Training in endoscopic mucosal resection and endoscopic submucosal dissection: face, content and expert validity of the live porcine model

Introduction: Endoscopic mucosal resection and endoscopic submucosal dissection are demanding procedures. This study aims to establish face, content and expert validity of the live porcine model in performing endoscopic mucosal resection, endoscopic submucosal dissection, complication management and to assess it as a training tool. Material and methods: Tutors and trainees participating in live porcine model endoscopic mucosal resection and endoscopic submucosal dissection workshops filled out a questionnaire regarding the realism of the model compared to human setting and its role as a learning tool. A 10-point Likert scale was used. Results: Ninety-one endoscopists (13 tutors; 78 trainees) were involved in four workshops. Median global classifications for the realism of the life porcine model ranged between 7.0–8.0 (interquartile range 5.0–9.0). Procedures resembled human cases with a median of 9.0 (8.0–9.0) for oesophageal multiband endoscopic mucosal resection; 8.5 (8.0–9.0) for oesophageal endoscopic submucosal dissection; 9.0 (8.0–10.0) for gastric endoscopic submucosal dissection; and 9.0 (8.5–9.75 and 8.0–9.69) for complication detection and management. The animal model as a learning tool had median scores of 9.0 (7.0–10.0) considering how procedures are performed; 9.0–9.5 (8.0–10.0) for usefulness for beginners; and 9.0–10.0 (5.0–10.0) regarding it a prerequisite. Conclusions: Training in a live porcine model was considered very realistic compared to the human setting and was highly appreciated as a learning tool. This is the first study to establish face, content and expert validity of the live porcine model in performing multiband endoscopic mucosal resection, oesophageal and gastric endoscopic submucosal dissection. The validation of this model provides the rationale to incorporate it into formal teaching programmes.info:eu-repo/semantics/publishedVersio

Effective optical identification of type "0-IIb" early gastric cancer with narrow band imaging magnification endoscopy, successfully treated by endoscopic submucosal dissection

Background Endoscopic submucosal dissection (ESD) is currently considered the minimal invasive endoscopic treatment for early gastric cancer. Most superficial gastric neoplastic lesions are depressed type ”0-IIc” (70-80%), while totally flat, classified as type ”0-IIb” early gastric cancer, is rarely reported (0.4%). The aim of the present study was to assess the efficacy of narrow band imaging (NBI) magnification endoscopy in identifying type “0-IIb” early gastric cancer and ESD treatment with curative intention.Methods Twelve of 615 (2%) patients (10 males, median 72 years), treated by ESD at our center, were diagnosed as type “0-IIb” gastric cancer. Ten had exclusively type “0-IIb”, while two had combined types “0-IIb+IIc” and “0-IIa+IIb” gastric cancer. Initial diagnosis was made during screening gastroscopy, while NBI magnification endoscopy combined with indigo-carmine chromoendoscopy were also used.Results White light endoscopy showed only superficial redness. One patient with signet-ring carcinoma showed whitish appearance. Indigo-carmine chromoendoscopy showed better visualization, while NBI magnification endoscopy revealed abnormal mucosal microsurface and microvascular findings which enabled border marking. ESD with curative intention was completed without complications. Histological examination showed complete (R0) resection, in 10 patients (83%). One patient with positive margins received additional surgery (8%). Mean procedure time was 149 (range 60-190) min. One to six years post-ESD all patients remain alive.Conclusions ESD is considered a safe and effective curative treatment for type “0-IIb” gastric cancer, resulting in long-term disease-free survival. NBI magnification endoscopy is effective for accurate optical identification and border marking of type “0-IIb” early gastric cancer

Endoscopic Submucosal Dissection of Gastric Neoplastic Lesions. An Italian, Multicenter Study

