'Don’t take shortcuts,' endoscopy researcher advises

Manol Jovani, MD, MPH, has published more than 70 research papers on clinical GI research, some resulting in the publication of international guidelines. But the work he’s most proud of took place when he was a graduate student at Harvard, working on a master’s degree in epidemiology and biostatistics.

Jovani compared two different types of needles for tissue acquisition with endoscopic ultrasound. His finding that fine needle biopsy is better than fine needle aspiration for lesions isn’t groundbreaking, yet “the reason why I feel proud of that one is because it’s the first paper I did completely by myself,” said Jovani, medical director for advanced therapeutic endoscopy with Gastro Health Florida, in Miami, Florida. 

Dr. Jovani has since contributed to countless peer-reviewed articles and book chapters and has presented research findings at meetings across the globe. He will be program director of the upcoming gastroenterology fellowship program at Florida International University School of Medicine, Miami, and participates in several endoscopy panels in the U.S. and in Europe to set guidelines and improve the quality of endoscopic procedures. 

Therapeutic endoscopy is a clinical interest of his, specifically in the areas of third space, biliopancreatic and bariatric endoscopy. In an interview, he discussed how he used third space endoscopy to save a patient and improve her quality of life.

Indeed, helping patients feel better is the most satisfying part of his career. 

“A lot of people may have acute pain or an early cancer or many other problems that they need solving. As a physician, you can be the one who solves it,” Jovani said.

But training in medicine involves hard work, he advised. In the interview, he explained why young doctors should never rely on shortcuts to solve problems.

Therapeutic endoscopy is a specific interest of yours. How has this field advanced since you’ve been practicing gastroenterology?

Dr. Jovani: In the last 10 to 15 years, significant improvements have come along. As an example, lumen-apposing metal stents have revolutionized the way we do therapeutic endoscopy. A lot of procedures were not possible beforehand, and we would have to send patients to surgery. Now, these can be done with endoscopy.

Examples include drainage of pancreatic collections, gallbladder drainage, or gastrojejunostomy (a connection between the stomach and the intestine) or reversal of Roux-en-Y gastric bypass to reach and drain the bile duct. 

Many of these procedures can be done with these metal stents that were not possible beforehand. Bariatric endoscopy is a relatively new field, and that has significantly changed the management of obesity. There’s also third space endoscopy for the treatment of gastroparesis, achalasia, and early cancer. 

What is third space endoscopy and how are you applying it in your practice?

Dr. Jovani: Third space endoscopy refers to a new space that’s created between the mucosa and the muscularis propria into the submucosa. We go in the submucosa, we inject some fluid there, and we cut the submucosa and we separate the mucosa from the muscle.

This allows us to do a lot of procedures. For patients with achalasia, we can tunnel through the submucosa, get into the muscle and perform myotomy, meaning that we can cut the muscle. By doing so, we can treat achalasia with a minimally invasive method. Patients can either go home the next day or even on the same day.

The same thing applies for gastroparesis. With early cancer, we can go through in the submucosa, and if the cancer is in the mucosa only, or if it is in the very superficial submucosa, we can treat it without a need for surgery. Sometimes the procedure is simple, but other times it can be very challenging. 

Can you discuss a challenging case where you applied third space endoscopy?

Dr. Jovani: It was a gastric cancer case. I did an endoscopic ultrasound for staging purposes. When I saw the lesion, it looked very superficial, like an early cancer of the stomach. I called the surgeon and said I could take it out with endoscopy. And it was in a very difficult location, so it was a very challenging procedure. It took about 12 hours to do it, but I was able to completely take it out. More than a year later, the patient was cancer free and more importantly, we preserved the stomach. Before I did this, she was prepared to undergo total gastrectomy, which meant I would have taken out her entire stomach.

Instead, with this minimally invasive procedure, I was able to take the cancer away and keep the stomach, which preserved her quality of life as well. 

When you don’t have the stomach, obviously you adapt, but the quality of life is never the same. The type of food you eat, the frequency of eating, the quality of food you eat is not the same. The fact that we could avoid that in this patient feels very good. 

What advice would you give to aspiring medical students?

Dr. Jovani: Do the hard work that’s required to be a doctor. Being a physician is a hard job, but it’s very rewarding. It’s like going to the gym — there really are no shortcuts. You have to do the work, you have to get tired, you have to study hard. You may study things you might not think will be useful to you necessarily in the future field that you choose. If it is GI, you still need to study all the other fields because sometimes patients may have GI diseases that are connecting with other diseases and you won’t know that if you haven’t studied the other diseases.

Patients are not only one disease, but they are also complex patients. Sometimes if you try to correct one disease, you create a complication with the other disease and you might not be aware of that. 

Don’t create shortcuts like ChatGPT, things that are becoming fashionable with younger people today. Do the hard work the old way in which you have to memorize things. Knowledge is the only thing that really can help the patient.

Go to GI meetings. Offer to meet people, collaborate, network. Don’t be shy about it. Even if it is not natural to you, just do it. It’ll become more natural as you do it. GI, like any other field, any other endeavor in human society, is something that also depends on interactions. Therefore, it’s good to learn how to interact, how to network, how to do research projects.

Even with people from far away, communication is very easy. You don’t really need to do research projects only with people in your local environment. You can do research projects with people who are on the other side of the state or even on the other side of the world.

You place an emphasis on individualized patient care. Can you discuss what that means to you?

Dr. Jovani: It basically means that there isn’t one size fits all in the management of diseases. Obviously there are some general principles that are applicable to everybody, but sometimes for the single specific patient, what works for one patient might not necessarily work for the next patient.

With Endoscopic Retrograde Cholangiopancreatography (ERCP) for example, there are so many things that go into that. Most papilla are in a certain position and it’s relatively easy to cannulate. But there are others that are in very different positions or in different angulations and they might require specific techniques that are not applicable in the majority of cases. You have to adapt to the single patient. How you speak to the patient is also important. Some may prefer a certain type of communication and other patients may prefer another type of communication involving patients or family. You have to adapt to the single patient.

You have to understand the different types of personalities and adapt how you explain things or how you communicate disease, or management of disease or even complications to the specific patient. Different approaches are more appropriate for different patients with different needs. At the end of the day, patients are single individuals after all. 

Where do you see the field of GI medicine advancing internationally over the next 5 years?

Dr. Jovani: Artificial intelligence or AI is a big player. It will help with diagnostics primarily, at least over the short term. Potentially it can help with therapeutics as well. There’s a lot of investment and excitement and interest in artificial intelligence.

Therapeutic endoscopy robotics, especially in interventional endoscopy, third space endoscopy, is also gaining attention.

With regards to bariatric endoscopy, we should have a CPT code for it in January 2027. This will increase volume because it’ll be covered more by insurance. These are things that will help advance GI in the next five or 10 years.

Lightning Round

What’s one hobby you’d like to pick up?

Kite surfing

What’s your favorite season of the year?

Summer

What’s your favorite way to spend a weekend?

Traveling or going to the beach

If you could have dinner with any historical figure, who would it be?

Jesus Christ 

What’s your favorite holiday tradition?

New Year’s Eve

Are you a planner or more spontaneous?

Planner

What’s the best piece of advice you’ve ever received?

You can do it!

What’s your comfort food?

Lasagna