My charge now is to dive a little bit deeper into the concept of therapeutic endoscopy and what the APP needs to know. So just to set the stage, we are a little bit behind, so I'll try to cover the more pertinent aspects and maybe some of the more deeper data you can reflect on in the enduring material. That's number one. And number two, instead of going too deep into the technical aspects of the procedures themselves, I'll focus a little bit more on the actual role of the APP in practice that is focused on therapeutic endoscopy. These are my disclosures. The objective of this talk is to, of course, define therapeutic endoscopy and also understand that there are many phrases and other interchangeable terms that are used to describe this field. Interventional endoscopy is something that we are preferring right now, advanced endoscopy and so forth. So you'll come across some of these as you look at practices or you look at the literature in this topic and so forth. I'll talk a little bit about the training that goes into it, the infrastructural and resource needs that speak to a successful establishment of a service like this. And then, of course, dive into the meat of the topic, which is how does the APP position themselves in the best manner as a huge attribute to such a practice, and then talk about the practice goals and so forth. So what is therapeutic endoscopy? These are, as I said, multiple terms have been used. I think the least, the most non-denominational phrase that is now acceptable is interventional endoscopy, very similar to what cardiology has as interventional cardiology. I think that's kind of settling down as the preferred term, because that's what we do in most of these procedures is interventions using an endoscope. This is a field that really started several decades ago, but really has blossomed in the last decade or so, you know, almost an exponential jump in the kind of procedures, devices, technologies and paradigms that have come into play. But I do believe that there are two seminal points that, if you will, for interventional endoscopy that kind of, you know, planted the seed, and they were around the same time frame in the mid-70s, early 80s, when ERCP started, you know, in most places of the world around the same time, and then colonoscopy started with the ability to remove polyps. They were really the first interventions that set the stage for us. So what goes into the making of an interventional endoscopist, so to speak? This person is still a gastroenterologist and a clinician and a physician and a clinical provider, which is something I try to emphasize every day to the trainees and to anyone who wants to listen to me. But the basic construct is four years of medical school, just like any other doctor, three years of internal medicine residency. So now you're in the internal medicine pathway, not in the surgical pathway. And then three years of an advanced fellowship, of a general GI fellowship, which has exposure to advanced procedures, but you don't nowadays get to do too many of these in that three-year construct outside of certain institutions that still have a high enough volume to afford that in the three-year time frame. And then, of course, what has emerged as a very important paradigm in the last decade or so is the concept of dedicated training for the established board eligible or board certified gastroenterologist to then spend another year, sometimes two years, learning a lot of the procedures that I'll talk about now and some of those that Dr. Shields referred to. So it's a fairly long 10 to 12 or 13-year experience. And if you happen to be a practicing GI, someone in the middle, or a practicing internist, this could be up to a 15, 20-year pathway, depending on how an individual frames their career path. So it's a long time before you actually are eligible to practice independently. I should say that at this time, whereas there is a certificate for medical school graduation, there is a certificate for internal medicine residency under the ABIM, and for a GI fellowship, there is not an ABIM certified certification, so to speak, for interventional endoscopy. But it does exist for interventional cardiology, it does exist for transplant hepatology, it exists for several other different specialties. But we don't quite yet have an ABIM certified fellowship pathway. So most of these certifications come from the training institution, and they are still valid. But I just wanted to highlight that difference. This here slide talks about a spectrum of diverse interventional procedures that by no means represent all of the procedures. But just to highlight that we now have established platforms for small bowel evaluation for a while, the double balloon and single balloon endoscopes, and the soon-to-arrive in the US, the motorized spiral endoscope, where you actually take a motorized endoscope that rotates and finds its way from the mouth almost all the way to the distal ileum using a motorized technique. It's been well established in Far East as well as in Europe, but it's about just around the corner for us to reduce the small bowel evaluation time from the two and a half to three hours or four hours in certain cases to about a half hour procedure. So that's something that's on the advent. Endoscopic therapy for Barrett's and early neoplasia is a full lecture that I will be presenting tomorrow, but that's here to stay. ERCP and EUS, of course, you've heard about. And there's a lot of additional EUS-based interventions, such as a pseudocyst drainage, a gallbladder drainage, EUS-guided gastrogygenostomies, and all kinds of EUS-based ablations, a lot of which is beyond the scope of this lecture, but