Program

Endoscopic bariatric and metabolic therapies (EBMTs) are procedures using endoscope and associated devices to induce weight loss. Endoscopic intragastric balloon is one of the popular methods to make weight loss by occupying the gastric space. Around 500 - 700 ml of saline will be filled in the elastic spherical balloon, causing satiety to the patient. It is suggested to be placed in the stomach for six months and then removed. The procedure for the placement and removal of the balloon is not complex, but the effect of weight loss depends.

Endoscopic sleeve gastroplasty is an emerging endoscopic procedure for weight loss. It is created by a series of endoluminal, full-thickness sutures through the gastric wall from low body to the gastroesophageal junction by using an endoscopic suturing device. This procedure reduces the volume of the stomach and form an endoscopically created sleeve. Aspiration therapy is given rise from the concept of gastrostomy, but the flow of the food material is in opposite position. This device allows aspiration of 30% of the ingested meal 20 minutes after ingesting it. The results of weight loss by these two endoscopic therapies are effective from recent studies.

Other endoscopic interventions include duodenal mucosal resurfacing, self-assembling Magnets for endoscopy GI windows, and duodenojejunal bypass sleeve. However, these methods are still during experimental periods.

The rising prevalence of obesity and the success of surgical interventions lead to a marked increase in the number of bariatric surgeries, including Roux-en-Y gastric bypass and sleeve gastrectomy, and the role of the endoscopist has been gradually increasing in the management of these patients. It is therefore essential for the endoscopists to be knowledgeable in all areas of their care, including preoperative and intraoperative evaluations, the postoperative recognition and management of complications. Endoscopic bariatric and metabolic therapies (EBMT) include devices that are placed or removed via flexible endoscopy, and procedures that utilize instruments that require flexible endoscopy for the indications of weight loss. The EBMTs are generally divided into gastric EBMT and small bowel EBMTs. Some EBMTs are temporary devices and others are irreversible procedures. Preoperative screening endoscopy should be considered for symptomatic patients who might have contraindications to EBMTs. Postoperative endoscopy should also be performed in symptomatic patients to evaluate potential complications after EBMTs. However, more evidence is needed for the recommendations of routine endoscopic surveillance in patients following irreversible EBMTs.

Endoscopic bariatric and metabolic therapy encompasses a range of endoscopic procedures aimed at inducing weight loss. These procedures can be classified into two categories: restrictive procedures (such as gastric balloon insertion (GBI) and endoscopic sleeve gastroplasty (ESG)) and malabsorptive procedures (such as endoscopic duodenal-jejunal bypass sleeve). This talk will focus on gastric rapproach.

GBI is an effective and minimally invasive approach for weight loss. This technique involves placing an inflatable balloon into the stomach to create a feeling of fullness, thus reducing food intake. It offers several advantages, including shorter recovery times, lower complication rates, and potential reversibility. ESG is another innovative and minimally invasive procedure for obesity management. It involves using sutures and specialized tools to reduce the size of the stomach, mimicking the effects of a surgical sleeve gastrectomy. Without the need for incisions, ESG makes it a less invasive alternative to traditional weight loss surgeries. ESG offers benefits such as shorter recovery times and lower complication rates. Both GBI and ESG are effective options for individuals with a body mass index over 30, seeking a non-surgical approach to weight loss. When combined with lifestyle modifications and medication, these procedures can contribute to sustainable long-term weight management.

Obesity is a public health epidemic with an increasing number of related complications with rising healthcare costs. Bariatric surgeries have promising response in achieving a higher total body weight loss but higher risk of complication. Recent developments using endoscopic bariatric therapies (EBTs) have proven safer, cost-effective, and reversible alternative to traditional surgical bariatric procedural methods. EBTs include both gastric and small bowel interventions. These procedures fall into two separate categories depending on the primary mechanism of action involved: restrictive or malabsorptive. Restrictive EBT procedures mostly are gastric interventions to restrict size of stomach, such us intragastric balloon or endoscopic sleeve gastroplasty (ESG). In contrast ,malabsorptive EBT procedures like small bowel interventions bypass the stomach to influence satiety and gastrointestinal (GI) motility, such as the EndoBarrier®, interfere with the small intestine's ability to absorb food while restoring normal GI hormone levels regulating satiety. This section we will focus on the current evidence/efficacy/status of malabsorptive EBT procedures/endoscopic devices, such us Endoluminal Bypass, EndoBarrier, and Duodenal Mucosal Resurfacing.

The TACOS trial, one of the largest randomized controlled trials (RCT) in the field of gastrointestinal (GI) endoscopy, was initiated in 2018 and successfully concluded in 2020, involving the randomization of 4,270 subjects across six centers in Taiwan. This groundbreaking trial not only represents the world's largest RCT on cold snare polypectomy but also pioneers the adoption of bleeding, one of the most common complications of polypectomy, as the primary endpoint.

The implications of the TACOS trial are manifold and highly significant, particularly within the field of GI endoscopy. Firstly, it challenges the prevailing reliance on apprenticeship-based training for endoscopists in Taiwan, instead advocating for a more evidence-based approach. The invaluable insights gleaned from this study have the potential to catalyze a paradigm shift in endoscopy training practices. Secondly, the TACOS trial stands out as a remarkable example of a multicenter RCT in the field of GI endoscopy, a rarity in Taiwan where patient volume often dissuades the implementation of such trials. By successfully conducting this trial, the participating centers have not only accumulated essential expertise but have also demonstrated an increased willingness to contribute to future clinical trials. Furthermore, the longitudinal follow-up data obtained from the TACOS trial cohort hold great promise in enriching the evidence on metachronous neoplasms following polypectomy in Taiwan. This data will serve to further validate the utilization of cold snare polypectomy as the gold standard in the management of polyps smaller than 1 cm, solidifying its position as the standard-of-care.

In summary, the TACOS trial represents a significant milestone in the field of endoscopy, providing invaluable lessons and insights. Its implications extend beyond Taiwan, offering a compelling case for evidence-based endoscopy training, promoting multicenter RCTs, and bolstering the use of cold snare polypectomy as the preferred approach for managing small polyps.

References

1. Chang LC, Chang CY, Chen CY, Tseng CH, Chen PJ, Shun CT, Hsu WF, Chen YN, Chen CC, Huang TY, Tu CH, Chen MJ, Chou CK, Lee CT, Chen PY, Wu MS, Chiu HM. Cold Versus Hot Snare Polypectomy for Small Colorectal Polyps: A Pragmatic Randomized Controlled Trial. Ann Intern Med. 2023 Mar;176(3):311-319.
2. Chang LC, Shun CT, Hsu WF, Tu CH, Chen CC, Wu MS, Chiu HM. Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting. Endosc Int Open. 2019 Feb;7(2):E232-E238.
3. Chen YN, Chang LC, Chang CY, Chen PJ, Chen CY, Tseng CH, Chiu HM. Comparison of cold and hot snaring polypectomy for small colorectal polyps: study protocol for a randomized controlled trial. Trials. 2018 Jul 6;19(1):361.
4. https://www.medscape.com/viewarticle/988625?icd=login_success_email_match_norm

