2019-4-17 lecture note (New training of EGC and ESD) Thank you chairman for your nice introduction. It¡¯s a great honor for me to talk in this prestigious meeting today. Topics of my presentation will include various issues of ESD. First topic is endoscopy training with simulators. It is difficult for surgeons to learn endoscopy skills in Korea. But we, at Samsung Medical Center, teach anyone who wants to learn endoscopy, such as surgeons, and family medicine doctors. Our new style learning starts with box simulator training followed by description exercise. What is BOXIM? In 2005, I found a box simulator in the Olympus company booth. I bought the simulator immediately, and started BOXIM training at my center. What kind of simulator is the best for the beginners? Do you think the computer simulator is better? NO. Box simulator is much useful for the endoscopy beginners. We are using the Olympus system at SMC clinical simulation center. We also use the Fujifilm systems at the simulator room in the endoscopy unit. For BOXIM workshops, we mostly use the rental endoscopes from Pentax, which is a brand new system. For the biopsy training, home-made simulator box is used. We are running the regular BOXIM workshop twice a month. We are running the regular BOXIM workshop twice a month. During the KINGCA2019 Master Class, we had a special BOXIM training for foreign surgeons. We support BOXIM training at local hospitals. Picture in the left is the BOXIM training at Chungbuk University Hospital. I recently started teaching the medical student. To my surprise, they learned the endoscopy skills very quickly. I think is because they are young and flexible. For the endoscopy learning, the younger is the better. This is a typical program for BOXIM workshop. There are three short lectures, and 2 hours of hands-on training, and 1hour of self training. How to hold the endoscope is quite important. I recommend three finger method, because it does not make pain in your forearm. One of the most common musculoskeletal problem is DeQuervain¡¯s tenosynovitis of the left thumb. By using three finger method, you can prevent it. Torque rotation is the most important concept of moving the endoscope. Swinging the left hand is not efficient and it may cause pain in your shoulder. Torque rotation is like twisting the axis of a clock by rotating the minute hand. In the real procedure, torque rotation is made by lifting the boots portion This is the sequence of stomach observation. Passing the throat is a very important skill. Many surgeons are coming to our training center, and every one in this room is welcome. Next topic is description exercise workshop We recommend to describe following the SMC style, which means location, size, major finding, minor finding, impression, and classification. Description exercise workshop is a very interactive course. The next topic is how to learn ESD This is the first small clinical report on endoscopic treatment of early gastric cancer in Korea in 1996. Professor Á¤Çöä performed all the procedures, and I was the first author of that report. At that time, I was a senior resident at Seoul National University Hospital. When I learn the ESD from Japanese doctors, I made a memo about the technical details. And posted it in my personal webpage EndoTODAY. The title of the posting was õ±â´©¼³. This is one of my early experiences of gastric ESDs in 2005. I used paper medical records and polaroid films at that time. This is a national statistics. For about 3 years, 23 thousands ESDs for EGC was done. In the year 2014, it was 7,734. The mean age of patients were 65 years and male was 74%. Mean duration of hospital stay was 5 days. Mean medical cost in 2014 was 1,305 US dollars. Surgery was done in 6.6% within 3 months. This is the volume of surgery and ESD at my institution. More than 35% of gastric cancer patients are initially treated by ESD in the year 2018. There are 4 must knows before starting ESD. Indications and skills for careful endoscopic evaluation for candidate lesions, Advantages and disadvantages of each instrument, Strategies for technically successful ESD, How to manage complications. And¡¦ Hands-on training must be side by side. There are so many different types of ESD knives in the market. We need to understand characteristics of each instrument. My favorite tool is Dual knife and IT-2 knife. Recently we are also using Korean ESD knifes. Some of them have water-jet functions. This is my recent favorite ESD knife from a Korean company named Finemedix. It has IT-knife like function and Dual-knife like function at the same time. 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 speedy submucosal dissection. I think it can make the procedure quite short. Another company named Endo-upex introduced Onestep ESD knife integrating both injector and ball type knife in a single catheter. This is how I do the circumferential precutting with needle type knife - left side first, right side second, and finally horizontal cutting of the proximal part. Location also matters. In this case, en face view of the lesion is easy, but close up approach was difficult. So a large loop approach was used like this cartoon. Management of complications is a great part of ESD education. Most perforations can be treated endoscopically without surgery. When the resection is big and close to the cardia or pylorus, short-term oral steroid can be used for the prevention of obstruction. The hospital stay for gastric ESD is usually 4 days. For the beginners, hands on training using a pig stomach model is very useful. Special ESD hands-on training was held during the KINGCA2019 for the foreign surgeons at Samsung Medical Center. Before starting ESD for the first time, beginners should have some experience as the first assistant. With some cases, the main operator usually give the beginners to do part of the ESD steps. This ESD is the first procedure of my young fellow. 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, send me an e-mail (stomachlee@gmail.com). Finally, I¡¯d like show you a unforgettable case. I performed an ESD procedure in a surgical ICU. The patients was on ECMO due to dilated cardiomyopathy and was waiting for cardiac transplatation. During the pre-cardiac transplatation workup, an early gastric cancer was found. So I performed an ESD at a surgical ICU. The procedure was done as usual, but the problem was delayed bleeding. The patient cannot stop warfarin. Anyway after a successful cardiac transplantation, the patient is still doing well. Ladies and gentlemen, I¡¯d like to conclude my presentation by saying that learning endoscopy starts with box simulators trainings and description exercises in SMC. BOXIM and DEX workshops are open not only to physicians but also surgeons. Starting the role of the first assistant is the beginning of learning ESD techniques.