Impact of formal training in endoscopic submucosal dissection for early gastrointestinal cancer: A systematic review and a meta-analysis.

AIM: To summarize the clinical impact of a formal training for the effectiveness and safety of endoscopic submucosal dissection for gastrointestinal cancer. METHODS: We searched databases including PubMed, EMBASE and the Cochrane Library and Science citation Index updated to August 2014 to include eligible articles. In the Meta-analysis, the main outcome measurements were en bloc resection rate, local recurrence rate (R0) and the incidence of procedure-related complications (perforation, bleeding). RESULTS: En bloc resection was high for both, dissecting stomach tumors with an overall percentage of 93.2% (95%CI: 90.5-95.8) and dissecting colorectal tumors with an overall percentage of 89.4% (95%CI: 85.1-93.7). Although the number of studies reporting R0 resection (the dissected specimen was revealed free of tumor in both vertical and lateral margins) was small, the overall estimates for R0 resection were 81.4% (95%CI: 72-90.8) for stomach and 85.9% (95%CI: 77.5-95.5) for colorectal tumors, respectively. The analysis showed that the percentage of immediate perforation and bleeding were very low; 4.96 (95%CI: 3.6-6.3) and 1.4% (95%CI: 0.8-1.9) for colorectal tumors and 3.1% (95%CI: 2.0-4.1) and 4.8% (95%CI: 2.8-6.7) for stomach tumors, respectively. CONCLUSION: In order to obtain the same rate of success of the analyzed studies it is a necessity to create training centers in the western countries during the "several years" of gastroenterology residence first only to teach EGC diagnose and second only to train endoscopic submucosal dissection.

Learning curve in a Western training center of the circumferential en bloc esophageal endoscopic submucosal dissection in an in vivo animal model.

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.

Endoscopic submucosal dissection in dogs in a World Gastroenterology Organisation training center.

AIM: To evaluate if canine models are appropriate for teaching endoscopy fellows the techniques of endoscopic submucosal dissection (ESD). METHODS: ESD was performed in 10 canine models under general anesthesia, on artificial lesions of the esophagus or stomach marked with coagulation points. After ESD, each canine model was euthanized and surgical resection of the esophagus or stomach was carried out according to "The Principles of Humane Experimental Technique, Russel and Burch". The ESD specimens were fixed with needles on cork submerged in a formol solution with the esophagus or stomach, and delivered to the pathology department to be analyzed. RESULTS: ESD was completed without complications using the Hook-knife in five esophageal areas, with a procedural duration of 124 +/- 19 min, a length of 27.4 +/- 2.6 mm and a width of 21 +/- 2.4 mm. ESD was also completed without complications using the IT-knife2 in five gastric areas, with a procedural duration of 92.6 +/- 19 min, a length of 32 +/- 2.5 mm and a width of 18 +/- 3.7 mm. CONCLUSION: ESD is feasible in the normal esophagus and stomach of canine models, which are appropriate for teaching this technique.

[Chromoendoscopy]. / Cromoendoscopia.

Accurate detection of premalignant lesions and early cancers in the gastrointestinal tract is essential for curative endoscopic or surgical therapy, because prognosis of the affected patients is closely related to the size and stage of the neoplastic lesion. Recently, it has emerged new endoscopic devices that allow even cellular images in vivo during an endoscopic procedure. These technologies will change and improve endoscopic diagnosis. The combination and integration of different technologies in a multifunctional endoscope will offer new optical features in GI endoscopy. Cytoendoscopy will characterize the surface architecture, confocal laser endomicroscopy will immediately clarify the nature of the lesions by in vivo histology of the mucosal layer, and optical coherence tomography will accurately grade the invasion depth. It will need some additional time before this scenario comes true. Endoscopy will become more complex due to the new visible details. Education and training will play an important future role in GI endoscopy. However, it is not possible to use these novel technologies without before learn to identify early GI cancers lesions. Meanwhile these technologies are perfectionated and we overcome the learning curve to identify early GI lesions, chromoendoscopy will continue to be a safe, easy and inexpensive method.