For several reasons, cold snare polypectomy (CSP) is preferred for small and diminutive polyps: 1. Safety: CSP is considered safer than hot snare polypectomy (HSP). It does not use electrocautery, which reduces the risk of complications such as post-polypectomy bleeding and perforation, 2. Efficiency: CSP allows for the quick removal of small and diminutive polyps, which can improve the efficiency of the colonoscopy procedure. However, there are still some unsolved issues and challenges associated with this technique. The first one is the complete resection of larger polyps by CSP. For larger polyps, especially those over 10 mm, other methods such as HSP, endoscopic mucosal resection, or endoscopic submucosal dissection are often used. While CSP is effective for small and diminutive polyps, its efficacy in completely removing larger polyps (greater than 10 mm) is less clear. More research is needed to determine the best techniques for larger polyp removal. Secondly, the management of antithrombotic therapy in CSP is another issue. While CSP is generally safer than HSP in terms of bleeding risk, the management of antithrombotic therapy in patients undergoing CSP is still a complex issue that requires further study. Thirdly, standardization of technique is vital to improve the quality. There is currently a lack of standardization in the technique of CSP, including the type of snare used and the technique of polyp removal. More research is needed to determine the most effective and safe strategies.

Most colonic polyps detected at screening colonoscopy are smaller than 10 mm. Efficient and safe removal of those small polyps plays an important role in ensuring colonoscopy quality. Cold snare polypectomy (CSP) outperforms hot snare polypectomy in several aspects, including shorter procedure time, higher histological eradication rate, and a lower risk of delayed post-polypectomy bleeding, which has been demonstrated in several large-scale randomized controlled trial. Several clinical practical guidelines have affirmed the use of CSP for sessile polyps 6-9 mm in size because of its superior safety profile.

Although CSP has become the mainstay for resecting small polyps for the efficiency and safety, complete resection, which is crucial for long-term outcome, is one of the potentially major concern for CSP. In contrast to hot snare polypectomy (HSP), in which some degree imprecision could be compensated by the application of diathermy for residual pathology, precise technique is necessary to optimize CSP outcomes because there is no perimeter of tissue destruction outside the mucosal excision defect.

In this talk, several aspects will be discussed to enhance the efficacy of CSP including the choice of snare, knowing the different concepts between CSP and HSP, and the technique for adequate specimen obtaining.

The success of the TACOS study can be attributed to several factors. Firstly, the researchers clarified the current evidence and identified unmet needs before designing a novel clinical study. Secondly, endoscopists demonstrated a passion for participating in the research and established good collaboration with one another. Thirdly, education played a crucial role in the study, with all participants learning the endoscopic technique for cold snare polypectomy and the study design. The young investigators were exposed to all aspects of the study process, including the development of original ideas, through discussions on study hypothesis, aims, and methods. The core value of executing a randomized controlled trial was also emphasized. Lastly, much support from various hospitals was vital for the success of this multi-center study. To foster a favorable learning and study environment in the GI endoscopy community in Taiwan, our endoscopy society should provide more training courses on study designs such as RCTs, meta-analyses, and cohort studies for the younger generation.

The TACOS study sets a positive example for the GI endoscopy community in Taiwan, demonstrating that successful clinical research requires clear identification of unmet needs, a passion for participation, good collaboration, education, and a favorable study environment.

FMT is the administration of a solution of fecal matter from a donor into the intestinal tract of a recipient in order to directly change the recipient's gut microbial composition and confer a health benefit. FMT has emerged as a remarkably effective and safe alternative for patients with recurrent or refractory Clostridium difficile infection (CDI) unresponsive to standard antibiotic regimens, with a cure rate of at least 80%. There are preliminary indications to suggest that it may also carry therapeutic potential for other conditions such as inflammatory bowel disease (Crohn's disease or ulcerative colitis), obesity, DM, and metabolic syndrome.

In the procedure of FMT, the donor was instructed to collect feces in a small container and to bring it to our hospital. Then we filtered the mixed fecal contents, resulting in one bottle of fecal microbiota suspension. The fecal suspension was administered into the intestine of the recipient via colonfibroscope.

In the analysis of alpha diversity, the observed_otus index increased in the fecal specimen of recipient (post-transplant), which compared to pre-transplant. A comparison of the taxonomic data revealed that the children with CDI exhibited relatively high abundances of Proteobacteria and Fusobacteria at the phylum level and a relative underrepresentation of the phylum Bacteroidetes and Firmicutes.

FMT may regulate the intestinal dysbiosis of the recipient with an increased diversity of gut microbiota and modifications of intestinal microorganisms.

Fecal microbiota transplantation (FMT) has been used for the treatment of recurrent C. diff infection (CDI) and diseases beyond CDI. The latest progress on FMT mainly involves the development as new drug for CDI in pharmaceutical factory and washed microbiota transplantation as medical therapy in hospital. This presentation will focus on the latest development and pilot studies on FMT

Emerging evidences showed a connection between gut microbiota dysbiosis the development of various gastrointestinal and non-gastrointestinal disorders such as Clostridium difficile infection, inflammatory bowel disease, metabolic syndrome, cardiovascular disease and neurologic disorders.

In recent years, there has been a growing interest in non-medical treatments for dysbiosis, specifically targeting the gut microbial environment itself. One promising therapeutic strategy if fecal microbiota transplantation (FMT), which involves infusing a healthy donor's fecal solution into the intestinal tract of an individual with an illness.

Several of delivery routes are currently utilized for conducting FMT including the upper gut, mid-gut and lower gut. Here, we review the methodology, efficacy, safety, and delivery route of fecal microbiota transplantation.

In recent years, fecal microbiota transplantation (FMT) has gained attention for its potential therapeutic effects beyond gastrointestinal disorders. FMT has been shown to positively influence the human microbiome, immune system, and metabolism, which may have implications for treating a variety of conditions.

Studies have suggested that FMT may be effective in treating liver cirrhosis, autoimmune diseases, neurological disorders, and cardiovascular disease, among others. However, the clinical application of FMT beyond gastrointestinal disorders is still in the early stages, and further research is needed to fully understand its potential benefits and risks.

Despite the challenges and limitations in the use of FMT, the promising results thus far suggest that FMT may be a valuable tool in treating a range of diseases in the future. As such, it is important to continue exploring the expanding applications of FMT and to establish safe and effective protocols for its use in non-gastrointestinal conditions.

Endoscopic resection is a minimally invasive technique used to remove abnormal or diseased tissue from the body using an endoscope. The technique has evolved significantly over the years, with new technologies and innovations improving the accuracy, safety, and effectiveness of the procedure.

In the 1960s, Dr. Hiromi Shinya developed the technique of polypectomy using a wire snare, which is still widely used today. In the 1980s, the development of video technology revolutionized endoscopy, allowing for better visualization of the body's interior and more precise invasive procedures. The introduction of high-definition cameras and monitors in the 1990s further improved the quality of images and enables physicians to perform more complex procedures.

The early 2000s saw the introduction of advanced endoscopic resection techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). These techniques allowed physicians to remove larger lesions and tumors from the GI tract with fewer complications and a shorter recovery time.

