Welcome. Our newly created webinar series called ASG Global Spotlight. This new series was created with our global audience in mind and at a different time from our usual offerings to make sure that you all have a chance to join live. These webinars will feature global experts in their field, and I'm very excited for today's presentation. We have attendees joining us from all over the world and the American Society for Gastrointestinal Endoscopy appreciates your participation. Today's event is entitled esophageal cancer in Africa, relevance for ASG members. The discussion of this webinar will focus on problem of squamous cell esophageal cancer in East Africa, remote endoscopic teaching and learning, and also you can find out ways you can become involved in the program. My name is Reddy Akova, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by clicking the Q&A feature on the bottom of your screen. Once you click on their 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 in GILeap as part of your registration. Now, it is my pleasure to introduce our two moderators for today, Dr. Violet Kayamba, who is a medical gastroenterologist at the University of Zambia School of Medicine in Lusaka, and Dr. David Fleischer, who is an emeritus physician at Mayo Clinic, Arizona and a professor of medicine at College of Medicine, Mayo Clinic. Dr. Fleischer is a master endoscopist and a recipient of Rudolf B. Schindler Award by ASGE. He is acknowledged for his pioneering work with laser therapy for esophageal cancer, band litigation, and snare polyptomy for premalignant esophageal lesions, video endoscopy, capsule endoscopy, and radiofrequency ablation for Barrett's esophagus. Dr. Fleischer has published more than 300 original articles and editorials and has edited several books. He has lectured throughout the United States and internationally and has spoken on all seven continents, including Antarctica. Some of you may know him for his roles in Hollywood productions such as 30 Minutes of Less, Venom, Zombieland, Double Tap, just to name a few. We could really spend the whole hour talking about Dr. Fleischer's achievements, but we are very fortunate and honored to have him and Dr. Kayamba present today's webinar. Now I will hand the presentation over to him. Good. Well, welcome, everyone, to the Global Spotlight webinar. I'll be co-moderating this with my good friend, Violet Kayamba, who is at the University of Zambia. Importantly for this talk, and Dr. Dawsey will get into what an AFREC is, it's different than that AFLEC thing you see on commercials about insurance, but AFREC, the African Esophageal Cancer Consortium, and Violet currently serves as the chair, so she's been a heart and soul of the AFREC, and Violet will be with us, and hello to Violet. The way that this is set up and the overview has been given by Reddy is really to say to you, if you wanted to know about esophageal cancer in Africa, and specifically the role of the African Esophageal Cancer Consortium, and you wanted to know how this project goes on both in real time and with remote, this is the place to be, and these are the four people you'd want to hear from that. Dr. Dawsey, who I'll introduce formally in a second, I'll give a background. Dr. Hilary Depazian will talk about the actual capacity and boots on the ground and who's there, and she was a lead author in the most important study that's been done recently to assess the resources for managing esophageal cancer as well as endoscopic issues in many countries in East Africa. Dr. Wei, who again I'll introduce formally, has been the leader in a remote program for teaching and education that I think sets both, not the standard for only for now, but what the future will be, and Dr. Machiro, who's at TENWIC, who's a surgeon there and head of the endoscopy, and again I'll introduce Mike formally, has been the driving spirit in terms of the teaching programs. You'll hear from all of those. So this is a program, if this is of interest to you, you couldn't just go into a grab bag and pick four people to be better to do this. We'll begin the program with Dr. Dawsey. Dr. Dawsey is a close personal friend of mine. His position is as a senior investigator. Actually, hello, Violet. Hello. Hello, everyone. Hi, Violet. Welcome. Violet is, as I mentioned, is actually the head of the AFREC steering committee and is on the faculty and a very important faculty at the University of Zambia. She'll have the first introduction for Dr. Dawsey. Violet, welcome and take it away. Thank you very much, David. Now, I think I've just joined in. I think you must have already said something about Dr. Dawsey. I'm very happy to introduce him as our first speaker for this session. Dr. Dawsey, please. Thank you for the introduction. Ladies and gentlemen, this morning, I would like to have a brief overview of esophageal cancer in Africa and the development of the African Esophageal Cancer Consortium, or AFREC. Esophageal cancer is the sixth leading cause of cancer death in the world, killing about 500,000 people each year. 85% of these cases are in developing countries and 85% are esophageal squamous cell carcinoma. One of the characteristic features of esophageal cancer is its unusual geographic distribution with distinct high-risk belts across Central Asia and down the east coast of Africa. The risk in these areas is 10 to 50 times the risk in low-risk populations, and 90% of the cases are esophageal squamous cell carcinoma. In low-risk populations, 90% of the risk for esophageal squamous cell carcinoma are due to tobacco and heavy alcohol consumption. In the United States, the hazard ratio for current tobacco smoking is nine, and the hazard ratio for drinking more than three alcoholic drinks per day is about five. In high-risk populations, however, tobacco and alcohol are much less important, at least today, with hazard ratios around one. Instead, there is a list of other risk factors that seem to be more important, including diet, especially a low-selenium diet, tobacco carcinogens such as polycyclic aromatic hydrocarbons from non-tobacco sources, hot temperature drinks, and poor oral health, which we think is related to an abnormal oral microbiome. In Africa, there is a clear high-risk corridor for esophageal cancer along the east coast, and this area is significantly understudied. One striking feature, however, is the young age of many of the cases. 