00:00:00: Hello everyone, my name is Egle and I'm the host of UEG Talks.

00:00:04: Educational hopefully fun dive into GI world and beyond!

00:00:08: We're happy to have you with us for another exciting episode And today is a very special one, and the first-year resident in me just overwhelmed with excitement.

00:00:18: Today's guest is a titanine endoscopy prolific researcher, innovator, educator, entrepreneur and chief of one of biggest hospitals in the world – A legend who does not need any introductions!

00:00:30: Professor Nageshwar Reddy Welcome to UEG Podcast professor.

00:00:33: Thank you Egle.

00:00:34: thank you so much.

00:00:35: We're happy to have you here.

00:00:37: So, let's dive in.

00:00:39: Today we're talking about endoscopy and how it changed through the years.

00:00:43: so for you personally what is the biggest breakthrough in endoscopy?

00:00:48: Actually... For me.. The biggest breakthrough was not now.

00:00:51: It occurred about maybe six-years back when fiber optic endoscopic actually came.

00:00:57: because you are now transiting from a rigid endoscope to a fiberoptic endoscope which totally change whole game plan of endoscopes And I think that to me was the single most important breakthrough in endoscopy.

00:01:12: Since then, incremental steps have occurred like a video and scope image enhancements in the endoscope better optics, better channels so you can do lot of procedures... ...and whole new lot of axiaries came on this side.

00:01:28: we also had capsule endoscopic development occurring there.

00:01:32: So it's actually fundamentally The change from a rigid to fiber optic endoscopy, we changed the whole way that endoscopic progressed.

00:01:41: If those tingles didn't occur... ...we would have never gone to this stage.

00:01:44: where now!

00:01:45: Okay so you can divide one single like breakthrough?

00:01:49: No it breaks through.

00:01:50: what's the fiberoptic endoscopy?

00:01:52: It looks very ancient now.

00:01:54: For people like me who are B or also ancient We realized as we looked Through these transition That This was the single most important point which causes a transition.

00:02:05: And then of course, it's been very incremental.

00:02:08: in fact I remember when the video scopes came.

00:02:11: we are very reluctant to use that... Why?

00:02:14: ...in the eighties late eighties because they all used.

00:02:17: looking through the fiber optic gave an intimate feeling between yourself and the mucosa and the papilla.

00:02:22: We were actually here looking at it ourselves but the disadvantage was everybody around not able see Whenever the professor said, look this is a difficult papilla.

00:02:32: We all thought it was a difficult Papilla but only when video came everybody else could judge what you are doing.

00:02:38: so that was major advantage of video scope not to actually improve your precision and improved their ability for other people see whats happening in room.

00:02:48: When they started seeing it there were multiple opinions telling us where this is And also helping with accessories became easier.

00:02:58: Otherwise, I remember as assistants because when i started it was fiber optic and I used to assist my professor with ERCPs.

00:03:06: It will ask together just pushing the guide where not knowing what is happening inside of a very boring job.

00:03:12: but now everybody's involved everyone interested so become quite interesting.

00:03:16: So that single most important thing video scope did.

00:03:20: But in last maybe ten years endoscoping manufacturers have start thinking about increasing the image enhancement, quality of images.

00:03:30: These things definitely have now made a difference.

00:03:32: in terms of third space endoscopy before ERCP there are no differences but we're looking at Third Space Endoscopy ESDs and so on.

00:03:41: then you require much better image.

00:03:43: So this is The next evolution is going to be how to include all these into disposable scopes because We are not talking about lot of environmental factors.

00:03:55: So disposable scores with enhanced imaging is the next challenge that manufacturers are going to have.

00:04:01: So regarding the disposable or single use endoscopes, what's your opinion?

00:04:07: Because actually medical field is one of the most contributing factors to environmental pollution.

00:04:14: so where is their place here?

00:04:18: Of course hygiene on one side but the environmental impact as in other.

00:04:24: Yeah, so I absolutely agree with you.

