Current status of gastrointestinal endoscopy in Thailand
Article information
Abstract
The Thai Association for Gastrointestinal Endoscopy (TAGE) has played a pivotal role in advancing gastrointestinal (GI) endoscopy in Thailand through its strategic focus on clinical services, education, and research. Since its establishment in 2005, TAGE has united gastroenterologists and surgeons, helping standardize endoscopic practices across the country. Through national training programs, clinical guideline development, hands-on workshops, and international collaborations, TAGE has elevated the quality and accessibility of endoscopic care. Despite challenges such as workforce shortages and the uneven distribution of services, particularly in rural areas, TAGE continues to address these gaps through outreach training, model development, and regional research initiatives. Society leadership in cholangiocarcinoma management, advanced endoscopy, and educational model innovation reflects its commitment to improving outcomes and establishing Thailand as a regional hub for GI endoscopy.
INTRODUCTION
Flexible gastrointestinal (GI) endoscopy dates back to the 1960s with the introduction of the flexible fiberscope by Hirschowitz.1 In Thailand, endoscopy was initially performed by both surgeons and gastroenterologists, with surgeons dominating in the early years. The development of endoscopy began in the 1970s at major academic centers, following the introduction of fiberoptic endoscopes imported from Japan. Early pioneers trained abroad, mainly in Japan and the United States, and subsequently established nationwide endoscopic services. Although academic curricula for digestive endoscopy were introduced during this period, practice remains divided between surgeons and gastroenterologists. The growing number of trained endoscopists, the need for standardization, and successful early collaborations among specialists eventually led to the formal establishment of Thai Association for Gastrointestinal Endoscopy (TAGE) as a professional society, evolving from the “Endoscopy Club” founded in 2001.
The “Endoscopy Club” co-founders included Professors Pinit Kulawanich, Surapol Cheunratanakol, Sukij Panpimanmas, Pairoj Luengrojanakul, Thawee Ratanachu-ek, Udom Kachintorn, Yudhtana Satthawatthamrong, and Rungsun Rerknimitr. This initiative ultimately led to the establishment of the TAGE in December 2005.2 TAGE was founded with the mission of elevating the quality of GI endoscopy in Thailand through multidisciplinary collaboration, education, research, and public awareness, and by fostering unity among Thai endoscopists.
ESTABLISHMENT OF THE ENDOSCOPY SOCIETY
Over the past two decades, since the establishment of TAGE, GI endoscopy in Thailand has advanced rapidly in terms of clinical services and training. Initially limited to basic diagnostic procedures, practice has expanded to include therapeutic interventions, such as endoscopic retrograde cholangiopancreatography (ERCP), small bowel enteroscopy, therapeutic endoscopic ultrasound (EUS), endoluminal resection, and third-space endoscopy. Training based on an apprenticeship model has evolved into structured programs complemented by TAGE-developed hands-on workshops, facilitating the nationwide adoption of complex endoscopic procedures.
TAGE formation marked a significant milestone in Thailand’s endoscopic community by formalizing national efforts to promote high-quality endoscopy services through standardization, education, and research. In addition to its services and educational missions, TAGE has played a pivotal role in developing national practice guidelines,3-5 fostering multicenter collaborative research,6 and advancing the creation of endoscopic training models.7
INTERNATIONAL COLLABORATION
TAGE has established robust collaborations between local members and international partners, forging connections with renowned societies such as the Asia Pacific Society for Digestive Endoscopy (APSDE), Korean Society of Gastrointestinal Endoscopy (KSGE), International Digestive Endoscopy Network (IDEN), Asian Endoscopic Ultrasound Group (AEG), Asian Novel Bio-Imaging and Intervention Group, Japan Gastrointestinal Endoscopy Society, Taiwan Interventional Pancreatobiliary Endoscopy Society, Asian Pacific Association of Gastroenterology, Gastrointestinal Endoscopy Taskforce Asian Pacific, World Gastroenterology Organisation, World Endoscopy Organization, and American Society for Gastrointestinal Endoscopy (ASGE). These partnerships have fostered a strong network for education, research, and professional exchange and have improved the quality of local practices by enhancing their skills and knowledge through workshops and conferences.