20% of the cases are under the age of 40. For example, at Tenwick Hospital in western Kenya, they see about 400 ESCC cases each year, and they have a much younger age distribution than in Asia, Europe, or the Americas. As you can see in the bar graph, where the Tenwick cases are in black and the U.S. cases from the SEER registry are in gray, the Tenwick cases are dramatically shifted to the left, to younger ages. At this hospital, 17% of the cases are under the age of 40, 7% are under 30, and 1% are under 20 years old. 90% of the patients are unresectable and need palliation. Other hospitals in the African ESCC high-risk corridor report similar findings. In 2017, a group of African and international investigators working on ESCC in Africa got together and formed the African Esophageal Cancer Consortium, or AFRIC. The goals of this consortium are to raise awareness of ESCC in Africa, to support young African researchers, to coordinate case control studies, GWAS studies, and genomic studies, to coordinate training and capacity building, to make affordable stents available throughout Africa, and to develop early detection and treatment programs. This is our organizational chart. We have a full membership group, we have a steering committee, and we have working groups on etiologic studies, clinical studies, and advocacy and awareness. Currently, we have 10 collaborating sites in six countries, which you can see on the map. We have five international members, including NCI, the International Agency for Research on Cancer, UC San Francisco, UNC, and the Mayo Clinic. We have bimonthly conference calls with 20 to 30 people on each call, and we have in-person meetings every two years at AORTIC, or the African Organization for Research and Training in Cancer. This is not a cardiology conference. We currently have seven case control studies, two of which are finished and five ongoing, for a total of 2,400 cases and controls. We've harmonized the questionnaires of the five ongoing case control studies so that the results can be better compared and possibly combined. We have a mobile phone app for primary capture of all data. We also are doing a joint GWAS study up and down the high-risk belt, collecting saliva as a DNA source. And by the end of this year, we will have screened 2,000 cases and 2,000 controls. And we're biobanking tissues and other biosamples for genomic studies. Finally, we have endoscopic capacity surveys, which you'll hear about in a minute. We're partnering with Boston Scientific to provide access to affordable stents and stent insertion training, which you'll also hear about later on. And we do quality of life and survival studies. So today, you're going to hear from Hilary Topazian on the AFRIC endoscopy capacity study, from Dr. Wei on remote endoscopy teaching in Africa, and from Mike Machiro on the AFRIC stent access initiative. Thank you for your attention. Thank you, Sandy. Before I introduce Dr. Topazian, a few background information about Dr. Dossie. He is reporting on his work in East Africa. But Sandy actually started his work in China in the 1980s. He's done similar work in Iran, South Africa, and throughout the world. And as I've said on other fora, there's no one that I know who has been done more or been more involved for work related to this than Dr. Dossie. So Sandy, thank you for your presentations. And when we get to the question and answers, if there's anything you want to know, either about esophageal cancer around the world, the NCI, or the Washington National Baseball Team, Sandy's your guide to speak to that. I want to remind everyone that there's an opportunity for questions in the chat and an opportunity for questions and answers. And so feel free at any time to start sending in the questions and answers. We'll have time for those at the end as we go forward. The second speaker is Hilary Topazian. Hilary first worked with esophageal cancer when she was at Tenwick Hospital, where Mike Machiro is and others. Her father, who's Mark Topazian, who is a well-known to many, put in some of the very first stents that were put in Tenwick. And since then, there's been approximately 4,000. So Mark probably put in numbers six, seven, and eight through 23. And then Mike and Russ White and others took over from that time. She then did cancer control work at the NCI, just recently finished her doctorate at the University of North Carolina, and will be getting her postdoctoral work at the Imperial College in London, from which she speaks. Her topic is endoscopic capacity study. And you really can't have an intelligent conversation about how you address any medical issue, any cancer issue, unless you have some background information. And none of that had been done in a sophisticated way until Hilary's study, which she'll discuss with us. So welcome, Hilary, and we look forward to your commentary. All right. Well, I'm just going to be presenting today on behalf of a large number of people, including Mike, who's on the call as well. And I'll be presenting on the AFRIC endoscopy capacity study, which was an effort to quantify available endoscopy capacity, and to qualitatively assess barriers to performance and access to care in four of our AFRIC consortium countries, Ethiopia, Kenya, Malawi, and Zambia. The objectives of our study were to first estimate the number of endoscopists practicing in our four countries of interest, and to assess the extent of their training, scope of practice, and characterize the health facilities where they practice. Second, we wanted to determine the amount of functioning GI equipment in use. And finally, we wanted to compare the endoscopy capacity of these countries with published data from the rest of the world. So to do this, we developed an online survey using Google Forms, which we targeted towards health providers practicing endoscopy. And we created standardized questions across countries and tweaked them slightly in each location to address differences in terminology. And the survey was developed by our AFRIC country champions with input from other health providers within each country. We sent out the survey link via email invitations in partnership with medical and surgical societies of each country, and then distributed the link to the practicing endoscopists using the society membership lists. And we sent periodic reminders throughout the study period, which ran from August 2018 to August 2020. And this was primarily a descriptive study with analysis conducted at the individual and facility levels. And we adjusted our estimates for non-response. So a total of 87 individuals participated in our survey and reported working from a total of 91 health facilities. And each individual could record up to three health facilities where they practice, and then also list additional locations where they know that services are offered in their country. And the health facilities are mapped on the left with the size of the bubble indicating the number of survey respondents from each city. The response rate for the survey was only 25% as we distributed the survey link to all members of surgical and medical societies. And this created a large denominator, even though many members of these societies never perform endoscopy. But despite this rate, we were still able to capture information on 82% of all facilities listed by respondents. Most participants in our survey were surgeons or MD non-surgeons. Respondents were from both public and private institutions with 46% from the public sector and a quarter practicing in both capacities. 