- Email: [email protected]
Italian gastroenterology: eyes on the new millennium
EDUCATION,ETHICSAND ECONOMICS
WEST LlUER DIS 2000;32:3-8
Italian Gastroenterology: eyes on the new millennium R. Naccarato F. Di Mario
FitllR: Surgical end Department of Gastroentarologicwl Science “P. G. Cevese”, Section Gastroenterology, University of Padua, Italy. -AuEnrrnywrlsascr Dr. F. Di Mario, Dipartimento di Scianze Chirurgiche e Gastroenterologiche, Sezione Gastroenterologia. Vi piano Monoblocco Dspedalieru, Via Giustinieni 2, 35120 Fadova, Italy. Fax: +39-049-876l7820. The authors are indebted to Dr. N. Dal B& G Battaglia. G. Del Favero, G. Mastropaolo. Submitted August 30,1999. Revised 29 December 1999. Accepted January IO, 2OLID
As we enter the new millennium, the historical perspective of those who witnessed the birth of gastroenterology as a medical discipline in Italy and who traced its first steps, from an autonomous entity to the burgeoning growth of its subspecialties, has led us to review its history in this country. Gastroenterology was born from internal medicine as knowledge of its clinical and pathophysiologic features gradually deepened and advances in technology demanded a separation of this rapidly developing field from what was then a too vast doctrinal body. In our country, the merit of having conceived this new discipline must be attributed to the school of Bologna, which, thanks to the inspiring beginnings of G. Sotgiu, led to the formation of a group headed by G. Labb. This work was then carried forth by L. Barbara, in whose department research in gastroenterology flourished in all areas. Numerous other pioneers in gastroenterology in Italy must be remembered, including M. Coppo, with a research group entirely dedicated to hepatology, A. Torsoli, who is responsible for having promoted scientific journalism in gastroenterology, E. Pisi, M. Arullani and R. Cheli, a pioneer in digestive endoscopy. While the temptation to praise and anecdotal reminiscence in such a context is strong, it is certainly of more interest to the reader to approach the subject with a critical eye, particularly with regards to areas still found wanting and the many deficiencies that have led to problems at various levels. Like other disciplines, gastroenterology has a mission statement that aspires for its dissemination by promoting its science and training its physicians with the aid of scientific societies. These endeavours obviously cannot be removed from the scientific research, which can be divided into basic and applied branches. Over the last thirty years, the fundamental discoveries in basic research and the technological progress which has allowed revolutionary applications in therapeutic and diagnostic pharmacology (Table I) were essential to the rapid development of gastroenterology. Some critical advancements must be noted.
Fundamentaldiscoveries Oesophageal disorders and rejlux disease The innovative use of botulin toxin in oesophageal achalasia was revolutionary, as were some new concepts that emerged in gastro-oesophageal reflux disease (GERD). Now that ulcerative disease is classified as infectious and curable, this remains the only acidic disease of relevance to combat in the future. It is now known that GERD is a disorder of extrinsic gastroenterology (oesophagus and nearby structures) that develops at the level of the systemic nervous system with considerable motor neuron influence from endbrain centres. Still with regard to oesophageal pathology, and also of interest to the field of oncology, is the significant change in the histotype of oesophageal neoplasia, particularly in the western world, with an increase in adenocarcinoma as opposed to squamous cell carcinomas.
Italian
gastmenterology:
eyes
on the
new
millennium
TaLla I. Milestones. -
HBV and HCV identification Discovery of the Hz-histamine receptor and protonic pump in the parietal cell Identification of toxic fragments of glutin Ulcer disease es infectious illness W. pylor~l Frogmss in gastrointestinal endoscopy Llltrasonography in diagnostics of abdomen Organ transplants Artificial liver
Gastro-duodenal pathologies Certainly, the discovery in 1983 of the pathogenic role of Helicobacter pylori (H. pylori) in gastritis and ulcerative disease can be defined as revolutionary. There is now a real possibility that this disease will eventually disappear if the guidelines proposed by the WHO for the eradication of infection as first line therapy for ulcer are followed. Diseases of the small and large intestine Numerous discoveries related to small intestine pathology and physiology have been made. Gliadin was discovered in the Fifties, and anti-gliadin and anti-endomysium antibodies were isolated in the Nineties. The variability in the clinical spectrum of coeliac disease was more fully defined, as well as the real possibility - anxiously awaited by all patients - for the transgenic production of a gluten-free grain. Also worth noting are the identification of the aetiologic infectious agent for diseases such as Whipple’s Disease and the characterization of clinical entities such as NSAIDs (non-steroidal anti-inflammatory drug) enteropathy, which has significantly broadened our clinical conscience regarding the iatrogenic aspects of these widely used therapeutic agents. Chronic inflammatory bowel diseases, still awaiting a decisive aetiopathogenic factor, have at least benefited from advancements in their diagnosis (i.e., dedicated abdominal ultrasound) and treatment (new active compounds) over the last twenty years, as well as standardization of surgical techniques (pouch, etc.) and the management of acute phases (enteral nutrition, parenterals, etc.). With regard to malignancies of the colon, the simple identification of familial risk factors was a significant step forward in the understanding in this disease, as well as the identification of the pathogenic sequence of modifications that occur in adenoma carcinoma. Liver diseases It is difficult to even begin to define the extraordinary progress made in hepatology. The identification of the 4
Dane particle in 1968 proved the way for the characterization of the hepatotropic viruses. The subsequent cascade of progress in the diagnostic and therapeutic field (vaccines, etc.) culminated with the realization of organ transplants, from which thousands of patients have already benefited. Nevertheless, research and technology are already leading away from transplants, with alternative techniques and treatment protocols/regimes on the horizon. Genetic studies and new insights From a more general point of view, gastroenterology has greatly benefited from progress in technology and in research techniques such as biomedical engineering. The possibility to modulate certain pathological conditions, at genetic level, will soon be a reality, particularly as far as concerns those, diseases involving one dysfunctional gene. Technology has accompanied gastroenterology, hand in hand, from its birth and advancements continue to emerge, not least of which virtual endoscopy and mini-invasive surgery.
