Chris H. Fraser

Driving Plasticity in Human Adult Motor Cortex Is Associated with Improved Motor Function after Brain Injury

Changes in somatosensory input can remodel human cortical motor organization, yet the input characteristics that promote reorganization and their functional significance have not been explored. Here we show with transcranial magnetic stimulation that sensory-driven reorganization of human motor cortex is highly dependent upon the frequency, intensity, and duration of stimulus applied. Those patterns of input associated with enhanced excitability (5 Hz, 75% maximal tolerated intensity for 10 min) induce stronger cortical activation to fMRI. When applied to acutely dysphagic stroke patients, swallowing corticobulbar excitability is increased mainly in the undamaged hemisphere, being strongly correlated with an improvement in swallowing function. Thus, input to the human adult brain can be programmed to promote beneficial changes in neuroplasticity and function after cerebral injury.

A Prospective Study of MR Enterography Versus Capsule Endoscopy for the Surveillance of Adult Patients With Peutz-Jeghers Syndrome

OBJECTIVE The objective of our study was to assess the utility of MR enterography compared with capsule endoscopy for the detection of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS). SUBJECTS AND METHODS Adult patients with PJS scheduled for surveillance capsule endoscopy were prospectively recruited and underwent MR enterography and capsule endoscopy. Polyps > 10 mm were regarded as clinically relevant. When appropriate, large polyps (> 15 mm) were removed at enteroscopy, enabling correlation with MR enterography and capsule endoscopy findings. Interobserver agreement for MR enterography and capsule endoscopy was calculated. Patient comfort, convenience, and test preference were assessed. RESULTS Nineteen patients (median age, 39.6 years) underwent both procedures. There was no significant difference between techniques for the detection of polyps > 10 mm (18 vs 23 polyps at capsule endoscopy and MR enterography, respectively; p = 0.35) or in the number of patients in whom > 10 mm polyps were detected (eight vs 11 patients at capsule endoscopy and MR enterography, respectively; p = 0.38). However, in three patients, large polyps (> 15 mm) detected on MR enterography were not detected on capsule endoscopy; large polyps were seen in six patients at capsule endoscopy and in nine patients at MR enterography (p = 0.25). Interobserver agreement was high for MR enterography but was only fair for capsule endoscopy (kappa = 0.81 and 0.27, respectively). Size assessments of large polyps (> 15 mm) appeared more reproducible with MR enterography than with capsule endoscopy. Patients rated capsule endoscopy as more comfortable than MR enterography. There was no significant difference between the techniques with regard to patient convenience or preference. CONCLUSION MR enterography is a promising alternative to capsule endoscopy for small-bowel surveillance in adults with PJS. Although our results suggest that capsule endoscopy is more comfortable for the patient, MR enterography may be less prone to missing large polyps and may be more reliable in their size assessment.

Feasibility of video capsule endoscopy in the management of children with Peutz-Jeghers syndrome: a blinded comparison with barium enterography for the detection of small bowel polyps.

Objectives: Peutz-Jeghers syndrome (PJS) in children may present with anaemia, intussusception, or obstruction from an early age and surgery is common. Prophylactic polypectomy may reduce subsequent complications. Traditional barium enterography (BE) has poor sensitivity and requires significant radiation. We compared the performance of capsule endoscopy (CE) with BE in children with PJS. Materials and Methods: Children with PJS (ages 6.0–16.5 years) were prospectively recruited and underwent BE followed by CE, each reported by expert reviewers blinded to the alternate modality. Number of “significant” (>10 mm) and total number of polyps were recorded. Child preference was assessed using a visual analogue questionnaire. Definitive findings were assessed at laparotomy or enteroscopy, when performed. Results: There was no significant difference for >10 mm polyp detection. Six polyps were found in 3 children by both modalities: 3 polyps in 2 children at CE, 3 polyps in 1 child at BE (P = 0.50). Re-review of 1 CE identified 3 polyps that were missed in 1 child at initial reading. Significantly more <10 mm polyps were identified by CE than BE: 61 vs 6 (P = 0.02). CE was significantly more comfortable than BE (median score CE 76 [interquartile range 69–87] vs BE 37 [interquartile range 31–68], P = 0.03) and was the preferred investigation in 90% (P = 0.02). Conclusions: CE is a feasible, safe, and sensitive test for small bowel polyp surveillance in children with PJS. It is significantly more comfortable than BE and is the preferred test of most children for future surveillance. There is a learning curve for reporting CE studies in PJS and appropriate training is essential.

