Previous Endoscopic Therapy Research Articles

Initial experience and outcomes of per oral pyloromyotomy for the treatment of refractory gastroparesis.

Gastroparesis can be a debilitating disease process for which durable treatment options are lacking. While dietary changes and pharmacotherapy have some efficacy, symptoms frequently recur and some patients progress to needing supplemental enteral feeding access. Per oral pyloromyotomy (POP) has been shown to be a durable minimally invasive treatment option for refractory gastroparesis with a low side effect profile, and therefore has been performed at this institution for the past 6 years. This was a retrospective case series of all patients who underwent a POP at a single institution over a 6-year period (2018-2023). Patient demographics, preoperative symptomatology and subsequent workup, postoperative complications, and symptom recurrence were collected and analyzed. There were 56 patients included in the study. There was a 1.8:1 female:male ratio. The average patient age was 56 years old (range 23-85). The average duration of symptoms was 1-3 years. Thirty-eight percent of patients had undergone previous endoscopic therapy for gastroparesis (pyloric botox injection or pyloric dilation) and 16% of patients underwent multiple endoscopic therapies. Twenty-nine percent of patients were on a medication for gastroparesis. Past surgery was the most common gastroparesis etiology for POP (50% of patients). Diabetes (23%) and idiopathic (19%) were the other most common gastroparesis etiologies for POP. Nausea was the most common symptom at first follow-up (30%) but these patients continued to improve with 14% of patients continuing to endorse nausea at 6 months. Twenty-seven percent of patients developed symptom recurrence. Forty percent of patients with symptom recurrence underwent a repeat endoscopic or surgical therapy. In this present study, POP leads to durable results in approximately 75% of patients with minimal complications. Furthermore, the majority of patients who do develop symptom recurrence do not require additional gastroparesis interventions.

Bile acid sequestrants in poor healing after endoscopic therapy of Barrett's esophagus.

Endoscopic therapy for neoplastic Barrett's esophagus (BE) has become the standard of care over the past two decades. In clinical practice, we regularly encounter patients who fail to achieve complete squamous epithelialization of the esophagus. Although the therapeutic strategies in the individual stages of BE, dysplasia, and esophageal adenocarcinoma are well studied and largely standardized, the problem of inadequate healing after endoscopic therapy is only marginally considered. This study aimed to shed light on the variables influencing inadequate wound healing after endoscopic therapy and the effect of bile acid sequestrants (BAS) on healing. Retrospective analysis of endoscopically treated neoplastic BE in a single referral center. In 12.1% out of 627 patients, insufficient healing was present 8 to 12 weeks after previous endoscopic therapy. The average follow-up duration was 38.8±18.4 months. Complete healing was achieved in 13 patients already after intensifying proton pump inhibitor therapy. Out of 48 patients under BAS, 29 patients (60.4%) showed complete healing. An additional eight patients (16.7%) improved, but only partial healing was achieved. Eleven (22.9%) patients showed no response to BAS augmented therapy. In cases of insufficient healing even under exhaustion of proton pump inhibitors, treatment with BAS can be an option as an ultimate healing attempt.

Endoscopic submucosal dissection combined with clip for closure of gastrointestinal fistulas including those refractory to previous therapy.

Gastrointestinal (GI) fistula is a life-threatening condition and a therapeutic challenge. Endoscopic approaches include mucosal abrasion, clip closure, or stent diversion, with moderate success rates in the long term. We assessed whether fistula endoscopic submucosal dissection with clip closure (FESDC) could lead to complete resolution of fistulas even after failure of previous endoscopic therapy. Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. The primary outcome was long-term (> 3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with FESDC success. 23 patients (13 refractory 57 %) were included. Tight immediate sealing was achieved in 19 patients (83 %; 95 % confidence interval [CI] 61 %-95 %). Long-term closure was achieved in 14 patients (61 %; 95 %CI 39 %-80 %), with median follow-up of 20 months. Complications occurred in two patients (9 %). Previous local malignancy (P = 0.08) and radiotherapy (P = 0.047) were associated with a higher risk of failure. This novel FESDC strategy was demonstrated to be safe and feasible for permanent endoscopic closure of GI fistulas. Further studies are warranted to determine the place of this technique in the management of chronic GI fistula.

Contemporary Outcomes after Transurethral Procedures for Bladder Neck Contracture Following Endoscopic Treatment of Benign Prostatic Hyperplasia.

