Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves

Background: Endoscopic submucosal dissection (ESD) has revolutionized the resection of GI superficial neoplasms, but adoption in Western countries is significantly delayed. Objective: To evaluate a stepwise colorectal endoscopic submucosal dissection (ESD) learning and operative training protocol. Design: Prospective study in the Western setting. Setting: This study took place in a nonacademic hospital with one endoscopist expert in therapeutic endoscopy but novice in ESD. Patients: Indications for ESD were superficial neoplasms 20 mm and larger without ulcerations or fibrosis. Intervention: Training consisted of 5 unsupervised ESDs on isolated stomach, an observation period at an ESD expert Japanese center, 1 supervised ESD on isolated stomach, and retraining on 1 rectal ESD under supervision. The operative training on patients was performed without supervision moving from the rectum to the colon according to the competence achieved. Main Outcome Measurements: Competence was defined as an 80% en bloc resection rate plus a statistically significant reduction in operating time per square centimeter. Learning curves were calculated based on consecutive blocks of 5 procedures. Results: From February 2009 to February 2012, 30 rectal and 30 colonic ESDs were performed. The rectal ESD learning curve showed that the en bloc resection rate was 80% after 5 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .0079); perforation occurred in 1 patient. The colonic ESD learning curve showed that the en bloc resection rate was 80% after 20 procedures (P = not significant); the operating time per square centimeter significantly decreased after 20 procedures (P = .031); perforations occurred in 2 patients. Limitations: Single-center design. Conclusions: A minimal intensive training seems sufficient for endoscopists expert in therapeutic procedures to take up ESD in a not overly arduous incremental method with separate and sequential learning curves for the rectum and colon. (Gastrointest Endosc 2012;76:1188-96.)