Program

Serrated lesions of the colorectum are the precursors of perhaps one-third of colorectal cancers (CRCs). Serrated lesions should be classified pathologically according to the World Health Organization criteria as hyperplastic polyp, sessile serrated adenoma/polyp (SSA/P) with or without cytological dysplasia, or traditional serrated adenoma (TSA). Serrated polyps are considered precursor lesions that account for 15% to 30% of colorectal cancers, and they are overrepresented as a cause of interval cancers.  Cancers arising in serrated lesions are usually in the proximal colon, and account for a disproportionate fraction of cancer identified after colonoscopy. Endoscopic screening reduces incidence and mortality of colorectal cancer (CRC) because precursor lesions, such as conventional adenomas or serrated polyps are removed. However, guidelines for surveillance intervals after diagnosis of a precursor lesion, particularly for individuals with serrated polyps, vary widely, and lack sufficient supporting evidence. Individuals with polypectomies are advised to undergo colonoscopy surveillance to prevent CRC. Consequently, some high-risk patients do not receive enough surveillance and lower-risk subjects receive excessive surveillance. Otherwise, serrated polyposis syndrome should undergo surveillance every 1 to 2 years once the colon is cleared of larger lesions.

Colorectal polyps are common, occurring in 25-50% of all patients at screening age (50-74 years). Moreover, it is estimated that 20-50% of patients who undergo polypectomy will develop metachronous polyps in the future; hence surveillance colonoscopy is widely recommended. However, as many patients will never develop metachronous polyps and as few will progress to malignancy, it is inefficient and unnecessary to put all patients for surveillance. It is preferable to risk-stratify patients and only perform surveillance on those with a higher likelihood of developing metachronous pre-malignant polyps or cancer. The current surveillance guidelines risk-stratify patients based on polyp histology, grade of dysplasia, size, and number. The presence of high-grade dysplasia, larger polyp size, and an increasing number of adenomas found at index colonoscopy have been associated with a greater risk of future advanced adenoma and colorectal cancer. Current risk stratification measures are insufficient, and surveillance still places a significant burden on patients and endoscopy services, with surveillance accounting for a marked proportion of overall colonoscopies performed. By further refining risk stratification, it may be possible to relieve pressure on endoscopy services and avoid unnecessary invasive investigations.

Three updated guidelines based on the comprehensive summarized from the literature for post-polypectomy colonoscopy surveillance have been published recently. Although some recommendations are similar, different intervals of surveillance ware suggested by endoscopic finding of specific types of polyps. The most important impaction of current clinical practices is that surveillance interval could be lengthening in low-risk group patients or return to previous screening method. In case of the availability of colonoscopy and quality of colonoscopy in Taiwan, clinician should adhere to Taiwan colon cancer screening guideline coordinated by Taiwan Health Promotion Administration and The Gastroenterological Society of Taiwan.

After colonoscopic polypectomy, surveillance colonoscopies should be offered after an optimal interval to maintain the protection against colorectal cancer (CRC). According to current guideline, the surveillance interval should be tailored by each individual’s risk of metachronous advanced neoplasm (AN) and the only reference to stratify such risk is the index colonoscopy findings. However, the efficacy of current surveillance scheme has not been evaluated and interval CRC still occurred. To improve the effectiveness of current surveillance strategy and reduce the incidence of interval CRC, a more individualized stratification of metachronous AN risk is needed.

Several evidence had revealed, not only endoscopic findings, several personal or lifestyle factors have also been proven to be closely associated with the risk of metachronous AN formation, such as gender, comorbidity with metachronous syndrome and lacking of physical activity during surveillance interval. A more detailed understanding of these non-colonoscopic factors can help us to do a better individualized evaluation of the risk of metachronouss AN and to recommend a proper surveillance interval accordingly. In addition, searching modifiable lifestyle factors with impact on metachrnous AN formation can also give these subjects an opportunity to reduce their own risk of metachronous AN by adopting a positive lifestyle modification.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most technically challenging endoscopic procedures for the endoscopists, with high risk for procedure-related complications, such as pancreatitis, bleeding, and perforation. Because ERCP is associated with greater morbidity and mortality when compared to other endoscopic procedures like gastroscopy or colonoscopy, qualitative assessment of ERCP should be done using specially designed assessment tools to maximize procedure quality and safety for the patients. The American Society of Gastrointestinal Endoscopy (ASGE) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines have published guidelines for quality measures in ERCP. The ASGE divided the quality indicators into three parts, which include pre- procedure, intra-procedure, and post-procedure, whereas the ESGE divided the performance measures into seven quality domains. Though the details were different between the guidelines, the key measures include adequate prophylactic antibiotic use, bile duct canulation rates, common bile duct stones rates, appropriate stent placement for biliary obstruction below the hilum, procedure-related complications. To improve the quality of ERCP and to decrease the adverse events, self-assessment of every step by using quality indicators proposed in the guidelines is necessary. Although various endoscopic organizations have published their guidelines for quality measures, there is no standardized measurable tools, and these guidelines may not be suitable in everyday practice or difficult to apply in all hospitals in Taiwan. Therefore, establishing a simple self-assessing indicator list to improve the quality of ERCP in Taiwan is important.

Endoscopic retrograde cholangiopancreatography (ERCP) is invasive therapeutic procedure demanding specific individual approach for learning and mastering. It is associated with greater morbidity and mortality than any other procedure in gastroenterology. The risk for complications and harm for patient inevitably require strict guidelines to be followed regarding training, certification and proficiency. In an attempt to reduce the risk of complications, various endoscopic societies worldwide have established so called “Quality measures” which proved to be the back bone for safety and quality in ERCP. Recently developed ERCP quality network allowing data comparison between endoscopist is the key of reducing complications and creating a state of the art teaching program for beginner endoscopist.

This topic will review the literatures of quality measurement and patient outcomes improvement in ERCP service.

ERCP and its related procedures have been evolved from diagnostic to therapeutic intervention. These procedures are associated with a spectrum of complications such as pancreatitis, bleeding, infection and perforation. Standardized definitions were introduced fist in 1991.1 by Peter Cotton. These complications can range from mild to severe resulting in prolonged hospitalization, requiring surgical intervention, permanent disability or even death. Several factors are important risk factors of adverse events (AEs), such as patient selection, skills of endoscopist and difficulty of procedure. For endoscopists, it is important to understand the mechanisms of these complications. We should be familiar with prevention and management of these adverse events. This lecture with attempt to present current consensus-based definitions of complication, different ways to prevent and manage post-ERCP complications.

The indicators of ERCP quality measurements include pre-procedural period, intraprocedural period, and post-procedural period. Therefore, it is critical for endoscopists to prepare complete report of the procedure which describes the specific techniques performed, accessories used, and overall outcomes. It is desirable to have a video recording of the entire procedure, including fluoroscopic images, the success of the cannulation, the consecutive sequence of events, and a clear description of the overall outcome so that the endoscopist can view the entire procedure repeatedly to track and improve ERCP performance. Or at least there should be a photographic record, including any critical event. In the event of failure, discussion with a more experienced ERCP endoscopist by using these video or photo recordings can also help improve ERCP performance. Using ERCP reporting documentation software or quality network for automated tracking of ERCP quality metrics is useful to identify areas for improvement, both for self-comparison of intervals and for comparison with other ERCP endoscopists. Finally, educational and corrective measures can improve performance for motivated individuals who are made aware of below-standard procedure outcomes.

Obesity represents a growing public health threat and is associated with increased socioeconomic burden due to increased risk of obesity-related comorbidities such as type 2 diabetes, dyslipidemia, metabolic syndrome, coronary artery disease, hypertension, and cancer. Since obesity is multifactorial, treatments for obesity include comprehensive lifestyle interventions such as nutrition therapy, physical activity, behavior therapy, and pharmacotherapy. However, non-surgical treatments are less effective to patients with morbid obesity. Metabolic and bariatric surgery remains the mainstay treatment for morbidly obese patients because of its significant weight loss and long-term durability. Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (RGYB) are the two most common bariatric procedures. However, because of its technical simplicity and low complication rate, LSG is now the most common bariatric surgery. Endoscopic bariatric therapy (EBT) can bridge the gap in patients who do not fit the BMI criteria for surgery and fail conservative or medical therapy. Intragastric balloons (IGBs) are the most widely available EBT. However, they are temporary measures and should be removed six months after placement. Endoscopic sleeve gastroplasty (ESG) that alter gastric anatomy to reduce gastric volume and accommodation is found to have good effectiveness in weight reduction and also has longer durability. To optimize the effect of surgical or non-surgical treatments, they should be used in conjunction with a multidisciplinary program that includes lifestyle intervention, dietary support, and physician supervision.

