Barrett’s esophagus (BE) is not only a complication of gastroesophageal reflux disease (GERD), but also a precancerous lesion of esophageal adenocarcinoma (EAC). The prevalence of BE and incidence of EAC has been increased in Western Counties. In the past, the prevalence of BE in Asia was lower than that in Western Countries. Differences in study design, enrolled population, and endoscopic biopsy protocols used have led to substantial variability in the reported BE prevalence (0.06% to 19.9%) across Asia. However, with lifestyle changing, the prevalence of GERD symptoms and reflux esophagitis has increased. In Taiwan, some studies revealed the prevalence of BE was ranging from 0.8% to 2.0% between 1997 and 2010. We designed a first prospective multicenter study to evaluate the current prevalence of BE in Taiwan. Ten hospitals have participated this study since November, 2020. We have enrolled 2259 patients and 62 patients were diagnosed Barrett’s esophagus. The preliminary result showed the prevalence of BE in Taiwan was 2.7%. Compared with ten years ago, the prevalence of BE has increased.

Key Words: Barrett’s esophagus, Esophageal adenocarcinoma, Gastroesophageal reflux disease, Prevalence.

Two major system are used for diagnosing Barrett’s esophagus (BE), the American College of Gastroenterology (ACG) vs British Society of Gastroenterology (BSG). The ASG system, which is used by the pathologists in Taiwan, focuses on the presence of intestinal metaplasia and goblet cells. The definition of goblet cells is objective and currently there are no specific objective methodology, such as histochemical or immunohistochemical stainings. The same situation is also seen in diagnosing the degree of dysplasia. It is important to evaluate the status of dysplasia in the diagnosis of BE. However, the criteria for evaluating dysplasia is not clear and not objective. Moreover, currently no stainings, such as p53, are specific enough and the situation is similar as seen in evaluating the presence of goblet cells. More studies are needed for more objective methodology in determining the presence of intestinal metaplasia and degree of dysplasia.

Although Barrett esophagus (BE) is uncommon in Taiwan, adenocarcinoma due to progression of BE remained a problem not to be ignored. In the past decades, the incidence of BE increased gradually in proportional to that of reflux esophagitis. However, the diagnosis and endoscopic therapy of BE are still challenging in Taiwan. Standardization of diagnosis and management for BE are crucial.

In July 2020, a multi-center survey focusing on current diagnosis and endoscopic therapy of BE was done on behalf of the digestive endoscopy society of Taiwan (DEST). Pre questionnaire surveys of the current status about the diagnosis and endoscopic therapy of BE were taken, followed by literature reviews of currently updated guidelines. After literature reviews, the post questionnaire surveys with similar questions were performed followed by detail discussion.

Only half participants agreed IM as an essential feature for the diagnosis of BE. However, IM was regarded as a diagnostic criteria of BE by pathologists in real world practice. This remained the major dispute in Taiwan. Seldom endoscopists followed the Seattle protocol but almost all participants preferred to use Plaque C & M criteria to describe the extension of BE. Controversies existed between the top of gastric fold and lower border of palisading vessel as a landmark of ECJ. More than one third participants would like to take aggressive measures to manage BE with low-grade dysplasia. Endoscopic resection still is the 1st choice of treatment for Barrett mucosa with high-grade dysplasia. Additional therapy with radio-frequency ablation (RFA) for remaining Barrett mucosa is strongly recommended after eradication of dysplastic part.

This survey demonstrated the real-world condition of the diagnosis and treatment for Barrett disease in Taiwan. Further communication between the endoscopists and the pathologists will be arranged to make a consensus by DEST in the future.

In the West, endoscopic surveillance every 2 to 5 years is recommended for Barrett's esophagus (BE) patients. However, there is no established surveillance method in Japan. In recent years, the incidence of adenocarcinoma from BE longer than 2 cm in Japan have been reported to be similar with the West. In Japan, random biopsies are rarely performed, and targeted biopsies of suspected lesions are commonly done. There are many reports of observation of Barrett's mucosal pattern by magnifying endoscopy with image-enhanced endoscopy (IEE), such as acetic acid, Narrow Band Imaging (NBI), and Blue light image (BLI) as an effective alternative to random biopsy.

In addition, the usefulness of Linked Color Imaging (LCI) has also been reported recently. For surveillance of adenocarcinoma arising from BE, recognizing the characteristics of superficial Barrett's adenocarcinoma and careful observation of the entire BE are needed. Representative characteristics of Barrett's adenocarcinoma are a reddish area and a lesion located on the anterior to the right sidewall. Favorable long-term outcomes with endoscopic submucosal dissection (ESD) have been observed in patients with Barrett’s adenocarcinoma who met the low-risk criteria for lymph node metastasis. It is needed to establish the surveillance methods for BE sooner in Japan.

Pancreatic duct strictures present one of the most challenging diagnostic and therapeutic pancreatic disorders. Patients present with a variety of symptoms, including persistent or recurrent abdominal pain, particularly in the setting of chronic pancreatitis. Other presenting symptoms may be those generally present with chronic pancreatitis and include weight loss, steatorrhea, malnutrition, nausea, and vomiting. In fact, pancreatic duct strictures remain a challenging diagnosis. The etiologies are multiple and diverse. Differential diagnosis includes acute and chronic pancreatitis, pseudocysts, and neoplasm. An accurate diagnosis requires one or more radiographic studies. Appropriate use of endoscopic retrograde cholangiopancreatography (ERCP) allows for the conformation of pancreatic duct strictures, diagnostic tissue sampling, and therapeutic treatment options. Endoscopic techniques in the treatment of strictures have included dilation and pancreatic duct stenting. Several studies have demonstrated the success of placement, safety, and efficacy of transpapillary stenting in benign disease. Complications of stenting have been reported to include stent migration, stent occlusion, episode of acute pancreatitis, and anatomic changes of the main pancreatic duct similar to chronic pancreatitis.

Endoscopic retrograde cholangiopancreatography (ERCP) remains the first-line approach to achieving relief from malignant biliary obstruction. Multi-detector computed tomography is usually performed to assessment the operability of malignant bile duct strictures. In the operable cases, pre-operative drainage should not be routinely done. In the borderline resectable cases using neoadjuvant therapy to downstage disease, biliary metal stent placement is the choice of biliary drainage.

For the palliative drainage of malignant biliary obstruction, self-expandable metal stent (SEMS) has a larger diameter and a longer patency than plastic stent. Bare stent integrates into bile duct wall and stable in the stricture site. Recurrent bile duct obstruction is common due to tumor or tissue ingrowth. Partially covered SEMS prevents tissue embedding and stent-induced hyperplasia and prolongs patency by stopping tumor ingrowth. The limitation of covered SEMS is migration. It can be overcome by anti-migration design of the SEMS. In our study, using the nitinol fully covered SEMS with anti-migration design, the migration rate is only 3%.

Palliative treatment of malignant hilar obstruction (MHO) is more technically demanding. Metal stents designed for bilateral intrahepatic duct placement with sequential, simultaneous side-by-side or stent-in-stent fashions are available on the market. To reduce the patient’s discomfort, avoidance of percutaneous biliary drainage (PBD) is of a paramount importance in patients MHO. As length of survival of MHO patients is continue to improve, initial plastic stent placement and exchange to metal stent later as step-wise endoscopic approach can be considered a better drainage policy to lower risk and rate of rescue of PBD.

Benign biliary strictures (BBS) are challenging to manage. The commonest causes are post-surgical (post-cholecystectomy, post-liver transplantation, bilio-enteric anastomosis) and inflammatory conditions (chronic pancreatitis).

Endoscopic drainage remains the first-line management of benign biliary strictures. The primary goal is to resolve bile duct obstruction, to achieve long-term ductal patency and to maintain liver function. After biliary access, endoscopic sphincterotomy and stenting can be achieved. Single plastic stent insertion is no longer the standard care for BBS. Currently, multiple plastic stent therapy and placement of fully covered self-expandable metal stent (FCSEMS) are the recommended treatments of BBS. For multiple plastic stenting, serial stricture dilation is usually required for the management of severe BBS. Plastic stents should be exchanged tri-monthly with an increasing number and diameter for up to one year. Therefore, several ERCP sessions are needed. On the other hand, FCSEMS placement requires fewer endoscopic sessions and shorter stent duration. In this session, I will present how to management BBS in different etiology and stricture condition (site, length). Update data, tips and stent selections will also be addressed.

Colonoscopy quality is closely associated with the risk of post-colonoscopy colorectal cancer (PCCRC) and affect the effectiveness of a screening program. We analyzed the colonoscopy key quality indicators in the Taiwan CRC Screening Program, which offers biennial FIT screening for people aged 50 to 74 (50 to 69 during 2004 to 2013), using the screening database and linking to Taiwan Cancer Registry database. We calculated the colonoscopy key quality indicators in terms of adenoma detection rate (ADR) and cecal intubation rate (CIR) from 2004 to 2019 and the rate of interval type PCCRC (PCCRCi) of those who underwent colonoscopy after positive FITs during 2004 to 2014 and were followed up till the end of 2017. The PCCRCi was defined based on the consensus of World Endoscopy Organization expert panels (Gastroenterology. 2018;155:909-925.) and the rate was calculated as the event per 1000 person-years.

Overall, 41 753, 217 894, and 265 944 colonoscopies were performed after positive FIT during the inaugural (2004 to 2009), rolling-out (2010-2014), and full program (2015-) stages in Taiwanese CRC Screening Program. ADR was 32.2 %, 42.9 %, and 48.6 %, and CIR was 79.0 %, 93.7% and 97.0% in the correspondent stages. The incidence rates per 1000 person-year of overall 3-year PCCRCi and PCCRCi after negative colonoscopy declined gradually from 2.0 to 1.5 and from 1.9 to 1.1 from inaugural to rolling-out stage, respectively.

