PSG Rumblings Newsletter Summer 2023

Rumblings

/ David L. Diehl, MD, FASGE, AGAF

President’s Message / David L. Diehl, MD, FACP, FASGE

“So Long, and Thanks for All the Fish”

The Importance of Mentoring

www.pasg.org

PSG/SOCIAL:

The PSG is launching a mentorship program for GI Fellows and early career GI physicians. We will be reaching out to those of you who would like to participate in this project.

attending physicians at one’s own training program work very hard to train GI fellows, but this is generally different from a mentoring relationship.

Well, the time has come. The end of my 2-year term as President of the PSG is here. I am grateful to the members of the PSG Board for their ongoing support of our efforts to continue the greatness of the PSG. I have enjoyed having the privilege of leading the PSG and doing what I can to make sure that the PSG remains a viable and important resource for Gastroenterology in Pennsylvania. I would like to thank Jessica Winger for her hard work at organizing and attending to all the details that go in to putting on the annual meeting. And of course, my sincere appreciation goes out to Audrey Dean, our Executive Director. I have met nearly weekly with Audrey for the past 2 years to keep all the balls in the air, and to make sure that all our initiatives could be shepherded into reality.

As I look back at my 2-year term, there is much that I am proud of. Certainly, the accomplishments listed below would not be possible without the collaboration and guidance of my colleagues on the board, and to them, I am very grateful. But I would like to bring everyone’s attention to these projects and initiatives that occurred in the PSG over the past 2 years:

1. The great success of the 2022 Annual meeting in Hershey: Our course director, Shyam Thakkar, put together an outstanding line-up of speakers. It was great to be able to meet in person again for the first time since before the COVID pandemic in 2019. Our ability to have an in person meeting really underscored what these gatherings are about: not just great academic content but also providing the opportunity to network again with our old friends as well as new acquaintances in the PSG. Not to mention providing a family-friendly venue so that physicians can bring their families along for the meeting.

Many of us have benefitted from mentors. Perhaps some of us have suffered for the lack of a mentor during our education or training. Mentors can have a lifelong impact on their trainees, but the relationship does not go in only one direction. Mentors can get as much benefit and satisfaction as their mentees can. Gastroenterology, like other areas of medical training is akin to a “guild”, where the experienced take the novice under their wing to train them in the arts of their chosen field. All GI fellows, including us way back when, had trainers and coaches that typically were staff gastroenterologists at our program. Many medical schools provide for mentor relationships, but this is less common in GI training. Certainly,

I have been lucky enough to have some important mentors in my medical career. The first was assigned to me when I was a firstyear medical student. His name was Eugene “Skip” Felmar, MD and he was a Family Practice attending in the San Fernando Valley area of Southern California. I enjoyed going out to his office and shadowing him closely while he saw outpatients, rounded on inpatients, and did office procedures. Beyond gaining valuable insight into the practice of medicine, I found out why his nickname was “Skip” after he took me out on his sailboat which he kept docked at the Los Angeles harbor. Skip Felmar became a role model for me, and the mentor-mentee relationship was mutually rewarding.

Another highly impactful mentor that I had was someone that I chose myself. Dick Kozarek, MD was (and

2. The Annual Meeting will be back in the western part of the state for the first time in years, and in Pittsburgh for the first time in more than a decade. Many thanks are due to this year’s course director Dr. Gursimran Kochhar as well as the Education Committee. We have had many meetings over the past months to hone the schedule, and we are looking forward to an outstanding meeting.

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PSG/SOCIAL: @PAGastroSoc

@DavidDiehlMD

President’s Message

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3. Creation and development of the PSG Webinar series: This has offered a wonderful educational opportunity for our membership, in addition to providing a CME opportunity, and it also feeds our Social Media efforts. Some of the content will be archived on the Website for future availability. There have been 5 Webinars in the past year, two of which moderated by PSG physicians, and three more with industry sponsorship. More are planned in the future. Of course, we welcome any ideas of topics for these Webinars.

4. PSG Mentorship Program: Mentorship is such an important part of what we do as physicians, and we are blessed to have an outstanding cadre of gastroenterologists in this state. I have created a program to link Mentors to Mentees in a variety of areas in GI including clinical practice, advocacy, and many others. While we are just getting this off the ground, I am hopeful that this will be an important service of the PSG to our membership and trainees for a long time to come.

