S Thayalasekaran

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).

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.

Detection and characterization of colorectal polyps using high-definition white light and i-Scan: Evidence-based consensus recommendations using a modified Delphi process:

Background i-Scan is an image enhancement modality, which provides enhanced views of mucosal structures and vascular patterns. Methods A modified Delphi process was used to develop a series of evidence-based statements on the role of high-definition white light (HDWL) and i-Scan for the detection and diagnosis of colorectal neoplasms. Each statement was voted to achieve consensus (i.e. >80% agreement). Results Seven proposed statements achieved consensus: (1) HDWL is recommended rather than standard definition (SD) for detection and diagnosis of colorectal neoplasms; (2) HDWL colonoscopy with i-Scan improves polyp and adenoma detection rates when compared with SD colonoscopy; (3) HDWL + i-Scan is superior to HDWL alone for the optical diagnosis of colorectal neoplasms; (4) HDWL + i-Scan in expert hands meets American Society for Gastrointestinal Endoscopy (ASGE) in the Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) standards for optical diagnosis of diminutive neoplasms; (5) HDWL + i-Scan in non-expert hands does not meet ASGE PIVI standards for optical diagnosis of diminutive neoplasms; (6) optical diagnosis of polyps with i-Scan has a learning curve and needs systematic training; and (7) the performance of i-Scan for the in vivo diagnosis of colorectal neoplasms is similar to Narrow Band Imaging (NBI) and Fuji Intelligent Chromo Endoscopy (FICE). Conclusions Seven proposed statements on the use of HDWL and i-Scan for the detection and diagnosis of colorectal neoplasms achieved consensus.

PTH-054B The clinical applications of the pillcam colon capsule endoscopy: a single centre experience

Introduction The PillCam Colon Capsule is a minimally invasive colonic imaging modality that is emerging as a safe and effective tool to visualise the colon. To date the majority of studies have focused on its use in research settings where it has been evaluated for colonic polyp and cancer detection. Method The aim of this study is to report on the current clinical use of colon capsule in a large teaching hospital in the South of England. This was a single centre retrospective review of all the PillCam colon capsules performed from April 2015 to November 2016. Results A total of 37 patients (27 females, 10 males), median age 43.5 (maximum age 82 years and minimum age 20 years) were evaluated. 22/37 (59.5%) had a previous attempt at colonoscopy. Reasons for colon capsule over colonoscopy were: 12/37 pain. 12/37 need for small bowel investigations, 4/37 anxiety, 2/37 patient choice, 2/37 reaction to IV contrast for CT, 1/37 learning difficulties, 1/37 Ehlers-Danlos, 1/37 tachycardia at flexible sigmoidoscopy and 1/37 agorophobia. The colon capsule was completed in 23/37 (62%) of patients. In 4/14 cases the capsule did not exit the stomach, so a clinic appointment is scheduled to discuss positioning of the capsule with gastroscopy. In 10/14 patients the colon capsule was incomplete; 3 reached the left colon and 7 reached the rectum. In 2/14 incomplete colon capsules a flexible sigmoidoscopy completed investigations. 3/14 incomplete colon capsule patients were discharged as a functional disorder was diagnosed. 2/14 patients are awaiting colonoscopy under GA and 1/14 a flexible sigmoidoscopy for polyp removal. 1/14 had a colonoscopy and polypectomy under sedation. 1 patient subsequently died, but this was unrelated to the colon capsule. 87% of the cases avoided subsequent colonoscopy. There were no complications observed in the series. 16/23 (69.6%) completed colon capsules identified pathology. 7 had features of inflammatory bowel disease. 6 identified polyps; 2 proceeded to endoscopic resection and the remaining 4 diminutive polyps are scheduled a clinic appointment to discuss the relative merits of endoscopic resection. The remaining 3 colon capsules identified threadworms; diverticular disease and angioectasia respectively. Conclusion Colon capsule is safe and colonoscopy was avoided in 87% of patients. It is associated with a high pick up rate for pathology. The failure rate is high but usually in the left colon where a flexible sigmoidoscopy can complete examination easily. We believe that it is an effective approach for investigation of patients where tolerance to colonoscopy is likely to be poor, or where additional small bowel investigation is required, particularly in the evaluation of IBD or obscure bleeding where radiological imaging may be less effective or contraindicated. Disclosure of Interest None Declared

