Endoscopic Resection Techniques Research Articles

Outcomes of Hemospray therapy in the treatment of intraprocedural upper gastrointestinal bleeding post-endoscopic therapy.

With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient's quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. Data was prospectively collected on the use of Hemospray from 16 centres (January 2016-November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0-9). The median Rockall score was six (interquartile range 5-7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

Evaluation of recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions.

the process that leads to the development of colorectal cancer takes many years and most tumors originate from polyps and non-polypoid lesions. Techniques of endoscopic resection are surgical treatment options, even in case of large lesions or with initial invasion. This study aimed to evaluate the recurrence and surgical complementation rates after endoscopic resection of large colorectal non-pedunculated lesions. a retrospective, longitudinal and descriptive trial was performed via an analysis of colonoscopies with the resection of non-pedunculated lesions larger than 3 cm, performed between 2014 and 2017. sixty-two lesions were included from 61 patients and 32 (52.5 %) were female. The age ranged from 36 to 89 years, with a mean age of 60.5 years. Lesions had an average diameter of 40.08 mm, ranging from 30 to 80 mm. Regarding the location of the lesions, the most frequent colonic segments were the ascending and rectum, both accounting for 22.6 %. Considering the morphologic endoscopic classification, 67.7 % were granular laterally spreading tumors (LST), 38.8 % were homogeneous granular and 29 % were mixed granular. The most frequent histological types were tubulovillous adenoma (30.7 %) and intramucosal adenocarcinoma (29 %). The resection technique was piecemeal mucosectomy in 85.5 %. Five lesions were removed by en bloc mucosectomy, two (3.2 %) by endoscopic submucosal dissection (ESD) and two (3.2 %) by a hybrid technique. The recurrence rate was 25.8 %. Three patients needed complementary surgical treatment and the clinical success of endoscopic treatment was 95.1 %. recurrence rate after endoscopic resection of large colorectal lesions was 25.8 % and surgical complementation rate due to failure in the endoscopic treatment of recurrence was 4.8 %.

Update on endoscopic treatment of Barrett's oesophagus and Barrett's oesophagus-related neoplasia.

Endoscopic therapy of early Barrett’s oesophagus–related neoplasia is the treatment of choice for low-grade-dysplasia, high-grade dysplasia and mucosal Barrett’s cancer. Low-grade-dysplasia without any visible lesion should be ablated, preferably with radiofrequency ablation. In cases with the presence of a visible lesion, high-grade dysplasia and early Barrett’s adenocarcinoma, endoscopic resection techniques like multiband ligation endoscopic resection or endoscopic submucosal dissection should be applied. After complete resection of all visible neoplastic lesions, ablation of the remaining Barrett’s oesophagus should be performed to prevent recurrence. Ablation techniques available are radiofrequency ablation, argon plasma coagulation and cryoablation.

A new endoscopic submucosal resection -ligation technique for gastric tumors.

Although most subepithelial lesions are benign, the malignant forms could present as serious life-threating cancers. Their accurate diagnosis depends on complete surgical resection. Different endoscopic methods have been recommended for the resection. Recently, the EMR has been considered as a safe and effective technique, while various revised EMR techniques have been introduced. In this study, a new version of EMR has been evaluated in two patients. Two middle-aged cases with gastric subepithelial tumors were admitted to Taleghani gastrointestinal department. The polyps were resected via our new Endoscopic Mucosal Resection (EMR) technique. In this technique, the needle knife was used for un-roofing the mucosal surface. Then, the polyps were resected with hot snares. The hemoclips were applied for ligation too. We found no early or delayed complications. Furthermore, the microscopic margins of the lesions were free. Our study represented a safe and cost-beneficial technique for subepithelial lesions and no complications was found and the margins were free. However, further investigations are required for confirming the validity of this new EMR technique.

Endoscopic resection techniques for squamous premalignant lesions and early carcinoma of the esophagus: ER-Cap, MBM, and ESD, how do we choose? A multicenter experience.

