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A Task and Performance Analysis of Endoscopic Submucosal Dissection (ESD) Surgery

Berk Cetinsaya1, Mark Gromski2, Sangrock Lee3, Zhaohui Xia3, Doga Demirel1, Tansel Halic4, Coskun Bayrak1, Cullen Jackson5, Suvranu De3, Sudeep Hegde5, Jonah Cohen5, Mandeep Sawhney5, Daniel Jones5. 1University of Arkansas at Little Rock, 2Indiana University School of Medicine, 3Rensselaer Polytechnic Institute, 4University of Central Arkansas, 5Beth Israel Deaconess Medical Center, Harvard Medical School

Introduction: ESD is an endoscopic technique for the en bloc resection of gastrointestinal lesions. ESD is a widely-used technique in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for ESD procedure. The VESS platform will aim to provide an objective training and assessment platform. In this work, we performed task analysis of ESD surgery to determine procedural steps and performance metrics for assessment.  

Methods and Procedures: We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, lesion marking, injection, circumferential cutting, dissection, intraprocedural complication management and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics for each task. We measured task times and scores of 16 colorectal ESD surgeries performed by four different endoscopic surgeons.

Results: The average time of the marking phase, injection phase, and circumferential cutting phase are 203.4 sec. (min: 23 sec., max: 885 sec., σ:205.46), is 83.5 sec. (min: 24 sec., max: 212 sec., σ: 49.92), 908.4 sec. (min: 301 sec., max: 2390 sec., σ: 584.53) respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 sec. (min: 75 sec., max: 3196 sec., σ: 908.43). We also performed correlation analysis (Pearson’s correlation test) among the performance scores of the tasks. There is a moderate positive correlation (R=0.528, p=0.0355) between marking scores and total scores. We identified a strong positive correlation (R=0.7879, p=0.0003) between circumferential cutting and submucosal dissection scores and total scores. Similarly, we noted a strong positive correlation (R=0.7095, p=0.0021) between circumferential cutting and submucosal dissection scores and marking scores.

Conclusions: We elaborated tasks of ESD and developed quantitative performance metrics. We performed time analysis and also analyzed actual surgery performance using our metrics. These ESD metrics will be used in future validation studies of our VESS simulator for performance score computation of trainees.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 87601

Program Number: S074

Presentation Session: Flexible Endoscopy Session

Presentation Type: Podium

113

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