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Tonishi T, Ishibashi F, Okusa K, Mochida K, Suzuki S. Effects of a training system that tracks the operator's gaze pattern during endoscopic submucosal dissection on hemostasis. World J Gastrointest Endosc 2025; 17:104315. [PMID: 40125505 PMCID: PMC11923982 DOI: 10.4253/wjge.v17.i3.104315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2024] [Revised: 02/16/2025] [Accepted: 02/27/2025] [Indexed: 03/14/2025] Open
Abstract
BACKGROUND The early acquisition of skills required to perform hemostasis during endoscopy may be hindered by the lack of tools that allow assessments of the operator's viewpoint. Understanding the operator's viewpoint may facilitate the skills. AIM To evaluate the effects of a training system using operator gaze patterns during gastric endoscopic submucosal dissection (ESD) on hemostasis. METHODS An eye-tracking system was developed to record the operator's viewpoints during gastric ESD, displaying the viewpoint as a circle. In phase 1, videos of three trainees' viewpoints were recorded. After reviewing these, trainees were recorded again in phase 2. The videos from both phases were retrospectively reviewed, and short clips were created to evaluate the hemostasis skills. Outcome measures included the time to recognize the bleeding point, the time to complete hemostasis, and the number of coagulation attempts. RESULTS Eight cases treated with ESD were reviewed, and 10 video clips of hemostasis were created. The time required to recognize the bleeding point during phase 2 was significantly shorter than that during phase 1 (8.3 ± 4.1 seconds vs 23.1 ± 19.2 seconds; P = 0.049). The time required to complete hemostasis during phase 1 and that during phase 2 were not significantly different (15.4 ± 6.8 seconds vs 31.9 ± 21.7 seconds; P = 0.056). Significantly fewer coagulation attempts were performed during phase 2 (1.8 ± 0.7 vs 3.2 ± 1.0; P = 0.004). CONCLUSION Short-term training did not reduce hemostasis completion time but significantly improved bleeding point recognition and reduced coagulation attempts. Learning from the operator's viewpoint can facilitate acquiring hemostasis skills during ESD.
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Affiliation(s)
- Takao Tonishi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba 272-0827, Japan
- International University of Health and Welfare Graduate School of Medicine, Chiba 286-8686, Japan
| | - Fumiaki Ishibashi
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba 272-0827, Japan
- International University of Health and Welfare Graduate School of Medicine, Chiba 286-8686, Japan
| | - Kosuke Okusa
- Department of Data Science for Business Innovation, Chuo University, Tokyo 112-0003, Japan
| | - Kentaro Mochida
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba 272-0827, Japan
- International University of Health and Welfare Graduate School of Medicine, Chiba 286-8686, Japan
| | - Sho Suzuki
- Department of Gastroenterology, International University of Health and Welfare Ichikawa Hospital, Chiba 272-0827, Japan
- International University of Health and Welfare Graduate School of Medicine, Chiba 286-8686, Japan
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Ansari J, Bapaye H, Shah J, Raina H, Gandhi A, Bapaye J, B R A, Pagadapelli AA, Bapaye A. Clinical audit of endoscopic sub-mucosal dissection performed for complex lateral spreading colorectal tumors from a region non-endemic for colorectal cancer. Indian J Gastroenterol 2024; 43:1002-1011. [PMID: 39102130 DOI: 10.1007/s12664-024-01631-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 06/10/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Endoscopic resection is currently the treatment of choice for laterally spreading tumors (LSTs). Endoscopic sub-mucosal dissection (ESD) can achieve higher enbloc resection and R0 resection, albeit at a slightly higher risk of complications. Given scarce data on ESD from India, we performed a retrospective analysis of our experience with colorectal ESD (CR-ESD) to know its clinical efficacy and complications as well as to assess the learning curve of CR-ESD in non-endemic-areas. METHODS Retrospective analysis of prospectively maintained datasheet performed. All patients with large (>2cm), complex or recurrent colorectal LST who underwent ESD at our center between 2012 and 2021 were included in the study. Various baseline lesion-related parameters, procedure-related parameters, enbloc resection (ER) rates, R0 margins and adverse event rates were retrieved. CUSUM analysis was performed to calculate the minimum required procedures to achieve competency in CR-ESD. RESULTS Total 149 patients were included in the study; mean patient age was 61.36±18.21 years. Most patients had lesions in rectum (n=102; 68.5%) followed by sigmoid colon (n=25; 16.8%). The mean lesion size was 46.62 ± 25.46 mm and the mean procedure duration for ESD was 219.30 ± 150.05 min. ER was achieved in 94.6% of lesions. R0 resection was achieved in 132 patients (88.6%). Overall, six (4%) adverse events were noted, of which one required surgical intervention. As many as 105 patients (70.5%) had adenomatous lesions on histology. Seventy-four patients underwent follow-up colonoscopy, of which three had a recurrence of adenomatous lesions and five had post-resection stricture requiring endoscopic dilation. CUSUM curve analysis calculated the learning curve for ESD was 47 resections for ER and 55 for the occurrence of AEs, with a composite CUSUM at 47 procedures. CONCLUSION CR-ESD even in non-endemic area is associated with high en bloc resection rates, R0 resection rates and acceptable complication profile. Approximately 50 cases of CR-ESD are required to achieve competency.
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Affiliation(s)
- Jaseem Ansari
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India
| | - Harsh Bapaye
- Department of Internal Medicine, Byramjee Jeejeebhoy Medical College, Pune, 411 001, India
| | - Jimil Shah
- Department of Gastroenterology, Post Graduate Institute of Medical Research, Chandigarh, 160 012, India
| | - Hameed Raina
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India
| | - Ashish Gandhi
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India
| | - Jay Bapaye
- Department of Gastroenterology and Hepatology, Virginia Tech Carillon School of Medicine, Roanoke, VA, USA
| | - Ajay B R
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India
| | - Arun Arora Pagadapelli
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, 411 004, India.
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Koseki M, Nishimura M, Nammour T, Nagao S, Schattner MA. Feasibility of esophageal endoscopic submucosal dissection after radiofrequency ablation treatment in patients with Barrett's esophagus. Gastrointest Endosc 2024; 100:128-131. [PMID: 38340874 DOI: 10.1016/j.gie.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/25/2024] [Accepted: 02/03/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND AND AIMS Radiofrequency ablation (RFA) is a well-established treatment for Barrett's esophagus (BE) in the United States. Similarly, endoscopic submucosal dissection (ESD) has been widely performed for early esophageal carcinoma. However, conducting ESD after RFA can be technically challenging. The aim of this study was to assess the feasibility and safety of ESD in patients with prior RFA. METHODS This study was a single-center retrospective analysis of patients who underwent esophageal ESD after undergoing prior RFA treatment for BE. RESULTS Of 44 esophageal ESD cases, 7 underwent prior RFA. In those 7 cases, the en bloc resection rate was 100%, and the R0 resection rate was 86%. No acute or delayed adverse events or rehospitalizations occurred in any patient. CONCLUSIONS ESD may be a feasible and safe option for patients with a history of RFA. It could be considered for esophageal neoplasms in patients previously treated with RFA for BE.
