Rapat Pittayanon

Background and Aim: Helicobacter pylori infection remains a major cause of gastric cancer, peptic ulcer disease, and dyspepsia‐related morbidity across ASEAN. Since the first Bangkok Consensus Report in 2018, major advances have emerged in epidemiology, antimicrobial resistance, diagnostics, and eradication therapy. The Bangkok II Consensus Report aimed to provide updated evidence‐based recommendations tailored to Southeast Asia. Methods: A multidisciplinary panel from ASEAN and international partner countries updated regional guidance through three working groups covering epidemiology and indications for treatment, diagnostic testing and confirmation of eradication, and treatment strategies. Clinical questions and statements were developed from structured evidence review. Evidence quality and recommendation strength were graded using GRADE, with consensus defined as ≥ 80% agreement. Results: Twenty‐one clinical questions were addressed. The consensus emphasizes that H. pylori remains an important public health problem in ASEAN; eradication is central to gastric cancer prevention and ulcer management; diagnostic tests should be selected according to indication and local availability; 14‐day bismuth quadruple therapy is the preferred empirical first‐line regimen because of high clarithromycin resistance; PCAB‐based regimens are promising alternatives; and posttreatment confirmation of eradication should be routinely performed. Conclusions: The Bangkok II Consensus Report provides regionally relevant recommendations integrating antimicrobial resistance, healthcare disparities, and resource‐adapted strategies across ASEAN, addressing gaps in global guidelines and supporting reduction of H. pylori ‐associated disease, including gastric cancer, across Southeast Asia.

Gastric microbiota dysbiosis has been implicated in gastric carcinogenesis; however, the specific sampling method for assessing non-Helicobacter pylori microbiota associated with gastric cancer (GC) remains unestablished. This study compared gastric mucosal brushing with conventional biopsy for microbiota profiling in patients with GC and controls. We enrolled treatment-naïve GC patients and controls and analysed paired brushing and biopsy specimens using 16 S rRNA sequencing. Microbial analyses were compared between sampling methods and between the GC and control groups, and taxa–GC associations were assessed using age- and sex-adjusted mixed models. Overall brushing samples exhibited higher α-diversity than biopsy, including genus richness 60 ± 46.5 vs. 25.5 ± 19.5, Shannon 3.45 ± 0.71 vs. 2.80 ± 0.79, and Simpson 0.95 ± 0.03 vs. 0.92 ± 0.06 (all p < 0.0001), with different β-diversity (R² = 0.05, p < 0.001). In brushing samples, GC showed reduced α-diversity compared with controls (richness 39.5 ± 35 vs. 82 ± 51.8, p = 0.01; Shannon 3.20 ± 0.53 vs. 3.78 ± 0.52, p < 0.0001; Simpson 0.94 ± 0.05 vs. 0.96 ± 0.02, p = 0.002) and altered β-diversity (R² = 0.05, p = 0.01), whereas biopsy showed no α- and β-diversity differences. Our study demonstrates that brushing yielded higher bacterial diversity and different gastric microbiota profile compared with conventional biopsy sampling. Brushing also revealed depleted microbial diversity and altered microbial profile in gastric cancer. These findings suggest that brushing may improve the detection of certain gastric cancer–associated microbiota alterations.

Introduction Esophagogastroduodenoscopy (EGD) requires effective training to ensure technical proficiency. Tip-control simulation models are widely used for trainees; however, the optimal training schedule and standardized quality assessment methods remain unclear. This study aimed at determining the optimal training schedule for tip-control training and at piloting a structured assessment tool for performance evaluation. Methods In all, 73 first-year gastroenterology fellows, including the classes of 2024 and 2025, were included. In 2024, trainees self-selected training schedules, retrospectively categorized as short (15–30 min) or long (>30–60 min) sessions. Based on 2024 results, all trainees in the 2025 validation cohort followed a standardized short-session schedule (15 min, four times per week). Tip-control performance was assessed at weeks 2 and 4 using a structured assessment form and task completion time. Competency was defined as completion time <60 s with satisfactory performance across all domains. Results In 2024, the long-session group demonstrated higher scores at week 2 (2.7 ± 0.5 vs. 2.3 ± 0.3, p = 0.04). By week 4, the short-session group achieved significantly higher scores (3.6 ± 0.5 vs. 2.7 ± 0.5, p < 0.001) and greater improvement (p < 0.001), supporting selection of short-session training for validation. In 2025, trainees using short sessions demonstrated greater improvement (p = 0.01) and a trend toward higher week-4 scores (p = 0.05), despite less total training time. All trainees achieved competency by week 4. Conclusions Short, frequent training sessions improve tip-control skills more effectively and efficiently than longer sessions, supporting distributed practice in endoscopy training.