Continuous improvement of colonoscopy key quality indicators along with the decline of 3-year PCCRCi rate was observed in FIT-based Taiwan CRC Screening Program since its launch. Nevertheless, improvement in ADR and CIR could only explain 72% of PCCRC reduction. “One-and-done” phenomenon, mis-reporting of cecal intubation, insufficient mucosal exposure technique, incomplete resection of high-risk adenoma and non-adherence to surveillance recommendation are the issues that require further exploration and need to be dealt with.

The protection over colorectal cancer from colonoscopy is by detection of precancerous lesions. The proximal protection is less than the distal and the detection of proximal lesions are crucial. We will review and discuss the progression of IEE, attachment or AI to improve proximal polyp detection.

Colonoscopy is a common procedure aimed to detect polyps and resect these detected lesions to reduce to risk of colorectal cancer. Common complications include bleeding or perforation. In this talk, we will review ways to avoid these complications during the procedure.

Gastrointestinal (GI) motility disorders account for nearly half of outpatient gastroenterology visits, and motility tests are widely utilized to assess a multitude of chronic GI complaints. Along these lines there is a growing trend of motility sub-specialization among gastroenterologists and surgeons. In response to market demands, motility labs are increasingly initiated and grown. The prior landscape with scant motility labs scattered across the nation has dramatically shifted, and nowadays, motility labs are accessible across private and university-based settings, hospital and ambulatory surgical centers, small and large provider groups. Distinct from the more familiar clinic or endoscopic procedure setting, motility labs require unique considerations within the following domains (the four Ps). 1) Physical: this refers to the physical space, size, location and equipment considerations; 2) Process: this refers to scheduling, testing, pre- and post-testing considerations; 3) People: this refers to the team, personnel roles and responsibilities, and training considerations; and 4) Price: this refers to the economic structure and sustainability of the lab. During this presentation we will review these domains and discuss methods to optimize the motility lab.

Esophageal manometry is useful for evaluation and management of patients with suspected esophageal disease. The advancement of high resolution manometry made the exam more easily to be performed and more tolerable for patients. Before high resolution manometry, medications that may influence the esophageal motility can be considered to be discontinued. Endoscopy may be considered to exclude obstructing lesions. When performing manometry, Chicago’s classification can be used for guidance of manometry examination. In the updated Chicago’s classification version 4.0, esophageal manometry can be performed in sitting and supine position. Some provocation tests including multiple rapid swallowing, rapid drinking challenge, solid test swallow or meals can assist evaluation. In interpretating the result of esophageal manometry, the study is usually performed well, while some technical problems may exist, including gagging/repeated swallowing, inability to transverse LES or diaphragmatic crura, inability to traverse nasal passage, prominent vascular or respiratory artifact and sensor malfunction. For patients with esophageal partial stenosis or inability to transverse LES or diaphragmatic crura, endoscopy assisted catheter insertion can help catheter insertion.

Gastroesophageal reflux disease (GERD) is prevalent in modern societies. Despite the efficacy and safety of proton pump inhibitors (PPIs), treatment remains challenging because about 40% of patients are refractory to PPIs therapy. Of them, insufficient acid suppression, reflux hypersensitivity, and incorrect diagnoses may be attributable to the unmet need. Recent Lyon consensus recommends pH, pH/impedance, and wireless pH testing as the objective measures in those with non-erosive reflux disease or erosive esophagitis Los Angeles classification grade A or B and refractory to PPIs therapy.

The utility of reflux monitoring involves indications, availability, local expertise, cost, patient acceptance, off/on PPIs, interpretations, and pitfalls of the testing. The report of reflux monitoring mainly consists two parameters: one is the total percent time of esophageal acid exposure, the other is the symptoms-reflux association. The use of pH-impedance for detecting non-acidic or weakly acidic reflux may increase the yield of defining a positive symptom reflux correlation, while extended pH monitoring of wireless pH will identify patients with day-to-day variation in reflux burden.

The consequence of the testing is to get conclusive or inconclusive diagnoses. The former is subject to continue or modify medications or shift to invasive therapy, while the latter needs adjunctive evidence such as novel impedance parameters, number of reflux episodes, or incompetent barrier of esophagogastric junction in high resolution manometry if invasive endoscopic or surgical procedures are planned.

Anorectal manometry is a basic examination for various functional anorectal disorders such as dyssynergic defecation, fecal incontinence, rectal intussusception or prolapse and neurological disease. Currently, both water-perfusion system and solid-state system are available but the absolute reported values are different depending on which catheter you use. Before performing anorectal manometry, the operator should be familiar with the machine and system in use, setting of the catheter, patient preparation, study protocol (IAPWG protocol), data acquisition and interpretation.

The indication and whole procedure should be well explained to the patient and gain the permission before performing anorectal manometry. A digital rectal examination is needed before the procedure and always make sure that the patient understands all test maneuvers before starting the examination. A quiet and private environment is important during the procedure. Although the London Classification provides the diagnosis of disorders of anorectal function based on objective, physiological measurements, patient factors such as gender, advanced age, and parity should be considered because the normal range on sphincter tone and rectal sensory function will be influenced.

It is important to keep in mind that anorectal manometry alone is generally inadequate to establish the true final pathophysiological cause of anorectal disorder for guiding best treatment. Other tests such as colonic transit, balloon expulsion test, defecography, and transrectal ultrasonography are sometimes necessary to provide a comprehensive interpretation of patient’s clinical issue

The development of endoscopic ultrasound (EUS) in the early 1980s overcame some of the limitations of transabdominal ultrasound for imaging the gastrointestinal tract wall and retroperitoneum. The technical evolution of EUS has led to the development of small caliber intraductal ultrasound (IDUS) miniprobes, which can be passed through standard endoscopes directly into the bile or pancreatic duct. The small caliber, flexibility, and excellent image quality produced by these catheters makes them ideal for evaluating a variety of biliary and pancreatic disorders. IDUS has proven be to very useful in the evaluation the nature of biliary strictures, in staging (T) of cholangiocarcinoma and in the diagnosis of small bile duct stones. For pancreatic diseases, IDUS also helps for detecting the etiology of pancreatic duct stricture and the type of intraductal papillary mucinous tumors.

Cholangioscopy is a noninvasive endoscopic method used for both direct visual diagnostic evaluation and simultaneous therapeutic intervention of the bile ducts. Peroral cholangioscopy overcomes some of the limitations of endoscopic retrograde cholangiopancreatography (ERCP).

Early cholangioscopes had several limitations: they were very fragile and could break up; required two endoscopists; had only a two-way steering mechanism, which severely limited negotiation of ducts; and lacked working channels and irrigation ports. Thus, in the absence of more modern endoscopic technologies, this procedure was restricted to a few specialized centers worldwide for very specific indications. However, the Spyglass cholangioscopes have overcome many of the limitations posed by these earlier cholangioscopes.

Indeed, the Spyglass cholangiopancreatoscopy showed promising results in a multicenter international study for diagnostic and therapeutic applications during endoscopic procedures in the pancreaticobiliary system. Studies have evaluated clinical efficacy of peroral cholangioscopy in characterizing benign versus malignant natures of biliary strictures, diagnosing intraductal tumors, better defining unknown biliary pathologies, and treating biliary and pancreatic stones.

This topic will review the recent advances in cholangioscopy and pancreatoscopy performed during ERCP using currently available instruments.

In Taiwan, digital single-operator cholangiopancreatoscope, SpyGlass (Boston Scientific), has been applied for patients with indetermined biliary stricture, refractory biliary stone, and biliary anastomotic stricture failed to approach. For large or difficult biliary stones, the system provides the performance of f electrohydraulic lithotripsy (EHL) and laser lithotripsy within the bile ducts to facilitate stones removal. In addition to the bile duct stones, application of SpyGlass to the pancreatic duct stones is also available. However, only few cases were reported. We will have a review and share our limited experience of EHL and laser lithotripsy in the treatment of biliary and pancreatic duct stones. In the meanwhile, we will present our preliminary results of laser lithotripsy in patients with cystic duct stones.

Confocal laser endoscopy (CLE) is an endoscopic technique that uses the fluorescent pigment to observe cells in vivo, create a magnification of the mucosal layers, enabling virtual biopsy through real-time histological evaluation.

In patients with indeterminate biliary tract strictures, although endoscopic diagnosis could be performed by endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS), intraductal ultrasonography, and cholangioscopy, the low sensitivity of transpapillary biopsy and cytology were remained the clinical problems.

During ERCP, probe-based confocal laser endomicroscopy (pCLE) can be advanced through the duodenoscope channel and inserted into the biliary tracts. The classification of Miami and the Paris inflammatory criteria have been developed in order to distinguish a malignant from a benign biliary stricture.

In addition, pancreatic cystic lesions (PCLs) are increasingly detected recently. The natural history of pancreatic cysts can be classified as benign, pre-malignant, or malignant. Making an accurate diagnosis among these categories remains challenging currently. A study showed that prior to 2006, approximately 40% of patients who underwent surgery for asymptomatic PCLs had benign cysts.

CLE could also be used in PCLs. However, due to its extraluminal location, the PCLs are difficult to assess using the pCLE method; therefore, a needle-based confocal laser endomicroscopy (nCLE) was designed to overcome these technical difficulties assessing cystic lesions of the pancreas. nCLE enables real-time histopathology assessments of cystic pancreatic lesions.

