Cold Forceps Research Articles

Optimization of endoscopic treatment strategies for R0 resection of rectal neuroendocrine tumors smaller than 10 mm

BackgroundThe optimal histologically complete (R0) resection methods of endoscopy for rectal neuroendocrine tumor (NET) ≤ 10 mm remains controversial. We aimed to assess the optimal endoscopic treatments for NETs. MethodsThe retrospective enrolled patients (n = 208) with rectal NETs were divided into 3 subsets according to pathological tumor size: 2 - 3 mm, 4 - 5 mm, and 6 - 10 mm NETs. Factors associated with R0 resection according to different endoscopic treatments (accidental diagnostic biopsy by cold forceps, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD)) and tumor size were investigated. All patients underwent follow-up and no local recurrence or metastasis were identified. ResultsA total of 208 patients were enrolled. In patients with 2 - 3 mm NETs, the R0 resection rate was 100.0 % for biopsy, EMR, and ESD. The R0 resection rate for biopsy of 4 - 5 mm and 6 - 10 mm NETs was 34.3 % and 0.0 % respectively, which was inferior to the EMR/ESD rate (4 - 5mm: p < 0.001; 6 - 10 mm: p < 0.001: respectively). For patients with ≤ 10 mm NETs, EMR and ESD had a comparable en bloc (p = 0.082) and R0 resection rates (p = 0.651). ConclusionAccidental diagnostic biopsy by cold forceps could be considered as the possible treatment for 2 - 3 mm rectal NETs. And for patients with ≤ 10 mm rectal NETs, both EMR and ESD might be sufficient.

One-device colonoscopy: feasibility, cost savings, and plastic waste reduction by procedure indication, when performed by a high detecting colonoscopist.

Cold forceps and snares are each effective for removing polyps of 1-3 mm, while snares are more effective for polyps of 4-10 mm in size. If, in the same patient, polyps of 1-3 mm are removed with forceps and those of 4-10 mm with snares, two devices are used. If cold snares are used to resect all lesions of 1-10 mm (one-device colonoscopy), there is a potential for lower costs and less plastic waste. A single high detecting colonoscopist prospectively measured the feasibility of cold snaring all colorectal lesions of ≤10 mm in size, along with the associated costs and plastic waste reduction. 677 consecutive lower gastrointestinal endoscopies (not for inflammatory bowel disease) were assessed. Of 1430 lesions of 1-3 mm and 1685 lesions of 4-10 mm in size, 1428 (99.9%, 95%CI 99.5%-100%) and 1674 (99.3%, 95%CI 98.8%-99.7%), respectively, were successfully resected using cold snaring. Among 379 screening and surveillance patients, universal cold snaring of lesions ≤10 mm saved 35 and 47 cold forceps per 100 screening and surveillance patients, respectively. Cold snare resection of all lesions ≤10 mm (one-device colonoscopy) was feasible, and reduced costs and plastic waste.

Endoscopic treatment of colorectal polyps and early colorectal cancer

Background: Colonoscopy offers higher diagnostic sensitivity than other colorectal cancer screening methods and provides the advantage of both diagnostic tissue sampling and polyp removal. Since the majority of colorectal cancers evolve from adenomatous polyps, polyp resection through colonoscopy is widely considered an effective method of preventing colorectal cancer and reducing mortality rates.Current Concepts: Determining colorectal polyp size and shape requires comprehensive endoscopy with enhanced imaging techniques to choose treatment directions and the appropriate colorectal polypectomy method. The selection of the polypectomy method is contingent upon the polyp’s attributes and possible malignancy according to US Multi-Society Task Force on Colorectal Cancer and European gastrointestinal endoscopy guidelines. This article examines eight polypectomy procedures: cold forceps polypectomy, hot biopsy polypectomy, cold snare polypectomy, hot snare polypectomy, endoscopic mucosal resection (EMR), and modified EMR techniques. Each method has unique benefits and is suitable for particular polyp types and sizes. Piecemeal EMR and endoscopic submucosal dissection offer alternatives for larger or challenging lesions that require careful planning and follow-up. After endoscopic resection of early colorectal cancer, further surgery may be necessary depending on the risk of lymph node metastasis as determined by specific histologic findings following Korean and Japanese guidelines.Discussion and Conclusion: The choice of endoscopic resection technique, which depends on factors such as polyp shape, size, and location as well as endoscopist skill, is crucial for ensuring complete polyp removal.