We appreciate the constructive comments provided by Dr. Parena Maheshwari regarding our article, “Asia‐Pacific Survey on the Management of Helicobacter pylori Infection.” The objective of this study was to investigate the extent of overall agreement among clinicians in the Asia‐Pacific region regarding the management of H. pylori infection. Our findings highlight key challenges, including limited access to potassium‐competitive acid blockers, low implementation of antibiotic susceptibility tests, and continued reliance on empirical regimens. Although vonoprazan is widely used in Japan, its adoption elsewhere remains limited due to regulatory and economic barriers. Notably, only 14.3% of clinicians reported using susceptibility‐guided therapy, hindered by the decline in culture‐based methods, cost issues, and limited laboratory infrastructure. We emphasize the urgent need for expanded access to molecular diagnostic tools and cost‐effectiveness studies to inform future strategies. Subgroup analyses revealed regional variability; however, further studies are warranted to further examine specialty‐based and intra‐regional differences. Eradication therapy in pediatric and elderly populations also poses unique challenges. Concerns regarding long‐term safety limit standardized protocols in children, while in elderly patients, evidence for gastric cancer prevention, particularly in those aged ≥ 80 years, remains insufficient. We are encouraged by the interest our work has generated and believe that this exchange highlights critical areas for future research, including antimicrobial resistance surveillance, individualized treatment approaches, and strengthening of health system capacities. We hope this dialogue will facilitate further research and contribute to improved H. pylori management across the Asia‐Pacific region.

Background: Guidelines recommend endoscopic surveillance for gastric cancer without therapeutic intervention every 3 years in patients with high‐risk gastric intestinal metaplasia (GIM). This study aimed to evaluate the efficacy of radiofrequency ablation (RFA) in eradicating high‐risk GIM.Methods: This randomized self‐control trial was conducted between June 2020 and February 2023. Patients with histology‐verified high‐risk GIM were enrolled. The endoscopist performed a biopsy on both the left and right sides of the stomach (five each) by targeting the suspected GIM area where available; otherwise, a random biopsy was taken. Patients were randomized to receive a unilateral RFA on either the left or right side. A repeated RFA on the assigned side was performed every 2–3 months for a total of two to three times. The primary outcome was complete resolution of GIM at 1 year after RFA.Results: Forty‐six patients with a mean age of 66 ± 8 years were analyzed. The complete resolution rate of overall GIM lesions after RFA was significantly higher (49/142; 34/5%) than that in the observation group (29/127; 22.8%, RR = 0.84, 0.73–0.98, p = 0.03). For the subgroup analysis, the complete resolution rate after RFA revealed a significantly higher value than observation only in the incomplete GIM group (24/87; 27.6% vs. 11/82; 13.4%, RR = 0.83, 0.71–0.97, p = 0.02). The percentage of patients with extensive GIM regression after RFA (15/25; 60%) was higher than in the observation group (9/25; 36%) but did not meet statistical significance (RR = 0.62, 0.35–1.09, p = 0.09).Conclusion: In high‐risk GIM, RFA can significantly eradicate incomplete GIM when compared with observation alone.

