The Channel A COOK NEWS PUBLICATION

ISSUE 1, 2016

Our Generations series continues with physicians who trained with the pioneers featured in the 40 Years of Interventional ERCP series. page 7

Gastrointestinal cancer treatment solutions expand in China with a focus on early diagnosis and treatment, physician education and new techniques such as multi-band mucosectomy. page 12

Dr. Steve Bensen shares an update on training initiatives in Rwanda and discusses plans for continued expansion of education support. page 14

Focus on education and training Today’s clinicians are busier than ever and have less and less time and resources for training. To help customers meet educational needs, Cook Medical recently initiated Vista Education and Training Programs. The company annually hosts thousands of these hands-on, highly interactive events around the globe. It’s the latest initiative in Cook’s 30-plus-year commitment to provide education and training to help physicians, nurses and technicians deliver the best care possible for their patients. Continued on page 3

Remembering Bill Last October, the Cook Medical family lost one of its own when Bill Gibbons, Global Vice President of Engineering, and his teenage daughter, Abbey, died in a plane crash. Starting his career with Cook in 1999, Bill’s leadership abilities were recognized early, resulting in his presidency of the Cook Winston-Salem division and his major impact on its work developing and manufacturing GI endoscopic accessories. In 2009, Bill and his family moved to Bloomington, Indiana, where he would head Cook’s worldwide engineering efforts. In the wake of Bill’s passing, Cook family members and Cook customers, who knew directly of Bill’s passion for his work, shared memories of his influence, his example and his dedication. Countless people spoke of him as a friend and a mentor. His absence is a void in our lives and in our work, but his legacy is the inspiration to continue what he loved with similar commitment and enthusiasm for excellence. Bill treasured his roles of husband and father above all else. In speaking of his wife Emily and his twins, Abbey and Will, it was clear that, for Bill, his family priority informed the others in his life. As a fitting commemoration to Bill, we have planted a 20-foot southern magnolia on the Winston-Salem campus in recognition of his lifelong concern for the environment. A beautifully engraved wooden bench is located nearby and features his trademark motto, “Finish Something,” along with an inset replica of the wizard’s wand from the Harry Potter books in tribute to Bill and Abbey’s shared love of those stories. Thanks to everyone who contacted us to share memories of Bill. They will surely continue to inspire us for years to come.

President, Cook Medical Winston-Salem SBU Leader, Endoscopy

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Focus on Education and Training, continued from page 1 Vista programs offer the opportunity to focus on best practices and advanced techniques in a wide range of clinical specialties, such as ERCP, EUS, stricture management, hemostasis, EMR and more. Created and led by leading practitioners, each Vista event is customized to meet the specific training goals for its target audiences. Jeff Randall, Cook Medical Sales Development Manager, states, “Vistas are a great opportunity to tap the experience and knowledge of physicians, nurses, and technicians to educate their peers. With these excellent education events, we hope to further expand Cook’s ultimate goal of improving patient outcomes.” The following affords a closer look at four major Vista events which include participation by distinguished endoscopy educators who Jeff Randall collaborate with the Cook Medical team worldwide to address key learning needs:

MUSC Workshop for GI Nurses and Technicians Charleston, South Carolina Intended specifically to accommodate the educational interests of advanced therapeutic endoscopy nurses and technicians, this recurring series of workshops is held at the Medical University of South Carolina and supported by the course leadership and expertise of Drs. Brenda Hoffman and Gregory Cote. Patient and procedural aspects involved in the areas of ERCP, EUS, hemostasis and EMR are the primary focus for lecture discussion and hands-on device opportunities. Model simulation and review of specific case examples combine with live case observation to enhance participant learning. Steve Levy, Senior Field Product Specialist, shares his thoughts on device education via the Vista experience: “The Field Product Specialist team lends support through their extensive procedural and product knowledge. We assist with training in the hands-on segment and can review decision making options as to possible device selection and techniques depending on the case scenario. One-on-one training with Steve Levy devices and models, such as the ERCP Trainer, encourage questions that would be difficult to ask during actual procedures.”

Advanced Therapeutics and EUS: A Team Approach Jacksonville, Florida This team training format invites combinations of physician/ nurse or technician participants in the US to experience this learning opportunity together, which in turn expands the training benefit to their respective endoscopy programs. Dr. Michael Wallace describes this experience hosted by the Mayo Clinic GI faculty and clinicians: “The course is designed to enhance the professional expertise in advanced therapeutic endoscopy, particularly in the areas of endoscopic ultrasound biopsy and drainage procedures, as well as endoscopic mucosal resection. It is a small group format with our experts providing one-on-one training.”

Michael B. Wallace, MD, MPH Professor of Medicine Mayo Clinic, Jacksonville, FL Editor in Chief, Gastrointestinal Endoscopy

ERCP Basic Training at EETC (European Endoscopy Training Center) Rome, Italy Led by Course Directors Prof. Guido Costamagna and Dr. Ivo Boškoski, this learning experience provides f u n d a m e n t a l E R C P e d u c at i o n , including basic cannulation techniques, stricture and stone management, and considerations for potential ERCP procedural complications. The event includes didactic learning, live case discussion and hands-on device training, utilizing Prof. Guido a specially designed ERCP training Costamagna model to replicate scope maneuvers and facilitate learning specific device techniques. This program is primarily intended to support European physician training but can also involve special event regional training. International guest faculty physicians also participate in certain course offerings, which extends the diversity of expertise and clinical opinion offered to attendees. Dr. Ivo Boškoski

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Interventional Endoscopy Workshop for GI Fellows Downers Grove, IL With a curriculum focus mainly in ERCP, EUS and also EMR, this workshop experience offers advanced endoscopy GI fellows a chance to interact directly with multiple expert guest faculty instructing in these areas. Didactic presentations, followed by hands-on device technique discussion, facilitate learning and Q&A opportunities during a daylong session. Held at the ASGE’s ITT Center, state-of-the-art equipment and an environment geared to learning endoscopic skills support the attendee’s educational interests. “The Vista programs have been really beneficial because it allows fellows in training to work closely with experts in our field, and the way the programs are structured is to have a didactic session, where they’re learning about a technique and then move right to the animal lab to practice that technique. That type of experience is priceless.” — Course Director Seth A. Gross, MD, FACG, FASGE