Darkpits in Gastroenterology While the last thirty years have brought many new developments in gastroenterology, the many remaining grey areas must also be highlighted: 1. Oesophagus Failure to keep abreast with the latest research in the development of drugs for motor disorders; 2. Stomach Research was abandoned, years ago, on the so-called “cell or site protector” drugs due to the enormous profits made from the hydrochloric acid inhibitors, beginning with the revolutionary discovery of cimetidine in the late 1970’s, to the proton pump inhibitors of today, now the number one drug sold worldwide; 3. Small intestine Few investments and technological stagnation in diagnostic devices and therapeutics for diseases of the small intestine; 4. Large intestine Too little attention has been focused on screening tests and campaigns to identify the incidence of risk for neoplasms of the large bowel; 5. Pancreas Lack of a significant reduction in the death rate from pancreatic adenocarcinoma, together with the little interest, in terms of investments, in research for pancreatic diseases, obviously considering the non-lucrative prospects of such research; 6. Liver Insufficient public education (and of health system personnel?) concerning the well-known problems such as alcohol-related liver disease and its effects on the donation of organs.
Teachingin Gastroenterology Of fundamental importance, particularly for a’ branch of medicine as young as gastroenterology, is not only bringing the new information that is accumulating at a staggering rate to the attention of those working in the field but also the application of these scientific advancements to the clinical environment. Let us take a brief look at the academics of gastroenterology in Italy, focusing on certain areas still lacking rather than on the achievements made. The dissemination of information in gastroenterology follows, as in other disciplines, numerous channels that vary from academic teaching in medical schools, to teaching in technical-oriented programmes, post-medical school residencies, post-graduate continuing education courses, public education, in general, and for personnel within the education system (public schools, etc.). We will briefly discuss the situation at the Uni-
T&la II. Gastraanterology and digestive endosoopy schools in Italy. Rnd##rT Ancona Sari Bologna Cagliari Catania Catanzam Chiati Ferrara Firenze 1 Fireme 2 Genove
as
L’Aquita Messina Milan0 I Milan0 2 Milan0 “Cattoliia” Modena Napoli “Fedarico II Napoli II Ateneo Padova Palwno Parme
Pavia $yJia Roma “La Sapienza’ I Rome “La Sepienza” 2 Rome “La Sapienza” 3 Sassari Siene Torino Udina Varese Verona 1999~am
versity level, in scientific societies, in scientific journalism and in research conferences. The realization of a unified text in gastroenterology, embracing all its subspecialties, was critical to this coordinated effort of UNIGASTRO (Coordinamento Nazionale Docenti Universitari de1 Corso Integrato di MaIattie dell’Apparato Digerente). It is already in its third edition, being published every two years and in use in teaching programmes nationwide. The importance of realizing a text such as this is obvious, with its attempt - even with discrepancies and deficiencies particularly in the first edition, to offer, at a national level, a modem and unified vision of the discipline. The additional effort to supply students with an accompanying complete kit of slides from which the professors could draw their lectures guaranteed an appreciable uniformity in the information supplied, at the same time avoiding the risk of over-teaching of certain subspecialities researched at individual university centres. The distribution of medical schools with residencies in gastroenterology is shown in Table II. An uneven distribution of residencies in gastroenterology still exists nationwide, with gross shortages in certain regions. Furthermore, the minimal availability of residency positions (86 at the last census) will result in a marked shortage of professionals in the field. Fundamental research detailing demographics (departments - clinics, hospital beds - and operating units of gastroenterology and digestive endoscopy recognized in Italy) was published in no. 5, Vol. 30, 1998 of the Italian Journal Gastroenterology and Hepatology, coordinated by L. Capocaccia and L. Gandolfi and edited by Baraldi and Bodington 3. This study stressed the gross differences existing even between adjacent regions with regard to the number of beds and hospital stays per inhabitants (Liguria 8.03 beds/150,000 versus 0.57 beds/150,000 in Lombardy: Table III).