5. PSG Website improvements:

It has been several years since our PSG Website had an upgrade. We have been working on this with the IT department and hope to finalize these improvements before the end of the year.

6. We expanded membership to West Virginia physicians: This was a suggestion from Dr. Thakkar, and since its inception, several West Virginia gastroenterologists and gastroenterology fellows have joined the PSG. Having the PSG Annual Meeting in Pittsburgh will certainly continue to promote membership among our West Virginia colleagues and serve to expand PSG further.

7. PSG-sponsored Research Grant Competition:

This initiative was created by the PSG Board and sets aside $25,000 to fund 2 grants in the following areas:

(1) Increasing access and utilization of colorectal cancer screening, and

(2) Improving value in endoscopic care delivery. We will be funding our first grant this year, and the grant winner will be invited to present their research at the Annual Meeting the following year.

8. PSG Co-Sponsorship (with Medtronic) of the annual video capsule endoscopy course: It was held this past March in Danville and was well attended by faculty and fellows from many hospitals in Pennsylvania. This was nicely organized by Dr. Harshit Khara, and led by Dr. David Haas, who is recognized as a leader in this field. Our plans are to reprise this on an annual basis.

9. PSG Membership Group Discount Program:

The PSG has developed a program to promote membership by allowing a group discount for multiple members from the same practice. A few groups have taken advantage of this, and we hope to increase the number of members through this program as more practices learn about it.

10. Increased Diversity, Equity and Inclusion (DEI) awareness: The PSG Board composed and approved a DEI statement for the PSG for the first time in its history. While this is a big step, more is needed to be done. The PSG is committed to pursuing goals of inclusion and will be looking to increase diversity in membership and board representation going forward.

Some special acknowledgments are in order. I would like to thank David Sass for nominating me to the PSG board so many years ago, Richard Moses and Wilson Jackson for providing inspiration for leadership in this role, and Ravi Ghanta for his unwavering support and help to me in his role as immediate past President. I also am grateful to our very active board members for their significant time commitment. The Education Committee in particular has been very active with ad hoc meetings to drive forward several of the initiatives and projects listed above.

The future of the PSG is stronger than ever, and we hope to continue to drive membership with increased social media engagement, particularly with inclusion of GI fellows through Pennsylvania and West Virginia.

Off The High Dive

Thomas McGarrity, MD

I’ve never been much of a daredevil. However, by the third day of most vacations I become restless. A need to push myself. An hour-too-long hike or a bike ride with one too many hills leaves me sweaty, lightheaded (hypoglycemic?) and rubbery legged (lactic acid?) Satisfied, sated. The high dive at the community pool always gets my goat. Rising high above the concrete deck taunting me “You Wimp!” I get in line behind the antsy pre-teens and in front of the pushin’ and shovin’ teens. I wrap my arms together, resting on my bulging abdomen. The line creeps forward. Then I rise alone on the stairs. I look out from the board, no one is watching. I check to make sure the last diver has cleared. I lurch forward, small hop and jump. Mid-air I steel myself from toppling over, then plunge, contact, submerged. Survived.

I’ll be retiring soon. The 30th of this month. Then gone. Before you ask, “I haven’t a clue.” Forty-three years at one institution. My job hasn’t been a forty-hour work week. I spent many rewarding weeks on hospital rounding on the inpatient and consult services. I have learned so much from patients, medical students, residents, and fellows. In exchange I have shared lessons on organ physiology, Irish literature and basketball legends. I don’t have hobbies. I exercise, I read. I don’t golf, caddying for doctors during high school cured me of that pastime. I could attend GI Fellows clinics, but I don’t want to be that senior attending who relies on a wealth of experience but hasn’t read the latest journals. I plan to volunteer for the Communications Professional Ethics Humanities Courses for the first- and second-year medical students. That would be more to my liking. Universal skills that are essential for all care givers.

Should I step away from medicine entirely, view life from a different perspective? Volunteer at the Food Bank, provide service, and make people feel better. My snarky second son says I should volunteer as a greeter at Walmart. “You’re good at that sort of thing,” he smiles.

