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Education in practice
Learning endoscopic submucosal dissection in the UK: Barriers, solutions and pathways for training
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  1. Jamie A Barbour1,
  2. Paul O'Toole2,
  3. Noriko Suzuki3,
  4. Sunil Dolwani4
  1. 1 Department of Gastroenterology, QE Gateshead, Gateshead, Tyne and Wear, UK
  2. 2 Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  3. 3 Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
  4. 4 Department of Gastroenterology, Cardiff and Vale NHS Trust, Cardiff, UK
  1. Correspondence to Dr Jamie A Barbour, Gastroenterology, QE Gateshead, Gateshead NE9 6SX, UK; jamie.barbour{at}nhs.net

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Summary box

What is already known on this topic

  • International consensus recommends that patients with complex colorectal polyps with a significant risk of malignancy should be offered en bloc resection.

  • Only a few centres in the UK currently offer endoscopic submucosal dissection (ESD). Fewer still offer ESD training in a systematic manner with supervision and mentoring.

What this paper adds

  • Description of the barriers facing UK therapeutic endoscopists to taking on ESD training.

  • A suggested road map based on our personal experience to overcome these barriers.

What might be the impact on clinical practise in the foreseeable future

  • Improvements in the understanding of the barriers and potential solutions to ESD training in the UK.

  • Improvement in the appropriate referral of cases to endoscopists who have been appropriately trained and who provide a safe and effective ESD service.

  • Strengthening and formalisation of networks between ESD providers and the development of training pathways for the next generation of endoscopists associated with these providers.

Introduction

Endoscopic submucosal dissection (ESD) has increasingly been adopted as the optimal approach for gastrointestinal (GI) high-grade intramucosal neoplasia and superficially invasive cancer. En bloc resection allows the pathological assessment of completeness of excision and multiple histological markers to more accurately indicate the statistical chance of lymph node metastasis. For benign lesions, there is also the benefit of a lower risk of recurrence.1

Despite the advantages of ESD, piecemeal endoscopic mucosal resection (pEMR) is still considered by some the technique of choice in the West with potential advantages rarely outweighing the drawbacks.2 For many others, however, the main barrier preventing the adoption of ESD is difficulty in learning the new technique and incorporating it into local and regional practice.

This article explores the changing attitudes to ESD in the UK, the barriers faced by UK endoscopists wishing to adopt ESD, the potential solutions and a proposed structured approach to achieving safe independent practice.

Recent changes and trends

Many UK endoscopists who were initially sceptical about the value of ESD seem to be overcoming their hesitation and referring patients to regional ESD providers and/or embarking on ESD training. Several factors are driving this conversion.

Conferences, symposiums and hands-on training courses

Almost every gastroenterology meeting now has ESD as a part of the programme. The weight of evidence and the fact that units around the world are using ESD as a standard part of their practice is tipping the balance of opinion among UK endoscopists. Hands-on training courses have proliferated and offered a practical taster to ESD as well as discussions on the role and benefits in expert hands. Attendees are usually inspired and enthused by the technique.

Avoidance of incompletely excised malignant and benign polyps

The principle that piecemeal resection should be avoided in suspected malignant lesions has been strongly emphasised in recent guidelines3 and is gaining acceptance. Suspected malignant rectal polyps should have en bloc resection either by transanal surgery or ESD. Endoscopists discussing these patients (as well as patients themselves) see the need for ESD to be available as an option. Complete en bloc excision with ESD avoids both routine 6-month and 18-month follow-up and further EMR procedures for recurrence.

Increased detection of advanced adenomas and early GI malignancy

Colorectal screening programmes are increasing the yield of advanced adenomas and superficially invasive malignancy.4 About 2% of the adenomas detected in the National Health Service Bowel Cancer Screening Programme are classified as complex, requiring high-level skill for resection.5 In the upper GI tract, initiatives to improve performance standards in gastroscopy6 aim to improve the detection of premalignant lesions and early stage cancer.

