Defining competencies for endoscopic submucosal dissection (ESD) for gastric neoplasms

Effectiveness of a novel ex vivo training model for gastric endoscopic submucosal dissection training: a prospective observational study conducted at a single center in Japan

BACKGROUND/AIMS

The efficacy of endoscopic submucosal dissection (ESD) for early-stage gastric cancer is well established. However, its acquisition is challenging owing to its complexity. In Japan, G-Master is a novel ex vivo gastric ESD training model. The effectiveness of training using G-Master is unknown. This study evaluated the efficacy of gastric ESD training using the G-Master to evaluate trainees' learning curves and performance.

METHODS

Four trainees completed 30 ESD training sessions using the G-Master, and procedure time, resection area, resection completion, en-bloc resection requirement, and perforation occurrence were measured. Resection speed was the primary endpoint, and learning curves were evaluated using the Cumulative Sum (CUSUM) method.

RESULTS

All trainees completed the resection and en-bloc resection of the lesion without any intraoperative perforations. The learning curves covered three phases: initial growth, plateau, and late growth. The transition from phase 1 to phase 2 required a median of 10 sessions. Each trainee completed 30 training sessions in approximately 4 months.

CONCLUSIONS

Gastric ESD training using the G-Master is a simple, fast, and effective method for pre-ESD training in clinical practice. It is recommended that at least 10 training sessions be conducted.

Resection speed of endoscopic submucosal dissection according to the location of gastric neoplasia: a learning curve using cumulative sum analysis

BACKGROUND

There is few study evaluating the relationship between endoscopic submucosal dissection (ESD) resection speed and the lesion characteristics of gastric neoplasia. We investigated the learning curve of consecutive ESDs using cumulative sum (CUSUM) analysis.

METHODS

A total of 356 ESDs performed by a single endoscopist were grouped chronologically into three learning periods. The ESD procedure was defined to be fast when resection speed was > 9.0 cm²/hour. The CUSUM method was used to assess the number of ESDs required for achieving proficiency and mastery.

RESULTS

Mean resection speed was significantly faster in Phase III (15.1 cm²/hour) compared to those in Phase I (9.3 cm²/hour) and II (11.4 cm²/hour) (p < 0.001). Tumors in the stomach's upper and middle third location were significantly associated with difficulty in attaining the fast resection speed (odds ratios, 0.05 and 0.36) compared to the lower third location. The number of ESDs required to achieve a competency for fast resection was 15 for tumors in the lower third of the stomach and 98 for those in the upper/middle third location, respectively. In the lower third location of the tumor, the CUSUM curve revealed that 75 cases were needed to achieve proficiency and 174 cases to achieve mastery. However, mastery was not achieved in ESD for the upper/middle third tumor during the study period.

CONCLUSION

The time required to achieve relevant competency in gastric ESD depends on the tumor location.

Doppler probe method to reduce delayed bleeding after endoscopic submucosal dissection in the stomach: a propensity-score matched study (with video)

BACKGROUND

Prophylactic coagulation after gastric endoscopic submucosal dissection (ESD) decreases the rate of delayed bleeding; however, it cannot prevent bleeding completely, and delayed bleeding may occur from non-exposed vessels that were not detected immediately after ESD or where prophylactic coagulation was inadequate. Doppler monitoring systems which can evaluate vascular flow have been recently introduced in the endoscopic field. We developed the Doppler probe method (DOP) using the novel system and conducted a comparative study.

METHODS

Data were retrospectively collected at a tertiary hospital between January 2017 and May 2021. Patients who underwent DOP were matched to those who did not (no-DOP, 1:3 ratio). After successful ESD, DOP was performed, and coagulation was additionally performed as necessary. The primary outcome was the rate of 30-day delayed bleeding.

RESULTS

Fifty DOP patients were matched to 151 no-DOP patients. Although the differences were not statistically significant, the DOP group had lower rates of delayed bleeding (2.0% vs. 8.6%, P = 0.11; risk differences, 6.6%; 95% confidence interval [CI] 1.2-12.1%), readmission due to bleeding (0% vs. 2.7%), and blood transfusion (2.0% vs. 3.3%) compared to the no-DOP group. In the whole study population (n = 245), the log-rank test revealed that DOP was correlated to a lower incidence of delayed bleeding (P = 0.036). The Cox regression model revealed a marginally significant effect on delayed bleeding (hazard ratio = 0.17, 95% CI 0.022-1.26, P = 0.082). No procedure-related adverse events were observed.

CONCLUSION

DOP is safe and may reduce delayed bleeding; however, further prospective studies are required to validate our findings.

