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Advances in pancreaticobiliary disease interventions: More options and better outcomes
Highlights of advances in pancreaticobiliary disease interventions were reviewed at this year’s Digestive Disease Week (DDW) as part of the American Gastroenterological Association (AGA) postgraduate course.
Over the last several decades, the endoscopic treatment of pancreaticobiliary disease has advanced exponentially. Evidence-based advances are changing the landscape of pancreaticobiliary disease management.
While endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement is first-line for the treatment of biliary obstruction, endoscopic ultrasound (EUS)-guided biliary drainage has emerged as an effective alternative in cases of failed ERCP. These procedures can be performed via a transhepatic approach (hepaticogastrostomy) from the proximal stomach, an extrahepatic approach (choledochoduodenostomy) from the duodenum, or via the gallbladder. Numerous studies have proved the safety and efficacy of these interventions in malignant biliary obstruction. A recent systematic meta-analysis pooled all of these approaches and concluded that EUS-guided biliary drainage is also reasonable to offer in benign disease when ERCP has failed or is not technically possible.
EUS-guided gallbladder drainage is similarly emerging as an alternative approach for management of acute cholecystitis. This is a reasonable option in patients with acute cholecystitis who are poor surgical candidates, have no evidence of gallbladder perforation, and will tolerate sedation. Moreover, this approach may be preferred over ERCP with cystic duct stent placement in the setting of a large stone burden, gastric outlet obstruction, or when an indwelling metal biliary stent occludes the cystic duct. Multidisciplinary discussion with surgical and interventional radiology services is essential, especially given this technique may preclude future cholecystectomy.
Indeterminate biliary strictures historically pose a major diagnostic challenge, and current approaches in the evaluation of such strictures lack diagnostic sensitivity. ERCP with concurrent brushing of the bile duct for cytology remains the most commonly used method of acquiring tissue. However, the sensitivity of diagnosis on brush cytology remains frustratingly low. Recent compelling evidence for increasing the number of brush passes to 30 in an indeterminate stricture improves diagnostic sensitivity and is a simple, safe, and low-cost intervention. This approach may ultimately decrease the number of patients requiring surgical intervention, which is particularly important when up to one-fifth of suspected biliary malignancies are found to be benign after surgical resection.
Not only have studies addressed increasing the diagnostic yield of stricture evaluation, but the treatment of biliary strictures has also evolved. Various stents are available, and different practice patterns have emerged for management of this entity. In an updated meta-analysis of randomized controlled trials evaluating multiple plastic stents versus a single covered metal stent for benign biliary strictures, no difference was found in stricture resolution, stricture recurrence, stent migration or adverse events. However, those patients treated with covered metal stents required fewer sessions of ERCP for stricture resolution. Moreover, no difference in stricture resolution was seen in subgroup analysis between anastomotic strictures, chronic pancreatitis, or bile duct injury. Despite higher cost of the stent itself, covered metal stents may ultimately lead to an overall decrease in health care expenditure.
The above examples are only a small subset of the progress that has been made in endoscopic management of pancreaticobiliary disease. The armamentarium of tools and techniques will continue to evolve to help us provide better minimally invasive care for our patients.
Dr. Schulman is associate professor in the division of gastroenterology and hepatology and the department of surgery at the University of Michigan. She is the incoming chief of endoscopy and the director of bariatric endoscopy. She disclosed consultancy work with Apollo Endosurgery, Boston Scientific, Olympus and MicroTech. She also disclosed research and grant support from GI Dynamics and Fractyl.
Highlights of advances in pancreaticobiliary disease interventions were reviewed at this year’s Digestive Disease Week (DDW) as part of the American Gastroenterological Association (AGA) postgraduate course.
Over the last several decades, the endoscopic treatment of pancreaticobiliary disease has advanced exponentially. Evidence-based advances are changing the landscape of pancreaticobiliary disease management.
While endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement is first-line for the treatment of biliary obstruction, endoscopic ultrasound (EUS)-guided biliary drainage has emerged as an effective alternative in cases of failed ERCP. These procedures can be performed via a transhepatic approach (hepaticogastrostomy) from the proximal stomach, an extrahepatic approach (choledochoduodenostomy) from the duodenum, or via the gallbladder. Numerous studies have proved the safety and efficacy of these interventions in malignant biliary obstruction. A recent systematic meta-analysis pooled all of these approaches and concluded that EUS-guided biliary drainage is also reasonable to offer in benign disease when ERCP has failed or is not technically possible.