In recent decade, third space endoscopy, also known as submucosal endoscopy, developed using the basic technique of ESD. Unlike traditional endoscopic procedure, which only access the superficial layers of the digestive tract, third space endoscopy allows physicians to access and removed lesions in the “third space” between the mucosa (innermost layer) and the muscularis propria (outermost layer) of the digestive tract. Although it remained a technically challenging procedure that requires specialized training and expertise, per-oral endoscopic myotomy (POEM), Submucosal tunneling endoscopic resection (STER), and endoscopic full-thickness resection (EGFR) revolutionized endoscopic resection.

Overall, the revolution of endoscopic resection has led to significant improvements in patient outcomes, with shorter hospital stays, reduced pain, and lower risk of complications compared to traditional surgical procedures. As technology continues to advance, it is likely that endoscopic resection will become an increasingly important tool in the diagnosis and treatment of a wide range of medical conditions.

Third space endoscopy, ie submucosal endoscopy, used the submucosal space of the gastrointestinal tract to achieve therapeutic intervention for many disease. Based on the knowledge of endoscopic submucosal dissection (ESD), third space endoscopy derive various variant technique, such as per-oral endoscopic myotomy (POEM) for achalasia, G-POEM for gastroparesis, and Z-POEM for Zenker's diverticulum. The other development of third space endoscopy is to resect subepithelial tumor, and the derived techniques including submucosal tunneling resection (STER), endoscopic subserosal dissection (ESSD) or endoscopic full-thickness resection (EFTR), etc. The third space endoscopy has the advantage to easily and safely access mediastinum and peritoneal cavity, and this makes possible for natural orifice transluminal endoscopic surgery in the future.

Gastric submucosal tumors (SMTs) are found in 0.3-0.78% of patients undergoing routine endoscopic examinations. Unlike those outside of Japan, gastric SMTs are generally recommended follow-up rather than resection if small in size without evident endoscopic findings of malignant sign. According to the clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan (3rd edition 2014), issued by the Japan Society of Clinical Oncology, gastric SMTs, fulfilling the following criteria, are indicated for resection: (i) histologically confirmed to be a GIST; (ii) >5 cm in size; (iii) increasing in size; or (iv) suspicious malignant findings. Thus, in Japan, standard resection methods for gastric SMTs include complete excision of the lesions by surgery or laparoscopic and endoscopic cooperative surgery (LECS). Furthermore, as resection of gastric SMTs sometimes resulted in full-thickness resection, general anesthesia with intubation, of which is rarely available in Japanese endoscopic suits, is commonly mandatory. Endoscopic resection of gastric SMT is not covered by health insurance in Japan, which also hinders its widespread use (approved as an advanced medical care in September 2020). I would like to share my experience of endoscopic resection of gastric SMTs performed in China. Video clips focusing the technical aspect rather than literatures review will be shown in my talk.

Colorectal cancer is a leading cause of malignancy in the world and in Taiwan. National cancer screening program and health check-up help us to find out many pre-malignant lesions and early malignancies in general papulation. Prompt management of those lesions is crucial. In recent decades, endoscopic submucosal dissection (ESD) becomes more and more important in treatment of precancerous and cancerous lesions in the gastrointestinal tract, including esophagus, stomach, duodenum and colorectal area. As a minimally invasive procedure, ESD provides a therapeutic option in standard treatments of early cancer without sacrifice of organ. Among lesions in different segments of gastrointestinal tract, colorectal lesions undoubtedly are more difficult. There are several developments of colorectal ESD in the past few years, including new equipment, new devices and new technique. By applying those new knowledge in daily practice, endoscopists could increase en bloc resection rate of lesions and manage those lesions easier. Besides, new strategies also could help endoscopists managing difficult situations, such as salvage ESD.

Colorectal cancer (CRC) constitutes a significant public health concern globally. Numerous cohort studies and a recent randomized controlled trial have substantiated the effectiveness of colonoscopy in mitigating CRC incidence and mortality. Nonetheless, the procedure's efficiency in preventing CRC is largely contingent on the quality of its execution. Several investigations highlight considerable discrepancies in colonoscopy quality in general practice, contributing to incomplete examinations or overlooked lesions, culminating in post-colonoscopy colorectal cancer (PCCRC).

High-quality colonoscopies, which significantly reduce the risk of PCCRC, are characterized by several performance indicators, including the adenoma detection rate (ADR), cecal intubation rate (CIR), quality of bowel preparation, and scope withdrawal time. To address variations and potential shortcomings in colonoscopy quality, continuous quality improvement programs are indispensable. These initiatives should be robust, incorporating regular audits, feedback, and learning opportunities to ensure endoscopists stay abreast of the latest best practices and guidelines.

The Taiwan Colorectal Cancer Screening Program should also adopt this comprehensive approach. This program should not only integrate regular audits but also provide constructive feedback to each hospital and individual endoscopist. The aim is to help Taiwanese endoscopists stay up-to-date with the most current and best practices and guidelines, thereby ensuring optimal CRC screening and prevention efforts.

Thanks to the nation-wide CRC screening program, a significant stage shift among screening detected CRC was noted in comparison with non-screening detected CRC. That is, an increased proportion of early-staged CRC among all CRC patients nowadays. Among early-staged CRC, T1 CRC, defined as tumors with histologic tumor invasion through the muscularis mucosa and into, but not beyond, the submucosa, is a complicated scenario as its complexity of treatment option, potential need for additional surgery and surveillance policies. Knowing the prevalence and chronological trend of T1 CRC in Taiwan can help us clarify the task we are facing.

Practically, the treatment modality for T1 CRC largely relies on the risk of lymph node metastasis (LNM). For those with low LNM risk (low-risk T1CRC, T1aCRC), endoscopic resection is adequate without the need of additional surgery. On the other hand, for those with high LNM risk (High-risk T1 CRC, T1bCRC), surgical resection with lymph node dissection is recommended. If endoscopic treatment is performed for patients with high-risk CRC, an additional operation is inevitable. Because of the difference of patient care, treatment risk and quality of life after treatment, pre-treatment risk stratification is then being upmost importance.

Early-onset colorectal cancer (EOCRC), defined as CRC occurring in individuals under the age of 50, is increasing globally. Facing such substantial disease burden, the American Cancer Society (ACS) first issued a new CRC screening guideline in 2018, advising starting screening at 45 for individuals at average risk. However, whether this increase is real or attributable to greater access to screening remains debatable. Our study aimed to explore the chronological trend of prevalence of colorectal advanced neoplasm (AN) in the screening population. We retrospectively analyzed the screening colonoscopy cohort for the prevalence of AN in average-risk subjects aged 40-49 from 2003 to 2019, and found that the prevalence of AN increased from 1.87% to 3.65% over the past 17 years. The Age-period-cohort (APC) model showed a 170% increase in 2015-2019 for those aged 45-49 (2003-2008 as reference). Compared with the 1954-1958 birth cohort, the birth cohort of 1969-1974 had a 180% increase. According to the Taiwan Cancer Registry Database, the CRC incidence rate in those aged 40-44, 45-49 and 50-54 continue to rise since 1979. This change should be reflected in the development of screening policy to accommodate local epidemiology.

Sporadic colorectal cancer (CRC) typically affects individuals without a clear pattern of inheritance. It occurs sporadically due to a combination of genetic and environmental factors that accumulate over time. On the other hand, hereditary colorectal cancer (HCRC) like Lynch syndrome and familial adenomatous polyposis has a strong familial component and can be passed down from one generation to the next. HCRC is caused by inherited genetic mutations that predispose individuals to develop colorectal cancer and other neoplasms. These mutations are present in the germline cells and can be transmitted from affected parents to their offspring.

