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A searchable video library can show fifteen in a morning.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eInjection and snare technique.\u003c/strong\u003e The purpose of the lift, the amount of injection and snare placement at the lesion edge can all be understood in advance.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSupervised time is then spent on the movement itself and on responding to what is actually happening. That needs a unit and a trainer who treat training as an investment of time.\u003c/p\u003e\n\n\u003ch2\u003eFeedback, not volume\u003c/h2\u003e\n\u003cp\u003eSelf-taught ESD carries a learning curve of around 250 cases. Structured, supervised training brings that closer to 30 to 40.\u003c/p\u003e\n\u003cp\u003eJapan has the case volume, the experts and protected curriculum time. But the gap for Western trainees was not only volume. It was access to someone who would critique the case.\u003c/p\u003e\n\u003cblockquote\u003e\"It was not necessarily a problem of volume, but a problem of feedback, structured feedback.\"\u003c/blockquote\u003e\n\n\u003ch2\u003eFive layers\u003c/h2\u003e\n\u003col\u003e\n\u003cli\u003e\u003cstrong\u003eVirtual education.\u003c/strong\u003e Whole cases, including the ones that go badly, build decision-making before the trainee holds the scope. The technical act is often not the hardest part.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eSimulation.\u003c/strong\u003e Plant-based and ex vivo models now reproduce tissue behaviour well, and robotic systems can even model breathing. Tip control can be practised and measured, for example with an AI-graded tracing task on the HAM platform (Tornai et al., \u003cem\u003eEndosc Int Open\u003c/em\u003e 2026).\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eDeconstruction.\u003c/strong\u003e ESD breaks into marking, injection, circumferential incision, dissection, haemostasis, scope control, energy settings and defect review. A deconstructed logbook lets the trainee focus on one step at a time.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eVideo review.\u003c/strong\u003e Record every case. Review complications honestly. Feedback given later over a coffee, with a pointer on the screen, is more precise than feedback given under the stress of the procedure.\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eFeedback against a standard.\u003c/strong\u003e Competency assessment tools tell the trainee what they will be judged on and allow progression to be gated.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eCase selection follows a risk pyramid: gastric and rectal lesions first, then colon, oesophagus and duodenum.\u003c/p\u003e\n\n\u003ch2\u003eAfter the fellowship\u003c/h2\u003e\n\u003cp\u003eThe trainee goes from a high-volume centre to a low-volume one. The practical advice is simple: do not start with a circumferential ESD in the first weeks home. Continued case review, including by video from a distance, extends the fellowship beyond the time spent abroad.\u003c/p\u003e\n\u003cp\u003eThe evidence base is thin. There are no randomised trials of ESD training methods, and most of what we know comes from Eastern settings. The lecture closes with preliminary, unpublished data from repeated tip-control practice on a simulator, in which performance continued to rise across the first eight sittings.\u003c/p\u003e\n\n\u003ch2\u003eWho should watch\u003c/h2\u003e\n\u003cp\u003eTrainers who host international fellows, trainees planning an advanced endoscopy fellowship, and those building training pathways in units where complex cases are infrequent.\u003c/p\u003e\n1e:Tf21,Advanced endoscopy training in sub-Saharan Africa usually means going abroad. The slots are few, most fellowships are self-funded, and the trainee often leaves a family and a post behind for months at a time.\nSo the question is not only how to find a fellowship. It is how to make six months count.\nThis lecture from the South Africa 2026 postgraduate course takes the trainer's side of that problem. It was given in a joint session with Vikash Lala, who completed a six-month advanced endoscopy fellowship in Ghent after a two-and-a-half-year COVID delay.\n\n## Preparation changes the starting point\n\nVikash used the delay. He watched hundreds of EMR, ESD and third-space cases on virtual platforms before he arrived. By the time he was in the room, he knew what the next instruction would be before it was given.\nMuch of the background can be moved out of the room:\n\n- **Scope control.** Videos that show the hands and the endoscopic image together let the trainee connect a movement to its effect.\n- **Optical diagnosis.** A month in one unit may show few invasive lesions. A searchable video library can show fifteen in a morning.\n- **Injection and snare technique.** The purpose of the lift, the amount of injection and snare placement at the lesion edge c
1an all be understood in advance.\n\nSupervised time is then spent on the movement itself and on responding to what is actually happening. That needs a unit and a trainer who treat training as an investment of time.\n\n## Feedback, not volume\n\nSelf-taught ESD carries a learning curve of around 250 cases. Structured, supervised training brings that closer to 30 to 40.\nJapan has the case volume, the experts and protected curriculum time. But the gap for Western trainees was not only volume. It was access to someone who would critique the case.\n\u003e \"It was not necessarily a problem of volume, but a problem of feedback, structured feedback.\"\n\n## Five layers\n\n- **Virtual education.** Whole cases, including the ones that go badly, build decision-making before the trainee holds the scope. The technical act is often not the hardest part.\n- **Simulation.** Plant-based and ex vivo models now reproduce tissue behaviour well, and robotic systems can even model breathing. Tip control can be practised and measured, for example with an AI-graded tracing task on the HAM platform (Tornai et al., *Endosc Int Open* 2026).\n- **Deconstruction.** ESD breaks into marking, injection, circumferential incision, dissection, haemostasis, scope control, energy settings and defect review. A deconstructed logbook lets the trainee focus on one step at a time.\n- **Video review.** Record every case. Review complications honestly. Feedback given later over a coffee, with a pointer on the screen, is more precise than feedback given under the stress of the procedure.\n- **Feedback against a standard.** Competency assessment tools tell the trainee what they will be judged on and allow progression to be gated.\n\nCase selection follows a risk pyramid: gastric and rectal lesions first, then colon, oesophagus and duodenum.\n\n## After the fellowship\n\nThe trainee goes from a high-volume centre to a low-volume one. The practical advice is simple: do not start with a circumferential ESD in the first weeks home. Continued case review, including by video from a distance, extends the fellowship beyond the time spent abroad.\nThe evidence base is thin. There are no randomised trials of ESD training methods, and most of what we know comes from Eastern settings. The lecture closes with preliminary, unpublished data from repeated tip-control practice on a simulator, in which performance continued to rise across the first eight sittings.\n\n## Who should watch\n\nTrainers who host international fellows, trainees planning an advanced endoscopy fellowship, and those building training pathways in units where complex cases are infrequent.1f:Ta70,\u003cp\u003eA subepithelial lesion turns up in the second part of the duodenum and is referred for discussion. Reach for EUS? Resect it? Or can the diagnosis be made at the endoscope, in a couple of minutes, with the kit already in your hand?\u003c/p\u003e\n\u003cp\u003eThis short case works through that reasoning step by step.\u003c/p\u003e\n\n\u003ch2\u003eOrient before you touch anything\u003c/h2\u003e\n\u003cp\u003eThe lesion sits in the second part of the duodenum \u0026mdash; possibly the third. With a transparent cap on the scope, the major papilla is straightforward to identify, and the lesion lies distal to it. Holding the minor papilla and the underlying biliary and pancreatic anatomy in mind frames exactly where you are before any instrument goes near the lesion.\u
1003c/p\u003e\n\n\u003ch2\u003eIs it mucosal?\u003c/h2\u003e\n\u003cp\u003eLook at the surface. The mucosa draped over the lesion is identical to the mucosa around it \u0026mdash; the same duodenal lining covering a bulge, with no surface change of its own. That argues against a mucosal lesion and points to something subepithelial.\u003c/p\u003e\n\n\u003ch2\u003eTest mobility\u003c/h2\u003e\n\u003cblockquote\u003e\u0026ldquo;Anything that you think might be invasive, see if it\u0026rsquo;s mobile.\u0026rdquo;\u003c/blockquote\u003e\n\u003cp\u003eA freely mobile lesion is unlikely to be invasive or deeply tethered. You can assess this without even opening the forceps: bring a closed biopsy forceps alongside and nudge the lesion. Here it moves easily, sitting on a fold of mucosa rather than anchored into the wall.\u003c/p\u003e\n\n\u003ch2\u003eThe pillow sign\u003c/h2\u003e\n\u003cblockquote\u003e\u0026ldquo;Push into it like you\u0026rsquo;re laying on a pillow \u0026hellip; can you compress it?\u0026rdquo;\u003c/blockquote\u003e\n\u003cp\u003ePress into the lesion. A lipoma gives way \u0026mdash; the cushion, or pillow, sign. This one compresses readily. Combined with the appearance and the mobility, lipoma moves to the top of the differential.\u003c/p\u003e\n\n\u003ch2\u003eThe naked-fat sign\u003c/h2\u003e\n\u003cp\u003eThis is the confirmatory step. Biopsy repeatedly on the same spot \u0026mdash; open, close, open, close \u0026mdash; to unroof the lesion. Beneath the mucosa, yellow fatty tissue becomes clearly visible. That is the naked-fat sign, and it confirms a lipoma.\u003c/p\u003e\n\n\u003ch2\u003eThe teaching point\u003c/h2\u003e\n\u003cp\u003eOnce you see fat, you are finished. No EUS, no resection, no further work-up \u0026mdash; a benign duodenal lipoma needs nothing more. The rest of the subepithelial differential behaves differently: GISTs, neuroendocrine tumours and ectopic pancreas more often look white, feel firmer, or carry surface irregularity, and they neither compress nor yield fat.\u003c/p\u003e\n\u003cp\u003eOrient, confirm subepithelial, test mobility, compress, unroof. A structured bedside sequence turns a \u0026ldquo;refer for discussion\u0026rdquo; lesion into a confident diagnosis in three minutes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWatch the full case above.\u003c/em\u003e\u003c/p\u003e20:T98f,A subepithelial lesion turns up in the second part of the duodenum and is referred for discussion. Reach for EUS? Resect it? Or can the diagnosis be made at the endoscope, in a couple of minutes, with the kit already in your hand?\n\nThis short case works through that reasoning step by step.\n\n## Orient before you touch anything\n\nThe lesion sits in the second part of the duodenum â possibly the third. With a transparent cap on the scope, the major papilla is straightforward to identify, and the lesion lies distal to it. Holding the minor papilla and the underlying biliary and pancreatic anatomy in mind frames exactly where you are before any instrument goes near the lesion.\n\n## Is it mucosal?\n\nLook at the surface. The mucosa draped over the lesion is identical to the mucosa around it â the same duodenal lining covering a bulge, with no surface change of its own. That argues against a mucosal lesion and points to something subepithelial.\n\n## Test mobility\n\n\u003e \"Anything that you think might be invasive, see if it's mobile.\"\n\nA freely mobile lesion is unlikely to be invasive or deeply tethered. You can asse
