S Subramaniam

Incidence and Severity of Prepouch Ileitis: A Distinct Disease Entity or a Manifestation of Refractory Pouchitis?

Background:Restorative proctocolectomy with ileal pouch–anal anastomosis is the operation of choice for patients with treatment-refractory ulcerative colitis. However, after this intervention, up to 50% of patients develop pouchitis. Moreover, a subgroup will also develop inflammation in the afferent ileum proximal to the pouch, a condition named prepouch ileitis (PI). Methods:Data on 546 patients who underwent ileal pouch–anal anastomosis for ulcerative colitis were retrospectively collected from 3 tertiary inflammatory bowel disease referral centers in the Netherlands, Belgium, and England. PI was considered present if there was endoscopic and histological inflammation in the afferent limb proximal to the pouch. Crohns disease was excluded by reviewing the histology of colectomy resection specimens. Results:PI was present in 33/546 (6%) patients and all of these had concurrent pouchitis. One hundred forty-four (26%) patients had pouchitis without PI and 369 (68%) patients did not have inflammatory pouch disease. Of the 33 patients with PI, 6 (18%) received no specific treatment, 9 (27%) responded to antibiotics, and 18 (54%) required escalation in therapy to steroids/immunomodulators or anti–tumor necrosis factor agents. Potent immunosuppressive treatment was required more frequently in patients with PI than those with pouchitis alone. Conclusions:PI is less common and more treatment refractory than pouchitis alone. Once PI is diagnosed, clinicians should be aware that response to antibiotic therapy is less likely than in pouchitis alone. Immunomodulatory therapy and escalation to anti–tumor necrosis factor agents should be considered early in cases of nonresponse. The suggestion that PI represents misdiagnosed Crohns disease could not be substantiated in our cohort.

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.

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

PWE-038 Gastric endoscopic submucosal dissection (esd): outcomes from a uk tertiary referral centre

Introduction Gastric endoscopic submucosal dissection (ESD) is a technique developed in the East but its adoption in the West has been slow to take off due to the relatively higher risk of complications including bleeding and perforation. The aim of this study was to analyse the efficacy and safety data when this technique was used in a single large UK tertiary referral centre. Method A prospectively compiled database of all gastric ESDs carried out in a large tertiary referral centre between 2009 and 2017 was reviewed by two independent researchers. All gastric ESDs in our institution were discussed in a specialist MDT prior to resection. Post-resection histology were reviewed in the same MDT and further management decisions were made based on consensus. Results A total of 50 gastric ESDs were performed during the study period by a single operator. The mean age of patients was 73 years and 31 were male. Lesion characteristics are as shown in Table 1. Site  Cardia Antrum Body Pylorus  20 13 9 4 Size (mm) median, range 25 5 – 70 Paris classification  IIa IIa + IIc Is Ip Isp IIb  18 15 11 2 3 1 The en-bloc resection rate was 90% (45/50 patients). 16% had scarring due to previous resections (8/50 patients). Histological assessment was carried out for all patients apart from 1 where the lesion was not retrieved. Of the lesions retrieved 51% of the lesions contained cancer, 33% contained dysplasia, 12% hyperplastic, 2% carcinoid and 2% GIST. R0 resection rate was 71.4% which includes 6 patients with known submucosal (SM) invasion that underwent salvage ESD as they were not fit for curative surgery. The overall rate of complications in this series was 12% (5 bleeding, 1 perforation – all managed endoscopically). The median length of follow-up was 11 months. Recurrence was detected in 3 patients and all these patients were managed with further endoscopic resection. Conclusion Gastric ESD is a safe and effective technique in managing gastric neoplasia in a UK setting.The R0 resection rates for curative resection are high and complication rates are low. Gastric ESD should be considered a viable treatment option for early gastric neoplasia in the UK. Disclosure of Interest K. Kandiah: None Declared, S Subramaniam: None Declared, P Bhandari Conflict with: Receives educational grants from Fujifilm, Olympus and Pentax

PTH-021 A novel scissor and loop technique for endoscopic resection and closure of esd defects: resection of gastric submucosal tumour

