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Background/Aims The coronavirus disease 2019 pandemic has affected the worldwide practice of upper gastrointestinal endoscopy. Here we designed a modified N95 respirator with a channel for endoscope insertion and evaluated its efficacy in upper gastrointestinal endoscopy. Methods Thirty patients scheduled for upper gastrointestinal endoscopy were randomized into the modified N95 (n=15) or control (n=15) group. The mask was placed on the patient after anesthesia administration and particles were counted every minute before (baseline) and during the procedure by a TSI AeroTrak particle counter (9306-04; TSI Inc.) and categorized by size (0.3, 0.5, 1, 3, 5, and 10 µm). Differences in particle counts between time points were recorded. Results During the procedure, the modified N95 group displayed significantly smaller overall particle sizes than the control group (median [interquartile range], 231 [54–385] vs. 579 [213–1,379]×103/m3; p=0.056). However, the intervention group had a significant decrease in 0.3-µm particles (68 [–25–185] vs. 242 [72–588]×103/m3; p=0.045). No adverse events occurred in either group. The device did not cause any inconvenience to the endoscopists or patients. Conclusions This modified N95 respirator reduced the number of particles, especially 0.3-µm particles, generated during upper gastrointestinal endoscopy.

Objective: Sigmoid-type achalasia represents an advanced stage of achalasia characterized by significant dilation and tortuosity of the esophageal lumen. Considering the demonstrated efficacy of peroral endoscopic myotomy (POEM) in treating early-stage achalasia, this procedure may offer an alternative therapeutic approach for sigmoid-type achalasia. This study aimed to assess POEM’s feasibility and short-term efficacy in patients with sigmoid-type achalasia. Materials and Methods: We enrolled 16 consecutive patients with sigmoid-type achalasia (eight with type 1 and eight with type 2). The anticipated outcomes were symptom relief during the 12-month follow-up period (evaluated through a reduction in Eckardt symptom scores), an acceptable incidence of procedure-related adverse events, and a decrease in esophageal diameter and barium height. Results: POEM was successfully performed in all cases, with a median operative time of 118.50 minutes (range: 52–206 minutes). No serious complications associated with POEM were observed. During the 12-month follow-up period, the median Eckardt symptom score decreased from 6 (2-10) preoperatively to 1 (0-3) (P = 0.008). Complications were mucosal injuries (31.25% of cases), pneumoperitoneum (12.5%), and minor bleeding (6.25%), although no interventions were needed. Conclusion: POEM procedure has exhibited favorable treatment outcomes, showcasing a high clinical success rate in addressing sigmoid-type achalasia. Despite the occurrence of acceptable adverse events, the procedure remains a viable alternative treatment or bridging therapy for sigmoid-type achalasia. Nonetheless, it is crucial to acknowledge that this procedure presents greater challenges in comparison to the treatment of typical achalasia.

Peritoneal metastasis in gastric cancer has a poor prognosis and is increasing in prevalence. Neoadjuvant chemotherapy is used for advanced tumors; however, surgery is generally not considered for metastatic and unresectable diseases. Recently, conversion surgery, a treatment which aims for an R0 resection following chemotherapy, has become a novel therapeutic option with better survival rates. In addition to surgery, hyperthermic intraperitoneal chemotherapy (HIPEC) leads to significant tumor reduction, but it is limited by its morbidity. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) delivers high concentrations of chemotherapy, but does not remove the tumor, making it useful mostly in palliative settings. Intraperitoneal (IP) therapy, known for its minimally invasive nature and repeatability, shows promise but requires further research. Ultimately, an integrated approach involving systemic chemotherapy, radical gastrectomy, HIPEC, PIPAC and IP chemotherapy can be used to optimize treatment outcomes of gastric cancer patients with peritoneal metastasis.

In the highly contagious coronavirus disease 2019 pandemic, aerosol-generating procedures (AGPs) are associated with high-risk of transmission. Upper gastrointestinal endoscopy is a procedure with the potential to cause dissemination of bodily fluids. At present, there is no consensus that endoscopy is defined as an AGP. This review discusses the current evidence on this topic with additional management. Prevailing publications on coronavirus related to upper gastrointestinal endoscopy and aerosolization from the PubMed and Scopus databases were searched and reviewed. Comparative quantitative analyses showed a significant elevation of particle numbers, implying that aerosols were generated by upper gastrointestinal endoscopy. The associated source events have also been reported. To reduce the dispersion, certain protective measures have been developed. Endoscopic unit protocols are recommended for the concerned personnel. Therefore, upper gastrointestinal endoscopy should be classified as an AGP. Proper practices should be adopted by healthcare workers and patients.

