The ESGE curriculum outlines structured competency standards for endoscopic submucosal dissection (ESD) training, including minimum case volumes, supervised learning, and defined performance benchmarks (1). This study evaluated the first-year outcomes from two post-CCST advanced endoscopy fellows in a Western tertiary centre.

All consecutive ESD procedures performed by two fellows under expert supervision between October 2024 to October 2025 were prospectively recorded. All ESD procedures were performed using the saline-immersion/irrigation technique (SITE), due to its advantages, including improved visualisation through optical clarity and magnification, natural buoyancy, enhanced conductivity through saline (with optimal vessel pre-coagulation and management), and patient comfort. Descriptive analysis was performed for demographics, lesion characteristics, technical performance, and histopathological and safety outcomes. Training milestones were mapped against ESGE curriculum standards.

A total of 54 ESD procedures were performed in 42 patients, distributed as 29 and 25 procedures per trainee, respectively, either totally (15, 37.5%) or partially assisted by an expert supervisor (27, 64.3%). Median proportion of the procedure performed by fellows was 60% (IQR 30-100). Mean patient age was 66.9 ± 14.4 years; 64.3% were men. Median ASA was 1 (IQR 1–2). Lesions were located in the colon (61.9%), rectum (31%), and stomach (7.1%). Median lesion diameter was 50mm (IQR 40–65).

Macroscopic morphology included 57.2% LST-G, 26.2% LST-NG, 4.8% sessile lesions, 4.8% semi-pedunculated and 2.4% pedunculated and submucosal. A degree of submucosal fibrosis was present in 54.7% (F1–F2).

En bloc R0 and curative resection was achieved in 92.9%. One case (2.4%) was abandoned due to suspected deep submucosal invasion and referred for surgery which confirmed invasive adenocarcinoma. Median procedure time was 135 minutes (IQR 90–177). Overall median resection speed was 13.1 mm²/min (IQR 7.6–18.7). When analysed quarterly, resection speed progressively increased: Q1: 9.58 mm²/min, Q2: 13.46 mm²/min and Q3: 18.30 mm²/min, demonstrating steady procedural efficiency improvement during training. Also percentage of procedure performed by trainee was analysed quarterly increasing from a median of 65% (IQR 8.75-95) to 100% (IQR 50-100) from Q1 to Q3.

Adverse events included 3 intraprocedural perforations (7.1%), one (2.4%) in the rectum and 2 (4.8%) in the ascending colon; all were managed successfully endoscopically with through-the-scope clip-closure without hindering the procedure outcome or patient safety. Operator-delivered conscious-sedation was used in 92.9%, including all colorectal cases. General anaesthesia was only used for gastric lesions.

Training was conducted under full supervision, following ex-vivo and model-based practice, observation of >50 expert cases, and participation in >3 hands-on courses.

After one year of structured ESD training, which included completion of recommended preparatory steps such as ex-vivo courses, animal models, theoretical instruction, and acquisition of independent advanced endoscopic skills, both trainees achieved performance standards outlined in the ESGE curriculum. However, in our series, most lesions were located within the colon rather than the rectum, reflecting the real-world case availability within our centre. If training had been restricted exclusively to rectal lesions, the recommended case volumes could not have been met.

These findings suggest that while the ESGE curriculum is practical, safe, and feasible when implemented under direct expert supervision, some flexibility regarding the recommended lesion location may be necessary to allow trainees to reach adequate numbers within Western training environments. Allowing supervised exposure to colonic lesions earlier in training may support broader applicability of the curriculum without compromising safety or outcomes. The consistent performance and safety outcomes observed with SITE-ESD suggest that this technique may also be particularly advantageous for facilitating safer early training for colonic ESD.