Development of referral pathways for complex polypectomy

Complex colorectal polyps may be better described as significant polyp or early colorectal cancer (SPECC) lesions, reflecting uncertainty about whether they are benign or malignant prior to complete excision. In the UK, there have been calls for the development of regional SPECC Multi-disciplinary Team (MDT) networks.7 Where such networks have been established, a high proportion of lesions referred to have the potential for malignancy. Many others have been subject to previous attempts at endoscopic resection,8 9 resulting in submucosal fibrosis that makes removal by conventional pEMR either extremely challenging or impossible. Similarly, non-granular lateral spreading tumours (LSTs) in the colon may also show submucosal fibrosis and are often referred because of ‘failure to lift’: ESD is the recommended approach for dealing with such lesions.10

Barriers and solutions to ESD training

ESD is a challenging procedure to learn and easy to underestimate. The current structure of endoscopy training in the UK makes ESD training very unlikely to be achievable within the period of specialist training and challenging once consultant grade has been reached. In the UK, it seems likely that established endoscopists proficient at pEMR will be the group most eligible for training, but the authors can confirm from their own experience, as well as from published data, that there is a large step-up in skill level from EMR to ESD.11 12

The prospective ESD practitioner will face many challenges and barriers in training that must be overcome:

Workload

Established therapeutic endoscopists are invariably busy, with a significant case load as well as other significant responsibilities. Commitment to ESD training is an additional workload and is often unfeasible without system-level support. This support can start with informal mentorship between consultant trainer and consultant trainee ESD colleagues in different healthcare organisations, followed by a more formal mutual agreement between respective organisations/Trusts/health boards so that the junior consultant colleague can be released to spend periods of training with the senior consultant colleague. National bodies such as the British Society of Gastroenterology and Bowel Cancer Screening Programme can also promote the technique and provide leadership in spreading uptake and engagement across the country. As regional ESD services develop and endoscopists begin to recognise the potential long-term benefits, job plans can be adjusted to allow specialist training.

Reverting to the role of trainee

Experienced endoscopists often find it challenging to enter a field where they are relative novices. They will inevitably spend long periods outside their comfort zones both during training and in the early years of independent ESD practice. It is common for the novice in ESD (especially experienced EMR endoscopists) to be keen to take on cases beyond their technical ability—either through lack of insight or over=ambition. Mentorship with more experienced endoscopists and team working with other ESD trainees will smooth the transition from expert to novice back to expert again.

Availability of training/supervision

Progressing safely towards competence needs focused instruction, mentoring and expert supervision, especially when working with patients rather than models. At present, there are only a handful of centres in the UK and Europe able to offer direct supervision of ESD trainees. Most of these tend to focus on developing local endoscopist colleagues and have limited capacity to take on trainees from elsewhere. Few of them have formally structured ESD training programmes. The situation will be improved by greater networking between experienced endoscopists and the development of ESD user groups, recognised and supported by national bodies.

Availability of suitable cases

Japanese trainees perform 20 or more gastric procedures before progressing to colorectal cases.13 A more realistic approach in the UK, where appropriate gastric lesions are found more rarely, is to begin with LSTs in the rectum due to ease of access and favourable rectal anatomy.

Patient selection for ESD should be agreed upon by an MDT.3 14 For many Trusts, this will mean the colorectal MDT, where the focus is usually on established cancers and the discussions are surgically dominated. Transanal endoscopic microsurgery (TEMS) may be the locally established treatment for rectal SPECC lesions and novice ESD practitioners will find themselves competing for cases. In time, however, successful outcomes for appropriately selected training cases will convince the MDT that ESD offers advantages over TEMS, not least in terms of reduced costs and (usually) avoidance of hospital admission and general anaesthesia. With openness, cooperation and a degree of compromise, the MDT will soon learn to judge which lesions are suitable for ESD and which are better treated by TEMS. A well-functioning MDT will offer a holistic approach, taking into consideration the patient’s wishes. A specialist nurse is pivotal, supporting the patient through the process and helping them understand the options on offer.

Where regional SPECC or complex polyp MDT networks are established, there is likely to be more acceptance of ESD as a treatment option. Unfortunately, tertiary referred cases are often too complex for the novice to tackle by ESD. It is challenging to find relatively small rectal LSTs, without scarring or fibrosis, where ESD is genuinely indicated. The novice ESD practitioner should work with referring colleagues, helping them recognise lesions where morphology or surface appearance raises suspicion of advanced histology and encouraging them to refer promptly without prior manipulation.

