Referral Centre In London Research Articles

Clinical features, myocardial injury and systolic impairment in acute myocarditis

ObjectiveCardiovascular magnetic resonance (CMR) is increasingly used in the diagnosis of myocarditis, with myocardial injury and systolic dysfunction playing key roles in the prognosis of this clinical setting. The clinical...

617 Patient Harm Is Underreported Due to an Inadequate Reporting System for Serious Incidents

Abstract Aim The Royal Free London Skin Cancer Service (RFL-SCS) is the largest referral centre in London, having received 26,114 two-week-wait referrals since January 2022. Patients are filtered through a complex Skin Cancer Pathway (SCP) involving multiple disciplines (dermatology, plastic surgery, oncology). This root cause analysis of Serious Incidents (SIs) attempts to pinpoint their underlying causes and identify key themes for the re-design of the SCP to ensure patient safety. Method A retrospective analysis of SIs recorded by the RFL-SCS between January 2022 and September 2023 was conducted. Incidents were attributed to various stages in the SCP, which was mapped out in detail. Related information was gathered by interviewing staff at significant points in the pathway and reviewing relevant procedures. A survey of practitioners was conducted to understand if SI reporting through the Datix system was accurate. Results From 26,114 referrals, 1326 needed treatment. 657 of these patients breached the two-week-referral target, with 10 SIs identified. 83% of practitioners surveyed felt that this was an underestimation. Major event types involved no follow-up appointments being booked after: MDT (3); surgery (2); scans (5); patient lost to follow up (1); and poor communication with patients (2). Conclusions System-wide changes must be implemented to prevent SIs from reoccurring. The Datix reporting system was described as convoluted and inadequate, leading to under-reporting of patient harm. More research needs to be conducted in designing an automated tracking system to flag-up and action MDT outcomes for patients with completed excisions, histology, and scans. This will prospectively avoid delays in onward referrals.

Fetal Scoliosis: Natural History and Outcomes.

Scoliosis can be detected on prenatal ultrasonography and may be associated with structural and syndromic abnormalities. Associations and pregnancy outcomes related to the prenatal diagnosis of scoliosis are poorly understood. A retrospective cohort study was undertaken at a tertiary referral center in London. Referred cases with spinal deformities between 1997 and 2021 were identified from the prenatal ultrasonography database. Outcomes were ascertained from the database and electronic notes. One hundred twenty-three cases of fetal spinal deformities (scoliosis, kyphosis, or kyphoscoliosis) were identified from a referral population of 660,000 pregnancies, giving an incidence of approximately 0.2 per 1000 fetuses. Fifty-eight live births (47.2%) and 65 cases (52.8%) of fetal or neonatal demise or termination were observed. Most live births were isolated spinal deformities with a good postnatal outcome (n = 35, 60.3%). The commonest syndromic diagnosis in this group was VACTERL association (n = 7, 12.1%). Most cases of fetal loss were associated with severe malformations, most commonly spina bifida, body stalk anomaly and amniotic band sequence, or chromosomal abnormalities, except in 2 cases (3.1%). This is the largest reported cases series to date of prenatally diagnosed fetal spinal deformity. This confirms that fetal scoliosis and associated vertebral abnormalities are underdiagnosed prenatally, with the reported incidence (0.2 per 1000) lower than the recognized incidence of congenital scoliosis (1 in 1,000). The concurrent finding of severe malformations was strongly associated with fetal loss. When an isolated finding, most fetal spinal deformities had a good postnatal outcome, while 1:8 live births were diagnosed with VACTERL association.