Objectives: Bladder neck contracture (BNC) is a bothersome complication following endoscopic treatment for benign prostatic hyperplasia (BPH). The objective of our study was to give a more realistic insight into contemporary endoscopic BNC treatment and to evaluate and identify risk factors associated with inferior outcome. Material and Methods: We identified patients who underwent transurethral treatment for BNC secondary to previous endoscopic therapy for BPH between March 2009 and October 2016. Patients with vesico-urethral anastomotic stenosis after radical prostatectomy were excluded. Digital charts were reviewed for re-admissions and re-visits at our institutions and patients were contacted personally for follow-up. Our non-validated questionnaire assessed previous urologic therapies (including radiotherapy, endoscopic, and open surgery), time to eventual further therapy in case of BNC recurrence, and the modality of recurrence management. Results: Of 60 patients, 49 (82%) and 11 (18%) underwent transurethral bladder neck resection and incision, respectively. Initial BPH therapy was transurethral resection of the prostate (TURP) in 54 (90%) and holmium laser enucleation of the prostate (HoLEP) in six (10%) patients. Median time from prior therapy was 8.5 (IQR 5.3–14) months and differed significantly in those with (6.5 months; IQR 4–10) and those without BNC recurrence (10 months; IQR 6–20; p = 0.046). Thirty-three patients (55%) underwent initial endoscopic treatment, and 27 (45%) repeated endoscopic treatment for BNC. In initially-treated patients, time since BPH surgery differed significantly between those with a recurrence (median 7.5 months; IQR 6–9) compared to those treated successfully (median 12 months; IQR 9–25; p = 0.01). In patients with repeated treatment, median time from prior BNC therapy did not differ between those with (4.5 months; IQR 2–12) and those without a recurrence (6 months; IQR 6–10; p = 0.6). Overall, BNC treatment was successful in 32 patients (53%). The observed success rate of BNC treatment was significantly higher after HoLEP compared to TURP (100% vs. 48%; p = 0.026). Type of BNC treatment, number of BNC treatment, and age at surgery did not influence the outcome. Conclusions: A longer time interval between previous BPH therapy and subsequent BNC incidence seems to favorably affect treatment success of endoscopic BNC treatment, and transurethral resection and incision appear equally effective. Granted the relatively small sample size, BNC treatment success seems to be higher after HoLEP compared to TURP, which warrants validation in larger cohorts.

Endoscopic features of buried Barrett’s mucosa

Buried Barrett's mucosa is defined as intestinal metaplasia that is "buried" under the normal-appearing squamous epithelium. This can occur in Barrett's esophagus with or without previous endoscopic therapy. Dysplasia and neoplasia within buried Barrett's mucosa have also been reported. However, endoscopic features of buried Barrett's mucosa have not been described. At our tertiary referral center for Barrett's esophagus, several endoscopic features have been observed in patients who were found to have buried Barrett's mucosa on histology. These features are squamous epithelium which is (1) darker pink on white-light and darker brown on narrow-band imaging and/or (2) has a slightly raised or nodular appearance. It was also observed that either of these 2 features is frequently seen adjacent to a Barrett's mucosa island. This study aimed to (1) evaluate the diagnostic accuracy of these endoscopic features, and (2) evaluate the frequency of endoscopically identifiable buried Barrett's mucosa in patients with dysplastic Barrett's esophagus, before and after endoscopic eradication therapy. This was a retrospective analysis of a prospectively observed cohort of all cases of dysplastic Barrett's esophagus referred to St Vincent's Hospital, Melbourne. Endoscopy documentation software and histopathology reports of esophageal biopsy and EMR specimens between March 2013 and March 2019 were searched for terms "buried" or "subsquamous" Barrett's mucosa. Endoscopic reports, images, and histopathology reports of suspected buried Barrett's mucosa were then reviewed to apply the endoscopic features and correlate with the histologic diagnosis. In a cohort of 506 patients with dysplastic Barrett's esophagus, 33 (7%) patients (73% male, median age at referral 70.5 years) had buried Barrett's mucosa on histology. Twenty-seven (82%) patients had previous treatment for dysplastic Barrett's esophagus; radiofrequency in 2 (6%), EMR in 4 (12%), and both modalities in 21 (64%). Six (18%) had no previous treatment. Histologically confirmed buried Barrett's mucosa was suspected at endoscopy in 26 patients (79%). Endoscopic features were (1) darker pink or darker brown mucosa underneath squamous epithelium (24%), (2) raised areas underneath squamous mucosa (27%), and both features present concurrently (27%). These features were associated with adjacent islands of Barrett's esophagus in 48%. Forty-four cases of buried Barrett's mucosa were suspected endoscopically, and these were sampled by biopsy (50%) and EMR (50%). Buried Barrett's mucosa was confirmed in 26 cases, with a positive predictive value of endoscopic suspicion of 59%. Eighteen cases of endoscopically suspected buried Barrett's mucosa had no buried Barrett's mucosa on histology; inflammation or reflux was identified in 12 (67%) patients. Dysplasia was identified within buried Barrett's mucosa in 12 (36%) patients; 5 intramucosal adenocarcinoma, 1 high-grade dysplasia, and 6 low-grade dysplasia. Endoscopic features of buried Barrett's mucosa were observed in 11 of 12 cases harboring dysplasia or neoplasia, compared with 15 of 21 cases of buried Barrett's mucosa without dysplasia. In this retrospective analysis of prospectively observed patients with dysplastic Barrett's esophagus, buried Barrett's mucosa was identified in 7%, including treatment-naive patients. The proposed endoscopic features of buried Barrett's mucosa were seen in 79% of patients with histology confirmed disease. These endoscopic features may predict the presence of buried Barrett's mucosa, which may contain dysplasia or neoplasia. An overlap between the endoscopic features of inflammation, reflux, and buried Barrett's mucosa was observed. Future prospective studies are required to develop and validate endoscopic criteria for identifying buried Barrett's mucosa.