Local support

Removing lesions by ESD takes much longer than pEMR, especially during the early phases of training. Endoscopy unit managers are not keen on reducing case volume with implications for waiting times and financial reimbursement. There is however good evidence that ESD procedure times decrease as skill improves15 and in the longer term ESD reduces repeat procedures for site checks and for treatment of recurrence and reduces surgery rate for benign polyps and superficial cancers. At present, long-term cost-effectiveness and health economic data are relatively sparse. Recent outcomes and health economic analysis have compared ESD (expert) with surgical TEM type procedures and suggest equivalent outcomes with shorter lengths of stay and costs in favour of ESD.16

Availability of anaesthetic support

Patients can generally tolerate a 2–3 hours’ endoscopic procedure under conscious sedation. This should allow the intermediate ESD endoscopist to remove most rectal lesions smaller than 30 mm, especially if hybrid techniques are used. Longer lower GI procedures are often well tolerated if the patient is given a short break after a couple of hours. Prolonged procedures, especially those involving the upper GI tract, are much better performed under propofol sedation or general anaesthesia. Limited availability of anaesthetic support may be partly responsible for the slower uptake of ESD in the UK compared with mainland European countries, where propofol is often used as standard.

Reimbursement

The tariff for ESD remains similar to that of pEMR. However, the outcome of an en bloc resection can mean the difference between necessary and unnecessary surgery as well as reduced surveillance. The training involved and the skill level required to perform a high-quality ESD needs to be reflected in the reimbursement of the procedure. Careful reduction of financial barriers (without encouraging low-skill attempts at the procedure) is one of the ways to promote the more widespread uptake of training in the technique.

An approach to ESD skills acquisition in the West: our journey

The first wave of ESD operators in Europe often benefited from personal contact with expert Japanese endoscopists, usually involving individualised teaching and mentorship rather than participation in structured training programmes.17 Two of the authors (JAB and POT) were trained in lower GI ESD more recently, without the advantage of direct Japanese support. We describe and reflect on our experience and suggest a realistic pathway for training in the West.

Entry-level requirements

Before starting ESD training, we suggest that the endoscopist is comfortable with pEMR for level 4 lesions and is familiar with enhanced imaging techniques to assist endoscopic optical diagnosis.

Despite having had a long experience of advanced polypectomy, the degree of tip control required for ESD was a challenge for both of us. It was also apparent that selecting cases for ESD demanded a more considered and detailed approach to lesion assessment than we were used to in our EMR practice.

Beginners’ workshops

One day introductory workshops provide an overview of ESD technique and service implications. Trainees have a taster of hands-on experience using an ex vivo porcine model. Practising the technique in a controlled environment with the trainer providing step-by-step guidance is essential.

Intermediate level workshops

These have a similar format but are longer and allow more hands-on model practice. Ideally, they will provide experience with a live porcine model, which gives the trainee opportunity to deal with bleeding and (potentially) perforation. Larger and slightly more demanding lesions can be simulated, depending on the trainee’s skill level. Practising exit strategies when the situation goes beyond their skill level (as it often does in the early stages) is important. POT and JAB each attended seven ESD workshops over the period of several years (in Cardiff, Portsmouth, London, Germany and Japan).

Observation period

Observation of the technique is an important component of ESD training in Japan. Both JAB and POT spent 2 weeks in Japan on fellowships where we each observed about 15 cases and received further ex vivo model training. This allowed a much deeper technical understanding of the procedure as well as a valuable insight into expert lesion assessment. Observation is an active process requiring focus and concentration and cannot be underestimated.17 18 It has been suggested that at least 30 cases should be observed19 but this is very difficult to achieve in practice. Online videos and step-by-step guides illustrating various technical aspects of ESD are available20 21 as well as entire online training packages.22

Supervised practice

Encouraged by a positive experience during animal model training, both POT and JAB went on to gain their initial patient experience unsupervised, taking on small rectal lesions supported only by members of their local MDT. Attempting ESD independently made clear, very quickly, the vital need for supervision: we soon found ourselves in situations not encountered during model training and had nowhere to look for guidance. JAB was able to arrange supervision sessions with SD early on and started fortnightly visits to his centre in Cardiff. POT performed about 20 rectal ESD/hybrid procedures unsupervised before he too began regular visits to SD for mentoring. We both found mentored practice an invaluable experience—useful from novice to intermediate skill levels and beyond. We suggest that mentorship is essential, not only for the development of technical skills under direct supervision but also for guidance about clinical decision making, such as which lesions to take on independently and which ones to avoid. Above all, mentoring allowed patient safety to be maintained while we progressed towards competence.

