• Endoscopic submucosal dissection
• Esophageal cancer
• Training

• Humans
• Esophageal Neoplasms/surgery
• Endoscopic Mucosal Resection/education
• Endoscopic Mucosal Resection/methods
• Clinical Competence
• Esophagoscopy/education
• Esophagoscopy/methods

• Endoscopic resection (ESD, EMRc, ...)
• Endoscopy Upper GI Tract
• Quality and logistical aspects
• Training

• Endoscopic submucosal dissection
• Endoscopy
• Mucous membranes
• Plant components
• Simulation training

• Humans
• Endoscopic Mucosal Resection/education
• Endoscopic Mucosal Resection/methods
• Clinical Competence
• Retrospective Studies
• Female
• Male
• Stomach Neoplasms/surgery
• Middle Aged
• Aged
• Simulation Training/methods
• Gastric Mucosa/surgery

• 2021-005642 KOTOBUKI Medical

• animal model
• electrical surgical unit
• endoscopic submucosal dissection
• quantitative assessment
• training

• Animals
• Endoscopic Mucosal Resection/methods
• Gastric Mucosa/surgery
• Models, Animal
• Dissection/methods
• Learning Curve

• endoscopic submucosal dissection
• hemorrhage
• perforation

• Egypt
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Polypectomy
• Superficial bowel neoplasia

Management of superficial bowel neoplasia (SBN) in early stages is associated with better outcomes. The last few decades experienced a paradigm shift in the management of SBN with the introduction of advanced endoscopic resection techniques (ERTs). However, there are no clear data about the aspects of ERTs in Egypt despite the growing gastroenterology practice.

To investigate the knowledge, attitude, and practice of ERTs toward management of SBN among Egyptian practitioners and the suitability of the endoscopy units’ infrastructures toward these techniques.

An online 2-pages questionnaire was used. The first page comprised demographic data, and questions for all physicians, about the knowledge (11 questions) of and attitude (5 questions) toward ERTs as a therapeutic option for SBN. The second page investigated the practice of ERTs by endoscopists (6 questions) and the infrastructures of their endoscopy units (14 questions). The survey was disseminated through July 2021 and the data were collected in an excel sheet and later analyzed anonymously.

The complete responses were 833/2300 (36.2%). The majority of the participants were males (n = 560, 67.2%), middle-aged (n = 366, 43.9%), consultants (n = 464, 55.7%), gastroenterologists (n = 678, 81.4%), spending ≥ 15 years in practice (n = 368, 44.2%), and were working in university hospitals (n = 569, 68.3%). The majority correctly identified the definition of SBN (88.4%) and the terms polypectomy, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD) (92.1%, 90.2%, and 89.1% respectively). However, 26.9%, 43.2% and 49.5% did not recognize the clear indication of polypectomy, EMR, and ESD respectively. Although 68.1% of physicians are convinced about the ERTs for management of SBN; only 8.9% referred all candidate cases for ERTs. About 76.5% of endoscopists had formal training in the basic polypectomy techniques while formal training for EMR and ESD was encountered only in 31.9% and 7.2% respectively. About 71.6% and 88.4% of endoscopists did not perform EMR or ESD in the last one year. Consequently, the complication rate reported by endoscopists was limited to 18.1% (n = 103) of endoscopists. Only 25.8% of endoscopists feel confident in the management of ERTs-related complications and a half (49.9%) were not sure about their competency. Regarding the endoscopy units’ infrastructures, only 4.2% of the centers had their endoscopes 100% armed with optical enhancements and 54.4% considered their institutions ready for managing ERTs-related complications. Only 18.3% (n = 104) of endoscopists treated their complicated cases surgically because the most frequent ERTs-related complications were procedural bleeding (26.7%), and perforations (17%).

A significant deficiency was reported in the knowledge and attitude of Egyptian practitioners caring for patients with SBN toward ERTs. The lack of trained endoscopists in both EMR and ESD in part is due to unsuitable infrastructures of many endoscopy units.