Unresectable malignant biliary strictures, mainly cholangiocarcinoma, are traditionally treated with palliative measures, such as placing stents to relieve obstruction. However, it is difficult to keep the stent unobstructed due to neoplastic in- and over-growth, epithelial hyperplasia, and sludge deposition. Some efforts have been made to extend the stent patency, for which two endoscopic methods have been developed for this purpose: ERCP-directed radiofrequency ablation (RFA) and photodynamic therapy (PDT). ERCP-directed PDT in the management of cholangiocarcinoma was first published in 1991. Since then, a number of studies on patients with cholangiocarcinoma have shown that compared with placing a biliary stent alone, PDT can improve stent patency, biliary drainage, quality of life and patient mortality. ERCP-directed RFA was first reported in 2011 and is a modality being used with increasing frequency in the management of malignant biliary strictures. Multiple studies have confirmed the safety and feasibility of the clinical use of RFA in the palliative treatment of malignant biliary strictures, such as: preventing stent occlusion, ablation of blocked metal stents, extending stent patency, ablation of residual tumors after endoscopic ampullectomy. The detailed advantages and disadvantages of these two therapies will be introduced and discussed.

The description of depressed type colorectal cancer was firstly reported in Japan in 1977. In 1985, Muto et al. reported flat type adenoma. In 1986, Kudo et al. reported 20 of 184 such lesions (10.9%) presented with submucosal invasive colorectal carcinomas diagnosed over 10 years in Japan. With the findings of more advanced pathology of non-polypoid colorectal lesion (NPL), the recognition of the flat and depressed lesions was soon reported worldwide. Until present, identification and management of NPL are common in our clinical practice.

The prevalence of NPL was estimated about 30-40% among the detected colorectal lesions. Endoscopic experts build consensus on the nomenclature of the superficial colorectal neoplasm. The Paris classification 0-IIa, IIb, and IIc are used to describe NPL. Lesions with IIc component are usually lack of k-ras mutation and carries high risk of invasive pathology. Lateral spreading tumor (LST) is used to describe superficial flat lesions with diameter >10mm. LST is grouped into 4 subtypes and nongranular pseudodepressed type (LST-NG-PS) carries a high risk of invasive pathology. The sessile serrated lesions (SSL) are isolated as a unique group flat lesion because of their specific molecular alterations (higher prevalence of BRAF mutation) and gross features (usually presented as Paris 0-IIa, NICE type I, with cloudy appearance and mucus cap).

The implementation of AI technology in colonoscopy is becoming popular in our practice. Computer-aided detection (CADe) and computer-aided diagnosis (CADx) may assist endoscopists to improve our ability in the management of NPL.

“Old story, New normal, Same neoplasm”. Understanding the clinical significance and new knowledge of NPL will improve our quality of care and is essential for every endoscopist.

Non-polypoid lesion (NPL) is easily missed by screening colonoscopy and misjudged the risk of submucosal invasion (SMI), which increases the chance of interval cancer and the risk of over or under treatment. NPL can be classified into slightly elevated (0-Ⅱ a), flat (0-Ⅱ b) or slightly depressed (0-Ⅱc) and mixed types. Among them, 0-IIa and 0-IIb lesions larger than 1 cm that tends to grow parallelly to the intestinal wall is named lateral spreading tumor (LST). LST can be classified into granular (LST-G) and non-granular type (LST-NG) according to the surface appearance. LST-G can be further divided into homogeneous (LST-G-H) and nodular mixed (LST-G-M) type and LST-NG can be sub grouped into pseudo-depressed type (LST-NG-PD) and flat elevated type (LST-NG-FE). LST-Gs accounts for 60%-80% of all NPL, while LST-NGs around 20%-40% and depressed lesions accounts for only 1% - 6%. Different LST morphology has different risks of SMI (LST-NG-PD: 12.5% ​​in case of size <20 mm and 83.3% for diameters> 30 mm, LST-G-M :7.1% for lesions < 20 mm and 38% for those > 30 mm, LST-NG-FE: 8%, LST-G-H: < 2%). In addition, opportunities for multifocal SMI are not uncommon. Although depressed lesion is relatively rare, SMI can occur even when the tumor size is small. Endoscopic detection of flat or depressed lesions requires careful observation for signs of fold deformation, intensive stool/mucus attachment, amorphous vessel visibility or demarcated reddish area. Enhanced endoscopy classifications enable endoscopists judging the depth of tumor invasion according to microvascular and pit patterns, which are widely known as NICE and JNET classification of NBI image and Kudo pit pattern classification of magnified chromoendoscopy. The accuracy of these enhanced endoscopy classification for judging deep SMI is over 90%, which can guide subsequent treatment. The risk of lymph node metastasis (LNM) is low (< 2%) among intramucosal CRC and superficial SMI CRC that are suitable for endoscopic resection. However, deep SMI CRC has a high risk of LNM, and surgery is required. EMR and ESD are two main ways of endoscopic resection methods for large colorectal NPL. EMR has the advantages of low technique requirement, short procedure time and low cost, but it is not easy to achieve enbloc resection in lesions larger than 2 cm and mostly end up piecemeal resection (EPMR). In the other hand, ESD could almost achieve en bloc resection for large NPLs. According to previous studies, the local recurrence rate of EPMR is higher than that of ESD, and the specimen retrieved by EPMR is difficult for pathologists to diagnosed R0 resection confidently and to determine the risk features of LNM. In order to optimized the prognosis of patients with colorectal NPL, we should select appropriate treatment according the risk of SMI, which could be predicted by lesion morphology and enhanced endoscopy.

Sessile serrated lesion (SSL) is one of the most common subtypes of the serrated polyp. SSL is considered an essential precancerous neoplasm, and it is generally accepted that around 15 to 20% of CRC arising from SSL. More than two-thirds of SSL is located at the proximal colon, and it usually appears transparent and flat in morphology. Because of their proximal location and subtle appearance, SSL is therefore easy to be overlooked at colonoscopy. Based on the easily neglected nature, it is reasonable to speculate that SSL might contribute to post-colonoscopy CRC (PCCRC).

The specific molecular features of SSL provide a window to clarify the association between SSL and PCCRC. The conventional adenoma progressed into invasive cancer through the adenoma-carcinoma sequence, sequentially accumulated with APC, KRAS, and p53 mutations. In contrast, the SSL develops into cancer via the serrated pathway, characterized by BRAF mutation, microsatellite instability (MSI), and CpG island methylation phenotype (CIMP). A growing body of studies demonstrated that a substantial part of PCCRC presented with MSI and CIMP. Therefore, more and more evidence supports that SSL plays a critical role in CRC carcinogenesis and PCCRC. Thus, it is vital to understand the nature and endoscopic characteristics to improve its detection, thereby reducing PCCRC.

Non-polypoid colorectal lesions have higher recurrence rate than their counterparts after endoscopic resection. Thus, enbloc resection for lesions ≦ 20mm is desired to reduce recurrence and ensure accurate pathologic diagnosis. For lesions > 20mm, advanced endoscopic resection technique like endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are necessary for complete resection. The choice of techniques should be based on lesion characteristics, risk of invasive cancer, and local expertise. For lesions with low risk of invasive cancer, EMR is safe and effective, albeit adenoma recurrence rate may be as up to 15% with piecemeal resection. On the other hand, meticulous techniques and some novel strategies (underwater EMR, cold EMR for sessile serrated lesions) may minimize recurrence and further improve safety. ESD provides the best chance for enbloc resection, especially for lesions with suspicious superficial invasive cancer. However, the technical demand, increased time and cost, and higher risk of perforation make this procedure only suitable in experts’ hands. After endoscopic resection, surveillance is key to reduce future interval colorectal cancer. Surveillance at 1-y interval is suitable for enbloc EMR and ESD, while 3-6 months is necessary for piecemeal EMR or suspicious incomplete resection. An evidence-based approach will be reviewed here.

Lesions such as hepatocellular carcinoma (HCC) or other entities at the caudate lobe were located at the deep site of liver, which was not visualized well by transabdominal ultrasound, and there were intervening veins that would have made it not only difficult but also hazardous to attempt percutaneous ablative treatment due to the long trajectory. Endoscopic ultrasonography (EUS) has emerged as a highly sophisticated interventional modality. EUS guided therapy provide the best solution to treat the caudate lobe lesion, i.e., in close proximity to the stomach, which made it easily accessible by EUS. EUS have been developed for the interventional purpose in addition to the pancreatic disease. EUS-guided liver biopsy or ethanol injection, owing to its less invasiveness, appears to be a new innovative option for lesions that is difficult to treat by local percutaneous treatment.

EUS-guided fine needle aspiration (EUS-FNA) is a safe and useful method for pancreatic tissue sampling. However, inadequate specimens of EUS-FNA for appropriate pathological diagnosis is still concerned. Due to the potential for false-negative and nondiagnostic results, it became challenging to make an appropriate treatment strategy with inconclusive EUS-FNA diagnoses. A recent meta-analysis reported that having an on-site cyto-pathologist can enhance the accuracy and efficiency of EUS-FNA[1], but some centers do not have this capability. The sensitivity and overall diagnostic accuracy of repeated EUS-guided sampling only have 35 % – 100 % and 78% , but involved delay and higher costs[2].

Compared with repeated EUS-FNA using a second needle, contrast-enhanced harmonic ultrasonography (CH-EUS) have lower cost and can improve the diagnostic yield and sampling adequacy of EUS-FNA. CH-EUS can detect signals from microbubbles in vessels with a very slow flow without Doppler-related artifacts to characterize microvascularity in the pancreatic lesions, that is helpful for differential diagnosis of pancreatic tumors, especially small sizes[3, 4]. CH-EUS guided FNA(CH-EUS-FNA) can improve diagnostic yield because of detection of detect avascular areas[5].

According to the previous studies, there were still debates for the role of CH-EUS about improvement of diagnostic accuracy of EUS-FNA[6-8]. The latest meta-analysis considered CH-EUS-FNA seems to be superior to standard EUS-FNA for pancreatic masses in pooled diagnostic accuracy and sample adequacy[9]. Further randomized controlled trials are needed to confirm these results in the future.

