This talk is the final talk in this session, and it's therapeutic endoscopy what the APP needs to know, I'll try to go through this as quickly as I can so that we stay on topic. Try to move this guy along. There we go. So the objectives of this talk are to define therapeutic endoscopy what does it really mean therapeutic endoscopy understand the different monikers that we commonly use in a day to day practice which is advanced endoscopy interventional special endoscopy and so forth. Learn about the additional formal training skill sets nuances of how someone ends up becoming a therapeutic endoscopist, and what does that team look like what are the special skill sets that are required infrastructural needs training competencies, the nature of the work, and kind of bring it together to the whole team concept, best we can. And go from there. So therapeutic endoscopy is sometimes known as some other terminologies listed here on this slide advanced endoscopy is a very commonly used term. It's really a field that began evolving in the 1970s with the RCP, a little bit earlier than that with colonoscopy and from there, it has really evolved significantly into a major field, especially in the last 10 to 15 years and especially after advanced ERCP became well established and interventional us came into play. So what does someone need to do as a physician to become an advanced interventional endoscopist. So the usual four years of medical school three years of internal medicine training, three years of GI and hepatology fellowship, and then an additional typically one, in some cases, two years of advanced endoscopy fellowship training. Now, this is a fairly long pathway to get to this point. It's been understood, it's been in place, and it has served those people well, who have engaged thusly in this paradigm alternative training pathways do exist and they actually are becoming more attractive at this time, as interventional endoscopy becomes super super sub specialized. As we go towards an endoscopic resections and advanced hybrid procedures and robotics and so forth. So, the content of the training does differ from place to place institution to institution country to country even. And that's not a topic for today but there is a wide variability, due to a lot of factors in this but for the most part, the good programs and the good experiences are pretty standardized a litany of advanced endoscopic procedures I won't go through each of them but you already heard about your CP and us we'll talk a little bit about some of these guys down here bariatric endoscopy is a whole new field, which I feel deserves its own additional year of fellowship but that may be coming down in the future. So the talent and resources required to perform this work very clearly you need an expert physician and you're not born an expert physician but you are well trained you achieve competencies you build on those competencies and an experience is a huge part of it as well. But equally importantly you need a very solid nursing and associates associate team that is also well trained is invested is interested is excited about these procedures are quick learners and actually support this work on a regular basis. And on top of that, and besides this team this team you need a fully developed and committed anesthesia team, your surgical colleagues are invariably part of this discussion almost on a daily basis, and oncology is a huge service that for those of us who are GI cancer focused is a part of our daily discussion. Now, coming to the APP team team members is very relevant to this course. This I think has been an area where we haven't talked a lot about yet but I think as the programs and services have evolved and become more complex, I feel the importance of having, you know, core competency focused APP team members in such a team is it cannot be overstated. We have been very lucky to have dedicated Carter of APP colleagues in this realm and they help us with referral triage access as we mentioned earlier on this morning, resources, amazing sounding board for us to run cases by run cases with for them to run cases with us, and so forth. Huge investment on their part in the pre procedure assessment as was already discussed very well. And of course in complication management, we are an academic so we have fellows and residents as well, but our APP is also step up. If these issues arise during the work, work day and support and every which way with that and not in the least with with the compassionate element of things where we're running around getting the surgeries and and backup testing. But, but our APP colleagues are spending time with the family in the waiting room and and keeping those lines of communication open, especially if there is a catastrophic event. The resources and devices required are almost limitless I think if you were to hire a therapeutic endoscopist today you're easily looking at a two to $5 million budget at the chair and chief level. Over a three to five year period in terms of investment but some of those important ones that are listed here the specialty scopes. You need endoscopy suites that are safe and accommodative. You need the sea arms and fluoroscopy equipment, and of course a host of consumables as well. The most commonly performed advanced dusk we procedures are listed here you heard about ERCP and us endoscopic resection has really come of age, I like to call it our comfort with endoscopic resection comfort really is what leads us to push and has now led to what we call endoscopic full thickness the section, which basically means that the entire four