Advanced Endoscopic Procedures Research Articles

OC-047 New Platform for Trans-Anal Submucosal Endoscopic Resection- (TASER): Updated Clinical Results from Tertiary Centre

Introduction Current trans-anal surgical and advanced endoscopic resection procedures have the potential to resect complex rectal polyps (CRPs). However both approaches have limitations in terms of practicality and safety. Methods Consecutive patients (Jan13/April15), referred for the excision of CRPs, were being considered for proctectomy and/or had failed conventional endoscopic/trans-anal therapy. The GelPoint Path trans-anal access port allowed dynamic tissue manipulation to facilitate endoscopic-submucosal-dissection/ESD. Supplementary techniques were also used: piecemeal-endoscopic-mucosal-resection or ablation/P-EMR or EMA and trans-anal excision/TAE. The aim of this study was to evaluate the feasibility, technical success and safety profile of this new hybrid, endo-surgical Trans-Anal Submucosal Endoscopic Resection- (TASER) approach for CRPs. Results Thirty-two TASER procedures were employed in 31 patients (mean age 65 years/17 males-14 females) with 31 CRPs (mean size 8 cm/range 5 cm–18 cm). Complete endoscopic excision in a single session was achieved in 28/31 patients (93%); in one patient a second TASER session for completion of polypectomy, in another an elective laparoscopic-anterior-resection due to T1,sm3,N0,M0 and in a third patient a defunctioning-ileostomy due to intraperitoneal perforation before completion of polypectomy. Mean procedure time was 185 min, range 65–480 min. Thirty two TASER sessions were employed using ESD in 12/32, ESD+P-EMR in 6/32, ESD+P-EMR+EMA in 4/32, ESD+TAE in 3/32, ESD/P-EMR/TAE in 3/32 and ESD+P-EMR+EMA+TAE in 4/32. Intra-procedural bleeding was controlled with haemostatic endoscopic devices/surgical clipping. In 6/10 TASER-TAE cases there was a need for a full-thickness rectal dissection due to severe submucosal fibrosis: 4/6 cases were closed with surgical sutures/endoscopic clips and in 2/6 cases only endoscopic clips were deployed. Two episodes of delayed bleeding were reported with no transfusion/re-intervention requirement. All patients were discharged the day after the TASER apart from one patient who developed bacteremia requiring intravenous antibiotics/a 4 night hospital stay and the patient who required a defunctioning ileostomy, discharged on day 4 post-operation. First follow-up performed at 4–6 months interval in 25/31 patients showed: 21/25 with no recurrence/(84%) and 4/25/ (16%) with a minimal ( Conclusion TASER appears to be a safe and efficient endo-surgical approach providing an optimal platform for the minimally-invasive management of high- risk, complex rectal polyps. Disclosure of Interest None Declared

Adverse Events Following Gastrointestinal Endoscopy in Children: Classifications, Characterizations, and Implications.

To conduct a comprehensive study of postendoscopic adverse events (AEs) in children, categorizing them by the level of intervention required. Previous studies of endoscopic AE in children have focused on intraprocedural and short-term outcomes, such as bleeding, perforation, and infection, and may underestimate the incidence of AEs. Prospective observational study tracking AEs in pediatric patients within 72 hours of an endoscopic procedure. Single-center study performed at an academic, tertiary care, free-standing children's hospital over a 48-month period, from July 2010 through June 2014. Of 9577 pediatric endoscopic procedures, cases identified as having an AE during or following endoscopy were subject to additional chart review for abstraction of relevant data. Type, severity, and subsequent interventions of AEs were the primary outcome measures. Events were categorized by severity grade, with grade 1, no intervention; grade 2, outpatient evaluation; grade 3, hospitalization or repeat endoscopy; grade 4, surgery or intensive care unit admission; and grade 5, death. In total, 249 endoscopic AEs were recognized of 9577 procedures performed, yielding a rate of 2.6%. Of these, 160 were identified to result in medical evaluation and costs (≥grade 2) for a rate of 1.7%. Rates of endoscopic AE after advanced or interventional endoscopic procedures were higher, with 65 of 1167 events, resulting in a total AE rate of 5.6% and a rate of 4.4% for AE ≥ grade 2. There were 10 cases of significant bleeding (0.1%), 9 cases of infection (0.09%), and 12 cases of perforation (0.13%), primarily occurring with advanced/interventional procedures. Single-center study, lack of standardized criteria for ED referral. AEs presenting within 72 hours of endoscopy and resulting in medical intervention, occur more commonly than previously recognized in children. Standardized postendoscopy surveillance systems and definitions of AEs are needed.

