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future of GI

Discussion in 'Gastroenterology' started by pakijiga, Apr 24, 2004.

  1. pakijiga

    pakijiga Member
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    i was just curious what people feel about the future of GI after the invent of virtual colonoscopy replacing conventional colonoscopy within the next 5 years.
    most of the money GI docs make is through screening colonoscopies and with this gone i see a huge paycut in the next few years.
     
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  3. Docxter

    Docxter Senior Member
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    GI docs are unwise if they think virtual colonoscopy will decrease their business. By virtue of virtual colonoscopy, hopefully more people will actually be screened (now most people don't get screened) and more polyps will be found and the GI docs can then remove them. In the few hospitals that have active virtual colonoscopy programs, there has been no decrease in the number of optical colonoscopies and in one that I know, they have actually increased due to the increased referral post virtual colonoscopy.

    A note on the side, there are some unethical colonoscopists out there. One GI attending once told me that his group does biopsies of normal appearing colonic mucosa even if no polyp is seen, since the reimbursement between a diagnostic colonoscopy (only looking) and therapeutic colonoscopy (looking + tissue sampling/polypectomy) is quite dramatic and "taking a look at the colonic mucosa under the microscope is not a bad idea anyway". This way, they "optimize" their reimbursements.

    Optical colonoscopy will not go away at all. There "may" be a decrease in screening optical colonoscopy (or maybe not), but there will be an increase in therapeutic colonoscopy. And for those few unethical GI docs, they'll have to shift their focus to therapeutic colonoscopy for patients who actually need one.

    The bottom line is that there is enough work to go around. Do what you like and enjoy.
     
  4. AJM

    AJM SDN Moderator
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    Virtual colonoscopy in it's current form will not replace standard colonoscopy as a colon CA screening tool. I'll explain why.

    There are two reasons why people hate colonoscopies. They don't like taking the bowel prep, and they don't like getting a tube in their behind and getting insufflated with air. The big plus of standard colonoscopy is that patients are under conscious sedation, so with all the versed on board they typically don't remember the part where they have the tube in their rectum. The other plus is that if an abnormality is seen, it can be biopsied in the same session with no additional procedures.

    Now take virtual colonoscopies. To do a virtual colonoscopy patients have to take the same bowel prep as you would with standard colonoscopy. Hmmm, doesn't sound very good yet does it? Next, when they go to get it done, they have to get a rectal tube placed to get insufflated with air for the scan. But with this procedure, the patient gets no sedation, so they remember all the nice details of getting a tube in their rectum. Wait, didn't I say that this was the second bad thing about standard colonoscopies? To top it all off, if an abnormality is seen, the patient has to go to a gastroenterologist and get a standard colonoscopy to get biopsied, where they have to repeat all the bowel prep, etc.

    Virtual colonoscopies have been shown to be as sensitive as colonoscopies in picking up polyps, however they have not yet been shown to be any more cost-effective. Most patients I know would rather go straight to having one colonoscopy where they can get biopsies if they are needed rather than having the possibility of having to go through two separate tests, once the details of the virtual colonoscopy are explained to them.

    Even if virtual colonoscopies replaced standard colonoscopies as a screening tools, GI docs would never go out of business. This is because all of the abnormal virtual colos would have to get scoped, which would be a very large percentage of studies. Plus there are all the follow up colos after CA resections and on high risk patients (ie previous CA, multiple polyps, etc), EGDs, ERCPs, etc. So IMO the future of GI is still quite bright.
     
  5. Docxter

    Docxter Senior Member
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    1. The air insufflation part of virtual colonoscopy is less bothering for patients because in most protocols, the patient actually does the insufflation and controls the amount of air, so less air is actually insufflated. The tube for insufflating air is also very thin, thinner than a rectal examiner's finger or a colonoscope. It's as thick as a 12F Foley, so it causes minimal discomfort.

    2. In most (but not all) studies of virtual colonoscopy which have addressed the issue of patient comfort and satisfaction, most patients had stated that they preferred the virtual over optical colonoscopy in terms of discomfort and disruption to their daily schedule. In a minority of these studies, they were considered equal. I do not know of a metanalysis on this topic though. So your statement that the people who you personally know, would prefer optical colonoscopy is just exactly that, just your own anecdotal opinion.

    3. There is much research being done now in the radiology community to eliminate the need for a bowel prep (the newer ones only require a few hours NPO and semifluids the day before) by different stool tagging methods and also eliminate the need for insufflation of air. We'll have to see how this turns out in the next few years. Work is also being done in Europe on MRI virtual colonoscopy to eliminate radiation.

