Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, Incorporating New Skills into Your Practice, Fellowship and Beyond. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make sure the session is interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording on GILeap as part of your registration. Now it is my pleasure to introduce our two GI Fellow moderators, Shif Omar, an Advanced Endoscopy Fellow at the University of Chicago, and Rashmi Advani, another Advanced Endoscopy Fellow at Cedars-Sinai Medical. I will now hand over this presentation to our GI Fellows. Thank you, Marilyn. Hello, everyone. Welcome to the ASG Endo Hangout. Thank you for joining us today. So we'll be discussing today incorporating new skills in your practice. As we all know, medicine and gastroenterology, they're both evolving fields with new advances happening every day. And as we move further away from training, it becomes challenging to learn new skills and incorporate new technologies. So today we have four incredible faculty experts who have not only just incorporated new technologies and skills in their practice, but have also mastered them and become leaders in the field. And they will share their journey with us today. So I'll start with our first faculty panelist, Dr. Shalindra Singh. Dr. Singh, if you can start sharing your screen. So Dr. Singh is currently Director of Periatric Endoscopy. He's an Advanced Endoscopist and Associate Professor of Medicine at West Virginia University, Oregon Town. Dr. Singh's clinical and teaching interests include US ERCP, pancreatobiliary diseases, and minimally invasive endoscopic procedures, focusing on endoscopic treatment of obesity, GERD, and post-surgical complications. He's one of the leaders in the country in performing ESG and bariatric procedures for weight loss. He also devotes his time to research focusing on advanced endoscopic procedure outcomes, research using big database and innovative bariatric endoscopy procedures and devices. His work has resulted in numerous publications in reputed gastroenterology and bariatric journals and has received extensive media coverage. He's working on developing innovative endoscopic weight loss methods and devices and has been granted several patents. He's the editor and reviewer of several medical journals. He serves on national committees for ASGE, ACG, DDW, and AGA. And he's been a pioneer in bariatric endoscopy in West Virginia. So over to you, Dr. Singh. Thank you. Thank you, Shifa, for the great introduction. So today I will be discussing incorporating bariatric endoscopy into practice. These are my disclosures. So we'll be specifically focusing on training in bariatric endoscopy. So first I want to give a brief overview of what bariatric endoscopy is. So bariatric endoscopy involves primary therapy for obesity. There are additional therapies for patients with weight regain after bariatric surgery. There are metabolic therapies, which are in clinical trials right now, and it also includes management of complications post-bariatric surgery. So if we look at in terms of devices, we have intragastric balloons, which are currently FDA approved. Then there are devices which are being used elsewhere and are in clinical trials. These are also gastric devices. Then we have small ball therapies. Diurnal mucosal resurfacing is a promising new technology, which is in clinical trials for treatment of diabetes. Then we have these gastric placation or suturing devices. Endoscopic sleeve gastroplasty was recently FDA approved and is becoming popular. Now there are a lot of devices in trials of development, which is exciting for the field, but currently utilized devices are basically gastric balloon and endoscopic suturing. Suturing is used to perform endoscopic sleeve gastroplasty, transoral outlet reduction procedure and revision of previous sleeve gastrectomy, and is also used in the treatment of bariatric surgery complications. Therefore getting expertise in endoscopic suturing is the main component of training in bariatric endoscopy right now. Training in gastric balloon is usually not technically challenging for endoscopist and gastroenterologist and can be achieved with industry training. So my focus of this talk will be how to get training in endoscopic bariatrics, mainly in endoscopic suturing. So what I will do is I'll share my story because bariatric endoscopy is still in very early phase right now. There are not many training programs around the country and I can say most of the bariatric endoscopies have kind of gone through the same process. I expect, still we don't have many training programs. There are no certification or credentialing criterias which are being developed. And so this might be kind of the form of training will be, the form of training we might be undergoing to train in endoscopic bariatric. So when I, in my fellowship I was trained in US and ERCPs, but did not have any exposure to any endoscopic bariatric or endoscopic suturing. And this still may be the case with majority of fellowship program. One important point that I want to make is that advanced endoscopic skills are helpful, but especially in managing bariatric surgery complications, but is not required for training in endoscopic bariatric therapies or suturing. We have fellows right now who have learned this in their third years and are able to and are able to do procedures independently. And we also teach this to our advanced endoscopy fellow. When I started, I was very motivated to learn this procedure. And I think motivation is very important because developing skills in endoscopic bariatric therapies not only require that clinical training, but an important part is developing a program which can be time consuming and challenging both at the same times. Your goal should be clear why you want to learn this therapy. And as I interact with more people, then they can be as simple as your practices looking to serve more patients with obesity, looking for an additional revenue stream. There are weight loss centers for excellence, and there's a requirement to have a bariatric endoscopist in these centers. You want to create a niche for yourself or you're interested in device development or academics. So this is a great area to be in because there's a lot of new developments. So I started right after fellowship is by learning and reading about these devices to develop a good understanding of the field. I found a mentor, both in private practice and academic setting, who was performing these procedure. At the same time, I started my research around these procedure. I was reading a lot of articles. So I did some meta-analysis, including ESGs, gastric balloon, pose procedure, and kind of did some comparison between balloon and ESG procedure. So this helped me in developing a good understanding of where the field of bariatric endoscopy is and where it might be going in future. At the same time, I was also working on some device development for endoscopic therapies for weight loss. Now, I don't think you need to do all of this, go this far, but I think it's important to develop a good understanding of the devices, the field, obesity treatments, and find good mentors. So if we look at the procedural training in endoscopic bariatrics, so I think most important skill is the endoscopy skills. These skills, most of the fellow GI fellows, gastroenterologists, will have the endoscopy skills to perform endoscopic bariatric procedure. Then it comes, next most important step is the device management, learning the device, as well as learning the troubleshooting. So what I did is, every conference I was going to, I was doing the suturing courses. There's an ASGE star course, endoscopic suturing course. I also did an ASGE endoscopic bariatric course. Then there is an industry-based courses. There's an Apollo course, which is quite intensive. It's a two-day suturing course with hands-on and diuretics. And I was recently a faculty at that course. And I think participants really learn endoscopic suturing and the techniques involved with some of these procedures in that course. So I think you need to be motivated, willing to learn, and try and get as much hands-on experience at any conference. There are some of these courses, ASGE endoscopic star course, endoscopic bariatric course, and the other industry courses, which are really helpful in understanding the device procedure technique, and also troubleshooting with the device. So incorporating now, you have done some courses, incorporating these skills in clinical practice. Endoscopic bariatric procedures, such as an endoscopic sleeve gastroplasty, this might require that suturing skills required with the ASG are advanced. Then you might require for a fistula closure or a defect closure. So I started with simple cases with fistula closure and defect closure. I went to observe three to four live in-person cases, ASG, transoral outlet reduction. Then when I came, well, I worked with my hospital in developing credentialing criterias to perform ASG. I showed all the experience and the certifications I had. And then finally, we decided to do five proctor cases with assessment and an observer. Once I was done with five cases, I was credentialed to perform ASG at our hospital. We started getting consults mainly from some marketing and also word of mouth. And the program took off slowly, but as more and more people came to know about it, we started getting a constant flow of referral. Then I started a special clinic just to see these patients. And now we have a constant flow of patients and we are able to schedule them four to five weeks out. So we have full schedule for the next two to three months. When I was doing suturing, I also started getting a lot of referrals for placement of stent, stent suture, fistula closure, manage complications of bariatric surgery. That helped me