just an introduction to that. Endoscopic resection is one of the most, I should say, transformational interventional procedures that have come into play in the last decade with the introduction and refinement of techniques around endoscopic mucosal resection and endoscopic submucosal dissection. These are established procedures in the NCC and Cancer Care Guidelines. Now, the National Collaborative Consortium in Cancer Medicine is the founding and guiding principles for cancer care, and these find themselves firmly implanted there, right next to surgery and chemoradiation as established procedures. So keep these in mind for organ-sparing, minimally invasive, low-morbidity interventions that are guideline-based interventions out there. Endoscopic resection has gone transmural, which means instead of previously we being afraid of creating a perforation, in some cases we are now creating full-thickness perforations with the intent of removing a tumor and then closing the defect with suturing or with full-thickness lips. Of course, everyone by now has heard about the per-oral esophageal myotomy paradigm, and that has almost completely replaced laparoscopic Heller's myotomy, especially for the Achillesia type III, where the outcomes for POEM are by far exceedingly much better than any other intervention. And now to talk about bariatric endoscopy, you know, as you know, Roux-en-Y gastric bypass took the field by storm on the surgical side in the mid-90s to up until now. And this is a very highly popular procedure from the surgical side. But in the last decade, we have now endobariatic solutions such as balloons and metabolic endoscopy, endoscopic suturing, gastroplasty, whereas the weight reduction impact of these procedures is not quite at the surgical level. In other words, you're in the 10% to 20% estimated body weight loss, whereas surgery is in the 30% to 50% estimated body weight loss. They are still, you know, a good option for the relatively lower BMI category, which is in the 35% to 45% range. And then beyond that, the surgery is more effective. Palliative enteral stenting, such as esophageal stenting, duodenal stenting, colonic stenting, is a daily enterprise in units like ours, where patients come in, they're very sick. Many of them are terminally ill from cancer. And in the past, they were all getting morbid surgical procedures. And there is now randomized control trial data that suggests that not only is the patient outcome better, but the length of stay is better, and the cost of medicine is better. So this is really a game-changing intervention. So just a sampling of these procedures, a high-level overview. So what is required for an interventional endoscopist to get to this level? So obviously, you should be a good clinician first. You should be well-trained in medicine and in gastroenterology. And then, of course, you need to go and do the interventional fellowship, as I mentioned earlier. But once you arrive at an institution, the endoscopist has to then make sure that there are resources in the building that are available, anesthesia services, backup surgical expertise, radiology, interventional radiology. And of course, why we are here today is to talk about the fact that this is not a silo-based experience. This is a team experience. And at the core of that team is the advanced practice provider, who does a lot of the roles that I'll get deeper into as part of that therapeutic endoscopy practice, just short of not being able to do those procedures even just yet. But everything else outside of the procedure room is a huge attribute that falls on the APP in concert with their endoscopy physician. So what are the resources and devices that are required in delivering this service? The endoscopes is just a starting point of this. There are a lot of very, very specialized endoscopes that are out there available now, including the single-use endoscopy platforms, which we can talk about in the discussion section. The endoscopy suites have to be able to accommodate the equipment. The rooms have to be large enough and safe enough to allow that equipment to travel and move around for anesthesia machines and personnel. And a lot of these institutions, there are a lot of learners in the suite at all levels, nursing students, APP students, technical students, physician students, a lot of proctorships going on, preceptorships going on. Anesthesia has rotational dental residents, emergency room physicians. So it is not uncommon sometimes in my room to have seven to nine people who have nothing to do with the procedure, are just observing or learning in some way. The fluoroscopy equipment is highly specialized now. There are dedicated fluoroscopy machines that are available to support ERCP and other procedures. And of course, the endosurgical generators and a host of other devices and instruments that are literally mushrooming on a day-to-day basis. Now moving to a few of the common procedures, I refer to ERCP and EOS was discussed in detail by Dr. Shields. Endoscopic resection, I'll talk a little bit about ablation and then enteral stenting. These are very commonly done almost on a daily basis in units like ours. This is one of the earlier interventional rooms that I had the privilege of being part of constructing this. This room itself, probably about 13, 14 years ago, cost $2 million. and the costs have gone up since then of course, and now this type of a room would probably cost in the range of five to six million dollars in the post pandemic era. So this is a fair amount of money at stake. The equipment is specialized as was referred to by Dr. Shields, this is the EUS scopes that are used, this is the linear scope that is