present status of endoscopy, therapeutic endoscopy and the endoscopy training system in indonesia

Special Lecture

Present status of endoscopy, therapeutic endoscopy andthe endoscopy training system in Indonesia

Dadang Makmun

Division of Gastroenterology, Department of Internal Medicine, Medical Faculty, University of Indonesia/CiptoMangunkusumo National General Hospital, Jakarta, Indonesia

Recently, Indonesia was ranked as the fourth most populouscountry in the world. Based on 2012 data, 85 000 general prac-titioners and 25 000 specialists are in service around the country.Gastrointestinal (GI) disease remains the most common finding indaily practise, in both outpatient and inpatient settings, andranks fifth in causing mortality in Indonesia. Management ofpatients with GI disease involves all health-care levels with themain portion in primary health care. Some are managed by spe-cialists in secondary health care or are referred to tertiary healthcare. GI endoscopy is one of the main diagnostic and therapeuticmodalities in the management of GI disease. Development of GIendoscopy in Indonesia started before World War II and, today,many GI endoscopy procedures are conducted in Indonesia, bothdiagnostic and therapeutic. Based on August 2013 data, thereare 515 GI endoscopists in Indonesia. Most GI endoscopists are

competent in carrying out basic endoscopy procedures, whereasonly a few carry out advanced endoscopy procedures, includingtherapeutic endoscopy. Recently, the GI endoscopy trainingsystem in Indonesia consists of basic GI endoscopy training of3–6 months held at 10 GI endoscopy training centers. GI endos-copy training is also eligible as part of a fellowship program ofconsultant gastroenterologists held at six accredited fellowshipcenters in Indonesia. Indonesian Society for Digestive Endoscopyin collaboration with GI endoscopy training centers in Indonesiaand overseas has been working to increase quality and number ofGI endoscopists, covering both basic and advanced GI endos-copy procedures.

Key words: present status, diagnostic endoscopy, endoscopytraining system, GI disease, therapeutic endoscopy

INTRODUCTION

RECENTLY, INDONESIA WAS ranked as the fourthmost populous country in the world following China,

India and the USA. Based on new statistical data launchedby the Indonesian Central Statistical Bureau in July 2012,248 645 008 people are estimated to inhabit Indonesia’sislands with a mean age of 28.5 years and an average lifeexpectancy 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 inSouth-East Asia, comprising 17 504 islands that are locatedbetween the two continents of Asia and Australia. Adminis-tratively, Indonesia consists of 33 provinces and 497 cities.1

Countrywide statistics show a 1.49% population growthrate with a density of 121 people/km2. Highly dense prov-

inces are dominantly located on Java island with Jakarta asthe most densely populated city (13 890 people/km2).1 Basedon current statistics data from the Ministry of Health Repub-lic of Indonesia in 2012, 85 000 general practitioners and25 000 specialists are distributed throughout Indonesia’sprovinces. Using a 1:3000 doctor-to-population ratio, thosenumbers are almost proportionate with Indonesia’s currentpopulation; however, the conspicuous problem seeminglyconcerns its distribution system. Based on data launched inMarch 2013, Indonesian doctors are in service in 9510primary health-care centers and in 2083 hospitals in Indone-sia, including government and private-owned hospitals.2

Referring to data from the Ministry of Health Republic ofIndonesia in 2009, upper respiratory tract infection was themost common diagnosis of Indonesia’s 10 most prevalentoutpatient diseases, followed by hypertension, dermatologi-cal disease, fever, diarrhea and dyspepsia, respectively(Table 1).

Gastrointestinal (GI) disease remains the most commonfinding encountered in daily practice, both in outpatientand inpatient settings. Diarrhea placed second after pneu-monia in the 10 most prevalent inpatient diseases in Indone-sia’s hospitals, followed, respectively, by typhoid fever,

Corresponding: Dadang Makmun, Division of Gastroenterology,Department of Internal Medicine, Medical Faculty, University ofIndonesia/Cipto Mangunkusumo National General Hospital, Jl.Diponegoro no. 71, Jakarta 10320, Indonesia. Email: [email protected] 28 November 2013; accepted 8 January 2014.

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Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9 doi: 10.1111/den.12245

© 2014 The AuthorDigestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society

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hypertension, dengue hemorrhagic fever, fever withunknown origin and dyspepsia (Table 2). However, GIdisease is in fifth place regarding mortality-causing diseasein Indonesia, following vascular disease, infectious diseaseand certain parasitic disorders, certain conditions of the peri-natal period and respiratory system disease (Table 3). As adeveloping country, Indonesia’s health-care system isdesigned as a three-level system comprising primary healthcare by general practitioners or family physicians, secondaryhealth care by specialists, and tertiary health care by subspe-cialists. Each level requires accredited competence and sup-porting facilities based on requirements.2

Management of patients with GI disease involves all thehealth-care levels with the main portion of its managementexpected to be carried out in primary health care. With the

advancement of a referral health system, the number ofpatients with GI diseases are managed by specialists insecondary health care or further referred to tertiary healthcare.