1ss this without even opening the forceps: bring a closed biopsy forceps alongside and nudge the lesion. Here it moves easily, sitting on a fold of mucosa rather than anchored into the wall.\n\n## The pillow sign\n\n\u003e \"Push into it like you're laying on a pillow ⦠can you compress it?\"\n\nPress into the lesion. A lipoma gives way â the cushion, or pillow, sign. This one compresses readily. Combined with the appearance and the mobility, lipoma moves to the top of the differential.\n\n## The naked-fat sign\n\nThis is the confirmatory step. Biopsy repeatedly on the same spot â open, close, open, close â to unroof the lesion. Beneath the mucosa, yellow fatty tissue becomes clearly visible. That is the naked-fat sign, and it confirms a lipoma.\n\n## The teaching point\n\nOnce you see fat, you are finished. No EUS, no resection, no further work-up â a benign duodenal lipoma needs nothing more. The rest of the subepithelial differential behaves differently: GISTs, neuroendocrine tumours and ectopic pancreas more often look white, feel firmer, or carry surface irregularity, and they neither compress nor yield fat.\n\nOrient, confirm subepithelial, test mobility, compress, unroof. A structured bedside sequence turns a \"refer for discussion\" lesion into a confident diagnosis in three minutes.\n\n*Watch the full case above.*21:T242e,\u003carticle class=\"blog-post\"\u003e\n\n \u003c!-- Prominent ESGE Academy CTA banner (top) --\u003e\n \u003cdiv style=\"background:linear-gradient(135deg,#0D3B5E 0%,#3AAA9C 100%);border-radius:12px;padding:20px 24px;margin:0 0 28px 0;display:flex;align-items:center;gap:18px;flex-wrap:wrap;color:#FFFFFF;text-decoration:none;\"\u003e\n \u003ca href=\"https://academy.esge.com\" target=\"_blank\" rel=\"noopener\" style=\"display:flex;align-items:center;gap:18px;flex:1;min-width:0;color:#FFFFFF;text-decoration:none;\"\u003e\n \u003cimg src=\"https://academy.esge.com/api/static/favicon/apple-icon-180x180.png\" alt=\"ESGE Academy\" width=\"64\" height=\"64\" style=\"border-radius:8px;background:#FFFFFF;padding:6px;flex-shrink:0;\"\u003e\n \u003cdiv style=\"flex:1;min-width:0;\"\u003e\n \u003cdiv style=\"font-size:13px;letter-spacing:0.08em;text-transform:uppercase;opacity:0.85;margin-bottom:4px;\"\u003eOriginally published on\u003c/div\u003e\n \u003cdiv style=\"font-size:22px;font-weight:700;line-height:1.2;\"\u003eESGE Academy Video Journal â Issue 5\u003c/div\u003e\n \u003cdiv style=\"font-size:14px;opacity:0.9;margin-top:4px;\"\u003eAdverse Events in Endoscopy · Editor: Dr David J. Tate\u003c/div\u003e\n \u003c/div\u003e\n \u003c/a\u003e\n \u003ca href=\"https://academy.esge.com\" target=\"_blank\" rel=\"noopener\" style=\"background:#FFFFFF;color:#0D3B5E;font-weight:700;padding:10px 20px;border-radius:6px;text-decoration:none;font-size:14px;letter-spacing:0.04em;white-space:nowrap;\"\u003eVisit ESGE Academy â\u003c/a\u003e\n \u003c/div\u003e\n\n \u003c!-- Clickable poster (iframe is stripped by Next.js sanitiser; links to in-site player) --\u003e\n \u003ca href=\"/learning/video/1510\" style=\"display:block;position:relative;border-radius:8px;overflow:hidden;margin:0 0 32px 0;background:#000;text-decoration:none;line-height:0;\"\u003e\n \u003cimg src=\"https://i.vimeocdn.com/video/2154420016-728e38ff4e609cee5f93edfaac5c4a0fdc3a2ecdd71921491035e37f2a9c7732-d_1280x720?r=pad\u0026region=us\" alt=\"Watch the Editor's Introduction\" style=\"display:block;width:100%;height:auto;\"\u003e\n \u003cdiv style=\"position:absolute;inset:0;display:flex;align-items:center;justify-content:center;background:linear-gradient(180deg,rgba(0,0,0,0) 0%,rgba(0,0,0,0.35) 100%);\"\u003e\n \u003cdiv style=\"width:88px;height:88px;border-radius:50%;background:rgba(255,255,255,0.92);display:flex;align-items:center;justify-content:center;box-shadow:0 6px 24px rgba(0,0,0,0.4);\"\u003e\n \u003cdiv style=\"width:0;height:0;border-left:28px solid #0D3B5E;border-top:18px solid transparent;border-bottom:18px solid transparent;margin-left:6px;\"\u003e\u003c/div\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv style=\"position:absolute;
1left:0;right:0;bottom:0;padding:14px 18px;background:linear-gradient(180deg,rgba(0,0,0,0) 0%,rgba(0,0,0,0.7) 100%);color:#FFFFFF;font-size:14px;font-weight:600;line-height:1.3;\"\u003e\n â¶ Watch â Editor's Introduction (7:53)\n \u003c/div\u003e\n \u003c/a\u003e\n\n \u003cp\u003e\u003cem\u003eMost of the way endoscopic complications are taught frames them as bad luck â something that happened \u003cstrong\u003eto\u003c/strong\u003e the operator. The Editor-in-Chief of the ESGE Academy Video Journal argues the opposite.\u003c/em\u003e\u003c/p\u003e\n\n \u003ch2\u003eThe Thesis\u003c/h2\u003e\n \u003cp\u003eComplications are predictable. They cluster around the same four gaps in operator preparation. They are preventable at unacceptable rates only when one of four things is missing â theoretical understanding, familiarity with materials, preparation and equipment, or procedural excellence.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eThe complication rate is not a feature of the procedure. It is a feature of the operator.\u003c/strong\u003e\u003c/p\u003e\n\n \u003ch2\u003ePillar 1 â Theoretical Understanding\u003c/h2\u003e\n \u003cp\u003eKnowing what to look for is theory. The lesion you missed was not a hand problem. It was a knowledge problem.\u003c/p\u003e\n \u003cp\u003eIn Issue 5, \u003cstrong\u003eDr AlžbÄta Hujova\u003c/strong\u003e, with \u003cstrong\u003eDr Gianluca Esposito, Dr João António Cunha Neves and Dr David Roser\u003c/strong\u003e, defines misdiagnosis as an adverse event in the same category as a perforation. Their closing line:\u003c/p\u003e\n \u003cblockquote\u003eNot all adverse events bleed. Some are simply missed.\u003c/blockquote\u003e\n \u003cp\u003eTheir segment walks through the ESGE 2025 performance measures (â¥20-min procedure slot, â¥7-min inspection), the new GREY visibility scale, simethicone pre-medication, and symptom-driven biopsy strategy â including the detail almost everybody gets wrong on coeliac disease: \u003cstrong\u003eat least six biopsies, and at least two of them must come from the duodenal bulb\u003c/strong\u003e, or you will miss ultra-short coeliac.\u003c/p\u003e\n\n \u003ch2\u003ePillar 2 â Familiarity With Your Materials\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eDr Maria Eva Argenziano\u003c/strong\u003e leads the lower GI segment on perforation management. She does not talk about clips in the abstract â she talks about \u003cem\u003ewhich\u003c/em\u003e clip: its rotability, jaw width, stem length, whether it is single-use or reloadable, the cost, the environmental footprint.\u003c/p\u003e\n \u003cp\u003eThat is what familiarity looks like.\u003c/p\u003e\n \u003cp\u003eThe defect chooses the tool, not the other way around. She uses the Deep Mural Injury (DMI) classification 0â5 and the \u003cstrong\u003ezipper closure technique\u003c/strong\u003e: align the stem with the perforation line, push and suction together, mind gravity, place the defect on the anti-gravity side. When through-the-scope clips will not approximate, she has a salvage hierarchy ready: anchor-prong clips, clip + wire, over-the-scope clip, suturing, surgery as last resort.\u003c/p\u003e\n \u003cblockquote\u003eOne good clip beats three placed badly. Do less, but do it well.\u003c/blockquote\u003e\n \u003cp\u003eThat sentence is not a slogan. It is what familiarity sounds like.\u003c/p\u003e\n\n \u003ch2\u003ePillar 3 â Preparation and Equipment in the Room\u003c/h2\u003e\n \u003cp\u003ePreparation is what panic looks like in slow motion, done in advance.\u003c/p\u003e\n \u003cp\u003eThis pillar runs through Dr Argenziano's segment and through \u003cstrong\u003eDr Roos E. Pouw\u003c/strong\u003e's group on iatrogenic oesophageal perforation (with Dr Francesco Vito Mandarino, Dr Michele Montori, Dr Ernesto Fasulo and Dr Robert Bechara).\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eCOâ insufflation always on â switched \u003cem\u003ebefore\u003c/em\u003e you start, not after the perforation\u003c/li\u003e\n \u003cli\u003eCapnoperitoneum decompression kit (14G IV cannula, 10 mL syringe, saline) in the room before any therapeutic case. Not in a cupboard down the corridor. \u
1003cstrong\u003eIn the room.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eBroad-spectrum IV antibiotics drawn up â given the moment recognition happens, not five minutes later\u003c/li\u003e\n \u003cli\u003eSuction lines clear; nasogastric access ready; a colleague within calling distance\u003c/li\u003e\n \u003cli\u003eImaging pathway pre-arranged â low threshold for chest CT if doubt\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThe first second of a complication is no time to start looking for tools.\u003c/p\u003e\n\n \u003ch2\u003ePillar 4 â Procedural Excellence: A. B. C.\u003c/h2\u003e\n \u003cp\u003eDr Pouw and her group give the framework every endoscopist should be able to recite â the \u003cstrong\u003eABC of iatrogenic perforation management\u003c/strong\u003e:\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eA â Assess.\u003c/strong\u003e Size, location, depth, degree of contamination. Document the perforation before treating it.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eB â Breathe.\u003c/strong\u003e Stay calm. Confirm COâ is on. Suck the fluids. Start the antibiotics. Check for pneumothorax or pneumoperitoneum, decompress if found. Call a colleague.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eC â Close.\u003c/strong\u003e Through-the-scope clip. Over-the-scope clip. Stent. Endoscopic suture. Vacuum therapy. Surgery. The choice is driven by the assessment in A â not by the device you happen to know.\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eABC is not a slogan. It is a discipline that survives the moment. It works because it forces you to slow down at the precise moment your instinct is telling you to speed up.\u003c/p\u003e\n \u003cp\u003eThe most important part of pillar four is the part nobody trains: \u003cstrong\u003erecognise your limits. Escalate before the patient deteriorates, not after.\u003c/strong\u003e The strongest endoscopists pick up the phone first, not last.\u003c/p\u003e\n\n \u003ch2\u003eThe Hard Line\u003c/h2\u003e\n \u003cp\u003eIf you put the work into all four pillars, your complication rate is the rate the procedure dictates. If you skip any one of them, your patients experience complications at rates that are not acceptable. And in that case the rate is no longer a feature of the procedure. It is a feature of you.\u003c/p\u003e\n \u003cp\u003eThere is only one thing that closes those gaps.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTraining. Training. Training.\u003c/strong\u003e\u003c/p\u003e\n\n \u003c!-- Prominent ESGE Academy CTA banner (bottom) --\u003e\n \u003cdiv style=\"background:linear-gradient(135deg,#0D3B5E 0%,#3AAA9C 100%);border-radius:12px;padding:28px 24px;margin:40px 0 16px 0;text-align:center;color:#FFFFFF;\"\u003e\n \u003cimg src=\"https://academy.esge.com/api/static/favicon/apple-icon-180x180.png\" alt=\"ESGE Academy\" width=\"80\" height=\"80\" style=\"border-radius:10px;background:#FFFFFF;padding:8px;margin-bottom:14px;\"\u003e\n \u003cdiv style=\"font-size:24px;font-weight:700;margin-bottom:8px;\"\u003eWatch all of Issue 5 on the ESGE Academy\u003c/div\u003e\n \u003cdiv style=\"font-size:15px;opacity:0.9;margin-bottom:18px;max-width:560px;margin-left:auto;margin-right:auto;line-height:1.5;\"\u003eIssue 5 of the ESGE Academy Video Journal is themed \u003cem\u003eAdverse Events in Endoscopy\u003c/em\u003e. The Lower GI and Upper GI sections are available now; ERCP and EUS will follow.\u003c/div\u003e\n \u003ca href=\"https://academy.esge.com\" target=\"_blank\" rel=\"noopener\" style=\"display:inline-block;background:#FFFFFF;color:#0D3B5E;font-weight:700;padding:14px 32px;border-radius:8px;text-decoration:none;font-size:16px;letter-spacing:0.04em;\"\u003eOpen the ESGE Academy â\u003c/a\u003e\n \u003c/div\u003e\n\n\u003c/article\u003e22:T16b5,\u003cfigure style=\"margin:0 0 2em 0;\"\u003e\n \u003cimg src=\"https://i.vimeocdn.com/video/2144813945-a63a40c3cccaa59731fc0cc339a36f44860d1cfeabadd8290750f19e1b8e82e7-d_1920x1080?\u0026r=pad\u0026region=us\" alt=\"Robotics and Endoscopic Submucosal Dissection\" style=\"width:100%;border-radius:8px;display:block;\" /\u003e\n\u003c/figure\u003e\n\n\u003ch2\u003eOverview\u003c/h2\u003e\n\u003cp\u003eESD is technically demanding â adoption is limited by long learning curves (50 to 1,000 cases depen
1ding on who you ask), by the ergonomic burden on the endoscopist, and by the absence of a systematic, structured way to apply counter-traction during dissection. This 24-minute lecture asks whether robotic platforms can finally close those gaps, surveys every credible candidate, and lays out a pragmatic clinical roadmap.\u003c/p\u003e\n\n\u003ch2\u003eWhy ESD Needs Robotics\u003c/h2\u003e\n\u003cp\u003eA conventional endoscope has four degrees of freedom: push-pull, up-down, left-right, and rotation around its axis. Anything moving freely in 3D has six. A single robotic arm can add another seven to ten, and dual-arm robotic platforms inherit the endoscope's four and then layer joints on top â giving the operator something closer to two hands in the game instead of one. That extra dexterity, combined with structured traction and improved ergonomics, is what robotics promises to bring to ESD.\u003c/p\u003e\n\n\u003ch2\u003eThe Three Platform Families\u003c/h2\u003e\n\n\u003ch3\u003e1. Multi-tasking Dual-Arm Platforms\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEndoMASTER MASTER\u003c/strong\u003e â The original, developed by Professor V. Ho in Singapore. First-in-human in 2011, five cases, zero complications. Bi-manual control, custom endoscope.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEndoMASTER EASE\u003c/strong\u003e â Professor Philip Chiu's Hong Kong successor platform, published metrics in \u003cem\u003eEndoscopy\u003c/em\u003e comparable to expert human ESD.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSTRAS\u003c/strong\u003e â European sibling from a different group. No human studies, never reached market.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eK-FLEX\u003c/strong\u003e and the \u003cstrong\u003eMedrobotics Flex Robotic System\u003c/strong\u003e â the Flex Robotic is the cautionary tale: FDA-approved in 2017, then the company went bust. A reminder that the financial ground under robotic endoscopy is not solid.\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch3\u003e2. Add-on Traction Robots\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEndomina\u003c/strong\u003e (Endo Tools Therapeutics, Belgium) â a hybrid scope-mounted triangulation system already approved for bariatric procedures.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEndoFaster\u003c/strong\u003e â Chinese RCT data showing speed benefits and reduced muscular injury versus conventional ESD.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eGIFTS\u003c/strong\u003e ecosystem from a South Korean company, including a realistic ESD box simulator that reproduces patient breathing and tissue mechanics.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEndoRobotics ROBOPERA\u003c/strong\u003e â a detachable robotic gripper on the scope tip. FDA-approved, corporately backed, likely to reach market soon.\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch3\u003e3. Rigid Surgical Robots Adapted for Endoscopy\u003c/h3\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDa Vinci SP\u003c/strong\u003e â a single-arm variant adapted for transanal resection (robotic TAMIS). Already in clinical use at multiple US centres for the rectum.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEndoQuest ELS\u003c/strong\u003e â backed by the founder of Da Vinci, a novel rigid platform focused on endoscopy. Also rectum-only for now.