A single centre retrospective analysis of the management and outcomes of cardiac device-related infective endocarditis

Abstract Background/intro Cardiac device-related infective endocarditis (CDRIE) is a rare but serious complication of cardiac device insertion with a high mortality rate. Cardiac devices are increasingly being implanted in older patients amid an ageing population with more comorbidities. Our centre is a large cardiac surgery referral centre in London. The centre implants a large number of cardiac devices per year (an average of 2168 per year from 2016 - 2019). The IE multidisciplinary team (IE MDT) manages approximately 150 IE referrals from the region per year. Purpose We aimed to describe a cohort of patients with CRDIE, referred to the IE MDT over 5 years (2015-2020), to generate a contemporary representation of patients with CDRIE. Methods We carried out a retrospective review of all referrals to the IE MDT between 2015 and 2020, identifying all patients with CDRIE - infection extending to the electrode leads, cardiac valve lead(s) or endocardial surface (ESC). All patients who were discussed at the IE MDT between October 2015 and March 2020 were screened, based on inclusion criteria according to the ESC's definition of CDRIE. Patients who had an infection of the cardiac device pocket with no evidence of IE were excluded. Results 60 out of 928 IE patients had confirmed CRDIE after discussion in the IE MDT from 10/2015 and 03/2020. The average age of the cohort was 70.3 (male =44, 73%). 61.7% of the devices were PPM (n=37), 10% were ICD, 20% were CRT-D, and 8.3% were CRT-P. The average duration of device therapy before removal was 64 months. 66.7% of devices were extracted (n=40) and 33.3% were managed medically (n=20). 43.3% of the cohort had prosthetic valves (n=26), and 13.3% of the total cohort had tissue aortic valve implants (TAVI) (n=8). 85% had a transesophageal echo (TOE) procedure (n=51) and 61.7% went on to have a PET CT scan (n=37). The overall inpatient mortality was 25% (n=15), rising to 45% at 12 months (n=27). Patients managed medically had a significantly higher mortality at 6 and 12 months compared to those who received an extraction and antibiotics (figure 1). There was no difference in left or right ventricular systolic function pre- and post- treatment on average or degree of tricuspid regurgitation. Medically managed patients were frailer by Charlson Index (average Charlson Index score 3) than surgically managed patients (average Charlson Index score 2). Conclusions In a retrospective assessment of CRDIE, we found that there is a low incidence of CRDIE complicating cardiac device insertion at BHC when compared to the national average. We found that surgical removal improves the likelihood of survival at 6 and 12 months when compared to medical management in those with a severe Charlson score, suggesting that even in cases of frailty and multiple morbidities, device extraction is preferable (figure 2).Survival curve of all CDRIE patientsSurvival curve in the severely frail

P808 Risk of relapse after vedolizumab withdrawal in Inflammatory Bowel Disease for patients in histological remission

Abstract Background A key clinical question is whether we should be withdrawing advanced inflammatory bowel disease (IBD) medications after a period of sustained remission. There is data to suggest that risk of relapse on withdrawal of vedolizumab is higher than that of anti-TNF therapy1. Drug costs are still considerable and so withdrawal of medications will also have significant financial benefits. The aim was to review the outcomes of vedolizumab withdrawal in patients in remission, in particular for those where a clinical decision was made following confirmed histological remission of their IBD Methods This was a single-centre retrospective review of patients in the IBD clinic at a tertiary referral centre in London. We analysed all those who had stopped vedolizumab at least six months prior and were in either clinical, biochemical, radiological, endoscopic or histological remission. We assessed for evidence of a flare of disease following withdrawal of vedolizumab and the need of further biological treatment. Results 38 patients had vedolizumab withdrawal for remission with a median length of treatment of 36 months. 28 (74%) had a flare up of disease requiring medication change with 24 (63%) requiring biologics. 21 restarted vedolizumab and 79% responded to this medication. Importantly, 5 patients are still less than a year since stopping and so still at high risk of relapse. Of the 21 patients confirmed to be in histological remission, 17 (81%) had a flare of disease requiring further treatment, of which 15 (71%) required biologics. Median time to flare was 7 months with only two patients flaring after a year of cessation. All 15 were started on vedolizumab and 12 (80%) responded to this but one had a subsequent early secondary loss of response. Of those who did not respond to vedolizumab, one required emergency surgery, one responded to ustekinumab and one only has partial response to a third biologic. Conclusion Relapse following vedolizumab withdrawal occurs in a significant number of patients even when they have been in remission for a long period of time. It usually occurs quickly within the first year and having confirmed histological remission does not seem influence this risk. Recapture of response is reasonably good and occurs in four fifths of patients. Despite the significant cost savings of stopping vedolizumab, clinicians need to consider the risk to benefit ratio of stopping when relapse is such a common event. 1 Martin, A., Nachury, M., Peyrin-Biroulet, L., et al, GETAID-Vedo-STOP Study Group (2020). Maintenance of Remission Among Patients With Inflammatory Bowel Disease After Vedolizumab Discontinuation: A Multicentre Cohort Study. Journal of Crohn's & colitis, 14(7), 896–903. https://doi.org/10.1093/ecco-jcc/jjaa005

