ESD Endoscopy: The Hidden Truth About Who Really Needs to Learn It [2025 Guide]

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Endoscopic Submucosal Dissection (ESD) is one of the most technically demanding procedures in advanced endoscopy. It requires exceptional precision, advanced endoscopic dexterity, and careful judgment to achieve successful outcomes while minimizing complications. Although initially developed in Japan for the treatment of early gastric cancers, ESD has now become a crucial therapeutic option for superficial neoplasia in the esophagus, stomach, and colorectum. Its ability to achieve en bloc resection and provide superior histopathological assessment distinguishes it from conventional Endoscopic Mucosal Resection (EMR), particularly for larger or complex lesions. However, these advantages come at the cost of a steep learning curve and the need for highly specialized training.

Despite its growing clinical importance, the training landscape for ESD remains fragmented, particularly in Western countries. Data suggest that as many as 79 percent of surveyed participants had no prior hands-on experience with human ESD cases before enrolling in dedicated training courses. This finding underscores a critical gap in preparation and highlights the urgent need for structured, accessible, and standardized educational pathways. In the United States, there is currently no unified curriculum that outlines the essential components of ESD training, leaving trainees and institutions to rely on heterogeneous models of skill acquisition.

The American Society for Gastrointestinal Endoscopy has put forward a stepwise training framework that progresses from observation of expert cases to structured practice on ex vivo animal models, typically involving 9 to 30 cases, before advancing to supervised in vivo procedures. This staged approach reflects international consensus that ESD competence cannot be achieved through observation alone but requires intensive hands-on practice under expert supervision. Studies comparing different training paradigms further reinforce this point. For example, one investigation analyzing 75 gastric ESD cases performed by trainees demonstrated that structured, progressive training significantly improved procedural success and reduced complication rates.

Understanding the distinction between ESD and EMR remains essential in defining training priorities. While EMR is effective for small, superficial lesions, ESD is indispensable for en bloc resection of larger, fibrotic, or scarred lesions where EMR is less effective or associated with higher recurrence rates. Consequently, ESD should not be viewed as an extension of EMR but rather as a distinct therapeutic modality requiring its own dedicated training pathway.

This comprehensive review explores three central questions: who should be trained in ESD in 2025, what constitutes the realistic learning curve for achieving competence, and which training models are most effective based on current evidence. By synthesizing data from existing studies and professional society recommendations, this paper aims to provide clarity on the optimal training strategies for ESD and to highlight the pressing need for structured curricula in Western practice.

Keywords: endoscopic submucosal dissection, advanced endoscopy training, gastrointestinal neoplasia, learning curve, endoscopic education

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What is ESD Endoscopy and Why It Matters

Endoscopic submucosal dissection (ESD) represents a revolutionary advancement in minimally invasive gastrointestinal procedures. Originally developed in Japan, this technique has steadily gained global recognition as an essential tool for treating superficial gastrointestinal lesions. Unlike traditional surgical approaches, ESD offers comparable oncological outcomes with substantially less invasiveness, making it increasingly relevant for modern gastroenterology practice.

Definition and scope of ESD

ESD is a specialized endoscopic procedure that enables the removal of precancerous or cancerous growths from the gastrointestinal tract without making external incisions. During the procedure, a gastroenterologist inserts an endoscope—a flexible tube with a camera—through the mouth or anus, depending on the treatment area. The technique involves injecting fluid into the submucosa, creating an incision around the lesion’s perimeter, and carefully dissecting it from deeper tissue layers using specialized ESD knives.

The scope of ESD has expanded considerably since its inception. Initially developed in 1988 for treating early gastric cancer, the procedure now addresses lesions throughout the digestive tract. ESD is typically used to treat Barrett’s esophagus with dysplasia, colorectal cancer, esophageal cancer, small intestine cancer, and stomach cancer. Moreover, this technique shows excellent outcomes, with studies reporting tumor recurrence in only 1% of patients who undergo the procedure.

