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Background Data on the use of EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) for pathology is limited. Methods To prove superiority of the diagnostic rate of the newly designed modified Menghini-type needle with a beveled side-slot near the needle tip with slot cutting edge directed 20-gauge antegrade bevel (group A) over the original 22-gauge reverse bevel (group B) for EUS-guided fine-needle biopsy (EUS-FNB) of solid liver mass (SLM) in a prospective crossover randomized controlled trial. Results The overall diagnostic accuracy rate of the 52 passes was 86.5% (45/52) and of group A versus B were 88.5% (23/26) versus 84.6% (22/26), respectively, p = 0.858. Tissue adequacy levels of both groups were not significantly different (grade A: B: C = 18:6:2 versus 16:7:3), p = 0.839). Grading of blood contamination of both groups was not significantly different. However, it was found that the group-A needles could biopsy tissue of significantly longer length than that of the group B; 1.3 cm (SD = 0.76) versus 0.8 cm (SD = 0.54); p = 0.007. Conclusion The use of EUS-FNB of SLM is highly effective with similar levels of efficacy and number of adverse events between both types of needles. The trial registration number Thai Clinical Trial Registration No. TCTR2018081002.

Background Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures. Methods The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement. Results Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties. Conclusion Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.

Background and Aims By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy. Methods This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR ≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC). Results One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P Conclusions The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.)

Background Diagnostic laparoscopy is often a necessary, albeit invasive, procedure to help resolve undiagnosed peritoneal diseases. Previous retrospective studies reported that EUS-FNA is feasible on peritoneal and omental lesions, however, EUS-FNA provided a limited amount of tissue for immunohistochemistry stain (IHC). Aim This pilot study aims to prospectively determine the effectiveness of EUS-FNB regarding adequacy of tissue for IHC staining, diagnostic rate and the avoidance rate of diagnostic laparoscopy or percutaneous biopsy in patients with these lesions. Methods From March 2017 to June 2018, patients with peritoneal or omental lesions identified by CT or MRI at the King Chulalongkorn Memorial Hospital, Bangkok, Thailand were prospectively enrolled in the study. All Patients underwent EUS-FNB. For those with negative pathological results of EUS-FNB, percutaneous biopsy or diagnostic laparoscopy was planned. Analysis uses percentages only due to small sample sizes. Results A total of 30 EUS-FNB passes were completed, with a median of 3 passes (range 2–3 passes) per case. For EUS-FNB, the sensitivity, specificity, PPV, NPV and accuracy of EUS-FNB from peritoneal lesions were 63.6%, 100%, 100%, 20% and 66.7% respectively. Adequate tissue for IHC stain was found in 25/30 passes (80%). The tissues from EUS results were found malignant in 7/12 patients (58.3%). IHC could be done in 10/12 patients (83.3%). Among the five patients with negative EUS results, two underwent either liver biopsy of mass or abdominal paracentesis, showing gallbladder cancer and adenocarcinoma. Two patients refused laparoscopy due to advanced pancreatic cancer and worsening ovarian cancer. The fifth patient had post-surgical inflammation only with spontaneous resolution. The avoidance rate of laparoscopic diagnosis was 58.3%. No major adverse event was observed. Conclusions EUS-FNB from peritoneal lesions provided sufficient core tissue for diagnosis and IHC. Diagnostic laparoscopy can often be avoided in patients with peritoneal lesions.

Prognosis of unresectable pancreatic cancer is poor with the rate of surviving more than 5 years is less than 10% despite multi-modalities treatment. The American Society of Clinical Oncology suggested that all patients with metastatic pancreatic cancer should be offered information about clinical trials. Endoscopic ultrasound guided radio frequency ablation has been recently used in patients with advanced stage pancreatic cancer in a few studies. This article has reviewed information from published articles using endoscopic ultrasound guided radio frequency ablation for advanced pancreatic cancer.

Colorectal cancer (CRC) accounts for approximately 10.3% of new cancer cases in Thailand and is currently the 3rd most prevalent cancer found among the Thai population. Starting in 2017, the Thai government announced the national CRC screening program as a response to this important issue. Among the 70 million people currently residing in Thailand, 14 million require screening, while there are approximately a total of 1,000 endoscopists available to perform colonoscopy. Due to the limited resources and shortage of endoscopists in Thailand, applying a population-based one-step colonoscopy program as a primary screening method is not feasible. To reduce colonoscopy workload, with the help of others, including village health volunteers, institution-based health personnel, reimbursement coders, pathologists, and patients due for CRC screening, a two-step approach of one-time fecal immunochemical test (FIT), which prioritizes and filters out subjects for colonoscopy, is chosen. Moreover, additional adjustments to the optimal FIT cutoff value and the modified Asia-Pacific Colorectal Screening risk score, including body weight, were proposed to stratify the priority of colonoscopy schedule. This article aims to give an overview of the past and current policy developmental strategies and the current status of the Thailand CRC screening program. Clin Endosc 2021;54:499-504

Background and Aims: As on-call anesthesiologist administered propofol sedation (OAPS) is costly and not readily available in all endoscopy units, endoscopy nurse administered propofol sedation (NAPS) can be an effective alternative. This study aimed to compare the dosage of propofol used by NAPS versus OAPS, cardiopulmonary adverse events and recovery time in low risk patients undergoing outpatient elective colonoscopy. Methods: A retrospective propensity score-matched cohort study was conducted. Electronic medical records of elective colonoscopies performed by 3 experienced endoscopists from January 2016 to December 2019 were retrieved. OAPSs were performed by 10 certified anesthesiologists while NAPSs were performed by 8 experienced registered endoscopy nurses. Baseline characteristics, performing endoscopist, cecal intubation time, withdrawal time, propofol dosage per procedure, and adverse events were collected and analyzed using 3:1 (NAPS:OAPS) propensity score matching by age, performing endoscopist and difficulty of colonoscopy as co-variates with standardized mean deviation of

Video Video 1 Magnetic compression anastomosis via EUS-guided hepaticogastrostomy for recanalization of complete common hepatic bile duct transection.