73.6% of participants performed endoscopy procedures and most performed diagnostic EGD and colonoscopy, but there were very few participants who practiced ERCP or EUS. Respondents had been performing endoscopy for a median of five years and performed 10 upper GI endoscopies and three lower GI endoscopies per week on average. Of the 91 health facilities where survey participants practiced, 65 were private facilities and only nine were mission and 17 were public facilities. Mission hospitals tended to have more functioning gastroscopes, but all facility types had similar numbers of functioning colonoscopes. Public facilities had the highest capacity for upper GI procedures per week and lower GI procedures, but this did not reach statistical significance. One of the key findings from this table are that endoscopy fees are much lower at public facilities at 12 and 34 U.S. dollars for diagnostic and therapeutic endoscopy, whereas at mission and private hospitals the average cost ranges into hundreds of dollars. And another one of our objectives was to compare the endoscopy capacity from our survey countries to that of high resource countries. So we calculated estimates taking into account each country's population size and our survey response rates. So for example, to calculate the number of endoscopists, we divided the number of survey respondents saying they performed endoscopy by a total population of 206 million and then extrapolated using the survey response rates. So the adjusted survey values are shown in blue. And then using published literature, we found comparison values for the West Cape province in South Africa, the U.S. and the Netherlands. And comparing all these values, we calculated the relative capacity of our survey countries to these high income locations and found that endoscopy capacity in East Africa is only one to 10 percent of the capacity reported from resource rich countries. For instance, there's only 10 and 4.8 percent of endoscopists per 100,000 people in our separate survey countries compared to the U.S. and the Netherlands. There is also only one functioning gastroscope for every 400,000 to 1.3 million persons in participating countries, which is less than 10 percent of the minimum number of gastroscopes that we calculated are needed to support current endoscopy practice volumes in the U.S. and the Netherlands. Additionally, the maximum upper GI capacity in our survey countries is only 5.8 and 8.1 percent of that in the U.S. and Netherlands, and 1.4 and 3.0 percent of the lower GI procedure capacity. Broad barriers to endoscopy are listed in the table shown on the slide. A lack of functioning endoscopy equipment and supplies, as well as cost of equipment, procedures, and insurance were reported as barriers by most individuals within all countries. And closely following were personnel issues, including a lack of trained endoscopists and support staff. Endoscope procurement varies by country, but facility level purchases are common, and donations are an important source of endoscopes. Most respondents report limited or no access to endoscope repair. Nearly half of respondents must send their endoscopes to another continent for repair, and a quarter have no access to repair or else attempt self-repair. Many must also look outside of their facility for funds to pay for endoscope repair, and when funds are available, they usually come from research grants, the government, a donor, or the endoscopist themselves. So in summary, our study of health professionals in Ethiopia, Kenya, Malawi, and Zambia gave us the first national picture of endoscopy capacity in four of our AFRA consortium countries. We found that endoscopy capacity in our target population includes 1.2 endoscopists, 1.2 gastroscopes, and 0.9 colonoscopes per 1 million people. An adjusted maximum upper and lower GI endoscopy capacity were 106 and 45 procedures per 100,000 people per year, and these values represent only 1 to 10 percent of the capacity reported from the United States and the Netherlands. So these results led us to conclude that endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of GI disease among the population, as Sandy mentioned previously, and expanding capacity requires investment in human and material resources and technological innovations. Our results provide a starting point for measuring the impact of AFRIC's activities to improve physical infrastructure, human capacity, training, and efforts to lower costs for procedures and supplies, and these results also highlight gaps which future AFRIC activities could help to fill. And I just want to end by thanking our country champions pictured who helped with the survey development and implementation, and of course all the participants who took the time to contribute data to our project. Thank you. Thank you, Hilary. I'll be introducing the next speaker and then Dr. Kayamba will follow with the final speaker of the group before we get to questions. I want to remind folks that you have an ability to ask questions. We've received two questions so far, but again, most of the time for these webinars and seminars, the questions really get to what you want to know as opposed to what the speakers think you ought to know. So fire at us and we'll handle the questions for sure that you put forward. During the pandemic, it's been apparent that remote interactions through businesses and schools and just about every function of daily life is critical. One of the things that had characterized the AFREC training and teaching program before had been hands-on participation by different experts who came to Africa to teach and to learn from the sites who may have had more experience than they, but the interaction was critical. I was cut off by the pandemic and so remote education became important. Dr. Jerome Way, who's Professor Emeritus at Icahn School of Medicine in Mount Sinai, has been a leader in that area. When you talk about individuals that you're introducing, one of the common phrases for someone who's well-known is to say, literally, this person needs no introduction. And probably of all the colleagues with whom I work, that applies more to Jerry Way than to anyone else. In addition to his work with endoscopic teaching and training, he's been a leader in ways that few have. To be president of one of the GI societies is quite an accomplishment. Jerry is just about the only person I know who's been the president of three GI societies. He's been president of the ASGE, president of the American College of Gastroenterology, and also president of the World Endoscopy Organization. There's no one who I think is a better teacher ambassador than Jerry is, and when you see his presentation, you'll be aware of that. The one