The primary goal of ESD is to achieve an R0 resection—complete removal of the tumor with clear margins—allowing for comprehensive histological assessment. This approach aligns with established oncologic principles while offering patients faster recovery and less post-procedure pain compared to conventional surgery.

How ESD differs from EMR

Endoscopic mucosal resection (EMR) and ESD represent two distinct approaches to endoscopic tissue removal, each with specific advantages and limitations. The fundamental difference lies in their technical execution and capability to remove lesions en bloc (in one piece).

EMR uses a metal loop to cut away lesions in combination with fluid injection, primarily targeting tumors growing in the mucosa—the innermost lining of the GI tract. In contrast, ESD can address both mucosal tumors and those extending deeper into the submucosa, with the aim of resecting the entire lesion in a single piece.

The clinical outcomes between these techniques show meaningful differences. ESD achieves remarkably higher en bloc resection rates (93-100%) compared to EMR (53-72%). This translates to lower recurrence rates with ESD (0.5-1%) versus EMR (5-11%). In one comparative study, curative resection for early adenocarcinoma was achieved in 53% of patients undergoing ESD but only in 12% of those treated with EMR.

However, these benefits come with tradeoffs. ESD procedures typically require more time to complete—averaging 108 minutes compared to EMR’s shorter duration. Additionally, ESD carries a higher risk of perforation (5.7% versus 0.8% for EMR), though most perforations can be managed endoscopically without requiring surgery.

Why ESD is gaining attention in 2025

After years of limited adoption in Western countries, ESD is now experiencing growing acceptance in the United States and Europe. This shift can be attributed to several factors that have converged in recent years.

First, technological advancements have improved procedural safety and efficiency. The development of specialized ESD knives, traction devices, and closure techniques has made the procedure more accessible to Western practitioners. In addition, endoscopic closure techniques unique to Western practice, including suturing devices not commonly available in Eastern countries, facilitate complete closure of resection sites that would otherwise remain open.

Second, the clinical indications for ESD have expanded significantly beyond early gastric cancer. The procedure is increasingly utilized for colorectal lesions, esophageal cancers, and Barrett’s esophagus-associated neoplasia. This expansion stems from mounting evidence supporting ESD’s safety and efficacy across various gastrointestinal sites.

Third, contemporary practices are evolving to enhance patient convenience. Whereas patients were traditionally admitted for 3-5 days after ESD, recent studies show that ambulatory ESD is safe and feasible for carefully selected patients, with one study reporting a 57% same-day discharge rate that increased to 70% as endoscopists gained experience.

Moreover, recent high-quality evidence shows that compared with EMR, ESD is associated with significantly lower recurrence rates at 6 months (0.6% for ESD versus 5.6% for EMR). These compelling results are driving increased interest in the technique, especially for treating larger lesions where en bloc removal with EMR would be challenging.

 

Who Actually Needs to Learn ESD in 2025

The question of who should invest time in mastering endoscopic submucosal dissection (ESD) remains crucial as the technique gains traction in Western medical practice. Not all gastroenterologists need this advanced skill set, yet certain groups will find it increasingly valuable as ESD adoption expands beyond specialized centers. The learning curve is steep—acquiring proficiency requires dedication, resources, and institutional support that varies widely across practice settings.

Advanced endoscopists in academic centers

Academic centers serve as the primary hubs for ESD innovation and training in the United States. These institutions offer several advantages, first among them being higher case volumes necessary for developing and maintaining expertise. At academic medical centers considered high-volume for ESD (defined as performing more than 50 cases annually), some practitioners now complete over 120 procedures per year. This case volume notably surpasses what most community settings can provide.

Advanced endoscopists at academic institutions typically lead ESD training initiatives, developing programs that combine didactic teaching, hands-on supervision, and research opportunities. Their expertise enables them to handle complex cases with submucosal fibrosis caused by previous tattoos or incomplete EMR attempts. Essentially, these specialists serve as the backbone of ESD education, often traveling internationally to train with pioneers of the procedure before establishing programs at their home institutions.