In high-risk surgical patients with acute cholecystitis who are not candidates for early laparoscopic cholecystectomy, gallbladder (GB) drainage is an alternative treatment option. Percutaneous transhepatic gallbladder drainage (PTGBD) is a recommended first line intervention because of its high efficacy and feasibility in most centers. However, with the advent of endoscopic accessories and technology, endoscopic GB drainage has been chosen as a more favorable choice by endoscopists. Endoscopic transpapillary gallbladder drainage (ETGBD) can be performed under either fluoroscopic or peroral cholangioscopic guidance via endoscopic retrograde cholangiopancreatography by the transpapillary placement of a long double-pigtail stent. In a patient with common bile duct stones, this procedure is accompanied with stone removal. ETGBD is especially useful for acute cholecystitis patients who are contraindicated for PTGBD or those with severe coagulopathy, thrombocytopenia, and abnormal anatomy. Moreover, the advantage of ETGBD is its preservation of the external GB structure. Thereby it would not disturb the future cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic, fully covered metallic, or lumen-apposing metal stents transmurally has emerged as a modality for GB drainage with higher technical and clinical success rates. EUS-GBD can provide a more permanent GB drainage than PTGBD and ETGBD. Clin Endosc 2020;53:678-685

Background Adenoma detection rate (ADR) is a quality indicator for colonoscopy. However, many missed adenomas have subsequently been identified after colonoscopies performed by endoscopists with ADR ≥ 25 %. Adenomas per positive participant (APP; mean number of adenomas detected by an endoscopist among screenees with positive findings) correlates well inversely with adenoma miss rate. This study aimed to evaluate whether APP added additional information on the detection rate for advanced adenomas (AADR) and proximal adenomas (pADR) and among endoscopists with acceptable ADRs (≥ 25 %). Methods A total of 47 endoscopists performed 7339 screening colonoscopies that were retrospectively reviewed. Using a cutoff APP value of 2.0, endoscopist performance was classified as high or low APP. Endoscopist ADRs were also classified as acceptable (25 % – 29 %), high standard (30 % – 39 %) and aspirational (≥ 40 %). Generalized linear models were used to assess the relationship between AADR or pADR, and ADR and APP, after adjusting for potential confounders. Results After adjusting for endoscopist performance and patient characteristics, endoscopists with high APP had a significant 2.1 percentage point increase in AADR (95 %CI 0.3 to 3.9; P = 0.02) and a 2.1 percentage point increase in pADR (95 %CI – 0.8 to 5.1; P = 0.15) compared to endoscopists with low APP. In total, 11 (24 %), 18 (38 %), and 18 (38 %) endoscopists were classified as having acceptable, high standard, and aspirational ADRs, respectively. APP values higher than the cutoff were found in 18 %, 44 %, and 72 % of endoscopists with acceptable, high standard, and aspirational ADRs, respectively (P = 0.02). Conclusion APP is helpful for identifying more meticulous endoscopists who can detect a greater number of advanced adenomas. Endoscopists who achieved an only acceptable ADR had the lowest APP.

For management of endoscopy units during the worldwide coronavirus disease 2019 (COVID-19) outbreak caused by the new coronavirus SARS-CoV-2 in Thailand, a working group of the Thai Association for Gastrointestinal Endoscopy (TAGE) in collaboration with the Endoscopy Nurse Society (Thailand) (ENST) has developed the following recommendations for Thai doctors and medical personnel working in gastrointestinal endoscopy (GIE) units. Upper and lower GIE is considered as an aerosol generating procedure (AGP). Information regarding chance of infection in patients must be obtained before performing endoscopy to help determine the level of risk. Endoscopies should only be performed in emergency/urgency cases. Hospitals that have no confirmed cases and do not have a high incidence in their coverage area may consider performing selective endoscopies. For the confirmed infected patient, the recommendations are as follows; the endoscopist who performed the procedure must be an experienced one, wear the enhanced personal protective equipment (PPE) with correct practice how to wear and take off PPE, and strict hand hygiene. The endoscopic procedure should be performed in a negative pressure room; however, If not available, a bedside procedure in the cohort ward should be performed. Endotracheal tube intubation and removal should be done by an anesthesiologist. Most enzymatic detergent solutions can eliminate SARS-CoV-2. The use of an additional pre-cleaning process in order to prevent AGP from occurring during endoscope reprocessing is recommended. Patient(s) under investigation (PUI) should wait for the test result before considering endoscopic procedure. For the low risk patient for COVID-19 infection who needs an endoscopic procedure, standard PPE is recommended. Due to the limitation of medical resources, only medical personnel who are necessary for the procedure and at risk of COVID-19 infection should be allowed to use the recommended PPE.

Background Endoscopic retrograde cholangiopancreatography (ERCP) may not provide complete biliary drainage in patients with Bismuth III/IV malignant hilar biliary obstruction (MHBO). Complete biliary drainage is accomplished by adding percutaneous transhepatic biliary drainage (PTBD). We prospectively compared recurrent biliary obstruction (RBO) rates between combined ERCP and endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. bilateral PTBD. Methods Patients with MHBO undergoing endoscopic procedures (group A) were compared with those undergoing bilateral PTBD (group B). The primary outcome was the 3-month RBO rate. Results 36 patients were recruited into groups A (n = 19) and B (n = 17). Rates of technical and clinical success, and complications of group A vs. B were 84.2 % (16/19) vs. 100 % (17/17; P = 0.23), 78.9 % (15/19) vs. 76.5 % (13/17; P > 0.99), and 26.3 % (5/19) vs. 35.3 % (6/17; P = 0.56), respectively. Within 3 and 6 months, RBO rates of group A vs. group B were 26.7 % (4/15) vs. 88.2 % (15/17; P = 0.001) and 22.2 % (2/9) vs. 100 % (9/9; P = 0.002), respectively. At 3 months, median number of biliary reinterventions in group A was significantly lower than in group B (0 [interquartile range] 0–1 vs. 1 [1–2.5]), respectively (P Conclusions Combined ERCP and EUS procedures provided significantly lower RBO rates at 3 and 6 months vs. bilateral PTBD, with similar complication rates and no significant mortality difference.

Patients presenting with pancreatic ductal adenocarcinoma in an advanced inoperable stage receive chemoradiotherapy. Endoscopic ultrasound guided radiofrequency ablation (EUS-RFA) has been proposed as a new therapeutic option for these patients alongside chemotherapy. The evaluation of treatment response is mainly based on radiological evaluation of the changes in tumour size. Unfortunately, the currently available radiological methods cannot clearly differentiate between necrotic tissue and viable tumour. EUS elastography is an ultrasound technique that can grade the hardness of a lesion and classify it as benign, inflammatory or neoplastic as previously reported. This case report of 2 patients shows that using EUS elastography is beneficial in characterizing the nature of the changes occurring to the tumour mass following EUS-RFA of pancreatic tumour.

Background Gastrointestinal stromal tumor (GIST) was the most common mesenchymal tumor of the gastrointestinal tract predominately occurring in the stomach. Although GIST was a rare disease, it was considered to be a life-threatening malignancy. Objective To explore the current status of gastric GIST in Thai patients. Method The medical records of patients who were diagnosed with histologically proven gastric GIST from 2012 to 2016 in King Chulalongkorn Memorial Hospital were reviewed. Results Of 22 patients, there were 14 (63.6%) females and 8 (36.4%) males with the mean age of 62.6 ± 14.8 years. The average duration before the first presentation was 12 weeks. The initial symptoms were upper gastrointestinal bleeding (50.0%) followed by abdominal pain (31.8%). Tumor mostly located at the proximal part (fundus and cardia) in 20 (90.9%) patients. At the time of the diagnosis, three patients (13.6%) had distant metastasis. Of this group, 77.3% underwent surgical treatment. Discussion Although gastric GIST was an uncommon disease, early diagnosis and prompt treatment could save the lives of many patients.