Background:Endoscopic resection cap technique (ER-Cap), multiband mucosectomy (MBM), and endoscopic submucosal dissection (ESD) have been widely applied in the treatment of esophageal squamous neoplasia and cancer. However, little is known with regards to the comparison of these methods. This study aimed to compare the feasibility, safety, effectiveness, and costs of these three techniques.Methods:A retrospective analysis of patients with squamous premalignant or early malignant lesions of the esophagus undergoing ER-Cap, MBM, or ESD from January 2009 to December 2015 in one of the centers in China was performed. The procedural data and follow-up data for all patients were recorded.Results:A total of 672 patients with 733 lesions were included; 148 lesions (133 patients) were treated with ER-Cap, 427 lesions (388 patients) with MBM, and 158 lesions (151 patients) with ESD. The mean age was 61.59 years and the male-to-female ratio was 2.78:1. The operation time was significantly shorter for ER-Cap (29.26 ± 16.73 mins, p < 0.001) group, and the hospitalization costs were significantly lower in the MBM group (20,942.03 ± 8435.56￥, p = 0.003). The resection sample size of ESD was significantly larger (4.40 ± 1.20 cm, p < 0.001) and the en bloc resection rate of ESD was significantly higher (p < 0.001) than that of the other two groups. The frequencies of perforation, bleeding, and cicatricial stenosis were significantly lower in the MBM group (p < 0.001, p = 0.011, p = 0.009). Three local recurrences were observed in the ER-Cap group, while no recurrence was observed in MBM and ESD groups. There were three and two metastatic patients observed in the MBM and ESD groups, respectively.Conclusions:ER-Cap, MBM, and ESD are all minimally invasive, safe, and effective methods for treating early esophageal squamous cell carcinoma. MBM could be considered as a good alternative when performed by a less-experienced endoscopist in high-incidence areas with limited resources.

Fully Endoscopic Transforaminal–Transchoroidal Approach for Tectal Area Tumor Removal

The surgical approaches to lesions located in the tectal area have remained controversial. The essential functions in the surrounding areas and the difficulties in obtaining a good surgical view during tumor removal have made these procedures risky and challenging. Endoscopic transforaminal approaches have been previously described for biopsy and intraventricular tumor removal. However, the endoscopic transforaminal-transchoroidal gross resection technique for such cases has barely been described. The endoscopic entry points and trajectories were planned using preoperative magnetic resonance imaging. Once the endoscope was inside the ventricular system, the angles of work and tumor exposure of the upper posterior part of the third ventricle were carefully evaluated. If the angle of work was insufficient for tumor removal, the choroidal fissure was opened using endoscopic bipolar electrode and dissectors. Tumor removal was performed using an endoscopic ultrasonic aspirator. We have presented a 3-case series of patients affected by tectal tumors that were treated using a fully endoscopic transforaminal-transchoroidal approach. Total gross resection of the tumors was achieved in 2 patients. Subtotal resection was achieved in the third patient. No major complications had developed in relationship to the procedure. No new cognitive impairment was reported secondary to this technique. In our experience, a fully endoscopic transforaminal-transchoroidal approach was a suitable treatment for this complex pathological entity. Opening of the choroidal fissure added an extra angle of work and improved the exposure of the upper posterior part of the third ventricle.

Endoscopic full-thickness resection for treating small tumors originating from the muscularis propria in the gastric fundus: An improvement in technique over 15 years.