Since 2016, TAGE has supported the APSDE education program by organizing quarterly international workshops aimed at helping early-career endoscopists improve their technical skills. To further promote academic collaboration, TAGE adopted Siriraj Medical Journal as its official journal in 2020. In 2021, TAGE signed a Memorandum of Understanding with the KSGE, designating Clinical Endoscopy as an official journal. Furthermore, the TAGE–ASGE Joint Symposium has been held annually at Digestive Disease Week in the United States since 2023, addressing important topics such as hilar cholangiocarcinoma, endoscopic emergencies, and advances in pancreatic disease treatment.
These collaborations have greatly enriched the exchange of knowledge and best practices, strengthening the advancement of GI endoscopy both in Thailand and globally. The milestones of TAGE and international collaboration are shown in Table 1.
Milestones of the Thai Association for Gastrointestinal Endoscopy
ACTIVITIES AND INITIATIVES
TAGE members actively engage in academic activities, including lectures, hands-on workshops, and collaborative endoscopy training programs. Regular international conferences organized by TAGE, with the participation of neighboring Association of Southeast Asian Nations (ASEAN) countries, highlight Thailand’s regional leadership in GI endoscopy. The annual live endoscopy demonstration meeting attracted international faculty members and Southeast Asian participants. At the 21st Annual Meeting in 2025, TAGE partnered with IDEN to host a joint conference that featured shared scientific sessions. Beyond its own events, TAGE has contributed to major international meetings, such as the Asian EUS Congress, IDEN, and Asia-Pacific Digestive Week (APDW), through live case demonstrations. TAGE enhances the uniformity and quality of endoscopy practice by organizing scientific meetings, workshops, and annual endoscopy nurse meetings to strengthen the skills of endoscopic assistants.
Furthermore, the TAGE has played a leading role in initiating a national colorectal cancer screening program and in coordinating collaboration among regional and national healthcare providers. Colorectal cancer is the third most common cancer among Thai men and the second most common among Thai women.8 The Thai Ministry of Public Health and the National Cancer Institute of Thailand, in collaboration with TAGE, initiated a national colorectal cancer screening program. The program employs a one-time fecal immunochemical test (FIT) for initial screening, followed by colonoscopy of FIT-positive individuals.9
This large-scale screening initiative leverages existing local infrastructure to improve early detection and access to colorectal cancer screening in rural areas. Using data obtained from this program, TAGE has published research proposing a cut-off value for the FIT based on endoscopic findings, contributing valuable insights toward optimizing resource allocation and improving screening efficiency in resource-limited settings.6 Notably, a cholangiocarcinoma screening program using point-of-care transabdominal ultrasonography has been implemented in northeastern Thailand, where Opisthorchis viverrini infection is endemic. However, TAGE was not directly involved in this initiative.10 Given the low prevalence of gastric cancer in Thailand, a national screening program for early gastric cancer is not warranted.
ENDOSCOPY SERVICES
Thailand, with a population of over 65 million and a diverse geography spanning 77 provinces, provides endoscopy services across various hospital levels, from community hospitals to academic centers. However, facilities remained unevenly distributed with higher concentrations in urban areas than in rural regions. The most commonly performed procedures are esophagogastroduodenoscopy (EGD) and colonoscopy. Upper GI bleeding is the leading indication in emergency settings, whereas colonoscopy is the most frequent procedure in elective cases.
Referral centers in Thailand provide a full spectrum of endoscopic services, ranging from basic diagnostic procedures to advanced therapeutic interventions, endoscopic submucosal dissection, third-space endoscopy, EUS, and ERCP. In contrast, provincial hospitals primarily perform therapeutic gastroscopy, colonoscopy, and ERCP, which are limited by the availability of equipment and trained personnel. Although endoscopy services in major centers meet international standards, regional facilities continue to face resource constraints.
