Endoscopic resection of gastrointestinal tumors: Training levels and professional roles explored

Table 1 A comparative analysis of main endoscopic resection techniques

Technique	Indications	Pros	Cons
Endoscopic mucosal resection	Small, superficial lesions from the mucosal layer (ex. early-stage cancers and adenomas)	Preserves tissue, maintains function, simple technique	Limited size, risk of incomplete resection
Endoscopic submucosal dissection	Larger lesions reaching the submucosal layer	En bloc resection, enables complete resection	More complex, higher complication rate
Endoscopic full-thickness resection	Invasive lesions involving the full-thickness, reaching into the muscularis layer	Minimally invasive with lower recovery time compared to surgery	Complex procedure, significant perforation risk

Table 2 Summary of selected studies on the endoscopic submucosal or mucosal resection learning curve

Ref.	Modality	Number of cases	Tutored	Number of operators	Adverse events	En bloc rates	R0 rates	Number of cases when competency achieved	Notes
Hadjinicolaou et al[13]	ESD	60	No	1	Total: 16.7%, including perforation 13.3% and bleeding 3.3%	93%	80.7%	40-50
Khalaf et al[14]	ESD	503	No	1	Total: 3.2%, including two intraprocedural and 16 post-procedures	81.9%	71.1%	Between 250 and 350 procedures
Aliaga Ramos et al[15]	ESD	98	No	1	Total: 4%, including three cases of perforations (3%) and one case of bleeding (1%)	95.9%	80.6%	NA
Zorron Cheng Tao et al[16]	ESD	514	Yes	26	Perforation (experts = 3.7%; trainees = 6.9%), delayed bleeding (experts = 2.9%; trainees = 4.4%)	Experts = 95.6%; trainees = 94.7%	Experts = 85.7%; trainees = 83.6%	20-50	Colorectal ESD
Ramos-Zabala et al[17]	ESD	80	No	1	Perforations 7.5% and bleeding 3.7%	98.7%	75%	80	Colorectal ESD
Boda et al[18]	ESD	420	Yes	31	Total: 3%, including intraoperative perforation 2% and delayed bleeding 1%	94%	85%	20	Colorectal ESD
Spychalski et al[19]	ESD	298	Yes	1	Total: 16.78%, perforation 8.4%, bleeding 3.36%	NA	84.9%	36	Colorectal ESD
Zhang et al[8]	ESD	460	Yes	1	Total: 3.5%, including perforation 0.5%, delayed bleeding 2.1%, and others 0.7%	90%	80%	250	The learning thresholds in the study refer to proficiency rather than competence (which requires less stringent benchmarks such as en bloc resection > 80% rather than > 90%)
Rönnow et al[20]	ESD	301	Yes	1	Complications occurred in 24 patients (8%) divided into 12 immediate perforations, five delayed perforations, one immediate bleeding and six delayed bleedings. Six patients (2%), all with proximal lesions, had emergency surgery	80%	69%	120	Colorectal ESD was described in this study. Proficiency was used instead of competency
Yamamoto et al[21]	ESD	71	Yes	2	Total: 7.0% including two perforations, two post-operative bleeding, and one delayed perforation	80.3%	70.4%	20 for the first endoscopist and 51 for the second endoscopist	Colorectal ESD
Spychalski et al[22]	ESD	228	Yes	1	Total: 16.67%, perforation 7.9%, bleeding 4.4%	79.39%	86%	76	Colorectal ESD
Chong et al[23]	ESD	71	Yes	1	Perforation 15.5%	81.2%	58%	35	Colorectal ESD
Ohata et al[24]	ESD	80	Yes	2	Perforation 3%, delayed bleeding 3%	98%	100%	20	Colorectal ESD
Jacques et al[25]	ESD	62	Yes	2	Perforation 6.4%, delayed bleeding 9.6%	100%	85.5%	NA	Colorectal ESD
Yoshida et al[26]	ESD	334	Yes	7	Perforation 1%	100%	95%	30
Aslan et al[27]	ESD	95	No	1	Total: 3% including Perforation in one patient (1%), and bleeding in two patients (2%) after the procedure	93%	92%	NA