IS THERE A PLACE FOR CHOLANGIOSCOPIC EVALUATION OF BILIARY ANASTOMOTIC STRICTURE AFTER DECEASED DONOR LIVER TRANSPLANT?

Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

A Novel Hybrid Stent with Endoscopic Vacuum Therapy for Treating Leaks of the Upper Gastrointestinal Tract

Introduction: Self-expanding metal stents (SEMS) are an established option for treating leaks in the upper gastrointestinal tract, and endoscopic vacuum therapy (EVT) has become a promising alternative. A novel approach is the use of an esophageal hybrid SEMS (VACStent®), which can maintain esophageal passage during EVT. We present the first study demonstrating successful use of the VACStent® for treating leaks of the upper gastrointestinal tract. Method: We performed a retrospective, single-center study of all patients who underwent endoscopic stenting with the VACStent® of leaks in the upper gastrointestinal tract. Results: Indications for treatment with the VACStent® were: iatrogenic esophageal perforation (n = 1), spontaneous perforation (n = 2), esophageal fistula (n = 2), and anastomotic leak after upper gastrointestinal surgery (n = 5). Successful application of the VACStent® was achieved in all patients (n = 10; 100%) with a total of 15 interventions. VACStent® therapy was used as a first-line treatment in 5 patient (success rate 80%; 4 out 5 patients) and as a second-line treatment after failed previous endoscopic therapy in 5 patients (success rate 60%; 3 out of 5 patients). Overall, VACStent® treatment was successful in 70% of the patients (7 out of 10). No severe VACStent® treatment-related adverse events occurred. Conclusion: The initial experience has been that the technical application of the VACStent® is safe and technically feasible. However, due to the small number of patients this study could not show the clear advantages of this novel hybrid stent. More studies are necessary to show significant advantages.

Endoscopic full-thickness resection using an over-the-scope device for treatment of recurrent / residual colorectal neoplasia: a single-center case series

BackgroundEndoscopic mucosal resection (EMR) in piecemeal technique is the treatment standard for larger flat or sessile colorectal lesions. The method is burdened by a high recurrence rate mostly presenting as difficult to resect lesions. In these situations, endoscopic full thickness resection (EFTR) with an over-the-scope device offers the option of complete resection despite scar formation.MethodsWe conducted a retrospective case review of 30 consecutive EFTR interventions on small (< 20 mm), difficult to resect recurrent / residual colorectal neoplastic lesions treated by EFTR.ResultsEFTR was technically feasible in 28/30 (93,3%) of the cases with an R0 resection in 24/30 (80%) and a median procedure time (marking to full thickness resection) of 34,5 min (11–120). After the first 15 procedures, the per-protocol rate increased from 13/15 to 15/15 and the R0 resection rate increased from 9/15 (69,2%) to 15/15 (100,0%; p < 0.01). One patient suffered from a delayed perforation the day after the procedure and needed emergency surgery (3,6%). Minor bleeding occurred in 3/28 patients (10,7%) and post-interventional fever in one patient (3,6%). The 30-day mortality rate was 0%.ConclusionsEFTR with an over-the-scope device is a useful method for endoscopic resection of difficult to treat recurrent or residual colorectal neoplasia after previous endoscopic therapy. High R0 resection rates were observed after a relatively short learning curve. The complication rate in this series seems acceptable given the complexity of the resected lesions.

