I am Jun Haeng Lee from Samsung Medical Center, Seoul, Korea. Today, I's like to talk about diagnostic and therapeutic endoscopy with emphasis on how to teach and learn with simulators and hands-on trainings.

The first topic is the diagnostic endoscopy training with simulators.

Traditional endoscopy training was observation and do it yourself. But recent endoscopy training starts with box simulator training followed by description exercise. 

What¡¯s the goal of a box simulator training? It¡¯s teaching basic skills and good habits. 

Left-hand side is a Koken simulator endoscopy video clip and you can compare with the real patient endoscopy. As you can see, it is quite similar. Beginners can learn a lot of technical tips with gastroscopy simulator training. 

For the box simulator training, BOXIM, we need simulators, endoscopes and training programs. 

I found a box gastroscopy simulator at the Olympus booth in 2005. 

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 more useful for the endoscopy beginners. 

Professor Jin Hyuck Lee developed a new gastroscopy simulator using a 3D printing technology. It is more realistic than the Koken simulators, but a little bit difficult for the beginners. So, I use the Korean simulator only in the final stage of the hands-on training. 

Regarding endoscopes, Olympus, Fujifilm, and Pentax are dominant players in Korean endoscopy market. All three vendors are providing state-of-the-art endoscopes. At Samsung Medical Center, we are using endoscopes from all three vendors for endoscopy training. I think every endoscopist should be familiar with all three vendors. 

We are using the Olympus system at SMC clinical simulation center. We call it ¡°the retirement home of the old endoscopes.¡± 

We also use the Fujifilm systems at the small simulator training room in the endoscopy unit. It¡¯s my main playground. 

I am using the Pentax endoscopy system for the therapeutic endoscopy training. Pictures in the right-hand side is an EndoGEL docking station that I developed with the Pentax company. 

For the biopsy training, home-made simulator box and baskets are used. 

This is a typical program for 2-day BOXIM workshop for foreign doctors. Basic and intermediate course is 4 hours each. We also have one day program for busy Korean doctors. 

BOXIM workshops at SMC clinical simulation center are open to anyone who want to learn endoscopy. It¡¯s not only for physicians. Surgeons, OK. Family medicine doctors, OK. Pathologists, OK. Medical students, OK. Everyone is welcome here. 

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 in the year 2019. 

My second topic is the ESD training. The ESD training should be stepwise. 

Stepwise ESD training at SMC starts with a ESD training bag. 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 bags.

This is an ESD training bag. 

In the training endoscopy, it looks like this. 

You can train the horizontal and circular movement with biopsy forceps on the ESD bag. What is important in this step is feeling the tactile sense. Try to touch the surface softly. 

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. 

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

Step 3 is ex vivo pig stomach ESD.

For the realistic training. the ex vivo pig stomach is connected with Koken gastroscopy simulator. We are doing the ex vivo pig stomach ESD training at the animal surgery lab. 

Step 4 is the live pig ESD. We are doing the live pig ESD training at KTEC endoscopy training center at Songdo, near the international airport. 

The final step is of course a real patient ESD. 

We divide the ESD steps into trainer steps and trainee steps. Experience is more important in the trainer steps like marking and hemostasis. Technical aspects are more important in the trainee steps like circumferential cutting and submucosal dissection. 

This is an example. I started with careful observation with white light, iScan, indigocarmine and then make markings and submucosal injection. And my fellow did the initial partial circumferential cutting. I do some more submucosal injection, and my fellow did the next step. And then give and take, give and take¡¦ until the end of the procedure. 

From now on, I¡¯d like to talk more about the endogel ESD training. 

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

Needle type knife typically has a 2mm tip for the detailed cutting. 

Insulated tip knife looks like this. The electronic knife is usually 4 mm long. 

This is my typical EndoGEL ESD setup.

For the endogel ESD, we use monopolar current EndoCUT with Q effect 1, duration 3 and interval 3. 

We usually teach two kinds of procedures. Procedure 1 is mostly a needle type knife method. Procedure 2 if mostly IT-2 knife method. 

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. 

Steps of EndoGEL ESD hands-on training

You need to cut the whole mucosal layer.

Initial partial submucosal dissection is done with needle type knife without traction. 

In the submucosal dissection step, traction method is usually needed due to the mucosa is not real. 

In the submucosal dissection step, the approach angle is very important. It can be changed with small wood blocks.

Initially, we use a needle type knife. 

In the middle of the submucosal dissection, we change into IT-2 knife. 

These are the images from the first EndoGEL ESD of a GI fellow with one year diagnostic endoscopy experience. 

We are organizing a lot of EndoGEL ESD hands-on training sessions in various occasions.  We regularly have EndoGEL ESD training sessions at SMC endoscopy unit. 

EndoGEL ESD hands-on training is also possible at local hospitals. This is a recent endoGEL ESD training at ÀüºÏ university hospital. The fellows really enjoyed the hands-on training. If you want to hold an EndoGEL ESD hands on training at your hospital, please give me a call. I will help you. 

This was the 3rd TED conference in Daegu last year. 

We hand an EndoGEL ESD hands-on training session at the Korea GI endoscopy society conference 2019. 

EndoGEL ESD training can be done at any place even at a conference booth. It was a live demonstration and hands-on training at KDDW 2019.

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 diagnostic and therapeutic endoscopy simulators are very useful tools for the endoscopy beginners. 
ESD learning should be stepwise. 

Thank you very much.