Pediatric Gastroenterology, Hepatology, and Nutrition Training in the Asia-Pacific Region: An International Survey of Training Centers

Abstract

Purpose

Published data on pediatric gastroenterology, hepatology, and nutrition (PGHN) training centers in the Asia-Pacific region are limited. This study aimed to evaluate the infrastructure, resources, and training opportunities in PGHN centers across the region to inform future development of training programs.

Methods

We conducted an international multicenter, cross-sectional survey among Asia-Pacific nations between August 2023 and July 2024.

Results

A total of 43 responses were received from 11 countries. Most centers (58.1%) operated with ≤3 specialists, and trainees in these centers were less likely to receive formal supervision or participate in research. Procedural exposure varied significantly: although endoscopy was widely available, 50% of centers reported fewer than 100 colonoscopies performed annually. Access to training in specialized procedures was limited (pH/impedance, 48.8%; high-resolution manometry, 34.9%; intestinal ultrasound, 41.9%), with radiologists performing most liver biopsies and intestinal ultrasounds in many centers.

Conclusion

This first comprehensive survey of PGHN training in the Asia-Pacific region identified considerable variations, with key challenges in training infrastructure and procedural exposure. Most centers operate with limited specialist numbers, impacting supervision and research opportunities, and many struggle to meet international volume-based training requirements for essential procedures. Enhanced regional collaboration and alternative training approaches may help address these gaps.

INTRODUCTION

Pediatric Gastroenterology, Hepatology, and Nutrition (PGHN) has been recognized as a pediatric specialty in recent decades, with growing awareness that the management of digestive disorders in children differs substantially from adult care. The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was established in 1968, followed by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN), founded in 1988 in Australia [1]. PGHN has gained increasingly formal recognition in many Asia-Pacific countries, alongside the progressive establishment and provision of clinical services to meet demand; however, comprehensive formal training pathways and access to specific training curricula remain variable [2,3,4,5,6].

The quality of any medical training program is influenced by the availability of qualified supervising personnel and trainers, as well as the infrastructure and facilities of the training centers. A recent ESPGHAN National Societies Network survey highlighted discrepancies among PGHN training centers across Europe [7]. Although training guidelines and syllabi are well established in North America and certain parts of Europe [8,9], no consensus standards exist in the Asia-Pacific region. A recent survey by APPSGHAN described current pediatric endoscopy training; however, other aspects of PGHN training in this region were not examined [10]. Understanding the current state of PGHN training in the region and identifying areas of need are essential foundations for developing future training standards and courses. Collaborative approaches to training and education may foster mutual understanding within the region, enhancing the quality of care provided to children with gastroenterological, liver, or nutritional conditions.

This study aimed to describe and evaluate the current state of PGHN training in the Asia-Pacific region, including the number of specialists, patient volume, and procedural volume.

MATERIALS AND METHODS

Study design

This international, multicenter, cross-sectional observational study was conducted using a survey. Hospitals in the Asia-Pacific region with pediatric gastroenterology departments, services, or training programs were invited to participate. Hospitals were identified through members of the Asia-Pacific Association of Gastroenterology Emerging Leader Committee pediatric focus group, either directly or by contacting their respective national PGHN societies to identify training centers. Invitations to participate were sent by email to the head of the PGHN department, a designated representative, or, alternatively, the head of the pediatric department where no formal PGHN department existed. One survey response was obtained from each training site.

Survey responses were collected between August 1, 2023, and July 31, 2024. Minor adjustments were made to some responses following follow-up correspondence with respondents to clarify data, such as in cases of erroneous or duplicate entries.

Given the complexity of training duration and certification requirements, responses were verified through direct communication with participants, consultation of official sources, and confirmation by authors from the respective countries. Additional contacts were made with non-responding countries to provide a more comprehensive Asia-Pacific region overview.

Survey design

The survey utilized a modified version of a previously used questionnaire [7], tailored to the Asia-Pacific region (Supplementary File 1). Detailed questions relating to endoscopy were omitted, given that a recently published survey focused on endoscopy [10]. Comprehensive information across multiple domains of training centers, including program structure (existence of formal training programs, certification status, and trainee numbers), curriculum content, specialized clinics, patient volume, availability and volume of diagnostic and therapeutic procedures, emergency service coverage, and specialist and allied healthcare professional composition, was collected. The questionnaires were disseminated via Qualtrics^TM (Qualtrics, LLC).

