Polyp Surveillance Research Articles

Prevalence and Progression of Incidental Terminal Ileitis on Non-diagnostic Colonoscopy: A Systematic Review and Meta-analysis.

Incidentally diagnosed terminal ileitis [IDTI] has been reported among asymptomatic persons undergoing non-diagnostic colonoscopy. The purpose of our study was to determine the prevalence and long-term outcomes of asymptomatic terminal ileitis. We performed a systematic review using three biomedical databases [Medline, Embase, and Web of Science] and relevant scientific meeting abstracts. We identified observational studies that reported the prevalence of IDTI in adults undergoing screening or polyp surveillance colonoscopy and/or the long-term outcomes of such lesions. A random-effects meta-analysis was conducted to determine the pooled prevalence rate of IDTI. The progression of IDTI to overt Crohn's disease [CD] was also described. Of 2388 eligible studies, 1784 were screened after excluding duplicates, 84 were reviewed in full text, and 14 studies were eligible for inclusion. Seven studies reported the prevalence of IDTI in 44 398 persons undergoing non-diagnostic colonoscopy, six studies reported follow-up data, and one study reported both types of data. The pooled prevalence rate of IDTI was 1.6% (95% confidence interval [CI] 0.1-21.8%) with significant heterogeneity [I2 = 99.7]. Among patients who had undergone non-diagnostic colonoscopy and had follow-up data [range 13-84 months reported in five studies], progression to overt CD was rare. IDTI is not uncommon on non-diagnostic colonoscopies. Based on limited data, the rate of its progression to overt CD seems low, and watchful waiting is likely a reasonable strategy. Further long-term follow-up studies are needed to inform the natural history of incidental terminal ileitis, factors that predict progression to CD, and therapeutic implications.

Amalgamation of cloud-based colonoscopy videos with patient-level metadata to facilitate large-scale machine learning.

Background and study aims Storage of full-length endoscopic procedures is becoming increasingly popular. To facilitate large-scale machine learning (ML) focused on clinical outcomes, these videos must be merged with the patient-level data in the electronic health record (EHR). Our aim was to present a method of accurately linking patient-level EHR data with cloud stored colonoscopy videos. Methods This study was conducted at a single academic medical center. Most procedure videos are automatically uploaded to the cloud server but are identified only by procedure time and procedure room. We developed and then tested an algorithm to match recorded videos with corresponding exams in the EHR based upon procedure time and room and subsequently extract frames of interest. Results Among 28,611 total colonoscopies performed over the study period, 21,170 colonoscopy videos in 20,420 unique patients (54.2 % male, median age 58) were matched to EHR data. Of 100 randomly sampled videos, appropriate matching was manually confirmed in all. In total, these videos represented 489,721 minutes of colonoscopy performed by 50 endoscopists (median 214 colonoscopies per endoscopist). The most common procedure indications were polyp screening (47.3 %), surveillance (28.9 %) and inflammatory bowel disease (9.4 %). From these videos, we extracted procedure highlights (identified by image capture; mean 8.5 per colonoscopy) and surrounding frames. Conclusions We report the successful merging of a large database of endoscopy videos stored with limited identifiers to rich patient-level data in a highly accurate manner. This technique facilitates the development of ML algorithms based upon relevant patient outcomes.

One-Third of Open Access Colon Cancer Screening Requests Require a Clinic Appointment