00:04:26: Of course hygiene is important but if we're talking about routine endoscopy like colonoscopy or upper GI Hygiene is not so important in the sense that they are not breaching the vessels going into the vascular system.

00:04:40: So it's predominantly limited to that.

00:04:42: and we know anyway gut has a lot of bacteria itself.

00:04:44: It doesn't make any difference When doing invasive procedures like ERCPR-US hygen comes into factor.

00:04:51: And we of course know that the two companies have introduced disposable ERCP scopes, which haven't taken off as they expected mainly because there's a factor to cost.

00:05:00: The environmental factors now.

00:05:03: so unless you get a bio-friendly endoscopes, disposal endoscopes are going add lot into this problem of carbon footprints being added in environment.

00:05:14: So my feeling is it will be confined certain small centers especially western countries.

00:05:21: But more importantly, we did a very interesting study recently along with group in Netherlands.

00:05:27: Marco Bruno, Italy Repici and with Pittsburgh.

00:05:31: what we do is look at bacteria in the gut.

00:05:35: how much antibiotic resistant bacteria were there?

00:05:38: And we found surprisingly that in a country like India, eighty three percent of patients coming for ERCP already had a gut-resistant bacteria I mean antibiotic resistant bacterial in their gut.

00:05:51: So what's the point in using a disposable scope?

00:05:53: Whereas in a country like Netherlands it was ten percent, Italy twenty percent.

00:05:57: In US again same twenty percent.

00:06:00: so this is published in Lancet recently and we concluded from that.

00:06:05: at least in emerging nations or where there economy resources are not good There absolutely no point to use disposable scopes.

00:06:15: I know i'm going have problems with companies but This Is What I Feel.

00:06:20: It is what it is.

00:06:21: But why do you think this?

00:06:22: Because Italy, for instance... ...is one of the most predominantly antibiotic-resistant countries in Europe and that's only twenty percent.

00:06:31: And Why Do You Think India Is Such An Arplier In This Case In Antibiotic Resistance?

00:06:37: Yeah!

00:06:37: That's a very important point.

00:06:39: We Actually Looked At It Carefully.

00:06:41: One Of Course.

00:06:42: In India Antibiotics Are Prescribed Over The Counter.

00:06:46: You Don't Have To Get A Doctor's Prescription.

00:06:49: Any patient can go and I want amoxicillin, the pharmacist gives it to him.

00:06:54: So this is one problem.

00:06:55: The second problem that a lot of people are very anxious And take antibiotics unnecessarily Viral fever for example.

00:07:03: You have fear of one day or two days.

00:07:05: you just wait It out and goes up.

00:07:07: they don't first year fewer They're going to take an antibiotic.

00:07:10: Third important thing Is taking incomplete courses five-day or seven day course.

00:07:16: They take it for one, two days a feeling better.

00:07:18: they stop

00:07:18: it.".

00:07:19: So these are the medical reasons.

00:07:21: but there's also something outside medicine and that is.

00:07:24: we now know that lot of antibiotics are used in animal husbandry agriculture And therefore what is happening?

00:07:34: Even in food that we use even vegetables There're lots of antibiotics.

00:07:38: so when you actually looked at patients or people coming for procedures who had this drug-resistant bacteria, then visited a doctor.

00:07:47: They hadn't taken antibiotics but because from the food source right?

00:07:51: From agriculture milk and other things they were getting these antibiotic resistant issues.

00:07:56: so I think This is a big problem.

00:07:58: in India The government Is very actively looking into this.

00:08:02: just A month ago our Prime Minister addressed whole nation asking people not to take antibiotics unnecessarily and telling doctors be careful, preferably only in certain.

00:08:11: So it's become a big issue.

00:08:13: so when you actually relate this along with the disposable scopes You realize that It is different problem altogether from West.

00:08:20: We at present have tackle larger problems than just looking at disposable scops.

00:08:26: Forgive me for my lack of knowledge but would restriction on antibiotic use?

00:08:33: would be a solution for this problem?

00:08:35: or is it just not feasible due to rural areas there?

00:08:41: The patients might not find the doctor in time when they really need antibiotics.