This study was approved by the Joint Institutional Review Board, Taipei Medical University (study code N202308057), which granted a waiver of written informed consent. The study involved a survey of healthcare professionals regarding their institutional training programs and was classified as minimal risk. No patient data or personal health information was collected. An introductory statement outlining the study’s purpose and investigator contact information was provided at the beginning of the survey.

Statistical analysis

Descriptive analyses were conducted for all variables. Categorical data were presented as absolute numbers and proportions (in percentages), whereas continuous variables were reported as median and interquartile range (IQR). Chi-square tests were used for categorical data analysis. Correlations between ordinal categorical variables (such as patient volume categories) and continuous variables were analyzed using Spearman’s rank correlation test, as appropriate for the ordinal nature of these data.

RESULTS

Summary of responding centers

A total of 43 responses were received from 11 countries: India (10), Hong Kong (8), Australia (5), Malaysia (5), Taiwan (4), Indonesia (3), Thailand (3), Vietnam (2), New Zealand (1), the Philippines (1), and the Republic of Korea (1) (Fig. 1).

Fig. 1. Geographic distribution of training centers responding to the Survey. Map created with mapchart.net.

Training program, duration, and certification

To better understand PGHN training structures, correspondence was conducted with Singapore and Japan regarding their training structures. Among the participating countries, only Hong Kong lacked specific PGHN training programs. All eight Hong Kong centers provided training integrated with general pediatrics, with three (37.5%) incorporating adult gastroenterology/hepatology training.

Training duration requirements varied significantly across the Asia-Pacific region, with most countries requiring either a 24- or 36-month program (Supplementary Table 1). The Republic of Korea operates a uniquely tiered system requiring 24 months for subspecialty board examination eligibility and a minimum of 12 months for fellowship program certification. Vietnam reported a training duration of 6 months.

Accreditation responsibilities differed substantially across the region. Training programs were overseen by various bodies, including physician societies, medical councils, government specialist boards, pediatric associations, PGHN societies, or multiple bodies, with some countries lacking formal certification structures (Supplementary Table 1).

India demonstrated considerable variation, reflecting its complex medical training structure (Supplementary Table 2). Training duration ranged from 12 to 36 months, with accreditation provided by the PGHN society, government medical councils, or national examination boards, and local state universities.

Japan operates a dual-tier certification structure distinguishing between "Senmon-i (Board Certified Specialist)" and "Nintei-i (Certified Physician)," with Senmon-i representing the higher level [11]. The only pediatric gastroenterology-specific qualification is the "Certified Physician of Japanese Society of Pediatric Gastroenterology, Hepatology and Nutrition," operating at the lower Nintei-i level through membership maintenance and case summary submission without requiring formal institutional training [12]. Although many centers offer packaged PGHN training programs, these programs lack formal oversight and do not lead to recognized qualifications. Consequently, many pediatric gastroenterologists pursue adult gastroenterology board certifications from organizations like the Japanese Society of Gastroenterology, which grants the official "Senmon-i" qualifications recognized by the Japan Medical Specialty Board (JMSB) [11,13]. These adult programs require structured training, including examinations and mandatory periods at JMSB-accredited institutions, offering comprehensive gastroenterology expertise that complements pediatric practice within Japan’s medical specialty framework.

Number of total specialists

There was a wide distribution in the total number of specialists per center (median, 3; IQR: 1–6; Fig. 2). Most centers (62.8%, n=27) operated with ≤3 full-time specialists. Even when part-time specialists were included, over half of the centers (53.5%, n=23) still had ≤3 specialists.

Fig. 2. Number of specialists per center.

NA: not available, SD: standard deviation.

Thirty-eight centers (88.4%) maintained a ratio of ≤2 trainees per specialist when both full-and part-time specialists were counted. This ratio remained high (35 centers, 81.4%) when only full-time specialists were considered.