Dieulafoy-like lesion after cold forceps biopsy: a rare complication from routine practice

Dieulafoy-like lesion after cold forceps biopsy: a rare complication from routine practice

Cold snare polypectomy compared to cold forceps polypectomy for endoscopic resection of guideline defined diminutive polyps: A systematic review and meta-analysis of randomized trials.

International guidelines recommend cold snare polypectomy (CSP) for polyps < 10mm in size. However, recent randomized clinical trials (RCTs) showed conflicting results for the use of cold forceps polypectomy (CFP) vs. CSP for the resection of diminutive colorectal polyps (DCPs) (≤ 5mm), especially for polyps ≤ 3mm. Herein we compared CFP with CSP for patients with DCPs in this meta-analysis of RCTs. We systematically searched the Cochrane Library, PubMed and EMBASE databases from inception to November 24, 2022, (Registration number INPLASY2022110135). The primary endpoint was DCP complete resection rate. The secondary endpoints were mean polypectomy time, polyp retrieval rate and complications. Seven RCTs involving 1023 DCPs were included. The complete resection rate (91.6% vs. 94.7%) for CFP was not significantly lower for polyps ≤ 5mm (relative risk [RR] = 1.03; 95% confidence interval [CI]: 0.98-1.07). Sub-group analysis showed that the complete resection rate (88.7% vs. 92.4%) for CFP was not significantly lower for DCPs > 3mm (RR = 1.04; 95%CI: 0.97-1.12). Another sub-group analysis showed that the complete resection rate (97.0% vs. 96.3%) was similar for polyps ≤ 3mm for CFP vs. CSP (RR = 1.00; 95%CI: 0.98-1.03). The mean polypectomy time was not different between CFP and CSP (95%CI: -11.86-10.18). The polyp retrieval rate (100% vs. 96.9%) was not significantly higher for CFP (RR = 1.02; 95%CI: 0.98-1.07). There were no reported complications in the included studies. The overall study quality was moderate except for the removal of polyps ≤ 5mm (low-quality evidence). CFP was comparable to CSP for theresection of polyps ≤ 3mm; however, caution should be taken for DCPs > 3mm because of the low complete resection rate (< 90%).

Clinical and endoscopic characteristics and management of 220 cases with serrated polyps

BackgroundSerrated polyps are considered the precursor lesions of colorectal cancer through the serrated pathway. In the present study, we aimed to evaluate and discuss the clinical and endoscopic characteristics and management of serrated polyps. MethodsThe data of 220 cases with serrated polyps between September 2018 and November 2021 in Shenzhen People's Hospital were retrospectively analyzed. ResultsOf all these cases, 32 were hyperplastic polyps, 36 were traditional serrated adenomas, 126 were sessile serrated lesions, 25 were SSLs with dysplasia, and one was an unclassified serrated adenoma. Although most patients were males aged ≥50 years and most serrated polyps were located in the distal colon and rectum with a size of 6–10 mm and the shape of type 0-Is, there was no significant difference (P > 0.05). Serrated polyps of ≤5 mm in size and type 0-IIa were mostly removed by cold biopsy forceps. Cold snare polypectomy was primarily used for those of 6–10 mm in size. Endoscopic mucosal resection was used for those of 6–20 mm, and endoscopic submucosal dissection was used for those of ≥20 mm (P < 0.05). All complications occurred in SSL patients with or without dysplasia (P < 0.05). ConclusionsClinical and endoscopic characteristics were beneficial for distinguishing and diagnosing serrated polyps. In addition, management options were crucial to prevent recurrence and progression. However, the detection rate of serrated polyps was relatively low. Therefore, prospective multicenter studies with large samples are necessary to better assess colorectal serrated polyps.

Cold snare versus cold forceps polypectomy for endoscopic resection of diminutive polyps: meta-analysis of randomized controlled trials.

The practices for resection of diminutive colon polyps vary among endoscopists and US Multi-Society Task force (USMSTF) guidelines recommend use of cold snare polypectomy (CSP) for this purpose. In this meta-analysis, we have compared CSP and cold forceps polypectomy (CFP) for resection of diminutive polyps. We reviewed several databases to identify randomized controlled trials (RCTs) that compared CSP and CFP for resection of diminutive polyps. Our outcomes of interest were complete resection of all diminutive polyps, complete resection of polyps ≤ 3mm in size, failure of tissue retrieval and polypectomy time. For categorical variables, we calculated pooled odds ratios (OR) with 95% confidence intervals (CI); for continuous variables, we calculated mean difference (MD) with 95% CI. Data were analyzed using random effects model and heterogeneity was assessed using the I2 statistic RESULTS: We included 9 studies with 1037 patients. Rate of complete resection of all diminutive polyps was significantly higher in the CSP group, OR (95% CI) 1.68 (1.09, 2.58). Subgroup analysis including jumbo or large capacity forceps, found no significant difference in complete resection between groups, OR (95% CI) 1.43 (0.80, 2.56). We found no significant difference in the rates of complete resection of ≤ 3mm polyps between groups, OR (95% CI) 0.83 (0.30, 2.31). Rate of failure of tissue retrieval was significantly higher in CSP group, OR (95% CI): 10.13 (2.29, 44.74). We found no significant difference in polypectomy time between groups. CFP using large capacity or jumbo biopsy forceps is non-inferior to CSP for complete resection of diminutive polyps.