develop a good relationship with the surgeons, bariatric surgeons, and surgeons at our institution. We developed a good relationship and a multidisciplinary program. Finally, I also want to touch on that one part of endoscopic bariatric therapy is the training involved, clinical training involved. But also an important part is developing a comprehensive endoscopic bariatric program. While training, it is simultaneously to work on with the hospital administration or with your department to develop the program. Because once you learn it, you need to have patients to have more procedure. And in terms of getting the learning curve for this and procedures are for, especially for ESGs is 20 cases. I felt that I was more comfortable and efficient with the cases. I was doing good troubleshooting and at 40 to 50 cases where I felt it's kind of, I have mastered the skills and I was kind of looking into what suturing patterns might work, what suturing patterns might work and where can we define this technique. So developing a good program will help you get there to start with, to do those 50 cases and kind of build up a great program. Some of the other considerations is that most of these procedures are not covered by insurance and they might be self-model. So what I did is I start, I work with our hospital administration and the hospital insurance for our employees to cover these procedure. And we also developed a private pay model for these procedure. Right now, we have a good mix of insurance coverage and patients who are coming, who are privately paying for these procedures. Marketing and promotion of the program will go a long way to develop a comprehensive program and it will be an important component of the program since many of the patients don't know about these procedures. So just educating the patients will help drive consoles for this program. And secondly, building relationships with medical weight loss, bariatric surgeons and other endocrinologists, cardiologists, and kind of educating more about these procedures will also help drive some consoles. Thank you. Thank you so much, Dr. Singh. Now, I'm going to invite Dr. Advani, my co-moderator, to introduce the next speaker. Good evening, everyone. I have the pleasure of introducing Dr. Srivanthi Parasa. Dr. Parasa is a gastroenterologist and clinical researcher at the Swedish Medical Center in Seattle. Her research is at the intersection of epidemiology, biostatistics, machine learning with a passion to augment and advance clinical care through the meaningful applications of artificial intelligence. She also serves on several IEEE slash engineering and computer science conferences and program committees apart from GI society committees. By partnering with and serving on advisory boards of several world-renowned institutes, she has published several papers in areas of high-fidelity risk prediction models, application of computer vision, and natural language processing in medical space. All right. Rashmi, can I go? All right. So I kind of, thank you, I kind of put this a little fun thing because I was told this is for most fellows, but I think anybody can relate to it. So this is going to be an AI ninja talk. So we'll talk about the tips and tricks for gastroenterologists to kind of get started in AI. And these are my disclosures. So let me see if I can minimize this. Okay, there you go. So what I'm going to talk about today is just, most of us are just talking about AI in the search. And then once we think about doing some projects in artificial intelligence as it pertains to medicine or gastroenterology or, you know, some kind of a workflow, you can use the tool in any different way. But we'll also talk about, mostly talk about how you can get started in AI research. And then you can think about how you can use this research to, you know, start implementing from a practical standpoint, if you want to get a new device or a new software upgrade or, you know, some kind of a new algorithm into your clinical practice. So what are the steps that, you know, when we think about AI research, they are like four big pieces. You know, the three common pieces are methodology, writing papers, and where do you submit these articles. So when Rashmi introduced me, you must have heard that, you know, I talk about, you know, engineering fields and also, you know, medicine and stuff like that. The beauty about AI research, it's a hybrid or an interdisciplinary area where you cannot work independently. You need to work with your computer science partners. You need to work with your hardware, software companies to kind of develop new tools or new softwares that you can probably use in clinical practice. So when we think about the tools that we need, not that we need to know how to use these tools, common software that we use are Python or PyTorch. And most recently, if you haven't heard of JITPP or any kind of large language models, these are built on transformer technology. So these are some of the tools that if you want to venture into learning might be a good choice, but I would not recommend that you have to learn this to start any kind of AI research. The second piece that's very important when you're thinking about, you know, dabbling into AI research is what are the problems that you want to solve and what kind of experiments do you need to set up to solve those problems? And how do you evaluate both from an AI algorithm standpoint, whether it's performing well or not? And what are the metrics for that definition from just a pure data science standpoint? And how does it translate into clinical medicine? So your cutoff could be 95% or benchmark for the model performance in its model world. But in clinical performance, if it's only five points better than a human or what it is currently, then that could still be taken as a positive. So you need to know what those benchmarks are before you know what you want to do with that data and, you know, come up with some kind of an outcome question. Obviously, your papers, the way they're written would be different from a traditional, you know, gastroenterology or medicine type of paper. There are several guidelines as to how you write those kind of papers, because you need to mention some of the model performance as well as clinical performance. And then when you're thinking about publications, depending on the question that you choose, you can publish them in computer science journals, you can publish them in translational research. These are usually nature or nature of medical intelligence, machine intelligence on nature digital publications and so forth. Of course, you can purely submit them to medical journals and gastroenterology as well. Okay, so we talked about the tools, we talked about some of the methods you need to think about, you need to think about what type of papers you want to write and how you want to disseminate all that research once you're done with that. So, just like how Shailendra mentioned, I'm just going to talk a little bit about how I started my journey and where I am right now. Again, I won't go into great depth, but my research predominantly involves three areas of artificial intelligence. One is computer vision. That's what we see from an endoscope standpoint, what we call pattern recognition. And within the computer vision field, I have two areas of interest. One is purely from a gastroenterology standpoint, but the other one is more in terms of model development. How do we improve models? How do we come up with new benchmarks? These are type of research questions I work with my computer scientists, who together we come up with some solutions. The second type of research is on electronic health records, or what we call a large, massive set of unstructured and structured data that you want to pull to find patterns that you can tie to specific outcomes. For example, early onset colon cancer, or you want to know what are the new risk factors for Barrett's esophagus to progress to esophageal adenocarcinoma in a certain population or something like that. The third one, and this is something that I've been working for the past seven years, is natural language processing. And that field has completely changed in the last couple of years with the advent of what we call transformer large language models. So all your chat GPTs, your GPT-4, these kind of models are based on a concept called natural language processing. Okay, so now that you know some of the common areas, now if you want to choose, the first thing you want to think about when you're planning to do any kind of AI research is try to identify gaps. Now when I say identifying gaps, there are a lot of gaps or areas of improvement that we can add to the current literature. For example, right now we may have a set of 10 variables that you want to consider in a logistic regression to say whether a patient would be at risk for developing colon cancer or not. But if you add additional layers of detail, like maybe there is something on the pathology slide that a human can see or cannot see, or what you see on endoscopy, or what's going on in the social determinants of health or something that's buried in their longitudinal electronic health record data. So these are additional layers that you can add to your existing question as well to make the model more precise. And that can be done at any point. You don't have to have only one specific question. It could be pancreatic cancer. None of these problems are completely solved. So you have a great opportunity. So you just have to think through how you want to solve a problem, identify that specific gap, and then figure out where you can find that data so that you can work on these kind of problems. I'm going to just talk about how I and some of the AI researchers in medicine work on choosing the right question or a different style of research. So