Learning Curve in a Western Training Center of the Circumferential En Bloc Esophageal Endoscopic Submucosal Dissection in an In Vivo Animal Model

Gastroenterology Department, World Gastroenterology Organisation Training Center, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga No. 15, Colonia Seccion XVI, Delegacion Tlalpan, 14000 Mexico City, DF, Mexico.
Diagnostic and Therapeutic Endoscopy 10/2011; 2011(2):847831. DOI: 10.1155/2011/847831
Source: PubMed


Aim. Evaluate the feasibility to overcome the learning curve in a western training center of the en bloc circumferential esophageal (ECE-) ESD in an in vivo animal model. Methods. ECE-ESD was performed on ten canine models under general anesthesia on artificial lesions at the esophagus marked with coagulation points. After the ESD each canine model was euthanized and surgical resection of the esophagus and stomach was carried out according to “the Principles of Humane Experimental Technique, Russel and Burch.” The specimen was fixed with needles on cork submerged in formalin with the esophagus and stomach then delivered to the pathology department to be analyzed.
Results. ECE-ESD was completed without complications in the last 3/10 animal models. Mean duration for the procedures was 192 ± 35 minutes (range 140–235 minutes). All the procedures were done at the animal lab surgery room with cardio pulmonary monitoring and artificial ventilation by staff surgery members and a staff member of the Gastroenterology department trained during 1999–2001 at the Fujigaoka hospital of the Showa U. in Yokohama, Japan, length (range 15–18 mm) and 51 ± 6.99 width (range 40–60 mm). Conclusion. ECE-ESD training is feasible in canine models for postgraduate endoscopy fellows.

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    • "An endoscopist with previous training in an important endoscopy teaching center in Japan performed gastric ESDs in mongrel dogs that weighed 18 to 20 kg, either with a Hook knife or an IT-knife, successfully, and without any complications. The same group proved the feasibility of a similar canine model to train in circumferential esophageal ESD.23 Moreover, a learning curve was proven, as perforations occurred in the initial seven cases, whereas the last three cases were completed uneventfully. "
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    ABSTRACT: Endoscopic submucosal dissection is a technically challenging but highly effective technique for the treatment of well selected early neoplasms in the digestive tract. Although it is frequently performed in East Asian countries, the Western world has not adopted this technique yet, probably due in part to the difficulty to learn it. Ex vivo and in vivo animal models are invaluable tools to overcome at least the beginning of the learning curve, although the initial step is the acquisition of basic knowledge about early diagnosis of neoplasias, and observing real procedures in expert centers. The practical issues, advantages, and disadvantages of the ex vivo and in vivo models are discussed.
    Clinical Endoscopy 11/2012; 45(4):350-7. DOI:10.5946/ce.2012.45.4.350
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    • "The initial performances of ESD were associated with a high incidence of complications, the risk of which not dependent on previous experience in endoscopy.5 In other report of esophageal ESD using live canine models, perforation occurred in the first seven of 10 cases; the last three case were successful.6 Another study using the porcine model for gastric and esophageal ESD reported no serious complications such as perforation or major bleeding in 22 cases (esophagus 7, stomach 15) of ESD performed in six live pigs.2 "
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    ABSTRACT: Endoscopic submucosal dissection (ESD) is an established treatment for gastric neoplasias especially in regions with a high volume of gastric cancer. Although ESD has many advantages over endoscopic mucosal resection, ESD is technically more difficult and can result in severe complications. Therefore establishment of an effective training system is required to help endoscopists climb the ESD learning curve. Although a standard training system for ESD remains to be established, some centers are incorporating ex vivo and/or in vivo animal models to provide a safe and effective means of ESD training. However, it is unknown if these animal models are more effective than other programs. Moreover the efficacy of the animal model may vary according to socio-economic status and the volume of gastric cancer. In this article we introduce the basic and advanced ESD training model using the ex vivo and in vivo animal model from South Korea and review the associated literature from other regions.
    Clinical Endoscopy 11/2012; 45(4):358-61. DOI:10.5946/ce.2012.45.4.358
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    ABSTRACT: Introduction: Endoscopic submucosal dissection (ESD) has become a standard therapy for early gastric neoplasia, particularly in Asian countries. From a safety and efficacy standpoint, simulation training may empower the endoscopist to be able to learn the basic tenets of ESD in a safe, controlled and supervised setting before attempting first in humans. Methods and procedures: This study was designed as a prospective ex vivo study. Ex vivo porcine organs were utilized in the EASIE-R endoscopic simulator. A total of 150 artificial lesions, each 2 × 2 cm in size, were created in fresh ex vivo porcine stomachs at six different anatomical sites (fundus anterior and posterior, body anterior and posterior, antrum anterior and posterior). Three examiners (2 beginners, 1 expert) participated in this study. All parameters (procedure time, specimen size, en-bloc resection status, perforation) were recorded by an independent observer for each procedure. Results: All 150 lesions were successfully resected using the ESD technique by the three endoscopists. After 30 ESD cases, the two novices performed ESD with a 100% en-bloc resection rate and without perforation. For the procedures performed by the novices, the total procedure time and perforation rate in the last 30 cases were significantly lower than during the first 30 cases (p < 0.05). Conclusions: Our study suggests that performing 30 ESD resections in an ex vivo simulator leads to a significant improvement in safety and efficiency of performing the ESD technique.
    Surgical Endoscopy 07/2012; 27(1). DOI:10.1007/s00464-012-2402-5 · 3.26 Impact Factor
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