the APP needs to know. And this lecture is important because endoscopy, particularly therapeutic endoscopy, has evolved so much in the last decade, especially, and also in the last five years, particularly so, that we thought it's important that a lot of our APP colleagues work in and around endoscopy and complex endoscopy. There is a differentiation between the two. We'll talk about that a little bit. So, this was the reason this topic was selected. And hopefully, we'll try to squeeze into this timeframe, you know, what we can, because it is a large topic and a lot to cover here. So, with that, my disclosures and the objectives. So, as I mentioned, one of the first things to distinguish here is to try to explain what is therapeutic endoscopy. By the nature of this phrase, it's clear that we're talking about any endoscopy that has, you know, significant interventions, is providing therapy, you know, in terms of treatment. Some people will call it advanced endoscopy because the skill sets, the devices, the procedure complexities are more advanced than those that are typically seen in general endoscopy, which traditionally has been limited to EGD, upper endoscopy, colonoscopy, and PEG2 placement. So, the field has moved along quite significantly from that place in the 1970s and 80s. The second part is to really talk about what goes into the provider skill sets to make for a highly competent and high-quality therapeutic endoscopy service. APP is certainly an integral part of it, and which is why this topic is very relevant. The next thing I'll talk about is the key principles and nuances in clinical practice related to therapeutic endoscopy, and we'll speak a little bit to also the non-endoscopic cognitive elements that are very seminal for a good outcome. And finally, of course, I do want to spend a few minutes on specifically honing in on what the APP needs to know, can do, and what role he or she serves in those practices. So, finishing up with practice pearls as usual. So, in terms of the definition of it, as I mentioned, various monikers mentioned here are used to explain it, but suffice it to say, interventional endoscopy or advanced endoscopy is where I hear most of the commentary nowadays in most units. This is the label we have, but now you have an idea of what we are referring to. I should say that as an ERCP-focused person myself, ERCP was really one of the first complex or advanced endoscopic procedures that started in the 70s in different parts of the world, including in America and Japan, and really remains still one of the more traditionally difficult-to-learn and high-stakes advanced endoscopic procedures, even today, despite the nearly 50 years of its existence, because of the nature of ERCP and its relationship with post-ERCP pancreatitis, amongst other complications. Now, we have, of course, EUS, interventional EUS, more complex ERCPs, third space, poem-type procedures, parole myotomy. We have a complex array of resection procedures. Bariatric endoscopy has emerged as its own sub-subspecialty. We have all types of enteral stenting, ranging from the esophagus to the rectum, and everything in between. And we have a variety of ablation procedures, including the newly emerging field of endo-oncology, where we use endoscopy with the specific purpose of managing the cancer patient with a variety of interventions. So the field is pretty wide and diverse. Therefore, what training is involved? And that's a hot topic right now. As you know, most physicians will have undergrad and then four years of medical school, typically three years of internal medicine residencies, longer in surgery, then another three years of GI slash liver training, and then you get to be ready to be an advanced endoscopy trainee, which could be another one to two years. Now, if you look back at the gamut of the procedures on the last slide, it is becoming increasingly discussed that these one to two years, one year definitely may not be enough to impart all the skill sets to a trainee, to do all those procedures that I just mentioned. So it is possible that we may be splitting up this training here, which is already, what is it, 11 years of training might become 12 or 13 years of training in the future, depending on what the trainee wants to specialize in. So it's a long road. And then, of course, this is a little bit more impactful slide showing you some level of detail with what these advanced endoscopy procedures are. And just in the resection realm, you can look at the niche areas, and then, of course, all the other interventions that have emerged, such as pseudocyst drainage, and then, of course, biliary bypass, enteral bypass procedures. As I'll remind you, these are all non-surgical procedures that are done using the endoscope with a variety of devices, but obviously with a lot of training, competence, and safety checks built into the process. The talent and resources required, well, that's a whole different box. So once we're done with establishing a well-trained, competent endoscopist, we also need training for nurses. We did a couple of cases this week in the unit that were sort of re-emerging in the unit after COVID, right? So a new team, many of them are, you know, traveling nursing professionals. So we had an afternoon built in for an endovascular procedure where there were no fewer than 11 people in the room observing, learning, understanding what's being done so that we develop a team that is well-suited for these interventions. Similarly, the anesthesia, surgery, and oncology colleagues need to be made aware. They need to be, you know, aware of these procedures. They need to know when to send these patients, how these patients might do overnight if they're inpatients, what to expect the week after, can they give chemotherapy, can they not? So their collaboration is important in all of this. We work very closely with our radiology and interventional radiology colleagues. Similarly, in our key