Training in endoscopic submucosal dissection from a Western perspective

Abstract

Endoscopic submucosal dissection (ESD) is a mature endoscopic procedure that was developed in Japan to enable the en bloc, curative resection of superficial dysplastic lesions in the luminal gastrointestinal tract that have a low risk of lymph node metastasis. ESD requires a cognitive understanding of endosurgical principles, the ability to apply advanced optical imaging techniques to diagnose and stage lesions, and a high degree of endoscopic skill. Training in ESD should ideally begin with small lesions in the distal stomach, but such an approach is not applicable to endoscopists who are trying to learn and perform ESD in Western countries; as such, a “prevalence-based approach” is required that might vary from country to country. Proposed thresholds for attaining and maintaining competence in ESD, particularly for Western endoscopists, include rates of en bloc resection ≥80% and adverse events ≤10%. Endoscopists skilled in ESD should achieve rates of en bloc resection ≥90% and adverse events ≤5%. In order to offer ESD on a national level, a critical mass of endoscopists proficient in ESD is required who can then establish regional or national training centers and teach others with the requisite endoscopic skill and experience how to perform this elegant procedure. In the United States, ESD-specific billing codes are required to defray the procedural cost for endoscopy centers and health systems and to adequately compensate those endoscopists who offer this procedure as a life-saving alternative to more invasive surgical resection.