My topic today is ¡®Gastric ESD Training and Practice with Pentax Imagina Endoscope and Finemedix ClearCut Knife.¡¯

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 patient 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 the ESD training bag. In the training endoscopy, it looks like the right-side picture. 

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 have been using the EndoGEL with Koken gastroscopy simulator because it is more realistic. 

I recently made a docking station, or a platform for EndoGEL ESD for the Koken gastroscopy simulator. 

Step 3 is an ex vivo pig stomach ESD.

For the realistic training. the ex vivo pig stomach is connected to the 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, near the Incheon 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 start with careful observation with white light, iScan, indigocarmine and then make markings and submucosal injection. And my fellow do the initial partial circumferential cutting. I do some more submucosal injection, and my fellow do 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 knives. Pin knife is for the fiber by fiber cutting and ball knife is for the plane cutting. 

This is my typical EndoGEL ESD setup. Pentax Imagina system and i10c gastroscope, ERBE electrosurgical unit, and Koken simulator with EndoGEL platform. The Pentax company and I developed the EndoGEL ESD training manual. 

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

We usually teach two kinds of procedures. Procedure 1 is mostly a pin knife method. Procedure 2 is mostly ball knife method. 

This is how I do the circumferential precutting with a pin knife - left side first, right side second, and finally horizontal cutting of the proximal part. 

The round red marking is a small early gastric cancer. In the EndoGEL ESD training, we skip the marking and submucosal injection steps. / In this procedure, Pentax M knife was used. / Left hand-side circumferential cutting is usually done first, because it is easier. / And then right-hand side. 

In the circumferential cutting step, try to use the torque rotation and knob control at the same time. If you press the foot-pad continuously, intermittent cutting is done like this. 

After the full circular cutting, the initial partial submucosal dissection can be done with a pin knife without traction. 

In the submucosal dissection step, traction method is very helpful to expose the submucosal cutting surface like this picture.

The approach angle is very important. / It can be changed with small wood blocks.

Initially, we use a pin knife for the submucosal dissection. 

In the middle of the submucosal dissection, we can change into ball knife. 

These are the images from the first EndoGEL ESD by a GI fellow with one year diagnostic endoscopy experience. It was excellent. 

EndoGEL ESD hands-on training can be done at any place. This was the 3rd TED conference in Daegu two years ago. 

It was another EndoGEL ESD hands-on training  at the Korea Society of GI Endoscopy, KSGE, conference at °æÁÖ. 

EndoGEL ESD hands-on training can be done at any place even at a conference booth. I love this kind of live demonstrations. 

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 at 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 observations, (3) ESD conferences and ESD planning sessions, (4) Hands-on training using EndoGEL or a live pig. The tuition fee is 2,000 US dollars. You can contact our international training office. 

From now on, I¡¯d like to talk about Finemedix ClearCut knife for gastric ESDs.

This is a ball knife named O type and O2 type. O type has a circle shaped tip and O2 type has a cross shaped tip. 

I type is a typical pin knife. 

L type and Q type are similar to Hook knife and triangle knife. 

J type is a pin knife with water jet function. 

H type is a hybrid knife with pin and ball in a single catheter. I tip is for marking and precutting and O tip is for submucosal dissection. I tip and O tip can be changed very easily. 

H2 type is a similar model with cross shaped needle tip. 

A 58 years old male was referred for the endoscopic treatment of a small mucosal lesion at the lesser curvature side of the distal antrum, just proximal to the pyloric ring. The initial biopsy result was superficial gastritis with focally atypical epithelium suspicious for adenocarcinoma. We reviewed the outside pathology slide, and the result was tubular adenocarcinoma, moderately differentiated.

This is the low power view of the forceps biopsy sample. 

In the close up, you can see aggregated atypical cells forming some glands. 

In the outpatient clinic, I carefully explained the ESD procedure and the expected outcomes to the patients. 

These are setting for the ESD procedure. I used Pentax Imagina system, Pentax i10c gastroscope, Finemedix injection, Finemedix ClearCut H-type knife for this procedure. The ERBE setting is usually EndoCUT I effect 3, duration 3, interval 3.

[Images and video]

The resected specimen was cut at 2 mm interval for the pathological evaluation. 

As you can see in the low power image, the tumor was limited in the lamina propria layer. 

In the close up, it was moderately differentiated adenocarcinoma without lymphovenous invasion. 

The final conclusion was pathological curative resection. 

Ladies and gentlemen, I¡¯d like to conclude my talk by saying that ESD training with EndoGEL artificial layer, Pentax Imagina endoscope and Finemedix ClearCut knife is very useful for the beginners. Thank you for your attention.