Background Open access colonoscopy (OAC) allows for patients at low-risk for endoscopic complications to receive a colonoscopy (CSP) without a preprocedural appointment. This can reduce wait times for screening and increase appointment availability for symptomatic patients. Methods At Walter Reed National Military Medical Center, we enacted an OAC program in 2014 for our TRICARE beneficiaries. Patients due for colon cancer screening or polyp surveillance can submit an online questionnaire through a secure website. Our scheduling department reviews all questionnaires, and patients with prespecified criteria are seen in clinic prior to their procedure. The remainder of patients have their surveys reviewed by a gastroenterologist for suitability and are scheduled for CSP or computed tomographic colonography. In 2018, the OAC program was expanded to all military hospitals in the national capital region (NCR). Results Prior to expanding Walter Reed's OAC program, 6713 total screening requests were made. The requested procedure was CSP in 69.9% of patients. Of patients who fell outside the 45-75 age range, 14.1% were under the age of 45, and 2% were over the age of 75. 31.6% of OAC patients required a clinic appointment. Following incorporation of the NCR, 2290 screening questionnaires have been completed without significant change to the absolute percentages of those requiring appointments. Conclusion By avoiding unnecessary clinic visits for asymptomatic individuals, OAC programs increase availability in gastroenterology practices to see symptomatic patients.

S0328 Older Adult Preferences for FIT vs Colonoscopy for Colorectal Cancer Screening and Polyp Surveillance

S0328 Older Adult Preferences for FIT vs Colonoscopy for Colorectal Cancer Screening and Polyp Surveillance

S3127 Colonic Polyp Surveillance Guidelines Are Appropriate for Younger Patients Despite Having Higher Grade Polyps on Surveillance Colonoscopy Compared With Older Patients

INTRODUCTION: Over the past few decades, the incidence of colorectal cancer (CRC) in the United States has been decreasing for older patients (OP, ≥50 years old), but increasing for younger patients (YP, < 50 years old). Current colonic polyp surveillance guidelines are primarily based on data from OP and may not be appropriate to use in YP given the reported increase in rates of CRC in YP. Our aim was to investigate whether existing colonic polyp surveillance guidelines created for OP are appropriate for use in YP. METHODS: We performed a retrospective cohort study of patients from two academic medical centers. We generated Risk Stratification Groups (RSG) based on surveillance colonoscopy intervals recommended by the USMSTF for CRC (Table 1). To determine if current colonic polyp surveillance guidelines were appropriate, we measured whether a patient's RSG worsened from index to surveillance colonoscopy, signifying that higher grade polyps were found on the subsequent surveillance colonoscopy compared to the index colonoscopy. Changes in RSG between OP and YP was determined using a McNeamer Test. A multivariate analysis was used to determine independent risk factors for RSG worsening. RESULTS: 1892 patients were included in the study, comprising 1521 OP and 371 YP. At both index and surveillance colonoscopies, YP were more likely to be assigned to a lower RSG (lower grade polyps) compared with OP. However, a greater percentage of YP had their RSG worsen from index to surveillance colonoscopy compared with OP (32.34% vs 25.18%, P < 0.01) (Figure 1). YP were 1.63 times more likely to have RSG worsening compared with OP (95% CI = 1.2–2.2) after controlling for confounding factorsTable 1.: Risk Stratification of Patients Based on Surveillance Colonoscopy Time Recommendations from the US Multi-Society Task Force on Colorectal CancerFigure 1.: Risk Stratification Group (RSG) Changes Between Index and Surveillance Colonoscopies for Older Patients and Younger Patients.Figure 2.: Tier to Tier Risk Stratification Group (RSG) Changes Between Index and Surveillance Colonoscopies for Older Patients and Younger Patients.Most of the RSG worsening was from RSG 1 (normal colonoscopy or small hyperplastic polyps) to RSG 2 (1–2 small tubular adenomas) for both YP and OP (21.02% & 15.06%, respectively) (Figure 2). There were no cases of CRC found in YP and 5 cases of CRC diagnosed in OP on surveillance colonoscopy. CONCLUSION: In our cohort, RSG worsening between index and surveillance colonoscopy was more prevalent in YP compared with OP. Yet, most of the RSG worsening was not clinically meaningful in terms of progression to CRC. This would imply that for the sake of CRC prevention, current surveillance guidelines were indeed appropriate for YP in our cohort of patients. Further study is needed to determine why RSG worsening was higher in YP compared with OP and whether there is any clinical or practical significance to this RSG worsening.