For academic endoscopists, learning ESD represents not just a clinical skill but also an academic responsibility—they must develop protocols, conduct research, and create standardized training pathways for the next generation of practitioners.

GI fellows in advanced training programs

The integration of ESD into gastroenterology fellowship training has evolved considerably. Currently, ESD training primarily occurs during advanced endoscopy fellowships rather than standard three-year GI programs. Many fellowship programs now offer customized curricula in the second year, providing targeted training in advanced procedures like ESD, bariatric endoscopy, and third-space techniques.

Early research demonstrates that animal models effectively help fellows learn basic ESD skills. In one study, both third-year gastroenterology fellows and advanced endoscopy fellows showed improvement after practicing on ex-vivo models, although advanced fellows demonstrated a shorter learning curve. Fellows generally found esophageal lesions easier to master than stomach lesions on the training models.

Consequently, institutions like Johns Hopkins and UCSF have incorporated dedicated ESD training into their advanced endoscopy fellowships. These programs often require fellows to demonstrate competence in complex EMR before advancing to ESD training. As one academic endoscopist noted, “I do expect ESD, like EMR, to become an essential part of endoscopic training, like ERCP years ago”.

Community gastroenterologists expanding services

Community gastroenterologists face unique challenges when incorporating ESD into their practices. Chief among these is the limited number of appropriate cases to maintain proficiency. As one mid-career endoscopist at a community hospital observed, “ESD is a complex procedure with a steep learning curve, only a few training facilities and not enough cases in my community hospital”.

Nevertheless, some community gastroenterologists are successfully adopting ESD, particularly surgeons with previous endoscopic experience. One study documented a surgeon with experience in 25 gastric ESDs who successfully performed 57 colorectal ESDs over a 14-month period. The practitioner observed increasing speed and efficiency as experience accumulated.

For community physicians seeking to offer ESD, proctorship and hands-on training sessions remain essential. Numerous training courses now exist, such as the ASGE-JGES ESD Course, which targets endoscopists ready to begin their ESD journey.

Surgeons involved in minimally invasive GI procedures

Surgeons specializing in minimally invasive procedures represent another group well-positioned to adopt ESD. These specialists often possess technical skills that transfer well to endoscopic techniques. In particular, surgeons already familiar with laparoscopic approaches to GI disorders may find ESD provides a complementary, less invasive option for certain cases.

When appropriately selected, ESD can replace more invasive surgical procedures. As noted by one practitioner, “In the right scenario, it can replace an esophagectomy, a gastrectomy, or a colectomy, which can be life-altering surgeries, and allow us to remove the tumor while preserving the organ”. This organ-preserving benefit makes ESD particularly valuable for surgeons concerned with maintaining patient quality of life and functional outcomes.

Furthermore, surgeons are well-equipped to manage potential complications. Although rare, delayed perforations may require surgical intervention, as documented in one case where laparoscopic partial colectomy was performed after ESD complication. This built-in ability to address complications provides surgeons a safety advantage when learning the technique.

 

The ESD Learning Curve: What It Really Takes

Mastering endoscopic submucosal dissection (ESD) requires dedication, patience, and a substantial investment of time. The journey from novice to expert follows a steeper trajectory than most other endoscopic techniques, often demanding years of consistent practice before reaching proficiency.

Number of procedures to reach competency

The number of procedures required to achieve competency varies dramatically based on anatomical location and training context. In high-volume Japanese centers—where structured learning environments with onsite expert tutors and abundant gastric lesions exist—trainees typically need 30–40 ESDs to acquire early proficiency in gastric ESD. In contrast, Western practitioners face a considerably longer learning curve.

For colorectal ESD, studies involving endoscopists with prior esophageal or gastric ESD experience suggest 30-80 procedures are needed to achieve competence. This threshold increases for right-sided colon lesions, with one study calculating a minimum of 80 cases when only 40% of lesions were left-sided.

