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OC-085 Endoscopic revision of gastric bypass using apollo overstitch

Introduction Obesity is an increasing health problem worldwide. Roux-en-Y gastric bypass can produce a 56%–66% wt loss 2 years after surgery. Roughly 20% of patients fail to achieve 50% wt loss in the 1 st year after gastric bypass. Furthermore, 30% of patients regain weight 18 to 24 months after bypass. Revision surgery can be very challenging with higher complication and mortality rates than that of primary gastric bypass. Endoscopic therapy has the potential to be a suitable alternative in this patient set. The overstitch endoscopic suturing system (Apollo Endosurgery, Austin, Texas) is a disposable, single-use, in vivo reloadable device that is mounted onto a double channel gastroscope that enables suture application. Method We present a video and discuss the technical details of roux-en-y gastric bypass revision using the Apollo OverStitch. The procedure steps include (video): 1. OverStitch Endoscopic Suturing System Overview 2. Argon Plasma Coagulation (APC) application to the margins of the gastrojejunal anastomosis 3. Placement of sutures using the OverStitch system. Results A 28 year old female, 2 years after Roux-en-Y gastric bypass presented with increasing weight gain to 190 kg. Past medical history includes mild depression and moderate anxiety. A diagnostic OGD showed a very patent gastrojejunostomy anastomosis, measuring approximately 20 mm across. Endoscopic revision of the bypass anastomosis was performed using the Apollo OverStitch to encourage weight loss. The procedure was performed under a general anaesthesia, and involved the placement of an overtube. APC using a straight firing catheter at 1 litre/min (40 watts) was applied to the margin of the gastrojejunal anastomosis. 6 sutures were placed using the EndoStitch system to approximate the interior borders of the anastomosis with good results. There were no immediate complications. 8 months after placement of Apollo OverStitch, weight remained at 179 kg. Conclusion In one study of 25 patients where the OverStitch was used for revision of gastric bypass, patients lost an average of 11.7 kg at 6 months. Our case highlighed similar weight loss of 11 kg at 8 months. References . http://apolloendo.com/overstitch/ . Endoscopic therapy for weight loss: Gastroplasty, duodenal sleeves, intragastric balloons, and aspiration. Nitin Kumar. World Journal of Gastroenterology. Jul’15. . Jirapinyo P, Slattery. J, et al. Evaluation of an endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy2013; 45:532–536. Disclosure of Interest None Declared

PTH-039 The First Randomised Controlled Trial of Endocuff Vision® Assisted Colonoscopy Versus Standard Colonoscopy for Polyp Detection in Bowel Cancer Screening Patients (E-Cap Study): Abstract PTH-039 Table 1

Introduction Up to 25% polyps are missed during colonoscopy. The Endocuff Vision® is a cap with soft flexible arms that attaches to the colonoscope tip and improves views during withdrawal. We have performed the first randomised controlled trial to identify the role of Endocuff Vision® in improving polyp detection. We aim to investigate the impact of Endocuff Vision® assisted colonoscopy on polyp detection, as compared to standard colonoscopy, in the UK Bowel Cancer Screening Programme (BCSP). Methods Single centre, parallel group, randomised controlled trial. Ethics ref: 14/SC/0207. Adopted on UKCRN portfolio (ID: 16985). Patients attending for BCSP colonoscopy were stratified based on attendance for index screening colonoscopy or for polyp surveillance. Within each stratum participants were randomised to either Standard or Endocuff assisted colonoscopy. All procedures were performed by accredited BSCP endoscopists, who have carried out > 5000 colonoscopies and have caecal intubation rates of >90%. Results 534 patients recruited from Sep 2014 to Sep 2015. 3 excluded due to new diagnosis of polyposis syndrome. 531 were included and randomised to the 2 study arms. No significant difference was seen between the 2 groups for the primary endpoint of number of polyps per patient. Secondary endpoints: No significant difference was observed between the 2 groups for adenoma detection rate (ADR) or number of adenomas per patient (Table 1).Abstract PTH-039 Table 1 Standard Endocuff No. participants 265 266 No. of polyps 470 436 Polyps/patient 1.77 1.63 Adenomas 364 343 Adenomas/patient 1.37 1.28 Polyp detection rate 185/265 = 69.8% 187/266 = 70.3% Adenoma detection rate 167/265 = 63% 162/266 = 60.9% Cancer detection rate 15/265 = 5.7% 14/266 = 5.3% No significant adverse events were encountered during the study in either arm. The cecal intubation time was not prolonged and patients did not experience any additional discomfort due to the Endocuff Vision. Conclusion In the UK, bowel cancer screening is performed by highly experienced endoscopists. Our results suggest that in expert hands, ADR exceeds 60% even without Endocuff. In such settings, Endocuff Vision did not improve polyp detection rates (PDR) or ADR. However, it did not cause any adverse events, prolong procedure duration or cause additional discomfort. These data demonstrate the safety and feasibility of Endocuff. However, no additional gain was demonstrated in expert hands. Disclosure of Interest None Declared