Legacy of COVID‐19 – the opportunity to enhance surgical services for patients with colorectal disease

The COVID-19 crisis has undoubtedly taken a toll on the care of patients with colorectal disease. Elective services, be that face to face contact, endoscopy or operating all but ceased during the pandemic.

The Impact of the Coronavirus Disease-19 Pandemic on Access to Endoscopy Procedures in the VA Healthcare System

The Impact of the Coronavirus Disease-19 Pandemic on Access to Endoscopy Procedures in the VA Healthcare System

Early detection and follow-up of colorectal neoplasia based on faecal volatile organic compounds.

Early detection and removal of colorectal cancer (CRC) and advanced adenomas (AAs) decreases the incidence of and mortality from the disease. We aimed to evaluate the potential of faecal volatile organic compounds (VOCs) for detection and follow-up of colorectal adenoma using advanced electronic nose technology. This was a prospective multi-centre case-control cohort including two district hospitals and one tertiary referral hospital. Patients undergoing colonoscopy were instructed to collect a faecal sample prior to bowel cleansing and were included in the study when CRC, AAs, large adenomas (LAs; 0.5-1.0cm), small adenomas (SAs; 0.1-0.5cm) or no endoscopic abnormalities (controls) were observed. Patients undergoing polypectomy and controls were asked for a second sample after 3months. Faecal VOCs were measured with gas chromatography-ion mobility spectrometry. Random forest, support vector machine, Gaussian process and neural net classification were used to evaluate accuracy. In total, 14 patients with CRC, 64 with AAs, 69 with LAs, 127 with SAs and 227 controls were included. A second sample was collected from 32 polypectomy patients and 32 controls. Faecal VOCs discriminated CRC and adenomas from control [AUC (95% CI): CRC vs control 0.96 (0.89-1); AA vs control 0.96 (0.93-1); LA vs control 0.96 (0.92-0.99); SA vs control 0.96 (0.94-0.99)]. There were no significant differences between CRC and adenoma groups. Patients with adenomas and controls were discriminated prior to polypectomy, whereas 3months after polypectomy VOC profiles were similar [T0 adenoma vs control 0.98 (0.95-1); T1 adenoma vs control 0.55 (0.40-0.69)]. Faecal VOC profiles may be useful for early detection of CRC and adenomas and the timing of polyp surveillance as polypectomy led to a normalization of the VOC profile.

Lower gastrointestinal symptoms and symptoms-based triaging systems are poor predictors of clinical significant disease on colonoscopy

IntroductionLower gastrointestinal symptoms (LGS) are a common cause of referral to the gastroenterology service. International guidelines are available to prioritise referrals. Some studies have reported that symptoms alone are a...

Comparative quantitative survey of patient experience in Barrett’s oesophagus and other gastrointestinal disorders

ObjectiveTo assess health-related quality of life in patients with non-dysplastic Barrett’s oesophagus (NDBO) and endoscopically treated dysplastic Barrett’s oesophagus (DBO).DesignThis quantitative, self-administered questionnaire study was conducted across three National Health...

P183 The prevalence of incidental terminal ileitis in persons undergoing non-diagnostic colonoscopy: a meta-analysis