thing I want to warn you about, if something seems to disappear during the slides, many of you who know Jerry know about how gregarious he is and how good he is with people, but some of you may not know that he's actually a professional magician, and his odd crowds, not only with his medical expertise, but with his magic. So as they say in the musical Pippin, there's magic to do, and Jerry will talk to us about remote training for endoscopy. Jerry, welcome and thank you for participating. Thank you, David. That was a wonderful introduction. I'd like to discuss remote endoscopy training with you. Three years ago, the Director of Surgery at Mount Sinai in New York wanted to bring surgery to an area where there was no possibility of surgical interaction. He chose a small community in Uganda called Kiyobiro, which is four hours away from Kampala, the capital. I don't seem to be able to move that. He picked this community. It had no paved roads. Next slide, please. It had no indoor plumbing nor sewer capabilities. Next slide, please. Cooking was done by a wood fire in an outside shed, outside from the home. And it was done with a... Next slide, please. It was done with a pot balanced on three stones, typically being fed by a wood fire underneath the pot between the stones. This was the community in which he... Next slide, please. Built this surgical facility, which has two operating rooms, a wonderful, very modern recovery room. It has intake areas, treatment areas, administrative areas. And there is an ambulance that can go to the patient's home. And follow-up from this ambulatory surgical facility is done locally by a nurse who travels by their own motorcycle. Next slide, please. The ORs are fully equipped for operating capacities. Two ORs with having anesthesia capability as well. Dr. Marin asked me to come to Uganda to teach endoscopy, which I did... Next slide, please. In early 2020. Olympus lent a tower with an upper and lower scope. Next slide, please. And I traveled to Uganda to teach six surgeons in the techniques of upper and lower endoscopy. We spent an intensive week familiarizing them with endoscopy, with lectures, videos, and actual hands-on... Everybody got hands-on experience. Next slide, please. When I returned home, Dr. Marin asked me to continue to train his endoscopist at the Kiwibera Surgical Center, which I did. Here I am at home watching the procedures. And there is a camera on the operator's hands and a view of the scope output. And I can have instant communication with the operators as he goes about the end-of-heart procedure. It's actually very similar to being in the same room as the operator, just like being in the endoscopy room at Mount Sinai Hospital with one of the GI fellows. I can instruct him directly. He hears me. I can see what he's doing. And I can see what the scope is doing as well. Now, what's the difference between teaching and training, actually? Next slide, please. Teaching is different. Teaching is providing education. It's not very rigid. It usually refers to classroom learning, where training is hands-on and practical. It's intended to develop abilities. And exercises are repeated so that the operator learns how to do it. And it helps already knowledgeable person to learn new tools and techniques. But what does this mean for us? Next slide, please. The implication for GI endoscopy is teaching is like a three-day course that you attend with lots of live demo. And they show all the latest things that can be done, where training is actually side-by-side repeated instruction, such as fellow training in endoscopy. And that's the sort of thing that we can do with remote endoscopy teaching. Next slide, please. So here I am watching what's happening. Next slide, please. I was able to guide the endoscopist step-by-step through advancing the biopsy forceps into that small lumen in this patient with obstructing squamous cell carcinoma the esophagus. I could instruct him to go right a little bit, advance the forceps, put it in that aperture, twist the scope clockwise, take a biopsy specimen, and then put it in formalin for pathology. Next slide, please. The image transmission is excellent, as seen in this iPhone recorded video, where a small round worm was found in the duodenum. This round worm was captured with forceps and removed. The transmission of both video and voice had no perceptible lag, despite the distance between computers. Next slide, please. So here is the schema of what we need to do remote endoscopy. You'll see that at the very top is a Logitech Rally system, and we'll explain all of that to you, but it has its own camera and a small computer that comes with this whole system. We also need a connector to change the output from the Olympus system, which is SDI, which means serial digital interface, to USB, which is what's found on your laptop. So we need a converter here, and once we have that, the next thing we need is a microphone for the surgeon to speak. So let me show you what this means. Next slide, please. Here is the lapel microphone. Next slide, please. Here is the connection from the SDI output from the endoscope. This cable goes to the InnoGenie converter, which is here. So the cable comes from the endoscope tower to the converter, and then out to the laptop. So we get a signal directly from the endoscope output to the laptop. Next slide, please. Then we need this Logitech system, which has its own camera, and this is the camera that plays on the operator's hands. There is a speaker that they can hear what I'm doing, and then this portion is a mini computer, which collects the data from the endoscope tower, from the laptop, and transmits it to the internet. Next slide, please. This is connected. This small computer is connected to any monitor that we can see what's happening inside, to split the screen into two, into a split screen or a quad screen, or it combines the input from the laptop, from this camera, and transmits it to the internet. All of this is completely wireless, so this is all done by wireless internet connection. Next slide, please. Now the cost component is, this is the most important, this Logitech Rally system, it costs about $3,000, the lapel microphone, $165, the InnoGenie converter, $425, and you need a laptop with an SDI card, with an AVG card that will allow all this connection to occur. The total cost is less than $4,000 for the entire equipment for doing remote endoscopy teaching. Next slide, please. Here is a, can we run that video? Here is a polyp that we took off in the Kiribiru Surgical Center, all done remotely. Next slide, please. And here is a colonoscopy that I'm doing. I'm making a loop. Yes, you are. But sometimes you have to make a loop to keep going. Now I can see how much scope is in. If it looks like it's too much of a loop, we have to pull back again and straighten out the scope. And I'm watching all the time what happens, so