Untutored learning curve to establish endoscopic submucosal dissection on competence level.
OBJECTIVE
Endoscopic submucosal dissection (ESD) of early cancer allows precise staging and avoids recurrence or surgery. Tutored by experts, ESD has rapidly spread in Japan, but still demands untutored learning in Western countries. A step-up approach starts with easiest gastric neoplasias, but fails on their low prevalence in Western countries. A prevalence-based approach includes challenging colonic neoplasias.


METHODS
We analyzed an untutored series of initial 50 ESD procedures by an experienced endoscopist on consecutive lesions referred according to prevalence.


RESULTS
Overall, 48 lesions (20% upper gastrointestinal, 80% colorectal; 2 hyperplastic (inflammatory) lesions, 46 neoplasms) were completely resected intention-to-treat with ESD, 2 required a second ESD. Neoplasias were resected 76% en-bloc (46% ESD, 30% ESD with snaring), 17% by ESD with snaring in 2-3 pieces, and 6.5% as ESD with snaring in multiple pieces. None of 15 neoplasias with high-grade intraepithelial neoplasia or an early esophageal cancer (R0) had recurred. Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated. All patients were discharged within 9 days without long-term morbidity.


CONCLUSIONS
Untutored learning of ESD is feasible on colonic lesions. We propose to establish ESD in Europe with structured training and a prevalence-of-lesions-based approach.
Department of Internal Medicine I, Paracelsus Medical University/Salzburger Landeskliniken, Salzburg, Austria.
Frieder
F
Berr
Andrej
A
Wagner
Tobias
T
Kiesslich
Paul
P
Friesenbichler
Daniel
D
Neureiter
D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D003110:Colonic Neoplasms / Q000601:surgery; D004210:Dissection / Q000379:methods*; D004564:Electrocoagulation; D016099:Endoscopy, Gastrointestinal / Q000295:instrumentation / Q000379:methods*; D005260:Female; D005753:Gastric Mucosa / Q000473:pathology; D005770:Gastrointestinal Neoplasms / Q000601:surgery*; D006801:Humans; D057194:Intention to Treat Analysis; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D012004:Rectal Neoplasms / Q000601:surgery