ESD clinical tutoring

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ESD Tutoring Course concept

A supply network of ESD centers (>54 centers) across Europe now is on competent (>30 ESD) or professional level (>150 ESD), and 29 centers started ESD (Fig. 1B) – and at least 11 additional uninvolved ESD centers have published ESD series in Europe. Implementation of ESD – mainly in elderly often comorbid patients - was achieved with low risk mainly in colorectum (Fig. 2,3)(ref 1). Expert-guided training in live animals no longer is needed for starting clinical ESD by unsupervised self-learning (ref 2). Now, guidelines recommend to start clinical ESD (first ≤ 20 procedures) under supervision/tutoring by an ESD expert.

Published ESD series from Europe report similar en-bloc resection rates as in Japan (~85% vs ≥90%). However, curative resection rates have been on the average 15-20% lower in Europe than in Japan (60 – 70% vs. ~≥85%) (ref 2-4). Major factor was ESD on submucosal-invasive early cancer lesions (out of ESD indication) (ref 2). In conclusion, an effort is needed in Europe to improve the professional level of ESD centers (phase III - V, Fig. 1A) for reliable cure of patients (curative resection rate → ~ 85%).

Best format is a clinical training course for European ESD endoscopists tutored by Japanese ESD top experts:

  1. teaching assistance given by top Japanese expert to a local ESD endoscopist, as well as
  2. passive attendance of 4 ESD endoscopists during Endoscopic diagnosis and ESD procedure.

We have proven this „Clinical ESD Tutoring“ format on 118 lesions for difficult ESD (2011- 2015, Fig. 4 - 6) with excellent long-term outcome (9.8 [1.5–14.9] years) (ref. 5): Curative and En bloc resection rates of 88% and 95% with no recurrence after R0 resections. Long-term survival remained recurrence-free after endoscopic resection of 3 recurrent adenomas (at R1/Rx) and curative surgery /2nd ESD for 5 non-curative ESD. Adverse events (9.3%) occurred without emergency surgery or 30-day mortality. Trainees correctly applied curative ESD indications in 94% of all ESDs. Experts (28 ESD) resected larger lesions (22 cm²) at 9.3 cm²/h in 121 minutes. Tutored beginners (90 ESD) achieved a 75% [25–100%] self-completion on 33% smaller lesions in 112 min during routine treatment (duration ≤ 3 h) of difficult lesions (ref. 5).

Aims for the

  • COURSE (2-3 days), training of European ESD endoscopists (in phase III - V of Fig. 1) for ESD performance on professional level - both for a) endoscopic indication i.e. prediction of pT category (major factor!) and b) endosurgical skills on challenging lesions.
  • UPDATE (optional, 4th day), ESD LIVE demonstrations to additional endoscopists for ESD indication & performance.

This COURSE MODEL may promote networks of Early GI Cancer centers on professional performance in Europe.

Report of the first ESD tutoring course in Munich 2019
Fig. 4. Distribution of reference centers with participating ESD-implementing endoscopists. Patient referring active trainees n= 11 (RED), non-referring active trainees n= 11 (YELLOW), passive participants n= 36 (BLUE) with clinical ESD experience, from 15 countries including from Sydney/Australia, and Wellington/ New Zealand (ref.5).
Fig. 5. Modified ESD Difficulty Score. Colorectal ESD difficulty score (ref.6), in exploratory fashion extended to the upper GI tract based on the same scoring items and unfavorable anatomical locations as modified. In colorectum the score predicts difficulty of a planned ESD procedure and correlates best with duration time of ESD.
Fig. 6. Distribution of ESD-ITT in difficult sites and correlation of duration with difficulty score of ESD (ref.5).
a. Anatomic sites with increased difficulty score (dotted line = +1 point, solid lines = +2 points) for colorectum ), and in exploratory modification for the upper GI tract. Numbers give the number of ESD-ITT performed in these sites, i.e. in sum 50% of all ESD-ITT. Graphs on right panel show the duration (min) of ESD-ITT plotted for the ESD difficulty score of the lesion & location, b. for the validated Score of Li in the colorectum, and c. for the score modified for the upper GI tract (compare Fig. 5), where duration correlates as strong (R = 0.550, P<0.00001) with the score as in colorectum (R = 0.515, P<0001). Note the different icons for ESD-ITT procedures: ESD en bloc; h-ESD en bloc R0; h-ESD Rx (Nov. 2009); EID & pmEMR for rectum LST-GM; ESD & EID at cardia (score 6), and STER & EID for esophageal leiomyoma score 4).