Reminiscing the Fellows’ Office

New Hampshire, New Mexico, North Carolina, Oregon, Rhode Island, South Dakota, Tennessee, Texas, and West Virginia.

On January 5, 2023, the Federal Trade Commission (FTC) proposed a rule to ban noncompete clauses at the federal level. The proposed rule seeks to make it illegal for employers to enter into noncompete clauses with workers (employees or persons who perform work under contract). The rule would apply to anyone working for an employer, paid or unpaid, in addition to requiring employers to rescind existing noncompetes and actively inform workers they are no longer in effect. The comment period was extended to April 19, 2023. At the time of this writing, the federal proposed rule is still pending.

Conclusions

Although the enforceability of restrictive covenants is not guaranteed, without legislation otherwise, courts tend to rule with the employer as long as the restrictive covenant is reasonable with regard to time and geography. There is skepticism whether the FTC Proposed Rule will be successful in changing this environment. As the shortage of HCPs continues to increase, it will be interesting to see whether more states, including Pennsylvania, enact legislation that limit or void restrictive covenant enforceability.

As I moved my workstation from my place in the fellows’ office to the third years office, I could not stop thinking about what one of recently graduated fellows had said at graduation – “you all changed my life”. I could not agree more.

Over the years, my program had outgrown one room for all the fellows and therefore, the third years had the distinct honor of moving into an adjacent office, not more than 10-15 feet away from the OG fellows’ office - but somehow it feels like a different world. The independence and quiet of the “big kids” office reminded me that training would soon be coming to an end – and with that, the safety, comfort, and sometimes gossip of the fellows’ office will soon be gone.

The comradery we experience during training is one that I feel we do not acknowledge – or celebrate – enough. While we may not all be friends in the truest sense of the word, there is a unique relationship that forms amongst those who share the experience of medical training, whether that is medical school, residency, or fellowship. No one else can understand exactly what you are going or went through, but the ones who did it beside you.

Whether applauding a co-fellows first cecum, commiserating over yet another FOBT+ consult, insight into different attendings’ styles and expectations, reminders about conference deadlines, venting about a sleepless call night or personal struggles, the discussions behind closed doors in the fellows’ room is critical in our fellowship experience. The laughter, frustration, and success we share with our co-fellows has an immeasurable impact on our growth. I hope to never underestimate that the bonds forged during this transformative period go on to shape careers – and lives.

David L. Diehl, MD, FASGE, AGAF

Management of esophageal strictures is well within the repertoire of all gastroenterologists. GI fellows receive training in the use of through the scope (TTS) balloons, and also may get training in the use of wire-guided graded dilators (“Savary dilators”). However, endoscopists may encounter difficult esophageal strictures that may test the limits of their comfort and experience. In this essay, I aim to shed some light on these situations, and how best to address them.

What is a “complex stricture”?

Simple esophageal strictures can be passed with a standard gastroscope. “Complex” strictures are those with one or more of the following: length more than 2cm, diameter less than that of a regular gastroscope (1011mm), angulation, and mucosal irregularity. The presence of an esophageal diverticulum or tracheoesophageal fistula also contributes to complexity.

When is a stricture “refractory”?

The standard definition of a refractory stricture is one that cannot be dilated to a diameter of 14mm over 5 endoscopic dilation is at 2-week intervals. Often it is clear even before 5 dilations that the stricture is going to be difficult to manage. Cautionary note: malignancy should be considered in any stricture that is refractory to dilation.

The esophageal stricture is smaller than my endoscope; what should I do next?

If a standard gastroscope cannot be passed, the endoscope can be downsized to a “slim” gastroscope (about 6mm). This can allow scope passage and measurement of stricture length and the nature of the stricture, benign or malignant.

Reminder: A TTS balloon cannot be passed through the small channel of the slim gastroscope.