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Affiliation(s)
- Mako Koseki
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Makoto Nishimura
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Tarek Nammour
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sayaka Nagao
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark A Schattner
- Gastroenterology, Hepatology, and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Yang X, Fu S, Li L, Yang J, Ji R, Li Y, Zuo X. Robot-assisted endoscopic submucosal dissection contributes to efficient and safe learning for novices: Prospective pilot cross-over ex vivo study (with video). Dig Endosc 2023; 35:342-351. [PMID: 36107632 DOI: 10.1111/den.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/12/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The lack of effective countertraction to expose the submucosal layer contributes to the technical complication and adverse events in endoscopic submucosal dissection (ESD). We aimed to evaluate the efficacy and safety of a novel endoscopic robot (flexible auxiliary single-arm transluminal endoscopic robot [FASTER]) for ESD learning for novices. METHODS This was a prospective, cross-over designed pilot study in ex vivo porcine stomach. Four ESD novices were randomized to either FASTER-assisted ESD first (FC) group or a conventional ESD first (CF) group, performed 40 gastric ESDs using each technique, then crossed over to another technique. The performance and learning curve were compared between the two groups. RESULTS In the first phase, novices in the FC group demonstrated significantly better performance with shorter procedure time (25.6 ± 7.8 vs. 38.9 ± 13.4 min; P < 0.001) and submucosal dissection time (13.9 ± 5.5 vs. 23.1 ± 11.0 min; P < 0.001), higher direct-vision dissection ratio (84.0 ± 7.9% vs. 43.5 ± 20.7%; P < 0.001), and lower muscular injury (2.5 vs. 40.0%; P < 0.001) and task load (4 vs. 5; P < 0.001). Fewer ESDs were required to gain early proficiency in the FC group. When crossed to the second phase, procedure time in the FC group was prolonged but the muscular injury rate did not increase significantly. In total, endoscopists in the FC group tended to have a lower task load (4 vs. 5; P = 0.008) and less muscular injury (10.0 vs. 21.3%; P = 0.05). CONCLUSION Flexible auxiliary single-arm transluminal endoscopic robot-assisted learning reduces the technical difficulty of ESD for novices and the safety profile can sustain in following conventional ESD. These results indicated that FASTER has potential implications for ESD training in clinical practice.
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Affiliation(s)
- Xiaoxiao Yang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Shichen Fu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Lixiang Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Jialin Yang
- Robo Medical Robotics Institute, Shenzhen Robo Medical Technology Co., Ltd, Shenzhen, China
| | - Rui Ji
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiuli Zuo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
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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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Karanfilian B, Kahaleh M. New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review. J Clin Gastroenterol 2022; 56:465-477. [PMID: 35357336 DOI: 10.1097/mcg.0000000000001694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.
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Affiliation(s)
- Briette Karanfilian
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Emara MH, Zaghloul M, Ramadan HKA, Mohamed SY, Tag-Adeen M, Alzamzamy A, Alboraie M, Madkour A, Altonbary AY, Zaher TI, Elhassan AA, Abdeen N, Ahmed MH. Endoscopic resection of superficial bowel neoplasia: The unmet needs in the Egyptian practice. World J Gastrointest Endosc 2022; 14:235-249. [PMID: 35634486 PMCID: PMC9048489 DOI: 10.4253/wjge.v14.i4.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/22/2021] [Accepted: 03/26/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND 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. AIM 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. METHODS 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. RESULTS 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%). CONCLUSION 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.
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Affiliation(s)
- Mohamed H Emara
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
| | - Mariam Zaghloul
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
| | | | - Salem Youssef Mohamed
- Department of Internal Medicine, Faculty of Medicine, Gastroenterology and Hepatology Unit, Zagazig University, Zagazig 44519, Egypt
| | - Mohammed Tag-Adeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, South Valley University, Qena Faculty of Medicine, Qena 83523, Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11841, Egypt
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo11884, Egypt
| | - Ahmad Madkour
- Department of Endemic Medicine, Helwan University, Cairo 11795, Egypt
| | | | - Tarik I Zaher
- Department of Tropical Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Ahmed Abo Elhassan
- Department of Tropical Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Nermeen Abdeen
- Department of Tropical Medicine, Alexandria University, Alexandria 21526, Egypt
| | - Mohammed Hussien Ahmed
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
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Emara MH, Zaghloul M, Ramadan HKA, Mohamed SY, Tag-Adeen M, Alzamzamy A, Alboraie M, Madkour A, Altonbary AY, Zaher TI, Elhassan AA, Abdeen N, Ahmed MH. Endoscopic resection of superficial bowel neoplasia: The unmet needs in the Egyptian practice. World J Gastrointest Endosc 2022; 14:236-250. [DOI: 10.4253/wjge.v14.i4.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND 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.
AIM 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.
METHODS 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.
RESULTS 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%).
CONCLUSION 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.
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Affiliation(s)
- Mohamed H Emara
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
| | - Mariam Zaghloul
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
| | | | - Salem Youssef Mohamed
- Department of Internal Medicine, Faculty of Medicine, Gastroenterology and Hepatology Unit, Zagazig University, Zagazig 44519, Egypt
| | - Mohammed Tag-Adeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, South Valley University, Qena Faculty of Medicine, Qena 83523, Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo 11841, Egypt
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo11884, Egypt
| | - Ahmad Madkour
- Department of Endemic Medicine, Helwan University, Cairo 11795, Egypt
| | | | - Tarik I Zaher
- Department of Tropical Medicine, Zagazig University, Zagazig 44519, Egypt
| | - Ahmed Abo Elhassan
- Department of Tropical Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Nermeen Abdeen
- Department of Tropical Medicine, Alexandria University, Alexandria 21526, Egypt
| | - Mohammed Hussien Ahmed
- Department of Hepatology, Gastroenterology and Infectious Diseases, Kafrelsheikh University, Kafr Elshiekh 33516, Egypt
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Arantes V, Aliaga Ramos J, Pedrosa M. Disección endoscópica de submucosa para neoplasias gástricas superficiales en dos hospitales de referencia en Brasil: ¿se pueden igualar los resultados de Japón y Corea del Sur? REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 86:244-252. [DOI: 10.1016/j.rgmx.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
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Arantes V, Aliaga Ramos J, Pedrosa MS. Endoscopic submucosal dissection for superficial gastric neoplasias in two referral hospitals in Brazil: Can the Japanese and South Korean results be equaled? REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2021; 86:244-252. [PMID: 34210458 DOI: 10.1016/j.rgmxen.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/08/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION AND AIMS Endoscopic submucosal dissection (ESD) in the treatment of superficial neoplasias of the gastrointestinal tract is currently one of the greatest advances in therapeutic endoscopy. Due to its high technical complexity, it is not yet a routine procedure in Latin America. The aim of the present study was to present the experience in Brazil with ESD in superficial gastric neoplasias, based on training received from Japanese experts. MATERIALS AND METHODS A retrospective study was conducted, in which information was prospectively collected from a database that included all patients that underwent ESD due to superficial gastric neoplasias at two endoscopy referral centers in Brazil, within the time frame of June 2008 to June 2019. En bloc, complete, and curative resection rates were calculated, along with the local recurrence rate and adverse events. RESULTS A total of 103 ESDs for superficial gastric neoplasias were performed during the study period. Eighty of those patients (77.6%) presented with early malignant gastric neoplasias or premalignant lesions (adenocarcinoma: 52.5%, high-grade dysplasia: 27.5%, low-grade dysplasia: 16.3%, and neuroendocrine tumors: 3.8%). Overall en bloc and complete resection rates for the superficial gastric neoplasias were 96.3% and 92.5%, respectively, whereas the curative resection rate based on expanded criteria was 76%. CONCLUSIONS ESD for the treatment of superficial gastric neoplasias is a safe and effective therapeutic modality in Latin America, with results similar to those shown in the most representative Japanese studies.