OC-011 EMR VS ESD for Barrett’s Neoplasia: Time to Shift the Paradigm?

Introduction The risks of ESD in the oesophagus are perceived to be high and consequences potentially disastrous. For this reason, EMR is the most common technique to resect early Barrett’s cancer. However, the drawback of EMR is piecemeal resection with difficulties interpreting resection margins of cancers. The aim of this study was to evaluate feasibility, safety, and outcomes of ESD in the endoscopic treatment of Barrett’s neoplasia and to compare these with EMR. Methods All data was collected prospectively on a predesigned electronic database between 2006 and 2015. The database was interrogated by independent researchers blinded to the endoscopic procedures. Bleeding was defined as significant if patients required transfusion, endoscopic therapy or hospitalisation. Strictures were defined as significant if they were symptomatic or requiring dilatation. SPSS was used for statistical analysis of data Results 81 oesophageal ESDs were performed in 70 patients and 180 EMRs were performed in 112 patients during the study period. Table 1 demonstrates patient and lesion characteristics and outcomes following resection including deep R0 resection margin for cancer and histological outcomes. Lesion morphology and histology was significantly more advanced in the ESD group as compared to EMR.Abstract OC-011 Table 1 Barrett’s patient and lesion characteristics Mean age Mean Follow up Mean Length (cm) IIa IIb IIc Is Mean Size (mm) EMR n = 180 69.2 6.5 5.7 44% 37% 6% 12% 24 ESD n = 81 72.4 1.6 6.1 37% 2% 23% 35% 33 p-value NS NS NS NS <0.01 <0.01 <0.01 NS Resection Outcomes R0 Cancer En bloc HGD Cancer Recurrence Bleeding Stricture EMR n = 180 73% 30% 42% 57% 12% 4% 4% ESD n = 81 82% 89% 8% 88% 4% 2% 2% p-value NS <0.01 <0.01 <0.01 0.03 NS NS The endoscopic cure rate in the EMR group was 81% with 19% of patients upstaged requiring radical treatment. In the ESD group the endoscopic cure rate was 87% with 13% of patients upstaged requiring radical treatment. Conclusion This is the biggest reported comparison of EMR vs ESD for Barrett’s neoplasia. Proportionately more Is and IIC lesions were resected by ESD than by EMR which is reflected by significantly more cancers identified in the ESD group. Our data shows the safety and efficacy for ESD resection of Barrett’s cancers but EMR still remains a standard therapeutic option for non-cancerous Barrett’s neoplasia. This calls for a prospective RCT comparing ESD vs EMR for Barrett’s cancer. Disclosure of Interest None Declared

PTH-031 Knife Assisted Resection for Dysplasia Associated Lesion or Mass: A Video Abstract