Reference:

1. Hebert-Magee, S., et al., The presence of a cytopathologist increases the diagnostic accuracy of endoscopic ultrasound-guided fine needle aspiration cytology for pancreatic adenocarcinoma: a meta-analysis. Cytopathology, 2013. 24(3): p. 159-71.
2. Dumonceau, J.M., et al., Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline - Updated January 2017. Endoscopy, 2017. 49(7): p. 695-714.
3. Kitano, M., et al., A novel perfusion imaging technique of the pancreas: contrast-enhanced harmonic EUS (with video). Gastrointest Endosc, 2008. 67(1): p. 141-50.
4. Kitano, M., H. Sakamoto, and M. Kudo, Contrast-enhanced endoscopic ultrasound. Dig Endosc, 2014. 26 Suppl 1: p. 79-85.
5. Kamata, K., et al., Impact of avascular areas, as measured by contrast-enhanced harmonic EUS, on the accuracy of FNA for pancreatic adenocarcinoma. Gastrointest Endosc, 2018. 87(1): p. 158-163.
6. Hou, X., et al., Contrast-enhanced harmonic endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of solid pancreatic lesions: a retrospective study. PLoS One, 2015. 10(3): p. e0121236.
7. Seicean, A., et al., Harmonic Contrast-Enhanced Endoscopic Ultrasonography for the Guidance of Fine-Needle Aspiration in Solid Pancreatic Masses. Ultraschall Med, 2017. 38(2): p. 174-182.
8. Seicean, A., et al., Contrast-enhanced harmonic versus standard endoscopic ultrasound-guided fine-needle aspiration in solid pancreatic lesions: a single-center prospective randomized trial. Endoscopy, 2020. 52(12): p. 1084-1090.
9. Facciorusso, A., et al., Contrast-enhanced harmonic endoscopic ultrasound-guided fine-needle aspiration versus standard fine-needle aspiration in pancreatic masses: a meta-analysis. Expert Rev Gastroenterol Hepatol, 2021: p. 1-8.

Recently, EUS-guided biliary drainage (EUS-BD) is spread widely. Technical and functional success rate of EUS-BD is high and 0% to 20% complication rate is reported in published papers. EUS-BD is a basically safe procedure at now, however there is the possibility of severe complications. We should understand the trouble shooting to increase the success rate and to prevent the severe complications. it is a very important point in EUS-BD. In my lecture, I would like to mention the possible complications, how to prevent the severe complications and how to manage the trouble shooting. One of the most important points to prevent complications is the device selection. What is the best needle, guidewire, dilator, stent? In this way, we should always consider these important points to perform EUS-BD. For the trouble shooting, we should learn some technical tips. How to control the difficult guidewire insertion case? How to treat for early stent dislocation and dysfunction? How to treat for ascites patients? How to treat the mispuncture case? In my talk, I would like to mention the trouble shooting for safe EUS-BD.

Primary tumors of the small bowel are rare, and their clinical presentation is nonspecific. Although the small intestine makes up 75% of the length and 90% of the surface area of the gastrointestinal tract, small bowel tumors make up approximately 3% of all malignant gastrointestinal neoplasms. The most frequent small bowel tumors are adenocarcinoma, neuroendocrine tumors, lymphomas and gastrointestinal stromal tumors.  patients are often diagnosed in an advanced stage of the disease. Advances in imaging techniques such as wireless capsule endoscopy, CT and MRI enterography, and endoscopy (balloon enteroscopy) have improved our ability to diagnose, localize, and treat these patients. Early detection and surgical resection offer the best chance for long-term survival in all tumors except bowel lymphoma where chemotherapy plays the main role.

Small bowel tumors (SBTs) are rare and only representing 3-6% of GI tumors. In addition, only 1-3% of all malignant GI tumors are SBTs. The diagnosis of SBTs is difficult due to the rarity of these lesions and the nonspecific signs and symptoms. Benign SBTs are often asymptomatic and cured at the time of resection. Howevert, malignant primary SBTs which with a poor prognosis have often metastasized by the time when they are discovered. Metastatic small bowel tumors also present with poor prognosis and related to the primary area.

In a multicenter retrospective study utilized endoscopy database from 2006/11 to 2016/07 in Taiwan. Totally 103 (34 benign, 69 malignant lesions) patients with SBTs in 1070 single balloon enteroscopic examinations were enrolled. Hamartoma (32.4%) and adenoma (14.7%) were the most common benign histology. The four major malignant histological subtypes were lymphomas (29.0%), GISTs(27.5%), adenocarcinomas (26.1%) and metastatic cancers (14.5%). In the location of the SBTs, most of lymphomas and carcinoid tumors are located in the ileum and adenocarcinomas located in the duodenum.

The diagnosis of metastatic small bowel tumor is difficult and deep enteroscopy (including single and double balloon enteroscopy) and capsule endoscopy are the accurate examinations. Both of deep enteroscopy and capsule endoscopy have a high diagnostic concordance rate. Finally, although both of deep enteroscopy and capsule endoscopy are good tools for metastatic small bowel tumor, multidisciplinary team diagnosis is still regarded as the diagnostic reference standard.

The small bowel accounts for about 75% of the gastrointestinal (GI) tract length and nearly 90% of the GI mucosa, but it is the most difficult evaluation part of the GI tract due to its length and complex loops. Small bowel diseases are relatively rare in the GI tract, including vascular lesions, tumors, diverticular disease, inflammatory bowel disease, functional disease, and infectious disease.

Small bowel tumors are rare and accounts for approximately 3%-5% of all GI tumors. Small bowel tumors usually can be divided into malignant and benign tumors. Small bowel benign tumors include lipomas, adenomas, hyperplastic polyps, hamartomatous polyps, leiomyomas, etc. Patients with small bowel benign tumors may present asymptomatic or symptomatic (including GI bleeding, abdominal pain, vomiting, diarrhea, hypoalbuminemia, and others. Thus, pre-operative diagnosis of small bowel benign tumors is usually difficult because most small bowel benign tumors are clinically silent for a long period. Conventional diagnostic modalities of small bowel benign tumors include radiological images, angiography, nuclear medicine, abdominal ultrasound/ CT/MRI, and even surgery. However, the diagnostic yield of these above modalities is not very high and is usually too late. The newly developed diagnostic modalities, including deep enteroscopy and capsule endoscopy, have been shown the higher diagnostic yields for small bowel benign tumors.

In the past, surgical resection is the mainstay treatment for symptomatic small bowel benign tumors. However, deep enteroscopy also can provide the capacity of endoscopic therapy for small bowel benign tumors.

Although small intestine accounts more than 90% of the mucosal surface of gastrointestinal tract, the primary neoplasms comprise less than 5% of all tumors of the gastrointestinal tract. There are several small intestinal tumor mimic lesions. It’s important to make the differential diagnosis according to clinical presentations, laboratory data and image studies. We will review them in today’s presentation.

A systematic review and meta-analysis with five prospective randomized-controlled trials and 4311 subjects showed that AI-based polyp detection systems during colonoscopy increased detection of small, non-advanced adenomas and polyps, but not advanced adenomas; Mean number of adenomas per colonoscopy were significantly higher for small adenomas (≤5 mm) with AI compared to non-AI colonoscopy, but not for larger adenomas (5.1-10 mm and > 10mm respectively). Another systematic review and meta-analysis involving five randomized-controlled trials and 4354 subjects revealed that adenoma detection rate (ADR), adenoma per colonoscopy (> 5mm, 6-9 mm, >10 mm), detection rate of proximal, distal, flat, and sessile serrated lesion were all significantly higher in the real-time computer aided polyp detection group, with a nonsignificant trend for advanced ADR.

In recent years, several randomized trials comparing the performance of AI and conventional colonoscopy on adenoma detection have been published and AI has been consistently showing its superiority over conventional colonoscopy^1–3. Nevertheless, there are still some issues requiring exploration. First, all these RCTs failed to show the improvement of advanced or large (>1cm) polyps detection by AI and the improvement of ADR carried out by AI is mainly attributable to additional detection of diminutive (< 5mm) polyps. Since it was reported that the risk of post-colonoscopy CRC (PCCRC) was mainly derived from overlooked non-polypoid neoplasms⁴ and the likelihood of progression of diminutive lesions into invasive cancer were considered as low⁵.  Study using hard outcomes like incidence and mortality of CRC or PCCRC is highly anticipated. Second, there are image enhanced endoscopy (IEE) technologies are available nowadays and have been demonstrated to be useful in improving ADR⁶.  Its usefulness as adjunction to IEE also needs further exploration. Last but not least, given that AI can only detect the polyps that appeared on the exposed mucosa, the colonoscopists’ withdrawal and mucosal exposure techniques is still the fundamental factor for lesion detection^{7, 8}. Therefore, what skill level of the endoscopists that can be most benefited from AI is also intriguing.