Table 111.Relationship batwen admission!
0.57 3.13 From: cBppo8dya L, Gandolfi 1. Ital J f3l@wW
18.74 231.85
17.76 3.09
l&p&u1 1998 fmod&d~ 3.
5
Italian gastroenterology:
eyes on the new millennium
(i.e., Camitato Direttivo AlGCl
I Fig. 1. Gastmentemlogical
Scientific Societies in Italy.
Gastroenterology in the National Health Seruice The most critical aspect that has emerged from these data on the structure of gastroenterology units in Italy is the total inadequacy with respect to the clinical importance of the array of diseases. As shown in Table IV, the fifth leading cause of death in Italy in 1994 was digestive tract diseases, with 5.1% of all deaths. Furthermore, in 1990, the second leading diagnosis on discharge from public and private hospitals (Table V) was of a digestive tract disease (including neoplasms), involving 1,123,435 patients and 12.56% of the total hospital population. This also reflects the vast efforts that have been made to develop the field of gastroenterology, at local health system level, and which have led to better diagnosis and treatment of patients. There is a lack of data on the cost/benefits of patient hospitalization for gastroenterological diseases in a specialized versus general medicine department. Nevertheless, there is no doubt that the management of numerous gastroenterological diseases with multidisciplinary features (i.e., the treatment of chronic inflammatory bowel
ToLlr IY Causes of death in Italy tl9941
Circulatory disease Turnout-e Digestive tract Respiratory tract Respiratory tract diseases Digestive tract diseases Extraneous causes, trauma Mental disorders Other
6
disease requires the close collaboration of the abdominal surgeon, diagnostic and therapeutic methods such as TACE and ERCP are performed in collaboration with a radiologist, diagnostics for pre-cancerous lesions, in collaboration with the pathologist, etc.) requires a refinement in timing and collaboration that must be guaranteed within a structured framework. The widespread diffusion of digestive endoscopy in hospitals has not been followed by a formal recognition of its service within a specialized gastroenterology service. This administrative oversight is doubtless in very poor judgement considering the high-risk methods, such as emergency and surgical endoscopy, often performed. Almost all operating units of gastroenterology are equipped to perform the two principle methods of digestive endoscopy (EGDS and colonoscopy), while the percentages decrease for other functional exams (manometry and pH-metry) and ultrasound (Table VI). Certain procedures have become more widely practiced, such as the placement of biliary prostheses, papillo-sphincterotomies, etc. while other procedures are in a definite decline in keeping with the current scien-
Il. Naccarato
and F. Di Mario
Tebk II Patients discharged from public end private institutions according to cause of admission (19901. N. llisdtaqd Circulatory disease Digestive trect disease (including carcinoma1 Trauma and poisoning Complications in pregnancy and puerperium Respiratory tract disease Iincluding carcinoma) Tumours Urogenital tract diseese Undefined disease symptoms Osteomusculer system and connective tissue disease Nervous system disease Mental disease Endocrine gland disease
1 s225.965 1 ,I 23,435 957,621 872,402 739,815 E%E 486:752 486,069 483,069 284,022 252,393
%ofbtal 13.71% 12.56% 10.71% 9.75% 8.27% 7.07% 6.36% 5.46% 5.44% 5.40% 3.18% 2.63%
From: Cepocscci8 L, Gandolfi L. ltal J Gastroentaroi Hepatol 1998 ~modif8dl?
tific literature (laparoscopy etc.: Table VII). At this time of profound changes within the Italian social health system, it is difficult to hypothesize and define what might be the final, best possible scenario. The ideal approach to patient care and treatment is still under debate at a regional and national level.
