Gastroenterology

Endoscopy has traditionally been said to be one of the most painful examinations, but in our department, we use sedation to make the examination as painless as possible. More than 80% of patients responded that they felt little pain. After the examination, you will be sent home after resting on the recovery bed. If you wish, you can also use a narrow-diameter transnasal endoscope.

What is sedation endoscopy?

Sedation endoscopy at our department complies with the "Guidelines for Sedation" created by the "Japan Gastroenterological Endoscopy Society", making endoscopic examinations safer and less painful. The aim is to promote early detection of gastrointestinal cancer and less burdensome endoscopic treatment by reducing the patient's anxiety and stress about the examination and increasing the acceptability of the examination.

Conscious sedation is used for the sedation level to reduce side effects such as respiratory depression and blood pressure drop due to excessive sedation.

In addition, in order to conduct the examination more safely, all patients will be monitored with a biological information monitor during the examination, and after the examination, we will try to recover from the sedation in the recovery space. After about 30 minutes of observation, the sedation-arousal score is used to confirm that the patient's level of consciousness has fully recovered, and then the patient is sent home.

Elderly people are encouraged to come with an attendant.

On the day of the examination, please refrain from driving a car, motorcycle, or bicycle.

Painless testing is our motto. Equipped with the latest endoscopic equipment, the examination room is completely private and takes privacy into consideration.

The Endoscopy Center is located in the Imaging Medicine Department on the 1st floor, and is operated in the largest space (approximately 857m²) among clinical hospitals in the Kinki region. It has 6 endoscopy rooms, 2 X-ray fluoroscopy rooms, and 1 multi-purpose treatment room. We have introduced the latest electronic endoscopes including endoscopes. A 12-bed recovery space will be provided, and after the sedation test, patients will move to the recovery space while lying on their beds, where a dedicated nurse will check their respiratory and circulatory conditions using a centralized monitoring monitor. We strive to ensure that our patients have a safe and comfortable examination experience. We also have a day center, and we actively provide day care (colon polypectomy).

Questionnaire results for the sedation test

A questionnaire was conducted to evaluate patient satisfaction after upper gastrointestinal endoscopy (EGD) and lower gastrointestinal endoscopy (CS). Patients who underwent a sedation examination at our center in October 2014 (136 patients) for EGD and in January 2015 (55 patients) for CS cooperated.

The results are shown in the table.

When asked about their memory of having undergone EGD, 39/136 (29%) had no memory of the examination and barely remembered having undergone the examination. 50/136 patients (37%) only remembered the process from the start of the test until the scope was inserted. . In addition, when asked about the pain of the examination, more than 80% of the respondents said that they felt almost no pain during the examination, as those who had no memory of the examination naturally experienced no pain associated with the examination. As a result, 124/136 (91%) of those who underwent the sedation test answered that they would like sedation from the next time.

In CS, sedation is set to a small amount to use analgesics in combination. Therefore, most of the patients remember having undergone the examination, but 43/55 (79%) of the patients evaluated that they felt almost no pain, partly because of the effect of the analgesics. In addition, more than 90% of the respondents answered that they would be willing to undergo the next CS examination.
This evaluation exceeded our expectations, and we believe that the pain associated with endoscopy was reduced to an acceptable level.

In addition, regarding troubles after returning home, we confirmed the occurrence of adverse events associated with sedation, such as dizziness and falls, by interviewing at the outpatient visit after the examination. Most of the patients were able to lead a normal daily life without any problems after the examination, and some even returned to normal work after the examination. However, because there is a concern that this may cause a temporary decline in judgment and reaction, we ask patients to refrain from driving a car, motorcycle, or bicycle on the day of the examination.
Cancer has become a common disease with the progress of the aging society. Currently, one in two Japanese people will be diagnosed with cancer, and one in three people will die of cancer. We believe that even patients who have been hesitant about undergoing a gastroscopy or colonoscopy because they are too tired to undergo a sedation examination can feel at ease.

Colorectal cancer, which was said to be common in Westerners, is increasing in Japan as well. In recent years, the number of deaths from colorectal cancer has been higher in Japanese than in Westerners. However, colorectal cancer is a curable disease if detected early. For early detection, get a colorectal cancer screening (stool occult blood test) or an endoscopy.

colon cancer is on the rise

Colorectal cancer is on the rise due to the westernization of diet (high-fat/low-fiber diet), increased obesity, lack of exercise, alcohol consumption, and smoking. In terms of the number of patients, it is said to be the most common of all cancers. However, colorectal cancer is highly curable if detected early compared to other types of cancer. Treatment of colorectal polyps, which are said to be premalignant lesions, is known to reduce the risk of dying from colorectal cancer.

Get a colon cancer screening

For early detection of colorectal cancer, it is important to detect cancer before subjective symptoms such as abnormal defecation/blood stool/abdominal pain appear. Colorectal cancer is a disease that increases after the age of 40. People over the age of 40 should have a colorectal cancer screening every year.

A fecal occult blood test (stool hemoglobin test) is used to check for blood in the stool. If there is colorectal cancer or polyps, it is a test to check that the surface of the tumor is rubbed with stool, causing a small amount of bleeding. There is also a report that colorectal cancer mortality can be reduced by 60-80% by undergoing colorectal cancer screening.

Get a colonoscopy

Colorectal cancer is on the rise among gastrointestinal cancers and is the most common type of cancer death among women. Early-stage cancer has few subjective symptoms, and even today, it is often found in advanced cancer. Endoscopic treatment is also possible for early stage cancer.

A colonoscopy is an examination in which a soft tube (scope) is inserted through the anus to observe the surface of the large intestine. In advance, you will take a laxative and intestinal tract cleansing solution and excrete stool before observing. There is a report that the mortality rate of colorectal cancer is reduced by 40% by performing endoscopy, and our department is actively doing it. Polyps found are aggressively endoscopically resected. Small lesions can be treated on an outpatient basis.

In our department, more than 5,000 colonoscopies are performed annually, and more than 2,100 one-day polypectomy procedures are performed for colorectal polyps.

Early detection is important

Early-stage cancer has few subjective symptoms, and even today, it is often found in advanced cancer. Endoscopic treatment is also possible for early stage cancer. If you have persistent abdominal pain, abnormal bowel movements (constipation/diarrhea), or anemia, we recommend that you undergo an endoscopy. Many colonic polyps (called adenomas) and early cancers can be completely cured with an endoscope. In the case of advanced cancer, the department of surgery is committed to minimally invasive treatment such as laparoscopic resection, and in the case of distant metastasis, the Oncology actively performs chemotherapy to improve treatment results.

In recent years, we have been actively conducting small bowel endoscopy using a double-balloon type small bowel endoscope for small bowel diseases, which are on the rise. In 2019, it was performed in 50 cases, and accurate diagnosis and endoscopic treatment of small intestinal lesions that could not be detected by conventional examination methods have become possible. In addition, capsule endoscopy was also introduced in June 2008, and was performed in 66 cases in 2019. For small bowel lesions such as gastrointestinal hemorrhage of unknown cause, we have established a system that enables consistent medical care from screening with capsule endoscopy to detailed examination and treatment with double balloon small bowel endoscopy.

Small bowel endoscopy: shedding light on dark areas

Located between the stomach and the large intestine, the small intestine is the longest in the digestive tract, measuring 6 to 7 meters, and is responsible for the digestion and absorption of nutrients. It has long been called the "dark continent of the digestive system" because it is an organ that is difficult to inspect endoscopically. However, the development of a capsule endoscope in Israel in 2000 and a double-balloon enteroscope in Japan in 2001 have made rapid progress in the diagnosis and treatment of diseases of the small intestine.

Since 2003, our department has also performed small bowel endoscopy using a double-balloon small bowel endoscope (FTS EN450P5/20, EN450T5/W, EN-580XP, EN-580T, EC-450BI5) and achieved results. I came. In June 2008, we also introduced capsule endoscopy, which is less invasive and allows observation of the small intestine during outpatient examinations. We have established a system that allows us to provide consistent medical care, from detailed examination to treatment using a double-balloon small intestinal endoscope. We are one of the largest hospitals in the Kinki region, with more than 100 examinations per year including both.

Small bowel disease and endoscopy

As mentioned above, there were many unknowns about the disease of the small intestine, which was called the "dark continent". However, with the introduction of double-balloon endoscopy and capsule endoscopy, the detailed pathology is becoming clearer.

The slide shows the chief complaint (Fig. 1a) and the disease diagnosed as a result of the examination (Fig. 1b) of a patient who underwent double-balloon small bowel endoscopy at our hospital. As a result of the spread of small intestinal endoscopy, it has become clear that there are more small bowel diseases than previously thought.