Current CRC screening guidelines often emphasize population-based screening recommendations for average-risk individuals, primarily based on age and family history of CRC. However, these guidelines may not adequately address the unique needs and risks associated with HCRC. Identifying HCRC is crucial, even though it represents a small proportion (~5%) of all CRC cases. Recognizing HCRC is of utmost importance due to the potential implementations for early detection, preventive measures for at-risk family members, tailored management strategies, psychosocial support, and advancements in research.

Efforts to address the underserved population of HCRC in screening programs require a multi-dimensional approach involving education, access to services, policy changes, and patient advocacy to ensure that individuals at risk receive appropriate screening and preventive measures. It's important to note that these steps should be carried out with sensitivity, respect for privacy, and adherence to ethical guidelines regarding patient consent and confidentiality. By addressing the unique needs and risks associated with HCRC, we can improve outcomes and enhance the overall management of colorectal cancer.

Introduction:

Peri-hilar biliary strictures refer to strictures located between the bilateral extrahepatic ducts and the common hepatic duct, commonly presenting with obstructive jaundice. Initial evaluation includes transabdominal sonography, revealing diffuse intrahepatic duct dilations with or without adjacent liver hilum masses. While non-invasive imaging modalities like MRI, CT, and echoendoscopy (such as IDUS or EUS) aid in diagnosis, definitive identification relies on tissue analysis. However, acquiring suitable tissue samples can be challenging. This article explores various diagnostic approaches and emphasizes the importance of combining multiple modalities to enhance diagnosis yield rates.

Imaging Modalities:

MRI, CT, and echoendoscopy play a crucial role in non-invasive imaging diagnosis of peri-hilar biliary strictures. These techniques provide valuable insights into the nature, location, and extent of the strictures, aiding in the decision-making process.

Tissue Acquisition:

Tissue sampling remains the gold standard for definitive diagnosis. Brush cytology, transpapillary biopsy, or cholangioscopic direct biopsy are commonly performed during ERCP for biliary drainage. However, the yield rates of these procedures vary and may be influenced by the stricture's characteristics and sampling techniques. To improve diagnostic accuracy, it is recommended to repeat the procedures and combine multiple diagnostic modalities.

Advancements in Diagnostic Techniques:

In addition to conventional histology, newer diagnostic tools like FISH (fluorescence in situ hybridization) and pCLE (Probe-based confocal laser endomicroscopy) have emerged. These techniques provide additional insights into the genetic and cellular characteristics of the stricture, assisting in differentiating between benign and malignant strictures.

Molecular Diagnosis:

The advent of genetic and molecular diagnostics, such as NGS (next-generation sequencing) from tissue samples, has improved the accuracy of diagnosing peri-hilar biliary strictures. NGS not only aids in diagnosis but also enables precision medicine by identifying specific genetic alterations that can guide targeted treatment approaches. Additionally, liquid biopsy from bile juice, utilizing cell-free DNA, is an emerging area of research with potential diagnostic value.

Conclusion:

The diagnosis of peri-hilar biliary strictures requires a comprehensive and multidisciplinary approach. Combining non-invasive imaging modalities, tissue acquisition techniques, and advancements in genetic and molecular diagnostics enhances the diagnostic yield and helps guide appropriate treatment decisions. Ongoing research and development in diagnostic tools hold promising prospects for further improving the management and outcomes of patients with peri-hilar biliary strictures.

Patients with malignant hilar obstruction (MHO) are challenging to manage. At present, trans-papillary route biliary drainage (ERCP) with stent placement remains the standard treatment for biliary drainage in MHO. Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided biliary drainage (EUS-BD) are alternative modalities. The primary goal is to resolve bile duct obstruction, to achieve long-term ductal patency and to maintain liver function. Optimizing biliary drainage depends on several factors, including the extent and location of obstruction, choosing appropriate approach, stent selection and the expertise of medical team. ERCP provides internal drainage by insertion stents with better quality of life compared to percutaneous routes. Before ERCP, we should review cross-session imaging with emphasis on volumetric liver assessment. Endoscopist should try to achieve meticulous biliary drainage with limit injection of contrast, drainage >50% of viable liver volume, attempt drainage all injected segments, and appropriate stent selection (number, plastic or metal, target segment…) during ERCP. In some MHO patients, ERCP may not provide complete biliary drainage. Combination with PTBD or EUS-BD should be considered. I will focus on how to achieve optimal biliary drainage in trans-papillary route according to current evidences and guidelines. EUS-BD concepts and tips will be addressed in another session.

Malignant hilar biliary obstruction (MHBO) is usually treated by multiple biliary stenting under endoscopic retrograde cholangiopancreatography (ERCP) guidance. Endoscopic drainage for MHBO has several concerns such as unilateral or bilateral drainage, plastic or metal stent, or side-by-side or stent-in-stent deployment? Although recent development of dilation device or uncovered self-expandable metal stent (UCSEMS), technical success rate of multiple stenting for MHBO may be relatively high, re-intervention may be still challenging due to duodenal obstruction or complex hilar stenting. In addition, because of recent development of chemotherapy, patient's survival may be also prolonged. Therefore, the rate of encountering for challenging cases may increase.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely performed for patients with failed ERCP. In case of MHBO, stent patency might be favorable because SEMSs are not deployed across malignant tumor. In addition, re-intervention may be also easy. EUS-BD for MHBO can be divided into three access route, such as EUS-guided hepaticogastrostomy (HGS) (unilateral drainage), EUS-guided hepaticoduodenostomy with EUS-HGS (bilateral drainage), or bridging method (bilateral drainage). During EUS-HGS for MHBO, to obtain enough drainage area, the periphery intrahepatic bile duct should be punctured. Also, to prevent bile duct brunch obstruction, partially covered SMES should be used. EUS-HDS can be performed for isolated right intrahepatic bile duct obstruction. Usually, anterior bile duct can be detected from the duodenum. In this procedure, bile duct puncture itself may not be so challenging if the target bile duct can be detected. To detect bile duct, echoendoscope adjustment is performed under not only EUS guidance but also fluoroscopic guidance. During bridging method, guidewire deployment across stricture site is needed. This procedure step may be sometimes challenging. In challenging case, several devices may be helpful. Also, careful stent selection which is deployed stricture site is needed.

As re-intervention techniques, EUS-BD can be also performed from left or right intrahepatic bile duct drainage. According to previous reports, compared with re-intervention under ERCP guidance, stent patency may be longer in EUS-BD group. And technical success rate of EUS-BD may be higher than ERCP.

Although EUS-BD for MHBO may be feasible and safe, techniques may not be easy for all endoscopists. In the presented lecture, I would like to talk about technical tips of EUS-BD for MHBO with several videos.

Introduction:

Significant advancements have been made in endotherapy for chronic pancreatitis, a debilitating inflammatory disorder characterized by progressive pancreatic tissue damage. Endoscopic ultrasound (EUS) enables accurate diagnosis and staging, with EUS-guided fine-needle biopsy aiding in etiology identification and targeted therapies. EUS-guided celiac plexus neurolysis provides effective pain relief.

