The talk that I've been given today, again, this year is focused on therapeutic endoscopy, which I suspect that many of the folks in the audience and certainly many in the faculty have spent their career on, you know, for the most part, and same is the case with me. And at the nearly 25-year mark, I would say, 10 of them were spent, I would say, roughly with a mix of different APPs, but the last 15 have really been spent with Sarah and supporting our practice. And I can say that there is singularly, I mean, it's very difficult to really generate a high volume, high complexity, consistently high quality, patient-centric type of practice in complex endoscopy without really a team that works with you and supports you. And APP definitely is front and center as part of that team. So are your scheduling teams, you know, your advanced nursing colleagues, certainly in cases where there are trainees involved, they're definitely also a big part of the team. And of course, a supportive administration that helps you, you know, keep the business going as well as supporting you with new technology and with new commitments from time to time as they become real. So with that sentiment, I'll dive into the talk itself. These are my disclosures, which you're already familiar with from this morning. My objectives here really are to define the space, first up, in terms of how therapeutic endoscopy or different monikers, such as interventional endoscopy, therapeutic endoscopy, all of these different terms that we use, how is it different from general endoscopy, if you will? And then what is required really on part of the team, primarily the endoscopist, in terms of getting to that stage where they will be able to position themselves as therapeutic endoscopists in a community or in a region, or even at national level or international levels. There are a lot of key principles and nuances that go into making for a successful therapeutic endoscopist and for a practice for sure. But I will try to finish up with kind of outlining some specific roles that the APP team players can serve in this capacity. And I hope that some of you, or not many of you, but some of you leaving this weekend course will be thinking about looking at therapeutic endoscopy support as part of your future practice, because this is increasingly becoming where endoscopy is going. And we can talk about that in the panel as well. And one example being colonoscopy itself is turning more and more therapeutic as non-invasive options become a real deal in our daily practice. So what is therapeutic endoscopy? Well, to put it simply, it basically is any kind of advanced complex endoscopy, which requires more skill, more instrumentation, more time, more training. But really, if you harken back to the beginnings of it, truly the first forays into therapeutic endoscopy were at the level of colonoscopy and polypectomy early in the 60s and 70s. And then with ERCP and initially biliary sphincterotomy, which ended up being in the mid 70s. And then subsequently in the 80s, 90s, there was more significant advancement with endoscopic ultrasound being the next big thing in the mid 80s to the early 2000s when it got established. And then of course, everything became more and more complex from there on with bariatrics, with endotracexion. You'll hear a little bit more about ESD and EMR later on during the day and so much more. So, but it really all started in the 60s and 70s with colonoscopic polypectomy and ERCP as the initial kind of poster child for therapeutic endoscopy. What training is involved? Well, a fair amount of training. If you look over here, you have about four years of medical school, which is standard, three years of internal medicine residency for a physician, and then three years of standard GI fellowship, which is the current ACGME accredited curriculum. And then typically for an advanced endoscopy physician nowadays, it really is difficult to position yourself as such without having at least one more year of a therapeutic endoscopy fellowship that is at a reputable institution. In some cases, I believe such as Johns Hopkins, there will be a two-year fellowship, one of which will be devoted primarily to endoscopic research. Now, there are alternative pathways that exist for this. In fact, this particular fourth year of fellowship or additional training of fellowship is not accredited yet by the ACGME. I can say that the ASGE is at the forefront of trying to figure out what type of additional certifications and, you know, type of stamps would be appropriate here, such as those that are present in interventional cardiology and such, but we don't yet have that accreditation. So these are relatively variable curricula, if you will, but mostly incorporate similar type of experiences at the top institutions. But they're busy regardless, but the curriculum does vary and it depends on the volume, complexity of cases coming in, and of course, who your mentors are. Now, this is kind of a snapshot of the advanced endoscopic procedures in play today. I already referred to ERCP-EUS, but you can see here, POM has become very well established, bariatric endoscopy, all types of enteral stenting, which is stents in the lumen of the GI tract. And of course, some of the more common procedures nowadays are those that are related to psoriasis drainage and transluminal interventions. So a smorgasbord of procedures that you can imagine, some would argue that even one year of additional training is not enough, and that is probably true, such that if somebody wants to focus on bariatrics, that probably warrants another six months to a 12-month exposure, if that is going to be their career. But a majority of these can be accomplished in terms of competency, acquiring competency in one year, if not all of them. The talent and resources required to deliver advanced endoscopy services are also significant. Obviously, we referred a little bit to the amount of time and experience that the physician needs to have, but you also need a trained staff. Your technicians, your