (ESD) is a well-established advanced mucosal resection technique used in Japan, where it originated, and some other Asian countries. The technical difficulty and potentially higher rates of significant complications have been obstacles for its dissemination across the United States, on top of the lack of available equipment, candidate lesions in the gastrointestinal tract, and adequate training programs. Yet American physicians are becoming increasingly aware of the benefits of ESD. Simplification of technique, modification of tools and materials, and improved availability of training opportunities are essential in order to accelerate the adoption of ESD in the United States.
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Affiliation(s)
- Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B158, Aurora, CO 80045, USA.
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Murata A, Okamoto K, Muramatsu K, Matsuda S. Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis. Gastric Cancer 2014; 17:294-301. [PMID: 23801338 DOI: 10.1007/s10120-013-0282-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database. METHODS A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164). RESULTS No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001). CONCLUSIONS This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan,
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Chung WC, Kim BW, Lim CH, Kim TH, Park JM, Kim JS. Grasper type scissors for endoscopic submucosal dissection of gastric epithelial neoplasia. World J Gastroenterol 2013; 19:6221-6227. [PMID: 24115820 PMCID: PMC3787353 DOI: 10.3748/wjg.v19.i37.6221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/01/2013] [Accepted: 08/12/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy and safety of grasper type scissors (GTS) for endoscopic submucosal dissection (ESD) of gastric epithelial neoplasia. METHODS The study was performed by 4 endoscopists in 4 institutions affiliated to The Catholic University of Korea. ESD was performed in 76 consecutive patients with gastric epithelial neoplasia by using the GTS (37 patients) or the hook knife plus coagrasper (HKC) (39 patients). The complete resection rate, complication rate, total time elapsed and elapsed time per square centimeter of the dissected specimen were analyzed between the GTS and HKC group. RESULTS The mean age of the GTS group was 62.3 ± 11.4 years and mean age of the HKC group was 65.6 ± 10.1 years. Differentiated adenocarcinoma was found in 32.4% in the GTS group and 33.3% in the HKC group. The procedures were performed without interruption in every case in both groups. The en bloc resection rates of both groups were 100%. The total time elapsed during the procedure was 44.54 ± 21.72 min in the GTS group and 43.77 ± 21.84 min in the HKC group (P = 0.88) and the time elapsed per square centimeter of the resected lesion was 7.53 ± 6.35 min/cm(2) in the GTS group and 6.92 ± 5.93 min/cm(2) in the HKC group (P = 0.66). The overall complication rate was not significantly different between the two groups. CONCLUSION GTS is a safe and effective device for ESD compared with HKC. ESD can be performed with GTS alone, which can reduce the costs for ESD.
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Pham DV, Shah A, Borao FJ, Gorcey S. Endoscopic submucosal dissection training with ex vivo human gastric remnants. Surg Endosc 2013; 28:222-6. [PMID: 23996336 DOI: 10.1007/s00464-013-3164-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 07/31/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- David V Pham
- Department of Surgery, Monmouth Medical Center, 300 Second Avenue, Long Branch, NJ, 07740, USA,
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Hochberger J, Köhler P, Kruse E, Hûppertz J, Delvaux M, Gay G, Wedi E. [Endoscopic submucosal dissection]. Internist (Berl) 2013; 54:287-301. [PMID: 23455659 DOI: 10.1007/s00108-012-3179-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Endoscopic submucosal dissection (ESD) was developed in Japan but has now also become permanently established in various centers in Europe. ESD is an endoscopic en bloc mucosal resection technique for the treatment of early cancers with a diameter >1 cm and also superficial precancerous lesions, which could only be removed unsatisfactorily in several fragments or with uncertain lateral safety margins using previous loop excision procedures. Using ESD a lesion is excised after circular marking and generous submucosal injection with a safety margin of approximately 5 mm and subsequently resected at the level of the submucosa with a 1-3 mm short diathermic knife. ESD requires high technical skills in interventional endoscopy and is more time-consuming than snare resection techniques. However, numerous studies have shown a clear superiority for ESD with respect to the R0 resection rate and the local recurrence rate. The present article gives a current review of the use of ESD in the upper and lower gastrointestinal tract and demonstrates perspectives of the procedure.
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Affiliation(s)
- J Hochberger
- Sérvice de Gastroentérologie, Hôpitaux Universitaires de Strasbourg - NHC, 1 Place de l'Hôpital, 67000, Strasbourg (Cedex), Frankreich.
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Yoshida N, Yagi N, Inada Y, Kugai M, Yanagisawa A, Naito Y. Prevention and management of complications of and training for colorectal endoscopic submucosal dissection. Gastroenterol Res Pract 2013; 2013:287173. [PMID: 23956738 PMCID: PMC3727207 DOI: 10.1155/2013/287173] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 05/03/2013] [Indexed: 12/28/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is reported to be an efficient treatment with a high rate of en bloc resection for large colorectal tumors in Japan and some other Western and Asian countries. ESD is considered less invasive than laparoscopic colectomy. However, ESD carries a higher risk of perforation than endoscopic mucosal resection (EMR). Various devices and training methods for colorectal ESD have been developed to solve the difficulties. In this review, we describe the complications of colorectal ESD and prevention of those complications. On the other hand, colorectal ESD is difficult for less-experienced endoscopists. The unique step-by-step ESD training system is performed in Japan. Additionally, appropriate training, including animal model training, for colorectal ESD should be acquired before working on clinical cases.
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Affiliation(s)
- Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Nobuaki Yagi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yutaka Inada
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Munehiro Kugai
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Akio Yanagisawa
- Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Khashab MA, Saxena P, Sharaiha RZ, Chavez YH, Zhang F, Kord Valeshabad A, Aguila G, Canto MI, Pasricha PJ, Kalloo AN. A novel submucosal gel permits simple and efficient gastric endoscopic submucosal dissection. Gastroenterology 2013; 144:505-7. [PMID: 23313267 DOI: 10.1053/j.gastro.2013.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 01/01/2013] [Accepted: 01/08/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA.
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