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Learning curve of endoscopic submucosal dissection (ESD) with prevalence-based indication in unsupervised Western settings: a retrospective multicenter analysis

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Abstract

Background and aims

As there is still no consensus about the adequate training strategy for ESD in Western countries, we evaluated unsupervised prevalence-based learning curves including detailed organ-specific subgroup analysis.

Methods

The first 120 ESDs of four operators (n = 480) were divided into three groups (1: ESD 1–40, 2: ESD 41–80, 3: ESD 81–120). Outcome parameters were rates of technical success, en bloc and R0 resection, the resection speed, rates of conversion to EMR, curative resection, adverse events, surgery due to adverse events, and recurrence. In addition, we analyzed the achievement of quality benchmarks indicating levels of expertise.

Results

After exclusion of pretreated lesions, 438 procedures were enrolled in the final analysis. Technical success rates were > 96% with significant improvements regarding rate of en bloc resection (from 82.6 to 91.2%), resection speed (from 4.54 to 7.63 cm2/h), and rate of conversion to EMR (from 22.0 to 8.1%). No significant differences could be observed for rates of R0 resection (65.9 vs. 69.6%), curative resection (55.8 vs. 55.7%), adverse events (16.3 vs. 11.7%), surgery due to adverse events (1.5 vs. 1.3%), and recurrence (12.5 vs. 4.5%). Subgroup and benchmark analysis revealed an improvement in esophageal, gastric, and rectal ESD with achievement of competence levels for the esophagus and stomach within 80 and most of the benchmarks for proficiency level within 120 procedures. Some of the benchmarks could also be achieved in rectal ESD.

Conclusions

This trial confirms safety and feasibility of unsupervised ESD along the initial learning curve with prevalence-based indication and exclusion of colonic cases.

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Abbreviations

AE:

Adverse event

ASGE:

American Society for Gastrointestinal Endoscopy

CR:

Curative resection (of malignant lesions)

EBR:

En bloc resection

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

ESGE:

European Society of Gastrointestinal Endoscopy

FLD:

Franz Ludwig Dumoulin

HGIEN:

High-grade intraepithelial neoplasia

HPA:

Hans-Peter Allgaier

IS:

Ingo Steinbrück

LGIEN:

Low-grade intraepithelial neoplasia

MANEC:

Mixed adeno-neuroendocrine carcinoma

NET:

Neuroendocrine tumor

O:

Operator

RS:

Resection speed

SF:

Siegbert Faiss

SIN:

Squamous intraepithelial neoplasia

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Acknowledgements

The authors acknowledge the consultation of Dr. Erika Graf and Dr. Enya Weber from the Institute of Medical Biometrics and Statistics (University of Freiburg) for the statistical analysis.

Funding

No funding was received for this study.

Author information

Authors and Affiliations

  1. Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Freiburg, Germany

    Ingo Steinbrück & Hans-Peter Allgaier

  2. Department of Gastroenterology, Sana Klinikum Lichtenberg, Academic Teaching Hospital, University of Berlin, Berlin, Germany

    Siegbert Faiss

  3. Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany

    Franz Ludwig Dumoulin

  4. Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan

    Tsuneo Oyama

  5. Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital, University of Hamburg, Hamburg, Germany

    Jürgen Pohl

  6. Department of Gastroenterology, Hepatology and Endoscopy, Asklepios Klinik Barmbek, Academic Teaching Hospital, University of Hamburg, Hamburg, Germany

    Thomas von Hahn

  7. Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany

    Arthur Schmidt

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Correspondence to Ingo Steinbrück.

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Disclosures

Dr. Ingo Steinbrück, Prof. Dr. Siegbert Faiss, Prof. Dr. Tsuneo Oyama, and Prof. Dr. Hans-Peter Allgaier received lecture fees from Olympus Medical. Prof. Dr. Franz Ludwig Dumoulin received lecture fees from Falk and Olympus Medical. Prof. Dr. Thomas von Hahn received consulting and lecture fees from Olympus Medical. Prof. Dr. Jürgen Pohl and Prof. Dr. Arthur Schmidt have no conflicts of interest or financial ties to disclose.

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Supplementary file1 (JPG 226 kb) Fig. S1: Operator-specific development of case load

464_2022_9742_MOESM2_ESM.docx

Supplementary file2 (DOCX 16 kb) Table S1: Operator-specific Benchmark parameters for levels of expertise (X/blue bar= level achieved)

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Steinbrück, I., Faiss, S., Dumoulin, F.L. et al. Learning curve of endoscopic submucosal dissection (ESD) with prevalence-based indication in unsupervised Western settings: a retrospective multicenter analysis. Surg Endosc 37, 2574–2586 (2023). https://doi.org/10.1007/s00464-022-09742-5

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