assistants, your nurses need to be well-trained. The ASGE now also hosts, for the first time, an advanced endoscopy GI techs curriculum, which is available as well for practices to look at and subscribe to. Of course, your anesthesia and surgery and oncology colleagues need to be in the same space, working together as teams, meeting you at the multidisciplinary tumor boards, and then also serving as adjunct and or backup services when endoscopy is not entirely successful. Obviously, the APP team members play a very key role, and some of those engagements are listed here at the bottom. Those APPs who have a special interest in supporting advanced endoscopy are involved very acutely with triage and access. They obviously serve in periprocedural management issues and complication support, and of course, engage with family on a regular basis alongside the endoscopist. The infrastructure required is also pretty significant. You need a lot of equipment. You need rooms that are capable of hosting these types of equipment in place, multiple team members. Often, there are visitors and observers and students and trainees at all levels, certainly at the university level. There are trainees for everybody from nursing through techs and anesthesia students, APP students sometimes, visiting scholars. So, you do need a large room and a lot of equipment and a knowledge to run those as well as staff to run those, which can be a challenge sometimes. If you have three RCP rooms going and you only have one or two fluoroscopy technicians, you can imagine that that's a strain on the resources. So, this is one of our earlier rooms that we had established at our university. Back in the day, it was already a couple of million dollars. So, these are upwards of five to ten million dollars now by the time equipment is placed in. So, this is not an easy lift for entities to invest in, but this does represent the fact that, you know, if you're serious to get into the business, this is what it takes. And that's probably a true principle for most things in life. You know, it's hard to stake a claim without investment. I recently visited another world-class institution and I only took one picture at that place. And this is that picture. This is a boom. You can see how thick this boom is. I hope that it is transmitting. But this is one of the only platforms I've seen ever in my world travels that has every company's processor on one boom. So, you have, without naming them, pretty much all the major players in the market are represented so that this particular room actually is used for international transmission and any company can come in and plug in their scope without the need to bring additional towers. So, obviously, this is a little bit over the top, but just tells you where things are at the pinnacle of this space currently, even in America. Specialized equipment. This is an old picture for endoscopic ultrasound scopes. This is a radial scope, which is less often used now, but this is the linear echo endoscope that allows the passage of a needle to sample tissue when we are looking at different types of tumors. Each of them nowadays are in the range of about $100,000 to $140,000 each, and typically a unit like ours will have at least 8 to 10 of these in play on a daily basis between multiple providers. Some institutions need to have even more of these endoscopes. Examples of endoscopic procedures that are considered advanced, I've already referred to. I'll go a little bit deeper into them now. With ERCP in the U.S., for example, ERCP to me remains still one of the foremost, probably one of the most complex and risky interventional procedures in endoscopy, and that's primarily related to the risk from ERCP-related pancreatitis. That is not completely avoidable and quite unpredictable in its course, as opposed to managing bleeding, perforation, and infection. This is endoscopic ultrasound. Of course, you can see a small lymph node here that is being sampled. The resolution of machines today is unbelievable. The diagnostic and precision capability of these machines and the scopes and our ability to sample even subcentimeter lymph nodes is really, really amazing and has revolutionized the field. These are just a couple of clips showing you a liver lesion that is being biopsied. This happened to be an esophageal cancer patient who was going to go to surgery, and then just a week before, we found this liver lesion, and we avoided unnecessary morbidity. This is a video showing cannulation of the bile duct with ERCP catheters, and you can see here the intricacy involved here, the deliberateness of the movement, and the high-end optics that are required to facilitate these endoscopic procedures. And then, of course, after you cannulate, you do the sphincterotomy, which I think that video is not playing, but we'll move on. Endoscopic resection, so ERCP and EUS were most of the 90s and early 2000s, and then we got into what we call the endoscopic resection mode, which is very much in play today. Endoscopic mucosal resection and submucosal dissection are two areas that I'll speak to in another lecture down this afternoon, but full thickness resection has also come into play. So we have kind of become endoscopic surgeons truly speaking and that's where things stand today and I'll talk a little bit about that next. This is a video in a relatively young cirrhotic patient that came to me. This is a very old video actually. Had a sigmoid mass, rectosigmoid lesion that there was no way they were going to take him to surgery. He had a child c cirrhosis of the mild near 20 and if they operated on him he wouldn't have survived. So here we are resecting this lesion piece by piece. You know this was in the early days so ESD was not that firmly established although one could argue that we could probably easily do this with ESD today as well. So you can see here the bulk of this lesion and how we kind of go about systematically removing this lesion and this patient actually is doing well even today and is decompensated cirrhosis but is still