EUS-guided gallbladder drainage is similarly emerging as an alternative approach for management of acute cholecystitis. This is a reasonable option in patients with acute cholecystitis who are poor surgical candidates, have no evidence of gallbladder perforation, and will tolerate sedation. Moreover, this approach may be preferred over ERCP with cystic duct stent placement in the setting of a large stone burden, gastric outlet obstruction, or when an indwelling metal biliary stent occludes the cystic duct. Multidisciplinary discussion with surgical and interventional radiology services is essential, especially given this technique may preclude future cholecystectomy.
Indeterminate biliary strictures historically pose a major diagnostic challenge, and current approaches in the evaluation of such strictures lack diagnostic sensitivity. ERCP with concurrent brushing of the bile duct for cytology remains the most commonly used method of acquiring tissue. However, the sensitivity of diagnosis on brush cytology remains frustratingly low. Recent compelling evidence for increasing the number of brush passes to 30 in an indeterminate stricture improves diagnostic sensitivity and is a simple, safe, and low-cost intervention. This approach may ultimately decrease the number of patients requiring surgical intervention, which is particularly important when up to one-fifth of suspected biliary malignancies are found to be benign after surgical resection.
Not only have studies addressed increasing the diagnostic yield of stricture evaluation, but the treatment of biliary strictures has also evolved. Various stents are available, and different practice patterns have emerged for management of this entity. In an updated meta-analysis of randomized controlled trials evaluating multiple plastic stents versus a single covered metal stent for benign biliary strictures, no difference was found in stricture resolution, stricture recurrence, stent migration or adverse events. However, those patients treated with covered metal stents required fewer sessions of ERCP for stricture resolution. Moreover, no difference in stricture resolution was seen in subgroup analysis between anastomotic strictures, chronic pancreatitis, or bile duct injury. Despite higher cost of the stent itself, covered metal stents may ultimately lead to an overall decrease in health care expenditure.
The above examples are only a small subset of the progress that has been made in endoscopic management of pancreaticobiliary disease. The armamentarium of tools and techniques will continue to evolve to help us provide better minimally invasive care for our patients.
Dr. Schulman is associate professor in the division of gastroenterology and hepatology and the department of surgery at the University of Michigan. She is the incoming chief of endoscopy and the director of bariatric endoscopy. She disclosed consultancy work with Apollo Endosurgery, Boston Scientific, Olympus and MicroTech. She also disclosed research and grant support from GI Dynamics and Fractyl.
Highlights of advances in pancreaticobiliary disease interventions were reviewed at this year’s Digestive Disease Week (DDW) as part of the American Gastroenterological Association (AGA) postgraduate course.
Over the last several decades, the endoscopic treatment of pancreaticobiliary disease has advanced exponentially. Evidence-based advances are changing the landscape of pancreaticobiliary disease management.
While endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement is first-line for the treatment of biliary obstruction, endoscopic ultrasound (EUS)-guided biliary drainage has emerged as an effective alternative in cases of failed ERCP. These procedures can be performed via a transhepatic approach (hepaticogastrostomy) from the proximal stomach, an extrahepatic approach (choledochoduodenostomy) from the duodenum, or via the gallbladder. Numerous studies have proved the safety and efficacy of these interventions in malignant biliary obstruction. A recent systematic meta-analysis pooled all of these approaches and concluded that EUS-guided biliary drainage is also reasonable to offer in benign disease when ERCP has failed or is not technically possible.
EUS-guided gallbladder drainage is similarly emerging as an alternative approach for management of acute cholecystitis. This is a reasonable option in patients with acute cholecystitis who are poor surgical candidates, have no evidence of gallbladder perforation, and will tolerate sedation. Moreover, this approach may be preferred over ERCP with cystic duct stent placement in the setting of a large stone burden, gastric outlet obstruction, or when an indwelling metal biliary stent occludes the cystic duct. Multidisciplinary discussion with surgical and interventional radiology services is essential, especially given this technique may preclude future cholecystectomy.
Indeterminate biliary strictures historically pose a major diagnostic challenge, and current approaches in the evaluation of such strictures lack diagnostic sensitivity. ERCP with concurrent brushing of the bile duct for cytology remains the most commonly used method of acquiring tissue. However, the sensitivity of diagnosis on brush cytology remains frustratingly low. Recent compelling evidence for increasing the number of brush passes to 30 in an indeterminate stricture improves diagnostic sensitivity and is a simple, safe, and low-cost intervention. This approach may ultimately decrease the number of patients requiring surgical intervention, which is particularly important when up to one-fifth of suspected biliary malignancies are found to be benign after surgical resection.
