Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

doi: 10.1111/den.12245

Special Lecture

Present status of endoscopy, therapeutic endoscopy and the endoscopy training system in Indonesia Dadang Makmun Division of Gastroenterology, Department of Internal Medicine, Medical Faculty, University of Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia

Recently, Indonesia was ranked as the fourth most populous country in the world. Based on 2012 data, 85 000 general practitioners and 25 000 specialists are in service around the country. Gastrointestinal (GI) disease remains the most common finding in daily practise, in both outpatient and inpatient settings, and ranks fifth in causing mortality in Indonesia. Management of patients with GI disease involves all health-care levels with the main portion in primary health care. Some are managed by specialists in secondary health care or are referred to tertiary health care. GI endoscopy is one of the main diagnostic and therapeutic modalities in the management of GI disease. Development of GI endoscopy in Indonesia started before World War II and, today, many GI endoscopy procedures are conducted in Indonesia, both diagnostic and therapeutic. Based on August 2013 data, there are 515 GI endoscopists in Indonesia. Most GI endoscopists are

INTRODUCTION

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ECENTLY, INDONESIA WAS ranked as the fourth most populous country in the world following China, India and the USA. Based on new statistical data launched by the Indonesian Central Statistical Bureau in July 2012, 248 645 008 people are estimated to inhabit Indonesia’s islands with a mean age of 28.5 years and an average life expectancy of 71.62 years (average male life expectancy, 69.07 years; average female life expectancy, 74.29 years). Indonesia is well known as the largest archipelago country in South-East Asia, comprising 17 504 islands that are located between the two continents of Asia and Australia. Administratively, Indonesia consists of 33 provinces and 497 cities.1 Countrywide statistics show a 1.49% population growth rate with a density of 121 people/km2. Highly dense prov-

Corresponding: Dadang Makmun, Division of Gastroenterology, Department of Internal Medicine, Medical Faculty, University of Indonesia/Cipto Mangunkusumo National General Hospital, Jl. Diponegoro no. 71, Jakarta 10320, Indonesia. Email: hdmakmun @yahoo.com Received 28 November 2013; accepted 8 January 2014.

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competent in carrying out basic endoscopy procedures, whereas only a few carry out advanced endoscopy procedures, including therapeutic endoscopy. Recently, the GI endoscopy training system in Indonesia consists of basic GI endoscopy training of 3–6 months held at 10 GI endoscopy training centers. GI endoscopy training is also eligible as part of a fellowship program of consultant gastroenterologists held at six accredited fellowship centers in Indonesia. Indonesian Society for Digestive Endoscopy in collaboration with GI endoscopy training centers in Indonesia and overseas has been working to increase quality and number of GI endoscopists, covering both basic and advanced GI endoscopy procedures. Key words: present status, diagnostic endoscopy, endoscopy training system, GI disease, therapeutic endoscopy

inces are dominantly located on Java island with Jakarta as the most densely populated city (13 890 people/km2).1 Based on current statistics data from the Ministry of Health Republic of Indonesia in 2012, 85 000 general practitioners and 25 000 specialists are distributed throughout Indonesia’s provinces. Using a 1:3000 doctor-to-population ratio, those numbers are almost proportionate with Indonesia’s current population; however, the conspicuous problem seemingly concerns its distribution system. Based on data launched in March 2013, Indonesian doctors are in service in 9510 primary health-care centers and in 2083 hospitals in Indonesia, including government and private-owned hospitals.2 Referring to data from the Ministry of Health Republic of Indonesia in 2009, upper respiratory tract infection was the most common diagnosis of Indonesia’s 10 most prevalent outpatient diseases, followed by hypertension, dermatological disease, fever, diarrhea and dyspepsia, respectively (Table 1). Gastrointestinal (GI) disease remains the most common finding encountered in daily practice, both in outpatient and inpatient settings. Diarrhea placed second after pneumonia in the 10 most prevalent inpatient diseases in Indonesia’s hospitals, followed, respectively, by typhoid fever,

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Present endoscopy status in Indonesia 3

Table 1 Most common diseases in the outpatient setting of Indonesian hospitals as estimated in 2009 Rank

1 2 3 4 5 6 7 8 9 10

Disease

Sex

Upper respiratory tract infection Fever of unknown origin Dermatoses and other subcutaneous tissue disease Diarrhea and gastroenteritis caused by certain infectious agents (infection-associated colitis) Refraction and accommodation-related disorders Dyspepsia Essential hypertension Pulpal and periapical disease Ear disease and mastoid process-related disorders Conjunctivitis and other conjunctiva-related disorders