Endoscopic retrograde cholangiopancreatography (ERCP) has made remarkable progress in treating chronic pancreatitis. ERCP allows therapeutic interventions such as pancreatic duct stenting, stone extraction, and stricture dilation. Endoscopic sphincterotomy effectively manages obstructive pancreatitis due to sphincter of Oddi dysfunction. Endoscopic pseudocyst drainage techniques, including transmural drainage and endoscopic necrosectomy, have revolutionized the management of complications associated with chronic pancreatitis. EUS-guided pancreatic duct drainage is the preferred approach for symptomatic pancreatic duct obstruction or leakage. These procedures offer minimally invasive alternatives to surgery, reducing morbidity and promoting faster recovery.

Endotherapy has become a valuable tool for accurate diagnosis, pain relief, and effective treatment of complications in chronic pancreatitis. Ongoing technological advancements will continue to refine endoscopic techniques, leading to improved outcomes and enhanced quality of life for patients.

Achalasia is an incurable disease with the unknown underlying etiology. Achalasia happens due to the absence of peristalsis and is a lower esophageal sphincter (LES) disorder that equally affects both sexes and all ethnicities. Common presentations of achalasia include gradual dysphagia to both liquid and solid foods, chest fullness, and heartburn. In addition, food regurgitation due to dysphagia can cause pulmonary complications such as chronic cough, choking at night, and aspiration pneumonia. Consequently, chronic food regurgitation will lead to gradual weight loss. Pharmacological treatment has typically played a minor role in esophageal achalasia. Besides Per-Oral Endoscopic Myotomy(POEM), there are several options for the endoscopic treatment of achalasia. Endoscopic local injection of botulinum toxin into the LES muscle of patients with achalasia lowers LES tone and could lead to symptom resolution. This treatment option for achalasia is safe and has few complications. Endoscopic balloon dilations with Rigiflex dilator cause mechanical tears in the muscle fibers of the LES. The Rigiflex dilator is the commonly used dilator with a fully inflated diameter that usually ranges from 3 cm or more to achieve maximal pressure for a satisfactory result. Pneumatic dilations(PD) can be performed by either a fluoroscopy-guided procedure or endoscopy-guided procedure. Long-term remission could possibly be achieved by applying the “on-demand” strategy with repeated PD based on symptom recurrence. PD was found to be relatively safe with uncommon major complications. The main complication was esophageal perforations(0-2%). Reflux symptoms after PD can usually be controlled with proton pump inhibitors.

Achalasia is the most common primary esophageal motility disorder involving smooth muscle layer of esophageal body and lower esophageal sphincter. The key pathophysiological mechanism is loss of inhibitory nerve function that probably resulted from an autoimmune attack targeting esophageal myenteric nerve through cell-mediated and probably antibody-medicated mechanism. Achalasia is characterized by impaired relaxation of lower esophageal sphincter (LES), and spastic or absent contraction of esophageal body. The cardinal symptoms consist of dysphagia, regurgitation, body weight loss and chest pain. Besides, the incidence of esophageal cancer, lower respiratory infection and. Mortality is also higher in achalasia patient.

Oral pharmacotherapy is not particularly effective. Endoscopic management included Botulinum toxin injection, pneumatic dilation and peroral endoscopic myotomy (POEM).Botulinum toxin injection into the LES can temporarily relieve symptoms and function as a bridge to definitive therapy. Pneumatic dilation, POEM and laparoscopic Hell's myotomy (LHM) can provide durable symptoms benefit. End-stage esophagus with dilated, non-functioning esophagus require esophagectomy of enteral feeding into stomach.

POEM is a safe and effective procedure for achalasia. It is now becoming the 1st line therapy of achalasia. In the lecture, detailed procedure of POEM, meta-analysis result, our own experience will be discussed.

Gastroesophageal reflux disease (GERD) can be a debilitating condition that affects millions of people worldwide. There are promising endoscopic treatments available, including anti-reflux mucosal intervention (ARMI). ARMI encompasses two procedures: anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation (ARMA).

While there have been some studies on the efficacy of ARMI, few have provided a detailed analysis of objective reflux parameters. However, as more evidence emerges, modifications of ARMI are becoming more common.

In this section, we will present our findings on the effectiveness of ARMI and review the current evidence surrounding this promising treatment option. By doing so, we hope to shed light on this important topic and provide clinicians and patients with the information they need to make informed decisions about their treatment options.

With the advancement and implementation of "third-space endoscopy” or “submucosal endoscopy”, wherein endoscopists showed that one could breach the mucosa layer of the gut wall and enter safely into the submucosal space and perform further diagnosis or therapy such as myotomy, some functional gastrointestinal disorders could be managed endoscopically with minimal invasive intents. Among these techniques, peroral endoscopy myotomy (POEM) was first introduced by Professor Inoue for the management of esophageal achalasia in 2008, and then applied to pylorus-directed therapy of gastroparesis by Professor Khashab in 2013. With regard to G-POEM, recent evidence confirms its efficacy and safety in refractory gastroparesis. However, the long-term outcomes and predictors of clinical success of G-POEM are still not well understood. Additionally, the criteria for patient selection remain inconclusive. Herein, I will review the current role, pros and cons of G-POEM for the management of refractory gastroparesis.

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. Since there is no gold standard diagnostic test, there are many disease processes that can be misdiagnosed as IBD, given its often non-specific symptoms.

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, distinguish CD from UC, assess the disease extent and activity and monitor response to therapy.

Endoscopic features of intestinal tuberculosis (eg, transverse ulcers, pseudopolyps, involvement of fewer than four segments, and patulous ileocaecal valve) and Crohn's disease (eg, longitudinal ulcers, aphthous ulcers, anorectal lesions, cobblestone appearance) have high positive predictive value for both diseases. However, classical findings are often not present, and diffuse ulceration and nodularity could be a feature of both. The shape of the ulcers (eg, irregular, geographical, or round ulcers in Behcet's disease and longitudinal ulcers in Crohn's disease) and their distribution (eg, focal in Behcet's disease and segmental or diffuse in Crohn's disease) can help to differentiate between Behcet's disease and Crohn's disease.

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. Reviewing potential differential diagnoses should guide the search for the underlying cause.

Inflammatory bowel disease (IBD) is treated based on the activity and extent of the disease. Evaluations using the clinical index (CI) and endoscopic index (EI) are useful in determining the appropriate treatment, predicting prognosis, and evaluating or monitoring disease activity after treatment, Endoscopy also plays an integral role in estimating the severity of IBD as it makes it possible to evaluate mucosal healing, treatment efficacy and cancer surveillance.

Histopathological evaluation is able to assess disease activity, given different disease stages and phenotypes seen in IBD patients, more effective in assessing the benefit of therapy or in predicting clinical recurrences, the presence of histological inflammation in endoscopically quiescent disease should warn against the de-escalation of therapy

Inflammatory bowel disease is characterized with intestinal inflammation. In Crohn's disease, chronic inflammation may lead to bowel stenosis, fistula formation and abscess formation. In Ulcerative colitis, polyp or dysplasia and even malignancy may also happen after chronic inflammation. In severe inflammation, intestinal bleeding also may happen. Nowadays, endoscopic therapy can be used in management of these conditions. I'll discuss about roles and precaution of endoscopic therapies for IBD, including balloon dilation, stricturotomy, strictureplasty, fistulotomy, stenting, septectomy, banding ligation, incision and drainage, polypectomy, and check bleeding.