Obesity has been a pan-epidemic medical problem worldwide for the past two decades. Bariatric surgery has been an effective treatment for morbidly obese patients since the 80's. First laparoscopic bariatric surgery was vertical banded gastroplasty, which was no longer suggested currently. In 1994, Prof. Wittgrove proposed the first laparoscopic Roux-en-Y gastric bypass, and with the advent of surgical instruments, laparoscopic bariatric surgeries have become standard treatment for morbid obesity in 2000's. Sleeve gastrectomy, Roux-en-Y gastric bypass and one anastomosis gastric bypass are the endorsed procedures by surgical society.

Remission of obesity related comorbidities, including type II diabetes, hypertension, dyslipidemia and sleep apnea etc., after bariatric surgeries has been published enormously with the increasing number of surgeries performed, therefore, term of metabolic surgery for the treatment of obesity population with co-morbidities is now used. Many randomized trials comparing medical treatment and metabolic surgery for the obesity with type II diabetes suggested the better remission rate in the surgical groups. It is currently recommended, for the obesity with poor control diabetes, that metabolic surgery should be suggested to be an option on account of better remission, better quality of life and better long-term survival.

Bariatric surgery is a well-known and highly effective longlasting treatment for obesity. [1] However, less than 2% of patients with obesity that meet the criteria for bariatric surgery actually undergo the procedure. [2] As a result, there is a need to develop less invasive therapies to treat obesity, especially for the population with a lower BMI. Bariatric endoscopy appears as a less invasive option, more effective than pharmacological treatment, and lifestyle changes, with lower morbidity when compared with bariatric surgery. [3, 4]

Endoscopic sleeve gastroplasty (ESG) is a minimally invasive procedure that involves remodeling of the greater gastric curvature, using an endoscopic full-thickness suture device (Overstitch, Apollo Endosurgery, Austin, TX, USA), with the objective of reducing gastric lumen in order to shape it into a tube. [5, 6] Publications demonstrate not only technical feasibility and safety, but also sustained weight loss and improved comorbidities after ESG. [7-10] In a multicenter study, Galvao Neto et al. showed a 19.7% percentage of total body weight loss (TBWL) after 12 months of follow-up, in a group of 233 patients. [11] Although different suture patterns have been used by centers worldwide, a multicenter study evaluated results with a standard U-shape suture pattern. Data from 193 consecutive patients from seven centers showed a TBWL of 15.1%in 12months, with the percentage of excess weight loss (EWL) higher than 50%for all body mass index (BMI) groups at 1-year follow-up. [12] A recent systematic review analyzed 11 studies, with a total of 2170 patients. Pooled TBWL was 16.8% and EWL was 73% after 18 months, and no procedure-related mortality was reported. [13] In addition, ESG has shown improvement in type 2 diabetes mellitus, hypertension, and other comorbidities.[14]. A ESG consensus that we run in Brazil gather 1828 patients achieving a mean of 18.2% of TWL in 1 year with just 0.82% of SAE (1 mortality due to pulmonary embolism 2 weeks after) [15]. To end, new level 1 evidence not yet published comes from United States, The MERIT trial (NCT03406975), an RCT FDA-IDE trial the achieved all endpoints on safety and efficacy.

With all this exposed is on our vision that the ESG is keen to be a new and solid bariatric procedure that comes to stay.

References

1. Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416-25.
2. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg. 2013;23(4):427-36.
3. Force ABET, Committee AT, Abu Dayyeh BK, et al. Endoscopic bariatric therapies. Gastrointest Endosc. 2015;81(5):1073-86.
4. orce ABET, Committee AT, Abu Dayyeh BK, et al. ASGE Bariatric Endoscopy Task Force systematic review and metaanalysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc. 2015;82(3):425-38.e5
5. Lopez-Nava G, Galvao MP, Bautista-Castano I, et al. Endoscopic sleeve gastroplasty: how I do it? Obes Surg. 2015;25(8):1534-8.
6. Lopez-Nava G, Sharaiha RZ, Vargas EJ, et al. Endoscopic sleeve gastroplasty for obesity: a multicenter study of 248 patients with 24 months follow-up. Obes Surg. 2017;27(10):2649-55.
7. Galvao-Neto MD, Grecco E, Souza TF, et al. Endoscopic sleeve gastroplasty - minimally invasive therapy for primary obesity treatment. Arq Bras Cir Dig. 2016;29Suppl 1(Suppl 1):95-7.
8. Abu Dayyeh BK, Rajan E, Gostout CJ. Endoscopic sleeve gastroplasty: a potential endoscopic alternative to surgical sleeve gastrectomy for treatment of obesity. Gastrointest Endosc. 2013;78(3):530-5.
9. Sharaiha R. Endoscopic sleeve gastroplasty for obesity management. Gastroenterol Hepatol. 2019;15(7):390-2.
10. Kumar N, Abu Dayyeh BK, Lopez-Nava Breviere G, et al. Endoscopic sutured gastroplasty: procedure evolution from firstin-man cases through current technique. Surg Endosc. 2018;32(4):2159-64.
11. Neto MG, Moon RC, de Quadros LG, et al. Safety and short-term effectiveness of endoscopic sleeve gastroplasty using overstitch: preliminary report from a multicenter study. Surg Endosc. 2019;
12. Barrichello S, Hourneaux deMoura DT, Hourneaux deMoura EG, et al. Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study. Gastrointest Endosc. 2019;90(5):770-80.
13. de Miranda Neto AA, de Moura DTH, Ribeiro IB, et al. Efficacy and safety of endoscopic sleeve gastroplasty at mid term in the management of overweight and obese patients: a systematic review and meta-analysis. Obes Surg. 2020;30(5):1971-87.
14. Sharaiha RZ, Kumta NA, Saumoy M, et al. Endoscopic sleeve gastroplasty significantly reduces body mass index and metabolic complications in obese patients. Clin Gastroenterol Hepatol. 2017;15(4):504-10.
15. Galvao Neto M, Bezerra L, Quadros LG. Brazilian Consensus on Endoscopic Sleeve Gastroplasty. Obesity Surg. 2021 Jan:31(1):70-78

Obesity is related to many diseases such as T2DM, hypertension, dyslipidemia, obstructive sleep apnea, non-alcoholic fatty liver diseases, osteoarthritis, and some kinds of cancer. Furthermore, obesity per se also increases all-causes mortality. The global prevalence of obesity increases thereby it becomes a worldwide health problem. Appropriate weight reduction can reduce the obesity-related health burden. Lifestyle modification remains the core stone in the management of obesity. Restricted balanced diet and increased physical activity are encouraged in stages of weight reduction and maintenance. Pharmacotherapy may be considered if subjects have suffered from obesity-related comorbidities or high degree of obesity. In Taiwan, Xenical, Saxenda, and Contrave are three available anti-obesity drugs. The second generation of anti-obesity medicines such as semaglutide (Wegovy), Tirzepatide, and Setmelanotide, etc. will become available for more weight reduction. In clinical practices, health professionals should assess weight issues simultaneously when managing comorbidities. Laparoscopic or endoscopic bariatric surgery is indicated if the subjects fail to reduce adequate body weight with lifestyle modification and pharmacotherapy. In the future, more anti-obesity drugs will be on the market to assist obese people to control their body weight and co-morbidities.

Gastrointestinal tract malignancies, including esophageal, gastric and colorectal neoplasm, are among the most common causes of cancer death worldwide and in Taiwan. Early detection is of paramount importance to improve the overall outcome of these cancers. Eliminating environmental risk factors is one of the most important primary preventive measures. However, some subjects exposed to environmental risk factors encounter development of neoplasm without preceding symptoms. Therefore, regarding the second primary preventive strategy, stratifying population with risk factors and referral to endoscopic screening, particularly using image-enhanced endoscopy (IEE), could identify patients with early neoplasm before related symptoms occur. Herein, I will briefly review the current evidences about the application of IEE, especially narrow-band imaging, blue-light laser and linked-color imaging systems, for screening upper gastrointestinal tract cancers.

