Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for diagnosis and interventions in patients with biliopancreatic disorders. However, ERCP in patients with surgically altered anatomy (SAA) is considered more difficult compared to those with normal anatomy. Since balloon enteroscope (BE) was introduced for patients with small intestine disorders, single-balloon enteroscope (SBE) and double-balloon enteroscope (DBE) had also been used for biliopancreatic diseases in patients with SAA. The use of conventional SBE and DBE are limited by its long working length of 200 cm and a narrow working channel of 2.8-mm diameter; therefore, few ERCP accessories are available. A short-type SBE with a working length of 152 cm and a working channel of 3.2-mm diameter and a short-type DBE with a working length of 155 cm and a working channel of 3.2-mm were introduced to solve the difficulties. As a result, favorable outcomes have been reported recently. Moreover, it has also been reported that these procedures have several tips to accomplish procedural success and factors affecting procedure failure. In difficult cases, alternative techniques, such as percutaneous transhepatic biliary drainage and endoscopic ultrasound-guided biliary drainage are needed.

Endoscopic retrograde cholangiopancreatography (ERCP), in surgically altered anatomy (SAA), can be challenging and most common foregut interventions resulting to this burden consist of Billroth II gastrectomy, Whipple surgery and Roux-en-Y anastomoses, including gastric by-pass. An endoscopic ultrasound-guided biliary drainage (EUS-BD) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) in patients with SAA have been used to remove biliary duct stones from patients with SAAs. Some comparative data have been reported. However, the optimal technique selection remains debatable.

The EUS-BD afforded technical success and complete stone removal rates comparable with those of DB-ERC. But the procedure time was shorter in EUS-BD. The adverse event rate was acceptable. Further studies with larger sample sizes are warranted to confirm these findings and refine technique selection criteria.

Reference:

1. Dhir, V., et al. (2015). "Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach." Gastrointest Endosc 81(4): 913-923.
2. Teoh, A. Y. B., et al. (2018). "Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel." Gut 67(7): 1209-1228.
3. Isayama, H., et al. (2019). "Clinical practice guidelines for safe performance of endoscopic ultrasound/ultrasonography-guided biliary drainage: 2018." J Hepatobiliary Pancreat Sci 26(7): 249-269.
4. Nakai, Y., et al. (2019). "Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent." Endosc Ultrasound 8(2): 111-117.
5. Abu Dayyeh, B. (2015). "Single-balloon enteroscopy-assisted ERCP in patients with surgically altered GI anatomy: getting there." Gastrointest Endosc 82(1): 20-23.
6. Tanisaka, Y., et al. (2021). "Recent Advances of Interventional Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound for Patients with Surgically Altered Anatomy." J Clin Med 10(8).
7. Iwashita, T., et al. (2016). "Endoscopic ultrasound-guided antegrade treatment of bile duct stone in patients with surgically altered anatomy: a multicenter retrospective cohort study." J Hepatobiliary Pancreat Sci 23(4): 227-233.
8. van der Merwe, S. W., et al. (2022). "Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline." Endoscopy 54(2): 185-205.

Malignant gastric outlet obstruction (GOO) is a severe complication commonly seen in advanced gastric, pancreatic, and duodenal cancers, leading to significant morbidity due to obstructive symptoms like nausea, vomiting, and inability to eat. Endoscopic stenting has emerged as a minimally invasive, effective palliative treatment for malignant GOO, offering rapid symptom relief and improved quality of life.

This review examines the procedure, efficacy, and outcomes of endoscopic stenting for malignant GOO. The procedure involves the placement of a self-expanding metal stent (SEMS) across the obstructed area under endoscopic and fluoroscopic guidance. SEMS placement alleviates obstruction by providing a patent lumen, allowing the resumption of oral intake and minimizing the need for surgical intervention.

Clinical studies demonstrate high technical and clinical success rates, with immediate symptom improvement in most patients. Complications, although infrequent, can include stent migration, occlusion, and perforation. Advances in stent design, such as anti-migration features, have further enhanced the procedure's safety and efficacy.

In conclusion, endoscopic stenting for malignant GOO is a preferred palliative approach due to its minimally invasive nature, prompt relief of obstructive symptoms, and favorable safety profile, significantly improving patients' quality of life in the context of advanced malignancy.

Gastric outlet obstruction (GOO), caused by mechanical obstruction of the duodenum, pylorus, or antrum, can result from various diseases and was with symptoms such as abdominal pain, vomiting, malnutrition and dehydration. Traditionally, the primary treatment for malignant GOO has been either open or laparoscopic surgical gastroenterostomy, which has resulted in a high rate of complications. The endoscopic management with enteral self-expandable metal stent (SEMS) placement was less invasive, while it was more higher reintervention rate. In recent years, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed for the management of GOO. A biflanged fully covered LAMS was deployed for creation of a fistulous tract between the stomach and the duodenum or jejunum. EUS-GE has many different technical methods, such as direct technique, balloon-assisted technique etc. EUS-GE has high technical success rate (87%-100%) and clinical success rate (84%-100%). Common complications include misdeployment of the stent, bleeding, pneumoperitoneum, peritonitis, abdominal pain, and gastrocolic fistula. Compared to enteral stent placement, EUS-GE has a higher initial clinical success rate and a lower rate of stent reintervention for malignant gastric outlet obstruction. When compared to surgical gastroenterostomy, there are no significant differences in technical or clinical success, symptom recurrence, or reintervention rates. EUS-GE is an effective and safe method for managing malignant gastric outlet obstruction.

Endoscopic ultrasound guided gastroenterostomy (EUS-GE) with a lumen apposing metal stent (LAMS) is a novel technique described in the management of gastric outlet obstruction (GOO). It entails the insertion of the LAMS from the stomach to the small bowel distal to the obstruction, thereby effectively bypassing the luminal compromise. Several retrospective and prospective series have shown promising results with high clinical success, safety, and low risk for stent obstruction. However, the majority of the data on EUS-GE have involved patients with malignant GOO and its efficacy in benign disease is largely undefined. EUS-GE may be a promising modality in benign GOO especially in patients who have failed EBD, those with GOO etiologies that are unlikely to respond to dilation therapy, or when dilation is technically not possible. However, the long-term effects of an indwelling LAMS and the safety of its removal are still to be further elucidated, while the technique remains to be perfected. Until further data is available, EUS-GE in benign GOO is best reserved for patients who have failed EBD or if EBD is not possible. It may also be considered in GOO etiologies that tend to have a poor response to dilation, such as strictures secondary to pancreatitis or caustic injury.