Unexplained Gastrointestinal Bleeding: OGIB and Capsule Endoscopy

It may be an unfamiliar term, but Obscure Gastrointestinal Bleeding (OGIB) refers to bleeding from the gastrointestinal tract due to blood in the stool, melena, anemia of unknown cause, etc. It refers to a pathological condition in which a lesion that causes bleeding cannot be found even with conventional upper and lower gastrointestinal endoscopy. In such a condition, the cause is unknown and the patient is followed up, so anemia progresses due to repeated bleeding, and the patient's life is greatly restricted due to repeated hospitalization and discharge. Occasionally, excessive bleeding can lead to shock, which can be life-threatening. With the spread of small bowel endoscopy, it has become clear that OGIB includes cases of bleeding from small bowel lesions. For the diagnosis of OGIB, it is known that the shorter the time from bleeding to examination, the higher the diagnostic rate. Capsule endoscopy can also be used for emergency outpatient examinations, so it has the advantage of being able to respond relatively quickly to cases of sudden bleeding (Fig. 5).

On top of that, we continue to perform double-balloon enteroscopy for therapeutic indications such as hemostasis (Fig. 6).

Inflammatory bowel disease mainly refers to ulcerative colitis and Crohn's disease, and the number of patients is increasing significantly in Japan. Although it is an intractable disease with repeated relapses and remissions, new therapeutic agents have been approved one after another in recent years, and treatment options are increasing.

Ulcerative colitis and Crohn's disease are diseases in which erosions and ulcers occur frequently in the gastrointestinal tract, and many factors such as genetic predisposition, environmental factors, and intestinal bacteria are involved to cause immune abnormalities. It is a chronic disease that repeats relapses and remissions, and it is important to continue treatment steadily.

In the past, it was common to develop it in the teens to 30s, but in recent years it is not uncommon to develop it at an older age. As of June 2021, there are 309 patients with ulcerative colitis and 142 patients with Crohn's disease who regularly visit our clinic.

Symptoms include diarrhea lasting for several weeks to several months, bloody stools, abdominal pain, fever, and weight loss. Crohn's disease in particular may be accompanied by anal lesions such as anal fistula and perianal abscess. It is also known that ulcerative colitis increases the risk of developing colorectal cancer after a long period of time.

If these symptoms persist, lower gastrointestinal endoscopy and small bowel endoscopy are performed for diagnosis.

In addition to conventional drug treatments such as 5-aminosalicylic acid preparations, steroids, immunomodulators (azathioprine, tacrolimus), anti-TNF-α antibodies, and granulocyte removal therapy, since 2017 JAK inhibitors, anti-α4β7 Drugs with different mechanisms of action, such as integrin antibodies and anti-IL-12/23p40 antibodies, have been approved one after another, and even severe cases can now be controlled by medical treatment in a considerable number of cases.

In addition, some patients with Crohn's disease require multiple surgeries due to complications such as intestinal strictures and fistulas. The most common cause of surgery is intestinal stenosis, and in order to avoid surgery as much as possible, at our hospital, after performing sufficient medical treatment, we actively perform endoscopic balloon surgery using double-balloon endoscopy. I am doing dilation. In patients with Crohn's disease who have symptoms of stenosis such as abdominal pain and bloating, we performed endoscopic balloon dilatation for intestinal stenosis at our hospital, and as a result, surgery was avoided in 52.4% of cases.

Inflammatory bowel disease is a disease that can lead to the need for emergency surgery if the diagnosis is delayed. If you have persistent diarrhea or bloody stools, do not hesitate to get tested.

As a medical institution specializing in liver disease, we combine TACE (hepatic artery embolization) and RFA (radiofrequency ablation) to provide the best treatment for hepatocellular carcinoma. In addition to medical treatment, you can also receive highly curative surgical resection and minimally invasive radiotherapy.

Liver cancer is the fifth leading cause of cancer deaths in Japan. It used to rank fourth, but due to advances in treatment for viral hepatitis, it has been declining since peaking around 2000. However, nearly 30,000 patients still die from liver cancer each year. In our department, we have been providing multidisciplinary treatment according to the progress of the disease based on the "Clinical Guidelines and Treatment Algorithms for Liver Cancer". As a medical treatment, radiofrequency ablation (RFA) is performed in 77 cases (2019) per year.

In more advanced cases, transarterial chemoembolization (TACE) is selected. TACE is a catheter treatment (IVR) developed in Japan, and we have a track record of 157 cases (2019) per year at our hospital. In addition to Conventional TACE, which uses Gelpart® as an embolic material, we also perform DEB-TACE, which uses drug-eluting spherical embolic material.

Molecularly targeted drugs developed in recent years are oral drugs that have the effect of suppressing the growth of liver cancer over the long term. Currently, sorafenib, regorafenib, and lenvatinib are available, and are being actively introduced in patients with good hepatic reserve for unresectable advanced liver cancer.

Radiation therapy is also extremely effective as a local treatment for liver cancer, and since the burden on the patient is small, in cooperation with the Radiation Oncology, moving body tracking stereotactic radiation therapy (combined with percutaneous metal marker: VISICOIL® placement) was performed. I'm here.

If it is determined that resection is indicated, we will consult with a surgeon and recommend resection after evaluating the liver reserve function. In our hospital, we also actively perform laparoscopic liver resection.

Regarding liver cancer, it is important for each clinical department to cooperate in treatment in this way, and our hospital holds conferences every week to discuss the optimal treatment policy for each individual patient. In 2019, we treated a total of 251 liver cancer patients at our department.

Hepatitis C virus infection, which is said to be the cause of liver cancer, has been treated with IFN (interferon), but in 2014, treatment with oral drugs (DAAs) was introduced, and there have been more than 400 cases to date. 95% or more of cure (virus elimination) has been obtained by administering to patients. Hepatitis B can also be treated with oral medication.

Since the days of interferon (IFN) in the 1990s, our department has actively treated hepatitis C, which accounts for 60-70% of the causes of liver cancer. However, interferon injection has strong side effects such as fever and malaise, and the therapeutic effect was not sufficient, so less than half of the patients were cured. However, in the 2010s, direct-acting oral antiviral drugs (DAAs) were developed, and now it is possible to eliminate the virus in more than 95% of patients with almost no side effects just by continuing oral medicine for several weeks. I'm here.

However, since hepatitis C itself does not cause subjective symptoms, many potential patients do not know that they are infected with the hepatitis C virus. If you have ever had a blood transfusion or surgery, we recommend that you get a hepatitis virus screening in your community or consult your family doctor. As a medical institution specializing in liver disease, our hospital also strives to proactively treat hepatitis.

Hepatitis B also accounts for about 10 to 15% of liver cancer patients, and it is said that there are 1.1 to 1.3 million Japanese people infected with hepatitis B virus (including carriers). In addition, 400 million people are infected worldwide, and it is said that 2 billion people are infected including those who have already been infected. In the past, mother-to-child transmission was common, but a project to prevent mother-to-child transmission was started in 1986, and now the carrier rate is low. However, in recent years, the number of patients who contract hepatitis B through sexual intercourse is increasing, and countermeasures are necessary.

Therapeutic drugs for hepatitis B have also made remarkable progress, and in 2000 an oral drug (nucleic acid analogue) that inhibits the growth of the hepatitis B virus was released, and now it is possible to suppress the growth of the virus and improve hepatitis. increase. However, if the oral administration is stopped, the virus will re-proliferate, and this treatment cannot eliminate the virus from the body.

In addition, people who have acquired antibodies after being infected with HB (HB-infected people) may develop hepatitis B after contracting cancer, weakening their immune system, or using drugs that suppress their immune system (such as anticancer drugs). It is a problem that it reactivates and becomes a serious condition.

If a patient who visits our hospital tests positive for hepatitis B or C, we have introduced a "hepatitis check system" on the electronic medical record so that we can contact the patient and conduct a detailed examination and treatment. operating.

In our department, we actively perform endoscopic resection for early cancer. We perform ESD (submucosal dissection) for hypopharyngeal cancer, esophageal cancer, gastric cancer, and colon cancer. Compared to surgery, this treatment is less stressful on the body and is safe for the elderly.

The number of patients dying from cancer is on the rise as the population ages. It is said that one in two Japanese will get cancer, and one in three will die of cancer. Among gastrointestinal cancers, colorectal cancer ranks first and gastric cancer ranks second, with approximately 50,000 deaths each year. However, if cancer is detected early, it is a curable disease. Our department also actively performs endoscopic treatment for esophageal cancer, stomach cancer, and colon cancer.

Specifically, we introduce endoscopic submucosal dissection (ESD) and treat more than 200 patients annually. ESD is capable of en bloc resection of relatively large early cancers, but it requires advanced endoscopic manipulation techniques. In our department, three endoscopists play a central role, and we perform the procedure safely under the whole-body and respiratory management by the ecological information monitor. In particular, if necessary, we have established a system that allows us to perform endoscopic resection using an operating room under general anesthesia.

Endoscopic treatment of superficial esophageal cancer

In esophageal cancer, lesions confined to the epithelium (EP)/lamina propria (LPM) have almost no possibility of lymph node metastasis, and endoscopic treatment is said to be curative. .

Cancer that is deep in the muscularis mucosae (MM) and that slightly invades the submucosa (SM1: less than 200 μm in the submucosa) can be treated endoscopically, but the possibility of lymph node metastasis is about 10-20%. It is said that there is However, considering the invasiveness of other treatments, the ESD/EMR Guidelines for Esophageal Cancer recommend endoscopic treatment as the first treatment.