Hypopharyngeal cancer associated synchronous esophageal cancer is not unusual in Taiwan. The phenomenon has been termed “field cancerization” due to both share the same risk factors. Early detection using imaging-enhanced endoscopy (IEE) in high-risk patients improved survival and quality of life. However, there are still some controversies and challenges for early diagnosis. Herein, I will briefly introduce the optimal screening strategies of IEE and current role of EUS for invasion depth. Furthermore, new imaging system and technology of artificial intelligence would be much expected in the coming future.

With a high incidence rate, deaths form gastric cancer are not rare. Early diagnosis is important for the prognosis of gastric cancer. Methodology for the diagnosis and staging of early gastric cancer have improved since the development of imaging technology has been steadily evolving in the endoscopy field.

Improvements in the resolution of standard endoscopy images used in screening and surveillance provide greater opportunities to find gastric cancer earlier. Not only image enhancing endoscopy (IEE) but also endoscopic ultrasound (EUS) helps achieving accurate diagnosis before treatments.

Besides, endocytoscopy and confocal laser endomicroscopy bring us a new visions for diagnosis. Furthermore, artificial intelligence (AI) has involving into detection and differentiation of lesions in endoscopy, which helps diagnosis of early gastric cancer. Multi-modality approach helps physicians and endoscopists to detect gastric lesions earlier and diagnose early gastric cancer more accurately.

Early detection of early upper GI cancer is important to improve the prognosis of patients. Endoscopic submucosal dissection (ESD) enables En-bloc resection of dysplastic lesions and superficial early cancers of the GI tract. The short-term and long-term outcomes of ESD for early GI cancer have improved and the surveillance with endoscopy after ESD is important, including how to perform endoscopic surveillance and the follow-up strategy. Endoscopic surveillance should be performed using high-definition endoscopy with image-enhancing modalities(IEE), such as dye-based or electronic chromoendoscopy(NBI or BLI). In some conditions, central and peripheral biopsies of the post-ESD scar may had additional information to exclude recurrence.

Endoscopic ultrasound (EUS) represents one of the most fascinating fields to explore in the diagnosis and staging of GI and mediastinal mass lesions and conditions due to its relatively limited availability out of high-volume centers. This leads to a particular need to define widely accepted quality indicators and the ways to measure them. With the increasing demand for EUS, the number of physicians performing this complex procedure will continue to grow. It is the hope of the ACG, ASGE, and AGA that these measures and targets not only guide practicing endoscopists who perform EUS but also that they be incorporated into the training of new endosonographers to ensure that all patients receive the highest quality care possible.

EUS is an excellent tool for evaluation of the intra-luminal subepithelial lesions and extra-luminal neighboring lesions such as those in the bilio-pancreatic region. EUS-guided tissue acquisition has been well accepted as a safe and effective method for histopathological diagnosis in addition to sonographic evaluation.

We may increase the diagnostic yield of EUS-guided tissue acquisition with aids of the appropriate sampling equipment, sampling techniques, and processing techniques. Under contrast-enhanced EUS, tissue acquisition with specially designed FNB needles by fanning sampling lesions along with proper tissue processing and ancillary tests may be the most recommended way to maximize the diagnostic yield. Alternative options for rapid on-site cytology evaluation such as macroscopic on-site evaluation have been developed recently with nearly equivalent effects.

More well-designed clinical studies may unravel the best way to get the tissue diagnosis under EUS guidance. Continued efforts on maximizing the diagnostic yield in EUS-guided tissue acquisition will facilitate the clinical applications of related personalized medicine in the future.

Endoscopic ultrasonography (EUS) has emerged as important clinical modalities not only in diagnostic purposes but for therapeutic roles as well. However, the quality control of EUS examination is not well established. Quality indicators for the performance of EUS have been developed to monitor and improve service value and patient outcomes. Quality indicators should include pre-procedure, intra-procedure, and post-procedure items. Indications are the most important part of intra-procedure items. We should elucidate whether EUS is needed for the patients regardless of diagnostic or therapeutic purposes. Procedural aspects should indicate (1) description of the size, sonographic characteristics and landmark of the lesions, (2) sampling method and sample quality, including needle type and gauge, number of passes, tissue acquisition technique, if presence of rapid on-site evaluation, and intraprocedural adverse events, etc. Documentation and reporting play a vital role in post-procedure items. Description of a pancreatic lesion should be composed of parenchymal echogenicity, pancreatic duct anatomy, contour, dilation, etc. Standardizing pre-, intra-, post-procedure reporting elements may help improve the quality of EUS procedures.

In the last years, endoscopic ultrasound (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure. Recently, there have been significant advancements in interventional EUS procedures, including EUS-guided drainage procedures, EUS-guided anastomosis and tumor ablations over the past two decades. The described procedures include celiac plexus neurolysis and block, ablation of pancreatic neoplasm, EUS-guided drainage of pancreatic fluid collections, biliary drainage, pancreatic duct drainage, gallbladder drainage, and gastroenterostomy. Actually, the concept of performing EUS-guided anastomosis between two target organs is not new. In 1993, Grimm et al. first described EUS-guided drainage of a pancreatic pseudocyst. Thereafter, Giovannini et al. described EUS-guided cholechoduodenostomy in 2001. EUS-guided pancreaticogastrostomy and cholecystoduodenostomy were then described in 2002 and 2007, respectively using similar techniques. These procedures have been made possible with novel devices that can reduce the difficulties of the procedures and potentially reducing the risk of adverse events. The procedures are becoming standardized and evidence is accumulating demonstrating advantages of these procedures.

ESD is a challenging procedure developed for more than 10 years in Taiwan. The key point of successful ESD is efficient mucosal flap creation. In this talk, we will review several endoscopic tips to facilitate the ESD, including conventional flap creation by distal attachment, pocket/tunnel creation method, additional traction device, our current hybrid method and the future magnetic traction device in study.

Colorectal endoscopic submucosal dissection and other endoscopic interventions are technically demanding. One endoscope can offer one view and one working channel for the instrument. The idea of the double-endoscope platform is to offer additional functions from setting additional endoscopes. We will discuss the feasibility of the insertion of two endoscopes, double-endoscope ESD with multi-direction snare-based traction to fasten procedure and overcome difficult cases, double-endoscope hemostasis, EMR margin confirmation from the additional view, and looping stabilization with an additional endoscope.

The cost-effectiveness analyses on colonoscopic treatment for large colorectal neoplasms mainly pertain to large flat lesions—laterally spreading tumors (LSTs). The LST was originally proposed by Kudo for tumors that spread extensively and circumferentially along the colonic wall and are larger than 10 mm in diameter. Endoscopic mucosal resection (EMR) is a useful therapeutic technique for LST; however, the maximum diameter of the lesion for en bloc resection is approximately 20 mm, owing to the size of the snare, the technical difficulty, and the perforation risk. Evolving endoscopic submucosal dissection (ESD) provide less invasive curative treatment options. The appropriate position of ESD in clinical practice is worthy of consideration. In general, ESD is more costly than the traditional polypectomy or EMR, but the expense is much lower than surgery and related expenses (admission fee, anesthesia, etc.). If compared with conventional polypectomy or EMR, it can reduce local recurrence or even post-colonoscopy colorectal cancer (PCCRC); and, if compared with surgery, it can reduce post-treatment morbidity, shorten the duration of admission, and improve the quality of life of the patients. These therapeutic options should be precisely tailored to appropriate lesions that would benefit from individual treatment, thereby balancing effectiveness (PCCRC and CRC mortality), cost, and willingness-to-pay levels.

Colorectal ESD has become widely accepted with the increasing evidence of its usefulness; however, it is technically challenging. To evaluate the necessity of mastering ESD, we need to understand the indications of ESD. ESD is indicated for colorectal neoplastic lesions in which en bloc resection is warranted but EMR cannot achieve it. Laterally spreading tumor (LST)-nongranular type ≥2 cm and LST-nodular mixed type ≥3 cm are good indications for ESD due to their risk and pattern of submucosal invasion. With the improvement of endoscopy image quality, the chances to detect the lesions indicated for ESD, including these LSTs, increase. Nevertheless, their prevalence is much lower than the lesions indicated for polypectomy and EMR. This might limit the necessity to master ESD technique. However, due to the potential usefulness of chemoradiation therapy for endoscopically resected rectal submucosal invasive cancer and increasing evidence on the low metastatic potential of colorectal submucosal invasive cancer with no other risk factors except invasion depth, further utilization of ESD is expected. Therefore, I believe that it is necessary to provide dedicated training to a certain number of endoscopy specialists who can master the colorectal ESD technique, although not evert endoscopist needs to master it.