Impact of cold snare versus cold forceps resection of diminutive adenomas on segmental incomplete resection rate.

Polypectomy technique, for diminutive lesion resection, is variable amongst colonoscopists using either cold snare (CSP) or cold forceps (CFP) polypectomy. While it is well described that CSP is a preferred technique to resect small lesions, there is little data evaluating the impact resection techniques have on metachronous adenoma burden. The study aim was to evaluate the rate of incomplete resection attributable to CSP and CFP of diminutive adenomas. This is a two-center retrospective cohort study evaluating the segmental incomplete resection rate (S-IRR) of diminutive tubular adenomas (TA). S-IRR was calculated by subtracting the segmental metachronous adenoma rate in a specific colonic segment without adenoma from segments with adenoma on index colonoscopy. The primary outcome was the S-IRR of diminutive TA resected by CSP or CFP on index colonoscopy. 1504 patients were included in the analysis: 1235 with TA <6 mm and 269 with TA 6-9 mm as the most advanced lesion. The S-IRR in a segment that had a <6 mm TA incompletely resected by CFP on index colonoscopy was 13%. The S-IRR in a segment which had a <6 mm TA incompletely resected by CSP was 0%. Among 12 included colonoscopists, the range of overall S-IRR was 1.1% - 24.4% with an average S-IRR of 10.3%. S-IRR was 13% higher with CFP resection of diminutive TA than with CSP. A proposed S-IRR metric of <5% is a target goal for all diminutive polyp resection, as 3/12 colonoscopists achieved this low rate. S-IRR can be utilized as a methodology to compare and quantify the difference in segmental metachronous adenoma burden across various polypectomy removal methods.

WEO Newsletter.

WEO Newsletter.

Distal Cap-assisted Endoscopic Mucosal Resection for Non-lifting Colorectal Polyps: An International, Multicenter Study

Background and AimsSubmucosal fibrosis is a commonly encountered problem associated with complex polyps referred for endoscopic mucosal resection (EMR). Previous biopsies, submucosal tattoo injection, and previous unsuccessful attempts at polyp resection have all been shown to induce submucosal fibrosis, which makes subsequent EMR more difficult and increases the risk of recurrence. MethodsWe conducted a multicenter, international, retrospective study of 61 distal cap-assisted endoscopic mucosal resection (EMR-DC) cases done for the indication of a non-lifting colorectal lesion occurring after a previous biopsy, tattoo, or attempted resection at 3 tertiary referral centers. ResultsEMR-DC was preceded by attempted polypectomy or EMR in 88.5% of cases, submucosal tattoo injection in 2%, previous biopsy in 5%, and both biopsy and tattoo in 5%. Complete macroscopic resection was achieved in 100% of EMR-DC procedures in an average procedure time of 49.5 minutes. The adenoma recurrence rate for these adherent lesions at surveillance (average 6.6 months) was only 9.8%. Two serious adverse events occurred (3.3%) within 30 days of the procedure: one instance of postprocedural bleeding and one episode of post-polypectomy syndrome. ConclusionThis large, multicenter series demonstrates EMR-DC to be a safe, effective, and efficient approach to a difficult and common clinical problem: adherent and non-lifting polyps. It may offer several advantages over more expensive or invasive endoscopic techniques used for this indication. The use of EMR-DC for larger adherent polyps with adjuvant techniques such as hot avulsion or cold forceps avulsion with adjuvant snare tip soft coagulation for smaller adherent sections may represent an ideal approach.