Endoscopic submucosal dissection (ESD) allows removing neoplastic lesions on gastric mucosa, including early gastric cancer (EGC) and dysplasia. Data on ESD from Western countries are still scanty. We report results of ESD procedures performed in Italy. Data of consecutive patients who underwent ESD for gastric neoplastic removal were analyzed. The en bloc resection rate and the R0 resection rates for all neoplastic lesions were calculated, as well as the curative rate (i.e., no need for surgical treatment) for EGC. The incidence of complications, the one‐month mortality, and the recurrence rate at one‐year follow‐up were computed. A total of 296 patients with 299 gastric lesions (80 EGC) were treated. The en bloc resection was successful for 292 (97.6%) and the R0 was achieved in 266 (89%) out of all lesions. In the EGC group, the ESD was eventually curative in 72.5% (58/80) following procedure. A complication occurred in 30 (10.1%) patients. Endoscopic treatment was successful in all 3 perforations, whereas it failed in 2 out of 27 bleeding patients who were treated with radiological embolization (1 case) or surgery (1 case). No procedure‐related deaths at one‐month follow‐up were observed. Lesion recurrence occurred in 16 (6.2%) patients (6 EGC and 10 dysplasia). In conclusion, the rate of both en bloc and R0 gastric lesions removal was very high in Italy. However, the curative rate for EGC needs to be improved. Complications were acceptably low and amenable at endoscopy

A task and performance analysis of endoscopic submucosal dissection (ESD) surgery

BACKGROUND: ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries. METHODS: We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons. RESULTS: The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores. CONCLUSIONS: We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims  Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods  This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results  In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion  Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease

Today, in the endoscopist hands

Endoscopic submucosal dissection (ESD) was first described as a non-surgical promise for early gastric epithelial lesions

Endoscopic Submucosal Dissection Followed by Concurrent Chemoradiotherapy in Patients with Early Esophageal Cancer with a High Risk of Lymph Node Metastasis

Endoscopic submucosal dissection is recommended as an alternative therapy for early esophageal cancer. However, achieving curative resection in this procedure remains controversial since precise prediction of lymph node metastasis can be difficult. Here, we present the preliminary results of endoscopic submucosal dissection followed by concurrent chemoradiotherapy for early esophageal cancer with a high risk of lymph node metastasis. From May 2006 to January 2014, six patients underwent concurrent chemoradiotherapy after endoscopic submucosal dissection with a median follow-up period of 63 months. No complications were encountered during concurrent chemoradiotherapy. Although local recurrence did not occur in all patients, two patients were diagnosed with metachronous cancer. Overall, the survival rate was 100%. Thus, endoscopic submucosal dissection followed by concurrent chemoradiotherapy may be a feasible treatment for early esophageal cancer in patients with a high risk of lymph node metastasis. Future prospective large-scale studies are warranted to confirm our results

Feasibility of endoscopic submucosal dissection for gastric and colorectal lesions: Initial experience from the Gastrocentro - Unicamp

OBJECTIVE: Endoscopic submucosal dissection is a technique developed in Japan for en bloc resection with a lower rate of recurrence. It is considered technically difficult and performed only in specialized centers. This study sought to report the initial experience from the Gastrocentro - Campinas State University for the treatment of gastric and colorectal lesions by endoscopic submucosal dissection. MATERIALS AND METHODS: The guidelines of the Japanese Association of Gastric Cancer were used as evaluative criteria. For colorectal lesions, the recommended standards proposed by Uraoka et al. and Saito et al. were employed. The practicability of the method, the development of complications and histological analysis of the specimens were evaluated. RESULTS: Sixteen patients underwent endoscopic submucosal dissection from June 2010 to April 2011; nine patients were treated for gastric lesions, and seven were treated for colorectal lesions. The average diameter of the gastric lesions was 28.6 mm, and the duration of resection was 103 min without complications. All lesions presented lesion-free margins. Of the seven colorectal tumors, four were located in the rectum and three were located in the colon. The average size was 26 mm, and the average procedure time was 163 min. Two complications occurred during the rectal resection procedures: perforation, which was treated with an endoscopic clip, and controlled bleeding. One of the lesions presented a compromised lateral margin without relapse after 90 days. Depth margins were all free of lesions. CONCLUSION: Endoscopic submucosal dissection at our institution achieved high success rates, with few complications in preliminary procedures. The procedure also made appropriate lesion staging possible