The global and ascian prevalence of gastroesophageal reflux disease (GERD) is high and increasing. Emerging endoscopic antireflux therapies have been reported to reduce GERD symptom burden and PPI usage, which are less invasive than laparoscopic antireflux surgery. Our lecture will cover indications/contraindications of endoscopic antireflux therapy and modalities for preoperative evaluation, focusing on the pathophysiology of GERD.

The incidence of gastroesophageal reflux disease (GERD) is increasing. GERD not only affects the patient's quality of life, but also increases the risk of development of Barrett's esophagus and esophageal adenocarcinoma.

Proton pump inhibitors (PPIs) have been the mainstay of medical management of GERD. However, about 20% to 30% of patients with erosive reflux disease and 40% of patients with non-erosive reflux disease do not respond to PPIs. The potential adverse effects of long term PPIs use are also a matter of concern. These adverse effects include Clostridium difficile infection, bone fracture, hypomagnesemia, higher incidence of chronic kidney disease in susceptible populations and community-acquired pneumonia.

Anti-reflux surgery (ARS: open or laparoscopic fundoplication) has been the mainstay of treatment for patients not responsive to PPIs and documented reflux on pH-impedance analysis. However, a quarter of patients restart PPIs on long-term follow-up. Moreover, a requirement of re-intervention exists in about 15% and 30% patients after laparoscopic or conventional fundoplication, respectively. Other adverse events known to occur with ARS include dysphagia, gas bloating, and inability to belch. Patients with refractory GERD may not agree to ARS due to its invasive nature and possible adverse events as mentioned above.

There is an unmet need for minimal invasive treatment modalities for patients who do not respond to PPIs and are unwilling for ARS. Minimally invasive endoscopic options for GERD have been in place for more than a decade now. Some of these have not stood the test of time either due to inefficacy, non-durable response, or safety issues. These include implantation of injection devices (Enteryx [Boston Scienntific Corp, Natick, MA, USA], Gatekeeper [Medtronic, Minneapolis, MN, USA], Plexiglas microspheres [Artes Medical, San Diego, CA, USA], NDO Plicator [NDO Surgical, Mansfield, MA, USA]). The currently available endoscopic anti-reflux modalities (EARMs) include radiofrequency ablation (RFA), transoral incisionless fundoplication (TIF), medigus ultrasonic surgical endostapler (MUSE), and anti-relux mucosectomy/ mucosal ablation (ARMS/ARMA).

In this lecture, these novel procedures will be presented and discussed.

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. The risk factors of EAC from BE including male gender, smoking and a long segment of BE. Current guidelines for Barrett's esophagus patients recommend endoscopic surveillance intervals of 3-5 years for patients without dysplasia, 6-12 months for those with low-grade dysplasia (LGD), and every 3 months for HGD patients. In this section, we will discuss and update current surveillance of Barrett's esophagus and analysis the cost-effectiveness of long-term surveillance.

Key Words: Barrett's esophagus, Esophageal adenocarcinoma, Gastroesophageal reflux disease, Surveillance, Cost-effectiveness

Barrett's esophagus (BE), a precursor for esophageal adenocarcinoma (EAC), is defined as salmon-colored mucosa extending more than 1 cm proximal to the gastroesophageal junction with histological evidence of intestinal metaplasia. The actual risk of EAC in nondysplastic Barrett's esophagus (NDBE) is low with an annual incidence of 0.3%. The mainstay in the management of NDBE is control of gastroesophageal reflux disease along with enrollment in surveillance programs. However, BE with dysplasia has a higher cancer progression risk, and the management of Barrett's dysplasia or early cancers has evolved in recent years. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are the initial interventions of choice for nodular BE, with ESD reserved for endoscopists highly trained in the technique and for larger lesions that would warrant en bloc resection. Resection should then be followed by ablative therapy, which remains first line in the treatment of BE with visible dysplasia. Although there is a myriad of ablation techniques available to the endoscopist, recent review has found that radiofrequency ablation (RFA) continues to have the most robust safety and efficacy data to support its use despite a relatively high rate of recurrence.

Colorectal cancer (CRC) screening can reduce the incidence and mortality of CRC, and many countries with moderate-to-high incidences of CRC have implemented population screening programs. Many previous studies have investigated the economic impact of various CRC screening strategies. There are two main CRC screening methods: direct colonoscopy and two-tier noninvasive screening strategies using stool tests, such as guaiac fecal occult blood tests (FOBTs), fecal immunochemical test (FIT), or stool DNA tests, as the primary screening test followed by colonoscopy if positive test results are obtained. Colonoscopy has a higher ability to detect colonic neoplasms, especially early-stage CRC or precancerous neoplasms, than other noninvasive tests but is associated with higher risk and related costs. Although colonoscopy outperforms other noninvasive tests in detecting colorectal neoplasms, it is associated with higher cost, manpower, and invasiveness. Owing to the heterogeneity of healthcare systems in terms of the scale of health revenue, population demographics, and the payment systems in each country, the optimal or most cost-effective screening strategy may vary. Accordingly, economic appraisal of different approaches is essential, especially in organized screening programs within which the resources and the clinical capacity are constrained, and each step of the screening flow needs careful monitoring.

Colorectal cancer (CRC) remains one of the leading causes of cancer death in the world currently. Colonoscopy is very effective for reducing CRC risk since it can detect and remove precancerous colorectal polyps. However, increasing the rate of CRC screening with resultant adenoma detection will further stimulate the need for surveillance colonoscopy. Despite surveillance guidelines are available to help utilizing colonoscopy resources effectively and efficiently, previous research indicated that adherence to surveillance guidelines is insufficient.

The impact of too early surveillance on colonoscopy demand will be largely found in patients without adenoma or with low-risk adenoma in baseline colonoscopy, up to 33.6% to 48% of the patients received surveillance too early, and it will promise to further strain the capacity to deliver colonoscopy services.

Aside from asymptomatic screening and surveillance, lower gastrointestinal symptoms are the other main cause for colonoscopy examination. How we could find appropriate way to identify the high risk group for the colonoscopy is very important. Since the resources and manpower for colonoscopy are limited, adherence to evidenced-based practice is the best way for patients and also for the endoscopists.

Colorectal cancer (CRC) has been the most frequently diagnosed cancer in Taiwan since 2006. Hereditary colorectal cancer (HCRC) is a group of diseases or syndromes which have mutational genetic components with clinically different phenotypes. When considered together, they represent 3-5% of all cases of CRC in Western countries. HCRC can be divided into two large subgroups: non-polyposis syndrome (like Lynch syndrome) and polyposis syndrome(like familial adenomatous polyposis (FAP)).

The mutational mechanisms associated with HCRC is genomic instability. For example, mutations affect APC gene, a tumor suppressor gene, cause FAP. The other important mechanism is DNA mismatch repair deficiency(dMMR), which induced Lynch syndrome. Mutations on different genes of the DNA mismatch repair system are related to different cumulative incidence of cancer.

It is important to identify patients with HCRC because these patients have high risks of early-onset CRC and synchronous or metachronous advanced adenoma and even CRC. Moreover, in addition to colon or rectum, these patients might develop malignancy at organs. The inherited nature of HCRC makes it not only a single patient's problem but a whole family problem. How to screen the proband and his/her relatives adequately and timely is a big issue. Genetic exams and counseling are also indispensable.

Colonoscopy reimbursements meet challenges in balancing the goals of maximizing public health while carefully allocating limited resources. Is our colonoscopy under-paid? Before answering this question, several issues should be addressed include “payment model” and “quality of colonoscopy”.

• The payments of colonoscopy worldwide

Colonoscopy has highly variable costs in different countries. It usually is related to the payment model of healthcare system and gross domestic product (GDP) of the country. A recent study reported the payments of colonoscopy may range from less than 100 US$ in low GDP areas to more than 1000 US$ in high GDP areas.¹ The cost of screening colonoscopy in Taiwan is around 70-80 US$. This payment is lower than the average fee among similar GDP areas.