TH2.3 Elective versus emergency management of gallstone disease at a tertiary referral centre amidst the COVID-19 pandemic - should the protocol be altered?

BackgroundGallstones are a common pathology affecting approximately 15% of the population in UK, 20% of which are symptomatic. It is suggested symptomatic patients undergo cholecystectomies. Guidelines recommend this is performed within one week of initial emergency presentation or 52 weeks for elective case. Surgical capacity to manage emergency cholecystectomies was limited due to the COVID pandemic. We assessed wait time discrepancy between elective and emergency cholecystectomies.MethodsA retrospective review of all patients undergoing cholecystectomies between January and November 2021 in a major tertiary referral centre in London was undertaken. Initial pathology at the time of presentation, elective vs emergency presentation, pre-surgical biliary complications along and wait times were reviewed.Results219 (74 elective, 145 emergency) patients underwent surgery, mean age 48 years (23% Male and 77% Female). Average wait times for elective cholecystectomies were 69.7 days (min 0, max 246) in comparison to 68.9 days (min 1, max 253) for emergency surgery. 22 (15%) of the patients of initial emergency presentation re-attended hospital and 6 (4%) had adverse events such as gallbladder perforation or pancreatitis due to delayed treatment. Comparatively, 9 (12%) elective patients attended A&E due to pain, with no adverse outcomes.ConclusionsOverall wait time of emergency vs elective cholecystectomies were similar. This review indicates emergency cases require prioritisation over elective cholecystectomies due to the higher number of re-attendance and adverse events. Emergency cases need to be prioritised to meet guidelines, which could also reduce complication rates whilst awaiting surgery and lead to fewer adverse outcomes.

Patient perspective on the participation of ophthalmology residents in their cataract surgery

ObjectifDéterminer la proportion de patients qui acceptent que des résidents prennent part à leur chirurgie de la cataracte et découvrir les facteurs permettant de prédire le consentement. NatureÉtude transversale prospective. ParticipantsLes 330 patients consécutifs adressés à 3 chirurgiens dans un centre de soins tertiaires de London, en Ontario, en vue de l’évaluation de leurs cataractes entre février et avril 2021. MéthodesOn a demandé aux patients – en utilisant un outil de dialogue standardisé – ce qu'ils pensaient de la participation de résidents à leur chirurgie de la cataracte. Les données cliniques et démographiques ont été obtenues par téléphone et tirées des dossiers médicaux. Les facteurs de prédiction du consentement ont été évalués au moyen d'un modèle de régression logistique. RésultatsOn a obtenu des réponses de la part de 279 sujets (taux de réponse de 85 %), dont l’âge moyen était de 71,7 ± 8,6 ans et dont 113 étaient des femmes. Le taux de consentement s'est élevé à 71 %. Une expérience antérieure négative lors d'interactions avec des étudiants en médecine constituait un facteur de prédiction indépendant du refus de laisser participer des résidents (rapport de cotes [RC] = 3,10; intervalle de confiance [IC] à 95 %: 1,32–7,28; p = 0,009). Les sujets qui ont refusé de donner leur consentement avaient également eu plus d'expériences négatives dans leurs interactions avec d'autres médecins (35 % vs 23 %; p = 0,031) et connaissaient quelqu'un qui avait eu des problèmes après une chirurgie oculaire (36 % vs 22 %; p = 0,016). Les sujets dont la profession comprend un stage (RC = 2,87; IC à 95 % : 1,08–7,67; p = 0,035) et ceux dont l'acuité visuelle préopératoire était de 20/200 ou pire (RC = 2,78; IC à 95 % : 1,03–7,14; p = 0,043) étaient plus susceptibles de donner leur consentement. ConclusionsOn doit demander explicitement aux patients s'ils consentent à ce que des résidents prennent part à leur chirurgie. La personne qui a vécu des expériences antérieures négatives peut se montrer réticente à la participation d'un étudiant à ses soins de santé. La sensibilisation des patients envers le mode d'apprentissage par stages des étudiants en médecine pourrait encourager l'octroi du consentement.

