Surgical Endoscopy

, Volume 31, Issue 9, pp 3614–3622 | Cite as

Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators

  • Masao Yoshida
  • Naomi Kakushima
  • Keita Mori
  • Kimihiro Igarashi
  • Noboru Kawata
  • Masaki Tanaka
  • Kohei Takizawa
  • Sayo Ito
  • Kenichiro Imai
  • Kinichi Hotta
  • Hirotoshi Ishiwatari
  • Hiroyuki Matsubayashi
  • Hiroyuki Ono



Although endoscopic submucosal dissection (ESD) represents a significant progress in therapeutic endoscopy, little is known about how trainees attain its technical proficiency. The aims of this study were to evaluate the learning curve and clinical outcomes of gastric ESD performed by trainee endoscopists.


Between April 2009 and March 2014, 334 gastric ESD procedures were performed by seven trainees (42–50 consecutive cases per trainee). The learning curve for gastric ESD was evaluated using the cumulative sum (CUSUM) method. Long-term outcomes were also analyzed.


The calculated CUSUM learning curve comprised three phases: Phase I (the initial 15 cases), Phase II (the middle 15 cases), and Phase III (the final 20 cases). The resection speed was 5.7 ± 3.2 min/cm2 in Phase I, 4.7 ± 2.7 min/cm2 in Phase II, and 4.3 ± 2.2 min/cm2 in Phase III. The resection speed was significantly faster in Phase II than in Phase I (p = 0.019). The rate of self-completion reached more than 95% in Phases II and III. The overall complete resection rate was 95%, showing no significant differences between the three phases. Local recurrence was diagnosed in none of the patients during a median follow-up of 38 months.


For the trainees, 30 cases were required to attain a higher technical level of competence in gastric ESD. After the learning curve phase, trainee operators could be expected to complete the procedure successfully with favorable long-term outcomes.


Learning curve Trainee Endoscopic submucosal dissection Proficiency CUSUM 



The authors thank the SCC medical record management office (Ms. Mochizuki) for data collection.

Compliance with ethical standards


Masao Yoshida, Naomi Kakushima, Keita Mori, Kimihiro Igarashi, Noboru Kawata, Masaki Tanaka, Kohei Takizawa, Sayo Ito, Kenichiro Imai, Kinichi Hotta, Hirotoshi Ishiwatari, Hiroyuki Matsubayashi, and Hiroyuki Ono have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2016_5393_MOESM1_ESM.tif (35 kb)
CUSUM learning curve of trainee A (TIFF 35 kb)
464_2016_5393_MOESM2_ESM.tif (42 kb)
CUSUM learning curve of trainee B (TIFF 42 kb)
464_2016_5393_MOESM3_ESM.tif (39 kb)
CUSUM learning curve of trainee C (TIFF 39 kb)
464_2016_5393_MOESM4_ESM.tif (40 kb)
CUSUM learning curve of trainee D (TIFF 40 kb)
464_2016_5393_MOESM5_ESM.tif (39 kb)
CUSUM learning curve of trainee E (TIFF 39 kb)
464_2016_5393_MOESM6_ESM.tif (39 kb)
CUSUM learning curve of trainee F (TIFF 39 kb)
464_2016_5393_MOESM7_ESM.tif (38 kb)
CUSUM learning curve of trainee G (TIFF 37 kb)


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Masao Yoshida
    • 1
  • Naomi Kakushima
    • 1
  • Keita Mori
    • 2
  • Kimihiro Igarashi
    • 1
  • Noboru Kawata
    • 1
  • Masaki Tanaka
    • 1
  • Kohei Takizawa
    • 1
  • Sayo Ito
    • 1
  • Kenichiro Imai
    • 1
  • Kinichi Hotta
    • 1
  • Hirotoshi Ishiwatari
    • 1
  • Hiroyuki Matsubayashi
    • 1
  • Hiroyuki Ono
    • 1
  1. 1.Division of EndoscopyShizuoka Cancer Center HospitalSunto-gunJapan
  2. 2.Clinical Trial Coordination OfficeShizuoka Cancer Center HospitalSunto-gunJapan

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