Description: In Appreciation for the Significant and Enduring Contribution to My Career - ASGE Endoscopic Training Experience at Weil Cornell / New York Presbyterian Hospital, New York

Preface

I am humbled and excited to share my experiences with the ASGE Endoscopic Training at Weil Coneil / New York Presbyterian Hospital NY, USA on Jan 31^st 2024.

This training was delayed due to the challenges posed by the Covid-19 pandemic, and with the training program adapting to various modifications until 2022. Given New York's status as the epicenter of the pandemic and the stringent precautions taken by institutions in response to ongoing spikes, Weill Cornell implemented strict measures, including a ban on external rotations and volunteer roles from other centers.

Overall Experience at Weil Coneil / New York Presbyterian Hospital NY

I consider myself incredibly fortunate to have been chosen for the ASGE Endoscopic Training award, particularly at such a prestigious institution This center is truly a state-of-the-art facility, a beacon of excellence in the field. My experience during the rotation has been nothing short of exceptional.

The support and assistance I received from the faculty of the Division, the residents in General GI, and the fellows were invaluable. I am deeply grateful for their hospitality, especially from my mentor, Dr. David Carr Locke, whose mentorship has profoundly impacted my career trajectory.

The staff, including the nurses and endoscopic technicians, are highly trained and equipped to manage any complication that may arise. I have been thoroughly impressed by the commitment of the entire division to patient care. This experience has not only improved my technical skills but has also taught me the importance of taking necessary precautions before and after procedures. It has underscored the significance of the advanced endoscopist's expertise and skillfulness in patient outcomes.

Overall, my time here has been immensely educational, surpassing my expectations. I am leaving with a wealth of knowledge and a newfound appreciation for the intricacies of advanced endoscopy.

During the period from October 23 to January 24, I had the privilege to observe and learn a variety of advanced endoscopic procedures. The experience has significantly enhanced my confidence in advanced endoscopy, exposing me to procedures that were previously unavailable to me in Pakistan. Witnessing these refined techniques firsthand has been truly awe-inspiring and has provided valuable insights into their importance for patient care.

I outline the specific details of each procedure I observed during this duration:

1) ERCP

I observed a sizable number of procedures, with one standing out as the most common. ERCP, which I observed on more than fifty times during my stay, typically lasted between one to two hours, depending on its complexity and the time required for cannulation. The duration also varied based on the proficiency of the endoscopist.

Despite its frequency, observing this procedure alone proved invaluable. It provided me with insight into handling complex cases, mastering the intricacies of cannulation, and learning the necessary steps to take in the event of failed cannulation. Standing alongside Dr. Carr Locke, I witnessed firsthand the precision and efficiency with which he performed these procedures, even in challenging cases such as Post Liver Transplant Strictures, where cannulation presents a considerable challenge.

The experience taught me not only how to navigate through complex cases but also how to adapt and persevere when faced with initial difficulties in cannulation. This learning has left a profound impact on my skill development and will undoubtedly prove beneficial in my future practice in Pakistan. I am confident that the knowledge and techniques I acquired through observing these procedures will enhance patient care in Pakistan, providing me with the confidence and capability to manage challenging situations effectively.

2) EUS

Next on my rotation, EUS was the second most procedure I observed during my time there. EUS is often performed either independently or in conjunction with ERCP, highlighting the versatility and expertise of advanced endoscopists in this field.

Witnessing numerous EUS procedures has profoundly transformed my understanding and confidence in this complex area of endoscopy. Through continuous observation, I gained a deep appreciation for the intricacies of EUS, particularly in identifying key anatomical landmarks essential for successful procedure execution. Understanding how the pancreatic duct appears radiologically and recognizing liver structures were among the fundamental skills I honed during these observations.

I learned firsthand how EUS techniques enable clinicians to perform fine needle aspiration biopsies and effectively drain percutaneous fluid collections. I observed instances where EUS served as a valuable alternative when ERCP was unsuccessful, the papilla was inaccessible, or when anatomical alterations posed challenges.

Furthermore, I was fascinated by the therapeutic applications of EUS and its evolving utility in clinical practice. Witnessing these procedures being performed efficiently, often autonomously, highlighted the precision and expertise required in this field. Whether conducted independently or in conjunction with ERCP, each observation enriched my understanding of EUS and its therapeutic potential.

Undoubtedly, the knowledge and skills I acquired during these observations will be invaluable upon my return to Pakistan. The ability to accurately identify landmarks for biopsy and utilize EUS for therapeutic purposes will undoubtedly enhance patient care in my home country. I am grateful for the enriching experience and confident that it will translate into more effective and precise patient care practices in Pakistan.

3) POEM

I was pleasantly surprised to discover the extensive applications of POEM, especially considering that my prior exposure to it had been solely through YouTube videos. Witnessing it firsthand provided me with a deeper appreciation for its versatility and effectiveness in clinical practice. This experience reinforced the importance of hands-on learning and the invaluable insights gained from direct observation in a clinical setting.

It was truly a remarkable experience to witness the precision and skill with which Dr. Carr Locke performed this challenging and intricate procedure. Standing alongside him and observing this complex process felt like a dream come true.