    4. An advantage of virtual colonoscopy is that patients also get a free screening of their other intraabdominal organs as well, including liver, gallbladder, pancreas, adrenals, lymph nodes, retroperitoneum, aorta (for AAA screening-something that will become mainstream very soon), kidneys, bladder, uterus, etc. We all have heard of anecdotes of how someone's life was saved by these total body screening procedures. However, I agree that the cost-effectiveness and utility of such screening has not been proven or recommended, and more studies are needed.
     
  6. AJM

    AJM SDN Moderator
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    If a virtual colonoscopy procedure is developed that eliminates the need for a bowel prep, then it will become much more popular. Granted, that's assuming the sensitivity and specificity is the same. The virtual colos that have been studied (such as the one published in the New England Journal this year), have involved taking the full bowel prep (ie Golytely).

    Actually, I forgot to mention this as a DISadvantage in my previous post. Full body scans are not good screening tools, and will often lead to unnecessary additional testing, including potentially dangerous procedures. One of the reasons why it is not covered by insurance companies is because these shotgun approaches to "screening" lead to further expensive diagnostic workups with no evidence of any survival benefit. There was recently a case report at my medical center of a healthy patient who underwent a full body scan, and had some various minor abnormailities. Because these abnormalities were seen on the scan, Medicare had to pay for the additional workup. Her subsequent workup included a liver biopsy, cardiac catheterization, EGD, renal biopsy, and cholecystectomy (for asymptomatic gallstones). Her liver biopsy was also complicated by a bleed, for which she had to be hospitalized for a few days. The complete workup turned out to be completely negative, and cost Medicare over one million dollars. Now I know that this is just one patient, but it has been shown that these tests cost the healthcare system more money than they save through so-called "preventive" medicine. They can also put the patient at risk by forcing your hand to do a potentially dangerous procedure on a patient which otherwise would not have been indicated. This puts us at a somewhat ethical dilemma with virtual colos -- what are we to do with the additional information that is obtained in the study? Even if virtual colos turned out to be more cost-effective than the standard colos, what about all the additional findings -- there will be more patients getting liver biopsies for benign hemangiomas than ever before. IMO this is another reason virtual colos in their current form will put too much of a strain on the health care system to be covered by insurance companies.
     
  7. AJM

    AJM SDN Moderator
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    I forgot to mention this as well. It's true that the studies I've seen have demonstrated a slight preference (not overwhelming) by patients for the virtual colo over the standard colo. However, all of these studies assume that these patients would get one study or the other. In reality, as many of a third (or more) of the patients in the virtual colo group will have abnormal studies, so would have to get a standard colo as well. None of the studies that I'm aware of address this issue and how the fact that a large proportion of the patients have to get two studies affect their perception of comfort and amount of schedule disruption. I would argue that getting two studies would be more disruptive, and the patients with the abnormal virtual colo results would say that they would have preferred just going straight for the standard colo. Given the very modest patient preference for virtual colos over standard in previous studies, I would bet that if the above were taken into account in a study, we would find either equal patient preference overall, or preference leaning toward standard colos.
     
  8. june015b

    june015b Member
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    -The virtual colonoscopy is not proven to be cost-effective, yet. yeah, it's expensive.
    -Also, the total cost of screening increases by pursuing other studies for EXTRACOLONIC FINDINGS (i.e. asymptomatic adrenal cyst or small lung nodule..you don't screen everyone for lung cancer by CT-scan).
    -It still requires the same bowel prep+contrast and an insertion of rectal tube for insufflation of bowel with air/gas.
    -VT is not effective in detecting small polyps, flat polyps, hyperplastic polyps. For a larger size of polyp, it is similar to optical colonoscopy.
    -you do get a large dose of radiation
    -a patient with abnormal VT needs to be fully scoped. focal advanced lesion or cancers are still commonly seen in smaller polyps <5mm. I wouldn't wait another 3 to 5 years if a small polyp was seen on VT (as suggested by the NEJM paper 12/2003). I would want it out.
    -Vt will increase the amount of therap colonoscopies
    -Who knows, VT may be picked up by GI from Rad in the future (like MRI and CT of head by neuro..)

    GI is evolving fast. Especially, the endoscopic surgery is evolving fast. The lifestyle is still great compared to cardiology or others. If you think EGD and colonoscopy are onlything about GI, you are outdated and wrong.