Hereditary Systemic Autoinflammatory Diseases: Therapeutic Stratification.

Hereditary systemic autoinflammatory diseases (SAIDs) are rare, often severe conditions characterised by mutations in the key regulators of innate immune responses. Dramatic advances in the molecular genetics and next-generation sequencing in the past decade enabled identification of novel mutations that play a pivotal role in the mechanistic pathways of inflammation. Although genetic testing may not always provide straightforward guidance in diagnosis and clinical decision making, through translational research, it sheds light into molecular immunopathogenesis, particularly in IL-1 inflammasome and cytokine signalling pathways. These remarkable insights provided a better understanding of autoinflammatory conditions and their association with the innate and adaptive immune systems, as well as leading to development of cytokine-targetted biologic treatments. Use of targetted therapeutics not only helps control disease flares, reduce acute-phase responses and prevent devastating complications such as amyloidosis, but also improves health-related quality of lives and support patients to pursue almost a normal life. Herein, we discuss the commonest monogenic SAIDs, describe their immunopathology, and summarise the approaches in the management and targetted treatment of these conditions, including presentation of novel data based on a cohort of children with these rare diseases from a single quaternary referral centre in London.

145: THE USE OF MACHINE LEARNING FOR REAL-TIME DETECTION OF OESOPHAGEAL AND GASTRIC CANCER BASED ON DIFFUSE REFLECTANCE SPECTROSCOPY: A VALIDATION STUDY

Abstract Background and aim The lack of a fast and accurate intraoperative tumour margin assessment tool contributes to high positive circumferential resection margin rates for oesophageal and gastric cancers, which is associated with local recurrence and poor long-term survival. Diffuse reflectance spectroscopy (DRS) can provide non-invasive, accurate, and real-time tissue classification based on quantification of light reflectance in tissue, providing a unique optical fingerprint of the tissue. This study aimed to validate the use of DRS for discrimination between normal and cancerous tissues based on ex-vivo gastric and oesophageal cancer resection specimens. Methods Consecutive patients undergoing resections for gastric and oesophageal carcinomas at a tertiary referral centre in London between July 2020 and June 2021 were included. Reflectance data in the 468-720 nm spectral range were recorded on ex-vivo specimens within 15 minutes of surgical specimen excision. Based on video recordings of the data acquisition procedure and probe tip tracking, sampling sites were correlated with histological reports manually labeled as either normal or cancer (Figure 1). Following spectral data normalisation and feature selection, four supervised machine learning approaches were tested for classification using 5-fold cross-validation. Overall classification accuracy and Area Under the Curve (AUC) across machine learning approaches were compared. Results A total of 32 patients (median age 68, 75% male) were included. 11,862 mean spectra (2990 spectra for normal oesophagus, 4628 for normal stomach, 2305 for gastric cancer, and 1939 for oesophageal cancer) were collected. For oesophageal cancer, classification accuracy was 96.22 ± 0.50 and AUC was 99.24 ± 0.19, while for gastric cancer, the accuracy was 93.86 ± 0.66, and AUC 98.50 ± 0.28 for gastric cancer. For both malignancy types, Extreme Gradient Boosting was the best performing classifier. The differences in spectral data between patients receiving neoadjuvant treatment and treatment naïve were non-significant. Conclusion Machine learning can be used to accurately differentiate between normal and cancerous oesophageal and gastric tissues in an ex-vivo setting, based on DRS data. Features used for class discrimination should be investigated to find possible physiological correlates of spectral data differences. Future intraoperative validation is required to assess the utility of this technology for real-time tumour margin mapping and its effect on long-term outcomes.

