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Education in practice
Learning endoscopic submucosal dissection in the UK: Barriers, solutions and pathways for training
  1. Jamie A Barbour1,
  2. Paul O'Toole2,
  3. Noriko Suzuki3,
  4. Sunil Dolwani4
  1. 1Department of Gastroenterology, QE Gateshead, Gateshead, Tyne and Wear, UK
  2. 2Department of Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
  3. 3Wolfson Unit for Endoscopy, St Mark's Hospital, London, UK
  4. 4Department 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}

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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.


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 …

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  • 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.

  • Patient consent for publication Not required.

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

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