Importantly, de novo colorectal ESD training without prior gastric ESD experience requires substantially more cases, with Korean data suggesting at least 100 procedures may be necessary. One comprehensive Western study demonstrated that expert-level proficiency markers were achieved only after approximately 250 cases. Even more revealing, proficiency as measured by resection speed was achieved fastest in the stomach (150 cases), followed by the esophagus (170 cases), and slowest in the colon (280 cases).

The European Society of Gastrointestinal Endoscopy (ESGE) recommends performing at least 20 ESD procedures on models before human practice, with a goal of achieving en bloc complete resections in 8 of the final 10 training cases. Subsequently, the first 10 human ESD procedures should be performed under supervision of an ESD-proficient endoscopist.

Common mistakes and how to avoid them

First-time ESD practitioners commonly encounter several pitfalls that can compromise outcomes:

• Insufficient submucosal injection leading to perforation during initial mucosal incision
• Cutting too deep into submucosa during mucosal incision, causing bleeding from vessels beneath the muscularis mucosae
• Improper knife selection, with non-insulated knives potentially increasing perforation risk during the learning curve
• Inadequate traction obscuring the visual field and complicating the dissection plane
• Misidentification of tissue planes in areas with fibrosis, particularly in lesions with prior EMR attempts

To minimize these errors, beginners should start with easier anatomical locations such as the rectum or gastric antrum. Indeed, studies show that 90% of endoscopists perform their first human ESD in the lower third of the stomach or rectum. Additionally, training on animal models before human cases reduces complication rates substantially—one study found a 34% perforation rate among unsupervised novices compared to 7% for those with supervised training.

Why ESD is harder than it looks

The technical complexity of ESD exceeds most endoscopic procedures for several reasons. First, the procedure requires precise control in confined spaces with limited maneuverability. In the colon specifically, the thin walls, presence of folds and flexures, and ongoing peristalsis make the procedure technically more challenging than esophageal or gastric ESD.

Second, the risk profile demands constant vigilance. During a training workshop using porcine models, 65.22% of participants encountered perforations and 56.52% experienced bleeding during gastric ESD. This occurred despite these being controlled training environments.

Third, certain lesion characteristics dramatically increase difficulty. Tumors larger than 35mm, those with central depression or ulceration, and lesions with previous EMR or polypectomy attempts all independently predict technically difficult procedures. For instance, submucosal fibrosis after previous interventions increases the risk of cutting through the muscularis propria layer, leading to perforation.

Fourth, maintaining adequate exposure and traction throughout the procedure presents ongoing challenges, as evidenced by the development of numerous traction techniques to improve visualization of the dissection plane.

 

Training Pathways: From Beginner to Pro

Developing proficiency in ESD endoscopy follows a stepwise progression through structured learning experiences. The path to mastery begins with theoretical knowledge and culminates in hands-on clinical application under expert guidance.

Didactic and video-based learning

The foundation of ESD training starts with comprehensive theoretical education. Online platforms now offer self-paced courses comprising PowerPoint presentations with voice-over instruction and integrated knowledge assessments. These virtual learning environments allow practitioners to begin their ESD journey without the immediate pressure of clinical application. First and foremost, aspiring ESD practitioners should immerse themselves in literature, online videos, and textbooks to build basic understanding of techniques, efficacy, and risk profiles.

Live conferences and educational meetings serve as critical supplements to self-directed learning, therefore these should be attended both before and during practical ESD training. As one academic endoscopist noted, watching demonstration videos by experts helps trainees recognize proper technique across various anatomical locations and scenarios. In effect, this preliminary education creates the cognitive framework necessary for subsequent hands-on training.

Ex vivo and animal model training

After theoretical preparation, hands-on practice begins with ex vivo models—typically isolated pig stomachs. The European Society of Gastrointestinal Endoscopy (ESGE) recommends performing at least 20 ESD procedures on these models before attempting human cases. This recommendation includes achieving en bloc complete resections in 8 of the final 10 training cases.

