Well, thank you very much, Hiro, and also for Peter Dragunov for the kind invitation to be here. It's a huge honor to be here giving a lecture to all of my mentors who have basically taught me along the way. So how to train in ESD? I think there's a very easy answer, which is attend the ASGE ESD course, and I can actually basically just stop the lecture right here, and we can all get on with our day and go to Animal Lab. And it's an excellent photo, by the way. But this is the real lecture. So the 2025 manual of how to train and build a practice in ESD, because training, I think, is only really half of the problem at this point, because the other half is what do you do after you're done with your training, right? Like, how do you actually go from training and then incorporate what you learned? So disclosures, I think it's very important to kind of go back and understand that training in 2025 is very different than training that you read about in textbooks and articles, et cetera. When I was in medical school, one of the favorite quotes that I heard from one of the lecturers was that when you read up to date, by definition, you're not up to date. And so it's actually very important to know where we come from as a field. And so snare polypectomy has been around for like 55 years, and saline-assisted EMR in various forms has been around for close to 50 years. And even ESD has been around for close to, you know, we talk about early 2000s. And I'm making myself feel old now. When I think about early 2000s, it takes a while to realize that that's almost a quarter century ago. And so these are like all the early pioneers in ESD from Japan in the early 2000s. Wasn't easy then, still isn't easy now. And I think a lot of this has to do with perspective. So ESD is different than every other thing that you do in endoscopy. It's endoscopic surgery. It's not the same as EMR, it's not the same as ERCP, it's not the same as EUS. And what have we figured out in 25 years or in a quarter of a century is that the tools and techniques for ESD have become more mature, right? So it's more safe, it's more effective. But because ESD is surgery, we cannot really expect ESD to become easy. And I think there's always this sort of misconception that maybe we're here to somehow make ESD easy. It's not supposed to be easy. Because it's like you never hear a surgeon talk about, oh, the Whipple is now easy, right? If you consider everything that you've learned over the last two days, I had, I think I forgot who it was gave me the best quote yesterday. It's like, oh, you know, of the last eight rotations, all eight of you have taught me to do something completely different from each other. Right? So you have different techniques from different masters who teach you the same procedure. And if you consider the Whipple analogy, Dr. Whipple did the first Whipple in 1935. The technique continues to evolve today, depending on which center you learn how to do a Whipple from. And so it's not exactly feasible to standardize the technique, but it is necessary to standardize your outcome, right? So it's like, how do you, there are many, many different ways to carve that Thanksgiving turkey, and not any one of them is necessarily better. But the outcome is that you have a fantastic Thanksgiving dinner. So in the early days, this is sort of the first generation of ESD pioneers in the US. They were largely self-taught. And this was largely from inspiration from Japanese pioneers who were also early in their own learning curve. These are pictures, courtesy of one of our good friends Stavros, of ESD in 2004, where he basically, Jimmy rigged his own IT knife using a needle knife. And then he had a dentist give him a piece of dental wax, which he created into an IT knife. And Stavros published his own, sort of what they called an untutored prevalence-based approach. And Mohammed talked about this a little bit yesterday, of how long does it take to learn ESD if you have basically no tutelage, kind of do it yourself, pick up whatever comes through your door. And what he realized was that it took about 280 cases to, in the colon, to reach a dissection speed of about nine centimeters squared per hour, which is one of the measured benchmarks for proficiency in ESD. So when you fast forward a decade, oh yeah, who's that? What a gorgeous photo. So PoEM came around in the late 2000s, and what's interesting is that even though PoEM came later than ESD, the advent of PoEM is really what caused a lot of people in the West to really become interested in ESD. And so the ASGE course started in 2013, Olympus followed with the ESD course in 2014. And a lot of Western endoscopists during those years were going to high-volume centers in Asia, for example, including Peter Dragunov being sort of the most classic example of someone who made a long pilgrimage to Asia to learn ESD. Hero, you look so young. And so this is the first course in 2013, if you compare the faculty then versus the faculty now. And this is, again, the classic Peter Dragunov approach, the ESD learning curve after self-study and exposure to courses in a four-month stay. He spent four months in Japan learning ESD, and then he kind of published his entire experience on how to do that. So it started with very fundamental expertise in EMR, and