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Affiliation(s)
- V Arantes
- Unidad de Endoscopia, Instituto Alfa de Gastroenterología, Facultad de Medicina, Universidad Federal de Minas Gerais, Hospital Mater Dei Contorno, Belo Horizonte, Minas Gerais, Brazil.
| | - J Aliaga Ramos
- Servicio de Gastroenterología Clínica San Pablo, Surco, Lima, Peru, Facultad de Medicina Alberto Hurtado, Universidad Peruana Cayetano Heredia, Miembro de la Sociedad de Gastroenterología del Perú, Lima, Peru
| | - M S Pedrosa
- Departamento de Patología, Facultad de Medicina de la Universidad Federal de Minas Gerais, Belo Horizonte, Brazil
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Küttner-Magalhães R, Pimentel-Nunes P, Araújo-Martins M, Libânio D, Borges-Canha M, Marcos-Pinto R, Koch AD, Dinis-Ribeiro M. Endoscopic submucosal dissection (ESD): how do Western endoscopists value animal models? Scand J Gastroenterol 2021; 56:492-497. [PMID: 33556257 DOI: 10.1080/00365521.2021.1879251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/14/2021] [Accepted: 01/16/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic Submucosal Dissection (ESD)was introduced in the West later than in the East. Our aim was to assess how Western endoscopists performing ESD have been trained and how they value animal models for training. MATERIAL AND METHODS An online survey regarding training in ESD was sent to Western endoscopists who published articles on advanced resection techniques. RESULTS From 279 endoscopists, 58 (21%) completed the questionnaire, of which 50 confirmed performance of clinical ESD. Endoscopists had a median of 15 years of endoscopic experience (IQR 9.75-20.25) and all of them were performing conventional EMR, before starting ESD. Prior to clinical ESD, 74% (n = 37) underwent training with ex vivo models, 84% (n = 42) with live animal models and 92% (n = 46) with at least, one of the two models. After starting clinical ESD, as trainers, 52% (n = 26) were involved with ex vivo and 60% (n = 30) with live animal models. Personal usefulness of ex vivo and live animal models was rated with a median of 9 (IQR 8-10) and 10 (IQR 8-10), out of 10, respectively. Courses with ex vivo and live animal models were considered a prerequisite before clinical practice by 84% (n = 42) and 78% (n = 39), respectively. CONCLUSIONS Western endoscopists have extensive endoscopic experience before starting ESD. The majority had pre-clinical training with ex vivo and live animal models and more than half are acting as trainers of other endoscopists with these models. Animal models are considered very useful and deemed a prerequisite before clinical practice by the majority of the endoscopists.
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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
| | - Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Miguel Araújo-Martins
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS) and CINTESIS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marta Borges-Canha
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Endocrinology, Diabetes and Metabolism, São João University Hospital Center, Porto, Portugal
| | - 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, University of Porto, Porto, Portugal
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - 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, University of Porto, Porto, Portugal
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Yang D, Wagh MS, Draganov PV. The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging. Gastrointest Endosc 2020; 92:1016-1025. [PMID: 32504699 PMCID: PMC7267783 DOI: 10.1016/j.gie.2020.05.047] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/14/2020] [Indexed: 02/08/2023]
Abstract
The landscape of advanced endoscopy continues to evolve as new technologies and techniques become available. Although postgraduate advanced endoscopy fellowships have traditionally centered on ERCP and diagnostic EUS, the breadth of training has increased over the years in response to the ever-growing demand for therapeutic endoscopy. The increasing diversity and complexity of emerging endoscopic techniques accompanied by the shift in focus toward competency-based medical education requires innovative changes to the curriculum that will ensure adequate training yet without compromising best patient practices. The purpose of this review is to highlight the expansive array of advanced endoscopic procedures and the challenges of both defining and measuring competence during training. All authors are interventional endoscopists at their respective institutions performing these complex procedures, as well as training fellows in these techniques. We share our perspectives based on our experience navigating through these issues at our institutions and discuss strategies to standardize training and how to potentially incorporate these measures in the process of credentialing and privileging in endoscopy.
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Mihir S. Wagh
- Division of Gastroenterology, University of Colorado, Denver, Aurora, Colorado, USA
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida,Reprint requests: Peter V. Draganov, MD, 1329 SW 16th Street, Room #5263, Gainesville, FL 32608
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Barbour JA, O'Toole P, Suzuki N, Dolwani S. Learning endoscopic submucosal dissection in the UK: Barriers, solutions and pathways for training. Frontline Gastroenterol 2020; 12:671-676. [PMID: 34917325 PMCID: PMC8640414 DOI: 10.1136/flgastro-2020-101526] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jamie A Barbour
- Department of Gastroenterology, QE Gateshead, Gateshead, Tyne and Wear, UK
| | - Paul O'Toole
- Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
| | - Sunil Dolwani
- Department of Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
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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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15
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Dickinson KJ, Dunkin BJ, Nguyen-Lee JJ, Ali AB, Zajac S. Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus. World J Surg 2020; 44:2401-2408. [PMID: 32133568 DOI: 10.1007/s00268-020-05454-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment. METHODS Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance. RESULTS A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD. CONCLUSION The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.
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Affiliation(s)
- Karen J Dickinson
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA. .,Department of Surgery, Houston Methodist Hospital, Houston, USA.