Introduction The risk of colonic neoplasia is increased in inflammatory bowel disease. Dysplasia-associated lesion or mass (DALM) can be difficult to detect and challenging to resect endoscopically. Conventional endoscopic mucosal resection (EMR) has been used but as these lesions are often flat morphologically, the snare slips off. Endoscopic submucosal dissection (ESD) has been shown to be able to resect flat lesions, however, they carry a high perforation rate outside the rectum. Knife assisted snare resection (KAR) is a novel technique that combines the principles of EMR and ESD. We aim to evaluate the safety and efficacy of this technique in resecting DALMS as well as demonstrate the technique in the accompanying video abstract. Methods Data of all KARs undertaken by a single endoscopist in our institution from 2012 to 2014 were prospectively compiled in a pre-designed database. 2 independent researchers interrogated the database. Endoscopic follow-up was performed to identify recurrence. Results 9 patients underwent KAR during this period. 8 patients had ulcerative colitis and 1 had Crohn’s colitis. The mean polyp size was 29 mm (10–60 mm). Scarring was noted in 89% of resections despite no previous resection attempts. En-bloc resection was achieved in 7 patients (78%). Endoscopic curative resection was achieved in 7 patients and 1 patient is awaiting endoscopic follow-up. 1 patient experienced a delayed perforation, which was managed surgically. Histological assessment of the resected polyps revealed 8 adenomas with low grade dysplasia and 1 cancer. Conclusion DALMs are difficult to detect and challenging to resect endoscopically using conventional methods. We have demonstrated that KAR as a novel technique is safe and effective in resecting DALMs. As the learning curve of KAR is not as steep as ESD, we believe that is a viable endoscopic resection technique of DALMs in inflammatory bowel disease. Disclosure of Interest None Declared

PTU-036 Safety of Radiofrequency Ablation Following Endoscopic Resection in Barrett’s Neoplasia: Does Resection Method Matter?

Introduction The current standard of treating Barrett’s neoplasia is resection of visible lesions followed by ablative therapy to the Barrett’s segment. Endoscopic mucosal resection (EMR) is the conventional method of resection although there is growing evidence for the use of endoscopic submucosal dissection (ESD). Radiofrequency ablation (RFA) is a safe and effective ablation technique but carries a risk of complications including bleeding, stricture and perforation. ESD is associated with much deeper submucosal dissection then EMR, resulting in a deeper and thicker scar. This has been a cause for concern whilst performing RFA after ESD and experts have raised the possibility of higher stricture or perforation rates with RFA after ESD. We wish to compare the safety and efficacy of radiofrequency ablation following EMR and ESD and to ascertain if there are any significant differences. Methods An electronic database (from 2007–2015) of all patients who had endoscopic resections (EMR or ESD) for Barrett’s neoplasia followed by RFA was analysed. Data was collected on patient demographics, Barrett’s length, lesion size, number of ablations required and follow up period. The clearance of neoplasia (high grade dysplasia/intramucosal cancer) was also recorded (CE-N) along with procedural complications including bleeding, perforation and strictures. Results There were 30 patients in the EMR + RFA group (average age 73.1 years) compared to 19 in the ESD + RFA group (average age 74.6 years). Patients received circumferential ablation (HALO 360) or focal ablation (HALO 90/60/Ultra) depending on the extent of residual Barrett’s oesophagus post endoscopic resection. The table below shows the outcome of RFA following EMR or ESD. ESD was started in our institution later than EMR and that is reflected in lower numbers and shorter follow up in the ESD cohort but it is otherwise a well matched population.Abstract PTU-036 Table 1 EMR + RFA ESD + RFA Number of patients 30 19 Mean follow up (years) 4.1 1.6 Mean Barrett’s length (cm) 7.4 7.1 Mean lesion size (mm) 20.4 26.7 Mean number of ablations 1.9 1.7 CE-Neoplasia 93.3% 94.7% Bleeding (n,%) 0 1 (5.3%) Perforation (n,%) 0 0 Stricture (n,%) 2 (6.7%) 0 Conclusion This is the first UK series reporting on the safety and efficacy of RFA after ESD. RFA following ESD or EMR is equally safe and effective and the endoscopic resection method is not a significant factor when planning ablation therapy. Disclosure of Interest None Declared

PWE-108 Feasibility, Safety and Efficacy of Knife Assisted Resection (KAR) of Rectal Polyps Extending to The Dentate Line: How Low Can You Go?

