Skip to main content
SpringerLink
Log in

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

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

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

Similar content being viewed by others

References

  1. Ono H, Kondo H, Gotoda T, Shirao K, Yamaguchi H, Saito D, Hosokawa K, Shimoda T, Yoshida S (2001) Endoscopic mucosal resection for treatment of early gastric cancer. Gut 48:225–229

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Ohkuwa M, Hosokawa K, Boku N, Ohtu A, Tajiri H, Yoshida S (2001) New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife. Endoscopy 33:221–226

    Article  CAS  PubMed  Google Scholar 

  3. 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

    Article  PubMed  Google Scholar 

  4. Choi K-S, Jung H-Y, Lee G, Song H, Kim D, Lee J, Kim M-Y, Kim B, Oh S, Yook J, Jang S, Yun S-C, Kim S, Kim J-H (2011) EMR versus gastrectomy for intramucosal gastric cancer: comparison of long-term outcomes. Gastrointest Endosc 73:942–948

    Article  PubMed  Google Scholar 

  5. Cho J-H, Cha S-W, Kim H, Lee T, Ko W, Jin S-Y, Park S (2016) Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a comparison study to surgery using propensity score-matched analysis. Surg Endosc 30(9):3762–3773

    Article  PubMed  Google Scholar 

  6. Pyo J, Lee H, Min B-H, Lee J, Choi M, Sohn T, Bae J, Kim K, Ahn J, Carriere K, Kim J, Kim S (2016) Long-term outcome of endoscopic resection vs. surgery for early gastric cancer: a non-inferiority-matched cohort study. Am J Gastroenterol 111(2):240–249

    Article  PubMed  Google Scholar 

  7. Hiki N, Yamamoto Y, Fukunaga T, Yamaguchi T, Nunobe S, Tokunaga M, Miki A, Ohyama S, Seto Y (2008) Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 22:1729–1735

    Article  CAS  PubMed  Google Scholar 

  8. Goto O, Uraoka T, Horii J, Yahagi N (2014) Expanding indications for ESD: submucosal disease (SMT/carcinoid tumors). Gastrointest Endosc Clin N Am 24:169–181

    Article  PubMed  Google Scholar 

  9. Matsuda T, Hiki N, Nunobe S, Aikou S, Hirasawa T, Yamamoto Y, Kumagai K, Ohashi M, Sano T, Yamaguchi T (2016) Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video). Gastrointest Endosc 84(1):47–52

    Article  PubMed  Google Scholar 

  10. Rösch T, Sarbia M, Schumacher B, Deinert K, Frimberger E, Toermer T, Stolte M, Neuhaus H (2004) Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy 36:788–801

    Article  PubMed  Google Scholar 

  11. Kakushima N, Fujishiro M, Kodashima S, Muraki Y, Tateishi A, Omata M (2006) A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms. Endoscopy 38:991–995

    Article  CAS  PubMed  Google Scholar 

  12. Yamamoto S, Uedo N, Ishihara R, Kajimoto N, Ogiyama H, Fukushima Y, Takeuchi Y, Higashino K, Iishi H, Tatsuta M (2009) Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve. Endoscopy 41:923–928

    Article  PubMed  Google Scholar 

  13. Japanese Gastric Cancer Association (2011) Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer 14(2):113–123

    Article  Google Scholar 

  14. Tanaka M, Ono H, Hasuike N, Takizawa K (2008) Endoscopic submucosal dissection of early gastric cancer. Digestion 77(Suppl 1):23–28

    Article  PubMed  Google Scholar 

  15. Kakushima N (2011) Endoscopic submucosal dissection using the insulated-tip knife. Tech Gastrointest Endosc 13:63–69

    Article  Google Scholar 

  16. 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

    Article  PubMed  Google Scholar 

  17. Chaput de Saintonge DM, Vere DW (1974) Why don’t doctors use cusums? The Lancet 1:120–121

    Article  CAS  Google Scholar 

  18. Wohl H (1977) The cusum plot: its utility in the analysis of clinical data. N Engl J Med 296:1044–1045

    Article  CAS  PubMed  Google Scholar 

  19. Williams SM, Parry BR, Schlup MM (1992) Quality control: an application of the cusum. BMJ Brit Med J 304:1359–1361

    Article  CAS  PubMed  Google Scholar 

  20. Bokhari M, Patel C, Ramos Valadez D, Ragupathi M, Haas E (2011) Learning curve for robotic-assisted laparoscopic colorectal surgery. Surg Endosc 25:855–860

    Article  PubMed  Google Scholar 

  21. Zhu JG, Han W, Guo W, Su W, Bai ZG, Zhang ZT (2015) Learning curve and outcome of laparoscopic transcystic common bile duct exploration for choledocholithiasis. Br J Surg 102:1691–1697

    Article  CAS  PubMed  Google Scholar 

  22. Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method. Surg Endosc 29:1679–1685

    Article  PubMed  Google Scholar 

  23. Imagawa A, Okada H, Kawahara Y, Takenaka R, Kato J, Kawamoto H, Fujiki S, Takata R, Yoshino T, Shiratori Y (2006) Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 38:987–990

