Contributions from Japan to gastrointestinal endoscopy training and development: Special report.

Abstract

Endoscopes are now an indispensable medical device in digestive pathology, and digestive endoscopy is performed all over the world. Japan has made a great contribution to the development of this endoscopic instrument and the development of endoscopic diagnostics and endoscopic treatment. Therefore, we wrote this paper because we wanted to summarize the efforts to develop endoscopic instruments and gastrointestinal (GI) endoscopy training for overseas doctors in Japan. Endoscopy can trace its history back to the development of the gastrocamera in 1950, later followed by the fiberscope and videoscope. Today this technology has achieved an extraordinary level of sophistication, making training in GI endoscopy absolutely essential for practitioners worldwide. Moreover, every time a new diagnostic technique or endoscopic treatment technique is developed, new training and education programs need to be developed to accompany it and promote its dissemination. Curiously, despite the fact that the GI endoscope was mainly developed in Japan, training in endoscopy was rarely conducted in Japan. In 1980, not only were live demonstrations of endoscopy prohibited in Japan, but it was against the law for overseas doctors to practice or train in endoscopy. At that time, there was no legal framework to facilitate practical training of foreign doctors.1, 2 Complicating the problem was the language barrier. All of this led a foreign friend of mine to describe Japan as “a secretive country”. One of the first training programs for foreign doctors in Japan was an early gastric cancer diagnosis course in Japan organized in the 1960s under the auspices of the then Overseas Technical Cooperation Agency (OTCA), now called the Japan International Cooperation Agency (JICA).3 Most of these trainee doctors came from developing countries. Japanese physicians also travelled overseas to give lectures and hands-on training sessions — a trend pioneered by such prominent Japanese doctors as Tadasige Murakami, Hiroo Shirakabe, and Heizaburou Ichikawa. At that time the most commonly used means of diagnosis of the digestive tract was the double contrast X-ray examination. Pioneers of the Japan Gastroenterological Endoscopy Society established the first world organization, the International Society of Endoscopy [then the Organization Mondiale d'Endoscopie Digestive (OMED), currently the World Endoscopy Organization (WEO)] in Tokyo in 1966.4, 5 Around the same time, Tatsuo Uji at the Department of Surgery of the University of Tokyo Branch Hospital initiated development on the gastrocamera in Japan in collaboration with Olympus in 1950. Members of the First Department of Internal Medicine at the University of Tokyo, including Takao Sakita and Professor Hirofumi Niwa, subsequently picked up on the new technology, advancing it as a tool for gastric cancer diagnosis using the improved endoscope, and promoting endoscopy on a global scale. In 1958, B. I. Hirschowitz introduced the gastroduodenal fiberscope, and the age of fiberoptics began. By the beginning of the 1970s, endoscopy had evolved considerably with the advent of the diagnosis using fiberscopes and biopsies. Upper and lower GI fiberscopes, as well as the flexible duodenoscope, were developed in the 1970s, with Takeo Hayashida leading the University of Tokyo Branch Hospital and Tsutomu Kidokoro playing a critical role in the promotion of gastroenterological endoscopy. Meanwhile, in collaboration with Olympus and under the direction of Satoru Soma, Prof. Fujita was also engaged in the development of a flexible duodenoscope and conducting research and development into endoscopic pancreato-cholangiography, which would later be called endoscopic retrograde cholangiopancreatography. As the 1970s began, Japan entered the golden age of clinical research into early gastric cancer diagnostics. Double contrast X-ray examination and gastroscopy demonstrated their abilities and courses for diagnosis of early gastric cancer were held in Japan. Using double contrast X-ray examination as the main technique and gastroscopy as a supplementary technique made it possible to conduct detailed examinations based on pathological specimens of gastric tissue resected surgically. The pathological specimens were cut out in slices with 5-mm intervals. Various clinical cases were studied using reconstructed images of lesions and clinical examination findings. Prof. Fujita helped pioneer these studies in collaboration with Tsutomu Kondo. The Initial Gastric Cancer Study Group was set up in 1960 and the Early Gastric Cancer Study Group in 1964, both after the aggregation of clinical cases throughout Japan. The findings of these study groups were published in I To Cho (Stomach and Intestine).6 The reports were available only in Japanese, with summaries in English. The clinical case studies reported in I To Cho played a significant role in establishing early gastric cancer diagnostic methodology in Japan. They also had a significant impact on the foreign doctors who participated in those study groups, who brought that knowledge with them back to their home