Objective: The current standard of care for locally advanced rectal cancer is associated with multimodality therapy. Neoadjuvant chemoradiation significantly decreased the locoregional recurrence rate and improved survival. However, distant metastasis develops rather than local recurrence, which becomes the leading cause of death. This study aimed to evaluate the oncological outcomes of total neoadjuvant therapy (TNT) in locally advanced rectal cancer. Materials and Methods: This retrospective study recruited 18 patients diagnosed with locally advanced rectal adenocarcinoma (cT3-4 or cN1-2), treated with consolidation TNT. The primary endpoint was pathological complete response (pCR). The secondary endpoint included postoperative outcomes, local recurrences, and distant metastases. Results: The pathologic complete response was observed in 27.8% of consolidation therapy cases. Downstaging of the T-category was achieved in 10 (55.6%) patients, and downstaging of the N-category was achieved in 14 (77.8%) patients. Only one patient who achieved pCR developed distant metastasis, whereas all patients with pathological stage III developed distant metastasis. Conclusions: TNT is a promising approach for patients with locally advanced rectal cancer. This strategy improved complete pathologic response rates in TNT, and pCR was found to be associated with fewer local recurrences and greater disease-free survival.

Objective: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach that aims to optimize perioperative management, promote postoperative recovery, reduce postoperative complications, and improve long-term survival. The current study aimed to evaluate and compare the postoperative physical activity after gastrectomy between patients who underwent upper gastrointestinal surgery according to ERAS and those who underwent surgery based on the conventional care (CC) protocol. Materials and Methods: This prospective and retrospective review enrolled 60 patients (n = 31, ERAS group; n = 29, CC protocol group) diagnosed with adenocarcinoma of the stomach and esophagogastric junction who underwent curative surgical resection. Physical outcomes, including body weight, body mass index, body fat percentage, basal metabolic rate, muscle mass, gait speed, and handgrip strength at the preoperative and immediate postoperative periods and at 1, 3, and 6 months postoperatively, were comparedbetween the ERAS and CC protocol groups. Results: One month after surgery, the ERAS group had a lower percentage of body weight loss than the CC protocol group. There was no significant difference in terms of muscle mass loss between the two groups. The hand grip strength of the ERAS group increased after surgery. Further, at 1 month postoperatively, the gait speed of patients who underwent total gastrectomy in the ERAS group was significantly higher than that of patients in the CC protocol group. Conclusion: ERAS for gastrectomy was associated with a lower percentage of weight loss and a trend toward physical activity enhancement in the early postoperative period.

Abstract Background The SARS-CoV2 virus has been identified in abdominal cavity of the COVID-19 patients. Therefore, the potential viral transmission from any surgical created smoke in these patients is of concern especially in laparoscopic surgery. This study aimed to compare the amount of surgical smoke and surgical field contamination between laparoscopic and open surgery in fresh cadavers. Methods Cholecystectomy in 12 cadavers was performed and they were divided into 4 groups: laparoscopic approach with or without smoke evacuator, and open approach with or without smoke evacuator. The increased particle counts in surgical smoke of each group were analyzed. In the model of appendectomy, surgical field contamination under ultraviolet light and visual contamination scale between laparoscopic and open approach were compared. Results Open cholecystectomy significantly produced a greater amount of overall particle sizes, particle sizes

Objective: Bariatric surgery is considered the most effective treatment for morbid obesity, and is increasingly performed in Thailand and globally. We aimed to establish the outcomes of bariatric surgery performed at Siriraj Hospital, Bangkok. Materials and Methods: This was a retrospective study of patients who underwent bariatric surgery between January 2012 and June 2016. Results: The records of the first 100 patients who underwent bariatric surgery were reviewed, comprising 58 patients who underwent laparoscopic sleeve gastrectomy (LSG) and 42 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). The median patient age, preoperative body weight, and BMI were 36 years old, 129 kg, and 46.3 kg/m2. All the procedures were performed by a laparoscopic approach. The median operative times for LSG and LRYGB were 156 [85-435] and 265 [180-435] minutes. The median hospital stay was 3 days [3-14]. The major complication rate was 4%. There was no mortality in the 30-day postoperative period. The mean %excess weight loss (%EWL) of LSG was 56.8 ± 19.8%, 59.9 ± 21.7%, and 55.1 ± 21.3%, at 1, 2, and 3 years after surgery. The mean %EWL of LRYGB was 67 ± 18.3%, 66.2 ± 21.4%, and 63.6 ± 19.9%, at 1, 2, and 3 years after surgery. In the patients with type-II diabetes mellitus, 67% had complete diabetic remission at 1 year. The median FBS dropped from 127 to 99 mg/dL (p < 0.001) and HbA1c from 6.6% to 5.5% (p < 0.001). The remission rates of hypertension and dyslipidemia were 58% and 73%. Conclusion: The bariatric procedures are safe with a low complication rate. The procedures also provide good outcomes in postoperative weight loss and comorbidity resolution.

