Learning curve for endoscopic submucosal dissection (ESD) in the United States: a large, untutored single-operator experience

BACKGROUND and STUDY AIMS: Endoscopic submucosal dissection (ESD) allows removal of tumors en-bloc. The Western adoption of ESD has been hindered by its steep learning curve. Western data regarding ESD learning curve is limited. We analyzed the learning curve of a single endoscopist at a tertiary referral center in the US. PATIENTS & METHODS: All consecutive ESDs performed by a single endoscopist at a tertiary referral center in the United States from 2015 through 2022 were identified. Descriptive statistics and CUSUM analysis were used to describe the learning curve for en-bloc, R0 resection and resection speed. RESULTS: In our study, 503 patients with 515 lesions were included. Severe submucosal fibrosis was found in 17% of the lesions. The rates of en-bloc, R0, and curative resections were 81.9%, 71.1%, and 68.4%, respectively. CUSUM analysis showed that the learning curve plateaued at 268, 347, and 170 cases for en-bloc resection, R0 resection, and achieving a resection speed > 9 cm2/hr. Fibrosis significantly affected the R0 resection rate in the regression analysis (95% CI: 0.21, 0.55). In colonic ESD curve analysis, the learning plateau was reached after 185 cases for both en-bloc and R0 resection. CONCLUSIONS: Following ex-vivo training in an animal model, an untutored expert operator achieved competency in ESD between 250 and 350 procedures. Our data can inform the development of future training programs in the West.  

Publication History

Received: 20 September 2023

Accepted after revision: 29 May 2024

Accepted Manuscript online:
03 June 2024