title: Difficulties and outcomes in starting endoscopic submucosal dissection.
abstract: BACKGROUND
  Endoscopic submucosal dissection (ESD) is a technically demanding procedure associated with a higher risk of complications. This study aimed to assess the difficulties and outcomes experienced by endoscopists beginning to perform ESD.
  
  
  METHODS
  This prospective study investigated course participants in an ESD training workshop. The participants were asked at the end of the workshop about the ease of using various ESD knives, the occurrence of complications and their management, the procedural time, and the outcomes for the swine used for the procedure.
  
  
  RESULTS
  For this study, 24 endoscopists were trained in performing gastric and esophageal ESD techniques using a porcine model. The mean size of the specimen retrieved was 2.66 +/- 1.18 cm. The mean procedural times were 52.09 +/- 24.67 min for gastric ESD and 32.50 +/- 8.45 min for esophageal ESD. During gastric ESD, 15 participants (65.22%) encountered perforations, whereas bleeding occurred during 13 ESDs (56.52%). There were two procedure-related mortalities. Significantly, a higher proportion of perforations were encountered with the use of noninsulated knives. The perforated and nonperforated groups did not show a difference in prior endoscopic experience (P = 0.335). The majority of the participants agreed that the swine model is appropriate for simulating both human gastric (96%) and esophageal (96%) ESD.
  
  
  CONCLUSIONS
  The ESD procedure is technically challenging and associated with a high rate of complications for beginners. The use of noninsulated knives may increase the risk of perforations during the learning curve for gastric ESD, and future prospective trials must evaluate their use. The development of training models may augment the acquisition of skills in low-volume centers but will not replace a standardized patient-based training program.
authors.affiliation: Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China. anthonyteoh@surgery.cuhk.edu.hk
authors.forename: Anthony Yuen Bun
authors.initials: AY
authors.lastname: Teoh
authors.forename: Philip Wai Yan
authors.initials: PW
authors.lastname: Chiu
authors.forename: Simon Kin Hung
authors.initials: SK
authors.lastname: Wong
authors.forename: Joseph Jao Yiu
authors.initials: JJ
authors.lastname: Sung
authors.forename: James Yun Wong
authors.initials: JY
authors.lastname: Lau
authors.forename: Enders Kwok Wai
authors.initials: EK
authors.lastname: Ng
mesh_terms: D000818:Animals; D004210:Dissection / Q000193:education / Q000379:methods*; D004502:Education, Medical, Continuing / Q000379:methods*; D020776:Endoscopes, Gastrointestinal; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009367:Neoplasm Staging; D011446:Prospective Studies; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D013552:Swine; D016896:Treatment Outcome