principles of imaging-related questions, post-procedure care, combined procedures, we call them rendezvous procedures where two teams will meet and deliver care to the same patient in the same room. So the role of the APP in all of this is really integral. We practice this every day and whatever I have written here refers to that practical reality from every day. Every day, our teams are managing access, they're triaging these referrals with us, they serve as a cognitive resource around questions. Of course, they are involved with pre-procedure and post-procedure guidance and in many situations, they are also very good partners in complication management, especially if the primary endoscopist is out of town, unavailable immediately, or if there are multilateral engagements that need to be made in the care of a patient such as surgical consults, ICU care, and other types of family follow-up. So it's really again a team sport in this realm and the APP role is quite integral as stated. Now what does the institution need to have? Whether it's private practice or academics, the infrastructure needs to be at the same level. It really is important. It's the level of the procedure that decides what the infrastructure should be, specialty endoscopes, devices, many of them are very expensive, resources, which I mentioned there, suites, space, backup facilities for ICUs, OR capabilities, all kinds of equipment that need to be considered. Now it doesn't mean that you need every piece of equipment in every hospital, but depending on what particular type of procedure you're doing, you need to set it up right and do it well in advance and be familiar with what's in your unit. So an example of this, a picture is worth a thousand words, so this is one of our earlier units actually, rooms, suites, different names are used for calling these, and you can see here the amount of equipment that you can see, you know, starting with C-arm, anesthesia equipment, booms, monitors, fluoroscopy table, and very few wires on the floor, which is the concept nowadays is to have these modern spaces, but this was already almost a decade ago that we built this room and since then we have three additional ones. What is important to note, these echo endoscopes or EUS scopes are not cheap, each of them now is in the $100,000 to $110,000 range and they're expensive to repair, they're very delicate, they need to be handled with care, so that's a whole big discussion in terms of reprocessing and scope care, as we call it, and service contracts need to be in place and so forth. So that's more of an administrative thing, but suffice it to say that this is a big investment on part of the institution. So some of the examples I'll go through really quickly just to give a flavor of what these procedures are, so especially our new APPs who are onboarding or are relatively new in the space will get an idea of what we do. So here is an ERCP procedure showing a cholangiogram, the black thing here is the scope, this is the distal bile duct stricture here, there's dilatation of the bile duct proximally and the wire is going, and the next steps here will be brush cytology, potentially intraductal biopsy, maybe an endoscopic ultrasound, and then stent placement to relieve jaundice. This is a case who underwent EUS FNA of a pancreatic mass, and the needle is seen here coming in very clearly. So these are very high-end equipments that help us deliver care on a daily basis in a very minimally invasive way and get the answer quickly and move the patient along the care pathway. Now this is an example of a video, hopefully it's playing well on your end. This is the liver actually, and many years ago, this is a video from 2009 actually if you pay attention to the date, liver biopsy has come of age, but biopsying the liver lesions has been a paradigm for a long time, and you can see here how efficiently we can biopsy the liver internally through the stomach without any significant complications. And over on this one, we can see an ERCP cannulation video, which is showing the proper technique for cannulating the bile duct, which is the yellow portion, and orienting the sphincter dome into this relatively small papilla, and then doing wire-guided cannulation. So these are the skill sets that the endoscopist will learn over many years, and then refine over several more years, even as a practicing endoscopist. And then once you have bile duct access, you have a sphincterotomy here, which is being done, hopefully this will play as well, maybe not, I don't know why this one is not playing, but I think you get the idea. Once you have bile duct access, the next step for therapeutics is to open up the papillary orifice step-by-step, carefully, so you don't violate the transduridal interface and have a perforation. And then once this is done, a stone is delivered or a stent is placed. So very nuanced interventions, takes time to learn them, and I think it's good for APPs to know what the capabilities of the endoscope are in skilled hands so that they can appropriately triage patients to the right endoscopist to the right center for the right intervention. Now moving on from pancreatic obiliary to endoscopic resection mode. So here we have, this is a cirrhotic who had a very large rectosigmoid polyp. And here we have an endoscope looking backwards, a so-called retroflex position. We are using a lifting agent. The size of a lesion is being lifted. This patient cannot go to surgery. We have to try and remove it endoscopically. This is not a subtle lesion. And as you can see here, I think that I have the snare around this lesion completely and that we are removing it, what we call on lock, but lo and behold, despite removing such a large piece, we still have another similarly large piece remaining. And that's the problem with these cases is they are, you know, what you see may not meet, you know, may not meet what meets the eyes, what may not be the case. And these are