Not only have studies addressed increasing the diagnostic yield of stricture evaluation, but the treatment of biliary strictures has also evolved. Various stents are available, and different practice patterns have emerged for management of this entity. In an updated meta-analysis of randomized controlled trials evaluating multiple plastic stents versus a single covered metal stent for benign biliary strictures, no difference was found in stricture resolution, stricture recurrence, stent migration or adverse events. However, those patients treated with covered metal stents required fewer sessions of ERCP for stricture resolution. Moreover, no difference in stricture resolution was seen in subgroup analysis between anastomotic strictures, chronic pancreatitis, or bile duct injury. Despite higher cost of the stent itself, covered metal stents may ultimately lead to an overall decrease in health care expenditure.
The above examples are only a small subset of the progress that has been made in endoscopic management of pancreaticobiliary disease. The armamentarium of tools and techniques will continue to evolve to help us provide better minimally invasive care for our patients.
Dr. Schulman is associate professor in the division of gastroenterology and hepatology and the department of surgery at the University of Michigan. She is the incoming chief of endoscopy and the director of bariatric endoscopy. She disclosed consultancy work with Apollo Endosurgery, Boston Scientific, Olympus and MicroTech. She also disclosed research and grant support from GI Dynamics and Fractyl.
Breaking the glass ceiling in interventional endoscopy: Practical considerations for women
Subspecialty training in advanced endoscopy has become increasingly appealing to GI fellows. The allure of an ever-evolving and innovative field is demonstrated by a substantial increase in the number of training programs over the last 2 decades, from 10 in the year 2000 to over 100 currently.1 Despite its increasing popularity, women interventionalists have been a glaring absence in this phenomenon.
For the 2018-2019 academic year, women represented only 12% of incoming advanced endoscopy fellows who matched through the American Society for Gastrointestinal Endoscopy (ASGE) match program. Perhaps more concerning, studies have found that the percentage of female trainees interested in advanced endoscopy diminishes as general GI fellowship progresses.2
Several potential contributors have been cited that elucidate this disparity including work-life balance, radiation exposure, and lack of mentorship.2 Implicit bias also undoubtedly plays a role.
Choosing a career path: Academia vs. private practice
The decision to pursue academia versus private practice in the field of advanced endoscopy is not always straightforward. For a relatively saturated subspecialty, geographic constraints and availability of positions may limit one path or another. Although an interventional practice is best supported by a tertiary care center, there is a known opportunity conflict between the number of advanced endoscopy trainees and the availability of academic positions.3
Although private practice may offer more autonomy in scheduling and fewer nonclinical responsibilities, there may be increased pressure to retain high clinical volumes with direct financial consequences, as well as limitations in overall career advancement. Pursuing an academic path, however, may lead to less flexibility in scheduling, more travel involved with speaking engagements, and teaching and/or research responsibilities disrupting a favorable work-life balance.3 Regardless of career path, the best environment to thrive as an advanced endoscopist and a mother is one in which there is recognition and support of the challenging early family years.
Family planning
Given the long and arduous training, along with the pressures of the early faculty/clinical years, there is no perfect time for a pregnancy. Even when a pregnancy is planned, there is no certainty it will follow the intended course. The challenges specific to a career in advanced endoscopy are not well described.
Considerations during a pregnancy
When to divulge
For female interventionalists, determining when to divulge a pregnancy and the duration of maternity leave can be elusive. There is a fine balance between revealing prematurely given the risk of miscarriage and waiting so long that appropriate precautions are forsaken. One might consider disclosing the pregnancy to a few key personnel in the endoscopy unit and/or a radiation safety officer to optimize early measures to prevent occupational hazards.
Maternity leave
Every institution and practice differ in the details of maternity leave policies. These details should be reviewed and negotiated in advance. At a minimum, they are guided by the federal Family and Medical Leave Act, which entitles employees to 12 weeks of unpaid, job-protected leave.4 Each pregnancy, delivery, and postpartum period is unique and unpredictable. While early planning and consideration of coverage are crucial, it is imperative to be realistic and fluid about the postpartum journey. The unpredictable need for an extended leave has the potential to lead to career stagnancy. It is important to remember that this is a small fraction of time in the context of an entire career.
Fluoroscopy exposure
The exposure to fluoroscopy and potential adverse effects on a pregnancy has been cited frequently by women as a barrier to pursuing advanced endoscopy.2 Given the paucity of women in this field, there has yet to be definitive data on the management of fluoroscopy risk while pregnant. The ASGE Quality Assurance Endoscopy Committee has acknowledged the importance of such data and is currently preparing guidelines for radiation safety that will address the risks for pregnant endoscopists and strategies to minimize fetal exposure. The use of a fetal monitor and an early discussion with the institution’s radiation safety officer are essential to minimize fetal exposure.
Optimizing ergonomics
There have been several publications demonstrating the deleterious musculoskeletal impacts of poor ergonomics while performing endoscopy, with women being at greater risk.5The New Gastroenterologist has also published a primer on this topic. In addition to inadequate education on biomechanics and inconsistent implementation of preventative safeguards, poor endoscope design has been shown to contribute. This can be accentuated for women in advanced endoscopy who perform complex procedures with therapeutic endoscopes equipped with suboptimal handle size and dial placement.