Reference:

1. Wang P, Berzin TM, Glissen Brown JR, et al. Real-time automatic detection system increases colonoscopic polyp and adenoma detection rates: a prospective randomised controlled study. Gut. 2019;68(10):1813-1819. doi:10.1136/gutjnl-2018-317500
2. Repici A, Badalamenti M, Maselli R, et al. Efficacy of Real-Time Computer-Aided Detection of Colorectal Neoplasia in a Randomized Trial. Gastroenterology. 2020;159(2):512-520.e7. doi:10.1053/j.gastro.2020.04.062
3. Gong D, Wu L, Zhang J, et al. Detection of colorectal adenomas with a real-time computer-aided system (ENDOANGEL): a randomised controlled study. The Lancet Gastroenterology & Hepatology. 2020;5(4):352-361. doi:10.1016/S2468-1253(19)30413-3
4. Iwatate M, Kitagawa T, Katayama Y, et al. Post-colonoscopy colorectal cancer rate in the era of high-definition colonoscopy. WJG. 2017;23(42):7609-7617. doi:10.3748/wjg.v23.i42.7609
5. Sekiguchi M, Otake Y, Kakugawa Y, et al. Incidence of Advanced Colorectal Neoplasia in Individuals With Untreated Diminutive Colorectal Adenomas Diagnosed by Magnifying Image-Enhanced Endoscopy. Am J Gastroenterol. 2019;114(6):964-973. doi:10.14309/ajg.0000000000000261
6. Matsuda T, Ono A, Sekiguchi M, Fujii T, Saito Y. Advances in image enhancement in colonoscopy for detection of adenomas. Nat Rev Gastroenterol Hepatol. 2017;14(5):305-314. doi:10.1038/nrgastro.2017.18
7. Barclay RL, Johanson JF. Colonoscopic Withdrawal Times and Adenoma Detection during Screening Colonoscopy. The New England Journal of Medicine. Published online 2006:9.
8. Rex DK, Repici A, Gross SA, et al. High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial. Gastrointestinal Endoscopy. 2018;88(2):335-344.e2. doi:10.1016/j.gie.2018.02.043

As normal colonoscopy is associated with significant and sustained reduced risk for incident and fatal colorectal cancer according to previous studies. Based on the reduced risk, we recommend colorectal cancer screening in average-risk individuals be repeated 10 years after a normal high-quality examination complete to the cecum with adequate bowel preparation.

According to current U.S Multi-Society Task Force(USMSTF) and European Society of Gastrointestinal Endoscpy(ESGE) post colonoscopy surveillance guidelines, 10 year interval after negative index colonoscopy was recommended[1,2]. The evidence of such a recommendation is, however, rather weak without any randomized controlled trial. Besides, this recommendation is based solely on the endoscopic findings at baseline colonoscopy, without taking into account any other risk factors of colonorectal neoplasm. Recent studies have demonstrated that higher fecal hemoglobin concentration (FHbC) was associated with the risk of metachronous advanced neoplasm, no matter above or below the positive cutoff of fecal immunochemical test(FIT)[3-5]. A cohort study from FIT-based Taiwan Colorectal Cancer Screening Program has demonstrated that interval FIT after a negative colonoscopy could effectively reduce the risk of incident colorectal cancer(CRC). Furthermore, baseline FHbC was associated with the risk of such risk [6]. Not only FHbC, but also many other factors, such as age[7], family history[8-9], gender[10, 11]], metabolic syndrome or higher BMI[12-14] and smoking habit[14], were associated with different risk of metachronous advanced neoplasm or CRC. That means, even in negative baseline colonoscopy population, there were still some key factors other than colonoscopies finding that could be used for risk stratification. Further study is needed to help tailoring surveillance interval to balance between the risk of developing incident CRC and healthcare resource use.

Reference:

1. Gupta, S.et al, Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multisociety Task Force on Colorectal Cancer. Gastroenterology. 2020;91:463–485.e5
2. Hassan Cesare et al. Post-polypectomy colonoscopy surveillance: ESGE Guideline… Endoscopy 2013; 45: 842–851
3. Li-Sheng Chen et al. Baseline faecal occult blood concentration as a predictor of incident colorectal neoplasia: longitudinal follow-up of a Taiwanese population-based colorectal cancer screening cohort. Lancet Oncol 2011; 12: 551–58
4. Esmée J. Grobbee et al. Association Between Concentrations of Hemoglobin Determined by Fecal Immunochemical Tests and Long-term Development of Advanced Colorectal Neoplasia. Gastroenterology 2017;153:1251 – 1259
5. Chiu SY-H, et al. Faecal haemoglobin concentration influences risk prediction of interval cancers resulting from inadequate colonoscopy quality: analysis of the Taiwanese Nationwide Colorectal Cancer Screening Program. GUT 2017;66:293-300
6. Peng SM et al. Faecal immunochemical test after negative colonoscopy may reduce the risk of incident colorectal cancer in a population-based screening programme. Gut. 2020 Sep 28:gutjnl-2020-320761
7. Vatn MH, Stalsberg H. The prevalence of polyps of the large intestine in Oslo:an autopsy study. Cancer 1982;49(4):819e25.
8. Taylor DP. et al. Population-based family history-specific risks for colorectal cancer: a constellation approach. Gastroenterology. 2010;138(3):877-885.
9. Lowery JT, et al. Understanding the contribution of family history to colorectal cancer risk and its clinical implications: A state-of-the-science review. Cancer. 2016;122(17):2633-2645
10. Brenner H, et al. Incidence of colorectal adenomas: birth cohort analysis among 4.3 million participants of screening colonoscopy. Cancer Epidemiol Biomarkers Prev 2014;23(9):1920e7.
11. Waldmann E, et al. Risk factors cannot explain the higher prevalence rates of precancerous colorectal lesions in men. Br J Cancer 2016;115(11):1421e9.
12. Wallace K,et al. The association of physical activity and body mass index with the risk of large bowel polyps. Cancer Epidemiol Biomark Prev. 2005;14:2082–2086.
13. Slattery M, et al. Physical activity and colorectal cancer. SportsMed 2004;34:239 – 52
14. Chang LC, et al. Metabolic syndrome and smoking may justify earlier colorectal cancer screening in men. Gastrointest Endosc. 2014 Jul;80(1):189-90.

The average life expectancy in Taiwan in 2020 reached 81.3 years old (male 78.1, female 84.7). Health promotion and cancer prevention in the very elderly popular become a more and more important issue. However, in very elderly populations, only limited suggestions are stated in currently available guidelines proposed by different societies due to limited evidence from previous studies.

The American Gastroenterology Association and American Society of Gastrointestinal Endoscopy suggests that screening is potentially beneficial in persons up to the age of 86-year-old if there has not been previous screening but should be considered in the context of comorbidities and life expectancy.

From previous studies, risk of advanced histology in adenoma less than 10 mm still exists, especial in positive fecal immunochemical test populations. They can become more advanced lesions if not to be removed. Given the safety of polypectomy using cold snaring polypectomy and progress of hematemesis equipment and techniques, polypectomy for small polyps in those older than 80 years old is feasible and adequate.

The average lead time for progression of an small adenoma to cancer is around 10 years, which is similar to the average life expectancy of an individual aged 75 years or older. Because of this reason, current guidelines suggested that patients should be offered surveillance until age 75 years and beyond if they are well enough and have a reasonable life expectancy.

Once a colonoscopy in an older patient is done, the decision to remove a polyp needs to take into account that whether the benefit of polypectomy could overcome the risk. Patients’ comorbidities, the life expectancy, malignant potential of this polyp, and the risk of procedures should be taken into consideration.

Today’s talk will cover some concerns of polypectomy for the elder patients.

The incidence of colorectal cancer (CRC) has been increasing worldwide, including Asia populations, were used to have a lower disease burden in CRC. ^{1, 2 3} Although the effectiveness of biennial FIT-based CRC screening provided to the population aged 50 years and older has been proved in Taiwan, ⁴ the recent epidemiology studies have revealed warning information on the continued increase in the incidence of CRC among adults younger than 50 years. ^5,6 These early-onset CRCs that occurred in the young age group now account for 10% –12% of all newly diagnosed CRCs. Numerous researches have detected a rising incidence of CRC in young people, mainly rectal cancer. This finding raises the need for increased clinical suspicion when evaluating symptoms of a young patient. However, the diagnosis of CRC in younger patients is difficult. FIT may assist physicians in identifying which younger patients with higher risk symptoms may require a colonoscopy or other diagnostics. FIT is a non-invasive, quantitative immunoassay that detects the globin moiety of hemoglobin in faces and can reliably measure the fecal hemoglobin concentration (f-Hb). Some studies reported that FIT might indicate urgent investigation of patients with bowel symptoms; higher f-Hb conferred a higher risk of serious bowel disease, including colorectal cancer, advanced adenomas, and inflammatory bowel disease. ^7,8 FIT might be used for risk stratification for younger symptomatic patients who are likely to benefit from invasive investigations such as colonoscopy.

1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA: a cancer journal for clinicians 2016;66:7-30.
2. Arnold M, Sierra MS, Laversanne M, et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017;66:683-691.
3. Onyoh EF, Hsu WF, Chang LC, et al. The rise of colorectal cancer in Asia: epidemiology, screening, and management. Current gastroenterology reports 2019;21:36. doi: 10.1007/s11894-019-0703-8.
4. Chiu HM, Chen SLS, Yen AMF, et al. Effectiveness of fecal immunochemical testing in reducing colorectal cancer mortality from the One Million Taiwanese Screening Program. Cancer 2015;121:3221-3229.
5. Vuik FE, Nieuwenburg SA, Bardou M, et al. Increasing incidence of colorectal cancer in young adults in Europe over the last 25 years. Gut 2019;68:1820-1826.
6. Loomans-Kropp HA, Umar A. Increasing Incidence of Colorectal Cancer in Young Adults. Journal of Cancer Epidemiology 2019. doi: 10.1155/2019/9841295.
7. D'Souza N, Georgiou Delisle T, Chen M, et al. Faecal immunochemical test is superior to symptoms in predicting pathology in patients with suspected colorectal cancer symptoms referred on a 2WW pathway: a diagnostic accuracy study. Gut. 2021;70:1130-1138.
8. D’Souza N, Monahan K, Benton SC, et al. Finding the needle in the haystack: the diagnostic accuracy of the faecal immunochemical test for colorectal cancer in younger symptomatic patients. Colorectal Disease. 2021 (In Press)

According Asia Pacific Working Group consensus, population screening for colorectal cancer (CRC) is recommended in those aged 50-75 years. However, sequential studies have shown that the incidence of CRC in younger patients has been on the rise for the last several decades. Early onset CRC (EOCRC) patients, which under the age of 50, accounts for 10% of all CRC. Eighty five percent of EOCRC patients have symptoms, and the most common symptoms was rectal bleeding (50%), followed by abdominal pain (32%) and change in bowel habits (18%). Time from symptoms onset to diagnosis is 9-12 months in EOCRC patients compared with 1-2 months in patients age over 50 years with CRC. Generally, for a patient with bleeding under the age of 40 without any additional symptoms or risk factors, a flexible sigmoidoscopy is appropriate. However, for patients over the age of 40 or for those with symptoms/risk factors, a full colonoscopy is preferred. Clinicians should be aware of CRC alarm symptoms, family history, and genetic syndromes, to speed evaluation and diagnosis of younger patients and potentially improve outcomes.