complex cases. So after we have done resection, now there's bleeding. So we need to be prepared to handle bleeding. And this is where a lot of the times our team members come in very helpful. You know, this patient needs blood. This patient needs a coagulation manage. I rely on my nursing and APP teams, my fellows to help me manage that, you know, for to ensure the best outcome. And, you know, these patients will typically get admitted and have significant requirements institutionally and very procedurally for ensuring a good outcome. And here you can see the site is endoclip, patient did well, and he's still in follow-up with us. This is an example of an esophageal lesion in Barrett's, and this is resected using a cap. And you can see the semi-causal injection, which is blue, and then the muscle layer of the esophagus. It's pretty scary looking, but very efficient and very safely done when done right for the right reason. This is a paradigm that is relatively recent, which is full thickness resection. You can see there is a clip that goes and grabs the tumor, and then there's a blade that cuts it. And keeping the clip in place, it cuts the tumor above the blade, above the clip, and then you have a tumor resected, such as here. So for example, this is a polyp in the appendix orifice, very difficult to extract with traditional techniques. And you can see here that the polyp has been sucked in, and into this clip is deployed, and then the blade is sort of fired, and then this is a full thickness resection. This white stuff here is the muscle layer, and the specimen is completely outside. It's basically a retoscopic appendectomy on the inside. Heller myotomy has come of age. It is basically doing an achalasia treatment with the endoscope, not having to do a Heller myotomy, which used to be done very efficiently and still is being done with laparoscopic approaches. But now we have the endoscope, and we have a dilated esophagus with a tight lower esophageal sphincter, and then we go in with the POEM procedure, which makes a little divot in the wall of the esophagus, enters the so-called third space, and then creates this tunnel where we put the endoscope, believe it or not, in this tunnel, and then that's where we work. This is the incision. This incision is the gateway to the third space, and from there we enter the wall of the esophagus, and we do what we call submucosal tunneling. And once we do that, we clear up the submucosa with this knife, and then we start cutting the inner circular muscle fibers all the way from the mid-esophagus down to the GE junction, mind you, working in the third space, not in the real esophagus. And once you are done with that, the myotomy is complete, and it used to be the patient was kept overnight for a night or two, but you can see here the incision on the inner circular muscle fibers, and sometimes the outer longitudinal fibers are also cut. There may be some pneumomediastinum or pneumoperitoneum, but this is easily managed nowadays. Many of these patients are even going home the same day, actually, so it's quite amazing. And that's the full myotomy completed, and you can see there the inner circular muscle layer is completely gone, and you have the outer longitudinal layer. So endoscopic management of achalasia is now established in many randomized trials that show its efficacy, and it's here to stay a major advancement in this field. So the role of the APP in these type of procedures, really complex cases, you know, using a lot of skill, starts with referral triage. I mean, as I mentioned earlier, these are referrals coming in, these are referral centers, patients coming in high volume, they're coming on Epic, they're coming through FACTS, they're coming through email, texts, phone calls, papers, flying all around, and it takes a team to kind of figure out, and a lot of times, mind you, the information is pretty scarce. You don't have the images, you don't have all the reports, so this takes a team to triage these patients and bring them to justice, so to speak, in an organized manner. There's a significant amount of cognitive clinical assessment, which is done as part of our shared visits, both before the procedure as well as after the procedure. And of course, on the day of the procedure, you can imagine an endoscopist has three, four, five, six, seven of these cases, there's not a whole lot of time that person will have, so a lot of the backroom activities handled by the APP, who is free from endoscopy, but helping with some of these tasks that are needed, including keeping the family updated, other surgical specialties updated, and whatever else is required. So, there's a lot of interdisciplinary care coordination. Of course, in my first talk, I referred to complication management, and I think the well-trained, experienced APP, who is a true collaborator, can be a great asset in complication management for the endosurgical proceduralist. Now, on the cognitive side, obviously, it's important for APPs to be able to serve in this role. They need to know the guidelines, they need to know clinical indications, they need to know basic things like ERCP for abdominal pain is no longer being conducted, and that comes from reading, that comes from, you know, spending time with the appropriate mentors, going to meetings, coming to courses like these, and so forth. Also, basic knowledge of anatomy, in terms of what procedures are possible, and what particular anatomical construct or not, is very important, and that also comes from learning experience, and I should say, making mistakes, we all do, but it's important to gather that knowledge along the way, and then elevate the skill sets, cognitive skill sets, to that level. Anticipation, identification, and triaging of procedure complications is important, because this is where we need to own our complications, we need to bring patients back in, manage those rather than have an evasive or defensive attitude, where a