layers of five layers of the ball wall are intentionally removed. While removing a tumor, that's creating a perforation which we were of course afraid of before, but now doing it therapeutically, and then suturing up the defect. endoscopic resection has really come off age. And what I would like to say is what ERCP and us were in the 70s and 80s, that's where endoscopic resection is now at this point. Enteral stenting is a huge blessing for those patients who are at the end of life, and require minimally invasive palliative interventions to relieve a variety of symptoms ranging from ball obstruction to jaundice. This is one of our earlier advanced suites. It's not as pretty as the one that the Mayo Clinic but it comes a little close, you can see here on a more serious note the amount of equipment and and and just the the arrangements that need to have such a room, go into place it takes a better part of a year to get one of these suites ready to go, and a fair amount of capital investment. Now obviously, these, these range and their appearance and their shape and size from institution to institution but the point is that it is a significant and very serious level of commitment from the institution. This is equipment acquisition this is a radial equinox scope which is more of a diagnostic us scope. This is the therapeutic or linear equinox scope, which allows the passage of a needle and each of these is north of $110,000 each, along with the console which can range from 150 to $400,000 so a half a million dollar equipment, just for one room. These are classic pictures for ERCP the see the endoscope coming here this is the classic position. You see a relatively obstructed bile duct distal structure which could be malignant or could be one of those benign conditions such as chronic pancreatitis or autoimmune pancreatitis and this patient will be well served with tissue sampling, as well as a sedating to relieve the immediate problem. This is an example of an US or endoscopic ultrasound, with a very sharp picture here these technologies are really really good. You can pick up seven to 10 millimeter lymph nodes around the stomach and allow us to sample them safely with adequate sedation in place. I'll show a couple of video clips because endoscopy talks are not good without video clips. And these are short and sweet. Here's a liver lesion. It's a very impactful liver lesion actually I remember this particular video from way back when we put this on our website about 15 years ago. This was a patient with early stage esophageal cancer. And this patient was almost ready to go to surgery, and somebody sent him over for an US and. And lo and behold, this small liver lesion was picked up was picked up and then obviously stage the patient appropriately at stage four which is unfortunate, but did prevent an esophagectomy that would have been completely useless. Here's an example of a ERCP with biliary cannulation. Here's the major papilla. And here's the catheter coming in and some cases, the papilla is quite small. And this was a teaching video developed to show how to appropriately cannulate the bile duct. Once you get the bile duct, you proceed with an intervention known as biliary sphincterotomy which has been referred to already. And this opens up the gates for delivering the stone, or for brush cytology of the stricture or placing a stent, pretty much the cannulation and the sphincterotomy are the basic steps, without which you cannot proceed further with any other therapeutic intervention. Here are some examples of other endoscopic advanced endoscopy procedures. EMR is endoscopic mucosal resection, ESD is endoscopic submucosal dissection, and then full thickness resection which I alluded to. So a couple of examples here. This is an older video I think we presented at DDW before, it's a large colon polyp that was sent over in a patient with cirrhosis. So relatively low platelet counts, mildly altered coagulopathy, and we're in the sigmoid colon here and you can see the lesion is actually obscuring the lumen nearly right. And for all intents and purposes, this could be a colon cancer, but it appears resectable and through a series of steps, using therapeutic endoscopy concepts, the lesion is removed. This is also an older case, in today's day and age, it probably proceed with endoscopic submucosal dissection, but the end result is the same, the lesion has to be excised completely. And you can see here despite taking large chunks of the lesion, a lot of the lesion still remains, and then eventually you're dealing with a bleeding situation, you can see a spurting artery right there. So these are the skill sets you acquire in that additional year or two of training that make you comfortable doing these cases, doing them safely and enable complete therapeutics to take place. Bleeding control, control of the edge with argon plasma coagulation so that recurrence rates are decreased. And then of course towards the end, closure of the defect with endoclips or with newer modalities that are coming through. So that's just one example of how a case proceeds obviously that's a heavily edited video. But those are typically daily events in large institutions that perform high volume of therapeutic endoscopy. Moving on to the upper GI tract, this is a classic case of a Barrett's esophagus, which you'll hear a little bit more about tomorrow, with a nodular which is then very effectively removed using this CAP device, known as CAP EMR and you can see here the blue solution here, it's just above the muscle layer which is where you want to stay above the muscle layer in this