This session is again meant to give you guys more opportunity to ask questions, to make it more interactive. We have gone through the didactics, we did the hands-on, and this is just, you know what, any more questions that popped up in your mind, how else can we help? And also questions to the faculty also, if they have any questions, advice or suggestions for our industry counterparts. So this is just more an opportunity to give you guys time to have a little bit more one on one interaction. So the floor is open. I had a question around, there was someone, Dr. Lee's talk, he was talking about altered anatomy procedures. There were two that he described that I just, I couldn't grasp like what was happening, like what was going on in the procedure. And so the first one was the EUS gastroenteroscopy, like and why you're occluding the duct before there. I didn't quite understand that. And then, or occluding the small bowel. I was curious what that is and why you're doing it. And then also you had shown an overtube device that like tightens it and then makes it looser. Could you explain just like what's, why that's needed and how it works and like what anatomically was happening that that is required? That's what I couldn't envision. This is a trait of honor student. I know you have an exam coming up. You got A++ right there. The first one is an endoscopic ultrasound guided gastroenterostomy. So with a malignancy involving the pancreas or the bile duct, you can have a gastric outlet obstruction. It's the same field where the tumor is, head of the pancreas is obstructing the duodenum. So not only do we have to open up the bowel duct, we have to make sure that the patient can eat. And if duodenum is closed, even if you open up the bowel duct, the bowel is not going anywhere. It's still pulling up there in the stomach. So the best option is open surgery. You open up and connect the, you make a big hole in the stomach and pull up the jejunum and connect them together. And that's where you get something called a gastro jejunostomy. You heard probably about Roux-en-Y gastrojejunostomy and that's what it is. So now we can use an endoscopic ultrasound, find where the jejunum is or end of duodenum is under fluoroscopy and under ultrasound guidance. And we puncture through the stomach wall into the jejunum and put a lumen opposing dumbbell shaped stent connecting the two. The stent comes in the diameter of 10, 15, or 20. 20 is just about as large as open gastrojejunostomy. So with that, you're bypassing that area that's obstructed because the duodenum head of the pancreas, the duodenum and the distal end of the stomach is obstructed. So you're going through a gastric body to jejunum. So it works better than duodenal stent because it's a healthy area. The gastric body and the jejunum are not affected by the cancer. So it lasts longer. The second question about. So the reason then that you occlude the jejunum, because that's what confused me, right? Don't you block off two parts and then fill it with contrast? Did I make that up? Oh, yeah. No, you made that up. I made that up. You made that up. But that's actually knowing something about it. That's called the EPAS system. It's invented by Dr. Itoi in Japan. They wanted to do multicenter trial in the US, including US. And Itoi and I are friends. I was asked to participate. I tried to get it through our FDA department within MD Anderson before going to FDA of USA. It got blocked. And I couldn't wait for that balloon any longer. So what that balloon does is, he's right. There are two balloons and they go down to the jejunum. And then those two balloons are filled with contrast. And in between, you're filling that space of the jejunum with water. So sort of making a football there. When the target is so big, anybody can hit it. And it's not moving either. So that's a brilliant thing. But I'm not that patient. I couldn't wait any longer. So we went freehand. We poured a lot of water into the jejunum, gave some glucagon to stop the peristalsis. And then a half a second, we got in there and put the scent in. And we've done quite a bit, a good number of those cases. And the second thing about that rigidizing the pipe. So in certain patients, colonoscopy is very, very difficult because the angle that you have to go through at the rectosigmoid turn is very tough. So this rigidizing pipe was invented for that. It's soft and flexible. But when you're toggling the tip, it becomes rigid, strengthening the rectosigmoid angle. So we're thinking, you know, post-whipple, post-whipple, whipple anatomy is you take part of the pancreas, head of the pancreas, part of the duodenum, and part of the bile duct at the cystic duct take off. And then you connect. Whenever you take off any part of your body, you use a jejunum to hook them up all together. Why? Because jejunum is about 600 centimeters long, small bowel. So you pull that up and connect to the bile duct, connect to the pancreatic duct. So you use the jejunum. So because of that man-made anatomy, going through that creates a lot of turns. So we're thinking, maybe we can use it in that anatomy also. So we tried and it worked. So we published. Did I answer your questions? Okay. Thank you. Yes. My question is more, not clinically related, but more admin related. The one thing that we all have to deal with, you know, to be proactive is the VAC