Thank you once again for the opportunity to give this talk on setting up an ESD practice, what to do and what not to do. And I want to make this interactive and actually get some opinions from our other Western endoscopists of sort of what they've gone through and what's worked for them. Here are my relevant disclosures. And I would say the same way that you're giving time, care, and attention to learning the ESD technique. You have to give that same care, time, and attention to setting up your ESD or endo-oncology practice. I think there are three main areas that you need to concentrate on. One is your endoscopy suite with your techs, your nurses, and your anesthesia, your hospital, which includes your surgeons, your oncologists, your tumor board, and your administrators, and your region, where your referrals are going to be coming from. So I'll start off with the endoscopy suite because I think this is something that goes wrong for many people, and it goes wrong early when they start ESD. And I've sort of heard this same story now from multiple people starting ESD in the West. They're eager to get started. They get a lesion that's sent to them that's large, tattooed, and has high-grade dysplasia or cancer, so they want to get the patient in early. So they add it on to an already full endoschedule. They start the case at 5 p.m. At this point, the nurses don't know what they're about to get into. Anesthesia is like, what's going on? And you're there, they're there just struggling, trying to get this case, kind of raging against the system to get it done. Before you know it, it's 11 p.m., anesthesia has stopped the case, you can no longer continue, the case is a failure. And the next day when you come into work, the conversation is like, oh my God, I can't believe this guy did a six-hour case, he's keeping everybody late, he wasn't even successful at the end. We've had two stories where anesthesia and nurse managers have actually gone to leadership and stopped these physicians from performing ESD. So that is not how you want to start. You want to control the narrative. Don't start with a big, complex lesion late in the day. The truth is our endoscopy suites in the West are used to fast turnaround procedures. That's what they're built around. Our anesthesia expects it, our nurses expect it. They're very different than the staffing in the OR, where if a case goes to seven, eight hours, nobody blinks an eye. Support comes in and helps you for that case. So one of the ways I think you can, this is how we did it, right? We really worked on building a team around our ESD procedures. We got our nurses involved. They actually attend some of our tumor boards. They understand why these patients are undergoing those cases. We've taken them and showed them esophagectomy, so they understand what a patient would go through if we fail esophageal ESD. In a way, they feel vested in this patient's outcome. Not only is their success dependent on us, but they feel that they're contributing to it. We talked to our anesthesiologists beforehand and explained to them why we're doing these longer or more complex procedures. So control that narrative and really take a team approach. That's what's worked for me. Also start small, start easy, and start early. It's very easy to adapt to a more difficult procedure. If you have a perforation, you need a closure, you have to adapt to something if you're starting it early in the morning rather than later in the day. And also, it's good to talk to anesthesia beforehand and set up some routine that how you do these cases. For me, we just make a standard protocol. My first three cases in the day are my resection procedures. We come in, and I do a lot of upper tract resection, and anesthesia knows that all these patients are going to get endotracheal intubation and general anesthesia, and that's sort of the protocol that we have moving forward. But I also want to hear from Norio, Adam, Robert. What are your experiences with your endoscopy suites with your ESD practice? Yeah, I think you brought up a lot of excellent points. So I think in the beginning, it's quite challenging. I've had former fellows that have gotten trained and came back and tried to fit this into a busy schedule, and it didn't work. So when I first started, I scheduled cases for five hours, and many of them took five hours. Because in Japan, they'll book four hours for a case, and they're exceptionally experienced. So five hours, and then over time, they get shorter and shorter and shorter, four hours, three hours. Now I book them typically two hours. But you have to give yourself that ability and start the first thing in the morning when everyone is fresh. The worst thing you can do is, like you said, start them at five o'clock. Some people do that because they're like, well, it doesn't matter when I finish. Well, I mean, your staff cares, your anesthesia colleagues care. So you're right. I think you want to set yourself up for success, and you want to start with things that look that they can be feasibly accomplished. So my experience, I was really, when I went back from Japan, I was like, I want to start right away. But I basically spent the first six months when I came back in terms of doing talks for the nurses, talks for the surgeons, talks to the periphery, and building a relationship and building support, and going to the surgeons' rounds, like their own specific rounds, and just building a relationship before I started. And I found that very, very helpful because from the very beginning, they're on my side. I was frustrated because I wanted to start right away, but in the end, I really thought that was one of the most important things because they helped me a lot in terms of supporting me, the resources. And in Canada, that's a big issue in terms of the resources. For example, anesthesia time. So they would give me their own anesthesia time. For patients, they would refer me because I didn't have enough anesthesia time. So I had thoracic surgeons giving me their anesthesia time, colorectal surgeons, because I built that relationship