Double-balloon endoscopy (DBE) provides both diagnosis and treatment in overt obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the rebleeding rate after DBE. This retrospective review was conducted between January 2006 and July 2018, 166 patients with overt OGIB who underwent DBE were enrolled. Therapeutic intervention was defined as endoscopic treatment, embolization, or surgery. Primary outcome was rebleeding rate after DBE. The patients were divided into 3 groups based on their DBE; (1) positive DBE requiring therapeutic intervention (G1), (2) positive DBE without therapeutic intervention required (G2) and (3) negative DBE (G3). Cumulative incidence of rebleeding was estimated using the Kaplan–Meier method. Cox regression was used to assess the association of DBE with rebleeding risk. This study was approved by our Institutional Review Board. Sixty-eight patients (41%) were categorized in G1, 34 patients (20%) in G2 and 64 patients (39%) in G3. Overall rebleeding occurred in 24 patients (15%). The cumulative incidence of rebleeding for G1 was the lowest. The 1-year and 2-year cumulative probability of developing rebleeding after DBE in G1 were 3.5% and 3.5%, 8.2% and 14.0% in G2, and 18.2% and 20.6% in G3, respectively (p = 0.02). After adjusting for bleeding severity and comorbidities, patients with positive DBE requiring therapeutic intervention had a significantly lower rate of rebleeding when compared with patients who did not receive intervention (hazard ratio 0.17; 95% CI 0.03–0.90). DBE-guided therapeutic intervention was associated with a lower risk of rebleeding when compared with those with negative and positive DBE without therapeutic intervention. One-fifth of patients with overt OGIB had false negative after DBE.

Background/Aim The global problems of chronic liver disease and non‐alcoholic fatty liver disease (NAFLD) are increasing. We examined the prevalence of NAFLD and significant liver stiffness in an asymptomatic population and identified the predictors of significant fibrosis in NAFLD. Method We prospectively enrolled Thai subjects, aged 18–80 years, from four regions (Bangkok, Central, North, South) of Thailand from March 2013 to November 2016. All participants underwent controlled attenuation parameter (CAP) measurement for liver fat quantification and transient elastography (TE) for liver stiffness measurement (LSM). NAFLD was defined as liver fat ≥10% (CAP ≥ 306 dB/m). Of 1145 participants, 782 (68.3%) were eligible for analysis. Result The mean age ± standard deviation (SD) was 53.1 ± 4.6 years, and 71.6% were female. The mean ± SD values of CAP and LSM of the overall cohort were 241.9 ± 61.4 dB/m and 5.5 ± 3.8 kPa, respectively. The prevalence of NAFLD was 18.0%, whereas 5.4% of the cohort had nonobese NAFLD (BMI, Non‐alcoholic fatty liver disease (NAFLD) with significant fibrosis (transient elastography > 8 kPa) is prevalent in asymptomatic populations. The predictors of significant fibrosis in NAFLD were male gender and history of dyslipidemia. Screening for NAFLD using CAP/TE in asymptomatic population should be considered in hospitals with available facilities.

Background Cholangioscopy provides direct intraductual imaging, which can enhance diagnostic efficacy during endoscopic retrograde cholangiopancreatography in patients with biliary strictures. This study aimed to review the diagnostic yield of different cholangioscopes for the diagnosis of malignant biliary stricture (MBS). Methods A comprehensive literature review was performed. Full papers of prospective studies using any type of peroral cholangioscope (POC) were included without language restriction. The primary outcomes were sensitivity, specificity, and accuracy of various POCs to diagnose MBS. Results Data from 20 published articles, involving 1141 patients, were extracted. Overall sensitivities of POCs for diagnosing MBS were higher for the diagnosis made under visual impression compared with those from cholangioscopy-guided biopsy (67 % – 100 % vs. 38 % – 100 %), whereas the overall specificities were generally high and comparable (73 % – 100 % vs. 75 % – 100 %). Newer video cholangioscopes (digital single-operator POC [digital SOC], direct POC) with the exception of video dual-operator mother – baby POC (video DOC), provided better sensitivity of cholangioscopy-guided biopsy compared with fiberoptic scopes (digital SOC 80 % – 85 %, direct POC 80 % – 100 %, video DOC 38 % – 100 %, and fiberoptic SOC 49 % – 100 %, respectively). Among these video cholangioscopes, the digital SOC provided the highest technical success rate, at 100 %. Conclusions POCs enhanced the diagnostic yield for diagnosis of MBS. Compared with fiberoptic POCs that only provide good image impression, the digital SOC and direct POC were good at both image impression and cholangioscopy-guided biopsy to diagnose MBS. To ensure high technical success for MBS diagnosis, the digital SOC is a good option.

Walled-off necrosis is considered one of the most severe complications after an episode of severe acute pancreatitis. Traditionally, percutaneous drainage is selected as the first treatment step, while open surgery can be planned as a secondary option if necrosectomy is required. In recent years, endoscopic necrosectomy has evolved as a more favorable approach. To date, a step-up treatment strategy is recommended, particularly when a plastic stent is selected as the drainage device. Multi-gateway endoscopic therapy may be used in a step-up fashion if only one stent fails to clear debris. Over many years, there has been an evolution in stent selection, from plastic to metallic stents. Within a few years of its clinical usage, lumen-apposing stents are gaining more popularity as they offer direct endoscopic necrosectomy and only require a few sessions.

Background and Objectives Drainage of symptomatic walled-off peripancreatic fluid collections (WPFCs) can be achieved by endoscopic, percutaneous, and surgical techniques. The aim of this study was to determine the current trends in management of WPFCs and the outcome of such modalities in Asian population. Methods In this retrospective analysis, all patients diagnosed with pancreatitis from 2013 to 2016 in King Chulalongkorn Memorial Hospital, Bangkok, Thailand, were analyzed. Relevant clinical data of all patients with peripancreatic fluid collections (PFCs) was reviewed. Clinical success was defined as improvement in symptoms after drainage. Results Of the total 636 patients with pancreatitis, 72 (11.3%) had WPFCs, of which 55 (8.6%) and 17 (2.7%) had pancreatic pseudocyst (PP) and walled-off necrosis (WON), respectively. The commonest etiologies of WPFCs were alcohol (38.9%) and biliary stone (29.2%). Post-procedure and pancreatic tumor related pancreatitis was found in 8.3% and 6.9% patients, respectively. PP was more common in chronic (27.8%) than acute (5.5%) pancreatitis. Of the 72 patients with WPFCs, 31 (43.1%) had local complications. Supportive, endoscopic, percutaneous, and surgical drainage were employed in 58.3%, 27.8%, 8.3%, and 5.6% with success rates being 100%, 100%, 50%, and 100%, respectively. Complications that developed after percutaneous drainage included bleeding at procedure site (n = 1), infection of PFC (n = 1), and pancreatic duct leakage (n = 1). Conclusion Over the past few years, endoscopic drainage has become the most common route of drainage of WPFCs followed by percutaneous and surgical routes. The success rate of endoscopic route is better than percutaneous and comparable to surgical modality.