BACKGROUNDThe fundus of the stomach is regarded as a difficult area for endoscopic resection of small tumors originating from the muscularis propria (MP tumors). Three endoscopic resection techniques have been developed to treat these tumors, including ligation-assisted endoscopic full-thickness resection (L-EFTR), snare-assisted EFTR (S-EFTR), and endoscopic submucosal dissection-assisted EFTR (E-EFTR). To date, no studies have compared these techniques.AIMWe aimed to evaluate and compare S-EFTR with L-EFTR and E-EFTR for treating small MP tumors in the gastric fundus.METHODSWe retrospectively reviewed patients with primary small MP tumors in the gastric fundus and treated by these three techniques between January 2016 and December 2018 at Shengjing Hospital, China. Standard demographic and clinicopathologic data, including sex, age, tumor size, surgeon details, and pathological results, were collected. Data regarding operation duration, cost, en-bloc resection, and severe complications were also extracted and compared.RESULTSA total of 36 patients (27 women) with a mean age of 55.8 ± 10.20 years were included in this study. The mean tumor size was 9.0 ± 3.98 mm. All the methods showed a 100% en-bloc resection rate and 0% severe complication rate. There was no statistically significant difference among the three groups in the operation duration (P = 0.148). The cost comparison for the whole procedure was as follows: E-EFTR > L-EFTR > S-EFTR (5837.5 ± 7212.96 CNY, 5970.7 ± 3465.27 CNY, 5852.0 ± 6438.25 CNY, respectively, P < 0.001).CONCLUSIONS-EFTR, L-EFT, and E-EFTR are all effective for resection of small MP tumors in the gastric fundus. S-EFTR is superior in terms of cost-effectiveness.

Comparison of different endoscopic resection techniques for submucosal tumors originating from muscularis propria at the esophagogastric junction

BackgroundTo compare the outcomes of submucosal tunneling endoscopic resection (STER) and submucosal excavation (ESE) for the treatment of submucosal tumors (SMTs) arising from the muscularis propria (MP) at the esophagogastric junction (EGJ).MethodsA retrospective analysis of patients with SMTs at EGJ who underwent STER and ESE from October 2011 to October 2017 was performed. The outcomes evaluated were operation time, complete resection rate, adverse events, and tumor recurrence.ResultsNinety patients were included in this study. Complete resection rates in the STER group were higher than those of the ESE group (100 vs. 92%, p < 0.05). For tumors ≤15 mm, both techniques achieved 100% complete resection rate; but for tumors > 15 mm, complete resection rate was higher in the STER group than the ESE group (100% vs. 77.8%, p < 0.05). Subgroup analyses revealed that the operation time of STER for in cardiac-gastric group was longer than that for ESE (145.14 ± 42.43 min vs. 70.32 ± 39.84 min, p < 0.05). The air leakage symptoms were more frequent in STER group (90.9% vs. 50.0%, p < 0.05). No tumor recurrence occurred in both the STER and ESE groups.ConclusionsFor SMTs ≤15 mm, both STER and ESE have similar satisfactory therapeutic outcomes. However, in the cardiac-gastric subgroup, STER had a longer operative time compared to the ESE procedure. For SMTs > 15 mm, STER is the preferred choice due to its higher complete resection rate.

1201 Clinical and Pathologic Risk Factors for Lymph Node Metastases in Gastric Neuroendocrine Tumors

INTRODUCTION: Among gastric neuroendocrine tumors (GNETs), type III is believed to have higher risk of lymph node (LN) metastases than type I or II; however, few studies have explored the clinical history and pathologic attributes correlating with LN metastases. With advances in endoscopic resection techniques like endoscopic submucosal dissection and endoscopic full thickness resection allowing endoscopic removal of these tumors, it is important to understand which lesions are at risk of LN metastases and not candidates for endoscopic resection. Our study aims to determine clinical and pathologic risk factors associated with GNET LN metastases in the US. METHODS: This single center retrospective study evaluated consecutive patients at a large tertiary referral center undergoing surgical resection of biopsy proven GNET from April 1988 to January 2019. Demographics, past medical history, and serum studies (gastrin, B12, chromogranin) were included as available. Endoscopic and pathologic tumor features, such as size, number of lesions, depth of invasion, and lymphovascular invasion were studied. Tumor grading was characterized as high (poorly differentiated/WHO 3) or low (well differentiated/WHO 1 &amp; 2) as some patients preceded WHO classification. If unreported, GNET type was based on presence of atrophic gastritis and/or gastrin levels. LN metastases were defined by positive nodes on surgical resection. RESULTS: Thirty patients underwent gastric surgical resection for GNET. There were 14 type 1, 8 type 3, and 8 unclassified GNETs (insufficient serum and/or pathology description for classification); no type 2 GNETs were identified based on documented history (Table 1). Of the 37.9% of patients who underwent LN dissection, 3 patients (27%) had positive LN on pathology. No patients that did not have LN dissection developed evidence of LN metastasis on surveillance imaging. Of the endoscopic and pathologic factors in Table 2, high tumor grade (P = 0.093) and deep invasion (P = 0.058) were statistically associated with LN metastasis, as with 1 high grade type 3 GNET invading the subserosa. CONCLUSION: High grade or deeply invading GNETs are associated with LN metastases; endoscopic resection should be avoided in these patients. In our case series, low grade type 3 GNETs were not associated with LN metastasis. Endoscopic resection with close surveillance may be considered in small, low grade type 3 GNET, especially if patients are poor surgical candidates. Further studies are needed to confirm these findings.

