The management of foregut disorders, which include achalasia, gastroesophageal reflux disease (GERD), Barrett’s esophagus, esophageal cancer, and obesity, has evolved over the past decade. Advances in high-resolution diagnostics and minimally invasive treatments have transformed how clinicians approach these conditions, which account for about half of referrals to gastroenterologists in the United States. Patients presenting with symptoms like heartburn and dysphagia benefit from more precise diagnoses and a wide range of effective, less invasive treatment options.
Experts supported by the American Foregut Society (AFS) have proposed a one-year advanced foregut fellowship program aimed at training a new type of specialist: the interventional foregut expert. This role links the gap between diagnostic evaluation and advanced therapeutic procedures, preparing physicians to work collaboratively with surgeons and other specialists in multidisciplinary care settings.
The need for this specialized training is driven by three major trends. First, the burden of foregut disease continues to rise. Millions of gastrointestinal procedures are performed annually, and esophageal disorders alone contribute significantly to healthcare costs. Second, the global obesity epidemic compounds this burden. Obesity remains a key risk factor for GERD and its complications, including Barrett’s esophagus and esophageal adenocarcinoma. Third, as prevalence increases, so does the demand for clinicians who can provide comprehensive, long-term, and value-based care.
There is a growing complexity gap in diagnostics and treatment. Modern tools like high-resolution manometry (HRM) and functional lumen imaging probes (FLIP) provide detailed insights into esophageal function, but interpreting these results requires specialized expertise. Clinicians must integrate multiple diagnostic modalities to make accurate decisions specifically in borderline or complex conditions like atypical achalasia. Traditional gastroenterology training does not fully prepare physicians for this level of complexity.
The therapeutic landscape has been revolutionized by advanced endoscopic procedures. Techniques like per-oral endoscopic myotomy (POEM), transoral incisionless fundoplication (TIF), and endoscopic sleeve gastroplasty (ESG) offer effective options to traditional surgery for conditions like achalasia, GERD, and obesity. These procedures expand treatment options but also introduce new challenges, like the management of complications and the need for ongoing, specialized care across a patient’s treatment journey.
Existing training pathways are not designed to meet these evolving demands. General gastroenterology fellowships offer limited exposure to motility disorders and advanced foregut procedures. Advanced endoscopy fellowships focus mainly on ERCP and EUS. Motility fellowships highlight diagnostics without procedural training. The proposed advanced foregut fellowship fills this gap by integrating diagnostic, cognitive, and procedural skills in a single and comprehensive program.
The fellowship is structured as a one-year program after standard gastroenterology training. Fellows gain hands-on experience in advanced endoscopy, participate in multidisciplinary clinics, and develop expertise in interpreting diagnostic studies. The curriculum focuses on 3 core domains: esophageal motility disorders, reflux and mucosal disease (cancer), and obesity and metabolic disorders. Regular multidisciplinary meetings and research opportunities are integral components of the program.
A defining feature of the fellowship is its competency-based assessment model, which uses Entrustable Professional Activities (EPAs) to evaluate clinical readiness. This framework assesses an ability of fellows to perform real-world clinical tasks independently instead of relying on procedure counts. Progression is guided by structured evaluations and directed by a clinical competency committee.
Training centers must meet minimum procedural and diagnostic volume requirements to ensure adequate exposure. The program allows flexibility, which enables institutions to specialize in 2 out of 3 core domains on the basis of their strengths. This method improves feasibility and maintains high training standards. Graduates of programs are expected to take on leadership roles in multidisciplinary foregut care and work along with surgeons and advanced endoscopists. They will be equipped to manage complex cases, perform advanced procedures, and contribute to research and innovation within the field.
A pilot implementation in select centers is planned to assess feasibility and refine training standards and outcomes. If successful, this fellowship model could play an important role in addressing current gaps in the training and improving care for patients with complex foregut diseases.
Reference: Shah ED, Dunst CM, Awad MM, et al. American Foregut Society Education Committee: Development of the Advanced Foregut Fellowship Program for Gastroenterology Trainees. Foregut. doi:10.1177/26345161261434388
