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Background and aimsA new external additional working channel (AWC) was recently introduced by which endoscopic submucosal dissection (ESD) can be converted to a technique termed “ESD+ ”. We aim to systematically evaluate this novel technique in flat gastric lesions and compare it to classical ESD.MethodsThe study was prospectively conducted in a pre-clinical ex vivo animal model (EASIE-R simulator) with porcine stomachs. Prior to intervention, we set standardized lesions measuring 3 cm or 4 cm in antegrade as well as in retrograde positions.ResultsOverall, 64 procedures were performed by an experienced endoscopist. Both techniques were reliable and showed en bloc resection rates of 100%. Overall, ESD+ reduced time of procedure compared to ESD (24.5 vs. 32.5 min, p = 0.025*). Particularly, ESD+ was significantly faster in retrograde lesions with a median of 22.5 vs. 34.0 min in 3 cm retrograde lesions (p = 0.002*) and 34.5 vs. 41.0 min (p = 0.011*) in 4 cm retrograde lesions. There were 0 perforations with both techniques. In ESD+ , 1 muscularis damage occurred (3.13%) compared to 6 muscularis damages with ESD (18.75%, p = 0.045*).ConclusionsBy its grasp-and-mobilize technique, ESD+ allows potentially faster and safer resections of flat gastric lesions compared to conventional ESD in an ex vivo porcine model. The potential advantages of ESD+ in terms of procedure time may be particularly relevant for difficult lesions in retrograde positions.

BackgroundEsophageal endoscopic submucosal dissection (ESD) is the gold standard for the treatment of precancerous lesions or superficial esophageal cancers. This procedure is currently performed by expert endoscopists only, and poorly standardized. We aimed to assess the technical results and outcomes of a \"tunnel + clip\" strategy for esophageal ESD procedures performed by less experienced operators for the treatment of superficial neoplasms.MethodsAll consecutive esophageal ESDs performed with the “tunnel + clip” technique for patients with early esophageal cancer in 3 centers were enrolled. Procedural characteristics, clinical outcomes, and complications were recorded.ResultsAmong 195 esophageal ESD procedures performed, early adenocarcinomas or high-grade dysplasia complicating Barrett’s esophagus were predominant (132/195, 67.7%) compared with early squamous cell carcinomas (63/195, 32.3%). The en bloc, R0 and curative resection rates were 100% (195/195), 78.5% (153/195) and 67.2% (131/195), respectively. The mean rate of ESD was 29.7 mm2/min. One (0.5%) perprocedural perforation and 7 (3.6%) postprocedural bleedings occurred, all managed endoscopically. No delayed perforation occurred. Overall, 31 patients (31/195; 15.9%) of patients developed stenosis.ConclusionsThe “tunnel + clip” strategy is safe, and allows to achieve high en bloc, R0 and curative resection rates. This standardized procedure could be used by physicians with little experience and might help spreading esophageal ESD in Western countries.

Societies need to develop more sustainable ways of living, working, and doing business. Education for sustainable development (ESD) plays a pivotal role in this endeavor. The aim is to provide people with the necessary knowledge, values, and skills for the needed transformation. Therefore, organizations of adult and continuing education must address issues of climate protection and sustainability in their programs and act accordingly in the way the organization is managed. This article reports on a qualitative study that involves leaders of adult education institutions in China, Germany, and the USA. This study seeks to investigate what these leaders do and how they act to implement ESD in their organizations. It specifically looks at current challenges, management strategies, beliefs, and values of the leaders. The results of this study show that leaders of adult and continuing education organizations recognize the need to address sustainability in adult education. However, they face many challenges in implementing ESD, including a lack of resources (e.g., finances and staff), structural barriers, and difficulties in reaching new target groups. Despite these challenges, many participants strive to develop their organizations in a more sustainable way, such as through curriculum design and campus management. Some leaders take a comprehensive approach, guided by the Whole Institution Approach, by integrating ESD into their institution’s vision and mission, establishing dedicated working groups, and forming new partnerships with external stakeholders. Overall, this study highlights the crucial role of leadership in advancing sustainability efforts.