    If you are intersted in endoscopic surgery, Gi does many procedures such as EGD, ERCP, Endoscopic ultrasound, capsule endoscopy, diagnostic and therapeutic colonoscopy, liver biopsy, percunaeous cholecystomy, PEG, banding, endoscopic laser therapy, chromo-endoscopy (using dye to coat the mucosa for better visualization of irregularities and lesions), endoscopic fundoplication, endoscopic assisted laser treatment of Barrets, pancreatic drainage of psuedocyst, and endoscopic piecemeal resection of gastric/duodenal ulcers..many more. There many more emerging tech's. More of Gen. surgery procedures and radiographic studies will be pick up by GI in the future.


    MSIV (15 more days...)
     
  9. Goofy

    Goofy Senior Member
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    While the immediate future of gi looks bright, I am less enthused as the above posters about the distant future.

    The reason being that many of the procedures that gi docs do are relatively easy. This means it is amenable to being usurped by primary care docs. Since gi relies heavily on the primary guys/gals for work, its only a matter of time before primary docs realize they are quite capable of completing a lucretive 5 minute endoscopy and even colonoscopy.

    Many primary docs, both IM and FM did sigmoidoscopy in the past. It is not done quite as much now having fallen out of favor. Many would argue that colonoscopy is easier since you are working on a sedated patient. Primary care docs are getting reamed and will eventually realize that many procedures they refer for, can actually be done at home.

    I realize many in the gi field will attempt to debunk my argument, but what I have described is actually being done! There are plenty of IM and FP practices carving out practices with particular niche procedures in mind. They are doing colonoscopy and endoscopy right now!

    To further compound the problem, colorectal surgeons have made these procedures their bread and butter as well. Right now I see plenty of work in the immediate future, but that might rapidly change, especially with family medicine on the brink of extinction. These fields will naturally look for ways to survive, and heaven forbid, thrive.

    One barrier might be malpractice, a common argument brought up by the gi guys. Having spoken to many primary people doing colonoscopy and endoscopy, they have indicated that malpractice barely budged. What has changed however, is a huge bump in salary.

    Unfortunately the nature and ease of gi procedures mark them as clear targets for suffering primary care docs, and I see a clear and present danger for gi as a result.
     
  10. june015b

    june015b Member
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    Yeah, PC will pick up everything--from echocardiogram, stress test, ultrasound, derm skin biopsy, bronchoscopy, obsterics, and x-ray in the future. These are relatively easy, too. The medicine will be less subspecialty driven..NOT. Also, when was the last time you saw a patient reffered to a surgeon for a CRC screening?
     
  11. Kalel

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    I agree with the previous poster. There are many things that primary care docs could do, but it just wouldn't be time-efficient or cost effective for them to do. It doesn't make any sense for a primary care doc to do one colonoscopy per week with the cost of equipment, training of staff, meds on premises, etc. There may be a few that try to "specialize" in doing these sort of procedures, but ultimately, you can't have a PCP running a colonoscopy only clinic; malpractice, state licensing boards, and insurance co's wouldn't allow it. Actually, insurance co's seem to be pressuring medicine to become further specialized these days, by doing things like declining reimburement for physicians not in a particular speciality to even write medicines and follow up for certain conditions.

    I don't agree with the last statement of the previous post though, I do know that some surgeons have been doing endoscopic procedures such as colonoscopies and bronchoscopes just because they are easier to do and reimburse better then whatever they are trained to do.
     
  12. Goofy

    Goofy Senior Member
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    Many primary care docs are doing exactly what your list suggest, save the obstetrics. I don't think there is going to be a mad rush on what might financially bankrupt em.

    In fact, there are procedure 'fellowships' popping up that provide specific training in many of these procedures. Primary care docs wield a very powerful sword, being the gatekeeper. Once they realize how easy many of these lucretive procedures are, subspecialists will be clamoring.

    In the case of the gi doc, we might see what happened before endoscopy/colonoscopy was mainstream, actually utilizing that medicine degree by practicing primary care to establish a nice pipeline.
     
  13. Goofy

    Goofy Senior Member
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    State licensing boards have nothing to do with a physician proficient in a procedure, actually doing the procedure. I might argue central lines are more challenging than endoscopy. I don't see state boards worried.

    Further, your argument about what insurance company will and will not allow is ridiculous. Maybe they will stop allowing cardiologists to do echos, or pulmonologists from doing spirometry.

    In point of fact, primary care ARE doing these procedures, whether you think they are 'allowed' to or not. In most cases, the difference in premiums is minimal when taking into account the numbers to insure a private practice.