Abstract Background Incidentally diagnosed terminal ileitis has been reported among asymptomatic persons undergoing non-diagnostic colonoscopy. The purpose of our study was to determine the prevalence and long-term outcomes of asymptomatic terminal ileitis. Methods We developed and executed a systematic search strategy in three biomedical databases (Medline, Embase and Web of Science) and relevant scientific meeting abstracts, from inception to May 1, 2019, to identify observational studies that reported the prevalence of asymptomatic terminal ileitis in adults undergoing screening or polyp surveillance colonoscopy, and/or the long-term outcomes of such lesions. A random-effects meta-analysis was conducted to determine the pooled prevalence rate, confidence interval (CI), and report the heterogeneity score I2. Risk factors for progression to overt CD were abstracted. Results Of 2388 eligible studies, 1784 were screened after excluding duplicates, 84 were reviewed in full text and 14 studies were eligible for inclusion. Eight studies reported the prevalence of asymptomatic terminal ileitis in 46,460 persons undergoing non-diagnostic colonoscopy, and eight (two of eight reporting prevalence) studies reported follow-up data. The pooled rate of asymptomatic terminal ileitis was 1.5% (CI 1.0%, 16.3%), with I2 of 0 (Figure). The use of non-steroidal anti-inflammatory drugs varied between 0% and 37%. Of 147 persons with asymptomatic terminal ileitis with follow-up data (range 13–63.6 months in three studies), five had progression to CD, three were treated for CD with steroids, 5-amino salicylates, azathioprine and vedolizumab, and lesions resolved in four. Three studies reported the absence of symptoms as a predictor of lack of progression. Conclusion Asymptomatic terminal ileitis can be found incidentally in 1.5% of non-diagnostic colonoscopies. Based on limited data, the rate of its progression to overt CD seems low, and watchful waiting could likely be a reasonable strategy. More long-term follow-up studies are needed to inform the natural history of incidental terminal ileitis, factors that predict progression to CD and therapeutic implications.

Does Colon Polyp Surveillance Improve Patient Outcomes?

Colon polyp surveillance now accounts for 25% of all colonoscopies performed. The evidence that colonoscopy surveillance reduces colorectal cancer (CRC) incidence or mortality is weak. The biology of the baseline lesions and quality of the baseline exam are two primary factors contributing to post-colonoscopy CRC. Prior recommendations for surveillance were based largely on the likelihood that patients with adenomas would develop advanced adenomas, a surrogate for CRC. There is now evidence that baseline colonoscopy findings are strongly associated with the risk of incidence or death from CRC. This evidence provides a basis for updated evidence-based recommendations for surveillance. In addition, there is also growing evidence that the quality of the baseline exam is an important predictor of the likelihood of developing post-colonoscopy CRC.

147 Colorectal Mucosal Schwann Cell Hamartomas in a Community Gastroenterology Practice

INTRODUCTION: Mucosal Schwann cell hamartoma (MSCH) is a benign mucosal lesion composed of spindle cells surrounding colonic crypts that can arise anywhere in the colon; usually in the rectosigmoid. Most reports of colonic MSCH are limited to case reports and two case series from tertiary-care academic settings involving 20 and 26 patients. Our retrospective study is the first to describe the characteristics of colorectal MSCH in a community gastroenterology practice. METHODS: We retrospectively identified patients with colorectal MSCH from the pathology database of a large, community gastroenterology practice of 157 physicians in Texas and Louisiana working at 24 outpatient centers. Data were collected from consecutive patients diagnosed with MSCH from 2015–2019. MSCH were confirmed by positive immunohistochemical staining for S-100. Historical data recorded included the endoscopic size and appearance of the polyps, location, indication(s) for colonoscopy, and patient age, sex, and race. RESULTS: 184 colorectal MSCH from 179 patients were identified out of a total of 335,635 colon specimens. The median age of 59 years (range, 40–84). Sixty percent were female, 67% were White, and 25% were Black. The most common indications for colonoscopy were screening (55%), polyp surveillance (35%) and diagnostic (35%), which often overlapped. The polyps were described as sessile (65%), pedunculated (2%), mixed sessile/pedunculated (1.6%), and not specified (32%). The average size was 3.8 mm (range, 1–15 mm), and most were in the distal colon and rectum (77%) followed by transverse (11%) and proximal colon (10%). One MSCH was at an anastomosis and in one, the site was not specified. CONCLUSION: This large retrospective series is the first to describe colorectal MSCH in a community gastroenterology practice. Additionally, the large number of patients provides a better description of MSCH characteristics in comparison to prior small case series. MSCH were most commonly found during screening and surveillance colonoscopies in patients who were older, female and white. Most were located in the distal colon and rectum. Colorectal MSCHs are found infrequently at an approximate rate of 1 every 4 years by a community gastroenterologist, or 0.05% of colonoscopy biopsies.