Complete endoscopic removal rate of detected colorectal polyps in a real world out-patient practical setting

Objectives Colonoscopy with adenomatous polypectomy reduces the incidence and mortality of colorectal cancer. We introduced a strategy of removing all neoplastic polyps in single-session out-patient colonoscopy using cold polypectomy. We aimed to investigate the achievement of single-session complete removal rate of detected colorectal polyps in clinical practice. Materials and methods This retrospective study included colonoscopy-scheduled 40–79-year-old outpatients, with at least one colorectal neoplasm, between January 2015 and December 2016. Exclusion criteria were: colorectal neoplasms 21 mm or larger in size; pre-examination for colorectal surgery or endoscopic submucosal dissection; colonoscopy performed by health check program; ongoing antithrombotic treatment; inflammatory bowel disease; familial adenomatous polyposis. We defined ‘clean colon’ as the removal of all detected neoplastic polyps in a single-session colonoscopy. We evaluated clean colon rate, factors relating to clean colon failure and complications. Results We evaluated 2527 patients (mean age 68 years; 799 women) with 8203 colorectal polyps (7675 adenomas, 423 serrated lesions, 105 Tis and T1 cancers). In 1–4 mm polyps, cold snare polypectomy (CSP; 51.8%) and cold forceps polypectomy (CFP; 45.8%) were applied. Clean colon rates were 95.1% per patient and 97.1% per lesion. The significant factors denoting clean colon failure were inadequate bowel preparation, ≥5 lesions, and the most advanced estimated histology of adenocarcinoma, on multivariate analyses. Post-polypectomy bleeding requiring endoscopic hemostasis occurred in five patients (0.2%) who had undergone endoscopic mucosal resection (EMR) or hot snare polypectomy (HSP). Perforation occurred in one patient (0.04%) with EMR. Conclusions The clean colon rates were satisfactory in single-session out-patient colonoscopy using cold polypectomy.

S2242 Taking Caution at Road’s End: Incidental Finding of Appendiceal Goblet Cell Tumor on Colonoscopy

Introduction: Appendiceal cancer is uncommon and rarely diagnosed on colonoscopy. We present a case of incidentally discovered goblet cell adenocarcinoma of the appendix and its subsequent management. Case Description/Methods: 81-year-old male presented to GI clinic for persistent epigastric pain and reflux. Symptoms had been worsening for several years and were refractory to medical therapy. He denied unintentional weight loss, nausea, melena, or a family history of colorectal cancer. He had 9 colonoscopies between 1999 and 2016 for rectal bleeding due to hemorrhoids and diverticulosis, with a single 2mm TA removed in 2016 and 5-year follow-up advised. Repeat EGD and colonoscopy were scheduled, during which the appendiceal orifice (AO) had a “heaped-up” appearance and was biopsied with cold forceps. Histology revealed goblet cell adenocarcinoma (GCA.) CT of the abdomen and pelvis showed a mildly enlarged appendix, no LAD, and no evidence of metastasis. The patient underwent a laparoscopic right hemicolectomy. Pathology clarified that carcinoma extended from appendix to mesoappendix and cecum with extensive lymphovascular and perineural invasion. Resected margins and 19 resected lymph nodes were negative for malignancy and ultimately staged pT4aN0 (IIB). Colonoscopy 1 year later revealed healthy ileocolonic anastomosis without signs of polyps or other masses (Figure). Discussion: Appendiceal cancer is categorized into 2 types: epithelial and neuroendocrine. GCA histologically has features of both. Incidence is rare, reportedly 0.05/100,000/year. It is usually an incidental finding following appendectomy for acute appendicitis and uncommonly found via colonoscopy. The AO is a key endoscopic landmark that should be identified on all colonoscopies to ensure completeness. Endoscopists should have a low threshold to biopsy abnormal-appearing tissue surrounding the AO. While no established risk factors for GCA, cases report an association with schistosomiasis and caucasian proclivity. Clinical diagnosis is difficult as presentations range from abdominal pain to appendicitis. Swift work-up and therapy are essential as appendiceal GCA can aggressively spread nodally or intraperitoneally. While evidence-based guidelines are not available, current management is similar to that of colon cancer with hemicolectomy for localized disease, adjuvant chemotherapy based on the surgical pathology, and post-treatment surveillance. We hope this case highlights the rarity of appendiceal GCA and the need for evidence-based guidelines.Figure 1.: A) Appendiceal orifice with “heaped-up” appearance B) Healthy ileocolonic anastamosis C) Clusters of goblet-like mucinous cells with invasion into and through the lamina propria (10X) D) High power view (20X) of cohesive groups of goblet-like mucinous cells. Nuclear atypia is mild and mitotic figures are inconspicuous E) Cytokeratin AE1/AE3 highlights the colonic mucosa and the infiltrative goblet-cell tumor (10X) F) Chromogranin highlights scattered endocrine cells (10X).