Prevention of stenosis after endoscopic treatment

When the resection area is wide, post-resection stenosis becomes a problem, especially for circumferential lesions. Stenosis is inevitable if stricture prevention measures are not taken, and quality of life is significantly reduced due to obstruction. When stenosis occurs, the narrowed part is dilated under an endoscope, but the improvement may be poor and the treatment may be difficult.

In recent years, it has become possible to prevent stenosis to some extent by administering local steroid injections to the ulcer site immediately after endoscopic treatment or taking steroids internally. Nevertheless, the risk of stenosis is high in lesions that are circumferential and have a wide resected area. For lesions with a major diameter of 50 mm or less, endoscopic treatment combined with stenosis prevention is recommended, and for lesions larger than 50 mm, surgery or chemoradiotherapy is recommended from the beginning.

Endoscopic treatment of early gastric cancer

Endoscopic treatment for early gastric cancer preserves the stomach, resulting in a better quality of life than surgery. However, since endoscopic treatment for early gastric cancer is a local treatment, lesions that do not metastasize to lymph nodes around the stomach are targeted. Lesions for which the risk of lymph node metastasis is estimated to be extremely low (less than 1%) and long-term prognosis equivalent to that of surgical gastrectomy are called absolute indication lesions. Currently, the results of multicenter prospective clinical studies by the Japanese Clinical Oncology Research Group, JCOG0607 and JCOG1009/1010, have clarified the long-term results of endoscopic treatment for early gastric cancer. ”, lesions that meet the following conditions are considered absolute indication lesions.

1. Nonulcerative, differentiated, intramucosal carcinoma of any size (M)
2. ≤3 cm, ulcerated, differentiated, intramucosal carcinoma (M)
3. ≤2 cm, non-ulcerated, undifferentiated, intramucosal carcinoma (M)

For early gastric cancer other than the above, the standard treatment is surgical gastrectomy. However, although the cure rate decreases, endoscopic treatment may be completely curable, so endoscopic treatment may be performed as a relative indication depending on the patient's situation (such as surgical gastrectomy being difficult).

Endoscopic treatment of early colorectal cancer

Many colon polyps are treated with snares, but some early colon cancers (intramucosal carcinoma [M], mild invasion into the submucosa [SM1: submucosa less than 1000 μm]) On the other hand, it is difficult to treat with snare, and en bloc excision is performed by ESD.
Lesions that meet the following conditions are indicated for ESD.

1. Larger than 2 cm, en bloc excision with snare is difficult
2. Lesions with fibrosis in the submucosa
3. Lesions with chronic inflammation such as ulcerative colitis
4. Local residual disease after previous endoscopic treatment

In addition to diagnosing and treating pancreatic cancer and biliary tract cancer, we are also actively working on early detection. Above all, we perform follow-up by endoscopic ultrasonography (EUS) positively for pancreatic cancer high-risk patient.

In recent years, pancreatic cancer has been on the rise, and about 37,000 people die of pancreatic cancer every year. Looking at changes in the cancer mortality rate for each organ, gastric cancer, colorectal cancer, and liver cancer are decreasing due to advances in medical care, but no signs of pancreatic cancer are observed.

Pancreatic cancer is a disease with a poor prognosis, with a 5-year survival rate of less than 10%. However, pancreatic cancer of 1 cm or less in size is said to have a 5-year survival rate of 80%. In general, early detection of pancreatic cancer is difficult, but we believe that early detection is possible by conducting appropriate tests at appropriate times for high-risk patients with pancreatic cancer. For this reason, we are actively testing high-risk pancreatic cancer patients who are referred by local medical institutions. Even if there are no abnormalities at the time of referral, we believe that it is important to conduct regular examinations.

Imaging tests for pancreatic cancer include abdominal ultrasonography, CT, MRI, and endoscopic ultrasonography (EUS). EUS is an imaging test that uses an ultrasound probe at the tip of the endoscope to examine surrounding organs such as the pancreas and bile ducts through the walls of the gastrointestinal tract, such as the stomach and duodenum. Since EUS has excellent spatial resolution, it is possible to detect minute pancreatic cancers of 1 cm or less in size. Therefore, in our hospital, we actively perform EUS for pancreatic cancer high-risk patients. Recently, we have newly introduced the latest ultrasound diagnostic equipment, and we are accumulating daily examinations for the early detection of pancreatic cancer.

If EUS is used, a thin needle can be inserted into the pancreatic tumor from the stomach or duodenum and tumor cells can be collected. This method is called endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Collecting tissues and making a definitive diagnosis using EUS-FNA is extremely useful in deciding on a treatment policy for tumors.

Regarding the final decision on the treatment policy for pancreatic cancer, we hold conferences with the Department of Gastroenterology, Surgery, Diagnostic Radiology, and Oncology to select the optimal treatment method. In recent years, treatment methods for pancreatic cancer have also advanced, and efforts are being made to improve the patient's prognosis and quality of life.

Since 2007, our department has regularly held a "liver disease class". Based on this experience, since 2012, we have been holding a bimonthly “Digestive Diseases Class” that covers all digestive diseases. It consists of lectures by Gastroenterology staff, topics provided by pharmacists/nutritionists, and question corners from participants. Not only patients but also family members and anyone interested in the disease are welcome to participate.

What is the Digestive Disease Class

Liver diseases such as chronic hepatitis, liver cirrhosis, and liver cancer have been said to be "national diseases" among many Japanese people. In particular, hepatitis C was once called non-A, non-B hepatitis (hepatitis that is neither A nor B), but since HCV antibody was measured in 1989, chronic hepatitis・It has become clear that 60-70% of liver cancers are caused by hepatitis C, and that there are 1.5 to 2 million hepatitis C virus carriers in Japan. Therefore, in 2007, we started the "Liver Disease Class" so that patients with chronic liver disease and their families can receive effective treatment with accurate knowledge of the disease. Among them, interferon (IFN) treatment can cure hepatitis C, there are effective medical and surgical treatments such as TACE/RFA for liver cancer, drugs and nutrition related to liver disease, etc. has become established as a place where patients and medical staff such as doctor, pharmacists, and nutritionists study together.

However, since there are many types of gastrointestinal diseases other than liver disease, such as gastrointestinal diseases and pancreatic diseases, we developed the "Digestive Diseases Classroom" to expand the theme to the whole digestive system. It is held once a year, six times a year. Every time, 40 to 60 people participate, and it is held in a friendly atmosphere.

Contents of the Digestive Disease Class

The theme of the classroom is determined by the annual plan. First, the doctor will give a lecture on the pathology, and then the pharmacist will gently explain the topic of medicine, and the nutritionist will gently explain the topic of diet. After the lectures, there is a corner where we answer questions from participants, and we take various questions each time. Each specialist staff member carefully answers questions such as questions about illness, questions about treatment, questions that are difficult for the doctor in charge to ask, questions about medicines, questions about dietary contents, etc. so that the participants can answer their questions. Even if you are not a patient of our hospital, or if you are a family member, you are free to participate, so we would like you to feel free to participate.

The venue is the conference room on the first floor of the hospital. It is in front of a convenience store that is open 24 hours a day. There is no cost and no pre-registration is required.

October 18, 2021

*This content is intended for doctor and is intended to deepen the understanding of this medical institution, and is not intended for publicity or advertising for the general public.

Nice to meet you, my name is Tetsuro Tetsuro Inokuma Gastroenterology Kobe City Medical Center General Hospital.
As a main hospital in Kobe City, our department has 9 staff members and 7 Senior Resident for a total of 16 people, who are engaged in acute treatment of digestive diseases 24 hours a day. Last year, the number of hospitalized patients decreased to less than 2,000 due to the effects of the new coronavirus infection, but emergency hospitalizations accounted for 1/3 of the hospitalized patients.
The Endoscopy Center, which is located next to the Critical Care Center on the 1st floor, has 7 examination rooms and 2 X-ray fluoroscopy rooms in a space of over 800m2. We also have a recovery corner. Because it is possible to take a sufficient rest after the examination, almost all cases are currently undergoing endoscopic examinations under sedation (sedation), and approximately 18,000 examinations are performed per year. .
This time, Yohei Yabuuchi M.D. of our department, will introduce endoscopic treatment that makes full use of cutting-edge equipment and techniques.

Vice President
Gastroenterology Director
Tetsuro Inokuma

Nice to meet you, I am Yohei Yabuuchi Yabuuchi, M.D. of Gastroenterology Kobe City Medical Center General Hospital.
The field of gastrointestinal endoscopy is advancing day by day. In terms of diagnosis, real-time histological diagnosis is becoming possible, and in terms of treatment, less invasive treatment methods are being explored while ensuring curability.
In this article, I would like to explain the approach to endoscopic treatment at our hospital.

