Latin-American Gastrointestinal Endoscopy Training Center

PERSPECTIVES Latin-American Gastrointestinal Endoscopy Training Center A center for therapeutic endoscopy in the midst of a large international city, where patients, both private and public, are sent from several institutions and where advanced endoscopy training is offered to qualified endoscopists for free seems like an impossible dream. However, this is the current situation at the Latin-American Gastrointestinal Endoscopy Training Center in Santiago, Chile, established in 1997. Because of the foresight and dedication of a small but highly trained group of endoscopists, the center was developed as an outreach program from the Clinica Santa Maria, which is 50 meters away from the clinic. Both inpatients (transferred from private and public hospitals) and outpatients are seen. Seventy percent of the patients are sent from public hospitals and are paid by the Ministry of Health at the lowest insurance rate to cover minimal costs. The Ministry of Health has determined that sending patients to this clinic for advanced endoscopic procedures saves money and decreases the length of hospital stay. Transfer patients travel by ambulance, usually with a resident or nurse, and have procedures performed that could not be done in their local hospital. They are sent back the same day, after the procedure. Private patients pay a fee for service or are covered by private insurance plans. They are charged both a physician fee and a clinic fee that partially supports the center expenses. Patients are usually referred by a telephone call from referring physicians, and inpatients are sent with their hospital records or summaries. The waiting list is relatively short; patients are usually seen within 1 week and emergencies are often solved in the same day in which the referral is made (for cholangitis or acute pancreatitis). The clinic is built with 4 endoscopy rooms, two with radiograph and two without, in which are performed EUS, colonoscopy, and upper GI endoscopy. The ancillary staff consists of a nurse and VOLUME 57, NO. 1, 2003

Table 1. Therapeutic procedures ERCP Upper & lower GI EUS Total

1997

1998

1999

2000

2001

824 192 — 1016

1042 133 — 1175

954 176 — 1130

1147 564 123 1836

1091 507 166 1764

3 technicians, and trainees often pitch in to help in moving the patients through the endoscopy center. Up to 15 procedures can easily be performed in a day, and the record is 22 procedures. The concept of the training center did not spring up overnight. The staff did not build a unit and open the doors expecting patients and referrals to come in. The core group of physicians had already established local, national, and international reputations as good endoscopists who were willing to work hard and to set up a training program as well. Their success has been earned by the quality of the endoscopy that they perform. The main language in the endoscopy center is Spanish, and “Portuñol” for Brazilian Portuguese speaking fellows. “Our English is not that good, but not that bad. We communicate with trainees from France in half-French.” There is an exchange program with Marseille with Dr. Sahel’s group and also with Antioquia University in Colombia. The training program emphasizes therapeutic endoscopy procedures with a “hands-on” basis. All applicants must have at least the basic diagnostic endoscopy training. Trainees have access to the video library at the endoscopy training center where there are over 10,000 cases on file. The program also includes training in cardiovascular emergencies and airway management supervised by a university anesthesiologist. The working group is comprised of 5 gastroenterologists, 6 surgeons, 3 anesthesiologists, 1 nurse, 3 technicians, and 2 secretaries. The clinic has access to the latest in endoscopic equipment, with the Clinic of Santa Maria (the priGASTROINTESTINAL ENDOSCOPY

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Letters to the Editor

Table 2. Countries of origin and number of trainees • Argentina (31) • Bolivia (2) • Brazil (4) • Chile (54) • Colombia (21) • France (1) • México (6) • Perú (18) • USA (1)

