Today¡¯s topic is ESD training in Korea. 

According to a recent WHO report, Korea is number 3 in the incidence of gastric cancer both in males and females. 

However, the incidence of gastric cancer in Korea is slowly decreasing. For the last 20 years, the age-standardized incidence has decreased by 32%. 

Treatment of gastric cancer is rapidly changing. In recent years, one third of gastric cancers are treated by endoscopy and two third of gastric cancers are treated surgically. 

Every year, about 10 thousands of early gastric cancers are treated by ESD in Korea.

I think that endoscopists should learn the ESD techniques in their training course, which is a very rare situation. The ESD training must be stepwise. EndoGEL ESD training is the ideal model for the ESD beginners. 

The first topic is the basic knowledge for ESD.

In order to start gastric ESD, you should know the advanced diagnostic endoscopy including chromoendoscopy and magnifying endoscopy, indications, knives and snares, ESD techniques, and pathology interpretation skills. 

There are two types of indications. Absolute indication means differentiated type mucosal cancer without ulcer and not bigger than 2 cm.  Expanded indications include differentiated type EGCs bigger than 2 cm and selected cases of undifferentiated type EGCs.

By the Korean guideline, absolute indications are strongly recommended and expanded indications are weakly recommended.

There are so many different types of ESD knives in the market. We need to understand advantages and disadvantages of each instrument. 

Many knives and snares are developed locally in Korea. Some of them have multifunctional characteristics and water-jet functions. 

This case shows how I use the H-type ESD knife. At first I start with I-type tip for marking and circumferential cutting. And than I change into O-type knife for fast submucosal dissection. I think it can make the procedure quite short. 

The hospital stay for gastric ESD is usually 4 days. 

ESD training should be stepwise.

From now on, I¡¯d like to talk more about ESD training. Stepwise ESD training at my institution starts with basic training with an ESD training bag and doll. Next step is EndoGEL ESD, Ex-vivo pig stomach ESD, live pig ESD and finally the real clinical case ESD. 

Movement of ESD knife is mostly circular and horizontal. For the training of knife control in the circular and horizontal direction, I developed an ESD training bag and doll.

This is the artificial layer EndoGEL.

It was originally released in a paper box, but the paper box setting is unstable and un-natural to do the ESD procedure. 

So, we developed an EndoGEL ESD training module with the Koken gastroscopy simulator.

I recently made two docking stations, or a platforms for EndoGEL ESD in the Koken simulator setting, one with Penxtax and one with Olympus. 

This is my recent EngoGEL ESD training unit with Pentax Imagina system and its training manual. 

For the EndoGEL ESD, I use an electrosurgical unit from the ERBE company, model 300D. My ESU setting is monopolar EndoCut Q with coagulation effect 3, duration 3, interval 3. 

For the real patient ESD, I use EndoCut I rather and EndoCut Q. 

For the EndoGEL ESD training, we are using two kinds of endoscopic knifes. Dual knife is for the fiber by fiber cutting and IT-2 knife is for the plane cutting. 

The pin knife usually has a 2mm tip. It is useful for detailed procedure such as gastric ESD at difficult location, colonic ESD, esophageal ESD and POEM procedures. 

I will show you the EndoGEL ESD procedure using a pin knife named M knife from the Pentax company. For the circumferential cutting with a pin knife, I usually do the left side clockwise cutting first, right side counter-clockwise cutting second, and finally do the horizontal cutting of the proximal part. 

Now, I'd like to start the EndoGEL ESD hands-on training. I put the EndoGEL plate on the Koken gastroscopy simulator using a docking station. The red circle is the target of today's training. In the EndoGEL ESD hands-on training, we will pass the marking and submucosal injection steps. The first step is the circumferential cutting, and the mucosal pucture will be done at the seven o'clock direction. The cutting is done continuously in the clockwise direction. The second cutting is done from the 5 o'clock to the 12 o'clock in the counter-clockwise direction. Press the M knife slightly and keep going on the mucosa. It's something like a surfing. Control the knob and gently rotate your body to make a counter-clockwise movement. To make a horizontal cutting, lifting the control part is helpful. We call it "boots-up". In this position, you can use right-and-left knob to make a horizontal movement. In order to do the submucosal cutting, exposuring the sumbucosal layer is very important. To do this, we use a traction method using a clip and weight. Now, you can clearly see the exposed submucosal layer. Submucosal cutting is usually from the right to left direction. You should control the catheter carefully to make a best cutting depth. Cut the submucosal layer, fiber by fiber using control-and-cut technique. In the submucosal dissection step, the approach angle is important. The ESD knife should be close to the mucosa. In order to simulate this low approach angle, we are using a few wood blocks like this... Now, the approach angle became lower. The final cutting-line should follow the the mucosal surface to avoid the submucosal tunneling. That's it. The ESD simulation is done. I recommend to do the EndoGEL ESD training 10 times before you try the live pig ESD or a real patient ESD. Thank you very much.

