ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries.
We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons.
The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson’s test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores.
We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.
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Key Statistics for Colorectal Cancer. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Accessed 14 Aug 2017
Worldwide data | World Cancer Research Fund International. https://www.wcrf.org/int/cancer-facts-figures/worldwide-data. Accessed 28 May 2018
Cancer of the Colon and Rectum—Cancer Stat Facts. https://seer.cancer.gov/statfacts/html/colorect.html. Accessed 13 Apr 2017
Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, Kwon R, Mamula P, Rodriguez S, Shah RJ, Song LMWK, Tierney WM (2008) Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 68:11–18. https://doi.org/10.1016/j.gie.2008.01.037
Yamamoto K, Michida T, Nishida T, Hayashi T, Naito M, Ito T (2015) Colorectal endoscopic submucosal dissection: recent technical advances for safe and successful procedures. World J Gastrointest Endosc 7:1114–1128. https://doi.org/10.4253/wjge.v7.i14.1114
Fujihara S, Mori H, Kobara H, Nishiyama N, Matsunaga T, Ayaki M, Yachida T, Morishita A, Izuishi K, Masaki T (2014) Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection. BioMed Res Int. https://doi.org/10.1155/2014/925058
Saito Y, Yamada M, So E, Abe S, Sakamoto T, Nakajima T, Otake Y, Ono A, Matsuda T (2014) Colorectal endoscopic submucosal dissection: technical advantages compared to endoscopic mucosal resection and minimally invasive surgery. Dig Endosc Off J Jpn Gastroenterol Endosc Soc 26(Suppl 1):52–61. https://doi.org/10.1111/den.12196
Shono T, Ishikawa K, Ochiai Y, Nakao M, Togawa O, Nishimura M, Arai S, Nonaka K, Sasaki Y, Kita H (2011) Feasibility of endoscopic submucosal dissection: a new technique for En Bloc resection of a large superficial tumor in the colon and rectum. Int J Surg Oncol 2011:e948293. https://doi.org/10.1155/2011/948293
Wang J, Zhang X-H, Ge J, Yang C-M, Liu J-Y, Zhao S-L (2014) Endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal tumors: a meta-analysis. World J Gastroenterol WJG 20:8282–8287. https://doi.org/10.3748/wjg.v20.i25.8282
Hotta K, Oyama T, Shinohara T, Miyata Y, Takahashi A, Kitamura Y, Tomori A (2010) Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc 22:302–306. https://doi.org/10.1111/j.1443-1661.2010.01005.x
Oka S, Tanaka S, Kaneko I, Mouri R, Hirata M, Kawamura T, Yoshihara M, Chayama K (2006) Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer. Gastrointest Endosc 64:877–883. https://doi.org/10.1016/j.gie.2006.03.932
Niimi K, Fujishiro M, Goto O, Kodashima S, Koike K (2012) Safety and efficacy of colorectal endoscopic submucosal dissection by the trainee endoscopists. Dig Endosc 24:154–158. https://doi.org/10.1111/j.1443-1661.2012.01251.x
Sakamoto T, Takamaru H, Mori G, Yamada M, Kinjo Y, So E, Abe S, Otake Y, Nakajima T, Matsuda T, Saito Y (2014) Endoscopic submucosal dissection for colorectal neoplasms. Ann Transl Med. https://doi.org/10.21037/3536
Kato H, Sakamoto T, Otsuka H, Yamada R, Watanabe K (2012) Colorectal cancer—from prevention to patient care. InTech
Fukami N (2014) Endoscopic submucosal dissection, an issue of gastrointestinal endoscopy clinics, E-Book. Elsevier Health Sciences