| | - Brian J Dunkin
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - John J Nguyen-Lee
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - Aman B Ali
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
| | - Stephanie Zajac
- Houston Methodist Institute for Technology, Innovation and Education (MITIE), 6670 Bertner Ave, Houston, TX, 77030, USA.,Department of Surgery, Houston Methodist Hospital, Houston, USA
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Matsuzaki I, Hattori M, Yamauchi H, Goto N, Iwata Y, Yokoi T, Tsunemi M, Kobayashi M, Yamamura T, Miyahara R. Magnetic anchor-guided endoscopic submucosal dissection for colorectal tumors (with video). Surg Endosc 2019; 34:1012-1018. [DOI: 10.1007/s00464-019-07127-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022]
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Podboy A, Friedland S. Endoscopic submucosal dissection in the West. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019; 8:106-109. [DOI: 10.18528/ijgii190014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/22/2019] [Accepted: 07/22/2019] [Indexed: 08/30/2023] Open
Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University Hospital, Redwood City, CA, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University Hospital, Redwood City, CA, USA
- Department of Gastroenterology and Hepatology, VA Palo Alto Health Care System, Palo Alto, CA, USA
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18
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Development and clinical outcomes of an endoscopic submucosal dissection fellowship program: early united states experience. Surg Endosc 2019; 34:829-838. [DOI: 10.1007/s00464-019-06836-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/15/2019] [Indexed: 02/06/2023]
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Endoscopic submucosal dissection: a cognitive task analysis framework toward training design. Surg Endosc 2019; 34:728-741. [PMID: 31102078 DOI: 10.1007/s00464-019-06822-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 05/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND One of the major impediments to the proliferation of endoscopic submucosal dissection (ESD) training in Western countries is the lack of sufficient experts as instructors. One way to address this gap is to develop didactic systems, such as surgical simulators, to support the role of trainers. Cognitive task analysis (CTA) has been used in healthcare for the design and improvement of surgical training programs, and therefore can potentially be used for design of similar systems for ESD. OBJECTIVE The aim of the study was to apply a CTA-based approach to identify the cognitive aspects of performing ESD, and to generate qualitative insights for training. MATERIALS AND METHODS Semi-structured interviews were designed based on the CTA framework to elicit knowledge of ESD practitioners relating to the various tasks involved in the procedure. Three observations were conducted of expert ESD trainers either while they performed actual ESD procedures or at a training workshop. Interviews were either conducted over the phone or in person. Interview participants included four experts and four novices. The observation notes and interviews were analyzed for emergent qualitative themes and relationships. RESULTS The qualitative analysis yielded thematic insights related to four main cognition-related categories: learning goals/principles, challenges/concerns, strategies, and decision-making. The specific insights under each of these categories were systematically mapped to the various tasks inherent to the ESD procedure. CONCLUSIONS The CTA approach was applied to identify cognitive themes related to ESD procedural tasks. Insights developed based on the qualitative analysis of interviews and observations of ESD practitioners can be used to inform the design of ESD training systems, such as virtual reality-based simulators.
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20
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Suture pulley countertraction method reduces procedure time and technical demand of endoscopic submucosal dissection among novice endoscopists learning endoscopic submucosal dissection: a prospective randomized ex vivo study. Gastrointest Endosc 2019; 89:177-184. [PMID: 30148993 DOI: 10.1016/j.gie.2018.08.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The lack of reliable countertraction in endoscopic submucosal dissection (ESD) contributes to its technical demand and increased procedure time. We aimed to prospectively evaluate the efficacy of the suture pulley countertraction method in endoscopists new to both suturing and ESD. METHODS Two 30-mm circular lesions were created in an ex vivo porcine stomach model. Endoscopists considered novices for both endoscopic suturing and ESD were randomized to either traditional or suture pulley ESD first and performed ESD using each technique. Procedure time was recorded including time of circumferential incision, suture pulley placement, and submucosal dissection. After completion of each ESD, participants graded the difficulty of the procedure using the National Aeronautical and Space Administration (NASA) Task Load Index. RESULTS Thirteen participants (8 fellows, 5 attendings) completed the study using both methods. Mean total procedure time was shorter using suture pulley ESD compared with traditional ESD (26.7 ± 7.3 vs 59.4 ± 20.4 minutes, P < .001). The suture pulley required a mean 6.2 ± 2.1 minutes to place. Submucosal dissection time was shorter using suture pulley ESD compared with traditional ESD (8.4 ± 2.9 vs 47.2 ± 16.3 minutes, P < .001). All 7 individual indices and total score on the NASA Task Load Index were significantly improved using the suture pulley ESD method (P < .001). CONCLUSIONS The suture pulley countertraction method significantly decreases procedure time and technical demand of ESD among endoscopists at all skill levels who are new to ESD. The results of this study have potential implications for ESD training in the United States.
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Kotzev AI, Yang D, Draganov PV. How to master endoscopic submucosal dissection in the USA. Dig Endosc 2019; 31:94-100. [PMID: 30022521 DOI: 10.1111/den.13240] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/17/2018] [Indexed: 02/08/2023]
Abstract
Endoscopic submucosal dissection (ESD) is an established technique for the endoscopic therapy of dysplastic and early cancerous lesions throughout the gastrointestinal tract. The procedure requires both a sophisticated knowledge for lesion characterization and high-level endoscopic skills. As a result, the learning curve is very steep and, in Japan, it takes years to gain proficiency under the traditional Master-Apprentice teaching model. At present, as a result of multiple limitations, this training model is not applicable to the USA. Nevertheless, a unique, multipronged, stepwise approach has emerged as a viable pathway to train US endoscopists in ESD. Although this approach deserves refinement, it has already led to the expansion of ESD in the USA, has contributed to the widening of the indications for ESD, and has further developed ESD techniques. Multiple challenges remain, but they can be overcome by active collaboration between Japanese and US endoscopists and professional societies. The robust interest in ESD in the USA has drawn industry attention with a few innovations already coming to fruition and many more in development.
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Affiliation(s)
- Andrey Iskrenov Kotzev
- Clinic of Gastroenterology, University Hospital "Alexandrovska", Medical University, Sofia, Bulgaria
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, College of Medicine, University of Florida, Gainesville, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, College of Medicine, University of Florida, Gainesville, 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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Ebigbo A, Probst A, Römmele C, Messmann H. Step-up training for colorectal and gastric ESD and the challenge of ESD training in the proximal colon: results from a German Center. Endosc Int Open 2018; 6:E524-E530. [PMID: 29713678 PMCID: PMC5909775 DOI: 10.1055/a-0584-6457] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/12/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The endoscopic submucosal dissection (ESD) of cancerous and precancerous lesions in the gastrointestinal (GI) tract is an effective but difficult-to-learn procedure, especially for Western endoscopists. We developed a step-up training protocol and evaluated its outcome on a single endoscopist using specific performance measures. PATIENTS AND METHODS The training protocol included a 12-month period of 50 observational and supervised ESD cases as well as 24 animal procedures. After completion of the protocol, ESD competency was evaluated in the first 30 independent ESD cases. Majority of lesions were located in the stomach and rectum. Performance measures included R0-resection rate, complication rate and resection speed. RESULTS R0 resection rate was 93 %, complication rate was 7 % and median resection speed was 6,77 cm 2 /h. 1 case of delayed perforation with subsequent hemicolectomy occurred in the descending colon. CONCLUSION The ESD step-up training protocol used in this study on a single endoscopist showed excellent outcomes for lesions in the rectum and stomach. However, ESD training in the upper colon remains a challenge.
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Affiliation(s)
- Alanna Ebigbo
- Department of Gastroenterology, Klinikum Augsburg,Corresponding author Dr. Alanna Ebigbo Central Clinic of Augsburg – GastroenterologyStenglinstr. 2Augsburg 86156Germany+00498214002748
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Spychalski M, Skulimowski A, Dziki A, Saito Y. Colorectal endoscopic submucosal dissection (ESD) in the West - when can satisfactory results be obtained? A single-operator learning curve analysis. Scand J Gastroenterol 2017; 52:1442-1452. [PMID: 28942690 DOI: 10.1080/00365521.2017.1379557] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Up to date we lack a detailed description of the colorectal endoscopic submucosal dissection (ESD) learning curve, that would represent the experience of the Western center. The aim of this study was to define the critical points of the learning curve and to draw up lesions qualification guidelines tailored to the endoscopists experience. MATERIALS AND METHODS We have carried out a single center prospective study. Between June 2013 and December 2016, 228 primary colorectal lesions were managed by ESD procedure. In order to create a learning curve model and to carry out the analysis the cases were divided into six periods, each consisting of 38 cases. RESULTS The overall en bloc resection rate was 79.39%. The lowest en bloc resection rate (52.36%) was observed in the first period. After completing 76 procedures, the resection rate surged to 86% and it was accompanied by the significant increase in the mean procedure speed of ≥9 cm2/h. Lesions localization and diameter had a signification impact on the outcomes. After 76 procedures, en bloc resection rate of 90.9 and 90.67% were achieved for the left side of colon and rectum, respectively. In the right side of colon statistically significant lower resection rate of 67.57% was observed. CONCLUSION We have proved that in the setting of the Western center, colorectal ESD can yield excellent results. It seems that the key to the success during the learning period is 'tailoring' lesions qualification guidelines to the experience of the endoscopist, as lesions diameter and localization highly influence the outcomes.