Successful Closure of Upper GI Leaks by Endoscopic Vacuum Therapy

Endoscopic Vacuum Therapy (EVT) is a novel approach in the management of GI perforations and leaks. We report 3 cases of post-surgical leaks that failed previous endoscopic therapy but were closed by EVT. In all cases, a wound vacuum sponge (KCI-V.A.C. GranuFoam) was affixed to the distal end of a 12 or 16Fr NG tube (Covidien) with 2-0 sutures and endoscopically guided to the defect. The sponge was then placed either intracavitarilly or intraluminally. In case 1, a 58 year old man developed a 15mm duodenal leak after surgical resection of a 20cm retroperitoneal hemangiopericytoma. The sponge/NG tube was inserted nasally over a guidewire, endoscopically guided into the duodenal perforation using a snare, and secured with hemoclips. The NG tube was kept at low continuous suction (30 mm Hg) and was replaced once over a 28-day period, ultimately resulting in leak closure. Patient was discharged tolerating oral diet with CT showing resolution of fluid collections. In case 2, a 62 year old woman with gastric adenocarcinoma developed a persistent 0.6cm anastomotic leak after total gastrectomy and esophago-jejunal anastomosis. EVT was employed intracavitarilly with NG tube kept at low continuous suction (30mm Hg) for 7 days, leading to leak closure. After sponge removal, the patient was discharged tolerating full liquid diet with imaging confirming leak resolution. In case 3, a 48 year old woman with history of lap band placement underwent gastric bypass surgery with development of a small abscess and esophageal leak. EGD showed a leak 2cm above the GE junction. An OTSC, one partially covered and, later, one fully covered esophageal metal stent were placed. Repeat EGD showed a persistent 4mm opening near the OTSC with radiographic evidence of leak. The EVT sponge/NG tube was placed intraluminally over the leak. The NG tube was kept on low continuous suction (30mmHg) and replaced once over a 17-day period. After removal of the sponge, the patient was discharged on full liquid diet. Follow-up CT demonstrated resolution of the leak and the abscess. EVT is a promising approach to the management of upper GI luminal defects. The appeal of the technique lies in its minimally invasive nature, ease of use, and cost effectiveness. Our cases support EVT's reported efficacy and provides evidence for its role as a viable alternative to surgical closure, OTSC, or metal stent placement in the repair of upper GI perforations/leaks2123_A Figure 1. The vacuum sponge affixed to the distal end of a NG tube2123_B Figure 2. The sponge/NG tube placed intracavitarilly within the defect

Sa1303 IS THERE A PLACE FOR SPYGLASSTM EVALUATION OF POST LIVER TRANSPLANT BILIARY ANASTOMOTIC STRICTURE?