Endoscopy during the peak of COVID-19 pandemic: impact on activity and financial implications for a tertiary referral center in London.

BackgroundCOVID-19 pandemic is an unprecedented global medical emergency. National and international gastrointestinal societies recommended that any endoscopic activity during the lockdown phase of the pandemic should be limited to emergency or non-deferrable procedures only. We assessed the financial implications and impact on endoscopy activity of the lockdown phase in a tertiary referral endoscopy unit.MethodsThe number of endoscopy procedures canceled and performed in our endoscopy unit during our “delay phase” (16-22/03/2020) and “lockdown phase” (23/03-29/05/2020) was reviewed and compared with endoscopy activity conducted during the same period in 2019. The financial impact was subsequently analyzed.ResultsBetween 16/03/2020 and 29/05/2020, 683 procedures were canceled and 365 non-deferrable procedures were performed. In contrast, in 2019, 3437 procedures were performed over the same timeframe, resulting in a revenue contraction of approximately €2,062,857. We estimated that the number of lists required to recuperate the canceled endoscopic activity, ranges from 103-155, depending on the level of personal protective equipment required and mitigating policy relating to COVID-19.ConclusionOur results highlight that COVID-19 pandemic had a substantial negative impact on our endoscopy activity and on the revenue generated by our endoscopy unit.

Cardiothoracic surgery in the midst of a pandemic: Operative outcomes and maintaining a coronavirus disease 2019 (COVID-19)–free environment

ObjectiveIn the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. MethodsData on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19–free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus. ResultsA total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage. ConclusionsOur early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection.

Mainstreamed genetic testing in ovarian cancer: patient experience of the testing process

ObjectivePathogenic BRCA variants account for 5.8–24.8% of ovarian cancers. The identification of such a variant can have a significant impact on the affected individual and their relatives, determining eligibility for...

Radiology report alerts - are emailed ‘Fail-Safe’ alerts acknowledged and acted upon?

BackgroundGuidelines from the Royal College of Radiologists and National Patient Safety Agency highlight the crucial importance of “fail-safe” alert systems for the communication of critical and significant clinically unexpected results between imaging departments and referring clinicians. Electronic alert systems are preferred, to minimise errors, increase workflow efficiency and improve auditability. To date there is a paucity of evidence on the utility of such systems. We investigated i) how often emailed radiology alerts were acknowledged by referring clinicians, ii) how frequently follow-up imaging was requested when indicated and iii) whether practise improved after an educational intervention. Methods100 cases were randomly selected before and after an educational intervention at a tertiary referral centre in London, where the email-based ‘RadAlert’ system (Rivendale Systems, UK) has been in operation since May 2017. ResultsFollowing educational intervention, ‘accepted’ alerts increased from 39% to 56%, ‘abandoned’ alerts reduced from 55% to 37% and ‘declined’ alerts decreased from 5% to 3%. There was evidence to confirm that, when indicated, further imaging had been requested for 78% of all alerts, 78% of ‘accepted’ alerts and 76% of ‘abandoned’ alerts both before and after educational intervention. ConclusionsAcknowledgment of report alerts by referring clinicians increased after departmental education / governance meetings. However, a proportion of email alerts remained unacknowledged. It is incumbent on reporting radiologists to be aware that electronic alert systems cannot be solely relied upon and to take the necessary steps to ensure significant and clinically unsuspected findings are relayed to referring clinical teams in a timely manner.

