Skip to main content
SpringerLink
Log in

Training Methods and Models for Colonoscopic Insertion, Endoscopic Mucosal Resection, and Endoscopic Submucosal Dissection

  • Review
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Colonoscopic examination is considered an effective examination for the detection of colorectal cancers. Additionally, early colorectal cancers can be resected using endoscopic techniques such as endoscopic mucosal resection and endoscopic submucosal dissection. However, those examinations and treatments need special techniques. Various training methods are practiced to acquire such endoscopic techniques throughout the world. In clinical cases, magnetic positioning devices help endoscopic insertion by less experienced endoscopists. There is a physical model made by polyvinyl chloride and a virtual simulator for training of colonoscopic insertion. Various techniques including a method to apply pressure to the abdomen and consideration for patient’s pain can be trained using these models. In view of extensive training of endoscopic mucosal resection and endoscopic submucosal dissection, animal models are useful and actually used. Live animal models of minipig, which entails blood flow, are ideal and used frequently, but are cumbersome to prepare. On the other hand, ex vivo animal models using intestine of porcine and bovine are convenient for preparation and less expensive. Unique ex vivo animal models with blood flow have been developed recently and techniques for hemostasis can be practiced. With respect to a method of training for colorectal endoscopic submucosal dissection, a stepwise system has been adopted throughout the world. Thus, first they observe the expert’s technique, then practice training of animal models, and finally, they perform clinical rectal cases. The system is useful for a safe and definite procedure. In this review, we reveal various training methods for colonoscopic examinations and treatments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. International Agency for Research on Cancer. World Health Organization. Cancer Mondial. http://www-dep.iarc.fr/. Accessed 15 Jan 2013.

  2. Kudo S, Hirota S, Nakajima T, et al. Colorectal tumours and pit pattern. J Clin Pathol. 1994;47:880–885.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Sano Y, Ikematsu H, Fu KI, et al. Meshed capillary vessels by use of narrow-band imaging for differential diagnosis of small colorectal polyps. Gastrointest Endosc. 2009;69:278–283.

    Article  PubMed  Google Scholar 

  4. Yoshida N, Naito Y, Kugai M, et al. Efficacy of magnifying endoscopy with flexible spectral imaging color enhancement in the diagnosis of colorectal tumors. J Gastroenterol. 2011;46:65–72.

    Article  PubMed  Google Scholar 

  5. Tanaka S, Haruma K, Oka S, et al. Clinicopathological features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest Endosc. 2001;54:62–66.

    Article  CAS  PubMed  Google Scholar 

  6. Saito Y, Fukuzawa M, Matsuda T, et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc. 2010;24:343–352.

    Article  PubMed  Google Scholar 

  7. Yoshida N, Naito Y, Yagi Y, et al. Importance of histological evaluation in endoscopic submucosal dissection and endoscopic mucosal resection for early colorectal cancer. World J Gastrointest Pathophysiol. 2012;3:44–59.

    Article  Google Scholar 

  8. Yoshida N, Naito Y, Inada Y, et al. Multicenter study of endoscopic mucosal resection using 0.13% hyaluronic acid solution of colorectal polyps less than 20 mm in size. Int J Colorectal Dis. 2013;28:49–56.

    Article  PubMed  Google Scholar 

  9. Parry BR, William SM. Competency and the colonoscopist: a learning curve. Aust N Z J Surg. 1991;61:419–422.

    Article  CAS  PubMed  Google Scholar 

  10. Saunders BP, Bell GD, Williams CB, Bladen JS, Anderson AP. First clinical results with a real time, electronic imager as an aid to colonoscopy. Gut. 1995;36:913–917.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  11. Shah SG, Brooker JC, Williams CB, Thapar C, Saunders BP. Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial. Lancet. 2000;356:1718–1722.

    Article  CAS  PubMed  Google Scholar 

  12. Hill A, Horswill MS, Plooy AM, et al. Assessing the realism of colonoscopy simulation: the development of an instrument and systematic comparison of 4 simulators. Gastrointest Endosc. 2012;75:631–640.

