Results
Skills/competence to start ESD
Advanced endoscopy diagnostic practice is advised before initiating ESD training.
Level of agreement 95 %.
As recommended in the ESGE guidelines of 2015 [6], lesion assessment by an experienced endoscopist using advanced diagnostic techniques
(virtual or dye-based chromoendoscopy with or without magnification) is an essential
prerequisite to ESD resections. In fact, ESD with curative intent is only justified
in the various ESGE guidelines when lesions are clearly neoplastic and do not show
features of deep invasion [6]
[7]
[8]. So, mastering classifications like Paris [9], Inoue’s intrapapillary capillary loop (IPCL) [10]
[11], and Sano’s [12] for esophageal lesions; simplified narrow-band imaging (NBI) [13]
[14], vessel plus surface [15]
[16], and depth-predicting scores for superficial gastric lesions [17]; and Kudo’s [18], the narrow-band imaging international colorectal endoscopic (NICE) [19], and/or Japan NBI Expert Team (JNET) [20]
[21] for colonic lesions is pivotal in decision-making when determining the appropriate
lesions for which ESD is indicated and to correctly define the margins of the lesions.
The endoscopic reports of ESD trainees on any gastrointestinal (GI) neoplasia must
contain: the macroscopic type and characteristics; the microvascular and microsurface
structure; the endoscopic diagnosis of predicted tumor category; and the indication
for recommended resection technique. Therefore, advanced endoscopic diagnostic skills
are required and should be mastered before the performance of any ESD procedure.
Training in ESD should be considered only by fully trained endoscopists. Proficiency
in EMR and adverse event management is recommended before starting ESD training.
Level of agreement 100 %.
An endoscopy background is needed to begin ESD procedures safely. Japanese experts
consider that a minimum of 4 years of endoscopy experience after graduation is needed
[22], although they underline the importance of acquiring the skills whatever time is
needed for this [23]. As ESD is a precise and challenging procedure, operators should have knowledge
of therapeutic endoscopy and particularly of resection of superficial digestive neoplasia
(i. e. using EMR) [22]. An objective indicator to consider starting ESD training is to have performed at
least 1000 upper GI endoscopies, because it has been shown that trainees with that
number of endoscopies can efficiently acquire gastric ESD skills [24]. For colorectal ESD, a minimum of 500 colonoscopies appears to be required before
considering training [25]. ESD trainees must acquire proper handling and control of the endoscope with all
left-handed angulations of the scope, and rotation of the shaft using the left wrist
and arm. Right-handed controls of insertion/retraction of the scope may support rotation
of the shaft, even in diagnostic procedures [26].
Overall, management of adverse events is also required before starting to perform
the ESD technique, with experience at least in hemostatic techniques for active bleeding
and closure techniques for perforations using clips, over-the-scope clips (OTSCs),
endoscopic suturing, and stent placement (for esophageal perforations). Expertise
in hemostasis is strongly advised because most of the difficulties during ESD procedures
and training are related to uncontrolled bleeding [24]
[27].
ESD is an advanced endoscopy technique demanding precise control of the endoscope.
Obviously, beginning endoscopy with the ESD technique is not advised and previous
experience in endoscopic resection using EMR is logically recommended. All of the
reports on the ESD learning curve have involved experienced endoscopists who are already
routinely performing EMR. From a technical point of view, maneuverability of the scope,
placement, submucosal injection, and management of adverse events are required to
perform EMR. The precision required for ESD, with meticulous movements, is a further
step that would seem impossible to master without baseline EMR skills [28]
[29]
[30]
[31]. At the time of writing this curriculum, initial ESD teaching without previous EMR
skills has not been evaluated nor compared with the training of EMR-skilled endoscopists.
In units with large volumes of ESD cases, some trainees may have early access to ESD
without a large experience in EMR but the basic skills of injection, hemostasis, and
perforation closure should be mastered before undertaking any independent ESD procedure.