Introduction Rectal polyps extending to the dentate line (RPDL) pose a technical challenge to endoscopic resection due to the narrow lumen, rich venous/haemorrhoidal plexus and proximity to the skin. Conventional snare EMR is challenging due to the restrcited space and lack of precision with the snare. This has led to the use of surgical techniques like TEMS and TAR for resection of RPDLs. Knife Assisted snare Resection (KAR) allows for precise mucosal incision at the dentate line and the dissection of the polyp from the anorectal junction. We aim to assess the feasibility, safety and efficacy of KAR for RPDLs. Methods This is a prospective observational study of patients who underwent KAR with a mean follow up of 32 months (range 1–83 months). All procedures were done on a day case basis and were carried out under sedation by two endoscopists using high definition gastroscopes with a distal transparent cap. The polyp margin on the anal side was injected with lifting solution consisting of gelofusin, indigo carmine, 1% lignocaine and adrenaline. Haemostasis was maintained using a combination of the endoscopic knife and coag-grasper (Olympus Medical). A mucosal incision was extended around the margins of the polyp, followed by submucosal dissection to facilitate snare deployment to achieve complete polyp resection. Post-procedural antibiotics were not routinely given. Results A total of forty patients (20 female, median age 69 years) underwent KAR for RPDLs over the study period. The polyp characteristics and histology are described in Table 1. The curative resection after a single KAR was achieved in 33 (82.5%) patients. 7 of the 40 patients required further KARs, leading to a total curative resection rate to 97%. The risk factors for multiple resections are polyps measuring >60 mm and encompassing >50% of the circumference (p < 0.01). Overall, there was one complication where the patient had delayed bleeding which was managed conservatively. None of the patients experienced perforation, or post-procedural sepsis.Abstract PWE-108 Table 1 Lesion characteristics and histology Lesion size, median (range), mm 50 (12–150) Morphology, n (%) - LST – G, nodular mixed- LST – G, homogenous- LST – NG- Is 29 (72.5)2 (5)2 (5)7 (17.5) Scarring, n (%) 13 (32.5) Histology, n(%) Adenoma with LGDAdenoma with HGDCancerOther – Condyloma acuminatum 30 (75)6 (15)3 (7.5)1 (2.5) Conclusion This is the largest reported series of KAR for RPDLs. Our data demonstrates that for Western endoscopists, KAR is a very safe and effective technique in the treatment of RPDLs. As KAR is a viable alternative to full ESD, TEMS and TAR, it will play an increasingly significant role in the management of RPDLs. Disclosure of Interest None Declared

OC-054 Development and Validation of a Classification System to Identify Barrett’s Neoplasia Using Acetic Acid Chromoendoscopy: The Predict Classification

Introduction Neoplasia in Barrett’s can be discrete and patchy. Acetic acid chromoendoscopy (AAC) has been demonstrated to highlight neoplastic areas allowing for earlier treatment. Previous efforts to create a classification system for AAC have not been systematic and rigorous in their methodology. We aimed to develop and validate a classification system to identify Barrett’s neoplasia using AAC. Methods Three expert AAC endoscopists (PB, GLW, OP) formed a working group to identify AAC component criteria of non-dysplastic and dysplastic Barrett’s using a modified Delphi Method. Following this, a panel of 7 AAC experienced endoscopists assessed the performance of each individual criterion by reviewing a bespoke online database of 40 images and 40 videos of non-dysplastic and dysplastic Barrett’s lesions. Finally, we assessed the diagnostic reproducibility of the validated criteria by asking 13 non-AAC experienced endoscopists to complete an assessment tool of 40 images and 20 videos. Results The component criteria identified by the expert AAC endoscopists were as follows Early focal loss of acetowhitening Present: Indicates the presence of neoplasia Absent: Indicates the absence of neoplasia Surface pattern Normal (Large uniformly distributed pits): Indicates non-neoplastic Barrett’s Abnormal (Compact, irregular or absent pits): Indicates neoplastic Barrett’s A total of 560 observations were undertaken to validate these criteria. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) are shown in Table 1:Abstract OC-054 Table 1 Validation results of the classification criteria Criteria Sensitivity Specificity NPV PPV Loss of acetowhitening 96.2%(93.4–97.9%) 93.8%(88.9–96.9%) 90.9%(85.5–94.8%) 97.5%(95.4–98.8%) Surface pattern• Normal• Abnormal 77.0%(69.7–83.3%)99%(97.5–99.7%) 99.0%(97.5–99.7%)77.0%(69.7–83.3%) 91.4%(88.4–93.9%)96.9%(92.2–99.1%) 96.9%(92.2–99.1%)91.4%(88.4–93.9%) When the AAC validated criteria are applied by the 13 endoscopists, the sensitivity, specificity, NPV and PPV of detecting neoplastic Barrett’s are 98.5%, 64.0%, 97.5% and 72.5% respectively. Conclusion We have developed and established the validity of a simple classification system to identify Barrett’s neoplasia using AAC. When non-AAC experienced endoscopists apply these criteria, the sensitivity and NPV meet the recommended PIVI threshold. Disclosure of Interest None Declared