with them. So I think it's really, really important. Don't underestimate the importance of building that relationship with them and getting them on your side well beforehand. I echo what's being said. I had a different experience because my ESD was started way, way before. Initially, I did the one ESD, went super well, and that's too confident. I went back. I mean, the first one was in OR. Second one, I brought into the endoscopy suite. During the gastric ESD, there's a perforation I couldn't complete. A patient was admitted. It was really a disaster. So there's no need to be overconfident. I recommend stagger several cases in a day and no other scheduled procedures. If you're being late, you're being in a hurry, and you make mistakes. So you have to clear the day. One case, if you're allowed, just put one case, that would be great. But typically, that looks really bad. So you can do one case in the morning, one case in the afternoon. If there's anything, you can cancel the afternoon case. Probably that would be good practice. And set the expectation of what's going to happen. I agree. You have to talk to anesthesia colleagues. You have to talk to nursing colleagues to set the expectation. It could be a long procedure. The anesthesia can be expecting long anesthesia times so that they can prepare. Pathology is another thing. You have to be discussing how you process the specimen as well. Otherwise, they get surprised. All this pain tissue, they don't know what to do with it. So lay ground how to practice. And then get the mentor. That would be really the best if you can get the mentor at the beginning. Get the first one, two cases to have somebody to oversee, give advice, that would be the best. If you cannot get it, unfortunately, that's how it goes. But get the easy case, stagger two cases, just be done with the ESD cases. Don't put the ERCP. Don't be serving other patients. You have to focus on those success. That's the important thing. Thank you so much, guys. So the next place that you have to concentrate on once you've moved past your endoscopy suite is your hospital. And it's very important to work well with your surgical and oncology colleagues. And I think there's a lot of misconceptions in the hospital system about what endoscopic resection is, what we can potentially do, and what our outcomes are. I know for me, there was actually a lot of trepidation from both cardiothoracic surgery and surgery about me starting my ESD program. And when we were started, I was frankly told that they would not give me surgical backup if I perforated because they were so scared I was going to take surgical volume away from them. But the truth is that an ESD program actually builds surgical volume. I would say probably about 50% of the cases of patients who come in to see me are not ESD candidates. Patients look you up. They come with their T3, T2 tumor, hoping that they can get minimally invasive therapy. But these are patients that you go on to send to your surgical colleagues. As soon as they understand that you're actually sending them cases and helping them build their program, I think that tune really changes. And they really come on board for these ESD programs. And I collaborate very closely with them. And I would say probably now one third of my referrals actually come from cardiothoracic surgeons wondering if I would be able to do a staging ESD and a marginal surgical candidate, for instance. The other group that has a lot of misconceptions is oncology. I was very surprised when I started going to tumor boards. I kept hearing this line that surgery was the only curative treatment for cancer and that recurrences happen after endoscopic resection. And I think partly is they've been burned by poor endoscopic resection, piecemeal resections in the past where patients have got recurrence. So I was extremely active. I went to my tumor board. I made sure to present each of my cases that I was doing resections on, show pictures, show the pathology results, and show them the success that you're having for your patients. And before you know it, ESD becomes part of that conversation that everybody's wondering if they can get their patient in. And once again, I think a collaborative relationship with them is great. At this point, we co-collaborate a lot of patients where we'll actually do intentional non-curative resections in patients with T1B esophageal cancer where if they're not surgical candidates, they go on to get chemo-radiation or immunotherapy. It allows us to really broaden what we're able to offer. We've also started doing some post-induction therapy ESD where patients are getting chemo-radiation for a T2 tumor, can't go under surgery, and we're selectively removing some of these tumors with ESD. The other and probably one of the most important groups in the hospital to address is your administration. It is, I can't emphasize enough, is to address billing and address it early. So for us, we establish unlisted codes for our ESDs, and we use surgical counterparts to make up those costs. So partial gastrectomy or partial colectomy was the equivalent that we did for our ESD procedures. We became very involved to find out how much revenue was the hospital getting, what percentage of cases they're getting reimbursed for, and if they have issues, we want to get involved. And also make sure that it's not only the hospital that's getting the money, but you're getting the RVU credit, which is necessary. And we sort of did this very early on, and I think it really helped us because as your program grows, what's going to happen is you're going to end up doing less ERCP, less EUSs, less other complex procedures, which are now going to get replaced by ESD. So you want your administrators to be happy that your program's growing and that it's going to continue to generate money for the hospital and the endoscopy suite. So also wanted to get your guys' opinion on what was your experience with surgery, oncology, and administration while building your programs? Yeah, so if it's not in the NCCN, for some oncologists, it's not a thing. And the