Inflammatory bowel disease (IBD), particularly ulcerative colitis (UC), is associated with 6 times increase in the risk of colorectal cancer (CRC) as a result of long persisting inflammation and its carcinogenetic consequence. In purpose of earlier detection of cancer development at more curable stages and prevention of the pre-cancerous lesions from further progress, surveillance colonoscopy at intervals are long considered an essential part of clinical management of UC and also one of the main reasons for endoscopy in the practice of IBD care. Unlike surveillance colonoscopy for average patients at risk of sporadic cancers, there are significant variations in the way surveillance is being performed for patients with IBD because of great heterogeneity in patients' individual risk, endoscopists' experience levels, and capabilities of medical instruments. Furthermore, small cancers in the long-inflamed colon are subtle and difficult to be seen. Cancer precursors, dysplasias, are even more confusing regarding their distinction from the surrounding already diseased mucosa, both macroscopically and microscopically. To address that, the fundamentals in the performance of surveillance colonoscopy stated in the current guidelines will be shown, in accordance with the scientific evidence that justified the recommendations. Also, the field of controversies and uncertainties will be discussed.

Contrast- enhanced harmonic EUS (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[1,2]. Therefore, evaluation of vascularity using the recently developed technique of CH-EUS may improve the characterization of intra-abdominal lesions. In fact, CH- EUS is increasingly being used in the diagnosis of intra- abdominal lesions, and its utility has been extensively reported. However, indications and standardization of methods and settings for CH-EUS remain to be deter-mined. The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) aimed to provide internationally applicable information based on current scientific evidence reviewed by a panel of internationally renowned experts on the aforementioned topics, to allow further utilization and research in the field of CH-EUS possibly throughout Asia and the rest of the world[3]. According to the guidelines, use of CH-EUS is recommended for characterization of pancreatic solid masses, pancreatic cancer staging in selected patients with suspected major vessel involvement, pancreatic subtle lesions and detection of mural nodules in pancreatic cystic lesions. But, there were still debates for the role of CH-EUS about improvement of diagnostic accuracy of EUS-FNA because of detection of detect avascular areas [4-7]. 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[8].

Consequently, an international consensus was obtained for some of the techniques and indications for CH-EUS although further clinical trials are needed to resolve issues not fully discussed in these guidelines because of a lack of reports with high-quality evidence.

Reference

1. 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.
2. Kitano, M., H. Sakamoto, and M. Kudo, Contrast-enhanced endoscopic ultrasound. Dig Endosc, 2014. 26 Suppl 1: p. 79-85.
3. Kitano, M., et al. (2021). "The Asian Federation of Societies for Ultrasound in Medicine and Biology (AFSUMB) Guidelines for Contrast-Enhanced Endoscopic Ultrasound." Ultrasound Med Biol 47(6): 1433-1447.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.

Endoscopic ultrasound is useful for gallbladder (GB) disease that cannot be concealed under abdominal ultrasound, and can further distinguish its nature. The previous research aimed at the diagnosis of cholesterol polyp by using endoscopic ultrasound. The diagnostic accuracy is as high as 94%, whereas the diagnostic accuracy of abdominal ultrasound is only 66.7%. Combing past studies, it was found that GB malignant lesions have the following characteristics under contrast agent endoscopic ultrasound: 1) inhomogeneous enhancement, 2) perfusion defect, 3) irregular vessels, 4) Brindled enhancement.

In addition, we have tried to use the time intensity curve (TIC) to evaluate gallbladder lesions, and draw a curve similar to that published in the previous literature. The “intensity strength” and “time to peak time” may be administered to differentiate benign GB lesions from malignant gallbladder tumors.

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, abscess aspiration or ethanol injection or radiofrequency ablation for HCC, owing to its less invasiveness, appears to be a new innovative option for lesions that is difficult to treat by local percutaneous treatment.

Endoscopic ultrasound-guided drainage techniques, including endoscopic ultrasound-guided biliary drainage (EUS-BD), endoscopic ultrasound-guided pancreatic drainage (EUS-PD), endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are rapidly expanding in their applications. EUS-BD has become comparable to endoscopic retrograde cholangiopancreatography (ERCP) and is now considered a first-line intervention for certain biliary obstructions.

The latest review studies show that the adverse event rate of EUS-BD has dropped from the previously reported 23% [1] to 9.3-16% [2,3]. In studies published after 2013, due to the introduction of newer, safer stents [4,5], organized procedural tips/clear step-by-step processes for EUS-BD [6,7], and the richer experience of endosonographer [2], there is a noticeable trend of increased success rates and decreased adverse events.

These EUS techniques are minimally invasive and can be widely introduced into community hospitals when performed by appropriately trained physicians, with surgical and radiological backup. They can aid patient recovery, reduce the economic burden of long hospital stays, and circumvent the difficulty of seeking treatment at distant medical centers.

Key elements in establishing an EUS service in a community hospital include patient selection (indications), preoperative preparation (staff training and equipment management), postoperative nursing and complications handling (surgical and radiological backup).

Patients with intrahepatic bile duct obstruction or highly complex multi-site bile and pancreatic obstructions have a higher failure rate of EUS drainage when performed by beginner endosonographer. Discussion with patients about referral treatment or accepting traditional surgery or external drainage is necessary.

The basic steps of EUS drainage treatment are puncture, guidewire placement, fistula dilation, and stent placement. Participants must be familiar with the process and prepare the necessary instruments and medical materials in advance.

Ward nurses or referring physicians also need to understand possible complications and care steps, such as the time to resume eating, signs of gastrointestinal bleeding/perforation, so that complications can be handled promptly if they occur.

Retrospective analysis of the effectiveness, safety, and clinical results of EUS-guided drainage performed at our hospital showed technical success rates of 100% for EUS-GBD (n=4), EUS-GE (n=2), 90% for EUS-PD (n=10), and 75% for EUS-BD (n=8). The most serious complication was pneumoperitoneum caused by incorrect placement of a plastic stent in the choledochoduodenostomy (CDS). We successfully managed the complication and bile duct obstruction by endoscopically removing the stent, closing the choledochoduodenostomy with hemoclips, and percutaneously draining the pneumoperitoneum and bile duct. In these few cases, there was no procedure-related mortality, and the clinical success rate exceeded 90%.

Through the sharing of our experiences and the preliminary results of our implementations at community hospital, my aim is to consistently improve our skills, thereby enhancing patient care and quality of life. I also hope to inspire beginning endosonographers to commence their own practice.

1. Wang; et.al. Gastrointest. Endosc. 2016, 83, 1218-1227
2. Han, S.Y.; et.al. Sci. Rep. 2019, 9, 16551
3. Artifon, E.L.A.; et.al. Endosc. Ultrasound 2019, 8, S72-S78
4. Itonaga, M.; et.al. Dig. Endosc. 2019, 31, 291-298.
5. Amato, A.; et.al. Endoscopy 2021, 53, 1037-1047
6. Minaga, K.; et.al. Dig. Endosc. 2018, 30, 38-47.
7. Ogura, T.; et.al. Gut Liver 2021, 15, 196-205.