The total number of specialists per center correlated with the outpatient (Spearman’s rho=0.649, p<0.001) and inpatient volumes (Spearman’s rho=0.702, p<0.001).

Centers with ≥4 specialists were significantly more likely to have assigned supervisors at regular meetings (76.5% vs. 30.4%, p=0.015), requiring trainees to participate in research or quality improvement projects (100.0% vs. 73.9%, p=0.035) (Table 1). They were also more likely to have affiliated research laboratories (64.7% vs. 17.4%; p=0.022). In addition, these centers were more likely to provide supervision for research activities (94.1% vs. 69.6%, p=0.325) and training in research methodology (58.8% vs. 34.8%, p=0.611) compared with centers with fewer specializations; however, these differences were not statistically significant.

Table 1. Comparison of supervision, research involvement, and resources based on specialist group size.

Characteristics		Center with <4 specialists	Center with ≥4 specialists	p-value
Number of centers		23	17
Formal supervision or regular meeting				0.015*
	Assigned supervisor with regular meetings	7 (30.4)	13 (76.5)
	No assigned supervisor, but regular meetings	5 (21.7)	3 (17.6)
	No designated supervisor, no scheduled meetings, but informal supervision possible	9 (39.1)	1 (5.9)
	No response	2 (8.7)	0 (0.0)
Expected to participate in a research or quality improvement project				0.035*
	Yes	17 (73.9)	17 (100.0)
	No	5 (21.7)	0 (0.0)
	No response	1 (4.3)	0 (0.0)
Supervision for research activities		16 (69.6)	16 (94.1)	0.325
Research laboratories		4 (17.4)	11 (64.7)	0.022*
Training in research methodology		8 (34.8)	10 (58.8)	0.611

Values are presented as number only or number (%). A total of 40 centers replied to the questions.

^*p-value <0.05.

p-values were calculated using the chi-square test.

Patient volume

All responding training centers reported outpatient and inpatient volumes (Fig. 3, Supplementary Table 3). Approximately half of the centers had an outpatient volume of approximately 501-3,000 annually, with nearly a quarter (23.3%) of the reported volumes exceeding 5,000 annually (such as Australia, India, Taiwan, and Vietnam). Most centers had an inpatient load <1,500 patients annually (72.1%).

Fig. 3. Patient volumes of the training centers per year.

Specialized PGHN facilities and emergency coverage

Approximately one-third of the responding centers (13 centers, 30.2%) had separate specialized PGHN wards or beds, with most utilizing general pediatrics facilities for inpatient admissions. Despite this, most institutions (30 centers, 69.8%) provided 24/7 pediatric gastroenterology emergency coverage, with some offering partial monthly coverage. Up to 20% of centers lacked on-call pediatric gastroenterologist/hepatologist services (Supplementary Table 4).

Endoscopy and Intestinal Ultrasound (IUS)

Most centers performed upper gastrointestinal (GI) endoscopy and colonoscopy (Table 2). The median numbers of upper GI, lower GI, and therapeutic endoscopies per center annually were 292, 85, and 50, respectively. Among centers that reported their procedure volumes, 80.7% performed ≥100 upper GI endoscopies annually, with only 50% conducting ≥100 lower GI endoscopies annually.

Table 2. Number of endoscopic procedures and liver biopsies.

Procedure	No. responded	Number of procedures per year
		Median (interquartile range)	<100	100–199	200–499	≥500	Not reported
UGI endoscopy	42	292.0 (127.5–500.0)	5 (19.2)	6 (23.1)	7 (26.9)	8 (30.8)	16
LGI endoscopy	38	85.0 (50.0–200.0)	12 (50.0)	2 (8.3)	9 (37.5)	1 (4.2)	14
Therapeutic endoscopy	33	50.0 (40.0–137.5)	14 (63.6)	3 (13.6)	4 (18.2)	1 (4.6)	11
Procedure	No. responded	Number of procedures per year
		Median (interquartile range)	≤10	11–50	51–100	>100	Not reported
Liver biopsies	41	25.0 (10.0–62.5)	8 (36.4)	10 (45.5)	3 (13.6)	3 (13.6)	19

Values are presented as number only, median (interquartile range), or number (%). The denominator for the percentage was the number of centers that reported the number of procedures.

