R Willert

Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome.

UK cancer guidelines recommend patients with colonic obstruction due to suspected malignancy be considered for stenting with a self‐expanding metal stent (SEMS). Considerable variation in practice exists due to a lack of expertise, technical difficulties and other, as yet ill‐defined features. This retrospective multi‐centre study aims to determine the outcome following colonic stenting for large bowel obstruction and identify factors associated with successful intervention.

Endoscopic balloon dilatation of Crohn's disease strictures: results from a large United kingdom series.

Introduction:Stricturing is a common complication of Crohns disease. Endoscopic balloon dilatation (EBD) offers a valuable alternative to surgical intervention, but there are limited data on factors influencing its safety and efficacy. Methods:A multicenter retrospective audit across 4 U.K. teaching hospitals was performed on the use of EBD for Crohns strictures between 1998 and 2011. Demographics, smoking status, medications, C-reactive protein, endoscopic findings, and subsequent surgery at follow-up were recorded. Success of EBD was defined as symptomatic improvement without the need for surgery at follow-up. Results:Seventy-nine patients (47 women; median age, 48 yr) were identified for this study. Forty-eight (61%) patients had ileocolonic anastomotic strictures, whereas the rest had de novo strictures. In total, 191 EBDs (range, 1–11; median 2) were carried out on 93 strictures (range, 1–5; median 1) over a median duration of 12 months (range, 1–84). There were no serious adverse events. Success at index EBD was 34%, with a further 43% achieving long-term benefit from additional EBDs. Eighteen (23%) patients required surgery. Time to surgery after the first EDB was 2.6 to 71.1 months (median, 12.8 mo). Longer Crohns disease duration (P = 0.03) and high C-reactive protein (P = 0.008) were associated with an increased need for subsequent surgery. Conclusions:EBD was safe and effective in achieving long-term symptom improvement and avoidance of surgery in most patients. Prospective controlled trials are needed to evaluate the effect of other factors, including Crohns disease phenotype, and the role of concomitant medication to identify those best suited to EBD.

Amyloidosis: an EUS view.

Abut et al6 reported a similar case of situs ambiguous ith polysplenia incidentally diagnosed in a female paient aged 62 years. We report this case for the extremely are occurrence of situs ambiguous with polysplenia with id-gut malrotation in the adult age group and its presnce making the laparoscopic bariatric surgery impossible or a morbidly obese patient. This also gives us an opporunity to review the role of endoscopic interventions as a ridging step toward definitive bariatric surgical treatent in such difficult situations. Endoscopic bariatric herapies can be considered early-on in the manageFigure 2. Laparoscopic view showing small intestines to left of the left lobe of the liver.

Multi-centre audit to determine factors associated with success and failure in treating colonic obstruction with self expanding metals stents (SEMS)

Introduction UK cancer guidelines recommend patients with malignant colonic obstruction are considered for stenting either as a bridge to curative surgery or as a palliative procedure. Considerable variation in practice persists due to lack of expertise, technical difficulties and hazards associated. Reported series include only small numbers so true success rates are unclear. Our aim is to determine outcomes following colonic stenting and factors associated with complications. Methods All colonic stents inserted for large bowel obstruction in 5 North-West Teaching hospitals between 2005 and 2010 were audited retrospectively for outcomes including relief of obstruction, survival, complications and re-intervention. Results 334 patients had stents inserted (mean age 71 years, mean ASA grade III) for palliation (76%), bridge to surgery (15.5%) and other indications (8.5%) (mostly benign strictures). Procedural success was 86%, with immediate complication rate of 14% due to: inability to deploy (6%), intraprocedural perforation (2.7%), malposition (0.6%), migration (2%), insufficient expansion (1%) and peri-interventional morbidity (1.2%). Technical success did not vary by indication (p=0.4) but using a through-the-scope (TTS) technique (65% of procedures) produced a higher success rate than radiological placement (93% v 80%; p=0.01) with fewer complications (12% v 20%; p=0.05). Perforation rates were lower for operators performing >20 procedures (p=0.04). Tumour position (above or below splenic flexure) did not affect success (p=0.3) or complications (p=0.6). 64% for palliation required no further intervention but 21% underwent subsequent colostomy and 5 perforated. 75% of ‘bridge’ patients had a single stage primary anastomosis. 30-day mortality was 14.6% for palliative group, 7.7% for bridge group, 17% for benign obstruction and 33% for extra–colonic malignant obstruction. Conclusion This large audit reports similar problems to published smaller series but suggests that experienced operators using a TTS technique achieved better outcomes. High re-intervention rate in palliative stenting was disappointing. Significant mortality for extra-colonic malignant obstruction and benign strictures suggests that stenting should be carefully considered for these indications.