Figure 1 shows the nationwide distribution of the advanced endoscopic procedures. Population density by province (Fig. 2A) and the geographic distribution of endoscopy services (Fig. 2B) highlight the service gaps in remote areas. Most advanced endoscopists are concentrated in Bangkok, which limits access to underserved regions. Under Thailand’s National Health Insurance system, patients can be referred to tertiary centers for specialized procedures. Nonetheless, ERCP is available in most provinces, whereas EUS remains confined to major centers. Annual procedural volumes typically range from 500 to 1,000 ERCPs and 300 to 600 EUS cases in large centers, compared with 200 to 350 and 100 to 300, respectively, in smaller hospitals.
The proportion of advanced endoscopic procedures performed according to the 2024 national survey (total 71 responses). ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasound; ERCP, endoscopic retrograde cholangiopancreatography.
The Thailand map shows each province with a different population density. (A) The darker area denoted a higher density of population. (B) The distribution of endoscopy performed by gastroenterologists and surgeons in each province. Dark grey denotes the provinces where endoscopic procedures are performed by both gastroenterologists, and light grey denotes the provinces where procedures are performed only by surgeons, with no gastroenterologist available in the province.
ENDOSCOPY TRAINING
Formal Gastroenterology Fellowship Training in Thailand began in 1997. The medical pathway includes a six-year undergraduate program, a one-year internship, and a two-year rural service before specialty training. The journey to gastroenterology training consisted of a three-year internal medicine residency, followed by a two-year fellowship emphasizing core procedures such as EGD, colonoscopy, hemostasis, and polypectomy. Currently, 15 accredited centers train approximately 35 to 40 fellows annually. For surgical endoscopists, the pathway includes a four-year general surgery program that provides for endoscopic training with required proficiency in diagnostic EGD and colonoscopy with polypectomy. The extent of exposure varies according to institutional resources and faculty expertise.
Advanced procedures such as ERCP, EUS, and therapeutic interventions are pursued post-fellowship through specialized programs, although structured training is limited to four centers, mainly in Bangkok. Some endoscopists receive training abroad, while others, particularly surgical endoscopists, rely on proctorships and hands-on workshops. As surgeons outnumber gastroenterologists, especially in rural areas, most endoscopic procedures outside of major cities are performed by surgeons. A national survey conducted in 2024 showed that only 25% of practitioners performing endoscopy are trained in advanced procedures. When such expertise is required, over half of the patients are referred to regional centers, and the rest are referred to Bangkok. The primary barriers to performing advanced procedures are limited training and supervision. To address this issue, TAGE launched short-course workshops in rural areas to enhance local endoscopy skills and patient access.
Furthermore, TAGE has developed “TAGE models” for EUS procedures, from fine-needle aspiration to EUS-guided biliary drainage (EUS-BD), which have been used in annual live endoscopy workshops since 2018.7 The second-generation TAGE-2 model features improved materials and a realistic hepatobiliary anatomy, including components simulating hepaticogastrostomy and choledochoduodenostomy. A long-term evaluation showed that 85.7% of trainees could independently perform EUS-BD within three years of training.4 The TAGE-2 model, which does not use biological material and does not require fluoroscopy, has been widely adopted in hands-on workshops such as ENDO 2017, APDW 2018, and EUS Confluence Day 2019.
Regarding formal fellowships, TAGE supports various regional and international educational programs. Since 2016, it has participated in locoregional APSDE training programs across Thailand, Vietnam, Myanmar, Indonesia, and Cambodia, offering 2-day hands-on workshops, live cases, and lectures on both luminal and pancreaticobiliary endoscopies. TAGE also contributes to AEG short-course EUS training by providing budget-friendly, all-synthetic, non-fluoroscopy EUS models for diagnostic and therapeutic practice, widely used in international workshops.7
RESEARCH IN ENDOSCOPY
The key strength of TAGE in endoscopy research lies in its commitment to innovation and boundary-free collaboration between surgeons and gastroenterologists. This unique synergy has accelerated the development and dissemination of highly complex therapeutic procedures and research collaborations across Thailand and neighboring countries. The rapid expansion of advanced techniques has been supported by structured educational programs and training initiatives throughout the region.