used for fine needle aspiration. And these are some of the images from ERCP procedure showing the high quality cholangiogram and a sampling of a lesion with EUS guided FNA. You can see how sharp these pictures are. This is what they call high-end ultrasound. This is not your regular garden variety ultrasound that's available for other applications. This is called high-end ultrasound. The mechanics of this are extremely expensive and specialized and delicate. Each of these consoles is, you know, put together is about half a million dollar per room so it's not small change. Here are some examples, hopefully you can see the videos playing. This is an FNA of a liver lesion in a patient who was sent for what we call early esophageal cancer, had a negative PET scan, negative CT scan, but endoscopic ultrasound was able to find this tumor and unfortunately for the patient the tumor was upstaged and therefore the patient did not go for esophagectomy but instead went to chemotherapy. So unfortunate finding but actually in the big picture better for the patient because such a patient should not undergo esophagectomy. So this procedure was able to appropriately triage them into the correct treatment pathway. So that's the impact of these procedures. And here is a procedure showing the sphincterotomy that Dr. Shields referred to, a very basic intervention that was developed in the 70s and has since been very very much refined and is able to deliver stones, allow us to place stents across tumors, and a host of other things including intraductal endoscopy known as cholangioscopy. So examples of endoscopic procedures are EMR and endoscopic full thickness resection. I alluded to them a little bit. Here's an example of an endoscopic mucosal resection of a very very large colon polyp. I should say this is a patient who has cirrhosis and was referred to me because he cannot undergo colorectal surgery. As a child sees cirrhotic and you can see here how big this lesion is and we are in a sorry we're in a retroflex position trying to, I'll just move this along if I can, trying to grab this with a snare after the appropriate injection has been used to lift the agent lift the lesion away from the muscularis and just let it run through and you'll see the enormity of this intervention in terms of the lesion. When I thought I had resected the whole lesion there was still as much lesion available for further resection and you can see what happens next. So there we have a bleeder and this is the kind of devices you need to have on hand. This is a coagulation grasper forceps. It's about $450 but just see how effectively it manages bleeding. One pinch and the bleeding is gone. So the appropriate procedures, this is an argon plasma coagulation probe and it's killing any residual neoplastic cells at the edge of the resection and then we have these amazing endoclips now that seal the defect and the patient actually can go home the same day. So this particular patient I kept him in house because he came from a distance and had very low platelets and INR problem but typical patients like this if they are normal and healthy I will send them home the same day. And previously all of them underwent either hemicolectomies or major resections. This is again a construct showing the endoscopic resection of Barrett's. We'll talk a little bit about more detail tomorrow and you can see the muscle layer here, completely removed tumor and off he goes. Full thickness resection has now come on board. This is a clip device that basically clips the tumor shut and then seals it and cuts it off above the clip so that you have a full resection that is possible. Here is an appendicial tumor that was removed with this technique and it's a full thickness resection so that if this clip does not deploy properly you're going to have a perforation but thankfully it does deploy almost all the time properly and you can send the patient home. Peroral esophageal myotomy is here to stay. I don't need to belabor this particular procedure but safe to say this is a major paradigm shift where you take patients with echolesia and you're able to treat them with an endoscope and I've personally witnessed this procedure being done in about under 30 minutes by expert endoscopists who have done several hundreds of these. The basic construct here is that you have a patient with a dilated esophagus and a spastic lower esophageal sphincter and then you go ahead and you create an incision inside the esophageal wall by appropriate injection of solution and you're cutting it open. This is the incision you can see here and then you travel down the third space which we call submucosal tunneling. The scope is inside the walls of the esophagus and then you approach the muscle layer and you cut it and then you have the myotomy over there. So this is the muscle layer that has been cut right there. You can see it the inner circular layer is being cut while preserving the outer longitudinal layer and sometimes we do enter the mediastinum but that's okay and this way you have about seven to ten centimeter of muscle cut all the way from the top down to the bottom and then you achieve the full myotomy and this patient typically is still being kept overnight. The defect is closed by endoclips but increasingly many centers are sending these patients home the same day which is amazing. So what is the role in the last few slides? The role of the APP starts with the complex endoscopy referral triage and all the way through shared visits, independent visits, peri-procedure management with the physician, a follow-up on the results and ancillary testing in conjunction with the physician and of course really trying to coordinate