These past decades have been a wonderous time in medicine and gastroenterology. I graduated from medical school in 1979. The first case of AIDS in the United States was reported in 1981. The COVID pandemic which descended in the spring of 2020 had similarities to the AIDS epidemic. AIDS and COVID patients often died alone. AIDS families often abandoned their sons. COVID patients passed in respiratory isolation. Care givers heroically tried to fill their void to provide care and comfort. In both cases anger and distrust were directed at the medical and research community. There was one big difference, it took 15 years for effective AIDS therapy to become available. Whereas, with COVID, an effective vaccine was developed, tested and available within a year.

The face of gastroenterology has changed dramatically over this time period. The Gastroenterology Fellowship at Hershey Medical Center began in 1973. Our first female fellow arrived in 1987. Today our Division celebrates the diversity and many hues of our attending staff and fellows more reflective of our patients. There have been wonderful advances in gastroenterology. Peptic ulcer disease was discovered to be primarily an infectious disease in the early 1980’s. Endoscopy evolved from being a primary diagnostic to a therapeutic tool, effective in staunching bleeding, and treating cholangitis. Screening colonoscopy has markedly decreased the incidence and mortality of colorectal cancer. As gastroenterologists have become endoscopists, we are at risk of reducing our practice and patients to procedures, “the colon in Room 2 is waiting for you.” These technical advances should supplement but not replace the privilege of being a clinician, serving at our special place at the bedside. Striving to cure some and comfort many.

I’m in one of my last out-patient clinics. I’m saying goodbye to Dawn, at 52 years now my longest patient. She was an angry teenager who didn’t want to be sick when I diagnosed Crohn’s disease. For years her disease dominated her life. I attended to her during multiple hospitalizations and surgeries. Fortunately, biologic therapy became available, which has put her in deep remission from debilitating intestinal and perianal disease. She told me that with prior therapy she was always aware of her Crohn’s disease, but with the biologic therapy finally, “the spigot was turned off.” I remind her that I have used her metaphor when counseling other patients about the need and benefits of more aggressive therapy. She complains about her teenage son who can’t wait to get off to college. “Oh Dawn,” I say, “you were such a difficult teenager.” We smile. We face directly to each other, her cheeks stained with tears, my eyes glistened. She promises to be more faithful with her weightlifting program at the gym to prevent osteoporosis.

“Take care of yourself.”

The looming gastroenterologist shortage

By R. Fraser Stokes, MD, FACG Chairman, PSG Practice Management Task Force

The practice of gastroenterology is being compromised by a GI physician supply-demand mismatch that is upon us now and is projected to worsen.

The December 2021 AMA physician Masterfile showed that there were 15,678 active gastroenterologists with 14,116 providing patient care. In January 2023, Physician Thrive (a UPMC-based physician wellness program) released a survey projecting that by 2025 there would be a shortage of 1630 GI physicians. This shortage issue isn’t unique to gastroenterology, but it is particularly bad in our specialty. Recent data from the recruiting firm Merritt Hawkins showed that the top 3 specialties with the highest number of job openings are neurology, psychiatry, and GI.

Several factors are driving this gastroenterologist labor shortage. First, physicians are getting older. Data from 2021 found that 51% of gastroenterologists were 55 years of age or older. In the next ten years, the average age of a practicing gastroenterologist will continue to rise.

As physicians age, the number that transition into retirement naturally increases. COVID accelerated this process. A 2021 Doximity survey of 2000 physicians found the cumulative physician retirement rate went from 4% to 10% in in the preceding year. In addition, another 21% of physicians were considering early retirement. The drive toward retirement is due to several factors, including physician discontent from personal COVID health risks, practice finance hardships, burdensome electronic health record duties, and overwhelming administrative challenges. For some gastroenterologists, a new interest in retirement came from monetizing their practice via a practice and / or ASC sale that secured their retirement savings.

A third cause of the looming physician shortfall may be tied to different work patterns for younger physicians. Their economic circumstances and desires for better work-life balance are typically different from graduating fellows of more than 10 years ago. Younger GI’s (appropriately so!) give a higher priority to off-work quality time, maternity (and paternity!) leave, shorter workdays, and less on-call responsibilities.

In addition to a reduced supply of GI docs, we have seen an increased demand for gastroenterology care. The change in national colorectal cancer screening guidelines is an important part of this increased demand. Average risk screening colonoscopy is now recommended starting at age 45, instead of 50, and screening for healthy individuals is now often continued until age 85, instead of 75. Another factor driving increased demand for our services is the obesity epidemic, as this has led to higher incidence of GERD and nonalcoholic fatty liver disease.