then a lot of self-study, participation in whatever training courses there possibly could be at the time, some ex vivo training with pigs, and then observation of live courses in high-volume centers across Asia. He published his experience in 2019, showing what his experience was. And you can see here, a lot of it depends on lesion selection. So there was a very esophagus-heavy ESD practice as he was early in his learning curve, and that has to do with the realities of that time. So US pioneers who went to Asia then realized that there was a problem, and the problem was that they were just simply not encountering the same lesions as they saw in Asia in the US. And so there was a lack of gastric antrum cases in the US. If you waited for gastric antrum cases to show up in your practice, you're going to be pretty old by the time you get proficient, right? And so there were a couple of misconceptions. The first misconception is that stomach automatically means easy. Not necessarily true. Gastric cancers in the US are often in harder locations. They're located in a cardia. They're located in a proximal body. They're located in areas that are a little bit different than the classic Japanese or Chinese or South Korean locations. There's also this misconception that gastric cancers in the US must be exactly like gastric cancers in Japan. Mohamed showed a lot of good data yesterday on the risk of lymphovascular invasion, the risk of lymph node metastasis. There's actually a very interesting paper from the MD Anderson Surgical Group that showed that lymph node metastasis for stage one or T1 gastric cancers are higher than we think. And instead, of course, instead of gastric cancers, we get lots of big polyps instead in hostile locations with tattoos and other stuff. And then there was another problem, which is that there's an education gap too, right? So in the US, there's a lack of basic training in optical diagnosis. This top picture on the top right was something that was referred for surgery, which we realized this is a semi-pedunculated polyp. And this bottom lesion was a lesion that was referred for endoscopic resection. And this is actually very malignant in appearance. And polyps get misdiagnosed and sent to surgery, or they get misdiagnosed and sent to us. And then we look at it, and we're like, that doesn't look very resectable. And by a show of hands in the room, for all the people who are learning ESD, how many of you guys in your training outside of here actually ever got a formal lecture in optical diagnosis? Show of hands. OK, it's like a minority, right? So I went to what I consider to be a good GI program. I went to UCLA. I never got a single lecture on optical diagnosis. I got a world-renowned lecture on acute intermittent porphyria. I got a world-renowned lecture on familial Mediterranean fever. And I never got a single lecture on how to properly diagnose a colon polyp. And I did not ever get a single lecture on tumor biology. And so a lot of this comes down to basic lack of education in the United States and a lack of standardized fellowship education as well. And when you go to advanced endoscopy fellowship, they prioritize EUS, ERCP. And after that, money takes over, and practice takes over, and family takes over, and there's a lack of subsequent time or interest. So we don't get these. Or sometimes we do. Instead, we get these. So welcome to the USA. And when I started my advanced fellowship with Hero, we actually looked at this. And this is one of those like, well, obviously kind of moments where it's like big lesions, presence of tattoo prior EMR, all of these predict longer procedure times, possibly negative outcomes in ESC. So what does training really look like today, right? So I think there's still four primary approaches. But those four primary approaches have changed over the course of the last quarter century. So there's still this sort of self-taught Stavros approach that's a little bit more uncommon. The ESGE does not recommend it anymore, as you guys heard from Mohamed yesterday. There's still the traveling to Asia approach, the Peter approach. But that's a little bit more uncommon now, just because there are increasing opportunities in the US to learn this here. There's the dedicated fellowship training approach, which is sort of, I guess, the Phil Hero approach. And now there's increasing opportunities to do that as well, because now all of us as faculty are more and more established and more and more able to train fellows to start getting exposed to ESD, at least. And then there's the sort of, I guess, your approach, which is the intensive postgraduate coursework approach, right? So you might be either in training or finishing up training or in practice now. And how do you actually go through all the coursework to build proficiency? It's still non-standardized. There are several, quote, unquote, standard courses now in ESD, one of which is this course, the ASGE JGS course. There's industry-level courses that are very advanced now, like the Boston Scientific and Olympus courses. And then what I consider to be the best institutional course in the country, which is Dennis's course in Orlando. I've never seen a course where you had multiple days of live pigs. That's like out of this world. So kudos, Dennis. And