Differences in routine esophagogastroduodenoscopy between ...

Digestive Endoscopy 2016; 28 (Suppl. 1): 16–24

doi: 10.1111/den.12629

Recommendation for Appropriate Endoscopic diagnosis of gastric epithelial / nonepithelial tumor in Asian Countries

Differences in routine esophagogastroduodenoscopy between Japanese and international facilities: A questionnaire survey Noriya Uedo,1 Takuji Gotoda,2 Shigetaka Yoshinaga,3 Tokuma Tanuma,4 Yoshinori Morita,5 Hisashi Doyama,6 Akira Aso,7 Toshiaki Hirasawa,8 Tomonori Yano,9 Norihisa Uchita,10 Shiaw-Hooi Ho11 and Ping-Hsin Hsieh12 1

Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka, Japan, 2Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan, 3Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan, 4Department of Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan, 5Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan, 6Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan, 7Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Fukuoka, Japan, 8Division of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan, 9 Endoscopy Division, Department of Gastroenterology, National Cancer Center Hospital East, Kashiwa, Japan, 10 Department of Gastroenterology, Kochi Red Cross Hospital, Kochi, Japan, 11Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia, and 12Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chimei Medical Center, Tainan, Taiwan Background and Aim: The mortality rate of gastric cancer (GC) is close to the incidence rate worldwide. However, in Korea and Japan, the mortality rate of GC is less than half of the incidence rate. We hypothesized that good-quality routine esophagogastroduodenoscopy (EGD) contributes to a high detection rate for early GC (EGC) and improves mortality in these countries. Methods: To clarify the differences in routine EGD, a questionnaire survey was conducted in 98 Japanese and 53 international institutions.

examination time was similar (mostly 5–10 min) between Japanese and international institutions. Japanese endoscopists took more pictures (>20 in almost all institutions) than international endoscopists (≤20 in two-thirds of institutions). In Japanese institutions, biopsy specimens were more frequently taken from areas of mucosal discoloration, unevenness or spontaneous bleeding rather than from obvious endoscopic lesions such as ulceration or polyps. In most Japanese institutions, one or two biopsy specimens were taken per lesion, compared with ≥three in international institutions.

Results: Prevalence of screening examination among routine EGD was higher in Japanese than in international institutions. Japanese endoscopists noted that endoscopic mucosal atrophy was the most significant risk factor for GC, whereas international endoscopists paid more attention to clinical information such as age, symptoms and family history. Antispasmodics, mucolytics and defoaming agents were used more frequently in Japanese institutions. The

Conclusion: There were some discrepancies between Japanese and international institutions for routine EGD. Thus, standardization is required for adequate risk assessment, proper techniques, and knowledge of endoscopic diagnosis of EGC.

INTRODUCTION

type of cancer and the third leading cause of cancer death worldwide.1 Korea has the highest incidence rate globally, followed by Mongolia and Japan. The global mortality rate of GC is close to the incidence rate (Fig. 1), meaning that most patients with GC die from the disease after diagnosis. However, in Korea and Japan, the mortality rate of GC is less than half of the incidence rate.1

A

LTHOUGH THE INCIDENCE of gastric cancer (GC) has been declining, it remains the fifth most common

Corresponding: Noriya Uedo, Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Disease, 3–3, Nakamichi 1-chome, Higashinari-ku, Osaka 5378511, Japan. Email: [email protected] Received 5 January 2016; accepted 2 February 2016.

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Key words: biopsy, early diagnosis, esophagogastroduodenoscopy, gastric cancer, gastrointestinal endoscopy

Although mortality is high in patients with advanced GC, when GC is diagnosed at an early stage, 5-year survival rate

© 2016 The Authors Digestive Endoscopy © 2016 Japan Gastroenterological Endoscopy Society


Routine EGD in Japan and overseas

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institutions were selected from among hospitals and clinics related to the main investigators in this study. A questionnaire about indications, preparation, instruments and procedures of routine EGD was formulated by two investigators (N.U. and T.G.). The questionnaire was sent to a representative doctor in each institution by email in May 2015, and retrieved by the end of June 2015. Results were circulated and presented to attendees of the Endoscopy Forum Japan on 1 August 2015 and interpretation of the data was discussed.

RESULTS

R Figure 1 Age-standardized rate (ASR) of incidence and mortality of gastric cancer in the 20 highest countries in the world. Reproduced with permission from WHO International Agency for Research on Cancer. GLOBOCAN 2012. http:// globocan.iarc.fr/Pages/online.aspx. , Incidence; , Mortality.

exceeds 95%.2 Early diagnosis and treatment are effective strategies to improve mortality of patients with GC; therefore, population-based screening has been implemented in Japan and Korea.3,4 In Japan, 7 million people underwent population-based screening in 2012, and GC lesions were detected in 5400, with 74% diagnosed as stage I GC.5 However, this accounted for only 4% of patients with GC nationwide.6 The leading Japanese cancer hospital reported that detection of early GC (EGC) by population-based screening accounted for only 7.6% of all their cases of EGC.7 The remaining 92.4% of cases were diagnosed by routine endoscopic examinations in outpatient clinics or individual health checks.7 Cancer statistics showed that 38 806 of 62 665 (61.9%) patients with GC who were treated in designated cancer care hospitals throughout Japan had stage I disease.6 According to these findings, we assumed that good-quality routine esophagogastroduodenoscopy (EGD) contributed more than population-based screening to the high detection rate of EGC in Japan, and resulted in improved mortality. In the present study, we aimed to clarify the differences in settings and practice of routine EGD between Japanese and international facilities, and to establish clues to improve EGC detection outside Japan.