The development of information and communication technology has had a dramatic impact on people’s lives, including medical matters. The Internet has made it possible for telemedicine to be implemented with excellent image quality at low cost; such telemedicine was first applied between Japan and South Korea in 2002. The technology is not restricted to advanced countries: it can also be applied in developing nations, and it has expanded rapidly to other parts of Asia and beyond. In 2005 Thailand became the seventh country to be associated with the Telemedicine Development Center of Asia (TEMDEC). As of 2017, TEMDEC operates 144 programs in Thailand, mainly in endoscopy (55, 38%) and surgery (40, 28%): 17 hospitals or medical institutions are active members, and there are 165 telemedicine connections. Siriraj Hospital, Mahidol University was the first participant; it has 71 telemedicine connections; King Chulalongkorn Memorial Hospital became the second participant; it has 52 such connections. These two hospitals account for 74.5% (123/165) of all telemedicine activities in Thailand. Compared with outside Bangkok, the number of telemedicine connections is 14 times (154/11) greater and the number of such connections per hospital is 10 times (15.4/1.6) greater in the capital-even though the number of hospitals is only 1.4 times (10/7) greater in Bangkok. To efficiently meet local needs, we strongly hope that telemedicine will expand into rural parts of Thailand and into more medical specialties through ongoing technological development.

Robotic surgery, currently monopolized by the Intuitive “da Vinci Surgical System” (dVSS) has now established its strong foothold in the USA and a few other countries in Europe and Asia. However, because of its high cost and lack of evidence to support its superiority over the traditional laparoscopic technique, its utility especially in less affluent countries remains controversial. In this article, we studied the adoption and development of robotic programs in Thailand, a middle income country, that had its head start relatively early with the acquisition of the first generation da Vinci system by the private international hospital. The systems have since been installed in 5 other institutions, 4 of which are academic centers. We analyzed and discussed the causes of success of the urological program and failure of others. In the end, we concluded that instead of resisting the trend, it should be selectively and rationally embraced. We then suggested steps to help with the program development that are best suited to the Thailand financial and health care conditions.

Objective To evaluate short-term postoperative outcomes compared between before and 1 year after the establishment of the Siriraj Upper Gastrointestinal Cancer Center (UGICC). Materials and Methods Medical records of 211 patients who underwent radical gastrectomy at Siriraj Hospital during January 2012-September 2018 were reviewed (before UGICC; B-UGICC). Data of 40 patients operated upon during October 2018-September 2019 were prospectively collected after the establishment of UGICC (A-UGICC). Propensity score (PPS) matched analysis was conducted, and short-term outcomes were compared. Enhanced Recovery After Surgery (ERAS) protocol was applied to some patients in A-UGICC. Results of conventional care (CC) were compared with ERAS protocol. Results PPS matched 78 patients in B-UGICC, and 40 patients in A-UGICC. Median postoperative length of stay (POS) was significantly shorter in A-UGICC than in B-UGICC; however, complications and time to oral diet tolerability were not significantly different between groups. In A-UGICC, median POS and time to toleration of oral diet were significantly shorter among 15 ERAS patients than among 25 CC patients. Intestinal recovery and time to ambulation trended to be earlier in ERAS. 103 CC and 15 ERAS patients were matched to 36 non-ERAS and 13 ERAS patients. Median time to toleration of oral diet was significantly shorter in ERAS than in CC (P

