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Learning curve analysis for duodenal endoscopic submucosal dissection: A single-operator experience.

Yuichiro Ozeki¹, Kingo Hirasawa¹, Atsushi Sawada¹

¹Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan.

Journal of Gastroenterology and Hepatology

|September 6, 2022

Summary

Achieving proficiency in duodenal endoscopic submucosal dissection (ESD) requires approximately 25 cases, with mastery reached around 50 cases, even for experienced endoscopists. This learning curve analysis informs training for duodenal ESD procedures.

Keywords:

Cumulative sum analysis Duodenal neoplasms Endoscopic submucosal dissection Learning curve Retrospective studies

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Area of Science:

Gastroenterology
Endoscopy
Surgical Education

Background:

Superficial duodenal tumors are increasingly treated with endoscopic submucosal dissection (ESD).
The learning curve for duodenal ESD is not well-defined.
Competence acquisition in duodenal ESD needs elucidation.

Purpose of the Study:

To determine the learning curve for duodenal endoscopic submucosal dissection (ESD).
To define the number of cases required for an endoscopist with prior non-duodenal ESD experience to achieve proficiency and mastery in duodenal ESD.

Main Methods:

Retrospective observational study of 100 consecutive duodenal ESD cases by a single endoscopist.
Cumulative sum (CUSUM) curve analysis to assess procedural speed and identify learning phases.
Comparative analysis of procedural outcomes across identified learning phases.

Main Results:

Four phases identified: learning (1-25), proficiency (26-47), mastery (48-72), and post-anesthesia (73-98).
Procedural speed significantly increased from the learning to proficiency phase (7.0 mm²/min vs 11.1 mm²/min).
Perforation rates decreased progressively through proficiency, mastery, and post-anesthesia phases, with delayed perforations only in early phases.

Conclusions:

Duodenal ESD requires approximately 25 cases to achieve proficiency.
Around 50 cases are needed to attain mastery in duodenal ESD.
These benchmarks apply even to endoscopists with substantial experience in non-duodenal ESD.