As we increasingly face the GI physician shortage, this can lead to problems with quality of care. In many GI practices, wait times for consults and procedures are becoming longer. This results in many patients not getting care when needed and potentially worse outcomes. This problem is amplified even more in underserved rural and inner-city urban areas. Many GI physicians have been forced to work harder with longer hours to meet this heightened demand which results in significant physical and mental stress. This is not only bad for us, but also bad for our patients.

Ultimately, the solution to this problem is increasing the supply of gastroenterologists by funding a greater number of fellowship positions. Recently Congress approved funding for 1000 postgraduate medical training positions. Some of these will be allotted to GI, but many more GI fellowship spots will be needed. In the meantime, other strategies to cope with our increasing manpower shortage are being activated. Many practices are using more advanced practice providers (physician assistants and nurse practitioners) for care responsibilities as part of a GI team model. This permits gastroenterologists to spend more time on procedures and more clinically challenging cases.

Gastroenterology practices are committing to physician retention in several important ways. One is to reduce physician administrative responsibilities by joining supergroups or hospital systems where skilled business professionals assist with compliance, revenue cycle, recruitment, personnel, accounting, benefits, etc. Another strategy is to prioritize physician wellness practices and introduce measures to prevent burn-out. Some groups are intentionally making it easier for older GI doctors to stay in the workforce by increasing schedule flexibility, allowing for less call, shorter hours, part time work, and job sharing.

Hopefully, technological advances to reduce work demand, for example via effective blood testing for colorectal cancer screening or using artificial intelligence to streamline documentation. However, in the near term, the gastroenterologist supply-demand mismatch is an increasingly important issue for those in our profession. Meeting this challenge will not be easy but will need to be proactively dealt with over the next decade.

PSG Mentorship Program

We are looking for PSG members who are interested in serving as mentors to trainees and early-stage GI practitioners. This promises to be a mutually rewarding activity. Time commitment is variable, but interaction between mentor and mentee should be at least quarterly. In addition, the mentor should be willing to have contact (by email, text, telephone call) on an as needed basis.

Please contact Audrey Dean (adean@pamedsoc.org) or David Diehl (dldiehl@geisinger.edu) if you are interested in becoming a PSG Mentor or for any questions. Thanks for your participation in this!

Disease specific categories

Barrett’s esophagus

Eosinophilic esophagitis

Inflammatory bowel disease

Gastrointestinal Motility

Functional bowel diseases / GI Psychology

Pancreaticobiliary diseases

Bariatrics and Nutrition / Endobariatrics

Hepatology

Interventional endoscopy

BOARD&STAFF

Other categories

Women’s GI Health

PRESIDENT

Diversity and Inclusivity in GI

David L. Diehl, MD

Private practice issues and early practice

Advocacy

Clinical trials

Geisinger Medical Center

Gastroenterology/Nutrition

570-271-6856

dldiehl@geisinger.edu

Clinical research

@DavidDiehlMD

Invention and Innovation in GI

Work/Life Integration

1st Vice-President

Karen Krok, MD

Penn State Hershey

Gastroenterology

(717) 531-4950

kkrok@pennstatehealth.psu.edu

TREASURER

Neilanjan Nandi, University of 215-662-8900

Neilanjan.Nandi@pennmedicine.upenn.edu

@fitwitmd EDITOR

David L. Diehl, Geisinger Medical

Gastroenterology/Nutrition

570-271-6856

dldiehl@geisinger.edu @DavidDiehlMD

LEGAL CORNER

Richard E. Moses, DO, JD

Restrictive Covenants

Employment contracts generally set forth the terms and conditions for the employee’s services to the employer. While most of the terms are easy to understand (e.g., salary, benefits, vacation), contracts for many industries, including those for healthcare providers (HCPs), include “restrictive covenants” which are not self-explanatory. This article will explain restrictive covenants in general and explore their current status in the United States, especially as they apply to HCPs.

A restrictive covenant is a condition that restricts, limits, prohibits, or prevents the actions of someone an individual named in an enforceable agreement (employment contract). The phrase “restrictive covenant” is a general catch-all term. It encompasses non-competition, non-solicitation of patients and employees, and nondisclosure provisions, in addition to other provisions, that are frequently included in standard employment contracts, or ownership agreements., and ancillary agreements to the employment relationship. The most common restrictive covenants causing HCPs concern are noncompete and non-solicitation provisions restricting the HCP’s conduct during and after employment. As a general rule, non-solicitation and noncompete provisions are usually closely associated in healthcare employment contracts.