Cap-assisted EMR (EMRc) or band-ligation EMR (EMRb) are advanced resection techniques
essentially used for esophageal and, to a lesser degree, gastric and rectal lesions.
Their techniques are different from the ESD technique and this step does not seem
absolutely necessary to pave the ESD training pathway. ESD training programs based
on specific EMRb or EMRc experience have never been specifically tested, as their
specific technical skills do not seem to be linked to ESD skills. However, when ESD
is proving difficult to perform, knowledge and experience with these techniques may
be helpful as they may be used as rescue therapeutic options in some situations.
Knowledge of the “ESD theory” is necessary before and during training.
Level of agreement 95 %.
Before beginning ESD in models, the theory has to be understood [24]. Starting to learn a new technique has little value without a knowledge of its aims,
indications, and the results that can be expected. Learning the different steps (marking,
injection, cutting, dissection), the basic strategy (use of gravity or traction),
and the use of tools (needle-type knives, insulated tools, water jet) is a prerequisite.
A lot of information is now available on ESD technique (books, DVDs, or on the web,
including videos). Attending live demonstrations, meetings, and ESD procedures performed
by experts is recommended to understand the steps and the goals of this technique
and in parallel to improve diagnostic skills when faced with neoplastic lesions. The
ESD trainee should have a real perspective of the workings of an ESD expert center
if they are to implement similar practices in their own center.
Training
Live conferences and meetings are suggested before and during ESD training.
Level of agreement 95 %.
ESGE discourages the starting of initial ESD training in humans.
Level of agreement 95 %.
Once the basic theoretical knowledge has been mastered, and before beginning ESD in
models, attending live demonstrations or meetings is probably a good way (controlled
information) to learn the prerequisites from experts [22]. These attendances may help trainees to learn some tricks, understand techniques
with different devices, in both easy and difficult locations, with the aim of improving
their performance. Nevertheless, this point is based on expert opinion and clinical
evidence is still lacking [32], because it has not yet been demonstrated that attendance at live demonstrations
is able to improve ESD outcomes in trainees.
With regard to beginning ESD training in humans, it is our opinion that this should
be strongly discouraged. The complexity of the technique and the potential serious
side effects, as well as several alternative options for training, are strong reasons
to avoid taking the initial training steps in humans. A French study on initial rectal
ESD experience in humans without supervision demonstrated how dangerous ESD can be
in non-experienced hands [33]. In this study, the initial perforation rate was 34 % and the initial R0 resection
rate only 52 %. Therefore, beginning ESD training in humans is strongly discouraged
as it may be both dangerous and ineffective.
Practice on animal and/or ex vivo models is useful to gain the basic ESD skills. ESGE
recommends performing at least 20 ESD procedures in these models before human practice,
with the goal of at least eight en bloc complete resections in the last 10 training
cases, with no perforation.
Level of agreement 95 %.
ESGE recommends supervision during training as it seems effective in improving the
skills of trainees.
Level of agreement 95 %.
There is some clinical evidence to support the positive impact of animal model training
before beginning ESD in humans, but prospective comparative studies are still not
available. Nevertheless, training in a live porcine model was considered very realistic
by participants compared with the human setting and was highly appreciated as a learning
tool [34]
[35]. Moreover, the outcomes of ESD, even with previous animal training albeit not in
the respective human organ [33], do not encourage the proposal of comparative studies between trainees who have
experienced previous animal training and those who have not.
ESD training is associated with a clear learning curve both in animal models and in
human procedures [36]
[37]
[38]
[39]
[40]. Hands-on training on animal models produces an improvement in ESD outcomes, with
an increase in the complete resection rate and a decrease in the perforation rate
[30]
[31]
[38]
[41]. In an American experience with three trainees who performed 30 procedures each,
the inflexion of the learning curve was achieved after nine procedures on a colonic
model, although students were still progressing throughout the 30 procedures [41]. Animal model training is also effective in improving the skills needed for the
management of ESD adverse events (bleeding and perforation) [42].
