Читать книгу Successful Training in Gastrointestinal Endoscopy - Группа авторов - Страница 102

Standard snare polypectomy and endoscopic mucosal resection of polyps are skills that are generally learned during colonoscopy training, as these procedures are more commonly performed in the colon. In the United States, endoscopic submucosal dissection (ESD) is not yet widely practiced, unlike in Asia where it is frequently used to treat early gastric cancer in endemic areas. Training for ESD and related techniques such as tunneling resection or per‐oral endoscopic myotomy (POEM) is generally not part of standard gastroenterology fellowship programs; after acquiring skills in standard EGD, physicians that are interested in learning ESD or POEM may choose to obtain training in specialized advanced endoscopy programs in the United States or overseas [25]. Educational courses, such as those offered by ASGE, can provide an introduction to the techniques and may include hands‐on training using ex‐vivo porcine models, which provide a realistic experience aside from the absence of bleeding and fibrosis. There are several noteworthy technical aspects of ESD that deserve mention. Many gastric lesions are best approached with the endoscope retroflexed because the endoscope tip is often more stable in retroflexion (the angulated portion of the shaft rests stably in contact with the gastric wall) and because the electrocautery knives used often approach the lesion at an optimal angle parallel to the submucosal plane. During training, the endoscopist must therefore become familiar with maneuvering of the retroflexed endoscope. Fine tip control using both the up–down and left–right dials is important during ESD. For this reason, many endoscopists performing the procedure hold the endoscope in an alternative position in which the index and middle finger wrap around to support the dials rather than resting on the suction and insufflation buttons (Figure 5.13). Because of the complex and repetitive motions required during ESD, some endoscopists prefer to have an expert assistant hold the shaft or advance the electrocautery knife as required.

Figure 5.12 (a) Mid‐esophageal cancer with luminal obstruction. (b) Subsequent stent placement over the area occupied by the neoplasm.

Figure 5.13 Alternative hand position for ESD in which the index and middle finger wrap around to support the dials.