\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eWhat Does the Evidence Say?\u003c/h2\u003e\n\u003cp\u003eThe Genidy 2026 meta-analysis pooled 115 patients across robotic ESD series. Heterogeneity is maximal and the numbers are small, but in the hands of expert interventional endoscopists â mostly at university centres â complete resection, R0 resection, and intraoperative metrics are solid. A separate randomised trial of five ESD-naïve endoscopists comparing conventional to robotic ESD found shorter procedure times, lower perforation rates, and better ergonomics in the robot arm. The study is small and platform-specific, but the signal is real: robotic platforms may flatten the ESD learning curve and standardise practice.\u003c/p\u003e\n\n\u003ch2\u003eThe AI-Integrated Future\u003c/h2\u003e\n\u003cp\u003eLooking forward, combine a robotic platform with current AI capabilities and you can imagine real-time vessel avoidance, highlighted safety planes, automatic KPI reporting, and in-procedure performance feedback. Most of these individual capabilities already exist; integrating them into one workflow is the next obvious step.\u003c/p\u003e\n\n\u003ch2\u003eDrawbacks and Implementation Barriers\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCost.\u003c/strong\u003e Robotic surgery consumables add â¬3,000+ per case. ESD is not a profitable procedure line in most hospitals â adding a robot makes the economics worse before they get better.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRegulation.\u003c/strong\u003e Europe's medical device regulation is too slow; innovations are coming out of China and not out of Europe. None of the European platforms have made it to market.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTraining gap.\u003c/strong\u003e Nobody yet knows what it takes to train an endoscopist on these platforms, because nobody's had them in their hands.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePhysical space.\u003c/strong\u003e Endoscopy rooms are already crowded. There is, in the speaker's words, \"no room for a robot â there's hardly room for me.\"\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eRealistic Roadmap\u003c/h2\u003e\n\u003cp\u003eFirst FDA-approved robotic ESD device likely 2027. Specialist-centre uptake in the years that follow. Meaningful democratisation to community practice: 5-to-10 years. Near-term, the most actionable gain is not a robot at all â it's adopting a reliable traction device and figuring out how
1it integrates into standard ESD practice. The evidence base is small and needs real-world data from outside the university setting.\u003c/p\u003e\n\n\u003ch2\u003eWho Should Watch\u003c/h2\u003e\n\u003cp\u003eInterventional endoscopists, ESD trainees, and anyone on a hospital's endoscopy equipment committee who needs a grounded, 24-minute map of the robotic ESD landscape â what's real, what's vaporware, and where the field is actually going over the next decade.\u003c/p\u003e\n23:Tb17,\u003cfigure style=\"margin:0 0 2em 0;\"\u003e\n \u003cimg src=\"https://i.vimeocdn.com/video/2140908413-a4b5c037e6dbde97e37439c172eeffa50e858ce46b66e717e22896fde6b78dc5-d_1920x1080\" alt=\"Live Case - Perforation Management After Colorectal Polypectomy\" style=\"width:100%;border-radius:8px;display:block;\" /\u003e\n\u003c/figure\u003e\n\n\u003ch2\u003eOverview\u003c/h2\u003e\n\u003cp\u003ePerforation is a complication every colonoscopist must be prepared to manage. In this 28-minute live case, a significant perforation following underwater polypectomy at the splenic flexure is managed from haemostasis to final clip closure â with expert dual commentary narrating every decision as it unfolds, including moments where clips fail and the team diagnoses the failure mode out loud.\u003c/p\u003e\n\n\u003ch2\u003eKey Learning Points\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eHaemostasis before closure.\u003c/strong\u003e When extraluminal bleeding is present, attempting closure first risks losing access permanently. Address active bleeding first â even while the perforation remains open and enlarging.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEscalate to Kerr grasper when snare tip coagulation fails.\u003c/strong\u003e Omental fat accumulates coagulum and prevents effective diathermy contact. Recognise the failure pattern early and switch tools.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClip stem positioning is the critical variable.\u003c/strong\u003e The stem must run exactly along the perforation line with legs perpendicular to maximise tissue capture across the full defect depth.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStart on the gravity-dependent side and suction maximally before deploying each clip.\u003c/strong\u003e Once a good position is achieved after suction, trust it and deploy â repositioning releases the advantage you just created.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHigh-density clip closure:\u003c/strong\u003e successive clips placed flush with no gap between them achieve the tissue apposition required for complete closure of large defects.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eRecognise clip failure modes and switch clip type.\u003c/strong\u003e When two consecutive clips fail for the same reason, switching to a different design (e.g. Instinct) provides greater closure force.\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eClinical Relevance\u003c/h2\u003e\n\u003cp\u003eThe transparency of this case is its greatest teaching value. The instructors narrate uncertainty, diagnose errors in real time, and stay calm and adaptive throughout. The overriding message: \"Pretty much everything in endoscopy is lost in poor decision-making, including time.\" Even a technically demanding, stressful perforation can be resolved endoscopically when systematic thinking is maintained.\u003c/p\u003e\n\n\u003ch2\u003eWho Should Watch\u003c/h2\u003e\n\u003cp\u003eAll endoscopists performing polypectomy or advanced resection who need to be confident in perforation recognition and clip closure technique. Particularly valuable for those who have not yet encountered a significant perforation and want to rehearse the decision-making framework before they do.\u003c/p\u003e24:T9bc,\u003cfigure style=\"margin:0 0 2em 0;\"\u003e\n \u003cimg src=\"https://i.vimeocdn.com/video/2140955282-0a3e47486edea4d4262d929e5aa1fae3210e8f42b441e59c62a38bfddcc49885-d_1920x1080\" alt=\"Live Case - Muscle Retraction Sign in Oesophageal ESD\" style=\"width:100%;border-radius:8px;display:block;\" /\u003e\n\u003c/figure\u003e\n\n\u003ch2\u003eOverview\u003c/h2\u003e\n\u003cp\u003eThe Muscle Retraction Sign (MRS), first described by Toyonaga for colorectal ESD, is increasingly recognised as a pan-GI tract phenomenon. In this live case, the sign is captured in real time during ESD of a biopsy-proven mid-oesophageal squamous cell cancer â with expert commentary narrating every decision from initial recognition through to final dissection.\u003c/p\u003e\n\n\u003ch2\u003eKe
1y Learning Points\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eDirectionality is everything.\u003c/strong\u003e MRS detection requires working from the surface in a neutral endoscope position and matching orientation between the external view and the tunnel interior.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAsymmetric submucosal lift is the diagnostic signal.\u003c/strong\u003e On injection, the normal margin lifts with blue staining while the zone of maximal abnormality shows no submucosal plane â the invasive front is optically identified before a single cut is made.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMRS indicates deep SM invasion, not T2.\u003c/strong\u003e Deep SM invasion may still be manageable within an ESD resection, while T2 disease generally precludes endoscopic cure.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eThe EID principle:\u003c/strong\u003e \"If you want to go back into the submucosa, all you have to do is cut between two known submucosal planes.\" The muscular patch on the specimen confirms the resection line passed through and beyond the zone of invasion.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMRS applies throughout the GI tract.\u003c/strong\u003e The oesophageal appearance is almost identical to the colorectal image first described â validating its use as a pan-GI deep margin indicator.\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eClinical Relevance\u003c/h2\u003e\n\u003cp\u003eFor advanced endoscopists performing oesophageal ESD, the ability to optically diagnose deep margin involvement during dissection â and modify the dissection plane accordingly â determines whether a resection achieves a negative or positive deep margin. This case is linked to an in-preparation publication describing MRS specifically in the oesophagus.\u003c/p\u003e\n\n\u003ch2\u003eWho Should Watch\u003c/h2\u003e\n\u003cp\u003eAdvanced endoscopists with experience in ESD who want to deepen their understanding of deep margin optical diagnosis and deliberate intramuscular plane management in oesophageal lesions.\u003c/p\u003e25:T2ef6,\u003carticle class=\"blog-post\"\u003e\n\u003cdiv class=\"video-teaser-prominent\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the key moment:\u003c/strong\u003e See how intraoperative arterial bleeding is managed with a systematic three-step framework â optimise gravity, fill with water, identify and tamponade the vessel.\u003c/p\u003e\n\u003c/div\u003e\n\n\u003ch2\u003eIntroduction\u003c/h2\u003e\n\u003cp\u003ePreviously attempted polypectomy represents one of the most demanding scenarios in therapeutic endoscopy. Residual or recurrent lesions are characterised by submucosal fibrosis, scarred margins, distorted anatomy, and an unpredictable injection response â all of which compound the technical challenges of standard resection. This expert live case from the GIEQs teaching library demonstrates a complete hybrid ESD/EMR workflow for a previously attempted duodenal lesion at the D1-D2 junction, with real-time decision-making commentary from initial assessment through to defect closure.\u003c/p\u003e\n\n\u003cp\u003eWhat makes this case particularly valuable for trainees is its honesty. Equipment limitations, difficult angles, intraoperative bleeding, patient positioning adjustments, and late decisions are all shown without editing â precisely the conditions that define real endoscopic practice.\u003c/p\u003e\n\n\u003ch2\u003eCase Overview: When Surveillance Is Not Enough\u003c/h2\u003e\n\u003cp\u003eThe session opens with a case discussion that frames the critical clinical question: when should a large polyp that has previously been surveilled be resected? The assessment shows a lesion with significant \u003cstrong\u003efold convergence\u003c/strong\u003e, raising the differential between malignancy and post-resection scarring. Systematic optical evaluation is essential â fold convergence alone does not define cancer, and this case illustrates how previous intervention dramatically complicates the endoscopic picture.\u003c/p\u003e\n\n\u003cp\u003eThe key learning point: do not assign malignancy based on a single feature in a previously attempted lesion. A complete optical assessment, ideally by an experienced operator, is mandatory before committing to any management strategy.\u003c/p\u003e\n\n\u003ch2\u003eTechnique Selection: The Submucosal Purist Principle\u003c/h2\u003e\n\u003cp\u003eBefore injection, the operator articulates a guiding philosophy that shapes the entire case: \u003cem\u003e\"I am a submucosal purist. I do not want to change from that unless I have to.\"\u003c/em\u003e This means full-thickness resection techniques (FTRD) are not the default response to a difficult case â they are a last resort when submucosal access is genuinely lost. The default is to attempt underwater hybrid ESD first, accepting that the approach may need to evolve.\u003c/p\u003e\n\n\u003cp\u003eThe chosen technique is a \u003cstrong\u003ehybrid underwater ESD\u003c/strong\u003e using saline as the distension medium, with an electrosurgical knife for circumferential incision and piecemeal snaring where anatomy allows. The setup includes:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eGenerator settings:\u003c/strong\u003e EndoCut Q effect 2 for cutting, Precise Sect 4.1 for underwater tissue dissection\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInjection medium:\u003c/strong\u003e Colloid initially, then saline (after a reminder from the transcript's off-screen mentor about terminology)\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSnare selection:\u003c/strong\u003e Captivator 2 from Boston Scientific as the primary resection snare; Snare Master Plus 15mm for piecemeal fragments\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eScope:\u003c/strong\u003e Standard gastroscope transitioning to paediatric colonoscope (PCF) for improved access in the final stages\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eLive Case: Step-by-Step Teaching\u003c/h2\u003e\n\n\u003ch3\u003eMarking and Injection\u003c/h3\u003e\n\u003cp\u003eMarking is performed with soft coagulation, with the operator acknowledging from the outset that the posterior margin is being marked wide to compensate for poor visualisation. The immediate \u003cstrong\u003ejet sign\u003c/strong\u003e on injection confirms expected submucosal fibrosis from previous intervention. The anterior margin demonstrates reasonable lift; the posterior does not â exactly as predicted. This is critical decision-making: knowing when a predicted finding confirms your approach rather than prompting retreat.