this has been published, Hero and one of his later fellows, Tom McCarty, published a paper on listing the every-course approach, like what does it take to take every single course and actually learn ESD that way? And then we have, oh, Mohamed, look at that. This is a picture from Mohamed when he was learning ESD in 2014 at Winthrop, Long Island, with Ping Hong Zhao in Long Island. And he published his experience, again, showing, as he elaborated yesterday, 265 cases to reach unblocked resection for all procedures. You look so young. Yeah, I know. I'm going to make a knife myself, actually. Yes, sir. So then there's the tutored approach, right? So this is the ESD fellowship approach. And some people asked me yesterday, like, how did I learn ESD? And I think this is becoming increasingly more common now, which is good. And that is people who, in their third year of GI fellowship, got a partial EUSCRCP training already, had maybe several hundred cases under their belt of EUSCRCP, who then, when they start their fourth year, they could fully take advantage of, you know, you're not spending half a year learning how to cannulate, right? You're actually able to do it. You're not spending half a year learning how to cannulate, right? You're actually able to really fully take advantage of endoscopic resection. I actually, just kind of for background, I had never even heard of ESD until I hit the interview trail and met colleagues that I interviewed with, who were like, oh, have you heard about ESD? I was like, you what? You know, I was like, what are you talking about? And then I interviewed with Stavros, and I was stuck in his room for 10 hours watching a 10-centimeter CECL lesion being resected. And when you have that experience, you can either walk away and say, this is crazy, I'm never doing this. Or you can walk away and say, this is crazy cool, and I am going to do this. And so that's sort of that approach. And so, you know, during that one-year training experience, basically, we started, you know, this started immediately with human ESD cases. And that was interspersed with additional ex vivo cases to kind of solidify fundamental techniques with increasing levels of involvement, difficulty, and trust as allowed by your own progress. And so this kind of started with observation, assistance, doing the easier parts of harder cases under like a very tightly tutored kind of environment. And then with the goal to eventually move towards being able to independently perform cases. So I was lucky enough where my first case with Hero was actually an Antrim case. I can't believe my luck with that type of approach. And this is one of the later cases that I kind of, quote unquote, graduated the year with. It did come with an oops. This is an oops with an IT knife on the bottom left, but with a successful resection. And so with that, with possibly qualified trainees, you can take a graduated approach, close supervision. Thankfully, I don't think I really adversely impacted Hero's outcomes, minus that oops picture that I showed you on the last one. There was a trend towards prolonged procedure time. So I guess if I stayed longer and had more N, it would become significant that I slowed him down. But it may be a viable pathway for qualified trainees who kind of possess that partial EUS ERCP experience to walk in. There's a risk though, and that risk is that you better get along with your mentor. So if you don't get along with your mentor, or if you don't have this sort of proper learning posture when you go in, you're not gonna quite get the same results out of it, right? So it is a little bit of your mileage may vary type of take on this. So in terms of some final thoughts about training before we go into practice, Juha and I had the privilege of giving this lecture at DDW last year, which was irrespective of your pathway of training, you kind of have to figure out several categories, right? So there's the cognitive skills, which is the optical diagnosis and everything. That's arguably the most important, but the least taught, or at least in my fellowship experience. There's the hands-on skills, which is arguably the least important, but most sought after. There's the observation part, which is, you know, there's much to learn from watching. There's fellowship, should you do one or not? There's mentorship and proctorship. So if you don't do a fellowship, then you at least have to identify a mentor somehow or some way. And then there's credentialing. So you have to understand your own reality as well, right? Depending on where you go in practice. And that's something that a lot of people don't quite realize until they're there. So shifting gears in the last couple of minutes here. So what happens when you do start? So I think all of us who do ESD in clinical practice have had the classic trap, which is, you know, I start in September as faculty, and this young guy immediately goes, hey, Phil, I got this referral for you. I have this four centimeter lesion in the rectum. All of us who do ESD knows that four centimeters is a euphemism. It's never four centimeters, but you know, it's always like the, I have a four centimeter lesion for you. So, you know, I have to look at my institution, right? It's like, does this apply to you? My colleagues are very