Kesavan Kandiah

Knife-assisted snare resection: a novel technique for resection of scarred polyps in the colon.

BACKGROUND AND STUDY AIMS There have been significant advances in the management of complex colorectal polyps. Previous failed resection or polyp recurrence is associated with significant fibrosis, making endoscopic resection extremely challenging; the traditional approach to these lesions is surgery. The aim of this study was to evaluate the efficacy of a novel, knife-assisted snare resection (KAR) technique in the resection of scarred colonic polyps. PATIENTS AND METHODS This was a prospective cohort study of patients, in whom the KAR technique was used to resect scarred colonic polyps > 2  cm in size. Patients had previously undergone endoscopic mucosal resection (EMR) and developed recurrence, or EMR had been attempted but was aborted as a result of technical difficulty. RESULTS A total of 42 patients underwent KAR of large (median 40  mm) scarred polyps. Surgery for benign disease was avoided in 38 of 41 patients (93 %). No life-threatening complications occurred. Recurrence was seen in six patients (16 %), five of whom underwent further endoscopic resection. The overall cure rate for KAR in complex scarred colonic polyps was 90 %. CONCLUSIONS KAR of scarred colonic polyps by an expert endoscopist was an effective and safe technique with low recurrence rates.

Knife-assisted snare resection (KAR) of large and refractory colonic polyps at a Western centre: Feasibility, safety and efficacy study to guide future practice.

Objective Endoscopic mucosal resection (EMR) is widely practiced in western countries. Endoscopic submucosal dissection (ESD) is very effective for treating complex polyps but colonic ESD in the western setting remains challenging. We have developed a novel technique of knife-assisted snare resection (KAR) for the resection of these complex lesions. Here we aim to describe the technique, evaluate its outcomes, identify outcome predictors and define its learning curve. Methods We conducted a prospective cohort study of patients who had large and refractory polyps resected by KAR at our institution from 2007 to 2013. Polyp characteristics and procedure details were recorded. Endoscopic follow-up was performed to identify recurrence. Results A total of 170 patients with polyps 20–170 mm in size were treated by KAR and followed up for a mean of 31.5 months (range 12–84 months). 29% of the polyps were >50 mm, 22% had fibrosis from previous unsuccessful interventions and 25% were in the right colon. The perforation rate (1.2%) and bleeding rate (4.7%) were acceptable and managed conservatively in most patients. Recurrence rate after the first attempt was 13.1%. Recurrence was significantly increased by polyp size >50 mm (p = 0.008; OR 5.03, 95% CI 1.54–16.48), presence of fibrosis (p = 0.002; OR 6.59, 95% CI 1.97–22.07) and piecemeal resection (p < 0.001; OR 0.31, CI 0.078–1.12). Cure rates were 87% after the first attempt, improving to 95.6% with further attempts. En bloc resection rate showed a linear increase and reached almost 80% as the endoscopist’s cumulative experience approached 100 cases. Conclusion This is the largest reported Western series on KAR in the colon. We have demonstrated the feasibility, efficacy and safety of this technique in the treatment of complex polyps, with or without fibrosis and at all sites. KAR has shown better outcomes than either EMR or ESD. We have also managed to identify significant outcome predictors and define the learning curve.

International development and validation of a classification system for the identification of Barrett’s neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT)

Background Barrett’s oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett’s neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use. Objective To develop and validate a simple classification system to identify Barrett’s neoplasia using AAC. Design The study was conducted in four phases: phase 1—development of component descriptive criteria; phase 2—development of a classification system; phase 3—validation of the classification system by endoscopists; and phase 4—validation of the classification system by non-endoscopists. Results Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett’s mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001). Conclusion We developed and validated a classification system known as PREDICT for the diagnosis of Barrett’s neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett’s neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

Early squamous neoplasia of the esophagus: The endoscopic approach to diagnosis and management

Considerable focus has been placed on esophageal adenocarcinoma in the last 10 years because of its rising incidence in the West. However, squamous cell cancer (SCC) continues to be the most common type of esophageal cancer in the rest of the world. The detection of esophageal SCC (ESCC) in its early stages can lead to early endoscopic resection and cure. The increased incidence of ESCC in high-risk groups, such as patients with head and neck squamous cancers, highlights the need for screening programs. Lugols iodine chromoendoscopy remains the gold standard technique in detecting early ESCC, however, safer techniques such as electronic enhancement or virtual chromoendoscopy would be ideal. In addition to early detection, these new “push-button” technological advancements can help characterize early ESCC, thereby further aiding the diagnostic accuracy and facilitating resection. Endoscopic resection (ER) of early ESCC with negligible risk of lymph node metastases has been widely accepted as an effective therapeutic strategy because it offers similar success rates when compared to esophagectomy, but carries lesser morbidity and mortality. Endoscopic submucosal dissection (ESD) is the preferred technique of ER in lesions larger than 15 mm because it provides higher rates of en bloc resections and lower local recurrence rates when compared to endoscopic mucosal resection (EMR).

