Philip Boger

A UK-based cost-utility analysis of radiofrequency ablation or oesophagectomy for the management of high-grade dysplasia in Barrett's oesophagus.

Aliment Pharmacol Ther 2010; 32: 1332–1342

Comparing outcome of radiofrequency ablation in Barrett’s with high grade dysplasia and intramucosal carcinoma: a prospective multicenter UK registry

BACKGROUND AND STUDY AIM Mucosal neoplasia arising in Barretts esophagus can be successfully treated with endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA). The aim of the study was to compare clinical outcomes of patients with high grade dysplasia (HGD) or intramucosal cancer (IMC) at baseline from the United Kingdom RFA registry. PATIENTS AND METHODS Prior to RFA, visible lesions and nodularity were removed entirely by EMR. Thereafter, patients underwent RFA every 3 months until all visible Barretts mucosa was ablated or cancer developed (end points). Biopsies were taken at 12 months or when end points were reached. RESULTS A total of 515 patients, 384 with HGD and 131 with IMC, completed treatment. Prior to RFA, EMR was performed for visible lesions more frequently in the IMC cohort than in HGD patients (77 % vs. 47 %; P < 0.0001). The 12-month complete response for dysplasia and intestinal metaplasia were almost identical in the two cohorts (HGD 88 % and 76 %, respectively; IMC 87 % and 75 %, respectively; P = 0.7). Progression to invasive cancer was not significantly different at 12 months (HGD 1.8 %, IMC 3.8 %; P = 0.19). A trend towards slightly worse medium-term durability may be emerging in IMC patients (P = 0.08). In IMC, EMR followed by RFA was definitely associated with superior durability compared with RFA alone (P = 0.01). CONCLUSION The Registry reports on endoscopic therapy for Barretts neoplasia, representing real-life outcomes. Patients with IMC were more likely to have visible lesions requiring initial EMR than those with HGD, and may carry a higher risk of cancer progression in the medium term. The data consolidate the approach to ensuring that these patients undergo thorough endoscopic work-up, including EMR prior to RFA when necessary.

Therapeutic upper gastrointestinal tract endoscopy in Paediatric Gastroenterology

Since the first report of use of endoscopy in children in the 1970s, there has seen an exponential growth in published experience and innovation in the field. In this review article we focus on modern age therapeutic endoscopy practice, explaining use of traditional as well as new and innovative techniques, for diagnosis and treatment of diseases in the paediatric upper gastrointestinal tract.

Increased expression of the 5-lipoxygenase pathway and its cellular localization in Barrett’s adenocarcinoma

Boger P C, Shutt J D, Neale J R, Wilson S J, Bateman A C, Holloway J W, Patel P & Sampson A P 
(2012) Histopathology 61, 509–517

53 Six Year Disease Durability Outcomes on Patients Treated With Endoscopic Therapy for Barrett's Related Neoplasia From the UK Registry

Introduction Endoscopic therapy with combined Endoscopic mucosal resection (EMR) followed by Radiofrequency ablation (RFA) is now the recommended first line treatment for patients with Barrett’s (BE) related neoplasia confined to the oesophageal mucosa. Method We examine prospective data from the United Kingdom registry of patients undergoing RFA/EMR for BE neoplasia since 2008. Before RFA, visible lesions and nodularity were entirely removed by EMR. Thereafter patients underwent RFA 3 monthly until all visible BE was ablated or cancer developed (endpoints). Biopsies were taken at 12 months or when endpoints reached. Follow up endoscopies were performed periodically in all patients to check for recurrences thereafter. All patients who had completed at least 12 months of follow up after successful treatment were included in the analysis to examine durability of disease reversal long term. Results 282 patients (81% male, mean age 70 years) have completed the 12 month treatment protocol with a minimum of 12 months follow up thereafter. At median follow up of 37 months (IQR 29–49), 93% of patients with successful disease reversal were still free of neoplasia and 88% free of intestinal metaplasia recurrence. Cancer progression at this same time was seen in 1.4% of patients. Kaplan Meier (KM) statistics demonstrated a predicted 3 year neoplasia free survival in 88% of patients. At 5 and 6 years this was 86%. Similarly KM analysis showed that at 3 years 81% of patients would be free form BE and at 5 and 6 years this figure was 73%. Conclusion We report long term outcomes of a large cohort of patients with BE neoplasia who have had successful endoscopic therapy with RFA/EMR. This approach appears to have a lasting disease free benefit in the majority of patients. Recurrences do occur in a minority of patients and highlights the need for follow up in those fit for endoscopy. All collaborators of the UK RFA registry are acknowledged for their contributions to data collection for this work. Disclosure of interest None Declared.