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Seth A. Gross, MD

Accra, Ghana physicians advance ERCP skills through EETC Basic Training Lars Aabakken, Professor of Medicine and Chief of GI Endoscopy at Oslo University Hospital in Oslo, Norway, was the expert guest faculty physician participating in the December 2015 EETC course. In addition to the fellows from the local Agostino Gemelli Teaching Hospital, faculty and staff welcomed attendee physicians Dr. Nii Armah Quarmina Adu-Aryee and Dr. Adwoa Afrakoma Agyei from Korle Bu Teaching Hospital,the largest referral center in Ghana and the third largest hospital in Africa. Prof. Aabakken explained the specific objectives of this learning experience as follows: “This specific course addressed the needs of our colleagues from Accra, Ghana, who have had very modest exposure to ERCP but who want to set up this service in Accra. The objectives were to cover the theoretical basics of ERCP, show some telltale examples by live transmission and do hands-on practical training in the context of expert tutoring and guidance.” Regarding the ERCP Trainer, Prof. Aabakken remarks, “The utility of the ERCP Trainer to mimic the real life handling and movements of the endoscope and to practice all the basic moves of ERCP without worrying about a real patient was very effective. It created a very relaxed and stimulating teaching atmosphere which appeared hugely useful for the attendees. It goes a long way in reducing the gap between theory lectures and real live cases, which can sometimes be daunting.” All Vista faculty are paid consultants for Cook Medical.

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ERCP Trainer enhances teaching and learning The ERCP Trainer is a model simulator, which is a key contributor to learning throughout many Vista training events. Designed by Prof. Guido Costamagna and Dr. Ivo Boškoski in a collaborative effort with Cook Medical, this model design offers a mechanical replication of the relationship between the endoscope and its target of examination, the pancreatobiliary anatomy.

Simon Brouwers

Simon Brouwers, Cook Medical Global Projects Manager, supported the physician efforts in the development of the Trainer and now, together with his Cook colleagues, facilitates its ongoing teaching benefit. “The most difficult task in ERCP is to get access and to understand the directions of the common bile duct and the pancreatic duct,” says Brouwers. “Previously, there was no mechanical simulator that replicates the necessary scope maneuvers in advance of the papilla, and this model allows early training practice with a real scope and understanding of what movements are needed in typical patient anatomy presentations.”

To learn more about the ERCP Trainer and how it supports fundamental ERCP device training needs, please contact your local Cook Medical representative.

Vista

®

Education and Training

Interested in Cook’s Vista programs? For more information on the Cook Medical Vista Education and Training Programs, contact your local Cook sales representative or go to vista.cookmedical.com.

Professor Norman Marcon receives insignia of Officer of the Order of Canada In February, prominent Toronto gastroenterologist Professor Norman Marcon (left) was presented the insignia of Officer of the Order of Canada by His Excellency the Right Honourable David Johnston, Governor General of Canada. The insignia acknowledges outstanding achievement, dedication to the community and service to the country. In bestowing the honor, the Order recognized Prof. Marcon for “his contributions to the treatment of gastrointestinal diseases and for his work to disseminate the latest advances in therapeutic endoscopy.” In the early 1980s, Prof. Marcon worked closely with Cook’s Endoscopy division co-founder Don Wilson to adapt radiological devices for endoscopic use, changing the field of gastroenterology forever. Marcon also founded the world’s premier international course in therapeutic endoscopy, which has disseminated the latest developments in the field for over a quarter century. Learn more about Prof. Marcon and the development of GI endoscopy through the video interview series with Dr. Greg Haber at cookmedical.com/p/marcon. ■ Prof. Norman Marcon is not a paid consultant for Cook Medical.

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Photo by MCpl Vincent Carbonneau, Rideau Hall © OSGG, 2016

Generations: Continuing the legacy of the interventional ERCP pioneers

Gary Vitale

Gary C. Vitale, MD FACS Professor of Surgery University of Louisville Louisville, KY

Cotton: And you did. That must have been a great experience in many ways. Please tell us all about that.

Our Generations series continues with physicians who trained with the pioneers featured in the 40 Years of Interventional ERCP series (information about the two volume Channel Pioneer series is available at the conclusion of this interview). Peter Cotton: Gary, thanks for agreeing to participate in this project. As you know, I have recently interviewed the pioneers of therapeutic ERCP, including Claude Liguory. I know that you studied with him and became a close friend. We would like to know more about that. But, first, let’s hear about you. Where does your name come from?

Claude taught me about gastronomy as well as gastroenterology.

Vitale: It started off with my wife and I both learning French. We took a full-immersion Berlitz course. That turned out to be a good decision, even though Claude spoke English, and some of the team members liked to practice their English. If you spoke French, you were really accepted much better. We had a great time there, but it was a little traumatic initially, especially finding an apartment. Peter B. Cotton, MD, FRCP, FRCS Professor Gastroenterology and Hepatology Digestive Disease Center Medical University of South Carolina Charleston, SC

G a r y V i t a l e : I t ’s I t a l i a n . M y g re at grandparents immigrated in the 1890s through Ellis Island. My mother’s side was from Abruzzo, and the Vitale family came from the Naples area. The Vitales settled in Connecticut. That’s where I was born, but I grew up in Florida, after my dad moved with his business. Cotton: You’re now a professor of surgery at the University of Louisville?

Vitale: Yes. I did my residency at the University of Louisville from ‘79 onward, and then a two-year fellowship in biliary-pancreatic surgery with Alfred Cuschieri in Dundee, Scotland. It was there that I recognized the need for ERCP, but was kind of laughed at when asking if I could find some place to learn it. That was in the early ‘80s and people, at least in Louisville, thought that it was foolish. One person who really understood was our chairman, Hiram Polk. He’s always been a bit of a visionary. Fortunately, a famous French pancreatic surgeon named Maurice Mercardier used to visit Louisville for the Kentucky Derby. Hiram called Maurice, who said, “If he’s going to learn the ERCP, there’s only one person I would send him to, and that’s Claude Liguory.”

