A one-to-one training program would be valuable in learning how to perform esophageal endoscopic mucosal resection

We read the article by van Vilsteren et al. [1] with interest. The training program they describe is a well designed and structured approach to learning the complex procedure of esophageal endoscopic mucosal resection (EMR). This would provide guidance to endoscopists from other countries in designing such a training program. The authors conclude that there was a 5 % perforation rate in the first 120 cases in total performed by six trainees. We do agree that performance of 20 EMRs is probably inadequate for reaching the plateau of the learning curve, mainly because of the complexity of the procedure.

Esophageal EMR is a team effort and involving the endoscopy nurses and the pathologist in the program is commendable. Nevertheless, the value of a state-of-art endoscopy unit with involvement from surgical colleagues is paramount in managing Barrett’s early neoplasia. This needs to be tailored to each center to which the endoscopists return to work. The traditional approach of training one-to-one in a fixed endoscopy training fellowship is valuable in this setting. The advantage is that the trainee endoscopist is eased into independent practice with minimal supervision rather than abruptly returning to independent practice after a training program. Further advantages are better understanding of local needs and acquiring a knowledge of how to set up a department when a trainee starts independent practice elsewhere. A one-to-one training program should be supplemented with beginner hands-on training on pig models, and reviewing of videos of EMR as performed by previous trainees. Once trainees had begun the program, regular attendance at upper gastrointestinal (UGI) cancer multidisciplinary meetings would enhance their knowledge significantly. Training programs such as those described in this paper are invaluable in advancing the skills of such endoscopists who are trained in a one to-one setting so that specific areas of weakness can be addressed.

A centralized approach to management of esophageal early neoplasia is worth mentioning. The centers providing such a service should be UGI cancer centers offering comprehensive cancer care. The endoscopists who provide such a service should be accredited by a central organization, based on performance auditing and peer assessment. An approach similar to this, for accrediting bowel cancer screening endoscopists, is in place in the UK, guided by the Joint Advisory Group on GI Endoscopy (JAG) [2].

It is interesting to note the number of endoscopic resection-cap (ER-cap) procedures compared with multiband mucosectomies (MBMs). All perforations happened in the ER cap-arm, even though this was not statistically significant probably because of the small absolute number of complications. More procedures were done using ER-cap which we suspect would not reflect practice in UK centers. There are a few possible reasons for this. The training program would probably have started before the introduction of MBM. Also, the trainee endoscopists might have chosen the ER-cap procedure more often as this technique is more challenging than the MBM technique and it would be valuable to learn it from an expert endoscopist. Another reason would be that most of the cases were complicated early neoplasia and the operators would have aimed to conduct en bloc resection. Whatever the reason was, we feel that the MBM piecemeal technique is safer and a substantial number of cases could be managed with this technique [3] [4].

• References

• 1 van Vilsteren FG, Pouw RE, Herrero LA et al. Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program. Endoscopy 2012; 44: 4-14
• 2 JAG Joint Advisory Group on GI Endoscopy. www.thejag.org.uk
• 3 Alvarez HerreroL, 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
• 4 Pouw RE, van Vilsteren FG, Peters FP et al. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett’s neoplasia. Gastrointest Endosc 2011; 74: 35-43