The potential for musculoskeletal injury increases during pregnancy. The standard measures to optimize biomechanics include screen at eye level, bed at hip height, a cushioned mat, and an athletic stance.6 In addition, back injury during pregnancy in advanced endoscopy is not uncommon. Several considerations should be entertained including use of double lead versus standard two-piece 0.5-mm lead with shielding curtains and walls, sitting during procedures when possible, and incorporating short breaks in the endoscopy schedule. Furthermore, more focus and innovation are required from endoscope manufacturers to tailor toward female hand anatomy. Until then, these small but meaningful measures may help to ensure optimal biomechanics to prevent injury.
Breastfeeding/pumping
Breastfeeding in the field of advanced endoscopy has traditionally been challenging. Navigating the collection and storage of breast milk during a busy day of interventional cases can be overwhelming. The previously stagnant industry of electric breast pumps has recently been revolutionized by the innovation of wearable breast pumps. Women are no longer required to find private space to connect to a loud, wired, contraption at least 30 minutes at a time, several times a day. In the context of a busy endoscopy schedule, this antiquated ritual is nearly incompatible with the continuation of breast feeding after returning to work. With relatively silent, wearable breast pumps, it is now possible to continue patient care whether in the clinic or in the endoscopy suite with minimal disruption to a productive day.
Resources
Although there continues to be a void for dedicated mentorship for female interventionalists, there have been many organizational initiatives to unite female gastroenterologists and promote the advancement of women. Several specific initiatives have been particularly effective. Women in Endoscopy (WIE) is a global organization that champions the advancement of women in GI through education, professional growth, and leadership development. In collaboration with the American Gastroenterological Association, they have recently held a virtual event focused on career advancement in the context of unique challenges for women, “Cross Your T’s to Success: How to Deliver a Great Talk, Get Your New Title and Seize Your Next Career Twist.” WIE has also recently launched a webinar series, “Women in Advanced Endoscopy: Fellows Educational Series,” that highlights practicing female interventionalists and illuminating the path to entering the field for trainees. In addition, the ASGE Leadership Education and Development (LEAD) Program has had longstanding success in providing young female gastroenterologists an opportunity to enhance their career advancement skills and facilitate the path to leadership positions. The popularity and success of the LEAD program has led the ASGE to create a special interest group known as ASGE Women in Endoscopy (AWE) with a mission to develop resources for career development during the first 5 years after fellowship. The American College of Gastroenterology also has a unique networking platform for women known as the Women in GI Circle. Furthermore, social media platforms such as Facebook’s Physician Moms Group (PMG) and Ladies of the Gut (LOG; group accessible by invitation only) have proved powerful in connecting female endoscopists and providing a great resource for quick guidance, encouragement, and commiseration. There are also multiple Facebook groups for breastfeeding physicians including Dr. Milk and other pump-specific groups. These online communities have facilitated the dissemination of high-quality resources for troubleshooting and general camaraderie.
Conclusion
Women remain a minority in GI, and especially in advanced endoscopy. Compared with surgical subspecialties that have witnessed substantial progress in the recruitment of women over the past decade, advanced endoscopy seems to be lagging far behind. Recent studies have shown that unified efforts from the surgical societies, such as establishing mentorship programs for trainees, have managed to increase the rates of women in general surgery programs from 14% in 2001 to 40% in 2017.7,8 As the barriers for women entering advanced endoscopy are further understood, the underlying concern of reconciling a challenging field and motherhood has emerged as a common thread. While the practical information presented here cannot overcome the cultural constructs and implicit biases in which women practice advanced endoscopy, the hope is to provide a pragmatic approach to the perceived barriers and promote dialogue among women so that they, too, can pursue and thrive in the field of advanced endoscopy.
References
1. Trindade AJ et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc. 2012;76(5):939-44.
2. Pollack MJ et al. Gender disparities and gastroenterology trainee attitudes toward advanced endoscopic training. Gastrointest Endosc. 2010;72(5):1111.
3. Granato CM et al. Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013. Gastrointest Endosc. 2016;84(2):266-71.
4. Family and Medical Leave Act. US Department of Labor. Accessed May 15, 2020. https://www.dol.gov/agencies/whd/fmla.
5. Pedrosa MC et al. Minimizing occupational hazards in endoscopy: Personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc. 2010;72(2):227-35.
6. Singla M et al. Training the endo-athlete: An update in ergonomics in endoscopy. Clin Gastro Hepatol. 2018;16(7):1003-6.