Despite the lack of evidence demonstrating a relationship between ESD results in animal
training and subsequent initial human experience, ESGE recommends an initial experience
in animal models before human practice. Different animal models (ex vivo pig stomach
or esophagus, bovine or pig colon, living animal models) exist, but there are no comparative
data on the training capacity of these different models. For initial experience, ex
vivo models are probably sufficient to allow training without sacrificing animals.
In expert centers with strong supervision, initial training experience in humans may
sometimes be proposed but clinical evidence is lacking to sustain this strategy.
In Japan, the number of ex vivo or animal training courses needed before starting
ESD training in humans is five or less [24]. However, learning curves are different from one trainee to another; therefore,
determining a minimum number of courses and/or procedures appears difficult. A performance
objective appears more relevant and each student should record their results (complete
resections, perforations) during animal training (Appendix 1s; see online-only Supplementary material). ESGE proposes a quality goal of a complete
resection rate of at least 80 % without perforations during 10 consecutive procedures
to define a trained student, as previously suggested [31]
[43].
In a prospective comparative study in a bovine rectum model, 20 % of 20 students without
any supervision reached this goal after 10 procedures, 50 % after 20 procedures, and
55 % after 30 procedures [31]. With virtual supervision, the rate of students who achieved the goal was 32 %,
63 %, and 74 % after 10, 20, and 30 procedures, respectively, underlining the positive
effect of supervision during animal training. In a study from USA and Japan, video-based
post-procedure analysis and recommendation by an expert allowed two students to complete
three successive R0 resections without perforations after 25 procedures [44].
The role of dedicated software or video watching is not yet clearly defined. When
point-by-point supervision is available, this was shown to increase the number of
students who reached an 80 % rate of complete resections without perforations after
30 procedures [31]. These results underline the effectiveness of supervision during training [44], either with on-site experts if possible or with virtual supervision if a local
expert is not accessible.
To reach the goal, ESGE recommends a minimum number of 20 procedures, with supervision
if possible, but half of the trainees will probably need more training to fulfill
the quality threshold of an 80 % rate of en bloc complete resections (all marks visible
in the specimen) without perforation in 10 consecutive procedures.
In order to understand strategies and risk management, ESGE recommends observation
of experts performing ESD in tertiary referral centers. At least 20 ESD procedures
observed and five procedures as assistant, ideally within a short period of time,
are recommended.
Level of agreement 91 %.
Observing procedures performed by experts is effective in improving ESD skills, as
demonstrated by Draganov et al. [45]. The ESD procedure time was clearly reduced between the pre-observation period (63
minutes) and the post-observation period (32 minutes). This study compared nine procedures
performed in an animal model before and after an observation period of 5 weeks. Assisting
an expert during some procedures is probably a better option than only watching as
it increases the involvement and the concentration needed. Furthermore, as these procedures
are time-consuming, this might also teach the trainee to be patient, even during bleeding
episodes. Japanese experts recommend a minimum of 20 procedures observed and five
as an assistant before starting ESD in patients [22]. A high number of procedures observed increases understanding of a wide variety
of situations, different organs, and adverse event (bleeding, perforation, and stenosis)
management.
Performance of ESD in humans should start on carefully selected lesions, ideally small
(< 30 mm), located in the antrum or in the rectum for the first 20 procedures (initial
period). Beginning human practice in the colon is not recommended.
Level of agreement 95 %.
ESGE recommends that at least the first 10 procedures in humans should be done under
the supervision of an ESD-proficient endoscopist.
Level of agreement 91 %.
In Japan, experts recommend training in ESD on small lesions (≤ 20 mm) of the antrum
without ulceration or scarring [22], as these lesions are associated with the lowest risk of non-curative resection
[46]. Lesions of the mid and upper third of the stomach are far more difficult for beginners
to complete ESD [28]
[31]
[47]. Nevertheless, this recommendation must be adapted to the incidence of each lesion
in different parts of the world.