I know how he's torquing. I'm on the big control all the time to keep the lumen in view. Keep pulling back, keep pulling back, don't be timid about it. We can always get to this point again, but we have to pull back a lot. Pull back, pull back, take out a little bit of air. So this is just as if I'm next to him right there in the endoscopy room. Okay, down, down, down with the tip, down the tip, okay. So this time I pulled back counterclockwise. Yep, okay, sometimes counterclockwise helps. That's good. We're doing, we're taking the loop out now, up with the tip. You have to make sure that you use your tip control all the time as you use torque, so that you can keep the lumen in view. Now we don't know where the lumen is, so just pull back a little bit more. Pull back a little bit more. There, okay. Now we know where the lumen is. Yeah, okay. Okay, advance it in. Very good, very good. Okay, so this demonstrates the ability to instantaneously communicate with the operator via the Zoom platform. I can see what he's doing with his hands. I can see what's happening inside, but I'd like to now show you something we did last week, which is introduction of a new technique, and it was fairly easy, but one of my fellows, Yakira David at Mount Sinai, joined me in the first application of remote variceal banding from New York to Uganda. Next slide, please. Yeah, it feels like I'm making a loop. Next slide. Here's Yakira. Because some of them almost look like they have what we call a red wheel sign, which is those sort of reddish spots on them, which indicate they are at high risk of rebleeding. So let's spend some time, because we'll start banding distally. So we'll be banding distally down here, which would decompress, which would be the goal of decompressing the entire column of varices, the acquisition, and then you hold down your suction. Yeah. And while you're holding on your suction, never let it go. Then you fire one band on it. So good. Apply suction now. Suction, a lot. Yeah, let's deploy the band. So deploy. So keep the suction down, and then with your right hand, let somebody hold the scope, deploy. Okay. Yeah, right there. Good job. Now find another varice and do the same thing. Okay. Okay, so this is a representation of how we can introduce a new technique that hadn't been done before, and this is the first time that they were able to do it. So let's go ahead and do it. So we're going to do banding of esophageal varices under very close supervision between us here in the New York area and Uganda. So I think it's a feasibility. Next slide, please. Next slide. So it's possible. It's feasible. It's relatively inexpensive. It's really just like being in the same endoscopy room with the operator. New techniques and new procedures can be taught. However, it does require time and patience on both ends of the internet. The instructor, the mentor must set aside time to be there for the entire procedure, but the trainer no longer has to spend a long time, days and weeks away from home, and there's no need for flights, hotels, different food, or terista. We can now do it all. Just do it. Thank you. Thank you very much for that really illuminating presentation. Congratulations to you and your team. I think this is very impressive, and we can only hope that such an initiative can be extended to other remote sites within Africa. So before I introduce the next speaker, I would like to remind the attendees that you can type in your questions in the provision there, and we will direct them to the panelists later. So now, let me introduce the next speaker, Dr. Michael Machiru, who is a consultant general surgeon and director of the endoscopy unit at Tenwek Hospital, Bomet in Kenya. He's a founder member of AFRIC, and one of the top esophageal cancer researchers in Africa. He's also currently serving on the ASGE international committee and the international editorial board for GIE. Within Africa, Dr. Machiru has been very instrumental in the stent program for AFRIC, and also linking AFRIC to several other partners within the continent. I must say that as African scientists, we're really very proud of Dr. Machiru as he represents us on the international platform. Dr. Machiru. Thank you, Dr. Kayamba, for the kind introduction. It's a pleasure to be here today to talk about the AFRIC stent access initiative. My name is Michael Machiru. I'm a surgeon at Tenwek. And so just to get us going, Dr. Dorsey had given us a brief overview of this, the beginning of the talk, the member sites, and these are the same places that we were doing this stent access project. So some prior work that we have done, just particularly on stenting, over the last two decades, have been focusing on the introduction of stents without using fluoroscopic assistance. So majority of them were looking, actually all our cases, we've been doing mainly with direct visualization. And in the last 10 years, we've switched to doing the technique that uses measurements only. And there've been a number of studies, including looking at the small versus large stents, looking at stenting in proximal tumours, and I'm now currently doing outcomes of patients who've been stented compared to other modalities. So I'll demonstrate the non-fluoroscopic stent technique very briefly. The first step is usually you pass down the endoscope, you localize the tumour. If you're able to pass the scope, then it's much easier. But if you're unable to, then you have to pass a guide wire through. So this is done gently. And the key thing is to ensure that the wire slides smoothly. And once you have enough length of wire across the stricture and into the stomach, then you can move to the next step, which is tumour dilation. At the beginning of this project, we used to do this without sedation, but now almost all our patients get sedation to make this process much easier. And as you can see here, the dilator is slid gently over the guide wire, and we do serial dilation from 18 French and work our way up to 36 French. The dilator has gone smoothly, and so we move on to the next stage, which is passing the endoscope down and then determining the tumour length. Here you can see wire coiled in the stomach. The examination has been completed already. We're just focusing on getting the tumour length, and the endoscope is pulled back gently. We record the squamo-columna junction, and you can see this tumour is quite friable. The guide wire is in place, and then you find the distal margin of the tumour, which is right there. We go for a little bit until we are quite sure we have the exact distal margin, and then the rest is now to pull back the endoscope, the same time looking for fistulas, assessing how much of the esophagus is involved with the tumour, how friable it is, and then we find the proximal margin and record that. Once you have the two measurements, then the next step becomes much easier, because now