M.D. Gastroenterology
Yohei Yohei Yabuuchi

<Specialty field>
Endoscopic treatment of early cancer
<Academic specialist/ Certified Physician >
The Japanese Society of Internal Medicine　Board Certified Member of the Japanese Society of Internal Medicine
The Japanese Society of Gastroenterology　Gastroenterology Specialist and Supervisor
Japan Gastroenterological Endoscopy Society　Board Certified Fellow of the Japan Gastroenterological Endoscopy Society

A new standard for endoscopy Providing safe and comfortable examinations

Endoscopy has traditionally been said to represent a painful examination.
In fact, some patients who underwent endoscopy in the past said, "I don't want to undergo such a painful examination again." However, after the introduction of sedation examinations using sedatives and analgesics at the time of examinations, almost no complaints of pain have disappeared. Some patients have no recollection of having undergone the test, so we believe that they will be able to undergo the test without anxiety.

On the other hand, the most common complications (including deaths) associated with endoscopy are also related to sedation.
For this reason, in our department, we continuously centrally manage and record patient information monitors during and after examinations, and alarms are set off when blood pressure or SpO2 drops, making it possible to respond quickly. We provide a comfortable inspection with a firm guarantee of safety.

Picking up early cancer using state-of-the-art equipment

Medical progress is remarkable, and new treatments and devices are being developed one after another in the gastrointestinal field.
As part of our mission to provide state-of-the-art medical care, this year we have introduced the Endocyto® endoscope, which enables ultra-magnified observation up to 520 times. It is an epoch-making device that can obtain microscopic-level visual fields in vivo.
Conventional magnifying endoscopes are limited to 80x magnification, but ultra-magnifying observation not only improves the diagnosis rate of microscopic cancers, but also has the potential to make definitive diagnoses without removing tissues.

The scope itself has an outer diameter of 9.7 mm, which is smaller than a normal endoscope, and it is possible to continuously zoom from normal to 520 times magnification simply by operating the magnifying zoom lever.
Being able to observe cell nuclei may also enable tissue diagnosis by evaluating cell atypia. With the recent increase in the number of patients taking antithrombotic drugs, we believe that there is also the advantage of avoiding the risk of bleeding due to biopsy tissue examination.

Observation of nuclei in mucosal cells is possible with a super-magnifying endoscope

In addition, we plan to introduce “Endo BRAIN-EYEⓇ”, the first AI diagnosis support system for endoscopy, ahead of hospitals nationwide. We expect that the use of AI will enable the qualitative diagnosis of early cancers and the detection of minute tumors.

Endo BRAIN-EYE points out tumors in real time during examination

State-of-the-art therapeutic technique ESD is now possible for early-stage cancers in the entire gastrointestinal tract

With the development of endoscope equipment in recent years, many early cancers have come to be found in the gastrointestinal tract as a whole.
With the development and progress of endoscopic submucosal dissection (ESD), lesions that were previously indicated for surgery have become Entire resection is possible regardless of the size of the lesion, enabling good local control and accurate pathological evaluation It is. Endoscopic treatment has become the first choice for many early-stage cancers, since radical cure can be expected for lesions with an extremely low possibility of lymph node metastasis, although there are some differences in criteria depending on the organ. .

The greatest merit of endoscopic treatment is that the physical burden during treatment is minimal and organ function can be preserved. At our hospital, we basically operate on the path of hospitalization the day before treatment, treatment day, starting drinking water the day after treatment, and resuming eating two days after treatment.

ESD is a technique that is becoming more popular, and standard lesions are widely treated, but it is also true that there are lesions that are technically difficult depending on the lesion site and size. In endoscopic treatment, only one device that can be pulled out from the scope is a weapon, but the bottleneck is that it is not possible to expand the field of view using multiple hands as in surgical operations. However, in recent years, in order to overcome this problem, it has become possible to apply countertraction by using a clip with thread or a method using a special loop.

Countertraction method

In addition, at our hospital, there are three specialists who have sufficiently studied at a high-volume center for endoscopic treatment in Japan, and we hope for treatment after sufficient discussion and treatment strategy in advance.
Recently, due to the aging society, there are some patients who do not wish to undergo surgery due to the risk of postoperative QOL deterioration, even if they are judged to have early-stage cancer that is suitable for surgery. In such cases, if the patient agrees that curability is inferior to surgery, a policy of performing only endoscopic resection and monitoring the progress is presented as an option (ESD as a relative indication). ).
If you think there is even the slightest possibility of endoscopic treatment, please do not hesitate to introduce us.

Cooperate with other departments in the hospital to provide care from the entrance to the exit of the gastrointestinal tract

At our hospital, we perform endoscopic treatment for superficial cancer of the entire gastrointestinal tract from the entrance to the exit, including the pharynx, esophagus, stomach, duodenum, and large intestine.
For pharyngeal lesions, joint treatment with an otolaryngologist is performed, laryngeal expansion using a curved laryngoscope, ESD techniques, orally inserting forceps or electric scalpel under the assistance of an endoscope. We perform resection by ELPS (Endoscopic Laryngo-Pharyngeal Surgery), which performs subepithelial detachment.

Regarding lesions of the duodenum, it is said that the risk of intraoperative and delayed perforation associated with ESD is high due to poor operability and exposure to digestive juices such as bile and pancreatic juice. To ensure safety, we also provide treatment by LECS (Laparoscopy and Endoscopy Cooperative Surgery), which is performed jointly with surgical laparoscopy.

To reduce colorectal cancer mortality -colorectal cancer screening and clean colon-

Colorectal cancer is on the rise due to the westernization of diet (high-fat/low-fiber diet), increased obesity, lack of exercise, alcohol consumption, and smoking.
Colorectal cancer is ranked 2nd in men and 1st in women in the predicted number of cancer deaths by site (2020). Colorectal cancer ranks third among males and second among females in the predicted number of cancer incidences by site (2020). The mortality rate from colorectal cancer is higher in Japan than in Europe and the United States. It is believed that colon cancer screening, mainly using endoscopy, has been successful in reducing the number of colon cancer deaths in Europe and the United States.

Colorectal cancer is a curable disease if detected early.

Colorectal cancer screening (fecal occult blood test) and endoscopy are useful for early detection and early treatment.
Multiple RCTs have demonstrated the effect of fecal occult blood testing on colorectal cancer mortality. Multiple large-scale cohort studies have also shown the effect of endoscopy on reducing colorectal cancer mortality.

In Japan, low screening and detailed examination rates are issues. Recently, in the pandemic of the new coronavirus, refraining from seeing patients has become a problem. From overseas, it has been reported that the longer the period until the endoscopic examination of the fecal occult blood is positive, the more advanced the colorectal cancer is found, and the higher the risk of colorectal cancer death.

The longer the period between a positive fecal occult blood test and colonoscopy, the higher the rate of colorectal cancer (especially advanced cancer).

At our clinic, in parallel with corona countermeasures, we are striving to maintain the medical system so that we can provide normal medical care safely and securely under sufficient infection control measures. For example, prior to an endoscopy, based on the guidelines of the academic society, we conduct a preliminary risk assessment through medical interviews and temperature checks, and ensure that personal protective equipment is worn during the examination.

Neoplastic lesions can be treated on the same day

At our hospital, we actively perform colonoscopies combined with sedation to minimize patient discomfort. Based on the concept of clean colon, we actively perform outpatient day care to remove all neoplastic lesions found during the examination. We have secured a sufficient recovery room for post-tests, and we ask patients to return home after confirming that they have recovered from the sedation.

A scope with a magnifying function is used in all cases, enabling accurate pretreatment diagnosis and treatment selection based on magnified observation.
For low-grade adenomas of less than 10 mm, endoscopic resection without applying current, called cold snare polypectomy (CSP), is commonly performed. As the number of patients taking oral antithrombotic drugs increases as the population ages, safer minimally invasive treatment with a low bleeding risk is now possible. is.

message to teachers

Due to the spread of the new coronavirus infection since last year, I understand that many medical institutions are restricting medical treatment.
As a designated hospital for infectious diseases, our hospital also built a temporary corona ward in the hospital parking lot to accept severely ill patients in Hyogo Prefecture, and has treated more than 1000 patients so far. Reflecting on the in-hospital cluster that occurred at the beginning of the response, we have established a system to safely treat general patients by establishing the distinction between red (corona positive), orange (suspected corona), and white (general, corona negative). .
In addition, for emergency and scheduled hospitalization patients, PCR tests are performed on all cases before hospitalization to check for viruses brought in. Please feel free to introduce yourself.

A senior who has experienced three years as a Gastroenterology Senior Resident at our department (if you have also experienced two years as an Junior Resident-stage resident at our hospital, please include that period as well) and send a message to juniors who wish to become gastroenterologists.

A senior who has experienced three years as a Gastroenterology Senior Resident at our department (if you have also experienced two years as an Junior Resident-stage resident at our hospital, please include that period as well) and send a message to juniors who wish to become gastroenterologists.

Dr. T (2016-2030: Specialist in our Senior Resident) (Later worked at Teine Keijinkai Hospital)

Thank you for your interest in our Department of Gastroenterology.