The Lyon Consensus 2.0 revises the definition of actionable gastroesophageal reflux disease (GERD) to enhance management strategies for symptomatic patients. A significant revision is the classification of Los Angeles (LA) grade B esophagitis as definitive evidence of GERD, thereby recognizing LA grades B, C, and D esophagitis, biopsy-confirmed Barrett’s esophagus, and peptic stricture as conclusive indicators. Additionally, the consensus recommends conducting endoscopy within 2–4 weeks following the discontinuation of proton pump inhibitors to heighten diagnostic precision in ambiguous GERD cases. Initially, impedance electrodes and later an inflatable balloon with electrode arrays were used to assess esophageal mucosa via endoscope, but both methods are currently unavailable. A novel endoscopic cap device is now under development to evaluate the esophagus and differentiate GERD-related changes from non-GERD phenotypes during index endoscopy. Finally, a normal endoscopic examination does not exclude GERD, but identification of a hiatus hernia during endoscopy can be associated with increased reflux burden. This talk will elucidate the clinical implications and rationale for these updates, hoping to stimulate discussion and feedback.

Recent strides in endoscopic anti-reflux treatment mark a transformative shift towards minimally invasive interventions for gastroesophageal reflux disease (GERD), spotlighting antireflux mucosal intervention, radiofrequency ablation (RFA), and endoscopic plication devices.

Antireflux mucosal interventions offer a promising avenue for reinstating the integrity of the gastroesophageal junction. Leveraging techniques like endoscopic suturing and tissue apposition, these interventions fortify the antireflux barrier, thereby mitigating reflux symptoms and enhancing patients' quality of life.

RFA, Stretta procedure, offers a minimally invasive approach for GERD, utilizing radiofrequency energy to strengthen the lower esophageal sphincter. Clinical studies show promising results in symptom relief and quality of life improvement.

Endoscopic plication devices present a minimally invasive alternative to traditional surgical interventions for GERD. These devices facilitate the formation of enduring plications or folds in the gastroesophageal junction, leading to superior reflux control and symptom alleviation sans invasive surgery.

In summary, recent advancements in endoscopic anti-reflux treatment, encompassing antireflux mucosal interventions, radiofrequency ablation, and endoscopic plication devices, hold substantial promise for revolutionizing GERD management. Ongoing research and clinical innovation are vital to further hone these techniques and optimize outcomes for individuals grappling with reflux disease.

Third space endoscopy, also known as submucosal endoscopy, involves the utilization of endoscopy through the virtual intramural space created by dissecting and expanding the tissue layer between the mucosa and the muscularis propria.

In 2007, Sumiyama et al. first demonstrated the secure closure of the mucosal flap used to access the submucosa with standard endoscopic devices, thereby restoring luminal integrity. Pasricha et al. demonstrated the feasibility of esophageal myotomy in an animal model. In 2008, Inoue et al. performed the first human case of per-oral endoscopic myotomy (POEM) for achalasia treatment. POEM has since been shown to be an effective treatment method for achalasia worldwide in recent decades, with good long-term efficacy, irrespective of manometric classification type. It has been found to have a higher treatment success rate compared with pneumatic dilation and to be non-inferior to laparoscopic Heller's myotomy plus Dor's fundoplication in the treatment of achalasia. However, post-POEM gastroesophageal reflux disease (GERD) remains a clinical concern. POEM plus fundoplication may be used to prevent GERD occurrence.

In addition to achalasia, POEM has been used for the treatment of esophagogastric junction outflow obstruction (EGJOO) or spastic esophageal motility disease. It has also been employed in the treatment of Zenker's diverticulum or esophageal diverticulum. Gastric POEM has been shown to improve both symptoms and gastric emptying in patients with severe gastroparesis. In recent case series, per-rectal POEM (PREM) has been used to treat Hirschsprung's disease. Furthermore, cricopharyngeal POEM has been used to relieve dysphagia in patients with cricopharyngeal bar or Parkinson's disease. Third space endoscopy continues to develop and increase its clinical utility in the management of GI motility diseases.

Oropharyngeal dysphagia, is common among patients with laryngeal and hypopharyngeal cancer. They often experience symptoms such as coughing, gastroesophageal reflux, food residue in the mouth, drooling, weight loss, fever, and aspiration pneumonia during or after eating. If the feeding method is incorrect, it can also increase the risk of complications such as aspiration pneumonia; therefore, patients need to closely monitor their throat function and oral hygiene status, and take appropriate measures to reduce the occurrence of complications. Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed laryngeal and hypopharyngeal cancer patients with oropharyngeal dysphagia to maintain their nutritional demand. Aspiration pneumonia is a common cause of death in these patients. We aimed to evaluate the role of oropharyngeal dysphagia in laryngeal and hypopharyngeal cancer patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Oropharyngeal dysphagia, is common among patients with laryngeal and hypopharyngeal cancer. They often experience symptoms such as coughing, gastroesophageal reflux, food residue in the mouth, drooling, weight loss, fever, and aspiration pneumonia during or after eating. If the feeding method is incorrect, it can also increase the risk of complications such as aspiration pneumonia; therefore, patients need to closely monitor their throat function and oral hygiene status, and take appropriate measures to reduce the occurrence of complications. Nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) are widely used techniques to feed laryngeal and hypopharyngeal cancer patients with oropharyngeal dysphagia to maintain their nutritional demand. Aspiration pneumonia is a common cause of death in these patients. We aimed to evaluate the role of oropharyngeal dysphagia in laryngeal and hypopharyngeal cancer patients on long-term enteral feeding for risk stratification of pneumonia requiring hospitalization.

Modified flexible endoscopic evaluation of swallowing (FEES) is a mature technology for evaluating oropharyngeal dysphagia which enables assessment of the aspiration risk by directly visualizing the test material accumulating in the pharyngolaryngeal region or penetrating the vocal cords. We performed modified FEES to evaluate oropharyngeal dysphagia in laryngeal and hypopharyngeal cancer patients and conducted prospective follow-up for aspiration pneumonia requiring hospitalization. Oral-feeding patients and tube-feeding patients were enrolled. Multivariate Cox analysis was performed to identify risk factors of aspiration pneumonia requiring hospitalization.