all you have to do is to decide based on the length what type of stent you're going to use, and what diameter you're going to use, and whether it is a proximal versus a distal release. Because of the partnership that we've had with Boston Scientific, we've now been using this stent for this stent access initiative project for all our trainings and also for clinical care. So you can see here, the stent is lubricated gently and slid over the wire. And usually we go beyond the structure and then pull back a little bit. The next step is to ensure that you've gone to the exact place where you want it to be marked. Usually give a margin of around two centimetres above the top of the tumour. The assistant verifies that we are at the mark, the endoscopist verifies, and then once everyone has agreed, we secure the stent delivery system in place and then you deploy the stent. For this particular stent, the deployment is simply pulling on the string that is attached until the stent has completely released. And once that is done, usually you wiggle the stent a little bit, deliver the system a little bit, and then you pull out the stent delivery sheet. Once the stent has been deployed, then the next step is to confirm positioning. And as you can see in this view, the endoscope is passed down. We can see the stent opened successfully, the wire is removed, and the top of the stent is recorded. And in this particular instance, there was no need to do any additional manoeuvres and the procedure is finished. So I'll now switch to talk about the stent training project. One of the first things we did was to do site visits. So we went around all the four countries that were participating, went to Tanzania, went to Malawi, went to Zambia, and then went to Tenerife. This is a picture of Tenerife Hospital. And while at each of these sites, we looked at a number of things. First of all, we talked to the endoscopist about what are the barriers that they were facing for access to stents in those parts. And as you can see, these are in different levels. At the patient level, there were issues to do with low health literacy, there was stigma around the cancer diagnosis, patients had to go long distances to get endoscopy units, prioritisation of other computing responsibilities, both at the patient level like childcare and generation of income, and then the cost of high quality stents. The next barrier level was hospital level, and here it was really availability of the medical devices, where mainly they were dependent on donations or ad hoc procurement. There was deprioritisation of devices, so the hospital spends on other things as opposed to the needed stents. And there's limited endoscopy equipment, and where there wasn't equipment, and there was other issue of limited access to endoscopy repair services. And then we noticed there was a limited number of trained endoscopists who are competent to deploy these stents. The system level issues were mainly the cost of supply of the stents, having many patients who's now exceeding their supply of stents, inadequate insurance cover, bureaucracy and expense of the best registration and regulatory processes, and then a number of issues regarding transparency and reliability in the stent procurement system. After this, the next thing we looked at was now, now that we're ready to set up this project, we looked at the guiding principles, and as you can see here, there are five main categories. The first category was prioritisation of the sites for participation, so they had to be members of AFRIC, they had to have a capacity to align the procurement processes, they had a high volume of patients with cancer, and then they should be motivated to be able to have the hospital sustain the procurement process. Then for the catering sites, all they had to do is ensure they had an endoscopy unit that was functioning, and being able to host training back home once we had done the initial training, and then we ensure that they're able to recruit patients and located where patients could reach them. For the trainers, essentially we chose skilled endoscopies who are competent, and then we looked at cultural competencies, essentially because this was key to keep this going, so we had preference for instructors who had prior collaborations at these AFRIC sites, and then we needed them to have accountability for continuing to provide mentorship and feedback to the project. For trainees, essentially they were competent in endoscopy, so we started with either surgeons or GI endoscopies, and then having a high interest to pursue this once the same training has been done, and leadership to continue education. We also added a component for accountability and reporting, whereby we collected data on the training that had happened, the outcomes, and we have such a registry which I'll talk about later, and then we made sure that they had a willingness to do quarterly audits or report data as it was requested. This schematic shows the developmental framework, and I think the main thing that I want to highlight in this slide, which is a bit busy, is this part where we did an analysis of the market demand, so we partnered with the Clinton Health Access Initiative, who are doing a lot of chemotherapy work in Africa, and they helped us to develop a model. We looked at the demand that we needed, which was going to be around 3,000 for the countries per year, and then the next step was to identify an industry pattern. In this case, we talked to a number of companies, we solicited engagement, and eventually Boston Scientific agreed to partner with us, and we therefore launched this at actually one of the DDW conferences in the last two years, and therefore they agreed to provide these stents at a subsidized price for this region, and due to this collaboration, we've been able to supply the stents and maintain that supply going forward. So here I'll just highlight the training, the trainer model. So we started at Tennec Hospital, and the trainers were myself, Dr. Fleischer, Dr. Mark Topazian, and then we went to Tanzania, where our first two trainees who had come to Tennec, Dr. Rimbaugh and Dr. Ketembo, did training while there, and we watched them do the stents, and just recently, actually during the pandemic last year, they were able to do another set of training entirely on their own, and this just goes to show the multiplicative process that this project has had. So each of the countries is working its way through this same model. This montage just shows the different aspects of the training. This was at Tennec, demonstrating these are the first two trainers, trainees, and then we went to Tanzania, and here we had the team from Boston Scientific help us to go through the device, and here we were looking at the different discussions about stent selection, stent diameter, stent length, and here we watched the two trainees deploy stents. So