Independent practice

When performing ESD independently at the base unit, we suggest that the patient must be at the centre of all considerations. Safety is paramount. The consent process should clarify the experience of snare polypectomy and ESD and ongoing supervision by ESD trainers. Most patients can understand the benefits of single-fragment excision provided their safety is not compromised. Ample time should be allowed to avoid working under pressure and, with proper planning, hybrid techniques can be used if appropriate.

ESD masterclasses/training others

Some centres offer advanced ESD masterclasses. Skills learnt on these courses might include tunnelling, pocket formation method, countertraction techniques and use of specialist knives. The best of such courses will provide opportunities to practice these techniques on the live pig model.

Both of us attended an excellent masterclass at Kobe, in Japan (the Kobe International Endoscopy Hands-on Seminar). To gain maximum learning from such courses, it is important that the trainee is at an appropriate level; it is difficult to make sense of the subtle insight provided by top experts unless you have had at least some experience of ESD in clinical practice.

Discussion

Piecemeal EMR is often seen as a necessary compromise in the West because ESD is considered out of reach for the majority of western endoscopists. Learning ESD in the UK is undoubtedly challenging but feasible, as our experience testifies. Following evidence-based practice and differences in outcome for selected groups, patients should not be denied the possibility of en bloc endoscopic resection just because it is not available locally. We would encourage all endoscopists to consider referring suitable lesions to regional ESD providers and for specialists undertaking tertiary-referral complex polypectomy to consider adding ESD to their skill set.

Good clinical governance requires that those performing ESD are properly trained and competent. In the absence of an agreed training pathway, ‘proper training’ is hard to define. Likewise, without defining the knowledge, skills and attitudes required for safe ESD, it is difficult to judge when a trainee is competent for independent practice. A competency-assessment based assessment tool would be useful, as well as for summative sign-off. Without the well-developed mentorship training pathway that they have in Japan, the UK ESD trainee would benefit from this type of objective measure of competence leading to insight into their skill levels and future goals. Takao et al 23 took an important step by establishing consensus among 14 Japanese experts regarding the essential competencies required for gastric ESD. They published 34 items covering all aspects of the procedure. The challenge remains to embed these competencies into a workable trainee assessment framework and prove its validity. A similar process was used to develop Direct Observation of Procedural Skill (DOPS) assessment tools for other aspects of therapeutic endoscopy in the UK; a validated DOPS assessment tool for ESD would be very helpful. We are currently in the process of developing such a tool to provide some structure to ESD training and competency.

Given the prolonged duration of ESD skills acquisition, training should not be restricted to just senior endoscopists. Recognition of ‘specialist endoscopist’ as a career path for some UK trainees might allow selected individuals to be singled out for ESD training earlier in their careers, at a time when their job plans allow greater flexibility and when they are still comfortable in the trainee role. Accelerated training programmes involving periods of observation and practice on animal models have been suggested.18

ESD courses are becoming more common, teaching methods are improving and the number of useful videos and teaching material available online is increasing. The biggest hurdle for trainees remains the limited opportunity to spend time at an established, high-volume ESD centre for observation and direct supervision. Establishing organised national and international networks, through which training can be structured and coordinated, may be a way forward but these would require proper funding.

JAB and POT embarked on ESD training entirely independently but the paths we followed were remarkably similar. Our training was somewhat circuitous, however, and took years rather than months to reach the intermediate level. The transition from EMR to ESD proved to be far more challenging than we had anticipated (figure 1). By sharing our experiences, we hope that others may enjoy a more planned and efficient journey to competence in ESD. We also propose an initiative to develop a structured competency-based training framework for ESD and deeper engagement between national organisations and structures to help coordinate an effective, safe, structured and networked training programme for ESD in the UK

Figure 1

Expectation and reality of training in endoscopic submucosal dissection. Other factors include lengthy and mentally/physically challenging procedure, lack of training, lack of resources, time pressure.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors JB and SD planned the paper. JB wrote the outline of the paper. POT reviewed the paper and extensively contributed to the development. NS reviewed the paper and made valuable contributions to the edit.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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