Usefulness of training using animal models for colorectal endoscopic submucosal dissection: is experience performing gastric ESD really needed?

 

 Buy Article Permissions and Reprints

Background and study aims: Despite the clinical advantages of colorectal endoscopic submucosal dissection (ESD), an effective training system, especially for Western endoscopists, has been challenging to establish. Herein, we propose a novel training program using ex vivo animal models and evaluate the learning curve of colorectal ESD trainees without gastric ESD experience.

Patients and methods: A total of 80 colorectal lesions were prospectively collected and removed by two novice operators. Before human ESD procedures, they received ESD training using an ex vivo porcine “proximal colon” model, which simulates a lumen with many folds and flexions. To assess the validity of our training system, the self-completion and en bloc R0 resection rates, the operation time, and prevalence of complications were compared between the first and latter period. Moreover the factors associated with prolonged operation time were evaluated.

Results: The overall rates of self-completion and en bloc R0 resection were 98 % (78/80) and 100 % (80/80), respectively. The operation time during the first period was significantly longer than that during the latter period (86 ± 50 minutes vs. 60 ± 36 minutes, P = 0.01). Regarding complications, only two cases of perforations and delayed hemorrhage were observed during the first period; however, all of the complications were successfully managed endoscopically. The presence of fibrosis was identified as a significant independent predictor of a prolonged operation time during the first period (coefficient, 5.90; 95 %CI, 2.36 – 9.44, P = 0.002).

Conclusions: Our trainees achieved high rates of self-completion and R0 resection without severe complications even during the first 20 cases, suggesting that our training programs using ex vivo animal models are useful for trainees without gastric ESD experience.