one common one is called nail versus hammer driven. So basically, a problem versus two. Right now, what we see a lot in endoscopy and gastroenterology research is a hammer driven type of research style, meaning you have a new tool, which is artificial intelligence, machine learning, and you are trying to solve every problem that you can see in gastroenterology. Similar application. So whether you are detecting a polyp or you're detecting dysplasia in barrets or whether you want to detect abnormal tissue in a pancreatic cyst or whatever it is, it is what we call a hammer driven. For nail driven, you want to choose the problem and then figure out what AI technologies do you want to use to solve the problem. So let's say we want to solve the problem about pancreatic cyst. Trying to figure out if there is malignancy, what are the features in it that can help with getting to a better diagnosis. Then you will go with the demographic features, your EHR type data, your labs. Then you can add an MRI or a CT scan and figure out what are the features within the MRI that could be causing it. Then you can have the FNA sample right there and kind of add to the value. So then you're using multiple types of AI technologies to solve one problem. That's what we call multimodal type of research. Again, it could be very narrow, very specific to a disease process, or you can try to kind of broaden it out from a population standpoint. You can do it as an individual project or as a collaborative project. When I say collaborative project, you can collaborate with pathologists because they are the ones identifying the regions of interest on your pathology slides. You can be a trailblazer, completely go off path and try to find new areas of research, or you can add an additional layer to what you're doing right now. Again, I briefly discussed about interdisciplinary research where you can work with computer scientists, take it to the next step, try to build foundational models, or something that you can create pipelines for easy adoption into medicine and stuff like that. So it all depends where you want to be and how you want to do stuff and how much you want to be involved. Now, basically, at the end of it, it's just a tool. And that tool is rapidly evolving to solve different types of problems. So that's why it's very exciting to be in this field and try to adopt that to medicine as well. Of course, you can work on regulation. You can work on ethics. You can work on human-AI interaction. And all of these get you closer to clinical implementation as more and more algorithms become available. So the second point I want to emphasize is when you're working on any kind of research project, be it AI-based research or your traditional research, start with a goal in the end. And then you should find a good research question. When you're designing a good research question, that is the foundation for how you will carry on the project, what type of collaborators you need, what kind of data you need, what kind of analysis tools you would be doing, and what are the metrics or performance metrics that you want to benchmark your data set to. So again, as you frame the question, you will understand what the data requirements are, what are the type of tech expertise you would need. Because all of these computer scientists have their own niche areas, just like all of the gastroenterologists have. So you need to find the right partners, depending on the complexity of the task. Now, asking good questions. How do I do it? Every night before I go to sleep, I have like 1,000 ideas come into my mind. Half of them are bullshit. So I just write down all of those ideas on a piece of paper. You talk to other people, try to see if you feel like from a domain perspective, meaning from an endoscopy or a gastroenterology perspective, you are pretty good. You don't need to bounce off your ideas, that's fine. But from a technical perspective, and you need to know whether this is doable, or you're thinking out of the blue, or is it going to be hypothesis generating, you need to talk to your technical team to find out what are the technologies that are available to help you solve the problem. And then, in general, when you're thinking out of the box, it's always very important to have some time for yourself for creative thinking. If you're running around all day, you're doing a lot of work, you cannot think creatively. So that is very important. And the second thing is also trying to know if you're asking the right question. So how do you make steady progress? First, you need a mentor or an advisor or a good friend who can guide you through the process. You need to develop some kind of basic skills, research skills, and in our case, we don't need to know completely about how to write code in Python or any of the other languages. But trying to know what to ask from your technical counterparts, your data scientists or computer scientists, is very important because they do not think like us, and we do not think like them. Trying to understand how you can translate your question to how they can understand is very important. And having those key collaborations, whoever it is, across the globe is very important for success as well. So again, research can be lonely, discouraging, and tedious, especially when you just get started. We all go through it. I'm not going to repeat this. We all know that. But you've got to be passionate about your topic. You need to know what you want to get out of it. And then the beauty about AI research is it gives you freedom of thought. And you are basically creating your own path and discovering new things and challenging your technical counterparts to develop new methods for you so that you can succeed in solving a question. So I'll stop there. But if anybody is interested in learning more about how to get started and how to actually build an algorithm, we do have a primer workshop at DDW on May 5th. Thank you. Thank you, Dr. Parasa, for expert insights on how to incorporate artificial intelligence into your GI practice. I'm sure many of our interested listeners are feeling more inspired to explore this important space. I'm going to give it to Shifa to introduce the next speaker. You're muted, Shifa. Thank you. I'm very excited to introduce Dr. Sethi. Dr. Sethi, although she really does not need any introduction, Dr. Sethi started her career in GI and endoscopy at VCU in Richmond, where she completed her GI fellowship in 2007, followed by her interventional endoscopy fellowship at the University of Colorado. She joined the interventional endoscopy services at Columbia University in 2008, where now she is a professor of medicine and director of interventional endoscopy, as well as program director for the advanced endoscopy fellowship. Since starting her career at Columbia, she has mentored over 24 interventional endoscopy fellows, participated in numerous collaborative studies in ERCP and cholangioscopy, EUS, endoscopic resection, and third space endoscopy. She has authored several papers and reviews on these topics as well. She's participated in numerous life endoscopy courses around the world. Dr. Sethi has served the ASG in numerous capacities, most recently as course director for the DDW 2022 postgraduate course and course director for the ASG form course in the summer of 2022. She won the ASG Don Wilson Travel Award in 2011, was also part of the inaugural lead class in 2014. Dr. Sethi has served as ASG ambassador in Myanmar in 2015, and she has received the Master Endoscopist Award as well. Dr. Sethi is the founder and president of Women Endoscopy Organization that strives to promote women in the field of endoscopy. She has served as past president of NYSG, and she is the rising chair of American Gastroenterological Association Center for GI Innovation and Technology, and needless to say, an inspiration and role model for all female advanced endoscopists. Dr. Sethi. Thank you, Shifa. I have to remember to keep that bio reaper. But no, thank you so much for that intro. So I'm going to talk to you about learning third space and kind of taking it from the perspective of once you've finished fellowship, thinking that perhaps if you haven't had the opportunity to really pick up these skills as you had introduced in the beginning of the session. So I think it's important to just understand how we're defining third space endoscopy these days. So it's a lot of terms that get used together like submucosal endoscopy. So what is submucosal endoscopy? It's basically working within the submucosal layer, which is really a potential space. We can expand, we can dissect, we can resect. It definitely requires specific dissection techniques as well as things like closure methods that were described earlier and management of complications such as bleeding and perforations. And in terms of the procedures that we kind of include in the category of third space endoscopy, there's absolutely ESD, which serves as our fundamental skill set. And then POEM would be the second most common. And this can be performed anywhere. And then using POEM and dissection together for submucosal tunneling resections or full thickness resection, whether it's using device or ESD. So in terms of ESD, it's important to know the principles of it. It's an organ sparing technique that we want to use to perform curative resection of early mucosal neoplasms throughout the GI tract. And it serves as a foundation for third space endoscopy. There are conventional methods that we can learn how to perform ESD. And then as we progress in our techniques, there's all sorts of variations that can be described for various types of lesions and anatomical locations that really change sometimes the definition of how you actually perform the procedure. But it all starts with some pretty fundamental principles. And then POEM is parole