as I conclude, these pictures are from pre-COVID era. We were in Manawi. This was one of the last trainings, and here we were working with the endoscopy nurses, and the endoscopists were there, and we spent three days just doing this process of going through the stent training and watching them do the stents. Here we're doing discussions about how the stent performs, and you can see part of the team there. So what is the future? One is the stent registry. We started this, and we are logging all stents that have been tested. We are tracking the stents, and we're doing 30-day follow-up with patients as quality control. For this, we partnered with UCSF to develop this red cup access bottle, and then we have research and outcome studies that are ongoing, and these are there for looking at therapies for special cancer across the sites in East Africa, depending on resource availability, and we're looking at the different modalities here, stenting, radiation, chemotherapy, chemoradiation, phagectomy, or brachytherapy, and we do follow-up at 30 days, three months, six months, one year, and five years. So what are the opportunities for collaboration? One is involvement of multiple pairs like what we're doing with ASG. Dr. Topazian talked about the endoscopy survey to assess endoscopic capacity. There's really a big need for training in other aspects of endoscopy like ERCP, PUS, management of upper GI bleeds, and polypectomy, and as you saw from Dr. Wei's presentation, there's additional role for collaboration. Equipment access is a big issue, and then I talked about research, and we'd really invite people who are interested to join us and participate in the future STEM trainings that we'll have. Thank you very much for your kind attention. We look forward to continued collaborations, and we're really grateful to the ASG for this platform to be able to share our work. Thank you. Thank you, Mike. What we'll do now is Dr. Kayamba and I will oversee the questions. I wanted to mention to the audience, as well as to the speakers, although it's 59 minutes after the hour and we're due to end at the hour, we have a few extra minutes. I want to make sure everyone knows not only will we get to each of the questions, but before we end the session, you'll have the email addresses of all the different panelists available to you so that if you have a question that wasn't answered properly, then we'll make sure that it gets answered. I'm going to ask Dr. Kayamba to direct the first question, and then we'll just go back and forth. If you'll pick a panelist, and when you choose a certain panelist, they can answer, but of course, anyone else can contribute to this. Violet, if you want to start the questions, please. Yes. Thank you very much, David. The first question is on tobacco and alcohol, and it says, how can ASGE members and others throughout the community address trends related to patient education with tobacco and alcohol consumption as anticipated this significantly elevates incidence? The next question, probably we could tackle them together in view of time, is asking about how best to address differences in incidence between genders and whether gender-associated behaviors and exposures are likely to be implicated. Dr. Dorsey, would you like to attempt to address these two questions? Sure, I'll try. The question about tobacco and alcohol, as we know, tobacco and alcohol are extremely important in low-risk countries. As I mentioned, in high-risk countries, they seem to be less important. Probably, this is because people don't have enough money to buy tobacco and alcohol as we do. We have preliminary data from four case control studies now in Africa, and all four of them show no association with tobacco consumption. This is probably because people roll their own, and a smoker smokes about five cigarettes a day, something like this. For alcohol, only one of the case control studies showed a strong association. The other three showed none. Clearly, tobacco and alcohol are very important, and as people get more money, it will become more important. I don't know how people in the GI community can affect this except by talking individually to patients that their tobacco and alcohol consumption is bad for them. As far as gender-specific exposures, the main exposures that we see in high-risk countries for men include consumption of hot drinks. It's a macho thing, and people want to drink tea or porridge hotter than the next person. That's important. Also, the smoking and drinking that is taking place is almost exclusively among men. For women, the great majority of the, we think, the biggest exposure is indoor air pollution from cooking on open fires in kitchens or cooking rooms that are virtually unventilated. The walls throughout the room are completely black, and the ceilings are, too. You can go with your finger, and there's soot all over your finger. We've shown, looking at urine metabolites of PAHs, that the women have to have levels that are twice that of the men, and that's because they do all the cooking. They seem to have different exposures based on gender. I'd like to address this question to Dr. Wei. One of the audience participants points to a publication in the literature that talks about mislesions with thalianocarcinoma in the United States and a group of Barrett's. Of course, you're quite familiar with the issue of mislesions with colon cancer, Jerry. Is your sense that with this remote program, you have ways that would be comparable to addressing that question, your thoughts about the question in general, both with colon cancer and esophageal cancer? I guess it's a question of commentary about both mislesions, number one, and whether the remote process would increase the likelihood. If you can take that, that would be great, Jerry. I think that introduction of endoscopy, no matter where it is, whether it's in an endoscopy center and the instructor can be right next to the student or whether it's 6,000 miles away, doesn't really make much difference. It's dependent on the observational propensity of the instructor and student that allows one to identify and pick up abnormalities that may be dysplastic lesions or adenomas. I think that's only a matter of experience and careful mentoring that allows us to find lesions that may be difficult to see. Certainly, there's no doubt that even in the best of hands, we miss a number of adenomas. However, they're usually fairly small, the ones that are missed in the colon. With this new advent of artificial intelligence, it's picking up a lot more tiny little lesions that one may miss on visual inspection alone. However, I think that it all depends on developing the skill and technique of being able to look behind foals. I think all of this can be done in a remote training session while the instructor does not have to be right next to the student in the same room. We can now do it far