I met Claude first on a Saturday morning in his clinic, cleaning up a few cases. He said, “Well, let’s go to lunch.” We went to a restaurant called Chez Georges, which was one of his favorite places near the Porte Maillot, past the Arc de Triomphe. He was impressed with my rudimentary French, but it did not extend to gastronomy. Turns out, he was testing me to see if I was going to be a suitable friend for the next year in the restaurant scene. He ordered a particularly difficult dish, some kind of tripe with sauce. I had no idea. I just ate it. Claude was extremely impressed. He said after that lunch that he accepted me. He said I spoke French, and I ate one of his favorite country dishes without complaining. He said he’d never seen an American do either of those two things. My time in Paris turned out to be a great fellowship in gastronomy, as well as gastroenterology. The French were in no way slouches about working. We started at 7 a.m. sharp every day. If I was five minutes late, he would say, “Where’s the American?” He loved to tease me about that. We stopped for lunch weekdays around noon or 1 p.m. and we picked back up around 3 p.m. We would finish 8 or 8:30. By the time I walked and took the metro, I’d get home anywhere from 9:30 to 10 p.m., so it was a very long day. One thing that I remember very distinctly was, when the elevators would go out, the porters would carry the patients from the second floor on their shoulders, up about five flights of stairs and lay them on the table. I remember also that the patients all had a little bottle of wine on their lunch trays. They called it the French oxygen. I have great memories of learning ERCP. It was difficult. When we started, we did not have a video scope. It was a scope with a teaching attachment, which was really difficult.

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Claude Liguory enjoying the canyon.

“The best interventional gastroenterologists see, think and talk like surgeons.” – Gary Vitale Cotton: Tell us a little bit more about Claude. Vitale: He was and is a special guy. He had a surgical mentality, aggressive, getting things done. He was a hard worker, and that was different, too, than the average person around there. He had very few problems or complications because of his technical skill. He started off very early in all of this. He was one of the originators in his part of the world and innovative for both ideas and techniques. He did the first ERCP in France, and the first sphincterotomy. He talks about having a wire tied to the top of the catheter and touching an electric coagulation cautery to the wire. Cotton: Were there other people training with him at the time? Vitale: Yes, there were two Brazilian guys. Cotton: He’s had a close connection with Brazil ever since that time. Changing the subject. Why do you think it was that surgeons, in general, were rather dismissive of endoscopy in the early days? Vitale: They did miss out. They caught up a little bit with EGD and colonoscopy, certainly in rural areas, but they missed out on ERCP. Once surgeons got interested it was difficult to get good training, and you don’t want two tiers. If you’re going to do it, you want to do it as well as anybody else. Cotton: Surgeons were also slow to embrace laparoscopy, I think?

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Vitale: Yes, most in the main centers had the concept that the bigger the incision, the better. Our GI group was doing diagnostic laparoscopy in the ‘70s and ‘80s. Cotton: I know that Claude Liguory did laparoscopy and I believe that he did at least one laparoscopic cholecystectomy. Vitale: I was with him when he did it! It was in Bordeaux, with Jacques Perissat, who I had met before going to France at the SAGES meeting in the spring of ‘89. He had asked to present his work on removal of the gallbladder through a scope. He was denied, but he was given a booth in a corner. He had the video going and crowds came around. This was before it had been done in the US. I said to him, “I’m going to France in a couple of months to Claude Liguory to learn ERCP. Can I come and visit you in Bordeaux?” He said, “By all means.” That turned out to be a lifelong friendship, as well. I used to take the night train from the Gare Austerlitz, and I would arrive in Bordeaux at about 6:30 in the morning. I would take a shower in the train station and take a bus to the hospital. I’d get an afternoon train and get back at probably 10 at night. It was an unbelievable experience. Claude got interested, partly because I kept telling him of my experience. He said, “You know, I did laparoscopy and I should learn this.” He came down and did at least one cholecystectomy. It was a routine case and I remember it very well. He held up the gallbladder, but said, “You know, with 1,200 ERCPs a year, I’m not sure I need to do this.” Out of that experience, Claude and I wrote the article called “Biliary Perestroika,” discussing the need for multidisciplinary collaboration in the new world of biliary intervention. Cotton: I remember that article well. As you know, I’ve been preaching about med-surg collaboration for a long time, which led to my development of the center here at MUSC.

“I would like to emphasize for the young people that it is absolutely worth taking a little risk and doing extra training, even if it means going someplace unusual or even where you don’t know the language. Sometimes, very good things come out of it.” – Gary Vitale

Gary Vitale with faculty colleague, Mike Bahr, who he trained, thus Claude’s “grand fellow.”

Was it difficult getting established and doing ERCP back home? Was there competition? Vitale: It was not a problem. No one in our GI group was overly interested in it. Eventually, they could see I was getting busy, so they hired Whitney Jones, who trained in Canada with a special interest in ERCP. We’ve helped each other a lot. Things built up pretty quickly. My mantra was, “I’m not interested in doing just simple diagnostic ERCPs; I’m a surgeon, I’m interested in interventional problems.” I focused on pancreatitis, and quickly built up a busy practice. Cotton: Did the two of you train other gastroenterologists and surgeons together, or did you keep the trainees separate? Vitale: The trainees ended up being separate. We were working at different hospitals. I did get an appointment in GI, as well, and I have trained some gastroenterologists. Cotton: I trained some surgeons to do ERCP in the early days in England and even some radiologists. As you know, some of the early ERCP pioneers, like Nib Soehendra and Guido Costamagna, started off as surgeons. Do you think that surgical training gave you an advantage in pursuing some of the more complicated stuff? Vitale: I always have thought that it did. I was a little more willing to be aggressive, and I can certainly take care of my own complications. What you don’t want is an inadequately trained surgeon doing ERCP. The best interventional gastroenterologists see, think and talk like surgeons. There is a subset of gastroenterologists, who probably could do therapeutic laparoscopy, and are developing some of these ideas in the natural orifice therapy, NOTES. Cotton: Do you think NOTES is going to blossom sometime? It’s been a bit quiet for the last few years.

