Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves

BackgroundEndoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed.ObjectiveTo evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol.DesignProspective study in the Western setting.SettingThis study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD.PatientsIndications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis.InterventionTraining consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved.Main Outcome MeasurementsCompetence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures.ResultsFrom February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .031); perforations occurred in 2 patients.LimitationsSingle-center design.ConclusionsA minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon.