Early clinical exposure has been implemented worldwide as an effective method of medical education. The duration of early clinical exposure is 1 year in some universities in Western countries. In Japan, however, early clinical exposure occurs most often through health and welfare services, and its duration varies. One-year early clinical exposure and reflection upon it were implemented for first-year students at Mie University School of Medicine in 2006 to motivate them and to teach them about professionalism. The effectiveness of this program was evaluated with a questionnaire, a daily log, and a portfolio.1) The questionnaire survey revealed that students considered the program extremely valuable. They had learned much about communication skills, the relationship between medicine and society, patients' families, and professionalism.2) An analysis of the daily logs clearly showed that students were unsure and hesitant at the start of the program. However, they gradually became accustomed to participating in this program and began to learn earnestly.3) Qualitative analysis of the portfolios revealed that students considered 10 items important in the practice of medicine, including communication skills, responsibility, the value of being a physician, professionalism, and the motivation to study medicine.4) In their final reports, the students described the expected behaviors of physicians they should seek to perform, by learning medical ethics or through professionalism.5) In conclusion, 1-year early clinical exposure is a more effective method than short-term or intermittent exposure for medical students because of its uniqueness and the maintenance of motivation.

No abstract available.
Cholangiopancreatography, Endoscopic Retrograde ; Humans

Placement of a plastic or metal stent via endoscopic retrograde cholangiopancreatography (ERCP) currently serves as the first-line procedure for obstructive jaundice and acute cholangitis. Dysfunction of the biliary stent causes recurrence of symptoms and often requires reinterventions and hospitalizations. Therefore, duration of stent patency is commonly used as the primary endpoint in clinical studies of biliary stents. However, owing to considerable heterogeneity between studies in reporting of biliary stent patency, it has been difficult to compare and integrate results of independent studies. There has been between-study heterogeneity in definitions of stent patency, statistics reported for survival curves of stent patency, and methods to treat censored cases. In addition to stent occlusion, stent migration is a major cause of recurrent biliary obstruction after covered metal stent placement, which further complicates the reporting of stent patency. Reporting of functional success and adverse events has been also inconsistent between the studies. From the perspective of evidence-based medicine, the variations in the definitions of outcome variables potentially hinder robust meta-analyses. To overcome the issues due to the lack of outcome reporting guidelines on the topic, the TOKYO criteria 2014 for reporting outcomes associated with endoscopic transpapillary placement of biliary stents have been proposed. Due to their comprehensiveness, the TOKYO criteria can be readily utilized to evaluate various types of biliary stent placement using ERCP, irrespective of types of stents and location of biliary stricture. In this article, we review the TOKYO criteria as a standardized reporting system for endoscopically-placed biliary stents. We also discuss potential controversial issues in the application of the TOKYO criteria. Given that endoscopic ultrasound-guided biliary drainage is increasingly utilized for cases with failed ERCP or altered gastrointestinal anatomy, we further propose a potential application of the TOKYO criteria to reporting of outcomes of this procedure.
Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis ; Common Bile Duct ; Constriction, Pathologic ; Drainage ; Endosonography ; Evidence-Based Medicine ; Hospitalization ; Jaundice, Obstructive ; Plastics ; Population Characteristics ; Recurrence ; Self Expandable Metallic Stents ; Stents

No abstract available.
Dreams*

Endoscopic transpapillary biliary drainage is the current standard of care for unresectable hilar malignant biliary obstruction (MBO) and bilateral metal stent placement is shown to have longer patency. However, technical and clinical failure is possible and percutaneous transhepatic biliary drainage (PTBD) is sometimes necessary. Endoscopic ultrasound-guided biliary drainage (EUS-BD) is increasingly being reported as an alternative rescue procedure to PTBD. EUS-BD has a potential advantage of not traversing the biliary stricture and internal drainage can be completed in a single session. Some approaches to bilateral biliary drainage for hilar MBO under EUS-guidance include a bridging method, hepaticoduodenostomy, and a combination of EUS-BD and transpapillary biliary drainage. The aim of this review is to summarize data on EUS-BD for hilar MBO and to clarify its advantages over the conventional approaches such as endoscopic transpapillary biliary drainage and PTBD.
Constriction, Pathologic ; Drainage ; Endosonography ; Methods ; Standard of Care ; Stents