PTH-032 Knife Assisted Resection of Right-Sided Colonic Polyps: The Right Way Round!: Abstract PTH-032 Table 1

Introduction Endoscopic resection of right-sided colonic polyps carries a higher risk of complications including bleeding and perforation. This risk is heightened in the resection of polyps that are tethered, flat or on background of colitis (complex polyps). In the West, complex polyps in the right colon are frequently managed by endoscopic mucosal resection (EMR) or surgery although recurrence rates can be as high as 20%. Endoscopic submucosal dissection (ESD) is an effective technique in the resection of complex polyps. However, ESD is technically challenging with a long learning curve and carries a significant perforation rate (6% in Eastern series and 17% in Western series) leading to a poor uptake of this technique in the West.[i]We aim to examine the safety and efficacy of a novel technique of knife assisted snare resection (KAR) in resecting complex polyps in the right colon. Methods Data of all KARs undertaken by a single endoscopist in our institution from 2009 to 2015 were prospectively compiled in a pre-designed database and interrogated by independent researchers blinded to the technique. Polyps in the right colon (distal transverse to caecum) were included in the analysis. Polyp characteristics and procedure details were prospectively recorded. Endoscopic follow-up was performed to identify recurrence. Results A total of 52 patients with complex polyps 10–80 mm in size were resected by KAR. The mean follow up time was 35 months. 42% of the polyps were >40 mm in size, and 51% were scarred from previous attempts. The majority of the polyps resected (91%) exhibited flat morphology (Paris Classification IIa, IIa+IIb, IIa+IIc). Table 1 shows the patient baseline and lesion characteristics. There were 2 cases of delayed bleeding (4%) neither of which required surgery. The endoscopic cure rate was 96% after single procedure, improving to 98% with further attempts.Abstract PTH-032 Table 1 Patient baseline and lesion characteristics Age years, (mean) 46-83 (70) Sex (M:F) 2.7:1 Mean polyp size, mm (range) 35 (7–80) En Bloc Resection, n (%) 24 (45%) Scarring, n (%) 28 (51%) Histology, n• Adenoma• SSP• DALM• Cancer 361234 Conclusion This is the first reported Western series of KAR of complex polyps in the right colon. Our data demonstrates that this novel technique is safe and effective for resection of complex polyps in the right colon. The recurrence rates are superior to EMR and complication rates are lower than ESD. As the learning curve for KAR is shorter than that for ESD, we believe that this technique is ideal for the Western setting. Reference 1 Saito Y, Uraoka T, Yamaguchi Y, et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections. Gastrointest Endosc. 2010;72:1217–1225 Disclosure of Interest None Declared

PTH-018 Endoclot Prophylaxis Following Complex Endoscopic Resection of Gastrointestinal Neoplasia: No Need to Bleed!