The Asia-Pacific Working Group on Inflammatory Bowel Disease was established in Cebu, Philippines, under the auspices of the Asia-Pacific Association of Gastroenterology with the goal of improving inflammatory bowel disease care in Asia. This consensus is carried out in collaboration with Asian Organization for Crohn's and Colitis. With biologic agents and biosimilars becoming more established, it is necessary to conduct a review on existing literature and establish a consensus on when and how to introduce biologic agents and biosimilars in conjunction with conventional treatments for ulcerative colitis and Crohn's disease in Asia. These statements also address how pharmacogenetics influences the treatments of ulcerative colitis and Crohn's disease and provides guidance on response monitoring and strategies to restore loss of response. Finally, the review includes statements on how to manage treatment alongside possible hepatitis B and tuberculosis infections, both common in Asia. These statements have been prepared and voted upon by members of inflammatory bowel disease workgroup employing the modified Delphi process. These statements do not intend to be all-encompassing, and future revisions are likely as new data continue to emerge.

Background and study aims The aim of the current study was to review the outcomes of a large-scale international registry on endoscopic ultrasound-guided gallbladder drainage (EGBD) that encompasses different stent systems in patients who are at high-risk for cholecystectomy. Patients and methods This was a retrospective international multicenter registry on EGBD created by 13 institutions around the world. Consecutive patients who received EGBD for several indications were included. Outcomes include technical and clinical success, unplanned procedural events (UPE), adverse events (AEs), mortality, recurrent cholecystitis and learning curve of the procedure. Results Between June 2011 and November 2017, 379 patients were recruited to the study. Technical and clinical success were achieved in 95.3 % and 90.8 % of the patients, respectively. The 30-day AE rate was 15.3 % and 30-day mortality was 9.2 %. UPEs were significantly more common in patients with EGBD performed for conversion of cholecystostomy and symptomatic gallstones (P Conclusion EGBD was associated with high success rates in this large-scale study. EGBD performed for indications other than acute cholecystitis was associated with higher UPEs. The number of cases required to gain competency with the technique by experienced interventional endosonographers was 25 procedures.

Background Peroral cholangioscopy (POCS) can be useful for difficult bile duct stone clearance. Large prospective multinational data on POCS-guided lithotripsy for clearing difficult bile duct stones in a single session of endoscopic retrograde cholangiopancreatography (ERCP) are missing. Methods Patients with difficult bile duct stones (defined as one or more of: largest stone diameter ≥ 15 mm, failed prior attempt at stone clearance, impacted, multiple, hepatic duct location, or located above a stricture) were enrolled at 17 centers in 10 countries. The principal endpoint was stone clearance in a single ERCP procedure using POCS. Results 156 patients underwent 174 sessions of POCS-guided electrohydraulic or laser lithotripsy. Stone clearance had failed in a previous ERCP using traditional techniques in 124/156 patients (80 %), while 32 /156 patients (21 %) were referred directly to POCS-guided therapy based on preprocedural assessment of the difficulty of stone clearance. In 101/156 patients (65 %), there were impacted stones. POCS-guided stone clearance was achieved in a single POCS procedure in 125 /156 patients (80 %, 95 % confidence interval [CI] 73 % – 86 %), and was significantly more likely for stones ≤ 30 mm compared with > 30 mm (odds ratio 7.9, 95 %CI 2.4 – 26.2; P = 0.002). Serious adverse events occurred in 3/156 patients (1.9 %, 95 %CI 0.4 % – 5.5 %), and included pancreatitis, perforation due to laser lithotripsy, and cholangitis (n = 1 each), all resolved within 1 week. Conclusion POCS-guided lithotripsy is highly effective for clearance of difficult bile duct stones in a single procedure and successfully salvages most prior treatment failures. It may also be considered first-line therapy for patients with difficult choledocholithiasis to avoid serial procedures.

Background and aim Helicobacter pylori is a class I carcinogen. Nowadays, the problem of antibiotic resistance is increasing worldwide. The latest prevalence rates of infection and resistant status in Thailand vary or are out of date. Our aims are to identify the current prevalence and antibiotic resistance patterns in Thailand and to suggest regimens for treatment-naive and -resistant patients. Methods This descriptive retrospective study was conducted, using a urea breath test, on patients in King Chulalongkorn Memorial Hospital between 2013 and 2017. They were categorized into the diagnostic group and posttreatment group. Specimens from some patients were cultured to identify the antibiotic-resistant pattern. Results There were 1894 patients included in our study. The prevalence of H. pylori infection in dyspeptic patients was 28.4%. Of 1258 patients, 1165 (92.61%) responded to initial treatment. The 95 patients who failed to respond could respond to second-line treatment of longer period, at higher doses, or using other antibiotics (success rate 68.42%). There were 21.43, 14.29, and 10.71% of patients resistant to ciprofloxacin, metronidazole, and clarithromycin, respectively. However, no patients resistant to amoxicillin, tetracycline, and levofloxacin were found. Conclusion The prevalence of H. pylori infection in Thailand has increased slightly. Initial regimens (triple therapy or sequential therapy or quadruple therapy) can be effective for the eradication of H. pylori infection, with a success rate of > 90%. For patients who failed to respond to initial triple therapy, using a longer duration of triple therapy or changing to quadruple therapy could be a good alternative. The resistance rates of amoxicillin, metronidazole, levofloxacin, and tetracycline are declining, but those of clarithromycin and ciprofloxacin are increasing.

Background Endoscopic papillary large-balloon dilation (EPLBD) allows for the complete removal of large common bile duct (CBD) stones without fragmentation; however, a significant proportion of very large stones and stones floating above a tapering CBD require lithotripsy. Mechanical lithotripsy and cholangioscopy-guided laser lithotripsy are both effective for stone fragmentation. This study aimed to directly compare, for the first time, the efficacy of these two techniques in terms of stone clearance rate, procedure duration, patient radiation exposure, and safety. Methods 32 patients with very large CBD stones or with stones floating above a tapering CBD, and in whom extraction after standard sphincterotomy and/or EPLBD had failed, were randomly assigned to mechanical lithotripsy or cholangioscopy-guided laser lithotripsy at two tertiary referral centers. Crossover was allowed as a rescue treatment if the assigned technique failed. Results Patients’ demographic data were not different between the two groups. Mechanical lithotripsy had a significantly lower stone clearance rate in the first session compared with laser lithotripsy (63% vs. 100%; P Conclusions Although mechanical lithotripsy is the standard of care for a very large CBD stone after failed EPLBD, where available, cholangioscopy-guided laser lithotripsy is considered the better option for the treatment of this entity as it provides a higher success rate and lower radiation exposure.