915 A Comparison of Endoscopic Submucosal Resection (EMR) vs. Endoscopic Submucosal Dissection (ESD) on Histologic Margins and Pathologic Evaluation for Endoscopically Managed Early Esophageal Adenocarcinoma

INTRODUCTION: Accurate histologic determination is important to determine the completeness of endoscopic resection for esophageal adenocarcinoma (EAC) and gauge risk of recurrence. EMR and ESD are both endoscopic resection techniques used for the treatment of early EAC. ESD advocates believe ESD specimens allow for more precise histopathologic analysis than EMR, but this has never been proven. We aim to determine the effect of EMR vs ESD techniques on histologic analysis in endoscopically treated early EAC. METHODS: This is a retrospective, single center study of EMR and ESD resection specimens with pathologic confirmation of HGD or T1 EAC between 1/15-12/18. Lesions with suspected invasion into the muscularis mucosa or beyond (T2 carcinoma or higher) were excluded. Endoscopic and histologic characteristics were collected. Pathology slides were re-analyzed by a blinded GI pathologist for typical pathologic features. RESULTS: 52 patients with early EAC were analyzed (23 ESD;29 EMR) [Table 1]. ESD-resected tumors were larger compared to those resected by EMR (20 mm [20.0, 28.0] vs 11 mm [9.0, 13.0], P &lt; 0.001) [Table 2]. As per Table 3, EMR specimens were more likely to have positive lateral margins compared to ESD (38% vs 13%, P &lt; 0.005) and have lower confidence in determining lateral margins. Reasons for lower confidence in the EMR group included cautery artifact (37.9%) and difficulty in orientation (20.7%). When accounting for differences in specimen thickness, EMR had a higher percentage of cauterized tissue per total tissue thickness (11.8% vs 3.9%, P &lt; 0.001). EMR specimens had cautery effect abutting the lesion while ESD did not (0 μm vs 2259 μm distance of lesion from nearest cautery, P = 0.001). Cautery effect was more likely to interfere with margin evaluation in EMR (38% vs 13%, P = 0.04). ESD specimens were well-oriented compared to EMR (P = 0.011). EMR and ESD had no difference in positive vertical margins (7% vs 9%, P = 0.33), lymphovascular invasion (P = 0.11), or submucosal invasion (P = 0.62). CONCLUSION: Cautery effect and the inability to orient the specimens appropriately play a role in limiting the evaluation of EMR specimens. EMR and ESD had similar rates of positive vertical margins but rates of positive lateral margins were significantly higher in EMR, despite a smaller lesion size resected with EMR. We postulate that this is a limitation of EMR technique and there is a certain lateral size that is unsuitable for EMR as it may not be able to resect enough of a “normal” margin to the tumor compared to ESD.