ASGE Standards of Practice Committee, Faulx AL, Lightdale JR, Acosta RD, Agrawal D, Bruining DH, Chandrasekhara V, Eloubeidi MA, Gurudu SR, Kelsey L, Khashab MA, Kothari S, Muthusamy VR, Qumseya BJ, Shaukat A, Wang A, Wani SB, Yang J, DeWitt JM (2017) Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 85:273–281. https://doi.org/10.1016/j.gie.2016.10.036
Gromski MA, Cohen J, Saito K, Gonzalez J-M, Sawhney M, Kang C, Moore A, Matthes K (2017) Learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator. Surg Endosc. https://doi.org/10.1007/s00464-017-5484-2
Kato M, Gromski M, Jung Y, Chuttani R, Matthes K (2013) The learning curve for endoscopic submucosal dissection in an established experimental setting. Surg Endosc 27:154–161. https://doi.org/10.1007/s00464-012-2402-5
Parra-Blanco A, Arnau MR, Nicolás-Pérez D, Gimeno-García AZ, González N, Díaz-Acosta JA, Jiménez A, Quintero E (2010) Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol WJG 16:2895–2900. https://doi.org/10.3748/wjg.v16.i23.2895
Berr F, Ponchon T, Neureiter D, Kiesslich T, Haringsma J, Kaehler GF, Schmoll F, Messmann H, Yahagi N, Oyama T (2011) Experimental endoscopic submucosal dissection training in a porcine model: learning experience of skilled Western endoscopists. Dig Endosc Off J Jpn Gastroenterol Endosc Soc 23:281–289. https://doi.org/10.1111/j.1443-1661.2011.01129.x
Fujishiro M (2009) Endoscopic submucosal dissection for colorectal neoplasms. World J Gastrointest Endosc 1:32. https://doi.org/10.4253/wjge.v1.i1.32
Tsuji Y, Fujishiro M, Kodashima S, Niimi K, Ono S, Yamamichi N, Koike K (2014) Desirable training of endoscopic submucosal dissection: further spread worldwide. Ann Transl Med. https://doi.org/10.3978/j.issn.2305-5839.2014.02.05
Sankaranarayanan G, Li B, Miller A, Wakily H, Jones SB, Schwaitzberg S, Jones DB, De S, Olasky J (2016) Face validation of the virtual electrosurgery skill trainer (VEST©). Surg Endosc 30:730–738. https://doi.org/10.1007/s00464-015-4267-x
Demirel D, Yu A, Halic T, Sankaranarayanan G, Ryason A, Spindler D, Butler KL, Cao C, Petrusa E, Molina M, Jones D, De S, Demoya M, Jones S (2016) Virtual airway skills trainer (VAST) simulator. Stud Health Technol Inform 220:91–97
Qiao W, Bai Y, Lv R, Zhang W, Chen Y, Lei S, Zhi F (2014) The effect of virtual endoscopy simulator training on novices: a systematic review. PLoS ONE 9:e89224. https://doi.org/10.1371/journal.pone.0089224
Triantafyllou K, Lazaridis LD, Dimitriadis GD (2014) Virtual reality simulators for gastrointestinal endoscopy training. World J Gastrointest Endosc 6:6–12. https://doi.org/10.4253/wjge.v6.i1.6
Aggarwal R, Black SA, Hance JR, Darzi A, Cheshire NJW (2006) Virtual reality simulation training can improve inexperienced surgeons’ endovascular skills. Eur J Vasc Endovasc Surg Off J Eur Soc Vasc Surg 31:588–593. https://doi.org/10.1016/j.ejvs.2005.11.009
Pan JJ, Chang J, Yang X, Liang H, Zhang JJ, Qureshi T, Howell R, Hickish T (2015) Virtual reality training and assessment in laparoscopic rectum surgery. Int J Med Robot Comput Assist Surg MRCAS 11:194–209. https://doi.org/10.1002/rcs.1582
Beyer-Berjot L, Berdah S, Hashimoto DA, Darzi A, Aggarwal R (2016) A virtual reality training curriculum for laparoscopic colorectal surgery. J Surg Educ 73:932–941. https://doi.org/10.1016/j.jsurg.2016.05.012