    Article  PubMed  Google Scholar 

  13. Sedlack RE, Kolars JC. Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study. Am J Gastroenterol. 2004;99:33–37.

    Article  PubMed  Google Scholar 

  14. Park J, MacRae H, Musselman LJ, et al. Randomized controlled trial of virtual reality simulator training: transfer to live patients. Am J Surg. 2007;194:205–211.

    Article  PubMed  Google Scholar 

  15. Ahlberg G, Hultcrantz R, Jaramillo E, Lindoblom A, Arvidsson D. Virtual reality colonoscopy simulation: a compulsory practice for the future colonoscopist? Endoscopy. 2005;37:1198–1204.

    Article  CAS  PubMed  Google Scholar 

  16. Cohen J, Cohen SA, Vora KC, et al. Multicenter, randomized, controlled trial of virtual-reality simulator training in acquisition of competency in colonoscopy. Gastrointest Endosc. 2006;64:361–368.

    Article  PubMed  Google Scholar 

  17. Qiao W, Bai Y, Lv R, et al. The effect of virtual endoscopy simulator training on novices: a systematic review. PLoS One. 2014;9:e89224.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Rosenburg N. Submucosal saline wheal as safety factor in fulguration or rectal and sigmoidal polyp. AMA Arch Surg. 1955;70:120–122.

    Article  Google Scholar 

  19. Tada M, Shimada Y, Murakami F, et al. Development of the strip-off biopsy [in Japanese with English abstract]. Gastroenterol Endosc. 1984;26:833–839.

    Google Scholar 

  20. Karita M, Tada M, Okita K. The successive strip biopsy partial resection technique for large early gastric and colon cancers. Gastrointest Endosc. 1992;38:174–178.

    Article  CAS  PubMed  Google Scholar 

  21. Saito Y, Fukuzawa M, Matsuda T, et al. Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection. Surg Endosc. 2010;24:343–352.

    Article  PubMed  Google Scholar 

  22. Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc. 1992;38:303–309.

    Article  CAS  PubMed  Google Scholar 

  23. Tajika M, Niwa Y, Bhatia V, et al. Comparison of endoscopic submucosal dissection and endoscopic mucosal resection for large colorectal tumors. Eur J Gastroenterol Hepatol. 2011;23:1042–1049.

    PubMed  Google Scholar 

  24. Iishi H, Tatsuta M, Iseki K, et al. Endoscopic piecemeal resection with submucosal saline injection of large sessile colorectal polyps. Gastrointest Endosc. 2000;51:697–700.

    Article  CAS  PubMed  Google Scholar 

  25. Kobayashi N, Yoshitake N, Hirahara Y, et al. A matched case-control study comparing endoscopic submucosal dissection and endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol. 2012;27:728–733.

    Article  PubMed  Google Scholar 

  26. Uraoka T, Fujii T, Saito Y, et al. Effectiveness of glycerol as a submucosal injection for EMR. Gastrointest Endosc. 2005;61:736–740.

    Article  PubMed  Google Scholar 

  27. Yoshida N, Naito Y, Kugai M, et al. Efficacy of hyaluronic acid in endoscopic mucosal resection for colorectal tumors. J Gastroenterol Hepatol. 2011;26:286–291.

    Article  PubMed  Google Scholar 

  28. Fujishiro M, Yahagi N, Kashimura K, et al. Different mixtures of sodium hyaluronate and their ability to create submucosal fluid cushions for endoscopic mucosal resection. Endoscopy. 2004;36:584–589.

    Article  CAS  PubMed  Google Scholar 

  29. Yoshida N, Naito Y, Inada Y, et al. Endoscopic mucosal resection with 0.13% hyaluronic acid solution for colorectal polyps less than 20 mm: a randomized controlled trial. J Gastroenterol Hepatol. 2012;27:1377–1383.

    Article  PubMed  Google Scholar 

  30. Gotoda T, Kondo H, Ono H, et al. A new endoscopic mucosal resection procedure using an insulation-tipped electrosurgical knife for rectal flat lesions: report of two cases. Gastrointest Endosc. 1999;50:560–563.

    Article  CAS  PubMed  Google Scholar 

  31. Tanaka S, Oka S, Kaneko I, et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc. 2007;66:100–107.

    Article  PubMed  Google Scholar 

  32. Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc. 2010;72:1217–1225.