\u003c/p\u003e\n\n\u003ch3\u003eHybrid Knife Incision\u003c/h3\u003e\n\u003cp\u003eThe circumferential incision begins underwater, exploiting the optical advantages of saline distension to define the submucosal plane. The operator uses a short knife tip to minimise perforation risk, particularly relevant in the duodenum where the wall is thin and folds create difficult working angles. Real-time commentary covers the challenge of CO2 accumulation diluting the underwater field, respiratory movement affecting stability, and the importance of managing water pressure to avoid obscuring tissue planes.\u003c/p\u003e\n\n\u003cp\u003eThe transition from full knife ESD to piecemeal snaring is openly discussed mid-procedure: \u003cem\u003e\"I am not someone to just wish to continue with ESD for the sake of it. This is benign disease â if a snare becomes attractive at a certain point, fine.\"\u003c/em\u003e This pragmatic stance avoids the common trainee error of persisting with a difficult technique when a safer hybrid approach is clinically equivalent.\u003c/p\u003e\n\n\u003ch3\u003eIntraoperative Bleeding Management\u003c/h3\u003e\n\u003cp\u003eArterial bleeding is encountered during ESD, providing an unscripted but highly educational demonstration of the operator's structured response:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eOptimise gravity\u003c/strong\u003e â reposition scope and patient to allow blood to pool away from the operative field\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFill with water\u003c/strong\u003e â saline irrigation clears the field immediately where gravity alone cannot\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIdentify the source\u003c/strong\u003e â every intraoperative bleed is a blood vessel; systematic cap-based tamponade identifies the precise point\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTreat precisely\u003c/strong\u003e â targeted soft coagulation rather than broad thermal application, which is highlighted as a major risk in the duodenum specifically\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe operator explicitly references a serious historical complication from overuse of soft coagulation in the duodenum: \u003cem\u003e\"One of the worst complications I have ever had is overuse of soft coagulation in the duodenum â just let's be clear with each other. I was lucky.\"\u003c/em\u003e This level of transparency about personal experience and complications is rare in educational content and is part of what defines GIEQs teaching.\u003c/p\u003e\n\n\u003ch3\u003ePiecemeal Completion and Margin Ablation\u003c/h3\u003e\n\u003cp\u003eOnce the dominant ESD portion is complete, piecemeal snaring is used to clear residual fragments. The operator compares this to \u003cem\u003e\"cutting a cauliflower\"\u003c/em\u003e â short, precise snare bites using water distension to define fragment borders and prevent inadvertent muscle capture. Margin ablation with argon plasma coagulation or STSC is described as non-negotiable after hybrid evulsion-assisted procedures: \u003cem\u003e\"Part of the avulsion technique is putting STSC over the top â this is non-negotiable.\"\u003c/em\u003e\u003c/p\u003e\n\n\u003ch2\u003eAccess Optimisation: A Lesson in Late Adaptation\u003c/h2\u003e\n\u003cp\u003eOne of the most candid moments in the case is the operator's acknowledgement that the transition to a paediatric colonoscope (PCF) was made too late: \u003cem\u003e\"I should have used the PCF way earlier when I stopped doing ESD. This is a mistake â something to put down for next time. The view is so much better. The evulsion could have been more precise.\"\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003eThis is a valuable lesson for trainees: scope selection for complex duodenal lesions is not fixed. The PCF offers significantly better angulation at the D1-D2 junction, and switching midway through a procedure â though logistically demanding â can be justified when the standard gastroscope is limiting access to residual lesion or the defect.\u003c/p\u003e\n\n\u003cp\u003ePatient positioning is equally important. Drift from left lateral to supine position was identified as contributing to poor access during closure, and repositioning to fully lateral restored visualisation. In complex duodenal procedures, patient positioning should be actively managed throughout, not assumed to be stable.\u003c/p\u003e\n\n\u003ch2\u003eDefect Closure: High-Risk Management\u003c/h2\u003e\n\u003cp\u003eClosure is emphasised as mandatory for this case type. The operator explains: \u003cem\u003e\"These duodenal defects â especially in previously attempted cases â are extremely high-risk for delayed bleeding. A lot of the patients we ever admit for endoscopy are with duodenal bleeding after exactly this type of procedure.\"\u003c/em\u003e\u003c/p\u003e\n\n\u003cp\u003eThe closure strategy employs a combination of:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eMantis clip\u003c/strong\u003e â for approximating the widest point of the defect initially\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStandard through-the-scope clips\u003c/strong\u003e â for sequential closure along the defect length\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOlympus retention clips (12mm)\u003c/strong\u003e â selected for their strength-to-cost ratio and short stem, which reduces the risk of impinging on adjacent structures\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePartial closure followed by complete foreclosure is achieved, with discu
1ssion of the risk of bridging clips that might leave an open channel. The clip type discussion (EasyClip vs standard clips) is informative: EasyClip is rotatable and reopenable, which gives flexibility in difficult positions, while retention clips offer greater tensile strength for high-risk closure.\u003c/p\u003e\n\n\u003ch2\u003ePost-Procedure Plan\u003c/h2\u003e\n\u003cp\u003eFollow-up endoscopy is planned at one year. The resection site is staged as piecemeal with hybrid technique; histological clearance will be confirmed from the retrieved specimens. Delayed bleeding prophylaxis via closure is the primary mechanism; no pharmacological bridging is discussed.\u003c/p\u003e\n\n\u003ch2\u003eKey Teaching Points Summary\u003c/h2\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eBe a submucosal purist:\u003c/strong\u003e FTRD is a last resort, not a default for difficult duodenal lesions\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePredict and accept fibrosis:\u003c/strong\u003e Jet sign in previously attempted cases is expected â don't stop, adapt\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eTransition to piecemeal when appropriate:\u003c/strong\u003e Hybrid ESD/EMR is not failure; it is pragmatic technique selection for benign disease\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBleeding management is systematic:\u003c/strong\u003e Gravity â water â tamponade â precise treatment. Avoid broad thermal application in the duodenum\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eScope selection matters:\u003c/strong\u003e Switch to PCF earlier for complex D1-D2 lesions\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eClosure is non-negotiable:\u003c/strong\u003e Previously attempted duodenal cases carry high delayed bleeding risk; foreclosure with combination clips is the standard\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePatient positioning is dynamic:\u003c/strong\u003e Actively manage throughout the procedure, especially during closure\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eEquipment Referenced\u003c/h2\u003e\n\u003ctable\u003e\n \u003cthead\u003e\n \u003ctr\u003e\u003cth\u003eEquipment\u003c/th\u003e\u003cth\u003eUse\u003c/th\u003e\u003cth\u003eKey Feature\u003c/th\u003e\u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\u003ctd\u003eOlympus EZ 1500\u003c/td\u003e\u003ctd\u003ePrimary scope (preferred)\u003c/td\u003e\u003ctd\u003eSuperior underwater imaging in near-field, no near-focus switching needed\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003ePaediatric colonoscope (PCF)\u003c/td\u003e\u003ctd\u003eRescue scope for D1-D2 access\u003c/td\u003e\u003ctd\u003eBetter angulation for distal duodenum\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eCaptivator 2 (Boston Scientific)\u003c/td\u003e\u003ctd\u003ePrimary resection snare\u003c/td\u003e\u003ctd\u003eOval, stiff, hot-capable\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eSnare Master Plus 15mm\u003c/td\u003e\u003ctd\u003ePiecemeal fragments\u003c/td\u003e\u003ctd\u003eHexagonal shape for smaller or irregular fragments\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eEndoCut Q effect 2\u003c/td\u003e\u003ctd\u003eCutting current\u003c/td\u003e\u003ctd\u003eAllows cutting while flushing underwater\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003ePrecise Sect 4.1 (ERBE VIO3)\u003c/td\u003e\u003ctd\u003eUnderwater dissection\u003c/td\u003e\u003ctd\u003ePreferred underwater cutting with coag component\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eOlympus retention clip 12mm\u003c/td\u003e\u003ctd\u003eHigh-risk defect closure\u003c/td\u003e\u003ctd\u003eStrength, short stem, cost-effective\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eEasyClip\u003c/td\u003e\u003ctd\u003eFlexible closure\u003c/td\u003e\u003ctd\u003eRotatable and reopenable\u003c/td\u003e\u003c/tr\u003e\n \u003ctr\u003e\u003ctd\u003eMantis clip\u003c/td\u003e\u003ctd\u003eWide defect approximation\u003c/td\u003e\u003ctd\u003eStrong jaw, good for large gaps â use cautiously re: sharp teeth in ESD defects\u003c/td\u003e\u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\n\u003cdiv class=\"cta\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the full 77-minute procedure\u003c/strong\u003e to see every step of this complex hybrid ESD from initial decision-making through to high-risk defect closure.\u003c/p\u003e\n\u003cp\u003e\u003ca href=\"https://gieqs.com/video/1479\"\u003eWatch the full video â\u003c/a\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/article\u003e26:Te3f,# Decision Making in Complex Polypectomy: Hybrid ESD, Bleeding Control, and Defect Closure â A GIEQs Live Case\n\n\u003e **Watch the key moment:** See how intraoperative arterial bleeding is managed with a systematic three-step framework â optimise gravity, fill with water, identify and tamponade the vessel.\n\n## Introduction\n\nPreviously attempted polypectomy represents one of the most demanding scenarios in therapeutic endoscopy. Residual or recurrent lesions are characterised by submucosal fibrosis, scarred margins, distorted anatomy, and an unpredictable injection response â all of which compound the technical challenges of standard resection. This expert live case from the GIEQs teaching library demonstrates a complete hybrid ESD/EMR workflow for a previously attempted duodenal lesion at the D1-D2 junction, with real-time decision-making commentary from initial assessment through to defect closure.\n\n## Case Overview: When Surveillance Is Not Enough\n\nThe session opens with a case discussion that frames the critical clinical question: when should a large polyp that has previously been surveilled be resected? The assessment shows a lesion with significant **fold convergence**, raising the differential between malignancy and post-resection scarring.\n\n**Key learning:** Do not assign malignancy based on a single feature in a previously attempted lesion. A complete optical assessment is mandatory before committing to any management strategy.\n\n## Technique Selection: The Submucosal Purist Principle\n\nBefore injection, the operator articulates a guiding philosophy: *\"I am a submucosal purist. I do not want to change from that unless I have to.\"* FTRD is a last resort, not the default response to a difficult case.\n\n**Setup:*