• Australia (1) • Costa Rica (3) • Ecuador (4) • El Salvador (1) • Guatemala (2) • Honduras (3) • Panama (1) • Uruguay (2 )

vate medical center) contributing staff and the physical plant for the center as well as offering support for any hospitalization that may be required on an emergency basis. The University of Chile provides academic support, and the staff all hold academic appointments at the university. The Olympus endoscopic equipment is purchased by the Clinica Santa Maria at a favorable rate, and Wilson Cook has also provided an acceptable reimbursement cost through the Clinica Santa Maria. They supply disposable devices, stents, guidewires, etc. Local experts often visit the center to get the “state of the art” advanced endoscopic techniques and to learn about the most recent innovations in endoscopes and equipment. The advanced procedures performed in the center (Table 1) include argon plasma coagulation, EUS, magnification endoscopy, esophageal variceal ligation, endoscopic mucosal resection, advanced ERCP techniques including papillotomy, cystogastrostomies, percutaneous endoscopic gastrostomy, treatment of Zenker’s diverticulum, and other procedures such as dilation, stent insertion, and clip placement. Surgical laparoscopy and bronchoscopic procedures are performed as well. Capsule endoscopy has recently been incorporated into the armamentarium of advanced endoscopic techniques. Patients are sent from 48 hospitals in Santiago and from cities nearby to use the center as a reference center. Access to highly complex procedures that could not be performed in various hospitals throughout Santiago is provided, as is cost savings over a broad range of institutions because of reduction of morbidity and length of stay. Every other year, the center has an advanced endoscopy course. Last year, the instructors were Dr. Nib Soehendra and Dr. Annette Fritscher-Ravens, both from Germany, and Dr. Arturo Kirberg from Chile. Next year, the visiting faculty will be Dr. Isaac Raijman and Dr. Robynne Chutkin from the United States, Dr. Archie Brane from England, and Dr. Horst Grimm from Germany. Up to now, the center has trained 54 endoscopists from Chile and 101 endoscopists from 17 different (Table 2) countries. 146

GASTROINTESTINAL ENDOSCOPY

The center has also trained 13 endoscopic assistants and welcomes applicants for training and visitors. Claudio Navarrete, MD Cecilia Castillo, MD Carlos Reyes, MD Roque Sáenz, MD Santiago, Chile Jerome D. Waye, MD New York, New York doi:10.1067/mge.2003.20

LETTERS

TO THE

EDITOR

Trans-PEG ultra thin endoscopy for PEG/J Placement To the Editor: We read with interest the article by Adler et al.1 However, we call into question the “newness” of the technique they described. This was described by our group in 1994,2 by Berger et al.3 in 1996, and again in 2001.4 Trans PEG endoscopy for PEG/J placement allows periodic replacement of a PEJ tube over a guidewire without repeating endoscopy and without replacing the entire “single-piece” double lumen balloon tube device used by Adler et al.1 It does require a larger PEG lumen (i.e., Bard 28F) to allow passage of an ultrathin endoscope. Established gastrostomy tracts smaller than 28F can be “up-sized” by hydrostatic balloon dilation of the stoma. This allows 12F PEJ tube placement, the same size as used in the study of Adler et al.1 We agree fully with these investigators that the use of ultrathin endoscopes, either through established stomas or established large caliber PEG lumens, represents an advance in the ease of PEG/J insertion. The 8-year experience of our group with this technique continues to be rewarding, with near 100% success in deep jejunal access, this usually being accomplished in less than 10 minutes of procedure time. William Baskin, MD John F. Johanson, MD Rockford, Illinois REFERENCES 1. Adler DG, Gostout CJ, Baron TH. Percutaneous transgastric placement of jejunal feeding tubes with an ultra-thin endoscope. Gastrointest Endosc 2002;55:106-10. 2. Baskin WN, Johanson JF. Trans-PEG endoscopy for rapid PEJ placement [abstract]. Am J Gastroenterology 1994;89:1701. 3. Berger WL, Shaker R, Dean RS. Percutaneous endoscopic gastrojejunal tube placement. Gastrointest Endosc 1996;43:63-6. 4. Baskin, WN. Percutaneous endoscopic gastrostomy and placement of a jejunal extension tube. Tech Gastrointest Endosc 2001;3:30-41. doi:10.1067/mge.2003.18

Response: We appreciate the comments from Drs. Baskin and Johanson. We acknowledge their longstanding interest in VOLUME 57, NO. 1, 2003