Enteral stenting (ES) with self-expandable metal stent (SEMS) has been proven as a safe and effective method for palliation of malignant gastric outlet obstruction (MGOO) and has replaced surgical bypass as mainstream management. It is a relatively simple and easy procedure and does not require the operator to have expertise in endoscopic ultrasound. Studies have reported the technical and clinical success rates are high, 97% (range 91-100%) and 89% (range 63-95%), respectively. However, frequent stent dysfunctions including stent obstruction and migration, which require repeated interventions, have not been solved. Recently, the emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with lumen-apposing metal stent (LAMS) shows promising results with comparable outcome and safety profiles with a lower reintervention rate compared with ES. However, it is a highly skill-requiring procedure and remains an evolving endoscopic technique in its early stages of development. Besides, the techniques of EUS remain unstandardized and all available studies are performed at tertiary care centers with experted advanced endoscopists. Therefore, the adverse event rates might not be generalizable. Further prospective randomized controlled trials comparing EUS-GE and ES are needed to tell us what’s better for MGOO.

Nowadays, EUS-guided procedures have several advantages over other classical approaches. EUS-guided celiac plexus neurolysis (EUS–CPN) can be performed for alleviating pain originating from the upper abdominal organs and, particularly, when the primary indication for pain is pancreatic cancer pain. EUS-guided direct celiac ganglia neurolysis (EUS–CGN) has also been introduced as a new method. Despite this success story, there are still controversies about these two different techniques. EUS-CPN for pain relief is safe and effective, especially for patients with pancreatic cancer, while the results are modest for chronic pancreatitis. EUS-CPN complication rate is around 40%, and a self-limited hypotension is the most common one (20%). It was suggested that bilateral injection would enhance the efficacy of celiac plexus EUS-guided neurolysis, but the studies available did not confirmed this suspicion. Today, we will review the most up-to-date indications and techniques of EUS–CPN.

Pancreatic cancer is the seventh cause of cancer related death in Taiwan (data from ministry of health and welfare Taiwan 2020). Because 5-year survival in referral centers is less than 20%, clinical management of most patients involves palliation of the symptoms of which 90% are weight loss, jaundice, and pain. Pancreatic pain is often difficult to control. Initial therapy with non-steroid anti-inflammatory agents (NSAIDs) is often rapidly overwhelmed by the intractable pain and necessitates being associated with opioid administration. Although opioids effectively relieve pain, they are associated with many different side effects, such as dry mouth, constipation, nausea, vomiting, drowsiness, and delirium, which can determine a great decrease in quality of life and may also impair the immune function. The first report of EUS-guided CPN (EUS-CPN) via the trans-gastric route was published in 1996 and was shown to be safe. Celiac ganglion neurolysis means ethanol injection to celiac ganglion directly to destroy the nerve fibers in reaching the analgesic purpose.

Inflammatory bowel disease (IBD), which comprises both Crohn disease (CD) and ulcerative colitis (UC), represents chronic inflammatory diseases of the gastrointestinal tract. The clinical presentation of IBD is not specific, and diagnosis is based on the combination of symptoms, laboratory findings, imaging, endoscopy, and histopathology. However, many diseases may mimic features of IBD. The differential diagnosis of IBD is quite broad and encompasses both infectious and noninfectious etiologies. Infectious etiologies include viruses, bacteria, mycobacteria, fungi, protozoa and helminths. Particular attention for tuberculosis is required for patients from endemic areas. Noninfectious etiologies include vascular diseases, diversion colitis, diverticula or radiation-related injuries, drug-induced inflammation, and monogenic diseases in very-early-onset refractory disease. In addition, a superinfection with cytomegalovirus or Clostridium difficile can aggravate intestinal inflammation in IBD, especially in patients who are immunocompromised.

We must pay attention to specific patient profiles that should trigger the search for an underlying cause, different from that of IBD. A careful history and physical examination may help to both narrow the differential diagnosis and order specific testing that will culminate in a diagnosis.

A 57-year-old ulcerative colitis male patient suffered from bloody stool passage intermittent for one month. Ulcerative colitis with acute flare up was suspected. Oral vancomycin and IV ganciclovir were prescribed due to stool culture positive for clostridium difficile and endoscopy biopsy showed CMV positive. The patient still suffered from bloody diarrhea, with Mayo score 11 points after full dose of 5-ASA and steroid. Biologics with vedolizumab was applied. Clinical condition mild improving with Mayo score 7 points, but still not achieved clinical remission in 10 weeks. What’s your opinion for the next step? Wait-and-see, escalation with shortening drug interval, switch to other class biologic?

Inflammatory bowel disease (IBD) is a chronic and idiopathic inflammatory disease of the digestive tract showing a remitting and relapsing disease course. Ulcerative colitis (UC) and Crohn’s disease (CD) are two major forms of IBD.A single reference standard for the diagnosis of IBD does not exist. The diagnosis of IBD is based on a combination of clinical, biochemical, stool, endoscopic, cross-sectional imaging, and histological investigations.

There is a broad differential diagnosis IBD, however most of the etiologies generally fall into two categories: infectious and non-infectious. Endoscopy is an important diagnostic and therapeutic modality in IBD. Endoscopy is used to make an initial diagnosis of IBD, assess the disease extent and activity, monitoring the treatment response and surveillance for colon cancer.

IBD may be complicated by intestinal cancer, potentially because of local and systemic inflammation. A nationwide study conducted by Korean revealed the estimated cumulative risk of UC-associated CRCs was 0.7% for patients that had UC for 10 years and 7.9% for patients that had UC for 20 years.

Clinicians can accurately diagnose most cases by fully understanding the typical endoscopic findings. In some cases, however, it is difficult to differentiate IBD due to an atypical presentation. Therefore, not only endoscopic features but also clinical symptoms, as well as laboratory, pathological, and radiological findings should be considered in order to make a correct diagnosis.

Inflammatory bowel disease (IBD) is a disease of the chronic inflammation of GI tract. Management of IBD often requires a multimodal approach including medical therapy, endoscopy, and surgery. In the past decade, surgery often needs for IBD related complications, such as stricture, fistula, and neoplasm. Now, endoscopic therapy offers a minimally invasive approach to treating the complications previously managed by surgery.

A stricture is a narrowing of the GI lumen and is diagnosed by endoscopy or trans-abdominal imaging, such as CT or MRI. Endoscopic evaluation allows tissue acquisition to exclude malignancy, and it can also treat it with balloon dilatation, needle knife stricturotomy and stent placement.

A fistula is commonly seen in conjunction with strictures. The pathogenesis is not fully understood, although one underlying mechanism is increased luminal pressure upstream from a stricture in the presence of transmural inflammation. Endoscopic management of the fistula are includied deepithelialization of the fistulous tract, closure of the luminal and maintaining external drainage.

The risk of IBD-colitis associated neoplasia is well known now. There are two methods of lesion resection: piecemeal and or enbloc resection.

In conclusion, we are able to offer minimally invasive management with endoscopy to our IBD patients with associated complication as an adjunct to medical therapy and surgery, and avoiding unnecessary surgery recently.

The incidence and prevalence of inflammatory bowel disease (IBD) is increasing in Taiwan and other Asian countries. In clinical practice of long term caring of IBD patients, detection of colitis-associated dysplasia or cancer (CAD or CAC) is a rising issue for long standing ulcerative colitis (UC) or colonic Crohn’s disease (CD). The risk of colorectal cancer increased 8-10 years after the onset of symptoms in UC patients. From the current international guidelines, dye spraying chromoendoscopy with targeted biopsy was recommended for colonoscopy surveillance of CAC. However, conventional dye spraying chromoendoscopy is time consuming. In addition, the improvement of disease management as well as endoscopic technique and quality, the management of colonoscopy surveillance has changed. High definition (HD) colonoscopy is more common currently in clinical application. Some updated data showed that the detection rates of CAD/CAC using HD colonoscopy with virtual chromoendoscopy (narrow band imaging or i-SCAN) or white light alone are not inferior to that using conventional dye spraying chromoendoscopy for colonoscopy surveillance. In conclusions, some conditions including control of inflammation, use of high-definition endoscopes, good bowel preparation, and target biopsy for suspected lesion should be optimized for the improvement of quality of colonoscopy surveillance in IBD patients.

Inflammatory bowel disease is increasing in Asian population. Endoscopists should be aware the standards of recording the findings related to IBD. In this talk, we will review the recommended ways to record endoscopy findings for IBD patients.

With the convenience of endoscopy in clinical practice, the diagnosis of gastric subepithelial tumor (SET) is becoming more and more common.

Gastrointestinal stromal tumor (GIST) is the most common GI mesenchymal neoplasm, and has malignant potential. The management of incidentally encountered GISTs smaller than 2 cm remains controversial, and NCCN suggest endoscopic surveillance at 6-12 months intervals may be an option. However, many patients do not want to have the stress of lifelong endoscopic surveillance. This method may increase economic burdens and delay diagnosis of malignancy. The poor compliance of patients in regular Some literatures indicate that endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can be used to evaluate the benign and malignant tumors, but the accuracy of this method was about 60%.