    Article  CAS  PubMed  Google Scholar 

  24. Nagata S, Jin Y-F, Tomoeda M, Kitamura M, Yuki M, Yoshizawa H, Kubo C, Ito Y, Uedo N, Ishihara R, Iishi H, Tomita Y (2011) Influential factors in procedure time of endoscopic submucosal dissection for gastric cancer with fibrotic change. Dig Endosc 23:296–301

    Article  PubMed  Google Scholar 

  25. Pimentel Nunes P, Dinis Ribeiro M, Ponchon T, Repici A, Vieth M, De Ceglie A, Amato A, Berr F, Bhandari P, Bialek A, Conio M, Haringsma J, Langner C, Meisner S, Messmann H, Morino M, Neuhaus H, Piessevaux H, Rugge M, Saunders B, Robaszkiewicz M, Seewald S, Kashin S, Dumonceau J-M, Hassan C, Deprez P (2015) Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 47:829–854

    Article  PubMed  Google Scholar 

  26. Choi I, Kim C, Chang H, Kim S, Kook M-C, Bae J-M (2005) The learning curve for EMR with circumferential mucosal incision in treating intramucosal gastric neoplasm. Gastrointest Endosc 62:860–865

    Article  PubMed  Google Scholar 

  27. Gotoda T, Friedland S, Hamanaka H, Soetikno R (2005) A learning curve for advanced endoscopic resection. Gastrointest Endosc 62:866–867

    Article  PubMed  Google Scholar 

  28. Tsuji Y, Ohata K, Sekiguchi M, Ito T, Chiba H, Gunji T, Yamamichi N, Fujishiro M, Matsuhashi N, Koike K (2011) An effective training system for endoscopic submucosal dissection of gastric neoplasm. Endoscopy 43:1033–1038

    Article  CAS  PubMed  Google Scholar 

  29. Lin C-W, Tsai T-J, Cheng T-Y, Wei H-K, Hung C-F, Chen Y-Y, Chen C-M (2016) The learning curve of laparoscopic liver resection after the Louisville statement 2008: will it be more effective and smooth? Surg Endosc 30(7):2895–2903

    Article  PubMed  Google Scholar 

  30. 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

    Article  PubMed  Google Scholar 

  31. Oda I, Odagaki T, Suzuki H, Nonaka S, Yoshinaga S (2012) Learning curve for endoscopic submucosal dissection of early gastric cancer based on trainee experience. Dig Endosc 24(Suppl 1):129–132

    Article  PubMed  Google Scholar 

  32. Jeon H, Lee H, Youn Y, Park J, Park H (2016) Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD. Surg Endosc 30(6):2422–2430

    Article  PubMed  Google Scholar 

  33. Tsou YK, Chuang WY, Liu CY, Ohata K, Lin CH, Lee MS, Cheng HT, Chiu CT (2016) Learning curve for endoscopic submucosal dissection of esophageal neoplasms. Dis Esophagus 29(6):544–550

    Article  PubMed  Google Scholar 

  34. Neuhaus H (2009) Endoscopic submucosal dissection in the upper gastrointestinal tract: present and future view of Europe. Dig Endosc 21(Suppl 1):S4–S6

    Article  PubMed  Google Scholar 

  35. Ono S, Kato M, Nakagawa M, Imai A, Yamamoto K, Shimizu Y (2013) Outcomes and predictive factors of “not self-completion” in gastric endoscopic submucosal dissection for novice operators. Surg Endosc 27:3577–3583

    Article  PubMed  Google Scholar 

  36. McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P (2007) The Hawthorne effect: a randomised, controlled trial. BMC Med Res Methodol 7:30

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sekiguchi M, Suzuki H, Oda I, Abe S, Nonaka S, Yoshinaga S, Taniguchi H, Sekine S, Kushima R, Saito Y (2014) Risk of recurrent gastric cancer after endoscopic resection with a positive lateral margin. Endoscopy 46:273–278

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

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

Author information

Authors and Affiliations

  1. Division of Endoscopy, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, 411-8777, Japan

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

  2. Clinical Trial Coordination Office, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi, Sunto-gun, Shizuoka, Japan

    Keita Mori

Authors
  1. Masao Yoshida
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naomi Kakushima
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Keita Mori
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kimihiro Igarashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Noboru Kawata
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Masaki Tanaka
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Kohei Takizawa
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sayo Ito
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Kenichiro Imai
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Kinichi Hotta
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Hirotoshi Ishiwatari
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Hiroyuki Matsubayashi
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Hiroyuki Ono
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Naomi Kakushima.

Ethics declarations

Disclosures

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.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yoshida, M., Kakushima, N., Mori, K. et al. Learning curve and clinical outcome of gastric endoscopic submucosal dissection performed by trainee operators. Surg Endosc 31, 3614–3622 (2017). https://doi.org/10.1007/s00464-016-5393-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-016-5393-9

Keywords

Search

Navigation