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Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD

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Abstract

Background

Endoscopic submucosal dissection (ESD) for various colorectal neoplasms is more technically difficult than gastric ESD. We evaluated treatment outcomes and the learning curve for colorectal ESD of laterally spreading tumors (LSTs) based on the experience of a single endoscopist.

Methods

We included 93 colorectal ESD procedures for colorectal LST that were performed between March 2009 and June 2012 by a single experienced endoscopist who previously performed hundreds of cases of gastric ESD. The cases were grouped chronologically into three periods by multi-dimensional analyses. For procedure time, the learning curve was analyzed using the moving average method, and for complication, the learning curve was analyzed using cumulative sum (cusum) method.

Results

The median procedure time for 93 colorectal ESD was 45 min, and the rates of en bloc resection and R0 resection were 89.25 and 83.87 %. When results were compared among three periods in order to determine the learning curve, the procedure time and en bloc resection rates were not significantly different. However, the procedure proficiency (about 0.16 cm2/min) was significantly faster during the second period, after about 25 cases of colorectal ESD. In the third period (about 50 cases), the number and rate of en bloc resection (over 90 %) reached the same as that of en bloc R0 resection. When comparing outcomes based on LST subtype, the procedure proficiency of LST-granular type (LST-G) was significantly faster than that of LST-non granular type (LST-NG) (LST-NG, 0.072 cm2/min; LST-G, 0.157 cm2/min; p = 0.01).

Conclusion

Endoscopists fully experienced in gastric ESD need a relatively short learning period for colorectal ESD in terms of procedure time and complication. However, approximately 50 cases might be needed to acquire an adequate skill of colorectal ESD for LST in an experienced gastric ESD endoscopist. Colorectal ESD for LST-NG seems to have higher technical difficulty and a longer learning curve than LST-G.

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References

  1. Uraoka T, Kawahara Y, Kato J, Saito Y, Yamamoto K (2009) Endoscopic submucosal dissection in the colorectum: present status and future prospects. Dig Endosc 21(Suppl 1):S13–S16

    Article  PubMed  Google Scholar 

  2. Tanaka S, Oka S, Kaneko I, Hirata M, Mouri R, Kanao H, Yoshida S, Chayama K (2007) Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization. Gastrointest Endosc 66(1):100–107

    Article  PubMed  Google Scholar 

  3. Saito Y, Sakamoto T, Fukunaga S, Nakajima T, Kiriyama S, Matsuda T (2009) Endoscopic submucosal dissection (ESD) for colorectal tumors. Dig Endosc 21(Suppl 1):S7–S12

    Article  PubMed  Google Scholar 

  4. Kudo S (1993) Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 25(7):455–461

    Article  CAS  PubMed  Google Scholar 

  5. Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H, Watanabe H (1996) Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc 44(1):8–14

    Article  CAS  PubMed  Google Scholar 

  6. (2003) The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 58(6 Suppl):S3–S43

  7. Rembacken BJ, Fujii T, Cairns A, Dixon MF, Yoshida S, Chalmers DM, Axon AT (2000) Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK. Lancet 355(9211):1211–1214

    Article  CAS  PubMed  Google Scholar 

  8. Tsuda S, Veress B, Toth E, Fork FT (2002) Flat and depressed colorectal tumours in a southern Swedish population: a prospective chromoendoscopic and histopathological study. Gut 51(4):550–555

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Tanaka S, Haruma K, Oka S, Takahashi R, Kunihiro M, Kitadai Y, Yoshihara M, Shimamoto F, Chayama K (2001) Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest Endosc 54(1):62–66

    Article  CAS  PubMed  Google Scholar 

  10. Saito Y, Fujii T, Kondo H, Mukai H, Yokota T, Kozu T, Saito D (2001) Endoscopic treatment for laterally spreading tumors in the colon. Endoscopy 33(8):682–686

    Article  CAS  PubMed  Google Scholar 

  11. Tamura S, Nakajo K, Yokoyama Y, Ohkawauchi K, Yamada T, Higashidani Y, Miyamoto T, Ueta H, Onishi S (2004) Evaluation of endoscopic mucosal resection for laterally spreading rectal tumors. Endoscopy 36(4):306–312

    Article  CAS  PubMed  Google Scholar 

  12. Saito Y, Kawano H, Takeuchi Y, Ohata K, Oka S, Hotta K, Okamoto K, Homma K, Uraoka T, Hisabe T, Chang DK, Zhou PH (2012) Current status of colorectal endoscopic submucosal dissection in Japan and other Asian countries: progressing towards technical standardization. Dig Endosc 24(Suppl 1):67–72