Scientific Societies The separation of two important academic institutions has generated greatly differing societies: SIGE (Societa Italiana di Gastroenterologia), split from the Society of Internal Medicine, and AIGO (Associazione Italiana di Gastroenterologi Ospedalieri) was born as a clinical alternative to the university institutions. Digestive endoscopy, which has contributed so much to the rise in gastroenterology as a discipline, has assumed its own independence with the formation of the society, SIED (Societa Italiana Endoscopia Digestiva). This has expanded considerably throughout Italy and gener-
bbla UL Percentage of Gastroenterology operative units performing main instrumental procedures (19951. EGDS Colonoscopy ERCP Papillosphincterotomy Oesophageal mancmetq Continuous oesophegaal pH-metry Abdominal ultrasonography Ultrasound-guided biopsy
95% 91% 82% 73% 50% 65% 67% 54%
From: Capoceccia L, Gandolfi L. ltal J Gastroentatvl Hepatol 1998 Imodified 3,
ates a slight atmosphere of friction between the medical and surgical sectors. These three major scientific societies in gastroenterology have distinct territorial structuring, as illustrated in Figure 1, from which a variety of meetings has arisen at a local level (regional conferences, courses, etc.). In recent years, scientific societies have evolved into sub-specialities such as the AISF (Associazione Italiana Studio Fegato split from the Italian Society of Hepatology) and the AISP (Associazione Italiana Studio Pancreas). These are the offspring of various groups and structures dedicated to research in the sector, assisting in projects, epidemiological studies and funding. Gastroenterology research in Italy currently appears to be on par with that of our international colleagues, as witnessed by the large number of abstracts accepted for presentation at major international congresses and publication of articles in reputable scientific journals worldwide. The globalization of all fields of science and medicine has led to the birth of a unified annual world congress in gastroenterology organized by the major American societies. This congress takes place in May and lasts for one week, rotating between three to four large cities with adequate conference facilities. The transactions of the meeting are published in the official journal of the society, Gastroenterology. An opposing force is found in the American College of Gastroenterology, with its independent congress and transactions published in its official journal, the American Journal of Gastroenterology. In Europe, unification of the national meetings occurred in 1992 in Athens with the first European Week for Digestive Diseases (UEGW). The meeting was held in Roma, in 1999, exactly eleven years after Rome ‘88 where the cornerstone for UEGW was laid. The structure of this meeting offers advanced courses, ample poster sessions, learning comers, and satellite sym-
I
Italian gastrocntemlogy:
eyes on the new millennium
posia (although the organization of the latter within the meeting confines has, at times, been criticized. In Italy, the idea of SIMAD (Settimana Italiana di Malattie Digestive) was born from deliberations of the 1977 assembly of SIGE. SIMAD 1 was held in Roma in 1979, SIMAD 2 in Bologna in 1981 and SIMAD 3 in Bari in 1983. SIMAD is an initiative of five societies: SIGE, AISF, SIGP (Gruppo Gastroenterologia Pediatrica), AIGO and the gastroenterological section of the Italian Society of Radiology and Nuclear Medicine. Since 1995, the National Congress in Gastroenterology has involved all the major Italian societies (SIGE, AIGO, SIED, AISP, AISF, SIGP, CICD) and, finally, in 1999 the conjunction of the three major societies: SIGE, AIGO, SIED. Despite certain spontaneous initiatives (SIGE-INDUSTRIA pool, learning corner in partnership, sponsorship of UNIGASTRO teaching material, widespread use of endoscopic software, etc.), collaboration between scientific societies and industry in Italy is still extremely slow moving. This is perhaps a reflection of historical and cultural ethic, aptly summed up by the adage “profit is not a moral category, but neither is it a synonym for sin”, on the tracks of which, societies of the world have travelled. Over the last year, the Italian Journal of Gastroenterology and Hepatology (official publication of SIGE and AISF) has been positioning itself for a place among the like-publications in Europe, while also paying the price for its long history of provincialism, as well as its very low impact factor.
Conclusions We would like to draw this discussion to a close with emphasis on the following considerations:
1. consolidation of the scientific societies of gastroenterology will be achieved in a reasonably timely fashion, providing the opportunly to be more competitive at international level; 2. a reduction in the fragmentation of gastroenterological entities both at the national and local level should lead to a strengthening, harmonization and advancement of the discipline; 3. the delineation of quality standards, guidelines and cost containment within the health system should also favour the recognition the specialization that will then lead to better distribution of gastroenterologists throughout the country; 4. the attempt to maintain a standard in gastroenterology training, in stride with the times, derived from the teaching policy of UNIGASTRO, should be followed by research into an analogous project for the continuing education of specialists and their non-specialist colleagues (internists and general practitioners); 5. the integration of university and hospital centres should be followed with determination, defeating the expected tenacious and provincial resistance, in order to ensure Gastroenterology can benefit from a uniform the didactic, clinical and research experiences in gastroenterology.
References i Barbezat GO. Recent advanced gastroenterology. Br Med J 1998;316:125-8. 2 Decennial Reviews. Em J Gastroenterol Hepatol 1999; 11: l-54. 3 Capocaccia L, Gandolfi L. Analysis of the organisational aspects of Gastroenterology Services in Italy. Ital J Gastroenterol Hepato1 1998;30:451-61. 4 A new millennium of Gastroenterology. Mayo Foundation, Mayo Press; 1999. p. l-683.