METHODS

T

HIS WAS A questionnaire survey among Japanese and international medical institutions. Participating

ESPONDENTS CONSISTED OF 98 Japanese (54 hospitals and 44 clinics) and 53 international (50 hospitals and three clinics) institutions (Fig. 2). Because of the small number of respondents (n = 3), the data from the international clinics were excluded from analysis. Countries of the international institutions are listed in Table 1.

Indications for routine EGD Screening endoscopic examination was defined as endoscopy to identify precancerous or cancerous lesions in individuals without any signs or symptoms. Prevalence of screening examination among routine EGD procedures was higher in Japanese institutions (>50% of all routine procedures in ~30% of institutions) than in international hospitals (0–25% of all routine EGD procedures in 87% of hospitals) (Fig. 3a). Almost all (>95%) endoscopists in both Japanese and international institutions paid attention to GC risk during routine EGD (Fig. 3b). As risk factors for GC, Japanese endoscopists noted findings such as endoscopic mucosal atrophy and endoscopic features relevant to Helicobacter pylori infection, whereas international endoscopists paid

Figure 2 Distribution of participating institutions. , Japanese hospitals; , Japanese clinics; , International hospitals; , International clinics.


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N. Uedo et al.

Table 1 Countries of participating institutions Countries Taiwan Malaysia Thailand Korea China Italy USA Australia Colombia Hong Kong India Mexico Myanmar The Netherlands New Zealand Philippines Poland Russia UK Uruguay Venezuela

No. institutions 12 8 6 5 3 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1

(a)

more attention to clinical information such as age, symptoms and family history (Fig. 3c).

Preparation for routine EGD Antispasmodics were used more frequently in Japanese institutions (72% of hospitals and 55% of clinics) than in international hospitals (36%, Fig. 4a). Butylscopolamine bromide was the most common agent in both Japanese and international institutions followed by glucagon. L-Menthol (Minclea; Nihon Pharmaceutical Co. Ltd, Tokyo, Japan) was used in Japanese institutions (Fig. 4b). Mucolytic or defoaming agents were used in >90% of Japanese institutions, compared with only 48% of international hospitals (Fig. 4c). Pronase (Pronase MS; Kaken Pharmaceutical Co. Ltd, Tokyo, Japan) was more frequently used in Japanese than in international institutions (Fig. 4d). More than half of Japanese and international institutions frequently used sedation and/or analgesics, although in some institutions, sedation was not used unless patients strongly requested it (Fig. 4e). Midazolam was the most common drug used for sedation during routine EGD. Propofol was more frequently used in international than in Japanese institutions (Fig. 4f).

Instruments of routine EGD The videoendoscopic systems in Japanese institutions comprised mostly the 200 series processors (Olympus Medical

(b)

(c) Figure 3 (a) Percentage of screening examinations among routine esophagogastroduodenoscopy (EGD) procedures. , >76%; , 51–75%; , 26–50%; , 0–25%. (b) Awareness of gastric cancer (GC) risk during routine EGD. , No; , Yes. (c) Recognized risk factors for GC. , Others; , Sex; , Age; , Mucosal atrophy; , Symptom; , H. pylori infection; , Family history; ; Pepsinogen level



Routine EGD in Japan and overseas

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Figure 4 (a) Use of antispasmodics for routine esophagogastroduodenoscopy (EGD). , No; , Yes. (b) Types of antispasmodic. , Others; , Menthol; , Glucagon; , Butylscopolamine bromide. (c) Use of mucolytic/defoaming agents for routine EGD. , No; , Yes. (d) Types of mucolytic/defoaming agent. , Others; , Dimethicone; , Pronase. (e) Use of sedation/analgesia for routine EGD. , No, unless patient strongly requests; , Based on patient’s preference; , Yes, unless patient refuses to use the agent. (f) Types of sedation/analgesia. , Others; , Propofol; , Pethidine; , Pentazocine; , Flunitrazepam; , Midazolam; , Diazepam.

Systems, Tokyo, Japan), whereas the 100 series processors accounted for 30% of videoendoscopy processors used in international hospitals (Fig. 5a). Conventional non-zoom endoscopes were the most commonly used for routine EGD in Japanese and international institutions. Thirty percent of Japanese hospitals used zoom endoscopes for routine EGD. In 10% of Japanese hospitals and 30% of Japanese clinics, transnasal endoscopes were used for routine EGD (Fig. 5b). Image-enhanced endoscopy (IEE); that is, chromoendoscopy or narrow band imaging (NBI), was used in Japanese and international institutions in a similar way. In patients with no suspicious findings for EGC, IEE was mostly used in

0–25% of cases, whereas it was used in >75% of cases when there was a suspicious lesion (Fig. 5c).

Procedure of routine EGD The endoscopists in >70% of Japanese hospitals and those in >80% of Japanese clinics usually spent