• Reimbursement model: pay-for-performance (P4P) vs. current pay-for-service (P4S)

The P4S reimbursement model is the traditional healthcare model in recent decades. In this model, providers are paid every time they provide a service, so the incentive is to provide more services. The traditional P4S model is inherently inefficient. There are several concerns of P4S include: 1. Increased Health Care Costs. 2. Lack of Focus on Quality of Care. 3. Focus on Service Volume. 4. Barrier to Shift to Low-Cost Setting. 5. Little Focus on Preventive Care.²

In response to these concerns, there has been a shift away from P4S toward fee for value-based models. P4P is one of the value-based types of payments. Under this model, the provider receives performance-based adjustments in the form of bonuses for exceeding certain standards or punishments for falling short. P4P programs aim to upgrade healthcare quality by tailoring financial incentives for desirable behaviors, however, supporting evidence remained limited.²

• Improve quality of colonoscopy may raise the value of colonoscopy.

Colonoscopy plays a key role in preventing the development of CRC. Recent international guidelines have highlighted pre-procedural, peri-procedural, and post-procedural practices, which promise to improve patient outcomes and reduce the mortality and interval cancer rates in patients undergoing high quality colonoscopies.³ As a result, ensuring that high-quality colonoscopy is practiced widely by endoscopists can lead to the most cost-effective care.

• P4P may boost quality improvement?

P4P rests on several assumptions, such as: 1. Performance can be accurately ascertained. 2. The current payment system is too simple; more detailed contracts rewarding specific, important aspects of performance will improve quality. 3. Variation in performance is caused by variation in motivation. 4. Financial incentives will add to total motivation, not undermine it. These assumptions have some flaws and require supporting measures. Several key issues should be addressed in advance: What to incentivize? How to measure quality? Whom to incentivize? How to incentivize? and How to implement and administer a P4P program?^2,4

“Price is what you pay. Value is what you get.” New strategies to maximize quality and reduce cost are emerging. Are you ready?

Ref.

1. Cost-effectiveness of colonoscopy and related procedures: population screening perspectivesWF Hsu, HM Chiu Mini-invasive Surgery, 2022.
2. Improving healthcare quality in Europe: Characteristics, effectiveness and implementation of different strategies (2019). Reinhard Busse, Niek Klazinga, Dimitra Panteli, Wilm Quentin Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2019. European Observatory Health Policy Series.
3. High-Quality Colonoscopy: A Review of Quality Indicators and Best Practices Mason Soeder , Alla Turshudzhyan , Lisa Rosenberg and Micheal Tadros Gastroenterol. Insights 2022, 13, 162-172.
4. Holding Gastroenterologists Accountable for Colonoscopy Through MACRA Episode-Based Cost Measure Shazia Mehmood Siddique and Shivan J. Mehta Clinical Gastroenterology and Hepatology 2019;17:1015-1018

Indeterminate biliary stricture is defined as a diagnosis cannot be made after basic laboratory work-up, abdominal imaging and ERCP with biliary sampling. Indeterminate biliary stricture is a complicated challenge in diagnosis, requiring a multidisciplinary approach. An expert approach to indeterminate biliary stricture not only maximizes the possibility of correct diagnosis but also avoids unnecessary surgical intervention. Decision-making for patients with biliary strictures depends on detailed history, physical examination, laboratory testing, radiological tests (level of obstruction, presence or absence of a mass lesion), and endoscopic modalities including ERCP, EUS, IDUS and cholangioscopy. Per-oral cholangioscopy (POC)-targeted biopsies, potential to overcome the problems associated with inadequate tissue sampling and increase the diagnostic sensitivity of bile duct tumors. Combined POC-targeted biopsies with frozen section histopathology provides an immediate and efficient diagnosis and allows an early surgery for patients with bile duct tumors.

Solid lesions of the pancreas can be classified as primary or metastatic, benign or malignant, and arising from the exocrine or endocrine pancreas. The most common and potentially serious solid lesion of the pancreas, pancreatic adenocarcinoma, arises from the exocrine pancreas.

Cystic lesions of the pancreas often present a diagnostic and therapeutic challenge. Their pathology ranges from pseudocysts and pancreatic necrosis to benign and malignant neoplasms. Pancreatic cystic lesions may be encountered during the evaluation of a patient with pancreatitis or abdominal pain.

This topic will discuss the role of endoscopy in the evaluation and treatment of pancreatic neoplasm, focus on diagnostic endoscopic ultrasound (EUS) and EUS-guided tissue acquisition of pancreatic neoplasms which requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness.

Endoscopic biliary drainage via ERCP is the standard treatment for malignant distal biliary obstruction. There are two main types of stents: plastic stents (PS) and self-expandable metal stents (SEMS). Compared to PS, SEMS has longer patency and fewer re-intervention rate. Although FC-SEMS has the advantage of preventing tumor ingrowth, the most common adverse event is migration. Therefore, many attempts have been tried to prevent migration. Initially, we devised a method using an internal anchoring PS. In a multi-center RCT, the rate of stent migration at 6 months was significantly lower in patients with the FC-SEMS plus internal anchoring PS (15% vs. 40%; P = 0.02). There were no significant differences in adverse events. In long-term follow-up, there were some cases of migration of both stents and cholecystitis due to cystic duct obstruction. To manage these adverse events, we adopted another method, an external anchoring plastic stent. In a multi-center, retrospective study including our institution, external anchoring PS decreased the risk of migration (10.8% vs 27.7%, P = 0.006) and prolong the stent patency without a significant increase of adverse events. Recently, we started a multicenter RCT comparing FC-SEMS plus external anchoring PS and UC-SEMS and are currently enrolling patients (NCT05220475).

Keywords

Malignant biliary stricture, Self-expandable metal stent, Migration

Recently, the introduction of lumen apposing metal stents (LAMS) has allowed secure performance of a safe anastomosis between the stomach and other enteral organs. As a result, the stent can both act as a drainage device or a portal for accessing other enteric lumens. In the past few years, we have witnessed an exponential growth in the reports of EUS-guided gastroenterostomy. These include the performance of EUS-guided drainage of afferent loop obstruction, EUS-guided gastro-gastrostomy for performance of ERCP in patients with roux-en Y bypass for obesity and EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction. In this lecture, an overview in the current development of EUS-guided gastroenterostomy will be provided.

Gut dysbacteriosis is closely related to various intestinal and extraintestinal diseases. Fecal microbiota transplantation (FMT) transfers the gut microbiota from healthy individuals to patients in order to reconstruct the intestinal microflora in the latter. It has been proved to be an effective and safe therapeutic option for recurrent or refractory Clostridioides difficile infection. It is also an emerging therapy in other intestinal diseases including irritable bowel syndrome and inflammatory bowel disease.

Moreover, reconstruction of the healthy gut microbiota is a potential therapeutic strategy for treating the extraintestinal diseases associated with intestinal microbial dysbiosis, including liver, metabolic, chronic kidney, neuropsychiatric, allergic, autoimmune, and hematological diseases as well as malignancy. There are preliminary reports on the use of FMT therapy in a wide range of disorders including Parkinson's disease, fibromyalgia, chronic fatigue syndrome, myoclonus dystonia, multiple sclerosis, obesity, insulin resistance, metabolic syndrome, and childhood regressive autism. As we get a better understanding of the relationship between gut microbiota and systemic disease, FMT became a potential treatment to explore. It has become a more available and potential treatment option as a result of stool banks in Taiwan. In this way, we can provide another therapeutic choice for many refractory diseases. We will discuss these issues in this section.

Emerging evidences showed gut microbiota dysbiosis associating with the pathogenesis of intestinal & non-gastrointestinal disorders such as Clostridium difficle infection, inflammatory bowel disease, metabolic syndrome, cardiovascular disease and neurologic disorder.

In recent years, there has been growing interest in non-medical treatment for dysbiosis, including targeting the microbial environment itself. Fecal microbiota transplantation (FMT), infusion of fecal solution from a healthy donor into the intestinal tract of illness recipient, could be a promising therapeutic strategy for disease related to intestine dyspbiosis.

A number of delivery routes are in use for conducting FMT, which include include the upper gut, mid-gut and lower gut. Here, we review the methology, safety and delivery route of fecal microbiota transplantation.

