Endoscopy 2012; 44(01): 4-14
DOI: 10.1055/s-0031-1291384
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program

F. G. I. van Vilsteren
1   Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
,
R. E. Pouw
1   Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
,
L. A. Herrero
2   Gastroenterology, St Antonius hospital, Nieuwegein, The Netherlands
,
F. P. Peters
1   Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
,
R. Bisschops
3   Gastroenterology, University Medical Center Gasthuisberg Leuven, The Netherlands
,
M. Houben
4   Gastroenterology, Haga Teaching Hospital Den Haag, The Netherlands
,
F. T. M. Peters
5   Gastroenterology, University Medical Center Groningen, The Netherlands
,
B. E. Schenk
6   Gastroenterology, Isala Clinics Zwolle, The Netherlands
,
B. L. A. M. Weusten
2   Gastroenterology, St Antonius hospital, Nieuwegein, The Netherlands
,
M. Visser
7   Pathology, Academic Medical Center, Amsterdam, The Netherlands
,
F. J. W. Ten Kate
7   Pathology, Academic Medical Center, Amsterdam, The Netherlands
,
P. Fockens
1   Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
,
E. J. Schoon
8   Gastroenterology, Catharina Hospital Eindhoven, The Netherlands
,
J. J. G. H. M. Bergman
1   Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
› Author Affiliations
Further Information

Publication History

submitted 05 April 2011

accepted after revision 29 July 2011

Publication Date:
22 November 2011 (online)

Background and study aims: Endoscopic resection is the cornerstone of endoscopic treatment of esophageal high grade dysplasia or early cancer. Endoscopic resection is, however, a technically demanding procedure, which requires training and expertise. The aim of the current study was to prospectively evaluate efficacy and safety of the first 120 endoscopic resection procedures of early esophageal neoplasia performed by six endoscopists (20 endoscopic resections each) who were participating in an endoscopic resection training program.

Patients and methods: The program consisted of four tri-monthly 1-day courses with lectures, live-demonstrations, hands-on training on anesthetized pigs, and one-on-one hands-on training days. Gastroenterologists from centers with multidisciplinary expertise in upper gastrointestinal oncology participated, together with an endoscopy nurse and a pathologist. Outcome measures were complete endoscopic removal of the target area and acute complications.

Results: A total of 120 consecutive esophageal endoscopic resection procedures (85 ER-cap, 35 multiband mucosectomy [MBM]) were performed by six endoscopists: 109 in Barrett’s esophagus, 11 for squamous neoplasia; 85 piecemeal endoscopic resections (median 3 specimens, interquartile range 2 – 4 specimens). Complete endoscopic removal was achieved in 111 /120 cases (92.5 %). Six perforations occurred (5.0 %): five were effectively treated endoscopically (clips, covered stent), and one patient underwent esophagectomy. There were 11 acute mild bleedings (9.2 %), which were managed endoscopically. Perforations occurred in ER-cap procedures performed by four participants (7.1 % ER-cap vs. 0 % MBM; P = 0.18), and in 1.7 % of the first 10 endoscopic resections and 8.3 % of the second 10 endoscopic resections per endoscopist (P = 0.26).

Conclusion: In this intense, structured training program, the first 120 esophageal endoscopic resections performed by six participants were associated with a 5.0 % perforation rate. Although perforations were adequately managed, performing 20 endoscopic resections may not be sufficient to reach the peak of the learning curve in endoscopic resection.

Appendix e1 – e2 are available online:

 
  • References

  • 1 Ell C, May A, Pech O et al. Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer). Gastrointest Endosc 2007; 65: 3-10
  • 2 Inoue H. Endoscopic mucosal resection for esophageal and gastric mucosal cancers. Can J Gastroenterol 1998; 12: 355-359
  • 3 Peters FP, Kara MA, Curvers WL et al. Multiband mucosectomy for endoscopic resection of Barrett’s esophagus: feasibility study with matched historical controls. Eur J Gastroenterol Hepatol 2007; 19: 311-315
  • 4 Peters FP, Brakenhoff KP, Curvers WL et al. Endoscopic cap resection for treatment of early Barrett’s neoplasia is safe: a prospective analysis of acute and early complications in 216 procedures. Dis Esophagus 2007; 20: 510-515
  • 5 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut 2008; 57: 1200-1206
  • 6 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
  • 7 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009; 360: 2277-2288
  • 8 Pouw RE, Seewald S, Gondrie JJ et al. Stepwise radical endoscopic resection for eradication of Barrett’s oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010; 59: 1169-1177
  • 9 Pouw RE, Bergman JJ. Endoscopic resection of early oesophageal and gastric neoplasia. Best Pract Res Clin Gastroenterol 2008; 22: 929-943
  • 10 Pech O, Gossner L, May A et al. Endoscopic resection of superficial esophageal squamous-cell carcinomas: Western experience. Am J Gastroenterol 2004; 99: 1226-1232
  • 11 Kudo S, Tamegai Y, Yamano H et al. Endoscopic mucosal resection of the colon: the Japanese technique. Gastrointest Endosc Clin N Am 2001; 11: 519-535
  • 12 Ell C, May A, Gossner L et al. Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett’s esophagus. Gastroenterology 2000; 118: 670-677
  • 13 Kwaliteitsinstituut voor de Gezondheidszorg CBO. Richtlijn diagnostiek en behandeling oesofaguscarcinoom. Alphen aan den Rijn: Van Zuiden Communications; 2005
  • 14 Peters FP, Brakenhoff KP, Curvers WL et al. Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett’s esophagus. Gastrointest Endosc 2008; 67: 604-609
  • 15 Peters FP, Kara MA, Rosmolen WD et al. Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study. Am J Gastroenterol 2006; 101: 1449-1457
  • 16 Peters FP, Krishnadath KK, Rygiel AM et al. Stepwise radical endoscopic resection of the complete Barrett’s esophagus with early neoplasia successfully eradicates pre-existing genetic abnormalities. Am J Gastroenterol 2007; 102: 1853-1861
  • 17 Pouw RE, Gondrie JJ, Alvarez HerreroL et al. A randomized prospective trial comparing the cap-technique and multi-band mucosectomy technique for piecemeal endoscopic resection in Barrett’s esophagus [abstract]. Gastrointest Endosc 2008; 67: AB75
  • 18 Alvarez HL, Pouw RE, Van Vilsteren FG et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett’s esophagus. Endoscopy 2011; 43: 177-183
  • 19 van Vilsteren FGI, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
  • 20 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58 (Suppl. 06) : S3-43
  • 21 Pouw RE, Heldoorn N, Herrero LA et al. Do we still need EUS in the workup of patients with early esophageal neoplasia? A retrospective analysis of 131 cases. Gastrointestinal Endoscopy 2011; 73: 662-668
  • 22 Schlemper RJ, Riddell RH, Kato Y et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
  • 23 Alvarez HL, Pouw RE, Van Vilsteren FG et al. Risk of lymph node metastasis associated with deeper invasion by early adenocarcinoma of the esophagus and cardia: study based on endoscopic resection specimens. Endoscopy 2010; 42: 1030-1036
  • 24 Van Vilsteren FG, Alvarez HL, Pouw RE et al. Radiofrequency ablation for the endoscopic eradication of esophageal squamous high grade intraepithelial neoplasia and mucosal squamous cell carcinoma. Endoscopy 2011; 43: 282-290
  • 25 Gondrie JJ, Pouw RE, Sondermeijer CM et al. Stepwise circumferential and focal ablation of Barrett’s esophagus with high-grade dysplasia: results of the first prospective series of 11 patients. Endoscopy 2008; 40: 359-369
  • 26 Gondrie JJ, Pouw RE, Sondermeijer CM et al. Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system. Endoscopy 2008; 40: 370-379
  • 27 May A, Gossner L, Behrens A et al. A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus. Gastrointest Endosc 2003; 58: 167-175
  • 28 Moss A, Bourke MJ, Hourigan LF et al. Endoscopic resection for Barrett’s high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105: 1276-1283
  • 29 Larghi A, Lightdale CJ, Ross AS et al. Long-term follow-up of complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma. Endoscopy 2007; 39: 1086-1091
  • 30 Soehendra N, Seewald S, Groth S et al. Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus (with video). Gastrointest Endosc 2006; 63: 847-852
  • 31 Choi IJ, Kim CG, Chang HJ et al. The learning curve for EMR with circumferential mucosal incision in treating intramucosal gastric neoplasm. Gastrointest Endosc 2005; 62: 860-865
  • 32 Ohyama T, Kobayashi Y, Mori K et al. Factors affecting complete resection of gastric tumors by the endoscopic mucosal resection procedure. J Gastroenterol Hepatol 2002; 17: 844-848
  • 33 Deprez PH, Bergman JJ, Meisner S et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy 2010; 42: 853-858
  • 34 Herrero LA, Pouw RE, van Vilsteren FGI et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett’s esophagus. Endoscopy 2011; 43: 177-183
  • 35 Chennat J, Konda VJ, Ross AS et al. Complete Barrett’s eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma – an American single-center experience. Am J Gastroenterol 2009; 104: 2684-2692
  • 36 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
  • 37 Costamagna G. ERCP and endoscopic sphincterotomy in Billroth II patients: a demanding technique for experts only?. Ital J Gastroenterol Hepatol 1998; 30: 306-309
  • 38 Mertz H, Gautam S. The learning curve for EUS-guided FNA of pancreatic cancer. Gastrointest Endosc 2004; 59: 33-37