If a slim gastroscope is not available, the endoscopist can pass a spring tipped guided wire (“Savary wire” or “Cope wire”) through the channel of the scope, place the end of the wire in the antrum, and exchange the endoscope off the wire. This can be done with fluoroscopic control or also safely “by feel”. This is followed by graded Savary dilation. Often the “rule of threes” is followed: once mild resistance is felt with dilator passage, two more dilators, each 1mm larger than the previous, is passed through the structure. Experienced endoscopists may use a “3+1” approach. An advantage of Savary dilators is that the endoscopist gets tactile feedback of the effect of the dilator on the stricture.

If the endoscopist feels more comfortable with balloon dilation, a wire-guided balloon dilator can be used. The floppy wire is first inserted through the stricture, and the balloon advanced over the wire and across the stricture. The balloon size chosen varies depending on the initial stricture diameter. On occasion, more than one balloon is necessary for complete dilation.

If the guidewire or the wire-guided dilating balloon does not pass with ease, then fluoroscopic control is usually necessary. I have used a stiff biliary guidewire (extra floppy tip) as a useful work-around. Often these cases are referred to an interventional endoscopist, who will have more experience with these difficult strictures, as well as more ready access to fluoroscopy.

How to manage refractory strictures?

Examples of strictures that may be refractory include those associated with radiation (usually head and neck tumors) and surgical anastomotic strictures, for example, after esophagectomy. The refractoriness of strictures is generally related to stricture length, rather than initial diameter, with strictures >2cm being particularly difficult.

Steroid injection has been used for refractory strictures. This consists of triamcinolone, 50-100 mg injected in 4 quadrants after dilation. The steroid is injected directly into the raw tissue of the stricture. Injection is often difficult, as the needle is trying to inject into scar tissue. I have not found injection therapy (either with triamcinolone or with mitomycin C) very helpful for refractory strictures. Typical treatment for refractory strictures is repeated short interval dilation (every 2 weeks) until there seems to be a response, then see if you can back down on the interval between sessions. Try to increase the diameter of dilation with each session, if possible. The stricture will often appear to restenose between dilation sessions.

What is “incisional therapy” for esophageal stricture and when is it used?

Incisional therapy can be used for strictures that are “web-like” in appearance. Electrocautery is used to cut the fibrotic web. A classic example of this is a Schatzki ring, which are well-known to be recurrent. Incisional therapy is superior to balloon dilation alone, leading to longer periods without recurrence. Surgical anastomotic strictures, for example after esophagectomy, can also have a weblike appearance and can also benefit from incisional therapy. The advantage of incisional therapy is that the fibrotic web is cut during the procedure; dilation along may leave the fibrosis unchanged. I often do “triple therapy” for these cases: incise the ring, then dilate (usually up to 18mm) and then steroid injection. It is quite safe to dilate after incisional treatment.

Even though incisional therapy has been around for years, expertise with this technique is limited, and there seem to be few practitioners who know how to do it.

What is the role of selfexpanding metal stents (SEMS) for the management of benign esophageal strictures?

It is burdensome on both the patient and endoscopist to repeat dilation every 2 to 4 weeks. A fully covered SEMS can be placed to “remodel” the stricture. This accomplishes dilation of the stricture up to the diameter of the stent (usually 18-23mm) for as long as the stent is in place. However, limitations of this approach include:

1) pain after placement, sometimes requiring early removal,

2) migration of the stent into the stomach, 3) expense of the stent (>$2000), and 4) recurrence of stricture in many cases after stent removal.

The “Axios” lumen apposing metal stent (LAMS), originally designed for use for pancreatic fluid collections, has been used for refractory luminal strictures and has a low rate of stent migration. However, the cost is high (about $6000), and the length of only 1.5cm is not useful for longer strictures.

Newer stents with the anti-migratory LAMS design as well as more stent lengths at a more reasonable cost are eagerly awaited and should hit the US market in 1-2 years. Biodegradable esophageal stents which do not migrate have been developed. These have a dwell time of several months before dissolving away. Unfortunately, these stents are not FDA approved in the US.

Can patients be taught how to do self-dilation? Does this work?!