OC-068 Blue light imaging for barrett’s neoplasia classification (blinc): the development and validation of a new endoscopic classification system to identify barrett’s neoplasia

Introduction Neoplasia in Barrett’s can be subtle and difficult to identify. Blue light imaging (BLI) by Fujifilm is a novel advanced endoscopic technology that provides high intensity contrast imaging for superior visualisation of mucosal surface and vessel patterns. This can improve the identification of Barrett’s neoplasia. To date there is no formal classification system that enables the characterisation of neoplastic and non-neoplastic Barrett’s for BLI. The aim of our study was to develop and validate a classification to identify Barrett’s neoplasia using BLI. Method 3 expert endoscopists formed a working group to identify criteria characterising neoplastic and non-neoplastic Barrett’s on BLI using a modified Delphi method. A simple classification system utilising pit, vessel pattern and colour was developed using a database of 40 images. 6 experienced endoscopists then assessed a library containing 45 images of neoplastic and non-neoplastic Barrett’s using the proposed criteria. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) were calculated to assess its performance. The same parameters were then evaluated for each component criteria. Results The BLINC criteria are as follows: Non Neoplastic Neoplastic Pit pattern Circular, tubular or branching with normal density Irregular, crowded with increased density Vessel Pattern Regular, pericryptal, non dilated vessels with normal density Irregular, non cryptal, dilated vessels with increased density Colour Pale Focal darkness The table below shows the overall sensitivity, specificity, PPV and NPV of the classification in the identification of Barrett’s neoplasia. Sensitivity (95% CI) 96.7 (92.4–98.9)% Specificity (95% CI) 96.7 (91.2–99.1)% PPV (95% CI) 97.3 (93.3–99.0)% NPV (95% CI) 95.9 (90.7–98.2)% When each category in the classification was analysed separately the predictive values of pit and vessel pattern in neoplasia characterisation were high compared to colour. Sensitivity (95% CI) Specificity (95% CI) PPV (95% CI) NPV (95% CI) Pit Pattern 96.0 (91.5–98.5)% 98.3 (94.1–99.8)% 98.6 (94.8–99.7)% 95.2 (89.9–97.7)% Vessel Pattern 94.7 (89.8–97.7)% 93.3 (87.3–97.1)% 94.7 (90.1–97.2)% 95.2 (89.9–97.7)% Colour 86.7 (80.2–91.7)% 78.3 (69.9–85.3)% 83.3 (78.0–87.6)% 82.5 (75.6–87.7)% Conclusion We have developed the first internally validated simple classification system for the diagnosis of Barrett’s neoplasia using BLI. The classification criteria demonstrated high sensitivity and specifity. We aim to use the proposed classification in future studies for real time optical diagnosis of Barrett’s neoplasia. Disclosure of Interest S. Subramaniam: None Declared, K. Kandiah: None Declared, F. Chedgy: None Declared, R. Bhattacharyya: None Declared, P. Basford: None Declared, G. Longcroft-Wheaton: None Declared, P. Bhandari Conflict with: Receives educational grants from Fujifilm, Olympus, Pentax

Polypectomy and advanced endoscopic resection

Most colorectal cancers evolve from colorectal adenomatous polyps in a pathway known as the adenoma to carcinoma sequence. Early detection and removal of colorectal adenomas can prevent the development of colorectal cancer. The vast majority of these polyps can be resected endoscopically. Advances in endoscopic resection techniques have led to expanded indications for endoscopic polypectomy, whereby giant polyps, scarred lesions and early cancers may be cured. We will outline conventional endoscopic mucosal resection techniques as well as more complex resection methods such as endoscopic submucosal dissection, full thickness resection and the use of combined endoscopic and laparoscopic assisted approaches to resection. We will also explore the role of a virtual multidisciplinary team to aid decision-making when managing large and complex colorectal polyps. This review will provide an update on the endoscopic management of colorectal polyps and highlight exciting new developments in this ever-expanding field.