I spent two years at Rakuwakai Otowa Hospital in Kyoto, which specializes in general and emergency care. After much deliberation over what to choose as a field of specialization and which hospital to choose as a career path, I found (1) a large number of cases, including emergency care, (2) a well-developed guidance system, and (3) an environment where I could maintain my motivation. I considered it as a condition and decided. Looking back after three years of training, I realize that it was the training destination that met my expectations the most.

Our hospital has been featured in the media, but we have been ranked number one in the national critical care center evaluation for 5 years in a row. Cases that are difficult to treat at other hospitals are often referred to us. In addition, since other specialties are also influential, it is possible to experience rare diseases such as "gastrointestinal lesions of systemic diseases". However, if there are only a large number of patients, you will not know whether the treatment you are doing is appropriate or optimal, and you will be overwhelmed by the number. At our hospital, senior physicians specialize in gastrointestinal tract, bile pancreas, liver, and inflammatory bowel disease (IBD). Technology can also be improved. Depending on the hospital, there are some tests and treatments that cannot be performed due to lack of specialists, equipment, or lack of experience, but at our hospital, you can practice and learn a wide variety of specialized tests and treatments evenly in all areas. is considered to be the greatest advantage. Based on the wide range of experience I have cultivated during my three years of training as a Senior Resident, I believe that I will be able to aim for greater heights as I pursue my studies in my specialized field.

In addition, clinical and academic activities are like the two wheels of the wheel, and I feel that each other's abilities will be enhanced by the well-balanced functioning of both. In addition to giving presentations at regional conferences, there are many opportunities to participate in international conferences and write papers in English. There are many interesting cases, and preceptors are also actively involved. There is also an academic support center in the hospital, and the environment is well-equipped. I think that this is a very good opportunity to stop, think deeply, and learn from the busy clinical environment, so I encourage you to give it a try.

Deciding which way to go is a very difficult thing, but there are some scenery that you can only see once you take a step forward. Taking the first step as a Gastroenterology at our hospital is a big advantage for me. First of all, please take a tour and see what kind of training and guidance our Senior Resident receive.

We hope that our training will be fruitful for all of you.

Dr. M (2011-2012: Junior Resident, 2013-2015: Specialist in our Senior Resident) (After that, worked at the National Cancer Center Hospital East)

I had two years of initial training at our hospital, and three years of late training at the Department of Gastroenterology. Now that I have completed the latter term training, I would like to introduce the characteristics of the training at our hospital's Gastroenterology.

The first feature I would like to mention is that we are able to provide well-balanced training in the field of Gastroenterology, which deals with a wide variety of diseases. Gastroenterology broadly divided into the gastrointestinal tract area and the hepato-biliary-pancreas area by organ. In addition to treating many organs, we also target various pathologies such as malignant tumors such as stomach cancer and colon cancer, and inflammatory diseases such as chronic hepatitis and inflammatory bowel disease. At our clinic, we are able to provide unbiased, high-level training under the guidance of experienced staff who are well-versed in each area. The number of cases is also very large, so it may be more correct to say that there is no choice but to eliminate bias (laughs). Not to mention upper and lower gastrointestinal endoscopy, which is synonymous with Gastroenterology, we can actively participate in treatments such as ESD, ERCP, TACE, and RFA. For example, I was able to experience more than 50 cases of ESD during the second term training alone. Gastroenterology need not only knowledge of internal medicine but also the ability to perform complex procedures, so I think it was ideal to have such an experience.

The second feature is that we have an extremely large number of emergency cases as Kobe City 's premier general hospital that handles up to tertiary emergencies. You can experience a wide range of pathologies that require endoscopic treatment, such as hematemesis and cholangitis, and pathologies that require medical management, such as severe acute pancreatitis and fulminant hepatitis. At first, I had to hold the endoscope in a cold sweat (laughs). I think it's done.

The third feature is that they are proactive about academic aspects such as academic conferences and paper presentations. For myself, I was able to step up gradually and experience presentations at academic conferences, from regional conferences to general meetings and even international conferences. It was sometimes difficult to do academic activities during my busy clinical work, but I was able to acquire a lot of knowledge through making presentations, and I felt a great sense of accomplishment after finishing my presentation with other professors. .

Above, I have described the characteristics of the latter term training at the Department of Gastroenterology at our hospital. To be honest, it was a busy life, but I think it's an environment where you can improve as much as you want. We are looking forward to seeing as many people as possible come to our clinic!

Dr. H (2011-2012: Junior Resident, 2013-2017: Specialist in our Senior Resident) (After that, worked at Shizuoka Cancer Center)

During my training as a Senior Resident in Gastroenterology at our hospital, I was in charge of a large number of gastrointestinal disease cases, and was able to be involved in tasks such as endoscopic examinations and treatments, as well as ward and outpatient care. I was given many opportunities to respond to emergencies, and I was able to directly experience many cases such as melena and acute abdomen. From the beginning of my first year, I often received multiple consultations at the same time as an ambulance duty, and I think I was often confused at first. However, even in such a case, I was not exhausted by myself, and while consulting with senior doctors and senior Senior Resident around me, I was able to receive appropriate advice and learn how to respond. By being entrusted with the initial Senior Resident immediately as a specialist, I can take responsibility for my medical care and improve my skills on a daily basis. In addition, by becoming the attending physician of an inpatient, it is possible to be involved responsibly in determining the treatment policy. I was also given many opportunities to experience therapeutic endoscopy. In a busy and demanding environment, I sometimes feel discouraged, but I am able to continue my training with the support of the doctor and co-medicals around me. Through inpatient, outpatient, and emergency departments, you can experience a series of common gastrointestinal diseases and sometimes relatively rare diseases in three years. Many patients have social problems, and social problem-solving skills are required.

In addition, the whole department of Gastroenterology has an atmosphere of enthusiasm for academic activities, and since there are many cases, it is possible to participate in a wide range of academic activities such as regional meetings, general meetings, paper writing, and international conferences. am. I believe that these three years will allow me to grow significantly as a doctor and as a human being.

Dr. K (2010-2011: Junior Resident, 2012-2014: Specialist of our Senior Resident, 2015-2016: Staff of our department) (After that, he entered Kyoto University Graduate School of Gastroenterology)

I had two years of initial training at our hospital, followed by three years of specialized doctor as a Senior Resident in Gastroenterology Gastroenterology

I will write about the characteristics of this hospital based on my experience in each period.

First of all, regarding the initial training, our hospital is one of the leading emergency medical centers in Japan, and we accept many emergency patients day and night, and we handle a wide range of emergency cases from primary to tertiary emergencies. Due to the high level of medical care in an environment blessed with facilities and personnel, not only emergency cases but also cases that are difficult to treat at other hospitals are widely accepted, and appropriate diagnosis and treatment are performed for acute to chronic conditions. medical treatment is possible. I believe that experiencing the first step as a doctor in such an environment with high medical standards was important in laying the foundation as a doctor. I had a relatively long rotation in all internal medicine as a course focused on internal medicine, but I was able to experience many cases from common diseases to rare diseases. The training was also helpful.

Next, in the period of specialization in Gastroenterology Senior Resident a specialized training, from the beginning of the training, I will treat the patients in charge as the attending physician, and will proactively perform everything from examinations and treatments to management for discharge from the hospital. As a general rule, the hospital does not refuse emergency cases, so bed management is sometimes tight, and it is required to proceed with examinations and treatments without waste. I was able to develop a sense of assessing the condition of the patient. Regarding actual medical treatment, Gastroenterology one of the departments of internal medicine that requires manual procedures. I didn't have to scramble for cases with the Senior Resident (rather, I can experience it as much as I hate it). With the support of a senior doctor, I am able to accurately perform emergency examinations for emergency cases, so I was able to realize that my abilities are improving day by day.

Many people are transferred to other hospitals when they finish their Senior Resident, but I was fortunate enough to be able to stay because of the number of M.D., so I worked at this hospital for two more years after completing my Senior Resident. bottom. I had experience in general Gastroenterology Senior Resident until I became a specialist, but during my term as a fixed-term doctor, I was able to take a step further into my own area of expertise and provide medical care. While experiencing a wide range of cases during my time as a Senior Resident, I became interested in the treatment of inflammatory bowel disease and small bowel disease, so I was able to devote the remaining two years to improving my small intestinal endoscopy skills. I was able to have a good experience in making the foundation of.

Our department also puts a lot of effort into academic research, and we have made many presentations at academic conferences both in Japan and overseas. At first, I didn't know how to make the presentation slides, but as I went through the number of sessions, I was able to grasp the tricks of abstract creation and presentation, and it was adopted as a theme at the general assembly level. I was able to write three papers while I was enrolled, and I think that this facility has endless possibilities if you are motivated.

After gaining experience at our hospital as described above, I am currently enrolled in graduate school at Kyoto University. After completing the basics of Gastroenterology through training at our hospital, there are many doctors who aim to further deepen their specialized fields. It seems that there are many things to study. Since it is also an affiliated hospital of Kyoto University, it is relatively flexible to transfer between affiliated hospitals, so those who want to gain more experience in general Gastroenterology will not get lost. Although it is a busy hospital, there are many things that can only be experienced here.