endoscopic myotomy. Hopefully, all of you have heard of that. But it has four basic components to it. And that's how we talk to our patients about it as well. First step is a mucosotomy, really entering the GI tract wall, then tunneling in order to expose the muscle layer, if that's what we're doing with our POEM, and then performing the actual myotomy itself, and then ultimately performing closure. So we've excluded the third space and created a safe procedure and good outcomes. And POEM, as you know, is not just limited to the esophagus. Now we're really performing it from the oropharynx all the way to the rectum for various things like cricopharyngeal bars, anchors, even esophageal strictures, creating neolumens, certainly achalasia in the stomach. We're treating gastroparesis and Hirschsprung. And this has really created sort of an alphabet of POEM, if you will. So how should we think about getting started in third space? And what are the requirements? I kind of break it down into these four categories, passion for endoscopy, and I'll expand on that, the team, the need, and the infrastructure. So we'll start with passion for endoscopy. And this doesn't just mean like, I love endoscopy and I love performing third space. It really means having a true understanding for the indications for the procedures. And that means the oncologic principles, what are the goals of ESD? Being able to perform some of the background techniques that help you understand why you may want to apply ESD, for example, to a lesion as opposed to just EMR. So being able to assess lesions properly and perform optical biopsies. And then really understanding where you fit into the care of these patients, understanding what the surveillance plan is, what your follow-up care is, who you have to get patients to, depending on the outcomes of your results, and how the procedure, how the technique that you're using may affect these outcomes. Participating in a dedicated training program is a topic in and of itself. But this does not, as was stated earlier, have to be an advanced endoscopy fellowship program. You don't have to come from that background. Certainly it helps. But as you decide, make decision to enter this field, you should sort of commit to a dedicated training program. And then something I call, just in terms of your own technique or your own skill set, is really to be an elegant endoscopist. And what that means really is just that you scope with intention, that your movements are purposeful and efficient, that you're mindful of the space that you're in, the planes that you're seeing, and again, the movements that you're doing. And you're aware of your limitations. That's probably one of the more important parts, is to really know when you can push yourself and when you need to step back. We need to be endoscopists who expect complications. They're almost a rite of passage. And understand the management of these adverse events. And really be open to evolving techniques and innovations. As I said, there's sort of the conventional way to do ESD in poem that we learned in the beginning. But this really changes not only as you learn the skills, but as your lesions become more complex and as devices and innovation develop. So really, when you're in your third hour of ESD, you don't want to be kind of asking yourself, why am I doing this? Should I really have gone into this space? Because you can't leave that. You can't just walk away. You have to really commit yourself to being passionate and committed to this. And I use this as just a reminder that for me, for example, performing poem is like my Zen meditation. I really find that I love being in that space and I really enjoy it. So what about the team? This is probably one of more, not more critical, but it is one of the most critical parts, is that you have to work in a multidisciplinary group, whether it's ESD or poem procedures and other third space procedures. And this team has to include your surgical partners. And that's not just one type of surgeon. You really need to think about where you're performing these procedures. If it's a poem, you wanna be working with thoracic surgeons. If it's a lot of gastric and esophageal, you wanna work with foregut surgeons. If it's colorectal for all your colon lesions. And this is not only to deal with complications, but also to really help discuss which patients should get which procedures and kind of work together and share procedures in terms of realizing when it makes more sense for patients to go to surgery. Whereas when it is better for you to try for suction, for example. Anesthesiologists are really important to us during the procedures. There are very specific requirements that we have, particularly during poem or ESD. For example, paralysis or intubating patients for different indications. We absolutely wanna work with our motility gastroenterologists if you're in the field of, if you're practicing poem, because we have to remember that these patients may still have symptoms. And as we do more and more procedures, we're gonna be treating more complex patients. And I think it's a little unusual to have esophagologists and those who perform poem be the same person just in terms of where your training lies and your expertise lies. And so it's absolutely important to work with them and to make sure that you're discussing nuances of patients' findings and perhaps how that may even tailor your procedure. Obviously, we wanna work with our oncologists and our pathologists. This is a sort of, I think, underrated areas to actually work with your pathologists to specifically talk about how you want these procedures reported. The worst thing is to spend that three hours, all my ESDs are not three hours, but to spend all that time really working on a non-block resection to create these negative margins and then have pathologists not say exactly what the margins are or to really specify and give you the information that you're looking for, like, is there any lymphovascular invasion or exactly how clean is the margin so that we can consider it an RO resection. You wanna have a procedural team and a post-procedural team that really understands what you're trying to do, understands the complexity of the procedure, how to use the instruments, and how to manage adverse events. You wanna work with your hospitalists and your inpatient management team so they know how to treat your patients post-procedure since a lot of these patients get admitted, and then marketing and development to really develop your referral base and help spread the word that you're performing these procedures. And administration is really important to work with, and that was mentioned in the bariatric section too, because a lot of this doesn't have codes. Luckily, POEM has a dedicated code now, but ESD, for example, does not. And so you really have to work with your administrators to understand how you will be compensated for all the time that you spend both training and doing these procedures. And when you begin in the beginning, it's really about setting aside several hours to do these procedures. And then what about the need or the patients? So you really don't wanna just start doing, start setting up shops somewhere where there's not a lot of patients that are being identified with early mucosal neoplasms for ESD, or there's no motility person there who's gonna be able to provide patients with achalasia. So you wanna, if that's not available, before you get started, you really wanna start to educate your general GI and your surgeons regarding advanced resection indications and techniques. And that might be even starting with things like EMR. You definitely wanna educate general GIs about the motility disorders and changes in our recommendations by societies with regards to therapies that we're gonna use and the endoscopic options. And we wanna offer our alternatives to surgeons for difficult cases. And this is a relationship that really grows. Once they see that you can be successful, even perhaps in the beginning, if they think they're concerned that you're taking cases from them, as they see that you can actually offer them an out for some difficult cases, this volume will continue to grow. And consider working specifically with screening programs. For example, for gastric cancer screening, really work with those who are getting out there in the community to identify and get people screened and show them that there are solutions if they were found to have disease. And then for in terms of our infrastructure, this really refers to our equipment. So you wanna have excellent knowledge of the different scopes, both the length, the channel sizes, the bendability, the visualization. All scopes have little nuances. And as you get used to scoping with different kinds, you may even wanna develop your scope armamentarium a little bit more. Having access to a multiple number of, multiple knives, for example, as opposed to just having one knife would be really important. And really knowing as this will build as you're doing your procedures and knowing when you may need different things. The ESU or electrosurgical unit is very important and really understanding different settings. I think this is a very critical part of your GI fellowship that can begin in the general GI fellowship and is important to really master. All of these procedures have to be performed with CO2. So that's important. And even low flow CO2, if you're gonna get into POEM procedures is a good thing to start to access. The POEM ESD can be performed either in the endoscopy unit or the OR. This really depends on your institution. And it's worth working with them to demonstrate that it can be performed in the endoscopy unit if they're hesitant in the beginning. But you really need to work with the hospital on this. As well as with the anesthesia team, it's worth