case, and it allows for removal of a using endoscopy with EMR technique. Moving on to full thickness resection, about seven or eight years ago we were introduced to this device which is the EFTR device, and this has led to removal of many GI luminal tract lesions. You know that are typically under two centimeters in size, and they can basically deploy a clip, the full thickness clip and then incise the lesion above the clip to enable a full thickness resection. There are other techniques of doing full thickness resection but this is probably the most widely used and most easily practiced, but is mainly limited by lesion size. So here's an example of an appendixial adenoma, it's in the appendix orifice in the colon, it's very difficult to tease this out and remove it completely and safely by other standard techniques. So you take this clip device, and you ensnare it, and the clip is now deployed at the base, and then you have an inbuilt proprietary snare that will chop it off. And you can see here that this is the serosal aspect of things, but it's nicely secured at the base and the lesion is removed completely on block, just like a surgical specimen would be. There are potential complications to these including appendicitis and delayed perforation, but that's true for most procedures you'll always have a finite rate of complications, but does not prevent endoscopic technology techniques and interventions to progress in the care of our patients. Here's another difficult location this is a duodenal bulb, which is very very thin wall and standard endoscopic resection techniques will neither get this neuroendocrine tumor out completely nor will it assure a defect which, which is difficult to manage. So here we go with the full thickness device. And this one in the foregut and the upper GI tract has only recently been introduced so we're now having it and this is a full thickness resection with a layer of the muscle included which confirms this is a difficult location for the surgeon to go in for a relatively small lesion. Any of these patients might be looking at a bill Roth one type of gastrectomy or even a ripple if this lesion is further down. So this is a huge blessing to have this capability. And if performed correctly. So the hottest kid on the block in the last decade is poem or plural esophageal endoscopic myotomy endoscopic myotomy is cutting off the muscle. And essentially this technique was developed as a subsequent advancement of endoscopic submucosal dissection, and has been performed widely across the world with extremely good outcomes. We'll talk a little bit about that. So, this is used for the management of a condition known as a Malaysia which many or most of you will have seen or will see in your GI practice, a Malaysia is a difficult situation where you have a spasm of the lower esophageal sphincter with a dilated proximal esophagus, leading to difficulty with swallowing aspiration, and just a very poor quality of life. In the past, these patients underwent laparoscopic Heller's myotomy, which is a surgical procedure. But now these are being increasingly done with the poem approach. So the point approach is you go into the esophagus, and you create a blab here with a submucosal injection such as this one. And then you then incise that that blab with a dedicated knife. And then you move forward with the incision create a space, so called tunnel. And then you enter that tunnel. And then you start dissecting the submucosal fibers and space and not touch the muscle just yet just create the tunnel. And once you've created the tunnel all the way down from the upper esophagus to the LES, and then you start your myotomy which is cutting the muscle and from anatomy we know that the inner circular muscle layer is there and then there is the outer, outer longitudinal layer. And this is the, this is the technique of cutting the inner layer you can see the inner circular layer is being cut and then the outer longitudinal layer is being preserved. And basically, what you should know as you do know, is that the lungs and the media Steinem are only half a millimeter away so it's an amazing technique. That is performed very widely now and upstairs in the endoscopy units not necessarily in the ORs, and as being done very very safely and that represents a full myotomy right there. And, and the job is done. Most of these patients are still being observed overnight, and then the site will be closed and the patients will be observed overnight some are being sent home occasionally the same day, but I think overnight observation is still the rule. And the final frontier here at least for now is looking at further enhancing our endoscopic skills with robotics with 3d animation with artificial intelligence. It's a whole huge topic that we cannot get into details but safe to say that the future consoles for endoscopy and the future scopes may look very much like a men in black movie, but that time is yet to come. And I want to finish up with the last few slides focusing on the role of the APP and the advanced endoscopy team you looked at the, the specific roles in the pre procedure setting which is endoscopic referral triage very procedure management, help with complication management and interdisciplinary coordination such as that is required for cancer patients so that's really a key collaborative role that APP can play on these teams, but they also have a huge cognitive input. And they do need to be aware of the strong indications for procedures, which patients on a Friday afternoon need to be triage for Monday morning, or who has to come in as a transfer to the