Dr. O (2009-2020: Junior Resident, 2011-2013: Specialist in our Senior Resident) (After that, after working at the Japanese Red Cross Wakayama Medical Center, entered the Graduate School of Gastroenterology, Kyoto University University)

After two years of initial training at our hospital, and three years of later training, I am currently conducting basic research at a university. Looking back at the training at our clinic, we will introduce the characteristics of the early and late training.

The feature of the initial training is "the best of both city hospitals and university hospitals."

Our hospital's emergency outpatient department handles primary to tertiary emergencies from children to adults, so we can examine many patients who visit us and develop the ability to respond to various medical conditions. On the other hand, at our hospital, under the guidance of many excellent instructors, medical care at the level of a university hospital is provided. You can learn and practice how to diagnose and treat. In other words, you can experience a wide variety of cases of various pathological conditions, and you can practice diagnosis and treatment at the university level under the guidance of many excellent instructors, which is the best of both city hospitals and university hospitals.

The characteristics of the latter term training are "abundant cases", "many colleagues" and "scientific research".

The greatest feature of our hospital is the abundance of cases. You can acquire a lot of knowledge and skills by experiencing various procedures through abundant cases. It is said that "seeing is believing", but I believe that nothing can replace the experience gained not only by learning and hearing, but also by seeing the case firsthand.

The second feature is that there are "many friends". There are many post-doctoral trainees in our clinic, so we can stimulate each other and work hard. In addition, by observing what senior trainees are doing, practicing and teaching juniors, in other words, by practicing “see one, do one, teach one”, learn, acquire, and establish knowledge and skills You can. Of course, it is safe because the staff who are familiar with each field will firmly support the late trainees. On the other hand, when the second term training begins, you will be in charge of patients as the attending physician, and the sense of responsibility as the attending physician will cause a lot of pressure and worries. At that time, I was very grateful to have friends who were in the same environment, shared my feelings, and encouraged each other. In addition, there is concern that the number of cases and procedures that can be experienced will decrease due to the large number of post-doctoral trainees, but please rest assured that there is no such concern.

Finally, I would like to mention "scientific research" as the third feature. It is important not only for oneself but also for the development of medical care to transmit to the world a wealth of cases and experiences of unique diseases. There are systems in place to support you. By using this system, we are in an environment where it is very easy to make presentations.

I was busy with daily medical care in the early and late stages, and it passed quickly, but looking back, I feel that those days were very fulfilling. When I was transferred to another hospital, I realized that the knowledge and experience I had accumulated so far was useful, and I think that the path I have taken so far was not wrong.

There are many other attractions of the training at our clinic, but I can't write them all, so I hope you will come and visit us. We hope that many of you will be interested in training at our school.

Dr. M (2008-2009: Junior Resident, 2010-2012: Specialist in our Senior Resident) (After that, he entered Kyoto University Gastroenterology Graduate School)

After two years of initial training at our hospital, I immediately started specialized training as a late-stage resident (Senior Resident) in Gastroenterology. The reason why I chose to stay at our hospital as a doctor in charge is that the appearance of the senior doctors in charge of performing various procedures as a consultant is very lively and fulfilling from the standpoint of a doctor in charge of the Junior Resident in the emergency outpatient department. It was because it seemed that I was sending a training that I had done. I would like to introduce some of the features of our hospital's Gastroenterology that I have personally experienced through my experience in the latter term training.

One is that, in our department, there is a culture in place in which late-stage trainees are the main players in providing medical care and treatment. For example, it is not a training style of "learning about senior doctors" like sailing on a large ship called a senior doctor on a calm sea, but a training where you become a boatman and manage to make progress while being caught in rough seas. Close to style. Of course, it is premised that I will receive various guidance from senior doctors on a daily basis, but the knowledge and skills I have acquired through my own struggles will be many times faster than just being taught. You can feel that it is about. Especially with regard to treatment, once a certain foundation has been established, an environment in which a senior doctor will watch over you and tell you to “try it first” is a very blessed environment for those who want to learn about the digestive system. It can be said.

The second point, which can be said to be a feature of our hospital as a whole, is that we are focusing on emergency care, and at the same time, we are a high volume Kobe City and a medical institution that provides advanced medical care. The point is that there are many ambulance transports and referral consultations, and you can experience a lot of cases. Even in the Department of Gastroenterology cases that require emergency treatment, such as hematemesis and cholangitis, are brought to us almost every day. I can. In fact, in the first year, I myself had more than 800 upper endoscopies and more than 300 lower endoscopies (about 10% of which were emergency endoscopies), and I was trained in Gastroenterology at a general hospital. I have been able to experience endoscopy equivalent to three years. In addition to treatment and emergencies, you can experience many rare diseases and serious conditions that you cannot easily experience at general facilities.

In addition, IVR treatment such as hepatic artery embolization therapy and radiofrequency ablation therapy for liver cancer is mainly performed by the Department of Gastroenterology It is possible to conduct intensive training in an environment. I am looking forward to working hard with as many friends as possible.

Dr. A (2002-2015: Junior Resident, 2004-2018: Specialist in our Senior Resident)

Impressions about the Senior Resident training

I think it's attractive to be able to take charge of a large number of gastrointestinal disease cases as the attending physician in the gastrointestinal Gastroenterology Senior Resident training and be responsible for examination, diagnosis, and treatment. We hold a Gastroenterology conference every week for all cases, and the attending physician gives a presentation on the determination of the treatment policy, followed by a discussion, so that we can provide the best treatment. Gastroenterology is a clinical department with many examinations, there are many procedures that must be mastered. As for this point, while I have little experience, I will do it under the guidance of the staff, but since I can experience a lot, I can improve quickly. Since I have a stance that if my skills improve, I will be able to work independently, so I can live a training life where I can feel that my abilities are improving day by day. Characteristically, in the gastrointestinal tract area, upper and lower endoscopy, ESD, and double-balloon small intestine endoscopy are often performed, and in the bile pancreatic area, there are many cases of calculi and cancer, and there are many ERCP cases. Hepatic artery embolization and radiofrequency ablation/PEIT are also performed by the chief Gastroenterology so all Gastroenterology diseases can be treated consistently among the Senior Resident. We hold conferences with surgical departments, and the level of medical care is high because of coordinated medical care. In addition, since it is a regional core hospital that accepts primary to tertiary emergencies, we can experience a large number of Gastroenterology emergencies, so we are strong in judging and treating emergency cases. In transplant surgery, living-donor liver transplants are also performed, so you can experience a wide range of self-contained gastrointestinal treatments. I think that I will be able to think carefully about the choice for the subsequent career decision during the three years because I will definitely come across a case that interests me. I was able to spend the training period as a Senior Resident in a blessed environment, and even after going out, I realized that the experience, skills, and confidence I gained there were hard to obtain elsewhere.

Impressions about initial training

I think the biggest feature of the initial training at our hospital is that you can experience many different cases with independence. In particular, in the emergency outpatient duty duties that are trained throughout the two years of the initial training, we accept patients from primary to tertiary emergencies, so we will experience a busy emergency outpatient, but we will naturally study and gain knowledge through various experiences. You will also be able to learn the techniques from pediatric drip infusion to intubation. On-duty doctors in each specialized area are on duty during the shift, so you can feel at ease on duty, and if you consult, you can receive appropriate guidance. Internal medicine conferences and autopsy review case conferences (CPC) are held regularly in the hospital, so I think that I am blessed with opportunities to experience and study case presentations inside and outside the hospital. In addition, there are many trainees in the same class, so there are many friends. I was able to spend a very fruitful and fulfilling initial training period that I could not get anywhere else, and I think I was able to grow as a doctor. Irrespective of which department you go to, I think it is a recommended hospital for those who want to make a quick start as a doctor and those who want to start a fulfilling training with many fellow trainees. You can feel that the enthusiastic attitude of the trainees supports Kobe City Medical Center General Hospital, which is able to provide safe medical care as a municipal hospital that is trusted by patients.

Materials provided by: Hospital Cafe

Dr. T (2001-2004: Junior Resident, 2003-2017: Specialist in our Senior Resident)

Impressions about the Senior Resident training

If I am asked about the advantages of the Gastroenterology Senior Resident (3 years), I will answer without hesitation, "A large number of cases and a fulfilling guidance system." In our training, you can experience various cases in both the gastrointestinal tract area and the hepato-biliary-pancreatic area. In addition, because of the large number of cases, it is possible to experience and acquire examination techniques such as endoscopy in a short period of time Hemostasis for bleeding, varicose vein treatment, EMR or ESD, stent placement, etc. In the liver area, RFA, TAE, reservoir placement for liver biopsy and liver cancer, reservoir placement, etc. In the pancreaticobiliary area, ERCP, ENBD, IDUS, PTCD, metallic stent placement, etc.). In addition, there are an extremely large number of emergencies that require emergency treatment, and the primary Senior Resident will be the first call to treat them day and night. Of course, at first, I will be guided by my preceptor, but compared to other hospitals, I think I will be able to stand on my own in a relatively short period of time. This is because, especially in the first year of the Senior Resident, you will be called many times, and you will experience most of the gastrointestinal emergencies during this time, so you will inevitably acquire treatment techniques such as endoscopy.