Cholangioscopy allows bile duct visualization, tissue sampling and therapeutic interventions. The aims of this study were to evaluate the usefulness of SpyGlassTM in post orthotopic liver transplant (OLT) biliary anastomotic strictures (BAS) and eventually identify endoscopic predictors of treatment result. This is a prospective observational cohort study conducted at a tertiary center in Brazil. Institutional review board approval and informed consent were obtained. Consecutive eligible patients with suspected post OLT biliary complications referred to ERCP were considered to SpyGlassTM. Exclusion criteria were previous endoscopic therapy, pregnancy, age under 18 years old, and inability to provide informed consent. Once a stricture was confirmed, patients were submitted to SpyGlassTM cholangioscopy followed by deployment of a fully covered self-expandable metal stent (CSEMS). Stent removal was scheduled at 12 months, when SpyGlassTM evaluation was repeated. Primary outcome measures were cholangioscopy success rate and biliary ductal changes in post-OLT BAS before and after CSEMS treatment. Secondary outcome measure was description of adverse events. Between March/16 and June/17, a total of 42 patients with post-OLT biliary complications were assessed for eligibility, and 20 were enrolled (results are summarized in Table 1). Cholangioscopy was successfully performed in all patients and showed the stricture orifice and a pale scar area in all of them. Remarkable findings were the presence of surgical sutures visualized in 10 and debris in 5 patients. All 20 patients had a previous abdominal ultrasound and stones had been described in 5 (25%). However, only 1 was confirmed by cholangioscopy and the remaining 4 ended up being sutures and debris misinterpreted as stones. Cholangioscopy-assisted guide wire placement was necessary in 5 (25%) patients. Other cholangioscopic findings are in Table 1. Two patients died with the stent in place and were excluded. Five patients still have the stent in place. Acute pancreatitis was the most common procedure complication (6.6%). Distal CSEMS migration occurred in 55.5% (10/18) and proximal in 5.5% (1/18) of patients. CSEMS occlusion was found in 16.6% (3/18). So far, with median follow-up of 412 days, stricture resolution was achieved in 30.8%. In best-case scenario, the success rate reaches 50%. No cholangioscopic finding was statistically related to treatment outcome. There were no recurrences. The most interesting finding of cholangioscopic evaluation after stent removal or migration was sutures’ disappearance. The presence of sutures and debris at the anastomotic site in post-OLT patients was remarkable. SpyGlassTM was useful to transverse the stricture in severe cases. The role of diagnostic cholangioscopy in post-OLT patients remains to be defined.Tabled 1Summary of resultsN20Female : Male9:11Age (years)Average (range)50 (19 – 68)Median (±SD)54 (±14)Time from OLT to ERCP (days)Average (range)411.5 (30 - 2488)Median (±SD)159.5 (±657.2)BAS treatmentSuccess4/18 (22.2%)Failure9/18 (50%)In treatment5/18 (27.8%)Stent treatment duration (days)Average (range)180 (14 – 403)Median (±SD)136 (±156)Adverse eventsAbdominal pain with hospitalization2/33 (6.6%)Acute pancreatitis2/33 (6.6%)Distal migration10/18 (55.5%)Proximal migration1/18 (5.5%)Occlusion3/18 (16.6%) Open table in a new tab Table 2SpyGlassTM evaluation in in post orthotopic liver transplantation (OLT) biliary anastomotic strictures.SpyGlassTM findingsBefore CSEMSAfter CSEMSStricture orifice20 (100%)5 (55.5%)Pale scar area20 (100%)1 (11.1%)Granular surface10 (50%)7 (77.8%)Sutures10 (50%)-Prominent small caliber vessels6 (30%)4 (44.4%)Debris5 (25%)-Convergence of folds4 (20%)-Prominent enlarged vessels3 (15%)1 (11.1%)Ulceration2 (10%)-Friability2 (10%)-Mucosal projections1 (5%)-Necrotic tissue1 (5%)1 (11.1%) Open table in a new tab

Efficacy and Safety of Radiofrequency Ablation for Treatment of Low-Grade Gastric Epithelial Dysplasia: Results from the Animal Study and Clinical Trials

Background and study aims: Gastric low-grade dysplasia (LGD) is considered an precancerous lesion and can progress to invasive carcinoma. According to the Vienna classification, a diagnosis of LGD (category3) with forceps biopsy suggests endoscopic resection or follow up. We describe our initial experience regarding safety and efficacy of radiofrequency ablation (RFA) therapy in treating patients with LGD. Methods: This study includes animal experiments and clinical studies. We carried out RFA with two pigs in vivo. The clinical trials carried out on the basis of animal experiments results. We prospectively enrolled 114 patients with LGD who were treated with RFA at the General Hospital of PLA. Results: 2 pigs were successfully treated with radiofrequency ablation. With increasing frequency of radiofrequency the edema and congestion became obviously and With increasing of the RFA frequency the depth of interaction RFA became deepen. The 114 patients of LGD have 128 lesions that were underwent RFA procedures, which based the size of the lesion and were burning 2-12 times / person, average 5.25 times / person. There were no complications occurred in the RFA procedure. Postoperative complications is abdominal pain, 89 patients was follow-up, which contains 101 lesions, residual 5 cases, 7 / 89, 7.87%; elimination rate of 92.13%, 82/89. 20 patients with abdominal pain(20/89, 22.47%). Conclusion: RFA can be an effective treatment of LGD to previous endoscopic therapy. Additional studies are needed to identify which subset of patients will benefit the most with RFA treatment.