Objective: Microscopic residual tumor (R1 resection) may have a significant negative impact on prognosis of patients with adenocarcinoma of stomach and esophagogastric junction. Results of R1 resection on survival and recurrence patterns have not yet been thoroughly investigated in Thailand. The aim of this study was to study the oncological outcomes of R1 resection after curative intended surgery. Methods: We retrospectively analyzed the medical records of patients who underwent curative intended surgery from 2005 to 2013 at Siriraj Hospital. Results: 162 patients underwent curative intended gastrectomy with radical lymphadenectomy. 122 (75.3%) patients received R0 resection (non-residual group), 40 (24.7%) patients had microscopic residual tumor (residual group). Microscopic residual tumor was associated with tumor size (p=0.008), tumor extension (p=0.028), pT-stage (p=0.012), pN-stage (p=0.012), and AJCC/TNM stage (p

Endoscopy practice in Thailand is being performed and serviced by both surgeons and gastroenterologists. The number of endoscopy performed by each specialty is very much comparable. Before 2000, the services were done independently. On 15th December 2005 the Thai Association of Gastrointestinal Endoscopy (TAGE) has been found Since TAGE has been found there is a rapid progression in GI Endoscopy service, research, and teaching in Thailand and its neighbor. However, the workload for the current number of endoscopists is still overwhelm by day-to-day service. Thailand and TAGE require the support and collaboration from oversea to expand their need and to serve better for GI Endoscopy practice in Thailand.

Background: Self-expanding metallic stents (SEMS) have been acknowledged in management of acute colorectal obstruction. The surgical approach after SEMS insertion varies from open approach to laparoscopic-assisted approach. The primary objective of this study was to compare the outcomes of laparoscopic approach and open approach after SEMS insertion. Methods: From January 2007 to December 2010, cross-sectional medical records reviewed a total of 76 patients who underwent colorectal stenting with SEMS. Patients and tumor characteristics, complications, morbidity and mortality were obtained. Results: Forty-three patients underwent SEMS placement as a bridge to surgery. Laparoscopic-assisted surgery (LS) was performed in 24 patients (55.8%), and open surgery (OS) was performed in 19 patients (44.2%). All clinicopathological parameters were matched. The technical success of SEMS was found in 42 patients (97.7%), and the clinical stent success was 100%. LS had a higher chance of primary anastomosis than OS (p=0.012; Odd ratio 2.717; 95%CI: 1.79-4.012). LS had a lower permanent ostomy rate (p=0.031; Odd ratio 0.385; 95%CI: 0.259-0.572) and lower estimated blood loss (p=0.024; Odd ratio 0.23; 95%CI: 0.006-0.086). The post-operative complications, mortality rate, recurrence rate, disease free status, and overall survival rates between the two groups were non-significant. Conclusion: Colonic stent is an effective treatment of acute malignant colonic obstruction. The authors suggest the advantage of laparoscopic approach resection after colonic stenting results in a higher primary anastomosis rate, and lower blood loss than open surgery.

Objective: Duodenal diverticulum is not uncommon but most are asymptomatic. Surgery is recommended only for the patients with symptoms. Although laparoscopic diverticulectomy can be done, it is often with significant difficulties due to inherent limitations of the laparoscopic technique and posterior location of the lesion. The advent of the robotic surgical technology with superior imaging and instrumentation may provide an alternative minimally invasive approach for this situation. We herein report our case series utilizing the daVinci Surgical System (dVSS) for duodenal diverticulectomy. Methods: We retrospectively reviewed our robotic database for all duodenal procedures performed at a single institution (the Valley Hospital: VH). Only patients who underwent laparobotic duodenal diverticulectomy (LRDD) were included and their recorded videos reviewed. Data analyzed were patients’ demographic, perioperative outcomes, and technical details. We used the daVinci Si (Intuitive Surgical Inc. Sunny Vale, Calif.) for all cases. Results: 4 female patients underwent LRDD. All presented with abdominal pain. Diagnosis was made by CT scans or MRI with or without EGD. 3 patients had diverticula located in the second part of the duodenum (75%). Concomitant procedures (choledochoduodenostomy and CBD exploration) were performed in two patients. Mean operative time was 142.5 min. There was one complication but no mortality. Average length of stay was 4 days. Conclusion: LRDD is feasible, efficient, and safe. The dVSS provides the surgeon improved visualization and enhanced dexterity to perform complex procedure.

