Learning Curve for ESD: Experience From a South American Center

Abstract

Introduction: Endoscopic resection techniques such as endoscopic submucosal dissection (ESD) for early gastric cancer are gaining acceptance in many countries. However complication rates on this procedure reaches 20% on non-experienced hands. Experts recommend that ESD should first be carried out in animal models before starting to be performed in humans, in order to overcome the initial learning curve. Aims: To evaluate the learning curve during intensive ESD training on live porcine models under supervision of experts. Material and Methods: Forty endoscopists have performed ESD during an intensive training course on live porcine models, under experts’ supervision. This training had duration of two days. Simulation of a gastric lesion was obtained by aspirating the gastric mucosa with a cap on the tip of the endoscope. The following variables were analyzed: procedure time, resected specimen size, complete en bloc resection rate, circumferential incision time, submucosal solution injected volume, distance between the circumferential incision and the lesion (lateral margin) and complication rates as perforation, bleeding and death. And from the beginning to the end of the last procedure a questionnaire was given to the participants to see if they felt secure to perform ESD without supervision. Results: At the end of 2 days training, 125 gastric ESDs were achieved. Each participant performed at least 3 complete ESDs. The mean procedure time for the first cases were 32.69 min ± 15.89 (CI 95% 6.52 - 19.36) and at the end of the third case 19.7min ± 8.57 (CI 95% 6.52 - 19.36), p 0.001; the distance between the circumferential incision and the lesion (lateral margin) has increased from 2.54mm 1.75 (CI 95% 1.24 - 1.05) to 2.71mm ± 2.70(CI 95% 1.24 - 1.05), p=0.87 at the end of the third case. Bleeding rate has decreased from 18.75% to 15.63%. At the end of the training course 56.25% of the endoscopists felt secure to do ESD without supervision, a percentage that was 6.25% at the beginning of the course. Conclusion: Training ESD on live porcine models may help endoscopist overcome the learning curve but more training is needed to make it secure in humans.