remote and do it just as well. Mai, you want to take the next question for one of the speakers? Yes, thank you very much. There's this one, which I think is directed to Dr. Machiro. The attendee is asking about complications related to stent placements, including stent migration, tumor ingrowth, bleeding, and so on. Also, the next part of the question is asking about chemotherapy. Firstly, I'll ask you, Dr. Machiro, to comment on the complications with the stenting. Thank you. Thank you for the question. What we have been seeing is the most common complication that we see is tumor overgrowth. This is what brings them in usually after you've put in the stents and they go home. The way our model is set up is they get the stent and then they go home and they're enrolled into palliative care, or they get the stent and they go get their treatment and then come back for surgery. We've been using stents as a bridge to surgery. In the initial phase, usually the main issue is pain. Occasionally, we've had some bleeding if the tumor is viable, but not that much. We've not had many perforations. I think we've been able to show that the technique is easily reproducible. If you follow the principles, it's been fairly safe. The long-term complications, so delayed complications, is what in the initial set of data we actually are about to submit for publication. Because of our model, we didn't have much of that available. In the next study that is going on, we're now doing very rigorous follow-up. We'll be able to give a more in-depth look at this in the next set of stents that we publish, because now we're actually following these patients and tracking them. Overall, I can say the other comment is this question of combining treatment when they're on stents. This is where the oncologists split about what direction to take. Some of the data shows that it's okay to do this. There's actually some data out there about stents that have been imbued with radioactive beads, but that oncology, with some of them not very keen on radiating patients with stents, because after you shrink the tumor, the argument is that it may slide downwards into the stomach. Thank you for the question. That's a really good aspect of this stent care that we've been handling. We'll have a question for Dr. Topazian, and then unless there's any other questions that are put forth by the audience, we'll wrap up the session so people can get on with their daily lives. Before doing so, on behalf of Dr. Kamba and myself, we want to thank the panelists. As I say, if you know this topic, you know you've had four of the most knowledgeable people in the world and the most gracious people in the world make those presentations. We want to thank the ASG for putting on this global spotlight program so that AFRIC can share some of the things that we've done. We want to thank the ASG staff in particular, and the guy behind the scenes who really has made all this happen is Reddy Jacoba, who's the Director of Global Communications for the ASG, and through many interactions with Reddy, I can tell you he's a great asset for the ASG and certainly been helpful for us. A reminder that in two or three days, this will appear on GI Leap, which is on the ASG website, and you can see the whole presentations in full. If some of your colleagues didn't attend this, they can pick it up at a later date. Finally, to mention that you have the email addresses of the six individuals who've been involved in this, and I know speaking for the other five, everyone will be happy to take questions that you want to send in offline that may be valuable. To close, I'll posit a question to Dr. Topazian, and if she can answer this one in addition to her doctoral and postdoctoral work, she'll be in line for the Nobel Prize, I'm sure. Hillary, I want to ask you, you put up all these different barriers, and as someone who's involved in public health and epidemiology and global health, some of those barriers or many of those barriers seemed insurmountable, and since the way you solve problems in the world uses one footstep at a time, what would you see, Hillary, as some next steps that might address some of the barriers that you put forward? If you can answer that, please, Hillary. Right. Well, I guess from what I've seen and what we've all seen through the presentations today, APHREC is already doing a great job in working on some of these gaps. I mentioned cost and endoscopy equipment as being some of the top barriers, and also personnel, so lack of trained support staff and endoscopists, and we've seen videos showing how train the trainers and training people who are the ones performing endoscopy, even remotely, can be an effective strategy. I know some of our other activities include working with ministries of health and connecting governments with manufacturers and equipment providers to try and get reduced pricing for those and try and, I guess, shorten the supply chain so things can just go over more directly. So I think those are some of the major steps that I see already in place and already working on filling these gaps. Thank you, Hillary. With that, I'd like to thank Dr. Kayamba for co-chairing this, and we'll proceed to end the session now with great gratitude to the audience for participating, the speakers for coming and ready for his hard work. Thanks to all, and over and out we go. Thank you. Thank you so much, Dr. Fletcher, Dr. Kayamba, and Dr. Dawsey, and Dr. Topazian, Dr. Wei, and Dr. Machito for these excellent and informative presentations and for being with us today. And just before we close out, I will launch a very quick poll to check the quality of this presentation. It'll take just a few seconds. Your experience with these learning events is important to ASG, and we want to make sure that we are offering interactive sessions that fit your educational needs. At the conclusion of this webinar, if you could also go to the networking lounge, we have added a quick survey that takes less than a minute to complete, but we greatly appreciate your help with that as well. How do they get to the networking lounge? It's through the virtual platform. There is the navigating bar at the bottom. There is an icon that says Networking Lounge. Thank you. Thank you. I will end the poll. And as a final reminder, please do check ASG's calendar of events as we will continue to feature relevant sessions to our Global Spotlight series, and also do check out the DDW session of AFRIC that is happening on Sunday, May 23rd from 10 to 11 30 a.m. eastern time. In closing, thank you again to 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 in your practice, and we'll now conclude the session. Thank you so much.

Esophageal Cancer

Africa

ASGE Members

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Squamous Cell Esophageal Cancer

Challenges

Endoscopy Capacity

Affordable Stents

Education

Gender

Collaboration