From the second year onwards, you will develop your own examination and treatment plans for your patients, and further refine your examination and treatment skills. In my case, I was interested in diseases in the pancreaticobiliary region, so I actively participated in examinations such as ERCP and PTCD. In addition, while striving to improve their own skills, we also provide education for trainees who have been rotated and provide guidance to junior Senior Resident.

Due to the large number of cases, it is possible to conduct a wide range of academic activities such as regional meetings and general meetings. In addition, we can actively participate in educational and enlightenment activities for gastrointestinal diseases, such as giving lectures for trainees at emergency open conferences and holding lectures for patients and their families. increase.

Gastroenterology requires a wide range of knowledge because it covers a wide range of diseases. Even if I aim to become a specialist by organ in the future, I believe that it is necessary to be familiar with the diseases of each area because I call myself a Gastroenterology. It's a busy department, but that's why I think it's interesting and rewarding that other departments don't have.

The 3-year latter term training in such a department of Gastroenterology is very hard. There are times when I have very little private time. However, I believe that I will be able to build a solid foundation as a Gastroenterology as a clinician by devoting my full effort to the course over the next three years. We are waiting for the participation of those who have high aspirations as seniors and those who are motivated.

Impressions about initial training

When I became an Junior Resident, it was before the new clinical training system was enforced. At that time, there weren't as many hospitals as there are today that are recruiting trainees, but I was looking for a training hospital with the primary condition of providing comprehensive primary care training through emergency medicine. At that time, I visited the emergency site of the Kobe City Medical Center, which accepts all patients from primary to tertiary, and was very impressed by the high level of the intern doctors working there. This led me to choose Kobe City Medical Center as my training destination, and I can say that the actual content of the training exceeded my expectations.

First of all, I was involved in emergency and anesthesia training for the first six months of my first year, but the first two months were harder than I expected. I remember making repeated mistakes and being reprimanded each time by a senior doctor. However, after overcoming this period, about three months later, I began to realize the fun of clinical practice. If you don't understand something, you can ask for direct guidance from a second-year resident doctor or a supervising doctor in the emergency department or each department, and share useful cases with your fellow trainees. It repeats every day. Over time, you will begin to see clearly that you are getting stronger.

In the second year, the guidance of a new first-year trainee is required. Teaching also organizes the knowledge you have, so both the teaching side and the learning side grow. In addition, second-year students play a sub-leader role in emergency duty, so it is necessary to grasp the situation of the emergency outpatient department as a whole. For example, a wider perspective is required, such as checking if there are any seriously ill patients waiting for Walk-in, and following up on whether the assessment and plan of patients who have already been examined are correct. . It is through these roles that I further develop my competence as a clinician.

During my two years as an Junior Resident, I had the opportunity to see a wide variety of patients, including those on duty. I experienced many tertiary emergency cases such as myocardial infarction, cerebrovascular accident, and multiple trauma. was unaware of the pregnancy).

I believe that I was able to make full use of the experience I gained in the emergency department in the subsequent internal medicine rotation training (as it was called at the time). Kobe City Medical Center receives a large number of cases, not only in the emergency area. It was a short time to visit each department, but I was able to capture the characteristics of each department. In addition, I was able to come into contact with patients with various diseases and receive intensive training. After that, I went on to a specialized course, and for me, the experience of this training in internal medicine has been a great support for my current practice.

In clinical training, there is an idea that no matter where you go, after 10 years, everyone will be together. However, personally, I believe that what kind of experiences you have during your residency period will have a great impact on your growth as a doctor later on. Kobe City Medical Center is filled with a lot of things that I really want to learn, or should learn, during my time as a medical intern. If you are interested, please come and visit us first. I hope you can feel something there.

Dr. S (2002-2013: Junior Resident, 2002-2016: Specialist in our Senior Resident)

Impressions about the Senior Resident training

One of the great experiences I had during my three-year training as a Senior Resident was that I was able to experience many emergency cases of abdominal diseases. The Senior Resident is in charge of nighttime and holiday home visits, and is in a position to consult many emergency cases such as melena and acute abdomen. (Currently, on weekday nights, all the staff are on duty for the Gastroenterology, and on holidays, the general Senior Resident and the staff are on duty at home.) Immediately after completing one case of endoscopic hemostasis, I was consulted for a case of acute pancreatitis, so every day was extremely busy. It was a tough day, like a physical challenge, and I didn't have much time to sit at my desk and study textbooks slowly, but it was a fulfilling 3 that made each of my experiences come to fruition. It was a year. In addition, I think that it was a blessed environment as a training facility that the resident Senior Resident who consulted was not isolated and unsupported, and was able to consult with a senior doctor at any time. In this way, by being entrusted with the initial response, we can gradually expand the scope of what we can do while considering where and to what extent we can take responsibility for medical care and where we need support from. I was able to do the training I went through.

In addition, being able to experience many cases was very useful in acquiring diagnostics and techniques, and I was able to experience most of the general gastrointestinal diseases in three years. In particular, there are many outpatients with chronic hepatitis and cirrhosis of the liver, so being able to experience many emergency patients with ruptured esophagogastric varices and ruptured liver cancer has become a valuable experience now that I am working at another facility. increase. In addition, because it is a core doctor facility in the region, there are many opportunities to be in charge of relatively rare diseases. To do. The Senior Resident on the staff have a deep knowledge of their specialized fields, and looking back several years after finishing my specialty, I can't help but think that the advice they gave me, as well as the ear-study I learned in daily conversations, have contributed to my current medical practice. I feel alive.

As for the specific technical aspects, I was able to experience each examination equally, such as endoscopy, abdominal ultrasound, angiography, and gastroscopy, and was able to acquire these as my own skills. Currently, I work at a facility where I do not perform angiography or gastric fluoroscopy myself, but the experience I gained during my time as a Senior Resident is very useful in general medical care. In addition, it was a good experience for me to be involved in advanced Senior Resident and therapeutic techniques such as ESD, double-balloon small intestine endoscopy, and EUS puncture cytology. Finally, there was an atmosphere in which the entire Department of Gastroenterology was enthusiastic about giving presentations at academic conferences, and I was blessed with the opportunity to make a presentation as a speaker.

Impressions about initial training

I was able to handle a sufficient number of cases in each department, and I was able to experience a large number of acute and severe cases in particular. In particular, the ICU is well-equipped, and I had a good experience learning about systemic management for severe cases. Also, at the internal medicine conference held once a week, the trainees from each department brought together rare diseases and cases that were difficult to diagnose and treat, so I learned a lot. Emergency duty was a busy and tough training, but I was able to experience from the first to the third emergency, and I was able to train under the guidance of staff and Senior Resident who specialize in emergency, and there were always multiple trainees on duty. I think it was a very good environment where we were able to stimulate each other and work hard together.

Our department is one of the clinical hospitals in the Kinki region that has made the most academic presentations. Below are the impressions of the conference presentations made by the staff of our department.

We consider presentations at academic conferences to be an important part of our clinical activities.

It is possible to organize and share knowledge by summarizing and presenting what one has experienced and learned, such as valuable cases, interesting pathologies, and ingenuity in treatment. It is also expected that presentations at academic conferences will hone their presentation skills. Senior Resident are expected to grow into full-fledged Gastroenterology through presentations at gastroenterological conferences.
Our department is one of the clinical hospitals in the Kinki region that has made the most academic presentations.
Below are the impressions of the conference presentations made by the staff of our department.

Teacher T (2014-: Our department staff)

Society overview

Events and Impressions at Participating Conferences

Following DDW2016 (San Diego), I participated in Digestive Disease Week 2017 (DDW 2017) for four days from May 6th to 9th, 2017. This time it was held at McCormick Place in Chicago, Illinois, USA. DDW is one of the world's largest societies related to the gastrointestinal tract. It will be held jointly by four societies of the American Society of Gastroenterological Surgeons (SSAT).

First of all, I was surprised by the scale of the conference. It was a very stimulating conference with a wide range of presentations. In addition, we received presentations from all over the world, and my presentation this time was "Cross-wired metallic stent in endoscopic bilateral stent-in-stent placement for malignant hilar obstruction". It was something. The presentation will be a poster presentation, and you will stand in front of the poster during the allotted time and directly ask questions. Every time I participate in an international conference, I am keenly aware of my lack of proficiency in English, and at the same time it motivates me to study English in the future.

Also, as an option for the academic conference, I was able to attend a baseball game in Chicago, watch the MLB game between Chicago and the New York Yankees, and listen to the performance of the world-famous Chicago Symphony Orchestra.

Through this conference, I was able to see the world's most advanced treatments and research, and I was able to experience things that I would not be able to experience in Japan, so I was able to spend a meaningful time.

