All right, everyone, we are in the homestretch. It is my pleasure to introduce Dr. Peter Dragunov and to invite him and the panelists for this fireside chat to the stage at this time. Dr. Dragunov is Professor of Medicine and Director of Advanced Endoscopy and Therapeutics at the Division of Gastroenterology, Hepatology, and Nutrition at the University of Florida in Gainesville, Florida. He completed medical school in Bulgaria and then trained in medicine, gastroenterology, including advanced therapeutic endoscopy at the Medical University of South Carolina in Charleston, South Carolina. He has many clinical interests in the advanced therapeutic endoscopy space, including EMR, deep, small bowel, and enteroscopy, ESD, POM, and third space endoscopy. And so I will hand it over to Dr. Dragunov, who will introduce the panel for this fireside chat, and he will facilitate the discussion. Thank you very much. I will have much shorter introductions in order to concentrate on our talk. Right next to me is Dr. Shelby Sullivan from Denver, Colorado. And then we have Mir Mizrahi from Largo, Florida. And finally, Dr. Moamen Gaber from Boston. And the idea behind this is Dr. Buscaglia saw similar function, I think, at the AGA meeting, and I was puzzled in the beginning, do we do slides, do we not do slides? But this is meant to be a free conversation. And the main concept is that after graduating fellowship, I'm using myself as an example of probably 50% of what I do I picked up after fellowship. And that acquisition of additional skill can be quite difficult in many instances. In some cases, some procedure, what the AGA labels as a very easy tool, acquire, let's say, RFA for Barrett's esophagus. You take a couple of courses, probably have one or two proctor cases, you're good to go. On the other extreme, you have third space endoscopy, which requires many years of involvement in the field and training. But there's stuff in between, I mean, between this law and very high complexity. And I want to start with Shelby, bariatric endoscopy is one of those areas where a therapeutic endoscopy that is well versed in suturing anyway, can say, okay, I'm suturing, not much difference into suturing the stomach, off I go. How does it work? So I would say that, so we did write a position statement in 2015. And in that position statement, we did talk about the fact, and I know that in an earlier talk, Dr. Shulman had this question about, should you dabble? Is this something that you can kind of dabble in? Or how many cases do you really need in order to demonstrate competency in these procedures? So I would say just because you have some experience with suturing, it doesn't necessarily mean that you're able to do an endostopic sleeve gastroplasty. So I still think that you do need training in order to be able to do that. The second thing is that in our position statement, going back to that position statement, we do understand that there are going to be some people who are primarily going to focus on procedures. And they're not necessarily going to focus on the other aspect of obesity, but it's very important for you to have that in your practice. So if you're not going to be the person who actually manages the obesity, it's a chronic disease. And I would argue after Dr. Sun's lecture today that it would be a chronic disease that has multiple comorbidities associated with it. A lot of times I'm treating some of those things. So you would up code for those potentially and include that in your chronic disease list. But it is a complicated disease with a lot of things that you have to be thinking about. So if you're not going to get the additional training that you need to treat obesity, then you do have to have somebody that you work closely with who will follow up those patients and do that obesity treatment. We know that any of these endoscopic bariatric therapies are not as effective without behavior modification. Now, behavior modification and lifestyle therapy, which includes diet, exercise, and behavior modification, is not that successful by itself. That's why we have medications and we do these procedures. But in order to maximize the weight loss, you still have to do that in addition to doing these procedures. If you do these procedures in the absence of lifestyle therapy, you get less weight loss. So we don't want to do that to our patients. We want to be able to maximize the amount of weight loss that they get. In order to get that additional training, the ASGE is actually, we put together a STAR advanced bariatric suturing program. And that includes both, you have to do the fundamentals of obesity, so you do have to get some basic obesity education in order to be able to come to that course. And then you do have to have some experience in suturing as well before you come. But even with that, not everybody passes that course. So to say that just because you have some experience with suturing that you're going to be able to do ESG and revisions may not actually be the case. So it truly, if I'm hearing correctly, you need to have a programmatic approach to this patient. Yeah. On many levels, the procedural level and what we have experienced in our institution, even the billing and how you move people through the system, dietician and so forth, all that needs to be in place in order finally to have success. Because even if you take the course and you get proficient with the technical aspect of the procedure, that is not enough. It's not enough. It is not enough. The thing that I'm