Recently, many reports described that gut microbiota is associated with various diseases, including infectious conditions (infectious gastroenteritis, Clostridium difficile infection (CDI)), autoimmune diseases (allergic disease, diabetes, inflammatory bowel disease (IBD)), some general conditions (overweight, functional GI disorders), and behavioral diseases. Department of Medical Affairs in Ministry of Health and Welfare announce that fecal microbiota transplantation (FMT) can be done for Clostridioides difficile infection (CDI) on September, 2018 under the regulations of special medical techniques. To monitor and identify potential short-term adverse outcomes and to investigate for long-term safety concerns, Department of Medical Affairs established a system for FMT registry in Taiwan. The details of FMT registration system in Taiwan will be introduced. The potential applications of the registration system, such as personalized FMT, in the future will be discussed.

Gastrointestinal symptoms are quite common in patients infected with the SARS-CoV2 virus. These GI symptoms are related to COVID-19 severity. The SARS-CoV2 infection will reduce microbial diversity, disrupt the tight junction of epithelium, activate immune cells and cytokines, and lead to bacterial translocation. For those with post-acute COVID-19 syndrome, their microbiota diversity is significantly reduced. On the contrary, gut microbiota will influence the antibody responses to vaccines.

In the COVID-19 pandemic, fecal microbiota transplantation (FMT) needs re-organization according to FMT aims, with modified donor screening, testing, and quarantine after stool collection, FMT center facilities, and post-FMT follow-up, etc. The efficacy and durability of FMT in the COVID-19 pandemic are also important issues to be answered.

In conclusion, SARS-CoV2 has a great impact on the GI tract and gut microbiota. FMT services need re-organization in the COVID-19 pandemic. The COVID-19 pandemic does not change the effectiveness of FMT for recurrent Clostridium difficule.

Hypercontractile esophagus (HE), also known as jackhammer esophagus, is defined as 20% or more hypercontractile peristalsis (Distal Contractile Integral>8000 mmHg·s·cm) on high-resolution manometry (HRM). The symptoms of HE includes dysphagia, chest pain, and acid reflux. According previous literature, HE has been reported to constitute 1.5-3% of manometric diagnosis, and is encountered more frequently in females and in those older than 60 years.

HE should be first considered to give proton pump inhibitor as empirical treatment because of the overlap with gastroesophageal reflux disease. Endoscopic treatment with pneumatic dilation or botulinum toxin injection has variable response. For relieving dysphagia, per-oral endoscopic myotomy may be superior to laparoscopic Heller myotomy, but we still lack available data.

Ineffective esophageal motility (IEM) is the most common abnormality observed in high resolution manometry (HRM). It is characterized by a low distal esophageal body contraction vigor, breaks in peristaltic integrity, or failure of peristalsis on manometry in the context of normal lower esophageal sphincter relaxation. According to the Chicago classification version 3.0 (CC3.0), any combination of failed or weak peristalsis reaching ≥50% defined IEM. With advancing clinical applications and research investigations in the past few years, some limitations were identified with CC3.0 criteria, especially within hypomotility disorders. The CCv4.0 for ineffective swallows consist of weak esophageal body contraction vigor (distal contractile integral, DCI, 100-450 mmHg·cm·s), transition zone defects >5 cm, or failure of peristalsis (DCI < 100 mmHg·cm·s). The CCv4.0 updated the diagnostic threshold to require >70% weak or fragmented swallows or ≥50% failed swallows for a conclusive diagnosis of IEM. When the diagnosis is inconclusive (50%-70% ineffective swallows), supportive testing for a diagnosis of IEM could include poor bolus clearance on HRM with impedance (or barium radiography), or absence of contraction reserve on multiple rapid swallows. The new CCv4.0 protocol provides patients and clinicians with a conclusive diagnosis of IEM and helps to assess clinical relevance.

Dyspepsia, bloating, diarrhea and constipation are frequent , dyspepsia Functional GI disease patients often have 1.2. 3.

Hydrogen breath tests are widely used to explore pathophysiology of functional gastrointestinal (GI) disorders. With measurement of end-expiratory breath hydrogen and methane after oral ingestion of a fermentable carbohydrate that is processed by saccharolytic bacteria, the GI tract digestion function can be measured. Hydrogen breath test is a diagnostic tool for small intestinal bacterial growth, carbohydrate malabsorption and orocecal transit time. As abdominal symptoms such as dyspepsia, bloating, abdominal pain, diarrhea and constipation are frequent encountered in patients with functional GI disease. In recent years, several newly consensus are published to further standardize the test protocol for better implication in clinical practice. Further researches are needed to clarity its diagnostic and therapeutic role in management of functional gastrointestinal disease.

Chronic constipation is a common and troublesome medical problem in the GI clinics. The prevalence of constipation are ranged from 10 to 25% in previous studies. Clinically, physicians applied ROME criteria, Bristol stool chart or other clinical scoring systems for the diagnosis, but the mechanism and relationship between clinical severity and the recto-anal function remains unclear in large.

Anorectal manometry is a series of tests indicated for patients with fecal incontinence and constipation. Anorectal manometry is a basic tool to assess the anal sphincter competence (resting pressure, squeeze/endurance squeeze, cough test), screening test for rectal sensation / compliance (first sensation, first urge, intense urge) and useful for assessing recto-anal co-ordination and anorectal reflex in patients with defecation problems (RAIR, push/bearing down).

High-resolution anorectal manometry (HRAM) study increased pressure sensors and demonstrate pressure magnitude indicated by color intensity for the improvement of data interpretation and diagnostic performance. The International Anorectal Physiology Working Group (IAPWG) published a standardized protocol for HRAM investigation, and further defined the London Classification for HRAM interpretation. The London classification is a standardized method and nomenclature for description of alterations in anorectal motor and sensory function using office-based investigations, adoption of which should bring much needed harmonization of practice.

Some people are interested in cars, stereos, or mountain climbing. I have mine in endoscopy and I have been an endoscopy fan for all my life. In 1978, I received a scholarship from the President- Takemi Taro of the Japan Medical Association, and started to study gastrointestinal endoscopy in Tokyo and Kyoto. Through the guidance of numerous first-class mentors in Japan, from EST (avoid abdominal laparotomy, removal of common bile duct stones), painless colon endoscopy, magnification endoscopy, GI tract EMR, ESD to Gastric magnifying endoscopy. There were countless trips between Taiwan and Japan over the past 40 years, all with the purpose of introducing new knowledge and technologies to Taiwan, and provided these out-of-pocket medical services through the privately-owned practice - "Imperial Clinic". When looking back on the journey of how a primary care physician learned, developed and managed the road no one has taken, to share with my colleagues - "review the old and learn the new", "carry on the past and open up the future".

Achalasia is a rare primary motility disorder presenting with progressive dysphagia, regurgitation, chest pain, and weight loss. Currently, the gold standard diagnosis of achalasia is esophageal high-resolution manometry. Early diagnosis of achalasia is crucial for adequate treatment and helps to prevent progression to end-stage achalasia. Nevertheless, the overlapping symptoms and endoscopic findings between achalasia and gastroesophageal reflux disease (GERD) often lead to misdiagnosis. For the diagnosis of GERD, the updated Lyon consensus has suggested to apply mucosa histology as an adjunctive tool. Common histologic features of GERD include basal cell hyperplasia, elongated papillae, spongiosis, and inflammatory cells infiltration within the mucosa. Our study has shown the potential of esophageal mucosal biopsy as a useful tool to help differentiate achalasia from GERD since it is readily accessible in our daily endoscopic examinations. Histopathologic findings including basal cell hyperplasia or papillae elongation, eosinophilic infiltration, petechiae formation, and hypertrophy of the muscularis mucosae (MM) were assessed. We found a higher prevalence of petechiae formation and hypertrophy of the muscularis mucosae in achalasia than patients with refractory GERD. Therefore, with the assistance of esophageal histopathologic findings taken from esophageal mucosa during the endoscopic examination, earlier identification and treatment of achalasia can be achieved.

Endoscopy examinations are widely established in hospital and clinics. Therapeutic endoscopy was used to be performed in medical center due to hospitalization and also expensive equipment in the old times. However, patients are doing OPD endoscopic treatment without inward practices due to the advancement of the therapeutic endoscopy techniques.

Gastroenterology clinics used to only see patients with GI tract discomfort. Medication and general endoscopic examination are the major practices in gastroenterology clinics. We established a therapeutic endoscopic center setting in DaZhi.

State of art endosopic equipment is setup in our surgery room. Patients pay a day visit to our clinics to have GI tract examinations, and polypectomy if any polys are found at the same day. Endoscopic dissection procedure is routine procedure performed in our clinics. Above all major endoscopic procedures, ,we also perform stretta procedure.

