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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 28, 2015; 21(40): 11209-11220
Published online Oct 28, 2015. doi: 10.3748/wjg.v21.i40.11209
How to establish endoscopic submucosal dissection in Western countries
Tsuneo Oyama, Naohisa Yahagi, Thierry Ponchon, Tobias Kiesslich, Frieder Berr
Tsuneo Oyama, Department of Endoscopy, Saku Central Hospital Advanced Care Center, Nagano 3850051, Japan
Naohisa Yahagi, Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
Thierry Ponchon, Hôpital Edouard Herriot, Specialités Digestives, Pavillon H, Place, d’Arsonval, 69437 Lyon, France
Tobias Kiesslich, Frieder Berr, Department of Medicine I, University Hospital Salzburg and Institute of Physiology and Pathophysiology, Paracelsus Medical University, Salzburg 5020, Austria
Author contributions: Oyama T, Yahagi N, Ponchon T and Berr F contributed equally to the endoscopic submucosal dissection Training and to the proposed Learning Strategy (Phase I-IV); Ponchon T has been program deputy of ESGE; and Kiesslich T local organizer in this project; all authors have contributed equally to concept and writing of the manuscript and have read an approved the final version of the manuscript.
Supported by Leonie-Wild Charitable Foundation, Heidelberg-Eppelheim.
Conflict-of-interest statement: The authors have no conflict of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Frieder Berr, MD, Department of Medicine I, University Hospital Salzburg, Paracelsus Medical University, Muellner Hauptstr. 48, 5020 Salzburg, Austria.
Telephone: +43-662-44822801 Fax: +43-662-44822822
Received: June 5, 2015
Peer-review started: June 8, 2015
First decision: July 20, 2015
Revised: August 6, 2015
Accepted: September 28, 2015
Article in press: September 30, 2015
Published online: October 28, 2015

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.

Keywords: Endoscopic submucosal dissection, Early cancer, Endoscopic submucosal dissection clinical tutoring, Endoscopic submucosal dissection training, Gastrointestinal neoplasias, Endoscopic submucosal dissection learning curve, Endoscopic submucosal dissection techniques, Endoscopic submucosal dissection complications

Core tip: Endoscopic submucosal dissection (ESD) was developed in Japan for curative resection of early cancer. But Western countries take very long without tutoring to establish ESD on a professional level. A two-fold, sequential learning curve is necessary for endoscopic staging, and for endoluminal surgery of early neoplasias. This will need a sequential strategy: (1) education for diagnostic skills in routine endoscopy and in educational programs; and (2) endoscopists proficient in endoscopic snaring techniques must train for ESD and pass an untutored learning curve to become proficient. Then, Western ESD experts must instruct endoscopists from referral centers in their country.