In recent years, due to the development of endoscopic submucosal dissection (ESD), the removal of gastric SET by endoscopy instead of traditional surgery has become more and more popular. These methods will face the problem of perforation, so we have to consider to close the perforation during endoscopic resection.

Gastric Subepithelial Tumors (SETs) are classified into non-neoplastic and neoplastic lesions. Carcinoid tumors, lymphomas, glomus tumor and gastrointestinal stromal tumors (GISTs) are neoplastic and malignant potential. Most SETs are asymptomatic and clinically insignificant. Asymptomatic benign lesions such as lipomas, vascular lesions, cysts, pancreatic rests, and leiomyomas do not require any intervention. In follow-up studies, asymptomatic SETs increased in size in fewer than 10% of patients.

In the evaluation of gastric SETs, endoscopic ultrasound (EUS) is a useful tool for the layer of origin, the size, the details of tumor echotexture, and differentiation from external compression. If the EUS revealed a high-risk tumor (irregular border, cystic space, ulceration, echogenic foci, and heterogeneity), it should be removed. If there were no signs of high risk, the GISTs should be followed up at 6 to 12 months intervals and yearly thereafter[1, 2]. In one study, recommend EUS surveillance every 2–3 years for < 9.5 mm and every 6-12 months for ≥ 9.5 mm GIST[3]. If the lesions increase in size or became symptomatic, they should be removed[4, 5]. Asymptomatic small GIST(< 2cm) carried very good prognosis[6].

EUS-FNA is considered as diagnostic utility in gastric SETs[7]. However, it is difficult to measure the mitoses of GIST by EUS-FNA for differentiation from benign to malignant. The diagnostic accuracy of EUS-FNA ranges widely from 46% to 93% in the evaluation of gastric SETs[8]. In a European study, EUS-FNA with EUS-FNB needle could obtain more histologic tissue and increase diagnostic accuracy of more than 90%[9].

EUS evaluation of SETs can guide the endoscopist to evaluate the characteristics and to obtain the optimal tissue acquisition for diagnosis. Asymptomatic small size (< 2cm) of the SETs should be followed up at 6 to 12 months intervals and yearly thereafter.

Reference:

1. Lachter, J., et al., EUS clarifies the natural history and ideal management of GISTs. Hepatogastroenterology, 2008. 55(86-87): p. 1653-6.
2. von Mehren, M., et al., Gastrointestinal stromal tumors, version 2.2014. J Natl Compr Canc Netw, 2014. 12(6): p. 853-62.
3. Gao, Z., et al., The cut-off value of tumor size and appropriate timing of follow-up for management of minimal EUS-suspected gastric gastrointestinal stromal tumors. BMC Gastroenterol, 2017. 17(1): p. 8.
4. Dumonceau, J.M., et al., Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 2011. 43(10): p. 897-912.
5. Group, E.S.E.S.N.W., Gastrointestinal stromal tumours: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2014. 25 Suppl 3: p. iii21-6.
6. Fernandez, J.A., et al., Clinical and pathological features of "small" GIST ( Eur J Surg Oncol, 2018. 44(5): p. 580-586.
7. Mekky, M.A., et al., Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc, 2010. 71(6): p. 913-9.
8. Wani, S., V.R. Muthusamy, and S. Komanduri, EUS-guided tissue acquisition: an evidence-based approach (with videos). Gastrointest Endosc, 2014. 80(6): p. 939-59 e7.
9. Iglesias-Garcia, J., et al., Feasibility and yield of a new EUS histology needle: results from a multicenter, pooled, cohort study. Gastrointest Endosc, 2011. 73(6): p. 1189-96.

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Gastric hyperplastic polyps (GHPs) represent common lesions encountered in the upper gastrointestinal endoscopy. Large GHPs (>10mm) may cause troublesome complications e.g. bleeding, gastric outlet obstruction and have certain neoplastic risk, so previous expert’s recommendations tended to resect all large GHPs. However, it is too much burden for endoscopists to resect all lesions and resection procedure is not free from complications. As the clinical neoplastic risk factors clarified and imaging techniques advanced, we can now more accurately select the lesions carrying neoplasm for resection and let the remaining ones for periodic surveillance. Furthermore, several studies including randomized controlled trials demonstrated that in Helicobacter pylori infected patients, successful bacterial eradication could lead to GHPs regression even disappearance. In my opinion, if large GHPs have immediate complications and high risk for neoplasm, resection is mandatory. If not, we can check Helicobacter pylori status thereby prescribe eradication therapy. If no regression of polyps confirmed by surveillance endoscopy, then consider resection. By this strategy, we can reduce workload of endoscopists and avoid unnecessary resection- associated complications.

Endoscopic submucosal dissection (ESD) has been developed in the past two decades for management of early gastric cancer (EGC). The long term data revealed similar outcome when compared with surgery in terms of curative resection rate, long term remission and recurrence rate. Pathological margin free is of paramount importance to provide a successful ESD procedure. To define a sufficient distance between incision and the margin of tumor part is crucial. Under treatment is associated with lower curative resection rate and higher local recurrence rate, while over treatment leads to larger mucosal defect, longer procedure time and higher complication rate. Traditionally, chromoendoscopy with dye spraying, such as indigo carmine solution or acetic acid, is used before ESD. However, preparation of dye solution takes time and the flat type 0-IIb lesion is always difficult be delineated by chromoendoscopy. With magnifying endoscopy under narrow-band imaging (NBI), the microvascular and microsurface pattern could be observed not only to predict invasiveness and histology, but also to define the margin of tumor part. In this debate, I will demonstrate the superiority of NBI over chromoendoscopy for accurate delineation of tumor margin in gastric ESD.

To attain a successful endoscopic resection, accurate assessment of the lateral margins of gastric lesion before endoscopic submucosal dissection (ESD) is important. However, assessment of the margins of gastric tumors that are almost flat can be particularly challenging owing to its background changes of chronic active gastritis and intestinal metaplasia.

Currently, technique of margin delineation before gastric endoscopic submucosal dissection includes narrow band image (NBI) with or without magnifying and indigocarmine chromoendoscopy (ICC). The published data comparing ME-NBI with ICC are inconsistent. A larger randomized control study, which conducted by Nagahama et al and Kim et al showed no difference between the two groups.

In clinical practice, ICC remained the most preferred method to delineate tumor margins largely due to having a clearer far view and brighter under bright light.

Furthermore, Tiing and Uedo et al recommended stepwise usage of different technique may be superior to either one. Firstly, endoscopists may utilize ICC method as an initial approach. In cases where the tumor margins are less distinct under ICC, a different method such as ME-NBI can be used. Occasionally, margins remain unclear despite the use of both techniques, margin biopsies should be considered to determine horizontal extent of the lesion.

The COVID-19 pandemic has placed extraordinary demands on healthcare services worldwide. Strategic planning for acute COVID-19 care during the pandemic has overshadowed the provision of diagnostic services, which have been further restricted by the need to minimize viral transmission to reduce the risks to patients and staff. Its risk is compounded by the asymptomatic phase of COVID-19 infection and is particularly important concerning GI endoscopy, given the aerosol-generating nature of many endoscopic procedures.

When the pandemic comes to an end, we will face two significant problems: the prevention of new outbreaks and long waiting lists due to cancellations of endoscopic procedures in the pandemic period. The number of daily endoscopic examinations will not be able to return immediately to the levels at pre-pandemic. Sensible plans to ramp up endoscopic examinations will need to be formulated. Selection and stratification of patients according to an order of priority will be necessary. To prioritize, we could stratify patients according to clinical symptoms and fecal occult blood tests. Data collection during the post-pandemic period about the consequences of postponed endoscopy in the management of patients is also essential.

2019年12月陸續出現不明原因肺炎的個案，2020年1月定名由 SARS-CoV-2 病毒引起的 COVID-19新冠肺炎。COVID-19 的臨床表現變化多端，涵蓋從無症的輕度疾病到導致多重器官衰竭甚至死亡的嚴重呼吸道重症。

任何消化道內視鏡皆應視為氣霧生成醫療處置 (Aerosol-generating procedures, AGP)。根據研究，SARS-CoV-2 病毒顆粒可於氣霧化後保持三小時活性，甚至可於受汙染的物體表面保持至多三天活性。

受感染的醫療人員更可能將病毒傳播給他們的患者進而爆發院內感染，因此如何避免醫療人員在操作內視鏡檢查時被病患感染是非常重要的一環。而病患、家屬安全規劃同樣重要。

Since January 2020, more than 166 million persons were reported to be COVID-19 infected worldwide, and the number of deaths exceeded 3.44 million. Endoscopic procedures in particular pose risk of droplet and aerosol infection, and adequate infection control is therefore essential, to prevent droplet and aerosol infection during endoscopic procedures.

It is crucial for the training of endoscopy unit personnel on the prevention of COVID-19. Conversion of endoscopy units and redeployment of endoscopy unit personnel has profoundly changed. The need to reduce the transmission of COVID-19 makes the use of personal protective equipment compulsory among endoscopy unit staffs. We aim to share the available knowledge to prevent further dissemination of COVID-19 infection, maintain a high-quality endoscopy, protect the health, and keep the safety of endoscopy staffs in the era of the COVID-19 pandemic in Taiwan.

Policy for endoscopy units and reprocessing of instruments should be enhanced during COVID-19 pandemic. Based on available evidence, standard manual cleaning followed by high-level disinfection should be effective at eradicating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). At this time no changes to the reprocessing of gastrointestinal endoscopes are recommended. Endoscope reprocessing is limited to experienced staff, should be avoided by inadequately trained staff and new employees. Reprocessing staff should be properly trained in the use of personal protective equipment (PPE) that includes gloves, gowns, face shields, and masks.