Ex vivo models offer several distinct advantages:

• Negligible cost compared to live animal models
• No requirement for veterinary staff or anesthesia
• Ethical advantages for beginners learning basic movements

Once practitioners achieve competency with ex vivo specimens, they typically advance to in vivo animal models, predominantly using Sus scrofa (domestic pig). These living models create more realistic conditions with active peristalsis, intraluminal secretions, and potential bleeding complications. Experts recommend performing 5-10 resections in the ex vivo porcine model before transitioning to the live animal setting.

Supervised human case experience

The transition to human cases marks a critical juncture in ESD training. ESGE guidelines stipulate that the first 10 human ESD procedures per organ should be performed under direct supervision by an ESD-proficient endoscopist. This apprenticeship model helps trainees navigate the complexities of real clinical scenarios while maintaining patient safety.

A personalized curriculum tailored to each trainee’s background and prior endoscopic experience yields optimal results. In one documented case, a fellow performed their first human ESD after completing just 4 ex-vivo ESDs coupled with observation of 2 human cases, whereas another fellow required 15 ex-vivo cases and observation of 11 human procedures before performing their first case.

Mentorship and international observerships

Observation of expert practitioners represents an invaluable training component. ESGE recommends observing at least 20 ESD procedures and assisting in 5 procedures, ideally within a concentrated timeframe. Many Western endoscopists pursue international observerships in high-volume centers, particularly in Japan where ESD originated.

Short-term observational fellowships lasting just 1-2 weeks at centers in Japan add substantial value to training. For instance, one recipient of the ASGE Endoscopic Training Grant spent five weeks at Japan’s National Cancer Center, observing 3-5 ESD cases daily while practicing on animal models.

The final step before independent practice often involves expert proctorship for initial human cases. This supervised approach provides the necessary confidence and validation of newly acquired skills, ultimately completing the transition from novice to proficient ESD practitioner.

 

Barriers to Learning ESD and How to Overcome Them

Beyond the technical challenges of ESD endoscopy, practitioners face numerous systemic obstacles that complicate the learning process. These barriers extend from educational frameworks to financial considerations, often requiring creative solutions to overcome.

Lack of structured programs

The absence of standardized training pathways represents a fundamental obstacle to ESD adoption. In North America, no consistent curriculum exists for gaining competency, resulting in only a handful of centers and endoscopists across Canada having sufficient experience to practice ESD. This educational gap manifests in multiple ways. First and foremost, current programs frequently fail to integrate ESD teaching within existing curricula, creating disciplinary silos that complicate cross-disciplinary collaboration.

To address this barrier, medical educators recommend alternative educational models more suited to Western practice environments. A stepwise approach combining didactic self-study, training courses of increasing complexity, animal model practice, and expert observation has proven effective. Furthermore, educators should initially select lesions with well-established indications for ESD that present the lowest technical complexity.

Limited access to suitable lesions

The scarcity of appropriate cases presents a substantial challenge, particularly outside academic centers. Practitioners frequently cite difficulties in obtaining adequate case volumes necessary for skill development and maintenance. In practice, this limitation disproportionately affects community-based endoscopists who may encounter few suitable candidates for the procedure.

One effective solution involves educating referring physicians about practices that facilitate future ESD. Primarily, this means avoiding techniques that induce submucosal fibrosis, such as tattooing directly beneath lesions or performing partial snare resections for histopathology. Additionally, developing networks for patient referrals between community hospitals and academic centers can help concentrate suitable cases where learning opportunities exist.

Institutional and financial hurdles

Financial constraints impede ESD implementation across multiple dimensions. Many practitioners report difficulty securing essential resources like endoscopy time and anesthesia support, even while technical equipment appears relatively accessible. In fact, the majority of practitioners (55%) express dissatisfaction with their institution’s infrastructure to support ESD practice.

The underlying problem often stems from limited institutional support. Only 35% of surveyed practitioners felt their institutions were supportive or very supportive in expanding ESD practice. Overcoming these hurdles requires demonstrating the cost-effectiveness of ESD compared to surgical alternatives, especially for cases where ESD can replace more invasive procedures like esophagectomy or colectomy.