committee. So my question about the VAC committee is, what is the best way, like, as sales reps or our partner physician, we could be most efficient in getting, you know, new products through VAC? Because from my experience, I always deal with two types of physicians. One, they'll say, oh, I'll put it in VAC and then after that, it's like out of my hands because they'll figure it out. Or the second one I get a lot is, well, if you want me to put it through VAC, I need to trial it. But from a tronic policy, if you want to trial it, it has to be approved through VAC so we can get it through. So it's always like a gray area and I'm stuck because I can't like just give out trunk stock. So my question is, you know, to anyone here, I know there's not one specific answer. What is the best way we can be efficient so when we roll out something that's not stuck in VAC for months and, you know, that way we can be most proactive? Well, just real quick to clarify before that, I'm not aware of any policy that says we have to be on VAC before we go through VAC. Hospital policy. So when we do... Oh, the hospital says you got to be through VAC to do it. So they want product to try it and then once they try it and say, oh, I like this, let's take it to VAC so I can like, you know, advocate for it. But our policy says we can't ship... Well, their hospital policy is we can't bring that in unless it's approved through VAC already, if that makes sense. I can take that. I actually serve as the chair for our Geisinger VAC committee system-wide for GI. I think you hit it out of hand. Every hospital is different. Every private practice, every community hospital is going to be different on what their rules are. The best way to do that, to champion it is first, find a product champion. You got to get that person to believe in the product so they could go to VAC for it because U.S. industry are not allowed to be part of those discussions because of the inherent bias for it. So if there is a physician and that person wants to trial the product, then they have to submit it. So at Geisinger, you know, they go through a process called Lumere. So they put it through Lumere and that comes on the VAC committee. Our policy is the same. Even to trial it, it has to go through VAC because it goes through a financial analysis first. If it's a product, we're not going to be able to afford or it conflicts with our contract, why even trial it? Why put all those effort to try something you won't eventually get? So for a trial, even as a trial, we put it through VAC. As the physician, when somebody comes to me, I'm like, make my life easy. So I'll always ask for like a VAC package that will have the FDA approval, if there's any studies that are done, what is the Geisinger pricing, are you going to offer free product for trial or for trial, do I need to purchase product, what is the eventual price going to be? And then all that, I just submit into VAC. Most VAC committees are now intelligent, so they have all of these new products already in the system. So if you just type it in, it'll pop up. And then also it asks, is this going to replace a product or is this just added cost? So is this A going to be better than B? What are you trying to do? Our committee, we used to meet quarterly and then it was just pages long and it was not efficient, so I made it monthly. So that's the other part you got to ask, you know, how often do you guys meet? If you just missed a meeting, your product might not come up for the next three months to discuss. So always ask, what is that process? Again, every place is going to be different. So we meet every month, and then in between those months, I do a pre-VAC eval, where I'll just skim all the requests up front and decide what's not even worth discussing. And then I'll take that off the agenda. So our now discussions are done in 30 minutes. We'll go through everything, the financial analysis is done, this is what it's going to cost, yes trial, no trial, or adoption or replacement. After that, sorry, go. I was going to say your turnaround time is 30 days. 30 days for us. And also once that goes through, for industry, always I tell them, you know, touch base with me the day before to see if I need something. Touch base with me, and we do it on Thursdays, so touch base with me on that following Monday, just to find out what happened, or if there is something I need to do. So it's making my life easier. So on Monday, I'm like, yes, we discussed it. It's going to be approved. Please connect with person so and so, or no, we need some more information. And then that just flows. That's, you know, how our system works. Has a different setup than others? Yeah, ours is different. We, Allegheny Health Center of Pittsburgh, we actually allow free trials. Because when we take the part of the VAC, one of the questions we ask is, I'm also on the VAC committee, so it's like, have you tried this product? Why is this product different than the one you're already using? And what you're going to do, that's part of our VAC questionnaire. So we do allow trial, and the trial is very systematic. In fact, your guy's next powder wasn't in trial, because we had a, you know, Olympus Predominant Contracting. So the physician who's going to trial, he's going to fill out a form after trying. It has three or four questions on it. And if, let's say, five physicians