FEES allows visualization of oral cavity, tongue base, hard palate, pyriform sinus, laryngeal vestibule borders, vocal cords, and upper part of the trachea. Abnormal pooling secretions filling the pyriform sinus, entering the laryngeal vestibule increase the risk of pneumonia in patients with oropharyngeal dysphagia. Mortality rate was higher in patients with suboptimal protective cough reflex. FEES provides information need for further diagnostic and therapeutic interventions for patients with oropharyngeal dysphagia.

Endoscopic submucosal dissection (ESD) emerged in early 2000s and the indicated lesions are gradually expanded by technical advancements for en bloc resection and clinical evidence of better long-term outcomes. Traction methods such as the clip and line method are very helpful to conduct smooth and safe ESD in all organs. Despite these significant improvements, the duodenum remains the most challenging organ for ESD, because of the vascular-rich thinnest wall and the torturous structure with exposure of duodenal juices. However, establishment of water pressure method or device developments such as scissors-type devices has substantially contributed to overcome the technical difficulties. Furthermore, suturing immediately after duodenal ESD is very effective to prevent serious post ESD complications such as delayed bleeding and perforation. Different precautions must be considered for post ESD complications in the esophagus, stomach and colorectum; those are strictures after esophageal ESD, bleeding after gastric ESD and perforation or electrocoagulation syndrome after colorectal ESD. Several new attempts are tried to reduce these complications by using preoperative risk stratification, which enabled us to obtain more favorable outcomes. Owing to these advancements, the role of ESD will be further increased in the managements of GI neoplasms as future perspectives.

Gastrointestinal stromal tumors (GISTs) are rare digestive mesenchymal tumors, characterized by differentiation towards interstitial cell of Cajah. They can occur in any part of GI tract, mostly common in stomach (60%), and small intestine (30%). GISTs have variety of clinical behaviors with potentially malignant tendency. Currently, the treatment strategy for GISTs is somewhat controversial. Some study showed that active surveillance was a safe option for GISTs smaller than 2cm or even 3 cm. (excision is only considered when tumor grows). However, GISTs have inherent malignant potential, and the real risk of stratification is only known after resection. Therefore, several societies suggest resection once the diagnosis of GISTs is made, unless major morbidity is expected.

We will discuss more in this meeting.

In recent years, advancements in endoscopic suturing and clipping techniques have significantly improved the efficacy of wound closure during endoscopic procedures. This presentation will discuss the latest developments in these techniques and their clinical evidence. By examining the principles and applications of these technologies, we can better understand how to choose the most appropriate method for achieving wound closure under endoscopy, ultimately providing patients with better treatment outcomes and faster recovery.

Per-oral endoscopic myotomy (POEM) is a cutting-edge, minimally invasive procedure used to treat achalasia and other esophageal motility disorders. It has gained prominence due to its high efficacy and favorable safety profile. POEM has demonstrated significant success in alleviating symptoms of achalasia, such as dysphagia (difficulty swallowing), and chest pain. Patients typically experience substantial improvements in esophageal function and a reduction in lower esophageal sphincter (LES) pressure. Long-term studies show that these benefits are sustained, with most patients reporting lasting symptom relief for five years or more. Quality of life improvements post-POEM are also significant, confirming the procedure's long-term effectiveness.

POEM is considered safe, with a low incidence of severe complications due to its minimally invasive nature with shorter hospital stays and faster recovery times compared to traditional surgical methods like Heller myotomy. Endoscopists should keep alert to possible intraoperative and post-operative complications.

In this session, I will review the outcomes studies from published studies and share the results in our hospital. Cases with post-POEM complications will also be presented and further discussed.

Quality improvement is essential in gastrointestinal (GI) endoscopy, impacting patient treatment and outcomes. The quality of GI endoscopy varies with the endoscopist's training, proficiency, and sensory capabilities. Studies show that a low lesion detection rate increases interval cancer risk and mortality, while misrecognition of endoscopic features leads to incorrect treatments, raising complication and recurrence rates. Quality indicators like adenoma detection rate and withdrawal time in colonoscopy help maintain endoscopy quality but often provide retrospective analysis and are costly to implement. Taiwan's healthcare system lacks a pay-for-performance scheme, limiting endoscopy quality control.

Recent advances in machine learning have led to systems such as computer-aided detection (CADe), diagnosis (CADx), and quality (CAQ), improving endoscopic accuracy and real-time quality control. Natural language processing can automate data extraction from endoscopy and pathology reports, enhancing quality data collection and surveillance interval recommendations. While AI-assisted endoscopy shows superiority in randomized controlled trials, its effectiveness in real-world settings is less significant. Further research is needed to confirm AI's impact on endoscopist behavior and endoscopy quality in real-world contexts. Healthcare reimbursement should shift towards pay-for-performance to incentivize adopting AI technologies.

The potential of artificial intelligence (AI) to enhance patient care has captured the attention of gastroenterologists. Nevertheless, integrating AI into clinical workflows presents challenges, as it remains uncertain whether its adoption will lead to improved outcomes for patients, practitioners, and the healthcare system. Given that new medical interventions can yield both benefits and drawbacks, it is crucial to temper our enthusiasm for AI with a careful consideration of its potential downsides. This talk aims to offer a balanced perspective on the anticipated impact of AI in endoscopy, where its clinical application is currently most advanced in gastroenterology.

Red dichromatic imaging (RDI) represents a novel endoscopic technique designed to enhance hemostasis during gastrointestinal bleeding. By utilizing specific wavelengths of red light, RDI improves the visualization of blood vessels and bleeding sites, enabling more precise identification and treatment of hemorrhagic lesions. This advanced imaging method enhances the endoscopist's ability to control bleeding effectively, potentially reducing procedure time and improving patient outcomes. This talk reviews the principles of RDI, its application in clinical practice, and its benefits in achieving endoscopic hemostasis.

Endoscopic ultrasound (EUS) was firstly developed in the late 1970’s in an attempt to improved ultrasound imaging of pancreaticobiliary system in advantage of proximity between organs. In the late 1990’s, first EUS-guided fine needle aspiration in human was performed after the development of linear array EUS instruments and minimally invasive approaches to extraluminal organs could be achieved by trans-oral endoscopy. Since then, with the advancements in dedicated accessories and EUS techniques, several therapeutic intents are developed, including the management of pancreatic cystic neoplasm, drainage and necrosectomy for pancreatic fluid collections, gastroenterostomy, biliary, gallbladder and pancreatic internal drainage, tumor ablation using RFA or ethanol injection, coiling and glue injection for gastric varices, and celiac plexus block or neurolysis. In this lecture, I will review the current evidences and share experiences about the cutting edge breakthroughs in EUS-guided transmural drainage.