Total case findings

No. patient visits

Male

Female

243 578 143 167 99 303 88 275

245 216 132 087 147 953 83 738

488 794 275 254 247 256 172 013

781 881 358 942 371 673 223 318

67 231 55 817 55 446 54 004 53 463 46 380

89 429 77 345 67 823 68 463 52 142 52 815

156 660 133 162 123 269 122 467 105 605 99 195

203 021 220 375 412 364 234 083 153 488 135 749

Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia.2

Table 2 Most common diseases in the inpatient setting of Indonesian hospitals as estimated in 2009 Rank

1 2 3 4 5 6 7 8 9 10

Disease

Sex

Diarrhea and gastroenteritis caused by certain infectious agents (infection-associated colitis) Dengue hemorrhagic fever Typhoid and paratyphoid fever Fever of unknown origin Dyspepsia Essential hypertension Upper respiratory tract infection Pneumonia Appendiceal disorders Gastritis and duodenitis

Total case findings

No. deaths

CFR (%)

Male

Female

74 161

69 535

143 696

1747

1.22

60 705 39 262 24 957 18 807 15 533 19 115 19 170 13 920 12 758

60 629 41 588 24 243 28 497 21 144 16 933 16 477 16 783 17 396

121 334 80 850 49 200 47 304 36 677 36 048 35 647 30 703 30 154

898 1013 462 520 935 162 2365 234 235

0.74 1.25 0.94 1.10 2.55 0.45 6.63 0.76 0.78

* CFR : Case Fatality Rate. Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia.2

hypertension, dengue hemorrhagic fever, fever with unknown origin and dyspepsia (Table 2). However, GI disease is in fifth place regarding mortality-causing disease in Indonesia, following vascular disease, infectious disease and certain parasitic disorders, certain conditions of the perinatal period and respiratory system disease (Table 3). As a developing country, Indonesia’s health-care system is designed as a three-level system comprising primary health care by general practitioners or family physicians, secondary health care by specialists, and tertiary health care by subspecialists. Each level requires accredited competence and supporting facilities based on requirements.2 Management of patients with GI disease involves all the health-care levels with the main portion of its management expected to be carried out in primary health care. With the

advancement of a referral health system, the number of patients with GI diseases are managed by specialists in secondary health care or further referred to tertiary health care.

DEVELOPMENT OF GI ENDOSCOPY IN INDONESIA

G

ASTROINTESTINAL ENDOSCOPY HAS been used worldwide as one of the main diagnostic, as well as therapeutic, modalities in the management of GI disease. Development of GI endoscopy in Indonesia was almost similar to other countries in which a rigid endoscope was used before World War II. This rigid endoscope took the form of a rectosigmoidoscope that was specifically used by

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

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D. Makmun

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Table 3 Most common causes of death in Indonesian hospitals as estimated in 2008 Rank 1 2 3 4 5 6 7 8 9 10

Cause of death

No. deaths

CFR (%)

Vascular disease Infectious disease and certain parasitic disorders Certain conditions of the perinatal period Respiratory system disease Gastrointestinal disease Injuries, intoxications, and other external causes Endocrine, nutrition, and metabolic disease Urinary tract disease Neoplasm Unknown signs, symptoms, and abnormal laboratory findings

23 163 16 769

11.06 2.89

9108

9.74

8190 6825 5767

3.99 2.91 2.99

5585

6.73

4542 4332 4238

3.56 4.70 2.80

* CFR : Case Fatality Rate. Cited from Indonesian Health Profile 2009, Ministry of Health Republic of Indonesia.2