The call for integration of competences in tertiary education for sustainable development (ESD) has been heard. Helpful competence models for ESD are available but little exists about how to put them into practice. As illustrated in this article in an initial review of competence models for change agency, this is not easy because competences are fundamentally context-bound and generalized models make little sense. Faculty staff who wish to foster competences for SD therefore need help with contextualising and operationalising competences. They often lack the pedagogic-didactic understanding needed to implement competence orientation in their teaching, in an institutional context where knowledge transmission is traditionally rated higher than competence development. Using a reflective practitioner approach, this paper addresses the need for methodological guidance by introducing a heuristic procedure and a didactic planning tool from adult education that enable lecturers to establish coherent ESD teaching-and-learning environments and curricula: the tree of science model and constructive alignment. Two case studies show how these instruments can be used to increase coherence when operationalising competences for SD. The article concludes by outlining three factors that foster integration of competence orientation in ESD: pedagogic-didactic tools, professional development for ESD, and institutional change.

If we are to understand and address today’s social, environmental and economic crises through education, we must introduce education for sustainable development (ESD) into classrooms and approach it from an integrated perspective. In so doing, this study aims to provide an overview of the current status of the still-emerging research agenda on the integration of ESD into mathematical education and statistical education. To this end, we conducted a systematic review of Scopus and Web of Science databases of theoretical and research articles published between 2010 and May 2023. In total, 32 studies were identified, conducted mostly in Europe, followed by South America, which mainly address teacher training. The results suggest that mathematics education and statistics education are an effective means of providing education focused on ESD, but that teachers still have limited knowledge and resistant attitudes. Therefore, initial and ongoing training must move towards characterizing proposals that provide examples and involve teachers in response to this challenge.

BackgroundEndoscopic submucosal dissection (ESD) and hybrid-ESD techniques are treatment modalities for colorectal neoplasia, although mostly used in the Eastern hemisphere. Only few data on ESD for colorectal neoplasia have been published in the West. We report the outcomes of colorectal ESD and hybrid ESD in a single Italian center.MethodsWe retrospectively evaluated the outcomes of all ESD and hybrid-ESD procedures for colorectal neoplasia performed over the first 2-year experience from a prospectively recorded database. Neuroendocrine tumors and adenocarcinoma with submucosal infiltration through the submucosal (SM) 2 layer or deeper were excluded. The primary outcome was the recurrence rate at the 6- to 12-month follow-up.ResultsFifty-two patients were included in the study, of which 23 underwent ESD and 29 hybrid ESD. The mean lesion sizes for ESD and hybrid ESD were similar (25.8 vs. 25.4 mm, p = 0.940), while median procedure length was significantly longer for ESD (120 vs. 60 min, p < 0.001). ESD and hybrid ESD yielded similar en-bloc resection rate (82.6 vs. 82.8%) and R0 resection rate (34.8 vs. 31%). ESD had a lower neoplasia recurrence rate than hybrid ESD (11.7 vs. 20%) and a lower bleeding rate (0 vs. 8.7%). One perforation occurred in the hybrid-ESD cohort and two perforations in the ESD cohort, of which one required surgical intervention. Non-recurrence at follow-up was associated with R0 status, en-bloc resection, and lesion size ≤ 20 mm.ConclusionOur outcomes are comparable with other studies in Western series. Studies addressing the cost effectiveness of ESD and comparing its long-term outcome with endoscopic mucosal resection in the West are needed.

Background and aimsWith an external additional working channel (AWC) endoscopic mucosal resection (EMR) as well as endoscopic submucosal dissection (ESD) can be extended to techniques termed “EMR+” and “ESD+.” These novel techniques are systematically compared to EMR and ESD under the use of a double-channel endoscope (DC).MethodsOur trial was conducted prospectively in a pre-clinical porcine animal model (EASIE-R simulator) with standardized gastric lesions measuring 3 or 4 cm.ResultsEMR+ and EMR DC showed both good results for 3 cm lesions with no adverse events and an en bloc resection rate of 73.33% (EMR+) and 60.00% (EMR DC, p = 0.70). They came to their limits in 4 cm lesions with muscularis damages of 20.00% (EMR+), 13.33% (EMR DC, p ≥ 0.99) and decreasing en bloc resection rates of 60.00% (EMR+) and 46.67% (EMR DC, p = 0.72).ESD+ and ESD DC were both reliable concerning en bloc resection rates (100% in all groups) and adverse events (0.00% in 3 cm lesions, 12.50% muscularis damages in both ESD+ and ESD DC in 4 cm lesions).Resection time was slightly shorter in all groups with the AWC compared to DC although only reaching significance in 3 cm ESD lesions (p < 0.05*).ConclusionsWith the AWC, a standard endoscope can easily be transformed to double-channel functionality. We could show that EMR+ and ESD+ are non-inferior to EMR and ESD under the use of a double-channel endoscope. Consequently, the AWC presents an affordable alternative to a double-channel endoscope for both EMR and ESD.

