Role of observation of live cases done by Japanese experts in the acquisition of ESD skills by a western endoscopist.
OBJECTIVE
To evaluate the role of observation of experts performing endoscopic submucosal dissection (ESD) in the acquisition of ESD skills.


METHODS
This prospective study is documenting the learning curve of one Western endoscopist. The study consisted of three periods. In the first period (pre-observation), the trainee performed ESDs in animal models in his home institution in the United States. The second period (observation) consisted of visit to Japan and observation of live ESD cases done by experts. The observation of cases occurred over a 5-wk period. During the third period (post-observation), the trainee performed ESD in animal models in a similar fashion as in the first period. Three animal models were used: live 40-50 kg Yorkshire pig, explanted pig stomach model, and explanted pig rectum model. The outcomes from the ESDs done in the animal models before and after observation of live human cases (main study intervention) were compared. Statistical analysis of the data included: Fisher's exact test to compare distributions of a categorical variable, Wilcoxon rank sum test to compare distributions of a continuous variable between the two groups (pre-observation and post-observation), and Kruskal-Wallis test to evaluate the impact of lesion location and type of model (ex-vivo vs live pig) on lesion removal time.


RESULTS
The trainee performed 38 ESDs in animal model (29 pre-observation/9 post-observation). The removal times post-observation were significantly shorter than those pre-observation (32.7 ± 15.0 min vs 63.5 ± 9.8 min, P < 0.001). To minimize the impact of improving physician skill, the 9 lesions post-observation were compared to the last 9 lesions pre-observation and the removal times remained significantly shorter (32.7 ± 15.0 min vs 61.0 ± 7.4 min, P = 0.0011). Regression analysis showed that ESD observation significantly reduced removal time when controlling for the sequence of lesion removal (P = 0.025). Furthermore, it was also noted a trend towards decrease in failure to remove lesions and decrease in complications after the period of observation. This study did not find a significant difference in the time needed to remove lesions in different animal models. This finding could have important implications in designing training programs due to the substantial difference in cost between live animal and explanted organ models. The main limitation of this study is that it reflects the experience of a single endoscopist.


CONCLUSIONS
Observation of experts performing ESD over short period of time can significantly contribute to the acquisition of ESD skills.
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Peter V
PV
Draganov
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Myron
M
Chang
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Roxana M
RM
Coman
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Mihir S
MS
Wagh
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Qi
Q
An
Peter V Draganov, Roxana M Coman, Mihir S Wagh, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32608, United States.
Takuji
T
Gotoda
D000818:Animals; D002983:Clinical Competence; D004210:Dissection / Q000009:adverse effects / Q000193:education*; D016099:Endoscopy, Gastrointestinal / Q000009:adverse effects / Q000193:education*; D005431:Florida; D005770:Gastrointestinal Neoplasms / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007564:Japan; D059032:Learning Curve; D023421:Models, Animal; D019370:Observation; D011446:Prospective Studies; D013552:Swine; D013647:Task Performance and Analysis; D013997:Time Factors; D016896:Treatment Outcome
Animal models; Early gastric cancer; Endoscopic submucosal dissection; Learning curve; Training