Chronological Outcomes and Learning Curve of Endoscopic Submucosal Dissection for Colorectal Tumors

Sang Min Lee; Eun Soo Kim; Kyung Sik Park; Kwang Bum Cho; Dong Choon Kim; Yu Jin Kang; Yoo Jin Lee; Jung Min Lee; Eun Sung Choi; Jae Hyuk Choi; Ho Young Lee

doi:10.4166/kjg.2014.64.4.198

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Lee, Kim, Park, Cho, Kim, Kang, Lee, Lee, Choi, Choi, and Lee: Chronological Outcomes and Learning Curve of Endoscopic Submucosal Dissection for Colorectal Tumors

Original Article

Korean J Gastroenterol 2014;64(4):198-205.

Published online: 4 October 2014

DOI: https://doi.org/10.4166/kjg.2014.64.4.198

Chronological Outcomes and Learning Curve of Endoscopic Submucosal Dissection for Colorectal Tumors

Sang Min Lee, Eun Soo Kim, Kyung Sik Park, Kwang Bum Cho, Dong Choon Kim, Yu Jin Kang, Yoo Jin Lee, Jung Min Lee, Eun Sung Choi, Jae Hyuk Choi, Ho Young Lee

Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea

Correspondence to: Eun Soo Kim, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 700-712, Korea. Tel: +82-53-250-8096, Fax: +82-53-250-7442, E-mail: dandy813@hanmail.net

Received 1 May 20141 August 2014 Accepted 5 August 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Endoscopic submucosal dissection (ESD) is an effective procedure for en-bloc curative resection of the colorectal tumor. As it requires high technical skills and experience in therapeutic endoscopy, it is important to understand learning curve of ESD technique. The aim of this study was to retrospectively describe the clinical results of ESD and to evaluate learning curve for the ESD of colorectal tumors.

Methods

A total of 90 patients with 90 colorectal neoplasms, who had undergone ESD at a tertiary referral hospital from July 2009 to December 2012, were enrolled. The ESD was performed by a single endoscopist. All ESD cases were divided into three periods: first, cases 1–30; second, cases 31–60; and third, cases 61–90.

Results

The en-bloc resection rates in third period (100%) was significantly higher than that of the first (93.3%) and second period (80%) (p=0.025). The perforation rate in third period (0%) also significantly decreased compared with that of the first (13.3%) and second period (20%) (p=0.032). To calibrate the difference of tumor size among periods, proficiency was calculated, as the procedure time per specimen area (min/cm²). The proficiency in third period (4.3) was significantly shorter than that of the first (16.8) and second period (10.2) (p=0.004).

Conclusions

The learning curve of colorectal ESD in our study shows that at least 60 cases of ESD have to be conducted to acquire sufficient skill of degree without perforation.

Keywords: Learning curve, Colon, Endoscopy, Dissection

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Fig. 1.

Learning curve of procedure time per specimen area (min/cm²). The values represent mean proficiency in each period.

Table 1.

Patient Demographics and Endoscopic Characteristics of the Lesions by Treatment Period

Characteristic	1st period	2nd period	3rd period	p-value
Age (yr)	59.1 (36–79)	58.9 (41–76)	62.2 (35–81)	0.538
Gender (n, male:female)	14:16	18:12	21:9	0.183
Comobidity
Hypertension	12 (40.0)	12 (40.0)	9 (30.0)	0.650
Type 2 DM	8 (26.7)	3 (10.0)	5 (16.7)	0.236
CLD	2 (6.7)	0 (0.0)	1 (3.3)	0.770
CVD	0 (0.0)	0 (0.0)	2 (6.7)	0.326
CRD	2 (6.7)	1 (3.3)	0 (0.0)	0.770
Others ^a	2 (6.7)	3 (10.0)	2 (6.7)	1.000
Location of tumors ^b				0.426
Right colon	7 (23.3)	7 (23.3)	10 (33.3)
Left colon	3 (10.0)	6 (20.0)	7 (23.3)
Rectum	20 (66.7)	17 (56.7)	13 (43.3)
Endoscopic diagnosis				0.314
LST-G	11 (36.7)	15 (50.0)	14 (46.7)
LST-NG	3 (10.0)	4 (13.3)	8 (26.7)
Polypoid	6 (20.0)	3 (10.0)	4 (13.3)
Carcinoid	10 (33.3)	8 (26.7)	4 (13.3)
Tumor size, long axis (mm)	20.9 (9–40)	24.9 (10–55)	23.8 (9–45)	0.359
Duration per ESD (day)	16.5	13.1	12.1

Values are presented as mean (range), n (%), or mean only.

Chronologically all cases were divided according to three periods: first period, cases 1–30; second period, cases 31–60; third period, cases 61–90.

Type 2 DM, type 2 diabetes mellitus; CLD, chronic liver disease; CVD, cardiovascular disease; CRD, chronic renal disease; LST-G, laterally spreading tumor-granular type; LST-NG, laterally spreading tumor-nongranular type; ESD, endoscopic submucosal dissection.

^a First period: uterine cervical cancer, stomach cancer; second period: stomach cancer, hypothyroidism; third period: stomach cancer.

^b Right colon: cecum, ascending colon, transverse colon; left colon: descending colon, sigmoid colon.

Table 2.

Clinicopathological Outcomes by Treatment Period

	1st period	2nd period	3rd period	p-value
Pathology				0.217
Adenoma	11 (36.7)	13 (43.3)	14 (46.7)
Adenocarcinoma	8 (26.7)	9 (30.0)	13 (43.3)
Intramucosal cancer	6 (20.0)	6 (20.0)	11 (36.7)
Submucosal cancer
Shallow (<1,000 μm)	1 (3.3)	2 (6.7)	1 (3.3)
Deep (≥1,000 μm)	1 (3.3)	1 (3.3)	1 (3.3)
Carcinoid tumor	9 (30.0)	8 (26.7)	2 (6.7)
Others ^a	2 (6.7)	0 (0.0)	1 (3.3)
Procedure time, min	39 (10–100)	31.5 (8–133)	15 (5–100)	0.034
En-bloc resection	28 (93.3)	24 (80.0)	30 (100.0)	0.025
R0 resection ^b	27 (90.0)	21 (70.0)	27 (90.0)	0.056
Perforation	4 (13.3)	6 (20.0)	0 (0.0)	0.032

Values are presented as n (%) or median (range).

Chronologically all cases were divided according to three periods: first period, cases 1–30; second period, cases 31–60; third period, cases 61–90.

^a First period: chronic colitis, granular cell tumor; third period: atypical cells.

^b En-bloc resection without tumor involvement to the margins of the resected specimen.

Table 3.

Clinicopathological Outcomes by Treatment Period in Colorectal Epithelial Tumors

	1st period	2nd period	3rd period	p-value
Tumor size, long axis (mm), mean (range)	25.6 (20–40)	30.2 (21–55)	26.9 (20–47)	0.199
Procedure time (min), median (range)	51.6 (15–100)	47.4 (8–133)	27.7 (5–100)	0.023
En-bloc resection, n (%)	18 (90.0)	16 (72.7)	26 (100.0)	0.008
R0 resection ^a, n (%)	17 (85.0)	14 (63.6)	23 (88.5)	0.124
Perforation, n (%)	4 (20.0)	6 (27.3)	0 (0.0)	0.008
Proficiency (min/cm²), mean only	12.7	7.4	4.2	0.02

Chronologically all cases were divided according to three periods: first period, 20 cases; second period, 22 cases; third period, 26 cases.

^a En-bloc resection without tumor involvement to the margins of the resected specimen.

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