Development and validation of an endoscopic submucosal dissection video assessment tool

BACKGROUND

Despite a need for assessment of endoscopic submucosal dissection (ESD) skills in order to track progress and determine competence, there is no structured measure of assessing competency in ESD performance. The present study aims to develop and examine validity evidence for an assessment tool to evaluate the recorded performance of ESD for gastric neoplasms.

METHODS

The ESD video assessment tool (EVAT) was systematically developed by ESD experienced endoscopists. The EVAT consists of a 25-item global rating scale and 3-item checklist to assess competencies required to perform ESD. Five unedited videos were each evaluated by 2-blinded experienced ESD endoscopists to assess inter-rater reliability using intraclass correlation coefficients (ICC). Seventeen unedited videos in total were rated by 3 blinded experienced ESD endoscopists. Validity evidence for relationship to other variables was examined by comparing scores of inexperienced (fellows) and experienced endoscopists (attending staff), and by evaluating the relationship between the EVAT scores and ESD case experience. Internal consistency was evaluated using Cronbach's alpha.

RESULTS

The inter-rater reliability for the total score was high at 0.87 (95% confidence interval 0.11 to 0.99). The total score [median, interquartile range (IQR)] was significantly different between the inexperienced (71, 63-77) and experienced group (95, 91-97) (P = 0.005). The total scores demonstrated high correlation with the number of ESD cases (Spearman's ρ = 0.79, P < 0.01). The internal consistency was 0.97.

CONCLUSIONS

This study provides preliminary validity evidence for the assessment of video-recorded ESD performances for gastric neoplasms using EVAT.

Task Deconstruction of Colonic Endoscopic Submucosal Dissection (cESD): An Expert Consensus

BACKGROUND

Slow adoption of colonic ESD (cESD) in the US is multifactorial due to: lack of clinical training construct (e.g., gastric ESD in Japan), complication risks, and technical difficulty. More than 28,000 patients/year undergo colonic resection for benign lesions that could be managed effectively with cESD. Selected patients could avoid surgery if procedural adoption of cESD increased due to more accessible training. Current US cESD training is scarce, and existing programs are piecemeal. There is a need to develop an effective national training program for practicing endoscopists. A prerequisite to training development is a comprehensive task list delineating procedural steps. The aim of this work was to describe an evidence-based method of deconstructing cESD into the essential steps to provide a task list to guide teaching and assessment.

METHODS

Subject-matter experts (SMEs) performed a literature review to create an initial procedural step list. Eleven clinical cESD SMEs and four educational SMEs formed a 'cESD Working Group' to develop consensus regarding steps. Through a two-stage modified Delphi process, a consensus on a comprehensive standard cESD deconstructed task list was reached. The aim was to standardize cESD teaching to efficiently bring a novice to safe performance.

RESULTS

A literature review identified eight initial cESD steps. First-round Delphi consensus was gained on seven steps. Semi-structured focus group discussions resulted in consensus on a modified version of 7 of the initial steps, with addition of two steps. Consensus on procedural actions needed to perform each step was achieved after the hands-on laboratory. The final result was a ten-step deconstructed task list for standard cESD.

CONCLUSION

The development of a standardized cESD procedural task list provides a foundation to safely and efficiently teach cESD to practicing endoscopists. This list can be used to develop a training pathway to increase procedural adoption. Selected patients currently undergoing colonic resections could benefit from increased adoption of cESD.

Endoscopic Resection of Gastric Submucosal Masses by a Dental Floss Traction Method

BACKGROUND AND AIMS

ESE (endoscopic submucosal excavation) is widely used for the treatment of digestive diseases. The dental floss traction (DFT) method has been successfully used to facilitate ESE to resect mucosal lesions such as early gastric cancer. DFT has not been used in ESE to remove submucosal masses. This study aimed to examine the efficacy of DFT-assisted ESE (DFT- ESE) for the removal of submucous masses.

METHODS

From March 2017 to May 2017, a total of 12 patients with gastric submucosal masses at the First Affiliated Hospital of Nanchang University, Jiangxi, China, were enrolled. The tumor characteristics, en bloc resection rates, complications, and outcomes on follow-up were evaluated for all patients.

RESULTS

The 12 submucosal tumors were completely removed by DFT- ESE. Nine were gastrointestinal stromal tumors. Two were Schwannoma, located in the greater curvature of the gastric corpus. One was gastric ectopic pancreas. All the resected tumors were removed completely with intact tumor capsules. There was no more bleeding or perforation after the endoscopic closure of the perforation or the wound after the DFT-ESE, and no recurrences were identified at the time of follow-up.

CONCLUSIONS

The DFT method efficiently and safely facilitated the ESE procedure during the resection of gastric submucosal tumors. This study was registered with Chinese Clinical Trial Registry under Registration number ChiCTR-OOC-15005833).