Provision of service and training for small bowel endoscopy in the UK

Objective To determine the location and use of small bowel endoscopy services in the UK and to analyse training uptake to assess future demand and shape discussions about training and service delivery. Design Surveys of British Society of Gastroenterology (BSG) members by web-based and personal contact were conducted to ascertain capsule endoscopy practice and numbers of procedures performed. This was compared with expected numbers of procedures calculated using BSG guidelines, hospital episode statistics and published data of capsule endoscopy in routine practice. Analysis of data from two national training courses provided information about training. Results 45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohns disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy; 14 services are in development. 74% of trainees were interested in training and of those training in image interpretation, 67% are doctors and 28% are nurses. Conclusions Capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underused. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.

Deep enteroscopy using a conventional colonoscope and through-the-scope balloon catheter system: How deep is deep?

Yung et al emphasize the value of double-balloon enteroscopy (DBE) in completing cecal intubation in patients with prior incomplete colonoscopy. In 57 patients they achieved a cecal intubation rate of 96.5%. In a systematic review of 16 studies they found that DBE achieved a cecal intubation rate of 95% in 621 patients with prior incomplete colonoscopy. In our center, DBE is available and performed by several of my partners, but I use standard instruments (colonoscopes and occasionally push enteroscopes) in all patients referred with prior incomplete examinations. With standard instruments, I achieved a cecal intubation rate of 97.3% in 520 patients with no perforations and an adenoma detection rate of 53%. The advantages of using colonoscopes and other standard instruments include first a success rate in cecal intubation at least as high as that of DBE; once cecal intubation is achieved any necessary therapy can be applied with instruments that are shorter, generally have larger working channels, and handle considerably easier than double-balloon enteroscopes. For these reasons I recommend standard instruments as first line in patients with prior incomplete colonoscopies. However, although my preference is for standard instruments in patients referred for incomplete colonoscopy, I acknowledge that DBE may be the preferred alternative in some centers, depending on available instruments and expertise with standard instruments.

First evaluation of multi-modal fice for detection and differentiation of small bowel lesions at capsule endoscopy

Introduction Multi-modal Flexible spectral Imaging Color Enhancement (FICE) (Fujinon, Saitama, Japan) is a novel imaging technique, which attempts to augment endoscopic detection and differentiation of gastrointestinal lesions. FICE is computer aided reprocessing that enhances original white light (WL) images by reconstituting virtual ones for a range of different optical wavelengths. Recently FICE has also been incorporated into reporting software of the most widely available small bowel capsule endoscopy (SBCE) system (GIVEN Imaging, Israel). This is the first study to evaluate the usefulness of FICE computer aided detection and differentiation of small bowel (SB) lesions seen at SBCE. Methods 30 WL video clips (10 seconds each), subdivided into six diagnostic categories (angioectasias, ulceration, polyps, coeliac disease, bleeding, normal) were selected from our SBCE database by an experienced capsule endoscopist. Each of these clips was then reprocessed to generate an additional four multi-modal FICE versions in different optical wavelengths (red, blue, green and enhanced contrast FICE). This generated a total 150 SBCE video clips (including original WL clips) that were evaluated by three experienced capsule endoscopists, blinded to the content of each clip. The primary endpoint was the assessment of high confidence interpretation of the correct diagnosis. Results Interim analysis of the results at this stage, suggest that the correct identification of the lesions appeared to be broadly similar for WL and all multimodal FICE wavelengths (84% for WL vs 89% for FICE). However, the confidence level of reporting appeared to be higher for WL than for FICE (84% vs 68%) at this stage. Intra-group analyses for FICE showed that the confidence level of reporting was highest for high contrast FICE and lowest for blue FICE (68% vs 45%). Conclusion The preliminary results suggest that although the diagnostic accuracy of FICE appears to be similar to that of WL, the confidence of reporting with FICE appears to be lower. This may be reflective of the novelty of the technology and therefore, minimal operator experience in its use. Further larger studies are required to evaluate any potential benefit of FICE over WL SB lesion detection and differentiation.