1*\n- Generator: EndoCut Q effect 2 / Precise Sect 4.1 (ERBE VIO3)\n- Medium: Saline\n- Primary snare: Captivator 2 (Boston Scientific)\n- Secondary snare: Snare Master Plus 15mm\n\n## Intraoperative Bleeding Management\n\nWhen arterial bleeding is encountered, the structured response is:\n\n1. **Optimise gravity** â reposition to allow blood to pool away from the field\n2. **Fill with water** â saline irrigation clears the field\n3. **Identify** â every bleed is a blood vessel; cap-based tamponade identifies the source\n4. **Treat precisely** â targeted soft coagulation, avoiding overuse in the duodenum\n\n\u003e *\"One of the worst complications I have ever had is overuse of soft coagulation in the duodenum â I was lucky.\"*\n\n## Access Optimisation\n\nA key self-reported lesson: the transition to PCF (paediatric colonoscope) was made too late. The view at D1-D2 is significantly better with PCF, and switching earlier would have enabled more precise evulsion and closure.\n\nPatient positioning drift (left lateral â supine) was also identified as contributing to poor access during closure â actively manage positioning throughout.\n\n## Defect Closure\n\nClosure is mandatory for previously attempted duodenal cases due to high delayed bleeding risk. Strategy:\n- **Mantis clip** for wide defect approximation\n- **Standard TTS clips** for sequential closure\n- **Olympus retention clips 12mm** for strength in high-risk segments\n\n## Key Teaching Points\n\n- Be a submucosal purist: FTRD is a last resort\n- Predict and accept fibrosis in previously attempted lesions\n- Transition to piecemeal when appropriate â hybrid is not failure\n- Bleeding management is systematic: gravity â water â tamponade â precise treatment\n- Switch to PCF earlier for complex D1-D2 lesions\n- Closure is non-negotiable for previously attempted duodenal cases\n- Patient positioning is dynamic â manage actively throughout27:T101e,\u003carticle class=\"blog-post\"\u003e\n\u003cdiv class=\"video-teaser-prominent\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the key moment:\u003c/strong\u003e See how intraprocedural arterial bleeding is managed with a structured precision framework - cap, water, identify, and treat.\u003c/p\u003e\n\u003c/div\u003e\n\n\u003ch2\u003eIntroduction\u003c/h2\u003e\n\u003cp\u003eLarge sessile polyps in the transverse colon represent one of the most common yet technically demanding scenarios in therapeutic colonoscopy. This expert live case demonstrates the complete workflow for managing a bulky transverse colon polyp using \u003cstrong\u003epiecemeal endoscopic mucosal resection (EMR)\u003c/strong\u003e, from initial optical assessment through to defect closure.\u003c/p\u003e\n\n\u003ch2\u003eOptical Assessment with BLINK Criteria\u003c/h2\u003e\n\u003cp\u003eThe case begins with systematic polyp characterisation using the \u003cstrong\u003eBLINK\u003c/strong\u003e optical diagnosis framework. The operator methodically evaluates surface pit pattern, vascular architecture, and morphological features to confirm benign histology and plan the resection approach. This structured assessment is critical for determining whether en bloc or piecemeal resection is most appropriate.\u003c/p\u003e\n\n\u003ch2\u003eUnderwater and Injection-Assisted EMR Technique\u003c/h2\u003e\n\u003cp\u003eThe resection employs a hybrid approach combining \u003cstrong\u003eunderwater EMR\u003c/strong\u003e with targeted submucosal injection. Water immersion causes the polyp to float away from the muscularis propria, creating a natural safety margin. For areas requiring additional lift, dilute adrenaline with methylene blue is injected submucosally to ensure adequate tissue elevation before snare capture.\u003c/p\u003e\n\u003cp\u003eKey technical pearls include careful snare placement at the polyp-normal mucosa junction, controlled slow closure of the snare, and systematic resection in overlapping pieces to ensure complete removal.\u003c/p\u003e\n\n\u003ch2\u003eManaging Intraprocedural Bleeding\u003c/h2\u003e\n\u003cp\u003ePerhaps the most valuable teaching moment comes during management of \u003cstrong\u003eintraprocedural arterial bleeding\u003c/strong\u003e. The operator demonstrates a structured precision framework: cap the endoscope tip against the bleeding point, fill the lumen with water for improved visualisation, then systematically identify the exact bleeding vessel.\u003c/p\u003e\n\u003cp\u003eThe bleeding is controlled with targeted \u003cstrong\u003esoft coagulation\u003c/strong\u003e using the snare tip, applied directly to the identified vessel. The operator explains why this approach is preferred over clip placement at this stage, as clips can interfere with completion of the resection.\u003c/p\u003e\n\n\u003ch2\u003eMargin Assessment and Residual Ablation\u003c/h2\u003e\n\u003cp\u003eFollowing the bulk of the piecemeal resection, the operator performs meticulous inspection of the resection margins using white light and \u003cstrong\u003eNBI (narrow band imaging)\u003c/strong\u003e. Small islands of residual adenomatous tissue are identified and treated with \u003cstrong\u003esnare-tip soft coagulation (STSC)\u003c/strong\u003e, ensuring complete eradication while minimising thermal injury to the deeper wall layers.\u003c/p\u003e\n\n\u003ch2\u003eClip Closure of the Resection Defect\u003c/h2\u003e\n\u003cp\u003eThe case concludes with systematic \u003cstrong\u003eclip closure\u003c/strong\u003e of the mucosal defect. The operator demonstrates an efficie
1nt zipper technique, placing clips from one edge to the other to achieve complete closure. This step is emphasised as particularly important for transverse colon lesions, where the wall is thinner and the risk of delayed perforation or bleeding is higher.\u003c/p\u003e\n\n\u003ch2\u003eKey Takeaways\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003eSystematic optical assessment\u003c/strong\u003e using BLINK criteria should precede every polypectomy decision\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eHybrid underwater/injection EMR\u003c/strong\u003e combines the safety advantages of both techniques\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eStructured bleeding management\u003c/strong\u003e (cap, water, identify, treat) prevents escalation\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eComplete margin inspection\u003c/strong\u003e with NBI after piecemeal resection catches residual tissue\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eProphylactic clip closure\u003c/strong\u003e is recommended for large transverse colon EMR defects\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003cdiv class=\"cta\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the full 72-minute procedure\u003c/strong\u003e to see every step of this complex piecemeal EMR from optical assessment through to complete defect closure.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/article\u003e28:Tccf,# Mastering Piecemeal EMR: Lessons from a Complex Transverse Colon Polyp\n\n## Introduction\n\nLarge sessile polyps in the transverse colon represent one of the most common yet technically demanding scenarios in therapeutic colonoscopy. This expert live case demonstrates the complete workflow for managing a bulky transverse colon polyp using piecemeal endoscopic mucosal resection (EMR), from initial optical assessment through to defect closure.\n\n## Optical Assessment with BLINK Criteria\n\n\u003e \"Before we resect anything, we need to characterise this polyp using BLINK criteria to determine the best resection strategy.\" - 3:20\n\nThe case begins with systematic polyp characterisation using the BLINK optical diagnosis framework. The operator methodically evaluates surface pit pattern, vascular architecture, and morphological features to confirm benign histology and plan the resection approach.\n\n## Underwater and Injection-Assisted EMR Technique\n\n\u003e \"Watch how the underwater view gives us superior visualisation of the polyp margins compared to traditional air insufflation.\" - 12:45\n\nThe resection employs a hybrid approach combining underwater EMR with targeted submucosal injection. Water immersion causes the polyp to float away from the muscularis propria, creating a natural safety margin. For areas requiring additional lift, dilute adrenaline with methylene blue is injected submucosally.\n\nKey technical pearls include careful snare placement at the polyp-normal mucosa junction, controlled slow closure of the snare, and systematic resection in overlapping pieces.\n\n## Managing Intraprocedural Bleeding\n\n\u003e \"When you encounter arterial bleeding during piecemeal resection, the key is not to panic - cap the scope, fill with water, and identify the precise source.\" - 32:10\n\nThe most valuable teaching moment comes during management of intraprocedural arterial bleeding. The operator demonstrates a structured precision framework: cap the endoscope tip, fill with water for improved visualisation, then identify the exact bleeding vessel.\n\n## Margin Assessment and Residual Ablation\n\nFollowing piecemeal resection, the operator performs meticulous inspection of the resection margins using white light and NBI. Small islands of residual adenomatous tissue are treated with snare-tip soft coagulation (STSC).\n\n\u003e \"The decision between en bloc and piecemeal comes down to polyp size and morphology - above 20mm in the colon, piecemeal EMR remains the pragmatic choice.\" - 65:00\n\n## Clip Closure of the Resection Defect\n\n\u003e \"Complete clip closure of the resection defect significantly reduces the risk of delayed bleeding in large EMR cases.\" - 58:30\n\nThe case concludes with systematic clip closure using a zipper technique. This is emphasised as particularly important for transverse colon lesions where the wall is thinner.\n\n## Key Takeaways\n\n- Systematic optical assessment using BLINK criteria should precede every polypectomy decision\n- Hybrid underwater/injection
1EMR combines the safety advantages of both techniques\n- Structured bleeding management (cap, water, identify, treat) prevents escalation\n- Complete margin inspection with NBI after piecemeal resection catches residual tissue\n- Prophylactic clip closure is recommended for large transverse colon EMR defects29:Tbad,\u003carticle class=\"blog-post\"\u003e\n\u003cdiv class=\"video-teaser-prominent\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the key moment:\u003c/strong\u003e See EID precision dissection in action - the instructor explains why precision and understanding your plane is everything in intermuscular dissection.\u003c/p\u003e\n\u003c/div\u003e\n\n\u003ch2\u003eOverview\u003c/h2\u003e\n\u003cp\u003eThe PRIME algorithm represents a paradigm shift in how we approach early rectal cancer endoscopically. Standing for \u003cstrong\u003edeeP-maRgin optIcal diagnosis and endoscopic resection algorithM for Early rectal cancer\u003c/strong\u003e, this systematic approach ensures we make the right resection plane decision based on real-time tissue assessment rather than predetermined strategies.\u003c/p\u003e\n\n\u003ch2\u003eKey Learning Points\u003c/h2\u003e\n\u003cul\u003e\n\u003cli\u003e\u003cstrong\u003ePocket Detection Method (PDM):\u003c/strong\u003e Creating a submucosal pocket allows direct visualization of the tissue planes and assessment of invasion depth before committing to a resection strategy\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eMuscle Retraction Sign (MRS):\u003c/strong\u003e Recognition of this critical sign indicates muscle involvement and signals the need to change from standard ESD to intermuscular dissection\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eDeep Margin Optical Diagnosis:\u003c/strong\u003e Real-time assessment of the relationship between lesion, submucosa, and muscle layer guides plane selection\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eEndoscopic Intermuscular Dissection (EID):\u003c/strong\u003e When MRS is detected, EID allows dissection between circular and longitudinal muscle layers for adequate margins\u003c/li\u003e\n\u003cli\u003e\u003cstrong\u003eR0 as the Goal:\u003c/strong\u003e The algorithm emphasizes achieving clear margins rather than accepting the excisional biopsy mindset\u003c/li\u003e\n\u003c/ul\u003e\n\n\u003ch2\u003eThe PRIME Algorithm in Practice\u003c/h2\u003e\n\u003cp\u003eThe procedure begins with careful lesion assessment. In this case, the lesion displays BLINK positivity, central depression, and converging folds - features concerning for deep invasion. Rather than proceeding directly with standard ESD, the operator creates a pocket to assess the submucosal plane.\u003c/p\u003e\n\u003cp\u003eUpon identifying the muscle retraction sign during pocket creation, deep margin optical diagnosis confirms the need to change planes. The decision to switch to EID is made in real-time, demonstrating the adaptive nature of the PRIME algorithm.\u003c/p\u003e\n\n\u003ch2\u003eREACT Tool Integration\u003c/h2\u003e\n\u003cp\u003eThis case demonstrates integration of the \u003ca href=\"https://react.gieqs.com\"\u003eREACT tool\u003c/a\u003e for procedural support, highlighting how digital resources can enhance complex endoscopic procedures.\u003c/p\u003e\n\n\u003ch2\u003eWho Should Watch\u003c/h2\u003e\n\u003cp\u003eThis video is essential viewing for interventional endoscopists managing rectal lesions, particularly those looking to expand beyond standard ESD into intermuscular dissection techniques. The surgical-endoscopic collaboration also provides valuable anatomical perspectives for understanding safe dissection zones.\u003c/p\u003e\n\n\u003cdiv class=\"cta\"\u003e\n\u003cp\u003e\u003cstrong\u003eWatch the full 75-minute procedure\u003c/strong\u003e to master the PRIME algorithm and see how real-time decision-making leads to optimal oncological outcomes.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/article\u003e2a:T9eb,## Overview\n\nThe PRIME algorithm represents a paradigm shift in how we approach early rectal cancer endoscopically. Standing for **deeP-maRgin optIcal diagnosis and endoscopic resection algorithM for Early rectal cancer**, this systematic approach ensures we make the right resection plane decision based on real-time tissue assessment rather than predetermined strategies.\n\n## Key Learning Points\n\n- **Pocket Detection Method (PDM):** Creating a submucosal pocket allows direct visualization of the tissue planes and assessment of invasion depth before committing to a resection strategy\n- **Muscle Retraction Sign (MRS):** Recognition of this critical sign indicates muscle involvement and signals the need to change from standard ESD to intermuscular dissection\n- **Deep Margin Optical Diagnosis:** Real-time assessment of the relationship between lesion, submucosa, and muscle layer guides plane selection\n- **Endoscopic Intermuscular Dissection (EID):** When MRS is detected, EID allows dissection between circular and longitudinal muscle layers for adequate margins\n- **R0 as the Goal:** The algorithm emphasizes achieving clear margins rather than accepting the 'excisional biopsy' mindset\n\n## The PRIME Algorithm in Practice\n\nThe procedure begins with careful lesion assessment. In this case, the lesion displays BLINK positivity, central depression, and converging folds - features concerning for deep invasion. Rather than proceeding directly with standard ESD, the operator creates a pocket to assess the submucosal plane.\n\nUpon identifying the muscle retraction sign during pocket creation, deep margin optical diagnosis confirms the need to change planes. The decision to switch to EID is made in real-time, demonstrating the adaptive nature of the PRIME algorithm.\n\n## REACT Tool Integration\n\nThis case demonstrates integration of the [REACT tool](https://react.gieqs.com) for procedural support, highlighting how digital resources can enhance complex endoscopic procedures.\n\n## Who Should Watch\n\nThis video is essential viewing for interventional endoscopists managing rectal lesions, particularly those looking to expand beyond standard ESD into intermuscular dissection techniques. The surgical-endoscopic collaboration also provides valuable anatomical perspectives for understanding safe dissection zones.\n\n---\n\n**Watch the full 75-minute procedure** to master the PRIME algorithm and see how real-time decision-making leads to optimal oncological outcomes.\n\n*Watch on [GIEQs](https://www.gieqs.com/learning/video/1477)*e:[\"$\",\"main\",null,{\"className\":\"min-h-screen bg-blog-gradient overflow-hidden\",\"children\":[[\"$\",\"section\",null,{\"className\":\"relative pt-12 pb-6 md:pt-16 md:pb-8\",\"children\":[[\"$\",\"div\",null,{\"className\":\"absolute top-20 left-1/4 w-72 h-72 bg-[#EEC378]/5 rounded-full blur-[100px] pointer-events-none\"}],[\"$\",\"div\",null,{\"className\":\"absolute bottom-0 right-1/4 w-96 h-96 bg-[#1e3a5f]/50 rounded-full blur-[120px] pointer-events-none\"}],[\"$\",\"div\",null,{\"className\":\"container mx-auto px-4 relative z-10\",\"children\":[\"$\",\"div\",null,{\"className\":\"max-w-3xl mx-auto text-center\",\"children\":[[\"$\",\"p\",null,{\"className\":\"text-[#EEC378] text-sm font-semibold tracking-[0.2em] uppercase mb-4 animate-fade-up\",\"children\":\"Expert Education\"}],[\"$\",\"h1\",null,{\"className\":\"text-4xl md:text-5xl lg:text-6xl font-bold text-white mb-4 tracking-tight animate-fade-up-delay-1\",\"children\":[\"GIEQs\",\" \",[\"$\",\"span\",null,{\"className\":\"relative\",\"children\":[[\"$\",\"span\",null,{\"className\":\"text-transparent bg-clip-text bg-gradient-to-r from-[#EEC378] to-[#D4A85A]\",\"children\":\"Blog\"}],[\"$\",\"span\",null,{\"className\":\"absolute -bottom-2 left-0 right-0 h-1 bg-gradient-to-r from-[#EEC378]/60 to-transparent roun
