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

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• 作者：Federico Iacopini ; MD¹ ; ; Antonino Bella ; MSTAT² ; Guido Costamagna ; MD ; FACG³ ; Takuji Gotoda ; MD ; PhD⁴ ; Yutaka Saito ; MD⁵ ; Walter Elisei ; MD¹ ; Cristina Grossi ; MD¹ ; Patrizia Rigato ; MD⁶ ; Agostino Scozzarro ; MD ; PhD¹
• 关键词：c-ESD ; colonic ESD ; EPMR ; endoscopic piecemeal mucosal resection ; ESD ; endoscopic submucosal dissection ; LST ; laterally spreading tumor ; R0 resection ; resection with tumor-free margins ; r-ESD ; rectal ESD ; sm ; submucosal
• 刊名：Gastrointestinal Endoscopy
• 出版年：2012
• 出版时间：December, 2012
• 年：2012
• 卷：76
• 期：6
• 页码：1188-1196
• 全文大小：1844 K

文摘

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Background

Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed.

Objective

To evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol.

Design

Prospective study in the Western setting.

Setting

This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD.

Patients

Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis.

Intervention

Training 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 Measurements

Competence 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.

Results

From 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.

Limitations

Single-center design.

Conclusions

A 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.