7. Aziz HB et al. 2018 ACS Governors Survey: Gender inequality and harassment remain a challenge in surgery. Bulletin of the American College of Surgeons. Accessed August 22, 2020. https://bulletin.facs.org/2019/09/2018-acs-governors-survey-gender-inequality-and-harassment-remain-a-challenge-in-surgery/
8. Abelson JS et al. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-72.e1.
Dr. Hasan is director of interventional endoscopy, department of gastroenterology and hepatology, NorthBay Healthcare Group; Dr. Schulman is an assistant professor, director of bariatric endoscopy, division of gastroenterology and hepatology, University of Michigan, Ann Arbor.
Subspecialty training in advanced endoscopy has become increasingly appealing to GI fellows. The allure of an ever-evolving and innovative field is demonstrated by a substantial increase in the number of training programs over the last 2 decades, from 10 in the year 2000 to over 100 currently.1 Despite its increasing popularity, women interventionalists have been a glaring absence in this phenomenon.
For the 2018-2019 academic year, women represented only 12% of incoming advanced endoscopy fellows who matched through the American Society for Gastrointestinal Endoscopy (ASGE) match program. Perhaps more concerning, studies have found that the percentage of female trainees interested in advanced endoscopy diminishes as general GI fellowship progresses.2
Several potential contributors have been cited that elucidate this disparity including work-life balance, radiation exposure, and lack of mentorship.2 Implicit bias also undoubtedly plays a role.
Choosing a career path: Academia vs. private practice
The decision to pursue academia versus private practice in the field of advanced endoscopy is not always straightforward. For a relatively saturated subspecialty, geographic constraints and availability of positions may limit one path or another. Although an interventional practice is best supported by a tertiary care center, there is a known opportunity conflict between the number of advanced endoscopy trainees and the availability of academic positions.3
Although private practice may offer more autonomy in scheduling and fewer nonclinical responsibilities, there may be increased pressure to retain high clinical volumes with direct financial consequences, as well as limitations in overall career advancement. Pursuing an academic path, however, may lead to less flexibility in scheduling, more travel involved with speaking engagements, and teaching and/or research responsibilities disrupting a favorable work-life balance.3 Regardless of career path, the best environment to thrive as an advanced endoscopist and a mother is one in which there is recognition and support of the challenging early family years.
Family planning
Given the long and arduous training, along with the pressures of the early faculty/clinical years, there is no perfect time for a pregnancy. Even when a pregnancy is planned, there is no certainty it will follow the intended course. The challenges specific to a career in advanced endoscopy are not well described.
Considerations during a pregnancy
When to divulge
For female interventionalists, determining when to divulge a pregnancy and the duration of maternity leave can be elusive. There is a fine balance between revealing prematurely given the risk of miscarriage and waiting so long that appropriate precautions are forsaken. One might consider disclosing the pregnancy to a few key personnel in the endoscopy unit and/or a radiation safety officer to optimize early measures to prevent occupational hazards.
Maternity leave
Every institution and practice differ in the details of maternity leave policies. These details should be reviewed and negotiated in advance. At a minimum, they are guided by the federal Family and Medical Leave Act, which entitles employees to 12 weeks of unpaid, job-protected leave.4 Each pregnancy, delivery, and postpartum period is unique and unpredictable. While early planning and consideration of coverage are crucial, it is imperative to be realistic and fluid about the postpartum journey. The unpredictable need for an extended leave has the potential to lead to career stagnancy. It is important to remember that this is a small fraction of time in the context of an entire career.
Fluoroscopy exposure
The exposure to fluoroscopy and potential adverse effects on a pregnancy has been cited frequently by women as a barrier to pursuing advanced endoscopy.2 Given the paucity of women in this field, there has yet to be definitive data on the management of fluoroscopy risk while pregnant. The ASGE Quality Assurance Endoscopy Committee has acknowledged the importance of such data and is currently preparing guidelines for radiation safety that will address the risks for pregnant endoscopists and strategies to minimize fetal exposure. The use of a fetal monitor and an early discussion with the institution’s radiation safety officer are essential to minimize fetal exposure.
Optimizing ergonomics
There have been several publications demonstrating the deleterious musculoskeletal impacts of poor ergonomics while performing endoscopy, with women being at greater risk.5The New Gastroenterologist has also published a primer on this topic. In addition to inadequate education on biomechanics and inconsistent implementation of preventative safeguards, poor endoscope design has been shown to contribute. This can be accentuated for women in advanced endoscopy who perform complex procedures with therapeutic endoscopes equipped with suboptimal handle size and dial placement.