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-054A Hemospray use in the management of upper gastrointestinal haemorrhage: a 2-year experience across 2 teaching hospitals in the north and south of england

Introduction Hemospray (Cook Medical) is a haemostatic powder licensed for the management of non-variceal upper gastrointestinal bleeding (UGIB). Our aim was to describe the effectiveness of hemospray monotherapy vs adjunctive and salvage therapy, haemostasis and re-bleed rates. Method A retrospective use of hemospray use in UGIB at 2 teaching hospitals in the north and south of England was evaluated from June 2014-June 2016. Data was extracted from the endoscopy reporting system. Results A total of 44 patients (19 females and 25 males), median age 77.5 years (max 94 years and min age 25 years) with UGIB were treated with hemospray across the 2 centres over the 2 year period. Bleeding was secondary to peptic ulcer disease in 29/44 (65.9%), varices in 3 (6.8%), post biopsy bleeds in 3 (6.8%), unidentified lesion in 3 (6.8%), post sphincterotomy bleed in 2 (4.5%), mallory weiss tear in 2 (4.5%), portal hypertensive gastropathy in 1 (2.3%) and diffuse large b-cell lymphoma in 1 (2.3%). Forrest classification was calculated where information was available (34/44). Forrest Ia-9 cases. Forrest Ib-15 cases. Forrest IIa-8 cases. Forrest IIb-2 cases.Hemospray was utilised as a monotherapy in 10/44 (22.7%) of patients. It was used as adjunctive treatment in 25/44 cases (56.8%) and as salvage treatment in 9/44 (20.5%) of cases where previous treatment had failed.Haemostasis was achieved in 41/44 patients (93.2%). 1/3 patients without haemostasis had hemospray monotherapy and 2/3 patients had hemospray as salvage treatment. 2/3 patients without hemostasis who received hemospray salvage therapy went for interventional radiology. 1/3 patient without hemostasis with hemospray monotherapy application due to profuse bleeding was unstable from admission and palliated after the gastroscopy. 7/44 (15.9%) patients had a re-bleed. 4/10 (40%) had been treated with hemospray as monotherapy, 2/25 (8%) as adjunctive treatment and 1/9 (11.1%) as salvage therapy. Of the 7 re-bleeds, 3 were Forrest IIa classification, 3 were Forrest Ib classification and the 7th Forrest IIb classification. Haemostasis was achieved in 5/7 (71.4%) of the rebleeds. 2/7 re-bleeds did not achieve hemostasis and went for surgery. 4/7 re-bleeds achieved hemostasis with a combination of adrenaline, diathermy and clips. 1/7 re-bleeds did not receive treatment as there were no stigmata of recent haemorrhage. No adverse events occurred. Conclusion Hemospray as monotherapy appears to be associated with high rates of re-bleeding. It appears to be more effective as an adjunctive treatment or salvage therapy. Further larger studies are needed to establish where it can most effectively be used, but this data does not support its use as a primary monotherapy. Disclosure of Interest None Declared

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

Knife-assisted resection of flat dysplastic lesions in colitis

The risk of colonic neoplasia is increased in inflammatory bowel disease. Flat dysplastic lesions in colitis can be difficult to detect and challenging to resect endoscopically. Conventional EMR has been used, but because 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 evaluate the safety and efficacy of this technique in resecting flat dysplastic lesions in colitis, and we demonstrate the technique in Video 1. The data pertaining to all KARs undertaken by a single endoscopist in our institution from 2012 to 2014 were prospectively compiled in a predesigned database. Two independent researchers interrogated the database.

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