Tu1041 Decreasing Sedation-Related Procedure Failures in Advanced Endoscopic Procedures: An Endoscopy Unit Quality Improvement Project

Tu1041 Decreasing Sedation-Related Procedure Failures in Advanced Endoscopic Procedures: An Endoscopy Unit Quality Improvement Project

Sa1161 New Platform for Trans-Anal Submucosal Endoscopic Resection- (TASER): Updated Clinical Results From Tertiary Centre

Current trans-anal surgical and advanced endoscopic resection procedures have the potential to resect complex rectal polyps (CRPs), bu both approaches have limitations in terms of practicality and safety.

Sa1237 Development and Initial Validation of a New Endoscopic Training Model for Advanced Endoscopic Procedures - The HEAT International Endoscopy Study

Sa1237 Development and Initial Validation of a New Endoscopic Training Model for Advanced Endoscopic Procedures - The HEAT International Endoscopy Study

Minor Anesthesia-Related Events During Radiofrequency Ablation for Barrett's Esophagus Are Associated with an Increased Number of Treatment Sessions.

There is limited data regarding the prevalence and clinical impact of sedation-related adverse events (SRAEs) during radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE). Our primary aim was to measure SRAE during RFA. Secondary aims were to identify risk factors for adverse events, and to determine whether SRAEs impacted the number of RFA treatments to achieve complete eradication of dysplasia (CE-D). We conducted a retrospective analysis of 120 consecutive patients undergoing initial RFA for dysplastic BE between 2008 and 2014. The main outcome measures were SRAEs and the number of RFA sessions required to achieve CE-D. Of 120 initial RFA procedures, 83% were performed with MAC and 17% with GET. SRAEs occurred in 32%, including 25% of MAC patients (25/100) and 65% (12/20) GET patients. The most frequent SRAE was hypotension (23%, n=27/120), followed by hypoxia (n=9/120), arrhythmia (n=4/120), and one unplanned intubation. There were no premature procedure terminations. After adjusting for length of BE mucosa and ASA score, the occurrence of a SRAE was associated with requiring more (>4)RFA sessions to achieve CE-D, OR 3.45 (95% CI 1.49-7.99). Mean RFA sessions required to achieve CE-D was 5±1 in patients with SRAE, compared to 3±0.7 in patients without SRAE during the first treatment session (p<0.001). SRAE during RFA for dysplastic BE occurs at a rate typical of other advanced endoscopic procedures. Patients who experience minor events related to anesthesia during the first RFA are likely to require more RFA treatment sessions to achieve CE-D.

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Sedation for Gastrointestinal Endoscopy: Practical Issues in Patient Safety and Quality Management

Morphometric characteristic of thyroid cartilage in Gujarat region - A cadaveric study

Background: The larynx is the organ for production of voice & a sphincteric device used in respiration. Larynx from inside outward has a framework of mucosa surrounded by fibroelastic membrane which inturn surrounded by cartilages & muscles. Thyroid cartilage is largest among all the laryngeal cartilage. Aims: To find out dimension of various parameters of thyroid cartilage, variation, differences among all the data & to compare data between males & females. Material & Methods: Fourty five samples of adult thyroid cartilage (24 males & 21 females) of known sex were taken from embalmed cadavers. Morphometric measurement was taken using a digital vernier caliper & goniometer to see normal variation, sex differences and bilateral asymmetry. Observation were analysed after calculating mean &SD. Results: Parameters measured in thyroid cartilage were show significant difference in males & females. All the parameters of thyroid cartilage except thyroid angle were higher in males than females. Bilateral asymmetry in the size of thyroid lamina was seen in majority of specimens. However, in 3 cases (6.67 %) thyroid prominence was not in median plane, deviated towards left side. In one case asymmetry was also associated with asymmetry in direction of superior cornu. Conclusion: The detailed study of thyroid cartilage in the form of morphometric parameters of thyroid cartilage is useful for Anatomist, Plastic surgeons, ENT surgeons and Radiologist to perform advanced surgical & endoscopic procedure & surgeries, planning of laryngeal framework & facial feminization surgery & to analysis of CT-MRI scans of larynx.

Esophageal surgery in minimally invasive era.

