Merits and Challenges in Adopting the Japanese Style Endoscopy:- Need for Standardization

Japanese endoscopists are global leaders in both imaging and interventional endoscopy. Yet despite all the merits associated with their endoscopy advances, Japanese style endoscopic practice has not fully influenced the West. The author, who is privileged to have trained fellows from UK, US, and Japan, will put forward some reasons as to why this may be the case and how Japanese endoscopists can learn from these challenges in order to better ensure their style of endoscopy can be globalised to achieve its deserved impact.

Challenges to adoption of Japanese Style Endoscopy

1. Training & Technical Issues
Whilst Japan has pioneered ESD techniques, the West has yet to follow suit. Various reasons can account for this with a lack of training opportunities because of caseload differences, shortage of mentors, and the complexities associated with ESD in terms of the technical skill required, long procedure duration, and higher complication rates.
2. Standardization Issues
In the area of image enhanced endoscopy, while significant advances have arisen from Japan, including NBI, the West has not entirely advocated its use. Various reasons exist for this contrast, most likely due to the complexities of the criteria for diagnosis and the ever changing classification systems. Often the criteria are devised by experts with little consideration for their generalisability. Furthermore, agreement between observers varies considerably which may further hinder its widespread adoption.
3. Approach issues
Until recently, the standard diagnosis of GI neoplasia and pre-neoplasia is dependent on endoscopic visualization of the lesion and subsequent confirmation by histopathological examination. With advanced endoscopic imaging technologies allowing negative predictive values ≥90%, western endoscopic societies are beginning to allow the adoption of outcome driven strategies, including "diagnose and leave" strategy. Learning curve to achieve accurate optical diagnosis remains a challenge for most endoscopists; thus a realtime objective diagnostic tool is much needed.

What are the possible solutions to some of the challenges:-

1. Training - Asia has taken the lead to establish regional training groups including Asian EUS Group (AEG - http://www.asianeus.org/), and Asian NBI Group (ANBIG - http://www.anbig.org/) to promote adoption of these technologies, and advance practice standards to be on par with technological advances.
2. Standardization - Japanese and West specialists are beginning to come together to simplify image enhanced diagnosis methods.
3. Simplification of Technique - Newer technologies including the Raman spectoscopy based In-Vivo Molecular Diagnostic System, which can be used to provide real-time and operator-independent diagnosis of tissues during endoscopic examinations may enable strategies such as "diagnose & discard", "diagnose and target", "diagnose & resect", "diagnose & mark", and "resect & discard", in the near future. Endoscopic robot, which provides triangulation, can reduce learning curve of complex endoscopic procedures, and support a full range of endoluminal as well as transluminal endoscopic surgical procedures, which are the future of surgery.

Conclusion

In order to promote global adoption of Japanese style endoscopy, there needs to be greater collaboration between the two regions in terms of training, standardization, and innovation.