Credentialing and billing issues

Remuneration inadequacy represents a nearly universal concern, with 95% of surveyed endoscopists reporting dissatisfaction with ESD compensation. This payment gap discourages practitioners from investing the considerable time required to master the procedure.

Inadequate credentialing frameworks further complicate matters. Without standardized credentialing, institutions may hesitate to authorize ESD procedures or grant appropriate privileges. Creating objective, standardized measures of competency—similar to those established for other advanced procedures—would build trust between practitioners and institutions. Properly structured credentialing programs also protect the reputation of practitioners by establishing clear professional standards.

 

Simulation Models and Tools That Make a Difference

Effective simulation tools form the cornerstone of successful ESD training, enabling practitioners to develop technical skills before performing procedures on actual patients. These specialized models and devices create realistic learning environments while minimizing risk.

G-Master and other non-animal models

The G-Master, developed jointly by KOTOBUKI Medical Limited and Japan’s National Cancer Center Hospital East, represents a breakthrough in non-animal ESD training. This innovative model comprises a simulated mucous membrane sheet made of konjac flour and a setting frame capable of reproducing 11 different stomach locations. The mucosal sheet consists of three distinct layers that mimic the mucosal, submucosal, and muscular layers—each with varying hardness, strength, and density to replicate actual stomach tissue.

Studies using the G-Master demonstrate measurable skill acquisition. When analyzing learning curves with the CUSUM method, trainees typically progress through three phases: initial growth (understanding and adaptation), plateau (experimentation with improvements), and late growth (technique refinement). Most trainees require approximately 10 sessions to transition from the first to second phase and 19 sessions to reach the third phase.

Live animal models: pros and cons

In vivo porcine models offer superior realism compared to ex vivo alternatives. These living specimens provide authentic challenges including breathing movements, heartbeats, peristalsis, and intraluminal secretions. Moreover, practitioners can practice managing complications like bleeding and perforation in near-human conditions.

Nonetheless, animal models present ethical and logistical challenges. They require dedicated facilities, veterinary support, and anesthesia protocols. First, animals must follow specific preparation regimens—typically fasting for 8 hours after 3 days of liquid diet. Second, general anesthesia with endotracheal intubation becomes necessary.

Clip-with-line and traction devices

The clip-with-line method enhances visualization during ESD training. This technique involves attaching nylon thread to a standard endoscopic clip, creating traction that exposes the dissection plane. In one comparative study, perforation rates ranged from just 5% with the clip-with-line method to 40% using conventional approaches.

This traction system proves especially valuable for esophageal ESD, where the small clip and thin line minimize interference with endoscopic movement in the narrow lumen. The CONNECT-E trial confirmed that clip-with-line assisted ESD resulted in shorter procedure times without increasing adverse events.

Choosing the right ESD knife

For beginners, insulated-tip knives like the IT2 offer safety advantages by reducing perforation risk. Meanwhile, the DualKnife™ provides versatility through adjustable length settings—2mm for gastric ESD and 1.5mm for esophageal applications.

Alternative options include triangular tip knives featuring heat-permeable disks for precise dissection, flex knives with semicircular design for multi-directional cutting, and hook knives that enable horizontal and vertical tissue manipulation.

 

ESD vs EMR: Who Should Learn Which?

Selecting the appropriate endoscopic resection technique hinges on balancing clinical requirements against technical capabilities. Proficiency in both EMR and ESD offers complementary tools for managing gastrointestinal neoplasia, yet each serves distinct purposes in contemporary practice.

When EMR is enough

EMR remains the “workhorse” for treating Barrett’s esophagus and other superficial lesions due to its widespread availability, shorter learning curve, superior safety profile, and favorable return on investment. For lesions measuring ≤10mm, curative resection rates between EMR and ESD show comparable outcomes. In effect, EMR presents the optimal approach for smaller lesions where en bloc removal can be achieved without compromising margins.