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Evidence-Based Selection of Sedation Agents for Patients Undergoing Endoscopic Retrograde Cholangiopancreatography.

Sedating patients undergoing advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP) is challenging for the endoscopy team. Considering these challenges and concerns with the use of propofol for deep sedation of older adults and high-risk patients, colleagues of one of the authors (AS) were interested in the identification of techniques for the anesthetic management of subjects undergoing therapeutic ERCP. A search strategy revealed a total of 7 evidence sources. The appraised evidence examined the efficacy and sedation-related effects of anesthesia regimens. Deep sedation with propofol was identified as the most commonly used anesthetic technique for subjects undergoing therapeutic ERCP. The sedation-related unwanted effects of propofol appear to be dose-related and occur more frequently in the high-risk and elderly populations. However, the data were inconclusive in identifying an ideal agent offering superior efficacy with fewer unwanted sedation-related effects. Providers should strongly consider the subject's age, history of coexisting illness, and the pharmacological effects of selected anesthetic agents when choosing an appropriate anesthetic technique. Larger randomized controlled studies are needed to identify risk factors associated with sedation-related complications and to identify alternative options for the anesthetic management of subjects undergoing ERCP.

High efficacy with deep nurse-administered propofol sedation for advanced gastroenterologic endoscopic procedures.

Background and study aims: Whereas data on moderate nurse-administered propofol sedation (NAPS) efficacy and safety for standard endoscopy is abundant, few reports on the use of deep sedation by endoscopy nurses during advanced endoscopy, such as Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Ultrasound (EUS) are available and potential benefits or hazards remain unclear. The aims of this study were to investigate the efficacy of intermittent deep sedation with propofol for a large cohort of advanced endoscopies and to provide data on the safety. Patients and methods: All available data from patients sedated with intermittent deep NAPS for ERCP, EUS or double balloon enteroscopy (DBE, since the method was implemented in May 2007 through December 2012 were included for evaluation in a retrospective case-control design. Results: Data from 1899 patients undergoing 1899 procedures were included for evaluation. All but one procedure were completed with intermittent deep NAPS. The mean propofol dose was 397 mg (SD: 232.4) and the infusion rate was 23.9 mg/kg. The frequency of hypoxia was 4.3 % and 20 patients needed assisted ventilation (1.1 %). Anesthesiologic support was requested eight times (0.4 %). One patient was intubated due to suspected aspiration. Conclusions: Intermittent deep NAPS for advanced endoscopies in selected patients provided an almost 100 % success rate. However, the rate of hypoxia, hypotension and respiratory support was high compared with previously published data, but the method was still assessed as safe.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae.

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Neurosurgical training with simulators: a novel neuroendoscopy model.

The aim of this study is to present a novel neuroendoscopy simulation model in live animals, with the objective of enhancing patient safety with realistic surgical training. A simulation model using live Wistar rats was designed after the approval of the Institutional Committee for the Care and Use of Laboratory Animals. Under anesthesia, a hydroperitoneum was created in order to simulate a cavity with mesenteric membranes and vessels, viscera, and a solid and bleeding tumor (the liver) floating in a liquid environment. For validation purposes, we evaluated trainees' basal and final skills for each neuroendoscopic procedure, and we also acknowledged trainees' and instructors' opinion on the model's realism. This model is simple and low cost effective for complete and real-life training in neuroendoscopy, with the possibility of performing all the basic and advanced endoscopic procedures, such as endoscopic exploration, membrane fenestration, vessel coagulation, hematoma evacuation, and endoscopic tumor biopsy and resection using a ventricular neuroendoscopy set. Although the model does not represent human ventricular anatomy, a reliable simulation is possible in real living tissue in a liquid environment. Trainees' skills improvements were notorious. Minimally invasive endoscopic techniques require specific training. Simulation training can improve and accelerate the learning curve. The presented training model allows simulating the different neuroendoscopic procedures. We believe that due to its practical possibilities, its simplicity, low cost, reproducibility, and reality, being live animal tissue, it can be considered a fundamental model within a complete training program on neuroendoscopy.