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This lecture sets out what can be done before the trainee arrives, how to structure the fellowship around feedback rather than volume, and what support the trainee needs back home.\",\"content_html\":\"$1d\",\"content_markdown\":\"$1e\",\"meta_description\":\"Preparing for an advanced endoscopy fellowship, structuring ESD training around feedback, and supporting the trainee at home.\",\"quotes\":[{\"text\":\"It was not necessarily a problem of volume, but a problem of feedback, structured feedback.\",\"speaker\":\"Prof. David Tate\",\"timestamp\":\"04:36\",\"video_title\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\"},{\"text\":\"It's not necessarily the technical act that's that difficult. Decision-making is critical.\",\"speaker\":\"Prof. David Tate\",\"timestamp\":\"05:54\",\"video_title\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\"},{\"text\":\"If you do not, especially when you get a complication, look back at what went wrong and figure out why ... you will not learn.\",\"speaker\":\"Prof. David Tate\",\"timestamp\":\"12:16\",\"video_title\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\"},{\"text\":\"Everything you can do outside of an endoscopy room should be done outside of an endoscopy room.\",\"speaker\":\"Prof. David Tate\",\"timestamp\":\"13:37\",\"video_title\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\"},{\"text\":\"If we stop chasing case volume and start engineering how we feedback to trainees, I think we can do better.\",\"speaker\":\"Prof. David Tate\",\"timestamp\":\"16:25\",\"video_title\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\"}],\"still_urls\":null,\"excerpt_start_time\":202,\"excerpt_end_time\":296,\"excerpt_reason\":\"Self-contained argument with a concrete number: self-taught ESD takes around 250 cases, structured training 30 to 40, and the gap is feedback rather than volume. It needs no prior context and states the thesis of the talk.\",\"additional_previews\":null,\"video_id\":1553,\"status\":\"published\",\"tags\":[\"ESD training\",\"fellowship\",\"endoscopy training\",\"virtual learning\",\"simulation\",\"tip control\",\"competency assessment\",\"video feedback\"],\"generation_mode\":\"admin\",\"published_at\":null,\"created_at\":\"2026-09-24T16:02:46\",\"updated_at\":\"2026-09-27T08:14:52\",\"video\":{\"id\":1553,\"name\":\"Lecture - Bridging the Gap in Advanced Endoscopy Training: Preparation, Fellowship Structure and Feedback\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":\"1229935907\",\"thumbnail\":\"https://i.vimeocdn.com/video/2204722947-a970c416a6f622cb5dec5eec0cf326fedff5107deda36f3b147ed63550b3a40f-d_1920x1080\",\"duration\":1060,\"access_level\":\"FULL\",\"is_free\":true}},{\"id\":9,\"title\":\"The Pillow Sign and the Naked-Fat Sign: Diagnosing a Duodenal Lipoma at Endoscopy\",\"slug\":\"pillow-sign-naked-fat-duodenal-lipoma\",\"summary\":\"A subepithelial lesion turns up in the second part of the duodenum and is referred for discussion. Reach for EUS? Resect it? Or can the diagnosis be made at the endoscope, in a couple of minutes, with the kit already in your hand?\\n\\nThis short case works through the reasoning step by step â orientation against the major papilla, confirming the lesion
1is subepithelial rather than mucosal, testing mobility, the pillow sign, and the naked-fat sign that seals the diagnosis of lipoma.\",\"content_html\":\"$1f\",\"content_markdown\":\"$20\",\"meta_description\":\"A 3-minute duodenal case: how mobility, the pillow sign and the naked-fat sign confirm a lipoma at endoscopy â no EUS or resection needed.\",\"quotes\":[{\"text\":\"Anything that you think might be invasive, see if it's mobile.\",\"speaker\":\"GIEQs faculty\",\"timestamp\":\"1:13\"},{\"text\":\"Push into it like you're laying on a pillow ⦠can you compress it?\",\"speaker\":\"GIEQs faculty\",\"timestamp\":\"1:50\"},{\"text\":\"If you think it's a lipoma, then you can confirm by getting fat from inside it.\",\"speaker\":\"GIEQs faculty\",\"timestamp\":\"2:13\"}],\"still_urls\":[\"https://i.vimeocdn.com/video/2162402267-06bc3453daaa0b02578acf17af9742f4516512aa397dc40875f27b51cc481d6c-d_1280x720?\u0026r=pad\u0026region=us\"],\"excerpt_start_time\":104,\"excerpt_end_time\":192,\"excerpt_reason\":\"The compression (pillow sign) test flowing into the naked-fat reveal â the self-contained diagnostic climax of the case, ideal for a social teaser.\",\"additional_previews\":null,\"video_id\":1512,\"status\":\"published\",\"tags\":[\"duodenal lipoma\",\"subepithelial lesion\",\"pillow sign\",\"naked fat sign\",\"gastroscopy\",\"endoscopic diagnosis\",\"lipoma\"],\"generation_mode\":\"doctor\",\"published_at\":null,\"created_at\":\"2026-05-28T08:08:10\",\"updated_at\":\"2026-05-28T12:59:25\",\"video\":{\"id\":1512,\"name\":\"Live Case - Diagnosing a Duodenal Lipoma at Endoscopy\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":\"1195975366\",\"thumbnail\":\"https://i.vimeocdn.com/video/2162402267-06bc3453daaa0b02578acf17af9742f4516512aa397dc40875f27b51cc481d6c-d_1280x720?\u0026r=pad\u0026region=us\",\"duration\":202,\"access_level\":\"FULL\",\"is_free\":true}},{\"id\":8,\"title\":\"The Four Pillars: Why Endoscopic Complications Aren't Bad Luck\",\"slug\":\"four-pillars-endoscopic-complications\",\"summary\":\"Most teaching frames endoscopic complications as bad luck. Editor-in-Chief Dr David Tate argues the opposite in his introduction to Issue 5 of the ESGE Academy Video Journal: complications are predictable, clustering around four gaps in operator preparation. The complication rate is not a feature of the procedure â it is a feature of the operator.\",\"content_html\":\"$21\",\"content_markdown\":null,\"meta_description\":\"Endoscopic complications cluster around four predictable gaps in operator preparation. Editor-in-Chief Dr David Tate on what doing the work looks like.\",\"quotes\":[{\"text\":\"Not all adverse events bleed. Some are simply missed.\",\"speaker\":\"Dr AlžbÄta Hujova\",\"timestamp\":\"3:30\",\"video_title\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\"},{\"text\":\"One good clip beats three placed badly. Do less, but do it well.\",\"speaker\":\"Dr Maria Eva Argenziano\",\"timestamp\":\"5:00\",\"video_title\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\"},{\"text\":\"Preparation is what panic looks like in slow motion, done in advance.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"5:50\",\"video_title\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\"},{\"text\":\"ABC is not a slogan. It is a discipline that survives the moment.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"7:30\",\"video_title\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\"},{\"text\":\"The complication rate is not a feature of the procedure. It is a feature of the operator.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"1:50\",\"video_title\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\"}],\"still_urls\":null,\"excerpt_start_time\":null,\"excerpt_end_time\":null,\"excerpt_reason\":null,\"additional_previews\":null,\"video_id\":1510,\"status\":\"published\",\"tags\":[\"adverse events\",\"complications\",\"endoscopy training\",\"quality\",\"perforation\",\"editorial\",\"ESGE Academy\"],\"generation_mode\":\"doctor\",\"published_at\":null,\"created_at\":\"2026-05-08T07:35:00\",\"updated_at\":\"2026-05-08T09:58:38\",\"video\":{\"id\":1510,\"name\":\"Complications Are Predictable: Editor's Introduction to ESGE Academy Issue 5\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":\"1189810979\",\"thumbnail\":null,\"duration\":472,\"access_level\":\"FULL\",\"is_free\":true}},{\"id\":7,\"title\":\"Robotics and ESD: A 2026 Field Guide to Platforms, Evidence, and Roadmap\",\"slug\":\"robotics-and-esd-2026-field-guide\",\"summary\":\"A 24-minute survey of robotic platforms for endoscopic submucosal dissection â from EndoMASTER and EASE through STRAS, K-FLEX, Flex Robotic, Endomina, EndoFaster, GIFTS/ROBOPERA, Da Vinci SP, and EndoQuest ELS â with the Genidy 2026 meta-analysis, the drawbacks nobody wants to talk about, and a realistic clinical roadmap.\",\"content_html\":\"$22\",\"content_markdown\":null,\"meta_description\":\"Robotic platforms for ESD surveyed: EndoMA
1STER, EASE, STRAS, K-FLEX, Flex Robotic, Endomina, ROBOPERA, Da Vinci SP. Genidy 2026 meta-analysis and 2027+ roadmap.\",\"quotes\":[{\"text\":\"We're all making our own things to do our attraction, but there is nothing that is systematic and that is structured, just like laparoscopic surgery, where you can lift the megalosal flap out of the way to get another hand in play.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"0:42\",\"video_title\":\"Lecture - Robotics and Endoscopic Submucosal Dissection\"},{\"text\":\"This one got FDA approval in 2017, but the company went bust. The financials of creating a robotic endoscopy company are not particularly solid.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"10:03\",\"video_title\":\"Lecture - Robotics and Endoscopic Submucosal Dissection\"},{\"text\":\"There's no room for a robot in it. There's hardly room for me in it.\",\"speaker\":\"Dr David Tate\",\"timestamp\":\"21:53\",\"video_title\":\"Lecture - Robotics and Endoscopic Submucosal Dissection\"},{\"text\":\"The future of endoscopic surgery is to blur the lines between surgery and endoscopy to give the endoscopist the power to cut and mend.\",\"speaker\":\"Prof V. Ho (quoted)\",\"timestamp\":\"23:57\",\"video_title\":\"Lecture - Robotics and Endoscopic Submucosal Dissection\"}],\"still_urls\":null,\"excerpt_start_time\":1390,\"excerpt_end_time\":1470,\"excerpt_reason\":\"The talk's closing vision â a realistic 5-to-10-year timeline for robotic ESD democratisation and the signature quote from Professor V. Ho about blurring the lines between surgery and endoscopy. Self-contained, memorable, and captures the lecture's core message.\",\"additional_previews\":null,\"video_id\":1508,\"status\":\"published\",\"tags\":[\"Lecture\",\"Robotic endoscopy\",\"ESD\",\"Traction devices\",\"EndoMASTER EASE\",\"Flex Robotic\",\"Da Vinci SP\",\"ROBOPERA\",\"Degrees of freedom\"],\"generation_mode\":\"admin\",\"published_at\":null,\"created_at\":\"2026-04-11T17:29:30\",\"updated_at\":\"2026-09-27T15:46:22\",\"video\":{\"id\":1508,\"name\":\"Lecture - Robotics and Endoscopic Submucosal Dissection\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":null,\"thumbnail\":\"https://i.vimeocdn.com/video/2144813945-a63a40c3cccaa59731fc0cc339a36f44860d1cfeabadd8290750f19e1b8e82e7-d_1920x1080?\u0026r=pad\u0026region=us\",\"duration\":1484,\"access_level\":\"PREVIEW\",\"is_free\":false}},{\"id\":6,\"title\":\"Live Case - Perforation Management After Colorectal Polypectomy\",\"slug\":\"live-case-perforation-management-colorectal-polypectomy\",\"summary\":\"Expert live case documenting the complete management of a significant perforation following underwater polypectomy of a 30â35mm splenic flexure polyp. Running dual commentary narrates every decision â from haemostasis prioritisation and Kerr grasper use through to systematic high-density clip closure and real-time clip failure management.\",\"content_html\":\"$23\",\"content_markdown\":null,\"meta_description\":\"Live case: complete endoscopic management of a post-polypectomy perforation at the splenic flexure. Kerr grasper haemostasis, high-density clip closure technique, and clip failure management.\",\"quotes\":[{\"text\":\"The one thing that is happening with all this talking and all this trying to treat this bleeding is that the perforation is getting larger. So you do have to bear that in mind.\",\"speaker\":\"Instructor\",\"timestamp\":\"6:28\",\"video_title\":\"Live Case - Perforation Management After Colorectal Polypectomy\"},{\"text\":\"Assess where the fluid is, and start on the gravity side. The stem is right down the perforation line.\",\"speaker\":\"Instructor\",\"timestamp\":\"12:15\",\"video_title\":\"Live Case - Perforation Management After Colorectal Polypectomy\"},{\"text\":\"Pretty much everything in endoscopy is lost in poor decision-making, including time.\",\"speaker\":\"Instructor\",\"timestamp\":\"27:10\",\"video_title\":\"Live Case - Perforation Management After Colorectal Polypectomy\"}],\"still_urls\":null,\"excerpt_start_time\":300,\"excerpt_end_time\":430,\"excerpt_reason\":\"The Kerr grasper decision and first systematic clip placement sequence â instructors discuss haemostasis strategy, escalate tools, then begin clipping with narration of stem positioning and gravity-side-first te
