Training and competency in endoscopic mucosal resection

Endoscopic mucosal resection (EMR) should be the preferred method of removal for colonic laterally spreading lesions ≥2 cm in size since it is safer, more efficient, and more cost-effective than endoscopic submucosal dissection or surgery. Although competent endoscopists should be comfortable in removing colonic lesions up to 2 cm in size, removal of larger laterally spreading lesions by modern EMR requires advanced skills and meticulous execution of systematic technique to minimize incomplete resection and subsequent interval cancer. Determinations of competency in EMR are important to minimize patient risks and maximize patient outcomes. Assessments of competency may include procedural volumes, direct observational tools, simulators, and other metrics. Advanced training in EMR should be systematic, competency-based; learner- and patient-centered; and must include continual assessment, feedback, reflection, analysis ,and application of identified strategies for improvement. Two models for EMR training, in both the postgraduate and continuing education settings, are proposed along with resources for learning.