UGI: upper gastrointestinal, LGI: lower gastrointestinal.

Among the 33 centers performing therapeutic endoscopy, the most common procedures were foreign body removal and management of upper GI bleeding (variceal banding, hemostatic clips, or sclerotherapy) (both at 97.0%). The least commonly performed procedures were endoscopic retrograde cholangiopancreatography (54.6%) and percutaneous endoscopic gastrostomy (78.8%) (Supplementary Table 5). Most centers offered capsule endoscopy, with a median of approximately five procedures per year. The majority of centers (73.3%) performed fewer than ten procedures annually. Eighteen centers (41.9%) performed IUS; among those reporting annual procedure volumes, seven centers (63.6%) performed ≥40 procedures annually (Supplementary Table 6).

The volumes of upper and lower GI endoscopies were significantly associated with the outpatient and inpatient volumes (Supplementary Table 7). However, therapeutics and capsule endoscopy volumes did not correlate with patient volume.

Motility investigations

A total of 26 centers (60.5%) conducted pH monitoring or combined pH-Impedance Monitoring, and 15 centers (34.9%) performed high-resolution manometry (Supplementary Table 8). Eleven centers (25.6%) conducted pH monitoring alone, whereas 21 (48.8%) performed combined pH-impedance monitoring. The annual study volume varied widely, with a significant number of centers performing very few procedures (<10), representing 37.5% and 36.4% of reporting centers for pH/impedance and high-resolution manometry, respectively.

Liver biopsies

Most centers (95.4%) performed liver biopsies (Table 2). Among the 22 centers that reported annual procedures, 45.5% performed 11–50 procedures annually, while 36.4% performed ≤10 annual liver biopsies. The three centers that reported the highest number of annual liver biopsies (200 annually) were all located in India (New Delhi, Pune, and Lucknow). The number of liver biopsies significantly correlated with the center’s inpatient volume (Spearman’s rho=0.433, p=0.035; Supplementary Table 7).

Procedure performers and training inclusion

Most endoscopies were performed by pediatric gastroenterologists (92.9%); however, in some units, procedures were also performed by adult gastroenterologists (54.8%) and pediatric surgeons (31.0%) (Table 3). Motility examinations were mainly performed by pediatric gastroenterologists (63.6%), followed by adult gastroenterologists (51.5%). However, liver biopsies and IUS were often performed by other specialists, predominantly specialized radiologists (47.6% and 62.1%, respectively). Pediatric gastroenterologists performed liver biopsies in only 54.8% of centers and IUS in 34.5%. When analyzed by country/region, liver biopsies were predominantly performed by radiologists in Australia, Hong Kong, Malaysia, and Vietnam (Supplementary Table 9).

Table 3. Procedure performers.

Procedure	Pediatric gastroenterologist	Pediatric surgeon	Adult gastroenterologist	Radiologist	Procedures not available
Endoscopy	39 (92.9)	13 (31.0)	23 (54.8)	1 (2.4)	0
Motility	21 (63.6)	2 (6.1)	17 (51.5)	0 (0.0)	9
Liver biopsy	23 (54.8)	6 (14.3)	9 (21.4)	20 (47.6)	0
IUS	10 (34.5)	1 (3.4)	7 (24.1)	18 (62.1)	13

Values are presented as number (%). A total of 42 centers responded to this question. The denominator of the percentage was 42 minus the number of centers that were unavailable for the procedure.

IUS: intestinal ultrasound.

More than half of centers incorporated endoscopy as part of their formal PGHN training programs (27 centers, 62.8%), with liver biopsies in approximately half of the centers (23 centers, 53.5%). Motility studies and IUS were incorporated in 14 (32.6%) and six centers (14.0%), respectively.

DISCUSSION

This study represents the first comprehensive multinational assessment of PGHN training across the Asia-Pacific region, encompassing 43 training centers from 11 countries. Our findings highlight a rapidly developing subspecialty with structural challenges that may impact the quality of training and, ultimately, patient care across this diverse region.

Training duration and accreditation systems varied across the region. Although most countries require 2–3 year programs with standardized oversight, complex, multitiered systems exist in several countries. The significant heterogeneity identified warrants further investigation to examine implications for trainee mobility, credential recognition, and the standardization of PGHN competencies across the region.