From a practical standpoint, EMR offers substantial advantages—procedure times average 37.2 minutes versus 79.1 minutes for ESD. Additionally, general anesthesia requirements differ substantially (5% for EMR versus 24% for ESD). Considering these factors, EMR should constitute the first-line approach for most superficial neoplastic lesions, unless specific indications necessitate ESD.

When ESD is the better choice

Lesion size fundamentally determines the advantage of ESD over EMR. For colorectal lesions exceeding 20mm, ESD demonstrates clearly superior outcomes. Likewise, esophageal lesions larger than 15mm and gastric lesions exceeding 20mm generally warrant ESD over EMR.

Beyond size considerations, ESD achieves markedly higher en bloc resection rates (89% versus 43% for EMR) and R0 resection rates (73% versus 56%). As a result, recurrence rates after ESD drop dramatically to 3.5% compared with 31.4% for EMR. These differences prove particularly crucial for lesions with suspected superficial submucosal invasion where accurate histopathological assessment becomes paramount.

Training implications for each technique

The learning curve discrepancy between these techniques cannot be overstated. While EMR competency generally requires 50-300 procedures, ESD demands substantially greater investment—often 150-250 cases for untutored practitioners. Correspondingly, this affects training strategies and institutional resource allocation.

For trainees, EMR serves as the logical starting point before advancing to ESD. Experience with EMR provides essential skills that form the foundation for ESD training, including submucosal injection techniques and endoscopic tissue manipulation. In reality, most Western practitioners should first master EMR before considering ESD training, unless they practice in high-volume academic centers where adequate case exposure permits dedicated ESD skill development.

Overall, EMR appropriately serves most clinical scenarios, whereas ESD should be reserved for specific indications where its technical advantages outweigh its longer learning curve and procedural complexity.

 

The Future of ESD Training in the US and Beyond

ESD training pathways across the globe are rapidly evolving with standardized approaches gradually replacing the ad hoc training methods of the past.

Incorporating ESD into fellowships

Fellowship programs have begun implementing personalized curricula tailored to trainees’ backgrounds and prior endoscopic experience. These customized pathways combine ESD simulators, expert case observation, and ex-vivo practice on porcine models. At present, specialized one-year fellowships in advanced endoscopic resection offer immersive experiences where graduates perform approximately 75 ESDs during training. Henceforth, proficiency in EMR and adverse event management will remain prerequisites before initiating ESD training.

Role of societies like ASGE and ESGE

Professional societies have taken pivotal roles in standardizing ESD education. The European Society of Gastrointestinal Endoscopy has developed a comprehensive core curriculum for ESD practice across Europe. Similarly, the American Society for Gastrointestinal Endoscopy now offers immersive courses that combine essential didactic learning with hands-on practice from world-renowned faculty. These societies discourage starting initial ESD training directly on human patients.

Predictions for ESD adoption by 2030

By 2030, ESD will likely achieve broader integration into standard GI practice. Currently, maintaining proficiency requires a minimum case load of 25 ESD procedures annually. Forthcoming years will see increasing implementation of prospective databases tracking outcomes such as en bloc resection rates, complications, and final histopathology. Moreover, third-space endoscopy training will expand beyond academic centers as more community practices incorporate these techniques to address patient needs.

 

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Conclusion

Endoscopic submucosal dissection represents a transformative advancement in minimally invasive gastrointestinal procedures, though its widespread adoption faces substantial challenges. The technique demands exceptional skill acquisition through structured training pathways that most practitioners cannot access readily. Consequently, ESD mastery should primarily target specific groups – advanced academic endoscopists, fellows in specialized training programs, select community gastroenterologists with adequate case volumes, and surgeons involved in minimally invasive procedures.

The learning curve undoubtedly remains steep. Practitioners require anywhere from 30 procedures for basic competency to over 250 cases for expert-level proficiency, depending on anatomical location and prior experience. This investment proves worthwhile primarily when clinical outcomes justify the extensive training time. For many smaller lesions, EMR continues to offer comparable results with shorter procedural times and fewer complications.