ObjectivesIn the management of patients with bleeding peptic ulcers, recurrent bleeding is associated with high mortality. We investigated if added angiographic embolisation after endoscopic haemostasis to high-risk ulcers could reduce recurrent bleeding.DesignAfter endoscopic haemostasis to their bleeding gastroduodenal ulcers, we randomised patients with at least one of these criteria (ulcers≥20 mm in size, spurting bleeding, hypotensive shock or haemoglobinResultsBetween January 2010 and July 2014, 241 patients were randomised (added angiographic embolisation n=118, standard treatment n=123); 22 of 118 patients (18.6%) randomised to angiography did not receive embolisation. In an intention-to-treat analysis, 12 (10.2%) in the embolisation and 14 (11.4%) in the standard treatment group reached the primary endpoint (HR 1.14, 95% CI 0.53 to 2.46; p=0.745). The rate of reinterventions (13 vs 17; p=0.510) and deaths (3 vs 5, p=0.519) were similar. In a per-protocol analysis, 6 of 96 (6.2%) rebled after embolisation compared with 14 of 123 (11.4%) in the standard treatment group (HR 1.89, 95% CI 0.73 to 4.92; p=0.192). None of 96 patients died after embolisation compared with 5 (4.1%) deaths in the standard treatment group (p=0.108). In a posthoc analysis, embolisation reduced recurrent bleeding only in patients with ulcers≥15 mm in size (2 (4.5%) vs 12 (23.1%); p=0.027).ConclusionsAfter endoscopic haemostasis, added embolisation does not reduce recurrent bleeding.Trial registration numberNCT01142180.

The Thai bariatric surgery Society of Metabolic and Bariatric Surgery (TSMBS) has recently published a consensus guideline for the treatment of obesity, which has become an emerging health crisis in Thailand. As endoscopic sleeve gastroplasty (ESG) lately became available in the country, the TSMBS and the Thai Association for Gastrointestinal Endoscopy (TAGE) then agreed to propose this addendum statement that aims to standardize the patient selection protocol, physician credentialing, and procedural data monitoring in order to safely and effectively incorporate ESG into the armamentarium of bariatric treatment of Thailand.

Background Hepatocellular carcinoma (HCC) surveillance rates are suboptimal. We aimed to identify HCC surveillance barriers from both physician and patient perspectives and assess the effectiveness of physician education using social networks. Methods A nationwide survey with 513 physicians and another single-center survey with 315 HCC-risk patients were conducted. Regression analysis was used to identify surveillance barriers. We educated 143 physicians by sending brief notes on HCC surveillance guidelines via social networks and re-evaluated their knowledge at 60 days using paired T-test.Results Surveys showed 458 (86.3%), 254 (47.8%) and 225 (42.4%) physicians recommended surveillance in patients with cirrhosis, at-risk HBV and HCV infection, respectively. Only 228 (42.9%) and 241 (38.0%) respondents adhered to recommended surveillance tools and interval, respectively. The main surveillance barriers among physicians were the lack of knowledge and resource limitations. The lack of a doctor’s prescription was identified as main barrier by patients (relative risk 1.4, 95%CI 1.1-1.8, p=0.024). Social networks education enhanced physicians’ knowledge pre-and post-education scores for guideline awareness: (63.0%vs.84.3%, pConclusions Physicians’ knowledge gap was primary barrier for adherence to HCC surveillance protocols. Brief education via social networks showed effectiveness at increasing knowledge of HCC surveillance with medical residents.Clinical trial registry: This study was registered to the Thai clinical trial registry (TCTR number 20210127006). Registered 22 July 2021- Retrospectively registered. http://www.clinicaltrials.in.th/

Background/Aims: The Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them.Methods: A validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables.Results: Despite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (p=0.001, p=0.047, p

Background and Aim During the Coronavirus Disease 2019 pandemic, esophagogastroduodenoscopy (EGD) has been recognized as an aerosol‐generating procedure. This study aimed to systematically compare the degree of face shield contamination between endoscopists who performed EGD on patients lying in the left lateral decubitus (LL) and prone positions. Methods This is a randomized trial in patients scheduled for EGD between April and June 2020. Eligible 212 patients were randomized with 1:1 allocation. Rapid adenosine triphosphate test was used to determine contamination level using relative light units of greater than 200 as a cutoff value. All eligible patients were randomized to lie in either the LL or prone position during EGD. The primary outcome was the rate of contamination on the endoscopist's face shield. Results The majority of patients were female (63%), with a mean age of 60 ± 13 years. Baseline characteristics were comparable between the two groups. There was no face shield contamination after EGD in either group. The number of coughs in the LL group was higher than the prone group (1.38 ± 1.8 vs 0.89 ± 1.4, P = 0.03). The mean differences in relative light units on the face shield before and after EGD in the LL and prone groups were 9.9 ± 20.9 and 4.1 ± 6 (P = 0.008), respectively. Conclusion As measured by the adenosine triphosphate test, performing diagnostic EGD does not lead to contamination on the face shield of the endoscopist. However, placing patients in the prone position may further mitigate the risk.

Background Intestinal microbial dysbiosis is evident in chronic HIV-infected individuals and may underlie inflammation that persists even during antiretroviral therapy (ART). It remains unclear, however, how early after HIV infection gut dysbiosis emerges and how it is affected by early ART. Methods Fecal microbiota were studied by 16s rDNA sequencing in 52 Thai men who have sex with men (MSM), at diagnosis of acute HIV infection (AHI), Fiebig Stages 1–5 (F1-5), and after 6 months of ART initiation, and in 7 Thai MSM HIV-uninfected controls. Dysbiotic bacterial taxa were associated with relevant inflammatory markers. Results Fecal microbiota profiling of AHI pre-ART vs HIV-uninfected controls showed a mild dysbiosis. Transition from F1-3 of acute infection was characterized by enrichment in pro-inflammatory bacteria. Lower proportions of Bacteroidetes and higher frequencies of Proteobacteria and Fusobacteria members were observed post-ART compared with pre-ART. Fusobacteria members were positively correlated with levels of soluble CD14 in AHI post-ART. Conclusions Evidence of gut dysbiosis was observed during early acute HIV infection and was partially restored upon early ART initiation. The association of dysbiotic bacterial taxa with inflammatory markers suggests that a potential relationship between altered gut microbiota and systemic inflammation may also be established during AHI.