hospital and make sure that the team knows about it. They need to be knowledgeable about procedure contraindications especially if they are in clinic, and having those discussions, the anti coagulation and anti platelet management has already been referred to the understanding of post surgical The last, the first time you want to hear about the ruin why gastric bypass is not on the table. So both the physician and the APP and other people in the team need to know about these nuances. And of course anticipate problems before they arise. So a lot of these will be on the material that you will have access to. But this is a, this is a day to day effort that our APP colleagues perform while we are busy with long cases sometimes, and then we get a chance to talk about things, multiple times during the day. We can go over issues that can be checked off or issues that are pending, or issues that will require further investment of time and effort. So one of the things that becomes very important is being receptive to each other around questions, being able to reach each other at different times of the day, and just set up set up a way of communication that is efficient and allows you to do your job without too much noise. The interdisciplinary care coordination is really really important. It has been very important in the pandemic. Many of us have had to maintain our own lists and monitor and track down referrals with surgery oncology track down patients who have limited access with the phone lines being so busy and so forth. So I feel that this role has only become more significant and more indispensable for any serious team in this business that the APPs have to be a part of so this is a critical post pandemic. post pandemic profile that is emerged, where we cannot do without it informed consent and advanced endoscopy is a complex topic. All I'm going to say here is that typically the consent is and should be obtained by the performing MD. There are various kind of you know paradigms that exist intervention endoscopy fellows will do this, and they're and they're fully authorized to do this on behalf of the physician but typically the physician performing the procedure will almost always have the most time with these patients, and that's important as best practice is best important ethically, it's important medical legally, but the APP team member can certainly be a part of that conversation and and more documentation and more attempts at education towards the patient's knowledge can can never hurt. So that activity I think advanced endoscopy practices like any other subspecialty in GI lend themselves to a lot of opportunity for device related multi center registry based trials review articles, things that just get done. In a post pandemic or a private practice setting, there are multiple opportunities so work with your mentors work with your physician champions and your team members to seek out these opportunities, because they are bound in many different for finish up with practice goals, high quality advanced endoscopy service requires a team approach, it's no more true anywhere else than it is right here. The APP team member has a lot to contribute as I just elucidated in the previous slides. It's really important that the interdisciplinary complex care management, the APP be a fully a part of it and it really helps move the patient along the different specialties, several of the APP support functions are cognitive in nature, and the ability to learn about those, you know, items of knowledge and also the processes and the rationale for those goes a long way in making them successful and and and really enhancing the quality of the team, ongoing mentorship and professional engagement with the APP should not be forgotten, especially in this realm, because the nature of this work presents a lot of opportunity, big and small for them to really advance their career in this realm. Thank you for that and then I'll finish up with a couple of polling questions. So general GI practice advanced endoscopy practice requires which are the following, please select a single best answer so advanced endoscopy versus general GI enhanced GI physician training, enhanced nursing and GI associate training, additional equipment, longer procedure times, or all of the above. Only one answer is correct. Looks great. I think we're at 87% for all of the above. And, and enhanced GI physician training will address that in the, in the brief q&a that we'll have but thank you for that we can go to the next question, which is which statement regarding advanced endoscopy is true again a single answer ERCP is rarely used for diagnostic purposes only us is solely a diagnostic endoscopic modality EMR and ESD are different names for an identical procedure and pancreatic necrosis can only be debrided surgically. So only one of these is true. The rest are false. All right, so we are, we are beginning to split out here so ERCP is rarely used for diagnostic purposes that is the correct answer. It is still very very occasionally use for that but us is equal parts interventional as it is diagnostic, and of course EMR and ESD are different procedures, similar in some ways but different in many ways and pancreatic necrosis is mostly now debrided or managed endoscopically, so we'll, we can get into some details here but thank you again and I want to thank John Martin, a lot of the content on this particular talk was from his talk last year and I appreciate that as well. Thank you.

therapeutic endoscopy

advanced practice providers

training and skills

APP team

advanced ERCP

interventional endoscopy