LEARNING CURVE IN ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION BY WESTERN ENDOSCOSPISTS TRAINED IN JAPAN: EXPERIENCE IN LATIN AMERICA

ALIAGA RAMOS, Josué; YOSHIDA, Naohisa; ABDUL RANI, Rafiz; ARANTES, Vitor N

doi:10.1590/S0004-2803.20230222-168

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ORIGINAL ARTICLE • Arq. Gastroenterol. 60 (2) • Apr-Jun 2023 • https://doi.org/10.1590/S0004-2803.20230222-168 copy

LEARNING CURVE IN ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION BY WESTERN ENDOSCOSPISTS TRAINED IN JAPAN: EXPERIENCE IN LATIN AMERICA

Curva de aprendizagem de dissecção endoscópica de submucosa por endoscopistas ocidentais treinados no Japão: Experiência na América Latina

Authorship SCIMAGO INSTITUTIONS RANKINGS

HIGLIGHTS

•This study aimed to assess the learning curve effect on patient’s clinical outcome for EESD. Retrospective observational study, enrolling patients that underwent EESD from 2009 to 2021, divided in 2 groups. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). The learning curve in esophageal ESD could be overcomed effectively and safely by an adequately trained Western endoscopist.

ABSTRACT

Background:

Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists.

Objective:

This study aimed to assess the learning curve effect on patient’s clinical outcome for EESD.

Methods:

This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate.

Results:

Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%.

Conclusion:

The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.

Keywords:
Endoscopic submucosal dissection; learning curve; superficial esophageal neoplasms

	First period	Second period	P-value
	(n=49)	(n=49)
Patient factors
Age (years)	64 (37-86)	61.6 (32-82)	0.142
Sex (male/female)	31/9	25/14	0.132
Tumor factors
Location at upper esophagus	5 (10.2%)	12 (24.4%)	0.062
Involving >3/4 circumference	11 (22.4%)	16 (32.6%)	0.258

	First period	Second period	P-value
	(n=49)	(n=49)
Tumor size (mm)	34.1 (10-100)	32.7 (12-60)	0.234
Mean procedure time (min.)	111.8 (40-230)	103.6 (20-240)	0.004
En bloc resection	46 (93.8%)	48 (97.9%)	0.307
Complete (R0 resection)	39 (79.5%)	42 (85.7%)	0.424
Curative resection	32 (65.3%)	35 (71.4%)	0.258
Complications
Perforation	2 (4%)	1 (2%)	0.558
Bleeding	1 (2%)	0 (0%)	0.315

List of cases	Criteria of Incomplete and Piecemeal resection	Management plan	Possible factors for difficult ESD	Period
Case 3	SCC with compromise of lateral margins (converted to piecemeal)	Follow-up endoscopy	-	T1
Case 5	Adenocarcinoma with compromise of lateral margins + compromised deep margin	Follow-up endoscopy	-	T1
Case 6	SCC undifferentiated with compromise of lateral margins (converted to piecemeal)	Follow-up endoscopy	-	T1
Case 8	SCC with compromise of lateral margins	Follow-up endoscopy	Location at upper esophagus	T1
Case 12	Adenocarcinoma with SM2 invasion (1500 μ) + compromise of deep margin + compromise of lateral margins	Esophagectomy	-	T1
Case 23	SCC with compromise of lateral margins	Chemoradiotherapy	-	T1
Case 24	SCC with compromise of lateral margins	Follow-up endoscopy	-	T1
Case 40	SCC with compromise of lateral margins	Follow-up endoscopy	Tumor >3/4 circumference	T1
Case 42	Adenocarcinoma with SM2 invasion + lymphatic/vascular invasión + compromised deep margin + compromise of lateral margins	Chemoradiotherapy	-	T1
Case 49	SCC with compromise of lateral margins (converted to piecemeal)	Follow-up endoscopy	Tumor >3/4 circumference	T1
Case 52	HGD with compromise of lateral margins	Follow-up endoscopy	Location at upper esophagus	T2
Case 58	HGD with compromise of lateral margins	Follow-up endoscopy	Tumor >3/4 circumference	T2
Case 59	SCC with compromise of lateral margins	Follow-up endoscopy	Tumor >3/4 circumference	T2
Case 70	SCC undifferentiated with SM2 invasion + compromise of lateral margins	Esophagectomy	Tumor >3/4 circumference	T2
Case 72	SCC with compromise of lateral margins (converted to piecemeal)	Chemoradiotherapy	Tumor >3/4 circumference	T2
Case 88	SCC with SM2 invasion + compromise of deep margin	Esophagectomy	-	T2
Case 93	HGD with compromise of lateral margins	Chemoradiotherapy	Location at upper esophagus	T2

List of cases	Criteria for non-curative resection	Management plan	Possible factors for difficult ESD	Period
Case 17	HGD with signet ring cells	Follow-up endoscopy	-	T1
Case 28	SCC with SM2 invasion (1200 µm) + lymphatic/vascular invasión.	Follow-up endoscopy	Location at upper esophagus	T1
Case 30	SCC with SM2 invasion	Chemoradiotherapy	-	T1
Case 35	SCC with SM2 invasion (760 µm) + lymphatic/vascular invasión.	Follow-up endoscopy	-	T1
Case 39	SCC with SM2 invasion (700 µm)	Follow-up endoscopy	Tumor >3/4 circumference	T1
Case 43	SCC with SM2 invasion (630 µm)	Follow-up endoscopy	Tumor >3/4 circumference	T1
Case 54	SCC with SM2 invasion (280 µm)	Chemoradiotherapy	Tumor >3/4 circumference	T2
Case 71	SCC with SM2 invasion (600 µm)	Chemoradiotherapy	-	T2
Case 73	SCC with SM2 invasion (450 µm)	Chemoradiotherapy	-	T2
Case 74	SCC with lymphatic/vascular invasión	Chemoradiotherapy	-	T2
Case 78	SCC undifferentiated with lymphatic/vascular invasión	Chemoradiotherapy	-	T2
Case 85	SCC with SM2 invasion (1000 µm) + lymphatic/vascular invasión.	Follow-up endoscopy	Tumor >3/4 circumference	T2
Case 87	SCC with SM2 invasion (1100 µm) + lymphatic/vascular invasión.	Follow-up endoscopy	Tumor >3/4 circumference	T2
Case 92	SCC with SM2 invasion (1200 µm)	Chemoradiotherapy	Tumor >3/4 circumference + Location at upper esophagus	T2

Instituto Brasileiro de Estudos e Pesquisas de Gastroenterologia e Outras Especialidades - IBEPEGE. Rua Dr. Seng, 320, 01331-020 São Paulo - SP Brasil, Tel./Fax: +55 11 3147-6227 - São Paulo - SP - Brazil
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[1] Corresponding author: Vitor Arantes. E-mail: arantesvitor@ufmg.br