S2201 A Rare Case of Neuroendocrine Tumors Appearing in the Ascending and Transverse Colon

Introduction: Neuroendocrine tumors in the colon occur infrequently. When they do occur, they are most frequently found in the rectum. However, increasing incidence of neuroendocrine tumors in other portions of the colon suggests a need to re-evaluate current guideline related treatment. Case Description/Methods: A pleasant 77-year-old male with a PMH of COPD, CAD, HLD, recent diagnoses of LLL lung mass with hilar LAD, and significant metastatic disease in the liver, adrenal gland, and omentum, presented to the hospital for worsening fatigue. Patient’s first colonoscopy was at age 50, with subsequent colonoscopies at 5-year intervals. No adverse findings were found in previous evaluations. Denied changes in bowel habits and polyps. Patient had undergone colonoscopy which had shown numerous ‘volcano-shaped’ masses with central ulceration. The lesions were found to be hard when biopsies were performed using cold forceps. The majority of these lesions were seen in the ascending and transverse colon. He had a single sessile polyp in the rectum, which appeared morphologically different than the proximal colon lesions. Per request of oncology team, a colonoscopy and IR-guided liver biopsy were performed. Colonoscopy and liver mass biopsy demonstrate a high-grade neuroendocrine carcinoma with metastasis resulting in cecal, ascending colon, and transverse polyps. Rectal polyp was found to have fragments of tubular adenoma and did not have high-grade dysplasia. Fragments of colonic mucosa share foci that are morphologically identical to the mass in the liver biopsy. Immunohistochemical analysis on tissue from pertinent portions of colon identified cell populations positive for pancytokeratin AE1/AE3 (punctuate dot pattern), CD56, synaptophysin, chromogranin, SATB2 and TTF-1. CDX2 was found negative. Ki67 proliferative index for sample colon tissue was found to be greater than 90-95% (Figure). Discussion: This case illustrates morphological appearances of neuroendocrine tumors of the colon. Interestingly, patient did not have a rectal neuroendocrine tumor, the most common location for neuroendocrine tumor within the colon. This case also characterizes both the endoscopic and histological appearance of neuroendocrine tumors. It is important for gastroenterologists to be aware of luminal neuroendocrine tumors given their increasing incidence.Figure 1.: A: Transverse Colon. B: Hepatic Flexure. C: Cecum. D: Ascending Colon.

S1964 Metastatic Renal Cell Carcinoma Involving the Colon: An Unusual Cause of Lower Gastrointestinal Bleeding

Introduction: Renal cell carcinoma (RCC) is a common tumor of the kidney. RCC will frequently metastasize to the lungs, brain, liver and brain. Metastatic RCC in the gastrointestinal tract is very rare. Here we report a case of a patient presenting with hematochezia found to have metastasis of RCC to the colon. Case Description/Methods: 72 year old male with a history of metastatic renal cell carcinoma to the brain and bone, status post chemotherapy immunotherapy and right nephrectomy in 2020, most recently switched to cabozantinib, presented to our emergency department with lethargy and hematochezia. Hemoglobin on presentation was 4.6 g/dL. After resuscitation with intravenous fluids and blood products, the patient underwent an urgent colonoscopy which showed scattered polypoid lesions that were bluish in color, ulcerated and inflammatory appearing in the sigmoid colon, transverse, ascending colon and cecum. The largest lesion was found in the ascending colon and was at least 1 to 2 cm in size with central ulceration. The lesions were biopsied with cold biopsy forceps and sent for histopathological evaluation. On microscopic examination of the sections, a neoplasm arranged in compact nests and sheets of cells with clear cytoplasm and distinct membrane was noted.The tumor cells on immunostaining were positive for vimentin, carbonic anhydrase 9, CD10, AE1/AE3 and PAX8 supporting the diagnosis of metastatic renal cell carcinoma. Patient opted for hospice care given extensive and incurable state of disease with ultimate goal of pursuing comfort measures for the remainder of his life. He passed away 2 months after the diagnosis of metastatic RCC to the colon (Figure). Discussion: Renal cell carcinoma is the most common type of kidney tumor. The highest rates are observed in North America and Czech Republic. RCC is twofold more common in men compared to women and occurs in the sixth to 8 decade of life. RCC rarely metastasize to the gastrointestinal tract. Metastasis to the colon compared to the stomach and small bowel is very rare. The most common type of RCC is clear cell type as was seen in our patient. In patients with colonic metastasis of RCC, the overall 5 year survival is less than 10%. Our patient only survived 2 months after diagnosing metastatic disease to the colon. Therefore, metastatic RCC in the colon should be kept in the differential diagnosis of patients with lower GI bleeding especially in patients with prior history of kidney mass or nephrectomy.Figure 1.: On endoscopic examination, a bluish polypoid lesion (small yellow arrow) and a large ulcerated mass (larger yellow arrow) were seen in the ascending colon near the cecum (1A). On microscopic low power (100X) haematoxylin and eosin (H&E), tumor cells with clear cytoplasm arranged in sheets and nests were seen in the submucosa beneath normal overlying colon mucosa (1B). Immunohistochemistry stains were positive for Pax8, a marker of renal origin, in tumor cells (1C).