Although endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for benign biliary diseases, this procedure is technically difficult in some conditions such as a surgically altered anatomy and gastric outlet obstruction. After a failed ERCP, a surgical or a percutaneous approach is selected as a rescue procedure; however, various endoscopic ultrasound (EUS)-guided interventions are increasingly utilized in pancreatobiliary diseases, including EUS-guided rendezvous for failed biliary cannulation, EUS-guided antegrade treatment for stone management, and EUS-guided hepaticogastrostomy for anastomotic strictures in patients with a surgically altered anatomy. There are some technical hurdles in EUS-guided interventions for benign biliary diseases owing to the difficulty in puncturing a relatively small bile duct and in subsequent guidewire manipulation, as well as the lack of dedicated devices. A recent major advancement in this field is the introduction of a 2-step approach, in which EUS-guided drainage is placed in the first session and antegrade treatment is performed in subsequent sessions. This approach allows the use of various techniques such as mechanical lithotripsy and cholangioscopy without a risk of bile leak. In summary, EUS-guided interventions are among the treatment options for benign biliary diseases; however, standardization of the procedure and development of a treatment algorithm are needed.
Bile ; Bile Ducts ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage ; Gastric Outlet Obstruction ; Humans ; Lithotripsy ; Ultrasonography

Stent occlusion and cholangitis are common complications after endoscopic biliary stenting caused by duodenobiliary refluxes and food impaction. To prolong the stent patency, the concept of stenting above the papilla, so-called inside stent, has been developed. Various studies of the inside stent in the treatment of both benign and malignant biliary obstruction have been published, with a promising result. However, most studies were retrospective, with wide variation of stent type and the etiology of biliary obstruction. This review aims to summarize the principle, evidence, and the usefulness of inside biliary stent.
Cholangitis ; Cholestasis ; Retrospective Studies ; Stents

Endoscopic ultrasound-guided biliary drainage (EUS-BD), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepaticogastrostomy (EUS-HGS) can effectively palliate obstructive jaundice, but have not been well established yet. The incidence of complications is about 30% in EUSBD and higher for EUS-HGS. Several complications have been reported such as bleeding, perforation and peritonitis. Bleeding occurs due to puncture of portal vein, hepatic vein and artery, and we should use color Doppler. When a cautery dilator is used for fistula dilation, burn effects may cause delayed bleeding. Endoscopic hemostasis is only effective for anastomotic bleeding and embolization with interventional radiology technique is required for pseudo aneurysm. There are some types of perforation: failed stent placement after puncture or fistula dilation, double puncture during CDS procedure, and stent migration. Peritonitis with perforation requires surgery and can be fatal. Stent migration before mature fistula formation causes severe peritonitis because EUS-BD makes fistula between two unattached organs. Stents with flaps or long covered self-expandable metallic stents (cSEMSs) are effective to prevent migration. Recent development of lumen apposing stents may reduce early migration in EUS-CDS. Peritonitis without migration can be due to 1) leakage of bile juice or gastric/duodenal contents during EUS-BD or 2) leakage along the placed stent. We should make procedure time as short as possible, and cSEMSs reduce bile leak along the stent by occluding the dilated fistula. In summary, we should understand the mechanism of complications and the technique to prevent and manage complications. Development of dedicated devices to increase the success rate and reduce complications is required.
Aneurysm ; Arteries ; Bile ; Burns ; Cautery ; Choledochostomy ; Drainage* ; Fistula ; Hemorrhage ; Hemostasis, Endoscopic ; Hepatic Veins ; Incidence ; Jaundice, Obstructive ; Peritonitis ; Portal Vein ; Punctures ; Radiology, Interventional ; Stents