alive and does not have a lesion recurrence in that location. This is esophageal EMR in Barrett's. You can see here there's a nodule. The nodule has been targeted. It has been resected. The blue area is the muscle area here. You can see there is no perforation and then we are on our way to complete the resection in this case. This is also ESD looking at how we would inject a lesion, raise it up, and then slice it so to speak with these knives that are available and remove it more on block as opposed to a piecemeal resection that I showed you two videos ago. So ESD is now fully established. It has better overall curative resection rates. I'll dive into it a little bit deeper in my next lecture. Full thickness resection started with this device. This is a basically considered a cap and a suction device and then has a blade at the end which is got reconnected. So you basically suck up the lesion and then here is a lesion inside the appendix orifice. So you suck it up, you chop it off, and then you have it outside. Basically a semi or partial appendectomy using an endoscope. So that's where we are as well. This procedure is not without risk. In fact, the Dutch experience has shown us that perforation rates can go up to 10%. So you have to be really careful with your training in this procedure, your selection of the patients, and your aftercare after the procedure. POEM procedure is now very well established. As you well know, most centers are doing this. This is basically taking Heller's myotomy and doing it from the inside. These are the steps of the POEM procedure. You have an achalasia esophagus with the significant spasm at the lower esophageal sphincter and then you go ahead further up in the esophagus. You make a cushion of fluid and then you incise it by injecting submucosal fluid. You take a knife, you cut it open, then you enter the third space through this slit. The third space is the submucosal space. You tunnel your way and take away these submucosal fibers. This is the muscle at the bottom and then subsequently you start incising the inner circular muscle, which relaxes the achalasia and basically serves as a myotomy. So here we go. This is the initial incision and then you complete the incision in this fashion all the way down into the cardiac and the patient typically will go home the next day, although some practices are sending them home in the same night. So this is the POEM procedure and you've seen it probably many times, but then you close the defect in the mucosa, make sure there are no leaks and surprisingly and amazingly this procedure has shown time after time that it has really amazing outcomes for these patients, both in terms of safety but also in terms of clinical efficacy and in some cases it's even beating surgical outcomes in the new literature. So that's a really major advance. So now coming towards the last part of the topic is where does the APP fit into all of this. In my mind I think the APP involvement for these procedures in these practices really spans the entire gamut of the practice. It starts with the first phone call, the first EPIC fax that comes in, the EPIC referral, referral triage. You know our teams are involved with this process as well and then it moves on to the clinic visits, which we talked a little bit about this morning. Typically our practice is a shared clinic visit. We also have independent APP clinics as well and then as we move closer to the procedure we get involved with the periprocedural follow-up management, anticoagulants and so forth before the procedure and then the complex care coordination after the procedure. So there is absolutely no place in the spectrum of the patient journey where I think the APP should not and cannot be involved. On the advanced endoscopy team I think the APP should have a knowledge base which should circle around clinical indications, guideline-based interventions, understanding of anticoagulants and antiplatelet agents, looking at which patients have altered GI anatomy that may not be amenable to standard interventions. For example, a patient with gastric bypass will not be able to easily have a traditional ERCP so we have to consider either a double balloon endoscopy-assisted ERCP or an EUS-guided transgastric ERCP or a laparoscopic-assisted transgastric ERCP in the OR with the surgeon. But I think as much as the fancy procedures have great outcomes, every so often they also have bad outcomes and when somebody has a complication the endoscopist is at a low point in their life and that's when team members step up. And I cannot say enough about fellows and colleagues and APPs and nurses, when they step up in these moments it's a game changer for the patient and most certainly very, very important to the endoscopist. So I think to me that is a very important part of the practice paradigm. So I already referred to a lot of the stuff that the APPs can do around the procedures, but a couple of things that I found very useful is the ability to keep the channel of communication going. So the endoscopist moves from one procedure to another, one day to another, but the APP team will hold the fort in terms of liaising with the patient, like I mentioned in the morning, making sure the families are updated, the biopsy results are expedited, especially for cancer patients, and keeping the lines of communication going. For me also, it's important to have the APP as being part of the interdisciplinary care coordination team. Just yesterday we had a couple of calls out to regional oncology practices, asking them about why they sent the patient to us, what's the question that needs to be answered, and whether those referrals were made in error or should they go to the oncology team. So the APPs help me with that function while I continue other aspects of our practice. So that's really an important part. As our practices get more regional and outside the building, it becomes really important to be efficient, to understand which of the patients are coming in, who can you serve the best, and also to establish