00:08:47: Exactly, so its complex problematic.

00:08:50: what I think involves is not only government administration mentality of people doctors and so on.

00:08:58: So, if you restrict antibiotics very strongly like what happens in narcotics... In India, narcotics are well controlled.

00:09:06: We don't have people on unnecessary narcotics and all.

00:09:10: Government has a thing called Schedule X which is all the narcotics that hospitals had to keep, pharmacy as they kept record.

00:09:17: so no problem!

00:09:18: Very restricted.

00:09:19: it's very well regulated.

00:09:21: I've actually suggested to government that antibiotics also should come under Schedule x. So I think this is a problem we have to tackle very harshly.

00:09:31: The second issue here, because the complexity of that agriculture and animal husbandry poultry they are using antibiotics a lot so... This is a very complex issue.

00:09:44: it's a political issue.

00:09:46: how can control antibiotic?

00:09:47: there will be able see?

00:09:49: It not an easy problems to solve.

00:09:51: but one important thing.

00:09:52: remember maybe many years back thirty or forty year If you looked at this problem in say Netherlands, antibiotic resistance was thirty percent.

00:10:02: They've got it down to ten per cent now.

00:10:04: so we have an historical background which says that probably India.

00:10:08: if your very strict and hopefully the government is going into go-into this We can reduce antibiotic resistance problem.

00:10:16: I know we diverted from actual thing but this a very important issue for us currently

00:10:21: Of course, and who could have thought that choosing the duodenoscope will depend on your governmental policies in regards to antibiotics.

00:10:30: Yeah it's a complex problem but full disclosure I've watched a lot of interviews with you And uh... You had very interesting surrounding when you were growing up going back to Alexander Fleming And I would like to ask, who was the most inspiring medical figure in your life?

00:10:53: Or Who do you consider it be biggest influence on your career.

00:10:58: Of course there are many medical figures influenced me and endoscopy especially like Peter Cotton, Nipso Hindra and so on Michel Kramer.

00:11:07: but To Me The Most Influential Person In My Life Medical Person As A Doctor Was my father pathologist.

00:11:17: He was a very eminent pathologist, he was low middle class in terms of our economical situation.

00:11:24: so but he is the person with high integrity and when I took up gastroenterology and started practice i did it very well.

00:11:33: economically you know that somebody comes from lower-middle class wants to make lot's money or family happy etc.

00:11:41: So then he called me one day home for lunch and told me, son you're a total failure in life.

00:11:47: I said what do mean failure?

00:11:49: I did the top specialty.

00:11:50: he said no that's not success.

00:11:52: Success is have we build institutions?

00:11:54: Have we taught any students?

00:11:56: Have you published any papers?

00:11:58: Have done any work for poor patients?

00:12:01: I'd done nothing!

00:12:03: I realized then that um...I was really a failure in the sense that he looked at the world.

00:12:08: i changed immediately decided no more stop my practice.

00:12:12: We started this.

00:12:13: Fortunately, we got a lot of donors to help us giving us the Asian Institute Gastroenterology building build up.

00:12:19: a team of like-minded people Started publishing starting laws.

00:12:24: A lot of free patients used to treat going into community with vans and do endoscopy there and treat our patient.

00:12:30: All these give me immense satisfaction.

00:12:32: And then off course my father is no more but I look back.

00:12:34: i realized what he said Is absolutely true?

00:12:37: I would have made much more money probably But not happiness.

00:12:40: And I think a true happiness comes from doing what you think is the right thing.

00:12:44: Okay, so this was your father's definition of success when we were in our thirties?

00:12:50: So have you adopted his definition of Success?

00:12:54: Yes yes!

00:12:55: Whenever i go to conference and sometimes I'm asked to give talks on how to be successful... As people raise their hands because they think I am successful.

00:13:04: So, then you'll see some hands-raising and tell them that's not success.

00:13:11: Success is doing something which we like to do.

00:13:15: but how many of us are successful in this sense?

00:13:17: So it changes the whole definition of success for people unless what one likes or does doesn't

00:13:25: work out well.