Rücker G, Schimek-Jasch T, Nestle U (2012) Measuring inter-observer agreement in contour delineation of medical imaging in a dummy run using Fleiss’ Kappa. Methods Inf Med 51:489–494. https://doi.org/10.3414/ME12-01-0005
Shrout PE, Fleiss JL (1979) Intraclass correlations: uses in assessing rater reliability. Psychol Bull 86:420–428. https://doi.org/10.1037/0033-2909.86.2.420
Demirel D, Butler KL, Halic T, Sankaranarayanan G, Spindler D, Cao C, Petrusa E, Molina M, Jones DB, De S, deMoya MA (2016) A hierarchical task analysis of cricothyroidotomy procedure for a virtual airway skills trainer simulator. Am J Surg 212:475–484. https://doi.org/10.1016/j.amjsurg.2015.08.029
Demirel D, Yu A, Cooper-Baer S, Dendukuri A, Halic T, Kockara S, Kockara N, Ahmadi S (2016) A hierarchical task analysis of shoulder arthroscopy for a virtual arthroscopic tear diagnosis and evaluation platform (VATDEP). Int J Med Robot. https://doi.org/10.1002/rcs.1799
Hsu W-H, Sun M-S, Lo H-W, Tsai C-Y, Tsai Y-J (2013) Clinical practice of endoscopic submucosal dissection for early colorectal neoplasms by a colonoscopist with limited gastric experience. Gastroenterol Res Pract 2013:e262171. https://doi.org/10.1155/2013/262171
Matsui N, Akahoshi K, Nakamura K, Ihara E, Kita H (2012) Endoscopic submucosal dissection for removal of superficial gastrointestinal neoplasms: a technical review. World J Gastrointest Endosc 4:123–136
Maple JT, Dayyeh BKA, Chauhan SS, Hwang JH, Komanduri S, Manfredi M, Konda V, Murad FM, Siddiqui UD, Banerjee S (2015) Endoscopic submucosal dissection. Gastrointest Endosc 81:1311–1325. https://doi.org/10.1016/j.gie.2014.12.010
Ribeiro MS, Wallace MB (2015) Endoscopic treatment of early cancer of the colon. Gastroenterol Hepatol 11:445–452
Shida T (2011) Endoscopic submucosal dissection for colorectal lesions. In: Colonoscopy, InTech. https://doi.org/10.5772/20825
Yamamoto H (2010) Endoscopic submucosal dissection for colorectal tumors. Techn Gastroint Endosc 27:287–295. https://doi.org/10.1159/000258370
This project was made possible by the Arkansas INBRE program, supported by a grant from the National Institute of General Medical Sciences, (NIGMS), P20 GM103429 from the National Institutes of Health. This project was also supported by National Institutes of Health (NIH) Grant NIH/NHLBI 1R01HL119248-01A1, NIH/NIBIB 2R01EB005807, 5R01EB010037, 1R01EB009362, R01CA197491 and 1R01EB014305.
Tansel Halic reports grants from National Institutes of Health, during the conduct of the study. Cullen Jackson reports grants from NIH via subcontract from RPI, during the conduct of the study. Suvranu De grants from National Institutes of Health, during the conduct of the study. Sudeep Hegde reports grants from National Institutes of Health, during the conduct of the study; other from State University of New York at Buffalo, outside the submitted work. Daniel B. Jones reports personal fees from Allurion, outside the submitted work. Berk Cetinsaya, Mark A. Gromski, Sangrock Lee, Zhaohui Xia, Doga Demirel, Coskun Bayrak, Jonah Cohen, Mandeep Sawhney, Stavros N. Stavropoulos have no conflicts of interest or financial ties to disclose.
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Cetinsaya, B., Gromski, M.A., Lee, S. et al. A task and performance analysis of endoscopic submucosal dissection (ESD) surgery. Surg Endosc 33, 592–606 (2019). https://doi.org/10.1007/s00464-018-6379-6
- Endoscopic training
- Endoscopic submucosal dissection
- Colorectal cancer