Introduction Endoscopic submucosal dissection (ESD) is a technique developed in Japan to enable curative en-bloc resection of early gastrointestinal neoplasia. This technique has been slow to be adopted in the West due to the lack of training, endoscopic knives requiring significant manual dexterity and a high rate of complications. Efforts have been made to improve training but until recently, there have been few advances improving endoscopic knife technology and the development of devices to reduce complications. We present a video demonstrating the utility of a novel scissor-type knife which can potentially make ESD accessible to Western endoscopists and the use of a novel large defect ligation device. Method Various types of endoscopic knives (eg. insulated tip,hook,triangular,needle) have traditionally been used in ESD. The scissor-type knife was developed to facilitate the accurate grasping of tissue prior to dissection. The outer segment of the scissor arms are insulated and the inner segment of the arms have thin cutting blades for dissection. This knife is rotatable, thereby enabling dissection of difficult to access tissue. The novel large defect ligating loop device is a detachable plastic endoloop which can be dropped freely into the lumen. This is then caught and easily clipped along the edges of the defect. Finally the loop closure device can be reattached to the loop and ligate the defect. Results A 72-year-old man was found to have a large SM tumour in the upper body (lesser curve) of his stomach. Assessment with enhanced endoscopic imaging showed normal gastric mucosa surface pattern. Endoscopic ultrasound showed that the lesion was of submucosa in origin. The case was discussed in the Upper GI MDT. A scissor-type knife enabled controlled mucosal incision and SM dissection even on retroflexion. Haemostasis was maintained using the scissor type knife, which is able to carry out the function of a haemostatic forceps, negating the need to change instruments during the procedure. The large resection defect was closed using a novel ligating device that is approximated like a purse string. There were no immediate or late complications. The patient was routinely discharged home the next morning. Conclusion Novel scissor-type knives are technically easy to use even when the access is challenging. This type of knife can perform mucosal incision, SM dissection and maintain haemostasis effectively. A detachable large defect ligator can effectively close large ESD defects. Both novel devices have the potential to help facilitate the uptake of ESD in the West. Disclosure of Interest K. Kandiah: None Declared, S Subramaniam: None Declared, D Poller: None Declared, A Higginson: None Declared, P Bhandari Conflict with: Receives educational grants from Fujifilm, Olympus and Pentax Abstract PTH-021 Figure 1

PTH-019 Bleeding during endoscopic resection: a novel extracellular scaffold matrix is a safe and effective haemostatic agent

Introduction Bleeding is a well recognised complication of endoscopic resection (ER), particularly in endoscopic submucosal dissection (ESD). Electrocautery can be used to control bleeding but does increase the risk of perforation. A novel extracellular scaffold matrix (Purastat) has recently been approved for gastrointestinal haemostasis. This self-assembling peptide forms a transparent gel that can be applied via a catheter through the scope over the bleeding area. We conducted a feasibility study in a high bleeding risk cohort to assess its applicability, safety and efficacy. We also aimed to ascertain the mean volume of Purastat required to cover the resection base prophylactically. Method This was a prospective observational cohort study of patients undergoing complex ER in a tertiary referral centre from December 2015–2016. Purastat was used for prophylaxis over the resection base in high bleeding risk procedures or for primary haemostasis in active bleeding. Data was collected on patient and lesion characteristics including surface area, technical feasibility of gel application, haemostasis and delayed bleeding rate. Results Purastat was used in 74 patients (average age 69 years, male to female ratio of 2:1). All lesions were >2 cm and 33.8% (25/74) had cardiac co-morbidities with anticoagulant or antiplatelet usage reflecting a high bleeding risk. 60 (81.1%) had ESD and 14 (18.9%) had endoscopic mucosal resection. Table 1 shows the distribution of lesions according to location and size. Abstract PTH-019 Table 1 Location Number of lesions (%) Mean lesion size (cm) Oesophagus 39 (52.7%) 3.22 Rectum 11 (14.9%) 6.36 Gastric 9 (12.2%) 4.50 Colon (excluding rectum) 8 (10.8%) 2.76 Duodenum 7 (9.4%) 2.64 Abstract PTH-019 Table 2 Purastat® use Haemostasis achieved with Purastat® only Haemostasis achieved with Purastat® + heat/clips Delayed Bleeding Prophylaxis alone(n=26) N/A N/A 2 (gastric) Primary haemostasis(n=48) 35 13 1 (oesophageal) Purastat on its own was effective in stopping bleeding in 35/48 (72.9%) cases (see Table 2). It was successfully applied in all patients with no interference in visibility or catheter blockage The mean surface area of the resection base was 16.2cm2 requiring a mean Purastat® volume of 2.7mls, or 0.2mls/cm2. On follow up in 1 month, delayed bleeding was noted in 3/74 (4%) patients. All were managed with endoscopic intervention and no transfusion was required. Conclusion Purastat was effective in controlling bleeding in almost ¾ of the cases where it was used for primary haemostasis. It is safe, easy to use and does not hamper ongoing ER. Only a small amount is needed to effectively cover the resection base for prophylaxis. Our data has demonstrated its potential as a novel haemostatic agent that can minimise bleeding during ER. Disclosure of Interest S. Subramaniam: None Declared, K Kandiah: None Declared, S Thayalasekaran: None Declared, G Longcroft-Wheaton: None Declared, P Bhandari Conflict with: Receives educational grants from Fujifilm, Olympus and Pentax