S2108 Rare Inflammatory Granulation Polyp Inside a Diverticulum

Introduction: Inflammatory granulation polyps arising from a diverticulum are rarely reported in literature. They are typically observed in the setting of recurrent inflammation such as inflammatory bowel disease (IBD) or diverticulitis. They are difficult to distinguish from malignancy as these lesions are usually friable and occasionally covered in exudates. Endoscopic management can be technically challenging and often associated with increased risk of perforation and bleeding. We present a case of inflammatory granulation polyp arising from a diverticulum which was removed endoscopically. Case Description/Methods: 47-year-old Spanish-speaking female with a past medical history of obesity and hyperlipidemia was referred to us for evaluation of ongoing abdominal pain and acid reflux. Labs were notable for a hemoglobin of 12.3 g/dL. She had no prior history of endoscopy. Computed tomography of the abdomen and pelvis with contrast was normal. She subsequently underwent upper endoscopy and screening colonoscopy. Colonoscopy showed diverticulosis and a 7 mm polyp arising from the diverticulum in the sigmoid colon. An attempt was made to lift the polyp through submucosal injection with ORISETM gel but only minimal lifting effect was observed. Polypectomy was subsequently performed with cold biopsy forceps. Pathology was consistent with edematous granulation tissue (Figure). Discussion: Inflammatory granulation polyps are rarely encountered on colonoscopy and owing to it closely mimicking colon neoplasm endoscopists should be able to differentiate between the 2. Granulation polyps have irregular vessels on the surface along with absence of pit patterns. Removal of these polyps when arising from the diverticulum involves endoscopic mucosal resection and closing of the site using clips or sutures to prevent complications. When associated with diverticulitis these are benign polyps and hence could be approached with possible surveillance.Figure 1.: Top: Colonoscopy demonstrating a granulation polyp inside of a diverticulum in the sigmoid colon. Bottom: Narrow band imaging magnified irregular micro-vessels on the surface of the sigmoid colon polyp.

S2143 The Gang's All Here: A Rare Case of Polypoid Ganglioneuroma of the Colon

Introduction: Ganglioneuromas are rare benign growths characterized by proliferation of nerve ganglion cells, nerve fibers & supporting cells of the nervous system. These growths have mostly been described in children but occur in adults as well. They are usually found in the mediastinum, retroperitoneum and adrenal glands but rarely, they occur in the gastrointestinal tract. Clinical manifestations depend on the location and size but can include abdominal pain, constipation, bleeding or obstruction. There are no known modifiable risk factors, but in some cases, they are associated with rare genetic syndromes like Cowden, Juvenile Polyposis and Peutz-Jeghers. Herein, we report a rare case of an isolated cecal ganglioneuroma. Case Description/Methods: Our patient was a 63-year-old female with no pertinent past medical history who presented for a routine screening colonoscopy. She had normal vital signs and no abnormal laboratory findings. During the colonoscopy, cold forceps polypectomy was performed to retrieve 2 3-mm polyps in the ascending colon and one 2 mm polyp from the cecum. Hematoxylin and eosin staining of the cecal polyp revealed evidence of spindle cell proliferation accompanied by large cells with prominent nucleoli, consistent with ganglion cells. The immunostaining of the cecal polyp was reactive for the S100 protein but was negative for markers of stromal tissue (CD34, CD117, smooth muscle actin, desmin, epithelial membrane antigen). The concurrence of these findings was consistent with a diagnosis of polypoid ganglioneuroma (Table). Discussion: Colonic ganglioneuromas are divided into 3 major groups: polypoid ganglioneuromas, ganglioneuromatous polyposis & diffuse ganglioneuromatosis. Most of these tumors are found incidentally on screening colonoscopy. Though most of these tumors are benign, few reports have noted an associated incidence of colorectal cancer. Genetic testing is advised if there is existence of a genetic syndrome. There is a lack of guidelines regarding best practice management of these tumors as well as lack of consensus regarding screening measures & follow up surveillance colonoscopy for recurrence. However, similar to other cases reported in the literature that have been successfully treated with polypectomy, the tumor in our case was excised safely endoscopically. Thus endoscopic resection can be a curative method for solitary ganglioneuromas. We believe that awareness & proper counseling will translate into better care of patients with such tumors. Table 1. - Classification of colonic ganglioneuromas with identifying features 1. Polypoid ganglioneuroma - small (< 2cm) & solitary- sessile or pedunculated 2. Ganglioneuromatous polyposis - numerous (often 20-40)- sessile or pedunculated 3. Diffuse ganglioneuromatosis - can range from 1-17 cm in size- present as disseminated, nodular, intramural or transmural lesions