Use of Hemospray® in post-sclerotherapy bleeding

Abstract Background Hemospray® is a new device for endoscopic hemostasis used for non-variceal gastrointestinal bleeding. It enables hemostasis and platelet activation by increasing the concentration of clotting factors and forming a mechanical barrier on the wall of a bleeding vessel creating a mechanical plug at the site of bleeding. Within the main indications for use are injuries with difficult endoscopic access, massive gastrointestinal bleeding, multiple bleeding sites, modification of the anatomy by previous endoscopic therapy, presence of coagulopathy, difficulty in having direct visualization or when it is impossible to have contact with the bleeding lesion. However, its use in children has not been approved yet by the FDA. There is a case report of an 11-month-old patient successfully treated with Hemospray® for non-variceal gastrointestinal bleeding. Clinical case We report the case of a 2-year-old female with acute liver failure and primary biliary cirrhosis with portal hypertension and bleeding after sclerotherapy. We analyzed the case to support new therapies for massive bleeding control in post-sclerotherapy esophageal ulcers. Conclusions The application showed to be safe without side effects. Using Hemospray® is an effective alternative in controlling gastrointestinal bleeding.

PTH-244 Obscure gastrointestinal bleeding: are long acting somatostatin analogues a useful adjuvant treatment? results from a tertiary centre

Introduction Small bowel vascular lesions are a common cause of obscure gastrointestinal (GI) bleeding, particularly in the elderly. Enteroscopy for argon plasma coagulation (APC) can be difficult and a proportion of patients continue to have recurrent bleeding despite endoscopic therapy. Pharmacological drugs are useful adjuvant treatment. The aim of this study was to assess the role of long acting somatostatin analogues (lanreotide) in patients with refractory GI bleeding. Method We retrospectively evaluated the effect of lanreotide in patients with refractory GI bleeding. Baseline demographics, co-morbidities, medications and previous endoscopic therapy were recorded. Efficacy was evaluated in terms of improvement in mean haemoglobin, transfusion requirements and bleeding episodes (>2 g/dl drop in HB or overt bleeding). Results Eleven patients (64% males, mean age 73 years) were treated with lanreotide between 2010–2014. All patients had multiple comorbidities including ischaemic heart disease (n = 10), diabetes (n = 6) and chronic kidney disease (n = 5). Three patients had a diagnosis of hereditary haemorrhagic telangiectasia. Six patients were on anticoagulants and 4 patients on aspirin whilst 4 patients were on transexamic acid. All patients had been requiring regular blood transfusions. The median duration of anaemia was 72 months. Lanreotide was given at a dosage of 60 mg (n = 5), 90mg (n = 3) or 120 mg (n = 3). Nine patients received a monthly dose; 1 patient received a 6 weekly dose and 1 patient received a single dose. The mean duration of treatment was 10.5 months (range 1–29 months). Eight out of 11 patients received endoscopic therapy with APC prior to commencing lanreotide. Four patients had further enteroscopy and APC during the treatment period with lanreotide. There was a significant difference in mean baseline and follow up haemoglobin levels with lanreotide therapy: 8.7 g/dl (7.3–10) vs. 9.7 g/dl (7.9 −11.8); p = 0.03. Transfusion requirements were reduced in all but 2 patients (p = 0.042). Bleeding episodes were reduced during the treatment period (0 episodes (n = 6), 2 episodes (n = 4), 4 episodes (n = 1) (p = 0.02). Fif death was aspiration pneumonia. In the endoscopically managed group, the 30 day mortality was 0%. One year mortality was 33% for the surgical group and 8% in the endoscopically managed group. Conclusion Our data suggests that this procedure is safe and effective, particularly when compared to the surgical alternative in this high risk group. The success rate of this procedure was high, suggesting that by utilising this technique, surgery can be avoided in the majority of patients with buried bumper syndrome. Disclosure of interest None Declared. Reference Binnebossal M, Klink CD, et al. Endoscopic Removal of Buried Bumper. Department of Surgery. RWTH Aachen University: Endoscopy. 2010:42:E17–18

Radiofrequency ablation for treatment of refractory gastric antral vascular ectasia (with video).

Background and study aims: Gastric antral vascular ectasia (GAVE) is a known cause of gastrointestinal bleeding and chronic iron deficiency anemia. Endoscopic therapy with argon plasma coagulation (APC) is widely used for treatment of GAVE, but most patients continue to require repeated blood transfusions and multiple endoscopic procedures (refractory GAVE). We describe our initial experience regarding safety and efficacy of radiofrequency ablation (RFA) therapy in treating patients with refractory GAVE. Patients and methods: We prospectively enrolled seven patients with refractory GAVE who had multiple prior treatments with APC. These patients were treated with RFA (HALO90 ULTRA Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA) at Ertan Digestive Disease Center at our tertiary University Hospital. Results: Seven patients underwent a total of 12 RFA procedures for treatment of refractory GAVE. The median number of RFA procedures was 2 (Range, 1 – 3). Average pre- and post-procedural hemoglobin were 9.3 g/dL and 10.16 g/dL, respectively. Five of seven patients (71 %) were transfusion-free after the RFA treatments while two patients continued to require blood transfusions. There were no complications in this series. Conclusion: RFA can be an effective alternative to APC for treatment of GAVE refractory to previous endoscopic therapy. Additional studies are needed to identify which subset of patients will benefit the most with RFA treatment.