OC-025 The first report of the UK multicentre double balloon enteroscopy registry: broadening the international deep enteroscopy experience

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.

OC-015 Prognostic indicators for short and long-term outcomes of colorectal endoscopic mucosal resection (EMR): a multi-centre (CERT-n) study

Introduction EMR is an established treatment for large colorectal polyps, yet the data regarding efficacy and outcome are principally limited to single centre experience. We present a multicentre study to determine prognostic factors of short-term (3 month) and long-term (1 year) outcomes following an index (intention to treat (ITT)) EMR for large sessile colorectal polyps. Methods Endoscopy databases & hospital coding records identified patients that had an ITT EMR for colonic polyps 2 cm or greater between 2005 and 2010 in five North-West teaching hospitals. Patients were audited longitudinally for 1 year. Multivariate analysis (Logistic Regression Model) determined significant prognostic factors (OR [95% CI]; p<0.05 as significant). Results Demographics: 313 patients (mean [SD] age 69.7[10.4] years, 65.5% male, 86% ASA grade 1–2) underwent EMR for mean polyp size of 33.5 [11.5] mm. Morphologically; 63.8% were flat lesions and 21.7% were located in the right colon. Procedure: 26% were performed by inexperienced endoscopists (Outcomes: Cancer diagnosis was in 9.5% (6.3% invasive & 3.2% intra-mucosal). Complications; Perforation rate 0.5%, bleeding rate 0.5% & all cause 30-day mortality 0.6 %, with no procedure related mortality. Recurrence rate was 26% & treated endoscopically in 64.6%, & surgically in 8.5%. Overall, surgery was required in 7.3%, of which 8.7% were emergencies (to treat perforation) and 56% was for cancer. ITT short-term success rate was 68% and 1-year success rate was 82.4%, with an adjusted rate of 87.2%. Prognostic Factors: Predictors of recurrence were cancer histology (OR 9 [95% CI 4 to 22]=<0.05), piecemeal resection (OR 4 [95% CI 1.5 to 11] p<0.005) and EMR session >1 (OR 22 [95% CI 10 to 50] p<0.005). Poor prognostic indicators for long-term success were cancer (OR 11 [95% CI 4.5 to 28] p<0.005) and EMR session >1 (OR 3.6 [95% CI 1.5 to 8.4] p=0.003). While endoscopist inexperience, increasing polyp size, no adjuvant APC were poor prognostic factors univariately, on multivariate analysis they were insignificant. Gender, age, ASA, Training, site, morphology and complications were not significant factors. Conclusion While recurrence rates in EMR for large colonic lesions were high (>1/4), long-term outcomes were good (cure rate 87.2%) with complications similar to previous series. Most important poor prognostic factors were cancer histology and requirement of more than 1 session. Competing interests J Geraghty grant/research support from: Cook Medical, K Bodger: None declared, S Alam: None declared, W Jafar: None declared, M Gillon: None declared, C Babbs: None declared, J Ramesh: None declared, R Willert: None declared, S Lal: None declared, S Sarkar: None declared.

PWE-008 Clinical outcomes of ustekinumab in resistant crohn’s disease: UK IBD tertiary referral centre ‘real-world’ experience