S2265 A Rare Case of Esophageal Carcinoma After Tracheoesophageal Fistula Repair

Introduction: Tracheoesophageal fistula (TEF) constitutes one of the commonest congenital anomalies with an incidence of roughly 1 in 3500 births with treatment consisting of surgical correction in very early life. Chronic complications can include esophageal stricture, dysphagia, gastroesophageal reflux disease (GERD), Barrett’s esophagus, and esophageal cancer. While rare, these patients do have an increased risk of esophageal carcinoma attributable to chronic GERD leading to ongoing mucosal disruption. Sparce data on esophageal cancer after TEF repair appears to show an increased risk of this event occurring after 40 years of age. Case Description/Methods: The patient is a 32-year-old man with a past medical history of Cystic Fibrosis, GERD, osteoporosis, and tobacco use, and a past surgical history significant for Tracheoesophageal fistula repair. The patient presented to a primary care physician with complaints of dysphagia. He reported dysphagia only to liquids that started 2 months before presentation. The dysphagia was gradually progressed to solids. He was referred to gastroenterology, and an EGD was performed showing a single traversable mass measuring 5 cm in the esophagus (20 cms. from incisors) covering one-quarter of the circumference, and cold forceps biopsy was performed. The EGD also revealed signs of the previous tracheoesophageal fistula repair and mild generalized atrophic mucosa. Biopsies taken from the esophagus and stomach were sent for pathology. Pathology from the esophageal biopsy came back positive for moderately differentiated Squamous cell carcinoma and gastric biopsy revealed chronic gastritis with complete intestinal metaplasia. The patient was referred to oncology and underwent a PET scan which revealed the esophageal malignancy and bilateral pulmonary nodules. The patient was started on chemoradiation therapy and follows up with oncology regularly (Figure). Discussion: This case describes the importance of continuity of care during the transition from pediatrics to adult care in the field of gastroenterology in patients with a history of TEF repair, given the patient’s young age. While it appears esophageal cancer after TEF repair is rare, there should be an investigation into guidelines for adequate screening in this disease process.Figure 1.: Histopathology and endoscopic images.

S3716 A Rare Case of Ectopic Liver Tissue Incidentally Found in the Gastric Body

Introduction: Ectopic liver tissue (ELT) is seldom reported in the literature. It is usually asymptomatic and incidentally found. However, ELT has a strong association with malignant transformation to hepatocellular carcinoma (HCC), making removal of this tissue essential. Presented is a rare case of ELT found in the stomach. Case Description/Methods: A 78-year-old male with a past medical history of hypertension and gastritis presented to clinic for worsening gastroesophageal reflux disease (GERD) over the past six months. The patient reported GERD symptoms for the past twenty years that he had been self-treating with over-the-counter proton pump inhibitors, probiotics, and digestive enzymes without relief. On presentation his vitals, physical exam, and blood work were unremarkable. The patient underwent esophagoduodenoscopy (EGD) which revealed esophagitis, a large paraesophageal hernia, and a single 15-millimeter submucosal nodule in the anterior wall of the gastric body. Cold forceps biopsies obtained from the body and antrum of the stomach were unremarkable and negative for H. pylori. He was referred for endoscopic ultrasound (EUS), where a fine needle biopsy of the benign-appearing gastric body submucosal nodule was performed (figure 1a). Three passes were made with a 22-gauge ultrasound biopsy needle using a transgastric approach. A visible core of tissue was obtained. Final cytology demonstrated superficial gastric mucosa and detached benign liver tissue (figures 1b, 1c). No dysplasia or malignancy was seen. Discussion: ELT has an incidence of 0.24-0.47%. Of the reported cases, ELT is most commonly seen in the gallbladder or pancreas. The etiology of ELT is unknown but is thought to be associated with errors in embryological development. Most ELT is asymptomatic but can develop the same pathologies as the orthotopic liver. It can also cause abdominal pain, bleeding, and compression of neighboring tissues. There is also a strong association between HCC and ELT, necessitating biopsy and endoscopic removal. This case demonstrated ELT incidentally found in the gastric body during EGD and was biopsied by a fine needle using EUS guidance. Histology was without features to suggest malignancy, but to prevent malignant transformation endoscopic resection was recommended.Figure 1.: 1a. Arrow indicating nodule in gastric body, as seen by endoscopic ultrasound. Image 1b. Hematoxylin and eosin stain with 100x magnification. Normal gastric glandular mucosa. Arrow indicating benign unremarkable hepatic tissue found in gastric body. Image 1c. Hematoxylin and eosin stain with 200x magnification. Benign unremarkable hepatic tissue found in gastric body.