Vitale: It will, at some time in the future, when someone’s willing to invest to develop the tools. Right now, I’m not too excited about taking the gallbladder out though the mouth. Long term, if we can get some better instruments, the natural orifice approach may well be useful. Cotton: I agree. Let’s change subjects. As you know, this project was initiated and is being supported by Cook Medical. That was formerly called Wilson-Cook, which was founded by Don Wilson, a good friend of mine and a supporter of the pioneers, their trainees and courses. Tell us about your interactions with Cook. Vitale: They were very supportive of Claude. Marsha Dreyer, the international vice president, came once a year to Paris for Claude’s live course, which was the first of its kind. I went back every year as a faculty on that course, and there was a very close relationship there. Cotton: Do your kids have any memories of their time in Paris? Vitale: Yes. They all learned French and still speak French. Two of the kids are in medicine now. My daughter is in residency at Yale and she wants to do endocrinology. My son is doing pediatric gastroenterology at Cincinnati Children’s Hospital. They actually try to learn ERCP because there are some Peds GI people who do that. They have great memories of France because we went back, of course, and we had a lot of visits from our French friends here to the US. That fellowship started a long friendship. Claude and I just spent, with my wife, 12 or 13 days out West. This was an 80th birthday present from us to him, actually. We went to southern Utah with Bryce and Zion National Park, and then we went to Yellowstone and spent a good deal of time traveling around that area. Fly fishing is one of my hobbies, and so we stayed in our cabin for a while. Cotton: Any regrets looking back?

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Vitale: I have no regrets other than I kind of wish I had done two years in Paris. It was a tremendous effort on our part to learn French, to go without income for a year and the apartments there were very expensive. It just turned out to be a very good decision for me, though, long term. It steered my practice in the direction I wanted it to. One year seemed like enough. Hiram Polk was yelling at me to get back. I was going to be junior faculty there. They knew I had learned laparoscopy. “This thing’s going crazy here, you better get back.” I started an ERCP fellowship in 1990. I have had over 30 trainees and most of them are still doing ERCP. They all consider themselves part of the French Connection because I emphasized certain aspects of my French experience. I have a little wine cellar now, and we always talk about Claude, and he’s been over and met several of them at different times. This idea of a school of trainees, I think, is missing in modern medicine. It’s gone by the wayside, but at least with Claude and myself and my guys, there is that absolute shared thread of training that makes us all a part of this little French school. I know your trainees feel the same. To me, that’s a big plus in a world that’s become much less personal in recent years. I would like to emphasize for the young people that it is absolutely worth taking a little risk and doing extra training, even if it means going someplace unusual or even where you don’t know the language. Sometimes, very good things come out of it. Cotton: Gary, many thanks for sharing this conversation with us. It has been fun reminiscing about our friend Claude Liguory. Do you remember his often phrase, “La vie d’artiste c’est difficile”? Vitale: Yes, it was one of his favorite sayings. Peter, I want to thank you for doing this. This anecdotal history is just wonderful. I’m so glad you’re doing it. ■

Read about the ERCP pioneers who influenced generations of practitioners in Volumes 1 and 2 of 40 Years of Interventional ERCP. In these commemorative issues of The Channel, you will find fascinating, candid interviews by and tributes to the pioneers who created and shaped the field of interventional GI endoscopy. You can access Volume 1 and 2 at https://www.cookmedical.com/ endoscopy/40-years-of-interventional-ercp-stories-fromthe-pioneers-volume-2/. Or ask your regional sales representative for copies.

Dr. Gary Vitale is not a paid consultant for Cook Medical. Dr. Peter Cotton is a paid consultant for Cook Medical.

The Cotton/Vitale interview was recorded before the horrific events in Paris on November 13, 2015. Our hearts embrace all those affected by it, and we reemphasize our support and admiration for all our French friends.

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Early detection and treatment of gastrointestinal cancer popularized at community hospitals in China By G. Q. Wang, MD, PhD Director / Doctoral Supervisor Department of Endoscopy of Cancer Hospital Chinese Academy of Medical Sciences Chaoyang, Beijing, China

The “China Tour of Early Detection and Treatment of Cancer” is a series of academic exchange and training activities focused on the diagnosis and treatment techniques of early digestive system cancer in community medical institutions. Sponsored by the Cancer Foundation of China, Expert Committee of Early Detection and Treatment of Cancer Project, as well as Professional Committee of Tumor Endoscopy, Chinese Anti-Cancer Association, and organized by local cancer prevention and control institutions, this effort is designed to promote the standardization and professional level of the early digestive system cancer screening at the community medical institutions along with improving the efficiency of endoscopy and pathological diagnosis. Based on the “Early Detection and Diagnosis Project,” a special medical reform program launched by the Chinese government, the training in endoscopically assisted, minimally invasive treatment promotes the popularization of EMR and MBM in qualified community medical institutions, while also consolidating and improving the professional skills of local endoscopic and pathological physicians. In order to support the community medical institutions in carrying out endoscopically assisted, minimally invasive treatment of early gastrointestinal cancer, Cancer Hospital Chinese Academy of Medical Sciences offers a long-term training course on endoscopic treatment. Through two months of clinical teaching, operation observation, case discussion, academic lecture, animal explant models and animal experiment and technical support, specialist

physicians can be further trained to carry out the work as a regional demonstration center. In 2015, the Tour covered six cities including Hangzhou, Zhejiang Province; Anqing, Anhui Province; Gaotai, Gansu Province; Huzhu, Qinghai Province; Suining, Sichuan Province; and Xiangyuan, Shanxi Province.

Endoscopic resection Endoscopic resection (ER) is one of the most important and effective techniques for the treatment of early gastrointestinal cancer. However, higher requirements for surgeons hinder the development of ER technique because they need time to learn and accumulate the clinical experience. The imbalanced distribution of medical resources in China is a barrier to ER availability. A more appropriate and effective ER technique for early gastrointestinal cancer is a desperate need. Multi-band mucosectomy (MBM) is a therapeutic technique for esophageal cancer and precancerous lesions suitable as a clinical solution to patients in all areas of China. It has strong operability, and physicians can perform this procedure after standard training for a short period of time. In addition, it has significant advantages in terms of operation time and economic cost, higher safety and lower incidence of complication. Compared with en bloc resection in ESD, multi-band resection is operated under the principle of standardization, and residual lesion and relapse risks are also reduced to the controllable range. ■ Dr. G.Q. Wang is not a paid consultant for Cook Medical.