1chnique. Concentrated teaching across both decision-making and hands-on technique.\",\"additional_previews\":null,\"video_id\":1507,\"status\":\"published\",\"tags\":[\"Live Case\",\"perforation\",\"clip closure\",\"Colonoscopy complications\",\"Haemostasis\",\"Kerr grasper\"],\"generation_mode\":\"admin\",\"published_at\":null,\"created_at\":\"2026-04-02T12:17:28\",\"updated_at\":\"2026-09-27T15:46:30\",\"video\":{\"id\":1507,\"name\":\"Live Case - Perforation Management After Colorectal Polypectomy\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":null,\"thumbnail\":\"https://i.vimeocdn.com/video/2140908413-a4b5c037e6dbde97e37439c172eeffa50e858ce46b66e717e22896fde6b78dc5-d_1920x1080\",\"duration\":1701,\"access_level\":\"PREVIEW\",\"is_free\":false}},{\"id\":5,\"title\":\"Live Case - Muscle Retraction Sign in Oesophageal ESD\",\"slug\":\"live-case-muscle-retraction-sign-oesophageal-esd\",\"summary\":\"This live case captures real-time identification and management of the Muscle Retraction Sign (MRS) during ESD of a biopsy-proven mid-oesophageal squamous cell cancer. Learn how directionality and asymmetric submucosal injection reveal deep SM invasion, how to navigate the EID intramuscular plane deliberately, and how to re-enter the submucosa to achieve a negative deep margin.\",\"content_html\":\"$24\",\"content_markdown\":null,\"meta_description\":\"Live ESD case demonstrating Muscle Retraction Sign in the oesophagus: identify deep SM invasion optically and navigate the EID plane to achieve a negative deep margin.\",\"quotes\":[{\"text\":\"Directionality is everything in the detection of the muscle retraction sign. For deep margin optical diagnosis, you need to work from the surface.\",\"speaker\":\"Instructor\",\"timestamp\":\"1:21\",\"video_title\":\"Live Case - Muscle Retraction Sign in Oesophageal ESD\"},{\"text\":\"If you want to go back into the submucosa plane, all I have to do is cut between two known submucosal planes.\",\"speaker\":\"Instructor\",\"timestamp\":\"8:13\",\"video_title\":\"Live Case - Muscle Retraction Sign in Oesophageal ESD\"},{\"text\":\"I do believe we're looking at the invasive front here. That muscle retraction sign named by Toyonaga.\",\"speaker\":\"Instructor\",\"timestamp\":\"2:54\",\"video_title\":\"Live Case - Muscle Retraction Sign in Oesophageal ESD\"}],\"still_urls\":null,\"excerpt_start_time\":81,\"excerpt_end_time\":162,\"excerpt_reason\":\"The key diagnostic moment: instructor explains that directionality is everything, demonstrates working from the surface in neutral position, then shows asymmetric submucosal injection revealing no plane in the zone of maximal abnormality â MRS identified in real time.\",\"additional_previews\":null,\"video_id\":1506,\"status\":\"published\",\"tags\":[\"Live Case\",\"ESD\",\"muscle retraction sign\",\"Oesophageal cancer\",\"Deep margin\",\"EID\",\"Squamous cell cancer\"],\"generation_mode\":\"admin\",\"published_at\":null,\"created_at\":\"2026-04-02T12:16:59\",\"updated_at\":\"2026-09-27T15:46:36\",\"video\":{\"id\":1506,\"name\":\"Live Case - Muscle Retraction Sign in Oesophageal ESD\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":null,\"thumbnail\":\"https://i.vimeocdn.com/video/2140955282-0a3e47486edea4d4262d929e5aa1fae3210e8f42b441e59c62a38bfddcc49885-d_1920x1080\",\"duration\":553,\"access_level\":\"PREVIEW\",\"is_free\":false}},{\"id\":4,\"title\":\"Decision Making in Complex Polypectomy: Hybrid ESD, Bleeding Control, and Defect Closure â A GIEQs Live Case\",\"slug\":\"decision-making-complex-polypectomy-hybrid-esd-bleeding-closure-1772654255\",\"summary\":\"Expert live case teaching decision-making in complex polypectomy, featuring hybrid underwater ESD/EMR of a previously attempted duodenal lesion. Covers technique selection, intraoperative bleeding management with a systematic gravity-water-tamponade framework, and high-risk defect closure using mantis and retention clips. Includes candid discussion of when to transition from ESD knife to snare resection and the importance of patient positioning for optimal access.\",\"content_html\":\"$25\",\"content_markdown\":\"$26\",\"meta_description\":\"Live case: hybrid ESD for complex previously attempted duodenal polyp â technique selection, bleeding management, and clip closure with teaching commentary.\",\"quotes\":[{\"text\":\"I'm a submucosal purist and I don't want to change from that unless I have to â if you immediately go for FTRD, you can end up with a very expensive and invasive solution when a submucosal approach was always possible.\",\"timestamp\":\"3:00\",\"start_seconds\":180},{\"text\":\"On GIEQs, we want to show everything in its totality. We're not going to stop this movie just because David is feeling uncomfortable â it builds character, and the audience appreciates that.\",\"timestamp\":\"10:00\",\"start_seconds\":600},{\"text\":\"When it comes to intraoperative bleeding, the first thing is to get gravity optimal. If you can't, use water. Then it's always a blood vessel â identify it, tamponade it, and treat it precisely.\",\"timestamp\":\"36:00\",\"start_seconds\":2160},{\"text\":\"The decision to move to a colonoscope too late was a mistake I take on myself. The view was so much better â this is something to put down for next time.\",\"timestamp\":\"59:00\",\"start_seconds\":3540},{\"text\":\"Closure here is non-negotiable. These duodenal defects after previously attempted resection are extremely high-risk for delayed bleeding. The combination of mantis and retention clipping has given us foreclosure.\",\"timestamp\":\"70:00\",\"start_seconds\":4200}],\"still_urls\":null,\"excerpt_start_time\":2100,\"excerpt_end_time\":2220,\"excerpt_reason\":\"Structured bleeding management framework â demonstrates the gravity-water-tamponade approach for managing intraoperative arterial bleeding during hybrid ESD in the duodenum, with real-time teaching narration.\",\"additional_previews\":null,\"video_id\":1479,\"status\":\"published\",\"tags\":[\"ESD\",\"EMR\",\"hybrid technique\",\"duodenal polypectomy\",\"bleeding management\",\"defect closure\",\"endoscopy training\",\"decision making\",\"underwater EMR\",\"retention clips\"],\"generation_mode\":\"manual_ai\",\"published_at\":\"2026-03-04T20:40:11\",\"created_at\":\"2026-03-04T19:57:35\",\"updated_at\":\"2026-03-04T20:46:53\",\"video\":{\"id\":1479,\"name\":\"Live Case - Decision Making in Complex Duodenal Polypectomy with Hybrid ESD\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":null,\"thumbnail\":\"https://i.vimeocdn.com/video/2129385631-16ba9ee8caa2ddfee4f8d6a9abead68fa29a4712170ae94f4bcb9f4e368cd810-d?region=us\",\"duration\":0,\"access_level\":\"PREVIEW\",\"
1is_free\":false}},{\"id\":2,\"title\":\"Mastering Piecemeal EMR: Lessons from a Complex Transverse Colon Polyp\",\"slug\":\"mastering-piecemeal-emr-complex-transverse-colon-polyp\",\"summary\":\"Expert live case teaching piecemeal EMR of a large sessile transverse colon polyp, covering optical assessment with BLINK criteria, underwater and injection-assisted resection, intraprocedural bleeding management, and clip closure.\",\"content_html\":\"$27\",\"content_markdown\":\"$28\",\"meta_description\":\"Live case: piecemeal EMR for large colon polyps with optical assessment, bleeding management, and defect closure.\",\"quotes\":[{\"text\":\"Before we resect anything, we need to characterise this polyp using BLINK criteria to determine the best resection strategy.\",\"timestamp\":\"3:20\",\"start_seconds\":200},{\"text\":\"Watch how the underwater view gives us superior visualisation of the polyp margins compared to traditional air insufflation.\",\"timestamp\":\"12:45\",\"start_seconds\":765},{\"text\":\"When you encounter arterial bleeding during piecemeal resection, the key is not to panic â cap the scope, fill with water, and identify the precise source.\",\"timestamp\":\"32:10\",\"start_seconds\":1930},{\"text\":\"Complete clip closure of the resection defect significantly reduces the risk of delayed bleeding in large EMR cases.\",\"timestamp\":\"58:30\",\"start_seconds\":3510},{\"text\":\"The decision between en bloc and piecemeal comes down to polyp size and morphology â above 20mm in the colon, piecemeal EMR remains the pragmatic choice.\",\"timestamp\":\"65:00\",\"start_seconds\":3900}],\"still_urls\":null,\"excerpt_start_time\":1900,\"excerpt_end_time\":1990,\"excerpt_reason\":\"Intraprocedural bleeding management - demonstrates the cap-water-identify precision framework for managing arterial bleeding during piecemeal EMR\",\"additional_previews\":null,\"video_id\":1478,\"status\":\"published\",\"tags\":[\"EMR\",\"piecemeal resection\",\"colonoscopy\",\"polyp removal\",\"bleeding management\",\"clip closure\",\"BLINK criteria\",\"underwater EMR\"],\"generation_mode\":\"admin\",\"published_at\":\"2026-02-26T15:18:30\",\"created_at\":\"2026-02-26T15:18:30\",\"updated_at\":\"2026-02-27T07:20:37\",\"video\":{\"id\":1478,\"name\":\"Live Case - Piecemeal EMR of a Large Transverse Colon Polyp\",\"vimeo_id\":null,\"vimeo_hash\":null,\"vimeo_url\":null,\"thumbnail\":\"https://i.vimeocdn.com/video/2126419234-0da10ae104fe969c1cfb12f55bcda2ce158802a3942c976c9f75ea19a408b53e-d_1920x1080\",\"duration\":4315,\"access_level\":\"PREVIEW\",\"is_free\":false}},{\"id\":1,\"title\":\"The PRIME Algorithm: A Game-Changer for Early Rectal Cancer Management\",\"slug\":\"prime-algorithm-early-rectal-cancer-eid\",\"summary\":\"Watch the complete PRIME algorithm in action: from MRS detection and deep margin optical diagnosis to real-time EID plane selection. 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It's probably the goal of surgeons anyway.\",\"speaker\":\"Instructor\",\"timestamp\":\"3:43\",\"video_title\":\"Full Procedure - PRIME Algorithm with EID\"},{\"text\":\"We will encounter muscle retraction sign. 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1<div hidden id="S:1"><main class="min-h-screen bg-blog-gradient overflow-hidden"><section class="relative pt-12 pb-6 md:pt-16 md:pb-8"><div class="absolute top-20 left-1/4 w-72 h-72 bg-[#EEC378]/5 rounded-full blur-[100px] pointer-events-none"></div><div class="absolute bottom-0 right-1/4 w-96 h-96 bg-[#1e3a5f]/50 rounded-full blur-[120px] pointer-events-none"></div><div class="container mx-auto px-4 relative z-10"><div class="max-w-3xl mx-auto text-center"><p class="text-[#EEC378] text-sm font-semibold tracking-[0.2em] uppercase mb-4 animate-fade-up">Expert Education</p><h1 class="text-4xl md:text-5xl lg:text-6xl font-bold text-white mb-4 tracking-tight animate-fade-up-delay-1">GIEQs<!-- --> <span class="relative"><span class="text-transparent bg-clip-text bg-gradient-to-r from-[#EEC378] to-[#D4A85A]">Blog</span><span class="absolute -bottom-2 left-0 right-0 h-1 bg-gradient-to-r from-[#EEC378]/60 to-transparent rounded-full"></span></span></h1><p class="text-lg md:text-xl 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1<path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">September 24, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:1.125rem;line-height:1.3">Making a six-month fellowship count</h3><p class="blog-thumbnail__summary mt-2 text-xs text-[#B4C5D9]/80 line-clamp-2">A fellowship abroad is often the only route to advanced endoscopy training from sub-Saharan Africa. This lecture sets out what can be done before the trainee arrives, how to structure the fellowship around feedback rather than volume, and what support the trainee needs back home.</p></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-6 md:p-8 flex flex-col justify-center"><p class="text-[#B4C5D9] mb-6 line-clamp-4 leading-relaxed text-lg">A fellowship abroad is often the only route to advanced endoscopy training from sub-Saharan Africa. This lecture sets out what can be done before the trainee arrives, how to structure the fellowship around feedback rather than volume, and what support the trainee needs back home.</p><div class="flex items-center justify-end"><span class="text-[#EEC378] text-sm font-medium flex items-center gap-1 group-hover:gap-2 transition-all">Read article<svg class="w-4 h-4" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></div></article></a></div></div><p class="text-[#EEC378] text-xs font-semibold tracking-[0.15em] uppercase mb-6">More Articles</p><div class="grid grid-cols-1 md:grid-cols-2 lg:grid-cols-3 gap-6 lg:gap-8"><div class="animate-fade-up" style="animation-delay:0s"><a href="/blog/pillow-sign-naked-fat-duodenal-lipoma"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2162402267-06bc3453daaa0b02578acf17af9742f4516512aa397dc40875f27b51cc481d6c-d_1280x720?&r=pad&region=us" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35f2 0%, #0d1f35b3 45%, #0d1f3533 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">duodenal lipoma</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">subepithelial lesion</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">May 28, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">The Pillow Sign and the Naked-Fat Sign: Diagnosing a Duodena...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50">