Objective: Mesenteric and omental cyst are the rare intra-abdominal pathologies. We report laparoscopic excision of a large omental cyst in an adult patient. Methods: A 56 year-old female presented with a year history of upper abdominal pain with palpable mass at epigastrium. On physical examination, a non-tenderness mass, 8 cm in diameter, was noted in the right upper abdomen. Abdominal CT revealed large thin wall cyst without solid nodule or septation at right upper abdomen. Endoscopic ultrasonography revealed no demonstration of its origin without connection to duodenal wall, pancreatic and bile duct. The patient underwent a complete excision by laparoscopic approach. Intraoperative finding revealed an encapsulated thin wall smooth surface cystic mass in lesser sac. The patient made an uneventful postoperative recovery. Pathological examination showed simple mesothelial cyst. Discussion: Omental cysts often tends to be asymptomatic and is identified incidentally on imaging studies or at laparotomy. Ultrasonography, computed tomography and magnetic resonance imaging is a useful investigation to a correct diagnosis in patients with large cystic mass. Endoscopic ultrasonography is useful in distinguishing lesions arising in the wall of the GI tract from lesions. The complete excision is the treatment of choice. The advantages of laparoscopic approaches compared with open surgery are less postoperative pain, earlier recovery, shorter hospital stay, and better cosmetic. However, minimally invasive techniques should not compromise the basic surgical principles of complete excision. Conclusion: In our patient, we confirm the feasibility and safety of laparoscopic resection in large omental cyst.

Background: Single-incisionlaparoscopiccolectomy(SILC) isanevolvingtechnique withpotentialadvantages by reducing number of incisions that can reduce port-related complications and improve cosmetic results. The purposeof thisstudy wastocomparetheshort-termoutcomesbetweenSILC,hand-assistedlaparoscopiccolectomy (HALC) andstandard multi-port laparoscopic colectomy (MLC). Methods: Retrospectiveanalysesofatotalof90patientsbetweenMay2010and December2011, whounderwent SILC for coloncancer surgery, wereperformedin30patients. Clinicopathologicalparameters were matched1:1 withpatients whounderwent HALC (n=30)andMLC (n=30).Short-term outcomes werecollectedandanalyzed. Results: Operativetime wassignificantlyshorter inSILC comparedto HALC andMLC (p

Background: Self-expanding metallic stents (SEMS) have been acknowledged in management of acute colorectal obstruction. The surgical approach after SEMS insertion varies from open approach to laparoscopic-assisted approach. The primary objective of this study was to compare the outcomes of laparoscopic approach and open approach after SEMS insertion. Methods: From January 2007 to December 2010, cross-sectional medical records reviewed a total of 76 patients who underwent colorectal stenting with SEMS. Patients and tumor characteristics, complications, morbidity and mortality were obtained. Results: Forty-three patients underwent SEMS placement as a bridge to surgery. Laparoscopic-assisted surgery (LS) was performed in 24 patients (55.8%), and open surgery (OS) was performed in 19 patients (44.2%). All clinicopathological parameters were matched. The technical success of SEMS was found in 42 patients (97.7%), and the clinical stent success was 100%. LS had a higher chance of primary anastomosis than OS (p=0.012; Odd ratio 2.717; 95%CI: 1.79-4.012). LS had a lower permanent ostomy rate (p=0.031; Odd ratio 0.385; 95%CI: 0.259-0.572) and lower estimated blood loss (p=0.024; Odd ratio 0.23; 95%CI: 0.006-0.086). The post-operative complications, mortality rate, recurrence rate, disease free status, and overall survival rates between the two groups were non-significant. Conclusion: Colonic stent is an effective treatment of acute malignant colonic obstruction. The authors suggest the advantage of laparoscopic approach resection after colonic stenting results in a higher primary anastomosis rate, and lower blood loss than open surgery.

No Abstract

Background: Single-incision laparoscopic colectomy (SILC) is an evolving technique with potential advantages by reducing number of incisions that can reduce port-related complications and improve cosmetic results. The purpose of this study was to compare the short-term outcomes between SILC, hand-assisted laparoscopic colectomy (HALC) and standard multi-port laparoscopic colectomy (MLC). Methods: Retrospective analyses of a total of 90 patients between May 2010 and December 2011, who underwent SILC for colon cancer surgery, were performed in 30 patients. Clinicopathological parameters were matched 1:1 with patients who underwent HALC (n=30) and MLC (n=30). Short-term outcomes were collected and analyzed. Results: Operative time was significantly shorter in SILC compared to HALC and MLC (p< 0.001), as well as less estimated blood loss (p = 0.02). There were no significant differences in conversion rate and number of harvested lymph nodes. SILC had the advantage of less 24-hr postoperative pain score compared to HALC and MLC (p< 0.001), whereas length of stay and time to full diet were not different. Conclusion: In selected patients, SILC can be successfully and safely performed with shorter operative time, less estimated blood loss and less postoperative pain score. Keywords: Single-incision laparoscopic colectomy, single-port laparoscopic colectomy, hand-assisted laparoscopic colectomy, laparoscopic colectomy, colon cancer