    Article  PubMed  Google Scholar 

  33. Fujishiro M, Yahagi N, Kakushima N, et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol. 2007;5:678–683.

    Article  PubMed  Google Scholar 

  34. Yoshida N, Naito Y, Sakai K, et al. Outcome of endoscopic submucosal dissection for colorectal tumors in elderly people. Int J Colorectal Dis. 2010;25:455–461.

    Article  PubMed  Google Scholar 

  35. Yoshida N, Yagi N, Naito Y, et al. Safe procedure in endoscopic submucosal dissection for colorectal tumors focused on preventing complications. World J Gastroenterol. 2010;16:1688–1695.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Yoshida N, Wakabayashi N, Kanemasa K, et al. Endoscopic submucosal dissection for colorectal tumors: technical difficulties and rate of perforation. Endoscopy. 2009;41:758–761.

    Article  CAS  PubMed  Google Scholar 

  37. Takeuchi Y, Uedo N, Ishihara R, et al. Efficacy of an endo-knife with a water-jet function (Flushknife) for endoscopic submucosal dissection of superficial colorectal neoplasms. Am J Gastroenterol. 2010;105:314–322.

    Article  PubMed  Google Scholar 

  38. Toyonaga T, Man-I M, Morita Y, et al. The new resources of treatment for early stage colorectal tumors: EMR with small incision and simplified endoscopic submucosal dissection. Dig Endosc. 2009;21:S31–S37.

    Article  PubMed  Google Scholar 

  39. Kim ES, Cho KB, Park KS, et al. Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors. Endoscopy. 2011;43:573–578.

    Article  CAS  PubMed  Google Scholar 

  40. Lee EJ, Lee JB, Choi YS, et al. Clinical risk factors for perforation during endoscopic submucosal dissection (ESD) for large-sized, nonpedunculated colorectal tumors. Surg Endosc. 2012;26:1587–1594.

    Article  PubMed  Google Scholar 

  41. Repici A, Conio M, De Angelis C, et al. Insulated-tip knife endoscopic mucosal resection of large colorectal polyps unsuitable for standard polypectomy. Am J Gastroenterol. 2007;102:1617–1623.

    Article  PubMed  Google Scholar 

  42. Yoshida N, Yagi N, Inada Y, et al. Possibility of ex vivo animal training model for colorectal endoscopic submucosal dissection. Int J Colorectal Dis. 2013;28:49–56.

    Article  PubMed  Google Scholar 

  43. Uraoka T, Parra-Blanco A, Yahagi N. Colorectal endoscopic submucosal dissection: is it suitable in Western countries? J Gastroenterol Hepatol. 2013;28:406–414.

    Article  PubMed  Google Scholar 

  44. Ohata K, Ito T, Chiba H, et al. Effective training system in colorectal endoscopic submucosal dissection. Dig Endosc. 2012;24:84–89.

    Article  PubMed  Google Scholar 

  45. Gotoda T, Friedland S, Hamanaka H, et al. A learning curve for advanced endoscopic resection. Gastrointest Endosc. 2005;62:866–867.

    Article  PubMed  Google Scholar 

  46. Choi IJ, Kim CG, Chang HJ, et al. The learning curve for EMR with circumferential mucosal incision in treating intramucosal gastric neoplasm. Gastrointest Endosc. 2005;62:860–865.

    Article  PubMed  Google Scholar 

  47. Hotta K, Oyama T, Shinohara T, et al. Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc. 2010;22:302–306.

    Article  PubMed  Google Scholar 

  48. Akahoshi K, Motomura Y, Kubokawa M, et al. Endoscopic submucosal dissection of a rectal carcinoid tumor using grasping type scissors forceps. World J Gastroenterol. 2009;15:2162–2165.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Honma K, Kobayashi M, Watanabe H, et al. Endoscopic submucosal dissection for colorectal neoplasia. Dig Endosc. 2010;22:307–311.

    Article  PubMed  Google Scholar 

  50. Iacopini F, Bella A, Costamagna G, et al. Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves. Gastrointest Endosc. 2012;76:1188–1196.

    Article  PubMed  Google Scholar 

  51. Probst A, Golger D, Anthuber M, Märkl B, Messmann H. Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy. 2012;44:660–667.