Optical Coherence Tomography Findings After Childhood Lensectomy.

PurposeTo explore the impact of childhood lensectomy on posterior segment development.MethodsCross-sectional observational study at children's eye clinics at a tertiary referral center in London, UK. We included 45 children age 4 to 16 years with healthy eyes and 38 who had undergone lensectomy. We acquired posterior segment optical coherence tomography scans of both eyes. We used parametric and nonparametric tests in SPSS24 for the comparison of parameters between groups and within individuals; a P value less than 0.05 was considered significant. The main outcome measures were foveal pit depth and subfoveal choroidal thickness (CT). Secondary outcomes were inner and outer ring CT and photoreceptor layer parameters, macular and peripapillary retinal nerve fiber layer thickness.ResultsFoveal pit depth and subfoveal CT are significantly reduced in eyes that have undergone lensectomy compared with nonoperated eyes. Inner ring CT and outer ring CT are reduced. Foveal inner retinal layer thickness is increased. Mean inner retinal and outer nuclear layer thickness are not affected.ConclusionsChildhood lensectomy is associated with a reduction in developmental foveal pit deepening and lack of developmental thickening of the posterior choroid. Mechanical and optical disruption of foveal and subfoveal choroidal development may affect structural foveal development after childhood lensectomy.

Soft Contact Lenses to Optimize Vision in Adults with Idiopathic Infantile Nystagmus: A Pilot Parallel Randomized Controlled Trial

ABSTRACTPurpose: The optimal management of infantile nystagmus syndrome (INS) is still unclear. Contact lenses (CL) may be superior to glasses in improving visual function in INS but it is not known whether their beneficial effects are due to optical correction alone, or to an additional proprioceptive effect, and whether soft CLs would be as effective as rigid CLs. There is little data on feasibility and and the present study aimed to provide this information.Methods: We completed a pilot Randomized Control Trial (RCT) at a single tertiary referral centre in London, UK. We enrolled 38 adults with idiopathic INS and randomised them to either plano CL (with corrective spectacles if required) or to corrective CL. CL wear was required for a minimum of 2 weeks. Primary outcome measures were feasibility and safety of CL wear in INS; secondary outcome measures were visual acuity and nystagmus waveform parameters.Results: 27 completed the study (27/38,71%). 4 partcipants withdrew due to difficulty with CL insertion/removal and 7 were lost to follow up. CL tolerability was high (24/27,89%) - 2 found the CLs irritant, and 1 had an exacerbation of allergic eye disease. At two weeks, mean improvement in binocular visual acuity from baseline with plano CLs was 0.07 logMAR (95% confidence interval (CI: 0.03-0.11) and 0.06 logMAR with fully corrective CLs (95% CI:0.02-0.1). Mean improvement in the eXpanded Nystagmus Acuity Function (NAFX, a nystagmus acuity function based on eye movement recording) with plano CLs was -0.04(95% CI: -0.08-0.005) and -0.05 with fully corrective CLs(95% CI: -0.09–0.003).Conclusions: CLs are well tolerated, with a low risk profile. Whilst our study was not powered to detect significant changes in BCVA and waveform parameters between treatment arms, we observed a trend towards an improvement in visual function at two weeks from baseline with CLs.