tried, and all five said, okay, this is fantastic, then only it goes to the VAC committee. If 50% of physicians said, you know, it's not too different, the Coke powder is good, or the Olympus powder is good, so then we don't worry about it taking to the VAC committee as well. We also meet once a month. I think, so, it's a very intra-institutional thing. Each institution is going to do separately as to do the trial, a free trial or not, or take it straight to VAC. Our VAC is a combined network VAC. We don't have a separate GI VAC. So it's like a once a month, two-hour blast, but a lot of the work is already done. So we don't want people to come and reject something because of a question. So we do allow the free trials. That's the same exact setup for UT as well. We do allow free trials, and we do get evaluation from multiple faculty. Do you guys feel more inclined to use a product if it is collectively utilized by your peers for new products? You speak to NexPowder, right? If you know that your colleagues are starting to use it, or it's getting more and more traction around the country, are you more inclined to try it out, or do you guys still take an individualized approach to get your own, formulate your own opinion to then take it to VAC? I think it's a little complex question because a lot of the decisions to adopt a new technology obviously rests around how it's going to benefit the patients and make our life easy. But a predominant part also comes to the rev cycle and the finances as to what our contracting is. Is the contracting 85%, 90%, 95? What are the carve-outs? Which category that product goes to? So, if you take the example of NexPowder, we already had a competing Coke and Olympus product in that market, right? So, if let's say five of my colleagues out of 40 gastroenterologists like that, Nestle won't change my decision because I'm already comfortable with something and I'm already part of that contracting. But if there is something truly that is, you know, really gonna help our patients, then even if my other colleagues don't wanna use it, but I think this can help my patient population, I will go bad for it. I'll give you a small example. I do a lot of endoscopic structure or at least in IBD patients. There's a 6% post-procedure bleed rate. And we were using a lot of clips that was not preventing the bleeding rates. Till I started using PuraStat. And I went on the mountaintop to fight for that to come into our network and I'm the only one using it. None of my colleagues use it. But it helps me with my procedure. So, I think it really depends in the end how beneficial it is to the patient and then what contracting structure that institution has. Because most of the major institutions that I know are in some form of contracting right now with one or two vendors as their primary vendors. And that kind of dictates how much can they trial out of the contract and how much can they not try. And so, to that point, how much of that battle are you guys willing to fight if you're an advocate for a product, if you think it has validity? Or do you have to bend to the financial means of the hospital? I think if the product clearly benefits the patients, we don't get too much pushback. If we clearly say this is what's happening on the ground and we need it to, you know, for our patients benefit. I personally have not had a pushback, you know, in last six years that I've been in my institution. The most common challenge comes is when there is already a competing product and a new product comes without that much of benefit. Obviously, yes, this came in 2010, this came in 14, this is slightly better than the 10 version. But how much better? Is it truly that beneficial? Is the ROI that much on this product that we're gonna make one less readmission or something like that? So I think that's the debate. But if it's clearly game changer, it's clearly something that's gonna make your patients outcomes very good. We've not got a pushback on that. And I'll just add to the specifically the clenjoscopy issue. With Boston's device already, you know, fully integrated into the system, when we first brought Microtech scope, we all liked it and wanted to just bring it in. But it wasn't an issue of the hospital necessarily opposing it. There was a legal contract issue that prevented them from, you know, moving forward. Beyond that though, hospitals, if you make, if physicians take a stand and say, this is better for the patient's sort of outcomes, they usually are supportive. But the product has to speak volumes. It's similar to what happened with the Charcor. When the FNB needles came out, you know, there were FNA needles already, but FNB was wise, Charcor was so much more improved, such an improvement and was the first one on the market that there wasn't much pushback in terms of getting those approved. So I think the product has to speak for itself and then it becomes obvious that the organizations will support them. I think more of more institutions are heading towards a preference card for the physicians for cost cutting. I think down the road in coming years, that's going to be the reality. Even now, all of us who have been in practice for a number of years, we have seen that the number of toys that we have in our toy chest are much less than we used to have before. So that luxury is slowly getting chipped away. And I assume