    Perhaps the most assanine part of your argument is cost. I suppose primary care docs would much rather spend an hour seeing a capitated patient for 15 bucks a year than perform a 1000 dollar colonoscopy. Go figure.

    The primary care doc has better access to the patients requiring these procedures than gi guy. As a gatekeeper, they might decide which niche procedure they want to become proficient and rich on.

    Feel free to ignore what has been happening in medicine, but don't expect the rest of us to believe the garbage your peddling.
     
  14. novacek88

    novacek88 Senior Member
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    Except you forget that insurance companies will do whatever it can to avoid the lawyers. While there are plenty of competent PCPs doing colonoscopies, GI's are better trained in general due the volume and training they have received performing these procedures. Thus, insurance companies are aware patients are generally at less risk when receiving these procedures from a trained specialst than a PCP.

    Just because PCP's are doing these procedures, it doesn't necessarily mean there aren't enough procedures for specialists. There will always be people who will seek procedures from the most well trained physicians. There are plenty of PCP's who perform cosmetic procedures but you don't see plastic surgeons and dermatologists complain.

    You also failed to account for geography. Many PCPs who perform procedures typically performed by specialists practice in rural and less populated areas in which they are not competing with specialists. Less populated areas have difficulty employing specialists. Why do you think newly minted GI's can receive starting salaries with bonus in the 500K range in smaller cities.

    But you have to account for risk as well. PCP's are not stupid. They are not going to perform a procedure they are not well versed in. They could potentially harm their patient and risk being sued. Also, if a physician is seeing patients under capitated plans then it's likely he will also see them for procedures so you can imagine what those HMO's reimburse for a colonoscopy; it's probablyl not close to a 1000 dollars.

    That's not likely to happen once those primary care physicians are already in practice. Most PCP's who perform these procedures were those who chose to attend a residency which allowed them the opportunity to perform a large volume of these procedures and these programs are rare. It's very unlikely you will see an experienced physician decide he or she wants to do a lot of colonoscopies and receive the type of training to qualify them in the middle of their career. They just won't receive the training and volume that GI fellows and some PCP residents receive.

    I know this is an old post but it's this type of garbage that I unfortunately have to refute to clear up myths regardining GI.
     
  15. Wallachia

    Wallachia Member
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    November 14, 2006
    Prospects
    New Tests, New Future for Doctors
    By GINA KOLATA

    Gastroenterologists are worried about their future.

    The problem, as some of them see it, is that they have become so dependent on using colonoscopy to screen for cancer that many do little else. But the advent of new methods of detecting colon cancer could shove them out of the screening business.

    If that happens, what will gastroenterologists do? A committee of the American Gastroenterological Association says it is time to think about this possibility.

    It would not be the first time that the profession has had to change.

    A decade or so ago, gastroenterologists spent much of their time putting scopes down patients' throats and into their stomachs to look for ulcers. But over the last 20 years, for reasons that are not entirely clear, Helicobacter pylori, the bacterium that causes most ulcers, began to disappear in this country. Patients with chronic ulcers became less and less common.

    Asked how much chronic ulcers have diminished in incidence, Dr. Robert S. Sandler, chief of the division of gastroenterology and hepatology at the University of North Carolina, replied, "I can't give you a statistic, but a lot."

    But by chance, as endoscopies waned, a new test surged. This time, the focus was on the other end of the intestinal tract, the colon. By the late 1990s, people over age 50 were reporting to their doctors for screening colonoscopies, in which a gastroenterologist would thread a scope into the colon to look for cancer or for polyps, which can turn into cancer.

    Medical groups recommended colon cancer screening. In 2001, Medicare said it would pay for the tests. And suddenly, gastroenterologists were doing colonoscopies almost full time.

    The number of colonoscopies among Medicare recipients increased by 42 percent from 2000, when Medicare would pay only if patients were likely to have polyps or cancer, to 2002, when Medicare agreed to pay for colonoscopies as a screening test.

    In 2000, Medicare paid for 2,211,925 colonoscopies; by 2002 the figure had risen to 3,150,738. Soon, demand was so great that no matter how many colonoscopies doctors did, there were long lines of patients waiting to be screened.

    Those who needed to see gastroenterologists for other reasons often had long waits for appointments, said Dr. Douglas Rex, a gastroenterologist and professor of medicine at the Indiana University School of Medicine.