Hepatobiliary diseases, particularly cholangiocarcinoma, represent the area of greatest research focus.10 TAGE has spearheaded several landmark international collaborative projects, including the 2013 consensus guidelines on cholangiocarcinoma management,11 2022 consensus on the role of cholangioscopy in diagnosing indeterminate biliary strictures,12 and 2024 updated Asia-Pacific consensus statement on the endoscopic management of malignant hilar biliary obstruction.4 Furthermore, TAGE representatives have contributed to international consensus statements on the endoscopic management of biliary strictures, further solidifying their global influence13,14 and providing recommendations on quality indicators for EUS.15
Furthermore, TAGE has conducted pioneering research on the quality and efficacy of therapeutic EUS models, widely recognized as TAGE models, and has been validated using data from trainees worldwide.7,16 Beyond this, the society has been at the forefront of therapeutic EUS innovations, including EUS-guided gallbladder drainage17 and EUS-guided hepaticogastrostomy (HGS), in combination with endoscopic drainage for hilar cholangiocarcinoma.18
At the national level, TAGE actively collaborates with surgical societies to advance bariatric surgery, leading to the implementation of national recommendations for endoscopic bariatric and metabolic therapies5 and publishing context-specific guidelines, such as those for endoscopic practice during the coronavirus disease 2019 pandemic.3,19,20 In addition to clinical guidelines, TAGE has produced a series of endoscopic atlases that cover both basic and advanced diagnostic techniques and serve as a valuable educational tool for practitioners. These resources have helped shape endoscopic practices in Thailand by incorporating local epidemiological patterns and accounting for the availability of national healthcare resources. These efforts highlight TAGE’s leadership in integrating research, innovation, and multidisciplinary collaborations to shape the future of endoscopy in Thailand and the Asia-Pacific region.
LIMITATIONS AND CHALLENGES
Thailand faces several challenges in endoscopy practices, including workforce shortages in rural areas, limited access to advanced procedures outside tertiary centers, and reimbursement constraints. The uneven distribution of healthcare personnel, with most endoscopists concentrated in urban or tertiary care centers, leads to limited access in rural and remote areas. Thailand’s diverse geography poses logistical challenges regarding patient referral and timely access to endoscopic procedures. Furthermore, the restricted resources and infrastructure in peripheral hospitals hinder the availability of advanced endoscopic interventions, resulting in unequal service quality and delayed diagnosis and treatment across regions. TAGE plays a vital role in improving technical skills in advanced procedures and negotiating the government reimbursement system.
FUTURE PERSPECTIVE
Looking ahead, TAGE aims to strengthen its role as a national and regional leader in GI endoscopy through standardization, innovation, and collaboration. A unified advanced endoscopy training curriculum will continue to evolve to ensure equitable access, competency-based assessments, and certification across institutions. TAGE also plans to work with policymakers to integrate evidence-based practices into national healthcare strategies and to optimize resource allocation.
Future initiatives include expanding training tools beyond the TAGE-2 model to encompass emerging procedures, such as EUS-guided coil embolization for gastric varices and gastroenterostomy, with an emphasis on sustainability and accessibility. Evaluation of these novel models is ongoing, with plans for their implementation in upcoming international hands-on workshops.
Strengthened partnerships between surgeons and gastroenterologists will remain central to TAGE’s mission of supporting collaborative education and research tailored to regional needs. Through these initiatives, TAGE has become a global leader in endoscopic training, research, and clinical excellence, advancing the quality and reach of endoscopic care in Thailand.
CONCLUSIONS
The practice of GI endoscopy in Thailand has advanced considerably, propelled by the leadership and initiatives of TAGE in clinical services, education, and research. Despite the persistent challenges related to geographic and resource disparities, sustained efforts in training, innovation, and collaboration continue to drive progress. With growing national and international engagement, TAGE is positioned to strengthen its role as a regional leader in GI endoscopy.
Notes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Author Contributions
Conceptualization: NP; Data curation: all authors; Writing–original draft: all authors; Writing–review & editing: NP.