So, thanks, Dr. Fukami and Dr. Yahagi for inviting me here. I'm really happy to be part of this course, and I think everyone should also be very happy to be part of this course. We're really lucky to be able to meet and see a lot of these great talks and talk with these great endoscopists. So, I'll be talking to you about training in ESD. These are my disclosures, and the outline will go over the goals of training, some challenges in training in North America, and doing our best to overcome these challenges. So, all roads lead to the same place. So, traditionally, the master-apprentice model of training in Japan has really been the gold standard and has produced some of the best endoscopists in the world, and that's been the traditional training model. There are various other training models, so fellowship in Japan after doing therapeutics, so that's what I did. I went there for about 15 months with Dr. Inoue, or doing a fellowship in North America with multimodality training with explants, live models, courses such as this. And some other models are, you've been in practice for a number of years, and now you want to learn ESD, or a concomitant training in ESD during your therapeutics. So, all these are various ways that you could potentially train in ESD, and the hope is that they all get to the same place, which is proficiency in ESD. We have a high unblock resection rate, so greater than 90 percent, an R0 resection rate of greater than 80, and a complication rate, ideally, of less than 5 percent. So this is the traditional training model in Japan, and obviously there is variability, but it starts with didactic education, with extensive knowledge in optical diagnosis and magnification to ensure that it's being done on the appropriate lesions, then generally observing for at least 20 cases, equipment setup and assisting for at least 20 cases, and then performing the preoperative endoscopy with magnification, and performing initial ESD on gastric lesions, and now I understand they're also being done on rectal lesions, and then reviewing the videos of the procedures, and figuring out what went wrong, what went well, and how things can improve, and all being done under the supervision of an expert endoscopist. So some of the challenges to this in North America are generally the limited volume we have, the lower incidence of gastric cancer, optical diagnosis, differences in culture or differences in mindset, and setting expectations before you embark on training. So in terms of limited volume, there are relatively few North American endoscopists that are proficient in ESD and very high volume. So we know in Japan, for example, at NCC, at Keio University, at Jichi, and Kobe, they do several hundred ESDs a year, where there's not many North American centers that are able to do this. So implementing the Japanese training model is a bit challenging in that regard. In North America, the incidence of gastric cancer is generally about 5 per 100,000, whereas in higher incidence areas, it can be up to 40 or more per 100,000 per year. However, which comes to the optical diagnosis part, there are likely missed opportunities for us to perform gastric ESD. Missed rates of early gastric cancer are up to 20% in Western studies. So this is an example of a case that was missed over a few years, and it was one of the first gastric ESDs that I performed when I returned. So a very subtle flat lesion, but again, if examined properly, you can detect it, diagnose it, and resect it appropriately. So that brings us to optical diagnosis. So in Japan, this is ingrained in the training. It's an essential skill, and it's been available for quite some time, as far back as the 80s in prototype form. And only recently has the importance of optical diagnosis been recognized in North America. However, its practice and its training is still quite limited. But it is a critical skill to have. So in order to detect and characterize and choose the most appropriate treatment for lesions, which includes ESD, EMR, surgery, optical diagnosis is really a fundamental skill to have. So this is just an example, 386 patients. This is out of the US, 386 patients with polyps sent for surgery were retrospectively reviewed, and only about 16% contained invasive carcinoma, most of them being SM1, with the remaining being mucosal polyps. So at least 80% could have been resected endoscopically in this case. This is a series out of Canada, very similar results. Again, at least 60% of them could have been resected endoscopically, and more if they had included superficial carcinoma. Differences in culture or mindset. So this is one of the early circumferential ESDs I did in Canada. So it was a patient that had previous EMR, multiple RFAs, and they couldn't eradicate the Barrett's, then had persistent dysplasia, as well as buried Barrett's. And we subsequently did a circumferential ESD, which was successful. So one of the first questions I get from North American endoscopists is, how long did that take? Whereas speaking with my Japanese colleagues, they generally ask, what was the result? So definitely time is an important factor to consider, but it shouldn't be the first thing we consider. And we have to, I think, get out of the mindset that speed equals quality. So it's definitely important, but it shouldn't be the first thing that we think of, especially when we're starting to do ESD. So in terms of setting expectations, so this is a figure from Dr. Aihara. So the traditional master-apprentice training model, going from didactic education, assisting, and then doing early cases. So in Japan, generally takes, again, three to four years. And again, this varies depending on the center and the training, but three or four years' time. So this comprehensive Western approach, where courses such as this, formal didactic teaching, explant models, live porcine models, we hope that we can decrease that time to two to three years. The thing that I think is important for you to understand, or to set your expectations appropriately, that it takes years to become competent and proficient in ESD. And it's kind of a long-term investment of your time and effort that you're going to have to do to do it well. So in terms of overcoming the challenges, these are some of the ways we