229 Assessing Varying Techniques of Colonic Endoscopic Mucosal Resection and Subsequent Residual Adenoma at 6-Month Follow-Up

INTRODUCTION: Local recurrence at colonic endoscopic mucosal resection (EMR) sites of medium to large polyps is common at first follow-up (∼10–30%). Extended edge resection has not shown a benefit of reducing this rate; however, edge ablation with snare tip soft coagulation has shown reduced local recurrence. Hybrid argon plasma coagulation (APC) is a novel technique, which can be used to treat microscopic residual disease to prevent local recurrence at follow-up surveillance colonoscopy. This study aims to evaluate if treating both the edges and base of an EMR site with a novel technique, hybrid APC, can reduce the rate of local recurrence at 6-month follow-up versus standard EMR assessing a single endoscopist. METHODS: This is a single center retrospective case series of all colonic EMRs with 6-month surveillance performed by a single endoscopist at a tertiary care center using both standard EMR and hybrid APC assisted EMR from May 2018 to May 2019. The main outcome measure was recurrence of precancerous polyp at prior EMR site at 6-month surveillance colonoscopy. Secondary outcome measures were the rate of procedure associated complications, including post-polypectomy bleeding and post-polypectomy syndrome. RESULTS: A total of 84 EMRs, 38 utilized hAPC, were performed from in the study period. 25 patients (mean age: 65.4 years, 48% men) with 30 polyps were included who completed surveillance colonoscopy after 6 months to evaluate for recurrence (Table 1). The average resected polyp size was 32 mm. Residual polyp recurrence occurred at 4 prior EMR sites (13.3%), with all of the recurrences occurring in patients who underwent standard EMR (100%). There was no recurrence of residual polyps in patients treated with hAPC assisted EMR. Further, 4 patients (15.4%) experienced post-polypectomy bleeding complications within 6 months, with all complications associated with patients treated with standard EMR (Table 2). There was a statistically non-significant trend toward higher recurrence and complication rate in patients treated with standard EMR compared to hAPC assisted EMR. CONCLUSION: In this retrospective study of colonic EMRs, the use of hAPC at initial EMR was associated with decreased local recurrence rate of precancerous tissue at EMR sites and rate of early complications. The findings of this early retrospective study warrant further studies to determine the efficacy of hAPC in reducing the recurrence rate after 6 months and how it compares to standard EMR procedure with snare tip soft coagulation.

125 Underwater Versus Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Laterally Spreading Tumors: Results From an International, Multicenter, Randomized Controlled Trial

INTRODUCTION: Safe and effective resection of large colonic polyps remains a challenge for the practicing endoscopist. Recently, an underwater technique for endoscopic mucosal resection (UEMR) has emerged as an alternative to conventional injection-assisted EMR (CEMR). While the effectiveness of UEMR technique seems to be borne out in several case series and retrospective analyses, prospective data regarding its performance against CEMR technique is lacking. METHODS: This study was a prospective international multicenter randomized controlled trial involving 4 tertiary referral centers, 3 in the US and 1 in Italy, in order to compare the outcomes and safety of UEMR versus CEMR technique for large colon polyps (15 mm or larger). Block randomization was used to assign patients to either the UEMR arm or CEMR arm. Primary outcome was the rate of curative resection, as documented by presence of residual neoplasia on 3–6 month surveillance colonoscopy. Secondary outcomes included resection time, total procedure time, en bloc resection rates, and adverse events. RESULTS: A total of 303 patients with 303 lesions were enrolled in this trial. 145 patients were randomized into the CEMR arm, and 158 patients were enrolled in the UEMR arm. Among those in the CEMR arm, 13 patients crossed over into the UEMR arm at the discretion of the performing endoscopist. Among those in the UEMR arm, 1 patient crossed over to the CEMR arm. At follow up, a total of 95 patients had surveillance colonoscopy performed in the CEMR arm, with residual neoplasia found in 16 of these patients (16.8%). In the UEMR arm, 118 patients followed up, with residual neoplasia found in 10 of these patients (8.5%) [P = 0.06] The resection time and total procedure time were found to be less in the UEMR arm and there was a significantly higher rate of en bloc resection achieved by UEMR versus CEMR (P &lt; 0.01). There was no difference in the rate of adverse events. CONCLUSION: This large multicenter randomized study supports that UEMR technique is a safe and effective alternative to CEMR technique and should be considered a first line option in the management of large laterally spreading colorectal tumors.