for every procedure, common procedure that we do, for example, ERCP, number one indication is common bile duct stone or bile leak. What's my preference card? What equipment am I gonna need for that particular procedure and indication for reimbursement purposes? So I think that's where we are headed. I think that's an excellent point. We also put in preference card for our system. And that very fact that someone showed someone a product at some hospital, yeah, send five of these in, send 10 of these in. So we actually went network-wide, hospital by hospital, lab by lab to see what's sitting on the shelf already to reduce the waste. And we in tune of $2.6 million did savings last year by just cutting that waste. So now we have the preference cards. Now we have the lab. What can be ordered in this lab? Like there are places where people have ordered, for example, mentis clip. It's an expensive clip. Why do you need mentis clip at every lab? I mean, yes, it's a luxury if there's a perforation, but how many perforations happen? How many interventions you do? So we made all that analysis to make sure that not every product has to be ordered at every site. So that's where the preference card for therapeutics are separate. ASCs are separate. And that really helped us to cut the waste. Can you explain this preference card a little bit more? I'm not quite grasping it. So for example, I use a specific tome and a wire 99.9% of the times. So when you enter the lab, you'll see there's a little backboard that says kosher tome, name of the tome, kosher wire, name of the wire, kosher stent. Like nine out of 10 times, if it's a benign case, I'm gonna put a 10 by nine stent. I don't use 10 by seven stents, just preference. So like they have that preference listed out. So they know at par how many stents are there, how many need to be ordered. My partners, they use Coke tomes. I use Olympus tomes. So their preference card is made out there. My RB settings are already there, but it's already mentioned on a back page there, just in case that somebody took my RB to the OR to do a case and there's another RB, so they know what settings to put on. So stuff like that is already there, ready to use information, irrespective of the tech or the nurse. My room will be prepared accordingly. And then whatever product I have used, that has already been ordered from the pack without someone having managed to check it. So this way we have it all for therapeutic endoscopists. Simple things like, I use a lot of Pete's colonoscope for my colonoscopies. Some people use adult colonoscopes. It's already mentioned in there that if it's a stricture case, he's gonna use slim colonoscope. Non-stricture case, Pete's colonoscope. So just like that. Helps with room efficiency and then also to keep a tab who's ordering what products. So this is followed really very commonly in surgical world, where for example, if a surgeon is going to perform a laparoscopic cholecystectomy, they already know, okay, what are the equipment that will be needed for that particular case and they pull that out for that particular surgeon. And in fact, they try to standardize it across based on the disease diagnosis, not based upon the physician. That's a little bit different we are talking. Here we are talking my preference, his preference. In surgical world, it's based on the disease diagnosis. What type of surgery is going to get performed? What I'm saying is that's probably where we are headed. We will be doing, not what my preference is, this is what probably Johar likes for the CRCP. No, this is the indication and this is what I'm gonna use. Just predicated on how individualized all of these procedures are, predicated on how much gray area there is to this, does it concern you, the concept of having to all homogenize the tools that you use and the implications of that? I think I'll be unpopular for this opinion with my colleagues, but. I think I'm going to be with you. I mean, if I just wear a division chief's hat, I think it makes sense because 85 to 90% of the cases can be done with the similar equipment. There are very specific five, 10% cases that require very specialized equipment. Now you ask my partners, each one of them will say, no, this is not right. I like this clip, I like that clip. I mean, so I think at some point you have to understand is it truly making a difference at the patient level or this is just a personal preference issue. I think I'm not too worried about the homogenization part. The other thing is that we have done a multi-source contract. So we are contracted with Olympus, Coke, Microtech and Steris. So we have a lot of option to choose from already. But if you're one source vendor contract, I can see some limitations there. But these days, most of the companies carries most of the basic products that you need to take care of your patients barring those five to 10%. So it's not as bad in concept. But I don't know. I think we are, you know, to counter that, we are a one source primary Boston contract, right? But again, there is some flexibility and that's where you gotta pick your battles. Like what are you gonna go to bat for? You know, that 15% cleaver, you wanna use that wisely. You can't have every clip, 10 different sizes, every guide wire, 10 different types, right? I mean, as Simran said, for the most part, so we started something similar called