1512 A Rare Case of Sigmoid Leiomyoma Disguised as a Polyp

INTRODUCTION: Colonic leiomyomas are smooth muscle tumors which arise from either the muscularis mucosa or the proper muscle layer. Colonic and rectal leiomyomas are rare tumors and represent only about 3% of all gastrointestinal leiomyomas. Most patients are asymptomatic; however, some can have symptoms of abdominal pain, intestinal obstruction, hemorrhage, and perforation when the leiomyoma is of larger size. We present a case of sigmoid leiomyoma encountered on routine colonoscopy. CASE DESCRIPTION/METHODS: A 52-year-old man from Ecuador with a past medical history of hypertension, gastritis, osteoarthritis of the knees, presented to the clinic for evaluation of GERD symptoms. He was also due for repeat colonoscopy for surveillance of colon polyps. He underwent routine EGD and colonoscopy. EGD findings and biopsies of the stomach were unremarkable. The patient underwent a colonoscopy and was found to have an 8 mm sessile polyp seen in the sigmoid colon. The polyp was resected with cold snare and sent to pathology. The bowel preparation was excellent. Pathology revealed colonic mucosa containing smooth muscle proliferation. Immunostain with smooth muscle actin (SMA) supported the diagnosis. DISCUSSION: Leiomyomas have been first described by Virchow in 1854. They are usually considered benign and arise in the uterus, but may also be found in the skin, nipple, scrotum, and labia. Leiomyomas are less frequently encountered in the GI tract, and when found, are primarily seen in the esophagus or stomach. The management of leiomyomas is surgical resection, however, with the evolving field of gastroenterology, endoscopic removal is considered an alternative for resection. Given leiomyomas arise from the muscularis mucosa or the proper muscle layer, endoscopic resection represents a higher risk of perforation. Submucosal injection technique can be used to identify which layer the leiomyoma arises from. If the lesion cannot be lifted using a submucosal injection of saline, the lesion may have deep submucosal invasion or can originate from the proper muscle layer. This risk for perforation is higher when the leiomyoma arises from the proper muscle layer and it is a contraindication to endoscopic removal. We represent a rare case of sigmoid leiomyoma which was removed using endoscopic technique without any complication of perforation or bleeding.

3089 Orifice to Orifice Evaluation, in a Single Exam

INTRODUCTION: We present a case of a middle age Caucasian male with Peutz-Jeghers syndrome who underwent an antegrade double balloon enteroscopy (DBE) for surveillance of a known small bowel polyps. He has a history of right hemicolectomy for a large polyp and subsequent partial small bowel resection for intussusception of a jejunal polyp. He had a DBE a year ago which revealed several small bowel polyps, the larger ones requiring therapeutic intervention. We show a video demonstrating feasibility of complete entero-colonoscopy dictated by necessity. CASE DESCRIPTION/METHODS: A 55-year-old Caucasian male with Peutz-Jeghers syndrome presented for his surveillance antegrade DBE. He has history of right hemicolectomy &amp; partial jejunal resection due to intussusception deemed secondary to a large hamartomatous polyp. He has been getting EGD, Colonoscopy and antegrade DBE every 2 years given his history of multiple large hamartomatous polyps. His vital signs, physical examination and lab work were unremarkable. DISCUSSION: This patient underwent antegrade DBE with a therapeutic double-balloon enteroscope (Fujinon EN-450 T5) using push and pull maneuver, under general anesthesia and utilizing CO2 for insufflation. A stiffening device (Zutron medical) was used during portions of the procedure to help prevent loop formation. Around the distal jejunum, the stiffening device snapped within the biopsy channel at the boot of the insertion tube of the enteroscope. Given that a significant amount of time has been already invested in the procedure an attempt at reaching the anus was pursued with success. The stiffening device was pushed out of the channel using a biopsy forceps and the procedure was resumed. Multiple polyps (atleast 30) were observed in the small bowel ranging in size from 4-25 mm, some of which were oozing. The oozing polyps and those larger than 10 mm (total 6) were resected. The procedure was completed with no adverse events. The patient's oral cavity was cleaned using hydrogen peroxide swab before he was extubated and sent to recovery. The patient experienced no infection related complication, bleeding, perforation or pancreatitis. CONCLUSION: 1. It is feasible and safe to perform through and through entero-colonoscopy in specific scenarios. 2. Panendoscopy in one encounter may not always be achievable in patients without a history of bowel resection. 3. Advancing the enteroscopy outside the anus may be considered to clear an obstructed biopsy channel as an option to salvage a long procedure. Watch the video: http://bit.ly/2XTDKhY