00:13:26: This is the end goal, to do what you want.

00:13:29: What makes you happy and also contribute to this society?

00:13:33: But for an endoscopist to be successful... ...what do we consider it as cornerstones in order to build these

00:13:42: things

00:13:42: up?".

00:13:42: So I think that's a very important question!

00:13:45: Should an endoscopeist think of what should be their future?

00:13:48: The first thing is passion.

00:13:51: unless there are passions for doing certain things they shouldn't have done before In fact, I often when i'm selecting people for our institution.

00:13:59: Look at two things how passionate easy about what he wants to do.

00:14:02: second is How Compassionate Easy.

00:14:05: so we forget that endoscopy start acting like technicians and they lose a compassion For the patient.

00:14:11: So it's very important to have a compassion for The Patient.

00:14:14: And then of course passion for What you're doing?

00:14:17: uh...for me example When I started early..I wanted To be a hepatologist but I found that Hepatologists are getting little boring that I enjoyed doing mechanical things like cannulating a papilla gave me more enjoyment than reading all these hepatology papers.

00:14:31: So, I decided to train track and became an endoscopy.

00:14:35: Basically those who are endoscopies is the ones with hands-size skill which gives them passion for what they're doing most of whom actually make good carpenters or plumbers.

00:14:48: so we are like that.

00:14:49: fortunately in last few years there's some amount academic contents added to endoscopy, you start getting randomness control trials and evaluating endoscope in a more rigid fashion.

00:15:00: Otherwise before at least when I started Endoscopy it used to be like procedures.

00:15:04: how many procedures do?

00:15:05: what can we do?

00:15:06: What extent You Can Do?

00:15:08: but is changed now.

00:15:09: so person who wants to go into endoscopic should first have passion for doing those procedures.

00:15:15: Second, should have a little surgical mind and not get worried about complications.

00:15:20: How to manage them?

00:15:21: And so on your second most important thing.

00:15:23: otherwise if you get complicated or too sensitive about certain complication You can't proceed further.

00:15:29: third important thing is that he should be able To work hard in the sense of work extra hours.

00:15:34: endoscopy Is not like regular.

00:15:36: you can fix Your consultation upto five o'clock and then more.

00:15:40: you sometimes do procedures which go until seven eight o' clock.

00:15:43: So you have to have a situation where your capable of working hard.

00:15:48: But I tell them my fellows are going take endoscopy also, because the work is very difficult and people can't do it.

00:15:54: so be smart!

00:15:56: Convert your heartwork into Smart Work When start enjoying your work becomes Smart Work.

00:16:02: It's no longer Hard Work.

00:16:04: You had to work smart, passion And most important thing was compassion for yourself patient, that's very important.

00:16:13: And nowadays endoscopy has become complex.

00:16:15: in my time we should do everything We used to do third space ERCP.

00:16:19: now I think you have also be mentally fixed towards becoming a specialist in certain area.

00:16:25: It is very narrow.

00:16:26: Ultimately it becomes good third-space endoscopies or pancreatic bilir endoscopes.

00:16:32: Things like endo-hepatology are coming out.

00:16:33: so You had to subspecialize To really get into the area.

00:16:37: So all these factors should be considered when a person wants to take up endoscopy as their career.

00:16:43: Okay, so you touched upon glorified plumbers and doscopist-ass technicians that could substitute for carpenters.

00:16:51: but this was let's say a concept of many years where we are just plumbers.

00:16:58: But what do think with recent advances?

00:17:00: Where is the endoscope going in context of the entirety of medicine?

00:17:06: Are still technicians who would Take out the stones.

00:17:10: So we are still technicians, but we're thinking technicians you know?

00:17:14: We have started now thinking about for example if we have a CBD stone gallstone should you do being a EACP or should he do a combined procedure surgeon could do lap and then remove those stones...we also starting to think about say with an example in third space endoscopy now which patients will be eligible for doing ESD even now.

00:17:35: intramuscular dissections lot of discussions now going on, how deep we can cut full thickness restrictions.