    Article  PubMed  Google Scholar 

  13. Kakushima N, Fujishiro M, Kodashima S, Muraki Y, Tateishi A, Omata M (2006) A learning curve for endoscopic submucosal dissection of gastric epithelial neoplasms. Endoscopy 38(10):991–995

    Article  CAS  PubMed  Google Scholar 

  14. Yamamoto S, Uedo N, Ishihara R, Kajimoto N, Ogiyama H, Fukushima Y, Yamamoto S, Takeuchi Y, Higashino K, Iishi H, Tatsuta M (2009) Endoscopic submucosal dissection for early gastric cancer performed by supervised residents: assessment of feasibility and learning curve. Endoscopy 41(11):923–928

    Article  PubMed  Google Scholar 

  15. Probst A, Pommer B, Golger D, Anthuber M, Arnholdt H, Messmann H (2010) Endoscopic submucosal dissection in gastric neoplasia—experience from a European center. Endoscopy 42(12):1037–1044

    Article  CAS  PubMed  Google Scholar 

  16. Hong KH, Shin SJ, Kim JH (2014) Learning curve for endoscopic submucosal dissection of gastric neoplasms. Eur J Gastroenterol Hepatol 26(9):949–954

    Article  PubMed  Google Scholar 

  17. Hotta K, Oyama T, Shinohara T, Miyata Y, Takahashi A, Kitamura Y, Tomori A (2010) Learning curve for endoscopic submucosal dissection of large colorectal tumors. Dig Endosc 22(4):302–306

    Article  PubMed  Google Scholar 

  18. Sakamoto T, Saito Y, Fukunaga S, Nakajima T, Matsuda T (2011) Learning curve associated with colorectal endoscopic submucosal dissection for endoscopists experienced in gastric endoscopic submucosal dissection. Dis Colon Rectum 54(10):1307–1312

    Article  PubMed  Google Scholar 

  19. Saito Y, Uraoka T, Yamaguchi Y, Hotta K, Sakamoto N, Ikematsu H, Fukuzawa M, Kobayashi N, Nasu J, Michida T, Yoshida S, Ikehara H, Otake Y, Nakajima T, Matsuda T, Saito D (2010) A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 72(6):1217–1225

    Article  PubMed  Google Scholar 

  20. Tamegai Y, Saito Y, Masaki N, Hinohara C, Oshima T, Kogure E, Liu Y, Uemura N, Saito K (2007) Endoscopic submucosal dissection: a safe technique for colorectal tumors. Endoscopy 39(5):418–422

    Article  CAS  PubMed  Google Scholar 

  21. Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Yamamichi N, Tateishi A, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2007) Outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms in 200 consecutive cases. Clin Gastroenterol Hepatol 5(6):678–683 (quiz 645)

    Article  PubMed  Google Scholar 

  22. Saito Y, Uraoka T, Matsuda T, Emura F, Ikehara H, Mashimo Y, Kikuchi T, Fu KI, Sano Y, Saito D (2007) Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest Endosc 66(5):966–973

    Article  PubMed  Google Scholar 

  23. Hurlstone DP, Atkinson R, Sanders DS, Thomson M, Cross SS, Brown S (2007) Achieving R0 resection in the colorectum using endoscopic submucosal dissection. Br J Surg 94(12):1536–1542

    Article  CAS  PubMed  Google Scholar 

  24. Uraoka T, Saito Y, Matsuda T, Ikehara H, Gotoda T, Saito D, Fujii T (2006) Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 55(11):1592–1597

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Division of Gastroenterology, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Ilsan, Korea

    Han Ho Jeon

  2. Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea

    Hye Sun Lee

  3. Division of Gastroenterolgy, Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 135-720, Korea

    Young Hoon Youn, Jae Joon Park & Hyojin Park

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  1. Han Ho Jeon
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  2. Hye Sun Lee
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Correspondence to Young Hoon Youn.

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Disclosures

Han Ho Jeon, Hye Sun Lee, Young Hoon Youn, Jae Joon Park and Hyojin Park have no conflicts of interest of financial ties to disclose.

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Jeon, H.H., Lee, H.S., Youn, Y.H. et al. Learning curve analysis of colorectal endoscopic submucosal dissection (ESD) for laterally spreading tumors by endoscopists experienced in gastric ESD. Surg Endosc 30, 2422–2430 (2016). https://doi.org/10.1007/s00464-015-4493-2

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  • DOI: https://doi.org/10.1007/s00464-015-4493-2

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