DEVELOPMENT OF GI ENDOSCOPYIN INDONESIA

GASTROINTESTINAL ENDOSCOPY HAS been usedworldwide as one of the main diagnostic, as well as

therapeutic, modalities in the management of GI disease.Development of GI endoscopy in Indonesia was almostsimilar to other countries in which a rigid endoscope wasused before World War II. This rigid endoscope took theform of a rectosigmoidoscope that was specifically used by

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

Rank Disease Sex Total casefindings

No. patientvisits

Male Female

1 Upper respiratory tract infection 243 578 245 216 488 794 781 8812 Fever of unknown origin 143 167 132 087 275 254 358 9423 Dermatoses and other subcutaneous tissue disease 99 303 147 953 247 256 371 6734 Diarrhea and gastroenteritis caused by certain

infectious agents (infection-associated colitis)88 275 83 738 172 013 223 318

5 Refraction and accommodation-related disorders 67 231 89 429 156 660 203 0216 Dyspepsia 55 817 77 345 133 162 220 3757 Essential hypertension 55 446 67 823 123 269 412 3648 Pulpal and periapical disease 54 004 68 463 122 467 234 0839 Ear disease and mastoid process-related disorders 53 463 52 142 105 605 153 488

10 Conjunctivitis and other conjunctiva-related disorders 46 380 52 815 99 195 135 749

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 Disease Sex Total casefindings

No.deaths

CFR (%)

Male Female

1 Diarrhea and gastroenteritis caused by certaininfectious agents (infection-associated colitis)

74 161 69 535 143 696 1747 1.22

2 Dengue hemorrhagic fever 60 705 60 629 121 334 898 0.743 Typhoid and paratyphoid fever 39 262 41 588 80 850 1013 1.254 Fever of unknown origin 24 957 24 243 49 200 462 0.945 Dyspepsia 18 807 28 497 47 304 520 1.106 Essential hypertension 15 533 21 144 36 677 935 2.557 Upper respiratory tract infection 19 115 16 933 36 048 162 0.458 Pneumonia 19 170 16 477 35 647 2365 6.639 Appendiceal disorders 13 920 16 783 30 703 234 0.76

10 Gastritis and duodenitis 12 758 17 396 30 154 235 0.78

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

Digestive Endoscopy 2014; 26 (Suppl. 2): 2–9 Present endoscopy status in Indonesia 3


surgeons. In 1958, Pang reported the use of the first laparo-scope without a camera in Indonesia.3

Semi-flexible endoscopy was first introduced in Indonesiaas a semi-flexible gastroscope by Simadibrata in 1967. In1971, flexible gastroscopes were widely used (OlympusGTFA, Olympus Co., Japan). Ever since, more reports on theuse of flexible endoscopes have been published in Indonesia,especially after the establishment of the Indonesian Societyfor Digestive Endoscopy (ISGE) in 1974, chaired by Pang.4,5

The flexible colonoscope was first used in Indonesia byHilmy in 1973 with its first therapeutic use in the colonreported in 1978. Henceforth, more endoscopic polypecto-mies were reported in the main hospitals in Indonesia. In1984, endoscopic sclerotherapy was pronounced for the firsttime by Hilmy and colleagues by ethoxysclerol injections inpatients with esophageal varices related to liver cirrhosis.Endoscopic cauterizations were first reported by Aziz Raniin 1984, using an Olympus electro-surgical unit in patientswith post-esophageal transection strictures.3,6,7

Nowadays, more GI endoscopy procedures are conductedin Indonesia, both for diagnostic and therapeutic purposes.Currently, medical technology advancements contributevoluminous innovations in health-care trends, especially inGI endoscopy, with the distribution of more advanced GIendoscopes and accessories. Recently, diagnostic endoscopymodalities in Indonesia were commonly categorized asesophagogastroduodenoscopy, colonoscopy, capsule endos-copy, enteroscopy, and endoscopic ultrasonography. Mostendoscopists are competent in carrying out diagnostic

endoscopy procedures (esophagogastroduodenoscopy andcolonoscopy) whereas only a few carry out enteroscopy orendoscopic ultrasonography. This discrepancy is causedby the limited provision of both diagnostic modalities inIndonesia. In contrast, GI endoscopy is economically costlyas a result of the high cost of the GI endoscope and itsaccessories. In March 2013, there were only 313 hospitalscurrently providing GI endoscopy services, distributed in 33provinces around the country (Table 4).8