In acute bilio-pancreatic disease the timing of ERCP is crucial, procedures performed too early or too late being equally harmful. However, ERCP is a technically demanding procedure with potentially serious complications, even in expert hands. The most frequent complications include: acute pancreatitis (3.5-9.7%), infections (cholangitis up to 3%, cholecystitis up to 5.2%), bleeding (0.3-9.6%), and perforation (up to 0.6%).

Therefore, it is clinically useful to define the situations that require urgent endoscopic treatment for patients managed in the Emergency Department, or admitted to the clinical wards for acute bilio-pancreatic diseases.

This topic aims to discuss practical decision of the timing of ERCP in acute gallstone pancreatitis.

The severe acute pancreatitis was defined by the presence of organ failure or local complications, such as pancreatic necrosis. Pancreatic necrosis affects approximately 15%-20% of patients and is typically identified by focal areas of non-enhancing pancreatic parenchyma on contrast-enhanced CT scans. Most patients with necrotizing pancreatitis exhibit sterile necrosis, manageable through conservative treatment focusing on supportive measures and infection control. In the early phase, multi-organ failure is the major issue of necrotizing pancreatitis, whereas, infective necrosis from bacterial translocation is the main complication of the late phase. The Infected necrosis may necessitate intervention, transitioning from primary open necrosectomy in early disease stages to a step-up approach. Initially, catheter drainage may be employed, progressing to minimally invasive surgical or endoscopic necrosectomy once peripancreatic collections demarcate adequately. Intervention may be postponed for 3 to 4 weeks to mitigate complications such as bleeding or perforation. However, early intervention remains necessary if there is a deterioration in the clinical situation.

Pancreatic walled-off necrosis (WON) is a complication of severe pancreatitis. Open necrosectomy with drainage has been the standard treatment; however, in consideration of a significant morbidity and high mortality, minimally invasive therapeutic alternatives are in demand. Endoscopic management with set-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy is reasonable and might be more advantageous than a minimally invasive surgical intervention. The development of lumen-apposing metal stents (LAMSs), devices specifically dedicated to transmural EUS interventions, further prompted the progress of endoscopic management of WON. To avoid the associated risks of LAMSs related complications, early removal of LAMS at 3 weeks post-intervention is proposed. Concurrent use of coaxial double pigtail plastic stents can mitigate the overall adverse events. Some indicators may be promisingly effective in predicting and managing endoscopic necrosectomy intervals. Finally, multidisciplinary therapeutic approaches should be considered because the endoscopic limitations in treating complicated WON.

A pancreatic pseudocyst is an encapsulated fluid accumulation with a well-defined inflammatory wall that usually forms around the pancreas about four weeks after the onset of pancreatitis. Symptoms such as obstruction of adjacent organs, pain, infection, or hemorrhage indicate the need for treatment. Endoscopic drainage is preferred over surgical or percutaneous drainage due to its lower complication rates, shorter recovery times, and high success rates.

Two methods of endoscopic drainage for pancreatic pseudocysts are commonly used: Trans-papillary Drainage (TPD): Performed via ERCP with pancreatic duct stenting. Transmural Drainage (TMD): Performed via EUS with the placement of plastic or metallic stents. A meta-analysis has shown that combining TPD and TMD does not improve treatment outcomes compared to using either method alone. The choice between TPD and TMD depends on factors such as the size and location of the pseudocyst, pancreatic duct disruption or stricture, and the underlying disease of the patient. In TMD, both metallic and plastic stents have similar treatment outcomes for uncomplicated pseudocysts, but plastic stents have a higher rate of migration. Further prospective trials are needed to validate these findings and determine the optimal choice of stents.

In 1895, an English physician provided the first description of PJS, illustrated the following year by Hutchinson. These twin girls with oral pigmentation died at age 20 and 52 years, from intussusception and breast cancer respectively. In the 1920's Peutz (Peutz, 1921), described a family with autosomal dominant inheritance of gastrointestinal polyposis and pigmented mucous membranes, and two decades later Jeghers (Jeghers, 1949) defined the key clinical features of mucocutaneous pigmentation and gastrointestinal polyposis as a distinct clinical entity. The eponym Peutz-Jeghers syndrome was proposed in 1954.

Peutz-Jeghers syndrome appears to be inherited as a single pleiotropic autosomal dominant gene with variable and incomplete penetrance. The clinical management in early life is initially focused on preventing complications of small bowel polyposis related obstruction and bleeding and, in adulthood, the focus is primarily on management of cancer risk.

In today's talk, I'll review the disease with a long history, base on literature and experience from my institution.

According to Cancer Registry Annual Report, small intestinal malignant tumor cases accounted for 0.41% of all malignant tumor cases, and the number of deaths from malignant tumors in 2020 accounted for 0.29% of all malignant tumor deaths. The mortality rate ranks 23rd among men and 25th among women. After small bowel GIST and adenocarcinoma, small bowel lymphoma is the third small bowel malignancy.

Lymphoma is a heterogenous entity which includes Hodgkin's lymphoma and non-Hodgekin's lymphoma. The gastrointestinal tract is one of the most common organs that might be involved in extranodal lymphoma. Stomach is the most common site of primary gastrointestinal lymphoma, while primary small intestinal lymphoma is rare. In the past, primary small intestine lymphoma was easily overlooked and diagnosed when patients present with intestinal perforation or obstruction. In past decade, enteroscopy included capsule enteroscopy and device-assisted enteroscopy has been widely used as an examination and interventional tool in small bowel. So, it is necessary to renew the character of small bowel lymphoma.

Wireless Capsule endoscopy (CE) has been introduced in Taiwan for more than 20 years. It is used widely to detect small bowel bleeding or other pathologies in mid-gut including inflammatory bowel diseases, tumor, parasite, ulcer, angiodysplasia etc and can be the guidance for physicians selecting oral or anal route to perform balloon-assistant enteroscopy in therapeutic treatment of small intestinal pathologies.

When compared with traditional examinations to detect small intestinal diseases. CE has higher detecting rate than small bowel follow through, computer tomography and push enteroscopy. The key advantage of CE includes: ability to image entire small intestine, ability to review and share images, patient's preference, safety, clarify of image comparable to other endoscopic examinations.

In the beginning, the capsule endoscope is only used in diagnose small bowel diseases. However, the GIVEN company developed esophagus and colon capsules to diagnose upper GI and low GI tract diseases and improve the quality of reading software and CE images.