Limited specialist numbers and supervision quality

Most centers (62.8%) in the region have ≤3 PGHN specialists, similar to Europe, where the median number of full-time specialists per training center is three (range, 0–17) [7]. In contrast, a survey in the United States reported a median of 7.4 pediatric gastroenterologists per training program, with a wide range [14].

Centers with larger faculty numbers tend to provide more formal supervision, and trainees are more likely to participate in research activities. Faculty numbers and funding are often directly related to patient volume, with higher-load centers generally requiring more specialists to manage clinical demands. However, funding models vary considerably among nations, and some institutions without formal associations with universities or research laboratories may find it challenging to create pathways integrating research into their clinical roles. In response to these challenges, a collaborative approach to training between centers could be invaluable, utilizing local joint training programs or creating regional opportunities for trainees to rotate between centers through bodies such as the Asia-Pacific or local PGHN societies. Similar strategies could include supporting trainee participation in collaborative learning opportunities, such as the Young Research Curriculum by ESPGHAN or the Fellows Conference by NASPGHAN [15,16]. In addition to improving training opportunities and exposure, the administrative workload for training organizations could be more effectively shared across institutions and specialists.

Inadequate procedural training volumes

The second key aspect identified in our survey was the limited availability of procedural training opportunities. NASPGHAN recommends a minimum of 120 colonoscopies and 100 upper endoscopies before completion of training, whereas in Australia, 100 colonoscopies and 200 upper endoscopies are performed independently [8,17]. By this standard, current lower GI endoscopy numbers are insufficient to meet formal training requirements in more than half of the participating PGHN training centers, a finding similarly noted in a recent APPSPGHAN’s report [10]. For trainees, this may result in extended training duration and challenges when applying for consultant positions once they have completed their formal PGHN training program, if they have not yet achieved the requisite endoscopy numbers or certification.

The availability of pediatric GI motility and IUS training in centers is also a concern. Although 78% and 41% of European centers offer pH/impedance studies and high-resolution manometry, respectively, only 48.8% and 34.9% reported providing these services in our survey, respectively [18]. Many centers report limited motility studies, with only a third of training programs, including neurogastroenterology and motility, potentially hindering fellows’ ability to manage these conditions or pursue subspecialty interests in this area.

To increase the volume of training, the incorporation of simulation training, such as mechanical models or virtual reality simulation, may help address these shortcomings [19,20]. Centralized endoscopy training through external bodies like ESPGHAN’s Endoscopy Fellowship Program may provide trainees with additional procedural experience through focused 3–6 month rotations at specialized centers [21]. Collaboration among existing IUS-certified centers in Australia, Hong Kong, India, and Japan could enhance regional training opportunities in intestinal ultrasound [22].

The transition from volume- or case-based to competency-based programs, or so-called competency-based medical education, is also reflected in recent endoscopic training curricula [10,23,24]. However, in the recent APPSGHAN report, more than 70–80% of the participating centers did not incorporate quality assessment systems into their program [10]. This is because a validated assessment is needed to assess the competency [25]. NASPGHAN and ESPGHAN recently proposed a pediatric endoscopy quality improvement network (PEnQuIN) guidelines [26]. Competence assessment tools, such as the GI Endoscopy Competency Assessment Tool for pediatric endoscopy (GiECAT_kids) [27], and Direct Observation of Procedural Skills have also been developed and validated [28]. Implementation of these standardized tools can ensure each procedure is meaningful and that trainees achieve competency at the end of their training, regardless of whether it is a resource- or patient volume-limited center.

Evolving roles in procedure performance

The third key point is the variability in training competency requirements and the shifting roles of procedure performers. With advances in interventional radiology, an increasing number of liver biopsies (47.6% of centers in our study) are being performed by radiologists, a trend also observable in North America and Europe [8,29]. This shift is reflected in training competency requirements, as both NASPGHAN and ESPGHAN now require trainees to understand the indications, contraindications, complications, and interpretation of liver biopsies as a minimum standard, rather than requiring competency in liver biopsy procedure for every trainee [8,9]. Our survey results confirmed this trend, with liver biopsies included in only approximately half of the training programs.