Background and Aim: Gastric cancer (GC)‐related incidence and mortality rates remain high owing to Helicobacter pylori infection in Asia, and the importance of primary and secondary prevention of GC has been well recognized. We aimed to investigate the extent of overall agreement among clinicians in the Asia‐Pacific region regarding the management of H. pylori infection.Methods: The Upper Gastrointestinal (GI) Focus Group of the Asian Pacific Association of Gastroenterology‐Emerging Leaders Committee developed an international survey, which was distributed to 98 clinicians in the Asia‐Pacific region, compromising an online questionnaire focusing on the management of H. pylori infection.Results: Participants responded from Japan (15, 15.3%), Hong Kong (15, 15.3%), Thailand (33, 33.7%), Vietnam (23, 23.5%), Malaysia (4, 4.1%), Singapore (3, 3.1%), and others (5, 5.1%). The most common first‐line eradication regimen was clarithromycin (CAM) triple therapy, including proton pump inhibitor (PPI), amoxicillin (AMPC), and CAM (64.3%) for 14 days (70.4%). The most common second‐line eradication regimen was levofloxacin (LVX) triple therapy, including PPI, AMPC, and LVX (22.4%) for 14 days (67.3%). Eradication therapy was deemed necessary for all asymptomatic adults and minors (aged ≤ 17 years) currently infected with H. pylori by 81.6% and 64.3% of respondents, respectively, with 82.7% considering upper GI endoscopy for GC screening useful in the secondary prevention of GC.Conclusion: There appears to be a growing consensus among clinicians, acknowledging the necessity of eradication therapy. We anticipate that this study will establish a new benchmark in preventive medicine aimed at eradicating GC in the Asia‐Pacific region.

Background and study aims The Varix Trainer model 1 (VTM1) was created for trainees to safely practice basic endoscope manipulation skills. The VTM1 was tested to see if it could distinguish levels of endoscope manipulation skills (construct validity) and whether training with it could improve these skills faster (content validity). Patients and methods We enrolled 23 novice endoscopists, 18 second-year trainees, and 13 expert endoscopists. They were asked to point with the endoscope tip to 20 numbers in the model as quickly as possible using torque, single-hand small/large wheel manipulation (SHSW), and retroflexion techniques. Their mean times (t20) were compared to determine if the model could distinguish different levels of expertise. Subsequently, 14 novices trained for eight short sessions, and the pre-training and post-training t20 were compared. Nine novice endoscopists received no training and were retested after 4 to 6 weeks (controls). Results Experts had faster t20 than second-year trainees, who were faster than novices, for all three techniques (P < 0.001). After eight sessions, the mean t20 for novices improved from 112 to 66 seconds for torque, 144 to 72 seconds for SHSW, and 108 to 63 seconds for retroflexion, (all P < 0.001). Their t20 were equivalent to second-year trainees. Improvement in t20 was also seen with the control group, but total reduction was less than for the training group. Conclusions The VTM1 distinguished varying levels of expertise for all techniques, suggesting that it is a valid tool for assessing endoscope manipulation skill. A short curriculum improved novices’ manipulation skills faster than traditional practice.

INTRODUCTION: The efficacy of topical hemostatic agents, recommended for peptic ulcer bleeding, remains poorly characterized in malignant gastrointestinal bleeding (GIB). METHODS: We performed an individual patient data meta-analysis assessing the efficacy of topical hemostatic agents in malignant GIB. The literature was searched using OVID MEDLINE, EMBASE, and ISI Web of Science databases (database inception to November 2023). Only randomized controlled trials (RCTs) comparing topical hemostatic agents with conventional endoscopic modalities in malignant GIB were included. Original RCT patient-level data were obtained. Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were followed. Quality of the evidence was evaluated using the revised Cochrane risk-of-bias tool and certainty of evidence with the Grading of Recommendations Assessment, Development, and Evaluation approach. The primary outcome was immediate hemostasis; secondary outcomes were 30-day rebleeding and the composite measure of further bleeding (persistent bleeding or 30-day rebleeding). Other outcomes were all-cause mortality, adverse events, and need for additional nonendoscopic treatment. Odds ratios (ORs) from endpoint comparisons were pooled using logistic regression models. RESULTS: Overall, 985 citations were identified; 3 RCTs (n = 160 patients) were included with all assessing TC-325 (Hemospray). TC-325 achieved immediate hemostasis more often than conventional endoscopic modalities (OR 46.6, 95% confidence interval [CI] 5.89–369.1) (low-level certainty). Thirty-day rebleeding (OR 0.28, 95% CI 0.11–0.70) and further bleeding (OR 0.11, 95% CI 0.05–0.26) were both significantly lower with TC-325 (very-low-level certainty). All-cause mortality and need for additional nonendoscopic treatment did not differ between groups. No adverse events were reported. Subgroup analysis confirmed TC-325 superiority in patients with upper GIB. DISCUSSION: TC-325 seems superior to conventional endoscopic therapy in managing patients with malignant GIB. TC-325 results in improvements in immediate hemostasis, 30-day rebleeding, and further bleeding, based on very low-to-low certainties of evidence.