BBI Japanese Editor

KOFU, Japan — The 63rd Congress of the Japan Gastroenterological Endoscopy Society, held here this past spring, attracted some 3,500 practicing physicians drawn to more than 400 presentations and special lectures. The scope of the meeting was indicative of the fact that endoscopy is the highest-earning specialty among practices at hospitals and physicians' offices in Japan. With a theme of "Toward a Global Integration of Endoscopy," lecturers and presenters included many from abroad.

Professor Masayuki Fujino of Yamanashi Medical University (Kofu, Japan) said that endoscopy has become one of the most rapidly progressing medical branches with regard to applications of information technology (IT). He added that endoscopy will enhance its role as a cost-effective and safe procedure for the diagnosis and treatment of digestive tract diseases by promoting further use of IT in creating databases on infection protection, advanced prophylactic measures against endoscopy hazards, improved maintenance and management of instruments.

Hirohumi Niwa, president of the society and visiting professor at St. Marianna University School of Medicine (Kawasaki, Japan), addressed the history and prospects for colonoscopy. He said that while video endoscopy will remain in use for some time and picture analysis techniques will further improve, ultrasound videoscope also would develop as the broadening of frequency range continues and 3-D display improves. Niwa also discussed the future potential of capsule endoscopy.

Hiroaki Suzuki, a professor at Jikei University School of Medicine (Tokyo), discussed "Risk Management of Endoscopy Based on Incident Reports" and pointed out that in medical accidents, the focus is given to the settlement of disputes, while efforts toward prevention of such accidents have been inadequate. He cited Jikei University's approach, which established about two years ago a new incident report system under which incidents, including "near misses," are broadly collected and disseminated among medical workers to discuss preventive measures. Many endoscopy-related accidents were reported, indicating that endoscopy is a relatively risky area of medical practice. Suzuki is planning the publication of a "Manual of Measures for Gastroenterological Endoscope Problems: Lessons from Near Miss Cases" and invited physicians who are working in endoscopy to participate so the manual can be of optimal use to those in the field. He said he feels it is necessary to create an atmosphere that allows free discussion and active reports by those with negative experiences.

Masahiko Sakai, of the evaluation committee for the establishment of the department of endoscopy and an assistant director at Kansai Electric Power Hospital, lamented that the Japanese Ministry of Education is hesitant to sanction endoscopy as an independent faculty vested with the authority to graduate students from national university hospitals despite the fact that endoscopy procedures, both in the number of cases and dexterity required, are rated among the world's top programs in the Japanese university hospitals. Endoscopy is accorded a more appropriate status worthy of its economic impact in private university hospitals, Sakai said.

Several cases of new endoscopic treatment developed by researchers at University of Tsukuba division of gastroenterology were reported at a symposium on "Cutting-Edge Developments in Endoscopy." The Tsukuba team uses the simultaneous endoscopic fluorescence analyzing system (SEFAS), which consists of a fiber endoscope, an ultra-high-sensitivity camera, an image processor and a customized light source designed to supply both white light and violet excitation light. Through photodynamic diagnosis using aminoleveulinic acid (ALA), which has only six hours of half-life dissolved in a beverage for patients to drink, the team has observed specific increases of fluorescence in cancer lesions. While ALA itself emits no fluorescence, it is metabolized into fluorescent porphyrins in cancer cells. The discovery of SEFAS' capability in diagnosis of cancer lesions suggests a possible screening program directed toward a broad range of cancer patients.

A team at the Jikei University School of Medicine's department of gastroenterology has developed a new enteroscope for observing the small intestine. Hironori Yamamoto, MD, et al., reported that enteroscopic observation of the entire small intestine was possible using the device. A specially designed endoscope with an 8.5 mm outer diameter and 200 cm working length with an attachable balloon at its tip and a soft 140 cm long overtube with another balloon at the distal end were used. Safety in use and improved insertion were demonstrated, allowing precise observation of a variety of lesions through an entire length of small intestine. Balloons attached to the endoscope and at the tip of the overtube were made of latex for softness, and a pump, which allows inflation of balloons while monitoring inflating pressure and deflating the balloons in a one-touch action was developed. The team reported that the method allows insertion of the scope with either an oral or anal approach.