This evolution suggests a model of shared care in which competency and availability, rather than traditional disciplinary boundaries, determine optimal procedural roles. For example, while pediatric gastroenterologists are now increasingly performing real-time ultrasound due to improved device accessibility, radiologists with greater procedural volumes are better suited for liver biopsies [30]. Trainees should therefore be prepared for regional practice variations and trained in competencies aligned with local healthcare delivery models and their intended career paths.

Nevertheless, adequate procedural training should be available for trainees who wish to perform these techniques. According to NASPGHAN guidelines, trainees who elect to perform liver biopsies should complete a minimum of 15 supervised procedures [8]. By this standard, 19.5% of centers performing liver biopsies in our survey reported <15 procedures annually, indicating that these centers are unlikely to have sufficient case volume to utilize this procedure. Although specialized procedures such as liver biopsies or IUS, and topics such as liver and intestinal transplantation may not be essential for trainees planning careers outside academic centers, limited exposure to these procedures during training could restrict future practice capabilities. Training program directors and regional societies should strive to provide learning opportunities in these areas through the aforementioned collaborative approach.

Limitations and conclusions

This study has some limitations. Despite our best efforts, we were unable to obtain data from several nations in the region, including some with known active PGHN programs, such as Japan and Singapore, with Korea providing a single response. Since 2024, Korea has faced significant challenges due to a healthcare workforce crisis that severely disrupted hospital operations, making comprehensive survey participation extremely difficult. Among the participating countries, response rates also varied significantly, with India and Hong Kong contributing 42% of all responses (10 and 8 centers, respectively). Although our study provides valuable data from these regions, geographical distribution should be considered when interpreting the findings across the broader Asia-Pacific context. In addition, not every question was answered by every participating center. Furthermore, the survey was administered over a year due to difficulties encountered during the recruitment of centers; however, circumstances might have changed for the initial responding centers. Nevertheless, our findings correlate with APPSPGHAN’s report on the limited number of endoscopy procedures [10] and the global trend of radiologists increasingly performing liver biopsies [29]. This study provides important initial insights and an overview of the current status of PGHN training centers in this region.

Based on our findings, several concrete initiatives to address the identified training gaps should be created. Joint training programs modeled after ESPGHAN’s Endoscopy Fellowship Program provide high-volume procedural experience for trainees from smaller centers [21]. Regional collaboration through existing platforms such as APPSPGHAN’s masterclasses and joint educational webinars should be expanded to include structured rotation programs and shared curriculum development [31,32]. Implementation of competency-based assessment tools such as GiECAT_kids and PEnQuIN guidelines would ensure training quality consistency across centers with varying case volumes [26,27]. In addition, simulation training centers should be established in major regional hubs to supplement limited procedural exposure in resource-constrained settings [20].

In conclusion, our study reveals several important challenges. Notably, over half of the training centers operate with ≤3 specialists, impacting both supervision quality and research opportunities for trainees. Second, many centers struggle to meet the current number-based training requirements for procedures, such as LGI endoscopy, motility studies, and liver biopsies. Third, there is a growing trend of radiologist involvement in certain GI procedures. Future collaboration and educational endeavors should consider joint training initiatives between centers, the role of competency-based assessments alongside volume-based requirements, use of simulation-based training, and expanded opportunities for international collaboration to optimize PGHN training in the Asia-Pacific region and subsequent patient care for children with digestive conditions.

SUPPLEMENTARY MATERIALS

Supplementary File 1

APAC Pediatric GI training

Supplementary Table 1

Training duration and accreditation body

Supplementary Table 2

Training duration and accreditation body in India

Supplementary Table 3

Patient volumes of the training centers annually

Supplementary Table 4

Pediatric gastroenterologist and hepatologists on call

Supplementary Table 5

Therapeutic endoscopies

Supplementary Table 6

Number of capsule endoscopy procedures and intestinal ultrasound

Supplementary Table 7

Correlation between patient volume and procedure amounts

Supplementary Table 8

Motility investigations

Supplementary Table 9

Liver biopsies and intestinal ultrasound performer by countries or region