The learning curve for endoscopic submucosal dissection in an established experimental setting



Endoscopic submucosal dissection (ESD) has become a standard therapy for early gastric neoplasia, particularly in Asian countries. From a safety and efficacy standpoint, simulation training may empower the endoscopist to be able to learn the basic tenets of ESD in a safe, controlled and supervised setting before attempting first in humans.

Methods and Procedures

This study was designed as a prospective ex vivo study. Ex vivo porcine organs were utilized in the EASIE-R endoscopic simulator. A total of 150 artificial lesions, each 2 × 2 cm in size, were created in fresh ex vivo porcine stomachs at six different anatomical sites (fundus anterior and posterior, body anterior and posterior, antrum anterior and posterior). Three examiners (2 beginners, 1 expert) participated in this study. All parameters (procedure time, specimen size, en-bloc resection status, perforation) were recorded by an independent observer for each procedure.


All 150 lesions were successfully resected using the ESD technique by the three endoscopists. After 30 ESD cases, the two novices performed ESD with a 100 % en-bloc resection rate and without perforation. For the procedures performed by the novices, the total procedure time and perforation rate in the last 30 cases were significantly lower than during the first 30 cases (p < 0.05).


Our study suggests that performing 30 ESD resections in an ex vivo simulator leads to a significant improvement in safety and efficiency of performing the ESD technique.

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Both Endosim, LLC, Berlin, MA, USA and Olympus America Inc., PA, USA provided material support.


Masayuki Kato, Mark Gromski, Yunho Jung, Ram Chuttani, and Kai Matthes have no conflicts of interest or financial ties to disclose.

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Correspondence to Masayuki Kato.

Electronic supplementary material

Below is the link to the electronic supplementary material.

The ESD procedure by the inexperienced endoscopist after performing over 60 cases (MPG 116568 kb)

The ESD procedure by the inexperienced endoscopist after performing over 60 cases (MPG 116568 kb)

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Kato, M., Gromski, M., Jung, Y. et al. The learning curve for endoscopic submucosal dissection in an established experimental setting. Surg Endosc 27, 154–161 (2013) doi:10.1007/s00464-012-2402-5

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  • Education
  • Endoscopy
  • ESD
  • Learning curve
  • Educational cost
  • Ex-vivo