surgeons. In 1958, Pang reported the use of the first laparoscope without a camera in Indonesia.3 Semi-flexible endoscopy was first introduced in Indonesia as a semi-flexible gastroscope by Simadibrata in 1967. In 1971, flexible gastroscopes were widely used (Olympus GTFA, Olympus Co., Japan). Ever since, more reports on the use of flexible endoscopes have been published in Indonesia, especially after the establishment of the Indonesian Society for Digestive Endoscopy (ISGE) in 1974, chaired by Pang.4,5 The flexible colonoscope was first used in Indonesia by Hilmy in 1973 with its first therapeutic use in the colon reported in 1978. Henceforth, more endoscopic polypectomies were reported in the main hospitals in Indonesia. In 1984, endoscopic sclerotherapy was pronounced for the first time by Hilmy and colleagues by ethoxysclerol injections in patients with esophageal varices related to liver cirrhosis. Endoscopic cauterizations were first reported by Aziz Rani in 1984, using an Olympus electro-surgical unit in patients with post-esophageal transection strictures.3,6,7 Nowadays, more GI endoscopy procedures are conducted in Indonesia, both for diagnostic and therapeutic purposes. Currently, medical technology advancements contribute voluminous innovations in health-care trends, especially in GI endoscopy, with the distribution of more advanced GI endoscopes and accessories. Recently, diagnostic endoscopy modalities in Indonesia were commonly categorized as esophagogastroduodenoscopy, colonoscopy, capsule endoscopy, enteroscopy, and endoscopic ultrasonography. Most endoscopists are competent in carrying out diagnostic

endoscopy procedures (esophagogastroduodenoscopy and colonoscopy) whereas only a few carry out enteroscopy or endoscopic ultrasonography. This discrepancy is caused by the limited provision of both diagnostic modalities in Indonesia. In contrast, GI endoscopy is economically costly as a result of the high cost of the GI endoscope and its accessories. In March 2013, there were only 313 hospitals currently providing GI endoscopy services, distributed in 33 provinces around the country (Table 4).8 Unlike diagnostic endoscopy procedures which are commonly carried out by all GI endoscopists, therapeutic endoscopy, especially advanced endoscopy procedures, is not routinely done by all endoscopists. This has been argued to be related to the limitations of endoscopy facilities and accessories, endoscopist competency, poor distribution of patients with complicated GI diseases requiring advanced endoscopy procedures and the courage of the endoscopist to carry out advanced endoscopy procedures with all the risks contained therein. Today, therapeutic endoscopy procedures that are routinely done in Indonesia comprise the following. 1. Upper gastrointestinal endoscopy: • Sclerotherapy and esophageal varices ligation • Histoacryl injection in gastric varices • Polypectomy • Esophageal/pyloric dilatations • Percutaneous endoscopic gastrostomy (PEG) • Foreign body extractions • Endoscopic hemostasis (clips, adrenaline injection, coagulation) • Esophageal stenting 2. Lower gastrointestinal endoscopy: • Polypectomy • Endoscopic hemostasis (clips, coagulation) • Colonic stenting 3. Endoscopic retrograde cholangiopancreatography (ERCP): • Biliary stone extraction • Biliary and pancreatic stenting • Biliary dilatation 4. Enteroscopy: • Enteroscopic hemostasis • Foreign-body extraction 5. Endoscopic ultrasonography: • Pancreatic cyst/pancreatic pseudocyst drainage • Biliary drainage In Indonesia, competency in GI endoscopy comprises a three-level grading: basic, first-level advanced, and secondlevel advanced competency. Basic endoscopy competency includes esophagogastroduodenoscopy, colonoscopy, esophageal varices sclerotherapy, esophageal varices ligation and adrenaline-injection endoscopic hemostasis. First-level advanced endoscopy competency allows the endoscopist to

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Present endoscopy status in Indonesia 5

Table 4 Hospitals currently providing gastrointestinal endoscopy service in Indonesia No.

Province

No. hospitals July 2008

1 2 3 4 5 6

Java Jakarta Banten West Java Yogyakarta Central Java East Java

7 8 9

September 2010

July 2011

July 2012

March 2013

48 8 10 4 15 13

50 11 21 5 21 19

51 11 25 5 25 29

54 11 42 5 39 36

54 13 42 5 39 36

Nusa Tenggara Bali West Nusa Tenggara East Nusa Tenggara

2 1 0

6 3 1

7 3 1

11 3 1

12 3 1

10 11 12 13 14 15 16 17 18 19

Sumatra Lampung South Sumatra Bangka Belitung Bengkulu Jambi Riau Riau Islands West Sumatra North Sumatra Nanggroe Aceh Darussalam

1 3 0 1 2 3 0 2 8 1

4 3 1 1 2 7 1 4 17 7

4 6 1 1 2 9 2 4 22 8

5 7 1 1 4 9 4 4 27 9

5 7 1 1 5 9 5 4 27 10

20 21 22 23

Kalimantan West Kalimantan East Kalimantan South Kalimantan Central Kalimantan

2 5 2 1

4 8 3 1

5 9 3 1

9 9 3 1

9 9 3 1

24 25 26 27 28 29

Sulawesi West Sulawesi South Sulawesi North Sulawesi Central Sulawesi South East Sulawesi Gorontalo