    Gastroenterologists enjoy doing colonoscopies and believe they are important, because colon cancer is the most preventable cancer, Dr. Rex said. And, he added, there is a financial disincentive for treating patients with diseases like hepatitis or conditions like irritable bowel syndrome, which often require extensive, and poorly compensated, discussions with patients to help them cope.

    Now, though, the colonoscopy era may be coming to an end, the gastroenterology association's Future Trends Committee said. The panel predicted that before long, most colon cancer screening could be done by radiologists with CT scans or even by general practitioners who send stool samples off for tests looking for cancer cells. Or patients may swallow a pill containing a camera that will show images of the colon, a method that is being tested now in the upper gastrointestinal tract.

    So far, Medicare and other insurers do not generally pay for the CT scans to screen the colon, but that is expected to change as the technology improves.

    With a CT scan, as with colonoscopies, patients have to take powerful laxatives ahead of time to cleanse their bowels. But for the actual test, they simply lie down and hold their breath for about 10 seconds, exhale, then hold their breath again while a scanner X-rays their colons, creating detailed, three-dimensional images.

    With traditional colonoscopy, patients are sedated while a doctor threads a long tube into the colon. It takes about half an hour to examine the colon's walls. Then the patients wait in a recovery room for about an hour as the sedative wears off.

    Of course, if CT scans or other screening methods replace colonoscopy, the very nature of gastroenterologists' practice will be altered, said Dr. Timothy Cragin Wang, chief of the division of digestive and liver diseases at Columbia University Medical Center and the chairman of the gastroenterological association's committee. And, he added, "obviously it has economic consequences."

    "Things change very quickly," Dr. Wang said. "Dependence of a specialty on a single procedure is always a concern."

    His committee suggested that gastroenterologists think about what else they might do. Maybe obesity treatment, the group said, or perhaps more of a focus on liver disease or actually treating colon cancer instead of just finding it.

    Or maybe gastroenterologists will not have to cede CT screening to radiologists after all. Why couldn't a gastroenterologist read a CT scan of the colon? If that is the direction they want to go, gastroenterologists can look to cardiologists for inspiration, Dr. Wang added.

    In cardiology, when angiograms were developed to look at the heart, cardiologists invented a new subspecialty to do those tests themselves. They could have let radiologists take over angiography, but they didn't.

    Now these interventional cardiologists are expanding, going beyond the heart to blood vessels all over the body, putting stents into carotid arteries that feed the brain and into blocked blood vessels in the legs.

    "There are big political battles between the medical societies over who controls imaging," Dr. Wang said. "Gastroenterologists should be involved in making the decisions on which tests should be done. They should be aware of the technology and how to use it in order to ensure that patients get the best possible care."

    As the battle over colon cancer screening gets going, Dr. Wang said, "I would certainly use cardiology as an example."

    Not everyone would agree that the colonoscopy era is coming to an end. Those CT scans, sometimes called virtual colonoscopies, are not necessarily going to replace most traditional colonoscopies, some skeptics say, and if a CT scan or one of the more futuristic tests does find a polyp, the patient will still need a colonoscopy to take it out.

    "Dire warnings never happen," said Dr. James T. Frakes, a gastroenterologist in Rockford, Ill., and past president of the American Society for Gastrointestinal Endoscopy. "I think it always makes sense to look forward, but physicians, just by nature, are worriers. They can get so wrapped up in the worry that it paralyzes them."

    And even if the demand for colonoscopies starts to slacken, Dr. Rex said, gastroenterologists still have plenty of alternatives.

    "We have a lot of organs," Dr. Rex said. "The esophagus, the stomach, the small bowel, the liver, the pancreas. I think we've got a lot to do."

    Gastroenterologists, he added, "will still be able to make a comfortable living."
     
  16. Whisker Barrel Cortex

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    Yeah, just like gastroenterologists will read CT of the abdomen and pelvis (which includes numerous other organs other than the GI tract), which is essentially what a VC is. Its easy. Why go through a whole radiology residency?

    As a resident at one of the only places in the country with a very high volume of VC (all of the local HMOs cover it here and we do a lot of research on it), I can tell you that the volume of optical colonoscopy has actually gone up since the VC program began. More people are getting screened who otherwise might not have. Our GI departement and Radiology department work together so that any patient that has a finding that needs optical colonoscopy gets it the same day if they want it and any patient that has an incomplete colonoscopy gets a VC the same day if they want it. So the prep is only done once.

