Post written by Frieder Berr, MD, PhD, from the Department of Medicine I and Institute of Pathophysiology, Paracelsus Medical University, Salzburg, Austria.

Annual hands-on endoscopic submucosal dissection (ESD) courses (3.3 days; Paracelsus Medical University, Salzburg, Austria, 2009-2018) were conducted by leading Japanese experts to prime a senior endoscopist from 135 tertiary referral centers across Europe (plus 9 centers overseas lost to follow-up) regarding how to set up an early cancer center and implement ESD technique in an untutored practice based on the prevalence of indications and step-up of technical challenge (Oyama T, Yahagi N, Ponchon T, Kiesslich T, Berr F. How to establish endoscopic submucosal dissection in Western countries. World J Gastroenterol 2015;21:11209-20).

A cross-sectional questionnaire survey at the end of the program (in 2018 and 2019) addressed:

• The rate of implementation of ESD en bloc among participating referral centers and distribution of ESD organ sites during ESD implementation (starting centers [≤30 ESDs] vs competent category [31-150 ESDs] vs advanced centers [>150 ESDs]).
• The rate of severe adverse events for starting versus competent and advanced ESD implementation.

This ESD workshop program endorsed a prevalence-based approach including colonic ESD, whereas European guidelines (2015 and 2022) preclude colonic ESD during implementation of ESD technique because of high risk of adverse events and danger for the patients.

The survey was representative (feedback from 84% of centers; 7% had published ESDs; 9% centers had unknown status). In total, 83 centers (61.5%) performed ESD, providing a supply network across Europe (Figure). Four centers had been pre-established, and 79 implemented ESD on zero or starting prior experience. Cross-sectional survey data of 72 (91%) implemented ESD centers show, on all 3 levels of implementation, the majority (mean, 66%-72%) of ESD intention-to-treat (ESD-ITT) was performed in the colorectum.

Percentage of colonic ESD-ITT increased from 8% for starting to 33% for advanced ESD centers, percentage of esophageal ESD rose from 6% to 14%, and percentage of rectal and gastric ESD decreased. ESD en bloc increased from 64% to 84% of ESD-ITT, hybrid ESD (with final snaring) dropped from 26% to 11%, and conversion to piecemeal EMR declined from 10% to 5.2%.

Despite 66% to 72% colorectal ESDs, overall risks were low (30-day mortality, 0.03%; surgical repair, 3.5% vs 1.7%) for starting versus competent and advanced ESD centers (meeting Asian benchmarks), and the outcome was satisfactory (need for oncosurgery, 7.4% vs 5.2%; local recurrence, 1.5% vs 0.3%).

Unsupervised implementation of ESD technique was successful in the colorectum with a technical step-up approach to colonic ESDs. Western ESD centers must now strive for professional rates (ie, >80%) of histologic curative ESD by perfecting the endo-diagnostic accuracy of differential indications and endoscopic electrosurgical techniques.

Distribution of participating endoscopic submucosal dissection (ESD) centers across Europe and the Mediterranean Near East. The centers of ESD workshop trainees have implemented an ESD supply network of 83 active centers; by 2019, an additional 11 published ESD centers in Europe that had not participated are not shown. Circles represent centers, and the insert color represents the ESD category: gray = unknown, white = zero, red = starting (≤30 ESDs), green = competent (31-150 ESDs), blue = professional (>150 ESD ESDs).

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