conservative. My institution is even more conservative. And so any major misstep will be a big fat torpedo in my career. And so you have to think about your practice environment, your compensation models, and where, you know, the realities of like what you did not learn in training, right? No one in training ever taught you how do you figure out your salary, how do you figure out where you're gonna practice? So there's different practice environments. There's academic, there's private, there's hybrid models, there's different compensation models, there's salaried, there's RVU, there's collections-based. And so one of the things that Juha and I talked about at the DDW lecture is that, you know, perhaps the most supportive environment is an academic place where you're salaried, because then you really have the freedom to explore and not be punished financially for it. Probably the most difficult scenario to work with would be if you were in a private environment or you were a collections-based. And I think we had one person in the audience during that lecture who actually asked the question, how do I do this if I'm in private practice and collections-based? And I think Juha said, you're kind of out of luck. But this is our four-centimeter lesion. This is not four centimeters, obviously. This went from dentate line way past the first rectal valve. So, you know, when you have something like that, you kind of have this sort of sinking moment. I recently talked to Sergei about his experiences as a laparoscopic surgeon in the Soviet Union, and he told me a story about how there are certain moments in life where you can feel your hair start standing on the top of your head. And I remember Sergei even, yeah, I remember you even said, like, if you've never had that, I could quote him, it's like, if you've never had that feeling, Philip, it's a very interesting feeling. And that is that same feeling you get when you walk in on your first case and realize it's 10 centimeters and not four, and you kind of start thinking, do I have political support to do this? That is one of those hair-standing things because now you wonder, shoot, I'm in a different city, I'm in a foreign environment, I'm in Houston, I have no family in Houston, I'm about to get fired, my administration's gonna kill me. So hospital administration, surgeons, your own department, anesthesia is a big one, the endo-unit leadership, do they have your back as you start this career? Because if they don't have your back when you start this, and you started a 10-centimeter lesion as your first case, you're in for a world of hurt afterwards. You may physically hurt afterwards because you've been standing a long time, but you may politically hurt afterwards too. So I eventually kind of really thought this through, I'm not gonna read this to you because that's just, that's not how you give a lecture, but I eventually thought this through and actually distilled down, if I were to ask the 14 questions of how I need to prepare to start ESD, this is how I'm gonna ask those 14 questions, and you can find this on Video GIE. Eventually took it out, took like six and a half hours, electively admitted the patient for observation, just because, and he did fine and everything went great. So then, well, you really liked that experience, or did you really like it, took six and a half hours, being prepared that if you actually succeeded, then good work gets rewarded with more work, so then you end up working five days a week like I do, working, doing six and a half hour cases, and you're like, do you actually enjoy that? Good patient report is key for stuff like that. I did two ESDs on Friday, my patients have my cell number, it's a work cell, by the way, make sure you give your work cell. They have my PA cell number, this may be city dependent, like I don't know if that's a good idea in Los Angeles and New York, where patients are more, they're a little bit more high maintenance. I personally call patients with pathology results, my PA and I personally get involved with scheduling. It's one of those things where there are small things you can do to increase your quality of life, and then the best advice that was ever given to me was given to me by one of my techs in the room. It was like, you may want to consider wearing long socks for this. I was like, oh, that's a great idea. That's three years later. So since then, right, it's like you built this program and you have to realize what are you walking into. So I don't have a whole lot of time, I'm not gonna go through all of this, but we've built up quite the practice, like 400-something cases over six years, 85% colorectal, big lesions. In Texas, everything is bigger, the polyps are bigger in Texas because the barbecue is bigger. They all have something bad, they have tattoos, they have EMRs, they have fibrosis, they have surgical clips because they all have hemorrhoids, so they all had hemorrhoidectomy before too. It's always something bad, and you try to deliver on the outcomes and you hope that your outcomes are good. Sometimes you use traction, as you guys will see within the next 10 minutes or so when we go to the animal lab, and you try to keep your adverse outcomes low because if you have your adverse outcomes low, then people will trust you to