In the past 10 years, investigators of capsule endoscope try to control the capsule in human body and newly developed magnetic control capsule endoscope is invented to clinical use of viewing stomach diseases. The other company also developed a new 360-degree panoramic side view capsule and marketing in commercial usage now.

It can be expected that wireless control capsule endoscope can not only diagnose gastroenterological (GI) diseases but also can be used in therapeutic options in the coming years.

In the past, conventional diagnostic modalities for small bowel diseases include esopahgogastroenteroscopy (EGD), ileocolonoscopy, push enteroscopy, nuclear medicine, abdominal computed tomography (CT) scan or magnetic resonance imaging (MRI), abdominal ultrasound, small bowel series or follow-through, angiography, or even surgery. Since 2000, the newly developed diagnostic modalities, including deep enteroscopy and wireless capsule endoscopy (CE), have been shown the higher diagnostic yield for small bowel diseases. Deep enteroscopy, including balloon-assisted enteroscopy (double-balloon enteroscopy, single-balloon enteroscopy and balloon-guided enteroscopy) and spiral enteroscopy, can not only provide the diagnostic capacity, but also has the therapeutic intervention in small bowel disease. However, deep enteroscopy is an invasive, time-consuming, technically demanding and expensive technique compared to wireless CE.

By using deep enteroscopy, the endoscopists are now able to evaluate the entire small bowel. Indications for deep enteroscopy include small bowel tumors/polyps, bleeding, Crohn's disease, difficult ERCP, and difficult colonoscopy. However, there are some complications of deep enteroscopy, including bowel perforation, bleeding, acute pancreatitis and aspiration pneumonia Therefore, new endoscopic techniques via deep enteroscopy allow for an evolving role of endoscopic management of complications that traditionally required surgery. Twenty years after its first introduction in the form of double-balloon enteroscopy, deep enteroscopy is now becoming a standard modality in the diagnosis and treatment of small bowel diseases.

AI detection of colorectal polyps was the first target for AI technology in gastroenterology and now numbers of studies has reported the successful application of AI for the recognition of colon polyps using CADe, which 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) and adenomas detected per colonoscopy (APC) in multiple randomized controlled trials (RCTs). Despite these positive early results, some retrospective pragmatic studies yielded opposite results. In some studies, CADe did not increase ADR in routine practice. The explanations might be the “Ceiling” effect for polyp detection among high-performing endoscopists and unconscious behavioral changed by endoscopist. Another issue of cost-effectiveness of AI-assisted colonoscopy also needs to be examined carefully, as there are several ways this technology may increase health expenditure. 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.

Colorectal cancer poses a significant global health challenge, where early detection via polyp removal is imperative. Existing standard colonoscopy procedures face difficulties in distinguishing between neoplastic and nonneoplastic polyps, resulting in unnecessary removals and histopathological evaluations.

CADx system demonstrates comparable sensitivity to visual inspection in real-time optical diagnosis of neoplastic polyps during colonoscopy. Furthermore, CADx enhances the confidence levels of colonoscopists in polyp diagnosis, potentially reducing unnecessary polypectomies and histopathological assessments. However, CADx does not notably increase sensitivity for neoplastic polyps.

By implementing a modified AI model with improved feature extraction capabilities, we can enhance negative predictive value and predictive stability, thereby enhancing the accuracy of predicting small-sized and distant polyps.

In conclusion, CADx system holds promise in assisting colonoscopists in distinguishing between neoplastic and nonneoplastic polyps, leading to more assured optical diagnoses. CADx not only accurately identifies polyp types but also provides a spatial histology distribution map, potentially enhancing interpretability and offering user-friendly guidance for clinical management.

The use of artificial intelligence (AI) computer-aided detection (CADe) during colonoscopy may augment the detection of colorectal neoplasia, leading to higher adenoma detection rates (ADR) and lower adenoma miss rates (AMR). The initial evidence from randomized controlled trials (RCT) was quite supportive: A meta-analysis of 21 RCTs showed that CADe was associated with increased ADR (44% vs 36%) and lower AMR (55% relative reduction) compared to standard colonoscopy. However, the wave of enthusiasm for AI-assisted colonoscopy has been tempered by several studies showing that CADe afforded little or no benefit when deployed in real-world clinical settings. In fact, a meta-analysis of 8 non-randomized real-world studies showed no significant differences in ADR between CADe-assisted and standard colonoscopy. There are many factors that could explain these observed discrepancies between trial and non-trial settings. These include study-specific factors and heterogeneity, operator bias, variable benefit depending on endoscopist, evolution of AI, and very importantly, buy-in and engagement of the endoscopist with the technology. Universal implementation of CADe-assisted colonoscopy does not appear justified at this stage; however, given the rapid evolution of the field, this necessitates reassessment with appropriately designed studies.

Post-Colonoscopy Colorectal Cancer (PCCRC) refers to colorectal cancer (CRC) diagnosed after a colonoscopy where no cancer was initially detected and before the next recommended surveillance colonoscopy. Despite the effectiveness of colonoscopy in CRC detection and prevention, PCCRC remains a significant concern in clinical practice, accounting for 6% of all CRC cases in the USA and approximately 1.35 per 1000 patient-years in Taiwan, with a higher incidence observed in men and those with prior advanced colorectal neoplasms.

Several factors contribute to PCCRC development, including missed lesions during colonoscopy, incomplete polyp resection, suboptimal bowel preparation, and interval cancers from rapid tumor growth. Missed lesions during prior colonoscopy account for over 80% of PCCRC cases, with Taiwan reporting this factor in nearly 85% of instances. Therefore, to mitigate PCCRC occurrence, strategies for improving adenoma detection rates (ADR) and reducing adenoma miss rate (AMR) might be effective.

AI-colonoscopy is a novel modality to help endoscopists to detect neoplastic lesion during colonoscopy examination. Although several randomized controlled trials had demonstrated a robust improvement of ADR under the aid of CADe (Computer-aided detection) system, whether AI-colonoscopy reduce the incidence of PCCRC remains unclear. The talk today will focus on the newest evidence exploring the protective efficacy of AI-colonoscopy against CRC, especially PCCRC.

