Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis

Table 1 Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
ESD in patients	Case report
Report ESD successen blocresection rate, local recurrence rate	Comment
(R0) and the incidence of procedure-related complications	Review
(perforation, bleeding)	Letters to editor
Written in English	Insufficient data
	Guidelines

ESD: Endoscopic submucosal dissection.

Table 2 Endoscopic submucosal dissection studies in animal models

Ref.	Year	Model	n	Organ	Main conclusion
González et al[17]	2013	Porcine	30	Stomach	A sequential ESD training program of a unique endoscopist contributed to learning ESD for its subsequent application in humans, yielding good results in efficacy and safety
Takizawa et al[13]	2013	Porcine	30	Colon	Large mucosal target sites in the rectum and distal colon could be safely removed en bloc by means of a hybrid technique, SEMR, with blunt submucosal balloon dissection
Moss et al[115]	2012	Porcine	10	Colon	HK-ESD with SG submucosal injection is superior to CSI-EMR for en bloc excision of 50 mm diameter lesions. The technique is rapidly learn
Gostout et al[41]	2012	Porcine	16	Rectum and colon	Large mucosal target sites in the rectum and distal colon can be safely removed en bloc by means of a hybrid technique, ie, submucosal endoscopy with mucosal resection, combining elements of ESD with our SEMF method
Kumano et al[117]	2012	Porcine	24	Esophagus	PCH permits more reliable ESD of the esophagus without complications than do SH and HS
Balogh et al[51]	2012	Porcine	15	Esophagus	Training in live pig models could help endoscopists to overcome the learning curve and minimize the risk of complications before starting the procedure in humans Reduction in the resection time and low risk of complications, especially bleeding, could be achieved by the application of a flush knife
Tanaka et al[63]	2012	Porcine ex vivo	10	stomach	Ex vivo training model was helpful to endoscopists with experience in gastric ESD in acquiring the basic skills for performing esophageal ESD
Parra-Blanco et al[29]	2011	Porcine	18	Stomach	A Clip-band traction technique is feasible, safe, effective, and relatively inexpensive gastric ESD
Von Renteln et al[118]	2011	Porcine	12	Stomach	Submucosal mesna injection did not affect ESD procedure times but was associated with a trend toward a lower incidence of intraprocedural bleeding
Tanimoto et al[94]	2011	Canine	10	Esophagus	ECE-ESD training is feasible in canine models for postgraduate endoscopy fellows
Hon et al[96]	2010	Porcine	10	Colon	Technical proficiency improved by repetition. This setup may be a promising training model for endoscopists working in areas with a low incidence of early gastric cancer
Von Renteln et al[119]	2010	Porcine	12	Stomach	The flexible Maryland dissector was demonstrated to be efficient, safe, and feasible for facilitating gastric ESD
Parra-Blanco et al[34]	2010	Porcine	30	Esophagus stomach	Training in animal models could help endoscopists overcome the learning curve before starting ESD in humans
Moss et al[116]	2010	Porcine	10	Colon	CSI-EMR with submucosal injection of succinylated gelatin is safe and superior to conventional EMR.With experience, total procedure duration is comparable
Von Delius et al[120]	2008	Porcine	10	Stomach	PMT-ESD is feasible and safe. With the use of PA-ES, mucosal pieces of various sizes can be resected en bloc in gastric locations that are difficult to access by flexible endoscopy alone
Yamasaki et al[121]	2006	Porcine	2	Stomach	ESD by submucosal injection of viscous SCMC solution appeared to be an easy, safe, and technically efficient method for dissection of gastric lesions
Neuhaus et al[83]	2006	Porcine	17	Stomach	The R-scope (double channel endoscope) facilitated ESD of large gastric areas. Procedure is technically demanding and time-consuming, with a high risk of perforation may be related to an insufficient volume of solution being injected submucosally

HK: Hybrid knife; ESD: Endoscopic submucosal dissection; CSI-EMR: Circumferential submucosal incision endoscopic mucosal resection; SEMF: Mucosal safety valve flap; HS: Hypertonic saline solution; PCH: Photocrosslinkable chitosan hydrogel; SFC: Submucosal fluid cushion; SH: Sodium hyaluronate; ECE: En bloc circumferential esophageal; PA-ES: Percutaneously assisted endoscopic surgery; PMT-ESD: PEG-minitrocar ESD; SCMC: Sodium carboxymethylcellulose.