the Waste Warrior Project is to reduce that redundancy. The other piece that the supply chain loved is this list product they have to carry and maintain parts for. So we have something called the clamber. Geisinger has a storage facility where we keep two years worth of product across the system. If something goes out of stock, we never feel the backlog. Now that place carries a huge volume. Now imagine keeping 10 different wires in huge volumes. It doesn't work. So for the most part, we consolidate into what everybody's gonna use. And then little things like fiducial, when Boston has fiducials, but we said we are gonna use a preloaded fiducial. So we went to bat for the Medtronic FNF system. It has pre... So, you know, there are certain things you can make an easy case for is that's gonna add more time. You know, this works better. Yes, that's platinum, but this is preloaded or if it's a cook system, whatever it is. So certain products you can pick and choose, but again, we do it democratically. So at the back committee, every month I pick one product or a guide wires. Everybody, all the advanced and all space get together and democratically decide together what are the number one and then one backup, but we can't have five backups. And then everybody's then has skin in the game. So then it's not me dictating or the system dictating what you're gonna use. We all decided as a group. So then I can hold them accountable for it. Like, come on, we said we're gonna use A and B. We don't need CDEF. So I think that's some of the things that you can pick and choose. So I'm gonna differ here a bit because I think there are situations where two wires aren't enough. And I know it's just an analogy, but I think it depends on the practice pattern. It depends on what your practice is meant to be and you want it to be. If you want to say that you want to be the center where all complex ERCP needs to be done or can be done and is being offered, then by definition, we will have to have some of those niche elements, even if they're in small quantities because there are times when only a specific wire will work. So I think as physicians too, we can't get too caught up in the corporate world because that's gonna, the pressures are always gonna be on us. You need to cut down on cost. But when you put the patient in front of you and you know that there's a certain wire that works and I only need it 5% of the time or there's a certain angioplasty balloon that I don't ever need except for these five cases a year, we will have to push back a bit and say to them, I understand you are watching your bottom line here, but we need to have these devices for those certain situations where we need to take care of the patients. So I don't think there's any harm in us being non-wasteful, which is what you're suggesting by limiting. We have a lot of waste because we have too much, but I think there'll still be some low utilization items that we must carry. Otherwise, we'll be stuck in situations where you know what, now we'll bring the patient back on a different day and we'll get that special order going. So I think we'll have to find that balance, which is always going to be a tug of war. I think what we do is to make sure that we also say we have everything on the shelf because good endoscopy center, ideal good endoscopy center, we have everything for good patient care, but we evaluate our PARs every quarterly. That means every device has a PAR. That means six and 10, 10 and 20, and you guys know how the contract works and everything. So we look at it, which one was used and which is being underutilized. If something is very underutilized, we go decrease the PAR on that thing. Then again, in next quarter, we go back and check in our VAC committee. And our VAC is a little different because we have separated out our VAC from the central VAC. So this is only GI VAC committee. So everything is focused on us. So if we need anything, it can be done very quickly. So next quarter we go in and again, look all those products and everything. Is the PAR still the same or it was ordered more than which it should have been because we went down on PAR. If it is not and still underutilized, we again go further down to the point of the elimination that means this is a wasteful thing, which we are not using it. And if somebody uses it, what we do is we keep one of that so that we don't completely eliminate because once you eliminate out of the VAC, it's so difficult to get it back. Then we watch it for six to 12 months, how it goes. And if it doesn't, if it hasn't been used by now, that means this is a wasteful product. You just take it away. So that's another way where you can monitor your PARs of these things other than just throwing. All right, perfect, excellent. Thank you so much. And this concludes our course. Yay. On behalf of my co-pilot here, Dr. Mustafa Irine, and I would like to thank ASG and Medtronic for this partnership. Hope you guys had a fun learning today. Reception is right outside. And after that, you guys will have a shuttle taking you to the hotel. Please don't forget the post-session. We'll be back in a minute. Thank you. Test due date is April 2nd. And thank you so much. We appreciate your feedback. Enjoy the rest of your day.

EUS gastroenterostomy

overtube device

hospital VAC committees

preference cards

patient care

ASG and Medtronic