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. Traditional endoscopy training means observation and do it yourself. New style endoscopy learning starts with box simulator trainings 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 and basket are used. 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 also support BOXIM training at local hospitals. I performed 12 BOXIM workshops outside my hospital for the last 8 months. I recently started teaching the medical student. To my surprise, they learned the endoscopy skills very quickly. I think it 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. Of course, colonoscopy BOXIM is available at my institution. 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. Final topic is ESD education. 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. Next topic is endoscopes and knives These days, I have used a new endoscope system called Imagina from Pentax for gastric ESDs. Imagina endoscopes have many advantages such as brighter image, water jet function, low weight, but as a therapeutic endoscopist, better close up view and more angulation is the most attractive aspect. This is a recent ESD procedure using Pentax imagina endoscopes. +++++ 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. Due to the time limitation, it is difficult to talk a lot about technical aspects of ESD. 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. Traction method is also very useful for lesion at a difficult location. In my opinion, the ESD training should be stepwise. Stepwise ESD training at SMC starts with basic training with ESD bags and ESD brushes. 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 training modules. ESD bags for circular training, and ESD brushes for horizontal training. +++++ This is the artificial layer EndoGEL. Artificial mucosa (EndoGEL) is a good alternative of ex-vivo pig stomach. It was originally released in a paper box. But we are using the EndoGEL with Koken gastroscopy simulator, because it is more realistic. I recently made a docking station, or a platform for EndoGEL ESD in the Koken simulator. In the endoGEL ESD hands-on, traction method is usually needed due to the mucosa is not real. We are using Pentax Splash-M knife for the EndoGEL ESD hands-on training. Splash M-knife is a new multi-functional ESD knife from Pentax company. It has a needle-type tip with hooking mechanism. AT the distal end of the knife, there is a metal plate which is useful for bleeding control even in retracted position. The length of the ESD needle is 2mm in extended position and 0.5mm in retracted position. In my recent experience with Splash M-knife, I found three advantages. First the hooking mechanism is very useful for the submucosal dissection step. When a lesion is located at difficult location and the approach is not easy, I usually used the Dual knife and IT-2 knife for a patient. But with the Splash M-knife, I can do the procedure without using the IT-2 knife. Second, the metal plate at the distal end of the Splash M-knife provides enough contact area for the bleeding control during the ESD procedure. Finally, the procedure time is much saved due to the water jet function. In a recent study from Japan, ESD using Splash-M knife appeared to reduce the usage of hemostatic forceps during the gastric ESD without increasing the adverse effects. It can reduced the total cost of the treatment. This is my recent case of ESD using Splash-M knife. I didn¡¯t use hemostatic forceps in this case. This is EndoGEL ESD using needle type knife and traction method, which we will do in this morning. For the beginners, hands on training using a pig stomach model is very useful. Ex-vivo pig stomach ESD should be done in a special facility such as the animal lab, so it is very difficult and expansive to do ex-vivo pig stomach ESD workshop. So we don¡¯t do it often. The best and last option for ESD training before the real clinical case is live pig ESD hands-on training. We are regularly doing live pig ESD hands-on workshops at Songo, Incheon. 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). 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. The tuition fee is 2,000 US dollars. Ladies and gentlemen, I¡¯d like to conclude my presentation by saying that ¡¦ Thank you very much for your attention.