interdisciplinary care which is really surgical services, interventional radiology, oncology and of course complication management. These are messages that come first to the APP and then the APP and the physician together make sure that the patient is brought to safety. So the cognitive skill sets required of course is the knowledge of these disease states and the procedures, what are the indications, what are the contraindications, what is the latest data on this for example SOD type 3 no longer is subjected to ERCP based on the episode trial so it is the responsibility of the team to make sure that they discuss these type of data points and enhance the knowledge of each other in clinic and outside of clinic. Understanding the you know the fact that standard ERCP cannot be performed in a patient with RU and Y gastric bypass so knowing that in the clinic visit and setting the stage for alternative procedures is really important as well. So there's a lot of cognitive skill set that's involved and of course for the technical skill sets that are the peri-procedure procedure setup, the images acquisition, the looking up of the coagulation parameters, you know setting the stage for the patient to have the appropriate time slot you know for the procedure, communicating with the endoscopist what the needs are and transmitting that to the nursing team and really being available and willing to participate in the overall care of this patient not just, it's not just about the endoscopy procedure itself. So in my mind the APP on an advanced endoscopy team is really a core member not just for the GI service line but also for the cancer center and for the primary care physician and interventional radiologist and surgeons so forth because you know this is the hub around which all this activity occurs so the liaison function in that sense is very very important and I feel that without that it will be very difficult to deliver this type of care to all the to all the patients. So timely and clear communications especially around the end of days and going into weekends especially long weekends you know this handoffs are so important now in American medicine and I think the APP serve a very critical role in ensuring that that is the case. A comment was made on informed consent. I'll just say this that informed consent for complex procedures takes a whole different connotation. I do feel that unless it is expressly documented in institutional policy and in practice and practice policy for that particular entity that the APP can be surrogate. I do feel that for the vast majority of cases the endoscopist is ending up taking these consents but this is something we can talk about in the discussion section as well. Now I referred in my first lecture earlier on in the day about scholarly activity and I feel that you know being in a sub sub specialized clinic or practice this is a tremendous opportunity for for for APPs who are in the advanced endoscopy realm because there are so many new technologies at play so many unique and different diagnoses such gratifying interventional outcomes that this is a perfect platform to produce case reports case series be part of reviews and novel technology collaborate with the industry partners along with your physicians work alongside fellows if you have if you're in an academic setting and really get your name out there on on published manuscripts and tangible products that come out of your clinical practice. I think this is a you know a tremendous platform for that and I would highly encourage any and all of you who are involved with this type of practice to consider that as a byproduct outside of your clinical activities. Last slide practice pearls a high quality advanced endoscopy service requires a team approach a fair amount of infrastructure capital investment resources technical skill training commitment and so forth and that is true for both APPs and MDs. I do feel that the APP MD collaboration is extremely important for a safe and successful outcome especially when you're coordinating complex care. I think the communication aspect the timeliness of care delivery the peri-procedural aspects all of these are really something we cannot do without the APP support and so I think that's that's important to to keep in mind. I do feel very strongly as I've mentioned for about 90 times this morning that the APPs are really well positioned especially in such services to benefit from and participate in scholarly and non-clinical activities that come from being part of such a such a practice in the modern era of medicine. So I feel that ongoing mentorship and professional development of the APP is important in such a service because it is such a highly evolutionary paradigm that is changing from week to week even for people like myself who've been at it for about 25 years. So with that I'll close I know we're a little behind but thank you for your attention. All right so the first question we have is compared to a general gastroenterology practice advanced endoscopic practice requires which are the following? So please select single best answer and it could be all of the above but let's see enhanced GI physician training, enhanced nursing and GI associate training, specialized rooms and facilities, additional equipment or all of the above. All right 92 percent. So I think that the vast majority got this right. So really as I mentioned in my lecture you know this is a multi-faceted initiative and really requires every aspect to be covered as listed on the slide. Very good. Now over to Jill for the Q&A please. Thank you.

therapeutic endoscopy

advanced practice providers

interventional endoscopy

training

resources

APP role