For around a decade time, my clinics in Taipei city, we set up various contemporary endoscopic therapy practices.

Alpha-fetoprotein producing gastric cancer (AFP-GC) is a subtype of gastric cancer , which has more aggressive behavior, and has been considered as having unfavorable long term survival rate.

We illustrated a patient with advanced alpha-fetoprotein producing gastric cancer, who was treated with chemotherapy combined with trastuzumab, resulting in complete response in four months after therapy. It has been 5 years after his initial therapy, he is now healthy and shows no evidence of tumor recurrence. The efficacy of the trastuzumab therapy in breast cancer patients prompted studies to evaluate potential clinical benefit of the drug in patients with HER2 positive gastric cancer. The largest study, ToGA trial, has published a promising result leading FDA to approve the use of trastuzumab for HER2 positive gastric and gastroesophageal cancer. We discuss the need for the standardized assay method for HER2 status. We also bring attention to the existence of intratumoral heterogeneity in gastric cancer tissue which may cause false negative test for HER2 assay.

To the best of our knowledge, this patient is the longest survival in the literature.

This patient demonstrated that the cooperation between the primary clinic、local general hospital and the medical center can result in an amazing experience.

With the increasing incidence and prevalence of inflammatory bowel disease (IBD) in Taiwan, the quality of care becomes an important issue in order to minimize the differences among disease management which might result in disparity of outcomes. Years ago, a couples of indicators have been developed to reduce variation in care delivery and improve processes of care, patient outcomes and reduced healthcare costs.

According to the Crohn's and Colitis Foundation, the indicators could be divided into “process” and “outcome” two categories. Among the “process measures”, the indicators include: hepatitis B and tuberculosis testing before anti-TNF therapy, recommend steroid-sparing therapy after 4 months of treatment, appropriate initiation of steroid-sparing therapy, Clostridium difficile testing during acute flares, cytomegalovirus testing in steroid-refractory UC, colorectal cancer surveillance, recommend smoking cessation in CD, and vaccine education. As for the “outcome measures” which include: proportion of patients with steroid-free remission, days lost from work and school due to IBD, days hospitalized, number of emergency room visits, malnutrition, anemia, use of narcotics, incontinence, nighttime bowel movements, and proportion of patients with normal disease-targeted health-targeted quality of life.

Through the understanding, integrating and implementing these indicators in our management of IBD patients, hopefully we can decrease the variation in care delivery, decrease the cost of management, and most importantly, improve patients' outcomes.

The prevalence of malnutrition in IBD patients ranges from 12% to 85%. The main determinants of malnutrition in IBD includes decrease of oral food intake, gastrointestinal nutrient loss, malabsorption, increased energy expenditure and medication. It has been reported that more than one third of IBD patients suffered from sarcopenia. In addition, in most of them sarcopenia coexists with malnutrition as results of chronic inflammation. Sarcopenia has a negative impact on length of hospital stay, surgical outcomes and clinical course. Prompt nutrition assessment is the first step to early identify patients with high risk of malnutrition and /or sarcopenia status for provision of appropriate nutritional support. Today's presentation will discuss nutritional assessment methods and diet management for malnutrition and sarcopenia in IBD.

How to evaluate nutritional status of IBD patients? • Recognizing sarcopenia in IBD patients • How to manage common malnutritional conditions in IBD? • How to avoid and improve sarcopenia?

The purpose of this review is to evaluate the current literature regarding the impact of sarcopenia in the management of IBD, from mechanistic drivers through to assessment and management.

provision of appropriate nutritional suppor, then set adequate and customized nutrition therapeutic regimens. Today's presentation will discuss how to evaluate risk of malnutrition and sarcopenia, furthermore, to nutrition status and recognize across different studies, varying with different characteristics, phases of illness, and the criteria used to identify malnutrition Estimated 65-75% of patients with Crohn's disease and 18-62% of patients with Ulcerative disease have malnutrition problem. The Malnutrition is a major complication for inflammatory bowel disease (IBD). Malnutrition and /or The aim of this study was to evaluate nutritional status and sarcopenia in patients with inflammatory bowel disease (IBD) in clinical remission.

Methods

A total of 344 patients with IBD in clinical remission were included in this cross-sectional study. Patients with clinical activity (Harvey-Bradshaw index >5 for Crohn's disease and partial Mayo scores ≥5 for ulcerative colitis) were excluded. Sociodemographic, clinical, and anthropometric data were recorded. BMI was categorized according to WHO criteria. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) questionnaire. Body composition included fat-free mass (FFM) analyzed with Tanita-330 ST. Muscle strength was measured with a Takei digital hand grip dynamometer using a standard protocol. Physical performance was measured as 4-m gait speed. Sarcopenia was defined based on the European Working Group on Sarcopenia in Older People 2 criteria.

Results

Overall, 5.5% of patients were underweight, 9.9% were malnourished, and 39.5% were at risk of malnutrition. Sarcopenia and probable sarcopenia were diagnosed in 41.3% of patients. Total number of flares requiring hospitalization (100%) was the most important predictor of sarcopenia, followed by total number of flares (80.1%), FFMI (46.5%), age (44.6%), BMI (31.8%), MNA score (27.7%), serum creatinine (23.6%), anti-tumor necrosis factor alpha use (23.3%), and gender (17.8%).

Conclusion

In conclusion, our findings revealed a considerable proportion of IBD patients in clinical remission to be malnourished or at risk of malnutrition along with a high rate of sarcopenia. This emphasizes the need for concomitant screening for nutritional status and body composition analysis in patients with IBD for provision of appropriate nutritional support, even during the remission period, and prevention of sarcopenia-related surgical and poor clinical outcomes.

Anemia is a common complication as well as an extra intestinal manifestation of inflammatory bowel disease (IBD). It represents one of the major causes of decreased quality of life, frequent hospital admissions and increased healthcare burden. In spite of these, anemia is still often underdiagnosed and undertreated. Anemia in IBD is pathogenically complex, with several factors contributing to its development. The etiology of anemia among IBD patients is most commonly due to iron deficiency anemia (IDA) followed by anemia of chronic disease. Other causes include vitamin B12 and folate deficiency or the toxic effect of medications. Routine screening for anemia is important among patients with IBD. The initial work-up of anemia should start with evaluation of mean corpuscular volume (MCV), helping to distinguish between different etiologies: microcytosis such as IDA, macrocytosis (vitamin B12 and folate deficiency or thiopurine treatment) or normocytosis (chronic anemia). Secondly, reticulocyte count should be evaluated in order to assess the ability of bone marrow. A careful diagnostic workup is mandatory for optimized treatment. All IBD patients with IDA should be considered appropriate for therapy with iron supplementation. As the recurrence of anemia is common after resolution, the monitoring for recurrent anemia is equally important during the course of therapy.

Inflammatory bowel disease (IBD), which includes Crohn's disease (CD) and ulcerative colitis (UC), should be regarded as a systemic disorder not limited to the gastrointestinal tract because many patients will develop extraintestinal symptoms. Extraintestinal symptoms may involve any organ system with a potentially detrimental impact on the patient's functional status and quality of life. Successful therapy of EIM is essential for improving quality of life of patients with IBD.

Health-related quality of life is a concept that includes domains related to physical factors (such as natural history of disease and medications), mental factors (such as anxiety and depression), and social factors (such as job status and occupations). The patients with IBD had significant physical, psychosocial, and economic burden related to high risk of adverse health outcomes, including morbidity, hospitalization, surgery, work disability and even mortality. The prevalence of anxiety disorders in IBD is 21%; the prevalence of anxiety symptoms 35%. The prevalence of depressive disorder in OBD is 15%; the prevalence of depressive symptoms is 22%. IBD patients in active disease states have more depression and anxiety. Furthermore, an aspect rarely explored by healthcare providers is the influence of the disease on the sexual functioning of individuals. Sexual function is a constant concern in IBD patients that has been reflected in several studies, especially if we consider that the prevalence of sexual dysfunction in IBD is higher than that reported in the general population. In this section, we will discuss these important issues.