In any scenario, it seems that ESD should be learnt on easy cases before colonic ESD
is undertaken. In Hong Kong, despite a previous animal training program, initial experience
with colorectal ESD without any previous gastric procedures was dangerous and poorly
effective with rates of 32.2 % for R0 resection in the initial experience and 15.5 %
for perforations [26]. Results reported by Shiga et al. are less negative but the initial rate of perforation
was still 10 % in one study [28] and 12.5 % for another study from the same group [48]. In contrast, endoscopists experienced in gastric ESD produce effective and safe
outcomes during the learning curve in colorectal ESD, with an R0 resection rate of
more than 90 % [37]
[49].
A Japanese study showed the relative safety of rectal ESD for beginners who had experience
of only five gastric ESD procedures [28]. Shiga et al. showed that choosing small lesions in the rectum was safer to gain
experience than choosing colonic lesions. Furthermore, as demonstrated by Iacopini
et al. [29], for initial experience in colorectal ESD, the rectum should be preferred rather
than the colon to allow a progressive stepwise approach with fewer risks. Rectal location
was a predictive factor for success during the learning phase of ESD for trainees
without gastric ESD experience [50]. Progressive implementation from the rectum to more difficult parts of the colon
is safe and effective, with a perforation rate of only 5.7 % [51]. Because of the gap in difficulty between rectal and colonic ESD, it seems reasonable
to suggest a progressive move from small lesions of the rectum to the ascending colon
and then to the transverse or sigmoid colon, and finally to the cecum where the risk
of perforation is the highest [52]
[53]
[54]. Nevertheless, some rectal lesions with big nodular areas or with a history of scarring
can be associated with fibrosis and bleeding, making the procedure very difficult.
This phenomenon is relatively rare for small lesions. Therefore, after animal training,
it appears better to continue with initial human training in safe (rectum) or easy
locations (antrum) before starting to undertake procedures in technically difficult
locations (colon) or in locations where perforations are highly morbid (esophagus).
Antral lesions of 20 – 30 mm are rare in some European countries and should be reserved
for beginners but, to train in a relatively short period of time, we also have to
consider different locations. Several arguments (incidence, maneuverability, low morbidity
of rectal perforations) encourage training in the middle rectum (at least a few cm
above the anus). According to ESGE guidelines, ESD in the colorectum can be considered
instead of EMR for selected lesions larger than 20 mm. Therefore, choosing rectal
lesions slightly larger than 20 mm (< 30 mm) would probably be a good option [55]. The avoidance of cases with technical difficulty (scarring, incomplete resections,
ulcerative colitis, fibrosis) is also advised [22].
The number of ESDs required for endoscopists to become competent in the technique
is not precisely defined. For gastric ESD, 30 procedures was defined as the number
necessary to gain proficiency [56]. However, others have suggested that 50 – 100 gastric ESD procedures would be needed
for expertise [22]. For colorectal ESD, approximately 30 and 80 procedures are needed to achieve competent
and proficient levels of ESD, respectively [57]. In a recent European study, 120 colorectal ESD procedures were needed to reach
a plateau of high effectiveness and low morbidity [54]. However, achieving such a high number of procedures does not appear realistic in
Europe. The role of supervision has to be re-emphasized and the expert should be present
in the necessary procedures for the trainee to be competent. ESGE recommends therefore
that at least the first 10 human ESD procedures, ideally per organ, should be done
under supervision by an ESD-proficient endoscopist.
Furthermore, particularly in low volume centers, in order to avoid spaced training,
mixing practice on animal models with the first human procedures is a good option
to maintain regular and frequent ESD practice and to achieve high quality results
for R0 resection and perforation rates [58]. In fact, a step-up training protocol over a 12-month period of 50 observational
and supervised ESD procedures, as well as 24 animal procedures, showed excellent results,
particularly in the rectum and stomach, with more than 90 % of procedures achieving
R0 resections [53].