Introduction EMR / ESD of large lesions creates large mucosal defects and is associated with significant post-procedural bleeding. EndoclotTM is a topical hemostatic powder that rapidly absorbs water creating a high concentration of platelets, red blood cells and clotting factors – accelerating the natural coagulation cascade. Routine application of EndoclotTM to ESD or EMR defects is hypothesised to reduce the risk of significant post EMR/ESD bleeding. Methods A prospective registry was set up to record all EMR / ESD procedures since 2006. Prophylactic use of EndoclotTM, following endoscopic resection of lesions >20 mm, to prevent delayed bleeding was introduced in June 2014. The bleeding rate since the introduction of this strategy was compared with the bleed rate of our historic cohort since 2006. Bleeding was defined as significant if it required: readmission, transfusion or further intervention. SPSS was used for statistical analysis of data. Results Pre-Endoclot cohort: 496 patients underwent lower gastrointestinal EMR/ESD at our institution between 2006 and 2013 with a mean polyp size of 43 mm and 12% of these polyps were scarred due to previous intervention. Significant delayed bleeding was seen in 21/496 patients (4%). 264 patients underwent upper gastrointestinal EMR/ESD at our institution between 2006 and 2013. Significant delayed bleeding was seen in 9/264 patients (3%). Endoclot cohort: 71 patients have undergone colonic EMR/ESD (mean polyp size 46 mm, 38% scarred) (Table 1). 61 patients have undergone upper gastrointestinal resection (mean lesion size 33 mm, 37% scarred).Abstract PTH-018 Table 1 Colonic ER Outcomes Mean Lesion Size (mm) Scarring % Delayed Bleeding % Pre-Endoclot n = 496 43 12 4 Post-Endoclot n = 71 46 38 1 P-value NS <0.01 NS There was 1 significant delayed bleed in the colonic group (1%) requiring further endoscopic therapy. There were 2 bleeds (3%) in the upper GI group, which were managed with further endoscopic therapy without the need for blood transfusion. There have been no complications related to EndoclotTM use. Device clogging was experienced in 5% of upper gastrointestinal cases and 15% of lower gastrointestinal cases. Conclusion EndoclotTM shows promise in reducing the risks of delayed bleeding following endoscopic resection of large neoplastic lesions from the gastrointestinal tract. Our data demonstrates a 75% reduction in risk of delayed bleeding following EMR/ESD for large colonic polyps in a group with a significantly higher rate of scarring and therefore bleeding risk. A randomised controlled trial is required to clarify the role of routine use of EndoclotTM following EMR/ESD. Disclosure of Interest None Declared

PTU-017 Per Oral Endoscopic Myotomy (POEM) for Achalasia

Introduction Achalasia is an oesophageal motor disorder due to inhibitory neuron dysfunction, resulting in loss of oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. POEM is emerging as a viable alternative to laparoscopic Heller’s myotomy (LHM) for the treatment of achalasia. However, it is still in it’s infancy in the West with no reported cases from UK. We aim to present two videos and discuss the technical details of the procedure in a simple type II achalasia and in a complex sigmoid achalasia. Methods Prior to undertaking POEM patients are investigated with barium swallow, gastroscopy and high-resolution manometry to confirm the diagnosis of achalasia and delineate the anatomy of the oesophagus. Eckhardt score is calculated pre and post POEM. Informed consent is undertaken, including alternatives to POEM: LHM, pneumatic dilatation and Botox injection. The procedure steps include (video): 1. Submucosal injection and incision 2. Creation of submucosal tunnel 3. Endoscopic myotomy 4. Closure of mucosal entry. Results Case 1: A 61 year-old lady, presenting with dysphagia, retrosternal chest pain and regurgitation (Eckhardt score 6). Barium swallow demonstrated typical appearances of achalasia (see video). Pre-POEM manometry confirmed Type II achalasia with a resting lower oesophageal sphincter (LOS) pressure of 26. She underwent an uneventful POEM procedure via the anterior approach using a combination of flush-knife and triangular tip knife to achieve a 10+4 cm myotomy. On follow-up she has no symptoms (Eckhardt score 0) and repeat manometry shows a reduction in LOS pressure to 15. Case 2: A 52 year-old lady, presenting with dysphagia, retrosternal chest pain, regurgitation and weight loss (Eckhardt score 11). Barium swallow demonstrated advanced achalasia with severe dilatation and a sigmoid appearance (see video). She was treated at her local centre with two sessions of PD and one of Botox despite which she suffered ongoing symptoms. Pre-POEM manometry revealed Type II achalasia and an LOS pressure of 25.5. She underwent an uneventful POEM procedure via the posterior approach using the O-type Erbe hybrid knife to achieve an 11 + 4 cm myotomy. Significant fibrosis was encountered due to previous intervention. On follow-up her symptoms improved significantly. Repeat manometry is awaited. Conclusion Here we describe the technique of POEM at the two ends of the disease spectrum of achalasia We demonstrate the feasibility of the technique in the hands of a UK Endoscopist. We demonstrate two different approaches to POEMS (Anterior vs Posterior) and with two different knives and will discuss the Pros and Cons of these approaches. Despite previous intervention and submucosal fibrosis, POEM is still a viable treatment for patients with ongoing symptoms. Disclosure of Interest None Declared