225 Barriers to Endoscopic Mucosal Resection of Large Colorectal Lesions: Results of a Nationwide Survey

INTRODUCTION: Over 90% of complex colon polyps that lack overt features of cancer can be removed using endoscopic mucosal resection (EMR) techniques. EMR is more cost-effective and is associated with less morbidity and mortality than surgery. However, rates of surgical resection have been rising even though extensive evidence suggests endoscopic resection should be first line for the management of complex colon polyps. We aimed to assess perceived barriers towards the utilization of EMR for &gt;2 cm polyps among American endoscopists. METHODS: We administered a 21 question web-based survey with Qualtrics software (Provo, UT, USA). The American College of Gastroenterology distributed the survey to their mailing list on January 24, 2019 and closed it on February 21, 2019. We assessed endoscopist and practice characteristics as well as perceived barriers and facilitators of EMR, and compared responses between providers who performed 0–1 EMR per month with 2 or more EMR per month to determine which barriers and facilitators influence the utilization of EMR. RESULTS: A total of 8,797 practitioners received the survey, with 415 replies (4.7%). Provider demographics are summarized in Table 1. 275 providers (66.7%) reported performing 2 or more EMRs per month. 146 providers (35.1%) felt their fellowship prepared them poorly for large polyp resection. 237 providers (57.1%) felt that the incorporation of EMR training into fellowship would be very beneficial, followed by higher reimbursement (N = 176, 42.4%) and training on EMR technique (N = 154, 37.1%). Providers who performed 1 or fewer EMR per month were significantly more likely to report that lack of structured training, fear of complications, and uncertainty regarding which lesions were amenable to endoscopic management were barriers to routine use of EMR than providers who performed 2 or more EMR per month (Figure 1). They were also more likely to report improved training to be a facilitator for EMR utilization whereas providers who performed 2 or more EMR per month were more likely to report increased reimbursement as a facilitator for EMR utilization (Figure 2). CONCLUSION: We found that endoscopists identified lack of training to be a major barrier to performing EMR, especially for low-volume providers. Increasing reimbursement and training were important potential facilitators identified in our study. Future quality improvement efforts should target these key practice aspects to optimize the endoscopic management of complex colon lesions.

2194 Prevention of Excessive Gas Accumulation With a Biliary Dilation Balloon During Endoscopic Cryotherapy

INTRODUCTION: Endoscopic cryotherapy for the treatment of premalignant and malignant conditions has been demonstrated to be an effective tool in esophageal malignancy. However, there is concern for perforation from gas production during cryotherapy. Here we describe the use of a biliary dilation balloon to prevent distal gas accumulation in Roux-en-Y anatomy. CASE DESCRIPTION/METHODS: This is a case of a 77-year-old male with history of total gastrectomy with Roux-en-Y esophagojejunostomy for remote history of gastric leiomyosarcoma and locally advanced esophageal cancer. Two years prior he underwent Endoscopic Submucosal Dissection (ESD) of an esophageal nodule previously biopsied positively for adenocarcinoma. One year ago a surveillance EGD/EUS with biopsy showed no evidence of residual disease at the ESD site. Repeat surveillance EGD/EUS early this year identified thickening of subepithelial layers with a 6mm hypoechoic lesion at the level of the ESD scar. A hybrid ESD and endoscopic mucosal resection (EMR) technique was performed to remove the nodule. Pathology showed invasive poorly differentiated adenocarcinoma with the deeper cauterized margin involved. Endoscopic cryoablation was planned for the remaining margins. Close examination of the ESD defect using EGD and EUS showed no evidence of recurrence. Cryotherapy was then prepared with the insertion of a biliary dilation balloon via a nasal trumpet. The balloon was endoscopically guided to the jejunum distal to the esophagojejunal anastomosis and inflated to prevent distal leakage of cooling gases. A decompression tube was placed in the esophagus proximal to the treatment area. Using the cryocatheter, 3 treatments of liquid nitrogen at -190⁰ C were sprayed over the ESD scar to achieve uniform white frost, each treatment lasting 30 seconds with 60 seconds of defrost time between. Throughout the treatment, suction was provided via the decompression tube and the abdomen was palpated without significant distention. The patient tolerated the procedure well without complication and was discharged home. DISCUSSION: Gas by-products are produced during cryotherapy, which in the case of a patient with a Roux-en-Y, causes substantial risk for perforation. With a distally inflated biliary dilation balloon, gas is prevented from accumulating in the small intestine where it may be difficult to suction, reducing the risk of perforation. This technique may be applied to similar cases where perforation risk is elevated.