00:17:42: So a lot of thinking has to go into that.

00:17:44: plus Now we have randomized control trials.

00:17:47: We used to think the best thing for high-large strictures is to put in metal stents.

00:17:51: You know this as chain now?

00:17:53: Maybe it's a plastic stand with local ablative therapy like RFA and chemotherapy may be better than just putting metal stands there leaving patients.

00:18:03: so you're starting.

00:18:04: So, the major change that has been endoscopic now is not just technically doing things but also looking carefully at what happens and outcome of these results.

00:18:14: I think there's a different shift in artificial intelligence.

00:18:19: Of course Artificial Intelligence have come here today And this is another thing which will make it different when we start thinking where to apply artificial intelligence?

00:18:27: How can it help us as endoscopists do better things?

00:18:32: What about... kinds of futuristic new inventions like stem cell application for closures, things like that.

00:18:42: Are we becoming supernatural in this case?

00:18:47: No I think regenerative endoscopy is an extremely interesting concept.

00:18:52: that's coming and you know the work going on in Italy.

00:18:58: they have done a lot more than we've actually followed them.

00:19:01: now where we take out these stem cells, not just stem cells.

00:19:06: We take the stem cells with vasoactive factors from either abdominal fat or thigh fat and concentrate this.

00:19:14: And now you're starting to use this injecting it into fistulas in dramatic closure.

00:19:19: even large fistula openings upto two centimeters will be able to close the regenerative medicine.

00:19:25: so I think another additional dimension is coming to endoscopy.

00:19:29: This very exciting.

00:19:31: And then I think as endoscopies, we don't do this mechanically.

00:19:34: We start studying the physiology of what is happening how these stem cells are regenerating?

00:19:39: What are the vasoactive factors that they're coming in?

00:19:42: very exciting data and for me even being a mechanical endoscope is...I find this basic science concept interesting so i want to go more into it.

00:19:51: So I think these are very exciting times for the endoscopes.

00:19:54: Does being son of pathologist come into all their cells?

00:19:59: Yes, so I think this also where in fact i had my heart and pathology.

00:20:04: I specialized in pathology for short period of time till My dad who was a pathologist got me kicked out to the department another hospital because he said Pathologies don't have future only clinicians are future?

00:20:17: I Think it is right In that sense.

00:20:19: as a pathologists you're always hidden behind whatever we do.

00:20:22: people don't realize.

00:20:24: So, I was asked to leave the department and take up medicine then.

00:20:28: That's how I took up

00:20:28: medicine.".

00:20:29: So

00:20:30: he just kicked you

00:20:31: out?

00:20:32: Yes!

00:20:32: He just kicked me out...I mean so i got actually admitted into a very big pathology school one of the biggest ones in the country in the north in Chandigarh And the professor.

00:20:44: they were friend with my father.. I admitted myself without telling him whom am.

00:20:48: So they admitted me and later when he came to know who I was, He spoke with my father.

00:20:52: Who said get that fellow out of the department immediately And then again restart medicine.

00:21:00: so i have a long pathology link because both My grandfather maternal and paternal were pathologists.

00:21:06: My paternal grandfather Was very famous pathologist invented lot Of things.

00:21:11: he was close friend of Alexander Fleming who whenever is to come, India would stay in his house and he used like Indian food a lot.

00:21:18: So my grandmother was an expert so she'd cook Indian food for him.

00:21:22: that was

00:21:22: attraction.".

00:21:24: That's the first time I've heard someone being kicked out so they could have future?

00:21:29: Good reason!

00:21:31: Looking back what he did... He was a pathologist.

00:21:34: recognized how good you are.

00:21:36: it very difficult to be recognized.

00:21:38: They're really rare.

00:21:39: instead of Barry Marshall & Robbins Robin was a pathologist who ultimately got the Nobel Prize for H-Pilori Discovery.

00:21:47: But that's very unusual, most pathologists are not recognized

00:21:51: now.

00:21:52: Yeah but as an endoscopyist I always appreciate pathologists' input.