The potential for musculoskeletal injury increases during pregnancy. The standard measures to optimize biomechanics include screen at eye level, bed at hip height, a cushioned mat, and an athletic stance.6 In addition, back injury during pregnancy in advanced endoscopy is not uncommon. Several considerations should be entertained including use of double lead versus standard two-piece 0.5-mm lead with shielding curtains and walls, sitting during procedures when possible, and incorporating short breaks in the endoscopy schedule. Furthermore, more focus and innovation are required from endoscope manufacturers to tailor toward female hand anatomy. Until then, these small but meaningful measures may help to ensure optimal biomechanics to prevent injury.
Breastfeeding/pumping
Breastfeeding in the field of advanced endoscopy has traditionally been challenging. Navigating the collection and storage of breast milk during a busy day of interventional cases can be overwhelming. The previously stagnant industry of electric breast pumps has recently been revolutionized by the innovation of wearable breast pumps. Women are no longer required to find private space to connect to a loud, wired, contraption at least 30 minutes at a time, several times a day. In the context of a busy endoscopy schedule, this antiquated ritual is nearly incompatible with the continuation of breast feeding after returning to work. With relatively silent, wearable breast pumps, it is now possible to continue patient care whether in the clinic or in the endoscopy suite with minimal disruption to a productive day.
Resources
Although there continues to be a void for dedicated mentorship for female interventionalists, there have been many organizational initiatives to unite female gastroenterologists and promote the advancement of women. Several specific initiatives have been particularly effective. Women in Endoscopy (WIE) is a global organization that champions the advancement of women in GI through education, professional growth, and leadership development. In collaboration with the American Gastroenterological Association, they have recently held a virtual event focused on career advancement in the context of unique challenges for women, “Cross Your T’s to Success: How to Deliver a Great Talk, Get Your New Title and Seize Your Next Career Twist.” WIE has also recently launched a webinar series, “Women in Advanced Endoscopy: Fellows Educational Series,” that highlights practicing female interventionalists and illuminating the path to entering the field for trainees. In addition, the ASGE Leadership Education and Development (LEAD) Program has had longstanding success in providing young female gastroenterologists an opportunity to enhance their career advancement skills and facilitate the path to leadership positions. The popularity and success of the LEAD program has led the ASGE to create a special interest group known as ASGE Women in Endoscopy (AWE) with a mission to develop resources for career development during the first 5 years after fellowship. The American College of Gastroenterology also has a unique networking platform for women known as the Women in GI Circle. Furthermore, social media platforms such as Facebook’s Physician Moms Group (PMG) and Ladies of the Gut (LOG; group accessible by invitation only) have proved powerful in connecting female endoscopists and providing a great resource for quick guidance, encouragement, and commiseration. There are also multiple Facebook groups for breastfeeding physicians including Dr. Milk and other pump-specific groups. These online communities have facilitated the dissemination of high-quality resources for troubleshooting and general camaraderie.
Conclusion
Women remain a minority in GI, and especially in advanced endoscopy. Compared with surgical subspecialties that have witnessed substantial progress in the recruitment of women over the past decade, advanced endoscopy seems to be lagging far behind. Recent studies have shown that unified efforts from the surgical societies, such as establishing mentorship programs for trainees, have managed to increase the rates of women in general surgery programs from 14% in 2001 to 40% in 2017.7,8 As the barriers for women entering advanced endoscopy are further understood, the underlying concern of reconciling a challenging field and motherhood has emerged as a common thread. While the practical information presented here cannot overcome the cultural constructs and implicit biases in which women practice advanced endoscopy, the hope is to provide a pragmatic approach to the perceived barriers and promote dialogue among women so that they, too, can pursue and thrive in the field of advanced endoscopy.
References
1. Trindade AJ et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc. 2012;76(5):939-44.
2. Pollack MJ et al. Gender disparities and gastroenterology trainee attitudes toward advanced endoscopic training. Gastrointest Endosc. 2010;72(5):1111.
3. Granato CM et al. Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013. Gastrointest Endosc. 2016;84(2):266-71.
4. Family and Medical Leave Act. US Department of Labor. Accessed May 15, 2020. https://www.dol.gov/agencies/whd/fmla.
5. Pedrosa MC et al. Minimizing occupational hazards in endoscopy: Personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc. 2010;72(2):227-35.
6. Singla M et al. Training the endo-athlete: An update in ergonomics in endoscopy. Clin Gastro Hepatol. 2018;16(7):1003-6.
7. Aziz HB et al. 2018 ACS Governors Survey: Gender inequality and harassment remain a challenge in surgery. Bulletin of the American College of Surgeons. Accessed August 22, 2020. https://bulletin.facs.org/2019/09/2018-acs-governors-survey-gender-inequality-and-harassment-remain-a-challenge-in-surgery/
8. Abelson JS et al. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-72.e1.
Dr. Hasan is director of interventional endoscopy, department of gastroenterology and hepatology, NorthBay Healthcare Group; Dr. Schulman is an assistant professor, director of bariatric endoscopy, division of gastroenterology and hepatology, University of Michigan, Ann Arbor.
