Iatrogenic perforation of the gastrointestinal (GI) tract is one of the serious complications in GI endoscopy. With the advancement in technique of GI endoscopy especially therapeutic endoscopy, the risk of perforation has increased. Prompt detection is the only way to avoid delay treatment and poor outcome. Recently, there are new instruments and techniques developed that can be reliably applied for an endoscopic closure without the need for surgery. Therefore, endoscopists should be familiar with these instruments as the result of successful endoscopic closure has lower rate of morbidity than surgery. In this review, the techniques of endoscopic closure are described according to the organs of perforation. In addition, the general knowledge and management of perforation in other aspects including tension pneumothorax, abdominal compartment syndrome, or infection induced by contamination of GI content are explained.
Endoscopy ; Gastrointestinal Contents ; Intra-Abdominal Hypertension ; Pneumothorax ; Stents

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.

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.

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.

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.

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.

Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.
*Bile ; Biliary Tract Diseases/diagnosis/etiology/*surgery ; Coated Materials, Biocompatible ; Constriction, Pathologic ; Diagnostic Imaging ; Equipment Design ; Foreign-Body Migration ; Humans ; Metals ; Plastics ; Postoperative Complications ; Sphincterotomy, Endoscopic ; *Stents

Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα + cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

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.