Overview of early digestive cancer in China In China, the age-standardized incidences of esophageal cancer, gastric cancer and colorectal cancer rank fifth, second and sixth, respectively, among all malignant tumors, and fifth, fourth and third, respectively, in terms of age-standardized death rate. Current statistical data from a few tertiary hospitals in China showed that early gastric cancer only accounted for 15% of the gastric cancer confirmed, much lower than that of Japan (70%) and Korea (55%), while the early detection rate of colorectal cancer was lower than 10%.

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The data released by the Ministry of Health showed that postoperative five-year survival rate of early gastrointestinal cancer in China was over 90%, the incidence of postoperative complications was much lower than that of advanced cancers and postoperative quality of life was better than that of patients with advanced cancer. Under the current situation in which tumorigenesis cannot be prevented, early detection and treatment is the key to the diagnosis and treatment, which is the common prevention strategy for tumors proposed by the whole world.

Origins of China’s early detection and treatment of cancer project Based on thorough epidemiological design and technical protocol, screening, early detection and treatment are completed through rational population selection, cohort establishment and target population screening and control. Meanwhile, training and on-site instruction are also provided on a regular basis. It has been eleven years since the establishment of demonstration base of early detection and treatment of esophageal cancer in Linzhou, Henan Province: Cixian, Hebei Province; and Feicheng in Shandong Province. Eleven years of practice has seen fruitful achievements in terms of early detection and treatment of esophageal cancer/cardiac cancer. The current statistical data shows that: a total of 621,979 patients had been screened in 2006-2013, and cancer had been detected in 9,056 (1.46%) patients, of which there were 6,323 at early stage (69.82%), and 6,688 (73.85%) were treated. This has completely changed the situation featured with low detection rate (5%), high medical expenses and poor efficacy among the patients treated in large hospitals. Currently, the number of project sites for esophageal cancer/cardiac cancer has increased from 8 to 144, and the population screened has increased from more than 10,000 to more than 180,000 each year.

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Paying it forward The power of shared knowledge Editor’s note: Dr. Steve Bensen, an associate professor of medicine at Dartmouth’s Geisel School of Medicine and physician at DartmouthHitchcock Medical Center, was the first gastroenterologist to participate in the Human Resources for Health (HRH) program. In 2014, he spent two months helping to train physicians and residents at two hospitals in Rwanda. (See story in The Channel, Issue 3, 2015.) In 2015, Dr. Bensen, who specializes in gastroenterology and hepatology, made his second trip to Rwanda. Below he shares his thoughts with The Channel about the impact of the learning and his hopes of creating further teaching interactions now and in the future. The Channel: Can you update us on your endoscopy teaching collaboration with the Rwandans and the progress that is being made? Dr. Bensen: The second trip was even more powerful and in some ways more productive than the first one because we hit the ground running. In the interim period—between when I was in Rwanda the first two months last year and then going the second time in 2015—we were busy on a number of fronts. One was that we created external rotations for six of the Rwandan physicians to come here, five residents and one faculty, who was my “twin” or partner, Dr. Vincent Dusabejambo. The fact that they were able to come and train here [Dartmouth’s Geisel School of Medicine] in our internal medicine program for three months each just enriched the whole exchange experience. When we went back to Rwanda, we were very well received and had many, many friends. The other major front was an educational exchange. For the second trip, I brought two medical students and a GI fellow with me. In

While mountain biking the Congo-Nile trail, a patchwork of village dirt roads and trails through the mountains and hills overlooking beautiful Lake Kivo, a group of village children greeted me and are fascinated by the picture I had just taken of them on my iPhone.

preparation for them coming, we shared most of the curricula that we used for our first years of medical school here and facilitated it being uploaded to a University of Rwanda website, so Rwandan faculty can actually use our medical school curricula (lectures, PowerPoints, references) in the courses they’re designing. There was a lot of work that went into this transfer of course content before we went. Once we arrived, our GI Fellow, Zila Hussain, was an awesome instructor. She did a lot of teaching of the Rwandan doctors in the endoscopy unit at one hospital, CHUK [University Central Hospital of Kigali], which allowed me to work at other sites. Although the focus of our stay was our work during the day in the hospital and at the University of Rwanda in Butare teaching, there was a lot that went on outside of the hospital, which allowed for significant relationship building. We were well received by all the different doctors’ families, went into their homes for meals and really assimilated into their culture for the two months that we were there. It was richer this time in that regard because we’ve built many friendships and relationships now.

In remote Ruhengeri District Hospital, near the home of the mountain gorillas, Dr. Vincent Dusabejamo conducts a teaching session with a Congolese GP. With availability of this single thirtyyear-old fiberoptic endoscope, diagnostic upper endoscopy is now possible in this isolated area.

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In terms of their endoscopy, the physicians we have worked with are becoming increasingly skilled at therapeutic endoscopic procedures. When I was there, we continued to work on balloon dilation utilizing our donated device supplies. They had been working on balloon dilating pyloric stenosis and esophageal stenosis after my first trip and we continued refining these skills during the second visit. The other very important technique we continued to work on with our