Endoscopic plastic stenting for bile duct stones: stent changing on demand or every 3 months. A prospective comparison study

Endoscopic biliary sphincterotomy and stone removal is the standard of care for choledocholithiasis, with a success rate of > 90%. For stones ≤ 25 mm diameter, mechanical lithotripsy, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy can be used. In the case of failure, the next step is surgery. In elderly patients and in patients with an elevated surgical risk, stenting is the only treatment modality. In these cases the aim is to avoid the onset of acute obstructive cholangitis. The aim of the current study was to evaluate the best management of plastic stents in patients with biliary duct stones who were unfit for surgery and in whom previous endoscopic therapy had failed. Patients who were high surgical risks and in whom stone clearance was not possible due to the number and sizes of stones were included. Between March 2008 and September 2010 all patients were treated with endoscopic plastic biliary stenting at four tertiary care referral centers in Italy. Patients were randomly assigned to two groups: in Group A (n=39) plastic stents were changed every 3 months or sooner if symptoms appeared; in Group B plastic stents were changed on demand at the onset of symptoms, and ultrasonography and blood samples were performed every 3 months to check for signs of cholestasis and inflammation. The primary outcome was the rate of cholangitis. The secondary outcome was the rate of stone clearance after a period of stenting. A total of 78 patients were included in the study (43 M/35F; mean age 76 years). Acute cholangitis occurred in 3 patients from Group A and in 14 patients from Group B (P=0.03). Mortality related to cholangitis occurred in one patient from Group A and three patients from Group B (P=n.s.). The mean follow-up was 13.5 months (range 2-23). Stone clearance after long term stenting occurred in 24 patients from Group A (61.5 %) and in 21 patients from group B (53.8%) (P=n.s.). In patients with bile duct stones who were treated with biliary plastic stents, the best stent management to avoid cholangitis was stent changing at defined intervals (every 3 months in the current study). The data confirmed that plastic biliary stenting may decrease stone size with a high percentage of subsequent total stone clearance.

Radiofrequency Ablation for Treatment of Refractory Gastric Antral Vascular Ectasia

Purpose: Gastric antral vascular ectasia (GAVE) is a known cause of gastrointestinal bleeding and chronic iron deficiency anemia. Endoscopic therapy with argon plasma coagulation (APC) is widely used for treatment of GAVE, but a majority of patients continue to require repeated blood transfusions and multiple endoscopic procedures (refractory GAVE). We describe our experience with the use of radiofrequency ablation (RFA) therapy in treating patients with refractory GAVE. Methods: Prospective case series of seven patients with refractory GAVE who were treated with RFA (HALO90 ULTRA Ablation Catheter System; Covidien, GI Solutions, Sunnyvale, CA). Results: Seven patients (one male, six females, mean age of 69 years, range 56-82) underwent RFA for treatment of refractory GAVE (12 total procedures). All of the patients had previously undergone endoscopic therapy with APC. 4 (57%) of the seven required multiple RFA treatments. Average pre- and post-procedural hemoglobin were 9.3 (SD 0.78) and 10.16 (SD 1.72; p >0.05), respectively. Two (29%) of the seven patients required post-procedural transfusions. Conclusion: Radiofrequency ablation is an effective alternative to APC for treatment of GAVE refractory to previous endoscopic therapy. Five (71%) of seven patients are transfusion-free after the RFA treatment. Further studies are needed to identify which subset of patients will benefit the most with RFA treatment.Table 1: Patient demographics

PTU-212 To analyse the risk of stent migration with the Niti-S covered flared biliary stent

IntroductionStent migration occurs in 6%–12% of patients undergoing biliary stenting1 The Niti-S fully covered metal stent (Taewoong Medical, Seoul) has a flared end which acts as anti-migration.2 Few studies have...