patient outcome may be impacted negatively. So again, some of the same stuff, a lot of petty procedure support, phone calls, communication, you know, in our practice, you know, been doing this a long time, a lot of the serious diagnosis are conveyed by team members, you know, the physicians will chip in as they can, or for more complex discussions, but when a team does this well, it matters little who is doing it, but that it is done well, and the lines of communication are open. So that's an important concept I wanted to put out there. So again, a lot of the same stuff, I think, ensuring that people, families, patients, providers that are involved with the patient's care are well-informed, are talking to each other, is a lot of the roles, a lot of the work that falls on the APP's shoulder as well, especially because the endoscopist is having a, you know, a long case day and may not be able to address these in the moment, but eventually we work as a team and figure this out. Informed consent is an important concept in this realm, a lot of places will have the physician only do the informed consent, sometimes APP's will be involved with that by policy, by protocol, or by institutional diktat, or a process that's in place, sometimes senior fellows will do it, whatever policy you follow, I think, just make sure it's consistent, it's well-documented, and we can have a discussion on it offline as well. I do want to put a plug for scholarly and academic activity for APP's, I think Sarah and others have shown that this is possible, there is a fair amount of engagement that industry is interested in with all of you, there's a lot of trials and other types of activities coming in to the physician, partner with them and learn the art and science of publishing, presenting, it was discussed earlier as well, stake a claim on co-authorships on abstracts and manuscripts where you have done the work, it's absolutely justified and should be the case. So, advanced endoscopy opens up a very big box for academic and scholarly activity that is well-supported by both your physician champions as well as other collaborators, including industry. Finally, practice pearls, I think, in my mind, high-quality advanced endoscopy really requires a team approach, and APP is an integral person who is part of that team, does have to have the knowledge and skill sets, some of which are built up over time, to work collaboratively with the endoscopist. I see in this particular realm, the role of the APP is really, truly interdisciplinary complex care management, which is with other service lines, but also with the patient and their family, to ensure that everybody is on the same page, that imaging studies are not repeated, duplicated efforts are not in place, and that there's a streamlined pathway for these high-stakes patients coming in with cancer or other serious diagnoses. As I mentioned, I think there's a tremendous unmet need here in terms of engaging our APP colleagues in sub-specialty areas for clinical research, scholarly activity, and involving them in professional development aspects, including, you know, formal structured mentorship so that when they are masters, they can go on and pay it forward to their colleagues in the specialty. Thank you very much, and I think we'll go to polling question one. Compared to a general GI practice, advanced endoscopy practice requires which of the following? Please select a single best answer. This time, one of these five choices is the correct answer. There is no except. Enhanced GI physician training, enhanced nursing training, specialized rooms, additional equipment, or all of the above? Wow. Let's see here. Ninety-five. So, enhanced GI physician training. So, I think I will say that the percentage that went with the first choice, maybe the second, may not have necessarily seen the all-of-the-above option, which is an important skill for test-taking in the board. So, keep in mind, when you have all-of-the-above, it may be the answer, but well done, group, overall. So, let's see here. 95. So, enhanced GI physician training. So, I think I will say that the percentage that went with the first choice, maybe the second, may not have necessarily seen the all-of-the-above option, which is an important skill for test-taking in the board. So, keep in mind, when you have all-of-the-above, it may be the answer, but well done, group, overall. So, let's see here. The next one. Which statement regarding advanced endoscopy is true? Zenker's myotomy can be performed while on anticoagulation. ERCP is rarely used for diagnostic purposes only. EUS is solely a diagnostic modality. EMRDST is a diagnostic modality. So, I think I will say that the percentage that went with the first choice, maybe the second, may not have necessarily seen the all-of-the-above option, which is an important skill for test-taking in the board. So, keep in mind, when you have all-of-the-above, it may be the answer, but well done, group, overall. So, let's see here. The next one. Which statement regarding advanced endoscopy is true? Zenker's myotomy can be performed while on anticoagulation. ERCP is rarely used for diagnostic purposes only. EUS is solely a diagnostic modality. EMRDST are different names for the same thing. And pancreatic necrosis can only be debrided surgically. I think I elevated the stakes a little bit here. So, it's a question that has got one answer, and I think it's obvious, but we'll see. All right, so as expected, this brought out some responses. The majority got, let's see here, majority went with ERCP is rarely used for diagnostic purposes only. That is true, and it is absolutely correct, and the majority got that right. Zenker's myotomy cannot be done on anticoagulation, and the others are all wrong as well. But thank you very much. Well done, team.

therapeutic endoscopy

advanced endoscopic techniques

endoscopists training

team-based approach

APPs role in patient care

professional development