relationships with your referring colleagues so that people understand each other well and are able to read between the lines, especially for complex patients, and there's a good understanding and teamwork across the region. One area that I talk a lot about is informed consent and advanced endoscopy. The reason I bring it up here is because obviously this is not only a cornerstone of best practice, but it also has significant medical legal implications, as you can well imagine. In many practices, in general, it is either the endoscopist or their designee, typically either a trainee or a fellow or a junior colleague, if they're training with you, they're the team that gets this consent. But in some practices, APPs are also charged with getting these consents, and I think when that happens, it becomes increasingly important for the APP to actually be aware of the procedure, be able to justify that they are in a position to truly speak to the rationale for the procedure, the risks, benefits, alternatives, and potential complications from a competency perspective in terms of understanding the procedure. Otherwise, they should not necessarily get involved with that because that could be questioned. So informed consent and advanced endoscopy is an important topic, and we can talk about it in a panel discussion if folks have questions. Now, an important area that I highlighted in my earlier talk was scholarly activity and professional development. I think if there's any area in GI practice that is relatively easy to get started with, it is an endoscopy, because you know what, even a case report is something that big national meetings will look at, you know, to support trainees and APPs and junior faculty so that they can present their case, they get a seal with presenting cases, they share their knowledge, a unique case, a rare event. So I think scholarly activity is a very good area. Many of the endoscopy practices are part of multi-center national trials, and these are easy to get on as sub-eyes or sub-investigators or just start getting a flavor for research. So this is an area, I think, if you are part of a system where there is this ongoing clinical research activity, I would strongly encourage you to look at that. Practice goals, high-quality advanced endoscopy definitely requires a team approach, and the APP is a very, very core and integral member of the team for me. Having said that, the APP candidate, team person should have a very good knowledge of the advanced endoscopy procedures, and it behooves us as endoscopists and societies and courses like these that actually bring that understanding and knowledge to you. The practice of endoscopy should be guideline-based and evidence-based. Even when evidence is weak, it has to be best practice and consensus-based, and that's important because otherwise, if you have a negative outcome, it becomes very difficult to justify. Collaboration, communication, interdisciplinary coordination, liaising function, these are all so important, and the endoscopist cannot do it alone. Specifically, in the periprocedural period, the management of these patients is getting increasingly complex with anticoagulants, GLPs, all kinds of things going on, and this becomes a really important area for APPs to step in and help out with. And then finally, of course, I'm a big fan of professional development, and I think endoscopic practice really represents, from the clinic through the endoscopy spectrum, a very fertile ground for professional development for APPs, if they so choose to do. But with that, I will stop here. And a question, Michelle, if that's okay? This is, compared to a general gastroenterology practice, advanced endoscopy practice requires which of the following? Please select a single best answer. Now, this is more in compliance with the ABIM rules, so what is the best answer here? Enhanced GI physician training, enhanced nursing and GI associate training, specialized rooms, and additional equipment. So, which of these, or all of the above, are required for a high-quality endoscopy practice? You know, to be honest, I think that's what, you know, so the people who got it a little bit wrong are maybe the ones who just jumped at, they love their physician so much, it's that enhanced GI physician training. But no, I think all of the above are really important, as I showed in my talk, and I think the overwhelming majority of you got it right, so congratulations. And then we have a second question here real quick, which says, which statement regarding advanced endoscopy is true? So, again, a single best answer. A, Zenker's myotomy can be performed while on anticoagulation. ERCP is rarely used for diagnostic purposes only. EUS is only a diagnostic modality, which is basically saying you can just look at images. EMR and ESD are different names for an identical procedure, and pancreatic necrosis can only be debrided surgically. So, which is the single true statement? Zenker's on blood thinners, ERCP only for diagnosis, EUS only for diagnosis. Sorry, ERCP rarely for diagnosis. EUS only for diagnosis. EMR, ESD are basically the same procedure, and we never do endoscopic necrosis. A little tougher one, huh? Tough one. Okay, all right. But you know what? The majority still got it right. I'm impressed. This is a smart group, and we better step up our game for tomorrow. ERCP is rarely used for diagnostic purposes. That is correct. ERCP is rarely used for diagnostic purposes. In fact, after the advent of the EPISOD trial, E-P-I-S-O-D, which was, I believe, 2012, where Peter Korten showed conclusively that ERCP for abdominal pain, which was, believe it or not, the practice up until then should never be done because patients get more harm than benefit. So, that B is the correct answer, and the rest of them are obviously incorrect. Thank you very much, and I will now hand it back over to Caitlin to take over the next speaker. Thank you.

therapeutic endoscopy

advanced procedures

APPs role

interdisciplinary collaboration

professional development

infrastructure investment