WEST LlUER DIS 2000;32:3-8
Italian Gastroenterology: eyes on the new millennium R. Naccarato F. Di Mario
FitllR: Surgical end Department of Gastroentarologicwl Science “P. G. Cevese”, Section Gastroenterology, University of Padua, Italy. -AuEnrrnywrlsascr Dr. F. Di Mario, Dipartimento di Scianze Chirurgiche e Gastroenterologiche, Sezione Gastroenterologia. Vi piano Monoblocco Dspedalieru, Via Giustinieni 2, 35120 Fadova, Italy. Fax: +39-049-876l7820. The authors are indebted to Dr. N. Dal B& G Battaglia. G. Del Favero, G. Mastropaolo. Submitted August 30,1999. Revised 29 December 1999. Accepted January IO, 2OLID
As we enter the new millennium, the historical perspective of those who witnessed the birth of gastroenterology as a medical discipline in Italy and who traced its first steps, from an autonomous entity to the burgeoning growth of its subspecialties, has led us to review its history in this country. Gastroenterology was born from internal medicine as knowledge of its clinical and pathophysiologic features gradually deepened and advances in technology demanded a separation of this rapidly developing field from what was then a too vast doctrinal body. In our country, the merit of having conceived this new discipline must be attributed to the school of Bologna, which, thanks to the inspiring beginnings of G. Sotgiu, led to the formation of a group headed by G. Labb. This work was then carried forth by L. Barbara, in whose department research in gastroenterology flourished in all areas. Numerous other pioneers in gastroenterology in Italy must be remembered, including M. Coppo, with a research group entirely dedicated to hepatology, A. Torsoli, who is responsible for having promoted scientific journalism in gastroenterology, E. Pisi, M. Arullani and R. Cheli, a pioneer in digestive endoscopy. While the temptation to praise and anecdotal reminiscence in such a context is strong, it is certainly of more interest to the reader to approach the subject with a critical eye, particularly with regards to areas still found wanting and the many deficiencies that have led to problems at various levels. Like other disciplines, gastroenterology has a mission statement that aspires for its dissemination by promoting its science and training its physicians with the aid of scientific societies. These endeavours obviously cannot be removed from the scientific research, which can be divided into basic and applied branches. Over the last thirty years, the fundamental discoveries in basic research and the technological progress which has allowed revolutionary applications in therapeutic and diagnostic pharmacology (Table I) were essential to the rapid development of gastroenterology. Some critical advancements must be noted.
Fundamentaldiscoveries Oesophageal disorders and rejlux disease The innovative use of botulin toxin in oesophageal achalasia was revolutionary, as were some new concepts that emerged in gastro-oesophageal reflux disease (GERD). Now that ulcerative disease is classified as infectious and curable, this remains the only acidic disease of relevance to combat in the future. It is now known that GERD is a disorder of extrinsic gastroenterology (oesophagus and nearby structures) that develops at the level of the systemic nervous system with considerable motor neuron influence from endbrain centres. Still with regard to oesophageal pathology, and also of interest to the field of oncology, is the significant change in the histotype of oesophageal neoplasia, particularly in the western world, with an increase in adenocarcinoma as opposed to squamous cell carcinomas.
Italian
gastmenterology:
eyes
on the
new
millennium
TaLla I. Milestones. -
HBV and HCV identification Discovery of the Hz-histamine receptor and protonic pump in the parietal cell Identification of toxic fragments of glutin Ulcer disease es infectious illness W. pylor~l Frogmss in gastrointestinal endoscopy Llltrasonography in diagnostics of abdomen Organ transplants Artificial liver
Gastro-duodenal pathologies Certainly, the discovery in 1983 of the pathogenic role of Helicobacter pylori (H. pylori) in gastritis and ulcerative disease can be defined as revolutionary. There is now a real possibility that this disease will eventually disappear if the guidelines proposed by the WHO for the eradication of infection as first line therapy for ulcer are followed. Diseases of the small and large intestine Numerous discoveries related to small intestine pathology and physiology have been made. Gliadin was discovered in the Fifties, and anti-gliadin and anti-endomysium antibodies were isolated in the Nineties. The variability in the clinical spectrum of coeliac disease was more fully defined, as well as the real possibility - anxiously awaited by all patients - for the transgenic production of a gluten-free grain. Also worth noting are the identification of the aetiologic infectious agent for diseases such as Whipple’s Disease and the characterization of clinical entities such as NSAIDs (non-steroidal anti-inflammatory drug) enteropathy, which has significantly broadened our clinical conscience regarding the iatrogenic aspects of these widely used therapeutic agents. Chronic inflammatory bowel diseases, still awaiting a decisive aetiopathogenic factor, have at least benefited from advancements in their diagnosis (i.e., dedicated abdominal ultrasound) and treatment (new active compounds) over the last twenty years, as well as standardization of surgical techniques (pouch, etc.) and the management of acute phases (enteral nutrition, parenterals, etc.). With regard to malignancies of the colon, the simple identification of familial risk factors was a significant step forward in the understanding in this disease, as well as the identification of the pathogenic sequence of modifications that occur in adenoma carcinoma. Liver diseases It is difficult to even begin to define the extraordinary progress made in hepatology. The identification of the 4
Dane particle in 1968 proved the way for the characterization of the hepatotropic viruses. The subsequent cascade of progress in the diagnostic and therapeutic field (vaccines, etc.) culminated with the realization of organ transplants, from which thousands of patients have already benefited. Nevertheless, research and technology are already leading away from transplants, with alternative techniques and treatment protocols/regimes on the horizon. Genetic studies and new insights From a more general point of view, gastroenterology has greatly benefited from progress in technology and in research techniques such as biomedical engineering. The possibility to modulate certain pathological conditions, at genetic level, will soon be a reality, particularly as far as concerns those, diseases involving one dysfunctional gene. Technology has accompanied gastroenterology, hand in hand, from its birth and advancements continue to emerge, not least of which virtual endoscopy and mini-invasive surgery.
