Video-based supervision for training of endoscopic submucosal dissection

Background and study aim: Adoption of endoscopic submucosal dissection (ESD) in Western countries has been limited by the difficulty in learning the procedure. Although a porcine model is commonly used for ESD training, without expert guidance the procedure is difficult to master. The availability of Western ESD experts is limited, and expert supervision through a remote video-based system may be a practical method for Western endoscopists to learn ESD. The aim of this study was to assess the value of video-based remote evaluation in supervising ESD training.

Methods: Two Western endoscopists performed ESD training procedures in an ex vivo porcine model at least every 2 weeks until competency was achieved. Competency was defined as consistent en bloc resection of a 3-cm area within 30 minutes, and without perforation, using the proper ESD technique. A Japanese ESD expert at the National Cancer Center in Tokyo, Japan, analyzed the training videos, scored them, and provided written feedback for improvement after each training session and before the trainee’s next training session.

Results: Endoscopist 1 reached competency at 23 procedures and endoscopist 2 reached competency at 25 procedures. No difference in skill improvement between the two endoscopists was noted. One trainee subsequently completed eight ESD procedures in patients, with curative en bloc resection and no complications.

Conclusion: A standardized ESD training program including educational presentations/videos and preclinical animal training with expert guidance through a remote video-based system is an effective tool for learning ESD techniques in preparation for performing the procedure in humans.

• References

• 1 Gotoda T, Ho KY, Soetikno R et al. Gastric ESD: current status and future directions of devices and training. Gastrointest Endosc Clin N Am 2014; 24: 213-233
• 2 Draganov PV, Gotoda T, Chavalitdhamrong D et al. Techniques of endoscopic submucosal dissection: application for the Western endoscopist?. Gastrointest Endosc 2013; 78: 677-688
• 3 Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc 2012; 4: 162-166
• 4 Bhatt A, Abe S, Kumaravel A et al. Indications and techniques for endoscopic submucosal dissection. Am J Gastroenterol 2015; 110: 784-791
• 5 Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
• 6 Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013; 5: 369-378
• 7 Deprez PH, Bergman JJ, Meisner S et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy 2010; 42: 853-858
• 8 Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225-229
• 9 Gotoda T, Kondo H, Ono H et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc 1999; 50: 560-563
• 10 Oda I, Odagaki T, Suzuki H et al. Learning curve for endoscopic submucosal dissection of early gastric cancer based on trainee experience. Dig Endosc 2012; 24 (Suppl. 01) 129-132
• 11 Sakamoto T, Saito Y, Fukunaga S et al. Learning curve associated with colorectal endoscopic submucosal dissection for endoscopists experienced in gastric endoscopic submucosal dissection. Dis Colon Rectum 2011; 54: 1307-1312
• 12 Vazquez-Sequeiros E, de Miquel DB, Olcina JR et al. Training model for teaching endoscopic submucosal dissection of gastric tumors. Rev Esp Enferm Dig 2009; 101: 546-552
• 13 Parra-Blanco A, Arnau MR, Nicolas-Perez D et al. Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol 2010; 16: 2895-2900
• 14 Schumacher B, Charton JP, Nordmann T et al. Endoscopic submucosal dissection of early gastric neoplasia with a water jet-assisted knife: a Western, single-center experience. Gastrointest Endosc 2012; 75: 1166-1174
• 15 Harris PA, Taylor R, Thielke R et al. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377-381
• 16 Patel KS, Calixte R, Modayil RJ et al. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81: 1181-1187