• Endoscopic submucosal dissection
• Endoscopic mucosal resection
• Polypectomy
• Superficial bowel neoplasia
• Egypt

Over the last decades, visual endoscopy has become a gold standard for the detection and treatment of gastrointestinal cancers. However, mastering endoscopic procedures is complex and requires long hours of practice. In this context, simulation-based training represents a valuable opportunity for acquiring technical and cognitive skills, suiting the different trainees’ learning pace and limiting the risks for the patients. In this regard, the present contribution aims to present a critical and comprehensive review of the current technology for gastrointestinal (GI) endoscopy training, including both commercial products and platforms at a research stage. Not limited to it, the recent revolution played by the technological advancements in the fields of robotics, artificial intelligence, virtual/augmented reality, and computational tools on simulation-based learning is documented and discussed. Finally, considerations on the future trend of this application field are drawn, highlighting the impact of the most recent pandemic and the current demographic trends.

Gastrointestinal (GI) endoscopy is the gold standard in the detection and treatment of early and advanced GI cancers. However, conventional endoscopic techniques are technically demanding and require visual-spatial skills and significant hands-on experience. GI endoscopy simulators represent a valid solution to allow doctors to practice in a pre-clinical scenario. From the first endoscopy mannequin, developed in 1969, several simulation platforms have been developed, ranging from purely mechanical systems to more complex mechatronic devices and animal-based models. Considering the recent advancement of technologies (e.g., artificial intelligence, augmented reality, robotics), simulation platforms can now reach high levels of realism, representing a valid and smart alternative to standard trainee/mentor learning programs. This is particularly true nowadays, when the current demographic trend and the most recent pandemic demand, more than ever, the ability to cope with many patients. This review offers a broad view of the technology available for GI endoscopy training, including platforms currently in the market and the relevant advancements in this research and application field. Additionally, new training needs and new emerging technologies are discussed to understand where medical education is heading.

• GI endoscopy
• colonoscopy
• gastroscopy
• medical education
• medical simulation
• simulators
• training

• animal model
• duodenal neoplasms
• duodenal perforation
• endoscopic submucosal dissection
• superficial non-ampullary epithelial duodenal tumor

• Animals
• Duodenal Neoplasms/surgery
• Duodenum/surgery
• Endoscopic Mucosal Resection/adverse effects
• Retrospective Studies
• Swine
• Treatment Outcome

• Endo-knife
• Endoscopic submucosal dissection
• Ex vivo
• Porcine model
• Scissor-type

• Animals
• Dissection/adverse effects
• Dissection/instrumentation
• Endoscopic Mucosal Resection/methods
• Endoscopy/instrumentation
• Endoscopy/methods
• Microsurgery
• Mucous Membrane/surgery
• Stomach Neoplasms/surgery
• Surgical Instruments
• Swine

• Adult
• Clinical Competence
• Endoscopic Mucosal Resection/education
• Endoscopic Mucosal Resection/methods
• Female
• Humans
• Learning Curve
• Male
• Republic of Korea
• Surveys and Questionnaires

• Korea Health Industry Development Institute (KR)

• Computer simulation
• Endoscopic procedures
• Endoscopy
• Gastrointestinal
• Simulation training

• Endoscopic submucosal dissection
• Laparoscopic endoscopic cooperative surgery
• Nonexposed endoscopic wall-inversion surgery
• Sentinel node navigation surgery

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.

• 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

• Clinical Competence
• Dissection/adverse effects
• Dissection/education
• Dissection/methods
• Education, Continuing
• Education, Medical, Graduate
• Endoscopy, Gastrointestinal/adverse effects
• Endoscopy, Gastrointestinal/education
• Endoscopy, Gastrointestinal/methods
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Neoplasms/surgery
• Humans
• Japan
• Learning Curve
• Mentors
• Referral and Consultation
• Treatment Outcome
• Western World

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.

• Endoscopic submucosal dissection
• Training

• Animal model
• Colon neoplasia
• ESD
• Training

AIM: To evaluate the role of observation of experts performing endoscopic submucosal dissection (ESD) in the acquisition of ESD skills.

METHODS: This prospective study is documenting the learning curve of one Western endoscopist. The study consisted of three periods. In the first period (pre-observation), the trainee performed ESDs in animal models in his home institution in the United States. The second period (observation) consisted of visit to Japan and observation of live ESD cases done by experts. The observation of cases occurred over a 5-wk period. During the third period (post-observation), the trainee performed ESD in animal models in a similar fashion as in the first period. Three animal models were used: live 40-50 kg Yorkshire pig, explanted pig stomach model, and explanted pig rectum model. The outcomes from the ESDs done in the animal models before and after observation of live human cases (main study intervention) were compared. Statistical analysis of the data included: Fisher’s exact test to compare distributions of a categorical variable, Wilcoxon rank sum test to compare distributions of a continuous variable between the two groups (pre-observation and post-observation), and Kruskal-Wallis test to evaluate the impact of lesion location and type of model (ex-vivo vs live pig) on lesion removal time.