A logbook and a preclinical database suggested by ESGE for ESD training are available
for trainees on the ESGE website (https://www.esge.com/esd-training-curriculum/).
Knowledge and maintaining competence
Endoscopists involved in ESD should have specific knowledge of the instrumentation,
technique, and electrosurgical equipment.
Level of agreement 100 %.
ESD is a complex and technically demanding procedure. Accordingly, in order to perform
safe and effective treatment, while avoiding serious complications, endoscopists should
have a full understanding of not only the technique but also the different instruments
and the electrosurgical unit (ESU) that are needed to perform a safe ESD [59]
[60]. We recommend that endoscopists should have extensive knowledge of all the devices
that can be used for ESD, such as knives, injection agents, caps and hoods, and hemostatic
and traction devices, as this information can be important in more difficult and complex
situations [59]
[60]
[61]
[62]. In fact, there are several knives available to perform ESD, each one with its own
particularities and advantages over others for use in certain situations [59]
[60]
[63]
[64], but without enough evidence to recommend one knife over another. As a general rule,
we recommend that endoscopists should use the equipment that they feel comfortable
with, ideally the same as they have used in training, but at the same time should
know the full ESD “armamentarium” so they can choose other options in more difficult/complex
scenarios.
Endoscopists should also know the principles and features of the ESUs that can be
used for ESD. In fact, each ESU has its own settings and types of current; the recommended
settings vary according not only to the cutting device that is being used but also
with the lesions and organs in which the current is applied. Some manufacturers provide
specific instructions for performing ESD [65]. In the absence of these, we recommend that endoscopists contact the manufacturer
of their own ESU before starting ESD in humans.
Endoscopists performing ESD should be able to correctly estimate the probability of
performing a curative resection based on the characteristics of the lesion and should
know the benefit/risk relationship of ESD when compared with other therapeutic alternatives.
Level of agreement 95 %.
Endoscopists performing ESD should know how to interpret the histopathology findings
of the ESD specimen, namely the criteria for low risk resection (“curative”), local
risk resection, and high risk resection (“non-curative”), as well as their implications.
Level of agreement 100 %.
When performing ESD, endoscopists are responsible not only for a proper technical
execution of the procedure, but also for the clinical decision-making and clinical
care. This implies that endoscopists should be able to balance the benefits and risks
of ESD against alternative treatment options for that specific disease. As previously
stated, they should be familiar with advanced imaging diagnosis. Moreover, depending
on the organ, location, type, and other characteristics of the lesion, endoscopists
should be able to calculate the probability of performing a curative resection. There
are platforms available online that can help endoscopists calculate the a priori probability
of a curative resection and also the risk of post-resection bleeding [66]. Even though we recognize that, to avoid more aggressive procedures (like surgery)
in patients with several co-morbidities, endoscopists may sometimes assume a low probability
of a curative resection yet still proceed to ESD, we recommend that such situations
should always be discussed with the patient, and ideally within a multidisciplinary
team.
In addition, endoscopists are also responsible for the interpretation of the histopathology
of the ESD specimen. The issues here are the following: several histopathological
characteristics have different implications for different organs and diseases; the
definition of curative and non-curative resection varies between authors; and, in
fact, even after a non-curative resection, the probability of a patient being cured
is most often higher than the probability of their having residual or distant disease.
We therefore recommend that endoscopists should be familiar with the different types
of resection, as defined by the ESGE [6]:
Low risk resection (“curative”): low risk for local or distant recurrence; no further immediate therapy
is required; is defined as an R0 resection, with no poor prognosis features (less
than the cut-off invasion for the specific organ, and no lymphovascular invasion).
Local risk resection: as above, with the exception of positive lateral margins; even though this type
of resection increases the risk of local recurrence, most times the patient will be
cured in the long-term, so only endoscopic follow-up and putative treatment is recommended.
