Reply to Mannath & Ragunath

We thank Drs. Mannath and Ragunath for their thoughful comments on our study. They propose a one-to-one training program in endoscopic resection according to the traditional fellow-in-training approach, resulting in a gradual process towards independent practice. Although we agree that such an interaction enables gradual and prolonged training we thought that this would be less applicable in our country for teaching endoscopic management of early neoplasia in the upper gastrointestinal tract. We considered this to be a postgraduate training for which a certain level of endoscopic experience would be required. In addition, we wanted to train a limited number of centers, preferably geographically spread across the Netherlands. Finally, we wanted to ensure that centralized treatment would be available within a relatively short period of time (2 years). The traditional approach suggested by Mannath & Ragunath would not have enabled us to facilitate centralization to selected centers at this scale and time frame. In addition, the fellow-in-training approach does not ensure centralization of diagnosis and treatment, since the fellow trained may not necessarily be appointed in centers that are suitable for a referral function in this field and building such a referral function requires more than just the presence of a trained endoscopist.

With our training program set-up, we aimed at efficient centralization of endoscopic treatment of early upper gastrointestinal neoplasia in the Netherlands. To this end, we selected centers with multidisciplinary expertise in upper gastrointestinal oncology (including availability of endoscopic ultrasound, high volume upper gastrointestinal surgery, and oncologic care) with a geographical spread throughout the country, and gastroenterologists with a specific interest in interventional endoscopy. Thus, we used the existing organizational structures and experience of these centers for easy and sound implementation of endoscopic resection in the country. Furthermore, although this was not explicitly described, also in the current training program the intensity of supervision was tapered along with the growing skills and experience of the endoscopist in training.

Finally, Mannath & Ragunath comment on the relatively high perforation rate in endoscopic resection with cap (ER-cap) procedures compared with multiband mucosectomy (MBM) procedures. They noticed that the majority of endoscopic resections were performed with the ER-cap technique and suggest that training should best be focused on the MBM technique given its relative simplicity. Our series included more ER-cap than MBM procedures for three reasons: first, at the start of the training program, the ER-cap was our standard technique since the MBM was relatively new at that time; secondly, we thought that our endoscopists should be able to apply both techniques since there are particular indications where one might be preferred to the other; thirdly, some of the procedures were performed as part of a randomized trial comparing ER-cap and MBM [1]. Although the latter study did not result in showing a significant difference between techniques with regard to perforations, we share the opinion of Mannath & Ragunath that the MBM technique may be associated with fewer complications compared with ER-cap, and since it is faster and potentially easier to learn, MBM may be preferred for piecemeal resection of early neoplasia in Barrett’s esophagus.

• References

• 1 Pouw RE, Van Vilsteren FG, Peters FP et al. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett's neoplasia. Gastrointest Endosc 2011; 74: 35-43