continue building that sort of program. So again, like I said earlier at the beginning, how you carve that turkey may not matter as much as delivering consistent results and delivering results that satisfy your stakeholders in your institution, in your practice. What are your stakeholders? Again, your patients, your referrals, your surgeons, your anesthesiologists. If you instill confidence, chances are they're gonna continue to support you. So what does my learning curve look like? I don't have a fancy Q-sum thing just because I don't understand statistics as well as Mohamed does, but I was able to reach nine centimeters an hour after 62 cases in practice, and that, again, goes to show when you actually take that full year and do cases fully under supervision, it can't, there is a possible light at the end of the tunnel. I know that one of the criticisms, which bothers me as well personally, that people say, well, why would you publish something that shows that it's so difficult to attain? I think because there's value in that publication, and so I fully agree with Mohamed on this, but I think that there are ways now in 2025 that we can hopefully shorten that learning curve with more intensive upfront training, upfront exposure, so that hopefully we can get you guys there with fewer cases. It remains to be seen, the 2025 approach, what your learning curves will look like, and I would be very curious to review your paper when it comes out in terms of if you attended every course now versus had you attended every course 20 years ago, what your learning curve would look like. And so in 2025, it's still not easy, but at least it's teachable. And so this is sort of the stepwise representation that Hero put out a couple years back, starting with ESD courses, self-training. This is more interesting, kind of like the intermediate sort of gateway drugs, if you will, right? It's like, what's the gateway drug into ESD? That's like pre-cut EMR, hybrid ESD, learning circumferential incision, and it's slowly incorporating dissection into your practice. But training in the US is still a major challenge. There's many ways towards establishing proficiency. Fellowship training could be helpful in accelerating that proficiency and may allow you to start independent practice at a slightly higher point, but the next generation of physicians who are learning from this are actually now learning from the realities of today, which is exposure in advanced fellowship, a lot of intensive postgraduate coursework. I strongly suspect that your learning curves will be better than those of us who learned it without that sort of opportunity. And to kind of give you my own opinions about this, ESD is slowly becoming uniquely American. Why is that the case? When you go to Home Depot, you see all the different tools that you could possibly want to have in your garage, right? You know, when I spoke to my Japanese colleagues at dinner last night, they're trained on one tool and how to make it succeed with one tool. The American culture is you want to have every tool and use every single tool, and so it's different, right? But learning that ESD will now belong probably as part of some sort of Home Depot-like toolkit in your garage, depending on how big that garage is. And so that allows you to conquer certain things, like this. This was like one of my most extreme examples. This is like really one of those in Texas everything is bigger type examples. I have a patient with a BMI of like 55, so like a 400-pound patient, is absolutely not a surgical candidate for anything, and you find this. And so I started ESD, I failed, I told the patient I can't do it, this is not possible, and sent the patient just back to surgery, and the surgeon tells me, well, I'm sorry, I still can't take the patient to surgery just because you told me you can't do it. I guess we'll just have to watch and wait for him to get cancer and die of cancer. I'm like, well, that doesn't sit very well with me. So you think about doing this as part of a toolkit, right? So you shave it all the way down with the MR, so it's like, I don't care, 33-millimeter snare, we just go. ESD, the base, so I cut the base. I put a full thickness resection device on the core. I don't know how this happened, I somehow managed to get complete resection, no cancer on pathology for something like this, and that's two years later. So, you know, again, not really, he lost a couple pounds from this, probably. Maybe he lost a couple pounds from the recovery, but really, it kind of goes to show that this is increasingly part of a toolkit, right? So in conclusion, it was not easy in 2000, still not easy in 2025, but even though the technique originally is a Japanese and Asian technique, certain American diseases like obesity require American solutions, and in 2025, we do have that sort of mature toolkit with all of these things that hopefully ESD will become an integral part of your toolkit as you tackle these lesions, and we have multiple different pathways. Just some acknowledgments of everybody who raised me along the way, and thank you very much. This was just a couple days ago. Thank you, guys. Thank you.

Endoscopic Submucosal Dissection

ESD training

technical skills

surgical evolution

patient management

healthcare adaptation