Unlike diagnostic endoscopy procedures which are com-monly carried out by all GI endoscopists, therapeutic endos-copy, especially advanced endoscopy procedures, is notroutinely done by all endoscopists. This has been argued tobe related to the limitations of endoscopy facilities andaccessories, endoscopist competency, poor distribution ofpatients with complicated GI diseases requiring advancedendoscopy procedures and the courage of the endoscopist tocarry out advanced endoscopy procedures with all the riskscontained therein.

Today, therapeutic endoscopy procedures that are rou-tinely 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 athree-level grading: basic, first-level advanced, and second-level advanced competency. Basic endoscopy compet-ency includes esophagogastroduodenoscopy, colonoscopy,esophageal varices sclerotherapy, esophageal varices ligationand adrenaline-injection endoscopic hemostasis. First-leveladvanced endoscopy competency allows the endoscopist to

Table 3 Most common causes of death in Indonesian hospitalsas estimated in 2008

Rank Cause of death No. deaths CFR (%)

1 Vascular disease 23 163 11.062 Infectious disease and certain

parasitic disorders16 769 2.89

3 Certain conditions of theperinatal period

9108 9.74

4 Respiratory system disease 8190 3.995 Gastrointestinal disease 6825 2.916 Injuries, intoxications, and other

external causes5767 2.99

7 Endocrine, nutrition, andmetabolic disease

5585 6.73

8 Urinary tract disease 4542 3.569 Neoplasm 4332 4.70

10 Unknown signs, symptoms, andabnormal laboratory findings

4238 2.80

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

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


carry out basic endoscopy competency and esophageal dila-tations. Second-level advanced endoscopy competency con-sists of basic endoscopy competency and all therapeuticendoscopy procedures and advanced endoscopy procedures(i.e. enteroscopy and endoscopic ultrasonography). Cur-

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

Table 4 Hospitals currently providing gastrointestinal endoscopy service in Indonesia

No. Province No. hospitals

July 2008 September 2010 July 2011 July 2012 March 2013

Java1 Jakarta 48 50 51 54 542 Banten 8 11 11 11 133 West Java 10 21 25 42 424 Yogyakarta 4 5 5 5 55 Central Java 15 21 25 39 396 East Java 13 19 29 36 36

Nusa Tenggara7 Bali 2 6 7 11 128 West Nusa Tenggara 1 3 3 3 39 East Nusa Tenggara 0 1 1 1 1

Sumatra10 Lampung 1 4 4 5 511 South Sumatra 3 3 6 7 712 Bangka Belitung 0 1 1 1 113 Bengkulu 1 1 1 1 114 Jambi 2 2 2 4 515 Riau 3 7 9 9 916 Riau Islands 0 1 2 4 517 West Sumatra 2 4 4 4 418 North Sumatra 8 17 22 27 2719 Nanggroe Aceh Darussalam 1 7 8 9 10

Kalimantan20 West Kalimantan 2 4 5 9 921 East Kalimantan 5 8 9 9 922 South Kalimantan 2 3 3 3 323 Central Kalimantan 1 1 1 1 1

Sulawesi24 West Sulawesi 0 0 0 0 025 South Sulawesi 2 2 3 5 626 North Sulawesi 1 2 2 2 227 Central Sulawesi 1 1 1 1 128 South East Sulawesi 0 0 0 0 029 Gorontalo 0 0 1 1 1

Maluku Islands and Papua30 Maluku 0 0 1 1 131 North Maluku 0 0 0 0 032 Papua 0 0 0 1 133 West Papua 0 0 0 0 0

Total 136 205 242 306 313

Cited from Indonesian Society for Digestive Endoscopy Report, August 2013.8



ENDOSCOPY TRAINING SYSTEMIN INDONESIA

IN THE FIRST years of GI endoscopy development inIndonesia, doctors were studying endoscopy-related skills