Our GI fellow, Dr. Zila Hussain, supported many teaching opportunities with the Rwandan physicians, and during this endoscopy procedure, she is surrounded by a number of learning observers. Rwandan colleagues was variceal band ligation. Although I brought certainly no formal GI training. There’s no pulmonary training, no a lot of bands with me the first time I went, they had used them all up cardiology, no medical subspecialties, nor surgical subspecialties by the time I returned because they became so proficient at it. I was or pediatric subspecialties. able to bring a limited supply during the second visit but there is still One of the main charges, I feel, is to develop training in a big need for continued support in providing esophageal gastroenterology. There’s a big need. There are internists band ligators to treat esophageal varices. The burden and surgeons performing endoscopic procedures of chronic liver disease and noncirrhotic portal and treating people with chronic liver disease “We’re working on hypertension is very high in Rwanda. That’s a and chronic GI illness, but they’re not formally technique that few in the country were doing developing a GI fellowship trained yet. We’re working on developing a before and now we have five or six Rwandan program that would involve GI fellowship program that would involve physicians able to perform variceal band training within the country, as well as visits training within the country, as well as ligation, so all of the four referral hospitals to other African countries where there are visits to other African countries where in the country have the capability when centers of excellence, and maybe some there are centers of excellence, and supplies are available. exposure and training in the US, as well. maybe some exposure and training The Channel: What will be the next priority We put forth a proposal for a GI fellowship in the US, as well.” to focus on in terms of helping them expand that has gone to the Ministry of Health, and their capabilities? are hoping that will move through and that we – Dr. Steve Bensen can secure funding. We are also trying to establish Dr. Bensen: My visits to Rwanda were through relationships with other institutions internationally Dartmouth’s involvement with a program called Human within Africa and then elsewhere to grow the fellowship. Resources for Health, a seven-year partnership between the University of Rwanda and 12 leading medical schools in the US. This The Channel: How challenged are they with equipment availability? partnership is intended to facilitate medical education efforts in Dr. Bensen: They are challenged. They have endoscopes. They Rwanda and we are now into year four of the seven-year program. frequently, like ours, need maintenance, and then they break down. We’re going to have funding for GI involvement through the life They don’t have the “ready, send it off, it comes back a week later” of that program but we’re building relationships that we hope will repair support that we have. It’s always tenuous whether we have continue these exchanges into the future. At Dartmouth, we’ve had enough scopes to be actually functioning at the sites. Right now, we more than 15 physicians participate during the first three years of do, but that can change with one cable break. That’s a challenge. The HRH. I’ve been there the shortest time, two months times two. Others, consumables are a challenge, too. I came over with a lot of biopsy internists, pediatricians, general surgeons and anesthesiologists, forceps and snares, balloon dilators and variceal band ligators. We have gone for a whole year. There are a lot of people at Dartmouth do run out of balloons, and we definitely have run out of bands, so and at other academic institutions, too, that have made connections, we can really use more of those. We’re trying to secure pathways relationships. We’re trying to build on that and continue that into with industry so they can get them at discounted rates because, as the future, to have exchanges between our students and trainees you know, they have limited resources. and with the Rwandans. That’s one for the future. The GI burden of disease is very, very high. When we’re in the We’re really trying hard to establish a GI fellowship program for the endoscopy unit doing procedures as opposed to here, almost country. That was a charge from the Ministry of Health. There are everybody who’s coming in to get endoscopy, because they’ve basically only five specialty areas currently with training programs in had to go through so many levels to get to the four referral Rwanda—internal medicine, surgery, anesthesia, OB and pediatrics hospitals, has underlying pathology—ulcer disease, gastric cancer, but no subspecialty training. Most physicians in the country are outlet obstruction, esophageal stenosis. There’s a very, very high general practitioners without any specialty training, and there’s

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prevalence of serious pathology in the people who eventually come to get endoscopy. The Channel: What will be the challenges to train the local practitioners in getting these patients referred faster, to get them diagnosed faster? Dr. Bensen: The challenges are just resources. There are many brilliant young physicians and students in Rwanda eager to learn and work hard to develop the skills and expertise their country so desperately needs. In a country of 12 million people, there are 400 community health centers, which are pretty rudimentary clinics staffed by basically nurses and community health workers. Then there are about forty district hospitals, mostly staffed by general practitioners, meaning they have gone to medical school and have had one to two years of a general internship. They don’t have formal training in a specialty. Then there are only four referral hospitals for 12 million people that these district hospitals can refer to. That’s a very, very small number for so many people. The Ministry of Health is planning to open up three or four more new tertiary care centers by converting the bigger district hospitals into referral hospitals. These will need to be staffed by new trainees coming out of residency training, and they will need to have the equipment to provide care: bronchoscopy, endoscopy, have ICUs and NICUs; provide all that is currently being done in the referral hospitals. There are limitations, for sure, and funding is always an issue in providing this level of care, especially when it comes to supporting training programs. That’s part of our mission through the HRH program: To work with the people who are currently attendings but also to train the next generation of residents coming up that will staff these new referral hospitals.

My partner in our GI educational efforts, Dr. Vincent Dusabejambo, is first and foremost an excellent internist with a smaller practice focus in GI. Here he teaches the basics of a neurologic exam.

The Channel: You probably had a lot of surprises in this work, but was there anything that really stood out about this experience that was most surprising to you?

Dr. Bensen: We went with the intent to give in some way and to educate and to work but, in the end, I probably got more out of it than I was able to contribute. It’s hard to quantitate that, but just how it changes you as a person to see the great need and see the resilience of the people and how well “Industry and Dr. Bensen: Just do it, because there are so many they do with so little. We have a lot to learn from physicians both have areas of the world that need help, Rwanda them in that regard—the compassion, the family being one. There are a lot of NGOs [Nona responsibility in patient support of the sick patients, and the Rwandan or Governmental Organizations] and other care, facilitating the provision of the African attitudes towards life and death. It’s government-sponsored programs, such as resources and education and the really profound. the Human Resources for Health, through transfer of medical knowledge. It The surprise was how much it changed me which a physician, nurse or other health is what we are called to do as and how powerful an experience it was. The care provider can become involved. I was physicians.” friendships I have developed, the relationships that just in Togo with my daughter, who works for have been established. The gratitude was profound an NGO there, and that’s a country that’s very – Dr. Steve Bensen but, also, how I was able to connect with my Rwandan backward. It does not engage well with the West. colleagues, understand their lives a bit and what they have Their medical system is fifteen years behind Rwanda’s endured, hear their stories, meet their families, eat with them. That and way behind most of Africa. They’re right down there at was incredibly enriching. The surprise was just how much it affected the bottom of the world with Sierra Leone and Guinea in terms of me. I went there to give and serve, but you get so much back in return. medical care and other metrics by which countries are measured. You can see what happened in those two countries and how easily It reinforces why you went into this. We’re all busy clinicians. We have Ebola took off in that type of setting that is so impoverished with a our frustrations with productivity, with RVUs and electronic medical primitive healthcare system. We are so wealthy and spend so much records and our educational demands and responsibilities. It was on our healthcare in the US, we have an obligation to help. Industry an incredible sabbatical to be removed from all of that and really and physicians both have a responsibility in patient care, facilitating focus on why you went into medicine in the first place. ■ the provision of resources and education and the transfer of medical Photos by Dr. Steve Bensen knowledge. It is what we are called to do as physicians. The world is a much smaller place now than when I went to medical school. Dr. Steve Bensen is not a paid consultant for Cook Medical. We are much more interconnected. There is a great need in subSaharan Africa and in many, many countries, and there are many ways for us to get involved. The Channel: What would you say to your colleagues who are interested in getting involved and teaching and providing their support to this work?