0 2 1 1 0 0

0 2 2 1 0 0

0 3 2 1 0 1

0 5 2 1 0 1

0 6 2 1 0 1

0 0 0 0 136

0 0 0 0 205

1 0 0 0 242

1 0 1 0 306

1 0 1 0 313

30 31 32 33

Maluku Islands and Papua Maluku North Maluku Papua West Papua Total

Cited from Indonesian Society for Digestive Endoscopy Report, August 2013.8

carry out basic endoscopy competency and esophageal dilatations. Second-level advanced endoscopy competency consists of basic endoscopy competency and all therapeutic endoscopy procedures and advanced endoscopy procedures (i.e. enteroscopy and endoscopic ultrasonography). Cur-

rently, an estimated 515 endoscopists carry out GI endoscopy in Indonesia (Table 5). Almost 80% of the 515 endoscopists are accredited in basic endoscopy competency only, the rest are accredited in first-level and second-level advanced endoscopist competencies.8

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

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Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Table 5 Distribution of doctors carrying out GI endoscopy procedures in Indonesia No.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Province

Jakarta and Banten East Java North Sumatra and Jambi West Java South Sulawesi West Sumatra North Sumatra Yogyakarta Surakarta Central Java West Nusa Tenggara Malang Bali North Sulawesi, West Sulawesi, Central Sulawesi, Gorontalo, Maluku and Papua South Kalimantan East Kalimantan, West Kalimantan and Central Kalimantan Lampung Riau Banda Aceh Total

Specialization

Total

Internist

Pediatrician

Surgeon

General Practitioner

119 40 32 24 6 5 13 17 11 22 4 7 12 2

12 6 1 3 0 1 1 4 1 1 0 1 2 0

28 13 6 9 8 1 4 4 4 10 2 5 3 5

6 0 0 0 0 0 0 0 0 0 1 0 0 0

165 59 39 36 14 7 18 25 16 33 7 13 17 7

3 18 4 15 12 366

0 0 0 2 1 37

0 1 0 2 1 106

0 0 0 0 0 7

3 19 4 19 4 516

Cited from Indonesian Society for Digestive Endoscopy Report, August 2013.8

ENDOSCOPY TRAINING SYSTEM IN INDONESIA

I

N THE FIRST years of GI endoscopy development in Indonesia, doctors were studying endoscopy-related skills in several countries, such as Japan, Germany, and The Netherlands. Right after the establishment of the Indonesian Society for Digestive Endoscopy in 1974, endoscopy training was introduced to several main hospitals, such as Cipto Mangunkusumo National General Hospital in Jakarta, Sutomo General Hospital in Surabaya, Adam Malik Hospital in Medan and Hasan Sadikin General Hospital in Bandung. The mission of the Indonesian Society for Digestive Endoscopy is to maintain and to enhance the quality of GI endoscopy services in Indonesia professionally. Considering the number of GI endoscopists in Indonesia (515 doctors) who are in service all around the country, it is still far from ideal. For this reason, the Indonesian Society for Digestive Endoscopy keeps increasing the number of endoscopy training centers with the vision of enhancing the quality and quantity of endoscopists in Indonesia. Evidence is lacking on the ideal endoscopist-to-population ratio, but in the USA in 2003, the ratio between consultant gastroenterologist and population is 1:37 037, whereas in England in 2007, the ratio

ranged between 1:49 000 and 1:93 000. In Indonesia, the ideal number should be one gastroenterologist per one district (capable of carrying out GI endoscopy services). As the total population of Indonesia is assumed to be approximately 250 million and the average number of citizens per district is 100 000, therefore, ideally, 2500 consultant gastroenterologists are required. In recent years, only 10 gastrointestinal endoscopy training centers were established (Table 6). Thus, further development of well-distributed centers is in demand.8–10 In recent times, gastrointestinal endoscopy training in Indonesia consists of basic gastrointestinal endoscopy training which trainees are internists, surgeons, or pediatricians and further endoscopy training as part of fellowship for consultant gastroenterologists.8 Basic GI endoscopy training is under way in all GI endoscopy training centers in Indonesia with 3–6 months duration of training. Besides lectures on GI endoscopy, trainees are practically trained, starting from observational studies, followed by endoscopy under supervision and, finally, unsupervised endoscopy. During the training, trainees are expected to independently carry out 75–100 esophagogastroduodenoscopies and 30–50 colonoscopies. Trainees are also expected to undergo five to 10 unsupervised