Non-solicitation Provisions

Non-solicitation clauses restrict the employee’s post-employment activities. The purpose of the a non-solicitation clause is to limit the employee’s ability to solicit patients, employees, and referral sources,

which would otherwise result in a loss to the employer. These clauses need to be narrowly worded to be enforceable since patients have the right to choose their own HCP. “Solicitation” can be difficult for the employer to prove because i It requires an affirmative action by the employee. A patient seeking out the ex-employee HCP does not constitute a violation of the non-solicitation clause without the employee’s affirmative action.

Noncompete Provisions

Noncompete clauses restrict the employee from practicing within a defined geographic scope/area and timeframe after leaving the practice. The restricted geographyic area may be a radius of a certain number of miles from the employer’s office or facility, or even a larger area in rural situations. Noncompete clauses are intended to protect the employer/ practice/health system from the employee’s actions once employment terminates. Depending on the wording of the noncompete, the HCP may be restricted from completely practicing medicine or it could be a targeted restriction of a particular area of specialty practice.

protect the employer’s legitimate interest, (2) does not cause undue hardship to the employee, and (3) is not contrary to public interest. For the employer, protectable interests include employees, practice relationships with patients, referral sources, confidential information, and trade secrets learned by the employee during employment.

Laws and Restrictive Covenants

There is a recent trend against restrictive covenants. Some states have started banning or restricting restrictive covenants. California, North Dakota, and Oklahoma have state laws completely prohibiting restrictive covenants. Twenty-one other states have laws prohibiting restrictive covenants to one degree or another.

Reasonable

noncompete

clauses are enforceable. Courts determine enforceability based on the reasonableness of duration (time limit) and scope (geographic limitations). The more reasonable the restriction, the more likely the Court will enforce it. Commonly used restrictions in Pennsylvania HCP employment contracts are 2 years (timeframe) and a 5 mile radius from the original place of employment (or greater in rural locations), although these parameters vary from contract to contract. A noncompete is enforceable if it: (1) is necessary to

Unfortunately, Pennsylvania is not one of those states. PA House Bill 681 would have prohibited enforcement of noncompete covenants in HCP employment agreements. The bill was unfortunately removed from the table in September 2022. There is nothing pending currently in the Pennsylvania State Senate or House or Representatives. At this time, restrictive covenants have been held to be enforceable in Pennsylvania as to HCPs, provided the covenant is protecting a legitimate business interest and its scope is reasonable in both time and geography.

However, a number of states have laws prohibiting restrictive covenants. California, North Dakota, and Oklahoma have state laws completely prohibiting restrictive covenants. Other states have laws prohibiting restrictive covenants to one degree or another. These include: Alabama, Arkansas, Colorado, Delaware, D.C., Florida, Illinois, Indiana, Iowa, Kentucky, Massachusetts, Nevada,

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.

Zeba Hussaini, MD

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

“Difficult” benign esophageal strictures: what’s new and what to do

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

BougieCap

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

BOARD&STAFF

PRESIDENT

TREASURER

STAFF

David L. Diehl, MD

David L. Diehl, MD, FASGE, AGAF

Geisinger Medical Center

Gastroenterology/Nutrition

570-271-6856

dldiehl@geisinger.edu

@DavidDiehlMD

1st Vice-President

Karen Krok, MD Penn State Hershey

Gastroenterology

(717) 531-4950

kkrok@pennstatehealth.psu.edu

@klkrok

SECRETARY

Manish Thapar, MD

Thomas Jefferson University Hospital

(215) 955-8900

manishthapar@yahoo.com

Neilanjan Nandi, MD, FACP University of Pennsylvania

215-662-8900

Neilanjan.Nandi@pennmedicine.upenn.edu

@fitwitmd

EDITOR

Cindy Warren Marketing Coordinator

Jessica Winger Meeting Manager

Tom Notarangelo Design Manager

David L. Diehl, MD, FASGE, AGAF

David L. Diehl, MD Geisinger Medical Center

Gastroenterology/Nutrition

570-271-6856

dldiehl@geisinger.edu

@DavidDiehlMD

ADMINISTRATIVE OFFICE ASSOCIATION EXECUTIVE

Audrey Dean

(717) 909-2633

info@pasg.org