The work style of doctors gets attention within the Work Style Reforms that have been fully implemented since 2019. Now, we conducted a questionnaire survey at 10 institutions in Chugoku and Shikoku region and reviewed the latest work style of cardiovascular surgeons in comparison with other departments.

Background/Aims: Bleeding is a complication of endoscopic snare papillectomy for ampullary tumors. This study aimed to investigate the clinical efficacy of hypertonic saline-epinephrine (HSE) local injection before endoscopic papillectomy for prevention of bleeding. Methods: We retrospectively reviewed the data of 107 consecutive patients with ampullary tumors who underwent endoscopic papillectomy. The rates of en bloc resection, pathological resection margins, and prevention of immediate or delayed bleeding in the simple snaring resection group (Group A) and the HSE injection group (Group B) were compared. Results: A total of 44 and 63 patients were enrolled in Groups A and B, respectively. The total complete resection rate was 89.7% (96/107); the clinical complete resection rates in Group A and Group B were 86.3% (38/44) and 92.1% (58/63), respectively (p=0.354). Post-papillectomy bleeding occurred in 22 patients. In Groups A and B, the immediate bleeding rates were 20.5% (9/44) and 4.8% (3/63), respectively (p=0.0255), while the delayed bleeding rates were 7% (3/44) and 11% (7/63), respectively (p=0.52). The rates of positive horizontal and vertical pathological margin in both groups were 27% and 16%, respectively. Conclusions HSE local injection was effective in preventing immediate bleeding and was useful for safely performing endoscopic papillectomy for ampullary tumors.

Background/Aims: The optimal length of the uncovered portion of partially covered self-expandable metal stents (PCSEMSs) used in endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) remains unclear. This study investigated the safety and efficacy of PCSEMSs with different uncovered lengths, with a focus on stent migration and time to recurrent biliary obstruction (RBO). Methods: Outcomes of patients undergoing EUS-HGS using PCSEMSs with 5-mm and 20-mm uncovered portions at our institution from January 2016 to December 2021 were compared. Results: Sixty-two patients underwent EUS-HGS using PCSEMS (5/20-mm uncovered portions: 32/30). Stent migration occurred only in the 5-mm group. There were no differences in RBO rates (28.1% vs. 40.0%) or median time to RBO (6.8 vs. 7.1 months) between the two groups. Median overall survival (OS) was longer in the 20-mm group (3.1 vs. 4.9 months, p=0.037) due to the higher number of patients that resumed chemotherapy after EUS-HGS (56.7% vs. 28.1%, p=0.029). Good performance status, absence of hepatic metastases, and chemotherapy after EUS-HGS were independent predictors of longer OS. Conclusions No migration was observed in patients treated with PCSEMS with 20-mm uncovered portions. Patients treated with PCSEMS with 20-mm uncovered portions performed at least as well as those treated with 5-mm uncovered portions in all material respects.

Background/Aims: Bleeding is a complication of endoscopic snare papillectomy for ampullary tumors. This study aimed to investigate the clinical efficacy of hypertonic saline-epinephrine (HSE) local injection before endoscopic papillectomy for prevention of bleeding. Methods: We retrospectively reviewed the data of 107 consecutive patients with ampullary tumors who underwent endoscopic papillectomy. The rates of en bloc resection, pathological resection margins, and prevention of immediate or delayed bleeding in the simple snaring resection group (Group A) and the HSE injection group (Group B) were compared. Results: A total of 44 and 63 patients were enrolled in Groups A and B, respectively. The total complete resection rate was 89.7% (96/107); the clinical complete resection rates in Group A and Group B were 86.3% (38/44) and 92.1% (58/63), respectively (p=0.354). Post-papillectomy bleeding occurred in 22 patients. In Groups A and B, the immediate bleeding rates were 20.5% (9/44) and 4.8% (3/63), respectively (p=0.0255), while the delayed bleeding rates were 7% (3/44) and 11% (7/63), respectively (p=0.52). The rates of positive horizontal and vertical pathological margin in both groups were 27% and 16%, respectively. Conclusions HSE local injection was effective in preventing immediate bleeding and was useful for safely performing endoscopic papillectomy for ampullary tumors.