Darkpits in Gastroenterology While the last thirty years have brought many new developments in gastroenterology, the many remaining grey areas must also be highlighted: 1. Oesophagus Failure to keep abreast with the latest research in the development of drugs for motor disorders; 2. Stomach Research was abandoned, years ago, on the so-called “cell or site protector” drugs due to the enormous profits made from the hydrochloric acid inhibitors, beginning with the revolutionary discovery of cimetidine in the late 1970’s, to the proton pump inhibitors of today, now the number one drug sold worldwide; 3. Small intestine Few investments and technological stagnation in diagnostic devices and therapeutics for diseases of the small intestine; 4. Large intestine Too little attention has been focused on screening tests and campaigns to identify the incidence of risk for neoplasms of the large bowel; 5. Pancreas Lack of a significant reduction in the death rate from pancreatic adenocarcinoma, together with the little interest, in terms of investments, in research for pancreatic diseases, obviously considering the non-lucrative prospects of such research; 6. Liver Insufficient public education (and of health system personnel?) concerning the well-known problems such as alcohol-related liver disease and its effects on the donation of organs.
Teachingin Gastroenterology Of fundamental importance, particularly for a’ branch of medicine as young as gastroenterology, is not only bringing the new information that is accumulating at a staggering rate to the attention of those working in the field but also the application of these scientific advancements to the clinical environment. Let us take a brief look at the academics of gastroenterology in Italy, focusing on certain areas still lacking rather than on the achievements made. The dissemination of information in gastroenterology follows, as in other disciplines, numerous channels that vary from academic teaching in medical schools, to teaching in technical-oriented programmes, post-medical school residencies, post-graduate continuing education courses, public education, in general, and for personnel within the education system (public schools, etc.). We will briefly discuss the situation at the Uni-
T&la II. Gastraanterology and digestive endosoopy schools in Italy. Rnd##rT Ancona Sari Bologna Cagliari Catania Catanzam Chiati Ferrara Firenze 1 Fireme 2 Genove
as
L’Aquita Messina Milan0 I Milan0 2 Milan0 “Cattoliia” Modena Napoli “Fedarico II Napoli II Ateneo Padova Palwno Parme
Pavia $yJia Roma “La Sapienza’ I Rome “La Sepienza” 2 Rome “La Sapienza” 3 Sassari Siene Torino Udina Varese Verona 1999~am
versity level, in scientific societies, in scientific journalism and in research conferences. The realization of a unified text in gastroenterology, embracing all its subspecialties, was critical to this coordinated effort of UNIGASTRO (Coordinamento Nazionale Docenti Universitari de1 Corso Integrato di MaIattie dell’Apparato Digerente). It is already in its third edition, being published every two years and in use in teaching programmes nationwide. The importance of realizing a text such as this is obvious, with its attempt - even with discrepancies and deficiencies particularly in the first edition, to offer, at a national level, a modem and unified vision of the discipline. The additional effort to supply students with an accompanying complete kit of slides from which the professors could draw their lectures guaranteed an appreciable uniformity in the information supplied, at the same time avoiding the risk of over-teaching of certain subspecialities researched at individual university centres. The distribution of medical schools with residencies in gastroenterology is shown in Table II. An uneven distribution of residencies in gastroenterology still exists nationwide, with gross shortages in certain regions. Furthermore, the minimal availability of residency positions (86 at the last census) will result in a marked shortage of professionals in the field. Fundamental research detailing demographics (departments - clinics, hospital beds - and operating units of gastroenterology and digestive endoscopy recognized in Italy) was published in no. 5, Vol. 30, 1998 of the Italian Journal Gastroenterology and Hepatology, coordinated by L. Capocaccia and L. Gandolfi and edited by Baraldi and Bodington 3. This study stressed the gross differences existing even between adjacent regions with regard to the number of beds and hospital stays per inhabitants (Liguria 8.03 beds/150,000 versus 0.57 beds/150,000 in Lombardy: Table III).