finding right now, so I'm at the University of Colorado and I'm actually going to be moving, I'm going to be joining Dr. Calderwood and leaving the university. The interesting thing that I'm really finding as I'm moving on, because I am a gastroenterologist who does procedures and manages complex patients who have obesity, and in particular, my patients who have weight regain after gastric bypass or sleeve gastrectomy, that because I already have this additional training in obesity and I have the training in the procedural aspect of it, that in order for these patients to have the same level of care, I have to refer them back to bariatric surgery. If they're also on a medication, I need to refer them to the wellness center, to our physician-directed weight loss program, to be with our obesity medicine physicians, and they also have to be followed up in GI. To really do that kind of comprehensive care that I do with my dietician and some of the other resources, if you don't have that level of training, that's how many people you then need to refer back to where they could have just been seeing one person. It does tell you how much impact you can have on a patient, their quality of life, and just reducing the amount of medical care and medical costs that they need to have in order to manage. Great. The good news is that it appears that the ASG provides a pathway for somebody that is interested in bariatric endoscopy to get them from point A to point B, and you think that this is the main resource that is available nowadays. Yes. There are several pathways. There are some people who are doing specific training and specific fellowships, but there are very few places that are doing that. The Brigham is one of those. One of the reasons for that is to do with both experience in training and teaching, but also the volume of patients that we have, because it does take a certain amount of patients in order, as Dr. Shulman was talking about earlier, there's a range of numbers of patients that you have to do these procedures on in order to really attain that competency. Especially when you're talking about cash pay procedures, a lot of these are cash pay, you just don't have the volume at all centers to be able to have lots of fellowship programs. I think that there's going to be a shift. I think that as we get more insurance coverage, we will be able to get programs that have more volume and are able to do that training, but until that time, yes, ASGE and especially with our advanced bariatric suturing course, I think that's one step, but if you don't have a lot of training, you will likely need to do the STAR suturing course, get additional training from your local reps, from Boston Scientific, and then also take our course and then continue to practice and potentially get some proctoring in order to really be able to take care of your patients and do these procedures well. In one sentence, how far are we from having a dedicated billing call? At least two years, probably three. Got it. Okay. Well, I want to shift the focus and nothing against bariatric endoscopy, but to something that is even more complex to acquire, which is third space endoscopy. And we have here two prominent endoscopies that work in that area. And in between two of them, I want to bring the topic of how do you build the skill to start a third space endoscopy program in 2024? Because I think we are beyond the time where you have to go to Japan and spend six months there. What I did, fortunately, we have moved away. But let me start with Dr. Mizraki. Thank you, Dr. Bogdanoff. So I was trying before this appearance here on the podium, I was trying to find a few points that will highlight how you can engage, get more knowledge and knowledge in the sense of how to do the procedure, but also a theoretical knowledge behind those procedures. So I think, first of all, I want to say that what we all do here today, all those hours sitting here in this amazing postgraduate course, that's part of the way of how you learn about new procedures. You hear what other people can do in those procedures, and then you can think with yourself if you want or not to engage with that. First of all, if you think about third space endoscopy and mainly POM, GPOMs and ESDs. So in my case, I do ESDs for the last, I would say, almost 13 years. But as Dr. Bogdanoff said, at some point in my career, I decided that I want to give another boost to my third space endoscopy skills. And I spent a few weeks in Japan again to be able to get those boost of skills. And it did, it changed completely my practice. It's nice to see how other people works. So I definitely encourage anyone that wants to learn a new procedure is first decide with yourself if you can handle the intensity, let's say, of the procedure itself. And if you do, there are many various ways today, together with the ASG, as for bariatrics, to accommodate that. So first, I would say, as I said, curses like what we do here. Then there are many, many today. We are in 2024, as Dr. Bogdanoff said. And there are multiple videos that you can review and understand how the procedure is being done, what you need to have in your GI lab to be able to do those procedures. And then you should identify, I would say, a proctorship. You should identify a mentor that is approachable and that you will be able to discuss within the cases. You will be able to visit his institute and spend some time with him on real cases. And a lot of times those mentors are also able to come and visit you while you