    As for the issue of incidental findings. The vast majority do not require any further workup. The radiologist reading the study does have to be comfortable with a degree of uncertainty. We do not pursue non-specific low attenuation hepatic lesions or renal lesions unless there are unusual features. On the other hand, we have diagnosed several renal cell carcinomas and lymphomas.

    Bottom line is, this will increase the number of people that get screened for colon ca with an essentially non-invasive method without the risk of perforation or the need for sedation. It will not replace optical colonscopy.
     
  17. june015b

    june015b Member
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    I agree that VC will not replace colonoscopy. However; the joint task force from ASGE, AGA, and ACG recently published that:

    1) VC is not ready, yet. There is still a number of issues with this evolving technology (very,very low sensitivity for small or flat dysplasia/cancer, added cost to screening overall, same bowel prep & air insufflation, etc). However, GI should be ready for any emerging techonologies. The new issue of Gastroenterology said they will start training GI's for VC as early as 2007. Yes. I admit that GI got this idea from our cardiologist friends who train others & read their own cardiac MRI and CT angiograms. There are many GI entrepreneurs who think GI should able to offer both optical colonoscopy and VC at the same ambulatory surgical center (ASC) owned by GI's. This "one stop service" will offer the patients one bowel prep for both VC and optical colonoscopy if necessary.

    2) The endoscopic bariatric surgery has been a hot interest at the recent ACG meeting. The bariatric surgery is a growing multi-billion $ field. This will be one of the mainstream GI procedures in few years.

    3) The natural orifice transluminal endoscopic surgery (NOTES) is evolving fast. This field has been developed by GI using animal model. Various surgical options including transluminal cholecystectomy, appendectomy, biopsies, tubal ligations and others have been tested successfully. There is a joint force between ASGE and SSAT for this.

    4) EUS field is evolving fast in cancer staging and local chemo treatment (i.e. pancreatic ca). In other countries, GI are directly invloved in all GI cancer chemo treatments. I don't know this will ever happen in US GI; however, there is already growing role of GI in treatment of certain localized malignancies.


    Medical Resident
     
  18. boston

    boston Junior Member
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    What do you mean by "local chemo" for pancreatic ca?
    Are you talking about direct intratumoral injection via US-guidance?
    Just curious... Can you point me to the citations?
     
  19. june015b

    june015b Member
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    These are few examples. You can also check recent abstracts presented in GI meetings.

    Gastrointest Endosc. 2006 Jun;63(7):1059-62.
    EUS-guided alcohol ablation of an insulinoma.

    Endoscopy. 2006 Apr;38(4):399-403.
    Endoscopic ultrasound-guided interstitial brachytherapy of unresectable pancreatic cancer: results of a trial.

    Gastrointest Endosc. 2005 Nov;62(5):808-10.
    "Hot stuff": EUS-guided brachytherapy.

    Gastrointest Endosc. 2005 Nov;62(5):805-8.
    EUS-guided brachytherapy.

    Gastrointest Endosc. 2005 Nov;62(5):775-9.
    EUS-guided interstitial brachytherapy of the pancreas.
     
  20. Faebinder

    Faebinder Slow Wave Smurf
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    As someone who was part of two papers in two trials for brachytherapy of the pancreas I can tell you to take the above with a grain of salt because:

    1) Brachytherapy of the pancreas is far from perfection... maybe another 40 years. Look at all the things you cited... none of them are a clinical trial. Both clinical trials we had at our institution showed no difference in survival.. and that ladies and gentlemen is what matters... survival. (We even got more adverse events.) One of the trials will be published soon in Journal of GI surgery. I'd link the other published things but I value my anonymous status online.

    2) Whether you use ultrasound or go through the skin... the results will be the same... as a matter of fact the route through the skin is easier and done by nuclear medicine as well as interventional radiology under fluoroscopy.

    Overall though, gastroenterologists are in good shape... more endoscopy is needed for esophageal surgeries ... I wouldn't worry about the career... business wont die anytime soon in the future.
     
  21. jimmyc

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    How come this procedure isn't as mainstream as it should be. Just from looking at this pretty quickly, I can only see positive benefits.:thumbup:




    Experience renewed energy.
     
  22. boston

    boston Junior Member
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    Because... in a recent multicenter, double-blinded, RCT comparing Dual Action Cleanse vs. Triple Action Cleanse, Triple Action Cleanse was superior as measured by the primary endpoints of BFS (Bloatedness-free survival) rate and Overall radiant skin rate. Dual Action Cleanse is obsolete like Ranson's criteria.

    (This also provides evidence to support the rule that, in medicine, more is better.)
     

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