3087 Combined Endoscopic and Surgical Management of Small Bowel Polyposis in a Patient With Peutz-Jeghers Syndrome

INTRODUCTION: A 55-year-old male with history of Peutz-Jeghers syndrome was referred for a colonoscopy for management of a large ileal polyp. Surgical history was notable for two laparatomies for small bowel obstructions in the setting of intussusception as well as multiple enterotomies for removal of polyps. CASE DESCRIPTION/METHODS: Colonoscopy confirmed a polypoid mass in the distal ileum that was partially obstructing. Endoscopic submucosal dissection of the polyp stalk was performed but revealed two feeding arteries as well as a thick muscular band, concerning for muscularis propria, that precluded further safe dissection. Hemoclips were placed on the feeding arteries in an attempt to cause necrosis of the lesion. After discharge the patient developed hematochezia. Repeat colonoscopy did not show any ongoing bleeding but the mass appeared to be necrotic. Repeat colonoscopy was planned in the operating room to evaluate the mass. If the necrosis was not complete, dissection of the stalk would be re-attempted with plans to convert to surgical resection if needed. On endoscopy, the mass appeared to have revitalized. Another attempt at submucosal dissection of the polyp stalk was performed. However as the area had already been dissected through, the submucosal plane was not easily identified in the stalk and did not feel that it was safe to continue the submucosal dissection. Subsequently, the patient was converted to surgical resection of the ileal polyp, which also revealed multiple polyps more proximally throughout the small bowel. The bowel resection included the initial large polyp and another large polyp at a prior ileal anastomosis that could not be removed without a resection. Multiple other polyps were removed via enterotomies. To clear the remaining small bowel of residual polyps, we performed a clean sweep. A pediatric colonoscope was introduced orally and the scope was able to be advanced distally to the ileal anastomosis by plicating the bowel over the scope. Multiple further polypectomies were then performed using standard endoscopic mucosal resection technique. On 3 month follow up MR enterography, there were no convincing polyps identified in the entire small bowel. DISCUSSION: This case demonstrates the importance of a multi-disciplinary approach to the management of this patient's polyposis. The combination of endoscopic and surgical approach allowed for effective management of both the large ileal polyp as well as his overall polyp burden. Watch the video: http://bit.ly/2JWHRA2

Endoscopic transsphenoidal resection of hypothalamic hamartoma

This abstract discusses two clinical cases of hypothalamic hamartoma (HH) which have not yet been described in any Russian or international papers, and presents the details of endoscopic resection technique with a transsphenoidal approach. Patient R., 16 years old male with a 9-year history, epileptic seizures every 5–6 days. On MRI- 1.5 × 1.4 × 1.4 cm HH and FCD of the right occipital lobe. Three seizures were detected during video-EEG monitoring. Patient M., 23 years old female with a 16-year history of illness, epileptic seizures once in a week. On MRI - 2.44 × 2.79 × 2.68 cm HH. Two seizures were detected during video-EEG. In both cases surgical excision by transsphenoidal endoscopic approach was performed. First patient was discharged in satisfactory condition on the 7th day after surgery, and didn't have neurological deficit, electrolyte disorders (hypo- or hypernatremia, polyuria, polydipsia), visual disorders (hemianopsia or reduced visual acuity). Second patient in the early postoperative period had electrolyte disorders (hyponatremia), which were reversed after using hypo-osmolar solutions and mineralocorticoids. There were no visual impairments (hemianopia or visual acuity reduction). The patient was discharged in satisfactory condition on the 7th day after the surgery. In 18 months after surgery both patients are seizure free (Engel I). Clinical observation data suggest that transsphenoidal resection of HH in patients with drug-resistant epilepsy is possible. Our experience shows that refractory epilepsy associated with HH can be safely and effectively treated with transsphenoidal resection of HH, with the possibility of radical cure and disease control.