Back in the days before H2 blockers (never mind PPIs!) self-dilation of esophageal strictures was not rare.

These days, it is quite difficult to find a patient who is even willing to consider self-dilation. In my 30 years of GI practice, I have had only two patients who were willing to do this. The most recent patient had an extremely refractory radiation stricture of the distal esophagus. He had endoscopic dilations every 2 weeks without much improvement, and stents migrated. We instructed him how to perform self-dilation. A helpful resource was an instructional video produced by the ASGE, featuring several patients describing their personal experience. There are also several YouTube videos describing the technique.

This man did have a secret advantage in that his significant other was a health care professional who could assist him with the dilation procedure. And here is a Pro Tip that I learned from him: using flavored lubricant with the dilator makes it easier! The more you know…

What should I do about eosinophilic esophagitis strictures? Aren’t they at higher risk of perforation?

Medical and diet therapy remain the core treatments for eosinophilic esophagitis (EoE). However, some patients will have focal strictures or rings that result in dysphagia and/ or food impaction. In addition, some patients with long-standing or even “burned out” EoE may be left with a narrow caliber esophagus that presents a difficult management problem.

Dilation of EoE related strictures often results in deep mucosal tears, which can be alarming for the endoscopist that has not seen these before. Over dilating can result in a perforation, so serial dilations with only 1-2mm increase in diameter between sessions is recommended. Older studies quoted a perforation rate of 5-7% but the rate is lower in recent studies (0.03%) with post-dilation hospitalization in 0.7%. Chest pain after dilation of EoE strictures occurs in 3.6%.

TTS balloons or Savary dilators have been the standard for management of EoE strictures. A newer device is the BougieCap (Ovesco, Cary, North Carolina), which provides the ability to perform an “optical-haptic dilation” (OHD) of a stricture with great precision. These are clear tapered caps (available 8-18mm) which are attached to the end of an endoscope. The esophageal lumen and stricture can be directly observed through the cap during dilation.

The scope with the mounted cap is then passed to the level of the stricture. Using gentle but persistent pushing and twisting of the endoscope, the stricture can be dilated under direct vision (the optical part of the procedure) and with haptic feedback (the endoscopist can precisely define how hard to push based on the appearance through the cap). There is emerging medical literature on the use OHD with the BougieCap, and its use for EoE strictures is likely to expand as more endoscopists learn about it.

Conclusions

While gastroenterologists are quite experienced at managing the vast majority of esophageal strictures, there are complex cases that require more time, effort, tools, and expertise to get a successful outcome. These are often referred to an interventional endoscopist with proficiency at treating complex strictures, as well as having the expertise to manage potential complications. It is important to have a full toolbox when undertaking management of these cases to maximize success of the procedures, often multiple, that will be required.

dilator

Friday, September 8, 2023

12noon-2:00 p.m. Corporate Sponsor Lunch (Offsite Location TBD)

3:30-5:30 p.m. Board Meeting at the Hotel

6:00-8:30 p.m. Welcome Reception at the Hotel (Family friendly)

Saturday, September 9, 2023

7:00-7:30 a.m.

7:30-7:45 a.m.

Esophageal Disorders

7:45-8:10 a.m.

8:15-8:35 a.m.

8:40-9:00 a.m.

Registration/Continental Breakfast with Exhibitors/View Posters

Welcome/Presidential Address/Annual Business Meeting

David Diehl, MD, Geisinger

Intractable Reflux: How to Manage in the Modern Era?

Zubair Malik MD, Temple University

Eradicating Barrett’s Esophagus Whatever it Takes RFA, Cryo, EMR, ESD

Harshit Khara, MD, Geisinger

H Pylori- Changing Epidemiology and Management Trends in the USA

Shannon Tosounian, DO, St. Luke’s University Health Network

9:00-9:15 a.m. Q & A

Functional Bowel Disorders

9:15-9:35 a.m. How to Manage Functional Abdominal Pain: A Primer for General Gastroenterologist

9:40-10:00 a.m.