Artificial intelligence (AI) using a convolutional neural network (CNN) has demonstrated promising performance in radiological analysis. We aimed to develop and validate a CNN for the detection and diagnosis of focal liver lesions (FLLs) from ultrasonography (USG) still images. The CNN was developed with a supervised training method using 40,397 retrospectively collected images from 3,487 patients, including 20,432 FLLs (hepatocellular carcinomas (HCCs), cysts, hemangiomas, focal fatty sparing, and focal fatty infiltration). AI performance was evaluated using an internal test set of 6,191 images with 845 FLLs, then externally validated using 18,922 images with 1,195 FLLs from two additional hospitals. The internal evaluation yielded an overall detection rate, diagnostic sensitivity and specificity of 87.0% (95%CI: 84.3–89.6), 83.9% (95%CI: 80.3–87.4), and 97.1% (95%CI: 96.5–97.7), respectively. The CNN also performed consistently well on external validation cohorts, with a detection rate, diagnostic sensitivity and specificity of 75.0% (95%CI: 71.7–78.3), 84.9% (95%CI: 81.6–88.2), and 97.1% (95%CI: 96.5–97.6), respectively. For diagnosis of HCC, the CNN yielded sensitivity, specificity, and negative predictive value (NPV) of 73.6% (95%CI: 64.3–82.8), 97.8% (95%CI: 96.7–98.9), and 96.5% (95%CI: 95.0–97.9) on the internal test set; and 81.5% (95%CI: 74.2–88.8), 94.4% (95%CI: 92.8–96.0), and 97.4% (95%CI: 96.2–98.5) on the external validation set, respectively. CNN detected and diagnosed common FLLs in USG images with excellent specificity and NPV for HCC. Further development of an AI system for real-time detection and characterization of FLLs in USG is warranted.

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.

Intestinal microbial dysbiosis is evident in chronic HIV-infected individuals and may underlie inflammation that persists even during antiretroviral therapy (ART). It remains unclear, however, how early after HIV infection gut dysbiosis emerges and how it is affected by early ART.Fecal microbiota were studied by 16s rDNA sequencing in 52 Thai men who have sex with men (MSM), at diagnosis of acute HIV infection (AHI), Fiebig Stages 1-5 (F1-5), and after 6 months of ART initiation, and in 7 Thai MSM HIV-uninfected controls. Dysbiotic bacterial taxa were associated with relevant inflammatory markers.Fecal microbiota profiling of AHI pre-ART vs HIV-uninfected controls showed a mild dysbiosis. Transition from F1-3 of acute infection was characterized by enrichment in pro-inflammatory bacteria. Lower proportions of Bacteroidetes and higher frequencies of Proteobacteria and Fusobacteria members were observed post-ART compared with pre-ART. Fusobacteria members were positively correlated with levels of soluble CD14 in AHI post-ART.Evidence of gut dysbiosis was observed during early acute HIV infection and was partially restored upon early ART initiation. The association of dysbiotic bacterial taxa with inflammatory markers suggests that a potential relationship between altered gut microbiota and systemic inflammation may also be established during AHI.

We are currently living in the throes of the COVID-19 pandemic that imposes a significant stress on health care providers and facilities. Europe is severely affected with an exponential increase in incident infections and deaths. The clinical manifestations of COVID-19 can be subtle, encompassing a broad spectrum from asymptomatic mild disease to severe respiratory illness. Health care professionals in endoscopy units are at increased risk of infection from COVID-19. Infection prevention and control has been shown to be dramatically effective in assuring the safety of both health care professionals and patients. The European Society of Gastrointestinal Endoscopy ( www.esge.com ) and the European Society of Gastroenterology and Endoscopy Nurses and Associates ( www.esgena.org ) are joining forces to provide guidance during this pandemic to help assure the highest level of endoscopy care and protection against COVID-19 for both patients and endoscopy unit personnel. This guidance is based upon the best available evidence regarding assessment of risk during the current status of the pandemic and a consensus on which procedures to perform and the priorities on resumption. We appreciate the gaps in knowledge and evidence, especially on the proper strategy(ies) for the resumption of normal endoscopy practice during the upcoming phases and end of the pandemic and therefore a list of potential research questions is presented. New evidence may result in an updated statement.

Adenosine triphosphate (ATP) test based on one nucleotide has been applied as point-of-care testing (POCT) for bacterial contamination in the medical and food industries. Hypothetically, testing three adenylate nucleotides (A3) may provide better detection of duodenoscope bacterial contamination than ATP test.To evaluate performance characteristics and optimal cut-off value of A3 and ATP tests in predicting bacterial contamination of duodenoscopes.Four hundred duodenoscope samples obtained after 100 endoscopic retrograde cholangiopancreatography procedures were randomized into group A (A3 test) or B (ATP test). Samples were collected from the elevator at the four-step cleaning process of duodenoscope. We defined the new cut-off value of the test for reaching 100% negative predictive value (NPV) from our receiver operating characteristic (ROC).Using the cultures from the four-step cleaning process as the reference, the areas under ROC (AUROC) were 0.83 and 0.84 for group A (N = 200) and group B (N = 200), respectively. Using the cultures from post-high-level disinfection (HLD) as the reference, the AUROC were 0.35 and 0.74 for group A (N = 50) and group B (N = 50), respectively. We investigated ATP as a POCT after HLD with a new cut-off value of 40 RLU. However, this threshold did not allow detection of low numbers of bacteria.A3 and ATP tests provide good performances in predicting bacterial contamination of duodenoscopes for the four-step cleaning process. The ATP40 RLU is helpful as a POCT after HLD; however, the limitation of this cut-off value is its inability to detect low numbers of bacteria.

Background A newly designed duodenoscope with detachable distal cap may reduce bacterial contamination by allowing better access to the elevator. We compared bacterial contamination and organic residue evaluated by rapid adenosine triphosphate (ATP) test and culture from duodenoscopes with detachable vs. fixed distal caps after high-level disinfection (HLD). Methods During December 2018–April 2019, 108 used newly designed duodenoscopes were enrolled. In group A (n = 54), the distal cap of the duodenoscope was detached before manual cleaning. In group B (n = 54), the distal cap was not detached. After HLD, samples were collected from the elevator, submitted for culture, and evaluated using the ATP test, using the cutoff value of 40 relative light units (RLUs). Results After HLD, the proportion of potential bacterial contamination and organic residue in group A was significantly lower than in group B (37.0 % vs. 75.9 %; P Conclusions The detachable distal cap was more effective at eliminating bacterial contamination and reducing organic residue than a fixed cap. Nonpathogenic bacteria were detected in the fixed cap group after reprocessing. The ATP test with 40 RLU cutoff is a practical method to ensure the cleanliness of duodenoscope reprocessing without the need to wait for bacterial culture results.