I’m mid-career, and I just did it, and now I’m hooked and will continue to be involved. Next year I will go back, as will several of my colleagues and students.

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Enhancing nutritional support through education, advocacy and networking In this issue of The Channel, we speak with Lisa Crosby Metzger, Director of Community Engagement for the Oley Foundation, about Oley Foundation’s overarching mission and the programs aimed at accomplishing that mission.

Help along the way

The Channel: What is the mission of the Oley Foundation? What’s the primary focus of your work? Lisa Metzger: I’d like to share our mission statement almost verbatim: “Striving to enrich the lives of those living with home intravenous (or parenteral) nutrition and tube feeding (enteral nutrition) through education, advocacy and networking.” We are also a resource for consumers, family, clinicians, industry representatives and other interested parties. The Channel: When you think about that mission statement, generally how does Oley carry that out? What are the major overarching efforts that allow you to work towards accomplishing that mission? Lisa Metzger: We have a lot of programs in place to address the different aspects of our mission. We approach education, advocacy and networking all from different angles. Our bimonthly newsletter reaches all of our members. It is mostly educational and allows us to cover the medical and coping aspects of living with nutrition support with a goal of improving people’s quality of life. We have an annual consumer and clinician conference, which reaches a sector of our membership, maybe 300 to 400 people annually. We also have regional conferences, which give us a smaller presence in different parts of the United States. Our goal is to provide members with information that they may need, especially if they are working with a doctor who may not have a concentration in nutrition support. They can share that information with their doctor, who can then determine if it is appropriate for their care. We also share member-to-member coping skills to help people integrate tube feeding or parenteral nutrition into their lives. We have a body of volunteers, called our Oley Ambassadors, who are available to answer questions. They make their contact information available publicly on our website, and they are available to answer questions, to listen, to be a shoulder to lean on, and to share some of their own coping techniques. This program is not intended to provide medical advice but rather to help people with their dayto-day concerns. The Channel: Are the Ambassadors also patients who have had direct experience, or are they possibly clinicians who are interested in your mission and helping you with providing additional information? Lisa Metzger: They’re all consumers or caregivers or those who have been on therapy. They may be off therapy now but previously

received nutrition support. There is a range of diagnoses, ages and therapies represented through the Ambassadors. The Channel: How are Oley Ambassadors recruited? How do they find out about this program? Lisa Metzger: We were fortunate to add six new Ambassadors at the 2015 Annual Conference, which was great. They attended our Ambassador workshop and learned about the program, then applied and were accepted as Ambassadors. Potential Ambassadors reach out to us because they’re motivated by the desire to give back. We hear that a lot. They have found the help that they needed through the Oley Foundation and now they want to give back to the community. More often than not, they seek us out, but sometimes we’re really inspired to invite someone to apply because they’ve shown such balance in their own lives or they’ve set such a good example in dealing with some of the difficulties of home nutrition support. The Channel: In thinking about the different ways that you reach patients and their families, are you also interacting via social media? Is that a resource for you, as well? Lisa Metzger: We do have a Facebook page but our staffing support means the activity is more sporadic than we would like it to be. We also have the Oley-Inspire Forum. Inspire provides a platform for organizations like ours to set up a forum without having to do all the legwork involved. The Oley-Inspire forum has over 6,500 members. Oley has a YouTube channel where we share awareness information. Over the last two years, we’ve focused on sharing information during Feeding Tube Awareness Week in February and HPN Awareness Week in August. We put out press releases and we’re very active on social media during those two weeks. We produce a video, which can be seen on our YouTube channel, where we try to get the message out that people can survive and thrive with nutrition support.

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We share the message that it’s not an end-of-the-road therapy but rather can offer you opportunities to regain strength if you’ve lost a lot of weight or if your energy is waning. We communicate that this may be a way to help you get back on your feet and feel better. We also hope to convey the message that while managing it isn’t without challenges, nutrition support doesn’t have to keep you from doing the things that bring you joy, such as gardening, traveling or being with family. The Channel: For many people, the perception might be that nutrition support is an end-of-life therapy. Does this possibly impact people’s willingness to get involved with your work? Lisa Metzger: I don’t know if it makes them reluctant to get involved with Oley, but we have heard people say that they were reluctant to start on tube feeding until they saw one of the tube feeding videos. There are reports of parents who are sent home with babies on IV nutrition and they’re told that they’re basically just bringing their child home to die. When they hear stories of people who have survived for many years with intestinal failure on parenteral nutrition, they take heart and they’re maybe a little bit more aggressive in finding the kind of care that will help their child to thrive. We ran an article recently in the newsletter about a man who had had head and neck cancer. He was having trouble swallowing after the radiation and he just did not want to tube feed. He kept putting it off and described himself as being very macho and not wanting to undergo tube feeding. When he finally agreed, he said, “Wow, I should have done this years ago.” The Channel: Are any international organizations collaborating with you on issues where you have mutual interest or shared concerns on patients? Lisa Metzger: We collaborate with organizations in several other countries, especially on initiatives such as HPN Awareness Week. Several of the groups have a representative who also serves as an Oley Ambassador, which facilitates exchange between our organization and theirs. We try to form a relationship, when appropriate, with other organizations whenever we can, wherever they are. Our executive director or our medical advisor, Dr. Kelly, usually goes to ESPEN (see sidebar) meetings. Dr. Kelly has long been active with their HAN group, which is the Home Artificial Nutrition group. The Channel: What can be done to help clinicians become more aware of the work of your organization and others, such as A.S.P.E.N. and GEDSA, so that they can seek out your resource support? Lisa Metzger: That’s always been a big question. How do we let people know about the Oley Foundation? There are many different specialists who put people on nutrition support—from internists to gastroenterologists to surgeons—and most clinicians manage only a few patients, so it’s difficult to target them all. One way The Channel readers can help is to share the Oley information with their patients. The Internet has been a huge help to us. People hear about us via the Internet, through Google searches. Many people hear about us through our Equipment/Supply Exchange program. If your formula is not covered by insurance, we try to make a match with another consumer who has the product to donate. It’s often the need for formula that results in a call to us. Sometimes the only way someone has met another parent or another person on tube feeding has been through our Equipment/Supply Exchange. They realize it’s really beneficial for them and then they become part of the organization as a whole.