Saad Javed, MD, Allegheny Health Network

Diet and IBS: What to do, how to do?

Nitin Ahuja, MD, Penn Medicine

10:00-10:15 a.m. Q & A

10:20 – 10:50 a.m.

Keynote Address

11:00-11:25 a.m.

Break/Visit Exhibitors/View Poster Displays

Prevention of Chronic Pancreatitis in the Modern Era

David Whitcomb, MD, PhD, University of Pittsburgh Medical Center

Q & A

Practice Management

11:30 – 11:50 a.m. The Current Status of Clinical Practice Guidelines & Medical Professional Liability

Richard Moses, DO, JD

11:55 a.m.-12:15 p.m. Surveillance Colonoscopy – What do we know? What do we need to know?

12:20-12:40 p.m.

Robert Schoen, MD, University of Pittsburgh Medical Center

Social Media A Pyramid of Advantage or A Pitfall?

Austin Chiang, MD, Thomas Jefferson University Hospital

12:45- 1:00 p.m. Q & A

1:00 – 1:15 p.m.

Lifetime Achievement Award

Presented to Harvey Lefton, MD

HERE!

1:15 – 3:15 p.m.

Lunch & Hands on Course (non-CME)

1. Hemostasis Station

Facilitators: Adam Kichler, DO, Allegheny Health Network & Shailendra Singh, MD, West Virginia University

2. EMR Station: Traditional Cap EMR Resection with Various Lifting Agents & Band Ligator (Duette/Captivator)

Facilitators: Hadie Razjouyan, MD, Penn State Health & Harkirat Singh, MD, University of Pittsburgh Medical Center

3. Defect Closure Station Specifically for X Tack Device/BSI Clip

Facilitators: Bradley Confer, DO, Geisinger & Zubair Malik MD, Temple University

4. ERCP Station

Facilitators: David Diehl, MD, Geisinger & Shyam Thakkar, MD, West Virginia University Medicine

5. Hemorrhoid Station

Facilitator: Harshit Khara, MD, Geisinger

3:15-6:00 p.m. Free Time (on your own)

6:00-9:00 p.m. Family Fun Night: Reception and Dinner (pre-registration required)

Sunday, September 10, 2023

7:00-7:45 a.m.

Gut Immunology

7:45-8:05 a.m.

Registration/Continental Breakfast with Exhibitors/View Posters

Celiac Mimics and Auto-Immune Enteropathies

Kimberly Weaver, MD, Allegheny Health Network

8:10-8:30 a.m. Preventing Complications in IBD

8:35-8:55 a.m.

Nabeel Khan, MD, VA Medical Center

Present and Future Management of Eosinophilic Esophagitis

Justin Kupec, MD, West Virginia University

9:00-9:15 a.m. Q & A

Endoscopic Advances in GI

9:20 -9:40 a.m. Advances in Endoscopic Management of GI Bleed

Adam Kichler, MD, Allegheny Health Network

9:45-10:05 a.m. Incorporating Artificial Intelligence to GI practice, a Path Unknown

Piyush Mathur, MD, Cleveland Clinic

10:10-10:30 a.m. Management of Large Colorectal Polyps

Hadie Razjouyan, MD, Penn State Health

10:30-10:45 a.m. Q & A

10:45-11:10 a.m.

Hepatology

11:10-11:30 a.m.

11:35 – 11:55 a.m.

12:00-12:20 p.m.

Break/Visit Exhibitors/View Poster Displays

Updates on Management of NASH

Tavankit Singh, MD, Allegheny Health Network

Updates in Diagnoses and Management of AIH, PSC, and PBC

Karen Krok, MD, Penn State Health

Gut Microbiota and Management of Portal Hypertension

Jasmohan Bajaj, MD, Virginia Commonwealth University Medical Center

12:25-12:40 p.m. Q & A

12:40 p.m.

Awards and Closing Remarks

David Diehl, MD, Geisinger & Gursimran Singh Kochhar, MD, Allegheny Health Network

12:50 p.m. Adjourn