Real-world practices and barriers in endoscopic submucosal dissection training: International comprehensive survey

Background and study aims: Endoscopic submucosal dissection (ESD) enables curative resection of superficial gastrointestinal neoplasia but requires structured training. Although European Society of Gastrointestinal Endoscopy (ESGE)/American Society for Gastrointestinal Endoscopy (ASGE) curricula exist, real-world practices and barriers remain unclear. Methods: We conducted an anonymous web-based survey (April-July 2025) with 55 items assessing training opportunities, barriers, curriculum adherence, and quality metrics, stratified by role and annual ESD volume. Results: We received 288 responses (137 trainees, 151 trainers) from 39 countries across five geographic macro-areas. Nearly half (47.2%) had undertaken structured training, but only 46.5% fulfilled ESGE/ASGE curricula, with marked variation by center volume (69.6% in high-volume vs 26.8% in low-volume, P < 0.001). Lack of access to training models was reported by 46.5% overall, more frequently in low-volume centers. In vivo human training, animal models, and intensive courses were rated highest, whereas lack of simulators, fellowship costs, and limited time were leading barriers. Quality monitoring was reported in 62.5% of centers, prioritizing R0 and en bloc resection rates over procedure speed. Trainees valued traction and underwater techniques more than trainers. Regional differences were pronounced: North-West Europe and Asia-Pacific concentrated high-volume centers and greater curriculum adherence, whereas Africa/Middle East and South-East Europe faced resource and financial constraints. Conclusions: This international survey reveals substantial disparities in ESD training and calls for coordinated efforts to improve access to structured curricula, mentorship, and affordable training models.