Propofol Versus Traditional Sedative Agents for Advanced Endoscopic Procedures in Octogenarians

Propofol Versus Traditional Sedative Agents for Advanced Endoscopic Procedures in Octogenarians

Endoscopic Antireflux Therapies: Are We Near Closing the Treatment Gap in GERD

FigureIntroduction: Extra-esophageal symptoms of GERD such as Sore Throat, Laryngopharyngeal Reflux, Non-Cardiac Chest Pain and GERD induced Asthma and aspiration do not respond with the same regularity to PPIs. Regurgitation is quite common and difficult to relieve even with high-dose acid suppression. Until recently there was no minimally invasive alternative until recently. Several endoscopic therapies have been developed and tested in the hope of filling this “treatment gap”. Methods: Ultrasound Assisted Endoscopic Fundoplasty device or MUSE incorporates a video camera for direct visualization during insertion and staple site selection. After the staple site selected, the scope will be retroflexed which results in opposition of gastric fundus next the intrabdominal portion of the esophagus 3 cm above the gastroesophageal junction. At this point an alignment pin will be inserted from the distal tip to the shaft of the scope at the area of staple cartridge. This is followed by the insertion of two screws that compress the tissue between the tip and the shaft of scope under continues ultrasound measurements. When proper stapling gap is achieved, 5 standard 4.8mm titanium surgical staples are deployed simultaneously between the stomach and intrabdominal esophagus. During each application, 5 staples simultaneously will be inserted at each location. The scope will be withdrawn from the patient after each staple deployment. The scope will be reinserted after stapling cartridge change to identify the next stapling location. Generally, 3-5 locations will be staples in each patient. This results in deployment of 15 to 25 staples and creation of a 150-180° anterior fundoplication. Results: Average time per procedure is around 50 minutes. MUSE is a single physician procedure with a steep learning curve. A gastroenterologist with established experience in advanced endoscopic procedures generally is able to achieve 50 minutes, average time per procedure, after appropriate training and two independent procedures. 2/3 of patients post procedure usually can stay off of PPI for long term. Conclusion: Introduction of MUSE as a technically easy and safe platform, to perform Ultrasound Assisted Endoscopic Fundoplasty, sparked the interests again for endoscopic therapy in GERD. Early results showing promising improvement in subjective and objective parameters and potentially this novel technology could play a key role to close the treatment gap in GERD treatment.

Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia.

BackgroundDemand for endoscopic procedures scheduled with anesthesia is increasing and no-show to appointments carries significant patient health and financial impact, yet little is known about predictors of no-show.MethodsWe performed a 16-month retrospective observational cohort study of patients scheduled for outpatient endoscopy with anesthesia at a county hospital serving the safety-net healthcare system of San Francisco. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.ResultsIn total, 511 patients underwent endoscopy with anesthesia during the study period. Twenty-seven percent of patients failed to attend an appointment and were considered “no-show”. In multivariate analysis, higher no-show rates were associated with patients with a prior history of no-show (odds ratio [OR] 6.4; 95 % confidence interval [CI], 2.4- 17.5), those with active substance abuse within the past year (OR 2.2; 95 % CI 1.4-3.6), those with heavy prescription opioids/benzodiazepines use (OR 1.6; 95 % CI 1.0-2.6) and longer wait-times (OR 1.05; 95 % CI 1.00-1.09). Inversely associated with patient no-show were active employment (OR 0.38; 95 % CI 0.18-0.81), patients who attended a pre-operative appointment with an anesthesiologist (OR 0.52; CI 0.32-0.85), and those undergoing an advanced endoscopic procedure (OR 0.43; 95 % CI 0.19-0.94).ConclusionIn a safety-net healthcare population, behavioral and social determinants of health, including missed appointments, active substance abuse, homelessness, and unemployment are associated with no-shows to endoscopy with anesthesia.