Developing an Emotion- and Memory-Processing Group Intervention for PTSD with complex features: a group case series with survivors of repeated interpersonal trauma

ABSTRACTIndividuals who experience repeated interpersonal trauma exposure often present with posttraumatic stress disorder (PTSD) with more complex features. There is currently no consensus regarding whether current evidence-based interventions for PTSD need to be tailored to better account for these complex features. However, one recommended adaptation is to adopt a phase-based or sequenced approach involving three phases, each with a distinct function. This paper describes the development of a 12-session Emotion- and Memory-Processing Group Programme, adapted from Cloitre’s Skills Training in Affective and Interpersonal Regulation (STAIR) phase-based treatment protocol. A single case series provided a preliminary examination of the group-based intervention’s efficacy for three groups of women with a history of repeated interpersonal trauma and PTSD with complex features (N = 15; age 19–46 years) at The Haven Sexual Assault Referral Centre in London. Results revealed significant reductions in: PTSD, complex features of PTSD, and depression, along with improvements in process measures of maladaptive cognitions and emotion processing. Results from this case series demonstrate that an Emotion- and Memory-Processing Group Programme holds promise for treating individuals with a history of interpersonal trauma in outpatient settings, and provides evidence to warrant the completion of a feasibility trial.

Child sexual assault reported to an acute sexual assault referral centre in London

ObjectiveTo describe demographic and assault-related characteristics of children attending an acute sexual assault referral centre in London within a week of alleged sexual assault.DesignRetrospective case note review of all children...

PWE-105 Management of The Malignant Colorectal Polyp: Changes in Practice and Outcomes in A Tertiary Referral Centre in London: Abstract PWE-105 Table 1

Introduction Screening colonoscopy has resulted in increasing identification rates of colorectal polyps which can be endoscopically removed. Almost 10% will histologically prove to be pT1 cancers. Factors associated with cancer recurrence post polypectomy have been described (ie lymphovascular invasion, poor differentiation, R1 Methods Patients with pT1 cancers that had either endotherapy+surgery or endotherapy alone between 2008–2014 were included in the study (n = 61). Endoscopic, histologic and surgery data, including complication rates from both modalities and overall/ cancer-free survival were recorded. Management was compared between two different periods (2008–11, 2012–14) in order to identify changes in practice. Results 38 (62%) patients were treated with endoscopic resection alone. 23 had a completion surgery, 15 (65%) due to R1 resection. Adenomatous tissue was found in 6 surgical specimens but only one had residual cancer. Major complications occurred in 2 (3%) patients post endoscopy versus 6 (26%) postoperatively (p = 0.044), 2 of whom died. There were no cancer relapses at mean follow up of 41±24 months. 17/31 (55%) patients treated prior to 2012 had surgery compared to 6/30 (20%, p = 0.008) treated in 2012–14. More than one risk factors were apparent in 8 (33%) patients treated with endoscopy only within the last 3 years compared to no one previously (p = 0.017). Out of the overall 38 patients with R1 resection, 14 (74%) had completion surgery between 2008–11 compared to 31% recently treated (p = 0.022). Conclusion Endoscopic resection of polyp cancers is a safe and successful therapy with minor complications and recurrence rates similar to surgery. Changing our practice recently in favour of endotherapy alone did not lead to increasing cancer relapses, suggesting that presence of risk factors should not be an absolute indication for surgery, but instead an individualised decision should be made based on combination of factors. Disclosure of Interest None Declared