Tu1097 HALO Radiofrequency Ablation for High Grade Dysplasia and Early Mucosal Neoplasia Arising in Barrett's Oesophagus: Interim Results Form the UK HALO Radiofrequency Ablation Registry

Introduction Barrett9s oesophagus (BE) is the pre-cursor to oesophageal adenocarcinmoa (OAC). High grade dysplasia (HGD) and early mucosal neoplasia in BE has historically been treated with surgery. Recently there is a shift towards minimally invasive endotherapy with endoscopic mucosal resection (EMR) and Radiofrequency ablation (RFA). Methods Prospective registry from 14 UK centers to audit RFA outcomes in patients with HGD and early neoplasia in BE. Prior to RFA, any visible lesions were first removed by EMR. Patients then underwent RFA 3 monthly until all visible BE was ablated or cancer developed. Biopsies were taken at the end of this protocol. Results 216 patients have completed protocol, mean age 68.6 years (40–90), 81% male. Mean time to protocol end 11.3 months (IQR 8–14.3), median 2 ablations and mean of 2.4 (2–6) during protocol with mean 1.4 circumferential ablations and 1.2 focal ablations performed during protocol. Mean length BE segment ablated is 5.8 cm (1–20). CR-HGD was achieved in 83% patients at protocol end biopsy. CR-D was 76% and CR-BE 50% at this point. CR-D was more likely in short segment BE ( Conclusion This is the largest series to date of patients undergoing RFA from 14 UK centers. End of protocol CR-D is satisfactory at 76% and successful eradication appears to be durable. Patients with short segment BE are likely to respond better. Our data represent real life outcomes of integrating minimally invasive endotherapy into demanding endoscopy service commitments. Competing interests None declared.

OC-012 The Effect of Mental Workload Experienced During Colonoscopy on Endoscopists Performance

Introduction Studies have shown that there are a multitude of factors that affect the quality of colonoscopy. However, the effect of the endoscopist mental workload on their performance has been neglected. It is shown that health professionals exposed to excessive workloads and fatigue show degraded performance. The aim of this study was to measure the effect of mental workload as represented by the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), on colonoscopic performance relative to the experience of the endoscopist and colonoscopy scheduling. Methods Procedures were observed prospectively in one institution for 3 groups; trainees, consultants and bowel cancer specialist programme (BCSP) endoscopists. On reaching the caecum the endoscopist marked on a validated pro-forma their corresponding workload on six subscales; mental demand, physical demand, temporal demand, effort, frustration and own performance, to generate a NASA-TLX score. Data on performance which included caecal intubation times (CIT), patient comfort and polyp detection rate (PDR) were noted. In addition, withdrawal times, time of day (am or pm) and queue order for procedures were recorded. Results A total of 202 procedures were undertaken between 6 endoscopists with a mean CIT of 9.2 minutes and PDR of 42%. Increasing mental workload was associated with increasing CIT (r = 0.61, p = 0.07) and inversely associated with withdrawal time (r = 0.72, p = 0.03). The mean mental workload during colonoscopy was lower in BCSP endoscopist v consultants v trainees (188 v 254 v 352 p <0.01). On multivariate analysis, absence of polyp detection was associated with a procedure that was undertaken in pm with an above mean mental workload (OR 1.62, 95% CI 1.38–2.07) and withdrawal time of <5 minutes (OR 1.53, 95% CI 1.32–1.91). Increased patient discomfort was associated with increased frustration on the subscale of the NASA-TLX score (OR 1.59, 95% 1.37–1.93) and being a trainee (OR 1.11, 95% 1.03–1.22). The use of ScopeGuide reduced the mental workload of consultants (227 v 282 p<0.01), but not trainees or experts. Queue position had no impact on any of the markers of performance. Conclusion This study shows that high mental workload experienced during colonoscopy has a significant detrimental effect on the performance of endoscopists. Drop in PDR in pm procedures when only associated with high mental workload may explain some of the conflicting results of daily variations of PDR in other studies. Further studies are now required to look into measures that may reduce excessive mental workload. Disclosure of Interest None Declared