truth is a lot of these guidelines are biased because there's not endoscopists who perform these procedures on those committees. So it does take time. You have to show them the literature that's been established from Japan that the huge volumes that have been done that show that these patients can have curative resections and no recurrences. I'll just mention briefly on your topic right now, the unlisted codes, that could be a big issue as well. So our hospital had looked at a group of patients, and they noticed that they were getting $0 reimbursed because the insurance companies were like, there's no code for ESD. We're not going to pay these unlisted codes. But then we went and we looked at all of the cases. So 30% were not paid. They were paid zero. But the 70% that were paid were paid far more than EUS, ERCP. And we looked at like dollars per minute of time spent, and we were getting multiples. So it actually was profitable even when accounting for that. So it's really important to know these things to justify that you should be doing these procedures. In terms of the surgeons, oncologists, pathologists, I was pretty lucky in that everyone was quite supportive. I never really had any obstacles in that regard. The biggest obstacle has been in terms of funding, and it's still an ongoing thing. There's no funding for the hospitals for ESD. So they still take it as a loss. So all the ESDs are taken at a loss for the hospital, and the funding comes from the global budget. And we've written to kind of our bodies, the Cancer Care Ontario, and all the people in Canada who do ESD have signed letters and things. But they said there's no funding anytime soon for ESD. And that's kind of been the struggle in terms of with the volumes, because the hospital takes it as a loss. In terms of colleagues, in terms of remuneration for yourself, that's okay. But it's the funding of the hospital from the ministry that's been a big ongoing struggle. That's really unfortunate, because you would imagine ESD would actually be cost savings to a system, right? Compared to surgery, it's extremely cheaper. Even to EMR, if you're getting multiple reoccurrences, it's probably cheaper to have one ESD procedure versus multiple resections. So to give you an idea, for esophagectomy, our hospital gets about $60,000 from the government. For an ESD, it would just be like an EMR. So the hospital would get about $900, $1,000 or so of funding. So the hospital prefers, they don't want to say it, but prefer an esophagectomy financially versus an ESD. Yeah. So the way to, you know, esophagectomies can be done in a lot of hospitals, right? So the way that you can help build a program is that you're going to attract other patients who otherwise would not come to your facility, because they're coming for this unique procedure of ESD, right? A subset of patients are going to require surgery anyways. These surgeons would never have gotten their hands on this patient, because those procedures are already offered elsewhere. Once a patient comes into your system, they're unlikely to leave. That's interesting. One of the things we did was we tracked all that, just like you did. Like, how many of these cases are getting reimbursed? How many cases are going on towards surgery? And from a hospital standpoint, they see it as actually a growth metric for surgery and for endoscopic procedures. So they've actually given us support. We have our own schedulers. We have our own nurse practitioners to be able to grow this program. So finally, the other part that you have to take care of is your region. This is where your referrals come from. For me, I found it very difficult to just say I'm interested in ESD cases. Because I feel that you're giving the power to the referring physician to decide what needs ESD, what doesn't, and many of the times they don't know. So from my standpoint, I see everything. I have an endo-oncology practice. I will perform EMR, ESD, STIR, full thickness resection. Doesn't matter if it's early cancer, just tumor, colon polyp, amploid adenoma. Whatever the referring doctor has to send, I'll take care of it, match it up with the correct procedure. I found this has worked quite effectively because for them, they don't have to think much. It's just one call, send it to our center, and we'll get it taken care of. At the beginning, show off your beautiful work. One of the great things about ESD is it allows for these great photo opportunities where you can see these dissections. Take those pictures. Send them to your referring physicians. Let them know what the pictures are, what the pathology is, and the great outcomes that they're doing. Before you know it, that sort of snowballs and avalanches, and at this point, I would say probably 90% of my practice is endo-oncology. In general, I've found for colon polyps, they want these patients back for surveillance. I think one of their fears of always sending a patient to a tertiary center is that they'll lose them, but for cancers like esophageal or gastric cancer where the stakes are higher, they prefer for us to be able to take care of the surveillance. The other challenge that I think we all face is unfortunately in the U.S., there is a large amount of benign colon polyps that go into surgery, and that number is not getting smaller. It's actually increasing in size. Each year, there are more patients going to surgery for benign polyps. I think part of this is this sort of these referral patterns that have been set up between community GI, sending their large polyps. It's easier for them to say, oh, a gastroenterologist can't take care of this, I'm going to send you to a surgeon to take care of it, rather than sending you to an advanced endoscopist. These patterns are something I think that we have to go out and really sort of break and educate the community that we have these services for them. Thank you very much, and please let me know if you have any questions. Thank you. Thank you very much.

ESD practice

endoscopic submucosal dissection

setting up

endoscopy suite

hospital administration

referring physicians