Introduction Ustekinumab (UST) binds to the p40 subunit of IL12 and IL23 to prevent IL12RB1 cell-surface receptor activation and thus inhibits downstream inflammatory signalling. It is approved for moderately to severely active Crohn’s disease (NICE TA456). We assessed the clinical outcomes and safety of UST in a ‘real-world’ cohort of refractory Crohn’s disease patients treated at a single UK centre. Methods We retrospectively collected data from the electronic records of Crohn’s disease patients treated with UST at a single UK IBD tertiary referral centre. Patient demographics and adverse events were recorded. Clinical response to UST was evaluated at baseline and follow up using Harvey-Bradshaw Index (HBI) scores, C reactive protein (CRP), and faecal calprotectin (FC). Paired Student’s T Tests were used to determine statistical significance. Results 26 patients (mean age 36 years; age 18–62 years; M:F ratio=1:1.6) with a variety of Crohn’s disease phenotypes (L1=8; L2=6; L3=12) were treated with UST. 9 patients (35%) had stricturing disease and 5 patients (19%) penetrating disease. All patients had failed at least one anti-TNF agent. 15 patients (58%) had failed two anti-TNF agents, and 11 (42%) had failed an anti-TNF and subsequent vedolizumab therapy. 7 patients (27%) received immunomodulatory co-therapy (AZA=5; MTX=2), and 11 (42%) received bridging steroids. 12 week data was available for 20 patients. At 12 weeks, mean HBI significantly improved (5 vs 9; p<0.05). There was reduction in mean FC (763 vs 1026; ns), but no change in mean CRP (14 vs 11; ns). 10 patients (50%) demonstrated subjective and objective (FC +/-CRP +/- endoscopic) response to therapy. 6 of these patients received bridging steroids, of which all had reduced and 4 had completed their steroid course. Of all treated patients 2 discontinued UST (recurrence of a transitional cell carcinoma; primary non-response to therapy requiring surgery), and side effects were reported in 2 patients (Bell’s Palsy; lower respiratory tract infection). Conclusions UST appears clinically effective and safe in this cohort of treatment-refractory Crohn’s disease patients after 12 weeks of therapy. Future work to combine ‘real world’ data and to assess longer term outcomes will help us to better understand and place the use of UST in the management of Crohn’s disease.

A real-world, long-term experience on effectiveness and safety of vedolizumab in adult patients with inflammatory bowel disease: The Cross Pennine study

BACKGROUND Real-life data on vedolizumab effectiveness in inflammatory bowel disease (IBD) are still emerging. Data on the comparative safety of the gut selective profile are of particular interest. AIMS To assess clinical outcome and safety in IBD patients treated with vedolizumab. METHODS We retrospectively collected data of patients treated with vedolizumab at eight UK hospitals (August 2014-January 2018). Clinical response and remission at 14 and 52 weeks evaluated through Physician Global Assessment (PGA) and adverse events were recorded. Possible predictors of clinical response were examined. RESULTS Two hundred and three IBD patients (mean treatment 16 ± 8 months) were included. Of these, 135 patients (mean age 40.6 ± 16.0 years; F:M 1.9:1) had CD and 68 (mean age 44.5 ± 18.1 years; F:M 1:1.2) had UC. According to PGA, 106/135 (78.5%) CD and 62/68 (91.2%) UC patients (p = 0.02) had a clinical response/remission at 14 weeks, whereas 76/119 (63.9%) CD and 52/63 (82.5%) UC patients (p < 0.01) showed a sustained response or remission at 52 weeks, with a high adherence rate (97%). No predictors of clinical response were found. The cumulative incidence of infectious diseases was 11.9 per 100 person-years. CONCLUSION Vedolizumab is an effective therapy for inducing and maintaining remission of IBD, with better results for UC, and with a good safety profile.

PWE-065 Small Bowel Malignancies Diagnosed at Enteroscopy: An Improved Outcome?