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Affiliation(s)
- Michał Spychalski
- a Department of General and Colorectal Surgery , Medical University of Lodz , Lodz , Poland
| | - Aleksander Skulimowski
- b Department of General Surgery , Multidisciplinary Hospital Brzeziny , Brzeziny , Poland
| | - Adam Dziki
- a Department of General and Colorectal Surgery , Medical University of Lodz , Lodz , Poland
| | - Yutaka Saito
- c Gastrointestinal Endoscopy Division , National Cancer Center Hospital , Tokyo , Japan
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Küttner-Magalhães R, Dinis-Ribeiro M, Bruno MJ, Marcos-Pinto R, Rolanda C, Koch AD. Training in endoscopic mucosal resection and endoscopic submucosal dissection: Face, content and expert validity of the live porcine model. United European Gastroenterol J 2017; 6:547-557. [PMID: 29881610 DOI: 10.1177/2050640617742484] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/17/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction Endoscopic mucosal resection and endoscopic submucosal dissection are demanding procedures. This study aims to establish face, content and expert validity of the live porcine model in performing endoscopic mucosal resection, endoscopic submucosal dissection, complication management and to assess it as a training tool. Material and methods Tutors and trainees participating in live porcine model endoscopic mucosal resection and endoscopic submucosal dissection workshops filled out a questionnaire regarding the realism of the model compared to human setting and its role as a learning tool. A 10-point Likert scale was used. Results Ninety-one endoscopists (13 tutors; 78 trainees) were involved in four workshops. Median global classifications for the realism of the life porcine model ranged between 7.0-8.0 (interquartile range 5.0-9.0). Procedures resembled human cases with a median of 9.0 (8.0-9.0) for oesophageal multiband endoscopic mucosal resection; 8.5 (8.0-9.0) for oesophageal endoscopic submucosal dissection; 9.0 (8.0-10.0) for gastric endoscopic submucosal dissection; and 9.0 (8.5-9.75 and 8.0-9.69) for complication detection and management. The animal model as a learning tool had median scores of 9.0 (7.0-10.0) considering how procedures are performed; 9.0-9.5 (8.0-10.0) for usefulness for beginners; and 9.0-10.0 (5.0-10.0) regarding it a prerequisite. Conclusions Training in a live porcine model was considered very realistic compared to the human setting and was highly appreciated as a learning tool. This is the first study to establish face, content and expert validity of the live porcine model in performing multiband endoscopic mucosal resection, oesophageal and gastric endoscopic submucosal dissection. The validation of this model provides the rationale to incorporate it into formal teaching programmes.
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Affiliation(s)
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Oncology Portuguese Institute of Porto, Porto, Portugal.,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) and Center for Research in Health Technologies and Services (CINTESIS), Faculty of Medicine of Porto, Porto, Portugal
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Ricardo Marcos-Pinto
- Department of Gastroenterology, Santo António Hospital, Porto Hospital Centre, Portugal.,Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS) and Center for Research in Health Technologies and Services (CINTESIS), Faculty of Medicine of Porto, Porto, Portugal.,Abel Salazar Institute of Biomedical Sciences, University of Porto, Porto, Portugal
| | - Carla Rolanda
- Department of Gastroenterology, Braga Hospital, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga, Portugal
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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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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Endoscopic Submucosal Dissection Outcomes for Gastroesophageal Tumors in Low Volume Units: A Multicenter Survey. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2016; 2016:5670564. [PMID: 27891047 PMCID: PMC5116520 DOI: 10.1155/2016/5670564] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 08/29/2016] [Accepted: 09/07/2016] [Indexed: 02/06/2023]
Abstract
Background and Aims. Endoscopic submucosal dissection (ESD) outcomes have traditionally been reported from high volume centers in East Asia. Data from low volume centers in other parts of Asia remain sparse. Methods. A retrospective survey with a structured questionnaire of 5 tertiary centers in 3 countries in South East Asia was conducted. Details of training and clinical outcomes of ESD cases, with follow-up data from these centers, were analyzed. Results. Seven endoscopists from the 5 centers performed a total of 35 cases of ESD in the upper gastrointestinal tract (UGIT) over a 6-year duration. Details of the lesions excised were as follows: median size was 20 mm, morphologically 20 (68.6%) were flat/depressed and 6 (17.1%) were submucosal, and histologically 27 (77.1%) were neoplastic. The median duration of ESD procedures was 105 minutes, with an en-bloc resection rate of 91.4%. There was 1 (2.9%) case of delayed bleeding, but no perforation nor mortality in any of the cases. The recurrence rate after ESD was 5.7%. A prolonged ESD duration was influenced by a larger size of lesion (25 mm, p = 0.02) but not by factors related to the training experience of endoscopists. Conclusions. ESD in the UGIT is feasible and safe in low volume centers in Asia.
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Coman RM, Gotoda T, Forsmark CE, Draganov PV. Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett's esophagus: a Western center experience. Endosc Int Open 2016; 4:E715-21. [PMID: 27556083 PMCID: PMC4993890 DOI: 10.1055/s-0042-101788] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/23/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) carries significant advantages over endoscopic mucosal resection. As such, ESD is an established therapy for esophageal squamous cell carcinoma but there are only limited data on ESD as therapy for Barrett's esophagus (BE). Thus, we prospectively evaluated the outcomes of ESD in patients with BE with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) performed in a Western center. PATIENTS AND METHODS This is a prospective cohort study. Indications for ESD included: (1) early EAC defined as lesions with intramucosal cancer or superficial submucosal invasion; (2) early EAC with positive lateral margin after EMR; and (3) nodularity with HGD that could not be removed en-bloc with EMR Results: From October 2013 to July 2015, 36 consecutive patients (median age 69, 32 males) underwent ESD at our center. Median procedure time was 88 minutes, with median maximal diameter of resected specimens of 49 mm. En-bloc, R0, and curative resection rates were 100 %, 81 %, and 69 %, respectively. Intramucosal EAC was found in 13 patients (36 %), and submucosal invasion in 13 patients (36 %). In 59 % of the cases, there was discrepancy in the pre- and post-ESD histopathologic diagnosis. Adverse events occurred in 8 patients (22 %), including one episode of bleeding treated with endoscopy and seven esophageal strictures, which were successfully managed with dilations. CONCLUSIONS ESD for BE with HGD/early EAC is feasible and safe with resulting very high en-bloc and R0 resection rates. ESD provided for more accurate pathologic evaluation and significant discrepancy between the pre- and post-ESD histopathological diagnosis was noted.