00:21:57: yeah i think we owe a lot to pathologists.

00:22:00: Pathology is extremely important specialty For the endoscopies because i think Now you're working together To some extent, I also feel that we as endoscopies should become a little pathologist because using cytoscope and now we started to use all these magnification endoscopes.

00:22:16: And especially when you are using the cytoscopes which is called the pathology room along with him watch this pathology and explain whether these cells are abnormal or so on.

00:22:27: So still it's going be an endoscopic pathologist in future branch will come out.

00:22:34: So that's a very important part.

00:22:36: But the pure pathologist, unfortunately doesn't have access to the patients and there is limitation in it.

00:22:42: True!

00:22:42: Professor, finishing up with our first part of our talk... ...and finishing up on innovations… You do have your own stent?

00:22:51: Could you please tell us how this story came about?

00:22:57: This was called Nagi Stent.

00:22:59: First disclaimer – I don't get any royalty from this.

00:23:03: How

00:23:03: come?!

00:23:04: Yeah, so what happened was in twenty eleven.

00:23:06: when you're doing ERCPs at that time US is still not very common.

00:23:11: So we should drain the peripankeratic fluids with a side wing underscore wherever there's a bulge would make an opening and then put plastic stents.

00:23:20: Then we started trying this... At that time it didn't have covered billiaries stents too.

00:23:24: We just put standard billiary stents.

00:23:26: There are lot of limitations here.

00:23:29: I worked on this and actually created a small stand.

00:23:31: It's called the bi-flanger stand, it is a biflan stand but not lumen opposing because at that time i wanted to have a stand which has very short stem large opening and big flanges so they doesn't move.

00:23:44: using these stands we started draining peripankeratic fluids very easily just through side wing scope.

00:23:51: So it was starting with sidewing scope And later endosynology took it up This first publication.

00:23:57: and at the same time simultaneously Ken Binmola was developing his Lumen opposing stent, which had another concept.

00:24:06: It is actually for Galbladder not for pancreatic fluids whereas mine must be for pancretic fluid.

00:24:12: A company in Korea called The Taewoong Company were very interested with their drawing.

00:24:15: they said shall we develop this tent?

00:24:17: At that time controls are so much….

00:24:20: They just made it a week's with night in all, with covering and then got it to me.

00:24:25: We just took a local ethical committee permissions we didn't need to have government permission at that time And started using this tent.

00:24:32: The only thing I made clear was also that we should not patent This because once you patented All these problems come up.

00:24:39: the other people can't duplicate.

00:24:41: So they are not patented.

00:24:43: It is called Nagi Stent and of course thousands have been deployed across Asia now And in our country, that was the most commonly used tent till recently for penny pancreatic fluids.

00:24:55: Of course now they made another version of it called a hot nagi stand so people from your department call them Hot Nagis Now.

00:25:03: earlier on we had to make an opening and dilate with balloon and go.

00:25:10: As retrospectively look back this tent actually has advantage over luminal opposing stands because he doesn't compress mucosa.

00:25:19: The incidence of bleeding as a complication after this stent is much less than with the standard stents.

00:25:24: Of course, the disadvantage that many people are now duplicated... There're many stents in this part of our world where same stent has been dupliqued by different.

00:25:34: come-doesn't matter!

00:25:35: I think important thing it's that people are receiving good stent at low cost without having to look for patents and things like that.

00:25:43: So i feel very satisfied that there was space.

00:25:48: it has been very helpful for patients, especially those who can't afford.

00:25:53: And we still use a lot of Nagi stents in our department.

00:25:56: so I think to me that had again being something which is very satisfying.

00:26:00: You're living up your father's expectations and also have the very great name Hothnagi.

00:26:07: It's like superhero

00:26:10: In fact when this tent sometimes displaced So people used salvage you could get put back large paper they had, the title was how to salvage Nagi.

00:26:23: A good one!

00:26:25: Thank you professor.

00:26:26: we will wrap the first part here because we still have a lot of cover and we'll see in a bit

00:26:33: thank you.