Recent advances in endoscopic techniques have progressively added new tools to the armamentarium of endoscopists for a deeper assessment of the intestinal mucosa. Virtual electronic chromoendoscopy is widely available in most endoscopic units and enhances the mucosal and vascular intestinal architecture. Confocal laser endomicroscopy (CLE) provides 'in vivo histology' with very high magnification, and resolution of the images of the mucosal layer. In IBD, CLE was used for structural and functional assessment of the intestinal epithelium, classification of inflammatory activity and mucosal healing in active disease and dysplasia detection. The additional application of molecular endoscopy in IBD allows topical application of labelled probes, mainly antibodies, against specific target structures expressed in the tissue to predict response or failure to biological therapies. This leads to individualized and personalized IBD therapy. Endocytoscopy is a high-ultra magnification endoscopic technique that provides in vivo microscopic imaging during endoscopy, with ultra-high magnification ranging from 450-fold to 1400-fold. After the application on the mucosa of absorptive agents, endocytoscopy allows looking at cells and nuclei of mucosal surfaces by producing an image close to histology. Finally, AI systems support clinicians in interpreting and standardizing findings.

Endoscopic assessment of disease activity is important in clinical practice for IBD patients. Endoscopic mucosal healing is a therapeutic target for IBD, especially in UC patients, since it is associated with higher rate of steroid-free remission and lower rates of hospitalization and surgery. The application of artificial intelligence (AI) in gastrointestinal endoscopy assists endoscopists to identify colon polyps and cancers during colonoscopy, thereby further increasing the adenoma detection rate during the procedure. AI had showed promise for clinical research in IBD endoscopy. Emerging AI technologies can increase efficiency and accuracy of assessing the baseline endoscopic appearance in patients with IBD and evaluate the mucosa healing pattern after optimal therapy of IBD. Artificial intelligence may support precision endoscopy in IBD and is on the threshold of advancing inflammatory bowel disease clinical trial recruitment. There may be a time when we can use AI in clinical practice for IBD patients.

Inflammatory bowel disease (IBD) is a cause of an important problem to the healthcare setup of any country, as both ulcerative colitis (UC) and Crohn's disease (CD) require long-term therapy and continuous monitoring.

Currently, there are three classes of biologicals available to treat IBD. These are antagonists to tumor necrosis factor (TNF), anti-integrins and inhibitors of interleukin (IL) 12/IL-23. Although preceding biological agents have dramatically changed the IBD treatment strategy, many patients still require alternative therapies due to failure or side effects. In general, primary nonresponse is observed in 20-30% of patients, and another 30% of patients become refractory due to secondary loss of response.

The discovery of new pathways involved in the pathogenesis of IBD resulted in new drugs targeting Janus kinase/signal transducers and activators of transcription, IL-6, spingosine-1-phosphate, and phosphodiesterase 4, among others. While antibodies attach to cells and cytokines, small molecules develop effects within the cells. These new therapies might result in more advantageous safety profiles, fast onset of action, short half-life, and lacks immunogenicity.

The expected abundance of new therapeutic options will trigger a new effort toward a personalized and mechanism based IBD treatment. It is important for physicians to learn how to handle the emerging biologics and small molecule therapies in IBD.

Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), are complex disorders characterized by chronic inflammation of the gastrointestinal tract. Despite the expanding therapeutic options available, a significant proportion of patients exhibit suboptimal responses to standard treatments, leading to increased healthcare costs and reduced quality of life. Precision medicine approaches aim to address these challenges by tailoring care to individual patients based on their unique clinical and molecular characteristics. This talk will explore personalized medicine strategies in IBD drug therapy, focusing on the identification of predictive biomarkers for disease progression, treatment response, and optimal drug dosing. By integrating genetic, transcriptomic, proteomic, metabolic, and microbiota data, clinicians can make informed decisions to optimize patient outcomes and minimize adverse effects. The implementation of personalized medicine in IBD holds promise for improving treatment efficacy, reducing healthcare expenses, and enhancing patient well-being.

The prevalence of early-invasive colorectal cancer (T1 CRC) has seen a steady increase, attributed in part to the enhanced population of colorectal cancer screening. Concurrently, there has been a significant rise in the adoption of endoluminal treatment as a non-invasive curative treatment strategy, propelled by technological advancements in endoscopic technologies. Despite the popularity of ET, there is a significant gap in the understanding of the long-term outcomes and recurrence patterns associated with these treatments. Existing literature suggests a recurrence rate of 3% for T1 CRCs treated with endoscopic resection alone, with a 40% mortality rate following recurrence.

From the Taiwan Cancer Registry Database, T1 CRC patients treated only with endoluminal treatment had a higher risk of recurrence compared to T1N0 patients who underwent surgical resection, indicating potential undertreatment of deeply invasive lesions that might require surgical intervention. These findings underscore the need for precise colonoscopic diagnostic assessment of invasion depth and accurate pathological analysis to identify patients at risk of lymph node metastasis.

The incidence of T1 CRC is rising, thanks to widespread screening programs, with up to 40% of all screen-detected cancers being stage T1. Endoscopic resection of pT1 CRCs is an appealing option due to its conservative nature, preserving organ integrity and associated with lower morbidity, mortality, and costs compared to surgery. In the era of precision medicine, characterizing T1 CRC is crucial. This includes pre-treatment depth assessment using the NICE or JNET classification to differentiate between T1a and T1b CRC, which is vital for determining the eligibility for endoscopic resection. Additionally, precise post-endoscopic resection risk stratification of lymph node metastasis is essential to identify high-risk groups for additional treatment. Furthermore, the investigation into the role of artificial intelligence (AI) and biomarkers in managing T1 CRC is ongoing, playing a pivotal role in enhancing treatment strategies to minimize the risks of overtreatment and undertreatment.

Management of T1 rectal adenocarcinoma is a highly controversial and evolving issue, which involving disease oncological and patient functional outcome. The limit of endoscopic resection of rectal T1 cancer has two aspects: technical boundary and diagnostic boundary. Several techniques, such as endoscopic muscular dissection and full thickness resection, were proposed to break the technical boundary. Besides, there were more and more studies trying to stratify the risk of lymph node metastasis after endoscopic resection precisely. In this talk, we reviewed our data in the past five years and tried to propose the promising treatment guideline in the future.

With the widely spreading cancer screening and recent improvements in endoscopic diagnosis, the number of endoscopic resections of T1 colorectal cancer (CRC) has been increasing. The decision on the need for additional surgical resection after endoscopic resection is made according to histological findings. Unfavorable histological features, including high-grade histology, angiolymphatic invasion, high tumor budding, and a “positive margin”, are associated with adverse outcome, and further surgery with lymph node dissection is needed. In this lecture, we will introduce the histological features, which should be listed in the pathological report of endoscopic resected T1 CRC.

