Building Expertise in ESD: Insights from the French Training Program

Aims Endoscopic submucosal dissection (ESD) demands a high level of endoscopic skill and extensive training, even for experienced endoscopists, with a particularly steep learning curve for colonic ESD. Over the last three years, the French Society of Digestive Endoscopy (SFED) has implemented a structured ESD training program. This study aimed to evaluate the effectiveness of the SFED ESD training program to achieve competency in ESD and to identify factors associated with it.

Methods Participants who attended the SFED ESD training curriculum over the past three years were invited to join the study. After completing a standardized initial simulation training week, each participant was asked to document each ESD procedure performed in their training center, along with technical details (lesion size and location, en bloc resection, R0 resection status, and procedural complications). Additionally, participants completed an online survey to gather information about their practice environment, ongoing ESD activity, and demographic data. Successful dissection was defined as en-bloc resection with free lateral and deep margins (R0) and no need for surgical intervention due to complications. The performance threshold for achieving proficiency in ESD was defined, in line with ESGE guidelines, as achieving an en-bloc resection rate of>90% and a complication-related surgery rate of<1%. The learning curve to reach these competence standards was assessed using the LC-CUSUM method.

Results 45 students participated in the study, performing 2055 ESD procedures. The median number of ESDs conducted post-training was 34 (IQR 22-66), with the majority being colorectal (42.9% rectal and 42.7% colonic). Lesions had a median size of 45 mm (IQR 34-60), with a resection speed of 17.4 mm²/min (IQR 10.5-26.5). En bloc resection and R0 resection were achieved in 93.2% and 85.8% of cases, respectively, with a surgical complication rate of 0.94%. The overall success rate of ESD procedures was 92.7%. Success was more likely in rectal (97%) than colonic (90.4%) procedures. For skill acquisition, 16 students (35.6%) reached competence, while 29 students (64.4%) did not. Among those who reached competence, the median number of ESDs required was 45. Factors associated with successful competence attainment included years of experience (HR 0.82 [0.68-0.99]; p=0.04), prior interventional endoscopy experience (HR 0.31 [0.10-0.99]; p=0.05), and practicing in a high-volume center compared to a low-volume center (HR 3.93 [1.39-11.10]; p=0.01).

Conclusions This study provides the first assessment of the French ESD training program. Endoscopic experience and practice in high-volume dissection centers were key factors in achieving proficiency in ESD. These findings may help inform the selection of future candidates for ESD training to ensure effective skill acquisition and safe practice.

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Artikel online veröffentlicht:
27. März 2025