PWE-002 Short-Term outcomes following Surgical Treatment of benign Colonic Polyps: a Case-Matched Study

Introduction Patients diagnosed with complex colonic polyps (broad based, crossing two haustral folds, or being located at the ileocaecal valve or colonic flexures) unsuitable for endoscopic treatment undergo the same surgical procedure as patients with colon cancer. As a result of the bowel cancer screening programmes, the number of these patients has increased significantly and outcomes after hemicolectomy for benign colonic polyps (BCP) are poorly documented. We present a case-matched study examining short-term outcomes of patients with BCP versus those with colonic cancer (CC) from two institutions. Methods Consecutive patients undergoing surgery for BCP were identified in two hospitals from prospectively maintained databases (data collection period 2005–2006 and 2010–2012 respectively). Hospital coding database was also searched using operation codes to identify missing patients. Each patient was matched for age, sex, ASA grade, site and type of resection (laparoscopic, open, and converted) to two controls undergoing surgery for treatment of CC identified in each centre. The length of stay (LOS) and 30-day outcomes were analysed with further adjustments for BMI, blood loss and operation time. Multilevel linear and logistic regression analyses were performed. Results 46 BCP patients were matched with 81 CC patients. Almost all procedures were performed laparoscopically (42/46). Two procedures were converted to open and two patients underwent planned open surgery. Median size of BCP was 4 cm (IQR 2.5, 5.4). BCP group had a marginally longer LOS [median 5.5 days (IQR 4, 8) and 5 days (IQR 3, 7) respectively (p = 0.04)]. 21/46 (46%) patients with BCP had a postoperative complication compared to 25/81 (31%) CC patients (p = 0.12, OR = 2.11; CI 0.82–5.41). 4/46 (9%) BCP patients underwent reoperation and further 3/46 (7%) were readmitted versus 1/81 (1%) and 2/81 (2%) in CC group (p = 0.07 and 0.28 respectively). No deaths were observed in either group. Conclusion Complications following segmental colectomy for complex colonic polyps are not significantly different to those after cancer surgery. The results of this study provide further impetus for the development of a local full thickness colonic excision technique as an alternative, less invasive treatment option in order to improve patient outcomes. Disclosure of Interest None Declared

PTU-017 Systematic Review of Endoscopic full Thickness Resection (Eftr) Techniques for Colonic Lesions

Introduction Introduction of the English Bowel Cancer Screening Program has resulted in increase in the number of patients diagnosed with endoscopically irresectable colonic polyps. A significant proportion of these patients undergo hemicolectomy associated with a significant risk of death, anastomotic leakage and general complications. The need for an alternative, less invasive treatment option for this patient cohort is becoming increasingly clear. Abstract PTU-017 Table 1 Outcome measures Authors Study Procedure completed Intra-operative complications Procedure duration (min(range)) Specimen size (cm (range)) Survival Schurr et al. A&S 20/20(100%) 5/10(50%) & 0/10(0%) - Over 3 cm* A 20/20(100%) 3/10(30%) & 0/10(0%) - - Rajan et al. S 8/8(100%) 4/8(50%) 30.2 3.6(1.5–5.2) 8/8(100%) Raju et al. S 19/20(95%) 0/19(0%) 50(24.5– 67) 1.7(1–2.5) 19/20(95%) Von Renteln et al. A 9/20(45%) & 8/8(100%) 6/9(67%) & 2/8(25%) 14.8(7–36) & 31.5(21–42) 3.3(2.4–5.5) Rieder et al. A 2/2(100%) 0/2(0%) 33 +/- 4 2.2+/-0.1 Von Renteln et al. S 8/8(88%) 2/8(25%) 3(2–12) 7.6cm2(5.4–11 cm2) 7/8(88%) Kennedy et al. A&S 3/3(100%) & 4/4(100%) 0/3(0%) & 0/4(0%) 233(201–245)** 2.5(2–3) & 3.5(3.5–4) 4/4(100%) Total 101/113(89%) 22/101(22%) 48/50(96%) Abbreviations: A = acute study, S = survival study; *Reported for 5 animals only, ** Reported for survival group only Methods Systematic literature searches identified articles describing EFTR in the colon of adult pigs, published 1990–2012. Complication rates, anastomotic bursting pressures, procedure duration, specimen size and quality, and post-mortem findings were analysed. Results Four EFTR techniques using endoscopic stapling devices, T-tags, compression closure or laparoscopic assistance for defect closure before or after specimen resection were reported. 113 procedures were performed in 99 porcine models (Table 1), with an overall success rate of 89% and a 4% mortality. The intraoperative complication rate was 22% (0% > 67%).Post-resection closure methods (as opposed to simultaneous resection and closure) more commonly resulted in failure to close the defect (5% > 55%) and a high incidence of abnormal findings at post-mortem examination (84%). Significant heterogeneity was observed in procedure duration (average 3 min to 233 min) and size of the excised specimen (average 1.7 cm to 3.6 cm). Anastomotic bursting pressures and specimen quality were poorly documented. Conclusion The technique of EFTR is in development, with experience currently limited to preclinical studies. The inability to close the resection defect reliably is the primary obstacle to further progress. This review highlights the challenges that need to be addressed in future preclinical studies. Disclosure of Interest None Declared