Ileitis is an inflammation of the ileum, the last part of the small intestine. While Crohn's disease is a common cause, not all ileitis cases are due to Crohn's. Non-Crohn's ileitis can result from infections, ischemia, drug-induced reactions, or other inflammatory conditions. Infections causing ileitis include Yersinia, Salmonella, and Campylobacter, which mimic Crohn's symptoms but require different treatments. Ischemic ileitis results from reduced blood flow to the intestines, often seen in older adults with cardiovascular issues. Drug-induced ileitis can arise from medications like NSAIDs. Other conditions, such as celiac disease or eosinophilic enteritis, also contribute to ileitis. Accurate diagnosis requires a thorough medical history, laboratory tests, imaging studies, and sometimes endoscopic evaluation. Treatment varies significantly based on the underlying cause, highlighting the importance of distinguishing between Crohn's disease and other etiologies to provide appropriate and effective care. Understanding these distinctions is crucial for clinicians to avoid misdiagnosis and ensure optimal patient outcomes.

Crohn's disease (CD) frequently affects the small bowel, with lesions often beyond the reach of conventional ileocolonoscopy. Deep enteroscopy (DE), including double-balloon enteroscopy, single-balloon enteroscopy, and spiral enteroscopy, provides for comprehensive evaluation of the small bowel, allowing for accurate diagnosis and targeted treatment.

1. Diagnosis: DE is invaluable in identifying and characterizing small bowel lesions in patients with CD. DE helps in differentiate CD from other gastrointestinal diseases.
2. Therapeutic interventions: DE facilitates a range of therapeutic interventions, including balloon dilatation of strictures, hemostasis of bleeding lesions, and removal of foreign bodies.
3. Monitoring: In patients with established isolated ileal CD, DE is most useful for monitoring disease progression, assessing response to treatment, and performing routine surveillance to detect complications such as strictures or fistulas.
4. Research applications: DE provides the opportunity to obtain affected small bowel tissue for histologic and molecular analysis, thereby advancing the understanding of CD pathogenesis and aiding in the development of new therapies.

Proficiency in DE techniques and comprehensive understanding of its clinical applications can greatly improve patient care and outcomes in the management of CD. Further research and technological innovation will expand the potential applications of DE in the management of CD.

The risk of colorectal cancer is increased in patients with long-standing colonic inflammatory bowel diseases (IBD) such as ulcerative colitis and Crohn's colitis. Dysplasia is a precancerous lesion of colitis-associated colorectal cancer. Most dysplasias were considered invisible before late 1990s. However, with advancement in the endoscopic technology, most dysplasias became detectable via colonoscopy. Since the SCENIC recommendations in 2015, the Paris classification for colorectal polyp morphology has been adopted to describe the morphology of visible dysplasia. So, visible dysplasia can be divided into polypoid and non-polypoid dysplasia. Despite advanced endoscopic image quality, detecting suspected non-polypoid dysplasia and predicting its histology in IBD patients are much more challenging compared to non-IBD patients. Based on currently available evidence, recent guidelines recommend performing dye-chromoendoscopy (DCE) or virtual chromoendoscopy (VCE) to enhance the dysplasia detection rate in patients with IBD rather than using white light endoscopy (WLE). However, there are still some hurdles to applying these techniques in real practice. Moreover, a few studies using high-definition (HD) endoscopy systems suggest WLE can detect dysplasia as much as DCE or VCE. Therefore, as the endoscopic technology improves and more evidence is accumulated, the guidelines may be updated in the future.

Standardized endoscopic scores are crucial tools in assessing IBD activity in clinical practice. They provide a systematic way to evaluate the severity of mucosal inflammation, allowing doctors to:

1. Monitor disease course: Track changes in disease activity over time.
2. Guide treatment decisions: Determine treatment effectiveness and need for adjustments.
3. Standardize communication: Ensure clear and consistent reporting between healthcare providers.

Here's a breakdown of key points:

1. Importance of mucosal healing: A primary goal of IBD treatment is achieving mucosal healing, which refers to minimal or no visible inflammation during endoscopy.

2. Common scoring systems: Different scores are used for ulcerative colitis (UC) and Crohn's disease (CD):

   1. Ulcerative Colitis: Mayo Endoscopic Subscore (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS)
   2. Crohn's Disease: Crohn's Disease Endoscopic Index of Severity (CDEIS), Simplified Endoscopic Score for Crohn's Disease (SES-CD), and Rutgeerts score (for post-surgical recurrence)
3. Challenges in implementation: Despite their benefits, using standardized scores consistently can be challenging due to variability in how endoscopists perform and interpret the scoring systems, lack of universal adoption in clinical practice.

Overall, standardized endoscopic scores are valuable tools for assessing IBD activity. Their consistent use can improve communication, guide treatment decisions, and ultimately promote better patient outcomes.

Subepithelial lesions (SELs) of the upper GI tract represent a mix of benign and potentially malignant entities including lipomas, aberrant pancreas, leiomyoma, lymphangial cysts, extraluminal structures causing extrinsic compression of the gastrointestinal wall, gastrointestinal stromal tumors (GISTs) and neuroendocrine neoplasm etc. The prevalence of SELs is increasing and hence, diagnostic and therapeutic algorithm should be evaluated and established to tackle with this emerging condition. Previously, upper GI small SELs could be follow-up alone. However, there are insufficient evidence to recommend surveillance versus resection. With the improvements in endoscopic resection and wound closure techniques, endoscopic resection for those with histologically proof malignancy or indefinite diagnosis could provide an alternative management for upper GI SELs, depending on age, life expectancy, comorbidities and patient preferences. In addition, endoscopic resection for SELs < 2cm after failed obtain diagnosis may be considered to avoid unnecessary follow-up which mitigates cost burden on healthcare and psychological stress of patients. In this lecture, I will review the current guidelines on the management as well as the experiences about the endoscopic resection techniques for upper GI tract SELs.