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Affiliation(s)
- Roxana M. Coman
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States,Corresponding author Peter V. Draganov, MD University of FloridaDivision of Gastroenterology, Hepatology, and Nutrition1329 SW 16th Archer RoadPO Box 100214Gainesville, FL 32610
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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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Feurer ME, Draganov PV. Training for advanced endoscopic procedures. Best Pract Res Clin Gastroenterol 2016; 30:397-408. [PMID: 27345648 DOI: 10.1016/j.bpg.2016.04.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/04/2016] [Accepted: 04/28/2016] [Indexed: 02/07/2023]
Abstract
Advanced endoscopy has evolved from diagnostic ERCP to an ever-increasing array of therapeutic procedures including EUS with FNA, ablative therapies, deep enteroscopy, luminal stenting, endoscopic suturing and endoscopic mucosal resection among others. As these procedures have become increasingly more complex, the risk of potential complications has also risen. Training in advanced endoscopy involves more than obtaining a minimum number of therapeutic procedures. The means of assessing a trainee's competence level and ability to practice independently continues to be a matter of debate. The use of quality indicators to measure performance levels may be beneficial as more advanced techniques and procedures become available.
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Affiliation(s)
- Matthew E Feurer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, 1329 SW 16th Street, Room 5251, Gainesville, FL 32608, USA.
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida College of Medicine, 1329 SW 16th Street, Room 5251, Gainesville, FL 32608, USA.
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Mihmanli M, Ilhan E, Idiz UO, Alemdar A, Demir U. Recent developments and innovations in gastric cancer. World J Gastroenterol 2016; 22:4307-4320. [PMID: 27158199 PMCID: PMC4853688 DOI: 10.3748/wjg.v22.i17.4307] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/14/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
Gastric cancer has an important place in the worldwide incidence of cancer and cancer-related deaths. It can metastasize to the lymph nodes in the early stages, and lymph node metastasis is an important prognostic factor. Surgery is a very important part of gastric cancer treatment. A D2 lymphadenectomy is the standard surgical treatment for cT1N+ and T2-T4 cancers, which are potentially curable. Recently, the TNM classification system was reorganized, and the margins for gastrectomy and lymphadenectomy were revised. Endoscopic, laparoscopic and robotic treatments of gastric cancer have progressed rapidly with development of surgical instruments and techniques, especially in Eastern countries. Different endoscopic resection techniques have been identified, and these can be divided into two main categories: endoscopic mucosal resection and endoscopic submucosal dissection. Minimally invasive surgery has been reported to be safe and effective for early gastric cancer, and it can be successfully applied to advanced gastric cancer with increasing experience. Cytoreductive surgery and hyperthermıc intraperıtoneal chemotherapy were developed as a combined treatment modality from the results of experimental and clinical studies. Also, hyperthermia increases the antitumor activity and penetration of chemotherapeutics. Trastuzumab which is a monoclonal antibody interacts with human epidermal growth factor (HER) 2 and is related to gastric carcinoma. The anti-tumor mechanism of trastuzumab is not clearly known, but mechanisms such as interruption of the HER2-mediated cell signaling pathways and cell cycle progression have been reported previously. H. pylori is involved in 90% of all gastric malignancies and Japanese guidelines strongly recommend that all H. pylori infections should be eradicated regardless of the associated disease. In this review, we present innovations discussed in recent studies.
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Fukami N. Large colorectal lesions: Is it possible to stratify the lesions for optimal treatment in the right hands? Gastrointest Endosc 2016; 83:963-5. [PMID: 27102529 DOI: 10.1016/j.gie.2016.01.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/29/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Arizona
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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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EMURA FABIÁN, LIZARAZO JORGEIVÁN. DIAGNÓSTICO Y TRATAMIENTO ENDOSCÓPICO DEL CÁNCER GÁSTRICO TEMPRANO. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Rodrigues J, Carmo J, Carvalho L, Barreiro P, Chagas C. Endoscopic Submucosal Dissection for Gastrointestinal Superficial Lesions: Initial Experience in a Single Portuguese Center. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2015; 22:190-197. [PMID: 28868407 PMCID: PMC5579991 DOI: 10.1016/j.jpge.2015.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/05/2015] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a minimally invasive organ-sparing endoscopic technique which allows en bloc resection of premalignant and early malignant lesions of the gastrointestinal tract regardless of size. In spite of the promising results, mainly from Japanese series, ESD is still not being widely used in western countries. This study aims to report the feasibility, safety and effectiveness of ESD technique for treating premalignant and early malignant gastrointestinal (GI) lesions (esophagus, gastric and rectum) in a Portuguese center. PATIENT AND METHODS From December 2011 to November 2014, 34 GI lesions were treated by ESD. The location, en bloc and pathological complete resection (R0) rates, procedure time, complications and local recurrence were retrospectively evaluated. RESULTS From 34 resected lesions, 18 were gastric (GL), 15 were rectal (RL) and one esophageal (EL). En bloc resection for each location was 17/18 (94%), 11/15 (73%) and 1/1 respectively. R0 was achieved in 16/18 (89%) GL, 9/15 (60%) RL and 1/1 EL. Mean resection time was 67 min for GL, 142 min for RL and 40 min for EL. Complications included immediate (6%) and delayed (3%) minor bleeding but no perforation. One local residual lesion from a RL was reported in the follow-up, effectively treated with an endoscopic technique. Disease-specific survival was 100% over a mean follow-up period of 14 months. CONCLUSION ESD has shown to be a safe and feasible resection method, achieving high R0, low recurrence and complication rates. Our results are similar to those reported in other international series.
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Affiliation(s)
| | | | | | - Pedro Barreiro
- Gastroenterology Department, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
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Rushfeldt C, Aabakken L. Implementation of Endoscopic Submucosal Dissection for Gastric Lesions in Norway. Scand J Surg 2015; 105:90-6. [PMID: 26250354 DOI: 10.1177/1457496915596345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/09/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection is a minimal invasive method for an en bloc resection of dysplasia or early cancer in the stomach. It was developed in Japan in the 1990s, but thus far has not been widely adopted in Western countries. The aim of this study is to report from the introductory phase of gastric endoscopic submucosal dissection in a small-volume Scandinavian center. MATERIAL AND METHODS The 15 first patients operated on with endoscopic submucosal dissection in the stomach at the University Hospital of North Norway were consecutively registered in a prospective database and evaluated as a quality assurance study. The indications for the procedures were diagnostic or therapeutic. RESULTS Three patients had benign lesions, three had low-grade dysplasia, five had high-grade dysplasia, two had neuroendocrine tumors, and two had early gastric cancers (T1b). The R0 resection rate was 83%. One neuroendocrine tumor was directed to surgery. No recurrences have been detected after the median of 6 months, and with the exception of one delayed bleeding being treated endoscopically, no serious complications occurred. Two perforations were perioperatively closed with clips. CONCLUSION This is the first report on gastric endoscopic submucosal dissection in Scandinavia. Preliminary results from an introductory phase indicate that endoscopic submucosal dissection for dysplasia or early gastric cancer may be conducted safely and with acceptable results even in a small-volume center, assuming that surgeons and gastroenterologists in a region direct cases to one individual who can learn this skill.