Advances in the endoscopic diagnosis and treatment of Barrett's neoplasia.

Barrett’s oesophagus is a well-recognised precursor of oesophageal adenocarcinoma. The incidence of oesophageal adenocarcinoma is continuing to rise in the Western world with dismal survival rates. In recent years, efforts have been made to diagnose Barrett’s earlier and improve surveillance techniques in order to pick up cancerous changes earlier. Recent advances in endoscopic therapy for early Barrett’s cancers have shifted the paradigm away from oesophagectomy and have yielded excellent results.

Tu1019 A “Real World” Controlled Study of Liver Stiffness Measured by ARFI (Acoustic Radiation Force Impulse) Elastography in Hospitalised Patients With Decompensated Alcoholic Liver Disease (ALD): A New Paradigm in Assessment of Severity and Prognosis?

Introduction Acoustic Radiation Force Impulse (ARFI, Virtual Touch

Long term outcomes of initial infliximab therapy for inflammatory pouch pathology: a multi-Centre retrospective study

Abstract Background: Restorative proctocolectomy with ileal pouch-anal anastomosis is considered the procedure of choice in patients with ulcerative colitis refractory to medical therapy. Subsequent inflammation of the pouch is a common complication and in some cases, pouchitis fails to respond to antibiotics, the mainstay of treatment. In such cases, corticosteroids, immunomodulatory or biologic treatments are options. However, our understanding of the efficacy of anti-tumour necrosis factor medications in both chronic pouchitis and Crohn’s-like inflammation is based on studies that include relatively small numbers of patients. Methods: This was an observational, retrospective, multi-centre study to assess the long-term effectiveness and safety of infliximab (IFX) for inflammatory disorders related to the ileoanal pouch. The primary outcome was the development of IFX failure defined by early failure to IFX or secondary loss of response to IFX. Results: Thirty-four patients met the inclusion criteria; 18/34 (53%) who were initiated on IFX for inflammatory disorders of the pouch had IFX failure, 3/34 (8%) had early failure and 15/34 (44%) had secondary loss of response with a median follow-up of 280 days (range 3–47 months). In total, 24/34 (71%) avoided an ileostomy by switching to other medical therapies at a median follow-up of 366 days (1–130 months). Conclusions: Initial IFX therapy for pouch inflammatory conditions is associated with IFX failure in just over half of all patients. Despite a high failure rate, an ileostomy can be avoided in almost three-quarters of patients at four years by using other medical therapies.

Acetic acid-guided biopsies in Barrett’s surveillance for neoplasia detection versus non-targeted biopsies (Seattle protocol): A feasibility study for a randomized tandem endoscopy trial. The ABBA study

Background and study aims  Barrett’s esophagus is a potentially pre-cancerous condition, affecting 375,000 people in the UK. Patients receive a 2-yearly endoscopy to detect cancerous changes, as early detection and treatment results in better outcomes. Current treatment requires random mapping biopsies along the length of Barrett’s, in addition to biopsy of visible abnormalities. As only 13 % of pre-cancerous changes appear as visible nodules or abnormalities, areas of dysplasia are often missed. Acetic acid chromoendoscopy (AAC) has been shown to improve detection of pre-cancerous and cancerous tissue in observational studies, but no randomized controlled trials (RCTs) have been performed to date. Patients and methods  A “tandem” endoscopy cross-over design. Participants will be randomized to endoscopy using mapping biopsies or AAC, in which dilute acetic acid is sprayed onto the surface of the esophagus, highlighting tissue through an whitening reaction and enhancing visibility of areas with cellular changes for biopsy. After 4 to 10 weeks, participants will undergo a repeat endoscopy, using the second method. Rates of recruitment and retention will be assessed, in addition to the estimated dysplasia detection rate, effectiveness of the endoscopist training program, and rates of adverse events (AEs). Qualitative interviews will explore participant and endoscopist acceptability of study design and delivery, and the acceptability of switching endoscopic techniques for Barretts surveillance. Results  Endoscopists’ ability to diagnose dysplasia in Barrett’s esophagus can be improved. AAC may offer a simple, universally applicable, easily-acquired technique to improve detection, affording patients earlier diagnosis and treatment, reducing endoscopy time and pathology costs. The ABBA study will determine whether a crossover “tandem” endoscopy design is feasible and acceptable to patients and clinicians and gather outcome data to power a definitive trial.