High risk resection (“non-curative”): in this case there is a real risk of distant disease and adjuvant
treatment should be considered on a case-by-case basis; it is defined as an R1 resection
(positive vertical margins), deep sm invasion (beyond the organ-specific μm limit),
poorly differentiated tumor, or lymphovascular invasion.
Endoscopists should know that the specific criteria are different for each organ.
ESGE recommends that further decisions should be made by multidisciplinary teams.
Ideally, endoscopists properly trained in ESD should start performing ESD at their
own center only after an ESD expert has confirmed that they have the knowledge and
skills to start performing ESD.
Level of agreement 91 %.
ESD should be performed only in a setting where early and delayed complications can
be managed adequately, namely with the possibility of admitting patients to a ward,
and access to appropriate emergency surgical teams for the organ being treated with
ESD. In addition, centers performing ESD should have access to expert gastrointestinal
pathology.
Level of agreement 100 %.
The decision to start ESD in their own center has several implications for the endoscopy
team and in the hospital where ESD is going to be performed. Because ESD has the potential
for serious and fatal adverse events, it is our opinion that only someone with the
proper training, knowledge, and skills should start a new and risky technique on their
own. Moreover, the confirmation that an endoscopist fulfils these requirements cannot
be made objectively by that individual. For these reasons, it is our opinion that
confirmation of the ability of an endoscopist to start ESD should be made by someone
else, ideally an expert in ESD. However, we recognize that a definition of a “recognized
ESD expert” is lacking. We suggest that a recognized ESD expert could be a person
with extensive experience in ESD, with more than 100 ESDs performed and receiving
referrals from other hospitals on a regular basis. This recognition of competence
should preferably be provided by the ESD expert who has provided training. An ideal
scenario would be for an endoscopist to perform their first ESD procedure by themselves
in their own center but with the expert present in the endoscopy room.
With regard to the centers in which ESD can be performed, it is ESGE’s opinion that
ESD cannot be done in every center. Independently of the quality and skills of the
endoscopist, the possibility of significant bleeding and perforation is always present
and only centers that can handle these complications should be certified to perform
ESD. In Japan and Asia, patients undergoing ESD are usually admitted to hospital for
several days [67], in contrast to Western countries where they are only admitted for 1 – 2 days [68] or even treated as outpatients [69]. Nevertheless, it appears that a treatment strategy with at least the possibility
of admitting the patient to the hospital is fundamental to forearm a serious adverse
event [70]. Moreover, even though most ESD complications can be solved endoscopically, surgery
may be needed in almost 1 % of procedures, particularly in centers with less experience
[71]. For all these reasons, it is our opinion that ESD should be performed only in a
center where complications can be managed adequately, namely with the possibility
of admitting patients to a ward, and access to appropriate emergency surgical teams
for the organ being treated with ESD.
In addition, it is ESGE’s opinion that centers performing ESD should have access to
expert GI pathology. The histopathological diagnosis of an endoscopic resection specimen
is the basis for further clinical decision-making (low vs. high vs. local risk resection;
need for further treatment or not) [6]. Therefore, the report on the specimen needs to include all the relevant information
required to make that decision. For all ESD specimens, the following risk factors
have to be reported: depth of invasion, lymphatic vessel permeation, blood vessel
permeation, budding (for colorectal lesions), perineural invasion, resection margin
involvement, as well as typing and grading of the neoplasia according to the World
Health Organization (WHO) classification [6]. It is our opinion that this can be made in a proper manner only by an expert GI
pathologist who has continuous interaction with the endoscopist, ideally in an oncological
multidisciplinary team.
In order to maintain proficiency in ESD, ESGE recommends a minimum case load of 25
ESD procedures per year.
Level of agreement 100 %.
All procedures should be registered in a prospective database covering items such
as endoscopic classification, location and size of the lesion, technique used, en
bloc resection rate, complication rates, time of procedure, R0 resection rate, and
final histopathology (including type of resection). En bloc resection rates should
be above 90 %, and the perforation rate should be below 3 %, with a lower than 1 %
need for surgery because of complications.