Peroral Endoscopic Myotomy for Achalasia in a Thoracic Surgical Practice

Peroral endoscopic myotomy (POEM) is a new option in the treatment of achalasia. It has typically been performed by general surgeons and gastroenterologists familiar with advanced endoscopic procedures. Our objective was to assess the initial experience and outcomes with POEM by a thoracic surgeon. A retrospective chart review was performed of all patients who underwent POEM from October 2012 until December 2014. Pre- and post-POEM evaluation included upper endoscopy, high-resolution manometry, and a timed barium swallow. There were 35 patients (18 men and 17 women), with a median age of 53 years. Based on high-resolution manometry, there were 8 patients (23%) with type I, 21 (60%) with type II, and 5 (14%) with type III achalasia, and 1 patient had hypertensive lower esophageal sphincter. Prior therapy had been performed in 18 patients (51%). The POEM procedure was completed in all but 1 patient. On follow-up, dysphagia was improved in all patients. The Eckardt score was significantly reduced from 7 before POEM to 0 after POEM (p < 0.0001), and improved similarly for all manometric types of achalasia. Post-POEM upper endoscopy showed esophagitis in 55% of patients, but this condition resolved in all with acid suppression. Timed barium swallow showed a reduction of esophageal retention at 5 minutes from 63% before POEM to 5% after POEM. Ten patients had follow-up at 12 months or greater after POEM and the improvements persisted. Peroral endoscopic myotomy is a safe and effective therapy for achalasia. It provides reliable and persistent palliation of dysphagia and objective improvement in esophageal emptying. Esophagitis is common but resolves with acid suppression therapy. Thoracic surgeons with an interest in esophageal diseases and experience with endoscopy are encouraged to adopt the procedure.

Anesthesiologist-Administered Gastrointestinal Sedation: Time to Put It to Sleep?

In the ongoing debate regarding sedation administered during gastrointestinal (GI) endoscopy, supporters of sedation administered by anesthesia providers (AAP) argue that anesthesiologists best handle complications involving the airways. Furthermore, the product label for propofol, the most commonly used sedative for GI endoscopy, states: ‘‘it should be administered only by persons trained in the administration of general anesthesia.’’ Supporters of nonanesthesiologist-administered propofol (NAAP) sedation, specifically nurse-administered propofol administration under the guidance of the endoscopist, argue that the safety profile of NAAP is equivalent to AAP while being costeffective. For lowand average-risk procedures, overwhelming worldwide data support the hypothesis that NAAP has a comparable safety profile to AAP if sedation is administered after proper training, and according to implemented guidelines [1]. In this issue of Digestive Diseases and Sciences, Goudra et al. [2] conducted a comparative meta-analysis evaluating respiratory complications of AAPor NAAP-administered sedation during advanced GI endoscopic procedures. The authors provide data with regard to 3018 advanced GI endoscopic procedures carried out using NAAP-administered sedation and 2374 AAP-administered procedures. Regarding non-advanced GI endoscopy, a prior populationbased analysis studying complications of sedation reported that the use of anesthesiologist services was associated with a higher complication frequency, specifically respiratory adverse events [3], a finding not supported by the data reported by Goudra et al. who described similar pooled hypoxia rates in patients undergoing advanced endoscopic procedures sedated with propofol, irrespective of administering provider, although the rate of airway interventions such as jaw thrust, chin lift, mask ventilation, or endotracheal intubation was higher in the AAP group. As AAPs administered higher doses of propofol, patient satisfaction and endoscopist satisfaction were increased if AAP-administered sedation was used. Satisfaction might have been further influenced by the observed preference for co-administration of adjuvants used in AAP sedation, whereas propofol alone was preferentially administered in the NAAP group. Nevertheless, higher dosages of propofol administered during GI sedation usually increase complication rates [4], particularly hypotension and bradycardia, which were not evaluated in the study by Goudra et al. It would have been interesting to see whether the observed beneficial satisfaction of AAP sedation came at the expense of higher cardiovascular adverse events. Limitations to the study of Goudra et al. include the exclusive selection of non-randomized prospective trials for analysis as there exist no randomized control trials comparing hypoxia, airway intervention rates, and patient satisfaction after endoscopic sedation. Furthermore, potential biases such as differences in baseline patient and endoscopist characteristics were not analyzed. While NAAP sedation for GI endoscopy has successfully and safely been introduced to countries such as Germany [5], it remains unlikely that NAAP will be soon introduced in other countries despite literature supporting its safety and lower cost, due to financial and political issues. When moderate sedation is provided by a US endoscopist, a separate charge for this service is not permitted & Kilian Friedrich Kilian.Friedrich@med.uni-heidelberg.de

Su1573 The Learning Curve for Endoscopic Submucosal Dissection of Early Esophageal Neoplasm

Endoscopic submucosal dissection (ESD) is an advanced endoscopic procedure in resecting early esophageal neoplasm; however, it carries substantial risks, such as bleeding and perforation. Understanding of the procedural learning curve is important to the design of standardize training. This study aimed to clarify esophageal ESD's learning curve for endoscopists.

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol

Effectiveness of remifentanil & propofol infusion for procedural sedation in patients undergoing gastrointestinal endoscopic procedures: a systematic review protocol