developing protocols if they haven't done this before in terms of how they're gonna sedate these patients. and especially, for example, a lot of the colon ESDs now, particularly on the right side, I have patients intubated, and you have to explain why that is for a patient who otherwise wouldn't be. I mentioned this before, but your endoscopy staff, really, you should work with a dedicated staff who gets training, not only from industry for their specific equipment, but also by you, just in terms of what are the diseases we're treating, what are the indications, what are the goals of the procedure that we're doing, and you find that the staff around you really gets invested in the procedure, and they want to help make it go faster and for you to be more successful, and that can really make a difference, particularly when you're dealing with adverse events. And then having a dedicated post-procedure and admission protocols, such as, for example, keeping patients in the hospital overnight to do an esophagram for a POEM versus same-day discharge, it's important to start to develop these protocols. As I mentioned, for coding and billing, right now, finally, POEM does have a CPT code, although there are people who aren't that happy about this, because one of the things you can do is to work with your administrators to come up with surgically equivalent RVUs, which were quite high before we had the CPT code, but it's just important to be aware of this as you're starting to this field. So I would say if you have passion, but you don't have a team, don't start this yet. Make sure that you build that team around you and it's in place. If you have passion, but there's no patients to treat, wait. Start to build that up and maybe group them together or start once you have a number of patients ready. The infrastructure will come if you can offer everything else, but if you don't have a team and an infrastructure, maybe go somewhere where they do, or if you've trained in this and you wanna get a job, find a place that specifically has all of those requirements. I'm just actually gonna touch on training because I think we don't have dedicated training systems yet but there's a big difference between the Eastern and Western training systems in the West, or sorry, in the East, it's a master-apprentice model. They spend years doing this and they dedicate upper versus lower. It's a lot of observation and then starting step-by-step in supervised cases. In the West, we realize that this is not as feasible, certainly if you're starting after fellowship. So there have been some attempts to try to really create programs where you establish your expertise in EMR, this is done during fellowship, for example, or in practice, and then do your own self-study of the field and didactics, participate in dedicated training courses of which there are a few around the country, and then have hands-on training in ex vivo and in vivo models, observe live cases with preceptors, as well as use videos, and then start in on human cases, usually with a preceptor. And there are some outcomes we can look for, although again, these are changing. And the ESGE similarly offers a curriculum for that, but they all really are centered around the same thing. Start with a background of really knowing resection techniques, for example, if you're talking about ESD, move to ex vivo and in vivo models with your own training in terms of theory and stuff like that, and then you move to supervised live cases. And the ESG in 2021 also created a core curriculum, again, touching on all of these aspects. And I would definitely recommend taking a look at those. Again, how do we put this all together dealing with training now, and especially when we still, our advanced fellows, for example, have to go through all the rest of advanced endoscopy training. Well, Dennis Yang and a group have kind of, are trying to develop perhaps a model for how we can do this in fellowship for those fellows who are interested with different phases, including formal didactic training, hands-on training, and live cases with proctorship. And I think this is all in development, but hopefully we will have some more established curriculum to come. And then we have to remember that this is a virtual world, and a lot of this can be done virtually. I would definitely recommend watching courses, virtual courses, and checking out online libraries. I mean, even virtually, as you start to get into the field, you can do FaceTime proctoring and recording and reviewing other, your own procedures with other people. So in terms of my own journey, I will say, you know, one of my, sort of one of my biggest achievements I feel like has been able to perform POM at a live endoscopy courses all over the world. Most recently, ASGE's post-grad course, I mean, sorry, ASGE's live endoscopy course at DDW, as well as in Hyderabad, or image in Milan. And then also being able to give the privilege of opportunities like editing, you know, the updates by Charlie, by Dr. Lightdale, it was really an honor for me, and also, you know, made me realize where I am in this field. But how did I get there? I think I followed what I just mentioned as the training pattern, but more, probably more abbreviated. So I was an advanced endoscopy fellow in Denver, Colorado, when Noroi Fukami was there, and was really starting ESD in this country. And so I really thought I would consider as my time of observership and understanding what ESD was and understanding the value of it, and really starting to create a passion for me that knew that it was something I wanted to do. I then did some ex vivo and in vivo training in both ESD and POM at the same time, both at my own institution and at other facilities internationally. And then when I was finally ready to start cases, I actually brought my mentor Norio to Proctor. I grouped cases together and he was able to help me, and I could get him privileges to do that. And then as I went on to do them on my own, like I said, I FaceTimed if there were questions, or I just wanted some guidance. And then the same thing was true for POM. I also had the privilege of being invited to serve as faculty for ESD and POM courses. And for me, this was actually ongoing training and something I would say for anyone who gets into this field or who's already started is to always be open and learning from others and the experiences when you're teaching others, you get the opportunity to really stand by these masters and learn from them. And the field is constantly evolving as well as giving back and precepting. So these are various advanced endoscopy fellows who all watched and observed during their fellowship, participated in some animal labs, and then went on to start their own process and participate in courses and finally do their own cases. And I was able to come and Proctor them as I was Proctored, and that was really meaningful to me. And also I got an award and I was able to sort of do a little bit more observership. And this was after I've started, so I could go and learn some new techniques with the masters and that was really special. So that's really how I think I got in there. I would say tips, again, understand those principles, indications, and assessments, and make that commitment to training if you're gonna get into this as well as the other components that I mentioned. Always kind of self-assess and track your outcomes. Make sure you have a comprehensive team in place and ensure that you have all the resources and facilities and make sure that you're engaging your entire team in training. Always participate in ongoing learning. And I would say, remain really humbled no matter how many years and cases you have under your belt, things are always gonna be kind of more difficult. I think if you love it, nothing will be too difficult, but it's always important to remain humble. These are some future training options that are coming up for any of those. Any of you who are interested at the end of April in Houston at ASGE IT&T, we're gonna have the advanced ESD course. And then finally in December, there'll be a third space endoscopy course in Orlando. Thank you. Thank you so much, Dr. Sethi for sharing your journey and roadmap to learning third space endoscopy and incorporating it in practice and finally finding your zen in endoscopy. I'll hand over to Dr. Advani to introduce our fourth panelist. Thank you. I have the pleasure and honor of introducing Dr. Simon Lowe. Dr. Lowe received his MD from NYU and completed internal medicine residency at UCLA and GI fellowship at UCLA. He was later trained in biliary endoscopy under Dr. Keyes-Hybrexa at AMC in Amsterdam. He has been a full-time GI faculty member at Cedars-Sinai Medical Center since 2000. During these 22 years, he has built a large interventional gastroenterology and small bowel group that now consists of eight physicians, a NIH pancreas research center and a donor funded pancreatic disease research program. He has trained over 20 GI interventional fellows and mentored multiple international clinical scientists. Dr. Lowe is one of the very few endoscopy experts with proficiency in a wide range of endoscopy, including pancreatic biliary endoscopy, interventional EUS, third space procedures and endoscopies. He has pioneered many endoscopic techniques in ERCP and endoscopy and experimental innovations. His current clinical practice focuses on the management of pancreatitis and pancreatic cancer. He has published over 150 papers and delivered numerous lectures internationally. He is the founder and has been a co-director of the renowned Cedars-Sinai International Endoscopy Symposium for nearly 30 years. He is the director of Cedars-Sinai Department of Medicine's pancreatic disease program and head of its interventional gastroenterology group. He's the holder of the F. Widjaja Family Endowed