Success in ESD implementation relies heavily on overcoming several barriers. First, standardized curricula must replace the current fragmented training landscape. Second, appropriate case selection and referral networks need development to ensure adequate procedural volumes. Third, institutions must provide both financial support and dedicated resources for practitioners pursuing this advanced technique.

Looking ahead, professional societies like ASGE and ESGE will likely play crucial roles in establishing comprehensive training frameworks. Therefore, the future of ESD appears promising as more structured educational pathways emerge. Nevertheless, EMR will certainly remain the workhorse procedure for most superficial neoplastic lesions, while ESD offers superior outcomes for specific indications where complete en bloc resection proves essential.

Ultimately, the decision to pursue ESD training should balance patient needs against practical considerations of time investment, institutional support, and expected case volume. Those committed to this journey must recognize that mastery requires not just technical skill but also perseverance through an extended learning process. Despite these challenges, the exceptional clinical outcomes achievable through expert ESD performance make this technique an invaluable addition to the advanced endoscopist’s therapeutic arsenal.

Key Takeaways

ESD endoscopy represents a highly specialized technique that requires careful consideration of who should invest in learning it, given its steep learning curve and resource requirements.

• ESD training is primarily for specialized practitioners: Advanced academic endoscopists, GI fellows in advanced programs, select community gastroenterologists with adequate case volumes, and minimally invasive surgeons benefit most from ESD training.
• The learning curve is exceptionally steep: Practitioners need 30-250 procedures to achieve competency depending on anatomical location, with expert-level proficiency requiring up to 250 cases across different GI sites.
• EMR remains the first-line choice for most lesions: For lesions ≤10-15mm, EMR offers comparable outcomes with shorter procedure times, lower complication rates, and significantly reduced training requirements.
• Structured training pathways are essential: Success requires progression through didactic learning, ex-vivo models (20+ procedures), supervised human cases (first 10), and ongoing mentorship rather than ad-hoc approaches.
• Institutional support determines success: ESD implementation requires dedicated resources, adequate case volumes (minimum 25 annually for proficiency maintenance), and financial backing that many community settings cannot provide.

The future of ESD training lies in standardized curricula developed by professional societies, with realistic expectations about who can successfully master this demanding but transformative technique.

 

 

Frequently Asked Questions:

FAQs

Q1. What is ESD endoscopy and how does it differ from EMR? ESD (Endoscopic Submucosal Dissection) is an advanced endoscopic technique for removing precancerous or early-stage cancerous lesions from the gastrointestinal tract. Unlike EMR (Endoscopic Mucosal Resection), ESD allows for en bloc removal of larger lesions and those extending into the submucosa, resulting in higher complete resection rates and lower recurrence rates.

Q2. How long does it take to become proficient in ESD? Achieving proficiency in ESD requires significant dedication and practice. The number of procedures needed varies by anatomical location, but generally ranges from 30-80 cases for basic competency to over 250 cases for expert-level proficiency. This learning curve is considerably steeper than for most other endoscopic techniques.

Q3. Who are the ideal candidates for learning ESD? ESD training is best suited for advanced endoscopists in academic centers, GI fellows in specialized programs, select community gastroenterologists with adequate case volumes, and surgeons involved in minimally invasive GI procedures. The technique requires a substantial time investment and institutional support to master.

Q4. What are the main barriers to learning ESD? Key obstacles in ESD training include the lack of structured programs, limited access to suitable lesions, institutional and financial hurdles, and credentialing issues. Overcoming these barriers often requires creative solutions like international observerships, specialized training courses, and developing referral networks to concentrate cases.

Q5. How is ESD training likely to evolve in the coming years? The future of ESD training is expected to involve more standardized curricula developed by professional societies, integration into advanced fellowship programs, and expanded use of simulation models. By 2030, ESD will likely achieve broader adoption, with increasing implementation of outcome tracking databases and expansion beyond academic centers.

 

 

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