Table 111.Relationship batwen admission!
0.57 3.13 From: cBppo8dya L, Gandolfi 1. Ital J f3l@wW
18.74 231.85
17.76 3.09
l&p&u1 1998 fmod&d~ 3.
5
Italian gastroenterology:
eyes on the new millennium
(i.e., Camitato Direttivo AlGCl
I Fig. 1. Gastmentemlogical
Scientific Societies in Italy.
Gastroenterology in the National Health Seruice The most critical aspect that has emerged from these data on the structure of gastroenterology units in Italy is the total inadequacy with respect to the clinical importance of the array of diseases. As shown in Table IV, the fifth leading cause of death in Italy in 1994 was digestive tract diseases, with 5.1% of all deaths. Furthermore, in 1990, the second leading diagnosis on discharge from public and private hospitals (Table V) was of a digestive tract disease (including neoplasms), involving 1,123,435 patients and 12.56% of the total hospital population. This also reflects the vast efforts that have been made to develop the field of gastroenterology, at local health system level, and which have led to better diagnosis and treatment of patients. There is a lack of data on the cost/benefits of patient hospitalization for gastroenterological diseases in a specialized versus general medicine department. Nevertheless, there is no doubt that the management of numerous gastroenterological diseases with multidisciplinary features (i.e., the treatment of chronic inflammatory bowel
ToLlr IY Causes of death in Italy tl9941
Circulatory disease Turnout-e Digestive tract Respiratory tract Respiratory tract diseases Digestive tract diseases Extraneous causes, trauma Mental disorders Other
6
disease requires the close collaboration of the abdominal surgeon, diagnostic and therapeutic methods such as TACE and ERCP are performed in collaboration with a radiologist, diagnostics for pre-cancerous lesions, in collaboration with the pathologist, etc.) requires a refinement in timing and collaboration that must be guaranteed within a structured framework. The widespread diffusion of digestive endoscopy in hospitals has not been followed by a formal recognition of its service within a specialized gastroenterology service. This administrative oversight is doubtless in very poor judgement considering the high-risk methods, such as emergency and surgical endoscopy, often performed. Almost all operating units of gastroenterology are equipped to perform the two principle methods of digestive endoscopy (EGDS and colonoscopy), while the percentages decrease for other functional exams (manometry and pH-metry) and ultrasound (Table VI). Certain procedures have become more widely practiced, such as the placement of biliary prostheses, papillo-sphincterotomies, etc. while other procedures are in a definite decline in keeping with the current scien-
Il. Naccarato
and F. Di Mario
Tebk II Patients discharged from public end private institutions according to cause of admission (19901. N. llisdtaqd Circulatory disease Digestive trect disease (including carcinoma1 Trauma and poisoning Complications in pregnancy and puerperium Respiratory tract disease Iincluding carcinoma) Tumours Urogenital tract diseese Undefined disease symptoms Osteomusculer system and connective tissue disease Nervous system disease Mental disease Endocrine gland disease
1 s225.965 1 ,I 23,435 957,621 872,402 739,815 E%E 486:752 486,069 483,069 284,022 252,393
%ofbtal 13.71% 12.56% 10.71% 9.75% 8.27% 7.07% 6.36% 5.46% 5.44% 5.40% 3.18% 2.63%
From: Cepocscci8 L, Gandolfi L. ltal J Gastroentaroi Hepatol 1998 ~modif8dl?
tific literature (laparoscopy etc.: Table VII). At this time of profound changes within the Italian social health system, it is difficult to hypothesize and define what might be the final, best possible scenario. The ideal approach to patient care and treatment is still under debate at a regional and national level.