Background Peroral cholangioscopy (POCS) of indeterminate biliary strictures aims to achieve a diagnosis through visual examination and/or by obtaining targeted biopsies under direct visualization. In this large, prospective, multinational, real-life experience of POCS-guided evaluation of indeterminate biliary strictures, we evaluated the performance of POCS in this difficult-to-manage patient population. Methods This prospective registry enrolled patients, with indeterminate biliary strictures across 20 centers in Asia, the Middle East, and Africa. The primary end points were the ability to visualize the lesion, obtain histological sampling when intended, and an assessment of the diagnostic accuracy of POCS for malignant strictures. Patients were followed for 6 months after POCS or until a definitive malignant diagnosis was made, whichever occurred first. Results 289 patients underwent 290 POCS procedures with intent to biopsy in 182 cases. The stricture/filling defect was successfully visualized in 286/290 (98.6 %), providing a visual diagnostic impression in 253/290 (87.2 %) and obtaining adequate biopsies in 169/182 (92.9 %). Procedure-related adverse events occurred in 5/289 patients (1.7 %). POCS influenced patient management principally by elucidating filling defects or the causes of bile duct stricture or dilation. The visual impression of malignancy showed 86.7 % sensitivity, 71.2 % specificity, 65.8 % positive and 89.4 % negative predictive value, and 77.2 % overall accuracy compared with final diagnosis. Histological POCS-guided samples showed 75.3 % sensitivity, 100 % specificity, 100 % positive and 77.1 % negative predictive value, and 86.5 % overall accuracy. Conclusion In this large, real-life, prospective series, POCS was demonstrated to be an effective and safe intervention guiding the management of patients with indeterminate biliary strictures.

Coronavirus-19 (COVID-19) caused by SARS-CoV-2 has become a global pandemic. Risk of transmission may occur during endoscopy and the goal is to prevent infection among healthcare professionals while providing essential services to patients. Asia was the first continent to have a COVID-19 outbreak, and this position statement of the Asian Pacific Society for Digestive Endoscopy shares our successful experience in maintaining safe and high-quality endoscopy practice at a time when resources are limited. Sixteen experts from key societies of digestive endoscopy in Asia were invited to develop position statements, including patient triage and risk assessment before endoscopy, resource prioritisation and allocation, regular monitoring of personal protective equipment, infection control measures, protective device training and implementation of a strategy for stepwise resumption of endoscopy services after control of the COVID-19 outbreak.

BACKGROUND: The RV144 phase 3 vaccine trial in Thailand demonstrated that ALVAC-HIV (vCP1521) and AIDSVAX® B/E administration over six months resulted in a 31% efficacy in preventing HIV acquisition. In this trial, we assessed the immunologic impact of an additional vaccine boost to the RV144 regimen at varying intervals between the priming vaccine series and the boost. METHODS: RV306 is a double-blind, placebo-controlled, randomized clinical trial conducted in three clinical sites in Thailand. HIV-uninfected volunteers aged 20–40 randomly received the primary RV144 vaccine series at months 0, 1, 3, and 6, with no additional boost (Group I), additional AIDSVAX® B/E and ALVAC-HIV (vcp1521) at month 12 (Group II), AIDSVAX® B/E alone at month 12 (Group III), AIDSVAX® B/E and ALVAC-HIV at month 15 or 18 (Groups IVa or IVb), or placebo and were followed for 24 months. A randomization schedule was centrally generated with fixed sized strata for RIHES Chiang Mai (n=60) and combined Bangkok clinics (n=300). Primary outcomes were to assess the safety and tolerability of these vaccination regimens and characterize and compare cellular and humoral immune responses between the RV144 series alone and late boosts at different timepoints. Safety and tolerability outcomes were assessed by evaluating local and systemic reactogenicity and adverse events in all participants. Primary immunogenicity outcomes were evaluated by comparing peak humoral responses (HIV-specific IgG and IgA ELISA) and cellular responses (HIV-specific intracellular cytokine staining and polyfunctionality) two weeks post final vaccination among per-protocol participants who completed all vaccinations. This trial is registered at (ClinicalTrials.gov (NCT01931358); clinical follow up is now complete. FINDINGS: Between 28 October 2013 and 29 April 2014, 367 participants were enrolled, of whom 27 were assigned active vaccination in Group I, 102 in Group II, 101 in Group III, 52 in Group IVa, 51 in Group IVb, and 34 combined placebo across all groups. Late boosting did not induce vaccine-related serious adverse events. There were no significant differences in the occurrence or severity of local or systemic reactogenicity across active groups. Groups with late boosts (Groups II, III, IVa, and IVb) had increased peak plasma IgG binding antibody levels against gp70 V1V2 relative to Group I vaccine recipients with no late boost (gp70V1V2 92TH023 adjusted p < 0·02 for each; gp70V1V2 Case A2 adjusted p month 15 (Group IVa) > month 12 (Groups II+III) > no late boost (Group I). Groups with late boosts had increased both functionality and polyfunctionality scores relative to vaccine recipients with no late boost (all adjusted p < 0·05, except for polyfunctionality score in Group I vs in Group IVb p < 0·01). INTERPRETATION: Taken together, these results suggest that additional boosting of the RV144 regimen with longer intervals between the primary vaccination series and late boost improved immune responses and may improve the efficacy of preventing HIV acquisition. FUNDING: US National Institute of Allergy and Infectious Diseases (NIAID) and U.S. Department of the Army.

Vitamin D and its cognate intracellular nuclear receptor, namely, vitamin D receptor (VDR), are involved in the regulation of a variety of body metabolic processes, immune function, and oncogenesis. A large number of studies demonstrated the association of low vitamin D levels and variations in five common single nucleotide polymorphisms (SNPs), FokI, BsmI, Tru9I, ApaI, and TaqI, with the risk of several cancers, including colorectal cancers. However, these associations vary among different populations. This case-control study was aimed at analysing whether common single-nucleotide polymorphisms (SNPs) and haplotypes of the vitamin D receptor (VDR) gene contribute to colorectal carcinogenesis in the Thai population. We enrolled 364 Thai participants from King Chulalongkorn Memorial Hospital between 2014 and 2015. Half of the participants underwent colonoscopy and showed a normal colon without polyps (control group) and another half were newly diagnosed patients with colorectal cancer (CRC) by colonoscopy during the index period, were under treatment, or were followed up at the outpatient clinic (case group). Differences in allele and genotype frequencies of five common VDR SNPs, between the case and control groups, were the primary outcome measures. Differences in haplotype frequencies of the five SNPs between the case and control groups were the secondary outcome measures. Among the 364 participants, baseline characteristics were not significantly different between the case and control groups, except for the higher proportion of males in the CRC group. The mean vitamin D level was also not significantly different between the case and control groups (24.6±9.1 vs. 25.3±10.6 ng/mL, p=0.52). None of the five VDR SNPs was associated with CRC development (p>0.05). However, haplotype analysis of these polymorphisms demonstrated that the AGGT haplotype was associated with a decreased risk of CRC (odds ratio 0.24, 95% confidence interval 0.07-0.81, p=0.01). The AGGT haplotype was associated with a lower risk of CRC in the Thai population. This genetic linkage might support the role of vitamin D in colorectal carcinogenesis. However, this finding requires further study within a larger population and a multivariate analysis of other established risk factors.