During these observations, I learned about the technique of submucosal tunneling and its effectiveness, particularly in cases where traditional dilatations prove ineffective. This procedure typically lasted around 2 hours, and while I gained a good understanding of the different steps involved and when to cease, I acknowledge that mastering it will require more time and exposure.

Despite witnessing approximately 15 procedures, I recognize the need for further learning and observation to fully grasp the nuances of this intricate procedure. Given its time-consuming nature, often occupying an entire day for a single procedure, I am aware of the importance of patience and persistence in mastering it.

Each observation has been invaluable in deepening my understanding, but I remain eager to continue learning and refining my skills in this challenging aspect of endoscopy.

4) Single Ballon/ Double Balloon Enteroscopy

My exposure to these two procedures has been through my readings, as they were not commonly performed nor available in Pakistan. Observing them firsthand during my rotation provided me with invaluable practical insights that cannot be gained from reading alone. This experience underscored the importance of international exposure and the opportunities it presents for expanding one's knowledge and skill set beyond what is available in one's home country.

During my rotation, I had the opportunity to observe the wide-ranging utility of Double Balloon Enteroscopy, particularly in identifying lesions within the small intestine and facilitating their treatment. Witnessing its effectiveness in locating and coagulating lesions in cases of occult gastrointestinal bleeding was truly enlightening.

I learned how to effectively locate tumors and polyps using this technique, which proved to be invaluable.

Dr. Carr Locke's precision and expertise in each advanced procedure never ceased to amaze me. His skillful execution served as an inspiration, igniting within me a desire to follow him and become an expert endoscopist in my own right. His mastery of these techniques motivates me to strive for excellence and proficiency in my future practice.

Other Procedures Observed

My learning experience during my rotation was continuous and diverse. In addition to the procedures mentioned earlier, I had the opportunity to observe several other advanced endoscopic techniques, including:

1. Esophagogastroduodenoscopy (EGD) with Endoscopic Mucosal Resection (EMR): This procedure involves using an endoscope to visualize the esophagus, stomach, and duodenum, with the added capability of performing mucosal resection to remove abnormal or cancerous tissue.
2. Colonoscopy with Balloon Dilatation: Colonoscopy with balloon dilatation is a technique used to widen strictures or narrowing in the colon by inserting and inflating a balloon at the site of obstruction.
3. Percutaneous Endoscopic Jejunostomy (PEJ) Placement: PEJ placement is a procedure where a feeding tube is inserted into the jejunum (the middle part of the small intestine) via endoscopy, typically used for long-term nutritional support in patients unable to tolerate oral feeding.
4. Colonoscopy with EMR: Similar to EGD with EMR, colonoscopy with EMR involves using an endoscope to visualize the colon and rectum, with the added capability of performing mucosal resection to remove abnormal or cancerous tissue.

Each of these procedures provided me with valuable insights into the diverse applications of advanced endoscopy in diagnosing and treating gastrointestinal disorders. The opportunity to observe and learn from these procedures further enriched my educational experience and prepared me for future practice in the field of endoscopy.

Impact of Learning 

I am confident that the experience and knowledge gained during my rotation will greatly benefit my practice in Pakistan, particularly in performing procedures like ERCP. This rotation has equipped me with the skills to manage complexities and challenges effectively, enhancing patient care and outcomes.

I am eager to explore how industry partnerships can support the expansion of advanced endoscopic procedures in Pakistan. Procedures such as POEM (Peroral Endoscopic Myotomy) have the potential to significantly improve patients' quality of life, and I am keen to explore ways to introduce and develop these techniques in my home country.

I strongly believe that a large number of patients in Pakistan stand to benefit from advanced endoscopic procedures, and if given the resources and support, I am committed to developing these services to impact a wider community and population. I am enthusiastic to share my learning and experiences with my fellow colleagues in Pakistan, emphasizing the importance of adopting advanced endoscopy as a specialty and highlighting the role of ASGE in supporting this endeavor.

Future Directions

My observation of the wide application and emerging role of advanced endoscopy during this program has been truly life-changing and enriching. It has ignited a newfound passion within me for this field, increasing my interest tenfold in pursuing further training and specialization.

Through this experience, I have gained significant confidence in performing procedures like ERCP and EUS. Witnessing and participating in complex cases has equipped me with the skills and precision necessary to effectively manage demanding situations. I am confident that this newfound expertise will elevate patient care standards and benefit patients in Pakistan, as I apply the pearls of wisdom garnered from this invaluable experience.

The opportunity to consider applying for the ASGE match in the future feels like a natural progression, given my enhanced confidence and passion for advanced endoscopy. I am excited about the prospect of furthering my training and contributing to the advancement of patient care in this rapidly evolving field.

I extend my deepest gratitude to the ASGE staff, particularly Talin Artinian and Ed Dellert, for their exceptional support and encouragement throughout my journey.

This achievement would not have been possible without the generous assistance of our sponsor, Fujifilm.

I am extremely grateful to the entire ASGE staff for trusting me. I strived to give my best, and none of this would have been possible without your understanding and cooperation.

Thank you for such a great & everlasting contribution to my career.

Sincerely,
Talal Bhatti
Fellow Gastroenterology
January 31, 2024