1878 Migration of Over-the-Scope Clip (OTSC) Resulting in Intestinal Obstruction

INTRODUCTION: Iatrogenic perforations are a known and feared complication of diagnostic and therapeutic colonoscopy. Over-the-scope clips (OTSCs) have recently been utilized for management of these perforations. We present the case of a 40-year-old male patient treated with over-the-scope (Ovesco®) clip for an iatrogenic post-polypectomy perforation with subsequent intestinal obstruction occurring as a result of migration of the clip. CASE DESCRIPTION/METHODS: A 40-year-old male with familial adenomatous polyposis and total proctocolectomy, ileoanal anastomosis and a J pouch had an ileoscopy performed for polyp surveillance. A 3 cm flat polyp was removed with Eleview® injection lift technique. A hole like defect was noted in the postpolypectomy site that developed into an obvious small 2-3 mm perforation. To repair the defect, a one 14/6 mm type gc over-the-scope clip (Ovesco®) and a 12/6 mm type gc over-the-scope clip (Ovesco®) was successfully placed. Four months later the patient presented to the emergency department with severe anal pain. He felt a hard metallic object in the anal canal. He denied any fevers, chills, nausea, vomiting, or abdominal pain. Rectal tenderness was found on digital rectal examination. A CT abdomen and pelvis showed an object of metallic density at the anal verge with nonobstructive bowel gas pattern. Colonoscopy revealed two over-the-scope clips approximately 2 cm from the anal verge embedded in the mucosa (Figure 1) which were removed. The patient did well post procedure and was discharged home the next day. DISCUSSION: The Ovesco® clip (Ovesco, Tübingen, Germany) is a novel endoscopic method to achieve mechanical compression of gastrointestinal tissue with current indications including closure of fistulas, iatrogenic perforations, hemostasis and non-variceal gastrointestinal bleeding. Iatrogenic perforations during colonoscopy have an incidence ranging from 0.1% to 0.3% of cases. These complications carry a high mortality rate and in the past warranted surgical intervention. However, with the advances in therapeutic endoscopy many perforations can be managed effectively with endoclips, OTSCs and/or endosuturing. These new techniques do come with device-specific risks. Fischer et al. reported the first case of OTSC-induced bowel obstruction. Here we present another case of bowel obstruction as a result of OTSC placement for a perforation, treated with surgical intervention. All gastroenterologists should be aware of clinical scenarios in which the Ovesco clip can be used.