Introduction Small bowel malignancies are uncommon worldwide and account for only 1–2% of all gastrointestinal malignancies.1 However there is evidence of the rising incidence of small bowel malignancies through the last decades, with increases as high 2.3 per 100 000 population from 1973 to 20042.2-3 We sought to investigate the number of small bowel malignancies diagnosed by double balloon enteroscopy (DBE) and the 1 year outcomes at our institution. Methods We retrospectively reviewed all the DBEs performed at our UK tertiary centre from 2009 to 2015. Demographics, indications for DBE investigation, prior investigations, DBE findings and 12 month mortality were analysed. Results 294 DBEs were performed where 19 small bowel cancers were discovered. The original symptoms were anaemia (83.3%, n = 15), vomiting (11.1%, n = 2), and weight loss (5.6%, n = 1). All patients had undergone radiological imaging (76.5%, n = 13) or capsule endoscopy (58.8%, n = 10) prior to DBE. In 33.3% (n = 6) both radiological imaging and capsule endoscopy had been performed. The indication for DBE was abnormal capsule (41.2%, n = 7), abnormal imaging (52.9%, n = 9) and abnormal capsule and imaging (5.9%, n = 1). The histology findings were jejunal adenocarcinoma in 52.9% (n = 9), distal duodenal adenocarcinoma in 29.4% (n = 5), jejunal GIST in 11.8% (n = 2) and enteropathy associated T cell lymphoma in 5.9% (n = 1). 11 patients (57.9%) had capsule endoscopy prior to DBE, capsule endoscopy failed to diagnoses a malignancy in 3 patients (27.3%) who were subsequently found to have a malignancy on DBE (2 patients with Jejunal GIST and 1 patient with jejunal adenocarcinoma). In these 3 patients the capsule finding was reported as showing angiodysplasia. All the malignancies were deemed suitable for therapy by a multidisciplinary team. The treatment was surgery alone in 52.9% (n = 9), surgery and chemotherapy in 23.5% (n = 4) and chemotherapy alone in 17.6% (n = 3). The survival rate at 3 months was 88.2% and 66.7% at 1 year. In the patients with a diagnosis of adenocarcinoma the 1 year survival rate was 85.7%. Conclusion The 1 year survival of 85.7% is significantly higher than previous reports (survival rate of 30% at 1 year from small bowel adenocarcinoma)4 and may reflect the improved outcomes from earlier diagnosis using capsule and DBE. DBE also aided in the diagnosis of tumours not seen on video capsule endoscopy, as described in literature.5 References 1 Chow JS, et al. Int J Epidemiol 1996;35:722–728 2 Haselkorn T, et al. Cancer Causes Control. 2005;16:781–7. 3 Shack LG, et al. Aliment Pharmacol Ther. 2006;23:1297–306. 4 MH Fargat, A Shamseddine and K Barada. Small Bowel Tumours: Clincial presentation, prognosis and outcomes in 33 patients in a tertiary care centre. Journal of Oncology 2008. 5 Chong AK, et al. Gastrointest Endosc. 2006;64:445–9. Disclosure of Interest None Declared

PWE-066 Endoscopic Versus Histological Assessment Of Colonic Polyp Size

Introduction Colonic polyp size is a factor in determining management and prognosis of patients. Polyp diameters greater than 9 mm require ongoing colonoscopic surveillance.1 Accurate endoscopic estimation of polyp size can be affected by depth perception and parallax errors. We compared endoscopic versus histological size assessments to determine if accurate estimation was operator-dependent. Methods Symptomatic and asymptomatic (bowel screening) patients were identified from hospital databases. Endoscopic and histological polyp diameters were reviewed. Agreement levels between these were analysed by deriving intraclass correlation coefficient (ICC) using SPSS software (Version 20). Results Sixteen colonoscopists were included: 5 bowel screening, 7 non-bowel screening and 4 trainees. Five hundred and ten polyps (n = 510) were found among 299 patients (186 males, 104 females). Two hundred eighteen polyps were enbloc resected, retrieved whole and analysed. Overall accuracy of polyp size assessment was good (ICC > 0.70) with variability between skill levels (Table 1). Abstract PWE-066 Table 1 Reliability analysis of polyp assessment according to aolonoscopist Intraclass correlation coefficient p-value All 0.95 p < 0.001 Bowel screening colonoscopists 0.96 p < 0.001 Non-bowel screening colonoscopists 0.74 p < 0.001 All trainees (consultant-supervised) 0.86 p < 0.001 Accuracy was best among polyps ≥20 mm diameter (ICC 0.99, p < 0.001); all removed by bowel screening colonoscopists. Polyps between 8 to 12 mm demonstrated poor correlation (ICC (absolute agreement) 0.535, P = 0.002). Conclusion While endoscopic estimation of polyp diameter is accurate, variability exists. Estimations are more accurate among bowel screening endoscopists suggesting experience and/or colonoscopy workload contribute to this skill. Poor diameter estimations among polyps 8–12 mm has implications for polyp surveillance intervals. Standardising diameter using against closed or open biopsy forceps (width 2.2 and 8 mm respectively) to optimise accuracy should be used. Reference 1 Cairns, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010;59:666–690 Disclosure of Interest None Declared.