countries.7 Thus, these study groups propelled the forthcoming overseas deployment backed up by the JICA.3 In addition to the foreign trainee doctors who benefited directly from these studies, a number of books and papers were published in English that discussed the pioneering work being carried out in Japan during that period.8, 9 For example, R. J. Schlemper was an originator who created the prototype of the Paris Classification of Superficial Neoplastic Lesions in the Digestive Tract.10 His original idea was based on the Japanese early gastric cancer classification. He directed his attention to the great difference in interpretation of pathological findings between Japanese and Western pathologists. He brought this issue to the meeting of the Asian Pacific Society for Digestive Endoscopy (APSDE)11 held in Japan. A comparison of these differences was subsequently written up by Lambert12 and published in The Lancet.13 Finally, via the workshop of the OMED (currently WEO)4 held in Paris, Japan's early gastric cancer classification was popularized as the Paris Classification.13, 14 The first foreign doctor Prof. Fujita trained in endoscopy was L. Sanchez from the Dominican Republic. He was one of the attendees of the early gastric cancer diagnosis courses held by the JICA. His native languages were Spanish and French, but he received instruction from us in English. We have since been responsible for the instruction of numerous foreign doctors including R. Degollado from Mexico. Altogether, 338 doctors from across Latin America, Asia, Africa, the Middle East and the West have participated in this course over the last 50 years. During this period, Prof. Fujita also served as a director in charge of international affairs at the Japan Gastroenterological Endoscopy Society (JGES)15 as well as a director at the WEO16 together with former JGES President Niwa. Over the years, we have helped train another 400 or so endoscopists at various pan-Pacific, Southeast Asian, and other overseas society meetings — such as the APSDE,11, 17 and Japan–Korea Symposium for Gastrointestinal Endoscopy (JKSGE), Sino-Japan working for digestive endoscopy — as well as giving live demonstrations overseas. Prof. Fujita also served as the president of the Japanese Foundation for Research and Promotion of Endoscopy (JFE)18 until recently, which is also another testimonial to his long-lasting commitment to training and support for foreign doctors (Figs 1-3, Tables 1 and 2). With the dawn of the age of fiberscopes in the 1970s, the need for GI endoscopy training increased exponentially. We were involved in courses for foreign doctors held at the University of Tokyo Branch Hospital, Tokyo Metropolitan Cancer Detection Center, Showa University Fujigaoka Hospital, and Cancer Institute Hospital of JFCR. During this period, we also gave lectures and live demonstrations in various countries, and participated in congresses and seminars around the globe. Officially, foreign doctors were not allowed by the Japanese government to do live demonstrations or perform endoscopy but that changed gradually to allow overseas doctors to practise endoscopy.1 Prof. Fujita's training philosophy was based on the concept of letting the trainees learn by doing what they want to do on their own, while providing them with support and guidance. This was the basic credo of the International Learning Center for Endoscopy (ILCE). The main point was not to force the rote instruction methods typical of Japan on foreign doctors. The staff endoscopists who supported Prof. Fujita understood this idea and got along well with the foreign doctors, supporting and encouraging them as required. Although we gave them guidance mainly in Japanese, the staff endoscopists helped us in often just-learned English, Spanish, and other languages. Since there were many foreign trainee doctors at Fujigaoka Hospital, Prof. Fujita posted a set of rules for endoscopists called the “5Es for Endoscopists” (Table 3). These rules were intended not only for foreign trainee doctors but also for the staff endoscopists at the Fujigaoka Hospital. The rules seemed to strike a sympathetic chord with J. F. Riemann in particular. As for hands-on training, it was fortunate for us that Prof. Fujita had been using sedation since his time at the University of Tokyo Branch Hospital. When Prof. Fujita instructed on diagnosis of endoscopic images, he checked the foreign doctors' reports on the findings. Prof. Fujita then wrote what he called “love letters” and handed them out personally. Other endoscopy instructors also gave Q&A guidance to foreign doctors on an individual basis. Whenever possible, we also tried to accompany the foreign doctors to research groups and society meetings to help them feel more comfortable and less isolated. Discussions on clinical cases were frequently held in order to incorporate the opinions of the foreign trainees. At that time, Prof. Fujita was making frequent overseas trips. Staff endoscopists filled in for him while he was away, providing the foreign doctors with support and guidance. On days off, the staff endoscopists and Prof. Fujita held various recreation activities to socialize with their foreign charges — even