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Global initiatives Below, Lisa Metzger discusses international organizations with goals similar to the Oley Foundation, representing patient and consumer interests in their specific countries, including a recently formed international alliance that will enhance collaboration and shared resources. PINNT (British organization for homePEN consumers) is in the UK and PN Down Under (PNDU) serves Australia and New Zealand. There is also Appetite for Life in Poland and another group in Italy. Along with representatives from PINNT and PNDU, we had a representative from the Czech Republic at the 2015 Oley Annual Conference. Oley recognizes that consumers who are traveling abroad benefit from connecting with others familiar with nutrition support in the countries they are visiting. Whenever possible, we connect members to a consumer and/or clinician and whatever other resources we know of in that country. In the fall of 2015, an international alliance of home nutrition support consumer groups, including the Oley Foundation, was introduced with an exhibit at the annual meeting of the European Society for Clinical Nutrition and Metabolism (ESPEN) in Lisbon, Portugal. The newly organized International Alliance of Patient Organisations for Chronic Intestinal Failure and Home Artificial Nutrition (PACIFHAN) will facilitate the international sharing of information and resources to improve the quality of life of home artificial nutrition (HAN, the equivalent of our term “HPEN”) consumers. As of September 2015, the alliance included the Oley Foundation (US), PINNT (UK), PNDU (Australia and New Zealand), Život bez střeva (the Czech Republic), Un Filo per la Vita (Italy), Stowarzyszenie Apetyt na Życie (Poland) and Svenska HPN-Föreningen Barn & Ungdom (Sweden). The alliance website is www.pacifhan.org.

If we could reach more discharge planners and give them a sense of what the needs are for members when they go home, that could be a great way for us to reach both consumers and clinicians. The Channel: If I’m a clinician and I was interested in getting involved in your work, how do I reach out to Oley? How do I make contact to see how you could use my help? Lisa Metzger: There are five of us who make up the Oley staff, and we make a point of being very accessible. Anyone interested is welcome to contact us by phone and speak directly with any of our team members for more information on opportunities to support our work. We are also readily available by email. We also have a brand new website. It is easy to navigate and includes an integrated database. All of our member information remains completely private (we don’t share it at all), but members are able to record a little bit more about their circumstances. For example, on the new site, people are in charge of their own profiles and can update their personal details related to nutrition status at any time. This will help us to better understand our community and their needs, as well as what the community looks like overall. It is a really exciting opportunity for us.

The Channel: Do you have a speakers’ bureau that organizes supporting talks to interested audiences? Lisa Metzger: We don’t have a published speakers’ bureau, per se, but we have a body of volunteers that we’re familiar with who can help meet such needs. We have an active group that we can draw on, as with the awareness weeks when we really try to encourage in-services and we do a lot of press releases about individual members. We try to generate some interest within their local communities. Sometimes people ask us where we got our name. The Oley Foundation was founded in 1983 by Dr. Lyn Howard and one of her patients, Clarence “Oley” Oldenburg. Dr. Howard was involved in nutrition support here in Albany and saw the need and how much people benefited from being at clinic the same day. They were able to discuss their concerns and their issues with one another. That’s partly how the Oley Foundation was born.

From a clinician’s perspective, it may be important to know that the Oley Foundation was founded by a doctor and also that we have a very active board with a mix of clinicians and consumers. All of our pieces are medically reviewed if they have any medical component. Everything on our website or in our newsletter is fully reviewed. The Channel: In closing, can you tell us about plans for the 2016 Annual Conference? Lisa Metzger: We are excited to be in Newport Beach, California for the 2016 event. It will be held from July 5th through the 9th at the Marriott Newport Beach Hotel and Spa. This conference gives us a chance to obtain a lot of excellent feedback from participants, and that helps us continue to grow and plan to meet their needs. Please check our website (Oley.org) for more information coming soon. ■

Oley Foundation at a glance The Oley Foundation provides its 15,000+ members with critical information on topics such as medical advances, research, and health insurance. The Foundation is also a source of support, helping consumers on home IV nutrition and tube feeding overcome challenges, such as their inability to eat and altered body image. All Oley programs are offered free of charge to consumers and their families.

Leadership Joan Bishop Executive Director [email protected] Lisa Crosby Metzger Editor, LifelineLetter; Director, Community Engagement [email protected]

Oley Foundation Programs

Roslyn Dahl Communications & Development Director [email protected]

LifelineLetter: A bimonthly newsletter with articles about medical advances, personal experiences, tube feeding tips, and more

Cathy Harrington Administrative Assistant [email protected]

Information Clearinghouse: A resource designed for answering questions about home IV nutrition and tube feeding through a toll-free hotline, website, online education program, and DVD/video library

Andrea Guidi Executive Assistant [email protected]

Consumer Networking: A source of peer support that includes an online chat forum, and the ability to call or e-mail experienced consumers and caregivers

Darlene Kelly, MD, PhD, FACP Science & Medicine Advisor

Conferences: An opportunity for consumers, clinicians, providers, and industry representatives to share information and support Ambassador Network: A grassroots network of 60+ volunteer consumers and caregivers in the US, Australia, Canada, New Zealand, Norway, Poland, and the UK Equipment/Supply Exchange: A way to get supplies, formula, or equipment related to home IV nutrition or tube feeding from people who have them to donate into the hands of people who need these items

Lyn Howard, MB, FRCP, FACP Medical Director/Co-Founder Contact Information: 43 New Scotland Ave, MC28 Albany Medical Center Albany, NY 12208 518-262-5079 / 800-776-6539 FAX 518-262-5528 Oley.org

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