Subspecialty training in advanced endoscopy has become increasingly appealing to GI fellows. The allure of an ever-evolving and innovative field is demonstrated by a substantial increase in the number of training programs over the last 2 decades, from 10 in the year 2000 to over 100 currently.1 Despite its increasing popularity, women interventionalists have been a glaring absence in this phenomenon.
For the 2018-2019 academic year, women represented only 12% of incoming advanced endoscopy fellows who matched through the American Society for Gastrointestinal Endoscopy (ASGE) match program. Perhaps more concerning, studies have found that the percentage of female trainees interested in advanced endoscopy diminishes as general GI fellowship progresses.2
Several potential contributors have been cited that elucidate this disparity including work-life balance, radiation exposure, and lack of mentorship.2 Implicit bias also undoubtedly plays a role.
Choosing a career path: Academia vs. private practice
The decision to pursue academia versus private practice in the field of advanced endoscopy is not always straightforward. For a relatively saturated subspecialty, geographic constraints and availability of positions may limit one path or another. Although an interventional practice is best supported by a tertiary care center, there is a known opportunity conflict between the number of advanced endoscopy trainees and the availability of academic positions.3
Although private practice may offer more autonomy in scheduling and fewer nonclinical responsibilities, there may be increased pressure to retain high clinical volumes with direct financial consequences, as well as limitations in overall career advancement. Pursuing an academic path, however, may lead to less flexibility in scheduling, more travel involved with speaking engagements, and teaching and/or research responsibilities disrupting a favorable work-life balance.3 Regardless of career path, the best environment to thrive as an advanced endoscopist and a mother is one in which there is recognition and support of the challenging early family years.
Family planning
Given the long and arduous training, along with the pressures of the early faculty/clinical years, there is no perfect time for a pregnancy. Even when a pregnancy is planned, there is no certainty it will follow the intended course. The challenges specific to a career in advanced endoscopy are not well described.
Considerations during a pregnancy
When to divulge
For female interventionalists, determining when to divulge a pregnancy and the duration of maternity leave can be elusive. There is a fine balance between revealing prematurely given the risk of miscarriage and waiting so long that appropriate precautions are forsaken. One might consider disclosing the pregnancy to a few key personnel in the endoscopy unit and/or a radiation safety officer to optimize early measures to prevent occupational hazards.
Maternity leave
Every institution and practice differ in the details of maternity leave policies. These details should be reviewed and negotiated in advance. At a minimum, they are guided by the federal Family and Medical Leave Act, which entitles employees to 12 weeks of unpaid, job-protected leave.4 Each pregnancy, delivery, and postpartum period is unique and unpredictable. While early planning and consideration of coverage are crucial, it is imperative to be realistic and fluid about the postpartum journey. The unpredictable need for an extended leave has the potential to lead to career stagnancy. It is important to remember that this is a small fraction of time in the context of an entire career.
Fluoroscopy exposure
The exposure to fluoroscopy and potential adverse effects on a pregnancy has been cited frequently by women as a barrier to pursuing advanced endoscopy.2 Given the paucity of women in this field, there has yet to be definitive data on the management of fluoroscopy risk while pregnant. The ASGE Quality Assurance Endoscopy Committee has acknowledged the importance of such data and is currently preparing guidelines for radiation safety that will address the risks for pregnant endoscopists and strategies to minimize fetal exposure. The use of a fetal monitor and an early discussion with the institution’s radiation safety officer are essential to minimize fetal exposure.
Optimizing ergonomics
There have been several publications demonstrating the deleterious musculoskeletal impacts of poor ergonomics while performing endoscopy, with women being at greater risk.5The New Gastroenterologist has also published a primer on this topic. In addition to inadequate education on biomechanics and inconsistent implementation of preventative safeguards, poor endoscope design has been shown to contribute. This can be accentuated for women in advanced endoscopy who perform complex procedures with therapeutic endoscopes equipped with suboptimal handle size and dial placement.
The potential for musculoskeletal injury increases during pregnancy. The standard measures to optimize biomechanics include screen at eye level, bed at hip height, a cushioned mat, and an athletic stance.6 In addition, back injury during pregnancy in advanced endoscopy is not uncommon. Several considerations should be entertained including use of double lead versus standard two-piece 0.5-mm lead with shielding curtains and walls, sitting during procedures when possible, and incorporating short breaks in the endoscopy schedule. Furthermore, more focus and innovation are required from endoscope manufacturers to tailor toward female hand anatomy. Until then, these small but meaningful measures may help to ensure optimal biomechanics to prevent injury.