are trying to do your first steps in the field and do your first cases. I can tell you that from third space endoscopy part, we have an advanced endoscopy fellowship. Part of my fellows are sitting right here. And I can tell you that most of my fellows, when they come out of an advanced fellowship, even though they are trained in third space to some point, I would say, they feel much, much more comfortable in approaching POM and G-POM compared to ESD, which I think is actually a good step approach for third space endoscopy. And the reason is that with G-POM and POM, it's always the same direction. It's always the same movements. It's always the same thing that you need to do. So it's easier to have the muscle learning and get efficient in POM. More, it helps you also to identify the structures. So the muscularis propria and the muscularis mucosa, to who doesn't know that, looks the same. So if you do an ESD and you lose your orientation a little bit, you might do a big mistake and go towards the muscularis propria, for example. So POM and G-POM gives you this understanding. And I think that's something to think about. Now, as far as I will give another example, a small example about myself, I like to watch the Tokyo Live once a month, 7 a.m. on a Saturday. And through that Zoom meeting, I came to know about ARMA procedures, for example, that they are really emphasizing and really good. And actually, we already done a few cases of ARMA for patients post-bariatric surgery, for example, that cannot get any antireflux endoscopic procedures. So that's another example of how you can have the resources to build your own practice. Now, there are animal models in those meetings, the ASG hands-on during DDW, during ACG. You can get some more experience with different models and different techniques. I can tell you that today there are a lot of non-animal models that you can use. We recently purchased a Japanese device that is for pure training at Third Space Endoscopy. It's made from a Japanese type of potato. It has three layers and it's amazing. You inject to the second layer and it becomes blue like the submucosa. And you can tunnel for like 10 centimeters easily and do EFDs. How does it taste? Oh, I didn't taste. I didn't check that after the burning, sorry. That's okay. So, I mean, you made a couple of great points. The first one is the obvious that courses are still useful. The second one is that POEM and GPOEM are great stepping stone towards ESD. And the third one is that still getting some observation, either through virtual courses, which now are available, or going to a high volume center is still of value. Moamen, could you please take up on those points and add your perspective? Yes, so me and Meir has very similar like tracks and trajectories, so some of our stuff might be overlapping, but I will try to avoid some of those. So focusing on the education part, like basically teaching fellows to do these procedures, which is a big part of what we do in academia, is that we are not only expected to be good and skilled at the procedures that we do, but we have to be able to transfer this talent and skill to our trainees. And I can give perspective on that from our training program. We actually, from volume perspective, like the number of fellows per year interventional, we have three a year, which to my knowledge is probably the largest in the country, and being able to tailor that training and give them exposure on all of these procedures across the board is not an easy thing. So I think that the first thing we do is to sit with the fellows and understand, now with like the broad perspective of interventional procedures, you want to also understand from them what's like the main area of interest, because some fellows are mainly interested in pancreatic mobility stuff. We do give them exposure to third space during that single year of fellowship. So they do POMS, G-POMS, ESDs, full thickness resections, zincers, all kinds of procedures. And then depending on their interest, you can gear things towards that. And even the learning curve for different procedures is different, not across like different fellows, but in the same person. The way they acquire EOS skills might be different than like how the trajectory for ERCP is, than the trajectory for POMS and even the trajectory for ESD, which is very, very different. So tailoring that to every fellow definitely helps them acquire the skills and focusing onto the weakness points and explaining that. I will still relate to the part that visiting other institutions is very necessary, especially after fellowship, because when we're in fellowship, we're acquiring skills. And then once we graduate, sometimes we are in our own silos, basically. You do what you're trained to do, and it might be perfect, but you never try to explore and go visit other institutions. And it becomes not as easy as it was when you're a fellow to visit as like a preceptor in another institution. And I actually went and visited Dr. Dragunov. He might not even remember that. That was many years ago when I started doing ESD. I wanted to see he had this preceptorship that was set with one of the medical device companies. And I went and visited, and I learned from him two things, not only how to do the procedure itself, but also the way he teaches these procedures, which is very important because you can have a great endoscopist who's so skilled and unmatched in the skill, but as an educator, they cannot transfer that talent and skill to another