Ball knife has a insulated tip at the distal end. The ESD knife is usually longer than pin knife. In some models, there is a triangle shaped knife below the insulated tip. 

In the procedure 2, the initial step is a small puncture at 12 o¡¯clock direction. And then, using IT-2 knife, circumferential cutting is done following the steps.

ESD training with ball type knife is also possible in this training unit.

This is the first EndoGEL ESD of a second-year GI fellow. 

Recently, many local hospitals run their own ESD training session. This is a recent EndoGEL ESD training at ´ëÀüÀ»Áö hospital. 

Sometime foreign doctors visit SMC for EndoGEL ESD training.

The next step is the ex vivo pig stomach ESD. Classically we have used the simple silicon box. 

For the realistic training, we recently use a metallic box and connect it to the Koken gastroscopy simulator. Due to the safety concerns, the ex vivo pig stomach ESD should be done at the animal surgery lab. 

The next step is the live pig ESD. 

We are doing the live pig ESD session at KTEC endoscopy training center at Songdo, near the international airport. You can see Dr Amarbat in the picture. 

The final step is of course a real patient ESD. 

Real patient ESD is actually a give and take method. There are trainer steps and trainee steps. 

I start with careful examination of the lesion and make some markings around the lesion,,,

There are a lot of programs to help ESD beginners, such as bedside assistance, Wednesday ESD conference with in-depth case review, E-mail consultation, tele-mentoring, and on-line ESD seminars

When a young doctor finished his or her first ESD, I regularly have a 1:1 personal coaching session. In reviewing the endoscopic images, we usually have a long discussion about a lot of technical and oncological issues. 

This is a very difficult ESD case for the beginners. I helped the young doctor doing her ESD procedures.

This is a typical case for Wednesday ESD seminars. 

E-mail consultation is always available. Please send me an e-mail, when you have any questions about any issues regarding the ESD for EGC. 

The next topic is the training opportunities. Where can I get the EndoGEL ESD trainings?

Korean Society of Gastrointestinal Endoscopy organized a lot of diagnostic and therapeutic endoscopy workshops. Recently the Society organized the nice workshop with focus of the gastric and colonic ESD. In includes EndoGEL ESD, ex vivo pig stomach ESD, live pig stomach ESD and live pig colonic ESD.

Next Korean Society of GI Endoscopy hands-on workshop will be held on January 8th next year at Songdo Olympus training center. In the morning, live pig gastric ESD hands-on training will be done for fellow doctors. In the afternoon, more advanced techniques such as colonic ESD, esophageal ESD and POEM will be done for young faculty members.  

The Society sometime prepare EndoGEL ESD trainings sessions in the regular yearly conferences. 

There are some EndoGEL ESD training sessions in various medical meetings. This is the 3rd therapeutic GI endoscopy and ESD training, TED conference, in Daegu a few years ago. 

Many individual hospitals also have their regular or occasional EndoGEL ESD hands-on sessions. This is a recent EndoGEL training for Saudi Arabian fellows at my hospital. 

Some EndoGEL ESD training sessions are organized by endoscopy instrument companies. This is an Olympus EndoGEL ESD training workshops. 

For the foreign doctors, one-week ESD training course is also available at Samsung Medical Center. It consists of (1) introductory lectures, (2) ESD observation, (3) ESD conference and ESD planning session, (4) Hands-on training using EndoGEL (artificial layer) or live pig. 

Tele-mentoring using iPhone Facetime app is a very useful tool for ESD beginners. International mentoring is also possible. If you want some real-time comments from me, please send me an e-mail (stomachlee@gmail.com).

I¡¯d like to conclude my talk. ESD training in Korea, especially at Samsung Medical Center, is typically based on the EndoGEL ESD training and live pig ESD hands-on seminars. Our program is open to foreign doctors. You are always welcome.  

Thank you for your attention.