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Affiliation(s)
- C Rushfeldt
- Department of Gastrointestinal Surgery, Division of Surgery, Oncology and Women's Health, University Hospital of North Norway, Tromsø, Norway
| | - L Aabakken
- Department of Cancer, Surgery and Transplant Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
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Gallardo Cabrera VE, Hernández Mondragón O, Rascón Martínez DM, Blanco Velasco G, Ramos González R, Tun Abraham AE, Blancas Valencia JM. Disección endoscópica submucosa: curva de aprendizaje en modelos porcinos. ENDOSCOPIA 2015. [DOI: 10.1016/j.endomx.2015.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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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Aslan F, Alper E, Cekıc C, Yurtlu DA, Ekıncı N, Arabul M, Unsal B, Mıura Y, Yamamoto H. Endoscopic submucosal dissection in gastric lesions: the 100 cases experience from a tertiary reference center in West. Scand J Gastroenterol 2015; 50:368-75. [PMID: 25582554 DOI: 10.3109/00365521.2014.999253] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic submucosal dissection (ESD) is an endoscopic treatment method widely used in premalignant and malignant lesions in countries of the Far East. This method, which is difficult technically and has a high complication risk rate, has rarely been performed in the West, because of the fewer number of upper gastrointestinal lesions. In the present study, we aimed to present our results of gastric ESD procedures in respect to the learning curve. METHODS A total of 100 ESD procedures, which were performed in the stomach between April 2012 and September 2014, were recorded prospectively before and after the procedure. Patient data were analyzed retrospectively. ESD procedures were numbered chronologically; the first 30 patients constituted group 1, whereas the rest were classified as the group 2. ESD results were compared between the groups. RESULTS In a total of 95 patients, 100 gastric ESDs were performed. The overall en-bloc and complete resection rates were 93% and 92%, respectively. In respect of the learning curve, there were significant differences in the sizes of lesions and tissues obtained, procedure duration and dissection rate, snare use and knife preferences between groups (p = 0.002, p < 0.001, p = 0.003, p < 0.001, p = 0.009, and p < 0.001, respectively). No significant difference was detected in the en-bloc and complete resection rates and complications between the groups. CONCLUSION According to guideline recommendations and masters for ESD, if ESD training is initiated and continued, successful ESD may be performed in localized lesions in the stomach.
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Affiliation(s)
- Fatih Aslan
- Department of Gastroenterology, Ataturk Training and Research Hospital, Katip Celebi University , Izmir , Turkey
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Agapov M, Dvoinikova E. Factors predicting clinical outcomes of endoscopic submucosal dissection in the rectum and sigmoid colon during the learning curve. Endosc Int Open 2014; 2:E235-40. [PMID: 26135099 PMCID: PMC4424868 DOI: 10.1055/s-0034-1377613] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/23/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Colorectal endoscopic submucosal dissection (ESD) is associated with significant technical difficulty, long procedure time, and increased risk of complications, especially perforation. This study aimed to determine the factors associated with clinical results of ESD during the learning curve. PATIENTS AND METHODS In total, 44 patients with sessile and flat rectal and sigmoid colon lesions underwent ESD from November 2009 to September 2013. The procedure time, resection method, tumor size, location, gross morphology, presence of fibrosis, histologic findings, rates of en bloc and piecemeal resections and perforation were analyzed. The ESD procedure was classified as technically difficult in the case of procedure time > 120 minutes and/or piecemeal resection. The whole study time was divided into two periods: first period: resections 1 - 22, second period: resections 23 - 44. RESULTS En bloc and R0 resection have been achieved in 84.1 % of lesions. The mean procedure time was 119.95 ± 11.22 minutes (range 25 - 360 minutes). Perforation was seen in five cases (11.4 %). A larger tumor size was a risk factor for difficult ESD (P = 0.0001). A finding of fibrosis was a risk factor for piecemeal ESD (P = 0.0074), and perforation (P = 0.0012). There was a high direct positive correlation between tumor size and operation time (r = 0.83, P < 0.0001, 0.95 and 0.99 confidence interval for rho 0.71 - 0.904). There was no significant difference between the first and second period in terms of mean procedure time, en bloc resection or complication rate. CONCLUSION A larger tumor size was associated with technically difficult ESD. Severe submucosal fibrosis was a risk factor for both piecemeal resection and perforation.
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Affiliation(s)
- Mikhail Agapov
- Vladivostok Clinical Railway Hospital – Endoscopy, Vladivostok, Russian Federation,Corresponding author Mikhail Agapov Vladivostok Clinical Railway Hospital – EndoscopyVerhneportovaya, 25Vladivostok 690003Russian Federation+7-4232-248227
| | - Ekaterina Dvoinikova
- Vladivostok Clinical Railway Hospital – Endoscopy, Vladivostok, Russian Federation
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The usage of overtube has a favorable effect on endoscopic submucosal dissection. Surg Endosc 2014; 29:2561-8. [PMID: 25427415 DOI: 10.1007/s00464-014-3968-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 10/20/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) may be very time consuming, and depending on the anesthesia, the contents of the stomach may reflux to the esophagus and cause the patient to aspirate. To prevent these situations, many practitioners suggest using an overtube, but no study has been done to evaluate the effect of the use of an overtube while performing the ESD procedure. Our aim was to investigate the effects of performing an upper gastrointestinal ESD with and without overtube. METHODS Records of patients who underwent ESD were evaluated for histopathological results, complications, speed of dissection, dosages of anesthetic medications, and number of suctions performed during the procedure. The patients were classified into two depending on whether an overtube was used or not. RESULTS There were a total of 58 patients on which 63 upper gastrointestinal ESD procedures were performed. Regarding age, gender, localization of the lesions, duration of the procedures, dosage of propofol, histopathological results, rate of complete resection, and rate of en-bloc resection, there was no difference between the two groups (p > 0,05). But the size of the lesions, the size of the resected specimen, and the speed of dissection were statistically different in two groups (p = 0.018, p < 0.001, p < 0.001, respectively).The need for suction during the procedure was much lower in the overtube group than those with no overtube (p < 0.001). CONCLUSIONS We conclude that using an overtube during an upper gastrointestinal ESD decreases the need for suction, favors the speed of dissection, and eases the comfort of the procedure.
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Race/Ethnicity is predictive of lymph node status in patients with early gastric cancer. J Gastrointest Surg 2014; 18:1744-51. [PMID: 25060552 DOI: 10.1007/s11605-014-2590-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 07/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Race/ethnicity has long been suspected to affect survival in patients with gastric adenocarcinoma. However, the clinicohistopathological impact of race or ethnicity on early gastric cancer (EGC) is not known. METHODS From 2000 to 2013, 286 patients underwent gastrectomy and 104 patients had pathological confirmation of EGC. A retrospective analysis of pathological and clinical prognostic indicators was performed. RESULTS The study population consisted of 38 (37%) Asian Americans and 66 (63%) non-Asian Americans. Of these, 2 (5.3%) Asian Americans and 19 (28.8%) non-Asian Americans had pathological confirmation of lymph node metastasis (LNM) (p = 0.004). Univariate analysis comparing the clinicohistopathological characteristics in each group did not reveal significant difference regarding histotype, tumor size, grade, location, morphology, or lymphovascular invasion, except for the LNM rate and mean body mass index (23.2 versus 26.6, p < 0.001). Multivariate analysis showed that non-Asian race/ethnicity (odds ratio (OR), 9.09; 95% confidence interval (CI), 1.12-71.43; p = 0.038), younger age (OR, 1.11; 95% CI, 1.01-1.12; p = 0.046), and lymphovascular invasion (OR, 13.9; 95% CI, 2.40-79.99; p = 0.003) were significant predictors for LNM. CONCLUSIONS This study demonstrated that Asian American race in EGC is associated with a significantly decreased rate of LNM in comparison to non-Asian Americans, despite similar histopathological characteristics of each group.