2933 Outcomes of Endoscopic Submucosal Dissection (ESD): A Single Center Experience

INTRODUCTION: Endoscopic submucosal dissection (ESD) is a new and advanced endoscopic resection technique; initially developed in Japan for therapeutic and diagnostic management of superficial gastrointestinal malignancies that has limited submucosal involvement and has not metastasized to any regional lymph nodes. ESD provides an accurate histopathological assessment of resected specimens, as en bloc resection of the entire lesions is necessary. ESD is a well-established treatment modality in the East while its interest is beginning to peak in the West. METHODS: This is a single-site, internal database review project that was included in a larger study with the University of Florida. The objective of this retrospective study is to evaluate the clinical utility of ESD and its impact on the diagnosis and management of colorectal lesions. This abstract focuses on a sub-sample of 10 patients, over the age of 18, from Staten Island University Hospital, who underwent the ESD procedure for colorectal lesions between July 2014 and September 2018. The team collected demographic information, disease and surgical details: location of lesion, procedural and pathological findings, and any complications. RESULTS: The sample size was determined based on the number of colorectal ESD procedures performed in July of 2014 through September of 2018 at SIUH – Northwell Health. The encounters of 10 patients were recorded. The average lesion size was 39.5 mm and average resection size was 43 mm. The average total procedure time was 1 hour and 46.5 minutes. There were no adverse events during any of the procedures. 70% of patients achieved R0 and curative resection while the other 30% went onto Endoscopic Full Thickness Resection or surgical resection. CONCLUSION: ESD has proven to be effective for en-bloc and R0 resection for colorectal lesions in both our small sample size and throughout the multicenter analysis. ESD has the potential to offer patients a safer and less invasive option for their early stage colorectal lesions with minimal risk for adverse events as presented from our data (0%) but also confirmed from the larger study. As ESD can be done as an outpatient procedure, patients can avoid hospital admission. Subsequently, ESD provides a better quality of life to patients offering them alternatives to chemotherapy and surgery. ESD should be considered in the treatment algorithm for select advanced lesions in the rectum. Further research will be done for quality improvement measures for this procedure.

Early Esophageal Cancer: A Gastroenterologist's Disease.

Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.

Future of Endoscopy: Brief review of current and future endoscopic resection techniques for colorectal lesions.

Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.

A novel non-thermal resection tool in endoscopic management of scarred polyps.

Background and study aims Scarred polyps are challenging to resect using conventional endoscopic mucosal resection (EMR) techniques. The aim of this pilot study was to assess the feasibility of the EndoRotor device in resecting scarred polyps arising from previous endoscopic resection attempts. Patients and methods This was a prospective pilot study of patients with scarred colonic polyps treated using EndoRotor carried out in two centers. Results A total of 19 patients were included in this study. The overall cure rate using EndoRotor was 84 %; 10 patients (52.6 %) achieved cure after one attempt and six patients (31.5 %) achieved cure after two attempts. A total of three patients who had polyp recurrence after the first EndoRotor resection were referred for either endoscopic submucosal dissection (2 patients) or surgery (1 patient) due to difficult access. There were no perforations, delayed bleeding, post-polypectomy syndrome or complications requiring surgery. Conclusions In this pilot study, the novel non-thermal device (EndoRotor) has been demonstrated to be a safe and effective technique in challenging management of scarred polyps. Further randomized controlled trials comparing this technique with APC, hot avulsion, ESD and endoscopic full-thickness resection are required to ascertain the utility of EndoRotor in the hands of non-expert endoscopists.