Endoscopic Therapy with 2-octyl-cyanoacrylate (Dermabond®) for the Treatment of Gastric Varices: Indiana University Experience

Purpose: Endoscopic therapeutic options are limited for the management of gastric varices. Cyanoacrylate (CA) has been reportedly used for sclerotherapy in patients with variceal bleeding. This report describes a one institution experience with this intervention. Purpose of the study was to evaluate the effectiveness and safety of endoscopic therapy with cyanoacrylate in patients with gastric variceal bleeding. Methods: Observational study of patients receiving endoscopic therapy for gastric variceal hemorrhage at a tertiary center between Feburary 2006 and May 2011. Patient demographics, laboratory and procedural data were collected in a prospective fashion with IRB approval. Patients were followed to death, liver transplantation or last date of follow-up. Study outcomes were immediate control of bleeding, early rebleeding (within 1-5 days), short-term rebleeding (12 weeks), survival and serious complications. Results: A total of 26 patients including 24 cirrhotic patients undergoing 32 cyanoacrylate injections were identified, of which 77% were males with a mean age of 60. Cirrhosis was caused by Hepatitis C (HCV) ± alcohol (46%) and NASH ± HCV (32%). Mean MELD score at the time of first injection was 17 ± 8.6 and 16 patients were ineligible for TIPS or had previously failed TIPS. Median follow-up duration was 138 days [range 1-1013]. Type 1 and type 2 gastric varices were responsible for bleeding (active or recent) in 8% and 92% of patients respectively. Patients received a median of 2 injections (range 1- 4) to eradication of varices or last follow-up. Mean cyanoacrylate volume was 3.1 ± 1.6cc. Immediate hemostasis was achieved in 5 of the 6 active bleeders and 1 patient died from bleeding ulcer from previous gastric banding. Early rebleeding was seen in 1 patient (4%) and short term rebleeding was seen in 4 patients (1.6%). Four patients had minor bleeding during the procedure which was controlled with hemoclip. There were no other serious complications. Seven patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1) and rebleeding (1). Conclusion: Endoscopic cyanoacrylate therapy is effective to control bleeding in patients with gastric variceal bleeding who have not undergone previous endoscopic therapy. The risk of serious complications in this study was very low. Further comparative studies involving other interventions including TIPS are warranted.

Endoscopic Submucosal Dissection (ESD) of Large Flat Lesions in the GI Tract-A New Autofluorescence (AF)-Guided Technique

Endoscopic submucosal dissection (ESD) is an effective endoscopic method especially for large, flat lesions in the upper and lower GI tract. In flat lesions it can be difficult to visualize the margins and to determine the resection borders especially after previous endoscopic therapy (scarring) and during the resection after submucosal injection. Helpful tools in the visualization of such lesions are chromoendoscopy or narrow band imaging both in combination with magnification endoscopy, Autofluorescence endoscopy (AF) is a promising new technique to differentiate neoplastic from non-neoplastic tissue in vivo and might be another tool in the endoscopic management of such lesions.

SIR OCCAM ITʼS DOUBLE JEOPARDY

We describe a patient with two obscure sources of bleeding at once. Case Report: A 73-year-old African American man with a hx of alcoholisim and chronic pancreatitis(CP) was transferred to our institution with the diagnosis of UGI bleeding with large transfusion requirement. The patient had been admitted to an outside hospital with a hgb of 5.3 after complaining of mid-epigastric abdominal pain and melena occurring for 1 month. EGD was performed twice prior to transfer along with soft and colonoscopy that failed to reveal a source of bleeding. A CT of the abdomen revealed a dilated PD with 'chain of lakes' and CP. Repeat EGD was performed at our institution and revealed an actively bleeding Dieulafoy's lesion(DL) in the region of the posterior duodenal bulb that was treated with injections of epinephrine and gold probe application with good hemostasis. The next week he again experienced melena and was admitted with an hgb of 4. EGD was performed for the fourth time finding fresh blood in the duodenal bulb and ulceration from the previous endoscopic therapy. A side viewing ERCP scope revealed bright red blood intermittently welling up from the ampulla admixed with bile. [figure 1]Embolization was unsuccessful and the patient was not an operative candidate. Post-mortem examination revealed a 2 cm hemmorhagic pseudocyst.FigureDiscussion: This is the first case described of a bleeding DL in association with HP. In addition, this case highlights the difficulty and pitfalls in obtaining a diagnosis in HP emphasizing the need for a high index of suspicion in patients with obscure bleeding. Occam's razor is a logical principle attributed to the mediaeval philosopher William of Occam. The principle states that, “One should not increase, beyond what is necessary, the number of entities required to explain anything.” It underlies all scientific modeling and theory building. In this case, as with all cases of GI bleeding, it is important to consider all possibilities and to continue to evaluate the patient in a dynamic manner with the realization that Occam's razor may not always apply.