bringing their families along. To this day, the other staff endoscopists and Prof. Fujita keep in touch with their former students, including their families. Thanks to email, the latest news about everyone involved immediately flies around the world — one happy result of this that Prof. Fujita attended the wedding of a former trainee's daughter. Years of experience admitting and training foreign doctors at various facilities convinced Prof. Fujita that Japan should establish an endoscopy training center exclusively for foreign doctors. Accordingly, during our time at Showa University, we founded the International Learning Center of Digestive Endoscopy in cooperation with Kitajima Masaki of Keio University at 12 March 1995, celebrated by JGES and the Chinese embassy authorities. In 2001, Professor Shin-ei Kudo of Showa University took over as director of the International Center of Digestive Endoscopy, Showa University. This center was to be the only facility of its kind in Japan endorsed by the WEO.16 We are grateful to Professor Kudo — Prof. Fujita's successor— for turning this center into a WEO-approved training center. Nevertheless, we are somewhat dissatisfied by the fact that Japan — the birthplace of GI endoscopy — has no training center managed by the JGES. In the United States, for instance, there is a training center managed by the ASGE.19 Meantime, at the international level, new training centers are now being established by the WEO16 and World Gastroenterology Oraganization (WGO).20 We believe that Japan needs to launch new GI endoscopy projects and establish a new center for training and development. These activities not only promote advances in endoscopy, but also have the potential to benefit Japan's stagnant economy. We believe that live demonstrations are one of the most effective means of endoscopy training. When we accompanied Takeo Hayashida of the University of Tokyo to the Beijing Union Medical College Hospital in December 1972, we performed the first live GI endoscopy demonstration in China where we biopsied a gastric cancer lesion. The following day, the resected specimen of the stomach we biopsied was displayed for everyone to examine. We remember being really surprised that this pathological specimen was provided very quickly. Today, live endoscopy demonstrations are held around the world. In the near future, it is likely that demonstrations will be conducted live over the internet using advanced teleconferencing technology, making it possible for physicians and pathologists around the world to participate and engage in discussions. Professor Shuji Shimizu of Kyushu University has such a project underway now, and such teleconferences and live demonstrations are already a reality.21 As outlined at the beginning of this special report, endoscopy began with the gastrocamera, which subsequently evolved into the fiberoptic gastroscope, duodenoscope, and colonoscope. Ultimately, the fiberscope transformed into the videoscope, while endoscopy expanded into fields such as ultrasonography and laparoscopic surgery. Much of this progress took place in Japan. As the technology advanced, so too did the sophistication and variety of endoscopic treatment, with new techniques — such as biopsy, polypectomy, papillotomy, laparoscopic cholecystectomy, laser endoscopy, EUS,22, 23 endoscopic surgical techniques such as EMR, ESD24, 25 and AI-assisted endoscopy — appearing in rapid succession26. Mastering these techniques is of the utmost importance for contemporary endoscopists. Our personal and professional relations with foreign doctors learning GI endoscopy have always been intimately tied to the ever-changing diplomatic and historical relations between Japan and other countries. The objective of the JICA courses was to provide support for developing countries in Asia, Latin America, and Africa. Trainee doctors from Western Europe and North America came to Japan to get fresh ideas on endoscope development and to learn new techniques available in Japan. Supporting entities included endoscope manufacturers such as Olympus, Fujinon (presently Fujifilm), and Pentax, as well as OTCA (presently JICA),3 OMED (presently WEO),4 OMGE (presently WGO),27 and JFE. In addition to support from the private sector, Japan's Ministry of Foreign Affairs managed a scholarship program that helped attract and recruit potential trainees from overseas. Doctors endorsed by Japanese embassies in various countries, as well as doctors sponsored by other Japanese bodies such as the Lions Club of Japan, municipalities, and universities, were also invited. Although it is not unusual for foreigners in Japan to feel a sense of isolation and alienation due to the language barrier, those who worked with us did not suffer from these issues. Always concerned with how our students were feeling, we went out of our way to treat them well, not subjecting them to the sorts of embarrassment typically imposed on apprentices in Japan — for example, we never forced foreign doctors to wash the endoscope. As for the language barrier, other doctors and us, as well as nurses and technicians, eagerly learned English, Spanish, and other languages. Foreign doctors also did their best to learn