Background/Aims: Endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMNs) is useful in determining whether the lesions are benign or malignant. This study aimed to examine the usefulness of peroral pancreatoscopy (POPS) in determining the prognosis of IPMNs. Methods: POPS with videoscopy was performed using the mother–baby scope technique. After surgery, computed tomography/magnetic resonance cholangiopancreatography or ultrasonography and blood tests were performed every 6 months during the follow-up. Results: A total of 39 patients with main pancreatic duct (MPD)–type IPMNs underwent POPS using a videoscope, and the protrusions in the MPD were observed in 36 patients. The sensitivity and specificity of cytology/biopsy performed at the time of POPS were 85% and 87.5%, respectively. Of 19 patients who underwent surgery, 18 (95%) patients had negative surgical margins and 1 (5%) patient had a positive margin. Conclusions In IPMNs with dilatation of the MPD, POPS is considered effective if the lesions can be directly observed. The diagnosis of benign and malignant lesions is possible depending on the degree of lesion elevation. However, in some cases, slightly elevated lesions may increase in size during the follow-up or multiple lesions may be simultaneously present; therefore, careful follow-up is necessary.

Under the current postgraduate clinical training system for physicians, three principles have been emphasized in its basic tenets; cultivation of character appropriate for physicians, generation of awareness to the societal role of medical science and healthcare, and mastery of basic clinical skills needed to respond appropriately to injuries and illnesses frequently encountered in general practice. In accordance with its quinquennial review rule, the Clinical Training Committee under the Medical Caucus of the Healthcare Professions Council released draft revisions of a notification published by the Director general of the Health Policy Bureau of the Ministry of Health, Labor and Welfare in March, 2018. The document is entitled "On the operation of the ordinance concerning the postgraduate clinical training prescribed in the paragraph (1) of Article 16-2, Medical Practitioners Act" .　A Key distinction of the revised draft is new learning outcomes featuring core values shared by physicians: commitment to physicians' societal mission of public health, altruistic behavior, respect for humanity, and maintaining one's own integrity. Another key distinction is securement of longitudinal consistency in the set of required faculties, from medical school curriculum to continuing professional development programs. Further improvements in systems and environments to enhance devotion to life-long learning are needed.

Medical education towards a specialty is a core stage of training for medical doctors. The specialty training system in Japan was initially organized by various academic societies and was recently integrated under Japan Medical Specialty Board, which was established in 2014. From April 2018, a revised specialty training system will begin and be based on new program guidelines. Its main concepts are professional autonomy, quality assurance of the medical specialty board and trustworthy medical consultation. As with undergraduate education, global standards are recently required in postgraduate education. Consistent outcome policy throughout undergraduate and postgraduate education and workplace-based assessment can hopefully be established.

Orento is generally used for upper gastrointestinal symptoms. We have used orento for various diseases based on “upper heat and middle cold”. As a result of the evaluation of 30 responders to orento, the most frequent sign of “upper heat” was “yellow tongue coating” (29/30 responders), while the most frequent sign of “middle cold” was “preference for warm foods and beverages” (27/30 responders). Compared with the non-­responder group, the responder group showed significantly higher frequencies of “gastrointestinal cold”, which is the sum of “preference for warm foods and beverages” and “aggravation of gastrointestinal symptoms by cold foods and beverages” (29/30 responders, p = 0.047), and “upper/lower gastrointestinal symptoms” (29/30 responders, p = 0.014). These results suggest that “yellow tongue coating” is the most important sign for “upper heat” while “gastrointestinal cold” is the most important sign for “middle cold”. As Kampo patterns for orento, gastrointestinal symptoms often occur, but there is a possibility of upper or lower gastrointestinal symptoms, skin disorders, and sleep disorders.

Medical education towards a specialty is a core stage of training for medical doctors. The specialty training system in Japan was initially organized by various academic societies and was recently integrated under Japan Medical Specialty Board, which was established in 2014. From April 2018, a revised specialty training system will begin and be based on new program guidelines. Its main concepts are professional autonomy, quality assurance of the medical specialty board and trustworthy medical consultation. As with undergraduate education, global standards are recently required in postgraduate education. Consistent outcome policy throughout undergraduate and postgraduate education and workplace-based assessment can hopefully be established.