    Article  CAS  PubMed  Google Scholar 

  52. Deprez PH, Bergman JJ, Meisner S, et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy. 2010;42:853–858.

    Article  CAS  PubMed  Google Scholar 

  53. Draganov PV, Gotoda T, Chavalitdhamrong D, et al. Techniques of endoscopic submucosal dissection: application for the Western endoscopist? Gastrointest Endosc. 2013;78:677–688.

    Article  PubMed  Google Scholar 

  54. Parra-Blanco A, Arnau MR, Nicolás-Pérez D, et al. Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol. 2010;16:2895–2900.

    Article  PubMed Central  PubMed  Google Scholar 

  55. Berr F, Ponchon T, Neureiter D, et al. Experimental endoscopic submucosal dissection training in a porcine model: learning experience of skilled Western endoscopists. Dig Endosc. 2011;23:281–289.

    Article  PubMed  Google Scholar 

  56. CME Asge programs Committee. Updated guidelines for live endoscopy demonstrations. Gastrointest Endosc. 2010;71:1105–1107.

    Article  Google Scholar 

  57. Tanimoto MA, Torres-Villalobos G, Fujita R, et al. Endoscopic submucosal dissection in dogs in a World Gastroenterology Organisation training center. World J Gastroenterol. 2010;16:1759–1764.

    Article  PubMed Central  PubMed  Google Scholar 

  58. Parra-Blanco A, Gonzalez N, Arnau MR. Ex vivo and in vivo models for endoscopic submucosal dissection training. Clin Endosc. 2012;45:350–357.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Hon SS, Ng SS, Lee JF, et al. In vitro porcine training model for colonic endoscopic submucosal dissection: an inexpensive and safe way to acquire a complex endoscopic technique. Surg Endosc. 2010;24:2439–2443.

    Article  PubMed  Google Scholar 

  60. Parra-Blanco A, Saito Y, Yahagi N, et al. Recommendations about training for colorectal endoscopic submucosal dissection in the Western world. Results of a survey to experts. Gastrointest Endosc. 2011;73:AB419–AB420.

    Article  Google Scholar 

  61. Pham DV, Shah A, Borao FJ, et al. Endoscopic submucosal dissection training with ex vivo human gastric remnants. Surg Endosc. 2014;28:222–226.

    Article  PubMed  Google Scholar 

  62. Fujishiro M, Yahagi N, Kakushima N, et al. Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms. Endoscopy. 2006;38:1001–1006.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Yasuhisa Abe and Shigenori Shikata for providing ex vivo animal models. We also thank Ryohei Hirose, Kiyoshi Ogiso, Yasutaka Morimoto, Ken Inoue, Daisuke Hasegawa, Naoki Wakabayashi and all other members at the Department of Molecular Gastroenterology and Hepatology in Kyoto Prefectural University of Medicine for several studies related with this review.

Conflict of interest

Yoshito Itoh is affiliated with AstraZeneca Co., Ltd., Eisai Co., Ltd., Otsuka Pharmaceutical Co., Ltd., MSD K.K., Dainippon Sumitomo Pharma Co., Ltd., Chugai Pharmaceutical Co., Ltd., FUJIFILM Medical Co., Ltd. and Merck Serono Co., Ltd. Yoshito Itoh received research grants from MSD K.K. and Bristol-Myers K.K. Yuji Naito received research grants from Otsuka Pharmaceutical Co., Ltd. and Takeda Pharmaceutical Co., Ltd. The other authors have no conflicts of interest to declare. Besides, these things described above, there are no financial supports or relationships that may pose conflict of interest in our manuscript.

Author information

Authors and Affiliations

  1. Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan

    Naohisa Yoshida, Nilesh Fernandopulle, Yutaka Inada, Yuji Naito & Yoshito Itoh

Authors
  1. Naohisa Yoshida
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nilesh Fernandopulle
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yutaka Inada
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yuji Naito
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yoshito Itoh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Naohisa Yoshida.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yoshida, N., Fernandopulle, N., Inada, Y. et al. Training Methods and Models for Colonoscopic Insertion, Endoscopic Mucosal Resection, and Endoscopic Submucosal Dissection. Dig Dis Sci 59, 2081–2090 (2014). https://doi.org/10.1007/s10620-014-3308-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-014-3308-y

Keywords

Search

Navigation