Chair in Digestive Disease at Cedars-Sinai Medical Center and a clinical professor of medicine at both Cedars-Sinai and the David Geffen School of Medicine at UCLA. In 2022, ASGE presented the Distinguished Educator Award to Dr. Simon Lowe. Thank you. Well, thank you very much. I hope you can hear and see me here. And I'm gonna stop talking about this topic on developing a niche in interventional pancreatology and pancreatic diseases. My talk consists on three areas. One is why do interventionists need to acquire new skills, which is in keeping with their main topic? And what does it take to become a pancreatologist and how to practice pancreatology as a interventionalist? So I'll start with something way back since I'm the old guy here. And I was a fellow in the mid 1980s and the interventional endoscopy field that's really interesting. It's very minor stuff that you can define today. And most of it were in esophageal obstruction type problems, foreign body removal, hemostasis, sclerotherapy was very big at that time. ERCP was hot, but practiced by very few people. Laser endoscopy was thought to be a big deal in coming from that time on for treatment of tumor destruction and GI bleeding. But very few people were able to practice it because it was very expensive to afford these laser endoscopy equipments. The Guerin and Guerin started a gastric balloon for weight reduction, and they're mostly practiced by field endoscopists and mostly in the private practice world at that time. So fast forward to today, if you look at the same list that I listed, most of them were crossed off or in great shape because they are no longer considered a major interventional procedures. The only thing that kind of stand by itself is the ERCP that's still practiced by the best of the best interventionalists, but also in the community by the general gastroenterologist. The bariatric balloon was interesting. I thought that it was done and dead for about 25 years, and now it's been resurfacing. We don't know yet what the future is for this technology, but it's here at this point. And of course, there's now a new list of things that's been talked about earlier by the other speakers, EUS, the space endoscopy, bariatric endoscopy, and anti-reflux procedures. So it's really interesting. We all talked about how we get to do what we are doing. I think that I'm gonna show you a little bit also. As a fellow at that time in the mid 80s, we learned basic ERCPs and some of the simple GI interventions that I just mentioned about. And then over the last 30 some years from that time to even pre-pandemic time, I was still learning new things. There's a whole list of them. Now, some of them by formal training, like in Amsterdam, or some of them were informal by practicing with partners, and some were by research, and others I just acquired a variety of different things. And in the middle of my interventional career, I actually inserted capsule endoscopy and balloon endoscopy, which is really unusual for interventionalists to do, but nonetheless, that's my passion as well for small bowel diseases. So, but not all these new skills that I acquired over the years are really useful or can be incorporated in our current practice. You can see that in black are still the type of procedures I'm still performing, and in gray are things that are either not being done or still in developmental stage or still being researched at this point. So, what I'm trying to show you is that within the interventional endoscopy field, technology is constantly changing and expanding, and they are highly unpredictable. You really don't know what is gonna happen to them, and some may vanish with time, and others rarely become constantly in demand. So, you can learn something and think that you're going to be good at, for instance, sort of the space procedure, bariatric procedures, never know what's gonna be happening tomorrow where it's still being used for patients. So, and on the other hand, when the technology occasionally get widely adapted, then become no longer a part of your calling card or make you special and may become just part of a general GI procedures. So, if you really want to become and maintain your relevancy, be prepared to learn more, do more, and be prepared to evolve with time. So, let's switch to the practice of pancreatology and who are the practitioners? And really, there isn't any, like the other speakers talked about, that the field that they got into, there's really no particular requirement. You can be a general gastroenterologist, you can be fellowship, there's a new crop of fellowship trained pancreatologists, and then you have other people and the sonographer interventionalists, and don't forget our general surgeons, especially HPB surgeons. There are a lot of them who may not call themselves pancreatologists, but they actually operate on a lot of patients with pancreatic diseases. And now there's also unique pancreatic transplant surgeons and transplant pancreatologists, and even endocrinologists in the picture. Now, not all of these people, as I mentioned, devote all the time to daily practice of pancreatic diseases situation. So, I'm just guessing, just kind of giving you a ballpark of what I just envision is, if you are a fellowship trained pancreatologist, that means that you're really dedicated to that, you want to commit yourself, so you're probably going to spend 90% of your time seeing these patients. If you're an endocrinographer, by virtue of the work that you do, most likely you'll spend, oh, maybe 30, 40% of your time on pancreatic-related patients and so forth. And then even if you're an endocrinologist, you're going to see a few patients who have chronic pancreatitis, who have diabetes and who need your care. So, how do you get training? It's really hard to pick up both the technical skills and the management skill in a short time. You know, I find other fellows getting more and more impatient these days. I'm sure that some of you in the audience are like that, and you want to compress to the shortest amount of time and learning the most amount of things. But the reality is, it's very hard to do. So, in order to cram all this thing together, it's probably best for you to train and learn in a hospital environment because it can't train the patients in the hospital. And you need to have these best-worth multidisciplinary teams that you've heard quite a bit, and it's no different for pancreatology practice. And you need that type of service. And also, of course, you need a high-volume patient group within the hospital. But on the other hand, the management of patients with pancreas issues in outpatient is very, very different. They're not peculiarly ill. They come back with the same problem over and over again. So, their management is very different. They have a lot of pain, and so you need to learn how to manage them. So, it's really important that you also acquire a knowledge and skill set in the outpatient environment. So, now, the excellent place for you, if you're really dedicated, like mentioned before, if you're passionate about pancreatic diseases, you may be interested in some of this emerging medical pancreatology fellowship. There are at least seven of them. We are just starting one within the next few months. And there are a lot of established ones, like Mayo Clinic, for instance, that have training for fellows a long time. And how about learning a technical training aspect with a focus on the pancreas? Now, in general, most of the interventional training programs offer a very solid basic training in US. So, you probably will automatically learn a lot on the basic knowledge of managing patients with pancreas problem. Now, but not all of these US training programs or interventional programs have really high-tech, high-fashioned US interventions, such as suicide drainage, gallbladder stenting, and necrosectomy, et cetera. And so, you need to find this program if you are interested in taking the next step. And for sure, ERCP is an integral part in if you want to learn intervention in pancreas, but most of the programs are not really uniquely concentrating in this type of patients. So, you have to know what type of training program there are. And there are also different levels of observation and hands-on involvement in this procedures. And so, please make sure that you choose wisely when you are, if you're in this stage of learning as a fellow, but if you're not, if you want to learn something on the job, then you have to know how to partner or join a group that has a lot of this type of procedures expertise. How about a practice of interventional pancreatology? Well, my feeling is that if you use EUS as your calling card and enter a pancreatologist through it, the door is wide open. And there are actually a lot of medical pancreatologists who like to manage the medical aspect of pancreatitis and pancreatic cancer patients, but they use EUS to help themselves with some kind of technical expertise. So, some use that to just assess pancreatic cysts, other looking for diagnosis of pancreatic cancers. But the paths to do pancreatology through intervention with ERCP is a lot more treacherous because a lot more risky and require a lot more skills. So, you really have to equip yourself with that and do so carefully. And if you want to practice a consultative medical pancreatology is really highly valued. And a lot of hospitals would love to, a lot of medical colleagues would love to have you to manage and consult on their patients with pancreatitis. And pancreatic clinic is another way of practicing and have an enduring practice. Also that you can use it to enhance your referral to get your technical referral patients as well. And if you're interested, that there's another clinic that you really want, can establish some kind of a high-risk pancreatic cancer clinic. This like