At a luncheon seminar co-sponsored by Otsuka Pharmaceutical, Professor Masahiro Asaka, of the department of gastroenterology of Hokkaido University School of Medicine, discussed "Recent Topics Relating to Helicobacter Pylori." Reimbursement for the diagnosis and dezymotization of H. pylori with digestive ulcer became effective in Japan in November 2001. The Hokkaido researchers have constructed a pathway for the allopatric expression of cagA genes on gastric epithelial cell lines and examined the effect on gastric epithelial cells. Cells introduced with genes have hummingbird-like morphological changes, with phosphorylated cagA inside the cells binding with SHP-2 tyrosine phosphatase, which is involved with signal transmission, and by abnormally exaltating its activity, created proliferative stimulation-like cellular changes.

The study has attracted international attention by proving for the first time that abnormality of signal transmission is caused inside the cells as a result of infection by H. pylori. Uric preparations for diagnosing H. pylori infection (UBIT from Otsuka Pharmaceutical) and a simple testing device are available in Japan. Because false positive results are seen fairly frequently in urea breath tests, however, a film-coated uric preparation is being developed for solving this problem.

An interesting presentation at a luncheon seminar introducing the granulocyte adsorption column, Adacolumn, manufactured by Japan Antibody Laboratory, was titled "A New Strategy for Treating Ulcerative Colitis — Will the Era of Non-steroidal Preparation Come?" The treatment has been reimbursable since April 2000, paying 125,000 yen (about $1,000) per column of leukocyte adsorbing material and 20,000 yen (about $160) for the procedure. The material has been on the market for two years. Ulcerative colitis is on the increase in Japan, currently numbering about 66,000 cases. Steroid-free treatment for ulcerative colitis is attracting physicians in Japan in consideration of patients with steroid resistance and concern for its side effects. Granulocytes and monocytes are indispensable for the defense of the body against invading microorganisms. If these cells excessively or chronically infiltrate locally, however, tissue disorders have been seen to occur in various diseases. The leukocyte-removing Adacolumn was developed in order to treat such diseases. The disposable column requires no shunt and the blood is circulated for 60 minutes at a flow rate of 30 ml per minute. Heparin is used as an anti-coagulant, and the blood is circulated between veins. A standard cycle of treatment is once a week for five weeks.

Olympus (Tokyo) occupied approximately 40% of the exhibit floor space at the congress, demonstrating the company's undisputed leadership in the endoscope industry in Japan. Asahi Optical (Tokyo) had a booth at the center of the exhibit hall. Fujinon Toshiba (Tokyo) displayed an ultra-thin (5.9 mm) transnasal endoscope for upper digestive organs. According to the company, most patients preferred nasal insertion rather than oral insertion.

Virtually all companies displaying at the conference have committed to digital image filing systems to some degree or another. The future direction is to consolidate endoscope image management systems into hospital management systems and improve cost-effectiveness, thereby rationalizing the workload of healthcare personnel, who represent half of a typical hospital's expenses. This line of thought is applicable to practically all of the medical imaging device industry, in that rather than pursuing individual rationalization systems on their own, all the rationalization elements, including space savings, savings of time for physicians and nurses, and improvement of cost effectiveness will be far more justifiable if image-filing systems are integrated into existing hospital information systems.

Most of the systems currently under development are taking into account malpractice preventive measures and electronic patient records, which are currently used only by about 1% of all hospitals in Japan. For example, names of nurses and patients are read by barcode system, and when administering medications, discrepancies are checked by collating entries through use of barcodes. Treatments provided also are called up electronically in administrative offices to reflecting them in billings.

The congress featured a number of presentations on the sterilization of endoscopes, disinfection devices and other ideas for the handling of endoscopes. A team from the First Department of Medicine at Yamanashi Medical University (Kofu, Japan) made a presentation on "Infection of Helicobacter Pylori via Endoscopic Examinations," reporting that it was successful in completely eradicating occurrences of acute lesions on gastric mucoses, which was observed in 0.04% of endoscopic examination cases by handing over used scopes to a staff assigned to cleaning a scope without bringing it into contact anything, and to subject it to a 10-minute automatic cleaning using 2% glutaldehyde. A team from Jichi University reported that while 1,600 yen (about $12.80) was expended for cleaning and disinfection of each endoscope, in addition to quality assurance procedures for preventing infection, bacteria was found to exist in the automatic cleaning device and in the water from the supply water bottle for which expenses went higher. The team recommends that the reimbursement amount be revised in order to better reflect such realities.

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