generation. Locally, that was something I did. And then internationally, same thing as Meir did, and as Dr. Dragunov did, went to Japan. I think for ESD and third space, I mean, maybe we don't need to visit for six months anymore because we have a lot of like skills and experience here. But I think getting their perspective and also the teaching model is very different. That different in a good way doesn't necessarily mean that everything we see will be adopted and can be adopted here. But the structure that the fellow is like observing for a few months, like enormous number of procedures, and then taking for a few months, another enormous number of procedures. And then after that, assisting. And then after this, actually, they get the cases booked under their names, like ESDs, and they are responsible for the case. So learning that perspective and teaching, it helps a lot. Again, I don't expect our fellows will be ready to observe for three months and then take for another three months. But getting the perspective of that way of teaching certain kind of procedures is definitely helpful. And at the end of the day, our goal is like patient safety, right? We want to accomplish the procedures. We want to do it safely to our patients. And in the same time, we want to teach that future generation of fellows who will be teaching, you know, teaching their fellows in the future and taking care of other patients as well. Thank you. And Mohamed, I remember very well when you visited. I've seen how it works. So now I can definitely claim you as a trainee. I'm very proud of how you have done. I want to pick up on one of your points, which was the indication. Similar to bariatric endoscopy is not just about the endoscopy. And Jennifer made this point in her talk. You may be the best ERCPs in the world. If you do the procedure on the wrong patient, you will still get complications and you are in trouble. And most importantly, your patient is in trouble. One thing that consistently comes up is proctorship. How do you secure a proctor? And that's a tough one. Usually in our system is by the word of mouth and personal connections. I wish I can give you a shortcut to that, but as you go through courses of various kinds, which for ESD and third space endoscopy in general is much needed. One course is clearly not enough. You need to attend a few, stay in touch with the faculty that teach those courses. That will be a great resource. And of course, establishing a long term relationship once you're up and going on the research side, sharing patients for multi-center studies, another avenue that you can establish proctorship, but it requires work, but it's well worth it because you don't want to be rediscovering the wheel. Somebody guiding you through this process will be of great help. I think we are about out of time. Audrey, do we get any questions through the chat that you want to cover? Yeah. If you want to put up that code, we could wait for a minute to see if any more come through. Give it a minute. Yeah, of course. Yeah, of course. So one of the things that I can add in the meanwhile, we spoke about the ASG and everything, but definitely the industry is also part of the teaching process. And I think that you can engage in different ways with the industry. For example, I do a lot of R&D. That's how I keep myself up to date with new devices and tools. But definitely there are various companies that are actually providing semi-proctorship, I would call it. There is someone with a lot of knowledge and experience in ESD that comes and teach on animal models. And then maybe that's another way that you can engage with the proctors and maybe get a personal relationship and visit them, as we said. Absolutely. For those that are not familiar, both Boston Scientific and Olympus offer various level courses in ESD, and that's a great resource. And usually your local rep is your best contact for that. So don't ignore it. If nothing else, it's typically free, but let's see. Suturing in US. Yeah. So the question is, what are the options for training for endoscopic suturing in the US outside of an advanced fellowship? So there's a couple of things. We talked about the STAR Advanced Bariatric Suturing course through the ASGE. I will say that as both of you were talking about, and I brought up as well, the industry and Boston Scientific also has courses as well. But one course is not going to be sufficient for most people. And we have, even within our own STAR Bariatric Suturing course, because we are actually testing people at the end of that. So we're saying whether or not you have a pass-fail, whether or not you do have the skills to be able to do these individual components of these procedures. So we're scoring that, and that is true for the STAR program in general. But what we are offering is for people to be able to come back and retest after they get more experiencing more hands-on. And how you're going to be doing that is largely either through industry helping you with that, or with potentially being able to do some short stays at other academic institutions. I have had three people come and train with me for three months. That's not really sufficient. Like we were talking about, that's not a sufficient number of cases to be able to say that you have reached competency, but it's at least giving you enough experience so that you would be able to go to one of these courses and potentially be able to pass all of the required components of being able to do it. So there are some of us that are