Background The gut-associated lymphoid tissue (GALT) is a major reservoir of HIV-1 established early in acute HIV-1 infection (AHI). Sampling tissue from GALT can provide information about viral reservoirs and immune responses but may be complicated during AHI for reasons such as high viral replication, CD4 T cell depletion and immune activation. Risk of adverse events (AEs) associated with research sigmoid colon biopsies was assessed in participants with AHI in Bangkok, Thailand. Methods Between 2009 and 2016, 170 biopsies collected from the sigmoid colon were performed during AHI and at follow-up visits (median 24 weeks post AHI diagnosis). Adverse event incidence was evaluated, as well as the associations of procedure timing, repetition and clinical parameters with AE risk. Negative binomial regression models were used to calculate incidence rate ratios and 95% confidence intervals. Results Among 103 participants (median age of 27 years, 97.1% male, 96.1% men who have sex with men), 87 sigmoidoscopies were completed during AHI and 83 at a follow-up visit. Approximately 30 biopsies were obtained per procedure for assessment of colonic viral load and HIV-1 reservoir, immunohistochemistry or phenotypic assays. All 11 AEs were grade 1 (6.5%) and included abdominal discomfort (n = 5, 2.9%), mild rectal bleeding (n = 5, 2.9%) and difficulty passing stool (n = 1, 0.6%). Biopsy-related AE risk was not significantly associated with age, HIV-1 RNA, CD4 T cell count, or number and time of biopsy. Conclusions Complications of sigmoidoscopy with biopsy in participants with AHI were infrequent and mild. Longitudinal sampling of the sigmoid colon to evaluate the gut-associated HIV-1 reservoir can be safely performed as part of research studies.

Background/aims This study aimed to evaluate the diagnostic accuracy of dual-focus narrow-band imaging (dNBI) and Lugol'schromoendoscopy (LCE) combined with probe-based confocal laser endomicroscopy (pCLE) to screen for esophageal squamous cell neoplasms (ESCNs) in patients with a history of head and neck cancer. Methods From March to August 2016, dNBI was performed. Next, LCE was performed, followed by pCLE and biopsy. Histology has historically been the gold standard to diagnose ESCN. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI and LCE adjunct with pCLE were determined. Results Twenty-four patients were included. Ten ESCNs were found in 8 patients (33%). Forty percent of high-graded intraepithelial neoplasias and all low-grade intraepithelial neoplasias were overlooked by dNBI. The sensitivity, specificity, PPV, NPV, and accuracy of dNBI vs. LCE combined with pCLE were 50% vs. 80%, 62% vs. 67%, 36% vs. 44%, 75% vs. 91%, and 83% vs. 70%, respectively. Conclusion The use of dNBI to detect ESCN was suboptimal. LCE with pCLE following dNBI had additional value for detecting esophageal dysplasia not detected by dNBI. The use of pCLE to detect dNBI-missed lesions yielded a high NPV, while pCLE-guided biopsy could reduce the number of unnecessary biopsies.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed in a prone or left lateral decubitus (LLD) position. The ocular lens equivalent doses between the two positions may be different because in the LLD position the tube voltage will automatically increase to maintain the image quality, and the increased distance between the image intensifier and the X-ray tube may result in more scattered radiation. We aimed to compare the ocular lens equivalent doses of ERCP personnel between the two different positions. Patients and methods Fifty-five patients with ERCP indications were randomized to either prone or LLD positions. One patient in an LLD position was excluded due to technical reasons. Indications for ERCP, patients’ vertical thicknesses, fluoroscopy parameters, patients’ skin dose rates, and the ocular-lens equivalent doses of ERCP personnel were compared. Results Baseline characteristics were no different except for vertical thickness, which was significantly higher in the LLD group. The ocular lens equivalent doses (prone vs. LLD) of the primary endoscopist (19.2 vs. 30.7 µSv, P = 0.035), and the nurse anesthetist (17.3 vs. 42.2 µSv, P = 0.002) were significantly lower in the prone group than in the LLD group. The calculated annual number of procedures not to exceed the exposure allowance in prone and LLD positions were 1,042 and 651 procedures for the primary endoscopist and 1,157 and 473 procedures for the nurse anesthetist, respectively. Conclusions Ocular-radiation exposure to ERCP personnel was one-third lower in the prone than in LLD position. Therefore, more annual ERCPs could be performed by the personnel.

Background Pre-operative tissue diagnosis for suspected malignant biliary strictures remains challenging. Aim To develop evidence-based consensus statements on endoscopic tissue acquisition for biliary strictures. Methods The initial draft of statements was prepared following a systematic literature review. A committee of 20 experts from Asia-Pacific region then reviewed, discussed, and modified the statements. Two rounds of independent voting were conducted to reach a final version. Consensus was considered to be achieved when 80% or more of voting members voted "agree completely" or "agree with some reservation." Results Eleven statements achieved consensus. The choice of tissue sampling modalities for biliary strictures depends on the clinical setting, the location of lesion, and availability of expertise. Detailed radiological and endoscopic evaluation is useful to guide the selection of appropriate tissue acquisition technique. Standard intraductal biliary brushing and/or forceps biopsy is the first option when endoscopic biliary drainage is required with an overall (range) sensitivity and specificity of 45% (26%-72%) and 99% (98%-100%), and 48% (15%-100%) and 99% (97%-100%), respectively, in diagnosing malignant biliary strictures. Probe-based confocal laser endomicroscopy and fluorescence in situ hybridisation using 4 fluorescent-labelled probes targeting chromosomes 3, 7, 17 and 9p21 locus may be added to improve the diagnostic yield. Cholangioscopy-guided biopsy and EUS-guided tissue acquisition can be considered after prior negative conventional tissue sampling with an overall (range) sensitivity and specificity of 60% (38%-88%) and 98% (83%-100%), and 80% (46%-100%) and 97% (92%-100%), respectively, in diagnosing malignant biliary strictures. Conclusion These consensus statements provide evidence-based recommendations for endoscopic tissue acquisition of biliary strictures.