Barrett's esophagus (BE) is a precancerous condition that needs regular endoscopic surveillance to detect early neoplastic lesions and prevent invasive carcinoma. Early detection allows curative endoscopic treatments, which depend on thorough endoscopic assessment and improved outcomes. However, many neoplastic lesions in BE are still missed, probably due to suboptimal endoscopic surveillance. To enhance neoplasia detection in BE, advanced imaging techniques have been developed, such as virtual chromoendoscopy technologies. Moreover, artificial intelligence (AI) has transformed the field of diagnostic endoscopy and has a potential role in BE as well. This symposium aims to summarize the current evidence, recent research advances, and future directions of advanced imaging technology and AI in BE; the integration of computer-aided diagnosis and advanced imaging technologies is expected. It will also provide a practical guide for performing high-quality endoscopy in BE, in order to increase the diagnostic accuracy of endoscopy in clinical practice.

The global and ascian prevalence of gastroesophageal reflux disease (GERD) is high and increasing. Upper endoscopy is frequently employed as the initial test in individuals with alarm symptoms or when symptoms fail to respond to antisecretory therapy. However, the sensitivity for identifying reflux disease on esophagogastroduodenoscopy is imperfect. Where endoscopy fails to identify an etiology for patients' symptoms ambulatory reflux monitoring is performed to confirm or rule out pathological esophageal reflux burden. Novel metrics extracted from pH-impedance monitoring can augment the diagnosis of GERD. Artificial intelligence (AI) is being widely used to improve the diagnostic capabilities of various diseases. In this talk, we will share our experience and update the current literature regarding applications of artificial intelligence in measuring novel pH-impedance metrics. In conclusion, AI demonstrates high performance in the measurement impedance metrics and is expected to play a reliable role in facilitating measuring novel impedance metrics in patients with GERD in the near future.

The treatment of inflammatory bowel disease (IBD) has undergone significant advancements with the emergence and widespread acceptance of biological agents. However, introducing artificial intelligence technologies such as machine learning and deep learning represents another crucial turning point in IBD management in the future. In the realm of IBD research, there has been a growing interest in these methodologies over the past decade, as they offer a promising avenue for enhancing clinical outcomes among patients with IBD.

In this section, we will review the recent development of the application of AI for the management of inflammatory bowel disease.

Artificial intelligence (AI) is a rapidly growing field in gastrointestinal endoscopy. Polyp detection (computer-aided detection, CADe) and characterization (computer-aided characterization, CADx) during colonoscopy are popular clinical applications of AI in gastroenterology by far. AI systems might offer a promising solution to reduce variation in colonoscopy performance and could help reduce human error.

The application of CADe systems in real-time colonoscopy have been shown to increase adenoma detection rate(ADR) in multiple randomized controlled trials (RCTs) while other studies yielded opposite results. In some studies, CADe did not increase ADR in routine practice, especially among endoscopists with high baseline ADR. When it comes to CADx systems, including convolutional neural network (CNN)-based systems, some of the AI aided system's overall diagnostic accuracy could be impressively (95.0%) higher than experts and novices. However, most of the studies still have some methodological limitations, possibly including scientific, clinical, and legal issues.

Artificial intelligence and CAD technology offer great promise for colonoscopy with encouraging preliminary results, however, there are still several challenges to overcome before they are incorporated into routine clinical practice.

The clinical approach to small intestinal tumors involves the evaluation, diagnosis, treatment options, and subsequent management of these rare but significant gastrointestinal conditions. Assessment and diagnosis rely on a comprehensive analysis of the patient's medical history, physical examination, and relevant laboratory tests. Common imaging techniques such as ultrasound, colonoscopy, and small bowel endoscopy provide valuable information about tumor location, size, and structure. Definitive diagnosis is often achieved through histopathological examination of tissue samples.

Treatment strategies for small intestinal tumors encompass surgical resection, radiation therapy, and chemotherapy. Surgical removal is typically the preferred approach, although feasibility and extent of surgery depend on tumor location and size. For unresectable tumors, radiation therapy and chemotherapy can be employed to alleviate symptoms and control tumor progression. Subsequent management entails regular follow-up and imaging studies to monitor for tumor recurrence or metastasis. Genetic counseling and screening for hereditary tumor syndromes are also important considerations for high-risk patients.

In summary, the clinical approach to small intestinal tumors involves evaluation, diagnosis, treatment options, and subsequent management. A comprehensive utilization of various diagnostic and therapeutic modalities can provide individualized medical care to improve patient outcomes and quality of life.

Though small intestine is the longest region of the alimentary canal, neoplasms of the small bowel are very uncommon: even when benign and malignant lesions are considered together, they account for 5% to 10% of all gastrointestinal tumors. One third of these lesions are benign: adenoma, hemangioma, leiomyoma, lipoma, lymphangioma, inflammatory fibroid polyp, harmatoma, bruneroma, neurofibroma are often mentioned by literature review and encountered at our daily practice.

Despite the fact that these lesions are benign in nature, they still can cause symptoms as bleeding and intussusception, very low potential of malignant transformation is also the concern. Fortunately, with the aid of deep enteroscopy, it is possible to manage these lesions and avoid major surgery.

In today's speech, I will review and share the experience from Chang Gung Memorial Hospital.

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 because of its vague clinical symptoms.

In early course and difficulty in diagnostic approaching. 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 are relatively rare and can be challenging to diagnose and treat due to the location of the small intestine within the body. In the past, surgical resection was the primary treatment option for these tumors. However, advances in endoscopic techniques have made it possible to manage some small bowel tumors using minimally invasive procedures.

Endoscopic treatment for small bowel tumors typically involves the use of specialized instruments and techniques to visualize and access the tumor within the small intestine. These procedures may be performed using a traditional endoscope or more advanced techniques such as balloon-assisted enteroscopy or capsule endoscopy.

Therefore, my talk will focus on the indications and limitations of endoscopic treatment of small intestinal tumors.

Pancreatic ductal adenocarcinoma (PDAC) remains a leading cause of cancer death worldwide. Surgery remained the only possible completely treatment among these patients. However, only 15-20 % patients were diagnosed as resectable stage which made pancreatic adenocarcinoma 5-years survival rate less than 10 %.

Several attempt such as neoadjuvant chemotherapy and radiation therapy had been applied in treating disease for decades, but only got dismal improvement in survival. Lack of specific warning features and screening tool in real world made early diagnosis of pancreatic adenocarcinoma more difficult.

Radiofrequency ablation (RFA) is a thermal ablation which had been used in liver, thyroid tumor for a long time. It employs an alternative RF current to generate heat and induced coagulation inside tumor. It had also been reported to induce antigen presenting effect and amplify weak tumor related immunity. Moreover, the presented complication rate was acceptable and usually manageable in literature review. Although the overall survival benefit of combining RFA into PDAC treatment remains controversial. Several existed evidence still revealed a better outcome if combined with neoadjuvant chemotherapy.

Today we will make a brief summary of current role of pancreatic RFA in PDAC and shared our experience to the audience.