Level of agreement 95 %.
The volume of ESDs performed per year appears to be a very important factor as it
correlates strongly with most of the outcome measures and rates of complications [72]. This appears more important for colorectal than for upper GI ESD. A meta-analysis
comparing Eastern vs. Western ESD results concluded that Eastern results (with a larger
case load) were better, but this was particularly true for colorectal ESD and less
clear for esophageal and gastric ESD [73]. This appears more dependent on the experience of the endoscopist than on whether
they are Eastern or Western [74]. Indeed, in a larger Eastern colorectal ESD series, including 10 institutions, performing
less than 50 ESDs (total) was an independent risk factor for an increased number of
complications [75]. The authors concluded that performing ESD on a regular basis is important for improving
outcomes with less complications. Fuccio et al. calculated that performing at least
two ESDs per month is important in achieving higher R0 and en bloc resection rates,
with a lower incidence of adverse events requiring surgery and lower recurrence rates
[72].
Although beyond the scope of this specific ESD postgraduate curriculum training, ESGE
recommends a minimum case load of 25 ESDs per year in order to maintain proficiency
in the technique. Ideally, these 25 ESD procedures per year should be counted separately
for the different organs. However, we may argue that proficiency lies in the technique
and the technique is similar for every organ. Moreover, it does not seem realistic
to perform 25 ESDs per organ per year in every reference center and, for this reason,
ESGE advise setting the minimum standard as 25 ESDs per year, independently of the
organ. Future studies should compare the outcomes of centers with different case loads
(and case loads in different organs) in order to set a more evidence-based recommendation
for the minimum volume of ESDs per year.
In order to answer this and other questions, ESGE recommends that each center performing
ESD keeps prospective records of each procedure. Quality indicators for ESD have been
proposed [76]. We recommend that the following parameters should always be recorded for each procedure:
lesion characteristics (including advanced imaging diagnosis and Paris classification);
general (esophagus, gastric, colorectal) and specific location (upper or lower stomach,
rectum or sigmoid); size of the lesion; technique used (ESD, hybrid, tunneling); en
bloc (endoscopic) and R0 (histologic) resection rates; complication rates (immediate
and delayed bleeding, perforation, need for surgery because of complications, length
of hospital stay); time of procedure; and type of resection according to final histopathology
result (low, local or high risk resection). Follow-up variables should also be recorded,
such as recurrence, metachronous lesions, surgery because of non-curative resection
or because of recurrence, and medications that can interfere with outcomes (such as
proton pump inhibitors, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], and
anticoagulants). A clinical database suggested by ESGE for ESD training is available
on the ESGE website (https://www.esge.com/esd-training-curriculum/).
Given all the available evidence and published meta-analyses [72]
[73]
[77], ESGE recommends that the goal of every endoscopist performing ESD should be to
achieve a higher than 90 % en bloc resection rate, with a lower than 3 % perforation
rate. Ideally, R0 resections rates of at least 80 % – 85 % should be the goal. However,
we do recognize that this goal may be unrealistic, even for expert endoscopists, given
that ever bigger and more advanced lesions are being referred for endoscopic resection.
Nevertheless, as correct evaluation of the lesion and decision-making with regard
to the proper indication for ESD should be a prerequisite for an ESD endoscopist,
we do recommend that the goal for the rate of low risk resection (“curative”) should
be above 75 %.
Because bleeding depends on too many factors, sometimes completely independent of
the technique (such as medication), we have not set a specific goal for the bleeding
rate. Nevertheless, endoscopists performing ESD must be able to solve most of these
adverse events without surgery, so we recommend that the need for surgery because
of complications should occur in fewer than 1 % of procedures. Regarding the need
for surgery because of non-curative resection, this depends more on the characteristics
of the lesion than on the ESD technique and no goal has been set.