RESULTS: The trainee performed 38 ESDs in animal model (29 pre-observation/9 post-observation). The removal times post-observation were significantly shorter than those pre-observation (32.7 ± 15.0 min vs 63.5 ± 9.8 min, P < 0.001). To minimize the impact of improving physician skill, the 9 lesions post-observation were compared to the last 9 lesions pre-observation and the removal times remained significantly shorter (32.7 ± 15.0 min vs 61.0 ± 7.4 min, P = 0.0011). Regression analysis showed that ESD observation significantly reduced removal time when controlling for the sequence of lesion removal (P = 0.025). Furthermore, it was also noted a trend towards decrease in failure to remove lesions and decrease in complications after the period of observation. This study did not find a significant difference in the time needed to remove lesions in different animal models. This finding could have important implications in designing training programs due to the substantial difference in cost between live animal and explanted organ models. The main limitation of this study is that it reflects the experience of a single endoscopist.

CONCLUSION: Observation of experts performing ESD over short period of time can significantly contribute to the acquisition of ESD skills.

• Endoscopic submucosal dissection
• Training
• Animal models
• Early gastric cancer
• Learning curve

• Animals
• Clinical Competence
• Dissection/adverse effects
• Dissection/education
• Endoscopy, Gastrointestinal/adverse effects
• Endoscopy, Gastrointestinal/education
• Florida
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Neoplasms/surgery
• Humans
• Japan
• Learning Curve
• Models, Animal
• Observation
• Prospective Studies
• Swine
• Task Performance and Analysis
• Time Factors
• Treatment Outcome

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.

• Endoscopic submucosal dissection
• Training
• Learning curve
• Early gastrointestinal cancer
• Endoscopic mucosal resection

• Early gastrointestinal cancer
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Learning curve
• Training

Introduction of endoscopic submucosal dissection (ESD) has brought about a renaissance in therapeutic endoscopy. For the globalization and universalization of ESD, the number of physicians who can perform ESD has rapidly increased with general ex vivo and in vivo training using animal models and hand-on courses. In this focused review series, world-renowned ESD experts described the published studies or their own precious experiences about ESD training and performing ESD with accurate and safe techniques. First, Dr. Adolfo Parra-Blanco reviewed on ex vivo and in vivo models for ESD training. Next, Dr. Joo Young Cho described detailed practical settings and current status of hands-on courses using ex vivo and in vivo models in Korea. Dr. Takashi Toyonaga described quality controlled ESD and basic techniques to prevent complications. Dr. Tsuneo Oyama reviewed recently published methods to facilitate ESD. Dr. Jae-Young Jang reviewed the usefulness of magnifying and narrow band imaging to measure the depth of invasion before ESD.

• Animal models
• Endoscopic submucosal dissection
• Globalization
• Training
• Universalization

Endoscopic submucosal dissection (ESD) is an established treatment for gastric neoplasias especially in regions with a high volume of gastric cancer. Although ESD has many advantages over endoscopic mucosal resection, ESD is technically more difficult and can result in severe complications. Therefore establishment of an effective training system is required to help endoscopists climb the ESD learning curve. Although a standard training system for ESD remains to be established, some centers are incorporating ex vivo and/or in vivo animal models to provide a safe and effective means of ESD training. However, it is unknown if these animal models are more effective than other programs. Moreover the efficacy of the animal model may vary according to socio-economic status and the volume of gastric cancer. In this article we introduce the basic and advanced ESD training model using the ex vivo and in vivo animal model from South Korea and review the associated literature from other regions.

• Endoscopic submucosal dissection
• Endoscopic submucosal dissection training
• Ex vivo model
• In vivo model

Endoscopic submucosal dissection is a technically challenging but highly effective technique for the treatment of well selected early neoplasms in the digestive tract. Although it is frequently performed in East Asian countries, the Western world has not adopted this technique yet, probably due in part to the difficulty to learn it. Ex vivo and in vivo animal models are invaluable tools to overcome at least the beginning of the learning curve, although the initial step is the acquisition of basic knowledge about early diagnosis of neoplasias, and observing real procedures in expert centers. The practical issues, advantages, and disadvantages of the ex vivo and in vivo models are discussed.

• Animal models
• Endoscopic submucosal dissection
• Training