Cholangiocarcinoma (CCA) is a primary cancer of the bile ducts have a poor prognosis with a median survival of 3-6 mo for unresectable cancers. As a result of poor chemotherapeutic options, the mainstay of care for these patients with unresectable CCA revolves around ERCP, interventional radiologic, or EUS-guided biliary decompression with biliary stenting and/or percutaneous drainage. Keeping stent function and prolonging stent patency can preserve liver function and increase patients' survival rates.

Intraductal RFA represents a procedure that involves the use of a biliary catheter device and acts by delivering thermal energy within the tissue, leading to coagulative necrosis and cellular death. Several RCTs and meta-analysis studies1,2 showed that RFA with stenting has statistical superiority to biliary stenting alone in patients' medial survival time but no definite conclusion in stent patency due to heterogeneous reporting of stent type, placement techniques, and the location of biliary obstruction in those studies. Recent studies3 also show that the patient who received RFA combined with chemotherapy have significantly improved survival compared to chemotherapy alone, especially in non-metastasis status. Further studies are needed to assess the palliative, technical, clinical outcomes, and systemic effects of RFA.

1. Rebhun J, Shin CM, Siddiqui UD, Villa E. Endoscopic biliary treatment of unresectable cholangiocarcinoma: A meta-analysis of survival outcomes and systematic review. World J Gastrointest Endosc. 2023 Mar 16;15(3):177-190.
2. Fu Y, Yang W, Wu W. et.al Radiofrequency ablation in the management of unresectable intrahepatic cholangiocarcinoma. J Vasc Interv Radiol. 2012 May;23(5):642-9.
3. GC MA, Möhring C, MR Zhou T et.al. Impact of regular additional endobiliary radiofrequency ablation on survival of patients with advanced extrahepatic cholangiocarcinoma under systemic chemotherapy. Sci Rep. 2022 Jan 19;12(1):1011.

Cholangioscopy is an 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 “peroral cholangioscopic treatment for pancreato-biliary disease” during ERCP using currently available instruments.

Obesity is one of the most important public health burdens in the world, including Taiwan. Comorbidities of obesity include diabetes, hypertension, hyperlipidemia, gout, cardiovascular diseases, sleep apnea syndrome, cancers and many other digestive system diseases such as NAFLD, GERD, gall bladder diseases, pancreatic diseases, et al. Traditionally, obesity is treated in the clinics of endocrine and family medicine specialists in hospital. But when the prevalence of overweight and obesity, defined as BMI ≥ 24, in Taiwan is more than 50%, all physicians should take part in this big challenge.

The treatments of obesity are founded from diet, exercise, replacement meals, medication and surgery. These years, bariatric endoscopy including intragastric balloon and endoscopy sleeve gastrectomy emerges as a new method to treat obesity. GI man will be the most important role in this new therapy. At this time, what is your way to face the new era? We will discuss this issue in this speech. Welcome and join us.

Intragastric botulinum toxin A (BTA) injection is a potential treatment for weight reduction in obese patients. Current studies yielded conflicting results. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of intragastric BTA injection for weight management. We searched several databases to identify RCTs evaluating intragastric BTA injections for obesity. We applied random-effects models for all meta-analyses due to heterogeneity in the included studies. The mean difference (MD) and 95% confidence interval (CI) was calculated for continuous outcomes. A total of 6 RCTs including 192 subjects met the inclusion criteria and were included for the meta-analysis. Although the pooled data from 6 studies showed no difference in the absolute weight loss between intragastric BTA injection and control, subgroup analysis showed a significantly decreased absolute weight after a BTA injection dose ≥ 200 U (MD, -2.04 kg; 95% CI, -3.96 to -0.12) and after multiple injection regions in the stomach combined with diet control (MD, -4.44 kg; 95% CI, -6.54 to -2.33 kg) compared to the control. Regarding absolute weight loss, the impact of EUS guided injection and follow-up duration showed no difference. Intragastric BTA injection had a significant change in BMI (MD, -1.25 kg/m2; 95% CI, -2.18 to -0.32 kg/m2) and prolonged gastric half-emptying time (MD, 11.37 min; 95% CI, -3.69 to 19.06 min). Intragastric BTA injection is effective for obesity treatment and adequate doses (≥ 200 U), multiple gastric injection regions, and combined diet control are crucial.

New Perspectives on Enzymatic Detergents for Endoscope Reprocessing

Efficiently removing biofilms from medical devices is a significant challenge in healthcare, as it is essential for preventing hospital-acquired infections. This is especially true for delicate devices, such as flexible endoscopes, which cannot tolerate harsh chemicals or high temperatures during reprocessing. Therefore, gentler solutions, such as enzymatic detergents, must be utilized.

Enzymatic detergents play a critical role in the manual cleaning process during endoscope reprocessing. They assist in breaking down and removing organic debris, including biofilms, that may remain on the endoscope after use. Manual cleaning is vital in ensuring that all areas of the endoscope are thoroughly cleaned, particularly the hard-to-reach areas that may be missed. Enzymatic detergents are effective in removing organic matter and minimizing the risk of residual contamination, which can lead to infection transmission. Therefore, their use in manual cleaning is crucial to ensure the safety and efficacy of endoscope reprocessing.

When selecting enzymatic detergents for endoscope reprocessing, it is important to consider the type and level of soil present on the endoscope. Enzymatic detergents are designed to target specific types of soil, such as blood, mucus, or protein. Selecting the appropriate enzymatic detergents can help ensure effective cleaning. Additionally, it is crucial to choose a cleaner that is compatible with the endoscope's materials and does not cause any damage or degradation. Properly diluting the cleaner and following the manufacturer's instructions for use are also critical for optimal effectiveness.

ATP testing and protein testing involve verifying that the enzymes are breaking down protein-based soils. Performing these tests regularly can ensure that enzymatic detergents effectively remove biofilms and other organic matter from endoscopes, providing an additional level of assurance for patients' safety.

內視鏡高層次消毒

（一）自動化再處理

1. 說明自動化再處理6個步驟
2. 執行高層次消毒前，確認高層次消毒劑，有效日期、最低有效濃度、機內酵素清潔劑及酒精是否足夠。
3. 注意事項說明

（二）自動化再處理機優勢說明

（三）手工高層次消毒執行步驟說明

The purpose of deep enteroscopy is to identify abnormal lesions in the small intestine, facilitate diagnosis, obtain tissue samples, and perform lesion treatments when necessary. Common indications for this procedure include suspected small bowel bleeding, unexplained abdominal pain, pathological diagnosis of tumors, diagnosis and dilation treatment of inflammatory bowel disease, localization of small bowel lesions, and removal of benign tumors.

The technician plays a crucial role throughout the entire process. The endoscope requires high-level disinfection, and according to regulations, auxiliary instruments should be used only once and must not be reprocessed after sterilization. Some auxiliary instruments can be reused after disinfection and sterilization, following the guidelines for "Disinfection and Sterilization of Medical Devices."

Prior to performing the examination, the technician should assemble and test the deep enteroscopy system based on the operation manual, which typically takes around 10 minutes. After the examination, the technician should assist the physician in cleaning and organizing the relevant instruments and inspect them for any damage or malfunction. Subsequently, following the standard operating procedures outlined in the deep enteroscopy manual, the endoscope should be thoroughly cleaned, disinfected, and properly stored.