can do it in terms of building our knowledge base, hands-on training models, observing experts perform ESD, and if possible, being proctored by an ESD expert. This is a study that Dr. Yohagi was involved in. It was a prospect of RCT of about 40 students, both from France as well as Japan. And they're randomized to a self-learning software that was very detailed and gave specific tips on how to hold the scope in terms of maneuvers to do, how to avoid certain pitfalls versus a control, which is generally just a standard video showing the ESD. And the rate of complete resection at 30 explant lesions was 84% in the control group and 50% in the software group and 50% in the control group. And the perforation rate as well was significantly lower, 0% versus 20%. So this just kind of emphasizes the importance of the knowledge base as well as the hands-on training aspect. In terms of observing ESD, this is from Dr. Dragunov's paper and his experience of 38 explant ESDs and basically looked at the pre- and post-observation resection time. And they used a regression model in the middle cases to avoid the bias in terms of the learning curve and found, despite the correction, they still had a much shorter resection time, 32 minutes versus 61 minutes, after he observed the experts for about five weeks in Japan. This is a prospective study looking at the feasibility of rectal ESD and the complete resection rate over one year without a proctor. And it just shows you that without a proctor early on, there's a very high complication rate and a poor on-block resection rate. So here, in terms of the consecutive blocks, there are procedures of five procedure blocks where you can see that the perforation rate is up to 60% early on and the on-block resection rate is as low as 20% early on. So the supervision of an ESD expert, especially early on, is important to keep the complication rate as low as possible at an acceptable amount and also to ensure the on-block resection rate remains high. So to ensure the quality of the procedure persists despite being done by a trainee or someone early on in their learning curve. In terms of training at our center, this is the model that we are working with. We start with optical diagnosis knowledge base, setting up the equipment, assisting as well in cases, examination of lesions with magnification, initially starting the cases that are done with EMR with pre-cut or hybrid EMR, then doing mucosal incision and preliminary dissection for hybrid ESD cases, then dissection and flap creation for ESD, and then completion of cases. And during this time, there's ongoing practice with a simulator that we have as well as explant models with and without a proctor. So once you start performing ESD, I think the most important thing is a detailed review of your procedure videos, then continuing to observe experts and seeing how they manage things that you had challenges with, expanding your knowledge and skills by, again, courses like this and other courses and live demonstrations, continuing your independent ESD, and continuing a detailed review of your videos. And then when you have proficiency with easier lesions, you can slowly expand your experience with more challenging lesions and challenging locations, and then continue your detailed review of your cases. And this is really a way you should practice indefinitely throughout your career, and you can argue for any of your procedures. This kind of quality improvement should be something that you constantly do throughout your experience in your advanced therapeutic procedures. So in summary, we went over the goals of training, challenges of training in North America, and some ways that we can hopefully overcome it. So thank you very much for your attention. I know it's been a long day, and everyone's tired, so thank you. Any questions? Yes, Dr. Green? What issue in the United States is practical? What issue in the US is practical? Where do you find, you know, a, there's licensing issues that's practical, and b, it's not, and c, do you go to the practical practice once a year? If it's virtually, what's the legal responsibility for the practice? Do you have that issue in Canada? Yeah, I think in Canada the, Let me rephrase the question because, So the question was in terms of issues with proctors, so in terms of medical legal issues, in terms of accessibility issues, do we have that problem in Canada, as I'm sure it's an issue here. So I think that's where, you know, courses such as this are quite important, so in terms of trying to build a relationship, and if there are different proctors available in the US, so different experts that you have in the US, and or obviously the ability, if you can always go overseas, that's great, but if you can't, trying as best as you can to find, you know, proctors here, or even proctors on explant models to watch you work on explant models, similar to here, to refine your skills. But in terms of the medical legal aspects, especially in terms of virtual proctoring, I think that's, you know, still quite problematic, and I don't think there's an easy way around it, unfortunately. Yeah, one thing I'm going to add, the proctorship in the United States is a major difficulty come from licensing. The temporary licensing can be acquired depending on the institution, but they can have a significant hurdle. You may not be able to get the license easily. Insurance-wise, you can be potentially covered by your work insurance, or the day insurance is not that expensive, so the department or hospital can cover the physician's insurance, malpractice insurance for the day or two. But again, the licensing issues is a major thing, so the goal I had a long time ago was to raise the expert, one state, at least one expert in the state, to disseminate the teaching in that state. It may be successful so far, but it's very hard to see who's going to be your teacher, so hopefully we can create a network. ASG has an ESC SIG, so that we can probably get us more together. I apologize if the activity is not that high at this point, but we'll get it going. So, thank you. Any other questions or comments? Thank you, guys. Thank you, guys. Thank you.

endoscopic submucosal dissection

training models

gastric lesions

optical diagnosis

ESD expert