Variation in preparation for gastroscopy: lessons towards safer and better outcomes

Objective To identify the methods employed within the UK practice prior to diagnostic gastroscopy and compare with published guidelines for patients undergoing general anaesthesia. Design National Health Service (NHS) endoscopy units were invited to take part in a structured telephone survey to determine the length of time patients are kept nil-by-mouth (NBM) for food and fluids prior to gastroscopy, and whether a preprocedure mucolytic drink was used. Methods 212 NHS Trusts providing endoscopy services were identified from the Joint Advisory Group on GI Endoscopy. Trusts were excluded if they were childrens hospitals (n=5). Results 207 NHS Trusts were telephoned. 193 completed the survey (93%), 11 Trusts declined and there was no response from 3 Trusts. 13 separate policies regarding NBM timings were identified. 51 Trusts (21%) used the timings ratified by Surgical and Anaesthetic Societies (6 h NBM for food, 2 h for clear fluid). 135 Trusts (70%) used a policy which starved patients in excess of the standard surgical guidelines. No Trust used a mucolytic drink prior to gastroscopy. Conclusions The survey revealed large variation in NHS Trusts policies regarding the times patients were starved prior to gastroscopy. Results of surgical studies demonstrate increased risk of significant pulmonary aspiration with increased fluid-starvation periods, 68% of NHS endoscopy policy would be deemed excessive by surgical practice. There is no routine use of a mucolytic drink to improve mucosal visualisation in the UK practice.

UK guidelines on oesophageal dilatation in clinical practice

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques—including stents—will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

OC-013 Endoscopic Full-Thickness Resection (eFTR) in the Colon with the FTRD System: The First UK Experience

Introduction Standard endoscopic resection of non-lifting adenomas and subepithelial tumours are challenging and pose significant risks of adverse events. Various methods for full thickness resection of these lesions have been trialled, but have been fraught with difficulties. Here we report a simple technique for colonic resections using a novel endoscopic full thickness resection (eFTR) device. Methods Data on consecutive patients who underwent eFTR at 3 UK institutions from April 2014 – January 2015 were prospectively analysed. The procedure was undertaken using the, over-the-scope, full thickness resection device (FTRD). Main outcome measures were technical success, total procedure times, histological confirmation of full thickness, R0 resection and adverse events. Results A total of 11 patients underwent eFTR, of which 5 were non-lifting adenomas, 4 T1 polyps and 2 subepithelial tumours. Procedure was technically successful in 82% (9/11) cases. The median age was 76 years (range 64–93 yrs), median procedure time was 40 minutes (range 22–60 mins) with a median specimen size of 22 mm (range 15–25 mm). Histology confirmed full thickness resection in all cases, with a R0 resection in 89% (8/9) cases. At 3 month endoscopic follow the anastomotic clip was still in situ in 3 cases. In 1 case (known R1 resection) a small 5 mm area of residual adenoma was noted which was successfully treated by conventional endoscopic means. There were no cases of immediate or delayed bleeding or perforation. Conclusion eFTR using the FTRD system is a promising, simple technique to facilitate full thickness resections in the colon that may avoid the need for surgery in some selected cases. Further studies are now required to fully evaluate its efficacy. Disclosure of Interest None Declared