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Present endoscopy status in Indonesia 7

Table 6 Development of endoscopy training centers in Indonesia (2002-2012) No. Endoscopy training center

No. trainees

Total

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 1 2 3 4 5 6 7 8 9 10

Jakarta (Cipto Mangunkusumo National General Hospital) Surabaya (Dr Soetomo General Hospital) Medan (H. Adam Malik General Hospital) Bandung (Dr Hasan Sadikin General Hospital) Semarang (Dr Kariadi General Hospital) Yogyakarta (Dr Sardjito General Hospital) Denpasar (Sanglah General Hospital) Surakarta (Dr Moewardi General Hospital) Malang (Dr Saiful Anwar General Hospital) Makassar (Dr Wahidin Sudiro Husodo General Hospital) No. trainees

3 1 1 1

6 1 1 1

6

9

10 2 1 2

6 2 2 1

8 2 2 2

12 3 5 4 1

8 5 5 2 3

8 6 5 3 3 3 1

6 5 3 3 2 3 3

12 4 4 3 3 5 0 1

15

11

14

25

23

29

25

32

10 5 5 3 3 4 1 3 2 1 37

89 36 34 25 15 15 5 4 2 1 226

8

Cited from Indonesian Society for Digestive Endoscopy Report, August 2013.

Figure 1 Endoscopy training centers in Indonesia. Source: Indonesian Society for Digestive Endoscopy report, August 2013.8

esophageal varices ligations and esophageal varices sclerotherapy. Upon completion of the training, trainees should be prepared to appropriately recommend endoscopic procedures, as indicated, with explicit understanding of specific indications, contraindications, and diagnostic/therapeutic alternatives, carry out the procedures safely, including principles of conscious sedation and the use of anesthesiaassisted sedation where appropriate. They are also expected to have explicit understanding of pre-procedure clinical assessment and patient monitoring, interpret endoscopic findings and integrate them into medical or endoscopic therapy, identify risk factors for each procedure and appro-

priately manage complications when they occur and acknowledge the limitations of endoscopic procedures and personal skills and when to request help. Henceforth, they should periodically report endoscopy activities in their institution. Trainees are encouraged to continuously attend continuing medical education (CME), especially in the field of gastroenterology and GI endoscopy in Indonesia and overseas8,11 (Fig. 1). Gastrointestinal endoscopy training is also eligible as a part of a fellowship program for consultant gastroenterologists in Indonesia. During 3–4 years of fellowship, fellows also attain endoscopy modules according to the facilities

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

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Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Table 7 No. consultant gastroenterologists in Indonesia No.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Province

Jakarta and Banten West Java North Sumatra and Jambi West Java South Sulawesi West Sumatra South Sumatra Yogyakarta Surakarta Central Java East Nusa Tenggara Malang Bali North Sulawesi South Kalimantan West Kalimantan Lampung Riau Banda Aceh Total

No. consultant gastroenterologists 2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