Japanese. Usually, after a year or so, they were able to converse comfortably in Japanese. Edwin O. Reischauer, who once served as the United States Ambassador to Japan, said that while a language barrier certainly existed in Japan, it was not an insurmountable problem.28 As mentioned earlier, Prof. Fujita received foreign trainee doctors at the University of Tokyo Branch Hospital, the Tokyo Metropolitan Cancer Detection Center, Showa University Fujigaoka Hospital, Cancer Institute Otsuka Hospital, and Cancer Institute Ariake Hospital. Prof. Fujita also made overseas trips and conducted lectures and hands-on training, as well as live demonstrations. Because very few Japanese instructors were actively engaged in training foreign doctors, Prof. Fujita now feel that he gave them guidance on GI endoscopy according to the sense of duty and obligation peculiar to the Japanese as articulated by Ruth Benedict.29 Prof. Fujita thought that it was the developer's duty and obligation to make the equipment available to as many doctors as possible and show them the new techniques, no matter what country they were from. At that time in Japan, it was not legally allowed to provide foreign trainee doctors with hands-on training. Many facilities were also hesitant to use English, Spanish, or Chinese and for a long time live demonstrations were virtually prohibited by the JGES. Consequently, foreign doctors who visited the facilities where we worked would eventually move to our facilities because they were not satisfied with just visiting. Subsequently, training guidelines for GI endoscopy were stipulated internationally. In Prof. Fujita long years of service, he actually mentored a few parent-and-child pairs. So it is fair to say that not only was there a sense of duty and obligation, but also personal friendship and mutual trust. Because he was also involved in a wide variety of meetings such as those of the OMGE (presently WGO), OMED (presently WEO), United European Gastroenterology Week, Japan-Sino Workshop for Gastroenterology and Endoscopy, JKSGE, and Endoscopy Masters Forum, he was blessed with numerous opportunities to meet with leaders in GI endoscopy around the world. At Digestive Disease Week (DDW) in the United States, he renewed many old friendships. He has been involved in the development of fiberscopes and videoscopes since the 1970s, so he naturally felt that his endoscopy training was his mission and he has been doing it. Let us reiterate here that Prof. Fujita has been involved in GI endoscopy training for about 50 years. It began when he was at the University of Tokyo Branch Hospital, and continued when he moved on to Showa University Fujigaoka Hospital, where he developed and maintained long-term relationships with many foreign doctors. He played an active role in the international committee of the JGES and served as Secretary General at the OMED (presently WEO) under the chairmanship of Professor Niwa. He is honored to have been present at the inaugural meetings of Japan JDDW and Asian Pacific Society of Digestive Endoscopy (APSDE). Japan has been a world leader in the development of endoscopy, up to and including the rise of revolutionary AI-assisted endoscopic diagnostics. And for more than half a century, no single individual has played a greater role in the development and dissemination of endoscopy than me. But Prof. Fujita was not alone. Over the years, hundreds of other Japanese GI endoscopists, surgeons, and pathologists have contributed to the establishment of international consensus on endoscopic diagnostics. We are both proud and grateful for all the comments and feedback we have received from our trainees. The more feedback we get, the happier we are. We would like to express our indebtedness to the late Professors Satoru Soma and Tachio Kobayashi of the University of Tokyo for their exceptional instruction, to Professor Emeritus Nobuhiro Sato of Juntendo University, who chaired the 69th Congress of JGES, for introducing the international exchange situation at that time to Prof. Fujita in his lecture at the congress, to the late Professor Emeritus Masaki Kitajima of Keio University for supporting him when the ILCE was founded, and to the late JGES (OMED) President Professor Niwa as a supporter and mentor at overseas congresses. And we would like to express our gratitude to the former President Misao Yoshida of Foundation for Detection of Early Gastric carcinoma for his kind assistance. Our greatest gratitude go to the staff endoscopists who supported us at the Fujigaoka Hospital, University of Tokyo Branch Hospital, and Tokyo Metropolitan Cancer Detection Center. We also want to express our gratitude from the bottom of our heart to all the workers at the facilities We were at and apologize for any trouble we may have caused them. When it comes to preparing this special report, we are thankful to our subordinate doctors for helping us polish this report, and we thank Adolfo Parra Blanco MD, PhD and Frank Phillips for editing a draft of this manuscript. In addition, we are profoundly grateful to all the foreign doctors who have come to us from overseas to learn endoscopy. Authors declare no conflicts of interest for this article. None.