Study registration: UMIN000013566

• References

• 1 Siegel R, Desantis C, Jemal A. Colorectal cancer statistics, 2014. CA Cancer J Clin 2014; 64: 104-117
  CrossrefPubMedGoogle Scholar
• 2 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. New Engl J Med 1993; 329: 1977-1981
  CrossrefPubMedGoogle Scholar
• 3 Watanabe T, Itabashi M, Shimada Y et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for the treatment of colorectal cancer. Int J Clin Oncol 2012; 17: 1-29
  CrossrefPubMedGoogle Scholar
• 4 Kudo S, Kashida H, Nakajima T et al. Endoscopic diagnosis and treatment of early colorectal cancer. World J Surg 1997; 21: 694-701
  CrossrefPubMedGoogle Scholar
• 5 Sakai E, Ohata K, Chiba H et al. Methylation epigenotypes and genetic features in colorectal laterally spreading tumors. Int J Cancer 2014; 135: 1586-1595
  CrossrefPubMedGoogle Scholar
• 6 Soetikno R, Friedland S, Kaltenbach T et al. Nonpolypoid (flat and depressed) colorectal neoplasms. Gastroenterology 2006; 130: 566-576
  CrossrefPubMedGoogle Scholar
• 7 O'Brien MJ, Winawer SJ, Zauber AG et al. Flat adenomas in the National Polyp Study: is there increased risk for high-grade dysplasia initially or during surveillance?. Clin Gastroenterol Hepatol 2004; 2: 905-911
  CrossrefPubMedGoogle Scholar
• 8 Terasaki M, Tanaka S, Oka S et al. Clinical outcomes of endoscopic submucosal dissection and endoscopic mucosal resection for laterally spreading tumors larger than 20 mm. J Gastroenterol Hepatol 2012; 27: 734-740
  CrossrefPubMedGoogle Scholar
• 9 Fujishiro M, Yahagi N, Kakushima N et al. Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol 2007; 5: 678-683
  CrossrefPubMedGoogle Scholar
• 10 Ohata K, Nonaka K, Minato Y et al. Endoscopic submucosal dissection for large colorectal tumor in a Japanese general hospital. J Oncol 2013; 2013: 218670
  PubMedGoogle Scholar
• 11 Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 2006; 41: 929-942
  CrossrefPubMedGoogle Scholar
• 12 Cao Y, Liao C, Tan A et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Chiba H, Ohata K, Ohno A et al. Perforation with retroperitoneal emphysema after endoscopic submucosal dissection for a rectal carcinoid tumor. Endoscopy 2010; 42: E85-E86
  Article in Thieme ConnectPubMedGoogle Scholar
• 14 Probst A, Golger D, Anthuber M et al. Endoscopic submucosal dissection in large sessile lesions of the rectosigmoid: learning curve in a European center. Endoscopy 2012; 44: 660-667
  Article in Thieme ConnectPubMedGoogle Scholar
• 15 Hotta K, Oyama T, Shinohara T et al. Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc 2010; 22: 302-306
  CrossrefPubMedGoogle Scholar
• 16 Iacopini F, Bella A, Costamagna G et al. Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves. Gastrointest Endosc 2012; 76: 1188-1196
  CrossrefPubMedGoogle Scholar
• 17 Ohata K, Ito T, Chiba H et al. Effective training system in colorectal endoscopic submucosal dissection. Dig Endosc 2012; 24: 84-89
  CrossrefPubMedGoogle Scholar
• 18 Sakamoto T, Sato C, Makazu M et al. Short-term outcomes of colorectal endoscopic submucosal dissection performed by trainees. Digestion 2014; 89: 37-42
  CrossrefPubMedGoogle Scholar
• 19 Shiga H, Endo K, Kuroha M et al. Endoscopic submucosal dissection for colorectal neoplasia during the clinical learning curve. Surg Endosc 2014; 28: 2120-2128
  CrossrefPubMedGoogle Scholar
• 20 Fock KM. Review article: the epidemiology and prevention of gastric cancer. Aliment Pharmacol Ther 2014; 40: 250-260
  CrossrefPubMedGoogle Scholar
• 21 Ohya T, Ohata K, Sumiyama K et al. Balloon overtube-guided colorectal endoscopic submucosal dissection. World J Gastroenterol 2009; 15: 6086-6090
  CrossrefPubMedGoogle Scholar
• 22 Tanaka S, Oka S, Kaneko I et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 2007; 66: 100-107
  CrossrefPubMedGoogle Scholar
• 23 Hon SS, Ng SS, Lee JF et al. In vitro porcine training model for colonic endoscopic submucosal dissection: an inexpensive and safe way to acquire a complex endoscopic technique. Surg Endosc 2010; 24: 2439-2443
  CrossrefPubMedGoogle Scholar
• 24 Parra-Blanco A, Arnau MR, Nicolas-Perez D et al. Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol 2010; 16: 2895-2900
  CrossrefPubMedGoogle Scholar
• 25 Draganov PV, Chang M, Coman RM et al. Role of observation of live cases done by Japanese experts in the acquisition of ESD skills by a western endoscopist. World J Gastroenterol 2014; 20: 4675-4680
  CrossrefPubMedGoogle Scholar
• 26 Lee EJ, Lee JB, Lee SH et al. Endoscopic treatment of large colorectal tumors: comparison of endoscopic mucosal resection, endoscopic mucosal resection-precutting, and endoscopic submucosal dissection. Surg Endosc 2012; 26: 2220-2230
  CrossrefPubMedGoogle Scholar
• 27 Nishiyama H, Isomoto H, Yamaguchi N et al. Endoscopic submucosal dissection for laterally spreading tumours of the colorectum in 200 consecutive cases. Surg Endosc 2010; 24: 2881-2887
  CrossrefPubMedGoogle Scholar
• 28 Saito Y, Uraoka T, Yamaguchi Y et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
  CrossrefPubMedGoogle Scholar
• 29 Lee SP, Kim JH, Sung IK et al. Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: Pathologic review of 173 cases. J Gastroenterol Hepatol 2015; 30: 872-878
  CrossrefPubMedGoogle Scholar
• 30 Conlin A, Kaltenbach T, Kusano C et al. Endoscopic resection of gastrointestinal lesions: advancement in the application of endoscopic submucosal dissection. J Gastroenterol Hepatol 2010; 25: 1348-1357
  PubMedGoogle Scholar