Inflammatory bowel disease (IBD) is an emerging disorder of chronic inflammation in gastrointestinal tract which leads to several complications, such as bleeding, perforation, stricture, fistula and malignancies as well as bowel disability and poor quality of life (QoL). With increased awareness of physician, early diagnosis and advancing medical treatment, particularly with the application of biologics therapy, tight control of chronic inflammation could be achieved with avoidance of IBD-related complications. However, preventive medicine is easily overlooked in the strategy of IBD management. Several unexpected preventable conditions, such as IBD medication related adverse events, opportunistic infections, osteoporosis, intestinal and extra-intestinal malignancies, cigarette smoking and psychological disorders, occur to IBD patients during medical therapy. These episodes could be prevented by screening, surveillance with early diagnosis and intervention, such as vaccination for opportunistic infections. With these preventive measures during the treatment journal of patients with IBD, their disease activity could be well-controlled as well as improvements in disease outcome and QoL. In this lecture, I will briefly review the current evidence about the preventive medicine which could optimize the treatment strategy for IBD patients.

In recent years, the endoscopy examination has become an indispensable and important tool for medical procedure and diagnosis. In order to avoid the occurrence of healthcare-associated infections, the reprocessing of endoscopy after usage must be carried out in strict steps , to ensure patient safety. Endoscope reprocessing includes pre-cleaning, manual cleaning, automated reprocessing with high-level disinfection, and storage.

The course will introduce the importance of endoscope reprocessing and the requirements under regulations of Taiwan's infection control audit. In addition, refer to the guidelines of relevant international associations, this lecture will also try to evaluate if there is any room for improvement in Taiwan's endoscope reprocessing practice, to provide the most appropriate follow-up if needed.

The American Association for the Advancement of Medical Instrumentation (AAMI) standards (ST91, 2021) provide new guidelines for precleaning, leak-testing, cleaning, packaging, storage, high level disinfection, and sterilizing of gastrointestinal (GI) endoscopes. AAMI Members include manufacturers, governmental agencies (FDA), healthcare delivery organizations, accrediting organizations, and GI societies. American AAMI standards provide comprehensive guidance to achieve best practice for each stage of processing flexible endoscopes as well for competency and education of staff.

Proper reprocessing of endoscopes and accessories is imperative in ensuring patient safety. Infectious outbreaks attributed to endoscopes has brought an increased awareness of infection control programs. March 2022, American GI Societies Joint Statement on AAMI standards: GI societies vote no on AAMI revisions on endoscopic processing. American GI Societies Joint (2022) Stated that changes to AAMI standards for flexible create obstacles to implement standards and offer impractical, inappropriate, or conflicting guidance.

DEST 2022 Endoscopy Technician Section focused on comparative review of American GI Societies Joint Statement (2022) and AAMI standards (ST91, 2021). We provided the recommendation of the core principles of infection control including precleaning, leak testing, manual cleaning, high level disinfection, drying and storage protocol, cabinet design, microbiologic surveillance, cleaning of accessories, and maintenance of GI endoscopes for members of the Digestive Endoscopy Society of Taiwan.

The American Association for the Advancement of Medical Instrumentation (AAMI) standards (2021) provide new guidelines for pre-cleaning (point of use treatment) of gastrointestinal (GI) endoscopes. American GI Societies (2022) vote no on the final revised version because of AAMI standards 2021 varied significantly from the standards for guidelines. American GI Societies Joint Statement (2022) provides evidence-based recommendations for the reprocessing of flexible GI endoscopes.

Due to high microbial load after patient procedure; complex design of flexible endoscopes; and risk for biofilm formation that require meticulous cleaning and reprocessing in strict accordance with manufacturer guidelines before being reused. Cleaning is in effective processing of flexible endoscopes, beginning with pre-cleaning (point of use treatment), followed by meticulous manual cleaning in the reprocessing area. Pre-cleaning (point of use treatment) must be occurring immediately after patient used to prevent biofilm formation and drying of soil. Including pre-cleaning, disconnecting accessories, hand off communication, placing in an appropriately-labeled container, and transport to the reprocessing area for subsequent steps in HLD.

DEST 2022 Endoscopy Technician Section focused on comparative review of American GI Societies Joint Statement (2022) and AAMI standards (2021). We provided current recommendation of the core principles of pre-cleaning (point of use treatment) including (1) wiping, (2) suction, (3) function control, (4) visual inspection, and (5) transportation for members of the Digestive Endoscopy Society of Taiwan.

The American Association for the Advancement of Medical Instrumentation (AAMI) standards (2021) provide new guidelines for manual cleaning of gastrointestinal (GI) endoscopes. American GI Societies (2022) vote no on AAMI revisions on endoscopic processing.

Manual cleaning is a crucial part of the reprocessing pathway, and when pre-cleaning and manual cleaning are followed, the number of pathogens detected on endoscopes can be decreased by 99.9%. Manual cleaning steps included detaching all devices from the endoscope, exterior cleaning of the endoscope, brushing of all channels until they are clean of debris, flushing of channels with enzymatic cleaning solution, and rinsing the endoscope. Manual cleaning should follow the manufacturers' recommended time frame and commence once pre-cleaning is finished. If a time delay occurs for manual cleaning, then reprocessing personnel should follow manufacturers' delayed cleaning protocol. If no time frame is provided, manual cleaning should begin within 60 minutes of finishing a procedure. Enzymatic cleaning solutions and brushes used in manual cleaning need to follow manufacturers' recommendations. Endoscopes, accessories, and equipment should be visually inspected and evaluated DEST 2022 Endoscopy Technician Section focused on comparative review of American GI Societies Joint Statement (2022) and AAMI standards (2021). We provided current recommendation of the core principles of manual cleaning including (1) leak testing, (2) external cleaning, (3) internal cleaning, (4) brushing, (5) rinsing, and (6) visual inspection of GI endoscopes for members of the Digestive Endoscopy Society of Taiwan.

The American Association for the Advancement of Medical Instrumentation (AAMI) standards (2021) provide new guidelines for high level disinfection (HLD) and sterilizing of gastrointestinal (GI) endoscopes. American GI Societies (2022) vote no on AAMI revisions on endoscopic processing.

Per recommendations of multiple governmental agencies and professional organizations, flexible GI endoscopes must be subjected to at least HLD, and there is uniform consensus that HLD should be performed as an integral component of reprocessing of flexible GI endoscopes. Most reprocessing guidelines recommend following manufacturers' instructions for use (IFU) for the performance of HLD and to consider specific instructions for the use of multiple individual disinfecting agents.

GI endoscopy is performed to prevent, diagnose, and treat a host of digestive diseases and conditions. Throughout an endoscopic examination, the external surface and internal channels of flexible endoscopes are exposed to body fluids and contaminants. Consequently, reprocessing of these reusable, complex instruments is imperative to infection prevention. Reprocessing is typically achieved by mechanical and detergent cleaning, followed by HDL, rinsing, and drying; strict compliance with following established reprocessing guidelines can significantly reduce or eliminate pathogen transmission to patients undergoing endoscopy.

DEST 2022 Endoscopy Technician Section focused on comparative review of American GI society guidelines statement (2022) and AAMI standards (2021). We provided current recommendation of the core principles of HLD include (1) leak testing, (2) cleaning, (3) rinsing, (4) disinfection, (5) final rinsing, and (6) drying of GI endoscopes for members of the Digestive Endoscopy Society of Taiwan.

The American Association for the Advancement of Medical Instrumentation (AAMI, 2021) and American Societies for Gastrointestinal Endoscopy (ASGE, 2022) renew the guideline about the endoscopy processing. However, the AAMI standards varied significantly from the standards for guidelines. ASGE provides evidence-based recommendations for the reprocessing of flexible GI endoscopes.

Many studies figure out the outbreaks of waterborne organisms tied to inadequate endoscope drying. In the fact, we found some standards floundering of guideline in endoscopy processing (e.g., drying time, storage cabinets, air quality, cost etc.). After the endoscope has been reprocessed, the appropriate method of storage would promote drying and reduce the risk of environmental contamination. To get the balance between the reality and ideal would become the big challenge of endoscope reprocessing.

The microbiologic surveillance play an important role to identify the indicator of inadequate reprocessing or defective devices. We have not reached a consensus on the frequency, modalities, locations of the microbiologic surveillance. Besides, the definition of a “positive culture,” and the actions to be taken when a culture is positive is lacking.

DEST 2022 Endoscopy Technician Section focused on comparative review of AAMI standard (2021) and ASGE standards (2022). We provided current recommendation of the core principles of the drying and storage for members of the Digestive Endoscopy Society of Taiwan.