Implementation of endoscopic submucosal dissection in Europe: survey after 10 ESD Expert Training Workshops, 2009 to...

Adoption of the endoscopic submucosal dissection (ESD) technique for early GI cancer from Japan requires expert-supervised experimental training before unsupervised implementation of clinical ESD. The aim of this study was to evaluate unsupervised implementation of ESD intention-to-treat (ie, any resection planned and started as en bloc ESD).

ESD workshops (in vivo porcine model) lasted 3.3 days, including a 1-day theory seminar, for 177 participants from 135 Western referral centers. A questionnaire was sent to the senior participant of all 135 centers. This cross-sectional questionnaire survey included main outcome measurements such as performance, organ distribution, and severe adverse events of ESD intention-to-treat.

Feedback was received from 113 centers (84%): 73 (54%) ESD centers and 40 centers (30%) with zero ESDs. Ten (7%) had published ESDs; no feedback was received from 12 (9%) centers with unknown status. Altogether, 83 centers (61.5%) performed ESDs: 21 (16%) had >150 ESDs (professional category), 33 (24%) had 31 to 150 ESDs (competent category), and 29 (21.5%) had ≤30 ESDs (initial learning category). Most implemented ESD centers (91% [72 of 79]) were analyzed: centers on initial learning (420 ESD) compared with centers with >30 ESDs (5676 ESDs) performed en bloc ESDs in 64% versus 84%, hybrid ESD in 26% versus 11%, and piecemeal EMR in 10% versus 5.2%. The majority of ESDs (66%-68%) performed were in the colorectum, with a low risk overall (30-day mortality, 0.03%; surgical repair, 3.5% vs 1.7%) and satisfactory outcome (oncosurgery, 7.4% vs 5.2%; local recurrence, 1.5% vs 0.3%).

Beyond guideline recommendations, unsupervised implementation of ESD was successful in the colorectum with a step-up approach. Western ESD centers must now aim for professional (ie, >80%) curative ESD.