in several countries, such as Japan, Germany, and The Neth-erlands. Right after the establishment of the IndonesianSociety for Digestive Endoscopy in 1974, endoscopy train-ing was introduced to several main hospitals, such as CiptoMangunkusumo National General Hospital in Jakarta,Sutomo General Hospital in Surabaya, Adam Malik Hospitalin Medan and Hasan Sadikin General Hospital in Bandung.The mission of the Indonesian Society for Digestive Endos-copy is to maintain and to enhance the quality of GI endos-copy services in Indonesia professionally. Considering thenumber of GI endoscopists in Indonesia (515 doctors) whoare in service all around the country, it is still far from ideal.For this reason, the Indonesian Society for Digestive Endos-copy keeps increasing the number of endoscopy trainingcenters with the vision of enhancing the quality and quantityof endoscopists in Indonesia. Evidence is lacking on theideal endoscopist-to-population ratio, but in the USA in2003, the ratio between consultant gastroenterologist andpopulation is 1:37 037, whereas in England in 2007, the ratio

ranged between 1:49 000 and 1:93 000. In Indonesia, theideal number should be one gastroenterologist per one dis-trict (capable of carrying out GI endoscopy services). As thetotal population of Indonesia is assumed to be approximately250 million and the average number of citizens per districtis 100 000, therefore, ideally, 2500 consultant gastroenter-ologists are required. In recent years, only 10 gastrointestinalendoscopy training centers were established (Table 6).Thus, further development of well-distributed centers is indemand.8–10

In recent times, gastrointestinal endoscopy training inIndonesia consists of basic gastrointestinal endoscopy train-ing which trainees are internists, surgeons, or pediatriciansand further endoscopy training as part of fellowship forconsultant gastroenterologists.8

Basic GI endoscopy training is under way in all GIendoscopy training centers in Indonesia with 3–6 monthsduration of training. Besides lectures on GI endoscopy,trainees are practically trained, starting from observationalstudies, followed by endoscopy under supervision and, fin-ally, unsupervised endoscopy. During the training, traineesare expected to independently carry out 75–100 esopha-gogastroduodenoscopies and 30–50 colonoscopies. Train-ees are also expected to undergo five to 10 unsupervised

Table 5 Distribution of doctors carrying out GI endoscopy procedures in Indonesia

No. Province Specialization Total

Internist Pediatrician Surgeon GeneralPractitioner

1 Jakarta and Banten 119 12 28 6 1652 East Java 40 6 13 0 593 North Sumatra and Jambi 32 1 6 0 394 West Java 24 3 9 0 365 South Sulawesi 6 0 8 0 146 West Sumatra 5 1 1 0 77 North Sumatra 13 1 4 0 188 Yogyakarta 17 4 4 0 259 Surakarta 11 1 4 0 16

10 Central Java 22 1 10 0 3311 West Nusa Tenggara 4 0 2 1 712 Malang 7 1 5 0 1313 Bali 12 2 3 0 1714 North Sulawesi, West Sulawesi, Central Sulawesi,

Gorontalo, Maluku and Papua2 0 5 0 7

15 South Kalimantan 3 0 0 0 316 East Kalimantan, West Kalimantan and Central Kalimantan 18 0 1 0 1917 Lampung 4 0 0 0 418 Riau 15 2 2 0 1919 Banda Aceh 12 1 1 0 4

Total 366 37 106 7 516




esophageal varices ligations and esophageal varices sclero-therapy. Upon completion of the training, trainees should beprepared to appropriately recommend endoscopic proce-dures, as indicated, with explicit understanding of specificindications, contraindications, and diagnostic/therapeuticalternatives, carry out the procedures safely, including prin-ciples of conscious sedation and the use of anesthesia-assisted sedation where appropriate. They are also expectedto have explicit understanding of pre-procedure clinicalassessment and patient monitoring, interpret endoscopicfindings and integrate them into medical or endoscopictherapy, identify risk factors for each procedure and appro-

priately manage complications when they occur andacknowledge the limitations of endoscopic procedures andpersonal skills and when to request help. Henceforth, theyshould periodically report endoscopy activities in their insti-tution. Trainees are encouraged to continuously attend con-tinuing medical education (CME), especially in the field ofgastroenterology and GI endoscopy in Indonesia and over-seas8,11 (Fig. 1).

Gastrointestinal endoscopy training is also eligible as apart of a fellowship program for consultant gastroenterolo-gists in Indonesia. During 3–4 years of fellowship, fellowsalso attain endoscopy modules according to the facilities

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 Jakarta (Cipto Mangunkusumo National General Hospital) 3 6 10 6 8 12 8 8 6 12 10 892 Surabaya (Dr Soetomo General Hospital) 1 1 2 2 2 3 5 6 5 4 5 363 Medan (H. Adam Malik General Hospital) 1 1 1 2 2 5 5 5 3 4 5 344 Bandung (Dr Hasan Sadikin General Hospital) 1 1 2 1 2 4 2 3 3 3 3 255 Semarang (Dr Kariadi General Hospital) 1 3 3 2 3 3 156 Yogyakarta (Dr Sardjito General Hospital) 3 3 5 4 157 Denpasar (Sanglah General Hospital) 1 3 0 1 58 Surakarta (Dr Moewardi General Hospital) 1 3 49 Malang (Dr Saiful Anwar General Hospital) 2 2