a unique group of clinic and patients. So, they're quite emotional in this situation. So, you may not want to do that unless you're really prepared for that. And so, if you practice pancreatology mainly by doing interventions, Be sure you partner with a very thoughtful and, and a skillful pancreatic surgeon. Because you're going to need them to help you up and obviously you also need patients from them. Well, one thing about pancreatology or pancreatic intervention is that not all the symptoms. The science I think pancreatic diseases are pancreatic related, and not all the procedures you do in the pancreas are going to bring about good outcomes And, and just because you see something on scans and images doesn't mean that you need to do something with endoscopy or with the LCP so, but I know a lot of people who think that they can do the LCP and do it well and it's a kept doing procedures and that's not always the best thing for this group of patient, and for yourself. And for sure, just like Amrita were talking about you, you need to take good care of your patient during the procedure but also manage them after procedure, these patients need a lot of care you know and make sure that you give them IV hydration stop. Don't start them on peel right away and, and know when they get complications and follow them carefully. And certainly you should not do some of these more invasive procedure, or technically demanding procedures like minor synchrony canulations pancreatic rendezvous procedures or pancreatoscopies because they're high risk and require a lot of skills so you need to have the right required skill in order to do that. It is a known knowledge and and and it's a requirement that you're going to have complications and when you do a lot of pancreatic procedures, and some of them may lead to even death, or major prolonged hospitalization so if you are is a fine balance between knowing that you're going to have some problems, and, and just follow through with it all the continuously and all versus stopping it and learning. Sometimes just need to take a pause and make sure that you're doing the right thing and and question yourself whether you're doing the right thing for the patients. And then, once you know how to figure out how to resolve this problem that you can resume. But just be careful. So a few tips and cautions about interventional pancreatology, and it is a risky proceed with field and. And so you need to make sure that you always wait the pros and cons before you do anything. There are different levels of pancreatic technical expertise and and if you want to reach the highest level and practice at the highest level is very stressful, and you need to know if you're ready for those stress. Now it is not some advisable to just simply do procedures. There are some practice that people simply just do procedures and not manage the patients I don't recommend it, especially when you're dealing with pancreatic diseases. And one thing if you have a outpatient practice, you need to learn pain management and learn well. But you should not want to become a pain doctor so you have to set limits for yourself and for your patients. These patients are frequently have a lot of expectation that may not be realistic, even for yourself you may not have a realistic expectation expectation. What you can do for these patients so you need to make sure that you, you, you educate and manage the patient's expectation and make sure that you think about these things before you offer any invasive procedures. Now, now most of these patients have a lot of fear, and a lot of needs, and you need to be sympathetic empathetic with them, and a good listener and good educator. So in conclusion, medical pancreatology is a new and evolving field is a great place to enter and therapeutic endoscopies have a lot of skills set to offer these patients and, and a very valuable but you need to choose the patient as well, and and not just try to do procedures on these patients, and it's not hard to develop a niche in interventional pancreatology, and it's just as simple as starting just offering us service and offering and consultative services in the hospital, or in a clinical setting, and you just evolve over time and become better and better at it. And with that, that's the end of my talk. Thank you very much. Thank you Dr low for your expert opinion, it has been an honor hearing from someone who has had the level of skill and expertise such as yourself, treating pancreatic diseases require many important factors but under mainly understanding how to treat, not just the structural component, but the patients as a whole is an important takeaway from your talk. I'm going to open it up for question and answer section of the of this session. Shall we start. Dr. Yes. Okay. This was directly from one of the attendees. This is a question for Dr saying, when do you envision large scale insurance approval for ESG. When will happen and what are the barriers. Is there not enough data is there issues with the device. Do you see this procedure as a procedure of choice or an alternatives to surgical procedures in the future. So the first question was, when do you envision large scale insurance approval. So the CPT code so for bariatric endoscopic procedure gastric balloon is one of the oldest therapies and CPT code for gastric balloon with Medicare our views and all that came came out this year. So, working with insurances and getting approval is in place, and like with other procedure people were not happy about the RV use and the reimbursement for the gastric balloon some people are just happy if they have the volumes doing these procedures for self I don't have a time period, but it can take anywhere from three to 10 years when sleeve laparoscopic sleeve gastrectomy came out it was being performed for at least 10 years before it actually got approved with insurance. What are the barriers I think the biggest barriers, the biggest barrier is that the insurance companies don't want to pay for anything. And I think second is, we need more data we have one level one randomized control trial the merit trial that came out for endoscopic sleeve gastroplasty. So we need more and more data to support it, we need more and more collaborative efforts to kind of work with the insurance device problems or devices are being improved. And there are more and more new devices which are in the market, especially for the gastro plastic procedure. I think this this procedure, we have 40% of our population, which is obese so there is there is a very large number of patients. It's kind of an alternatives will pay patient will prefer, they can tell that they want the surgery they want the endoscopic procedure, or they're going to go for medication so I think it kind of more dictated by by the patient choices. I know practices there's a bariatric surgery practice and there is a endoscopy bariatric endoscopies bariatric surgeon who perform these in large scale so their practice is for with the ESG and the bariatric surgeries. So I think it's going to be where patients will have all the alternatives and they can make their choices so it's not going to be one or the other. Thank you so much for that. And I'm going to move to the next question for any of the panelists and we can move from Dr low backwards but what do you see in the future of the subspecialty of your GI practice, and do you see any new technology or innovation on the horizon. So my answer first. You for 35 plus years I guess I can say it's totally unpredictable. Just when you think that you need something, something it's going to be the next big thing is not going to happen. For example, is timing is everything right. I always like to, to refer to 1990 when Eli knew, Lily, just invented the new also dial to the south coast on they thought they dream of millions and millions of patients around the world, needing a whole treatment of medications, and lo and behold, on the other side of the continent, there is someone, some country doctors started doing laparoscopy and and took out all the gallbladder, and then within within months, the medication went away. So, I don't know if any of the panelists know, let me know. Thank you so much. I don't know if any other panelists would like to add any comments here. I'll say for, you know, for USD and third space. We obviously understand the value of traction so platforms that allow just more accessibility and use of different instruments and really why create sort of a, an OR type feeling where you can, you know, you're not limited by the motion of your scope, those I think AI actually we're, we're hoping can help streamline, not only training but you know which lesions and then also understand like during techniques themselves I think that's coming robotics I think is another area. All of this will somewhat depend on how willing, we are to adapt on a large scale. And then also, you know, again with reimbursement and and industries investments as well so a lot of work's being done in it but I think those are some, some things to look forward to. I think for me, since I started there has been a lot of changes and interventional us is really exciting with lumen opposing metal strength so I think he was guided that therapeutics Dr. talked about I don't know if they are gonna come back with third space definitely traction devices. I think procedures are complex so I something which can make these procedures, simpler and, and they can have a wider applicability endoscopic and within the bariatric endoscopy I think we have been focusing more on gastroplasty devices. We're working on trials with the journal mucosal resurfacing and there is a potential devices, which can work in the small intestine, whether these are magnets, or these are some kind of ablative therapies so that has been used and I think outcomes are