Application Of An Endoscopic Submucosal Dissection Training System Based On An Ex Vivo Training Model With Continuous Perfusion (ETM-CP) For Rural Gastrointestinal Endoscopists

Background:With the continuous development of endoscopic technology,endoscopic treatment has become more and more popular.Endoscopic submucosal dissection(ESD)is a new endoscopic treatment technique developed in recent years,and ESD is widely used in the treatment of early gastrointestinal cancer because it can completely remove large lesions,provide complete pathological diagnostic specimens and prevent recurrence of lesions at one time.However,ESD is currently difficult and time-consuming to perform,and requires a high level of operating ability from endoscopists,which makes ESD technology a potential obstacle in primary care hospitals.The current mainstream training models for ESD include:plastic and silicone models,3D printed models,virtual simulation,electronic computer simulation programs,various types of ex vivo animal models,and live whole pigs.As we know,the main complications of ESD are bleeding and perforation.And adequate training of hemostasis operation can be considered as the key to ESD training.However,only live whole pigs can achieve the ideal bleeding effect among the current ESD training models,which can be used for ESD hemostasis training.The live whole pig with ideal human simulation state has a series of limitations,which makes it difficult to meet the demand of promoting ESD at the rural level.In this regard,we can conclude that the current training model for ESD is the lack of an affordable and operational training model that can simulate blood perfusion.In addition,the current international training process for ESD training is a series of training processes such as clinical observation,mentor teaching,live animal training,observation and learning,and independent clinical operation.However,the training period of this training model is long and complicated.And the cost is huge.So it is difficult to promote in rural hospitals with relatively scarce medical resources in China.In addition,the traditional endoscopy training model of clinical observation and "pass-along" in China cannot meet the requirements of rural endoscopists to master the ESD technology.Objective:The existing ex vivo models of endoscopic submucosal dissection(ESD)cannot simulate intraoperative hemorrhage well.We aimed to establish an ESD training method by applying an ex vivo training model with continuous perfusion(ETM-CP).Methods:After we fully researched the grassroots ESD training situation.We conducted a training model development.We evaluated the simulation effects of the model.Four training sessions were conducted for 25 novices under the guidance of 2 experts.Eventually,10 novices completed ESD operations on a total of 89 patients after the training.The resection effectiveness,resection speed,complication rate,and novice performance before and after the training were compared.The data regarding the effects of the training and the model were gathered through a questionnaire survey.Results:The results of the questionnaire on rural hospitals showed that endoscopists in rural hospitals had fewer opportunities to complete ESD operations,while few had experience in ESD training.In terms of the simulation effect of the model,ETM-CP was evaluated as similar to the live pig in all aspects(P>0.05).In practice,operators using ETM-CP have higher heart rate,larger cutting area and faster cutting speed compared to plastic silicone models(P<0.05).The questionnaire analysis revealed that the ESD theoretical knowledge,skill operation,and self-confidence of novices were improved after the training(P<0.05).The resection time per unit area had a correlation with the number of training periods(rs=-0.232).For novice performance,the resection time per unit area was shortened(P<0.05).There was no difference in patient performance between the novice group and the expert group after the training in terms of en-bloc resection,R0 resection,complication rate,endoscopic resection bleeding(ERB)score,muscularis propria injury(MPI)score,and resection time per unit area(P>0.05).Conclusions:The ESD training system constructed based on the ETM-CP model has the ability to improve the level of rural gastrointestinal endoscopists and is suitable for promotion in rural medical institutions.