From Iraqi Kurdistan to Japan:science & picnic.

1-19/3/2011.

Dr. Mohamed ShekhaniDr. Hiwa Abubakir Husein.

Kurdistan center for gastroenterology & hepatology, As-Sulaimaniyah –Iraqi Kurdistan.

Arriving at Nagoya: the Suchi

welcome party

The popular Japanese suchi dish : Raw fish

Nagoya city center

Nagoya city center

Nagoya city center

Nagoya city center

Nagoya city center

Given a chance to present in Kumamoto RC Hospital.

Welcome party in Kumomoto city.

Kumomoto city & castle.

Kumomoto: Japanese gardensAso mountain& the green tea

Ice cream.

Given chance to deliver talks

in Aichi cancer center-Nagoya.

Aichi cancer center: Nagoya

Aichi cancer center endoscopy unit: withDr. yamao kenji

Endoscopy practice in Japan:• Updated.• Confident.• Hard working: • 9 AM- 9 PM.• Never leave before completing his case even if it is the time to leave or

rest.• Example: ESD for early CRC: 5 hours on his feet.• High standard patient care:• Not allowing any foreign doctor to touch the patient.• Patient data are patient privacy & should not be given to any one

without his consent.• Friendly & cooperative.• Excellent team working: • GIE U/L Team. • Hepatobiliary (ERCP-EUS Team).

Upper GIT endoscopy:• Patient has his code.• Patient presents with all the previous data in a big file.• Previous operations well illustrated graphically.• Previous endoscopic findings recorded & pictured.• Every patient appointed in advance, who will do the endoscopy.• Endoscopist will map the mucosa during entry & withdrawal.• Patients come to the endoscopy unit by appointment, 1-2 patients

only at the same time.• Qualified nurse will welcome the patient in the waiting room,

explain, take consent, give him/her antifoamimg agent to drink(semithscone + bicarbonate), xylocaine jell to keep in the mouth & throat for a period ( by an alarm watch given to the patient) then swallow or spit.

• Patient enters to the endoscopy room, his belongings put in a specified container.

Upper GIT endoscopy:• Endoscopist uses semithscone/bicarbonate to wash the mucosa through

syringing to see have better view.• Esophagus: use NBI, ME, Iodine chromoendoscopy for diagnosis of

early esophageal cancer & decide whether there is or no submucosal invasion to decide on doing ESD/EMR or send the patient for surgery or Chemoradiotherapy.

• Suck excess iodine pooled in the stomach (irritant) & neutrilize by thiosulphate once the procedure is complete.

• Map the antrum & incisura.• Go to the duodenum D1/D2.• Return to the antrum to do complete retroflexion to see the fundus by

rotating the scope 360 degrees.• Suck any pooling fluids in the fundus totally.• Use IEE by NBI,ME,Indigocarmine to characterize any suspected lesion

& avoid unnecessary biopsies.• The aim is an accurate endoscopic diagnosis.

Upper GIT endoscopy:• At least 40 endoscopic pictures are saved in the computer & 4

printed.• Time spent: around 40 mins for normal OGD & 40 mins for

abnormal ones.

Endoscopy practice in Japan:• Frontiers in endoscopy research contributing to both English &

Japanese literature.• Many Japanese GIT & GIE journals.• One English GIE journal ( digestive endoscopy).• Head of dept of GE: Yamao Kinji: 150 English article/300

Japanese.• Japanese endoscopic atlases& books.

Endoscopy practice in Japan:• Pioneers in chromoendoscopy, NBI, magnifying endoscopy, ERCP

& EUS. • Leaders in early diagnosis of GIT & pancreatobiliary cancers by

screening asymptomatic persons for upper GIT Cancers in addition to usual colorectal cancer screening.

• Open access endoscopy.• Even < 45 years old.• On request even if younger or asymptomatic( by Barium or by

endoscopy if requested by the person).• High risk persons: smokers , alcoholic or HN cancers.

Endoscopy practice in Japan:• Leaders in the endoscopic mucosal resection(ESD) of early GIT

cancers.• Excellent 5 year survival of most GIT cancers.

Intra-papillary capillary loops (IPCL)

AVM: arborescent vascular network, PA: perforating artery, PV: perforating vein

IPCL pattern

Non-magnifying NBI image

White-light image Lugol chromoendoscopyNBI image

Magnifying NBI imageMucosal esophageal squamous cell carcinoma

Magnifying NBI image

Submucosal esophageal squamous cell carcinoma

Stomach ME : Microvascular& Surface microstructure pattern

Case1 Case2

Which is a malignant lesion?

Focal gastritis Gastric cancer

Magnifying Endoscopy

CRC ME: Pit pattern

Ⅰ

Ⅱ

ⅢS

ⅢL

Ⅳ

ⅤN

ⅤI

Normal round crypts, regular

Enlarged stellar crypts, regular

Narrowed round pits, irregular

Branched or gyrus-like crests

Irregular surface

Amorphous surface

Elongated, sinuous crests

Pit pattern （ Kudo & Turuta’s classification ）

Ⅰ

Ⅱ

ⅢS

ⅢL

Ⅳ

ⅤN

ⅤI

normal pattern

Hyperplastic polypSerrated adenoma

irregular pattern

non-structure pattern

regular pattern

Pit pattern and treatment selection

No treatment

Endoscopic resection

Surgery

Endoscopic resectionor Surgery

Nonneoplastic

Neoplastic,adenomatous

Neoplastic,cancer

（インジゴカルミン散布）

0-IIa slightly elevated

Chromoscopy

（ Indigo carmine ）（ Magnify ）

Visiting Hiroshima: The Dome will remind us of the Destructive effects of WMD.

Nagoya city streets& markets

Nagoya city& castle Bullet train

Nagoya city streets& markets

Nagoya city streets& markets

Nagoya city streets& markets

Tempura farewell party&Healthy Japanese dishes.

Great thanks to:

• Aichi cancer center gastroenterology & endoscopy unit.

• Kumomoto red cross hospital.

• For their great help & support during our stay & training in their hospitals & cities.

• Special thanks to Dr. yamao kenji, head of department of gastroenterology in Aichi cancer center.