1<svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">A subepithelial lesion turns up in the second part of the duodenum and is referred for discussion. Reach for EUS? Resect it? Or can the diagnosis be made at the endoscope, in a couple of minutes, with the kit already in your hand? 2 3This short case works through the reasoning step by step â orientation against the major papilla, confirming the lesion is subepithelial rather than mucosal, testing mobility, the pillow sign, and the naked-fat sign that seals the diagnosis of lipoma.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.1s"><a href="/blog/four-pillars-endoscopic-complications"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><div class="absolute inset-0" style="background:linear-gradient(135deg, #0d1f35 0%, #15304a 50%, #1a3d5c 100%)"></div><svg class="absolute inset-0 w-full h-full" viewBox="0 0 400 225" preserveAspectRatio="xMidYMid slice" xmlns="http://www.w3.org/2000/svg"><defs><linearGradient id="grad_R_2amqnqbt5db_" x1="0%" y1="0%" x2="100%" y2="100%"><stop offset="0%" stop-color="#EEC378" stop-opacity="0.6"></stop><stop offset="50%" stop-color="#F5D9A8" stop-opacity="0.3"></stop><stop offset="100%" stop-color="#EEC378" stop-opacity="0.15"></stop></linearGradient><radialGradient id="glow_R_2amqnqbt5db_" cx="70%" cy="30%" r="60%"><stop offset="0%" stop-color="#EEC378" stop-opacity="0.2"></stop><stop offset="100%" stop-color="#0d1f35" stop-opacity="0"></stop></radialGradient><pattern id="pattern_R_2amqnqbt5db_" width="80" height="20" patternUnits="userSpaceOnUse"><path d="M0,10 Q20,0 40,10 T80,10" fill="none" stroke="#EEC378" stroke-width="0.6" opacity="0.15"></path></pattern></defs><ellipse cx="280" cy="70" rx="180" ry="100" fill="url(#glow_R_2amqnqbt5db_)"></ellipse><rect x="0" y="0" width="100%" height="100%" fill="url(#pattern_R_2amqnqbt5db_)"></rect><path d="M-30,180 Q100,150 200,120 T380,80 T500,50" fill="none" stroke="url(#grad_R_2amqnqbt5db_)" stroke-width="2.5" stroke-linecap="round"></path><path d="M-50,200 Q70,170 160,140 T320,100 T450,70" fill="none" stroke="url(#grad_R_2amqnqbt5db_)" stroke-width="1.5" stroke-linecap="round" opacity="0.5"></path><path d="M420,30 Q300,50 200,60 T50,90 T-30,110" fill="none" stroke="#EEC378" stroke-width="2" stroke-linecap="round" opacity="0.2"></path><g transform="translate(340, 25)" opacity="0.25"><circle cx="15" cy="15" r="12" fill="none" stroke="#EEC378" stroke-width="2"></circle><circle cx="15" cy="15" r="5" fill="#EEC378" opacity="0.5"></circle><line x1="15" y1="27" x2="15" y2="40" stroke="#EEC378" stroke-width="2" stroke-linecap="round"></line></g><circle cx="50" cy="170" r="8" fill="#EEC378" opacity="0.1"></circle><circle cx="70" cy="185" r="5" fill="#EEC378" opacity="0.15"></circle><circle cx="360" cy="180" r="6" fill="#EEC378" opacity="0.1"></circle></svg><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35ee 0%, #0d1f3550 40%, transparent 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">adverse events</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">complications</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24">
3<path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">May 8, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">The Four Pillars: Why Endoscopic Complications Aren't Bad Lu...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">Most teaching frames endoscopic complications as bad luck. Editor-in-Chief Dr David Tate argues the opposite in his introduction to Issue 5 of the ESGE Academy Video Journal: complications are predictable, clustering around four gaps in operator preparation. The complication rate is not a feature of the procedure â it is a feature of the operator.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.2s"><a href="/blog/robotics-and-esd-2026-field-guide"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2144813945-a63a40c3cccaa59731fc0cc339a36f44860d1cfeabadd8290750f19e1b8e82e7-d_1920x1080?&r=pad&region=us" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35f2 0%, #0d1f35b3 45%, #0d1f3533 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">Lecture</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">Robotic endoscopy</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">April 11, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">Robotics and ESD: A 2026 Field Guide to Platforms, Evidence,...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg>
3<span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">A 24-minute survey of robotic platforms for endoscopic submucosal dissection â from EndoMASTER and EASE through STRAS, K-FLEX, Flex Robotic, Endomina, EndoFaster, GIFTS/ROBOPERA, Da Vinci SP, and EndoQuest ELS â with the Genidy 2026 meta-analysis, the drawbacks nobody wants to talk about, and a realistic clinical roadmap.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.30000000000000004s"><a href="/blog/live-case-perforation-management-colorectal-polypectomy"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2140908413-a4b5c037e6dbde97e37439c172eeffa50e858ce46b66e717e22896fde6b78dc5-d_1920x1080" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35f2 0%, #0d1f35b3 45%, #0d1f3533 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">Live Case</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">perforation</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">April 2, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">Live Case - Perforation Management After Colorectal Polypect...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">Expert live case documenting the complete management of a significant perforation following underwater polypectomy of a 30â35mm splenic flexure polyp. Running dual commentary narrates every decision â from haemostasis prioritisation and Kerr grasper use through to systematic high-density clip closure and real-time clip failure management.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24">
3<path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.4s"><a href="/blog/live-case-muscle-retraction-sign-oesophageal-esd"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2140955282-0a3e47486edea4d4262d929e5aa1fae3210e8f42b441e59c62a38bfddcc49885-d_1920x1080" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35f2 0%, #0d1f35b3 45%, #0d1f3533 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">Live Case</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">ESD</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">April 2, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">Live Case - Muscle Retraction Sign in Oesophageal ESD</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">This live case captures real-time identification and management of the Muscle Retraction Sign (MRS) during ESD of a biopsy-proven mid-oesophageal squamous cell cancer. Learn how directionality and asymmetric submucosal injection reveal deep SM invasion, how to navigate the EID intramuscular plane deliberately, and how to re-enter the submucosa to achieve a negative deep margin.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.5s"><a href="/blog/decision-making-complex-polypectomy-hybrid-esd-bleeding-closure-1772654255"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2129385631-16ba9ee8caa2ddfee4f8d6a9abead68fa29a4712170ae94f4bcb9f4e368cd810-d?region=us" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0f2922f2 0%, #0f2922b3 45%, #0f292233 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#34D399;background-color:#0f2922cc;border-width:1px;border-color:#34D39933">ESD</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#34D399;background-color:#0f2922cc;border-width:1px;border-color:#34D39933">EMR</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0f2922cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24">
3<path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#34D399b3">March 4, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">Decision Making in Complex Polypectomy: Hybrid ESD, Bleeding...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#34D399"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#34D399b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #34D3994d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">Expert live case teaching decision-making in complex polypectomy, featuring hybrid underwater ESD/EMR of a previously attempted duodenal lesion. Covers technique selection, intraoperative bleeding management with a systematic gravity-water-tamponade framework, and high-risk defect closure using mantis and retention clips. Includes candid discussion of when to transition from ESD knife to snare resection and the importance of patient positioning for optimal access.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.6000000000000001s"><a href="/blog/mastering-piecemeal-emr-complex-transverse-colon-polyp"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2126419234-0da10ae104fe969c1cfb12f55bcda2ce158802a3942c976c9f75ea19a408b53e-d_1920x1080" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0f2922f2 0%, #0f2922b3 45%, #0f292233 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#34D399;background-color:#0f2922cc;border-width:1px;border-color:#34D39933">EMR</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#34D399;background-color:#0f2922cc;border-width:1px;border-color:#34D39933">piecemeal resection</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0f2922cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#34D399b3">February 26, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">Mastering Piecemeal EMR: Lessons from a Complex Transverse C...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50">
3<svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#34D399"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#34D399b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #34D3994d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">Expert live case teaching piecemeal EMR of a large sessile transverse colon polyp, covering optical assessment with BLINK criteria, underwater and injection-assisted resection, intraprocedural bleeding management, and clip closure.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div><div class="animate-fade-up" style="animation-delay:0.7000000000000001s"><a href="/blog/prime-algorithm-early-rectal-cancer-eid"><article class="group h-full blog-card flex flex-col"><div class="relative aspect-[16/10] overflow-hidden transition-transform duration-500 group-hover:scale-[1.02]"><div class="blog-thumbnail relative w-full h-full overflow-hidden "><img src="https://i.vimeocdn.com/video/2117821097-e61a8483b28f541b2c4a34dccebe68a46ac5f7c7e8f6ec6cd8c664790c73d96c-d_1920x1080" alt="" aria-hidden="true" class="absolute inset-0 w-full h-full object-cover" loading="lazy" decoding="async"/><div class="absolute inset-0" style="background:linear-gradient(to top, #0d1f35f2 0%, #0d1f35b3 45%, #0d1f3533 100%)"></div><div class="absolute top-3 left-3 flex gap-1.5"><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">PRIME algorithm</span><span class="blog-thumbnail__tag inline-block px-2 py-0.5 text-[9px] font-semibold uppercase tracking-wider backdrop-blur-sm rounded" style="color:#EEC378;background-color:#0d1f35cc;border-width:1px;border-color:#EEC37833">early rectal cancer</span></div><div class="absolute top-3 right-3"><span class="blog-thumbnail__video-badge inline-flex items-center gap-1 px-2 py-1 text-[9px] font-medium text-white/90 backdrop-blur-sm rounded" style="background-color:#0d1f35cc"><svg class="w-3 h-3" fill="currentColor" viewBox="0 0 24 24"><path d="M8 5v14l11-7z"></path></svg>Video</span></div><div class="absolute bottom-0 left-0 right-0 p-4"><p class="blog-thumbnail__date text-[10px] uppercase tracking-wider mb-2" style="color:#EEC378b3">February 6, 2026</p><h3 class="blog-thumbnail__title text-white font-semibold leading-tight drop-shadow-lg" style="font-size:0.9rem;line-height:1.3">The PRIME Algorithm: A Game-Changer for Early Rectal Cancer...</h3></div><div class="absolute bottom-3 right-3"><div class="blog-thumbnail__brand flex items-center gap-1 opacity-50"><svg class="w-3.5 h-3.5" viewBox="0 0 24 24" style="color:#EEC378"><circle cx="12" cy="12" r="10" fill="none" stroke="currentColor" stroke-width="2" opacity="0.6"></circle><circle cx="12" cy="12" r="4" fill="currentColor" opacity="0.8"></circle></svg><span class="text-[8px] font-bold tracking-wider uppercase" style="color:#EEC378b3">GIEQs</span></div></div><div class="absolute top-0 left-0 right-0 h-0.5" style="background:linear-gradient(to right, transparent, #EEC3784d, transparent)"></div></div></div><div class="p-5 flex flex-col flex-grow"><p class="text-sm text-[#9BA8B9] line-clamp-3 mb-4 flex-grow">Watch the complete PRIME algorithm in action: from MRS detection and deep margin optical diagnosis to real-time EID plane selection. A 75-minute teaching case demonstrating how to achieve R0 resection in early rectal cancer with the REACT tool.</p><div class="flex items-center justify-end mt-auto pt-4 border-t border-[#2a4a6f]/30"><span class="text-[#EEC378] text-xs font-medium flex items-center gap-1 group-hover:gap-1.5 transition-all">Read article<svg class="w-3 h-3" fill="none" stroke="currentColor" viewBox="0 0 24 24">
3<path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M9 5l7 7-7 7"></path></svg></span></div></div></article></a></div></div></div></section><section class="py-16 md:py-24"><div class="container mx-auto px-4"><div class="max-w-3xl mx-auto text-center"><div class="p-8 md:p-12 rounded-2xl relative overflow-hidden" style="background:linear-gradient(135deg, rgba(30, 58, 95, 0.6) 0%, rgba(22, 46, 77, 0.4) 100%);border:1px solid rgba(238, 195, 120, 0.2)"><div class="absolute -top-20 -right-20 w-40 h-40 bg-[#EEC378]/10 rounded-full blur-[60px]"></div><h2 class="text-2xl md:text-3xl font-bold text-white mb-4 relative z-10">Want to dive deeper?</h2><p class="text-[#B4C5D9] mb-8 relative z-10">Access our complete video library with expert-led courses on advanced endoscopy techniques.</p><a class="btn-blog-primary inline-block relative z-10" href="/courses">Explore Courses</a></div></div></div></section></main></div>
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