Breastfeeding/pumping
Breastfeeding in the field of advanced endoscopy has traditionally been challenging. Navigating the collection and storage of breast milk during a busy day of interventional cases can be overwhelming. The previously stagnant industry of electric breast pumps has recently been revolutionized by the innovation of wearable breast pumps. Women are no longer required to find private space to connect to a loud, wired, contraption at least 30 minutes at a time, several times a day. In the context of a busy endoscopy schedule, this antiquated ritual is nearly incompatible with the continuation of breast feeding after returning to work. With relatively silent, wearable breast pumps, it is now possible to continue patient care whether in the clinic or in the endoscopy suite with minimal disruption to a productive day.
Resources
Although there continues to be a void for dedicated mentorship for female interventionalists, there have been many organizational initiatives to unite female gastroenterologists and promote the advancement of women. Several specific initiatives have been particularly effective. Women in Endoscopy (WIE) is a global organization that champions the advancement of women in GI through education, professional growth, and leadership development. In collaboration with the American Gastroenterological Association, they have recently held a virtual event focused on career advancement in the context of unique challenges for women, “Cross Your T’s to Success: How to Deliver a Great Talk, Get Your New Title and Seize Your Next Career Twist.” WIE has also recently launched a webinar series, “Women in Advanced Endoscopy: Fellows Educational Series,” that highlights practicing female interventionalists and illuminating the path to entering the field for trainees. In addition, the ASGE Leadership Education and Development (LEAD) Program has had longstanding success in providing young female gastroenterologists an opportunity to enhance their career advancement skills and facilitate the path to leadership positions. The popularity and success of the LEAD program has led the ASGE to create a special interest group known as ASGE Women in Endoscopy (AWE) with a mission to develop resources for career development during the first 5 years after fellowship. The American College of Gastroenterology also has a unique networking platform for women known as the Women in GI Circle. Furthermore, social media platforms such as Facebook’s Physician Moms Group (PMG) and Ladies of the Gut (LOG; group accessible by invitation only) have proved powerful in connecting female endoscopists and providing a great resource for quick guidance, encouragement, and commiseration. There are also multiple Facebook groups for breastfeeding physicians including Dr. Milk and other pump-specific groups. These online communities have facilitated the dissemination of high-quality resources for troubleshooting and general camaraderie.
Conclusion
Women remain a minority in GI, and especially in advanced endoscopy. Compared with surgical subspecialties that have witnessed substantial progress in the recruitment of women over the past decade, advanced endoscopy seems to be lagging far behind. Recent studies have shown that unified efforts from the surgical societies, such as establishing mentorship programs for trainees, have managed to increase the rates of women in general surgery programs from 14% in 2001 to 40% in 2017.7,8 As the barriers for women entering advanced endoscopy are further understood, the underlying concern of reconciling a challenging field and motherhood has emerged as a common thread. While the practical information presented here cannot overcome the cultural constructs and implicit biases in which women practice advanced endoscopy, the hope is to provide a pragmatic approach to the perceived barriers and promote dialogue among women so that they, too, can pursue and thrive in the field of advanced endoscopy.
References
1. Trindade AJ et al. Characteristics, goals, and motivations of applicants pursuing a fourth-year advanced endoscopy fellowship. Gastrointest Endosc. 2012;76(5):939-44.
2. Pollack MJ et al. Gender disparities and gastroenterology trainee attitudes toward advanced endoscopic training. Gastrointest Endosc. 2010;72(5):1111.
3. Granato CM et al. Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013. Gastrointest Endosc. 2016;84(2):266-71.
4. Family and Medical Leave Act. US Department of Labor. Accessed May 15, 2020. https://www.dol.gov/agencies/whd/fmla.
5. Pedrosa MC et al. Minimizing occupational hazards in endoscopy: Personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc. 2010;72(2):227-35.
6. Singla M et al. Training the endo-athlete: An update in ergonomics in endoscopy. Clin Gastro Hepatol. 2018;16(7):1003-6.
7. Aziz HB et al. 2018 ACS Governors Survey: Gender inequality and harassment remain a challenge in surgery. Bulletin of the American College of Surgeons. Accessed August 22, 2020. https://bulletin.facs.org/2019/09/2018-acs-governors-survey-gender-inequality-and-harassment-remain-a-challenge-in-surgery/
8. Abelson JS et al. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg. 2016;212(4):566-72.e1.
Dr. Hasan is director of interventional endoscopy, department of gastroenterology and hepatology, NorthBay Healthcare Group; Dr. Schulman is an assistant professor, director of bariatric endoscopy, division of gastroenterology and hepatology, University of Michigan, Ann Arbor.