Teaching formats involving non-university partners are increasingly gaining importance to deliver key competencies needed in higher education for sustainable development. Such teaching formats may also create new transdisciplinary spaces that allow different actors to impact regional transition towards sustainable development. Against this background, this article focuses on how universities foster regional transition through teaching, particularly in collaboration with local non-university. Using the interdisciplinary certificate programs on sustainable development offered by the German Universities of Tübingen and Duisburg-Essen as case studies, we analyze the potentials and challenges of teaching programs on sustainable development for promoting regional transition. Leaning on the multi-level-perspective-approach, we have used qualitative interviews to shed light on the design of cooperation between the university and regional partners as well as the creation and integration of transdisciplinary learning spaces. This paper shows that the impact of such teaching formats on the regional transition consists primarily of awareness and network building. One of the most fundamental challenges faced is unequal power relations in terms of access to resources, financing, and doing the course planning. Simultaneously, co-design, mutual understanding, and collective decisions on roles and responsibilities and—especially—empathy and trust are crucial factors for successfully teaching cooperation towards regional sustainability.

A newly developed articulated through‐the‐scope traction device, TRACMOTION, has been used clinically for endoscopic submucosal dissection (ESD). However, there are few reports on the characteristics of this device and the lesion types for which it is most effective. Therefore, we evaluated its optimal use, efficacy, and safety clinically in animals. Subsequently, we confirmed the safety and efficacy of ESD using this device in humans. Two live swine were used; one underwent conventional ESD (C‐ESD) and the other traction‐assisted ESD (T‐ESD). To examine the traction effect at each resection site, three ESD ulcers (greater curvature/anterior wall/posterior wall) with a diameter of approximately 40 mm were created in each swine. Based on our preliminary experiments, scissor‐type and needle‐type knives were used in the T‐ESD and C‐ESD groups, respectively. The primary endpoint was the resection speed, and the secondary endpoint was the degree of muscle layer damage. T‐ESD was faster than C‐ESD on the posterior wall, similar to the greater curvature, and T‐ESD was slower than C‐ESD on the anterior wall. There were no cases of intraoperative perforations. Obvious muscle layer damage was observed in post‐C‐ESD wounds on the anterior wall. The submucosal layer was retained in all post‐T‐ESD wounds. Although this study showed that ESD with TRACMOTION may be safe and effective, it is necessary to consider that it may be unsuitable for some lesions. This may be due to device characteristics and requires further validation.

Although the evaluation of system strength under high penetration of renewable energy sources (RESs) has been widely studied, traditional short-circuit ratio (SCR) indicators mainly focus on the interactions among RESs and are concentrated on steady-state research, neglecting the dynamic regulation effect of energy storage devices (ESDs) on system stability. In addition, most of the existing optimization methods aim to improve economic efficiency and lack system stability analysis based on SCR quantification. Therefore, this paper proposes an ESD-considered short-circuit ratio (ECSCR) that incorporates the contribution of ESDs to the short-circuit capacity of nodes. A bi-layer optimization strategy for the active support long-and short-term energy storage device is developed. The upper-layer optimizes the installation locations of ESDs by maximizing the minimum ECSCR (MinECSCR) on the RES buses, while the lower-layer uses the Newton-Raphson algorithm to dynamically adjust the power distribution of ESD to balance stability and economy. Specifically, when the ECSCR is less than the critical short-circuit ratio (CSCR), the fast-response flywheel energy storage (FES) and battery energy storage (BES) prioritize the restoration of stability; when the ECSCR is greater than the CSCR, the lower-cost thermal energy storage (TES) serves as the main power generation unit to minimize operating costs. The verification of the improved IEEE 9-bus, 39-bus system, and 14-bus system shows that compared with traditional SCR indicators, the proposed ECSCR can significantly enhance the nodal strength and reduce operating costs while ensuring system stability.