looking good for metabolic therapy so I think if that comes out I think then endoscopist will be involved in treatment for diabetes so I think that might that might be a huge breakthrough for AI though what I can say is we are in the middle of a big storm. If anybody is following AI literature these days that keeping up with those foundational models and how what they're doing is going at a ridiculous pace in the last few months. But what I can say is if you zoom out of gastroenterology and just look at medicine in general, we will be several applications already working on drug discovery. We are finding new ways of doing clinical trials you know of course your computer vision trying to detect anything. It's no code. These days, and I'll be digging into your unstructured data trying to dig different things so I think there will be a huge wave of a lot of useless products in the market in the next few years but also very important ones. So I feel like as medical personnel, we need to know how these technologies work so that we can adapt them in our clinical practice, as well as bet which ones are the ones that need to be in our practice so I think that will. It's a big way of coming. Dr Sethi this question maybe for you. So do you recommend a certain like stepwise approach to incorporating third space procedures in your practice like either to start with form or ESD first, and then have you in your, in your personal practice did you face any like institutional barriers that you would like to share with the audience. I think, I think, starting with ESD is better because you really sort of understand the fundamentals of working in that space understanding the planes, use of your instruments, a lot of people will say that it's easier to do poem, because maybe it's the refinement is not necessarily there you know you can neck muscle it's that's you're going to be cutting it anyways you're going straight in a straight line you don't have to really think too much about it. But I think if you spend the time and really learn ESD first poem will come very easily to you and, you know, be less stressful. In terms of how to start an ESD I think it's well known that starting in the stomach particularly in the body and areas where you have a lot of space, or the, or the better lesions to start with, obviously smaller first and then get larger. Moving to the colon. And in terms of institutional barriers I think, you know, to a certain extent, I really, I was very very lucky that I had, I had surgeon surgical colleagues who were very interested in being a part of this and we started a gastric tumor board we started a gastric cancer outreach program. on what we each had to offer that, you know, could or were new developments in the field. I think probably the biggest limitations come down to when you're in procedures and you're taking a lot longer than you expected to and, you know, nurses are having to stay over time and not necessarily the ones in the room who are with you. And so I think that if you can get them invested in what you're doing they really become proud of it they become part of the procedure they want to help you make it work but people who are staying outside who know they're going to have to wait, wait, long hours and recover patients, you know, maybe not, they don't quite get it and so I think finding ways to work with them, thinking being conscientious about your schedule and your skills and not being too overconfident that you're going to finish that way can be critical but at the same time, you know, you have to stand up for what you do and the fact that there are going to be variations in your procedures when you have complications and you are sending a patient to the OR you're sending a patient to the ICU, you know, you can't feel defensive and you can't feel like, you know, you owe somebody to take help you take care of everything it's part of the process and everybody who participates kind of needs to know that. And, you know, I think that if you work collaboratively with them and ultimately show people the benefit of what you do, like saving a patient from having to go to the OR for surgery, you know, that that value will will start to speak for itself. Thank you. I think in the interest of time, this will be the last question. So, I think all of you shared, and probably agree with that learning any new skill takes a certain amount of time and time away from your clinical work as well. How have you, how have you guys manage that as, as like busy faculty or early career physicians and how have you financially supported yourself through this training process, whether it's by like you know from society support or industrial collaboration. Whoever wants to start first. I can start. There is, you know, when I started, there's no support it's my personal time. I used to work for full clinical days and then my day off I would work on my research, collaborate with different people. And what I brought to the table was domain expertise so you try to understand you need to do your homework, whatever it is, whether it's cognitive abilities or your skills. And then you build on it, be consistent, there'll be a lot of disappointments because you are nobody. You start as a nobody and you slowly, you know, consistently develop that expertise and there's a lot to learn. So I think that kind of principles as Dr safety also mentioned being humble trying to know what's out there, trying to find the opportunities trying to find the right mentors, trying to find the right people to collaborate with. Those are all important steps as you start any kind of new practice, whether it's cognitive or skill based. Yeah, I think when a couple things, you know, you definitely like, like I said, you want to really be aware of limitations and be humble about the time so if you are going to do an ESD procedure, save yourself the afternoon don't book cases after that if you're just starting. My partner was starting his practice and he so he would book it cases specifically on days when I was there so in case there was, you know, difficulties or to be able to provide some preceptorship that was available in terms of financial. I think, you know, again working with your administrator especially for things that are unlisted and don't have codes is really important and that's in the academic setting I can't really speak to more private practices. And the one other thing I was going to add, sir I should have said before was like, I think it's if you're developing a new practice, it's not a good thing to start like the first place you go to like when you first get there, because what you want to do is establish your name in those things that you're really good at so people see you and they see your skills they see your efficiency, they have trust in you, they see that your innovation and so when you offer something new. They're more inclined to believe in you and make it an easier process for you, whether it's giving you time as an institution financially to either go and do the training and understanding that you're going to pick something up and and bring back value, or you know making it available financially with you know our view accommodations stuff like that. Yeah, I think that you have to be in an environment that allows you to do things without a whole lot of pressure on you, whether it is your, your superior your institution administrator allowed you to do things without putting a lot of pressure on your, on or if you're working like I did initially in a county hospital where I was practically working for free. So no one is bothering me for doing things that I want to do is actually a lot of fun. So you, if you're working like a VA hospital or county hospital that tend to be able to allow you to be a little bit more free in in in wandering into different new things. Yeah, I agree. I think I'm a tourist right that if you're in a more traditional practice setting, you really want to establish your, your skill set for something that you're really good at, and that people trust you have really, at least for the first couple of years, and after that they'll give you give you a leeway to do other things. I agree. I think starting small and kind of building up your skill set, focusing on bring developing a program, you know, starting without good outpatient program follow up. That is really important. And I think, showing your value in the work you are doing, and the stators are always interested in that. And I think looking for mentorship so even you're going to take a difficult case always, you know, you can talk to your mentors, get some ideas and get their guidance and see how should you should approach those cases. Thank you so much. I think with this with these final remarks will conclude our session. Thank you so much to all our faculty experts for joining us today and and sharing all the right insight and take Thank you everyone for logging in. Thank you so much. Thank you. Thank you. Bye bye. Thank you to all our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASG educational events registration is open. Visit the website for a complete lineup of 2023 events and to register. session on management of pancreatic cysts will take place on Thursday, May 11 from 737 to 830pm Central Time, presented by Dr. Vanessa shammy from the University of Virginia. At the conclusion of this webinar you will receive a short survey, and we would appreciate your feedback. In closing, thank you again to all our panelists and moderators for this excellent presentation, and thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a good night.

third space endoscopy skills

GI practice

dedicated training

complications

multidisciplinary team

educating general GIs

interventional gastroenterology

pancreatology

bariatric procedures

sedation protocols

coding

stepwise training approach

AI