Jeon et al[28]	ESD	93	No	1	Overt perforation (2.15%) and micro perforation (4.3%)	89.25%	83.87%	50	Colorectal ESD
Pioche et al[29]	ESD	64	Yes	2	Perforation 6.2%	89.1%	92.2%	16	Colorectal ESD, animal study
Shiga et al[30]	ESD	120	Yes	2	Perforation 6.7%, postoperative bleeding 1.7%	94.2%	80%	40	Colorectal ESD
Spychalski and Dziki[31]	ESD	70	Yes	1	Perforation 5.7%, bleeding 5.7%	66%	96%	50	Colorectal ESD
Agapov and Dvoinikova[32]	ESD	44	No	1	Perforation 11.4%	84.1%	84.1%	NA	Colorectal ESD
Berr et al[33]	ESD	50	No	1	Complications were 2 bleedings (4%) and 7 perforations (14%), 5 clipped and 2 (4%) operated	76%	63%	22
Białek et al[34]	ESD	58	No	1	Total: 5.7%, including one case (1.9%) with moderate grade bleeding (delayed bleeding)	86.5%	81.1%	25	Colorectal ESD
Hong et al[35]	ESD	112	No	1	The bleeding rates of each quarter were 71% (2/28), 4.0% (1/25), 10.7% (3/28), and 3.3% (1/30), respectively. Only one perforation was reported in the last quarter	En bloc resection rates were 964% (27/28), 100% (25/25), 96.4% (27/28), and 96.7% (29/30) in each quarter	Complete resection rates were 96.4%, 100%, 100%, and 100%	60	Gastric ESD
Rahmi et al[36]	ESD	45	Yes	91	Perforation 18%, delayed bleeding 13%	64%	53%	40	Colorectal ESD
Shiga et al[37]	ESD	80	Yes	4	Perforation 7.5%, postoperative bleeding 3.8%	93.8%	75 %	40	Colorectal ESD
Hsu et al[38]	ESD	50	Yes	1	Perforation 6%	86%	86%	NA	Colorectal ESD
Iacopini et al[39]	ESD	60	Yes	1	Perforation 5%	68%	78%	20	Colorectal ESD
Inada et al[40]	ESD	518	No	6	Perforation 3.8%, postoperative hemorrhage 23%	91.5%	NA	NA	Colorectal ESD
Niimi et al[41]	ESD	115	Yes	2	Total: 7.7% including bleeding 1.1.%, and perforation 6.6%	Endoscopist A: 92.4%; endoscopist B: 95.7%	Endoscopist A: 73.9%; endoscopist B: 65.2%	23	Colorectal ESD
Ohata et al[42]	ESD	182	Yes	4	Perforation rate for the trainees ranged 2%-6.3%	The en bloc resection rate was 100% for all trainees	The R0 resection rates for trainees A, B, C and D were 94.0%, 93.8%, 94.0% and 98.0%, respectively	NA	Colorectal ESD
Probst et al[43]	ESD	82	No	2	Perforation (1.3%) and bleeding (7.9%)	81.6%	69.7%	25
Yamamoto et al[44]	ESD	1430	Yes	13	Total: 4% including bleeding 3.2% and perforation 0.8%	NA	95.5%	20
Sakamoto et al[45]	ESD	101	Yes	2	Perforation 2%	100%	29.4%	30	Colorectal ESD
Hotta et al[46]	ESD	115	Yes	1	The perforation rates for the first, second and third periods were 12.5% (5/40), 5% (2/40) and 5% (2/40), respectively	93%	85%	80	Colonic ESD
Saito et al[47]	ESD	1090	No	101	Total: 6.5% including perforation 5.2% and postoperative bleeding 1.5%	88%	NA	NA	Colorectal ESD
Saito et al[48]	ESD	198	No	NA	Perforation 5%, and postoperative bleeding 2 %	84%	83%	NA	Colorectal ESD
Fujishiro et al[4]	ESD	186	No	2	Perforation 6% and bleeding 1%	91.5%	71%	NA	Colorectal ESD
Tamegai et al[49]	ESD	70	No	NA	Perforation 1.4%	98.6%	95.6%	NA	Colorectal ESD
Tanaka et al[50]	ESD	70	No	2	Perforation 10%	NA	80%	NA	Colorectal ESD
Hurlstone et al[51]	ESD	42	No	1	Perforation 1.4%	78.6%	74%	NA	Colorectal ESD
Choi et al[52]	EMR	80	No	1	Three perforations were reported for the first 20 cases (15%), whereas only one was reported for the next 60 (1.7%). The frequency of major bleeding was 3.75% (3/80) and was not related to quartile	En bloc resection rates were 55%, 45%, 85%, and 85%	Complete resection rates were 65%, 60%, 90%, and 85%	40

¹Endoscopic submucosal dissection data over the numbered centers but trainee numbers not defined.

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; NA: Not appliable.