19 6 5 5 2 2 2 1 1 4 1 2 1 1 0 0 0 0 0 52

20 6 8 5 2 2 3 1 1 4 1 2 1 1 1 0 0 0 0 58

20 6 8 4 2 2 3 1 1 4 1 2 1 1 1 0 0 0 0 57

25 6 9 5 2 2 3 2 1 4 1 2 3 1 1 0 0 1 0 68

25 6 9 5 2 2 3 2 1 4 1 2 3 1 1 0 0 1 0 68

26 6 9 6 2 2 2 3 2 4 1 2 3 2 1 0 0 1 0 72

28 7 9 7 3 2 2 6 2 5 1 3 3 2 1 0 0 1 1 83

31 8 9 7 3 2 2 6 2 5 1 3 3 2 1 0 0 1 1 87

38 8 11 7 2 2 5 6 2 6 1 4 4 2 2 0 1 1 1 103

38 10 10 7 2 3 5 6 2 7 2 4 4 2 2 0 1 2 1 108

41 9 12 7 2 3 5 6 3 6 2 4 4 2 2 1 1 2 1 113

Cited from: Indonesian Society for Digestive Endoscopy Report, August 2013.8

provided in each center. Today, there are only six accredited consultant gastroenterologist fellowship centers in Indonesia (Jakarta, Surabaya, Medan, Yogyakarta, Semarang, and Bandung). As a result of the lack of facilities, there are limitations in the capacity to train fellow consultant gastroenterologists. As of July 2013, the number of consultant gastroenterologists in Indonesia was 113 doctors only (Table 7). This number is lacking considering the size of the Indonesian population and its health problems, especially GI disease. Problems regarding training at advanced GI endoscopy level are due to the limited number of competent doctors able to carry out advanced GI endoscopy and the poorly distributed facilities of advanced GI endoscopy among the centers. In daily practice, not all consultant gastroenterologists in Indonesia carry out advanced GI endoscopy procedures because of the poor distribution of patients with complicated GI disease requiring advanced GI endoscopy procedures.8

CONCLUSIONS

ment of GI disease, are still limited. The number of hospitals equipped with GI endoscopy facilities and doctors that are competent to carry out diagnostic and therapeutic GI endoscopy are prominently limited. Today, GI endoscopy remains a high-cost health-care service that is unaffordable for most citizens. Now and in the future, the government plans to broaden health-care coverage including GI endoscopy procedures, and to provide GI endoscopy facilities especially in government-owned hospitals. Concurrently, the Indonesian Society for Digestive Endoscopy has been collaboratively working with existing GI endoscopy training centers in Indonesia to increase both the quality and number of GI endoscopists, covering both basic and advanced GI endoscopy levels. The Indonesian Society for Digestive Endoscopy also plans to send potential members to enhance their skills and knowledge in international GI endoscopy training centers worldwide. In the coming years, the GI endoscopy service in Indonesia is envisioned to equal that of international standards and, specifically, to fulfil the standard of health care in the Asia–Pacific region.

G

ACKNOWLEDGMENTS

ASTROINTESTINAL DISEASE REMAINS one of the main health problems in Indonesia, both for outpa tients and inpatients, and is the fifth major cause of death nationwide. In contrast, GI endoscopy facilities, one of the main diagnostic and therapeutic modalities in the manage-

T

HE AUTHORS THANK Dr Jeffri A. Gunawan and Ms Shinta Lestiani for their editorial assistance.

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9

Present endoscopy status in Indonesia 9

CONFLICT OF INTERESTS

T

HE AUTHORS DECLARE no conflict of interests for this article.

REFERENCES 1 Indonesian Central Statistical Bureau. Indonesian demographic profile 2013. Cited on July 29th 2013. Available from URL: http://www.bps.go.id/ 2 Ministry of Health Republic of Indonesia. Indonesia health profile 2009. Cited on July 29th 2013. Available from URL: http://www.depkes.go.id/ 3 Pang, RTP. Observation with peritoneoscopy in liver disease in Indonesia. PhD [dissertation]. Jakarta: Universitas Indonesia; 1958. 4 Hadi, S. The development of gastrointestinal endoscopy in Indonesia and overseas. In: Endoscopy in Gastroenterohepatology. 1987. p.1–7. 5 Simadibrata, S. The use of gastroscopy in stomach disorder. In: Proceeding book of national congress of Indonesian Association of Internal Medicine. 1971. p.154–6.

6 Hilmy FA, Tilaar PC, Daldiyono, et al. Colonoscopy and sigmoidoscopy in Cipto Mangunkusumo National General Hospital Jakarta. In: Proceeding book of national congress of Indonesian Association of Internal Medicine. 1978. p. 221– 31. 7 Rani AA, Ali I, Daldiyono, et al. Endoscopic therapy in patient with post esophageal transection stricture. In: Proceeding book of national congress of Indonesian Association of Internal Medicine.1984. p.1186–9. 8 Makmun D, Syafruddin ARL. Indonesian Society for Digestive Endoscopy report. Center for information and publishing; Jakarta: 2013. 9 Graduate Medical Education National Advisory Committee. Target Physician to population ratio 2003. Cited on July 29th, 2013. Available from URL: http://www.health.mo.gov 10 Thompson, N, Romaya, C. Gastroenterology workforce report 2007. Cited on July 29th 2013. Available from URL: http:// gsg.org.uk 11 American Society for Gastrointestinal Endoscopy. Principles of training in GI endoscopy. Gastrointest. Endosc. 2012; 75: 231–5.

© 2014 The Author Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

Present status of endoscopy, therapeutic endoscopy and the endoscopy training system in Indonesia.

Recently, Indonesia was ranked as the fourth most populous country in the world. Based on 2012 data, 85000 general practitioners and 25000 specialists...
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