doing these shorter three-month kind of interval stays where you are actually doing cases. There are a few, at least one really standard fellowship that's in the Brigham. But again, if you're outside, some of us that are doing these short three-month stints may be something that you would be, that would be something that many people can do. Some people can't do because you can't take three months off of work. And in that case, you really want to focus on interacting with your Boston Scientific rep to be able to get some additional hands-on training outside of a human model. Right. Well, let me take in a rapid fire two questions that came through the chat. One is on TIF. TIF is a tricky one because the procedure itself is not overly complex. You can pick it up over one or two courses. The biggest challenge with TIF is that most patients with reflux have some degree of hiatal hernia. And then the TIF procedure may not be the best choice by itself. So most of us have converted of doing the so-called CT for combined TIF. But that is a tall order because then it requires close cooperation with surgery. And then it requires a programmatic approach. So it's not something that you can bring and start doing off the bat. But the technical aspect of TIF is relatively straightforward. But be ready that you need to talk with your surgeons, set up how to do those CT procedures together. And the last question is billing and CPT code for ESD. So at present, we do have a facility CPT code for ESD. And please use that on the facility site. I don't know the number off the top of my head, but it is available. We don't have a CPT code on the professional side. It is probably not coming anywhere close in the next two years. And the reason is that we withdrew our application. We got burned with POM. And when that happened, we took a step back and we did not want the same thing to happen with ESD, what happened with POM. Just as a reference point, hellermyotomy, our work, our views is 23 or so, and POM, our views is 12. So for two procedures that are basically very similar. So now we are regrouping, but the end result is that we will not have a CPT code for foreseeable future. All right. And maybe we'll squeeze in one last final, final question. And if you guys have more questions, I'm sure the panelists will speak with you after, but quickly, what are the sources of experimental models available in the US? You guys mentioned a few. Yeah. So it's very, very easy. Again, every company has their own, trying to develop their own model of training. The main models today are still animal models, I would say. The best model that I'm familiar with is what I described to you earlier, which you can actually have it in your GI lab. And whenever you have two, three hours, you can pull it out and do training with that. It's costly a little bit. The device itself that holds the tissue and everything can cost up to $10,000, but it's actually in the shape of, it resembles the shape of the stomach. So you can have lesser curvature lesion, you can have a greater curvature, retroflexion, whatever you want to make it happen. And they have also an extension for colon. So you can have the colon anatomy while you're doing training on ESD and especially in the colon. I'm not familiar with other models, unless I think you have something, right? I would say the best model is any model you can get your hands on, whether that's a wet pig stomach or live pigs or that amazing model that Mayer mentioned. The key is to get as much practice as possible. Of course, you wouldn't go for a dry model, that doesn't add much for a third space procedure, but any wet model, live model, or something like that will definitely be a way to practice because you will need multiple sessions. It's not like a one time and done. Yeah. And just to finish, I want to add one more opportunity to make you aware of it, Olympus offer what they call ESD in a box. So one of them will come to your institution, bring their own animal scope and it's on explant stomach, and they can work with you for a few hours there. Probably not the best place to start with ESD, taking one or two courses first and then filling the gaps in between with this. But again, it is out there, talk with your local Olympus rep. That's a great opportunity to squeeze some extra practice time at your own convenience rather than going elsewhere. Yeah. So we do it every year, actually, with the advanced fellows, we bring them and we do ESD in box. Yeah, absolutely. And same goes for the suturing. Boston has a truck, 18 wheeler that they travel around the country like a circus in the old days, and they put a camp. Every time the truck comes to Gainesville, I take some time. I consider myself quite proficient with suturing. Nevertheless, I go to the lab and keep working on it. It's one of those things where especially it's muscle memory. When you're dealing in particular with the overstitch device, there may be suturing devices coming down the pipeline that'll be a little bit easier to use, but this is multiple steps that you have to do for each one of these sutures. And it's very easy to drop your needle. It's very easy to cross your sutures. So it's really getting the practice and just those mechanical aspects of it, just so that you don't push the blue button at the wrong time and drop your needle. It's just getting that practice in and doing it repetition over and over and over again. Well, Audrey, take us home. Thank you.

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