Background. Traditionally, rectal cancer surgery is recommended 6 to 8 weeks after completing neoadjuvant chemoradiation. Extending the waiting time may increase the tumor response rate. However, the perioperative complication rate may increase. The purpose of this study was to determine the association between extending the waiting time of surgery after neoadjuvant chemoradiation and perioperative outcomes. Methods. Sixty patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiation followed by radical resection at Siriraj hospital between June 2012 and January 2015 were retrospectively analyzed. Demographic data and perioperative outcomes were compared between the two groups. Results. The two groups were comparable in term of demographic parameters. The mean time interval from neoadjuvant chemoradiation to surgery was 6.4 weeks in Group A and 11.7 weeks in Group B. The perioperative outcomes were not significantly different between Groups A and B. Pathologic examination showed a significantly higher rate of circumferential margin positivity in Group A than in Group B (30% versus 9.3%, resp.; P=0.04). Conclusions. Extending the waiting to >8 weeks from neoadjuvant chemoradiation to surgery did not increase perioperative complications, whereas the rate of circumferential margin positivity decreased.

Background: Situs inversus is a rare and silent autosomal recessive disorder occurring in 1:5,000 to 1:20,000 individuals. Laparoscopic cholecystectomy, a standard treatment for gallbladder disease in the general population, is very challenging in patients with situs inversus, especially for right-handed surgeons. We herein report a case involving our modified laparoscopic cholecystectomy technique for right-handed surgeons in a Thai patient with situs inversus who developed a symptomatic gallstone. We also include a short review of the literature. Case presentation: A 39-year-old female patient with dextrocardia presented with a 5-month history of episodic biliary colic. Abdominal ultrasonography revealed a left-sided gallbladder with gallstones. We performed laparoscopic cholecystectomy with our modified technique including port relocation. The operation went well, and our patient recovered satisfactorily. Conclusion: Laparoscopic cholecystectomy in patients with a left-sided gallbladder is not often confidently performed by right-handed surgeons. However, some modifications of "mirror image" ports focused on the more ergonomic port position are the keys to successful completion of this operation. The patient will thus still obtain benefits from this standard minimally invasive technique. [ABSTRACT FROM AUTHOR]

Solid pseudo-papillary tumor (SSPT) of the pancreas is a rare pancreatic tumor. It is distinct from other pancreatic tumors in its age and sex distribution. Following aggressive resection there is a favorable prognosis, with most patients going on to cure. This entity is widely reported in the surgical and pathological literature. We present a case of huge SSPT of the pancreas in a young woman who underwent successful Whipple's operation. She has been followed for two years without any evidence of recurrence. We also present a review of the literature on SSPT. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic esophagomyotomy (LEM) has become the standard treatment for achalasia. Recently, robot-assisted laparoscopic esophagomyotomy (RA-LEM) is emerging as a safe alternative to conventional LEM. We hypothesized that RA-LEM may reduce intraoperative complications compared with LEM. Objective: To compare RA-LEM with LEM in terms of intraoperative complications for the treatment of achalasia. Patients and Methods: A total of 42 patients underwent surgical treatment of achalasia at Siriraj Hospital between 1 December 2001 and 30 November 2013. A retrospective review of demographic data, perioperative course, complications, and hospital stay was performed. Patients were divided into 2 groups: group A (RA-LEM) consisted of 29 patients and group B (LEM) consisted of 13 patients. Operative time, estimated blood loss, duration of stay, intraoperative and postoperative complication were analyzed. Results: We could not demonstrate significant differences in esophageal perforation (13.8 vs. 15.4%; P= 0.999), aspiration (6.9 vs. 0%; P= 0.999) and operative time (195 ± 42 vs 197 ± 45 minutes; P- 0.999) between RA-LEM and LEM groups. There were significant reductions in blood loss (26.90 + 45.13 vs 74.62 ± 45.21 ml; P< 0.001) and postoperative length of stay (4.10 ± 1.18 vs 7.92 ± 6.43 days; P< 0.001). Conclusions: There was no significant reduction in intraoperative and postoperative complication between RA-LEM and LEM. We concluded that robotic surgery is equivalent in feasibility" and safety to conventional LEM. RA-LEM may be associated with less blood loss and shorter hospital stay. [ABSTRACT FROM AUTHOR]

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.