PWE-080 Eosinophilic Oesophagitis: Improving Diagnosis and Optimising Therapy

Introduction Eosinophilic oesophagitis (EoE) is a chronic condition of the oesophagus characterised by a dense eosinophilic infiltrate defined as >15 eosinophils/high power field (eos/hpf). The aim of this study was to capture the prevalence of EoE in a tertiary referral centre in London, to identify factors associated with a positive diagnosis and interrogate optimal response to therapy. Methods From February 2013 to November 2015, all patients presenting with solid food dysphagia to University College Hospital had a high resolution white light endoscopy. Those with cancer, achalasia, postoperative stricture or endotherapy for Barrett’s were excluded. Endoscopy, histology and clinical data were collected. >15 oes/hpf were defined as positive for EoE. A separate histopathology search identified patients with >15 eos/hpf and no dysphagia. A prospective follow-up was conducted in focusing on therapy and response in those with >15 eos/hpf. Results Out of the 1566 patients with dysphagia, 524 were excluded for reasons stated. 736/1042 (71%) had oesophageal biopsies. Of those, 67 (9.1%) had more than 15 eos/hpf. Another 14 patients with >15 eos/hpf with symptoms other than dysphagia were identified from histology records, making the total number with eosiniphilia 81. The mean number of biopsies taken in those with >15 eos/hpf (6.3) was greater than those with Conclusion A higher number of biopsies taken raises the diagnostic yield; however still up to 1/3 patients in a modern referral centre have no biopsies taken. EoE should be excluded in those with no dysphagia and refractory reflux symptoms. Although PPIs are provided as first-line therapy, a positive response to steroids is more likely in those with higher numbers eos/hpf, while those with fewer numbers and no endoscopic features could be considered for PPI therapy first. Such findings might be a useful tool to help tailor therapy. Disclosure of Interest None Declared

PWE-184 Eosinophilic esophagitis; presentation, diagnosis and response to therapy in a tertiary referral centre in london

Introduction Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by an increased eosinophil infiltrate combined with typical symptoms of dysphagia/food bolus obstruction although those with refractory-reflux symptoms without inflammation are not commonly suspected. Recent guidance has improved clinical awareness, endoscopic vigilance and biopsy protocols. This study captures recent trends in endoscopy, histology and subsequent response to therapy of patients with EoE in a London tertiary referral centre. Method Between February 2013 and January 2015, reports were collected for all patients who underwent high definition endoscopy and biopsies at University College London Hospital. Patients with oesophageal cancer or surgery were excluded. Demographics, clinical characteristics, eosinophil concentration and response to therapy were collected for all those with >15 eosinophils/high power field (eos/hpf). Mann-Whitney and Kruskal-Wallis tests were used to analyse non-parametric variables. Results Of the 848 patients with dysphagia who had biopsies, 39 (4.6%) had >15 eos/hpf; however a total of 46 patients were found to have >15 eos/hpf (30M; mean age 39.5 ± 14.5 years). Patients with eosinophilia presented mostly with dysphagia (25; 54%) and food impaction (22; 48%) while another 7 (15%) also presented with refractory-reflux symptoms (only 2 with Grade A esophagitis but with >80 eos/hpf in the proximal oesophagus). 22% had a history of atopy/asthma. 26/46 (57%) exhibited EoE-specific endoscopic findings; corrugated rings (18), strictures (5), furrows (6) and Schatzki ring (4). 7/46 (17%) had esophagitis Grade A (4), B (2) and C (1) esophagitis. The remaining 13 (28%) had a normal endoscopy. There was no difference in the mean eos/hpf between patients with EoE-specific endoscopic changes (47 ± 24), esophagitis (46.5 ± 21.2) and normal endoscopy (47.5 ± 24.9) (p = 0.915). Furthermore the mean eos/hpf between those who presented with dysphagia, food bolus obstruction or refractory-reflux was similar (p = 0.804). 37 patients were treated with either proton pump inhibitors (PPI; 19) or topical steroids (18). Of the 26 patients whose outcomes were reported, 10 responded to steroids and 9 to PPIs. Response to PPIs was more likely in those with reflux-predominant symptoms vs. dysphagia (p = 0.027). The maximum number of eos/hpf did not predict response to therapy as a whole (p = 0.586) nor in those treated with steroids versus PPI (p = 0.188). Furthermore, there was no association of response to treatment when compared to age, endoscopic appearance or atopy (p = NS). Conclusion It is increasingly recognised that EoE does not only present with dysphagia. Therapy targeted towards the predominant symptom can improve outcome in patients with EoE. Disclosure of interest None Declared.