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Endoscopic submucosal dissection in the colorectum: Feasibility in the Canadian setting. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:689-93. [PMID: 24340310 DOI: 10.1155/2013/536190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Endoscopic submucosal dissection is a minimally invasive endoscopic technique for the removal of gastrointestinal tumours that is increasingly being used for colonic neoplasms to spare resection of colon in selected patients. Colonic endoscopic submucosal dissection is technically challenging and was initially pioneered in Japan but increasingly used in selected western centres. Its use in Canada is currently limited, and the authors review the challenges and opportunities, in addition to the unique training infrastructure required to practice the procedure under supervision. Specific tools are required to perform endoscopic submucosal dissection and meticulous attention to detail is essential. The authors provide a combined Japanese and Canadian perspective to this technique, and discuss training and performance of endoscopic submucosal dissection as well as potential indications.
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Dumoulin FL, Sido B, Bollmann R, Sauer M. Endoscopic Submucosal Dissection (ESD) in Colorectal Tumors. VISZERALMEDIZIN 2014; 30:39-44. [PMID: 26288580 PMCID: PMC4513806 DOI: 10.1159/000358529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Endoscopic submucosal dissection (ESD) – initially developed for the treatment of early gastric cancer in Japan – is an attractive option for en bloc resection of larger sessile or flat colorectal neoplasia. Methods A review of the current literature on colorectal ESD was carried out. Results In contrast to conventional endoscopic mucosal resection (EMR), ESD for larger colorectal neoplasia yields high en bloc resection rates and very low recurrence rates. The frequency of delayed bleeding is similar for EMR and ESD. Higher perforation rates during ESD are mostly due to microperforations identified and treated during the intervention, and are therefore of minor clinical relevance. A major disadvantage of ESD is the necessity for high-level endoscopic skills and long procedure times. ESD also has the potential to replace laparoscopic surgery or transanal endoscopic microsurgery mainly due to its lower complication rates. Conclusion ESD for the resection of larger flat or sessile colorectal lesions has potential advantages over conventional EMR or minimally invasive surgery. Due to the low incidence of early gastric cancer, experience with ESD will remain limited in Western countries. The spread of colorectal ESD will depend on adequate training opportunities and also on modifications yielding a reduction in procedure time.
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Affiliation(s)
| | - Bernd Sido
- Department of General and Abdominal Surgery, Gemeinschaftskrankenhaus Bonn, Bonn, Germany
| | | | - Malte Sauer
- Department of Medicine and Gastroenterology, Bonn, Germany
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Sattianayagam PT, Desmond PV, Jayasekera C, Chen RY. Endoscopic submucosal dissection: experience in an Australian tertiary center. Ann Gastroenterol 2014; 27:212-218. [PMID: 24976337 PMCID: PMC4073016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 03/07/2014] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a technique for en bloc resection of superficial tumors of the gastrointestinal tract. In contrast to Japan and other Asian countries, few data are available in Western countries. The objective of the current study was to evaluate the experience of ESD in a single Australian tertiary center. METHODS The patient features, outcomes and complications of ESD of 20 lesions in 18 patients at a single center between 2008 and 2012, were evaluated retrospectively. RESULTS Twenty lesions, in 18 patients of median age 69.5 years, were resected with ESD. Ten patients had gastric lesions (of whom two had two synchronous lesions), four patients had rectal lesions, one had a colonic lesion, one had a duodenal lesion and two had esophageal lesions. The median (range) lesion size was 2.5 (0.5-6.5) cm. In the entire cohort, en bloc resection occurred in 80% cases and complete histological resection was achieved in 60% cases. Significant bleeding requiring repeat endoscopy and transfusion occurred in two cases and microscopic perforation occurred in 1 case. Surgery for unsuccessful ESD was pursued without complication in 6 cases. There were two recurrences during follow up of median 36 months, both of which occurred in cases of gastric ESD and one of which (carcinoid) occurred after surgery. CONCLUSIONS ESD appears feasible in an Australian population. It should however be contemplated in carefully selected patients whilst there is refinement of pre-treatment diagnosis, the ESD technique and the management of its complications.
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Affiliation(s)
- Prayman T. Sattianayagam
- Department of Gastroenterology, East Kent Hospitals University Foundation Trust, UK (Prayman T. Sattianayagam),Department of Gastroenterology, St. Vincent’s Hospital, Melbourne, Australia (Prayman T. Sattianayagam, Paul V. Desmond, Chatura Jayasekera, Robert Y. Chen)
| | - Paul V. Desmond
- Department of Gastroenterology, St. Vincent’s Hospital, Melbourne, Australia (Prayman T. Sattianayagam, Paul V. Desmond, Chatura Jayasekera, Robert Y. Chen)
| | - Chatura Jayasekera
- Department of Gastroenterology, St. Vincent’s Hospital, Melbourne, Australia (Prayman T. Sattianayagam, Paul V. Desmond, Chatura Jayasekera, Robert Y. Chen)
| | - Robert Y. Chen
- Department of Gastroenterology, St. Vincent’s Hospital, Melbourne, Australia (Prayman T. Sattianayagam, Paul V. Desmond, Chatura Jayasekera, Robert Y. Chen)
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Clinical practice of endoscopic submucosal dissection for early colorectal neoplasms by a colonoscopist with limited gastric experience. Gastroenterol Res Pract 2013; 2013:262171. [PMID: 24391666 PMCID: PMC3874345 DOI: 10.1155/2013/262171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/24/2013] [Indexed: 12/19/2022] Open
Abstract
Objectives. Endoscopic submucosal dissection (ESD) for early colorectal neoplasms is regarded as a difficult technique and should commence after receiving the experiences of ESD in the stomach. The implementation of colorectal ESD in countries where early gastric cancer is uncommon might therefore be difficult. The aim is to delineate the feasibility and the learning curve of colorectal ESD performed by a colonoscopist with limited experience of gastric ESD. Methods. The first fifty cases of colorectal ESD, which were performed by a single colonoscopist between July 2010 and April 2013, were enrolled. Results. The mean of age was 64 (±9.204) years with mean size of neoplasm at 33 (±12.63) mm. The mean of procedure time was 70.5 (±48.9) min. The rates of en bloc resection, R0 resection, and curative resection were 86%, 86%, and 82%, respectively. Three patients had immediate perforation, but no patient developed delayed perforation or delayed bleeding. Conclusion. Our result disclosed that it is feasible for colorectal ESD to be performed by a colonoscopist with little experience of gastric ESD through satisfactory training and adequate case selection.
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