OC-055 A Novel Technique for full Thickness Laparoendoscopic Excision of Colonic Lesions: an Experimental Pilot Study

Introduction Introduction of a National Bowel Cancer Screening Program in England has resulted in an increasing number of patients diagnosed with endoscopically irresectable colonic polyps. A significant proportion of these patients is referred for hemicolectomy and is subject to a significant risk of morbidity and mortality. Therefore, a less invasive treatment option is required and to address this, we modified a previously reported full thickness laparo-endoscopic excision (FLEX) technique. Methods Surgery was performed in five 70-kg pigs. A simulated colonic polyp was created by endoscopic injection of Spot® and the clearance margin delineated by circumferential placement of mucosal argon plasma coagulator (APC) marks. Full thickness eversion of the colonic wall, including the lesion, was achieved by endoscopic placement of prototype BraceBars (BBs). The everted section was excised using a linear laparoscopic stapler placed below the BBs. The first pig was terminated immediately and others were sacrificed 8 days after surgery. Results The median procedure duration, defined from placement of mucosal APC marks to specimen excision, was 26 min (range 20–31 min). All excised specimens contained three pairs of BBs, included the APC marks and had a median diameter of 5.1 cm (range 4.5–6.3 cm). Postoperative recovery in survival animals was uneventful. Post-mortem evaluation demonstrated well-healed resection sites with no evidence of intra-abdominal infection or inadvertent organ damage. Endoscopic evaluation of anastomoses at post-mortem demonstrated a widely patent lumen without evidence of stenosis at excision sites. Histological examination of the anastomoses showed primary closure by mucosal abbutal and regeneration, with repair and restoration of submucosal continuity. Conclusion This proof-of-concept study has demonstrated the feasibility and safety of a novel full thickness colonic excision technique that is now ready for translation as an alternative to hemicolectomy. The excision size will accommodate most colonic polyps that currently come to surgery. Accurate placement of endoscopic BBs ensures complete excision, reducing the risk of residual disease and recurrence, while laparoscopic overview avoids collateral damage. The ability to preserve mesenteric vasculature and colonic length is likely to result in less morbidity and mortality, better functional outcomes and the approach should reduce treatment costs. Disclosure of Interest None Declared

THE FIRST REPORT OF THE UK MULTICENTRE DOUBLE BALLOON ENTEROSCOPY REGISTRY

Introduction Double balloon enteroscopy (DBE) has been a pivotal endoscopic technology, transforming the investigation and management of small bowel (SB) disorders by facilitating direct endoscopic access of the entire small bowel. Methods We report the initial experience of the UK multicentre registry (six centres) since the introduction of DBE in the UK in 2005. Results 550 cases (322 men) were performed. Mean age was 56 years (16–94 years). 189 cases were done under general anaesthesia, 361 cases done under conscious sedation. 372 cases were performed via the oral route, 175 were performed via the rectal route while three cases were performed via an ileostomy. Calculated mean depth of insertion was 270±80 cm and 190±75 cm for oral and rectal routes, respectively. Mean time taken to complete procedures was 74±20 min. Carbon dioxide was used as the insufflating gas in 344 cases while air was used in the remaining 206 cases. DBE was preceded by capsule endoscopy (CE) in 403 cases. Concordance of diagnoses at CE and DBE was 66% and the overall diagnostic yield for DBE was 61%. The indications and therapies applied at DBE are shown (Abstract 025). Significant lesions missed by CE but diagnosed by DBE included large vascular lesions, polyps and other small bowel tumours. Endoscopic therapy at DBE was applied in 38% of procedures. There were three reported complications (2 perforations and 1 acute coronary syndrome); all complications occurred during therapeutic procedures. The overall complication rate for DBE in the series was 0.5%, with a complication rate for therapeutic procedures of 1.4%. There were no cases of acute pancreatitis. Limitations to DBE procedures included patient intolerance, the presence of adhesions and poor bowel preparation. Abstract OC-025 Indications and endotherapy applied Indictn. Cases Indictn. Cases Endo. Rx Cases OGIB 347 Rx-en-Y 2 - - APC 147 CD 58 - - Plpectmy 36 Polyps 49 - - Dilation 18 Strictr. 36 - - DPEJ 7 ?Tumour 28 - - Endoclip 2 Coeliac 15 - - Thrombin 1 DPEJ 8 - - Intussus 4 - - Ret. CE 3 - - Conclusion The initial UK experience is favourable and echoes the results of other national series published to date, showing that DBE is a feasible and safe and endoscopic advancement that enhances the management of small bowel disorders.