Reprocessing of endoscopic accessories should be performed according to published guidelines or recommendations. Suspected or confirmed patients prefer to use single-use endoscope accessories. Reusable accessories should be disinfected or sterilized in accordance with the original manufacturer’s recommendations. The water bottle and its connecting tube are typically changed at least daily, and the water bottle and tubing are sterilized after use.

Environmental decontamination is essential to reduce the risk of fomite transmission. Each endoscopy unit should have a plan in place for the cleaning and disinfecting of the entire unit at the end of the day. Staff involved in the cleaning of endoscopy rooms should utilize PPE. Perform meticulous cleaning of room after each procedure, which includes cleaning of all high touch and equipment surfaces in procedure rooms with an Taiwan centers for disease control approved surface disinfectant.

In the last decade numerous works have established a clear relationship between alterations in the gut microbiota composition and diverse human pathologies. In particular, obesity and associated metabolic disorders, autoimmune diseases, and several types of colon diseases, esp. colon cancer, are characterized by changes in the microbiome and gut dysbiosis.

The gut microbiota produces a diverse metabolite repertoire that may harm or benefit the host. Alterations in the intestinal bacteria balance could lead to changes in the levels of gut microbial metabolites such as short-chain fatty acids (SCFAs), polyphenols, vitamins, tryptophan catabolites and polyamines, which could be related to the pathogenesis of the human diseases described above.

Recently, several studies have demonstrated that gut microbiota can alter colon diseases susceptibility and progression by modulating mechanisms such as inflammation and DNA damage, and by producing metabolites involved in diseases(tumor) progression or suppression. Dysbiosis of gut microbiota has been observed in patients with CRC, with a decrease in commensal bacterial species (butyrate-producing bacteria) and an enrichment of detrimental bacterial populations (pro-inflammatory opportunistic pathogens). Therefore, a personalized modulation of the pattern of gut microbiome by dietary or non-dietary may be a promising approach to prevent the development and progression of colon diseases and to improve the efficacy of therapy.

Acid suppressive medicine is the first-line treatment for GERD. For refractory GERD surgical fundoplication has been recommended in long term. Surgical fundoplication is the only treatment procedure to control refractory GERD with sliding hernia.

ARMA (anti-reflux mucosal ablation) is a novel minimally invasive endoscopic treatment for refractory GERD with no sliding hernia. Some GERD patients just have open hiatus without sliding hernia. Those cases can be treated by this simple flexible endoscopic procedure. Semi-circumferential mucosal ablation at gastric cardia is conducted to induce artificial ulceration. Mucosal flap valve at junction is rebuilt and reinforced in its healing process.

If esophageal motility is extremely low such as achalasia, Dor (anterior patrial fundoplication) is selected in laparoscopic surgery. Now we can complete this procedure using flexible transoral endoscope. POEF (Per-oral endoscopic fundoplication) is a pure NOTES procedure which creates anterior partial fundoplication.

In diagnosis LES function is a crucial factor of GERD mechanism. Now LES function can be evaluated by EPSIS (endoscopic pressure study integrated system).

In this lecture these novel procedures are presented and discussed.

In addition to pit pattern diagnosis by magnifying colonoscopy with chromoagents, recently the progress of endoscopic technology has provided an image-enhancement endoscopy (IEE) magnification in clinical field. The Japan NBI Expert Team (JNET) classification, which is based on NICE classification, was proposed as a first unified narrow-band imaging (NBI) magnifying endoscopic classification for colorectal tumors in Japan. It has been widely used in Japan, and also graduately spreading to other countries. IEE magnification doesn’t need chromoagents. Although for NICE classification magnification is not essential, for JNET classification magnification is essential.

In this lecture, I will talk about the JENT classification in detail with the knack and pitfall to use it with case presentation, including further qualitative diagnosis by applying JNET classification. Also, I also want to mention AI/CADx about JNET classification and consider future perspective of magnifying colonoscopy in colorectal tumor.

Reference: Sumimoto K, Tanaka S, et al. Gastrointest Endosc 2017; 85: 816-21, Sumimoto K, Tanaka S, et al. Gastrointest Endosc 2017; 86: 700-9 and Okamoto Y, Tanaka S, et al. J Gastroenterol Hepatol. 2021 Sep 3. doi: 10.1111/jgh.15682.

The gastroscope was developed in the 1950s, followed by the Fiberscope, and the videoscope in the 1980s. In the 2000s, high-definition image quality was introduced. In addition to conventional dye chromoscopy, image-enhanced endoscopes (IEE) such as Narrow Band Imaging and Blue laser Imaging have been developed and are routinely used in daily practice. These IEEs have greatly contributed to the early detection of early-stage cancers, and have led to a significant shift in treatment strategy from surgery to endoscopic treatment.

In addition, innovative endoscopic treatment methods have been developed over the past 15 years since polypectomy in 1968, from the EMR era in the 1980s to ESD in the late 1990s. It was a breakthrough because it eliminated the limitation of tumor size for endoscopic treatment.

The fact that the number of cases of ESD now exceeds those of surgical procedures in the treatment of early-stage gastric cancer is proof of the clinical significance of ESD.I am convinced that in the next 20 years, endoscopic practice will move into the era of AI and molecular imaging in diagnosis, and that submucosal endoscopy and full-thickness resection will be more actively used in treatment beyond ESD.

Doudenoscope transmitted infections are well documented and can be fatal. The US Food and Drug Administration (FDA) issued in 2015 recommendation to implement supplemental measures for duodenoscope reprocessing. More recently in 2019 the FDA calls for “innovative device designs that makes reprocessing easier more effective or unnecessary”. Although, duodenoscope transmitted infections have gathered significant attention in the US the problem has been reported worldwide.

All major endoscope companies have updated their duodenoiscope design to include disposable Endcap. Although the new design allows bruising the backside of the elevator and it can reduce organic material, contamination, bacterial flora was still detected in more than third of reprocessed duodenoscopes. The most likely explanation is that bacterial contamination does occur outside of the elevator area such as the therapeutic channel, air/suction buttons or umbilical cord.

The Exalt Model D (Boston Scientific, Marlborough, MA, USA) is the first single use disposable duodenoscope. It’s use completely eliminates the risk of endoscope transmitted infections without compromising performance. In high quality randomized controlled studies (RCT) the Exalt dudenoscope has been shown to have an equivalent performance to traditional reusable duodenoscopes in the key ERCP related outcomes including image quality, reaching the papilla, successful cannulation, and successful therapeutic interventions. The use of the Exalt Model D should be strongly considered in selected clinical situations including: patients known to be infected with multi dug resistant bacteria, immunocompromised patients, and in patients with hilar strictures, and/or primary sclerosing cholangitis.

Recent epochal development of endoscopy are endoscopic ultrasonography (EUS), balloon endoscopy, and electrical image enhancement.

Now therapeutic EUS such as EUS-guided PFC/WON drainage, EUS-biliary drainage (EUS-BD, HGS and CDS), EUS-pancreatic duct drainage (EUS-PD), and EUS-gastrojejunostomy (EUS-GJ) etc. have been employed in the clinical fields.

Endoscopic diagnosis / treatment for surgically altered patients were not feasible practically before 2000. After introduction of balloon endoscopy (BE), these diagnosis / treatments have been possible year by year. In general, the rate of reaching blind end is around 90% with BE. Stenosis of anastomosis are treated by balloon dilation, plastic stent, and metallic stent.

Nowadays, special designed metallic stent has been developed for treating anastomotic stenosis. Hepatolithiasis and bile duct stone in surgically altered anatomy patients are also treated by EPLBD, balloon dilation, and EHL under direct cholangioscopy. However, remaining 10% could not be treated by BE. In this situation, collaborated with EUS-FNA techniques are essential to solve the problems. EUS-HGS will be useful in the treatment of not reaching blind end case such as biliary drainage and antegrade bile duct stone removal, etc. In case of complete anastomotic stenosis, direct puncture could create EUS-hepatojejunostomy and EUS-pancreaticjejunostomy with forward-viewing echo endoscope.

Recently new processor, X-1, has been developed. It has become possible to detect faint lesions with TXI (texture enhancement imaging). It has also become possible to identify bleeding point in case of UGI bleeding or during ESD with RDI (red dichromatic imaging).

Anyway I will share our experience with you in DEST.

Endoscopic procedures for diagnosis of pancreatobiliary diseases are divided into two categories, namely EUS-related and ERCP-related procedures. EUS has become an essential diagnostic tool for pancreatobiliary diseases. In addition to the fundamental B-mode imaging, the tissue harmonic imaging made the image clearer. The color or power Doppler imaging allowed the detection of vessels and the evaluation of vascularity in the lesions. The contrast-enhanced harmonic EUS (CE-EUS) with intravenous contrast injection enabled more minute evaluation of the vascularity.

Furthermore, recent advances in microflow imaging may improve the ability to detect microflow in small vessels without using contrast agents. EUS-elastography can evaluate the tissue hardness. In addition to the strain elastography depicting the tissue hardness by color scale, recent development of the shear-wave elastography may enable the quantitative measurement of tissue hardness. Recent development of various EUS-guided biopsy (FNB) needles enabled to obtain core biopsy samples easier. It may facilitate gene analysis of the tumor for the precision medicine. Peroral cholangioscopy and pancreatoscopy (POCS/POPS) enabled the direct visualization of the bile and pancreatic ducts. The novel scopes improved the image quality and maneuverability. It also equipped additional image enhancing functions. I will review such recent development on endoscopic diagnosis of pancreatobiliary diseases.