S2257 Cirrhosis, Varices, and Barrett’s Esophagus: WATS3D-only Surveillance and Band Ligation in the Management of Nondysplastic Barrett’s Esophagus Progressing to High Grade Dysplasia With Underlying Esophageal Varices

Introduction: Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS3D) is an emerging technique used to collect esophageal samples via transepithelial brushing. WATS3D can be a safe and useful tool in Barrett’s esophagus (BE) management in patients with underlying small esophageal varices (EV) where traditional 4 quadrant cold forceps biopsies (CFB) would be contraindicated due to the risk of adverse events such as bleeding. We describe the utility of WATS3D-only surveillance combined with band ligation in the management and eradication of BE which progressed to high grade dysplasia (HGD) in a patient with underlying cirrhosis and EV. Case Description/Methods: We present a 66-year-old male with a history of nondysplastic (ND) BE (C0-M1), small Grade 1 EV and cirrhosis who presented for BE surveillance. Due to underlying EV and associated risk of bleeding, CFB was not performed and sampling with WATS3D-only was undertaken. WATS3D was first performed with surveillance esophagogastroduodenoscopy (EGD) in 2015 and demonstrated ND BE. On further EGD surveillance, BE histology remained ND until early 2021 where WATS3D revealed low grade dysplasia (LGD). Repeat EGD with WATS3D brushing was performed 4 months later, which demonstrated progression to HGD. Interval surveillance EGD with WATS3D brushing was, again, performed 4 months later and demonstrated LGD with rare foci of HGD. Of note, in both instances band ligation of the dysplastic segments was done. EGD with WATS3D 3 months later revealed endoscopic clearance of BE post-banding and pathology report revealed, ND, non-goblet cell metaplasia. The final interval surveillance EGD with WATS3D, 3 months later, showed complete eradication of BE with no evidence of intestinal metaplasia. Table 1 provides a thorough chronological description from first EGD to complete resolution of BE, 8 years later. Discussion: WATS3D has been increasingly shown to be an effective BE surveillance and screening tool. However, given the lack of data regarding appropriate surveillance windows for WATS3D-only BE surveillance, we performed sampling at shorter intervals than what would otherwise be recommended, to confirm the lack of dysplasia. This case presents a unique approach to WATS3D-only surveillance combined with band ligation therapy of dysplasia in the management of BE in a cirrhotic patient with underlying EV. Additionally, this case is unique in clearly documenting progression of a short segment of ND BE to HGD with WATS3D sampling alone. Table 1. - Summary of findings and intervention from first EGD to complete resolution of BE (8 year window) Date Variceal Grade Prague Score Number of BE Islands Sampling done by WATS3D Pathology Findings Banding therapy (# of bands) 04/09/14 2 C0-M1 3 No N/A 0 07/29/15 2 C0-M1 Scattered No N/A 0 12/2315 1 C0-M1 Scattered Yes No dysplasia 0 06/15/16 1 C0-M1 Scattered Yes No dysplasia 0 02/08/17 2 C0-M1 Scattered No N/A 4 01/22/18 1 C0-M1 1 No N/A 0 01/30/19 2 C0-M1 2 No N/A 0 01/29/20 1 C0-M1 2 No N/A 0 02/01/21 1 C0-M1 2 Yes Low-grade dysplasia 0 06/01/21 1 C0-M1 2 Yes High-grade dysplasia 3 10/25/21 1 C0-M1 2 Yes Low-grade with rare foci of high-grade dysplasia 2 01/25/22 1 N/A 3 Yes Non-goblet cell metaplasia, no dysplasia 0 04/25/22 1 N/A 0 Yes Squamocolumnar, no dysplasia or metaplasia 0

Signet ring cell hilar cholangiocarcinoma diagnosed via direct transpapillary cold forceps biopsy under fluoroscopy

Signet ring cell hilar cholangiocarcinoma diagnosed via direct transpapillary cold forceps biopsy under fluoroscopy