Junior Resident Senior Resident

Society overview

Events and Impressions at Participating Conferences

UEGW is an international conference in the field of gastrointestinal tracts in Europe, and is a huge conference held annually with more than 10,000 participants. In the first place, the impetus for participating in the conference was an impure motive of wanting to visit the fashionable city of Vienna. From around January 2016, I consulted with a senior doctor about topics that could be presented at international conferences. I received a notice of acceptance in July, and from there I spent almost every day looking at the hotel I was planning to stay at and researching tourist information about Vienna before the conference in October.

The academic conference is scheduled for 5 days, with educational lectures on the first 2 days and general presentations on the remaining 3 days. Looking at the conference participants by region, 65% came from the European continent, 17% from the Middle East/Asia, and 5% each from the Americas, South America, and Africa. The number of participants was the largest in Asia. Most of the presentations from Japan were from cancer centers and university hospitals, and the number of presenters from general hospitals like our hospital was small, and it felt like we were away.

The content of the academic conference is similar to that of academic conferences in Japan, and various sessions are held in parallel at several venues from morning to evening. There was no luncheon seminar, so when it came time for lunch, catered sandwiches, water, and fruits such as apples were brought to a designated area of the venue, and participants were free to take and eat them. Poster presentations are posted in the poster exhibition area from morning to evening, and the poster presenters stand by the posters from 12:30 to 13:30 in the daytime to answer questions about the posters. It was not the case that all the participants would speak their posters. My own presentation was a bit of a maniac, and fortunately I was able to get through it without any difficult questions.

After the conference (which was the most enjoyable part of the trip), I spent as much time as my physical strength allowed to visit Vienna and watch the orchestra. Vienna has a lot of tourist attractions around the central area called the Ring, and all of them are reasonably sized to go around on foot, trams, and subways, and I was able to see most of them during my short stay .

It was my first time attending an international conference, so I was nervous, but not only was the city of Vienna wonderful, but Japanese doctor of a slightly older generation than me stood on the platform of the conference venue at symposiums and workshops, in front of Westerners. Seeing them confidently present their work was very stimulating and made me keenly aware of the need for English proficiency. I was away from the hospital for about a week, but I am very grateful to the doctors in the department for kindly sending me to the conference.

Dr. I (2012-2013: Junior Resident, 2014-2016: Specialist in our Senior Resident)

Society overview

Events and Impressions at Participating Conferences

Digestive Disease Week, held annually in the United States, is an authoritative conference on digestive diseases that gathers the latest basic and clinical research topics from around the world. In 2016, it was held from May 24th to 27th, and especially since the 24th and 25th were holidays, it was crowded with many participants. Every day, there were presentations in each area of specialization, and from 8:00 in the morning until the evening, there were many poster sessions during the lunch break, where enthusiastic discussions took place. This time, I was fortunate enough to make two presentations at the poster session on the 24th, "Treatment Predictors of Tolvaptan," and on the 26th, "The Lecture on Duodenal Stents."

At DDW2016, various latest researches from North America, Europe, and Asian countries were selected as the subjects, and we were able to see interesting presentations every day. Devices and treatment methods that have not been used in Japan were very new, and there were some that I really wanted to introduce. Discussions were more lively than at academic societies in Japan, and every session was extremely productive. It was a great experience for me to have the opportunity to present two presentations in the poster session. doctor from South America and the Middle East also took an interest in the presentation of tolvaptan, and asked questions from a different perspective than in Japan. Also, in the presentation of the duodenal stent, I actively discussed with an Indian doctor, and found that the way of thinking about stent selection and indwelling method is completely different from that of Japan. While continuing our good things, we would like to make each treatment more sophisticated by incorporating new methods. Also, the common language is English, and I often felt during the exhibition that I needed to improve my communication in English so that I could accurately convey what I wanted to say and think. This was my first time participating in DDW, but I learned a lot because I was able to come into contact with many different things. And I would like to make use of what I learned this time in clinical practice.

We will send messages from our department staff to doctors who are considering majoring in Gastroenterology and medical students who are interested in the field of gastroenterology.

In the spring of 2018, the internal medicine specialist training program will start.

As a core facility, our hospital will also disclose a program to train specialists in each area of internal medicine, so please refer to the hospital website.

As a policy of Gastroenterology, 4 months from the start of the first year are devoted to subspecies (digestive organs) training, and during this period, students learn the basics of digestive organs and basic procedures such as endoscopy. . After that, we will start basic area training, but while aiming to broaden our horizons as a physician by having them handle a specified number of cases in each area, we will also focus on work so that our experience in subspecial areas does not become hollow. I am taking care of The second year will be an out-of-hospital training period, but the affiliated facilities are Kobe City Municipal Medical Center Nishi Municipal Hospital, Nishi Kobe Medical Center, Hyogo Prefecture Amagasaki General Medical Center, Japanese Red Cross Wakayama Medical Center, Tenri Yorozu Consultation Center Hospital, and Otsu Red Cross. At hospitals and other hospitals affiliated with the Department of Gastroenterology Kyoto University, we provide training mainly in the subspecialty area. In the third year, as the final year of the Senior Resident, we plan to have the main force of medical treatment at our department.

In the Gastroenterology field, it is important to experience many cases and master many procedures. Aim.

1. Practical (Practical) Principle

The greatest feature of our department is the principle of actual combat (practice). It goes without saying that textbook knowledge is extremely important as a foundation, but in actual clinical practice, things that do not follow the textbook or are not found anywhere in the textbook often occur. Medical care exists to save the suffering patients right in front of us, and humans are not so simple as to be divisible by theory (and sometimes evidence). In this respect, medicine can be said to be both an academic field and a practical science. We consider experience to be the most important thing. I believe that the result of hard work, learning, and effort in order to save actual patients will not only improve the abilities of individual doctor, but also raise the level of the entire Gastroenterology group and the hospital as a whole. Would you like to sweat with us at the actual site?

2. One-on-one guidance system

For example, no one can suddenly perform a gastroscopy from the start. Of course, we do not want them to do so. First, they learn the significance of the examination, understanding of the pathology, diagnostics, and handling of equipment, etc., and then they aim to master the examination under the guidance of senior doctors. While the new doctor patient is sweating while performing the examination, the supervising physician is also present, his hands sweating. The moment they turn around and look at you, you will be able to get the appropriate guidance. We do not teach by hand-holding. While assessing the patient's ability, advice and a helping hand will be offered when more advanced judgment or treatment is needed.

3. Abundant and valuable cases (experience)

As one of the leading hospitals in the Kinki region, not to mention Kobe City, we are able to experience a wide range of conditions from mild to severe. Compared to general clinical training hospitals, we are in charge of many cases in a short period of time, so specialists such as the Gastroenterology Society, Endoscopy Society, Hepatology Society, etc. Rare conditions, such as one case per year (sometimes in a lifetime), are also commonly encountered. It is a hospital that considers 10 cases of pathological conditions that are reported as one case at research meetings and academic societies. However, just because there are many cases, we never neglect one case at a time. For patients, this is their first illness and their first anxiety, and as specialists, we are required to respond calmly and sincerely.

4. Clarification of complex pathologies by a group of experts

We often encounter seemingly "incomprehensible" pathologies. At that time, please consult a senior doctor first without worrying about it alone. You should be able to get valuable advice, but if you still have trouble, consult with each clinical department. It is a daily occurrence that cirrhotic patients with heart disease suffer from disturbance of consciousness due to electrolyte imbalance caused by respiratory infection and recover from the critical condition under ICU management. Of course, it is necessary for the doctor in charge to be fully active, but before you know it, the helping hands of specialists are reaching out from all over the place.

5.Traditional training system (training program)

For more than 30 years, our hospital has trained clinicians through our own clinical training program and sent them out across the country. In the training program for internal medicine specialists to start in 2018, based on that experience, we examined the guidance system for internal medicine as a whole. Please refer to the hospital website for details. What I would like to emphasize here is that this system was not created overnight, but was refined through repeated trial and error. This is still going on today, and every month we gather from hospital executives to young staff members to repeatedly review and improve problems. In other words, the postgraduate education that we have practiced is like a "cradle of toughness." becomes. I don't think there is necessarily a need for a charismatic instructor or a new and eccentric program.

15 years have passed since the start of the "new clinical training system" formulated by the Ministry of Health, Labor and ministry of Health, Labor and Welfare notation. The significance of aiming for training in a wide range of fields in the first two years after graduating can be evaluated, but it can be said that the merits and demerits are mixed, as it caused a crisis of medical collapse that became apparent afterwards. Even if the Buddha was created by a bureaucrat, it is only us medical professionals who can put the soul into it. "Tradition was not built in a day".

6.Let's Join Us!

We appeal to young people who will bear the future of medical care with passion. Would you like to sweat with us? It's a dizzying day, but it's also a day where I feel a sense of fulfillment. Even as medical care becomes highly specialized, the gastrointestinal field covers an extremely large number of diseases and pathological conditions, and can be treated with a variety of techniques. We welcome you with open arms.