336 Bowel Preparation for Patients With History of Inadequate Cleansing With 4L PEG-3350 (Golytely) Split-Prep: The 6 Liter PEG-3350 (Golytely®) Split-Prep

INTRODUCTION: No prior prospective study has assessed the efficacy of a more intensive bowel preparation (prep) for outpatients who have already failed a 4 liter (4L) PEG-3350 (GoLYTELY®) split-prep. This study assesses efficacy and safety of a 4L-2L PEG-3350 split-prep. METHODS: Inclusion Criteria- (a) colonoscopy for average-risk screening, FIT+, family history-CRC, or colon polyp surveillance; (b) history of inadequate prep with 4L GoLYTELY® or &gt;2 risk factors for inadequate prep (daily laxative, BMI &gt; 35, diabetes, daily tricyclic antidepressant, daily opioid). Intervention: 4L-2L PEG-3350 (GoLYTELY®) split-prep consisting of clear liquid diet (all day) and drink 4L GoLYTELY® starting at 6pm on day before procedure PLUS drink 2L of GoLYTELY® starting 5 hours before colonoscopy. Patients completed a questionnaire about demographics, adherence to prep protocol, ease of drinking prep, and adverse events. Primary Outcome: Adequate bowel prep, defined by 2-2-2 or better on Boston Bowel Preparation Scale (BBPS), among patients who failed 4L GoLYTELY® split-prep. Secondary Outcome: (a) Adequate bowel prep among patients who failed 4l GoLYTELY® pm-only prep or any lower volume prep; and, (b) patients with &gt; 2 risk factors for inadequate prep; Tertiary Outcome: Frequency of guideline-adherent recommendations for surveillance colonoscopy among patients with adequate prep and patients with inadequate prep (i.e., repeat colonoscopy in ≤ 1 year). Data Analysis: The intention-to-treat population included all patients who underwent colonoscopy and the per-protocol population only included patients who drank ≥ 75% of prep. RESULTS: 204 consecutive patients met inclusion criteria and presented for colonoscopy. Demographic data: mean age = 65 (40-79 years); M: F = 189:15. Frequency of adequate prep in each group is presented in Table 1. Frequency of guideline-adherent recommendations was 89.6% in patients with adequate prep and was 96.6% among patients with inadequate prep. Three serious adverse events occurred: vomiting with ED visit, asymptomatic bradycardia (HR = 30-40) and spontaneous paroxysmal atrial fibrillation. Based on questionnaires, 28% stopped to pass stool during trip to endoscopy center and 80% would be willing to repeat the prep in the future. CONCLUSION: The 6L GoLYTELY® split-prep achieves adequate prep in &gt; 85% of patients who have already failed a 4l GoLYTELY® split-prep.

1856 Immediate Air-Tight Seal With a Padlock Clip Defect Closure System for Iatrogenic Colonic Perforation

INTRODUCTION: Iatrogenic colonic perforations are an infrequent complication of endoscopy that often require immediate surgical repair. However, endoscopic suturing devices or endoscopic clips are increasingly being utilized for closure. Through-the-scope clips can have high rates of failure and often require multiple clips per closure to achieve a similar level success to over-the-scope clips. Ovesco over-the-scope clips (OTSC®) have been studied in small prospective studies with 89% successful closures of acute iatrogenic gastrointestinal perforations without adverse events1. More recently, the Padlock Clip® defect closure system has emerged as a newer over-the-scope clip with case reports showing high levels of efficacy and safety in a variety of uses. We present a case of iatrogenic colonic perforation repaired with the Padlock Clip with a concurrent laparoscopic air-leak test confirming immediate complete closure. CASE DESCRIPTION/METHODS: A 64-year-old female with a history of severe diverticulosis presented for routine colonoscopy for polyp surveillance. The patient became significantly uncomfortable with water irrigation and a perforation was identified approximately 20cm from the anal verge, likely consistent with a perforated diverticulum. The procedure was aborted with subsequent imaging confirming a sigmoid colon perforation. In the operating room, a Padlock Clip defect closure device was endoscopically deployed with subsequent laparoscopic leak test confirming immediate air-tight seal. A diet was subsequently initiated without evidence of a leak. DISCUSSION: This case illustrates the efficacy of an alternative over-the-scope clip in closure of an acute colonic perforation. Compared to prior over-the-scope clips, the Padlock Clip is easier to deploy with potentially similar rates of efficacy and safety. The design of the Padlock Clip better facilitates two-person deployment as opposed to the Ovesco OTSC®. The deeper cap length makes acquisition of tissue easier and obviates the need for additional graspers. This patient demonstrates the Padlock Clip system as a viable option for the management acute iatrogenic colonic perforations. Reference: 1Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.