10 Makassar (Dr Wahidin Sudiro Husodo General Hospital) 1 1No. trainees 6 9 15 11 14 25 23 29 25 32 37 226


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



provided in each center. Today, there are only six accreditedconsultant gastroenterologist fellowship centers in Indone-sia (Jakarta, Surabaya, Medan, Yogyakarta, Semarang, andBandung). As a result of the lack of facilities, there arelimitations in the capacity to train fellow consultant gas-troenterologists. As of July 2013, the number of consultantgastroenterologists in Indonesia was 113 doctors only(Table 7). This number is lacking considering the size ofthe Indonesian population and its health problems, espe-cially GI disease. Problems regarding training at advancedGI endoscopy level are due to the limited number of com-petent doctors able to carry out advanced GI endoscopyand the poorly distributed facilities of advanced GI endos-copy among the centers. In daily practice, not all consultantgastroenterologists in Indonesia carry out advanced GIendoscopy procedures because of the poor distribution ofpatients with complicated GI disease requiring advancedGI endoscopy procedures.8

CONCLUSIONS

GASTROINTESTINAL DISEASE REMAINS one ofthe main health problems in Indonesia, both for outpa

tients and inpatients, and is the fifth major cause of deathnationwide. In contrast, GI endoscopy facilities, one of themain diagnostic and therapeutic modalities in the manage-

ment of GI disease, are still limited. The number of hospitalsequipped with GI endoscopy facilities and doctors that arecompetent to carry out diagnostic and therapeutic GI endos-copy are prominently limited. Today, GI endoscopy remainsa high-cost health-care service that is unaffordable for mostcitizens. Now and in the future, the government plans tobroaden health-care coverage including GI endoscopy pro-cedures, and to provide GI endoscopy facilities especially ingovernment-owned hospitals. Concurrently, the IndonesianSociety for Digestive Endoscopy has been collaborativelyworking with existing GI endoscopy training centers in Indo-nesia to increase both the quality and number of GI endos-copists, covering both basic and advanced GI endoscopylevels. The Indonesian Society for Digestive Endoscopy alsoplans to send potential members to enhance their skills andknowledge in international GI endoscopy training centersworldwide. In the coming years, the GI endoscopy service inIndonesia is envisioned to equal that of international stan-dards and, specifically, to fulfil the standard of health care inthe Asia–Pacific region.

ACKNOWLEDGMENTS

THE AUTHORS THANK Dr Jeffri A. Gunawan andMs Shinta Lestiani for their editorial assistance.

Table 7 No. consultant gastroenterologists in Indonesia

No. Province No. consultant gastroenterologists

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

1 Jakarta and Banten 19 20 20 25 25 26 28 31 38 38 412 West Java 6 6 6 6 6 6 7 8 8 10 93 North Sumatra and Jambi 5 8 8 9 9 9 9 9 11 10 124 West Java 5 5 4 5 5 6 7 7 7 7 75 South Sulawesi 2 2 2 2 2 2 3 3 2 2 26 West Sumatra 2 2 2 2 2 2 2 2 2 3 37 South Sumatra 2 3 3 3 3 2 2 2 5 5 58 Yogyakarta 1 1 1 2 2 3 6 6 6 6 69 Surakarta 1 1 1 1 1 2 2 2 2 2 3

10 Central Java 4 4 4 4 4 4 5 5 6 7 611 East Nusa Tenggara 1 1 1 1 1 1 1 1 1 2 212 Malang 2 2 2 2 2 2 3 3 4 4 413 Bali 1 1 1 3 3 3 3 3 4 4 414 North Sulawesi 1 1 1 1 1 2 2 2 2 2 215 South Kalimantan 0 1 1 1 1 1 1 1 2 2 216 West Kalimantan 0 0 0 0 0 0 0 0 0 0 117 Lampung 0 0 0 0 0 0 0 0 1 1 118 Riau 0 0 0 1 1 1 1 1 1 2 219 Banda Aceh 0 0 0 0 0 0 1 1 1 1 1

Total 52 58 57 68 68 72 83 87 103 108 113

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



CONFLICT OF INTERESTS

THE AUTHORS DECLARE no conflict of interests forthis article.

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http://www.health.mo.gov

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http://gsg.org.uk

present status of endoscopy, therapeutic endoscopy and the endoscopy training system in indonesia

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