Subepithelial tumors (SETs) in gastrointestinal tract usually are found incidentally during gastrointestinal endoscopic examinations. Several SETs have a malignant potential, especially when they originate from the muscularis propria, such as gastrointestinal stromal tumor (GIST). Therefore, pathologic confirmation of resected SETs is mandatory for diagnosis and treatment, especially in ambiguous cases. There are several ways to have a pathologic diagnosis of SET including bite on bite, fine needle aspiration or fine needle biopsy with endoscopic ultrasonography (EUS), unroofing biopsy, and so forth. Recently, results from clinical studies of endoscopic resection of SETs including GIST in the stomach are being reported. There are several advantages of endoscopic resection of gastric GIST, such as provision of definite diagnosis and therapeutic plan, avoidance of frequent follow-up examination and reduction of patients' anxiety. It is encouraging that most of post-procedural complications were treated with conservative management, and a portion of patients did not show recurrence of tumor during long-term follow-up period. Selection of suitable cases and endoscopists' full experience are the most important factors for successful endoscopic resection of gastric GIST, and development of novel procedures as well as collaboration with laparoscopic surgeon are currently in progress.

Keywords: subepithelial tumor; diagnosis, pathology

Neuroendocrine tumors (NETs), which are derived from enterochromaffin cells, are the most frequent endocrine tumors of the gastrointestinal tract. The rectum is the third most common site of gastrointestinal NETs. The incidence of rectal neuroendocrine tumors is increasing day by day. I will discuss regarding Diagnostic, therapeutic and surveillance strategy for rectal neuroendocrine tumors.

Rectal endoscopic ultrasonography (EUS) is essential for rNETs before any intervention to determine tumor size, depth, and lymphovascular involvement (LVI). EUS is very accurate in measuring tumor depth. it was recommended to perform initial pelvis MRI if rNETs ≥10 mm or G2-G3 rNETs or involvement of lymph nodes was suspected in EUS.

Modified EMR is first choice for the small and low grade NET. If lymph node metastasis is excluded. ESD should be considered as the primary approach for NET between 1cm and 2cm . If size of tumor is over 2cm, surgical resection be performed.

Surveillance after rNETs resection are determined by size and mitotic grade. less than10mm in size, with no evidence of LVI or muscularis propria involvement are not recommended for surveillance. All rNETs 10-19 mm require annual endoscopic follow up. rNETs ≥ 20 mm require intensive follow-up due to the risk of metastasis.

It is important to be aware of the characteristics of rNETs and take care to identify them. Appropriate treatment and careful monitoring based on tumor size, radiological, and histological findings are of utmost importance.

The Anti-reflux Mucosal Ablation Surgery (ARMA surgery) emerged around 2020 as an interventional endoscopic procedure for treating selective cases with severe refractory gastroesophageal reflux symptoms. Similar in efficacy and prognosis to earlier ARMS (anti-reflux mucosectomy surgery), ARMA surgery offers advantages such as shorter operation time, high postoperative symptom improvement rates, low side effects, and relatively controllable surgical risks. However, this surgery still carries several potential risks, complications, and precautions. In this presentation, the speaker will briefly introduce the historical development, treatment principles, indications, and share personal experiences with cases treated in his clinic.

Synovial sarcoma is a malignant soft tissue tumor which commonly occurs in the young adult in the extremities. A few cases of the primary synovial sarcoma have been reported in the uncommon sites in the world literature.

We report a case of primary synovial sarcoma arising from the peritoneum. This was about a 47-year old male who presented with abdominal fullness and pain. Abdominal ultrasound revealed a large hypoechoic tumor which was confirmed by computer tomography.

Surgery was performed. The tumor originated from the peritoneum, the morphology and immunochemical stains confirmed the diagnosis of biphasic synovial sarcoma. We represent the first case of primary synovial sarcoma arising from the peritoneum.

Foreign body (FB) ingestion is a common scenario in daily practice. According to gastroenterologists' guidelines, the management of FB ingestion differs slightly between adult and children. Because toddlers are often too small to cooperate with treatment and require the assistance of an anesthesiologist. Timely and appropriate endoscopic procedure for GI FBs can save lives and prevent difficult- to-manage morbidities.

Although the approach to deal with gastrointestinal FBs is sometimes controversial, with different treatment options available in different disciplines and medical institutions, many studies have demonstrated the efficacy and safety of endoscopic procedures. Many factors influence the timing of endoscopy, including the swallowed substance, size, and location of the ingested object and the patient's clinical condition. Today, my lecture aimed to briefly review adult and children guidelines and establish an understandable association to reveal the requirements and timing of the endoscopic procedure, which is the most effective and least complicated technique for gastrointestinal FBs.

內視鏡再處理是指清除內視鏡上的所有污染物，目的是確保患者在內視鏡檢查或治療期間的安全，但隨著科技的進步，內視鏡的設計日益複雜，加上人力的不足，都會造成內視鏡再處理的品質控管不易，如何提高內視鏡再處理的有效性和安全性，並降低感染風險，是我們要面臨的挑戰。

內視鏡再處理指引共識大致擬定，但仍有差異。如執行前置清洗，內視鏡所吸⼊的清潔劑溶液量？進行手動清潔的可接受時間間隔是多久內？可重複使用的清潔刷子在進行手動清潔時的可接受性？應該都要使用單次拋棄式清洗刷嗎？

為了確保病人安全，必須對內視鏡及其配件進行適當正確的再處理。近年由內視鏡引起的傳染病爆發，提高了人們對感染管制計劃的認識，以減輕未來的風險。儘管全世界已經發布了⼀些內視鏡再處理指南，但內視鏡檢查單位的實施仍存在顯著差異和異質性。

Endoscope Reprocessing : High-level disinfection

High-level disinfection of endoscopes is essential to prevent healthcare-associated infections. It involves thorough cleaning and disinfection processes to eliminate microorganisms, ensuring patient safety during endoscopic procedures. Automated endoscope reprocessors (AERs) play a crucial role in reducing human errors and ensuring the consistency of endoscope reprocessing protocols.

The latest generation of AERs is equipped with RFID technology, which further improves their functionality. The RFID Connection Guide provides intuitive guidance for connecting the appropriate tubing to each endoscope, reducing the likelihood of misconnections and ensuring the correct configuration for reprocessing. Additionally, these advanced machines offer the capability to decontaminate a leaking scope before it is returned for service, thereby preventing potential exposure of healthcare personnel to infectious agents.

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 additional Drying, and there is uniform consensus that Drying should be performed as an integral component of reprocessing of flexible GI endoscopes.

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 2024 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 Endoscope Reprocessing include (1) leak testing, (2) cleaning, (3) rinsing, (4) disinfection, (5) final rinsing, (6) drying and (7) Storage of GI endoscopes for members of the Digestive Endoscopy Society of Taiwan.