EFFICACY OF TEDUGLUTIDE IN PATIENTS WITH SHORT BOWEL SYNDROME ON HOME PARENTERAL NUTRITION: A REAL LIFE STUDY

Teduglutide is a GLP-2 analogue indicated for treatment of adults with short bowel syndrome (SBS) reducing parenteral support (PS) requirements. The present report aims to describe the effects of teduglutide in 3 patients on HPN for SBS clinically heterogeneous and with variable length of parenteral support from 4 to 25 years. Between 2017 and 2018, 3 patients with short bowel syndrome in home parenteral nutrition, clinically stable for at least 6 months, receveid daily subcutaneous injection of 0,05 mg/kg/day teduglutide. All patients had undergone, before treatment, a colonoscopy/ileoscopy for the purpose of polyp surveillance and a abdomen ultrasound which was normal. A history of cancer with fewer than 5 years was excluded. A clinically significant reduction from baseline in weekly parenteral support volume and calories was observed in patients, respectively ranging from about -31,8% and -31,1% at 3 months, -49,1% and -48,2% at 12 months. This was associated with an increase in parenteral nutrition-free days, ranging from about 2,3 days/week in 3 months and 4 days/week in 12 months. Stool frequency and volume decreased and consistency increased. Nutritional status evaluation revealed stability in body weight and food intake altrought parenteral support reduction. No serious adverse events were observed during treatment. Patients reported an improvement of quality of life, assessed using SF-36. This real life study demonstrated safety and efficacy of teduglutide suggesting reduction in parenteral support is associated with improvement of quality of life.

Colon polyps in patients with short bowel syndrome before and after teduglutide: Post hoc analysis of the STEPS study series.

Teduglutide promotes intestinal growth and is approved for the treatment of short bowel syndrome and intestinal failure (SBS-IF). Based on the pharmacologic activity and preclinical findings, teduglutide can potentially induce proliferative colonic mucosal changes.The aim of this study is to report the occurrence of colorectal polyps in adult patients with SBS-IF who received teduglutide in clinical studies conducted to date. A post hoc analysis of the completed Study of Teduglutide Effectiveness in Parenteral Nutrition-Dependent Short Bowel Syndrome Subjects (STEPS) clinical study series (NCT00798967, EudraCT 2008-006193-15; NCT00930644, EudraCT 2009-011679-65; NCT01560403) evaluated electronic case report form data for baseline colonoscopies (performed before treatment) and for surveillance or end-of-study (performed after treatment with teduglutide 0.05mg/kg/day for 24 and 36 months) post-exposure procedures. In the STEPS studies, 73 patients treated with teduglutide had a baseline colonoscopy. No post-exposure colonoscopy was scheduled in STEPS. In STEPS-2/3, 50 of 65 patients with remnant colon (77%) underwent a protocol-mandated post-exposure colonoscopy. Colon polyps were reported at baseline in 12% (9/73) of patients and post-exposure in 18% (9/50) of patients. Two had polyps both at baseline and post-exposure. On histology, available for 7 patients, 5 had adenomas (1 serrated, 4 tubular) and none had malignancy or high-grade dysplasia. These data support recommendations for colonoscopic screening before teduglutide therapy and subsequent on-therapy colonoscopic surveillance for patients with SBS-IF. Further studies are required to assess the risk of polyp formation in patients with SBS-IF and the most appropriate colon polyp surveillance strategies.