Scientific Societies The separation of two important academic institutions has generated greatly differing societies: SIGE (Societa Italiana di Gastroenterologia), split from the Society of Internal Medicine, and AIGO (Associazione Italiana di Gastroenterologi Ospedalieri) was born as a clinical alternative to the university institutions. Digestive endoscopy, which has contributed so much to the rise in gastroenterology as a discipline, has assumed its own independence with the formation of the society, SIED (Societa Italiana Endoscopia Digestiva). This has expanded considerably throughout Italy and gener-
bbla UL Percentage of Gastroenterology operative units performing main instrumental procedures (19951. EGDS Colonoscopy ERCP Papillosphincterotomy Oesophageal mancmetq Continuous oesophegaal pH-metry Abdominal ultrasonography Ultrasound-guided biopsy
95% 91% 82% 73% 50% 65% 67% 54%
From: Capoceccia L, Gandolfi L. ltal J Gastroentatvl Hepatol 1998 Imodified 3,
ates a slight atmosphere of friction between the medical and surgical sectors. These three major scientific societies in gastroenterology have distinct territorial structuring, as illustrated in Figure 1, from which a variety of meetings has arisen at a local level (regional conferences, courses, etc.). In recent years, scientific societies have evolved into sub-specialities such as the AISF (Associazione Italiana Studio Fegato split from the Italian Society of Hepatology) and the AISP (Associazione Italiana Studio Pancreas). These are the offspring of various groups and structures dedicated to research in the sector, assisting in projects, epidemiological studies and funding. Gastroenterology research in Italy currently appears to be on par with that of our international colleagues, as witnessed by the large number of abstracts accepted for presentation at major international congresses and publication of articles in reputable scientific journals worldwide. The globalization of all fields of science and medicine has led to the birth of a unified annual world congress in gastroenterology organized by the major American societies. This congress takes place in May and lasts for one week, rotating between three to four large cities with adequate conference facilities. The transactions of the meeting are published in the official journal of the society, Gastroenterology. An opposing force is found in the American College of Gastroenterology, with its independent congress and transactions published in its official journal, the American Journal of Gastroenterology. In Europe, unification of the national meetings occurred in 1992 in Athens with the first European Week for Digestive Diseases (UEGW). The meeting was held in Roma, in 1999, exactly eleven years after Rome ‘88 where the cornerstone for UEGW was laid. The structure of this meeting offers advanced courses, ample poster sessions, learning comers, and satellite sym-
I
Italian gastrocntemlogy:
eyes on the new millennium
posia (although the organization of the latter within the meeting confines has, at times, been criticized. In Italy, the idea of SIMAD (Settimana Italiana di Malattie Digestive) was born from deliberations of the 1977 assembly of SIGE. SIMAD 1 was held in Roma in 1979, SIMAD 2 in Bologna in 1981 and SIMAD 3 in Bari in 1983. SIMAD is an initiative of five societies: SIGE, AISF, SIGP (Gruppo Gastroenterologia Pediatrica), AIGO and the gastroenterological section of the Italian Society of Radiology and Nuclear Medicine. Since 1995, the National Congress in Gastroenterology has involved all the major Italian societies (SIGE, AIGO, SIED, AISP, AISF, SIGP, CICD) and, finally, in 1999 the conjunction of the three major societies: SIGE, AIGO, SIED. Despite certain spontaneous initiatives (SIGE-INDUSTRIA pool, learning corner in partnership, sponsorship of UNIGASTRO teaching material, widespread use of endoscopic software, etc.), collaboration between scientific societies and industry in Italy is still extremely slow moving. This is perhaps a reflection of historical and cultural ethic, aptly summed up by the adage “profit is not a moral category, but neither is it a synonym for sin”, on the tracks of which, societies of the world have travelled. Over the last year, the Italian Journal of Gastroenterology and Hepatology (official publication of SIGE and AISF) has been positioning itself for a place among the like-publications in Europe, while also paying the price for its long history of provincialism, as well as its very low impact factor.
Conclusions We would like to draw this discussion to a close with emphasis on the following considerations:
1. consolidation of the scientific societies of gastroenterology will be achieved in a reasonably timely fashion, providing the opportunly to be more competitive at international level; 2. a reduction in the fragmentation of gastroenterological entities both at the national and local level should lead to a strengthening, harmonization and advancement of the discipline; 3. the delineation of quality standards, guidelines and cost containment within the health system should also favour the recognition the specialization that will then lead to better distribution of gastroenterologists throughout the country; 4. the attempt to maintain a standard in gastroenterology training, in stride with the times, derived from the teaching policy of UNIGASTRO, should be followed by research into an analogous project for the continuing education of specialists and their non-specialist colleagues (internists and general practitioners); 5. the integration of university and hospital centres should be followed with determination, defeating the expected tenacious and provincial resistance, in order to ensure Gastroenterology can benefit from a uniform the didactic, clinical and research experiences in gastroenterology.
References i Barbezat GO. Recent advanced gastroenterology. Br Med J 1998;316:125-8. 2 Decennial Reviews. Em J Gastroenterol Hepatol 1999; 11: l-54. 3 Capocaccia L, Gandolfi L. Analysis of the organisational aspects of Gastroenterology Services in Italy. Ital J Gastroenterol Hepato1 1998;30:451-61. 4 A new millennium of Gastroenterology. Mayo Foundation, Mayo Press; 1999. p. l-683.